189
Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited. You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose. NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis. ** Confidential and Proprietary ** March 2019 1 Nebraska Medicaid Program Monthly Maximum Allowable Cost (MAC) Listing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly. Generic Name Strength Form Route Effective Date MAC Price 0.9 % SODIUM CHLORIDE 0.9 % CARTRIDGE INJECTION 04/19/2016 0.08911 0.9 % SODIUM CHLORIDE 0.9 % SYRINGE INJECTION 04/19/2016 0.08911 0.9 % SODIUM CHLORIDE 0.9 % VIAL INJECTION 06/30/2015 0.06432 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN INTRAVEN 12/12/2018 0.00261 ABACAVIR SULFATE 20 MG/ML SOLUTION ORAL 04/25/2018 0.81963 ABACAVIR SULFATE 300 MG TABLET ORAL 10/10/2018 2.00978 ABACAVIR SULFATE/LAMIVUDINE 600-300MG TABLET ORAL 02/13/2019 7.38960 ABACAVIR/LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET ORAL 12/28/2016 23.35288 ABIRATERONE ACETATE 250 MG TABLET ORAL 02/06/2019 33.98097 ACAMPROSATE CALCIUM 333 MG TABLET DR ORAL 05/22/2018 0.79864 ACARBOSE 100 MG TABLET ORAL 10/24/2018 0.25983 ACARBOSE 50 MG TABLET ORAL 10/27/2015 0.24589 ACARBOSE 25 MG TABLET ORAL 10/24/2018 0.21306 ACEBUTOLOL HCL 200 MG CAPSULE ORAL 02/13/2019 0.29065 ACEBUTOLOL HCL 400 MG CAPSULE ORAL 02/13/2019 0.48173 ACETAMINOPHEN 500 MG CAPSULE ORAL 05/23/2018 0.03672 ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 03/06/2019 0.02111 ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 07/03/2018 0.29794 ACETAMINOPHEN 160 MG/5ML ELIXIR ORAL 10/17/2018 0.00634 ACETAMINOPHEN 160 MG/5ML SOLUTION ORAL 02/20/2019 0.34730 ACETAMINOPHEN 325/10.15 SOLUTION ORAL 02/20/2019 0.20488

MAC Listing - Nebraska Medicaid program

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Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20191

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20191

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

0.9 % SODIUM CHLORIDE 0.9 % CARTRIDGE INJECTION 04/19/2016 0.08911

0.9 % SODIUM CHLORIDE 0.9 % SYRINGE INJECTION 04/19/2016 0.08911

0.9 % SODIUM CHLORIDE 0.9 % VIAL INJECTION 06/30/2015 0.06432

0.9 % SODIUM CHLORIDE 0.9 % IV SOLN INTRAVEN 12/12/2018 0.00261

ABACAVIR SULFATE 20 MG/ML SOLUTION ORAL 04/25/2018 0.81963

ABACAVIR SULFATE 300 MG TABLET ORAL 10/10/2018 2.00978

ABACAVIR SULFATE/LAMIVUDINE 600-300MG TABLET ORAL 02/13/2019 7.38960

ABACAVIR/LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET ORAL 12/28/2016 23.35288

ABIRATERONE ACETATE 250 MG TABLET ORAL 02/06/2019 33.98097

ACAMPROSATE CALCIUM 333 MG TABLET DR ORAL 05/22/2018 0.79864

ACARBOSE 100 MG TABLET ORAL 10/24/2018 0.25983

ACARBOSE 50 MG TABLET ORAL 10/27/2015 0.24589

ACARBOSE 25 MG TABLET ORAL 10/24/2018 0.21306

ACEBUTOLOL HCL 200 MG CAPSULE ORAL 02/13/2019 0.29065

ACEBUTOLOL HCL 400 MG CAPSULE ORAL 02/13/2019 0.48173

ACETAMINOPHEN 500 MG CAPSULE ORAL 05/23/2018 0.03672

ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 03/06/2019 0.02111

ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 07/03/2018 0.29794

ACETAMINOPHEN 160 MG/5ML ELIXIR ORAL 10/17/2018 0.00634

ACETAMINOPHEN 160 MG/5ML SOLUTION ORAL 02/20/2019 0.34730

ACETAMINOPHEN 325/10.15 SOLUTION ORAL 02/20/2019 0.20488

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20192

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ACETAMINOPHEN 650MG/20.3 SOLUTION ORAL 02/20/2019 0.10682

ACETAMINOPHEN 160 MG/5ML LIQUID ORAL 07/25/2018 0.00677

ACETAMINOPHEN 500MG/15ML LIQUID ORAL 07/03/2018 0.01468

ACETAMINOPHEN 325 MG TABLET ORAL 03/06/2019 0.01508

ACETAMINOPHEN 500 MG TABLET ORAL 02/20/2019 0.01405

ACETAMINOPHEN 160 MG TAB CHEW ORAL 12/26/2018 0.27847

ACETAMINOPHEN 650 MG TABLET ER ORAL 03/06/2019 0.69501

ACETAMINOPHEN 120 MG SUPP.RECT RECTAL 09/22/2015 0.23678

ACETAMINOPHEN 325 MG SUPP.RECT RECTAL 01/29/2019 0.54916

ACETAMINOPHEN 650 MG SUPP.RECT RECTAL 04/24/2018 0.32659

ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION ORAL 12/16/2015 0.01474

ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION ORAL 07/03/2018 0.27762

ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION ORAL 08/08/2018 0.15543

ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET ORAL 08/22/2018 0.13186

ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET ORAL 05/26/2015 0.10589

ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET ORAL 02/06/2019 0.13620

ACETAMINOPHEN/CHLORPHENIRAMINE 325MG-2MG TABLET ORAL 06/07/2017 0.29815

ACETAMINOPHEN/D-BROMPHENIRAMIN 500MG-1MG TABLET ORAL 01/18/2017 0.12060

ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET ORAL 01/30/2019 0.03082

ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET ORAL 09/27/2017 0.09499

ACETAZOLAMIDE 500 MG CAPSULE ER ORAL 01/10/2018 1.60800

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20193

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ACETAZOLAMIDE 125 MG TABLET ORAL 01/23/2019 1.67781

ACETAZOLAMIDE 250 MG TABLET ORAL 05/26/2015 2.74019

ACETAZOLAMIDE SODIUM 500 MG VIAL INJECTION 02/06/2019 16.39050

ACETIC ACID 2 % SOLUTION OTIC (EAR) 12/12/2018 1.91084

ACETIC ACID 0.25 % IRRIG SOLN IRRIGATION 02/07/2018 0.00457

ACETONE LIQUID MISCELL 06/13/2018 0.02504

ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG TABLET ORAL 08/01/2018 1.93541

ACETYLCYSTEINE 200 MG/ML VIAL INTRAVEN 10/24/2018 2.94965

ACETYLCYSTEINE 100 MG/ML VIAL MISCELL 09/20/2017 0.42552

ACETYLCYSTEINE 200 MG/ML VIAL MISCELL 01/16/2019 0.45709

ACITRETIN 10 MG CAPSULE ORAL 12/19/2018 11.16427

ACITRETIN 25 MG CAPSULE ORAL 12/19/2018 15.90820

ACITRETIN 17.5 MG CAPSULE ORAL 09/24/2018 21.03360

ACTIVATED CHARCOAL 260 MG CAPSULE ORAL 06/04/2014 0.08096

ACTIVATED CHARCOAL POWDER ORAL 01/09/2019 0.91835

ACTIVATED CHARCOAL 25 G/120ML ORAL SUSP ORAL 09/24/2018 0.14908

ACTIVATED CHARCOAL 50G/240ML ORAL SUSP ORAL 04/04/2018 0.10558

ACYCLOVIR 200 MG CAPSULE ORAL 02/06/2019 0.10859

ACYCLOVIR 200 MG/5ML ORAL SUSP ORAL 12/19/2018 0.63667

ACYCLOVIR 800 MG TABLET ORAL 02/20/2019 0.12725

ACYCLOVIR 400 MG TABLET ORAL 02/20/2019 0.06700

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20194

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ACYCLOVIR 5 % CREAM (G) TOPICAL 02/20/2019 155.76925

ACYCLOVIR 5 % OINT. (G) TOPICAL 11/28/2018 3.74176

ACYCLOVIR SODIUM 50 MG/ML VIAL INTRAVEN 05/02/2018 0.44079

ADAPALENE 0.1 % GEL (GRAM) TOPICAL 02/13/2019 3.48597

ADAPALENE 0.3 % GEL (GRAM) TOPICAL 07/25/2018 3.70627

ADAPALENE 0.1 % CREAM (G) TOPICAL 01/09/2019 4.90395

ADAPALENE 0.3 % GEL W/PUMP TOPICAL 08/22/2018 3.78107

ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GEL W/PUMP TOPICAL 02/20/2019 1.54040

ADEFOVIR DIPIVOXIL 10 MG TABLET ORAL 09/24/2018 26.87106

ADENOSINE 3 MG/ML VIAL INTRAVEN 12/19/2018 1.47266

ADENOSINE 3 MG/ML VIAL INTRAVEN 01/30/2019 1.43983

ALBENDAZOLE 200 MG TABLET ORAL 01/23/2019 228.76463

ALBUTEROL SULFATE 2 MG/5 ML SYRUP ORAL 01/23/2019 0.12864

ALBUTEROL SULFATE 2 MG TABLET ORAL 01/30/2019 2.63980

ALBUTEROL SULFATE 4 MG TABLET ORAL 01/16/2019 2.63533

ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB INHALATION 02/13/2019 0.04988

ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB INHALATION 08/15/2018 0.29962

ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB INHALATION 01/16/2019 0.24388

ALBUTEROL SULFATE 5 MG/ML SOLUTION INHALATION 05/26/2015 1.03180

ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) TOPICAL 08/30/2016 0.88418

ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) TOPICAL 11/07/2018 0.56250

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20195

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ALCOHOL ANTISEPTIC PADS MED. PAD TOPICAL 02/06/2019 0.01146

ALENDRONATE SODIUM 10 MG TABLET ORAL 08/01/2018 0.19609

ALENDRONATE SODIUM 5 MG TABLET ORAL 04/25/2018 0.19309

ALENDRONATE SODIUM 70 MG TABLET ORAL 02/20/2019 0.73030

ALENDRONATE SODIUM 35 MG TABLET ORAL 02/20/2019 0.73030

ALFENTANIL HCL 500 MCG/ML AMPUL INJECTION 09/09/2015 1.56780

ALFUZOSIN HCL 10 MG TAB ER 24H ORAL 01/23/2019 0.10385

ALLOPURINOL 100 MG TABLET ORAL 02/20/2019 0.05360

ALLOPURINOL 300 MG TABLET ORAL 02/27/2019 0.10720

ALLOPURINOL SODIUM 500 MG VIAL INTRAVEN 01/23/2019 3890.17225

ALMOTRIPTAN MALATE 12.5 MG TABLET ORAL 03/07/2018 39.57525

ALMOTRIPTAN MALATE 6.25 MG TABLET ORAL 07/03/2018 39.57525

ALOE VERA/COLLAGEN SOLUTION TOPICAL 05/18/2016 0.01228

ALOSETRON HCL 1 MG TABLET ORAL 03/15/2017 34.08091

ALOSETRON HCL 0.5 MG TABLET ORAL 02/21/2017 14.56945

ALPHA LIPOIC ACID 200 MG CAPSULE ORAL 12/05/2018 0.27157

ALPHA LIPOIC ACID 300 MG CAPSULE ORAL 03/07/2018 0.11439

ALPHA LIPOIC ACID 100 MG CAPSULE ORAL 01/22/2013 0.04690

ALPHA LIPOIC ACID 50 MG CAPSULE ORAL 04/12/2017 0.08654

ALPHA LIPOIC ACID 600 MG CAPSULE ORAL 06/06/2018 0.32696

ALPRAZOLAM 0.25 MG TABLET ORAL 12/26/2018 0.01198

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20196

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ALPRAZOLAM 0.5 MG TABLET ORAL 08/18/2015 0.01351

ALPRAZOLAM 1 MG TABLET ORAL 11/21/2018 0.02680

ALPRAZOLAM 2 MG TABLET ORAL 02/13/2019 0.07477

ALPRAZOLAM 0.5 MG TAB ER 24H ORAL 05/22/2018 0.53600

ALPRAZOLAM 1 MG TAB ER 24H ORAL 05/22/2018 0.69233

ALPRAZOLAM 2 MG TAB ER 24H ORAL 02/14/2017 0.93800

ALPRAZOLAM 3 MG TAB ER 24H ORAL 06/20/2017 1.56557

ALPRAZOLAM 0.25 MG TAB RAPDIS ORAL 09/28/2016 1.44465

ALPRAZOLAM 0.5 MG TAB RAPDIS ORAL 07/03/2018 1.66307

ALPRAZOLAM 1 MG TAB RAPDIS ORAL 06/03/2015 2.30869

ALPRAZOLAM 2 MG TAB RAPDIS ORAL 07/03/2018 4.02442

ALPROSTADIL 20 MCG KIT INTRACAVER 01/23/2019 481.81150

ALPROSTADIL 10 MCG KIT INTRACAVER 01/23/2019 124.33250

ALUMINUM HYDROXIDE 0.275 % OINT. (G) TOPICAL 05/25/2016 0.23037

AMANTADINE HCL 100 MG CAPSULE ORAL 11/07/2018 0.97177

AMANTADINE HCL 50 MG/5 ML SOLUTION ORAL 10/12/2015 0.02792

AMANTADINE HCL 100 MG TABLET ORAL 01/16/2019 0.58311

AMIFOSTINE CRYSTALLINE 500 MG VIAL INTRAVEN 01/03/2018 289.53688

AMIKACIN SULFATE 500 MG/2ML VIAL INJECTION 02/06/2019 3.69864

AMIKACIN SULFATE 1000MG/4ML VIAL INJECTION 07/25/2018 1.52928

AMILORIDE HCL 5 MG TABLET ORAL 04/10/2018 0.45480

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20197

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

AMILORIDE/HYDROCHLOROTHIAZIDE 5 MG-50 MG TABLET ORAL 11/07/2018 0.43561

AMINO ACIDS POWDER ORAL 01/22/2013 0.19933

AMINO ACIDS TABLET ORAL 01/22/2013 0.04590

AMINO ACIDS/MV,TX,IRON,MINERAL LIQUID ORAL 01/22/2013 0.06008

AMINOCAPROIC ACID 500 MG TABLET ORAL 12/19/2018 19.60175

AMINOCAPROIC ACID 1000 MG TABLET ORAL 12/19/2018 34.44342

AMINOCAPROIC ACID 250 MG/ML VIAL INTRAVEN 05/06/2015 0.33232

AMIODARONE HCL 200 MG TABLET ORAL 12/19/2018 0.14507

AMIODARONE HCL 100 MG TABLET ORAL 01/10/2017 3.14820

AMIODARONE HCL 400 MG TABLET ORAL 05/09/2017 4.41672

AMIODARONE HCL 50 MG/ML VIAL INTRAVEN 07/03/2018 0.37341

AMITRIPTYLINE HCL 10 MG TABLET ORAL 03/06/2019 0.12315

AMITRIPTYLINE HCL 100 MG TABLET ORAL 12/05/2018 1.08013

AMITRIPTYLINE HCL 150 MG TABLET ORAL 02/13/2019 1.71493

AMITRIPTYLINE HCL 25 MG TABLET ORAL 01/23/2019 0.16120

AMITRIPTYLINE HCL 50 MG TABLET ORAL 06/09/2015 0.45557

AMITRIPTYLINE HCL 75 MG TABLET ORAL 02/06/2019 0.81552

AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG TABLET ORAL 06/19/2017 0.80549

AMLODIPINE BES/OLMESARTAN MED 10 MG-20MG TABLET ORAL 11/21/2018 0.81978

AMLODIPINE BES/OLMESARTAN MED 5 MG-40 MG TABLET ORAL 05/09/2017 0.77586

AMLODIPINE BES/OLMESARTAN MED 10 MG-40MG TABLET ORAL 05/09/2017 0.67536

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20198

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

AMLODIPINE BESYLATE 2.5 MG TABLET ORAL 12/12/2018 0.01662

AMLODIPINE BESYLATE 5 MG TABLET ORAL 01/30/2019 0.01444

AMLODIPINE BESYLATE 10 MG TABLET ORAL 01/30/2019 0.02606

AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-20 MG CAPSULE ORAL 02/13/2019 0.18894

AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE ORAL 02/06/2019 0.15812

AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE ORAL 09/06/2017 0.19564

AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAPSULE ORAL 01/16/2019 0.19899

AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG CAPSULE ORAL 10/10/2018 0.24964

AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG CAPSULE ORAL 10/10/2018 0.30163

AMLODIPINE BESYLATE/VALSARTAN 5 MG-160MG TABLET ORAL 10/31/2018 0.57933

AMLODIPINE BESYLATE/VALSARTAN 10MG-160MG TABLET ORAL 10/31/2018 0.48017

AMLODIPINE BESYLATE/VALSARTAN 5 MG-320MG TABLET ORAL 02/06/2019 0.54047

AMLODIPINE BESYLATE/VALSARTAN 10MG-320MG TABLET ORAL 11/28/2018 0.61863

AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET ORAL 07/03/2018 2.95812

AMLODIPINE/ATORVASTATIN 5 MG-20 MG TABLET ORAL 07/03/2018 3.10288

AMLODIPINE/ATORVASTATIN 5 MG-40 MG TABLET ORAL 10/27/2015 3.21200

AMLODIPINE/ATORVASTATIN 5 MG-80 MG TABLET ORAL 08/21/2018 5.10312

AMLODIPINE/ATORVASTATIN 10 MG-10MG TABLET ORAL 10/17/2017 3.11373

AMLODIPINE/ATORVASTATIN 10 MG-20MG TABLET ORAL 01/26/2016 3.11564

AMLODIPINE/ATORVASTATIN 10 MG-40MG TABLET ORAL 05/12/2015 3.11520

AMLODIPINE/ATORVASTATIN 10 MG-80MG TABLET ORAL 08/22/2018 5.38692

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 20199

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET ORAL 08/11/2015 3.98728

AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET ORAL 08/11/2015 5.68918

AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET ORAL 01/05/2016 6.14426

AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-12.5 TABLET ORAL 12/26/2018 2.81160

AMLODIPINE/VALSARTAN/HCTHIAZID 10MG-160MG TABLET ORAL 12/26/2018 3.65068

AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-25MG TABLET ORAL 12/26/2018 2.98364

AMLODIPINE/VALSARTAN/HCTHIAZID 10-160-25 TABLET ORAL 12/26/2018 3.95956

AMLODIPINE/VALSARTAN/HCTHIAZID 10-320-25 TABLET ORAL 12/26/2018 2.63399

AMMONIA 15 % (W/V) AMPUL INHALATION 02/06/2019 0.31700

AMMONIUM LACTATE 12 % CREAM (G) TOPICAL 09/19/2018 0.11591

AMMONIUM LACTATE 12 % LOTION TOPICAL 02/27/2019 0.11905

AMOXICILLIN 250 MG CAPSULE ORAL 11/14/2018 0.04811

AMOXICILLIN 500 MG CAPSULE ORAL 02/06/2019 0.07156

AMOXICILLIN 125 MG/5ML SUSP RECON ORAL 10/24/2018 0.01429

AMOXICILLIN 250 MG/5ML SUSP RECON ORAL 10/24/2018 0.01715

AMOXICILLIN 400 MG/5ML SUSP RECON ORAL 12/05/2018 0.02626

AMOXICILLIN 200 MG/5ML SUSP RECON ORAL 07/18/2018 0.02412

AMOXICILLIN 500 MG TABLET ORAL 02/13/2019 0.30150

AMOXICILLIN 875 MG TABLET ORAL 03/06/2019 0.15370

AMOXICILLIN/POTASSIUM CLAV 250-62.5/5 SUSP RECON ORAL 11/21/2018 0.64816

AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 SUSP RECON ORAL 02/27/2019 0.07732

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201910

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 SUSP RECON ORAL 12/05/2018 0.05775

AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 SUSP RECON ORAL 02/06/2019 0.06586

AMOXICILLIN/POTASSIUM CLAV 250-125 MG TABLET ORAL 08/09/2017 4.63120

AMOXICILLIN/POTASSIUM CLAV 500-125 MG TABLET ORAL 11/14/2018 0.33768

AMOXICILLIN/POTASSIUM CLAV 875-125 MG TABLET ORAL 02/06/2019 0.33299

AMOXICILLIN/POTASSIUM CLAV 400-57MG TAB CHEW ORAL 10/27/2015 2.66838

AMOXICILLIN/POTASSIUM CLAV 1000-62.5 TAB ER 12H ORAL 10/04/2017 5.94088

AMPHETAMINE SULFATE 10 MG TABLET ORAL 02/27/2019 6.53999

AMPHETAMINE SULFATE 5 MG TABLET ORAL 02/27/2019 6.53999

AMPICILLIN SODIUM 1 G VIAL INJECTION 08/15/2018 2.04350

AMPICILLIN SODIUM 10 G VIAL INJECTION 09/12/2018 33.82500

AMPICILLIN SODIUM 2 G VIAL INJECTION 08/08/2018 3.22212

AMPICILLIN SODIUM 250 MG VIAL INJECTION 08/08/2018 0.82410

AMPICILLIN SODIUM 500 MG VIAL INJECTION 01/23/2019 1.46060

AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL INJECTION 01/09/2019 1.92960

AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL INJECTION 01/09/2019 3.43200

AMPICILLIN SODIUM/SULBACTAM NA 15 G VIAL INJECTION 01/16/2019 21.81900

ANAGRELIDE HCL 0.5 MG CAPSULE ORAL 02/20/2019 1.29967

ANAGRELIDE HCL 1 MG CAPSULE ORAL 03/06/2019 2.59277

ANASTROZOLE 1 MG TABLET ORAL 04/18/2017 0.10928

ANISE OIL OIL MISCELL 01/10/2018 0.77541

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201911

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ANTI-INHIBITOR COAGULANT COMP. 651-1200 VIAL INTRAVEN 07/01/2018 1.82600

ANTI-INHIBITOR COAGULANT COMP. 400-650 VIAL INTRAVEN 07/01/2018 1.82600

ANTI-INHIBITOR COAGULANT COMP. 1750-3250 VIAL INTRAVEN 07/01/2018 1.82600

ANTIHEMO.FVIII,FULL LENGTH PEG 250 (+/-) VIAL INTRAVEN 01/01/2019 1.77555

ANTIHEMO.FVIII,FULL LENGTH PEG 500 (+/-) VIAL INTRAVEN 01/01/2019 1.77555

ANTIHEMO.FVIII,FULL LENGTH PEG 1000 (+/-) VIAL INTRAVEN 01/01/2019 1.77555

ANTIHEMO.FVIII,FULL LENGTH PEG 2000 (+/-) VIAL INTRAVEN 01/01/2019 1.77555

ANTIHEMO.FVIII,FULL LENGTH PEG 750 (+/-) VIAL INTRAVEN 02/23/2017 1.58400

ANTIHEMO.FVIII,FULL LENGTH PEG 1500 (+/-) VIAL INTRAVEN 02/23/2017 1.58400

ANTIHEMO.FVIII,FULL LENGTH PEG 3000 (+/-) VIAL INTRAVEN 10/01/2018 1.58400

ANTIHEMOPH.FVIII REC,FC FUSION 250 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 500 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 750 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 1000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 1500 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 2000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 3000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 4000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 5000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII REC,FC FUSION 6000 UNIT VIAL INTRAVEN 01/01/2019 1.94820

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 250 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201912

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 500 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 1000 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 1500 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 2000 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

ANTIHEMOPH.FVIII,B-DOM TRUNCAT 3000 (+/-) VIAL INTRAVEN 07/01/2018 1.39650

ANTIHEMOPH.FVIII,B-DOMAIN DEL 250 (+/-) VIAL INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 500 (+/-) VIAL INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 1000 (+/-) VIAL INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 2000 (+/-) VIAL INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 3000 (+/-) SYRINGE INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 1000 (+/-) SYRINGE INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 2000 (+/-) SYRINGE INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 250 (+/-) SYRINGE INTRAVEN 10/01/2018 1.28310

ANTIHEMOPH.FVIII,B-DOMAIN DEL 500 (+/-) SYRINGE INTRAVEN 10/01/2018 1.28310

ANTIHEMOPHIL.FVIII,FULL LENGTH 3000 (+/-) VIAL INTRAVEN 01/01/2019 1.36605

ANTIHEMOPHIL.FVIII,FULL LENGTH 2000 (+/-) VIAL INTRAVEN 01/01/2019 1.36605

ANTIHEMOPHIL.FVIII,FULL LENGTH 1500 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHIL.FVIII,FULL LENGTH 500 (+/-) VIAL INTRAVEN 01/01/2019 1.36605

ANTIHEMOPHIL.FVIII,FULL LENGTH 1000 (+/-) VIAL INTRAVEN 01/01/2019 1.36605

ANTIHEMOPHIL.FVIII,FULL LENGTH 250 (+/-) VIAL INTRAVEN 01/01/2019 1.36605

ANTIHEMOPHIL.FVIII,FULL LENGTH 4000 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201913

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ANTIHEMOPHILIC FACTOR, HUM REC 250 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHILIC FACTOR, HUM REC 1000 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHILIC FACTOR, HUM REC 500 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHILIC FACTOR, HUM REC 2000 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHILIC FACTOR, HUM REC 1500 (+/-) VIAL INTRAVEN 10/01/2018 1.39230

ANTIHEMOPHILIC FACTOR, HUMAN 500 (+/-) VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 1000 (+/-) VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 250 (+/-) VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 220-400 VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 401-800 VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 801-1500 VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR, HUMAN 1501-2000 VIAL INTRAVEN 10/01/2018 1.12350

ANTIHEMOPHILIC FACTOR/VWF 250-600 VIAL INTRAVEN 10/01/2018 1.17915

ANTIHEMOPHILIC FACTOR/VWF 1000-2400 VIAL INTRAVEN 10/01/2018 1.17915

ANTIHEMOPHILIC FACTOR/VWF 500-1200 VIAL INTRAVEN 10/01/2018 1.17915

ANTIHEMOPHILIC FACTOR/VWF 250 (100) VIAL INTRAVEN 10/01/2018 1.04160

ANTIHEMOPHILIC FACTOR/VWF 500 (200) VIAL INTRAVEN 10/01/2018 1.04160

ANTIHEMOPHILIC FACTOR/VWF 1000 (400) VIAL INTRAVEN 10/01/2018 1.04160

ANTIHEMOPHILIC FACTOR/VWF 1500 (600) VIAL INTRAVEN 10/01/2018 1.04160

ANTIHEMOPHILIC FACTOR/VWF 450-450 VIAL INTRAVEN 10/01/2015 1.06785

ANTIHEMOPHILIC FACTOR/VWF 900-900 VIAL INTRAVEN 10/01/2015 1.06785

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201914

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ANTIHEMOPHILIC FACTOR/VWF 500-500 VIAL INTRAVEN 10/01/2018 1.05945

ANTIHEMOPHILIC FACTOR/VWF 1K-1K UNIT VIAL INTRAVEN 10/01/2018 1.05945

ANTIHEMOPHILIC FACTOR/VWF 2000 (800) VIAL INTRAVEN 10/01/2018 1.04160

ANTITHROMBIN III (PLASMA DER) 500 (+/-) VIAL INTRAVEN 10/01/2015 3.53955

APRACLONIDINE HCL 0.5 % DROPS OPHTHALMIC 08/29/2018 9.12480

APREPITANT 80 MG CAPSULE ORAL 11/29/2017 167.08183

APREPITANT 125 MG CAPSULE ORAL 10/25/2017 261.07433

APREPITANT 40 MG CAPSULE ORAL 12/27/2017 90.13850

APREPITANT 125MG-80MG CAP DS PK ORAL 01/08/2018 197.13483

ARGATROBAN 100 MG/ML VIAL INTRAVEN 07/11/2018 104.25357

ARGATROBAN IN 0.9 % SOD CHLOR 50 MG/50ML VIAL INTRAVEN 02/20/2019 3.56400

ARGININE 500 MG CAPSULE ORAL 12/19/2013 0.10948

ARGININE 500 MG TABLET ORAL 06/13/2013 0.08821

ARGININE HCL 1000 MG TABLET ORAL 04/24/2013 0.21561

ARIPIPRAZOLE 1 MG/ML SOLUTION ORAL 02/27/2019 4.27671

ARIPIPRAZOLE 10 MG TABLET ORAL 03/06/2019 0.38940

ARIPIPRAZOLE 15 MG TABLET ORAL 11/07/2018 0.40066

ARIPIPRAZOLE 20 MG TABLET ORAL 12/26/2017 0.53868

ARIPIPRAZOLE 30 MG TABLET ORAL 04/24/2018 1.41237

ARIPIPRAZOLE 5 MG TABLET ORAL 02/20/2019 0.38940

ARIPIPRAZOLE 2 MG TABLET ORAL 11/21/2018 0.38940

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201915

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ARIPIPRAZOLE 10 MG TAB RAPDIS ORAL 02/13/2019 26.18908

ARIPIPRAZOLE 15 MG TAB RAPDIS ORAL 02/13/2019 28.41420

ARMODAFINIL 150 MG TABLET ORAL 12/19/2018 1.58165

ARMODAFINIL 50 MG TABLET ORAL 05/29/2018 3.75848

ARMODAFINIL 250 MG TABLET ORAL 02/13/2019 1.88047

ARMODAFINIL 200 MG TABLET ORAL 03/06/2019 1.90057

ARSENIC TRIOXIDE 10 MG/10ML VIAL INTRAVEN 02/27/2019 20.79000

ASCORBATE CALCIUM/BIOFLAVONOID 500-200 MG TABLET ORAL 03/06/2013 0.13501

ASCORBIC ACID 500 MG CAPSULE ER ORAL 06/06/2017 0.07147

ASCORBIC ACID 500 MG/5ML SYRUP ORAL 12/19/2018 0.07206

ASCORBIC ACID 1000 MG TABLET ORAL 05/12/2015 0.05958

ASCORBIC ACID 250 MG TABLET ORAL 12/12/2018 0.01997

ASCORBIC ACID 500 MG TABLET ORAL 06/28/2016 0.01875

ASCORBIC ACID 250 MG TAB CHEW ORAL 01/22/2013 0.01970

ASCORBIC ACID 500 MG TAB CHEW ORAL 01/30/2019 0.04569

ASCORBIC ACID 125 MG TAB CHEW ORAL 05/17/2017 0.05885

ASCORBIC ACID 1000 MG TABLET ER ORAL 04/25/2018 0.06354

ASCORBIC ACID 1500 MG TABLET ER ORAL 10/09/2013 0.07705

ASCORBIC ACID 500 MG TABLET ER ORAL 03/07/2018 0.03432

ASCORBIC ACID 500 MG/ML VIAL INJECTION 08/01/2018 2.40074

ASPIRIN 325 MG TABLET ORAL 03/06/2019 0.01387

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201916

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ASPIRIN 81 MG TAB CHEW ORAL 08/23/2016 0.03071

ASPIRIN 325 MG TABLET DR ORAL 12/05/2018 0.02191

ASPIRIN 81 MG TABLET DR ORAL 03/06/2019 0.01424

ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TABLET ORAL 12/19/2018 0.03183

ASPIRIN/CALCIUM CARBONATE/MAG 325 MG TABLET ORAL 12/26/2018 0.04329

ASPIRIN/DIPYRIDAMOLE 25MG-200MG CPMP 12HR ORAL 02/06/2019 6.46515

ATAZANAVIR SULFATE 150 MG CAPSULE ORAL 01/23/2019 24.79803

ATAZANAVIR SULFATE 200 MG CAPSULE ORAL 01/16/2019 11.06856

ATAZANAVIR SULFATE 300 MG CAPSULE ORAL 01/16/2019 13.83219

ATENOLOL 100 MG TABLET ORAL 12/19/2018 0.04489

ATENOLOL 50 MG TABLET ORAL 02/06/2019 0.03953

ATENOLOL 25 MG TABLET ORAL 01/30/2019 0.03886

ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET ORAL 03/16/2016 1.09840

ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET ORAL 04/12/2017 0.78202

ATOMOXETINE HCL 10 MG CAPSULE ORAL 11/28/2018 3.04304

ATOMOXETINE HCL 18 MG CAPSULE ORAL 11/28/2018 3.10508

ATOMOXETINE HCL 25 MG CAPSULE ORAL 12/05/2018 3.10508

ATOMOXETINE HCL 40 MG CAPSULE ORAL 01/16/2019 3.37128

ATOMOXETINE HCL 60 MG CAPSULE ORAL 11/28/2018 3.36160

ATOMOXETINE HCL 80 MG CAPSULE ORAL 01/16/2019 3.63352

ATOMOXETINE HCL 100 MG CAPSULE ORAL 11/28/2018 3.63352

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201917

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ATORVASTATIN CALCIUM 10 MG TABLET ORAL 02/13/2019 0.06328

ATORVASTATIN CALCIUM 20 MG TABLET ORAL 04/18/2016 0.08308

ATORVASTATIN CALCIUM 40 MG TABLET ORAL 03/06/2019 0.11330

ATORVASTATIN CALCIUM 80 MG TABLET ORAL 02/13/2019 0.16154

ATOVAQUONE 750 MG/5ML ORAL SUSP ORAL 02/13/2019 3.95994

ATOVAQUONE/PROGUANIL HCL 62.5-25 MG TABLET ORAL 12/19/2018 2.15901

ATOVAQUONE/PROGUANIL HCL 250-100 MG TABLET ORAL 11/28/2018 4.87630

ATRACURIUM BESYLATE 10 MG/ML VIAL INTRAVEN 03/06/2019 0.91924

AZACITIDINE 100 MG VIAL INJECTION 01/23/2019 94.30000

AZATHIOPRINE 50 MG TABLET ORAL 10/24/2018 0.42225

AZELAIC ACID 15 % GEL (GRAM) TOPICAL 02/27/2019 3.65904

AZELASTINE HCL 0.05 % DROPS OPHTHALMIC 02/27/2019 3.41880

AZELASTINE HCL 137 MCG SPRAY/PUMP NASAL 12/05/2018 0.29480

AZELASTINE HCL 205.5 MCG SPRAY/PUMP NASAL 02/13/2019 1.45658

AZITHROMYCIN 200 MG/5ML SUSP RECON ORAL 03/06/2019 0.62087

AZITHROMYCIN 100 MG/5ML SUSP RECON ORAL 10/06/2015 1.20511

AZITHROMYCIN 500 MG TABLET ORAL 06/23/2015 1.15538

AZITHROMYCIN 250 MG TABLET ORAL 02/20/2019 0.36180

AZITHROMYCIN 600 MG TABLET ORAL 02/13/2019 3.69380

AZITHROMYCIN 500 MG VIAL INTRAVEN 02/06/2019 3.20760

AZTREONAM 1 G VIAL INJECTION 02/06/2019 27.71600

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201918

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

AZTREONAM 2 G VIAL INJECTION 02/06/2019 55.43200

B COMPLEX W-C NO.20/FOLIC ACID 1 MG CAPSULE ORAL 06/13/2018 0.16254

B-COMPLEX WITH VITAMIN C CAPSULE ORAL 11/14/2018 0.08201

B-COMPLEX WITH VITAMIN C TABLET ORAL 07/03/2018 0.04516

B12/LEVOMEFOLATE CALCIUM/B-6 2-1.13-25 TABLET ORAL 01/23/2019 2.14132

BACILLUS COAGULANS/INULIN 1B-250 MG CAPSULE ORAL 08/09/2017 0.30284

BACITRACIN 500 UNIT/G OINT. (G) TOPICAL 12/12/2018 0.09112

BACITRACIN 50000 UNIT VIAL INTRAMUSC 01/09/2019 6.15950

BACITRACIN ZINC 500 UNIT/G OINT. (G) TOPICAL 08/08/2018 0.05941

BACITRACIN ZINC 500 UNIT/G PACKET TOPICAL 10/17/2018 0.13093

BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) TOPICAL 05/30/2018 0.35321

BACITRACIN/POLYMYXIN B SULFATE PACKET TOPICAL 11/01/2017 0.25212

BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) OPHTHALMIC 02/27/2019 2.68000

BACLOFEN 10 MG TABLET ORAL 05/19/2015 0.12258

BACLOFEN 20 MG TABLET ORAL 12/26/2018 0.19213

BACLOFEN 5 MG TABLET ORAL 03/06/2019 1.07160

BACLOFEN 10000/20ML VIAL INTRATHEC 01/16/2019 9.67725

BACLOFEN 40000/20ML VIAL INTRATHEC 01/16/2019 32.88098

BACLOFEN 20K MCG/20 VIAL INTRATHEC 01/16/2019 17.67150

BACTERIOSTATIC SODIUM CHLORIDE 0.9 % VIAL INJECTION 01/24/2018 0.07303

BALANCED SALT IRRIG SOLN NO.2 IRRIG SOLN INTRAOCULR 07/25/2018 0.07035

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201919

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BALSALAZIDE DISODIUM 750 MG CAPSULE ORAL 07/25/2018 0.65698

BEESWAX 100 % WAX MISCELL 02/06/2019 0.16131

BENAZEPRIL HCL 5 MG TABLET ORAL 09/05/2018 0.06681

BENAZEPRIL HCL 10 MG TABLET ORAL 02/13/2019 0.06512

BENAZEPRIL HCL 20 MG TABLET ORAL 02/13/2019 0.07038

BENAZEPRIL HCL 40 MG TABLET ORAL 02/13/2019 0.11926

BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG TABLET ORAL 02/27/2019 1.25652

BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET ORAL 11/07/2018 0.60193

BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET ORAL 11/07/2018 1.05860

BENAZEPRIL/HYDROCHLOROTHIAZIDE 20 MG-25MG TABLET ORAL 11/07/2018 1.05860

BENTONITE POWDER MISCELL 05/04/2016 0.16080

BENZALKONIUM CHLORIDE 0.13 % FOAM (ML) TOPICAL 03/21/2018 0.05982

BENZALKONIUM CHLORIDE LIQUID TOPICAL 01/22/2013 0.01995

BENZETHONIUM CHLORIDE 0.2 % LIQ-FILM TOPICAL 07/24/2018 0.16040

BENZETHONIUM CHLORIDE 0.1 % CLEANSER TOPICAL 10/25/2017 0.01554

BENZOCAINE 20 % MED. SWAB MUCOUS MEM 02/17/2016 0.82745

BENZOCAINE 10 % GEL (GRAM) MUCOUS MEM 08/30/2017 1.00972

BENZOCAINE 20 % GEL (GRAM) MUCOUS MEM 10/26/2015 0.06520

BENZOCAINE 20 % SOLUTION MUCOUS MEM 06/06/2018 0.32830

BENZOCAINE 20 % LIQUID MUCOUS MEM 09/13/2017 0.51702

BENZOCAINE/BENZETHON CL 20 %-0.2 % AEROSOL TOPICAL 08/22/2018 0.07672

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201920

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BENZOCAINE/MENTH/CETYLPYRD CL 2-0.5-0.1% SPRAY MUCOUS MEM 07/06/2016 0.20993

BENZOCAINE/MENTHOL 15MG-3.6MG LOZENGE MUCOUS MEM 01/06/2015 0.12953

BENZOIN TINCTURE TOPICAL 01/02/2019 0.04327

BENZOIN/ALOE VERA/STORAX/TOLU 10-2-8-4% TINCTURE TOPICAL 07/08/2015 0.05253

BENZONATATE 100 MG CAPSULE ORAL 02/06/2019 0.16377

BENZONATATE 200 MG CAPSULE ORAL 12/05/2018 0.14019

BENZONATATE 150 MG CAPSULE ORAL 05/22/2018 40.48750

BENZOYL PEROXIDE 5.3% FOAM TOPICAL 07/05/2017 1.00500

BENZOYL PEROXIDE 9.8 % FOAM TOPICAL 07/11/2017 0.76571

BENZOYL PEROXIDE 10 % BAR TOPICAL 05/18/2016 5.12763

BENZOYL PEROXIDE 10 % GEL (GRAM) TOPICAL 08/08/2018 0.10832

BENZOYL PEROXIDE 5 % GEL (GRAM) TOPICAL 01/12/2016 0.24135

BENZOYL PEROXIDE 6 % CLEANSER TOPICAL 02/10/2016 0.08406

BENZOYL PEROXIDE 10 % CLEANSER TOPICAL 12/05/2018 0.02577

BENZOYL PEROXIDE 5 % CLEANSER TOPICAL 04/06/2017 0.05690

BENZOYL PEROXIDE 7 % CLEANSER TOPICAL 01/22/2013 0.26655

BENZOYL PEROXIDE 6 % TOWELETTE TOPICAL 07/03/2018 6.84001

BENZPHETAMINE HCL 50 MG TABLET ORAL 10/31/2018 0.43845

BENZTROPINE MESYLATE 0.5 MG TABLET ORAL 07/21/2015 0.10053

BENZTROPINE MESYLATE 1 MG TABLET ORAL 06/16/2015 0.12824

BENZTROPINE MESYLATE 2 MG TABLET ORAL 07/07/2015 0.14432

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201921

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BENZTROPINE MESYLATE 2 MG/2 ML AMPUL INJECTION 07/08/2015 28.18238

BENZTROPINE MESYLATE 2 MG/2 ML VIAL INJECTION 09/26/2018 15.75000

BETA-CAROTENE 25000 UNIT CAPSULE ORAL 02/13/2019 0.03290

BETAMETHASONE ACETATE,SOD PHOS 6 MG/ML VIAL INJECTION 02/06/2019 8.64000

BETAMETHASONE DIPROPIONATE 0.05 % CREAM (G) TOPICAL 03/06/2019 1.31409

BETAMETHASONE DIPROPIONATE 0.05 % OINT. (G) TOPICAL 12/26/2018 1.51241

BETAMETHASONE DIPROPIONATE 0.05 % LOTION TOPICAL 08/29/2018 0.60121

BETAMETHASONE VALERATE 0.12 % FOAM TOPICAL 12/26/2018 0.65633

BETAMETHASONE VALERATE 0.1 % CREAM (G) TOPICAL 11/28/2018 0.76291

BETAMETHASONE VALERATE 0.1 % OINT. (G) TOPICAL 09/08/2015 0.83705

BETAMETHASONE VALERATE 0.1 % LOTION TOPICAL 04/19/2017 1.57182

BETAMETHASONE/PROPYLENE GLYC 0.05 % CREAM (G) TOPICAL 01/16/2019 0.12140

BETAMETHASONE/PROPYLENE GLYC 0.05 % OINT. (G) TOPICAL 10/17/2018 1.84974

BETAMETHASONE/PROPYLENE GLYC 0.05 % LOTION TOPICAL 03/06/2019 2.03367

BETAXOLOL HCL 10 MG TABLET ORAL 07/11/2018 0.63462

BETAXOLOL HCL 20 MG TABLET ORAL 07/05/2017 1.34978

BETAXOLOL HCL 0.5 % DROPS OPHTHALMIC 09/15/2015 8.84640

BETHANECHOL CHLORIDE 10 MG TABLET ORAL 02/06/2019 0.19175

BETHANECHOL CHLORIDE 25 MG TABLET ORAL 02/20/2019 0.57741

BETHANECHOL CHLORIDE 5 MG TABLET ORAL 02/20/2019 0.16281

BETHANECHOL CHLORIDE 50 MG TABLET ORAL 02/20/2019 0.44930

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201922

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BEXAROTENE 75 MG CAPSULE ORAL 03/06/2019 77.37469

BICALUTAMIDE 50 MG TABLET ORAL 12/26/2018 0.30463

BIMATOPROST 0.03 % DROP W/APP TOPICAL 08/29/2018 34.38192

BIMATOPROST 0.03 % DROPS OPHTHALMIC 11/21/2018 22.70100

BIOFLAV,LEMON/VIT BCOMP,C 200-100 MG TABLET ORAL 08/09/2017 0.22341

BIOTIN 10000 MCG CAPSULE ORAL 07/26/2017 0.27550

BIOTIN 5 MG CAPSULE ORAL 02/20/2019 0.05081

BIOTIN 2500 MCG CAPSULE ORAL 01/22/2013 0.09986

BIOTIN 10 MG TABLET ORAL 11/09/2016 0.22747

BIOTIN 1 MG TABLET ORAL 11/07/2018 0.05923

BIOTIN 5 MG TABLET ORAL 12/05/2018 0.14762

BISACODYL 5 MG TABLET DR ORAL 02/20/2019 0.00797

BISACODYL 10 MG SUPP.RECT RECTAL 04/19/2016 0.09492

BISMUTH SUBSALICYLATE 262MG/15ML ORAL SUSP ORAL 12/12/2018 0.00994

BISMUTH SUBSALICYLATE 525MG/15ML ORAL SUSP ORAL 05/30/2018 0.02093

BISMUTH SUBSALICYLATE 262 MG TABLET ORAL 05/30/2018 0.19668

BISMUTH SUBSALICYLATE 262 MG TAB CHEW ORAL 07/03/2018 0.07638

BISOPROLOL FUMARATE 10 MG TABLET ORAL 04/19/2016 0.49312

BISOPROLOL FUMARATE 5 MG TABLET ORAL 11/21/2018 0.49325

BISOPROLOL/HYDROCHLOROTHIAZIDE 2.5-6.25MG TABLET ORAL 12/19/2018 0.44580

BISOPROLOL/HYDROCHLOROTHIAZIDE 5-6.25MG TABLET ORAL 11/14/2018 0.41441

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201923

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BISOPROLOL/HYDROCHLOROTHIAZIDE 10-6.25MG TABLET ORAL 12/05/2018 0.26158

BIVALIRUDIN 250 MG VIAL INTRAVEN 11/14/2018 120.25300

BLEOMYCIN SULFATE 15 UNIT VIAL INJECTION 01/23/2019 28.15675

BLEOMYCIN SULFATE 30 UNIT VIAL INJECTION 01/23/2019 53.69975

BLOOD KETONE TEST, STRIPS STRIP MISCELL 09/05/2018 2.15472

BRIMONIDINE TARTRATE 0.2 % DROPS OPHTHALMIC 07/25/2018 0.36180

BRIMONIDINE TARTRATE 0.15 % DROPS OPHTHALMIC 05/16/2018 25.42960

BROMOCRIPTINE MESYLATE 5 MG CAPSULE ORAL 08/01/2018 7.10184

BROMOCRIPTINE MESYLATE 2.5 MG TABLET ORAL 02/27/2019 1.95729

BROMPHENIRAM/PHENYLEPHRINE/DM 1-2.5-5/5 SOLUTION ORAL 10/03/2017 0.04282

BROMPHENIRAM/PHENYLEPHRINE/DM 2-5-10MG/5 LIQUID ORAL 03/01/2017 0.05349

BROMPHENIRAM/PHENYLEPHRINE/DM 4-10-20/5 LIQUID ORAL 09/28/2016 0.02691

BROMPHENIRAM/PHENYLEPHRINE/DM 4-7.5-15/5 LIQUID ORAL 11/23/2016 0.11572

BROMPHENIRAMINE/PHENYLEPHRINE 1-2.5 MG/5 SOLUTION ORAL 05/29/2018 0.01531

BROMPHENIRAMINE/PSEUDOEPHED/DM 2-30-10/5 SYRUP ORAL 02/06/2019 0.12775

BUDESONIDE 3 MG CAPDR - ER ORAL 01/16/2019 5.05956

BUDESONIDE 9 MG TABDR - ER ORAL 01/23/2019 58.30883

BUDESONIDE 32MCG SPRAY/PUMP NASAL 08/01/2018 1.62771

BUDESONIDE 1 MG/2 ML AMPUL-NEB INHALATION 08/04/2015 7.36260

BUDESONIDE 0.25MG/2ML AMPUL-NEB INHALATION 06/09/2015 1.24106

BUDESONIDE 0.5 MG/2ML AMPUL-NEB INHALATION 02/13/2019 1.72279

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201924

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BUMETANIDE 0.5 MG TABLET ORAL 03/06/2019 0.55476

BUMETANIDE 1 MG TABLET ORAL 03/06/2019 0.47342

BUMETANIDE 2 MG TABLET ORAL 12/19/2018 0.87789

BUMETANIDE 0.25 MG/ML VIAL INJECTION 02/06/2019 0.31443

BUPIVACAINE HCL 2.5 MG/ML VIAL INJECTION 08/01/2018 0.07006

BUPIVACAINE HCL 5 MG/ML VIAL INJECTION 02/27/2019 0.06241

BUPIVACAINE HCL IN DEXTROSE/PF 0.75 % AMPUL INJECTION 07/25/2018 1.40499

BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL INJECTION 09/19/2018 0.25326

BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K VIAL INJECTION 09/19/2018 0.26559

BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 VIAL INJECTION 09/19/2018 0.40003

BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-1:200K VIAL INJECTION 08/01/2018 0.20408

BUPIVACAINE HCL/PF 7.5 MG/ML AMPUL INJECTION 01/22/2013 0.16231

BUPIVACAINE HCL/PF 2.5 MG/ML VIAL INJECTION 07/03/2018 0.05983

BUPIVACAINE HCL/PF 5 MG/ML VIAL INJECTION 08/01/2018 0.07343

BUPIVACAINE HCL/PF 7.5 MG/ML VIAL INJECTION 02/27/2019 0.13198

BUPRENORPHINE 5 MCG/HR PATCH TDWK TRANSDERM 12/05/2018 49.41013

BUPRENORPHINE 10 MCG/HR PATCH TDWK TRANSDERM 12/05/2018 74.12031

BUPRENORPHINE 20 MCG/HR PATCH TDWK TRANSDERM 12/05/2018 130.98988

BUPRENORPHINE 15 MCG/HR PATCH TDWK TRANSDERM 12/05/2018 106.93056

BUPRENORPHINE 7.5 MCG/HR PATCH TDWK TRANSDERM 01/30/2019 90.14106

BUPRENORPHINE HCL 2 MG TAB SUBL SUBLINGUAL 11/21/2018 0.67893

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201925

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BUPRENORPHINE HCL 8 MG TAB SUBL SUBLINGUAL 02/27/2019 1.94970

BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG FILM SUBLINGUAL 03/06/2019 4.09772

BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG FILM SUBLINGUAL 03/06/2019 7.59960

BUPRENORPHINE HCL/NALOXONE HCL 4MG-1MG FILM SUBLINGUAL 03/06/2019 7.06247

BUPRENORPHINE HCL/NALOXONE HCL 12 MG-3 MG FILM SUBLINGUAL 03/06/2019 12.23420

BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG TAB SUBL SUBLINGUAL 12/12/2018 3.95912

BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG TAB SUBL SUBLINGUAL 12/12/2018 4.76520

BUPROPION HCL 75 MG TABLET ORAL 12/05/2018 0.12636

BUPROPION HCL 100 MG TABLET ORAL 12/05/2018 0.18103

BUPROPION HCL 150 MG TAB ER 24H ORAL 02/06/2019 0.59541

BUPROPION HCL 300 MG TAB ER 24H ORAL 01/09/2019 0.68983

BUPROPION HCL 450 MG TAB ER 24H ORAL 02/27/2019 9.63623

BUPROPION HCL 150 MG TAB ER 12H ORAL 10/31/2018 0.46632

BUPROPION HCL 150 MG TAB SR 12H ORAL 02/06/2019 0.10693

BUPROPION HCL 100 MG TAB SR 12H ORAL 02/07/2017 0.12328

BUPROPION HCL 200 MG TAB SR 12H ORAL 05/09/2017 0.26175

BUSPIRONE HCL 5 MG TABLET ORAL 01/09/2019 0.02637

BUSPIRONE HCL 7.5 MG TABLET ORAL 09/24/2018 0.52568

BUSULFAN 60 MG/10ML VIAL INTRAVEN 02/13/2019 64.68288

BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 CAPSULE ORAL 02/13/2019 5.29184

BUTALB/ACETAMINOPHEN/CAFFEINE 50-300-40 CAPSULE ORAL 01/23/2019 3.10332

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201926

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 TABLET ORAL 02/06/2019 0.31507

BUTALBIT/ACETAMIN/CAFF/CODEINE 50-325-30 CAPSULE ORAL 02/13/2019 1.52747

BUTALBITAL/ACETAMINOPHEN 50MG-325MG TABLET ORAL 01/02/2019 1.33330

BUTALBITAL/ACETAMINOPHEN 50MG-300MG TABLET ORAL 11/22/2017 8.72988

BUTALBITAL/ACETAMINOPHEN 25MG-325MG TABLET ORAL 01/23/2019 11.99165

BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 CAPSULE ORAL 11/28/2018 1.33839

BUTENAFINE HCL 1 % CREAM (G) TOPICAL 01/31/2018 0.45403

BUTORPHANOL TARTRATE 1 MG/ML VIAL INJECTION 08/02/2017 5.01600

BUTORPHANOL TARTRATE 2 MG/ML VIAL INJECTION 08/02/2017 4.31640

BUTORPHANOL TARTRATE 10 MG/ML SPRAY NASAL 06/13/2018 11.80080

BUTYLATED HYDROXYTOLUENE GRANULES MISCELL 03/04/2015 7.09295

CABERGOLINE 0.5 MG TABLET ORAL 01/30/2019 6.95008

CAFFEINE 200 MG TABLET ORAL 01/09/2019 0.06762

CAFFEINE CITRATE 60 MG/3 ML SOLUTION ORAL 12/21/2016 4.34500

CAFFEINE CITRATE 60 MG/3 ML VIAL INTRAVEN 02/06/2019 2.24673

CALAMINE/ZINC OXIDE 8 %-8 % LOTION TOPICAL 01/09/2019 0.02174

CALCIPOTRIENE 0.005 % CREAM (G) TOPICAL 02/06/2019 2.27934

CALCIPOTRIENE 0.005 % OINT. (G) TOPICAL 01/23/2019 4.64574

CALCIPOTRIENE 0.005 % SOLUTION TOPICAL 04/21/2015 3.41000

CALCIPOTRIENE/BETAMETHASONE 0.005-.064 OINT. (G) TOPICAL 04/25/2018 7.46739

CALCITONIN,SALMON,SYNTHETIC 200/SPRAY SPRAY/PUMP NASAL 10/27/2015 11.23189

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201927

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CALCITRIOL 0.25 MCG CAPSULE ORAL 02/20/2019 0.42478

CALCITRIOL 0.5 MCG CAPSULE ORAL 08/01/2018 0.66531

CALCITRIOL 1 MCG/ML SOLUTION ORAL 07/18/2018 6.82075

CALCITRIOL 1 MCG/ML AMPUL INTRAVEN 07/18/2018 7.22694

CALCIUM ACETATE 667 MG CAPSULE ORAL 12/19/2018 0.24773

CALCIUM ACETATE 667 MG TABLET ORAL 02/28/2017 0.41453

CALCIUM ACETATE/ALUMINUM SULF 952-1347MG POWD PACK TOPICAL 08/01/2018 0.83638

CALCIUM CARBONATE 500 MG/5ML ORAL SUSP ORAL 08/30/2017 0.02328

CALCIUM CARBONATE 500(1250) TABLET ORAL 05/23/2017 0.02412

CALCIUM CARBONATE 600 MG TABLET ORAL 01/30/2019 0.03283

CALCIUM CARBONATE 500(1250) TAB CHEW ORAL 07/03/2018 0.04891

CALCIUM CARBONATE 200(500)MG TAB CHEW ORAL 10/24/2018 0.01215

CALCIUM CARBONATE 300MG(750) TAB CHEW ORAL 07/03/2018 0.02331

CALCIUM CARBONATE/VITAMIN D3 600 MG-200 CAPSULE ORAL 08/09/2017 0.09581

CALCIUM CARBONATE/VITAMIN D3 600 MG-400 CAPSULE ORAL 07/03/2013 0.03595

CALCIUM CARBONATE/VITAMIN D3 600 MG-500 CAPSULE ORAL 11/07/2018 0.08170

CALCIUM CARBONATE/VITAMIN D3 600 MG-200 TABLET ORAL 08/24/2016 0.03283

CALCIUM CARBONATE/VITAMIN D3 250 MG-125 TABLET ORAL 07/03/2018 0.01340

CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TABLET ORAL 05/23/2017 0.01795

CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TABLET ORAL 08/22/2018 0.01720

CALCIUM CARBONATE/VITAMIN D3 500 MG-200 TABLET ORAL 09/26/2018 0.02412

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201928

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CALCIUM CARBONATE/VITAMIN D3 500 MG-600 TABLET ORAL 05/29/2018 0.02140

CALCIUM CARBONATE/VITAMIN D3 600 MG-800 TABLET ORAL 07/03/2018 0.01776

CALCIUM CARBONATE/VITAMIN D3 500 MG-100 TAB CHEW ORAL 03/06/2019 0.03692

CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TAB CHEW ORAL 08/30/2017 0.05941

CALCIUM CHLORIDE 100 MG/ML SYRINGE INTRAVEN 07/03/2018 1.03475

CALCIUM CITRATE 200(950)MG TABLET ORAL 04/06/2017 0.02412

CALCIUM CITRATE 250 MG TABLET ORAL 04/13/2016 0.05333

CALCIUM CITRATE/VITAMIN D3 315 MG-200 TABLET ORAL 10/17/2017 0.02650

CALCIUM CITRATE/VITAMIN D3 315 MG-250 TABLET ORAL 05/23/2017 0.01675

CALCIUM CITRATE/VITAMIN D3 200 MG-250 TABLET ORAL 11/15/2017 0.04342

CALCIUM POLYCARBOPHIL 625 MG TABLET ORAL 07/03/2018 0.05896

CALCIUM/MAG/D3/B12/FA/B6/BORON 500-1.1MG TABLET ORAL 07/25/2018 0.27638

CALCIUM/MAGNESIUM/ZINC 333-133-5 TABLET ORAL 08/27/2014 0.02245

CANDESARTAN CILEXETIL 4 MG TABLET ORAL 01/30/2019 2.16961

CANDESARTAN CILEXETIL 8 MG TABLET ORAL 01/30/2019 2.20415

CANDESARTAN CILEXETIL 16 MG TABLET ORAL 01/30/2019 1.62006

CANDESARTAN CILEXETIL 32 MG TABLET ORAL 01/23/2019 2.66526

CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET ORAL 09/29/2015 4.48602

CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG TABLET ORAL 11/21/2018 4.57528

CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG TABLET ORAL 02/27/2019 4.95253

CAPECITABINE 150 MG TABLET ORAL 04/11/2016 3.24258

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201929

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CAPECITABINE 500 MG TABLET ORAL 02/27/2019 5.28108

CAPSAICIN 0.025 % CREAM (G) TOPICAL 11/07/2018 0.04618

CAPSAICIN 0.1 % CREAM (G) TOPICAL 08/23/2017 0.24567

CAPSAICIN/ME-SALICYLATE/MENTH 0.025%-25% LOTION TOPICAL 11/07/2018 2.51250

CAPSAICIN/ME-SALICYLATE/MENTH 0.002%-20% LOTION TOPICAL 01/07/2015 2.32987

CAPSAICIN/MENTHOL 0.0375%-5% ADH. PATCH TOPICAL 11/09/2016 18.37500

CAPTOPRIL 100 MG TABLET ORAL 11/14/2018 2.62439

CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07439

CAPTOPRIL 25 MG TABLET ORAL 07/07/2015 0.77291

CAPTOPRIL 50 MG TABLET ORAL 07/07/2015 1.70113

CARBAMAZEPINE 200 MG CPMP 12HR ORAL 12/21/2016 0.77720

CARBAMAZEPINE 300 MG CPMP 12HR ORAL 02/13/2019 2.19325

CARBAMAZEPINE 100 MG CPMP 12HR ORAL 02/13/2019 2.19325

CARBAMAZEPINE 100 MG/5ML ORAL SUSP ORAL 01/24/2018 0.16836

CARBAMAZEPINE 200 MG TABLET ORAL 06/02/2015 0.30537

CARBAMAZEPINE 100 MG TAB CHEW ORAL 04/19/2016 0.33500

CARBAMAZEPINE 200 MG TAB ER 12H ORAL 01/26/2016 1.75004

CARBAMAZEPINE 400 MG TAB ER 12H ORAL 01/26/2016 3.81757

CARBAMAZEPINE 100 MG TAB ER 12H ORAL 07/11/2018 0.59161

CARBAMIDE PEROXIDE 10 % SOLUTION MUCOUS MEM 09/13/2017 0.17107

CARBAMIDE PEROXIDE 6.5 % DROPS OTIC (EAR) 01/30/2019 0.12328

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201930

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CARBIDOPA 25 MG TABLET ORAL 02/07/2018 7.62000

CARBIDOPA/LEVODOPA 10MG-100MG TABLET ORAL 03/06/2019 0.14284

CARBIDOPA/LEVODOPA 25MG-100MG TABLET ORAL 02/06/2019 0.12459

CARBIDOPA/LEVODOPA 25MG-250MG TABLET ORAL 03/06/2019 0.17554

CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER ORAL 02/06/2019 0.54726

CARBIDOPA/LEVODOPA 25MG-100MG TABLET ER ORAL 02/13/2019 0.32160

CARBIDOPA/LEVODOPA 10MG-100MG TAB RAPDIS ORAL 12/19/2018 0.88882

CARBIDOPA/LEVODOPA 25MG-100MG TAB RAPDIS ORAL 12/19/2018 1.00366

CARBIDOPA/LEVODOPA 25MG-250MG TAB RAPDIS ORAL 12/19/2018 1.27876

CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG TABLET ORAL 07/03/2018 1.72900

CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 TABLET ORAL 07/03/2018 1.72900

CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG TABLET ORAL 12/19/2018 1.72900

CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 TABLET ORAL 07/03/2018 1.72900

CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG TABLET ORAL 07/03/2018 1.72900

CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 TABLET ORAL 07/03/2018 1.72900

CARBINOXAMINE MALEATE 4 MG/5 ML LIQUID ORAL 07/21/2015 0.12283

CARBINOXAMINE MALEATE 4 MG TABLET ORAL 01/06/2015 0.44488

CARBOPLATIN 10 MG/ML VIAL INTRAVEN 02/27/2019 0.75665

CARBOXYMETHYLCELLULOSE SODIUM 1 % DROPER GEL OPHTHALMIC 01/04/2017 0.43237

CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPERETTE OPHTHALMIC 07/03/2018 0.24165

CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPS OPHTHALMIC 12/05/2018 0.48543

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201931

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CARDIOPLEGIC SOLUTION NO.1 K+=16MEQ/L PLST BG PF PERFUSION 02/20/2019 0.06423

CARISOPRODOL 350 MG TABLET ORAL 01/30/2019 0.04757

CARISOPRODOL 250 MG TABLET ORAL 08/15/2018 2.79286

CARISOPRODOL/ASPIRIN 200-325 MG TABLET ORAL 09/19/2017 1.60130

CARISOPRODOL/ASPIRIN/CODEINE 200-325-16 TABLET ORAL 02/06/2019 4.62290

CARMUSTINE 100 MG VIAL INTRAVEN 12/26/2018 3783.35700

CARVEDILOL 25 MG TABLET ORAL 02/27/2019 0.03074

CARVEDILOL 12.5 MG TABLET ORAL 12/12/2018 0.02747

CARVEDILOL 3.125 MG TABLET ORAL 11/21/2018 0.02492

CARVEDILOL 6.25 MG TABLET ORAL 11/28/2018 0.02492

CARVEDILOL PHOSPHATE 10 MG CPMP 24HR ORAL 08/01/2018 7.49046

CARVEDILOL PHOSPHATE 20 MG CPMP 24HR ORAL 08/01/2018 7.50062

CARVEDILOL PHOSPHATE 40 MG CPMP 24HR ORAL 04/11/2018 7.53491

CARVEDILOL PHOSPHATE 80 MG CPMP 24HR ORAL 08/01/2018 7.47014

CASPOFUNGIN ACETATE 50 MG VIAL INTRAVEN 02/13/2019 70.87875

CASPOFUNGIN ACETATE 70 MG VIAL INTRAVEN 02/27/2019 73.33875

CASTOR OIL 100 % OIL ORAL 01/30/2019 0.02626

CASTOR OIL OIL MISCELL 03/06/2019 0.02368

CATHETER 14FR-6" EACH MISCELL 02/20/2019 0.50383

CEFACLOR 250 MG CAPSULE ORAL 07/10/2018 1.12975

CEFACLOR 500 MG CAPSULE ORAL 11/24/2015 1.74441

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201932

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CEFACLOR 250 MG/5ML SUSP RECON ORAL 01/23/2019 4.83322

CEFACLOR 375 MG/5ML SUSP RECON ORAL 05/02/2018 1.95908

CEFADROXIL 500 MG CAPSULE ORAL 11/21/2018 0.18103

CEFADROXIL 250 MG/5ML SUSP RECON ORAL 08/11/2015 0.37600

CEFADROXIL 500 MG/5ML SUSP RECON ORAL 03/07/2017 0.33089

CEFADROXIL 1 G TABLET ORAL 02/13/2019 4.09411

CEFAZOLIN SODIUM 1 G VIAL INJECTION 08/01/2018 1.17920

CEFAZOLIN SODIUM 10 G VIAL INJECTION 02/27/2019 8.91720

CEFAZOLIN SODIUM 500 MG VIAL INJECTION 08/01/2018 1.60800

CEFDINIR 300 MG CAPSULE ORAL 11/14/2018 0.55275

CEFDINIR 125 MG/5ML SUSP RECON ORAL 01/16/2018 0.19475

CEFDINIR 250 MG/5ML SUSP RECON ORAL 03/28/2017 0.13212

CEFEPIME HCL 1 G VIAL INJECTION 01/16/2019 4.45236

CEFEPIME HCL 2 G VIAL INJECTION 01/16/2019 6.01980

CEFIXIME 100 MG/5ML SUSP RECON ORAL 04/21/2015 5.15962

CEFIXIME 200 MG/5ML SUSP RECON ORAL 10/17/2018 6.64345

CEFOTAXIME SODIUM 1 G VIAL INJECTION 02/07/2018 6.37540

CEFOTETAN DISODIUM 1 G VIAL INJECTION 04/18/2017 11.01585

CEFOTETAN DISODIUM 2 G VIAL INJECTION 04/18/2017 46.12500

CEFOXITIN SODIUM 10 G VIAL INTRAVEN 10/31/2018 30.73975

CEFOXITIN SODIUM 1 G VIAL INTRAVEN 02/06/2019 3.65640

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201933

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CEFOXITIN SODIUM 2 G VIAL INTRAVEN 02/06/2019 7.37870

CEFPODOXIME PROXETIL 50 MG/5 ML SUSP RECON ORAL 07/08/2015 0.57734

CEFPODOXIME PROXETIL 100 MG/5ML SUSP RECON ORAL 11/14/2018 1.84706

CEFPODOXIME PROXETIL 100 MG TABLET ORAL 04/26/2016 5.29019

CEFPODOXIME PROXETIL 200 MG TABLET ORAL 10/20/2015 6.63956

CEFPROZIL 125 MG/5ML SUSP RECON ORAL 01/30/2018 0.11059

CEFPROZIL 250 MG/5ML SUSP RECON ORAL 07/25/2017 0.15196

CEFPROZIL 250 MG TABLET ORAL 05/14/2018 0.55262

CEFPROZIL 500 MG TABLET ORAL 05/30/2017 1.16044

CEFTAZIDIME 1 G VIAL INJECTION 11/14/2018 4.15074

CEFTAZIDIME 2 G VIAL INJECTION 02/27/2019 8.80800

CEFTAZIDIME 6 G VIAL INJECTION 08/29/2018 22.05000

CEFTAZIDIME 1 G VIAL PORT INTRAVEN 09/26/2018 6.15848

CEFTAZIDIME 2 G VIAL PORT INTRAVEN 02/27/2019 11.42985

CEFTRIAXONE SODIUM 1 G VIAL INJECTION 04/19/2016 1.83580

CEFTRIAXONE SODIUM 10 G VIAL INJECTION 03/06/2019 17.30400

CEFTRIAXONE SODIUM 2 G VIAL INJECTION 01/09/2019 3.15744

CEFTRIAXONE SODIUM 250 MG VIAL INJECTION 07/17/2018 0.08260

CEFTRIAXONE SODIUM 500 MG VIAL INJECTION 07/17/2018 1.20600

CEFUROXIME AXETIL 250 MG TABLET ORAL 02/27/2019 0.62511

CEFUROXIME AXETIL 500 MG TABLET ORAL 12/12/2018 1.11086

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201934

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CEFUROXIME SODIUM 750 MG VIAL INJECTION 07/15/2015 2.82150

CEFUROXIME SODIUM 1.5 G VIAL INTRAVEN 07/25/2018 5.42925

CEFUROXIME SODIUM 7.5 G VIAL INTRAVEN 07/06/2016 19.95000

CELECOXIB 100 MG CAPSULE ORAL 02/27/2019 0.21601

CELECOXIB 200 MG CAPSULE ORAL 01/23/2019 0.34840

CELECOXIB 400 MG CAPSULE ORAL 11/29/2016 0.61015

CELECOXIB 50 MG CAPSULE ORAL 10/17/2018 0.22400

CELLULOSE POWDER MISCELL 02/11/2015 0.15072

CEPHALEXIN 250 MG CAPSULE ORAL 02/27/2019 0.06925

CEPHALEXIN 500 MG CAPSULE ORAL 01/30/2019 0.11658

CEPHALEXIN 750 MG CAPSULE ORAL 10/18/2017 6.04749

CEPHALEXIN 125 MG/5ML SUSP RECON ORAL 05/14/2018 0.11785

CEPHALEXIN 250 MG/5ML SUSP RECON ORAL 12/05/2018 0.14070

CETIRIZINE HCL 10 MG CAPSULE ORAL 03/06/2019 0.36287

CETIRIZINE HCL 1 MG/ML SOLUTION ORAL 01/02/2019 0.02412

CETIRIZINE HCL 5 MG/5 ML SOLUTION ORAL 08/30/2017 0.56879

CETIRIZINE HCL 10 MG TABLET ORAL 03/06/2019 0.06566

CETIRIZINE HCL 5 MG TABLET ORAL 12/05/2018 0.05802

CETIRIZINE HCL 5 MG TAB CHEW ORAL 11/28/2018 2.22619

CETIRIZINE HCL 10 MG TAB CHEW ORAL 08/01/2018 3.34312

CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H ORAL 11/07/2018 0.84442

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201935

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CETYL ALC/STEARYL ALC/PG/SLS CREAM (G) TOPICAL 01/22/2013 0.03596

CETYL ALCOHOL/STEARYL ALCOHOL LOTION TOPICAL 01/22/2013 0.03303

CEVIMELINE HCL 30 MG CAPSULE ORAL 08/15/2017 2.08517

CHARCOAL/SORBITOL SOLUTION 25 G/120ML ORAL SUSP ORAL 04/11/2018 0.14908

CHARCOAL/SORBITOL SOLUTION 50G/240ML ORAL SUSP ORAL 10/10/2018 0.10558

CHLORDIAZEPOXIDE HCL 10 MG CAPSULE ORAL 01/31/2018 0.06821

CHLORDIAZEPOXIDE HCL 25 MG CAPSULE ORAL 03/01/2017 0.08043

CHLORDIAZEPOXIDE HCL 5 MG CAPSULE ORAL 03/01/2017 0.10720

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH MUCOUS MEM 11/28/2018 0.01295

CHLORHEXIDINE GLUCONATE 4 % LIQUID TOPICAL 03/06/2019 0.00087

CHLORHEXIDINE GLUCONATE 2 % LIQUID TOPICAL 02/06/2019 0.03937

CHLORHEXIDINE/GLYCERIN/HE-CELL JELLY (G) TOPICAL 09/26/2018 0.03417

CHLOROPROCAINE HCL/PF 30 MG/ML VIAL INJECTION 07/03/2018 1.34938

CHLOROPROCAINE HCL/PF 20 MG/ML VIAL INJECTION 07/03/2018 1.28506

CHLOROQUINE PHOSPHATE 250 MG TABLET ORAL 02/03/2016 2.00678

CHLOROQUINE PHOSPHATE 500 MG TABLET ORAL 02/26/2019 9.84104

CHLOROTHIAZIDE 500 MG TABLET ORAL 05/28/2014 1.06396

CHLOROTHIAZIDE SODIUM 500 MG VIAL INTRAVEN 01/16/2019 43.56250

CHLOROXYLENOL 0.43 % CLEANSER TOPICAL 01/22/2013 0.00333

CHLORPHENIRAMIN/PSEUDOEPHED/DM 1-15-5MG/5 LIQUID ORAL 03/25/2015 0.02535

CHLORPHENIRAMINE MALEATE 4 MG TABLET ORAL 12/12/2018 0.00587

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201936

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CHLORPHENIRAMINE MALEATE 12 MG TABLET ER ORAL 01/16/2018 0.41875

CHLORPHENIRAMINE/DEXTROMETHORP 2-15MG/5ML LIQUID ORAL 07/03/2018 0.06343

CHLORPHENIRAMINE/DEXTROMETHORP 4 MG-30 MG TABLET ORAL 12/05/2018 0.11139

CHLORPHENIRAMINE/PHENYLEPH/DM 2-5-10MG/5 LIQUID ORAL 01/17/2018 0.02224

CHLORPHENIRAMINE/PHENYLEPH/DM 4-10-15/5 LIQUID ORAL 12/09/2015 0.07755

CHLORPHENIRAMINE/PHENYLEPHRINE 4-10MG/5ML LIQUID ORAL 12/09/2015 0.06410

CHLORPROMAZINE HCL 10 MG TABLET ORAL 11/07/2018 2.96881

CHLORPROMAZINE HCL 100 MG TABLET ORAL 10/03/2018 11.87450

CHLORPROMAZINE HCL 200 MG TABLET ORAL 11/07/2018 10.30768

CHLORPROMAZINE HCL 25 MG TABLET ORAL 09/26/2018 5.61670

CHLORPROMAZINE HCL 50 MG TABLET ORAL 05/14/2018 7.56264

CHLORTHALIDONE 25 MG TABLET ORAL 11/21/2018 0.40133

CHLORTHALIDONE 50 MG TABLET ORAL 11/21/2018 0.53533

CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT CAPSULE ORAL 03/06/2019 0.02841

CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT CAPSULE ORAL 12/26/2018 0.02737

CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT CAPSULE ORAL 02/13/2019 0.11867

CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT CAPSULE ORAL 02/13/2019 0.19430

CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT CAPSULE ORAL 11/07/2018 0.05467

CHOLECALCIFEROL (VITAMIN D3) 400/ML DROPS ORAL 12/19/2018 0.07852

CHOLECALCIFEROL (VITAMIN D3) 2000/DROP DROPS ORAL 11/29/2017 2.36048

CHOLECALCIFEROL (VITAMIN D3) 400/DROP DROPS ORAL 11/14/2018 5.22720

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201937

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CHOLECALCIFEROL (VITAMIN D3) 5000/ML DROPS ORAL 07/02/2014 0.07631

CHOLECALCIFEROL (VITAMIN D3) 1000/DROP DROPS ORAL 04/13/2016 1.59460

CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET ORAL 02/28/2018 0.01662

CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TABLET ORAL 05/23/2017 0.01742

CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT TABLET ORAL 11/21/2018 0.01407

CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT TABLET ORAL 05/31/2017 0.03531

CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TAB CHEW ORAL 08/02/2017 0.03475

CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TAB CHEW ORAL 10/31/2018 0.03020

CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK ORAL 06/19/2017 2.16566

CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER ORAL 12/26/2018 0.26307

CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK ORAL 03/06/2019 2.35751

CHOLESTYRAMINE/ASPARTAME 4 G POWDER ORAL 11/14/2018 0.24265

CHORIONIC GONADOTROPIN, HUMAN 10000 UNIT VIAL INTRAMUSC 07/03/2018 235.79100

CHROMIUM PICOLINATE 200 MCG TABLET ORAL 02/27/2019 0.04342

CICLOPIROX 0.77 % GEL (GRAM) TOPICAL 09/26/2018 1.28015

CICLOPIROX 8 % SOLUTION TOPICAL 10/17/2018 3.36800

CICLOPIROX 1 % SHAMPOO TOPICAL 10/10/2018 0.74828

CICLOPIROX OLAMINE 0.77 % CREAM (G) TOPICAL 06/13/2017 0.15857

CICLOPIROX OLAMINE 0.77 % SUSPENSION TOPICAL 12/05/2018 2.35125

CICLOPIROX/UREA/CAMPH/MEN/EUC 8 % SOLUTION TOPICAL 01/23/2019 11.09315

CIDOFOVIR 75 MG/ML VIAL INTRAVEN 05/06/2015 147.60000

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201938

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CILOSTAZOL 100 MG TABLET ORAL 02/27/2019 0.13266

CILOSTAZOL 50 MG TABLET ORAL 11/14/2018 0.13824

CIMETIDINE 200 MG TABLET ORAL 02/28/2018 0.41017

CIMETIDINE 300 MG TABLET ORAL 01/30/2018 0.14665

CIMETIDINE 400 MG TABLET ORAL 11/07/2018 0.11712

CIMETIDINE 800 MG TABLET ORAL 01/30/2018 0.32843

CINACALCET HCL 30 MG TABLET ORAL 02/06/2019 16.23492

CINACALCET HCL 60 MG TABLET ORAL 02/06/2019 31.69659

CINACALCET HCL 90 MG TABLET ORAL 02/06/2019 47.54496

CIPROFLOXACIN 250 MG/5ML SUS MC REC ORAL 01/23/2019 1.66267

CIPROFLOXACIN 500 MG/5ML SUS MC REC ORAL 01/23/2019 1.94233

CIPROFLOXACIN HCL 250 MG TABLET ORAL 02/27/2019 0.10452

CIPROFLOXACIN HCL 500 MG TABLET ORAL 02/27/2019 0.11926

CIPROFLOXACIN HCL 750 MG TABLET ORAL 08/08/2018 0.29775

CIPROFLOXACIN HCL 0.3 % DROPS OPHTHALMIC 02/20/2019 2.20832

CIPROFLOXACIN IN 5 % DEXTROSE 200MG/0.1L PIGGYBACK INTRAVEN 08/30/2017 0.02896

CIPROFLOXACIN IN 5 % DEXTROSE 400MG/0.2L PIGGYBACK INTRAVEN 07/18/2018 0.01674

CIPROFLOXACIN/CIPROFLOXA HCL 500 MG TBMP 24HR ORAL 08/14/2013 9.52769

CIPROFLOXACIN/CIPROFLOXA HCL 1000 MG TBMP 24HR ORAL 08/14/2013 10.84743

CISATRACURIUM BESYLATE 10 MG/ML VIAL INTRAVEN 06/12/2018 11.28292

CISATRACURIUM BESYLATE 2 MG/ML VIAL INTRAVEN 09/19/2018 1.28372

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201939

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CISPLATIN 1 MG/ML VIAL INTRAVEN 01/16/2019 0.21172

CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION ORAL 05/23/2018 0.30362

CITALOPRAM HYDROBROMIDE 20 MG TABLET ORAL 11/14/2018 0.03551

CITALOPRAM HYDROBROMIDE 40 MG TABLET ORAL 01/09/2019 0.04127

CITALOPRAM HYDROBROMIDE 10 MG TABLET ORAL 01/09/2019 0.02273

CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION ORAL 06/13/2018 0.02652

CITRONELLA OIL OIL MISCELL 06/13/2018 0.28229

CITRULLINE POWDER ORAL 01/11/2017 0.08308

CLADRIBINE 10 MG/10ML VIAL INTRAVEN 01/23/2019 20.56845

CLARITHROMYCIN 500 MG TABLET ORAL 11/28/2018 0.63985

CLARITHROMYCIN 250 MG TABLET ORAL 11/07/2018 0.45426

CLARITHROMYCIN 500 MG TAB ER 24H ORAL 02/20/2019 4.21630

CLINDAMYCIN HCL 150 MG CAPSULE ORAL 02/13/2019 0.12556

CLINDAMYCIN HCL 300 MG CAPSULE ORAL 03/06/2019 0.33433

CLINDAMYCIN HCL 75 MG CAPSULE ORAL 02/13/2019 5.66649

CLINDAMYCIN PALMITATE HCL 75 MG/5 ML SOLN RECON ORAL 10/17/2018 0.28931

CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL (GRAM) TOPICAL 02/20/2019 2.13382

CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GEL (GRAM) TOPICAL 10/17/2018 1.22863

CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL W/PUMP TOPICAL 11/28/2018 5.04161

CLINDAMYCIN PHOS/BENZOYL PEROX 1.2%-2.5% GEL W/PUMP TOPICAL 02/27/2019 9.48440

CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL INJECTION 02/06/2019 0.31780

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201940

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CLINDAMYCIN PHOSPHATE 1 % FOAM TOPICAL 09/13/2017 5.81711

CLINDAMYCIN PHOSPHATE 1 % MED. SWAB TOPICAL 01/17/2018 0.41183

CLINDAMYCIN PHOSPHATE 1 % GEL (GRAM) TOPICAL 11/28/2018 3.07978

CLINDAMYCIN PHOSPHATE 1 % SOLUTION TOPICAL 01/23/2019 0.27626

CLINDAMYCIN PHOSPHATE 1 % LOTION TOPICAL 01/23/2019 4.38350

CLINDAMYCIN PHOSPHATE 900MG/6ML VIAL PORT INTRAVEN 01/23/2019 0.83026

CLINDAMYCIN PHOSPHATE 300 MG/2ML VIAL PORT INTRAVEN 01/16/2018 2.01000

CLINDAMYCIN PHOSPHATE 600 MG/4ML VIAL PORT INTRAVEN 01/16/2019 1.11689

CLINDAMYCIN PHOSPHATE 2 % CREAM/APPL VAGINAL 11/21/2018 2.40095

CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK INTRAVEN 03/06/2019 0.10663

CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK INTRAVEN 03/06/2019 0.16080

CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK INTRAVEN 03/06/2019 0.19944

CLINDAMYCIN/TRETINOIN 1.2-0.025% GEL (GRAM) TOPICAL 07/18/2018 11.62627

CLOBAZAM 10 MG TABLET ORAL 02/20/2019 0.64762

CLOBAZAM 20 MG TABLET ORAL 02/13/2019 1.32660

CLOBETASOL PROPIONATE 0.05 % FOAM TOPICAL 03/06/2019 2.92663

CLOBETASOL PROPIONATE 0.05 % SPRAY TOPICAL 01/09/2019 2.99992

CLOBETASOL PROPIONATE 0.05 % GEL (GRAM) TOPICAL 06/19/2017 2.67553

CLOBETASOL PROPIONATE 0.05 % CREAM (G) TOPICAL 02/27/2019 1.04520

CLOBETASOL PROPIONATE 0.05 % OINT. (G) TOPICAL 03/06/2019 0.43744

CLOBETASOL PROPIONATE 0.05 % SOLUTION TOPICAL 01/30/2019 1.18134

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201941

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CLOBETASOL PROPIONATE 0.05 % LOTION TOPICAL 03/06/2019 1.00388

CLOBETASOL PROPIONATE 0.05 % SHAMPOO TOPICAL 08/01/2018 1.71743

CLOBETASOL PROPIONATE/EMOLL 0.05 % FOAM TOPICAL 01/30/2019 2.62533

CLOBETASOL PROPIONATE/EMOLL 0.05 % CREAM (G) TOPICAL 12/12/2018 1.66473

CLOFARABINE 20 MG/20ML VIAL INTRAVEN 03/06/2019 59.24141

CLOMIPHENE CITRATE 50 MG TABLET ORAL 11/28/2018 0.93532

CLOMIPRAMINE HCL 25 MG CAPSULE ORAL 01/30/2019 5.13176

CLOMIPRAMINE HCL 50 MG CAPSULE ORAL 08/18/2015 5.13176

CLOMIPRAMINE HCL 75 MG CAPSULE ORAL 02/20/2019 5.63033

CLONAZEPAM 0.5 MG TABLET ORAL 11/21/2018 0.01447

CLONAZEPAM 1 MG TABLET ORAL 12/05/2018 0.01889

CLONAZEPAM 2 MG TABLET ORAL 01/30/2019 0.03055

CLONAZEPAM 0.125 MG TAB RAPDIS ORAL 02/13/2019 0.73410

CLONAZEPAM 0.25 MG TAB RAPDIS ORAL 02/27/2019 0.72740

CLONAZEPAM 0.5 MG TAB RAPDIS ORAL 03/06/2019 0.78345

CLONAZEPAM 1 MG TAB RAPDIS ORAL 02/13/2019 0.79775

CLONAZEPAM 2 MG TAB RAPDIS ORAL 02/20/2019 1.32057

CLONIDINE 0.1MG/24HR PATCH TDWK TRANSDERM 05/19/2015 16.14375

CLONIDINE 0.2MG/24HR PATCH TDWK TRANSDERM 07/03/2018 23.04750

CLONIDINE 0.3MG/24HR PATCH TDWK TRANSDERM 02/20/2018 30.75000

CLONIDINE HCL 0.1 MG TABLET ORAL 01/30/2019 0.02680

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201942

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CLONIDINE HCL 0.2 MG TABLET ORAL 03/06/2019 0.03323

CLONIDINE HCL 0.3 MG TABLET ORAL 03/06/2019 0.04569

CLONIDINE HCL 0.1 MG TAB ER 12H ORAL 01/23/2019 3.18472

CLONIDINE HCL/PF 1000MCG/10 VIAL EPIDURAL 11/21/2018 2.68000

CLONIDINE HCL/PF 5000MCG/10 VIAL EPIDURAL 08/01/2018 10.92500

CLOPIDOGREL BISULFATE 75 MG TABLET ORAL 01/23/2019 0.08543

CLOPIDOGREL BISULFATE 300 MG TABLET ORAL 08/15/2018 10.31512

CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET ORAL 05/03/2016 1.68063

CLOTRIMAZOLE 10 MG TROCHE MUCOUS MEM 12/05/2018 0.54117

CLOTRIMAZOLE 1 % CREAM (G) TOPICAL 02/13/2019 0.10988

CLOTRIMAZOLE 1 % SOLUTION TOPICAL 02/23/2016 2.84680

CLOTRIMAZOLE 1 % CREAM/APPL VAGINAL 02/20/2019 0.07653

CLOTRIMAZOLE 2 % CREAM/APPL VAGINAL 05/05/2015 0.32227

CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % CREAM (G) TOPICAL 11/21/2018 0.44220

CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % LOTION TOPICAL 04/25/2017 4.23632

CLOZAPINE 25 MG TABLET ORAL 01/09/2019 0.83063

CLOZAPINE 100 MG TABLET ORAL 12/19/2018 1.38188

CLOZAPINE 50 MG TABLET ORAL 01/30/2018 1.68036

CLOZAPINE 200 MG TABLET ORAL 02/20/2019 2.18822

CLOZAPINE 12.5 MG TAB RAPDIS ORAL 04/18/2018 1.49243

CLOZAPINE 150 MG TAB RAPDIS ORAL 05/03/2017 11.86877

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201943

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

COAGULATION FACTOR VIIA,RECOMB 1 MG VIAL INTRAVEN 07/01/2018 1.74828

COAGULATION FACTOR VIIA,RECOMB 2 MG VIAL INTRAVEN 07/01/2018 1.74828

COAGULATION FACTOR VIIA,RECOMB 5 MG VIAL INTRAVEN 07/01/2018 1.74828

COAGULATION FACTOR VIIA,RECOMB 8 MG VIAL INTRAVEN 07/01/2018 1.74828

COAL TAR 2 % FOAM TOPICAL 06/22/2016 0.20100

COAL TAR 0.5 % SHAMPOO TOPICAL 08/30/2017 0.02367

COAL TAR 2 % SHAMPOO TOPICAL 01/31/2018 0.11987

COAL TAR 1 % SHAMPOO TOPICAL 01/24/2018 0.05955

COCOA BUTTER CREAM (G) MISCELL 05/24/2017 0.21105

COD LIVER OIL CAPSULE ORAL 04/03/2018 0.03990

CODEINE PHOSPHATE/GUAIFENESIN 10-100MG/5 LIQUID ORAL 08/31/2015 0.03428

CODEINE PHOSPHATE/GUAIFENESIN 10-100MG/5 LIQUID ORAL 06/09/2015 0.15113

CODEINE PHOSPHATE/GUAIFENESIN 20-200/10 LIQUID ORAL 04/07/2015 0.07556

CODEINE SULFATE 30 MG TABLET ORAL 02/03/2016 0.50960

CODEINE/BUTALBITAL/ASA/CAFFEIN 30-50-325 CAPSULE ORAL 05/30/2017 2.01442

COLA SYRUP SYRUP ORAL 12/12/2018 0.02146

COLCHICINE 0.6 MG CAPSULE ORAL 12/26/2018 5.14219

COLCHICINE 0.6 MG TABLET ORAL 12/19/2018 5.99910

COLESEVELAM HCL 3.75 G POWD PACK ORAL 01/09/2019 22.09900

COLESEVELAM HCL 625 MG TABLET ORAL 03/06/2019 1.43715

COLESTIPOL HCL 5 G GRANULES ORAL 05/09/2018 0.49730

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201944

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

COLESTIPOL HCL 5 G PACKET ORAL 05/16/2018 3.98332

COLESTIPOL HCL 1 G TABLET ORAL 10/06/2015 1.15184

COLISTIN (COLISTIMETHATE NA) 150 MG VIAL INJECTION 01/23/2019 12.65000

COLLOIDAL OATMEAL 1 % CREAM (G) TOPICAL 03/06/2019 0.06298

COMPOUND VEH.SUSP SUGAR-FREE 1 ORAL SUSP ORAL 03/06/2019 0.06773

COMPOUND VEH.SUSP SUGAR-FREE 6 SUSP RECON ORAL 03/06/2019 1.21966

COMPOUND VEHICLE SUGAR-FREE 9 LIQUID ORAL 08/15/2018 0.03095

COMPOUND VEHICLE SUSP SF NO.20 ORAL SUSP ORAL 01/23/2019 0.04511

COMPOUNDING VEHICLE NO.8 LIQUID ORAL 02/06/2019 0.03062

COMPOUNDING VEHICLE SUSP NO.14 ORAL SUSP ORAL 12/19/2018 0.03124

COMPOUNDING VEHICLE SUSP NO.19 ORAL SUSP ORAL 01/23/2019 0.04511

COSYNTROPIN 0.25 MG VIAL INJECTION 12/08/2015 23.50845

CPD VEHICLE SOL.SUGARFREE NO.1 SOLUTION ORAL 12/05/2018 0.03266

CPD VEHICLE SUSP.SUGAR-FREE 12 ORAL SUSP ORAL 12/19/2018 0.03875

CROMOLYN SODIUM 20 MG/ML ORAL CONC ORAL 08/18/2015 0.86536

CROMOLYN SODIUM 4 % DROPS OPHTHALMIC 02/13/2019 0.80400

CROMOLYN SODIUM 5.2 MG SPRAY/PUMP NASAL 12/13/2017 0.59733

CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB INHALATION 07/11/2018 9.97730

CROTAMITON 10 % LOTION TOPICAL 09/05/2018 3.61252

CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TABLET ORAL 05/23/2018 0.01769

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ORAL 07/03/2018 0.02466

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201945

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CYANOCOBALAMIN (VITAMIN B-12) 250 MCG TABLET ORAL 12/05/2018 0.02325

CYANOCOBALAMIN (VITAMIN B-12) 500 MCG TABLET ORAL 01/30/2019 0.01719

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ER ORAL 01/30/2019 0.05531

CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL INJECTION 03/06/2019 0.71467

CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TAB SUBL SUBLINGUAL 01/22/2013 0.05347

CYANOCOBALAMIN (VITAMIN B-12) 2500 MCG TAB SUBL SUBLINGUAL 04/13/2016 0.04690

CYANOCOBALAMIN (VITAMIN B-12) 5000 MCG TAB SUBL SUBLINGUAL 03/02/2016 0.24569

CYANOCOBALAMIN/COBAMAMIDE 5K-100 MCG TAB SUBL SUBLINGUAL 07/18/2018 0.22311

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.5-25MG TABLET ORAL 01/09/2019 0.45977

CYANOCOBALAMIN/FOLIC AC/VIT B6 0.5-2.2-25 TABLET ORAL 06/13/2018 0.38126

CYANOCOBALAMIN/FOLIC AC/VIT B6 2-2.5-25MG TABLET ORAL 07/03/2018 0.44667

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25MG TABLET ORAL 01/09/2019 0.62551

CYANOCOBALAMIN/FOLIC ACID 0.5 MG-1MG TABLET ORAL 01/23/2019 0.89338

CYANOCOBALAMIN/MECOBALAMIN 600-600MCG TAB SUBL SUBLINGUAL 06/13/2018 0.30572

CYCLOBENZAPRINE HCL 10 MG TABLET ORAL 03/06/2019 0.02124

CYCLOBENZAPRINE HCL 5 MG TABLET ORAL 03/06/2019 0.02841

CYCLOBENZAPRINE HCL 7.5 MG TABLET ORAL 02/06/2019 3.04590

CYCLOPENTOLATE HCL 0.5 % DROPS OPHTHALMIC 01/30/2019 6.10108

CYCLOPENTOLATE HCL 1 % DROPS OPHTHALMIC 12/16/2015 2.41200

CYCLOPENTOLATE HCL 2 % DROPS OPHTHALMIC 07/25/2018 3.40032

CYCLOPHOSPHAMIDE 25 MG CAPSULE ORAL 02/06/2019 8.24424

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201946

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

CYCLOPHOSPHAMIDE 50 MG CAPSULE ORAL 02/27/2019 12.46520

CYCLOPHOSPHAMIDE 1 G VIAL INTRAVEN 11/07/2018 359.86725

CYCLOPHOSPHAMIDE 2 G VIAL INTRAVEN 11/07/2018 719.73450

CYCLOPHOSPHAMIDE 500 MG VIAL INTRAVEN 11/07/2018 179.93875

CYCLOSPORINE 100 MG CAPSULE ORAL 04/25/2017 9.43000

CYCLOSPORINE 25 MG CAPSULE ORAL 12/19/2018 4.01280

CYCLOSPORINE 250 MG/5ML AMPUL INTRAVEN 01/23/2019 12.02212

CYCLOSPORINE, MODIFIED 100 MG CAPSULE ORAL 11/14/2018 2.53305

CYCLOSPORINE, MODIFIED 25 MG CAPSULE ORAL 01/12/2016 0.54895

CYCLOSPORINE, MODIFIED 50 MG CAPSULE ORAL 03/07/2018 4.39234

CYCLOSPORINE, MODIFIED 100 MG/ML SOLUTION ORAL 02/04/2015 3.95380

CYPROHEPTADINE HCL 2 MG/5 ML SYRUP ORAL 08/15/2018 0.09478

CYPROHEPTADINE HCL 4 MG TABLET ORAL 11/21/2018 0.21440

CYTARABINE/PF 2 G/20 ML VIAL INJECTION 01/23/2019 1.04520

CYTARABINE/PF 100 MG/5ML VIAL INJECTION 12/28/2016 0.76380

CYTARABINE/PF 20 MG/ML VIAL INJECTION 02/27/2019 0.66276

D-METHORPHAN/PE/ACETAMINOPHEN 10-5-325MG CAPSULE ORAL 12/05/2018 0.26485

D-METHORPHAN/PE/ACETAMINOPHEN 5-325MG/15 LIQUID ORAL 12/26/2018 0.02657

D-METHORPHAN/PE/ACETAMINOPHEN 10-5-325MG TABLET ORAL 12/26/2018 0.26892

DACARBAZINE 200 MG VIAL INTRAVEN 01/23/2019 15.86235

DACTINOMYCIN 0.5 MG VIAL INTRAVEN 02/27/2019 1330.93175

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201947

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DALFAMPRIDINE 10 MG TAB ER 12H ORAL 02/13/2019 4.06978

DANAZOL 100 MG CAPSULE ORAL 02/07/2017 4.47480

DANAZOL 200 MG CAPSULE ORAL 11/22/2016 5.14760

DANAZOL 50 MG CAPSULE ORAL 02/06/2018 3.00960

DANTROLENE SODIUM 100 MG CAPSULE ORAL 11/07/2018 1.75902

DANTROLENE SODIUM 25 MG CAPSULE ORAL 05/22/2018 0.90410

DANTROLENE SODIUM 50 MG CAPSULE ORAL 07/11/2017 1.27059

DANTROLENE SODIUM 20 MG VIAL INTRAVEN 06/25/2014 78.87375

DAPSONE 100 MG TABLET ORAL 10/24/2018 1.59147

DAPSONE 25 MG TABLET ORAL 10/24/2018 1.90548

DAPSONE 5 % GEL (GRAM) TOPICAL 02/27/2019 5.14140

DARIFENACIN HYDROBROMIDE 7.5 MG TAB ER 24H ORAL 04/17/2018 5.19675

DARIFENACIN HYDROBROMIDE 15 MG TAB ER 24H ORAL 09/24/2018 4.23852

DAUNORUBICIN HCL 5 MG/ML VIAL INTRAVEN 02/27/2019 27.61991

DECITABINE 50 MG VIAL INTRAVEN 09/18/2018 584.25000

DEFEROXAMINE MESYLATE 500 MG VIAL INJECTION 12/19/2018 11.39600

DEFEROXAMINE MESYLATE 2 G VIAL INJECTION 10/17/2018 25.06350

DEMECLOCYCLINE HCL 150 MG TABLET ORAL 07/18/2018 3.95432

DEMECLOCYCLINE HCL 300 MG TABLET ORAL 02/13/2019 9.31500

DESIPRAMINE HCL 10 MG TABLET ORAL 03/06/2019 0.87422

DESIPRAMINE HCL 100 MG TABLET ORAL 03/06/2019 3.26304

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201948

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DESIPRAMINE HCL 150 MG TABLET ORAL 03/06/2019 5.22060

DESIPRAMINE HCL 25 MG TABLET ORAL 03/06/2019 1.01264

DESIPRAMINE HCL 50 MG TABLET ORAL 03/06/2019 1.98052

DESIPRAMINE HCL 75 MG TABLET ORAL 03/06/2019 2.52067

DESLORATADINE 5 MG TABLET ORAL 04/25/2018 0.57218

DESMOPRESSIN (NONREFRIGERATED) 10/SPRAY SPRAY/PUMP NASAL 04/18/2016 21.08190

DESMOPRESSIN ACETATE 0.1 MG TABLET ORAL 03/06/2019 0.98423

DESMOPRESSIN ACETATE 0.2 MG TABLET ORAL 07/19/2016 0.95354

DESMOPRESSIN ACETATE 4 MCG/ML AMPUL INJECTION 08/29/2018 43.39133

DESMOPRESSIN ACETATE 4 MCG/ML VIAL INJECTION 11/09/2016 19.83741

DESMOPRESSIN ACETATE 10/SPRAY SPRAY/PUMP NASAL 10/15/2014 25.85625

DESOG-E.ESTRADIOL/E.ESTRADIOL 21-5 (28) TABLET ORAL 12/19/2018 0.31107

DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET ORAL 02/06/2019 0.32080

DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET ORAL 11/07/2018 1.60577

DESONIDE 0.05 % CREAM (G) TOPICAL 01/03/2017 1.02555

DESONIDE 0.05 % OINT. (G) TOPICAL 01/23/2019 1.46931

DESONIDE 0.05 % LOTION TOPICAL 10/17/2017 1.52269

DESOXIMETASONE 0.25 % SPRAY TOPICAL 01/16/2019 1.92464

DESOXIMETASONE 0.05 % CREAM (G) TOPICAL 12/04/2018 4.33470

DESOXIMETASONE 0.25 % CREAM (G) TOPICAL 02/13/2019 0.66598

DESOXIMETASONE 0.25 % OINT. (G) TOPICAL 04/25/2017 0.40021

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201949

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DESOXIMETASONE 0.05 % OINT. (G) TOPICAL 03/21/2018 5.87829

DESVENLAFAXINE SUCCINATE 50 MG TAB ER 24H ORAL 09/12/2018 0.95095

DESVENLAFAXINE SUCCINATE 100 MG TAB ER 24H ORAL 12/05/2018 0.97626

DESVENLAFAXINE SUCCINATE 25 MG TAB ER 24H ORAL 12/12/2018 1.52894

DEXAMETHASONE 0.5 MG/5ML ELIXIR ORAL 08/18/2015 0.20089

DEXAMETHASONE 1.5 MG TABLET ORAL 01/16/2019 0.45138

DEXAMETHASONE 1.5MG (51) TAB DS PK ORAL 01/23/2019 9.24306

DEXAMETHASONE 1.5MG (35) TAB DS PK ORAL 01/23/2019 9.24377

DEXAMETHASONE 1.5MG (21) TAB DS PK ORAL 01/23/2019 9.24286

DEXAMETHASONE SODIUM PHOSP/PF 10 MG/ML VIAL INJECTION 02/06/2019 2.25120

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML VIAL INJECTION 12/05/2018 0.26398

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML VIAL INJECTION 03/15/2016 0.17870

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % DROPS OPHTHALMIC 10/11/2017 11.26400

DEXBROMPHENIRAMINE/PSEUDOEPHED 1MG-30MG/5 SOLUTION ORAL 09/21/2016 0.03116

DEXBROMPHENIRAMINE/PSEUDOEPHED 2 MG-60 MG TABLET ORAL 06/29/2016 0.29313

DEXCHLORPHENIR/PSE/CHLOPHEDIAN 2-60-25 MG LIQUID ORAL 09/09/2015 0.08165

DEXCHLORPHENIR/PSE/CHLOPHEDIAN 0.5-15MG/1 DROPS ORAL 09/09/2015 0.16057

DEXCHLORPHENIR/PSEUDOEPHED/DM 1-30-15/5 LIQUID ORAL 09/21/2016 0.07472

DEXCHLORPHENIRAMINE MALEATE 2 MG/5 ML SYRUP ORAL 01/09/2019 7.55596

DEXMEDETOMIDINE HCL 200MCG/2ML VIAL INTRAVEN 11/21/2018 2.52590

DEXMETHYLPHENIDATE HCL 5 MG CPBP 50-50 ORAL 03/06/2019 5.05837

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201950

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DEXMETHYLPHENIDATE HCL 10 MG CPBP 50-50 ORAL 02/20/2019 3.86509

DEXMETHYLPHENIDATE HCL 20 MG CPBP 50-50 ORAL 01/16/2019 3.94627

DEXMETHYLPHENIDATE HCL 15 MG CPBP 50-50 ORAL 02/20/2019 2.17790

DEXMETHYLPHENIDATE HCL 30 MG CPBP 50-50 ORAL 02/20/2019 4.22572

DEXMETHYLPHENIDATE HCL 40 MG CPBP 50-50 ORAL 02/20/2019 2.81279

DEXMETHYLPHENIDATE HCL 25 MG CPBP 50-50 ORAL 01/16/2019 3.11929

DEXMETHYLPHENIDATE HCL 35 MG CPBP 50-50 ORAL 02/20/2019 2.76989

DEXMETHYLPHENIDATE HCL 2.5 MG TABLET ORAL 01/09/2019 0.32133

DEXMETHYLPHENIDATE HCL 5 MG TABLET ORAL 12/12/2018 0.72226

DEXMETHYLPHENIDATE HCL 10 MG TABLET ORAL 07/03/2018 0.58679

DEXRAZOXANE HCL 500 MG VIAL INTRAVEN 02/20/2019 285.97500

DEXRAZOXANE HCL 250 MG VIAL INTRAVEN 12/08/2015 215.86500

DEXTRAN 70/HYPROMELLOSE 0.1%-0.3% DROPS OPHTHALMIC 11/07/2018 0.25460

DEXTRAN 70/HYPROMELLOSE/PF 0.1%-0.3% DROPERETTE OPHTHALMIC 07/19/2018 0.22000

DEXTROAMPHETAMINE SULFATE 10 MG CAPSULE ER ORAL 02/27/2019 1.17009

DEXTROAMPHETAMINE SULFATE 15 MG CAPSULE ER ORAL 02/27/2019 1.49196

DEXTROAMPHETAMINE SULFATE 5 MG CAPSULE ER ORAL 02/27/2019 2.93934

DEXTROAMPHETAMINE SULFATE 5 MG/5 ML SOLUTION ORAL 04/18/2016 2.23333

DEXTROAMPHETAMINE SULFATE 10 MG TABLET ORAL 06/06/2018 1.16580

DEXTROAMPHETAMINE SULFATE 5 MG TABLET ORAL 01/09/2019 1.15240

DEXTROAMPHETAMINE/AMPHETAMINE 10 MG CAP ER 24H ORAL 01/09/2019 3.59396

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201951

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DEXTROAMPHETAMINE/AMPHETAMINE 20 MG CAP ER 24H ORAL 01/09/2019 3.58288

DEXTROAMPHETAMINE/AMPHETAMINE 30 MG CAP ER 24H ORAL 01/09/2019 3.59423

DEXTROAMPHETAMINE/AMPHETAMINE 5 MG CAP ER 24H ORAL 01/16/2019 4.29000

DEXTROAMPHETAMINE/AMPHETAMINE 15 MG CAP ER 24H ORAL 01/22/2013 1.95975

DEXTROAMPHETAMINE/AMPHETAMINE 25 MG CAP ER 24H ORAL 12/05/2018 3.74893

DEXTROAMPHETAMINE/AMPHETAMINE 5 MG TABLET ORAL 12/12/2018 0.37038

DEXTROAMPHETAMINE/AMPHETAMINE 10 MG TABLET ORAL 12/12/2018 0.34103

DEXTROAMPHETAMINE/AMPHETAMINE 20 MG TABLET ORAL 12/12/2018 0.36676

DEXTROAMPHETAMINE/AMPHETAMINE 30 MG TABLET ORAL 01/16/2019 0.55064

DEXTROAMPHETAMINE/AMPHETAMINE 7.5 MG TABLET ORAL 01/23/2019 0.57285

DEXTROAMPHETAMINE/AMPHETAMINE 12.5 MG TABLET ORAL 01/23/2019 0.57285

DEXTROAMPHETAMINE/AMPHETAMINE 15 MG TABLET ORAL 12/12/2018 0.49942

DEXTROMETHORPHAN HB/DOXYLAMINE 15-6.25/15 SOLUTION ORAL 10/10/2018 0.02582

DEXTROMETHORPHAN HBR 15 MG CAPSULE ORAL 06/15/2016 0.27772

DEXTROMETHORPHAN HBR 10 MG/5 ML LIQUID ORAL 07/03/2018 0.06343

DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUS ER 12H ORAL 03/06/2019 0.08451

DEXTROMETHORPHAN/PHENYLEPHRINE 5-2.5 MG/5 LIQUID ORAL 10/04/2017 0.05204

DEXTROSE 5 % SOLUTION ORAL 01/14/2015 0.02153

DEXTROSE 4 G TAB CHEW ORAL 11/07/2018 0.09367

DEXTROSE 10 % IN WATER 10 % IV SOLN INTRAVEN 01/10/2018 0.01015

DEXTROSE 5 % AND 0.3 % NACL 5 %-0.3 % IV SOLN INTRAVEN 02/20/2019 0.00526

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201952

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DEXTROSE 5 % AND 0.9 % NACL 5 %-0.9 % IV SOLN INTRAVEN 02/06/2019 0.00402

DEXTROSE 5 % IN WATER 5 % IV SOLN INTRAVEN 07/03/2018 0.00315

DEXTROSE 5 %-0.2 % SOD CHLORID 5 %-0.2 % IV SOLN INTRAVEN 02/06/2019 0.00402

DEXTROSE 5 %-0.45 % SOD CHLORD 5 %-0.45 % IV SOLN INTRAVEN 06/14/2017 0.00267

DEXTROSE 5%-LACTATED RINGERS 5 % IV SOLN INTRAVEN 02/20/2019 0.00569

DEXTROSE 50 % IN WATER 50 % SYRINGE INTRAVEN 02/27/2019 0.19878

DEXTROSE 70 % IN WATER 70 % IV SOLN INTRAVEN 12/19/2017 0.00641

DIATRIZOATE MEGLUMINE, SODIUM 66 %-10 % SOLUTION ORAL 01/22/2013 0.35360

DIAZEPAM 5 MG/ML ORAL CONC ORAL 03/06/2019 1.23057

DIAZEPAM 10 MG TABLET ORAL 02/20/2019 0.02476

DIAZEPAM 2 MG TABLET ORAL 02/20/2019 0.02168

DIAZEPAM 5 MG TABLET ORAL 02/20/2019 0.02203

DIAZEPAM 5 MG/ML CARTRIDGE INJECTION 11/21/2018 12.03345

DIBUCAINE 1 % OINT. (G) TOPICAL 12/21/2016 0.17375

DICLOFENAC POTASSIUM 50 MG TABLET ORAL 12/26/2018 0.66759

DICLOFENAC SODIUM 25 MG TABLET DR ORAL 12/07/2016 1.40700

DICLOFENAC SODIUM 50 MG TABLET DR ORAL 11/14/2018 0.11725

DICLOFENAC SODIUM 75 MG TABLET DR ORAL 03/06/2019 0.10524

DICLOFENAC SODIUM 100 MG TAB ER 24H ORAL 01/16/2019 2.00498

DICLOFENAC SODIUM 1 % GEL (GRAM) TOPICAL 12/26/2018 0.43544

DICLOFENAC SODIUM 3 % GEL (GRAM) TOPICAL 01/23/2019 1.17486

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201953

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DICLOFENAC SODIUM 1.5 % DROPS TOPICAL 01/23/2019 0.33491

DICLOFENAC SODIUM 0.1 % DROPS OPHTHALMIC 08/22/2018 1.59460

DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 TAB IR DR ORAL 02/27/2019 2.55404

DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 TAB IR DR ORAL 02/13/2019 2.79554

DICLOXACILLIN SODIUM 250 MG CAPSULE ORAL 10/10/2018 0.55958

DICLOXACILLIN SODIUM 500 MG CAPSULE ORAL 10/17/2018 1.02095

DICYCLOMINE HCL 10 MG/5 ML SOLUTION ORAL 06/20/2017 0.20127

DICYCLOMINE HCL 20 MG TABLET ORAL 11/14/2018 0.15737

DICYCLOMINE HCL 10 MG/ML VIAL INTRAMUSC 02/13/2019 29.06798

DIDANOSINE 250 MG CAPSULE DR ORAL 09/05/2018 6.83562

DIDANOSINE 400 MG CAPSULE DR ORAL 09/05/2018 9.66789

DIDANOSINE 125 MG CAPSULE DR ORAL 11/27/2018 3.59930

DIDANOSINE 200 MG CAPSULE DR ORAL 03/08/2017 4.07572

DIETHYLPROPION HCL 25 MG TABLET ORAL 01/16/2019 0.22445

DIETHYLTOLUAMIDE 15 % AERO POWD TOPICAL 12/21/2016 0.03486

DIETHYLTOLUAMIDE 25 % AERO POWD TOPICAL 10/26/2016 0.03012

DIETHYLTOLUAMIDE 25 % SPRAY TOPICAL 09/28/2016 0.01564

DIETHYLTOLUAMIDE 40 % SPRAY TOPICAL 02/27/2019 0.02073

DIETHYLTOLUAMIDE 15 % SPRAY TOPICAL 06/08/2016 0.02974

DIETHYLTOLUAMIDE 7 % SPRAY TOPICAL 12/07/2016 0.01748

DIETHYLTOLUAMIDE 98.11 % SPRAY TOPICAL 08/31/2016 0.04831

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201954

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DIETHYLTOLUAMIDE 25 % SPRAY TOPICAL 09/12/2018 0.01889

DIFLORASONE DIACETATE 0.05 % OINT. (G) TOPICAL 02/27/2019 11.73333

DIFLUNISAL 500 MG TABLET ORAL 07/11/2018 1.28761

DIGOXIN 125 MCG TABLET ORAL 01/23/2019 0.52930

DIGOXIN 250 MCG TABLET ORAL 03/17/2015 0.53600

DIGOXIN 250 MCG/ML AMPUL INJECTION 07/25/2018 3.13434

DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL INJECTION 02/27/2019 105.37718

DILTIAZEM HCL 120 MG CAP ER 12H ORAL 09/04/2018 6.18630

DILTIAZEM HCL 60 MG CAP ER 12H ORAL 01/03/2017 4.37012

DILTIAZEM HCL 90 MG CAP ER 12H ORAL 01/10/2017 5.13942

DILTIAZEM HCL 180 MG CAP ER 24H ORAL 01/09/2019 0.32476

DILTIAZEM HCL 240 MG CAP ER 24H ORAL 01/09/2019 0.47704

DILTIAZEM HCL 300 MG CAP ER 24H ORAL 01/09/2019 0.64707

DILTIAZEM HCL 120 MG CAP ER 24H ORAL 01/09/2019 0.30153

DILTIAZEM HCL 360 MG CAP ER 24H ORAL 11/14/2018 6.29497

DILTIAZEM HCL 360 MG CAP SA 24H ORAL 12/12/2018 1.04684

DILTIAZEM HCL 120 MG CAP SA 24H ORAL 12/12/2018 0.46483

DILTIAZEM HCL 180 MG CAP SA 24H ORAL 12/12/2018 0.55506

DILTIAZEM HCL 240 MG CAP SA 24H ORAL 12/12/2018 0.75278

DILTIAZEM HCL 300 MG CAP SA 24H ORAL 12/12/2018 1.02793

DILTIAZEM HCL 420 MG CAP SA 24H ORAL 12/28/2016 1.64634

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201955

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DILTIAZEM HCL 180 MG CAP ER DEG ORAL 04/24/2018 0.36381

DILTIAZEM HCL 240 MG CAP ER DEG ORAL 06/06/2018 0.44207

DILTIAZEM HCL 120 MG CAP ER DEG ORAL 05/14/2018 0.35818

DILTIAZEM HCL 120 MG TABLET ORAL 04/28/2015 0.41352

DILTIAZEM HCL 30 MG TABLET ORAL 07/03/2018 0.11980

DILTIAZEM HCL 60 MG TABLET ORAL 08/29/2018 0.21437

DILTIAZEM HCL 90 MG TABLET ORAL 03/06/2019 0.34250

DILTIAZEM HCL 180 MG TAB ER 24H ORAL 06/20/2018 2.25864

DILTIAZEM HCL 240 MG TAB ER 24H ORAL 03/21/2018 2.50223

DILTIAZEM HCL 300 MG TAB ER 24H ORAL 10/04/2017 3.34444

DILTIAZEM HCL 360 MG TAB ER 24H ORAL 11/03/2015 3.59788

DILTIAZEM HCL 420 MG TAB ER 24H ORAL 11/16/2016 3.70920

DILTIAZEM HCL 5 MG/ML VIAL INTRAVEN 12/26/2018 0.29534

DILUENT FOR EPOPROSTENOL(GLYC) VIAL INTRAVEN 04/06/2016 0.35835

DIMENHYDRINATE 50 MG TABLET ORAL 02/06/2019 0.01491

DIMETHICONE 2 % SPRAY TOPICAL 10/01/2014 0.02872

DIMETHICONE 1 % CREAM (G) TOPICAL 01/20/2016 0.05877

DIMETHICONE 3 % LOTION TOPICAL 12/12/2018 0.03646

DIPHENHYDRA/PHENYLEPH/ACETAMIN 5-325MG/10 LIQUID ORAL 07/03/2018 0.06104

DIPHENHYDRAMINE HCL 25 MG CAPSULE ORAL 02/06/2019 0.03028

DIPHENHYDRAMINE HCL 50 MG CAPSULE ORAL 11/21/2017 0.02100

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201956

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR ORAL 03/14/2017 0.45059

DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID ORAL 12/26/2018 0.01050

DIPHENHYDRAMINE HCL 50 MG/30ML LIQUID ORAL 12/19/2018 0.02058

DIPHENHYDRAMINE HCL 6.25MG/ML DROPS ORAL 05/23/2018 1.67299

DIPHENHYDRAMINE HCL 25 MG TABLET ORAL 05/30/2018 0.02634

DIPHENHYDRAMINE HCL 25 MG TABLET ORAL 05/05/2015 0.00744

DIPHENHYDRAMINE HCL 50 MG/ML CARTRIDGE INJECTION 09/06/2017 1.92826

DIPHENHYDRAMINE HCL 50 MG/ML VIAL INJECTION 02/06/2019 0.80400

DIPHENHYDRAMINE HCL/ZINC ACET 2 %-0.1 % CREAM (G) TOPICAL 05/23/2017 0.01665

DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG TABLET ORAL 02/06/2019 0.41446

DIPYRIDAMOLE 25 MG TABLET ORAL 03/06/2019 0.38351

DIPYRIDAMOLE 50 MG TABLET ORAL 10/03/2017 0.57910

DIPYRIDAMOLE 75 MG TABLET ORAL 03/06/2019 0.82665

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE ORAL 01/23/2019 5.35229

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE ORAL 12/19/2018 2.96578

DISULFIRAM 250 MG TABLET ORAL 09/08/2015 1.34000

DISULFIRAM 500 MG TABLET ORAL 02/27/2018 3.93109

DIVALPROEX SODIUM 125 MG CAP DR SPR ORAL 07/12/2016 0.47731

DIVALPROEX SODIUM 125 MG TABLET DR ORAL 11/07/2018 0.05950

DIVALPROEX SODIUM 250 MG TABLET DR ORAL 09/22/2015 0.10034

DIVALPROEX SODIUM 500 MG TABLET DR ORAL 04/05/2016 0.13773

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201957

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DIVALPROEX SODIUM 500 MG TAB ER 24H ORAL 02/06/2019 0.32147

DIVALPROEX SODIUM 250 MG TAB ER 24H ORAL 01/30/2019 0.37968

DM/ACETAMINOPHEN/DOXYLAMINE 15MG-325MG CAPSULE ORAL 02/13/2019 0.26503

DM/ACETAMINOPHEN/DOXYLAMINE 15-325/15 LIQUID ORAL 01/30/2019 0.01362

DM/PE/ACETAMINOPHEN/DOXYLAMINE 5-325MG/15 LIQUID ORAL 11/01/2017 0.02689

DOBUTAMINE HCL IN DEXTROSE 5 % 500MG/250 IV SOLN INTRAVEN 09/26/2018 0.06326

DOBUTAMINE HCL IN DEXTROSE 5 % 1000MG/250 IV SOLN INTRAVEN 01/10/2018 0.16370

DOBUTAMINE HCL IN DEXTROSE 5 % 250 MG/250 IV SOLN INTRAVEN 12/20/2017 0.11235

DOCETAXEL 20MG/ML(1) VIAL INTRAVEN 06/02/2015 26.80375

DOCETAXEL 80 MG/4 ML VIAL INTRAVEN 01/30/2018 22.83488

DOCETAXEL 160 MG/8ML VIAL INTRAVEN 11/28/2018 32.13759

DOCETAXEL 80 MG/8 ML VIAL INTRAVEN 01/23/2019 17.65313

DOCETAXEL 20 MG/2 ML VIAL INTRAVEN 01/23/2019 17.65575

DOCETAXEL 160MG/16ML VIAL INTRAVEN 12/12/2018 14.20510

DOCOSAHEXANOIC ACID 200 MG CAPSULE ORAL 03/22/2017 0.33009

DOCUSATE CALCIUM 240 MG CAPSULE ORAL 07/27/2016 0.05130

DOCUSATE SODIUM 100 MG CAPSULE ORAL 03/06/2019 0.01960

DOCUSATE SODIUM 250 MG CAPSULE ORAL 03/06/2019 0.03437

DOCUSATE SODIUM 50 MG/5 ML LIQUID ORAL 12/20/2017 0.00974

DOCUSATE SODIUM 60 MG/15ML SYRUP ORAL 08/22/2018 0.00913

DOCUSATE SODIUM 100 MG TABLET ORAL 12/19/2018 0.02305

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201958

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DOFETILIDE 125 MCG CAPSULE ORAL 02/13/2019 5.29146

DOFETILIDE 250 MCG CAPSULE ORAL 02/13/2019 5.29146

DOFETILIDE 500 MCG CAPSULE ORAL 02/20/2019 5.29146

DONEPEZIL HCL 10 MG TABLET ORAL 08/22/2018 0.04690

DONEPEZIL HCL 5 MG TABLET ORAL 08/22/2018 0.03844

DONEPEZIL HCL 23 MG TABLET ORAL 05/17/2016 1.11667

DONEPEZIL HCL 5 MG TAB RAPDIS ORAL 05/22/2018 0.65303

DONEPEZIL HCL 10 MG TAB RAPDIS ORAL 04/18/2018 0.66375

DOPAMINE HCL IN DEXTROSE 5 % 800MG/.25L PLAST. BAG INTRAVEN 03/05/2019 0.05594

DOPAMINE HCL IN DEXTROSE 5 % 400MG/.25L PLAST. BAG INTRAVEN 08/01/2018 0.06126

DOPAMINE HCL IN DEXTROSE 5 % 800MG/0.5L PLAST. BAG INTRAVEN 01/10/2018 0.06199

DORZOLAMIDE HCL 2 % DROPS OPHTHALMIC 11/14/2018 1.71386

DORZOLAMIDE HCL/TIMOLOL MALEAT 22.3-6.8/1 DROPS OPHTHALMIC 02/13/2019 3.59436

DORZOLAMIDE/TIMOLOL/PF 2 %-0.5 % DROPERETTE OPHTHALMIC 02/06/2019 3.46764

DOXAPRAM HCL 20 MG/ML VIAL INTRAVEN 01/09/2019 3.73901

DOXAZOSIN MESYLATE 1 MG TABLET ORAL 03/06/2019 0.08616

DOXAZOSIN MESYLATE 2 MG TABLET ORAL 03/06/2019 0.08750

DOXAZOSIN MESYLATE 4 MG TABLET ORAL 03/06/2019 0.09246

DOXAZOSIN MESYLATE 8 MG TABLET ORAL 03/06/2019 0.09380

DOXEPIN HCL 10 MG CAPSULE ORAL 12/05/2018 0.34024

DOXEPIN HCL 100 MG CAPSULE ORAL 04/07/2015 1.78367

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201959

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DOXEPIN HCL 25 MG CAPSULE ORAL 10/03/2018 0.44674

DOXEPIN HCL 50 MG CAPSULE ORAL 04/07/2015 0.63873

DOXEPIN HCL 75 MG CAPSULE ORAL 01/23/2019 0.74300

DOXEPIN HCL 10 MG/ML ORAL CONC ORAL 02/13/2019 0.29368

DOXERCALCIFEROL 2.5 MCG CAPSULE ORAL 02/07/2017 18.56652

DOXERCALCIFEROL 0.5 MCG CAPSULE ORAL 07/05/2017 8.70984

DOXERCALCIFEROL 1 MCG CAPSULE ORAL 09/13/2017 16.59000

DOXERCALCIFEROL 4MCG/2ML VIAL INTRAVEN 01/23/2019 4.02085

DOXORUBICIN HCL 10 MG VIAL INTRAVEN 08/28/2018 29.99150

DOXORUBICIN HCL 50 MG VIAL INTRAVEN 08/29/2018 299.88425

DOXORUBICIN HCL 2 MG/ML VIAL INTRAVEN 02/27/2019 0.55195

DOXORUBICIN HCL 10 MG/5 ML VIAL INTRAVEN 12/13/2017 1.84009

DOXORUBICIN HCL 50 MG/25ML VIAL INTRAVEN 07/11/2018 0.68501

DOXORUBICIN HCL 20 MG/10ML VIAL INTRAVEN 02/27/2019 1.85590

DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML VIAL INTRAVEN 01/23/2019 61.97888

DOXYCYCLINE HYCLATE 100 MG CAPSULE ORAL 11/28/2018 0.37386

DOXYCYCLINE HYCLATE 50 MG CAPSULE ORAL 01/16/2019 0.56280

DOXYCYCLINE HYCLATE 100 MG TABLET ORAL 12/12/2018 0.20636

DOXYCYCLINE HYCLATE 20 MG TABLET ORAL 01/23/2019 0.45627

DOXYCYCLINE HYCLATE 75 MG TABLET ORAL 02/21/2018 19.45965

DOXYCYCLINE HYCLATE 150 MG TABLET ORAL 04/11/2018 19.45965

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201960

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DOXYCYCLINE HYCLATE 75 MG TABLET DR ORAL 02/13/2019 8.83360

DOXYCYCLINE HYCLATE 100 MG TABLET DR ORAL 02/13/2019 7.76400

DOXYCYCLINE HYCLATE 150 MG TABLET DR ORAL 05/12/2015 7.55650

DOXYCYCLINE HYCLATE 200 MG TABLET DR ORAL 01/30/2018 27.33333

DOXYCYCLINE HYCLATE 50 MG TABLET DR ORAL 06/13/2018 11.32520

DOXYCYCLINE HYCLATE 100 MG VIAL INTRAVEN 01/02/2019 19.42500

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE ORAL 03/06/2019 0.41433

DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE ORAL 02/06/2019 0.20529

DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE ORAL 04/10/2018 9.13000

DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE ORAL 10/03/2018 13.35530

DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR ORAL 11/09/2016 19.69135

DOXYCYCLINE MONOHYDRATE 25 MG/5 ML SUSP RECON ORAL 03/22/2017 0.31825

DOXYCYCLINE MONOHYDRATE 100 MG TABLET ORAL 03/06/2019 0.48910

DOXYCYCLINE MONOHYDRATE 50 MG TABLET ORAL 05/16/2017 1.42817

DOXYCYCLINE MONOHYDRATE 75 MG TABLET ORAL 04/19/2016 1.36211

DOXYCYCLINE MONOHYDRATE 150 MG TABLET ORAL 07/11/2018 7.48000

DOXYLAMINE SUCCINATE 25 MG TABLET ORAL 08/22/2018 0.20288

DOXYLAMINE/PSEUDOEPHEDRINE/DM 6.25-30-15 LIQUID ORAL 09/21/2016 0.20475

DRONABINOL 10 MG CAPSULE ORAL 11/07/2018 7.58780

DRONABINOL 2.5 MG CAPSULE ORAL 11/07/2018 2.64561

DRONABINOL 5 MG CAPSULE ORAL 11/07/2018 5.22563

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201961

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

DROSPIR/ETH ESTRA/LEVOMEFOL CA 3-0.02(24) TABLET ORAL 09/11/2018 3.63275

DROSPIR/ETH ESTRA/LEVOMEFOL CA 3-0.03(21) TABLET ORAL 03/29/2018 7.46657

DULOXETINE HCL 20 MG CAPSULE DR ORAL 11/21/2018 0.17683

DULOXETINE HCL 30 MG CAPSULE DR ORAL 02/06/2019 0.20100

DULOXETINE HCL 60 MG CAPSULE DR ORAL 08/09/2016 0.22333

DULOXETINE HCL 40 MG CAPSULE DR ORAL 01/30/2019 4.35556

DUTASTERIDE 0.5 MG CAPSULE ORAL 01/30/2019 0.17867

DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4 MG CPMP 24HR ORAL 01/23/2019 3.34180

ECONAZOLE NITRATE 1 % CREAM (G) TOPICAL 04/09/2018 0.28706

EFAVIRENZ 50 MG CAPSULE ORAL 01/23/2019 3.48436

EFAVIRENZ 200 MG CAPSULE ORAL 01/23/2019 11.60671

EFAVIRENZ 600 MG TABLET ORAL 10/31/2018 25.70995

ELECTROLYTE-MB SOLUTION/D5W 5 % IV SOLN INTRAVEN 05/24/2017 0.00256

ELECTROLYTE-R SOLUTION IV SOLN INTRAVEN 05/24/2017 0.00675

ELECTROLYTES/DEXTROSE SOLUTION ORAL 02/13/2019 0.00401

ELETRIPTAN HYDROBROMIDE 20 MG TABLET ORAL 11/14/2018 6.70560

ELETRIPTAN HYDROBROMIDE 40 MG TABLET ORAL 02/20/2018 10.69176

EMOLLIENT BASE CREAM (G) TOPICAL 04/06/2017 0.02695

EMOLLIENT COMBINATION NO.53 CREAM (G) TOPICAL 04/18/2018 0.35312

ENALAPRIL MALEATE 10 MG TABLET ORAL 10/12/2015 0.25339

ENALAPRIL MALEATE 2.5 MG TABLET ORAL 01/30/2019 0.20274

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201962

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ENALAPRIL MALEATE 20 MG TABLET ORAL 03/06/2019 0.33232

ENALAPRIL MALEATE 5 MG TABLET ORAL 03/06/2019 0.27014

ENALAPRIL/HYDROCHLOROTHIAZIDE 10 MG-25MG TABLET ORAL 07/03/2018 0.54257

ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG TABLET ORAL 11/28/2018 0.48763

ENALAPRILAT DIHYDRATE 1.25 MG/ML VIAL INTRAVEN 07/25/2018 1.53698

ENOXAPARIN SODIUM 30MG/0.3ML SYRINGE SUBCUT 01/23/2019 8.61200

ENOXAPARIN SODIUM 60MG/0.6ML SYRINGE SUBCUT 01/23/2019 9.00000

ENOXAPARIN SODIUM 80MG/0.8ML SYRINGE SUBCUT 01/23/2019 8.63550

ENOXAPARIN SODIUM 100 MG/ML SYRINGE SUBCUT 01/23/2019 8.97480

ENOXAPARIN SODIUM 40MG/0.4ML SYRINGE SUBCUT 01/23/2019 8.73300

ENOXAPARIN SODIUM 150 MG/ML SYRINGE SUBCUT 01/23/2019 12.28480

ENOXAPARIN SODIUM 120MG/.8ML SYRINGE SUBCUT 01/23/2019 12.02713

ENOXAPARIN SODIUM 300MG/3ML VIAL SUBCUT 01/23/2019 10.60683

ENTACAPONE 200 MG TABLET ORAL 01/23/2019 1.41102

ENTECAVIR 0.5 MG TABLET ORAL 01/09/2019 2.59692

ENTECAVIR 1 MG TABLET ORAL 10/03/2018 3.16800

EPHEDRINE SULFATE 50MG/ML(1) VIAL INTRAVEN 11/28/2018 29.08335

EPINASTINE HCL 0.05 % DROPS OPHTHALMIC 11/17/2015 7.11200

EPINEPHRINE 0.1 MG/ML SYRINGE INJECTION 02/27/2019 0.57164

EPINEPHRINE 0.3MG/0.3 AUTO INJCT INJECTION 12/05/2018 177.78881

EPINEPHRINE HCL/PF 1 MG/ML(1) AMPUL INJECTION 02/18/2015 499.84125

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201963

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

EPIRUBICIN HCL 50 MG/25ML VIAL INTRAVEN 02/13/2019 1.67339

EPIRUBICIN HCL 200MG/0.1L VIAL INTRAVEN 01/23/2019 1.99848

EPLERENONE 25 MG TABLET ORAL 12/19/2018 0.48017

EPLERENONE 50 MG TABLET ORAL 12/19/2018 0.48017

EPOPROSTENOL SODIUM (GLYCINE) 0.5 MG VIAL INTRAVEN 08/21/2014 18.64328

EPOPROSTENOL SODIUM (GLYCINE) 1.5 MG VIAL INTRAVEN 08/21/2014 43.95508

EPTIFIBATIDE 0.75 MG/ML VIAL INTRAVEN 02/27/2019 1.35528

EPTIFIBATIDE 2 MG/ML VIAL INTRAVEN 02/27/2019 4.09860

ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE ORAL 01/16/2019 0.24053

ERGOCALCIFEROL (VITAMIN D2) 8000/ML DROPS ORAL 01/31/2018 0.55364

ERGOTAMINE TARTRATE/CAFFEINE 1 MG-100MG TABLET ORAL 12/14/2016 9.26214

ERTAPENEM SODIUM 1 G VIAL INJECTION 11/21/2018 119.92500

ERYTHROMYCIN BASE 250 MG CAPSULE DR ORAL 04/18/2017 7.85184

ERYTHROMYCIN BASE 250 MG TABLET ORAL 03/29/2018 7.47780

ERYTHROMYCIN BASE 500 MG TABLET ORAL 11/28/2018 13.10327

ERYTHROMYCIN BASE IN ETHANOL 2 % MED. SWAB TOPICAL 01/17/2018 1.05581

ERYTHROMYCIN BASE IN ETHANOL 2 % GEL (GRAM) TOPICAL 04/19/2016 2.23289

ERYTHROMYCIN BASE IN ETHANOL 2 % SOLUTION TOPICAL 02/27/2019 0.51970

ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML SUSP RECON ORAL 01/23/2019 3.07283

ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GEL (GRAM) TOPICAL 03/06/2019 4.57013

ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION ORAL 11/07/2018 0.55778

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201964

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ESCITALOPRAM OXALATE 10 MG TABLET ORAL 03/06/2019 0.04409

ESCITALOPRAM OXALATE 20 MG TABLET ORAL 12/05/2018 0.05682

ESCITALOPRAM OXALATE 5 MG TABLET ORAL 09/24/2018 0.03390

ESMOLOL HCL 100MG/10ML VIAL INTRAVEN 01/30/2019 0.34880

ESMOLOL IN SODIUM CHLORIDE,ISO 2.5G/250ML IV SOLN INTRAVEN 09/19/2018 2.38143

ESMOLOL IN SODIUM CHLORIDE,ISO 2 G/100 ML IV SOLN INTRAVEN 09/19/2018 6.07967

ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE DR ORAL 02/06/2019 0.35689

ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE DR ORAL 12/05/2018 0.47150

ESOMEPRAZOLE SODIUM 40 MG VIAL INTRAVEN 07/30/2018 8.04000

ESTAZOLAM 1 MG TABLET ORAL 03/07/2018 0.80601

ESTRADIOL 1 MG TABLET ORAL 11/28/2018 0.15986

ESTRADIOL 2 MG TABLET ORAL 11/28/2018 0.19979

ESTRADIOL 0.5 MG TABLET ORAL 02/27/2019 0.11055

ESTRADIOL 0.1MG/24HR PATCH TDWK TRANSDERM 09/19/2018 12.15500

ESTRADIOL 0.05MG/24H PATCH TDWK TRANSDERM 05/19/2015 16.10700

ESTRADIOL .025MG/24H PATCH TDWK TRANSDERM 11/07/2018 11.68750

ESTRADIOL .075MG/24H PATCH TDWK TRANSDERM 11/07/2018 17.01788

ESTRADIOL 0.06MG/24H PATCH TDWK TRANSDERM 11/07/2018 16.78950

ESTRADIOL .0375MG/24 PATCH TDWK TRANSDERM 10/24/2018 20.36475

ESTRADIOL 0.05MG/24H PATCH TDSW TRANSDERM 11/14/2018 9.40350

ESTRADIOL 0.1MG/24HR PATCH TDSW TRANSDERM 11/14/2018 9.41700

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201965

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ESTRADIOL .025MG/24H PATCH TDSW TRANSDERM 11/14/2018 9.39600

ESTRADIOL .075MG/24H PATCH TDSW TRANSDERM 11/14/2018 10.43769

ESTRADIOL .0375MG/24 PATCH TDSW TRANSDERM 11/14/2018 8.45900

ESTRADIOL 0.01 % CREAM/APPL VAGINAL 10/31/2018 5.70454

ESTRADIOL 10 MCG TABLET VAGINAL 10/24/2018 10.16472

ESTRADIOL VALERATE 20 MG/ML VIAL INTRAMUSC 01/23/2019 36.50640

ESTRADIOL VALERATE 40 MG/ML VIAL INTRAMUSC 01/23/2019 60.55495

ESTRADIOL/NORETHINDRONE ACET 1 MG-0.5MG TABLET ORAL 01/16/2019 3.39287

ESTRADIOL/NORETHINDRONE ACET 0.5-0.1 MG TABLET ORAL 01/23/2019 4.09671

ESZOPICLONE 3 MG TABLET ORAL 01/23/2019 0.26800

ESZOPICLONE 2 MG TABLET ORAL 01/09/2019 0.28770

ESZOPICLONE 1 MG TABLET ORAL 12/05/2018 0.09559

ETHACRYNATE SODIUM 50 MG VIAL INTRAVEN 06/12/2018 1850.00000

ETHACRYNIC ACID 25 MG TABLET ORAL 10/09/2018 7.62000

ETHAMBUTOL HCL 100 MG TABLET ORAL 09/24/2018 0.45305

ETHAMBUTOL HCL 400 MG TABLET ORAL 01/23/2019 0.57406

ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG-3MG TABLET ORAL 12/19/2018 0.34712

ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TABLET ORAL 02/27/2019 0.93944

ETHOSUXIMIDE 250 MG CAPSULE ORAL 12/05/2018 1.47655

ETHOSUXIMIDE 250 MG/5ML SOLUTION ORAL 11/14/2018 0.27911

ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET ORAL 02/13/2019 0.49197

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201966

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-50MCG TABLET ORAL 07/03/2018 0.88536

ETODOLAC 200 MG CAPSULE ORAL 05/16/2018 0.90396

ETODOLAC 300 MG CAPSULE ORAL 11/14/2018 1.11073

ETODOLAC 400 MG TABLET ORAL 01/23/2019 0.67335

ETODOLAC 500 MG TABLET ORAL 02/27/2019 0.64856

ETODOLAC 600 MG TAB ER 24H ORAL 11/07/2018 2.10112

ETODOLAC 400 MG TAB ER 24H ORAL 07/25/2018 2.00384

ETODOLAC 500 MG TAB ER 24H ORAL 01/23/2019 1.65718

ETOPOSIDE 20 MG/ML VIAL INTRAVEN 01/23/2019 1.11327

EUCALYPTOL LIQUID MISCELL 03/06/2013 3.27202

EUCALYPTUS OIL OIL MISCELL 03/06/2019 0.07584

EUCALYPTUS OIL 100 % OIL MISCELL 02/04/2015 0.50920

EUCALYPTUS OIL/MENTHOL/CAMPHOR 1.2%-4.8% OINT. (G) TOPICAL 10/18/2017 0.00744

EXEMESTANE 25 MG TABLET ORAL 01/23/2019 4.21872

EZETIMIBE 10 MG TABLET ORAL 01/16/2019 0.16378

EZETIMIBE/SIMVASTATIN 10 MG-10MG TABLET ORAL 10/31/2018 2.61300

EZETIMIBE/SIMVASTATIN 10 MG-20MG TABLET ORAL 10/31/2018 2.61300

EZETIMIBE/SIMVASTATIN 10 MG-80MG TABLET ORAL 02/27/2019 2.61300

EZETIMIBE/SIMVASTATIN 10 MG-40MG TABLET ORAL 02/27/2019 2.61300

FACTOR IX 500 (+/-) VIAL INTRAVEN 10/01/2018 1.17495

FACTOR IX 1000 (+/-) VIAL INTRAVEN 10/01/2018 1.17495

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201967

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FACTOR IX 1500 (+/-) VIAL INTRAVEN 10/01/2018 1.17495

FACTOR IX CPLX(PCC)NO4,3FACTOR 1000 (+/-) VIAL INTRAVEN 01/01/2016 1.27575

FACTOR IX CPLX(PCC)NO4,3FACTOR 500 (+/-) VIAL INTRAVEN 01/01/2016 1.27575

FACTOR IX CPLX(PCC)NO4,3FACTOR 1500 (+/-) VIAL INTRAVEN 01/01/2016 1.27575

FACTOR IX HUMAN RECOMBINANT 250 UNIT VIAL INTRAVEN 10/01/2018 1.36920

FACTOR IX HUMAN RECOMBINANT 500 UNIT VIAL INTRAVEN 10/01/2018 1.36920

FACTOR IX HUMAN RECOMBINANT 1000 UNIT VIAL INTRAVEN 10/01/2018 1.36920

FACTOR IX HUMAN RECOMBINANT 2000 UNIT VIAL INTRAVEN 10/01/2018 1.36920

FACTOR IX HUMAN RECOMBINANT 3000 UNIT VIAL INTRAVEN 10/01/2018 1.36920

FACTOR IX REC, FC FUSION PROTN 500 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX REC, FC FUSION PROTN 1000 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX REC, FC FUSION PROTN 2000 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX REC, FC FUSION PROTN 3000 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX REC, FC FUSION PROTN 250 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX REC, FC FUSION PROTN 4000 UNIT VIAL INTRAVEN 01/01/2019 2.90400

FACTOR IX RECOM,ALBUMIN FUSION 250 (+/-) VIAL INTRAVEN 10/01/2018 4.49400

FACTOR IX RECOM,ALBUMIN FUSION 500 (+/-) VIAL INTRAVEN 10/01/2018 4.49400

FACTOR IX RECOM,ALBUMIN FUSION 1000 (+/-) VIAL INTRAVEN 10/01/2018 4.49400

FACTOR IX RECOM,ALBUMIN FUSION 2000 (+/-) VIAL INTRAVEN 10/01/2018 4.49400

FACTOR XIII 1000-1600 VIAL INTRAVEN 07/01/2018 8.62575

FAMCICLOVIR 250 MG TABLET ORAL 05/12/2015 0.30373

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201968

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FAMCICLOVIR 500 MG TABLET ORAL 02/13/2019 0.68563

FAMCICLOVIR 125 MG TABLET ORAL 02/06/2019 0.26487

FAMOTIDINE 20 MG TABLET ORAL 11/07/2018 0.03739

FAMOTIDINE 40 MG TABLET ORAL 11/21/2018 0.06392

FAMOTIDINE 10 MG TABLET ORAL 03/06/2019 0.11435

FAMOTIDINE 10 MG/ML VIAL INTRAVEN 07/03/2018 0.26130

FAMOTIDINE/CA CARB/MAG HYDROX 10-800-165 TAB CHEW ORAL 09/20/2017 0.26758

FAMOTIDINE/PF 20 MG/2 ML VIAL INTRAVEN 01/12/2016 0.46900

FAT EMULSIONS 20 % EMULSION INTRAVEN 02/07/2018 0.06924

FELBAMATE 600 MG/5ML ORAL SUSP ORAL 06/13/2018 0.90819

FELBAMATE 400 MG TABLET ORAL 01/16/2019 1.80471

FELBAMATE 600 MG TABLET ORAL 05/22/2018 4.98850

FELODIPINE 5 MG TAB ER 24H ORAL 03/06/2019 0.13011

FELODIPINE 10 MG TAB ER 24H ORAL 02/27/2019 0.19283

FELODIPINE 2.5 MG TAB ER 24H ORAL 02/27/2019 0.15437

FENOFIBRATE 160 MG TABLET ORAL 12/19/2018 0.65943

FENOFIBRATE 40 MG TABLET ORAL 01/17/2018 12.92525

FENOFIBRATE 120 MG TABLET ORAL 11/14/2018 36.13207

FENOFIBRATE 54 MG TABLET ORAL 12/26/2018 0.52096

FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET ORAL 04/19/2016 0.43922

FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET ORAL 11/07/2018 0.22676

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201969

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FENOFIBRATE,MICRONIZED 200 MG CAPSULE ORAL 01/16/2019 0.88668

FENOFIBRATE,MICRONIZED 67 MG CAPSULE ORAL 12/05/2018 0.45807

FENOFIBRATE,MICRONIZED 134 MG CAPSULE ORAL 01/12/2016 0.49902

FENOFIBRATE,MICRONIZED 43 MG CAPSULE ORAL 12/12/2018 0.80266

FENOFIBRATE,MICRONIZED 130 MG CAPSULE ORAL 12/12/2018 1.78845

FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR ORAL 08/01/2018 0.75263

FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR ORAL 08/23/2017 2.20787

FENOPROFEN CALCIUM 600 MG TABLET ORAL 10/02/2018 3.59093

FENTANYL 25 MCG/HR PATCH TD72 TRANSDERM 02/13/2019 2.11720

FENTANYL 50MCG/HR PATCH TD72 TRANSDERM 01/16/2019 3.29472

FENTANYL 75MCG/HR PATCH TD72 TRANSDERM 01/16/2019 4.51440

FENTANYL 100 MCG/HR PATCH TD72 TRANSDERM 01/16/2019 5.39496

FENTANYL 12 MCG/HR PATCH TD72 TRANSDERM 01/30/2019 4.37712

FENTANYL 62.5MCG/HR PATCH TD72 TRANSDERM 03/21/2018 48.64138

FENTANYL 87.5MCG/HR PATCH TD72 TRANSDERM 03/21/2018 66.22525

FENTANYL 37.5MCG/HR PATCH TD72 TRANSDERM 03/29/2018 33.47138

FENTANYL CITRATE 200 MCG LOZENGE HD BUCCAL 04/18/2018 7.12936

FENTANYL CITRATE 400 MCG LOZENGE HD BUCCAL 04/18/2018 8.53440

FENTANYL CITRATE 600 MCG LOZENGE HD BUCCAL 04/18/2018 10.01803

FENTANYL CITRATE 800 MCG LOZENGE HD BUCCAL 04/18/2018 11.35347

FENTANYL CITRATE 1200 MCG LOZENGE HD BUCCAL 10/27/2015 14.08995

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201970

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FENTANYL CITRATE 1600 MCG LOZENGE HD BUCCAL 04/18/2018 17.37750

FENTANYL CITRATE/PF 50 MCG/ML AMPUL INJECTION 09/05/2018 0.42646

FENTANYL CITRATE/PF 50 MCG/ML VIAL INJECTION 08/01/2018 0.30102

FENTANYL CITRATE/PF 100MCG/2ML CARTRIDGE INTRAVEN 08/30/2017 1.26228

FENTANYL CITRATE/PF 100MCG/2ML SYRINGE INTRAVEN 02/07/2018 1.26228

FERROUS FUM/VIT C/B12-IF/FOLIC 110-0.5MG CAPSULE ORAL 01/09/2019 0.26130

FERROUS FUMARATE 324(106)MG TABLET ORAL 09/23/2015 0.29721

FERROUS FUMARATE/FOLIC ACID 106 MG-1MG TABLET ORAL 01/23/2019 0.40723

FERROUS GLUCONATE 240(27)MG TABLET ORAL 02/27/2019 0.01983

FERROUS GLUCONATE 324(38)MG TABLET ORAL 02/06/2019 0.06419

FERROUS GLUCONATE 324(37.5) TABLET ORAL 06/14/2017 0.02486

FERROUS SULFATE 220 (44)/5 ELIXIR ORAL 02/06/2019 0.00842

FERROUS SULFATE 220 (44)/5 SOLUTION ORAL 12/19/2018 0.01143

FERROUS SULFATE 15 MG/ML DROPS ORAL 01/23/2019 0.06164

FERROUS SULFATE 325(65) MG TABLET ORAL 03/06/2019 0.00736

FERROUS SULFATE 325(65) MG TABLET DR ORAL 02/06/2019 0.32160

FERROUS SULFATE, DRIED 160(50) MG TABLET ER ORAL 10/28/2015 0.06912

FEXOFENADINE HCL 60 MG TABLET ORAL 12/19/2018 0.39552

FEXOFENADINE HCL 180 MG TABLET ORAL 03/06/2019 0.83903

FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H ORAL 10/31/2018 0.86988

FINASTERIDE 1 MG TABLET ORAL 02/21/2017 0.11256

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201971

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FINASTERIDE 5 MG TABLET ORAL 12/26/2018 0.09708

FISH OIL/BORAGE/FLAX/OM3,6,9 1 400-400 MG CAPSULE ORAL 10/16/2013 0.05550

FLAVOXATE HCL 100 MG TABLET ORAL 02/27/2019 1.11501

FLECAINIDE ACETATE 100 MG TABLET ORAL 02/27/2019 0.38766

FLECAINIDE ACETATE 150 MG TABLET ORAL 01/23/2019 0.56253

FLECAINIDE ACETATE 50 MG TABLET ORAL 02/06/2019 0.31825

FLOXURIDINE 500 MG VIAL INJECTION 02/06/2019 115.87625

FLUCONAZOLE 40 MG/ML SUSP RECON ORAL 02/01/2017 2.34270

FLUCONAZOLE 10 MG/ML SUSP RECON ORAL 01/30/2018 0.96748

FLUCONAZOLE 100 MG TABLET ORAL 11/17/2015 0.55833

FLUCONAZOLE 200 MG TABLET ORAL 06/20/2017 0.90450

FLUCONAZOLE 50 MG TABLET ORAL 05/17/2016 0.38190

FLUCONAZOLE 150 MG TABLET ORAL 01/16/2019 1.37127

FLUCONAZOLE IN DEXTROSE,ISO-OS 200MG/0.1L PIGGYBACK INTRAVEN 08/01/2018 0.11002

FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK INTRAVEN 10/03/2018 0.04125

FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK INTRAVEN 12/05/2018 0.02613

FLUCYTOSINE 250 MG CAPSULE ORAL 09/26/2018 30.74966

FLUCYTOSINE 500 MG CAPSULE ORAL 11/28/2018 58.08296

FLUDARABINE PHOSPHATE 50 MG VIAL INTRAVEN 02/27/2019 77.43875

FLUDARABINE PHOSPHATE 50 MG/2 ML VIAL INTRAVEN 11/21/2017 28.18750

FLUDROCORTISONE ACETATE 0.1 MG TABLET ORAL 02/13/2019 0.50676

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201972

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FLUMAZENIL 0.1 MG/ML VIAL INTRAVEN 05/31/2017 0.83080

FLUOCINOLONE ACETONIDE 0.01 % CREAM (G) TOPICAL 05/22/2018 2.65320

FLUOCINOLONE ACETONIDE 0.025 % CREAM (G) TOPICAL 03/21/2018 1.90459

FLUOCINOLONE ACETONIDE 0.025 % OINT. (G) TOPICAL 05/11/2016 1.69599

FLUOCINOLONE ACETONIDE 0.01 % SOLUTION TOPICAL 11/21/2018 1.77158

FLUOCINOLONE ACETONIDE 0.01 % OIL TOPICAL 01/09/2019 1.21940

FLUOCINOLONE ACETONIDE OIL 0.01 % DROPS OTIC (EAR) 03/06/2019 3.29208

FLUOCINOLONE/SHOWER CAP 0.01 % OIL TOPICAL 02/20/2019 0.83326

FLUOCINONIDE 0.05 % GEL (GRAM) TOPICAL 03/06/2019 1.63793

FLUOCINONIDE 0.05 % CREAM (G) TOPICAL 09/29/2015 0.69993

FLUOCINONIDE 0.1 % CREAM (G) TOPICAL 01/23/2018 1.50415

FLUOCINONIDE 0.05 % OINT. (G) TOPICAL 12/26/2018 0.86743

FLUOCINONIDE 0.05 % SOLUTION TOPICAL 11/28/2018 1.34826

FLUOCINONIDE/EMOLLIENT BASE 0.05 % CREAM (G) TOPICAL 04/10/2015 1.27523

FLUORESCEIN SODIUM 500 MG/5ML VIAL INTRAVEN 01/16/2018 6.07314

FLUORIDE (SODIUM) 0.5 MG/ML DROPS ORAL 12/12/2018 0.15142

FLUORIDE (SODIUM) 0.25(0.55) TAB CHEW ORAL 11/07/2018 0.07476

FLUORIDE (SODIUM) 0.5(1.1)MG TAB CHEW ORAL 10/03/2018 0.01548

FLUORIDE (SODIUM) 1MG(2.2MG) TAB CHEW ORAL 10/31/2018 0.01548

FLUOROMETHOLONE 0.1 % DROPS SUSP OPHTHALMIC 01/16/2019 14.42070

FLUOROURACIL 5 % CREAM (G) TOPICAL 04/25/2017 6.34937

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201973

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FLUOROURACIL 0.5 % CREAM (G) TOPICAL 09/26/2018 45.51239

FLUOROURACIL 500MG/10ML VIAL INTRAVEN 01/23/2019 0.29976

FLUOROURACIL 1 G/20 ML VIAL INTRAVEN 01/23/2019 0.26539

FLUOROURACIL 2.5 G/50ML VIAL INTRAVEN 04/11/2016 0.20448

FLUOROURACIL 5 G/100 ML VIAL INTRAVEN 01/23/2019 0.19671

FLUOXETINE HCL 10 MG CAPSULE ORAL 02/06/2019 0.03456

FLUOXETINE HCL 20 MG CAPSULE ORAL 02/06/2019 0.03714

FLUOXETINE HCL 40 MG CAPSULE ORAL 12/05/2018 0.08120

FLUOXETINE HCL 20 MG/5 ML SOLUTION ORAL 02/27/2019 0.60523

FLUOXETINE HCL 10 MG TABLET ORAL 04/18/2016 0.62534

FLUOXETINE HCL 20 MG TABLET ORAL 06/27/2017 0.42304

FLUOXETINE HCL 60 MG TABLET ORAL 02/20/2019 6.51129

FLURANDRENOLIDE 0.05 % CREAM (G) TOPICAL 11/14/2018 6.19675

FLURANDRENOLIDE 0.05 % OINT. (G) TOPICAL 01/23/2019 12.23640

FLURANDRENOLIDE 0.05 % LOTION TOPICAL 03/14/2017 5.32109

FLURBIPROFEN 100 MG TABLET ORAL 07/03/2018 0.42210

FLURBIPROFEN SODIUM 0.03 % DROPS OPHTHALMIC 01/09/2019 15.11580

FLUTAMIDE 125 MG CAPSULE ORAL 01/16/2019 0.61618

FLUTICASONE PROPION/SALMETEROL 100-50 MCG BLST W/DEV INHALATION 02/20/2019 3.20848

FLUTICASONE PROPION/SALMETEROL 250-50 MCG BLST W/DEV INHALATION 02/20/2019 3.98662

FLUTICASONE PROPION/SALMETEROL 500-50 MCG BLST W/DEV INHALATION 02/20/2019 5.24326

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201974

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FLUTICASONE PROPIONATE 0.05 % CREAM (G) TOPICAL 03/08/2017 0.43904

FLUTICASONE PROPIONATE 0.005 % OINT. (G) TOPICAL 06/20/2018 0.48329

FLUTICASONE PROPIONATE 0.05 % LOTION TOPICAL 05/12/2015 3.48546

FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP NASAL 12/26/2018 0.38274

FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP NASAL 03/06/2019 1.04493

FLUVASTATIN SODIUM 20 MG CAPSULE ORAL 11/28/2018 4.75820

FLUVASTATIN SODIUM 40 MG CAPSULE ORAL 11/28/2018 4.56500

FLUVASTATIN SODIUM 80 MG TAB ER 24H ORAL 03/20/2018 6.94055

FLUVOXAMINE MALEATE 100 MG CAP ER 24H ORAL 08/15/2018 8.86600

FLUVOXAMINE MALEATE 150 MG CAP ER 24H ORAL 11/07/2016 9.30848

FLUVOXAMINE MALEATE 25 MG TABLET ORAL 08/08/2017 0.34920

FLUVOXAMINE MALEATE 50 MG TABLET ORAL 05/22/2018 0.34023

FLUVOXAMINE MALEATE 100 MG TABLET ORAL 07/10/2018 0.58760

FOLIC ACID 0.8 MG CAPSULE ORAL 07/19/2017 0.05561

FOLIC ACID 0.4 MG TABLET ORAL 03/06/2019 0.01091

FOLIC ACID 0.8 MG TABLET ORAL 03/06/2019 0.00925

FOLIC ACID 1 MG TABLET ORAL 02/27/2019 0.01897

FOLIC ACID/B COMPLEX C NO.17 5 MG TABLET ORAL 09/05/2018 61.27581

FOLIC ACID/MULTIVIT,IRON,MINER 0.4MG-18MG TABLET ORAL 08/27/2014 0.04348

FOLIC ACID/MULTIVIT-MIN/LUTEIN 0.4MG-250 COMBO. PKG ORAL 11/07/2018 0.08157

FOLIC ACID/VIT B COMPLEX AND C 0.8 MG TABLET ORAL 11/07/2018 0.06794

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201975

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FOLIC ACID/VIT B COMPLEX AND C 400 MCG TABLET ORAL 01/30/2019 0.07147

FOLIC/B1/B6/B12/C/D3/NAD/Q10 1-25-12.5 TABLET ORAL 10/31/2018 19.19750

FOLIC/MVI THER-MIN/LYCOP/LUT 1.25-2.5MG TABLET ORAL 06/13/2018 0.51496

FOMEPIZOLE 1 G/ML VIAL INTRAVEN 02/27/2019 527.77250

FONDAPARINUX SODIUM 2.5 MG/0.5 SYRINGE SUBCUT 02/27/2019 25.08030

FONDAPARINUX SODIUM 10MG/0.8ML SYRINGE SUBCUT 09/05/2018 57.80359

FONDAPARINUX SODIUM 5MG/0.4ML SYRINGE SUBCUT 06/07/2016 115.60719

FONDAPARINUX SODIUM 7.5MG/0.6 SYRINGE SUBCUT 04/19/2016 77.07146

FOSAMPRENAVIR CALCIUM 700 MG TABLET ORAL 12/20/2017 15.74825

FOSINOPRIL SODIUM 10 MG TABLET ORAL 06/23/2015 0.22065

FOSINOPRIL SODIUM 20 MG TABLET ORAL 02/20/2019 0.27604

FOSINOPRIL SODIUM 40 MG TABLET ORAL 02/06/2019 0.41861

FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET ORAL 11/14/2018 1.50013

FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET ORAL 07/10/2018 0.86185

FOSPHENYTOIN SODIUM 100MG PE/2 VIAL INJECTION 09/26/2018 0.86564

FOSPHENYTOIN SODIUM 500 PE/10 VIAL INJECTION 04/24/2017 0.59831

FROVATRIPTAN SUCCINATE 2.5 MG TABLET ORAL 03/06/2019 38.89306

FRUCTOOLIGOSACCHARIDES/POLYDEX 15 G/30 ML LIQUID ORAL 08/03/2016 0.02374

FUROSEMIDE 10 MG/ML SOLUTION ORAL 04/25/2018 0.11658

FUROSEMIDE 20 MG TABLET ORAL 12/12/2018 0.03477

FUROSEMIDE 40 MG TABLET ORAL 07/10/2018 0.05014

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201976

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

FUROSEMIDE 80 MG TABLET ORAL 07/03/2018 0.05727

FUROSEMIDE 10 MG/ML VIAL INJECTION 01/16/2019 0.24656

GABAPENTIN 100 MG CAPSULE ORAL 01/09/2019 0.03157

GABAPENTIN 300 MG CAPSULE ORAL 03/06/2019 0.04038

GABAPENTIN 400 MG CAPSULE ORAL 02/06/2019 0.06741

GABAPENTIN 250 MG/5ML SOLUTION ORAL 07/18/2018 0.34159

GABAPENTIN 600 MG TABLET ORAL 03/06/2019 0.11178

GABAPENTIN 800 MG TABLET ORAL 02/13/2019 0.15021

GALANTAMINE HBR 8 MG CAP24H PEL ORAL 01/23/2019 1.74200

GALANTAMINE HBR 16 MG CAP24H PEL ORAL 02/27/2019 1.89744

GALANTAMINE HBR 24 MG CAP24H PEL ORAL 12/12/2018 1.74200

GALANTAMINE HBR 12 MG TABLET ORAL 03/06/2019 0.92080

GALANTAMINE HBR 4 MG TABLET ORAL 10/03/2017 0.69077

GALANTAMINE HBR 8 MG TABLET ORAL 02/27/2019 0.71824

GANCICLOVIR SODIUM 500 MG VIAL INTRAVEN 01/09/2019 86.34600

GANIRELIX ACETATE 250MCG/0.5 SYRINGE SUBCUT 02/20/2019 235.78075

GATIFLOXACIN 0.5 % DROPS OPHTHALMIC 07/25/2018 29.33960

GELATIN 600 MG CAPSULE ORAL 10/09/2013 0.03129

GELATIN POWDER MISCELL 03/06/2019 0.09481

GELATIN CAPSULES (EMPTY) CAPSULE ORAL 02/20/2019 0.01411

GEMCITABINE HCL 200 MG VIAL INTRAVEN 01/23/2019 7.50570

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201977

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GEMCITABINE HCL 1 G VIAL INTRAVEN 01/23/2019 19.70850

GEMCITABINE HCL 2 G VIAL INTRAVEN 05/02/2018 93.26475

GEMCITABINE HCL 1 G/26.3ML VIAL INTRAVEN 03/06/2019 0.88395

GEMCITABINE HCL 2 G/52.6ML VIAL INTRAVEN 03/06/2019 0.89749

GEMCITABINE HCL 200MG/5.26 VIAL INTRAVEN 03/06/2019 1.31198

GEMCITABINE HCL 100 MG/ML VIAL INTRAVEN 11/28/2018 2.66574

GEMFIBROZIL 600 MG TABLET ORAL 08/18/2015 0.14095

GENTAMICIN IN NACL, ISO-OSM 80 MG/50ML PIGGYBACK INTRAVEN 01/10/2018 0.10941

GENTAMICIN IN NACL, ISO-OSM 80MG/100ML PIGGYBACK INTRAVEN 03/08/2017 0.05818

GENTAMICIN IN NACL, ISO-OSM 100MG/0.1L PIGGYBACK INTRAVEN 03/08/2017 0.05690

GENTAMICIN SULFATE 40 MG/ML VIAL INJECTION 02/06/2019 0.42880

GENTAMICIN SULFATE 0.1 % CREAM (G) TOPICAL 07/11/2018 2.21011

GENTAMICIN SULFATE 0.1 % OINT. (G) TOPICAL 03/21/2018 2.98672

GENTAMICIN SULFATE 0.3 % DROPS OPHTHALMIC 02/20/2019 3.98640

GENTIAN VIOLET 2 % SOLUTION TOPICAL 12/27/2017 0.19202

GLATIRAMER ACETATE 20 MG/ML SYRINGE SUBCUT 01/09/2019 150.67500

GLATIRAMER ACETATE 40 MG/ML SYRINGE SUBCUT 05/16/2018 503.01363

GLIMEPIRIDE 1 MG TABLET ORAL 01/23/2019 0.02661

GLIMEPIRIDE 2 MG TABLET ORAL 11/21/2018 0.03870

GLIMEPIRIDE 4 MG TABLET ORAL 02/27/2019 0.05692

GLIPIZIDE 10 MG TAB ER 24 ORAL 12/19/2018 0.26264

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201978

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GLIPIZIDE 5 MG TAB ER 24 ORAL 02/06/2019 0.16068

GLIPIZIDE 2.5 MG TAB ER 24 ORAL 10/17/2018 0.22289

GLIPIZIDE 10 MG TABLET ORAL 09/15/2015 0.03288

GLIPIZIDE 5 MG TABLET ORAL 02/13/2019 0.02482

GLIPIZIDE/METFORMIN HCL 2.5-250 MG TABLET ORAL 02/13/2019 0.66866

GLIPIZIDE/METFORMIN HCL 2.5-500 MG TABLET ORAL 02/13/2019 0.83884

GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET ORAL 12/19/2018 0.37667

GLUC SU/CHONDRO SU A/VIT C/MN 500-400 MG CAPSULE ORAL 03/23/2016 0.12049

GLUCAGON,HUMAN RECOMBINANT 1 MG VIAL INJECTION 01/23/2019 273.98250

GLUCOSAMINE HCL/CHONDROITIN SU 500-400 MG CAPSULE ORAL 10/24/2018 0.17844

GLUCOSAMINE SULFATE 500 MG CAPSULE ORAL 05/14/2018 0.09201

GLUCOSAMINE SULFATE 500 MG TABLET ORAL 01/22/2013 0.53935

GLUCOSAMINE SULFATE 750 MG TABLET ORAL 01/22/2013 0.39028

GLUCOSAMINE/CHONDR SU A SOD 1500-1200 LIQUID ORAL 10/09/2013 0.01330

GLUCOSAMINE/CHONDRO SU A 500-400 MG TABLET ORAL 07/03/2018 0.10698

GLUCOSAMINE/CHONDROITIN A/MSM 500-200 MG TABLET ORAL 01/07/2015 1.18418

GLUCOSAMINE/D3/BOSWELLIA SERRA 1500MG-400 TABLET ORAL 06/27/2018 0.43483

GLUTAMINE POWDER MISCELL 02/20/2019 0.55436

GLUTATHIONE 100 % POWDER MISCELL 12/26/2018 11.38500

GLY/DIMETH/PETROLAT,WHT/WATER CREAM (G) TOPICAL 05/06/2015 0.04333

GLYBURIDE 1.25 MG TABLET ORAL 03/06/2019 0.04275

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201979

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GLYBURIDE 2.5 MG TABLET ORAL 03/06/2019 0.04824

GLYBURIDE 5 MG TABLET ORAL 03/06/2019 0.04466

GLYBURIDE,MICRONIZED 1.5 MG TABLET ORAL 12/05/2018 0.17447

GLYBURIDE,MICRONIZED 3 MG TABLET ORAL 02/27/2019 0.04232

GLYBURIDE,MICRONIZED 6 MG TABLET ORAL 05/19/2015 0.06752

GLYBURIDE/METFORMIN HCL 2.5-500 MG TABLET ORAL 10/27/2015 0.04141

GLYBURIDE/METFORMIN HCL 1.25-250MG TABLET ORAL 03/06/2019 0.03178

GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET ORAL 02/06/2019 0.03996

GLYCERIN PEDIATRIC SUPP.RECT RECTAL 07/29/2015 0.08603

GLYCERIN/MIN OIL/WH.PETROLATUM LOTION TOPICAL 02/10/2016 0.01649

GLYCERYL MONOSTEARATE POWDER MISCELL 05/27/2015 0.50920

GLYCINE POWDER ORAL 01/22/2013 0.36810

GLYCINE UROLOGIC SOLUTION 1.5 % IRRIG SOLN IRRIGATION 02/20/2019 0.00379

GLYCOPYRROLATE 1 MG TABLET ORAL 03/06/2019 0.12891

GLYCOPYRROLATE 2 MG TABLET ORAL 02/27/2019 0.25514

GLYCOPYRROLATE 0.2 MG/ML VIAL INJECTION 02/20/2019 3.28680

GRANISETRON HCL 1 MG TABLET ORAL 04/05/2016 2.94360

GRANISETRON HCL 1 MG/ML VIAL INTRAVEN 06/13/2018 3.03930

GRANISETRON HCL 1 MG/ML(1) VIAL INTRAVEN 07/25/2018 5.14800

GRANISETRON HCL/PF 100 MCG/ML VIAL INTRAVEN 04/19/2017 4.01280

GRANISETRON HCL/PF 1 MG/ML(1) VIAL INTRAVEN 06/12/2018 5.63880

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201980

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GREEN SOAP TINCTURE TOPICAL 07/03/2018 0.01556

GRISEOFULVIN ULTRAMICROSIZE 125 MG TABLET ORAL 09/26/2018 4.35600

GRISEOFULVIN ULTRAMICROSIZE 250 MG TABLET ORAL 02/27/2019 5.28000

GRISEOFULVIN, MICROSIZE 125 MG/5ML ORAL SUSP ORAL 11/28/2018 0.25907

GRISEOFULVIN, MICROSIZE 500 MG TABLET ORAL 01/02/2019 7.17762

GUAIFEN/DEXTROMETHORPHAN/PE 100-10-5MG LIQUID ORAL 08/22/2018 0.01484

GUAIFEN/DEXTROMETHORPHAN/PE 200-30-10 LIQUID ORAL 11/25/2015 0.03406

GUAIFEN/DEXTROMETHORPHAN/PE 300-15-10 LIQUID ORAL 04/16/2014 0.10902

GUAIFEN/DEXTROMETHORPHAN/PE 350-15-10 LIQUID ORAL 09/14/2016 0.03525

GUAIFEN/DEXTROMETHORPHAN/PE 100-15-5/5 LIQUID ORAL 09/14/2016 0.01979

GUAIFEN/DEXTROMETHORPHAN/PE 75-5-2.5/5 LIQUID ORAL 10/24/2018 0.00974

GUAIFEN/DEXTROMETHORPHAN/PE 200-10-5/5 LIQUID ORAL 07/03/2018 0.00974

GUAIFEN/DEXTROMETHORPHAN/PE 388-28-10 LIQUID ORAL 09/14/2016 0.01032

GUAIFEN/DEXTROMETHORPHAN/PE 400-20-10 LIQUID ORAL 10/31/2018 0.01554

GUAIFEN/DEXTROMETHORPHAN/PE 18-10MG/15 LIQUID ORAL 05/23/2018 0.13121

GUAIFEN/DEXTROMETHORPHAN/PE 50-5-2.5/1 DROPS ORAL 09/14/2016 0.11055

GUAIFEN/DEXTROMETHORPHAN/PE 5-2.5MG/ML DROPS ORAL 10/01/2014 0.16057

GUAIFEN/PHENYLEPH/ACETAMINOPHN 200-5-325 TABLET ORAL 03/06/2019 0.26892

GUAIFENESIN 1200 MG TAB ER 12H ORAL 02/13/2019 0.62597

GUAIFENESIN 600 MG TAB ER 12H ORAL 02/13/2019 0.45788

GUAIFENESIN 100 MG/5ML LIQUID ORAL 04/18/2016 0.00544

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201981

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GUAIFENESIN 200 MG TABLET ORAL 01/16/2019 0.04489

GUAIFENESIN 400 MG TABLET ORAL 01/16/2019 0.04858

GUAIFENESIN/DEXTROMETHORPHAN 200MG-10MG CAPSULE ORAL 10/11/2017 0.29815

GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 LIQUID ORAL 03/06/2019 0.01753

GUAIFENESIN/DEXTROMETHORPHAN 100-5 MG/5 LIQUID ORAL 02/27/2019 0.06104

GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 LIQUID ORAL 01/30/2018 0.02543

GUAIFENESIN/DEXTROMETHORPHAN 200-15MG/5 LIQUID ORAL 07/03/2018 0.06343

GUAIFENESIN/DEXTROMETHORPHAN 187-10MG/5 LIQUID ORAL 05/27/2015 0.07251

GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 SYRUP ORAL 01/30/2019 0.00779

GUAIFENESIN/DEXTROMETHORPHAN 400MG-20MG TABLET ORAL 12/05/2018 0.07002

GUAIFENESIN/DEXTROMETHORPHAN 600MG-30MG TAB ER 12H ORAL 11/28/2018 0.59764

GUAIFENESIN/DEXTROMETHORPHAN 1200-60MG TAB ER 12H ORAL 01/30/2019 0.85856

GUAIFENESIN/DM/PSEUDOEPHEDRINE 200-15-30 SOLUTION ORAL 09/14/2016 0.01947

GUAIFENESIN/DM/PSEUDOEPHEDRINE 50-5-15/5 LIQUID ORAL 09/14/2016 0.01593

GUAIFENESIN/DM/PSEUDOEPHEDRINE 187-10-30 LIQUID ORAL 02/04/2015 0.07251

GUAIFENESIN/DM/PSEUDOEPHEDRINE 200-10-30 TABLET ORAL 10/14/2015 0.14499

GUAIFENESIN/PHENYLEPHRINE HCL 100-5 MG/5 LIQUID ORAL 08/03/2016 0.03824

GUAIFENESIN/PHENYLEPHRINE HCL 400MG-10MG TABLET ORAL 12/19/2018 0.09559

GUAIFENESIN/PSEUDOEPHEDRNE HCL 600MG-60MG TAB ER 12H ORAL 03/06/2019 0.56153

GUANFACINE HCL 1 MG TABLET ORAL 01/02/2019 0.09259

GUANFACINE HCL 1 MG TAB ER 24H ORAL 01/16/2018 0.53774

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201982

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

GUANFACINE HCL 2 MG TAB ER 24H ORAL 04/19/2016 0.53774

GUANFACINE HCL 3 MG TAB ER 24H ORAL 07/10/2018 0.40130

GUANFACINE HCL 4 MG TAB ER 24H ORAL 04/19/2016 0.53774

HALOBETASOL PROPIONATE 0.05 % CREAM (G) TOPICAL 07/21/2015 1.24325

HALOBETASOL PROPIONATE 0.05 % OINT. (G) TOPICAL 02/27/2019 2.56288

HALOPERIDOL 0.5 MG TABLET ORAL 02/27/2019 0.26988

HALOPERIDOL 1 MG TABLET ORAL 11/14/2018 0.42398

HALOPERIDOL 10 MG TABLET ORAL 12/19/2018 0.93961

HALOPERIDOL 2 MG TABLET ORAL 04/28/2015 0.49995

HALOPERIDOL 20 MG TABLET ORAL 04/28/2015 2.52362

HALOPERIDOL DECANOATE 50 MG/ML AMPUL INTRAMUSC 12/26/2018 21.00000

HALOPERIDOL DECANOATE 100 MG/ML AMPUL INTRAMUSC 12/26/2018 38.54000

HALOPERIDOL DECANOATE 50 MG/ML VIAL INTRAMUSC 12/26/2018 17.32500

HALOPERIDOL DECANOATE 100 MG/ML VIAL INTRAMUSC 03/06/2019 26.03500

HALOPERIDOL LACTATE 5 MG/ML AMPUL INJECTION 04/18/2017 21.23415

HALOPERIDOL LACTATE 5 MG/ML VIAL INJECTION 12/05/2018 0.84956

HEPARIN SOD,PORK IN 0.45% NACL 25000/250 IV SOLN INTRAVEN 06/27/2018 0.04229

HEPARIN SOD,PORK IN 0.45% NACL 25000/500 IV SOLN INTRAVEN 06/27/2018 0.01540

HEPARIN SODIUM,PORCINE 1000/ML VIAL INJECTION 03/06/2019 0.16718

HEPARIN SODIUM,PORCINE 10000/ML VIAL INJECTION 08/01/2018 1.77845

HEPARIN SODIUM,PORCINE 20000/ML VIAL INJECTION 11/21/2018 5.70890

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201983

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

HEPARIN SODIUM,PORCINE 5000/ML VIAL INJECTION 03/06/2019 0.52678

HEPARIN SODIUM,PORCINE/D5W 25000/250 IV SOLN INTRAVEN 08/29/2018 0.04183

HEPARIN SODIUM,PORCINE/D5W 20K/500ML IV SOLN INTRAVEN 05/09/2018 0.01800

HEPARIN SODIUM,PORCINE/D5W 25000/500 IV SOLN INTRAVEN 08/29/2018 0.01924

HEPARIN SODIUM,PORCINE/D5W 12500/250 IV SOLN INTRAVEN 12/13/2017 0.03330

HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN INTRAVEN 03/14/2018 0.00879

HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML IV SOLN INTRAVEN 03/14/2018 0.00962

HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL INJECTION 02/06/2019 4.49222

HEPARIN SODIUM,PORCINE/PF 200/2 ML SYRINGE INTRAVEN 05/15/2013 0.21273

HEPARIN SODIUM,PORCINE/PF 300/3 ML SYRINGE INTRAVEN 04/19/2016 0.14181

HESPERIDIN/DIOSMIN 250-650 MG TABLET ORAL 09/14/2016 0.16047

HETASTARCH IN 0.9 % NACL 6 %-0.9 % PLAST. BAG INTRAVEN 12/20/2017 0.03709

HUMIDIFIER EACH MISCELL 01/15/2014 19.66073

HYDRALAZINE HCL 10 MG TABLET ORAL 12/05/2018 0.03953

HYDRALAZINE HCL 100 MG TABLET ORAL 04/25/2015 0.09554

HYDRALAZINE HCL 25 MG TABLET ORAL 09/06/2016 0.04998

HYDRALAZINE HCL 50 MG TABLET ORAL 02/13/2019 0.06238

HYDRALAZINE HCL 20 MG/ML VIAL INJECTION 01/16/2019 4.47480

HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE ORAL 01/16/2019 0.03511

HYDROCHLOROTHIAZIDE 25 MG TABLET ORAL 01/30/2019 0.00840

HYDROCHLOROTHIAZIDE 50 MG TABLET ORAL 02/06/2019 0.01735

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201984

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

HYDROCHLOROTHIAZIDE 12.5 MG TABLET ORAL 01/16/2019 0.06981

HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP ORAL 12/02/2014 0.05555

HYDROCODONE BIT/HOMATROP ME-BR 5 MG-1.5MG TABLET ORAL 05/16/2018 1.02689

HYDROCODONE/ACETAMINOPHEN 7.5-325/15 SOLUTION ORAL 02/27/2019 0.08392

HYDROCODONE/ACETAMINOPHEN 7.5-325/15 SOLUTION ORAL 02/06/2019 0.21708

HYDROCODONE/ACETAMINOPHEN 2.5-325 MG TABLET ORAL 09/15/2015 0.73278

HYDROCODONE/ACETAMINOPHEN 10MG-325MG TABLET ORAL 02/27/2019 0.10538

HYDROCODONE/ACETAMINOPHEN 5 MG-325MG TABLET ORAL 02/13/2019 0.08431

HYDROCODONE/ACETAMINOPHEN 7.5-325 MG TABLET ORAL 02/27/2019 0.10720

HYDROCODONE/ACETAMINOPHEN 10MG-300MG TABLET ORAL 02/20/2019 1.47400

HYDROCODONE/ACETAMINOPHEN 5 MG-300MG TABLET ORAL 02/20/2019 0.63277

HYDROCODONE/ACETAMINOPHEN 7.5-300 MG TABLET ORAL 02/20/2019 1.13900

HYDROCODONE/CHLORPHEN P-STIREX 10-8MG/5ML SUS ER 12H ORAL 01/23/2019 0.52483

HYDROCODONE/CPM/PSEUDOEPHED 5-4-60MG/5 SOLUTION ORAL 12/06/2017 0.74596

HYDROCODONE/IBUPROFEN 7.5-200 MG TABLET ORAL 02/06/2019 0.35724

HYDROCODONE/IBUPROFEN 5MG-200MG TABLET ORAL 03/14/2017 3.31742

HYDROCODONE/IBUPROFEN 10MG-200MG TABLET ORAL 06/07/2016 4.37527

HYDROCORTISONE 10 MG TABLET ORAL 03/01/2016 0.40200

HYDROCORTISONE 20 MG TABLET ORAL 02/13/2019 0.67000

HYDROCORTISONE 5 MG TABLET ORAL 02/13/2019 0.24120

HYDROCORTISONE 100MG/60ML ENEMA RECTAL 02/13/2019 0.18671

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201985

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

HYDROCORTISONE 0.5 % CREAM (G) TOPICAL 08/15/2015 0.10854

HYDROCORTISONE 1 % CREAM (G) TOPICAL 02/06/2019 0.07057

HYDROCORTISONE 2.5 % CREAM (G) TOPICAL 03/06/2019 0.11167

HYDROCORTISONE 1 % CRM/PE APP TOPICAL 07/05/2016 0.71243

HYDROCORTISONE 2.5 % CRM/PE APP TOPICAL 10/23/2018 0.83482

HYDROCORTISONE 1 % OINT. (G) TOPICAL 10/17/2018 0.20100

HYDROCORTISONE 2.5 % OINT. (G) TOPICAL 08/01/2018 0.10318

HYDROCORTISONE 1 % LOTION TOPICAL 05/15/2013 0.14851

HYDROCORTISONE 2.5 % LOTION TOPICAL 01/03/2018 0.25371

HYDROCORTISONE 1 % LOTION TOPICAL 09/29/2015 0.07714

HYDROCORTISONE BUTYRATE 0.1 % CREAM (G) TOPICAL 10/10/2018 2.23601

HYDROCORTISONE BUTYRATE 0.1 % OINT. (G) TOPICAL 12/11/2017 2.14400

HYDROCORTISONE BUTYRATE 0.1 % SOLUTION TOPICAL 02/27/2019 1.69934

HYDROCORTISONE BUTYRATE 0.1 % LOTION TOPICAL 02/27/2019 6.53606

HYDROCORTISONE BUTYRATE/EMOLL 0.1 % CREAM (G) TOPICAL 03/05/2019 4.66226

HYDROCORTISONE SOD SUCCINATE 100 MG VIAL INJECTION 01/23/2019 10.61450

HYDROCORTISONE VALERATE 0.2 % CREAM (G) TOPICAL 01/09/2019 1.28260

HYDROCORTISONE VALERATE 0.2 % OINT. (G) TOPICAL 01/30/2019 3.43244

HYDROCORTISONE/ACETIC ACID 1 %-2 % DROPS OTIC (EAR) 01/24/2018 9.75200

HYDROCORTISONE/ALOE VERA 1 % CREAM (G) TOPICAL 02/06/2019 0.07459

HYDROCORTISONE/IODOQUIN/ALOE 2 2 %-1 %-1% GEL (GRAM) TOPICAL 01/30/2019 132.22479

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201986

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

HYDROGEN PEROXIDE 3 % SOLUTION MISCELL 02/13/2019 0.00098

HYDROMORPHONE HCL 1 MG/ML LIQUID ORAL 01/30/2019 0.43570

HYDROMORPHONE HCL 2 MG TABLET ORAL 02/06/2019 0.15008

HYDROMORPHONE HCL 4 MG TABLET ORAL 05/03/2017 0.11452

HYDROMORPHONE HCL 8 MG TABLET ORAL 08/04/2015 0.27336

HYDROMORPHONE HCL 12 MG TAB ER 24H ORAL 02/27/2019 8.64000

HYDROMORPHONE HCL 32 MG TAB ER 24H ORAL 02/27/2019 20.16000

HYDROMORPHONE HCL 16 MG TAB ER 24H ORAL 02/27/2019 11.04000

HYDROMORPHONE HCL 8 MG TAB ER 24H ORAL 02/27/2019 7.42950

HYDROMORPHONE HCL 1 MG/ML CARTRIDGE INJECTION 08/30/2017 3.05976

HYDROMORPHONE HCL 2 MG/ML CARTRIDGE INJECTION 08/30/2017 3.28020

HYDROMORPHONE HCL 4 MG/ML CARTRIDGE INJECTION 01/03/2018 4.28868

HYDROMORPHONE HCL 1 MG/ML SYRINGE INJECTION 08/30/2017 3.05976

HYDROMORPHONE HCL 2 MG/ML SYRINGE INJECTION 08/30/2017 3.28020

HYDROMORPHONE HCL 0.5MG/.5ML SYRINGE INJECTION 01/03/2018 7.52400

HYDROMORPHONE HCL 2 MG/ML VIAL INJECTION 07/03/2018 1.53457

HYDROMORPHONE HCL/PF 10 MG/ML VIAL INJECTION 08/29/2017 1.75540

HYDROMORPHONE HCL/PF 2 MG/ML VIAL INJECTION 01/09/2019 4.51440

HYDROPHILIC OINTMENT OINT. (G) TOPICAL 07/03/2018 0.01599

HYDROXYCHLOROQUINE SULFATE 200 MG TABLET ORAL 07/12/2016 0.58971

HYDROXYPROGESTERONE CAPROAT/PF 250 MG/ML VIAL INTRAMUSC 02/27/2019 541.20000

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201987

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

HYDROXYPROGESTERONE CAPROATE 250 MG/ML VIAL INTRAMUSC 03/06/2019 865.73550

HYDROXYPROPYL CELLULOSE POWDER MISCELL 11/11/2015 0.26316

HYDROXYUREA 500 MG CAPSULE ORAL 01/23/2019 0.56468

HYDROXYZINE HCL 10 MG/5 ML SOLUTION ORAL 01/12/2016 0.06421

HYDROXYZINE HCL 10 MG TABLET ORAL 02/20/2019 0.05686

HYDROXYZINE HCL 25 MG TABLET ORAL 02/27/2019 0.05644

HYDROXYZINE PAMOATE 25 MG CAPSULE ORAL 03/06/2019 0.08134

HYPROMELLOSE 2.5 % DROPS OPHTHALMIC 02/13/2019 0.89869

HYPROMELLOSE POWDER MISCELL 03/06/2019 0.06041

HYPROMELLOSE CAPSULES (EMPTY) CAPSULE ORAL 02/06/2019 0.02765

HYPROMELLOSE DR CAP (EMPTY) CAPSULE DR ORAL 06/03/2015 0.18090

IBANDRONATE SODIUM 150 MG TABLET ORAL 02/06/2019 5.04240

IBANDRONATE SODIUM 3 MG/3 ML SYRINGE INTRAVEN 07/03/2018 30.75000

IBUPROFEN 200 MG CAPSULE ORAL 03/06/2019 0.09010

IBUPROFEN 100 MG/5ML ORAL SUSP ORAL 03/06/2019 0.03127

IBUPROFEN 50 MG/1.25 DROPS SUSP ORAL 01/30/2019 0.32071

IBUPROFEN 200 MG TABLET ORAL 03/06/2019 0.02076

IBUPROFEN 400 MG TABLET ORAL 03/06/2019 0.05909

IBUPROFEN 600 MG TABLET ORAL 03/06/2019 0.08329

IBUPROFEN 800 MG TABLET ORAL 03/06/2019 0.07713

IBUPROFEN LYSINE/PF 20 MG/2 ML VIAL INTRAVEN 08/01/2018 140.93750

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201988

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

IBUPROFEN/DIPHENHYDRAMINE CIT 200MG-38MG TABLET ORAL 12/19/2018 0.15164

IBUTILIDE FUMARATE 0.1 MG/ML VIAL INTRAVEN 08/01/2018 19.91745

ICARIDIN 20 % SPRAY/PUMP TOPICAL 06/20/2016 0.02974

IDARUBICIN HCL 1 MG/ML VIAL INTRAVEN 07/03/2018 7.42950

IFOSFAMIDE 1 G VIAL INTRAVEN 01/22/2013 34.30521

IFOSFAMIDE 1 G/20 ML VIAL INTRAVEN 01/03/2018 3.63974

IFOSFAMIDE 3 G/60 ML VIAL INTRAVEN 01/23/2018 2.33160

IMATINIB MESYLATE 400 MG TABLET ORAL 01/30/2019 14.33215

IMATINIB MESYLATE 100 MG TABLET ORAL 01/30/2019 4.98637

IMIPENEM/CILASTATIN SODIUM 250 MG VIAL INTRAVEN 10/05/2016 7.53110

IMIPENEM/CILASTATIN SODIUM 500 MG VIAL INTRAVEN 08/30/2017 11.16696

IMIPRAMINE HCL 10 MG TABLET ORAL 01/30/2018 0.06700

IMIPRAMINE HCL 25 MG TABLET ORAL 06/06/2017 0.08643

IMIPRAMINE HCL 50 MG TABLET ORAL 02/07/2017 0.12918

IMIPRAMINE PAMOATE 100 MG CAPSULE ORAL 08/12/2015 8.24760

IMIPRAMINE PAMOATE 125 MG CAPSULE ORAL 04/04/2018 8.24760

IMIPRAMINE PAMOATE 150 MG CAPSULE ORAL 09/04/2018 15.93060

IMIPRAMINE PAMOATE 75 MG CAPSULE ORAL 04/04/2018 7.70040

IMIQUIMOD 5 % CREAM PACK TOPICAL 12/12/2018 0.72751

INDAPAMIDE 2.5 MG TABLET ORAL 11/14/2018 0.20154

INDAPAMIDE 1.25 MG TABLET ORAL 12/05/2018 0.20100

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201989

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

INDOCYANINE GREEN 25 MG VIAL INJECTION 02/27/2019 82.56751

INDOMETHACIN 25 MG CAPSULE ORAL 08/21/2018 0.09179

INDOMETHACIN 50 MG CAPSULE ORAL 01/30/2019 0.07089

INDOMETHACIN 75 MG CAPSULE ER ORAL 11/14/2018 0.37504

INDOMETHACIN SODIUM 1 MG VIAL INTRAVEN 04/18/2018 447.92500

IODINE/POTASSIUM IODIDE 5%-10% SOLUTION TOPICAL 02/11/2015 0.28455

IODINE/SODIUM IODIDE 2 % TINCTURE TOPICAL 08/15/2018 0.06365

IPRATROPIUM BROMIDE 42 MCG SPRAY NASAL 05/06/2015 1.34000

IPRATROPIUM BROMIDE 21 MCG SPRAY NASAL 05/22/2018 1.31811

IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION INHALATION 02/27/2019 0.06218

IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 AMPUL-NEB INHALATION 02/13/2019 0.07214

IRBESARTAN 150 MG TABLET ORAL 11/14/2018 0.08918

IRBESARTAN 300 MG TABLET ORAL 11/07/2018 0.14874

IRBESARTAN 75 MG TABLET ORAL 04/18/2016 0.05941

IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TABLET ORAL 12/05/2018 0.09067

IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET ORAL 07/18/2018 0.15901

IRINOTECAN HCL 40 MG/2 ML VIAL INTRAVEN 01/23/2019 4.56060

IRINOTECAN HCL 100 MG/5ML VIAL INTRAVEN 10/31/2018 3.31056

IRON FM,PS NO.1/FOLIC/MV NO.18 106 MG-1MG CAPSULE ORAL 01/23/2019 0.78167

IRON FUM,PS/FOLIC ACID/VITC/B3 125-1-40-3 CAPSULE ORAL 01/23/2019 0.63680

IRON FUM,PS/FOLIC/BCOMP,C NO.9 125 MG-1MG CAPSULE ORAL 01/23/2019 0.79656

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201990

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

IRON FUM/FOLIC ACID/MV,MIN 15 106 MG-1MG CAPSULE ORAL 01/23/2019 0.68385

IRON FUMARATE/VIT C/VIT B12/FA 460-60MG CAPSULE ORAL 06/20/2018 0.56427

IRON POLYSAC/IRON HEME/FA/B12 22-6-1-25 TABLET ORAL 09/05/2018 1.84324

IRON POLYSACCH/IRON HEME POLYP 28 MG TABLET ORAL 07/08/2015 0.29904

IRON POLYSACCHARIDE COMPLEX 150 MG CAPSULE ORAL 08/15/2018 0.14070

IRON PS COMPLEX/B12/FOLIC ACID 150-25-1 CAPSULE ORAL 06/13/2018 0.16241

IRON,CARB/VIT C/VIT B12/FOLIC 100-250-1 TABLET ORAL 06/13/2018 0.29406

IRON,CARBONYL 15MG/1.25 ORAL SUSP ORAL 01/13/2016 0.71076

IRON,CARBONYL/ASCORBIC ACID 100-250 MG TABLET ORAL 02/07/2018 0.11055

IRON/FA/C/E/B12/BIO/COPPER/DSS 150-1-500 TABLET ORAL 05/23/2018 0.59987

IRON/FOLIC AC/VIT BCOMP,C/MIN 106 MG-1MG TABLET ORAL 06/13/2018 0.29359

ISONIAZID 100 MG TABLET ORAL 01/12/2016 1.19103

ISONIAZID 300 MG TABLET ORAL 01/23/2018 0.19443

ISOPROPYL ALCOHOL SOLUTION MISCELL 01/22/2013 0.00392

ISOPROPYL ALCOHOL 70 % SOLUTION MISCELL 12/20/2017 0.00288

ISOPROPYL ALCOHOL 99 % SOLUTION MISCELL 03/06/2019 0.01183

ISOPROPYL ALCOHOL IN GLYCERIN 95 %-5 % DROPS OTIC (EAR) 06/13/2018 0.09179

ISOPROPYL PALMITATE LIQUID MISCELL 01/22/2013 0.07236

ISOPROTERENOL HCL 0.2 MG/ML AMPUL INJECTION 01/23/2019 192.21251

ISOPROTERENOL HCL 0.2 MG/ML VIAL INJECTION 02/27/2019 82.69147

ISOSORBIDE DINITRATE 10 MG TABLET ORAL 01/30/2019 0.52957

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201991

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ISOSORBIDE DINITRATE 20 MG TABLET ORAL 01/30/2019 0.62614

ISOSORBIDE DINITRATE 5 MG TABLET ORAL 02/06/2019 0.65472

ISOSORBIDE DINITRATE 40 MG TABLET ER ORAL 07/10/2018 0.90953

ISOSORBIDE MONONITRATE 20 MG TABLET ORAL 11/01/2017 0.12971

ISOSORBIDE MONONITRATE 10 MG TABLET ORAL 05/14/2018 0.12221

ISOSORBIDE MONONITRATE 60 MG TAB ER 24H ORAL 10/31/2018 0.21378

ISOSORBIDE MONONITRATE 120 MG TAB ER 24H ORAL 01/23/2019 0.57955

ISOSORBIDE MONONITRATE 30 MG TAB ER 24H ORAL 10/10/2018 0.13673

ISOSULFAN BLUE 1 % VIAL SUBCUT 12/08/2015 212.13024

ISOTRETINOIN 10 MG CAPSULE ORAL 03/06/2019 10.36245

ISOTRETINOIN 20 MG CAPSULE ORAL 02/20/2019 10.75411

ISOTRETINOIN 40 MG CAPSULE ORAL 02/20/2019 13.02875

ISOTRETINOIN 30 MG CAPSULE ORAL 04/25/2017 11.31056

ISRADIPINE 2.5 MG CAPSULE ORAL 08/05/2015 1.29833

ISRADIPINE 5 MG CAPSULE ORAL 07/11/2018 1.75540

ITRACONAZOLE 100 MG CAPSULE ORAL 01/23/2019 1.84250

ITRACONAZOLE 10 MG/ML SOLUTION ORAL 11/14/2018 2.62443

IVERMECTIN 3 MG TABLET ORAL 01/08/2015 4.67148

KETOCONAZOLE 200 MG TABLET ORAL 01/23/2019 1.42085

KETOCONAZOLE 2 % FOAM TOPICAL 01/16/2019 7.87535

KETOCONAZOLE 2 % CREAM (G) TOPICAL 02/27/2019 0.74504

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201992

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

KETOCONAZOLE 2 % SHAMPOO TOPICAL 01/23/2019 0.20100

KETOROLAC TROMETHAMINE 10 MG TABLET ORAL 05/05/2015 1.18925

KETOROLAC TROMETHAMINE 30 MG/ML SYRINGE INJECTION 04/25/2017 4.35600

KETOROLAC TROMETHAMINE 15 MG/ML VIAL INJECTION 02/06/2019 0.99160

KETOROLAC TROMETHAMINE 30MG/ML(1) VIAL INJECTION 02/06/2019 1.09880

KETOROLAC TROMETHAMINE 0.5 % DROPS OPHTHALMIC 12/12/2018 3.43200

KETOROLAC TROMETHAMINE 0.4 % DROPS OPHTHALMIC 07/12/2016 12.26060

KETOROLAC TROMETHAMINE 60 MG/2 ML VIAL INTRAMUSC 01/16/2019 0.65660

KETOTIFEN FUMARATE 0.025 % DROPS OPHTHALMIC 12/26/2018 2.61300

KIT FOR PREP TC-99M/MEBROFENIN 45 MG VIAL INTRAVEN 10/03/2018 73.80000

KIT FOR TC 99M/SESTAMIBI NO.1 VIAL INTRAVEN 10/24/2018 278.80000

KRILL/OM-3/DHA/EPA/PHOSPHO/AST 1000-170MG CAPSULE ORAL 04/04/2018 0.40481

L-MEFOL/A-CYST/MEB12/ALGAL OIL 6-600-2 MG TABLET ORAL 01/31/2018 3.62985

L-NORGEST/E.ESTRADIOL-E.ESTRAD 150-30(84) TBDSPK 3MO ORAL 03/06/2019 1.31283

L-NORGEST/E.ESTRADIOL-E.ESTRAD 100-20(84) TBDSPK 3MO ORAL 12/19/2018 0.60359

L-NORGEST/E.ESTRADIOL-E.ESTRAD 0.15MG(84) TBDSPK 3MO ORAL 09/04/2018 3.49046

L. ACIDOPHILUS/L.BULGARICUS 100MM CELL POWD PACK ORAL 02/20/2019 0.72667

L. ACIDOPHILUS/L.BULGARICUS 100MM CELL GRAN PACK ORAL 05/16/2018 2.17638

L. ACIDOPHILUS/L.BULGARICUS 1MM CELL TABLET ORAL 03/06/2019 0.35108

L. ACIDOPHILUS/PECTIN, CITRUS 25MM-100MG TABLET ORAL 03/22/2017 0.07799

L.ACIDOPH/L.BULG/B.BIF/S.THERM 1B-250 MG TABLET ORAL 08/21/2014 0.33989

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201993

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LABETALOL HCL 100 MG TABLET ORAL 02/13/2019 0.26379

LABETALOL HCL 200 MG TABLET ORAL 02/27/2019 0.36421

LABETALOL HCL 300 MG TABLET ORAL 11/14/2018 0.49419

LABETALOL HCL 20 MG/4 ML SYRINGE INTRAVEN 11/07/2018 2.04853

LABETALOL HCL 5 MG/ML VIAL INTRAVEN 02/06/2019 0.15343

LACTASE 3000 UNIT TABLET ORAL 01/16/2019 0.10028

LACTASE 9000 UNIT TABLET ORAL 09/13/2017 0.24433

LACTOBACIL 2-S.THERMO-BIFIDO 1 112.5B CAPSULE ORAL 01/09/2019 1.05190

LACTOBACIL 2-S.THERMO-BIFIDO 1 450B CELL PACKET ORAL 07/18/2018 2.05824

LACTOBACIL 2-S.THERMO-BIFIDO 1 900B CELL PACKET ORAL 01/09/2019 6.76529

LACTOBACILLUS ACIDOPHILUS CAPSULE ORAL 08/10/2016 0.03685

LACTOBACILLUS ACIDOPHILUS 680 MG CAPSULE ORAL 11/03/2015 0.26800

LACTOBACILLUS ACIDOPHILUS/PECT 75 MM-100 CAPSULE ORAL 05/23/2018 0.03042

LACTOBACILLUS REUTERI 100MM/5DRP DROPS SUSP ORAL 12/26/2018 4.29000

LACTOBACILLUS REUTERI 100MM CELL TAB CHEW ORAL 05/06/2015 0.78167

LACTOBACILLUS REUTERI/VIT D3 100MM-400 DROPS ORAL 11/07/2018 3.05844

LACTULOSE 10 G PACKET ORAL 02/06/2019 8.42520

LACTULOSE 10 G/15 ML SOLUTION ORAL 02/20/2019 0.01869

LACTULOSE 10 G/15 ML SOLUTION ORAL 03/01/2016 0.01639

LACTULOSE 20 G/30 ML SOLUTION ORAL 01/10/2018 0.02878

LACTULOSE 10 G/15 ML SOLUTION ORAL 07/03/2018 0.06709

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201994

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LAMIVUDINE 10 MG/ML SOLUTION ORAL 05/22/2018 0.42327

LAMIVUDINE 150 MG TABLET ORAL 01/23/2019 0.70439

LAMIVUDINE 100 MG TABLET ORAL 08/04/2015 4.13820

LAMIVUDINE 300 MG TABLET ORAL 01/23/2019 1.61649

LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET ORAL 06/30/2015 2.45667

LAMOTRIGINE 25 MG TAB ER 24 ORAL 02/27/2019 1.56333

LAMOTRIGINE 50 MG TAB ER 24 ORAL 06/06/2018 2.77332

LAMOTRIGINE 100 MG TAB ER 24 ORAL 03/06/2019 2.52992

LAMOTRIGINE 200 MG TAB ER 24 ORAL 03/06/2019 2.66420

LAMOTRIGINE 300 MG TAB ER 24 ORAL 05/24/2016 14.00665

LAMOTRIGINE 250 MG TAB ER 24 ORAL 02/06/2019 9.56225

LAMOTRIGINE 100 MG TABLET ORAL 12/05/2018 0.03993

LAMOTRIGINE 25 MG TABLET ORAL 12/26/2018 0.02664

LAMOTRIGINE 150 MG TABLET ORAL 09/26/2018 0.06981

LAMOTRIGINE 200 MG TABLET ORAL 11/07/2018 0.07370

LAMOTRIGINE 25MG (35) TAB DS PK ORAL 06/13/2018 6.41485

LAMOTRIGINE 25(84)-100 TAB DS PK ORAL 07/11/2018 11.85306

LAMOTRIGINE 25(42)-100 TAB DS PK ORAL 07/11/2018 11.52980

LAMOTRIGINE 50 MG TAB RAPDIS ORAL 03/01/2016 8.14560

LAMOTRIGINE 25 MG TAB RAPDIS ORAL 03/01/2016 7.24280

LAMOTRIGINE 100 MG TAB RAPDIS ORAL 05/12/2015 8.68560

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201995

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LAMOTRIGINE 200 MG TAB RAPDIS ORAL 05/12/2015 9.93255

LAMOTRIGINE 25-50-100 TB RD DSPK ORAL 11/02/2016 11.45226

LAMOTRIGINE 25(21)-50 TB RD DSPK ORAL 12/06/2017 7.21315

LAMOTRIGINE 50(42)-100 TB RD DSPK ORAL 07/11/2018 13.52813

LAMOTRIGINE 25 MG TB CHW DSP ORAL 07/18/2017 0.30378

LAMOTRIGINE 5 MG TB CHW DSP ORAL 08/01/2018 0.28931

LANCETS 30 GAUGE EACH MISCELL 01/15/2014 0.01059

LANCETS 31 GAUGE EACH MISCELL 01/15/2014 0.36669

LANOLIN,ANHYDROUS OINT. (G) TOPICAL 12/07/2016 0.09676

LANOLIN/MINERAL OIL LOTION TOPICAL 08/30/2017 0.01094

LANSOPRAZOLE 15 MG CAPSULE DR ORAL 02/27/2019 0.46721

LANSOPRAZOLE 30 MG CAPSULE DR ORAL 01/30/2019 0.30626

LANSOPRAZOLE 15 MG TAB RAP DR ORAL 01/02/2019 13.15006

LANSOPRAZOLE 30 MG TAB RAP DR ORAL 02/20/2019 13.80761

LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 COMBO. PKG ORAL 06/13/2018 5.62304

LANTHANUM CARBONATE 500 MG TAB CHEW ORAL 02/20/2019 9.95466

LANTHANUM CARBONATE 1000 MG TAB CHEW ORAL 09/20/2017 10.65628

LANTHANUM CARBONATE 750 MG TAB CHEW ORAL 09/20/2017 10.65628

LATANOPROST 0.005 % DROPS OPHTHALMIC 05/19/2015 6.36016

LECITHIN 1200 MG CAPSULE ORAL 11/07/2018 0.06526

LECITHIN, SOY 1200 MG CAPSULE ORAL 01/30/2019 0.05881

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201996

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LECITHIN/PYRIDOXINE/KELP TABLET ORAL 10/09/2013 0.03370

LEFLUNOMIDE 10 MG TABLET ORAL 12/19/2018 1.02555

LEFLUNOMIDE 20 MG TABLET ORAL 02/27/2019 1.02555

LEMON EUCALYPTUS OIL 30 % SPRAY TOPICAL 12/21/2016 0.02821

LEMON OIL OIL MISCELL 02/04/2015 0.70350

LETROZOLE 2.5 MG TABLET ORAL 03/06/2019 0.14427

LEUCOVORIN CALCIUM 25 MG TABLET ORAL 12/12/2018 6.91286

LEUCOVORIN CALCIUM 5 MG TABLET ORAL 08/16/2017 0.83884

LEUCOVORIN CALCIUM 100 MG VIAL INJECTION 09/12/2018 8.66400

LEUCOVORIN CALCIUM 350 MG VIAL INJECTION 01/09/2019 16.28550

LEUCOVORIN CALCIUM 50 MG VIAL INJECTION 07/03/2018 5.52450

LEUCOVORIN CALCIUM 200 MG VIAL INJECTION 12/05/2018 13.06800

LEUCOVORIN CALCIUM 500 MG VIAL INJECTION 09/26/2018 94.13600

LEUPROLIDE ACETATE 1 MG/0.2ML KIT SUBCUT 01/23/2019 550.72225

LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB INHALATION 10/27/2015 0.59541

LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB INHALATION 01/30/2019 0.56563

LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB INHALATION 12/26/2018 0.68489

LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB INHALATION 11/28/2018 3.35852

LEVETIRACETAM 100 MG/ML SOLUTION ORAL 12/19/2018 0.04031

LEVETIRACETAM 500 MG/5ML SOLUTION ORAL 02/27/2019 1.40553

LEVETIRACETAM 250 MG TABLET ORAL 10/24/2017 0.06332

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201997

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LEVETIRACETAM 500 MG TABLET ORAL 11/28/2018 0.13676

LEVETIRACETAM 750 MG TABLET ORAL 10/24/2017 0.13303

LEVETIRACETAM 500 MG TAB ER 24H ORAL 01/09/2019 0.17867

LEVETIRACETAM 750 MG TAB ER 24H ORAL 02/27/2018 0.46878

LEVETIRACETAM 500 MG/5ML VIAL INTRAVEN 12/26/2018 0.41808

LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L PIGGYBACK INTRAVEN 10/02/2018 0.23551

LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 PIGGYBACK INTRAVEN 10/02/2018 0.38190

LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 PIGGYBACK INTRAVEN 05/01/2018 0.48014

LEVOBUNOLOL HCL 0.5 % DROPS OPHTHALMIC 01/12/2016 0.39307

LEVOCARNITINE 500 MG TABLET ORAL 04/13/2016 0.37163

LEVOCARNITINE 330 MG TABLET ORAL 02/28/2018 0.71858

LEVOCARNITINE (WITH SUGAR) 100 MG/ML SOLUTION ORAL 12/13/2017 0.18805

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML SOLUTION ORAL 10/17/2018 0.55711

LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET ORAL 12/19/2018 0.08844

LEVOFLOXACIN 250MG/10ML SOLUTION ORAL 12/26/2018 1.38904

LEVOFLOXACIN 250 MG TABLET ORAL 12/19/2018 0.13802

LEVOFLOXACIN 500 MG TABLET ORAL 11/14/2018 0.19966

LEVOFLOXACIN 750 MG TABLET ORAL 02/27/2019 0.34237

LEVOFLOXACIN 0.5 % DROPS OPHTHALMIC 02/06/2019 8.97120

LEVOFLOXACIN 25 MG/ML VIAL INTRAVEN 07/03/2018 0.32227

LEVOFLOXACIN IN DEXTROSE 5 % 250MG/50ML PIGGYBACK INTRAVEN 01/16/2019 0.05586

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201998

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LEVOFLOXACIN IN DEXTROSE 5 % 500MG/0.1L PIGGYBACK INTRAVEN 02/27/2019 0.02794

LEVOFLOXACIN IN DEXTROSE 5 % 750MG/.15L PIGGYBACK INTRAVEN 01/16/2019 0.02097

LEVOLEUCOVORIN CALCIUM 50 MG VIAL INTRAVEN 07/03/2018 122.62075

LEVOLEUCOVORIN CALCIUM 10 MG/ML VIAL INTRAVEN 02/27/2019 5.79410

LEVOMEFOLATE CALCIUM 7.5 MG TABLET ORAL 06/19/2017 2.65767

LEVOMEFOLATE CALCIUM 15 MG TABLET ORAL 02/27/2019 2.85985

LEVOMEFOLATE/ALGAL OIL 7.5-90.314 CAPSULE ORAL 01/30/2019 3.70612

LEVOMEFOLATE/ALGAL OIL 15-90.314 CAPSULE ORAL 01/31/2018 3.70612

LEVOMEFOLATE/B6/B12/ALGAL OIL 3-35-2 MG CAPSULE ORAL 07/03/2018 2.01000

LEVONORGESTREL 1.5 MG TABLET ORAL 12/26/2018 17.67675

LEVONORGESTREL-ETHIN ESTRADIOL 0.15-0.03 TABLET ORAL 04/07/2015 0.23673

LEVONORGESTREL-ETHIN ESTRADIOL 6-5-10 TABLET ORAL 08/15/2018 0.59024

LEVONORGESTREL-ETHIN ESTRADIOL 0.1-0.02MG TABLET ORAL 02/06/2019 0.29624

LEVONORGESTREL-ETHIN ESTRADIOL 90-20 MCG TABLET ORAL 09/26/2018 1.80262

LEVONORGESTREL-ETHIN ESTRADIOL 0.15-0.03 TBDSPK 3MO ORAL 12/19/2018 0.23560

LEVORPHANOL TARTRATE 2 MG TABLET ORAL 01/23/2019 45.61240

LEVOTHYROXINE SODIUM 25 MCG TABLET ORAL 01/06/2015 0.40481

LEVOTHYROXINE SODIUM 50 MCG TABLET ORAL 12/05/2018 0.39246

LEVOTHYROXINE SODIUM 75 MCG TABLET ORAL 01/06/2015 0.50612

LEVOTHYROXINE SODIUM 100 MCG TABLET ORAL 01/06/2015 0.49619

LEVOTHYROXINE SODIUM 112 MCG TABLET ORAL 01/23/2019 0.59107

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 201999

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LEVOTHYROXINE SODIUM 125 MCG TABLET ORAL 01/23/2019 0.62511

LEVOTHYROXINE SODIUM 150 MCG TABLET ORAL 01/23/2019 0.64052

LEVOTHYROXINE SODIUM 175 MCG TABLET ORAL 08/04/2015 0.76233

LEVOTHYROXINE SODIUM 200 MCG TABLET ORAL 04/21/2015 0.77774

LEVOTHYROXINE SODIUM 300 MCG TABLET ORAL 01/23/2019 0.94189

LEVOTHYROXINE SODIUM 88 MCG TABLET ORAL 01/23/2019 0.46726

LEVOTHYROXINE SODIUM 137 MCG TABLET ORAL 01/30/2019 0.54421

LEVOTHYROXINE SODIUM 200 MCG VIAL INTRAVEN 01/09/2019 214.22500

LEVOTHYROXINE SODIUM 500 MCG VIAL INTRAVEN 01/09/2019 485.65781

LEVOTHYROXINE SODIUM 100 MCG VIAL INTRAVEN 01/09/2019 97.13156

LIDOCAINE 5 % CREAM (G) TOPICAL 11/28/2018 1.69644

LIDOCAINE 4 % CREAM (G) TOPICAL 02/13/2019 1.15186

LIDOCAINE 5 % OINT. (G) TOPICAL 02/20/2019 0.37357

LIDOCAINE 4 % ADH. PATCH TOPICAL 05/22/2018 1.70716

LIDOCAINE 5 % ADH. PATCH TOPICAL 02/20/2019 5.10582

LIDOCAINE HCL 5 MG/ML VIAL INJECTION 08/30/2017 0.10100

LIDOCAINE HCL 10 MG/ML VIAL INJECTION 10/24/2018 0.05486

LIDOCAINE HCL 20 MG/ML VIAL INJECTION 01/16/2019 0.06207

LIDOCAINE HCL 2 % JEL/PF APP MUCOUS MEM 08/30/2017 0.69619

LIDOCAINE HCL 40 MG/ML SOLUTION MUCOUS MEM 01/09/2019 1.15722

LIDOCAINE HCL 2 % SOLUTION MUCOUS MEM 11/07/2018 0.11417

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019100

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LIDOCAINE HCL 4 % CREAM (G) TOPICAL 03/06/2019 0.09459

LIDOCAINE HCL 4 % SOLUTION TOPICAL 08/29/2018 7.60755

LIDOCAINE HCL/BENZALKONIUM CHL 2.5%-0.13% SPRAY TOPICAL 04/18/2018 4.47920

LIDOCAINE HCL/DEXTROSE 5 %/PF 4 MG/ML IV SOLN INTRAVEN 05/09/2018 0.01702

LIDOCAINE HCL/DEXTROSE 5 %/PF 8 MG/ML IV SOLN INTRAVEN 01/10/2018 0.04843

LIDOCAINE HCL/EPINEPHRINE 0.5-1:200K VIAL INJECTION 01/30/2019 0.08392

LIDOCAINE HCL/EPINEPHRINE 1%-1:100K VIAL INJECTION 10/05/2016 0.07370

LIDOCAINE HCL/EPINEPHRINE 2 %-1:100K VIAL INJECTION 07/03/2017 0.09005

LIDOCAINE HCL/EPINEPHRINE BIT 2 %-1:100K CARTRIDGE INJECTION 09/09/2015 0.22630

LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 CARTRIDGE INJECTION 09/09/2015 0.22630

LIDOCAINE HCL/MENTHOL 4 %-1 % GEL (ML) TOPICAL 03/07/2018 2.74901

LIDOCAINE HCL/MENTHOL 4 %-1 % CREAM (G) TOPICAL 09/12/2017 0.10405

LIDOCAINE HCL/MENTHOL 4 %-1 % ADH. PATCH TOPICAL 02/28/2018 18.37500

LIDOCAINE HCL/PF 15 MG/ML AMPUL INJECTION 01/23/2019 0.46940

LIDOCAINE HCL/PF 10 MG/ML AMPUL INJECTION 02/20/2019 0.27593

LIDOCAINE HCL/PF 20 MG/ML AMPUL INJECTION 08/22/2018 0.63248

LIDOCAINE HCL/PF 10 MG/ML VIAL INJECTION 02/07/2018 0.08755

LIDOCAINE HCL/PF 5 MG/ML VIAL INJECTION 02/27/2019 0.10295

LIDOCAINE HCL/PF 100 MG/5ML SYRINGE INTRAVEN 08/30/2017 0.78470

LIDOCAINE/MENTHOL 4 %-1 % ADH. PATCH TOPICAL 05/30/2018 2.01000

LIDOCAINE/MENTHOL 4 %-4 % ADH. PATCH TOPICAL 03/07/2018 25.46250

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019101

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LIDOCAINE/PRILOCAINE 2.5 %-2.5% CREAM (G) TOPICAL 11/03/2015 0.41719

LIDOCAINE/PRILOCAINE 2.5 %-2.5% KIT TOPICAL 01/23/2019 9.50130

LIDOCAINE/TRANSPARENT DRESSING 4 % KIT TOPICAL 01/16/2019 4.75200

LINCOMYCIN HCL 300 MG/ML VIAL INJECTION 02/27/2019 12.90080

LINEZOLID 100 MG/5ML SUSP RECON ORAL 07/03/2018 3.74000

LINEZOLID 600 MG TABLET ORAL 12/19/2018 2.41066

LINEZOLID IN DEXTROSE 5% 600MG/300 PIGGYBACK INTRAVEN 03/06/2019 0.09354

LIOTHYRONINE SODIUM 25 MCG TABLET ORAL 11/28/2018 0.59335

LIOTHYRONINE SODIUM 5 MCG TABLET ORAL 04/18/2016 0.48693

LIOTHYRONINE SODIUM 50 MCG TABLET ORAL 11/07/2018 1.33360

LIOTHYRONINE SODIUM 10 MCG/ML VIAL INTRAVEN 07/17/2018 278.36950

LISINOPRIL 10 MG TABLET ORAL 12/19/2018 0.01659

LISINOPRIL 20 MG TABLET ORAL 03/06/2019 0.02202

LISINOPRIL 40 MG TABLET ORAL 11/28/2018 0.04141

LISINOPRIL 5 MG TABLET ORAL 12/19/2018 0.01461

LISINOPRIL 2.5 MG TABLET ORAL 12/05/2018 0.01193

LISINOPRIL 30 MG TABLET ORAL 01/16/2019 0.04623

LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET ORAL 01/02/2019 0.04342

LISINOPRIL/HYDROCHLOROTHIAZIDE 20 MG-25MG TABLET ORAL 02/27/2019 0.05266

LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET ORAL 02/06/2019 0.03176

LITHIUM CARBONATE 150 MG CAPSULE ORAL 07/18/2017 0.12100

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019102

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LITHIUM CARBONATE 300 MG CAPSULE ORAL 04/11/2016 0.07440

LITHIUM CARBONATE 600 MG CAPSULE ORAL 05/22/2018 0.28797

LITHIUM CARBONATE 300 MG TABLET ORAL 03/21/2018 0.19644

LITHIUM CARBONATE 300 MG TABLET ER ORAL 01/23/2019 0.22512

LITHIUM CARBONATE 450 MG TABLET ER ORAL 11/21/2018 0.32066

LOPERAMIDE HCL 2 MG CAPSULE ORAL 03/06/2019 0.44960

LOPERAMIDE HCL 1MG/7.5ML LIQUID ORAL 02/13/2019 0.03564

LOPERAMIDE HCL 2 MG TABLET ORAL 12/26/2018 0.11032

LOPINAVIR/RITONAVIR 400-100/5 SOLUTION ORAL 02/27/2019 4.09109

LORATADINE 5 MG/5 ML SOLUTION ORAL 03/06/2019 0.04511

LORATADINE 10 MG TABLET ORAL 03/06/2019 0.07236

LORATADINE 5 MG TAB CHEW ORAL 08/08/2018 0.89333

LORATADINE 10 MG TAB RAPDIS ORAL 09/06/2017 0.34974

LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H ORAL 07/03/2018 0.60595

LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H ORAL 08/01/2018 0.84697

LORAZEPAM 2 MG/ML ORAL CONC ORAL 06/13/2018 0.62489

LORAZEPAM 0.5 MG TABLET ORAL 03/06/2019 0.04281

LORAZEPAM 2 MG TABLET ORAL 03/06/2019 0.06399

LORAZEPAM 2 MG/ML VIAL INJECTION 09/26/2018 0.65874

LORAZEPAM 4 MG/ML VIAL INJECTION 02/06/2019 1.21511

LOSARTAN POTASSIUM 25 MG TABLET ORAL 12/19/2018 0.02472

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019103

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

LOSARTAN POTASSIUM 50 MG TABLET ORAL 01/30/2019 0.03692

LOSARTAN POTASSIUM 100 MG TABLET ORAL 02/27/2019 0.04898

LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET ORAL 11/14/2018 0.04243

LOSARTAN/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET ORAL 01/30/2018 0.05954

LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG TABLET ORAL 09/19/2018 0.05813

LOVASTATIN 20 MG TABLET ORAL 03/06/2019 0.05025

LOVASTATIN 40 MG TABLET ORAL 02/20/2019 0.07276

LOVASTATIN 10 MG TABLET ORAL 03/06/2019 0.04971

LOXAPINE SUCCINATE 10 MG CAPSULE ORAL 06/27/2018 0.65848

LOXAPINE SUCCINATE 25 MG CAPSULE ORAL 02/21/2018 0.76420

LOXAPINE SUCCINATE 5 MG CAPSULE ORAL 07/08/2015 0.37118

LOXAPINE SUCCINATE 50 MG CAPSULE ORAL 07/08/2015 0.98865

LUTEIN 6 MG CAPSULE ORAL 01/24/2018 0.07722

LUTEIN 20 MG CAPSULE ORAL 06/22/2016 0.09045

LYSINE 500 MG TABLET ORAL 01/16/2019 0.02329

LYSINE HCL 500 MG TABLET ORAL 01/30/2019 0.07169

M-VIT,TX,IRON,MINS/CALC/FOLIC 27MG-0.4MG TABLET ORAL 07/03/2018 0.02670

MAFENIDE ACETATE 50 G PACKET TOPICAL 01/30/2019 95.55870

MAG CARB/ALUMINUM HYDROX/ALGIN 358-95/15 ORAL SUSP ORAL 08/24/2016 0.02047

MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-20 ORAL SUSP ORAL 02/20/2019 0.00588

MAG HYDROX/ALUMINUM HYD/SIMETH 400-400-40 ORAL SUSP ORAL 07/03/2018 0.00733

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019104

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-25 TAB CHEW ORAL 05/09/2018 0.03497

MAGNESIUM 200 MG TABLET ORAL 08/23/2017 0.04435

MAGNESIUM CARB/ALUMINUM HYDROX 105-160MG TAB CHEW ORAL 10/05/2016 0.08911

MAGNESIUM CHLORIDE 64 MG TABLET DR ORAL 02/06/2019 0.09659

MAGNESIUM CHLORIDE 71.5 MG TABLET DR ORAL 03/07/2018 0.15382

MAGNESIUM CHLORIDE 70 MG TABLET DR ORAL 12/05/2018 0.11223

MAGNESIUM CITRATE SOLUTION ORAL 01/30/2019 0.00251

MAGNESIUM GLUCONATE 27 MG(500) TABLET ORAL 08/16/2017 0.11899

MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP ORAL 03/06/2019 0.00396

MAGNESIUM HYDROXIDE 2400 MG/10 ORAL SUSP ORAL 05/06/2015 0.05146

MAGNESIUM L-LACTATE 84 MG TABLET ER ORAL 07/03/2018 0.27899

MAGNESIUM OXIDE 500 MG CAPSULE ORAL 01/18/2017 0.08989

MAGNESIUM OXIDE 400 MG CAPSULE ORAL 11/09/2016 0.08368

MAGNESIUM OXIDE 250 MG TABLET ORAL 04/24/2018 0.02948

MAGNESIUM OXIDE 400 MG TABLET ORAL 04/19/2016 0.01843

MAGNESIUM OXIDE 420 MG TABLET ORAL 03/09/2016 0.05414

MAGNESIUM OXIDE 500 MG TABLET ORAL 04/13/2016 0.05655

MAGNESIUM OXIDE 400 MG TABLET ORAL 12/19/2018 0.04511

MAGNESIUM STEARATE POWDER MISCELL 10/03/2018 0.09574

MAGNESIUM SULFATE 4 MEQ/ML VIAL INJECTION 11/14/2018 0.22023

MAGNESIUM SULFATE IN WATER 20 G/500ML IV SOLN INTRAVEN 04/25/2017 0.01021

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019105

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MAGNESIUM SULFATE IN WATER 40G/1000ML IV SOLN INTRAVEN 04/25/2017 0.00737

MAGNESIUM SULFATE IN WATER 2 G/50 ML PIGGYBACK INTRAVEN 02/06/2019 0.25567

MAGNESIUM SULFATE IN WATER 4 G/100 ML PIGGYBACK INTRAVEN 03/06/2019 0.07604

MAGNESIUM SULFATE IN WATER 4 G/50 ML PIGGYBACK INTRAVEN 04/24/2017 0.11765

MAGNESIUM SULFATE/D5W 1 G/100 ML PIGGYBACK INTRAVEN 02/06/2019 0.06459

MANNITOL 10 % IV SOLN INTRAVEN 12/27/2017 0.11255

MANNITOL 20 % IV SOLN INTRAVEN 08/30/2017 0.04608

MANNITOL 5 % IV SOLN INTRAVEN 12/27/2017 0.05771

MANNITOL 25 % VIAL INTRAVEN 11/23/2016 0.05907

MECLIZINE HCL 12.5 MG TABLET ORAL 03/20/2018 0.13389

MECLIZINE HCL 25 MG TABLET ORAL 02/20/2019 0.22929

MECLIZINE HCL 25 MG TAB CHEW ORAL 07/25/2017 0.01722

MECOBAL/LEVOMEFOLAT CA/B6 PHOS 2-3-35 MG TABLET ORAL 08/22/2018 1.04207

MECOBALAMIN 1000 MCG TAB RAPDIS SUBLINGUAL 10/24/2018 0.12931

MEDIUM CHAIN TRIGLYCERIDES 7.7KCAL/ML OIL ORAL 01/09/2019 0.07592

MEDROXYPROGESTERONE ACETATE 10 MG TABLET ORAL 10/17/2018 0.15911

MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET ORAL 12/26/2018 0.16337

MEDROXYPROGESTERONE ACETATE 5 MG TABLET ORAL 12/26/2018 0.24683

MEDROXYPROGESTERONE ACETATE 150 MG/ML SYRINGE INTRAMUSC 04/11/2018 53.76125

MEDROXYPROGESTERONE ACETATE 150 MG/ML VIAL INTRAMUSC 02/06/2019 30.55525

MEFENAMIC ACID 250 MG CAPSULE ORAL 11/02/2016 7.19667

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019106

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MEFLOQUINE HCL 250 MG TABLET ORAL 02/07/2018 8.12856

MEGESTROL ACETATE 400MG/10ML ORAL SUSP ORAL 06/06/2018 0.08925

MEGESTROL ACETATE 625MG/5ML ORAL SUSP ORAL 12/13/2017 4.23130

MEGESTROL ACETATE 400MG/10ML ORAL SUSP ORAL 07/03/2018 0.38591

MEGESTROL ACETATE 20 MG TABLET ORAL 06/10/2015 0.24187

MEGESTROL ACETATE 40 MG TABLET ORAL 01/31/2018 0.21397

MELATONIN 3 MG TABLET ORAL 01/09/2019 0.02546

MELATONIN 1 MG TABLET ORAL 03/06/2019 0.01910

MELATONIN 5 MG TABLET ORAL 11/21/2018 0.01407

MELATONIN 2.5 MG TAB CHEW ORAL 01/30/2018 0.07020

MELATONIN 3 MG TABLET ER ORAL 10/09/2013 0.05215

MELATONIN 5 MG TAB RAPDIS ORAL 12/12/2018 0.06692

MELATONIN 3 MG TAB RAPDIS ORAL 01/31/2018 0.04936

MELATONIN 10 MG TAB SUBL SUBLINGUAL 11/07/2018 0.15615

MELATONIN/PYRIDOXAL PHOSPHATE 2.5 MG-338 TAB SUBL SUBLINGUAL 04/12/2017 0.07571

MELATONIN/TRYPTOPHAN 3 MG-100MG CAPSULE ORAL 01/29/2014 4.90380

MELOXICAM 7.5 MG TABLET ORAL 12/12/2018 0.01608

MELOXICAM 15 MG TABLET ORAL 12/12/2018 0.02010

MELPHALAN 2 MG TABLET ORAL 06/26/2017 10.53308

MELPHALAN HCL 50 MG VIAL INTRAVEN 01/23/2019 248.15250

MEMANTINE HCL 7 MG CAP SPR 24 ORAL 12/12/2018 4.12720

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019107

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MEMANTINE HCL 14 MG CAP SPR 24 ORAL 02/06/2019 2.96692

MEMANTINE HCL 21 MG CAP SPR 24 ORAL 10/31/2018 4.09904

MEMANTINE HCL 28 MG CAP SPR 24 ORAL 01/02/2019 2.96692

MEMANTINE HCL 2 MG/ML SOLUTION ORAL 01/23/2019 1.75082

MEMANTINE HCL 10 MG TABLET ORAL 01/12/2016 0.16839

MEMANTINE HCL 5 MG TABLET ORAL 08/25/2015 0.14070

MEMANTINE HCL 5 MG-10 MG TAB DS PK ORAL 07/09/2015 0.38860

MENTHOL 8 MG LOZENGE MUCOUS MEM 01/22/2013 0.05360

MENTHOL 10 % GEL (GRAM) TOPICAL 01/22/2013 0.09441

MENTHOL 2 % GEL (GRAM) TOPICAL 01/30/2019 0.01131

MENTHOL 5 % ADH. PATCH TOPICAL 12/19/2018 0.96493

MENTHOL/CAMPHOR 3.5%-0.2% GEL (GRAM) TOPICAL 11/15/2017 0.06700

MENTHOL/CAMPHOR 0.5 %-0.5% LOTION TOPICAL 05/22/2018 0.02227

MENTHOL/ZINC OXIDE 0.44-20.6% OINT. (G) TOPICAL 08/26/2015 0.05226

MENTHOL/ZINC OXIDE 0.44 %-20% OINT. (G) TOPICAL 07/11/2018 0.04549

MEPERIDINE HCL 100 MG TABLET ORAL 02/14/2018 1.36760

MEPERIDINE HCL 50 MG TABLET ORAL 05/22/2018 1.04212

MEPIVACAINE HCL 10 MG/ML VIAL INJECTION 04/28/2015 0.23048

MEPIVACAINE HCL 20 MG/ML VIAL INJECTION 07/03/2018 0.23691

MEPIVACAINE HCL/PF 20 MG/ML VIAL INJECTION 11/03/2015 0.45560

MEPIVACAINE HCL/PF 15 MG/ML VIAL INJECTION 11/03/2015 0.37073

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019108

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MEPIVACAINE HCL/PF 10 MG/ML VIAL INJECTION 11/03/2015 0.27336

MEPROBAMATE 200 MG TABLET ORAL 12/11/2018 4.84850

MEPROBAMATE 400 MG TABLET ORAL 12/12/2018 7.38886

MERCAPTOPURINE 50 MG TABLET ORAL 01/23/2019 1.17352

MEROPENEM 500 MG VIAL INTRAVEN 02/06/2019 5.04240

MEROPENEM 1 G VIAL INTRAVEN 11/28/2018 8.33520

MESALAMINE 800 MG TABLET DR ORAL 02/20/2019 6.87402

MESALAMINE 1.2 G TABLET DR ORAL 03/06/2019 7.27572

MESALAMINE 1000 MG SUPP.RECT RECTAL 01/09/2019 29.00033

MESALAMINE 4 G/60 ML ENEMA RECTAL 05/05/2015 0.24193

MESALAMINE W/CLEANSING WIPES 4 G/60 ML ENEMA KIT RECTAL 09/26/2018 17.07600

MESNA 100 MG/ML VIAL INTRAVEN 07/25/2018 1.09344

METAXALONE 800 MG TABLET ORAL 02/27/2019 1.43139

METFORMIN HCL 1000 MG TAB ER 24 ORAL 01/09/2019 5.13789

METFORMIN HCL 500 MG TAB ER 24 ORAL 02/06/2019 5.39242

METFORMIN HCL 500 MG TABERGR24H ORAL 12/12/2018 14.70000

METFORMIN HCL 1000 MG TABERGR24H ORAL 12/12/2018 26.18432

METFORMIN HCL 500 MG TABLET ORAL 03/06/2019 0.01801

METFORMIN HCL 850 MG TABLET ORAL 03/06/2019 0.02838

METFORMIN HCL 1000 MG TABLET ORAL 03/06/2019 0.03166

METFORMIN HCL 500 MG TAB ER 24H ORAL 02/13/2019 0.03310

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019109

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

METFORMIN HCL 750 MG TAB ER 24H ORAL 01/23/2019 0.06633

METHADONE HCL 10 MG/5 ML SOLUTION ORAL 12/19/2018 0.48240

METHADONE HCL 5 MG/5 ML SOLUTION ORAL 12/19/2018 0.24120

METHADONE HCL 10 MG/ML ORAL CONC ORAL 07/03/2018 0.05214

METHADONE HCL 10 MG TABLET ORAL 12/26/2018 0.11484

METHADONE HCL 5 MG TABLET ORAL 03/06/2019 0.11819

METHADONE HCL 40 MG TABLET SOL ORAL 05/15/2013 0.32716

METHADONE HCL 10 MG/ML VIAL INJECTION 09/05/2018 17.55600

METHAMPHETAMINE HCL 5 MG TABLET ORAL 09/22/2015 7.47492

METHAZOLAMIDE 25 MG TABLET ORAL 11/14/2018 3.43992

METHAZOLAMIDE 50 MG TABLET ORAL 11/14/2018 6.61962

METHENAMINE HIPPURATE 1 G TABLET ORAL 02/14/2018 1.20600

METHIMAZOLE 10 MG TABLET ORAL 01/09/2019 0.17085

METHIMAZOLE 5 MG TABLET ORAL 10/17/2018 0.06700

METHOCARBAMOL 750 MG TABLET ORAL 02/06/2019 0.14161

METHOCARBAMOL 100 MG/ML VIAL INJECTION 02/13/2019 1.50080

METHOTREXATE SODIUM 2.5 MG TABLET ORAL 06/23/2015 0.87730

METHOTREXATE SODIUM 25 MG/ML VIAL INJECTION 06/19/2017 2.82150

METHOTREXATE SODIUM/PF 1 G VIAL INJECTION 01/23/2019 62.49425

METHOTREXATE SODIUM/PF 25 MG/ML VIAL INJECTION 10/31/2018 0.55208

METHOXSALEN 10 MG CAP LQ RAP ORAL 11/14/2018 42.76731

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019110

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

METHOXY PEG-EPOETIN BETA 50 MCG/0.3 SYRINGE INJECTION 02/21/2018 446.30208

METHOXY PEG-EPOETIN BETA 75 MCG/0.3 SYRINGE INJECTION 02/21/2018 669.45313

METHOXY PEG-EPOETIN BETA 100MCG/0.3 SYRINGE INJECTION 02/21/2018 892.60416

METHOXY PEG-EPOETIN BETA 200MCG/0.3 SYRINGE INJECTION 02/21/2018 1785.20833

METHSCOPOLAMINE BROMIDE 2.5 MG TABLET ORAL 02/27/2019 1.34000

METHSCOPOLAMINE BROMIDE 5 MG TABLET ORAL 02/27/2019 2.38967

METHYL SALICYLATE LIQUID TOPICAL 06/13/2018 0.07449

METHYL SALICYLATE OIL MISCELL 06/03/2015 0.14228

METHYL SALICYLATE/MENTH/CAMPH 30%-10%-4% CREAM (G) TOPICAL 01/30/2019 0.08844

METHYL SALICYLATE/MENTHOL 15%-10% CREAM (G) TOPICAL 01/30/2019 0.03235

METHYL SALICYLATE/MENTHOL 15 %-1 % CREAM (G) TOPICAL 07/03/2018 0.03975

METHYLDOPA 250 MG TABLET ORAL 07/03/2018 0.11042

METHYLDOPA 500 MG TABLET ORAL 03/04/2015 0.24442

METHYLERGONOVINE MALEATE 0.2 MG TABLET ORAL 12/12/2018 35.53333

METHYLERGONOVINE MALEATE .2MG/ML(1) AMPUL INJECTION 01/02/2018 17.63580

METHYLPHENIDATE HCL 10 MG CPBP 30-70 ORAL 02/06/2019 3.75144

METHYLPHENIDATE HCL 20 MG CPBP 30-70 ORAL 02/06/2019 3.75144

METHYLPHENIDATE HCL 30 MG CPBP 30-70 ORAL 01/23/2019 3.36851

METHYLPHENIDATE HCL 40 MG CPBP 30-70 ORAL 02/06/2019 5.10477

METHYLPHENIDATE HCL 50 MG CPBP 30-70 ORAL 02/06/2019 5.70903

METHYLPHENIDATE HCL 60 MG CPBP 30-70 ORAL 01/23/2019 4.71240

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019111

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

METHYLPHENIDATE HCL 20 MG CPBP 50-50 ORAL 02/13/2019 3.55780

METHYLPHENIDATE HCL 30 MG CPBP 50-50 ORAL 09/24/2018 3.75738

METHYLPHENIDATE HCL 40 MG CPBP 50-50 ORAL 03/06/2019 3.73996

METHYLPHENIDATE HCL 10 MG CPBP 50-50 ORAL 05/30/2018 11.44446

METHYLPHENIDATE HCL 18 MG TAB ER 24 ORAL 02/20/2019 8.40720

METHYLPHENIDATE HCL 36 MG TAB ER 24 ORAL 02/20/2019 8.88920

METHYLPHENIDATE HCL 54 MG TAB ER 24 ORAL 02/20/2019 9.35000

METHYLPHENIDATE HCL 27 MG TAB ER 24 ORAL 02/20/2019 8.61787

METHYLPHENIDATE HCL 72 MG TAB ER 24 ORAL 07/11/2018 19.95504

METHYLPHENIDATE HCL 5 MG/5 ML SOLUTION ORAL 04/18/2018 0.34837

METHYLPHENIDATE HCL 10 MG/5 ML SOLUTION ORAL 07/25/2018 0.48302

METHYLPHENIDATE HCL 10 MG TABLET ORAL 03/06/2019 0.26733

METHYLPHENIDATE HCL 20 MG TABLET ORAL 03/06/2019 0.42384

METHYLPHENIDATE HCL 5 MG TABLET ORAL 03/06/2019 0.20033

METHYLPHENIDATE HCL 2.5 MG TAB CHEW ORAL 04/11/2018 2.11486

METHYLPHENIDATE HCL 5 MG TAB CHEW ORAL 04/11/2018 2.97594

METHYLPHENIDATE HCL 10 MG TAB CHEW ORAL 04/11/2018 4.24248

METHYLPHENIDATE HCL 20 MG TABLET ER ORAL 02/27/2019 2.19639

METHYLPHENIDATE HCL 10 MG TABLET ER ORAL 04/19/2016 2.62640

METHYLPREDNISOLONE 16 MG TABLET ORAL 08/01/2018 2.82374

METHYLPREDNISOLONE 32 MG TABLET ORAL 08/01/2018 4.57248

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019112

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

METHYLPREDNISOLONE 4 MG TABLET ORAL 12/12/2018 0.64575

METHYLPREDNISOLONE 8 MG TABLET ORAL 05/19/2015 1.72699

METHYLPREDNISOLONE 4 MG TAB DS PK ORAL 12/12/2018 0.40710

METHYLPREDNISOLONE ACETATE 40 MG/ML VIAL INJECTION 07/03/2018 5.69000

METHYLPREDNISOLONE ACETATE 80 MG/ML VIAL INJECTION 07/03/2018 6.30047

METHYLPREDNISOLONE SOD SUCC 125 MG VIAL INJECTION 05/09/2017 5.28000

METHYLPREDNISOLONE SOD SUCC 40 MG VIAL INJECTION 05/02/2017 3.96000

METHYLPREDNISOLONE SOD SUCC 1000 MG VIAL INTRAVEN 01/23/2019 23.97150

METHYLTESTOSTERONE 10 MG CAPSULE ORAL 02/20/2019 76.23382

METOCLOPRAMIDE HCL 5 MG/5 ML SOLUTION ORAL 08/08/2017 0.04746

METOCLOPRAMIDE HCL 10 MG/10ML SOLUTION ORAL 01/23/2019 0.31988

METOCLOPRAMIDE HCL 10 MG TABLET ORAL 04/25/2018 0.04015

METOCLOPRAMIDE HCL 5 MG TABLET ORAL 11/15/2017 0.04409

METOCLOPRAMIDE HCL 5 MG/ML VIAL INJECTION 05/16/2018 0.57234

METOLAZONE 10 MG TABLET ORAL 11/21/2018 2.32142

METOLAZONE 2.5 MG TABLET ORAL 11/21/2018 1.69832

METOLAZONE 5 MG TABLET ORAL 06/20/2018 1.60042

METOPROLOL SUCCINATE 50 MG TAB ER 24H ORAL 01/16/2019 0.10720

METOPROLOL SUCCINATE 100 MG TAB ER 24H ORAL 01/02/2019 0.17192

METOPROLOL SUCCINATE 200 MG TAB ER 24H ORAL 01/23/2019 0.55405

METOPROLOL SUCCINATE 25 MG TAB ER 24H ORAL 01/02/2019 0.34837

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019113

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

METOPROLOL TARTRATE 100 MG TABLET ORAL 02/20/2019 0.02626

METOPROLOL TARTRATE 50 MG TABLET ORAL 02/06/2019 0.01822

METOPROLOL TARTRATE 25 MG TABLET ORAL 02/20/2019 0.01719

METOPROLOL TARTRATE 5 MG/5 ML AMPUL INTRAVEN 10/28/2015 4.86552

METOPROLOL TARTRATE 5 MG/5 ML VIAL INTRAVEN 02/27/2019 0.19832

METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET ORAL 05/09/2017 1.99647

METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET ORAL 05/12/2014 1.27823

METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-50MG TABLET ORAL 12/23/2014 1.25927

METRONIDAZOLE 375 MG CAPSULE ORAL 11/29/2017 11.30703

METRONIDAZOLE 250 MG TABLET ORAL 10/24/2018 0.20891

METRONIDAZOLE 500 MG TABLET ORAL 02/13/2019 0.24053

METRONIDAZOLE 0.75 % GEL (GRAM) TOPICAL 03/08/2017 2.21160

METRONIDAZOLE 1 % GEL (GRAM) TOPICAL 11/07/2018 2.74054

METRONIDAZOLE 0.75 % CREAM (G) TOPICAL 11/02/2016 2.50937

METRONIDAZOLE 1 % GEL W/PUMP TOPICAL 01/12/2016 4.16472

METRONIDAZOLE 0.75 % LOTION TOPICAL 11/11/2015 4.22730

METRONIDAZOLE 0.75 % GEL W/APPL VAGINAL 11/14/2018 1.56455

METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK INTRAVEN 02/27/2019 0.01770

MICONAZOLE NITRATE 2 % AERO POWD TOPICAL 10/17/2018 0.05168

MICONAZOLE NITRATE 2 % CREAM (G) TOPICAL 09/29/2015 0.08474

MICONAZOLE NITRATE 2 % OINT. (G) TOPICAL 01/31/2018 0.08591

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019114

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MICONAZOLE NITRATE 2 % POWDER TOPICAL 12/19/2018 0.06803

MICONAZOLE NITRATE 2 % TINCTURE TOPICAL 05/07/2014 0.81204

MICONAZOLE NITRATE 2 % CREAM/APPL VAGINAL 05/23/2018 0.19564

MICONAZOLE NITRATE 200 MG-2 % KIT VAGINAL 07/18/2018 12.61050

MIDAZOLAM HCL 2 MG/ML SYRUP ORAL 06/19/2017 0.48854

MIDAZOLAM HCL 5 MG/ML VIAL INJECTION 01/16/2019 0.24428

MIDAZOLAM HCL 2 MG/2 ML VIAL INJECTION 02/06/2019 0.19725

MIDAZOLAM HCL 5 MG/5 ML VIAL INJECTION 02/06/2019 0.13856

MIDAZOLAM HCL 10 MG/10ML VIAL INJECTION 10/17/2018 0.21768

MIDAZOLAM HCL 10 MG/2 ML VIAL INJECTION 02/06/2019 0.97954

MIDAZOLAM HCL 5 MG/ML(1) VIAL INJECTION 02/06/2019 0.79194

MIDAZOLAM HCL/PF 2 MG/2 ML SYRINGE INJECTION 02/28/2018 1.05860

MIDAZOLAM HCL/PF 5 MG/ML SYRINGE INJECTION 02/21/2018 2.70864

MIDAZOLAM HCL/PF 5 MG/ML(1) VIAL INJECTION 07/25/2018 1.30992

MIDAZOLAM HCL/PF 10 MG/2 ML VIAL INJECTION 07/25/2018 0.70333

MIDAZOLAM HCL/PF 2 MG/2 ML VIAL INJECTION 08/29/2018 0.34840

MIDAZOLAM HCL/PF 5 MG/5 ML VIAL INJECTION 07/25/2018 0.24518

MIDODRINE HCL 5 MG TABLET ORAL 02/06/2019 0.51711

MIDODRINE HCL 2.5 MG TABLET ORAL 02/06/2019 0.55704

MIDODRINE HCL 10 MG TABLET ORAL 02/06/2019 0.98115

MIGLITOL 25 MG TABLET ORAL 05/11/2016 2.11720

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019115

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MIGLITOL 50 MG TABLET ORAL 01/30/2019 2.53582

MIGLITOL 100 MG TABLET ORAL 05/11/2016 2.94703

MIGLUSTAT 100 MG CAPSULE ORAL 08/08/2018 321.28147

MILRINONE LACTATE 1 MG/ML VIAL INTRAVEN 01/23/2019 0.38860

MILRINONE LACTATE/D5W 20MG/100ML PIGGYBACK INTRAVEN 12/16/2015 0.20495

MILRINONE LACTATE/D5W 40MG/200ML PIGGYBACK INTRAVEN 01/31/2018 0.19154

MINERAL OIL OIL ORAL 04/25/2018 0.00618

MINERAL OIL ENEMA RECTAL 06/13/2018 0.01743

MINERAL OIL OIL TOPICAL 11/18/2015 0.01709

MINERAL OIL OIL MISCELL 06/13/2018 0.02616

MINERAL OIL/CARRAGEENAN 2.5 ML/5ML EMULSION ORAL 02/27/2019 0.01959

MINERAL OIL/HYDROPHIL PETROLAT OINT. (G) TOPICAL 05/09/2018 0.02173

MINERAL OIL/I-PROP MYR/WATER LOTION TOPICAL 09/06/2017 0.01438

MINERAL OIL/PETROLAT,WHT/WATER LOTION TOPICAL 12/07/2016 0.02630

MINERAL OIL/PETROLATUM,WHITE CREAM (G) TOPICAL 11/08/2017 0.01178

MINERAL OIL/PETROLATUM,WHITE 15%-85% OINT. (G) OPHTHALMIC 07/15/2015 2.65990

MINERAL OIL/PETROLATUM,WHITE 15 %-83 % OINT. (G) OPHTHALMIC 02/27/2019 1.24237

MINERAL OIL/PETROLATUM,WHITE 20%-80% OINT. (G) OPHTHALMIC 09/19/2018 2.41200

MINERAL OIL/PETROLATUM,WHITE 3 %-94 % OINT. (G) OPHTHALMIC 02/06/2019 0.95050

MINOCYCLINE HCL 100 MG CAPSULE ORAL 03/13/2015 0.55128

MINOCYCLINE HCL 50 MG CAPSULE ORAL 10/06/2015 0.29574

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019116

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MINOCYCLINE HCL 75 MG CAPSULE ORAL 06/06/2017 0.65312

MINOCYCLINE HCL 100 MG TABLET ORAL 10/10/2018 2.62640

MINOCYCLINE HCL 50 MG TABLET ORAL 04/19/2016 1.52760

MINOCYCLINE HCL 75 MG TABLET ORAL 10/10/2018 1.80002

MINOCYCLINE HCL 45 MG TAB ER 24H ORAL 04/11/2018 13.30000

MINOCYCLINE HCL 135 MG TAB ER 24H ORAL 01/02/2019 13.30000

MINOCYCLINE HCL 65 MG TAB ER 24H ORAL 04/10/2018 33.32207

MINOCYCLINE HCL 115MG TAB ER 24H ORAL 08/22/2018 39.27868

MINOCYCLINE HCL 55 MG TAB ER 24H ORAL 03/06/2019 36.53200

MINOCYCLINE HCL 80 MG TAB ER 24H ORAL 03/06/2019 6.17432

MINOCYCLINE HCL 105 MG TAB ER 24H ORAL 03/06/2019 6.17432

MINOXIDIL 10 MG TABLET ORAL 06/13/2018 0.29346

MINOXIDIL 2.5 MG TABLET ORAL 02/13/2019 0.15236

MINOXIDIL 5 % FOAM TOPICAL 01/16/2019 0.30425

MINOXIDIL 2 % SOLUTION TOPICAL 09/19/2018 0.09849

MINOXIDIL 5 % SOLUTION TOPICAL 02/20/2019 0.29413

MIRTAZAPINE 15 MG TABLET ORAL 11/21/2018 0.07727

MIRTAZAPINE 30 MG TABLET ORAL 04/15/2016 0.09603

MIRTAZAPINE 45 MG TABLET ORAL 04/04/2017 0.11122

MIRTAZAPINE 7.5 MG TABLET ORAL 05/30/2017 1.73619

MIRTAZAPINE 15 MG TAB RAPDIS ORAL 02/13/2019 0.82633

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019117

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MIRTAZAPINE 30 MG TAB RAPDIS ORAL 02/27/2019 0.82633

MIRTAZAPINE 45 MG TAB RAPDIS ORAL 08/08/2018 1.08317

MISOPROSTOL 200 MCG TABLET ORAL 01/30/2018 1.00165

MISOPROSTOL 100 MCG TABLET ORAL 12/07/2016 0.56392

MITOMYCIN 20 MG VIAL INTRAVEN 02/13/2019 285.71875

MITOMYCIN 40 MG VIAL INTRAVEN 02/13/2019 578.65350

MITOMYCIN 5 MG VIAL INTRAVEN 02/27/2019 125.69575

MITOXANTRONE HCL 2 MG/ML VIAL INTRAVEN 07/03/2018 9.87237

MODAFINIL 100 MG TABLET ORAL 11/14/2018 0.80355

MODAFINIL 200 MG TABLET ORAL 12/26/2018 0.78911

MOEXIPRIL HCL 7.5 MG TABLET ORAL 01/12/2016 0.77425

MOEXIPRIL HCL 15 MG TABLET ORAL 01/12/2016 0.73740

MOMETASONE FUROATE 0.1 % CREAM (G) TOPICAL 12/05/2018 0.44577

MOMETASONE FUROATE 0.1 % OINT. (G) TOPICAL 11/14/2018 0.19743

MOMETASONE FUROATE 50 MCG SPRAY/PUMP NASAL 04/25/2017 6.72353

MONTELUKAST SODIUM 4 MG GRAN PACK ORAL 01/23/2019 5.65785

MONTELUKAST SODIUM 10 MG TABLET ORAL 02/06/2019 0.08486

MONTELUKAST SODIUM 5 MG TAB CHEW ORAL 01/09/2019 0.10943

MONTELUKAST SODIUM 4 MG TAB CHEW ORAL 06/30/2015 0.10065

MORPHINE SULFATE 10 MG CAP ER PEL ORAL 07/24/2014 3.12320

MORPHINE SULFATE 20 MG CAP ER PEL ORAL 10/01/2014 4.18664

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019118

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MORPHINE SULFATE 50 MG CAP ER PEL ORAL 03/06/2019 8.47260

MORPHINE SULFATE 100 MG CAP ER PEL ORAL 10/01/2014 12.58895

MORPHINE SULFATE 80 MG CAP ER PEL ORAL 07/24/2014 10.64981

MORPHINE SULFATE 30 MG CAP ER PEL ORAL 10/01/2014 5.10866

MORPHINE SULFATE 60 MG CAP ER PEL ORAL 07/24/2014 8.40324

MORPHINE SULFATE 40 MG CAP ER PEL ORAL 11/14/2018 16.29285

MORPHINE SULFATE 10 MG/5 ML SOLUTION ORAL 08/01/2018 0.05684

MORPHINE SULFATE 20 MG/5 ML SOLUTION ORAL 08/29/2018 0.10057

MORPHINE SULFATE 100 MG/5ML SOLUTION ORAL 09/06/2016 0.22333

MORPHINE SULFATE 30 MG TABLET ER ORAL 12/12/2018 0.49352

MORPHINE SULFATE 60 MG TABLET ER ORAL 03/06/2019 0.60313

MORPHINE SULFATE 100 MG TABLET ER ORAL 01/16/2019 0.90705

MORPHINE SULFATE 15 MG TABLET ER ORAL 01/16/2019 0.24254

MORPHINE SULFATE 200 MG TABLET ER ORAL 02/23/2016 2.70521

MORPHINE SULFATE/PF 0.5 MG/ML AMPUL INJECTION 04/11/2018 5.14140

MORPHINE SULFATE/PF 1 MG/ML AMPUL INJECTION 08/09/2017 5.47148

MORPHINE SULFATE/PF 0.5 MG/ML VIAL INJECTION 01/22/2014 1.34683

MORPHINE SULFATE/PF 1 MG/ML VIAL INJECTION 04/22/2014 1.36720

MOXIFLOXACIN HCL 400 MG TABLET ORAL 02/20/2019 2.66552

MOXIFLOXACIN HCL 0.5 % DROPS OPHTHALMIC 12/05/2018 9.48750

MOXIFLOXACIN IN NACL (ISO-OSM) 400MG/.25L PIGGYBACK INTRAVEN 07/03/2018 0.28785

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019119

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MULTIVIT WITH IRON,MINERALS TABLET ORAL 08/30/2017 0.04650

MULTIVIT WITH MINERALS/LUTEIN TABLET ORAL 10/09/2013 0.02653

MULTIVIT,CALC,MINS/IRON/FOLIC 9MG-400MCG TABLET ORAL 05/23/2018 0.03721

MULTIVIT,CALC,MINS/IRON/FOLIC 500-18-0.4 TABLET ORAL 12/20/2017 0.09246

MULTIVIT,IRON,MINERALS/LUTEIN TABLET ORAL 10/09/2013 0.03245

MULTIVIT,STRESS FORMULA/ZINC TABLET ORAL 01/30/2019 0.05474

MULTIVIT-MIN 62/IRON FUM/FOLIC 106 MG-1MG CAPSULE ORAL 01/22/2013 0.08500

MULTIVIT-MIN/FA/LYCOPEN/LUTEIN .4-300-250 TABLET ORAL 03/04/2015 0.03337

MULTIVIT-MIN/FA/LYCOPEN/LUTEIN 500-300MCG TABLET ORAL 01/22/2013 0.07136

MULTIVIT-MIN/FA/LYCOPEN/LUTEIN 800-250MCG TABLET ORAL 09/09/2015 0.26733

MULTIVIT-MIN/FOLIC/VIT K/LYCOP 400-300MCG TABLET ORAL 01/30/2019 0.07797

MULTIVIT-MIN/FOLIC/VIT K/LYCOP 400-20-370 TABLET ORAL 11/07/2018 0.09632

MULTIVIT-MIN/IRON/FOLIC ACID/K 18-400-25 TABLET ORAL 10/31/2018 0.16321

MULTIVIT-MIN/IRON/VITAMIN K 18MG-25MCG TABLET ORAL 11/07/2018 0.07913

MULTIVIT-MINERALS/FERROUS GLUC 9 MG/15 ML LIQUID ORAL 12/19/2018 0.03317

MULTIVIT-MINERALS/FOLIC ACID 0.4 MG TABLET ORAL 02/07/2018 0.09755

MULTIVIT-MINERALS/FOLIC ACID 200 MCG TAB CHEW ORAL 01/30/2019 0.10162

MULTIVIT-MINS NO.61/IRON/FOLIC 27 MG-1 MG TABLET ORAL 01/22/2013 0.08500

MULTIVIT-MINS NO.7/FOLIC ACID 1 MG CAPSULE ORAL 06/13/2018 0.72583

MULTIVIT-MINS60/IRON FUM/FOLIC 27 MG-1 MG TABLET ORAL 06/13/2018 0.21440

MULTIVIT34/FOLIC AC/NADH/COQ10 1-5-50 MG TABLET ORAL 06/13/2018 21.79187

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019120

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

MULTIVITAMIN TABLET ORAL 10/17/2018 0.01119

MULTIVITAMIN TAB CHEW ORAL 05/23/2018 0.02734

MULTIVITAMIN WITH FOLIC ACID 400 MCG TABLET ORAL 01/23/2019 0.03082

MULTIVITAMIN WITH IRON TABLET ORAL 01/23/2019 0.01796

MULTIVITAMIN WITH IRON TAB CHEW ORAL 05/23/2018 0.02747

MULTIVITAMIN WITH MINERALS LIQUID ORAL 01/06/2016 0.07520

MULTIVITAMIN WITH MINERALS TABLET ORAL 06/22/2016 0.02538

MULTIVITAMIN,STRESS FORMULA TABLET ORAL 11/20/2013 0.04947

MULTIVITAMIN,THER AND MINERALS TABLET ORAL 10/09/2013 0.03211

MULTIVITAMIN,THERAPEUTIC TABLET ORAL 05/23/2017 0.02814

MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG TABLET ORAL 12/19/2018 0.01089

MUPIROCIN 2 % OINT. (G) TOPICAL 03/06/2019 0.21927

MUPIROCIN CALCIUM 2 % CREAM (G) TOPICAL 04/19/2016 7.91235

MV-MIN/IRON/FOLIC/CALCIUM/VITK 18-400-500 TABLET ORAL 11/07/2018 0.07467

MYCOPHENOLATE MOFETIL 250 MG CAPSULE ORAL 01/23/2019 0.24763

MYCOPHENOLATE MOFETIL 200 MG/ML SUSP RECON ORAL 02/20/2019 9.61141

MYCOPHENOLATE MOFETIL 500 MG TABLET ORAL 01/23/2019 0.35108

MYCOPHENOLATE MOFETIL HCL 500 MG VIAL INTRAVEN 08/15/2018 60.80556

MYCOPHENOLATE SODIUM 180 MG TABLET DR ORAL 01/16/2019 1.82318

MYCOPHENOLATE SODIUM 360 MG TABLET DR ORAL 12/05/2018 4.48910

NABUMETONE 500 MG TABLET ORAL 01/02/2019 0.22284

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019121

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NABUMETONE 750 MG TABLET ORAL 12/19/2018 0.23289

NADOLOL 20 MG TABLET ORAL 04/19/2016 0.60648

NADOLOL 40 MG TABLET ORAL 01/16/2019 2.10152

NADOLOL 80 MG TABLET ORAL 02/27/2019 0.99026

NADOLOL/BENDROFLUMETHIAZIDE 40 MG-5 MG TABLET ORAL 01/23/2019 9.09120

NADOLOL/BENDROFLUMETHIAZIDE 80 MG-5 MG TABLET ORAL 09/26/2018 11.47256

NAFCILLIN SODIUM 1 G VIAL INJECTION 01/30/2019 5.92963

NAFCILLIN SODIUM 10 G VIAL INJECTION 04/18/2017 42.02500

NAFCILLIN SODIUM 2 G VIAL INJECTION 02/06/2019 9.25750

NAFTIFINE HCL 1 % CREAM (G) TOPICAL 10/17/2017 5.92667

NAFTIFINE HCL 2 % CREAM (G) TOPICAL 12/19/2018 5.71020

NALBUPHINE HCL 10 MG/ML AMPUL INJECTION 01/24/2018 4.50186

NALOXONE HCL 0.4 MG/ML VIAL INJECTION 01/30/2019 5.78485

NALTREXONE HCL 50 MG TABLET ORAL 10/17/2018 0.84152

NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS OPHTHALMIC 07/03/2018 0.12730

NAPHAZOLINE HCL/GLYCERIN 0.012-0.25 DROPS OPHTHALMIC 04/01/2015 0.14516

NAPHAZOLINE HCL/PHENIRAMINE 0.025-0.3% DROPS OPHTHALMIC 02/20/2019 0.41160

NAPHAZOLINE/ZINC SULF/GLYCERIN 0.012-0.25 DROPS OPHTHALMIC 04/20/2016 0.32875

NAPROXEN 125 MG/5ML ORAL SUSP ORAL 02/21/2018 1.31025

NAPROXEN 250 MG TABLET ORAL 02/06/2019 0.05411

NAPROXEN 375 MG TABLET ORAL 11/21/2018 0.07196

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019122

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NAPROXEN 500 MG TABLET ORAL 02/20/2019 0.09460

NAPROXEN 375 MG TABLET DR ORAL 02/13/2019 0.21609

NAPROXEN 500 MG TABLET DR ORAL 02/13/2019 0.81070

NAPROXEN SODIUM 220 MG CAPSULE ORAL 03/06/2019 0.17264

NAPROXEN SODIUM 275 MG TABLET ORAL 04/24/2017 1.20935

NAPROXEN SODIUM 550 MG TABLET ORAL 12/19/2018 0.64374

NAPROXEN SODIUM 220 MG TABLET ORAL 12/12/2018 0.07397

NAPROXEN SODIUM 500 MG TBMP 24HR ORAL 12/26/2018 12.85186

NAPROXEN SODIUM 375 MG TBMP 24HR ORAL 12/19/2018 12.08889

NARATRIPTAN HCL 2.5 MG TABLET ORAL 08/11/2015 2.65907

NARATRIPTAN HCL 1 MG TABLET ORAL 06/27/2018 6.60400

NATEGLINIDE 120 MG TABLET ORAL 02/13/2019 0.57352

NATEGLINIDE 60 MG TABLET ORAL 02/20/2019 0.55193

NEBULIZER EACH MISCELL 01/15/2014 77.90000

NEEDLELESS DISPENSING PIN EACH MISCELL 12/23/2015 1.85858

NEEDLES, BLOOD COLLECTION 20GX1" DIS NEEDLE MISCELL 05/17/2017 0.07437

NEEDLES, BLOOD COLLECTION 21 G X 1" DIS NEEDLE MISCELL 05/17/2017 0.07437

NEEDLES, BLOOD COLLECTION 22GX1" DIS NEEDLE MISCELL 05/17/2017 0.07437

NEEDLES, DISPOSABLE 16 G X 1" DIS NEEDLE MISCELL 03/23/2016 0.09484

NEEDLES, DISPOSABLE 16GX1.5" DIS NEEDLE MISCELL 01/03/2018 0.18385

NEEDLES, DISPOSABLE 18GX1" DIS NEEDLE MISCELL 03/23/2016 0.04543

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019123

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NEEDLES, DISPOSABLE 18GX1 1/2" DIS NEEDLE MISCELL 03/23/2016 0.04543

NEEDLES, DISPOSABLE 19GX1" DIS NEEDLE MISCELL 06/21/2017 0.05467

NEEDLES, DISPOSABLE 19GX1 1/2" DIS NEEDLE MISCELL 06/21/2017 0.05467

NEEDLES, DISPOSABLE 20GX1" DIS NEEDLE MISCELL 06/21/2017 0.05360

NEEDLES, DISPOSABLE 20GX1 1/2" DIS NEEDLE MISCELL 06/21/2017 0.05467

NEEDLES, DISPOSABLE 21 G X 1" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 21GX1 1/2" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 21GX2" DIS NEEDLE MISCELL 02/14/2018 0.22494

NEEDLES, DISPOSABLE 22GX3/4" DIS NEEDLE MISCELL 05/17/2017 0.09715

NEEDLES, DISPOSABLE 22GX1" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 22GX1 1/2" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 23GX3/4" DIS NEEDLE MISCELL 05/17/2017 0.05762

NEEDLES, DISPOSABLE 23GX1" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 23GX1.25" DIS NEEDLE MISCELL 06/21/2017 0.09005

NEEDLES, DISPOSABLE 23GX1 1/2" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 25GX5/8" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 25GX1" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 25GX1 1/2" DIS NEEDLE MISCELL 11/08/2017 0.03343

NEEDLES, DISPOSABLE 26GX3/8" DIS NEEDLE MISCELL 06/21/2017 0.07973

NEEDLES, DISPOSABLE 26GX1/2" DIS NEEDLE MISCELL 03/29/2018 0.08707

NEEDLES, DISPOSABLE 26 G X5/8" DIS NEEDLE MISCELL 02/17/2016 0.05028

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019124

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NEEDLES, DISPOSABLE 26GX1.5" DIS NEEDLE MISCELL 05/17/2017 0.09715

NEEDLES, DISPOSABLE 27GX1/2" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 27GX1.25" DIS NEEDLE MISCELL 02/17/2016 0.04543

NEEDLES, DISPOSABLE 27GX1.5" DIS NEEDLE MISCELL 02/17/2016 0.05069

NEEDLES, DISPOSABLE 30GX1/2" DIS NEEDLE MISCELL 02/17/2016 0.04685

NEEDLES, DISPOSABLE 30GX3/4" DIS NEEDLE MISCELL 01/22/2013 0.07185

NEEDLES, DISPOSABLE 30GX1" DIS NEEDLE MISCELL 06/21/2017 0.23155

NEEDLES, FILTER 18GX1 1/2" DIS NEEDLE MISCELL 02/13/2019 0.34894

NEEDLES, SAFETY 25GX5/8" DIS NEEDLE MISCELL 07/18/2018 0.22860

NEEDLES, SAFETY 23GX1" DIS NEEDLE MISCELL 02/10/2016 0.16357

NEEDLES, SAFETY 27GX1/2" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 26GX1/2" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 25GX1" DIS NEEDLE MISCELL 07/19/2017 0.21882

NEEDLES, SAFETY 25GX1 1/2" DIS NEEDLE MISCELL 07/18/2018 0.22659

NEEDLES, SAFETY 18GX1" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 18GX1 1/2" DIS NEEDLE MISCELL 07/18/2018 0.33688

NEEDLES, SAFETY 19GX1" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 19GX1 1/2" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 20GX1" DIS NEEDLE MISCELL 02/10/2016 0.09903

NEEDLES, SAFETY 20GX1 1/2" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 21 G X 1" DIS NEEDLE MISCELL 02/10/2016 0.15464

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019125

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NEEDLES, SAFETY 21GX1 1/2" DIS NEEDLE MISCELL 01/09/2019 0.33956

NEEDLES, SAFETY 22GX1" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 22GX1 1/2" DIS NEEDLE MISCELL 07/18/2018 0.33688

NEEDLES, SAFETY 23GX1 1/2" DIS NEEDLE MISCELL 02/10/2016 0.16053

NEEDLES, SAFETY 30GX1/2" DIS NEEDLE MISCELL 02/10/2016 0.15464

NEOMYCIN SULF/BACITRACIN/POLY 3.5MG-400 OINT. (G) OPHTHALMIC 11/28/2018 4.62000

NEOMYCIN SULF/POLYMYXIN B SULF 40-200K/ML AMPUL IRRIGATION 09/20/2017 7.67016

NEOMYCIN SULFATE 500 MG TABLET ORAL 07/25/2018 0.80534

NEOMYCIN/BACIT/P-MYX/HYDROCORT 3.5-10K-1 OINT. (G) OPHTHALMIC 06/07/2017 3.36600

NEOMYCIN/BACITRACIN/POLYMYXINB 3.5-400-5K OINT PACK TOPICAL 11/07/2018 0.19718

NEOMYCIN/BACITRACIN/POLYMYXINB 3.5-400-5K OINT. (G) TOPICAL 02/13/2019 0.16169

NEOMYCIN/POLYMYXIN B/DEXAMETHA 3.5-10K-.1 OINT. (G) OPHTHALMIC 01/30/2019 4.00620

NEOMYCIN/POLYMYXIN B/DEXAMETHA 0.1 % DROPS SUSP OPHTHALMIC 08/25/2015 4.08408

NEOMYCIN/POLYMYXIN B/HYDROCORT 3.5-10K-1 SOLUTION OTIC (EAR) 07/11/2018 9.00000

NEOMYCIN/POLYMYXIN B/HYDROCORT 3.5-10K-1 DROPS SUSP OTIC (EAR) 10/31/2018 9.00000

NEOMYCN/BACITRC/POLYMYX/PRAMOX 3.5-10K-10 OINT. (G) TOPICAL 02/20/2019 0.19296

NEOSTIGMINE METHYLSULFATE 0.5 MG/ML VIAL INTRAVEN 02/27/2019 1.96766

NEOSTIGMINE METHYLSULFATE 1 MG/ML VIAL INTRAVEN 02/27/2019 2.14400

NEVIRAPINE 50 MG/5 ML ORAL SUSP ORAL 01/23/2019 0.98914

NEVIRAPINE 200 MG TABLET ORAL 03/06/2019 0.14628

NEVIRAPINE 400 MG TAB ER 24H ORAL 03/06/2019 5.71458

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019126

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NEVIRAPINE 100 MG TAB ER 24H ORAL 09/24/2018 5.26577

NIACIN 250 MG CAPSULE ER ORAL 02/20/2018 0.04583

NIACIN 500 MG CAPSULE ER ORAL 01/02/2019 0.06110

NIACIN 100 MG TABLET ORAL 08/01/2018 0.02193

NIACIN 250 MG TABLET ORAL 03/21/2018 0.04784

NIACIN 500 MG TABLET ORAL 07/03/2018 0.01954

NIACIN 500 MG TAB ER 24H ORAL 01/23/2019 0.75933

NIACIN 750 MG TAB ER 24H ORAL 11/21/2018 1.71222

NIACIN 1000 MG TAB ER 24H ORAL 12/12/2018 1.20600

NIACIN 250 MG TABLET ER ORAL 02/14/2018 0.02365

NIACIN 500 MG TABLET ER ORAL 07/03/2018 0.03591

NIACIN 750 MG TABLET ER ORAL 03/07/2018 0.08840

NIACIN 1000 MG TABLET ER ORAL 01/22/2013 1.18813

NIACIN (INOSITOL NIACINATE) 400(500MG) CAPSULE ORAL 12/05/2018 0.05360

NIACINAMIDE 500 MG TABLET ORAL 07/03/2018 0.03055

NIACINAMIDE 500 MG TABLET ER ORAL 03/07/2018 0.05836

NICARDIPINE HCL 20 MG CAPSULE ORAL 01/06/2015 2.10767

NICARDIPINE HCL 30 MG CAPSULE ORAL 01/09/2019 3.03409

NICARDIPINE HCL 25 MG/10ML AMPUL INTRAVEN 11/11/2015 13.13156

NICARDIPINE HCL 25 MG/10ML VIAL INTRAVEN 02/06/2019 2.14212

NICOTINE 7MG/24HR PATCH TD24 TRANSDERM 01/30/2019 1.81761

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019127

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NICOTINE 14MG/24HR PATCH TD24 TRANSDERM 01/02/2019 1.81761

NICOTINE 21 MG/24HR PATCH TD24 TRANSDERM 01/02/2019 1.70802

NICOTINE POLACRILEX 2 MG GUM BUCCAL 05/26/2015 0.25755

NICOTINE POLACRILEX 4 MG GUM BUCCAL 02/13/2019 0.24870

NICOTINE POLACRILEX 4 MG LOZENGE BUCCAL 04/18/2016 0.48267

NICOTINE POLACRILEX 2 MG LOZENGE BUCCAL 10/31/2018 0.44911

NIFEDIPINE 10 MG CAPSULE ORAL 10/03/2018 0.62243

NIFEDIPINE 20 MG CAPSULE ORAL 02/13/2019 1.79198

NIFEDIPINE 30 MG TAB ER 24 ORAL 02/20/2019 0.33071

NIFEDIPINE 60 MG TAB ER 24 ORAL 02/20/2019 0.29681

NIFEDIPINE 90 MG TAB ER 24 ORAL 08/18/2015 0.64454

NIFEDIPINE 30 MG TABLET ER ORAL 11/21/2018 0.17420

NIFEDIPINE 60 MG TABLET ER ORAL 11/21/2017 0.63744

NIFEDIPINE 90 MG TABLET ER ORAL 10/03/2018 1.01693

NILUTAMIDE 150 MG TABLET ORAL 02/22/2017 158.05158

NIMODIPINE 30 MG CAPSULE ORAL 05/12/2014 2.22440

NISOLDIPINE 8.5MG TAB ER 24H ORAL 01/31/2018 5.52818

NISOLDIPINE 17 MG TAB ER 24H ORAL 01/31/2018 6.67588

NISOLDIPINE 34 MG TAB ER 24H ORAL 01/31/2018 7.55612

NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE ORAL 02/06/2019 1.18925

NITROFURANTOIN MACROCRYSTAL 25 MG CAPSULE ORAL 12/12/2018 4.74012

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019128

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE ORAL 02/06/2019 0.71141

NITROGLYCERIN 400MCG/SPR SPRAY TRANSLING 08/25/2015 22.07786

NITROGLYCERIN 0.3 MG TAB SUBL SUBLINGUAL 01/16/2018 0.37788

NITROGLYCERIN 0.4 MG TAB SUBL SUBLINGUAL 09/24/2018 0.46712

NITROGLYCERIN 0.6 MG TAB SUBL SUBLINGUAL 01/16/2018 0.37172

NITROGLYCERIN 0.4MG/HR PATCH TD24 TRANSDERM 07/03/2018 0.58915

NITROGLYCERIN 0.6MG/HR PATCH TD24 TRANSDERM 06/13/2018 0.80936

NITROGLYCERIN 0.1MG/HR PATCH TD24 TRANSDERM 01/16/2018 0.81874

NITROGLYCERIN 0.2MG/HR PATCH TD24 TRANSDERM 08/22/2018 0.49982

NITROGLYCERIN IN 5 % DEXTROSE 50MG/250ML INFUS. BTL INTRAVEN 03/08/2017 0.03244

NITROGLYCERIN IN 5 % DEXTROSE 25MG/250ML INFUS. BTL INTRAVEN 03/08/2017 0.03463

NITROGLYCERIN IN 5 % DEXTROSE 100MG/250 INFUS. BTL INTRAVEN 04/12/2017 0.04700

NITROPRUSSIDE SODIUM 25 MG/ML VIAL INTRAVEN 12/26/2018 19.95000

NIZATIDINE 150 MG CAPSULE ORAL 05/22/2018 0.20100

NIZATIDINE 300 MG CAPSULE ORAL 09/05/2018 0.55387

NONOXYNOL 9 4 % GEL/PF APP VAGINAL 03/30/2016 0.42012

NOREPINEPHRINE BITARTRATE 1 MG/ML AMPUL INTRAVEN 01/23/2019 4.45764

NOREPINEPHRINE BITARTRATE 1 MG/ML VIAL INTRAVEN 02/06/2019 4.32861

NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) TAB CHEW ORAL 12/19/2018 1.55009

NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB CHEW ORAL 05/04/2016 4.14087

NORETHINDRONE 0.35 MG TABLET ORAL 12/19/2018 0.11438

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019129

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NORETHINDRONE AC-ETH ESTRADIOL 1.5-0.03MG TABLET ORAL 06/07/2017 1.09891

NORETHINDRONE AC-ETH ESTRADIOL 1MG-20MCG TABLET ORAL 12/19/2018 0.19483

NORETHINDRONE AC-ETH ESTRADIOL 1MG-5MCG TABLET ORAL 10/24/2018 1.60770

NORETHINDRONE AC-ETH ESTRADIOL 0.5MG-2.5 TABLET ORAL 02/20/2018 3.32671

NORETHINDRONE ACETATE 5 MG TABLET ORAL 04/18/2016 2.25120

NORETHINDRONE-E.ESTRADIOL-IRON 1.5-30(21) TABLET ORAL 07/03/2018 0.49317

NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(21) TABLET ORAL 05/12/2015 0.33277

NORETHINDRONE-E.ESTRADIOL-IRON 5-7-9-7 TABLET ORAL 11/07/2018 5.16654

NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) TABLET ORAL 12/12/2018 1.58997

NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) TAB CHEW ORAL 01/30/2019 2.63214

NORETHINDRONE-ETHINYL ESTRAD 0.4-0.035 TABLET ORAL 11/07/2018 0.68093

NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET ORAL 07/03/2018 0.82968

NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET ORAL 11/21/2018 0.52164

NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET ORAL 07/25/2018 0.54079

NORETHINDRONE-ETHINYL ESTRAD 7-9-5 TABLET ORAL 02/20/2019 2.75684

NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET ORAL 07/25/2018 0.52164

NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET ORAL 02/13/2019 0.14580

NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET ORAL 02/27/2019 0.20626

NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 LO TABLET ORAL 03/06/2019 0.36882

NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET ORAL 07/03/2018 0.68396

NORTRIPTYLINE HCL 10 MG CAPSULE ORAL 05/09/2018 0.09273

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019130

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

NORTRIPTYLINE HCL 25 MG CAPSULE ORAL 02/27/2019 0.15423

NORTRIPTYLINE HCL 50 MG CAPSULE ORAL 01/16/2019 0.19041

NORTRIPTYLINE HCL 75 MG CAPSULE ORAL 01/16/2019 0.26934

NYSTATIN 100000/ML ORAL SUSP ORAL 05/16/2017 0.08347

NYSTATIN 500K UNIT TABLET ORAL 07/01/2015 0.46900

NYSTATIN 100000/G CREAM (G) TOPICAL 04/09/2018 0.28721

NYSTATIN 100000/G OINT. (G) TOPICAL 02/27/2019 0.29659

NYSTATIN 100000/G POWDER TOPICAL 02/27/2019 0.31669

NYSTATIN/TRIAMCIN 100000-0.1 CREAM (G) TOPICAL 12/05/2018 0.25594

NYSTATIN/TRIAMCIN 100000-0.1 OINT. (G) TOPICAL 12/19/2017 0.37922

OCTREOTIDE ACETATE 50 MCG/ML AMPUL INJECTION 01/23/2019 14.07210

OCTREOTIDE ACETATE 100 MCG/ML AMPUL INJECTION 01/23/2019 26.64693

OCTREOTIDE ACETATE 500 MCG/ML AMPUL INJECTION 01/23/2019 128.52168

OCTREOTIDE ACETATE 200 MCG/ML VIAL INJECTION 02/27/2019 7.45490

OCTREOTIDE ACETATE 1000MCG/ML VIAL INJECTION 01/23/2019 27.79390

OCTREOTIDE ACETATE 50 MCG/ML VIAL INJECTION 10/31/2018 2.62238

OCTREOTIDE ACETATE 500 MCG/ML VIAL INJECTION 01/23/2019 13.26990

OCTREOTIDE ACETATE 100 MCG/ML VIAL INJECTION 02/06/2019 3.56664

OFLOXACIN 400 MG TABLET ORAL 02/13/2019 14.30940

OFLOXACIN 0.3 % DROPS OPHTHALMIC 01/16/2019 2.05288

OFLOXACIN 0.3 % DROPS OTIC (EAR) 11/28/2018 2.21368

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019131

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OLANZAPINE 7.5 MG TABLET ORAL 08/04/2015 0.11792

OLANZAPINE 10 MG TABLET ORAL 07/12/2016 0.13132

OLANZAPINE 5 MG TABLET ORAL 03/14/2017 0.07860

OLANZAPINE 2.5 MG TABLET ORAL 12/12/2018 0.07893

OLANZAPINE 15 MG TABLET ORAL 12/13/2016 0.22244

OLANZAPINE 20 MG TABLET ORAL 02/21/2017 0.26754

OLANZAPINE 5 MG TAB RAPDIS ORAL 02/13/2019 0.46945

OLANZAPINE 10 MG TAB RAPDIS ORAL 03/14/2017 0.69774

OLANZAPINE 15 MG TAB RAPDIS ORAL 07/11/2017 0.93344

OLANZAPINE 20 MG TAB RAPDIS ORAL 02/21/2017 1.21404

OLANZAPINE 10 MG VIAL INTRAMUSC 07/25/2018 23.62500

OLANZAPINE/FLUOXETINE HCL 6MG-25MG CAPSULE ORAL 08/25/2015 7.74960

OLANZAPINE/FLUOXETINE HCL 6MG-50MG CAPSULE ORAL 11/03/2015 9.22560

OLANZAPINE/FLUOXETINE HCL 12MG-25MG CAPSULE ORAL 11/03/2015 14.42280

OLANZAPINE/FLUOXETINE HCL 12MG-50MG CAPSULE ORAL 11/02/2017 9.99200

OLANZAPINE/FLUOXETINE HCL 3 MG-25 MG CAPSULE ORAL 04/25/2017 6.50790

OLIVE OIL OIL MISCELL 03/06/2019 0.02342

OLMESARTAN MEDOXOMIL 5 MG TABLET ORAL 12/12/2018 0.05896

OLMESARTAN MEDOXOMIL 20 MG TABLET ORAL 12/12/2018 0.06745

OLMESARTAN MEDOXOMIL 40 MG TABLET ORAL 12/12/2018 0.10631

OLMESARTAN/AMLODIPIN/HCTHIAZID 20-5-12.5 TABLET ORAL 08/22/2018 2.04008

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019132

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-12.5 TABLET ORAL 08/22/2018 2.57682

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 MG TABLET ORAL 02/28/2018 2.53394

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-12.5 TABLET ORAL 12/20/2017 2.57682

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-25MG TABLET ORAL 08/22/2018 2.57682

OLMESARTAN/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET ORAL 01/23/2019 0.15589

OLMESARTAN/HYDROCHLOROTHIAZIDE 40-12.5 MG TABLET ORAL 11/14/2018 0.24291

OLMESARTAN/HYDROCHLOROTHIAZIDE 40 MG-25MG TABLET ORAL 04/03/2018 0.21904

OLOPATADINE HCL 0.1 % DROPS OPHTHALMIC 02/20/2019 5.83438

OLOPATADINE HCL 0.2 % DROPS OPHTHALMIC 11/14/2018 6.16712

OLOPATADINE HCL 0.6 % SPRAY/PUMP NASAL 12/12/2018 3.60580

OMEGA-3 ACID ETHYL ESTERS 1 G CAPSULE ORAL 01/30/2019 0.33355

OMEGA-3 FATTY ACIDS 1000 MG CAPSULE ORAL 06/13/2018 0.14874

OMEGA-3 FATTY ACIDS/FISH OIL 300-1000MG CAPSULE ORAL 04/11/2015 0.06376

OMEGA-3 FATTY ACIDS/FISH OIL 360-1200MG CAPSULE ORAL 10/17/2018 0.06707

OMEGA-3/DHA/EPA/FISH OIL 300-1000MG CAPSULE ORAL 10/24/2018 0.06376

OMEGA-3/DHA/EPA/FISH OIL 1000 MG CAPSULE ORAL 11/15/2017 0.06075

OMEGA-3/DHA/EPA/FISH OIL 60 MG-90MG CAPSULE ORAL 05/23/2018 0.03845

OMEGA-3/DHA/EPA/FISH OIL 300-1000MG CAPSULE DR ORAL 12/19/2018 0.08587

OMEGA-3S/DHA/EPA/FISH OIL/D3 360MG-1000 CAPSULE ORAL 11/07/2018 0.11584

OMEPRAZOLE 20 MG CAPSULE DR ORAL 12/26/2018 0.05570

OMEPRAZOLE 10 MG CAPSULE DR ORAL 03/06/2019 0.32356

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019133

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OMEPRAZOLE 40 MG CAPSULE DR ORAL 03/06/2019 0.07437

OMEPRAZOLE 20 MG TABLET DR ORAL 12/19/2018 0.63985

OMEPRAZOLE MAGNESIUM 20 MG CAPSULE DR ORAL 07/03/2018 0.44411

OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G CAPSULE ORAL 07/03/2018 5.12996

OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G CAPSULE ORAL 07/03/2018 5.12996

OMEPRAZOLE/SODIUM BICARBONATE 20-1680MG PACKET ORAL 01/23/2019 107.54881

OMEPRAZOLE/SODIUM BICARBONATE 40-1680MG PACKET ORAL 11/02/2016 53.72845

ONDANSETRON 4 MG TAB RAPDIS ORAL 02/06/2019 0.26934

ONDANSETRON 8 MG TAB RAPDIS ORAL 01/23/2019 0.29301

ONDANSETRON HCL 4 MG/5 ML SOLUTION ORAL 02/20/2019 0.57915

ONDANSETRON HCL 4 MG TABLET ORAL 03/06/2019 0.10854

ONDANSETRON HCL 8 MG TABLET ORAL 02/27/2019 0.15544

ONDANSETRON HCL 2 MG/ML VIAL INTRAVEN 02/13/2019 0.08375

ONDANSETRON HCL/PF 4 MG/2 ML SYRINGE INJECTION 01/04/2017 0.76380

ONDANSETRON HCL/PF 4 MG/2 ML VIAL INJECTION 05/19/2015 0.25862

ORANGE OIL OIL MISCELL 07/15/2015 0.48240

ORNITHINE HCL 100 % POWDER MISCELL 01/02/2019 0.58162

ORPHENADRINE CITRATE 100 MG TABLET ER ORAL 01/06/2015 0.49272

OSELTAMIVIR PHOSPHATE 75 MG CAPSULE ORAL 03/06/2019 7.38886

OSELTAMIVIR PHOSPHATE 30 MG CAPSULE ORAL 03/06/2019 7.31266

OSELTAMIVIR PHOSPHATE 45 MG CAPSULE ORAL 03/06/2019 7.31266

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019134

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OSELTAMIVIR PHOSPHATE 6 MG/ML SUSP RECON ORAL 02/06/2019 1.60755

OXALIPLATIN 50 MG VIAL INTRAVEN 01/30/2018 61.50000

OXALIPLATIN 100 MG VIAL INTRAVEN 10/04/2017 123.00000

OXALIPLATIN 50 MG/10ML VIAL INTRAVEN 03/06/2019 1.34000

OXALIPLATIN 100MG/20ML VIAL INTRAVEN 03/06/2019 1.23280

OXANDROLONE 2.5 MG TABLET ORAL 02/20/2019 3.07560

OXANDROLONE 10 MG TABLET ORAL 05/16/2018 11.84297

OXAPROZIN 600 MG TABLET ORAL 11/28/2018 1.07843

OXAZEPAM 10 MG CAPSULE ORAL 07/20/2016 0.45510

OXAZEPAM 15 MG CAPSULE ORAL 08/24/2016 0.81841

OXAZEPAM 30 MG CAPSULE ORAL 08/11/2015 1.35103

OXCARBAZEPINE 300 MG/5ML ORAL SUSP ORAL 12/12/2018 0.47754

OXCARBAZEPINE 300 MG TABLET ORAL 08/09/2016 0.22110

OXCARBAZEPINE 600 MG TABLET ORAL 12/26/2018 0.40200

OXCARBAZEPINE 150 MG TABLET ORAL 11/18/2014 0.19368

OXICONAZOLE NITRATE 1 % CREAM (G) TOPICAL 04/09/2018 5.23939

OXYBUTYNIN 3.9MG/24HR PATCH TD 4 TRANSDERM 08/24/2016 3.11149

OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 ORAL 12/05/2018 0.82008

OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 ORAL 05/16/2018 0.82008

OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 ORAL 09/29/2015 0.82008

OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP ORAL 05/23/2018 0.02789

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019135

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OXYBUTYNIN CHLORIDE 5 MG TABLET ORAL 05/12/2015 0.22097

OXYCODONE HCL 5 MG CAPSULE ORAL 11/14/2018 1.09759

OXYCODONE HCL 10 MG TAB ER 12H ORAL 01/17/2018 2.09650

OXYCODONE HCL 15 MG TAB ER 12H ORAL 03/14/2016 3.19176

OXYCODONE HCL 20 MG TAB ER 12H ORAL 01/17/2018 3.85150

OXYCODONE HCL 30 MG TAB ER 12H ORAL 12/12/2018 9.56952

OXYCODONE HCL 60 MG TAB ER 12H ORAL 09/19/2018 8.91252

OXYCODONE HCL 80 MG TAB ER 12H ORAL 07/03/2018 12.19614

OXYCODONE HCL 5 MG/5 ML SOLUTION ORAL 05/26/2015 0.14644

OXYCODONE HCL 20 MG/ML ORAL CONC ORAL 02/13/2019 2.20743

OXYCODONE HCL 5 MG TABLET ORAL 06/21/2016 0.06676

OXYCODONE HCL 10 MG TABLET ORAL 02/20/2019 0.17152

OXYCODONE HCL 20 MG TABLET ORAL 06/19/2017 0.31758

OXYCODONE HCL 15 MG TABLET ORAL 02/12/2019 0.21654

OXYCODONE HCL 30 MG TABLET ORAL 04/04/2017 0.19497

OXYCODONE HCL/ACETAMINOPHEN 5 MG-325MG TABLET ORAL 02/06/2019 0.07142

OXYCODONE HCL/ACETAMINOPHEN 2.5-325 MG TABLET ORAL 01/30/2018 2.29314

OXYCODONE HCL/ACETAMINOPHEN 7.5-325 MG TABLET ORAL 12/26/2018 0.17353

OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET ORAL 12/26/2018 0.22512

OXYCODONE HCL/ASPIRIN 4.8355-325 TABLET ORAL 11/14/2018 1.49571

OXYMETAZOLINE HCL 0.05 % MIST NASAL 02/20/2019 0.45828

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019136

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

OXYMETAZOLINE HCL 0.05 % SPRAY NASAL 11/21/2018 0.04869

OXYMORPHONE HCL 5 MG TABLET ORAL 01/30/2018 0.53064

OXYMORPHONE HCL 10 MG TABLET ORAL 11/07/2018 0.70363

OXYTOCIN 10 UNIT/ML VIAL INJECTION 08/15/2018 0.87502

PACLITAXEL 6 MG/ML VIAL INTRAVEN 08/01/2018 0.88172

PALIPERIDONE 3 MG TAB ER 24 ORAL 02/20/2019 12.63605

PALIPERIDONE 6 MG TAB ER 24 ORAL 02/20/2019 19.32032

PALIPERIDONE 9 MG TAB ER 24 ORAL 02/20/2019 16.08250

PALIPERIDONE 1.5 MG TAB ER 24 ORAL 02/20/2019 15.45460

PALONOSETRON HCL 0.25MG/5ML VIAL INTRAVEN 02/13/2019 5.58800

PAMIDRONATE DISODIUM 30MG/10ML VIAL INTRAVEN 08/01/2018 1.67500

PAMIDRONATE DISODIUM 90 MG/10ML VIAL INTRAVEN 08/15/2018 4.58700

PANTOPRAZOLE SODIUM 40 MG TABLET DR ORAL 11/21/2018 0.09663

PANTOPRAZOLE SODIUM 20 MG TABLET DR ORAL 01/23/2019 0.09678

PANTOPRAZOLE SODIUM 40 MG VIAL INTRAVEN 01/23/2019 3.79896

PARAB/CET ALC/STRYL ALC/PG/SLS CLEANSER TOPICAL 11/15/2017 0.02680

PARAFFIN WAX MISCELL 06/03/2015 0.16574

PARICALCITOL 1 MCG CAPSULE ORAL 09/12/2018 4.14964

PARICALCITOL 2 MCG CAPSULE ORAL 02/27/2019 7.48880

PARICALCITOL 4 MCG CAPSULE ORAL 06/27/2018 17.49965

PARICALCITOL 5 MCG/ML VIAL INJECTION 12/19/2017 3.64426

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019137

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PARICALCITOL 2 MCG/ML VIAL INJECTION 07/05/2016 2.83642

PARICALCITOL 5 MCG/ML VIAL INTRAVEN 02/27/2019 10.83737

PARICALCITOL 2 MCG/ML VIAL INTRAVEN 02/06/2019 5.00702

PAROMOMYCIN SULFATE 250 MG CAPSULE ORAL 01/22/2013 3.74220

PAROXETINE HCL 10 MG TABLET ORAL 01/09/2019 0.06010

PAROXETINE HCL 20 MG TABLET ORAL 02/13/2019 0.06789

PAROXETINE HCL 30 MG TABLET ORAL 12/12/2018 0.08166

PAROXETINE HCL 40 MG TABLET ORAL 01/30/2019 0.09142

PAROXETINE HCL 25 MG TAB ER 24H ORAL 11/14/2018 5.26711

PAROXETINE HCL 12.5 MG TAB ER 24H ORAL 11/14/2018 5.24612

PAROXETINE HCL 37.5 MG TAB ER 24H ORAL 11/14/2018 5.42544

PAROXETINE MESYLATE 7.5 MG CAPSULE ORAL 10/17/2017 5.19640

PEANUT OIL OIL MISCELL 05/21/2014 0.06045

PED MVIT A,C,D3 NO.21/FLUORIDE 0.25 MG/ML DROPS ORAL 10/03/2018 0.36394

PED MVIT A,C,D3 NO.21/FLUORIDE 0.5 MG/ML DROPS ORAL 11/07/2018 0.37547

PEDI MULTIVIT 45/FLUORIDE/IRON 0.25-10/ML DROPS ORAL 02/06/2019 0.40709

PEDI MULTIVIT NO.12 W-FLUORIDE 0.25 MG TAB CHEW ORAL 01/22/2013 0.18000

PEDI MULTIVIT NO.12 W-FLUORIDE 0.5 MG TAB CHEW ORAL 01/22/2013 0.18000

PEDI MULTIVIT NO.12 W-FLUORIDE 1 MG TAB CHEW ORAL 01/22/2013 0.18000

PEDI MULTIVIT NO.16 W-FLUORIDE 0.25 MG TAB CHEW ORAL 12/30/2016 0.18000

PEDI MULTIVIT NO.16 W-FLUORIDE 0.5 MG TAB CHEW ORAL 12/30/2016 0.18000

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019138

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PEDI MULTIVIT NO.16 W-FLUORIDE 1 MG TAB CHEW ORAL 12/30/2016 0.18000

PEDI MULTIVIT NO.17 W-FLUORIDE 0.25 MG TAB CHEW ORAL 10/03/2018 0.20368

PEDI MULTIVIT NO.17 W-FLUORIDE 0.5 MG TAB CHEW ORAL 10/03/2018 0.20368

PEDI MULTIVIT NO.17 W-FLUORIDE 1 MG TAB CHEW ORAL 02/06/2019 0.20368

PEDI MULTIVIT NO.2 W-FLUORIDE 0.25 MG/ML DROPS ORAL 08/29/2018 0.40709

PEDI MULTIVIT NO.2 W-FLUORIDE 0.5 MG/ML DROPS ORAL 08/29/2018 0.40709

PEDI MULTIVIT NO.25/FOLIC ACID 300 MCG TAB CHEW ORAL 12/19/2018 0.03209

PEDIATRIC MULTIVITAMIN NO.81 750-35/ML DROPS ORAL 02/14/2018 0.11377

PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% DROPS OPHTHALMIC 01/23/2019 0.04958

PEG3350/SOD SULF,BICARB,CL/KCL 236-22.74G SOLN RECON ORAL 07/25/2018 0.00350

PEG3350/SOD SULF,BICARB,CL/KCL 240-22.72G SOLN RECON ORAL 04/19/2017 0.00347

PEN NEEDLE, DIABETIC 29 GAUGE DIS NEEDLE MISCELL 11/09/2016 0.22519

PEN NEEDLE, DIABETIC 29 G X1/2" DIS NEEDLE MISCELL 12/12/2018 0.14138

PEN NEEDLE, DIABETIC 30 GX5/16" DIS NEEDLE MISCELL 04/18/2018 0.20093

PEN NEEDLE, DIABETIC 31 GX5/16" DIS NEEDLE MISCELL 03/06/2019 0.10707

PEN NEEDLE, DIABETIC 31 G X1/4" DIS NEEDLE MISCELL 02/20/2019 0.11819

PEN NEEDLE, DIABETIC 31 GX3/16" DIS NEEDLE MISCELL 03/06/2019 0.10707

PEN NEEDLE, DIABETIC 32 GX 1/4" DIS NEEDLE MISCELL 03/06/2019 0.16750

PEN NEEDLE, DIABETIC 32 GX5/16" DIS NEEDLE MISCELL 09/14/2016 0.23443

PEN NEEDLE, DIABETIC 32GX 5/32" DIS NEEDLE MISCELL 03/06/2019 0.11819

PEN NEEDLE, DIABETIC 32 GX3/16" DIS NEEDLE MISCELL 12/19/2018 0.21561

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019139

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PEN NEEDLE, DIABETIC 33 GX5/32" DIS NEEDLE MISCELL 02/06/2019 0.21373

PENICILLIN G POTASSIUM 20MM UNIT VIAL INJECTION 01/08/2018 33.67125

PENICILLIN G POTASSIUM 5MM UNIT VIAL INJECTION 04/11/2018 7.49300

PENICILLIN V POTASSIUM 250 MG TABLET ORAL 04/11/2016 0.07930

PENICILLIN V POTASSIUM 500 MG TABLET ORAL 11/14/2018 0.08392

PENTAZOCINE HCL/NALOXONE HCL 50MG-0.5MG TABLET ORAL 07/18/2018 2.58620

PENTOBARBITAL SODIUM 50 MG/ML VIAL INJECTION 02/27/2019 30.45316

PENTOXIFYLLINE 400 MG TABLET ER ORAL 12/19/2018 0.16348

PERINDOPRIL ERBUMINE 4 MG TABLET ORAL 10/07/2015 0.48910

PERINDOPRIL ERBUMINE 2 MG TABLET ORAL 10/27/2015 0.44099

PERINDOPRIL ERBUMINE 8 MG TABLET ORAL 10/07/2015 0.62310

PERIT. DIALYSIS NO.6-1.5 % DEX 2.5MEQ(CA) IP SOLN INTRAPERIT 01/22/2013 0.00395

PERITON.DIALYSIS 7-2.5 % DEXTR 2.5MEQ(CA) IP SOLN INTRAPERIT 01/22/2013 0.00416

PERITON.DIALYSIS 8-4.25 % DEXT 2.5MEQ(CA) IP SOLN INTRAPERIT 01/22/2013 0.00426

PERMETHRIN 5 % CREAM (G) TOPICAL 07/12/2016 0.64767

PERMETHRIN 1 % LIQUID TOPICAL 10/07/2015 0.10395

PERPHENAZINE 16 MG TABLET ORAL 10/31/2018 1.35836

PERPHENAZINE 2 MG TABLET ORAL 10/24/2018 0.60809

PERPHENAZINE 4 MG TABLET ORAL 08/15/2018 0.83241

PERPHENAZINE 8 MG TABLET ORAL 12/19/2018 0.90865

PETROLATUM, YELLOW 100 % JELLY (G) MISCELL 02/04/2015 0.22110

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019140

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PETROLATUM,WHITE JELLY (G) TOPICAL 10/03/2018 0.00415

PETROLATUM,WHITE OINT PACK TOPICAL 01/16/2019 0.00856

PETROLATUM,WHITE OINT. (G) TOPICAL 03/19/2014 0.00711

PETROLATUM,WHITE 42 % OINT. (G) TOPICAL 07/11/2018 0.03008

PETROLATUM,WHITE/WATER LOTION TOPICAL 01/22/2013 0.00438

PHENAZOPYRIDINE HCL 200 MG TABLET ORAL 01/16/2019 0.37554

PHENAZOPYRIDINE HCL 95 MG TABLET ORAL 06/20/2018 0.17679

PHENDIMETRAZINE TARTRATE 35 MG TABLET ORAL 02/20/2019 0.17956

PHENELZINE SULFATE 15 MG TABLET ORAL 06/20/2018 0.73499

PHENOBARBITAL 20 MG/5 ML ELIXIR ORAL 04/04/2018 0.02000

PHENOBARBITAL 32.4 MG TABLET ORAL 12/28/2016 1.08093

PHENOL 1.4 % SPRAY MUCOUS MEM 08/15/2018 0.01682

PHENOL 1.5 % LIQUID TOPICAL 05/20/2015 1.38199

PHENOXYBENZAMINE HCL 10 MG CAPSULE ORAL 01/30/2018 70.72500

PHENTERMINE HCL 15 MG CAPSULE ORAL 11/21/2018 0.15504

PHENTERMINE HCL 30 MG CAPSULE ORAL 10/31/2018 0.14378

PHENTERMINE HCL 37.5 MG CAPSULE ORAL 11/14/2018 0.10720

PHENTERMINE HCL 37.5 MG TABLET ORAL 11/28/2018 0.06365

PHENTOLAMINE MESYLATE 5 MG VIAL INJECTION 02/27/2019 355.16250

PHENYLEPH/MINERAL OIL/PETROLAT 0.25 %-14% OINT/APPL RECTAL 02/13/2019 0.05449

PHENYLEPHRINE HCL 2.5 MG/5ML SOLUTION ORAL 10/04/2017 0.05016

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019141

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PHENYLEPHRINE HCL 10 MG TABLET ORAL 10/31/2018 0.04839

PHENYLEPHRINE HCL 10 MG/ML VIAL INJECTION 01/16/2019 4.21186

PHENYLEPHRINE HCL 10 % DROPS OPHTHALMIC 02/27/2019 8.50560

PHENYLEPHRINE HCL 2.5 % DROPS OPHTHALMIC 02/27/2019 7.29488

PHENYLEPHRINE HCL 1 % SPRAY NASAL 04/04/2018 0.30530

PHENYLEPHRINE HCL/ACETAMINOPHN 5 MG-325MG TABLET ORAL 01/16/2019 0.08654

PHENYLEPHRINE HCL/ACETAMINOPHN 5 MG-500MG TABLET ORAL 06/13/2018 0.05077

PHENYLEPHRINE HCL/COCOA BUTTER 0.25-88.44 SUPP.RECT RECTAL 02/27/2019 0.14796

PHENYLEPHRINE HCL/WITCH HAZEL 0.25%-50% GEL (GRAM) TOPICAL 06/06/2018 0.29222

PHENYLEPHRINE/ACETAMINOPHN/CPM 5-325-2MG TABLET ORAL 06/13/2018 0.07638

PHENYLEPHRINE/DIPHENHYDRAMINE 2.5-6.25/5 LIQUID ORAL 08/30/2017 0.05339

PHENYLEPHRINE/DM/ACETAMINOP/GG 5-325MG/15 LIQUID ORAL 12/19/2018 0.02836

PHENYLEPHRINE/DM/ACETAMINOP/GG 10-650/20 LIQUID ORAL 05/01/2018 0.05598

PHENYLEPHRINE/DM/ACETAMINOP/GG 5-325-200 TABLET ORAL 08/22/2018 0.28363

PHENYLEPHRINE/DM/ACETAMINOP/GG 5-10-325MG TABLET ORAL 07/20/2016 0.31758

PHENYLEPHRINE/PYRILAMINE 10 MG-25MG TABLET ORAL 02/25/2015 0.71556

PHENYTOIN 125 MG/5ML ORAL SUSP ORAL 09/18/2018 0.09073

PHENYTOIN 50 MG TAB CHEW ORAL 08/08/2018 0.21887

PHENYTOIN SODIUM 50 MG/ML VIAL INTRAVEN 07/25/2018 0.34626

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE ORAL 08/23/2016 0.26760

PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE ORAL 09/20/2016 1.98320

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019142

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE ORAL 01/05/2016 1.48526

PHOSPHORATED CARBO(DEXT-FRUCT) SOLUTION ORAL 05/30/2018 0.06633

PHYSIOLOGICAL IRRIG SOLN NO.1 140-5-3-98 IRRIG SOLN IRRIGATION 02/18/2015 0.00659

PHYTONADIONE (VIT K1) 5 MG TABLET ORAL 03/06/2019 54.92883

PHYTONADIONE (VIT K1) 100 MCG TABLET ORAL 07/22/2015 0.02084

PILOCARPINE HCL 5 MG TABLET ORAL 11/14/2018 1.10202

PILOCARPINE HCL 7.5 MG TABLET ORAL 11/14/2018 1.72190

PILOCARPINE HCL 1 % DROPS OPHTHALMIC 01/23/2019 7.49977

PILOCARPINE HCL 2 % DROPS OPHTHALMIC 01/23/2019 7.24800

PILOCARPINE HCL 4 % DROPS OPHTHALMIC 01/23/2019 7.59440

PIMECROLIMUS 1 % CREAM (G) TOPICAL 01/09/2019 9.02800

PIMOZIDE 2 MG TABLET ORAL 12/05/2018 3.35194

PIMOZIDE 1 MG TABLET ORAL 09/13/2017 1.77992

PINDOLOL 10 MG TABLET ORAL 10/24/2018 1.20600

PINDOLOL 5 MG TABLET ORAL 05/23/2018 1.06074

PIOGLITAZONE HCL 15 MG TABLET ORAL 02/07/2017 0.06823

PIOGLITAZONE HCL 30 MG TABLET ORAL 02/07/2017 0.10434

PIOGLITAZONE HCL 45 MG TABLET ORAL 02/07/2017 0.11004

PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-4 MG TABLET ORAL 05/30/2018 9.36503

PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-2 MG TABLET ORAL 05/30/2018 9.36503

PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG TABLET ORAL 03/21/2017 0.43818

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019143

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG TABLET ORAL 09/24/2018 0.43818

PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL INTRAVEN 02/27/2019 3.73560

PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL INTRAVEN 02/27/2019 5.08200

PIPERACILLIN SODIUM/TAZOBACTAM 4.5 G VIAL INTRAVEN 02/27/2019 7.44673

PIPERACILLIN SODIUM/TAZOBACTAM 40.5 G VIAL INTRAVEN 01/30/2019 63.12975

PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO TOPICAL 02/07/2017 0.06583

PIROXICAM 10 MG CAPSULE ORAL 08/01/2018 0.19430

PIROXICAM 20 MG CAPSULE ORAL 12/26/2018 0.88989

PNV 102/IRON/FOLIC/DHA/LUTEIN 27-800-200 COMBO. PKG ORAL 01/22/2013 0.04250

PNV 11/IRON FUM/FOLIC ACID/OM3 28-1-200MG CAPSULE ORAL 01/22/2013 0.08500

PNV 15/IRON FUM,PS/FOLIC ACID 85 MG-1 MG CAPSULE ORAL 01/22/2013 0.08500

PNV 16/IRON FUM,PS/FOLIC/OM-3 35-1-200MG CAPSULE ORAL 08/20/2015 0.08500

PNV 21/IRON PS,HEME PPEP/FOLIC 28-6-1 MG TABLET ORAL 12/02/2015 0.08500

PNV 22/IRON,GLUC/FOLIC/DSS/DHA 27-1-50 MG COMBO. PKG ORAL 01/22/2013 0.04250

PNV 30/IRON CARB,AG/FOLIC/OM3 30-10-1 MG CAPSULE ORAL 01/22/2013 0.08500

PNV 39/IRON/FOLIC/DOCUSATE/DHA 30-1.2-55 CAPSULE ORAL 01/22/2013 0.08500

PNV 66/IRON/FOLIC/DOCUSATE/DHA 26-1.2-55 CAPSULE ORAL 08/15/2014 0.08500

PNV 66/IRON/FOLIC/DOCUSATE/DHA 27-1.25-55 CAPSULE ORAL 01/22/2013 0.08500

PNV 69/IRON/FOLIC/DOCUSATE/DHA 28-1-50 MG CAPSULE ORAL 01/22/2013 0.08500

PNV 80/IRON FUM/FOLIC/DSS/DHA 29-1.25-55 CAPSULE ORAL 01/22/2013 0.08500

PNV 85/IRON/FOLIC/DHA/FISH OIL 40-10-1 MG CAPSULE ORAL 01/22/2013 0.08500

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019144

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PNV NO.118/IRON FUMARATE/FA 29 MG-1 MG TAB CHEW ORAL 12/12/2018 0.93143

PNV NO.5/FERROUS FUM/FOLIC AC 106.5-1MG CAPSULE ORAL 11/14/2014 0.08500

PNV NO.95/FERROUS FUM/FOLIC AC 28MG-0.8MG TABLET ORAL 12/05/2018 0.03628

PNV, CALCIUM 70/IRON/FOLIC/DHA 28-1-250MG CAPSULE ORAL 07/09/2014 0.08500

PNV/FERROUS FUM/DOCUSATE/FOLIC 90-50-1MG TABLET ER ORAL 01/22/2013 0.08500

PNV/IRON,CARB/DOCUSAT/FOLIC AC 90-50-1MG TABLET ORAL 01/22/2013 0.08500

PNV119/IRON FUM/FOLIC/DOCUSATE 29-1-25 MG TABLET ORAL 08/24/2016 0.49513

PNV19/IRON BG,S.P/FOLIC AC/OM3 29-1-400MG CMBPKGDRCP ORAL 01/22/2013 0.04250

PNV81/IRON EDTA,PS/FOLIC/OMEG3 27-1-430MG CMBPKGDRCP ORAL 01/22/2013 0.04250

PNV83/IRON,CARB,ASP/FOLIC ACID 30-20-1 MG TABLET ORAL 01/22/2013 0.08500

PODOFILOX 0.5 % SOLUTION TOPICAL 02/20/2019 12.80700

POLYDIMETHYLSILOXANES/SILICON GEL (GRAM) TOPICAL 03/01/2017 2.00933

POLYETHYLENE GLYCOL 1450 POWDER MISCELL 02/13/2019 0.01873

POLYETHYLENE GLYCOL 300 LIQUID MISCELL 02/13/2019 0.01729

POLYETHYLENE GLYCOL 3350 17G/DOSE POWDER ORAL 02/20/2019 0.02352

POLYMYXIN B SULF/TRIMETHOPRIM 10000-1/ML DROPS OPHTHALMIC 09/19/2018 0.67670

POLYMYXIN B SULFATE 500K UNIT VIAL INJECTION 12/19/2018 5.08762

POLYSORBATE 80 SOLUTION MISCELL 02/06/2019 0.04233

POLYVINYL ALCOHOL 1.4 % DROPS OPHTHALMIC 01/09/2019 0.36180

POTASSIUM ACETATE 2 MEQ/ML VIAL INTRAVEN 01/31/2018 0.20620

POTASSIUM BICARBONATE/CIT AC 25 MEQ TABLET EFF ORAL 05/20/2015 1.05197

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019145

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

POTASSIUM CHLORIDE 10 MEQ CAPSULE ER ORAL 02/08/2017 0.28930

POTASSIUM CHLORIDE 8 MEQ CAPSULE ER ORAL 04/04/2018 0.12971

POTASSIUM CHLORIDE 20 MEQ PACKET ORAL 02/20/2019 6.43848

POTASSIUM CHLORIDE 20MEQ/15ML LIQUID ORAL 03/06/2019 0.25901

POTASSIUM CHLORIDE 40MEQ/15ML LIQUID ORAL 02/06/2019 0.51805

POTASSIUM CHLORIDE 10 MEQ TAB ER PRT ORAL 02/20/2019 0.31611

POTASSIUM CHLORIDE 20 MEQ TAB ER PRT ORAL 12/26/2018 0.30699

POTASSIUM CHLORIDE 10 MEQ TABLET ER ORAL 10/27/2015 0.26176

POTASSIUM CHLORIDE 20 MEQ TABLET ER ORAL 05/22/2018 0.42030

POTASSIUM CHLORIDE 8 MEQ TABLET ER ORAL 07/07/2015 0.16913

POTASSIUM CHLORIDE 2 MEQ/ML VIAL INTRAVEN 01/09/2019 0.12730

POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLN INTRAVEN 06/14/2017 0.01032

POTASSIUM CHLORIDE IN 0.9%NACL 40 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01478

POTASSIUM CHLORIDE IN D5W 20 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01376

POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01509

POTASSIUM CHLORIDE IN WATER 10MEQ/0.1L PIGGYBACK INTRAVEN 09/12/2018 0.05715

POTASSIUM CHLORIDE IN WATER 20MEQ/0.1L PIGGYBACK INTRAVEN 09/12/2018 0.05887

POTASSIUM CHLORIDE IN WATER 40MEQ/0.1L PIGGYBACK INTRAVEN 09/12/2018 0.06010

POTASSIUM CHLORIDE IN WATER 10MEQ/50ML PIGGYBACK INTRAVEN 06/19/2017 0.11774

POTASSIUM CHLORIDE IN WATER 20MEQ/50ML PIGGYBACK INTRAVEN 09/12/2018 0.11774

POTASSIUM CHLORIDE-0.45% NACL 20 MEQ/L IV SOLN INTRAVEN 09/05/2018 0.00875

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019146

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

POTASSIUM CHLORIDE/D5-0.2%NACL 20 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01254

POTASSIUM CHLORIDE/D5-0.45NACL 10 MEQ/L IV SOLN INTRAVEN 09/12/2018 0.00831

POTASSIUM CHLORIDE/D5-0.45NACL 20 MEQ/L IV SOLN INTRAVEN 09/12/2018 0.00626

POTASSIUM CHLORIDE/D5-0.45NACL 30 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01278

POTASSIUM CHLORIDE/D5-0.45NACL 40 MEQ/L IV SOLN INTRAVEN 09/12/2018 0.00831

POTASSIUM CHLORIDE/D5-0.9%NACL 20 MEQ/L IV SOLN INTRAVEN 09/12/2018 0.00836

POTASSIUM CHLORIDE/D5-0.9%NACL 40 MEQ/L IV SOLN INTRAVEN 01/10/2018 0.01214

POTASSIUM CITRATE 5 MEQ TABLET ER ORAL 03/06/2019 0.70524

POTASSIUM CITRATE 10 MEQ TABLET ER ORAL 03/06/2019 0.98463

POTASSIUM CITRATE 15 MEQ TABLET ER ORAL 01/12/2016 2.28001

POTASSIUM CITRATE/CITRIC ACID 1100-334/5 SOLUTION ORAL 10/31/2018 0.07116

POTASSIUM GLUCONATE 595(99)MG TABLET ORAL 02/20/2019 0.03913

POTASSIUM GLUCONATE 550(90)MG TABLET ORAL 11/21/2018 0.02275

POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML VIAL INTRAVEN 02/27/2019 1.17834

POVIDONE-IODINE 10 % MED. SWAB TOPICAL 10/17/2018 0.23977

POVIDONE-IODINE 10 % OINT. (G) TOPICAL 10/03/2017 0.15792

POVIDONE-IODINE 10 % SOLUTION TOPICAL 01/30/2019 0.00404

POVIDONE-IODINE 7.5 % SOLUTION TOPICAL 05/14/2018 0.00510

POVIDONE-IODINE 0.3 % SOLUTION VAGINAL 01/04/2017 0.01119

PRAMIPEXOLE DI-HCL 1 MG TABLET ORAL 03/22/2017 0.07042

PRAMIPEXOLE DI-HCL 1.5 MG TABLET ORAL 06/20/2018 0.08427

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019147

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PRAMIPEXOLE DI-HCL 0.125 MG TABLET ORAL 08/15/2018 0.04035

PRAMIPEXOLE DI-HCL 0.25 MG TABLET ORAL 11/09/2016 0.04214

PRAMIPEXOLE DI-HCL 0.5 MG TABLET ORAL 01/09/2019 0.06313

PRAMIPEXOLE DI-HCL 0.75 MG TABLET ORAL 06/14/2016 0.08427

PRAMIPEXOLE DI-HCL 0.75 MG TAB ER 24H ORAL 06/20/2018 11.30795

PRAMIPEXOLE DI-HCL 0.375 MG TAB ER 24H ORAL 06/20/2018 11.30795

PRAMIPEXOLE DI-HCL 1.5 MG TAB ER 24H ORAL 06/20/2018 11.30795

PRAMIPEXOLE DI-HCL 3 MG TAB ER 24H ORAL 06/20/2018 11.30795

PRAMIPEXOLE DI-HCL 4.5 MG TAB ER 24H ORAL 06/20/2018 11.30795

PRAMIPEXOLE DI-HCL 2.25 MG TAB ER 24H ORAL 06/13/2018 13.01850

PRAMIPEXOLE DI-HCL 3.75 MG TAB ER 24H ORAL 08/10/2016 13.79455

PRAMOXINE HCL 1 % FOAM TOPICAL 01/03/2017 6.92573

PRAMOXINE HCL 1 % LOTION TOPICAL 12/05/2018 0.04080

PRAMOXINE HCL 1 % TOWELETTE TOPICAL 08/30/2017 0.38637

PRAMOXINE HCL/CALAMINE 1 %-8 % LOTION TOPICAL 08/01/2018 0.02888

PRAMOXINE HCL/CAMPH/ZINC ACET LOTION TOPICAL 06/13/2018 0.01756

PRASTERONE (DHEA) 25 MG CAPSULE ORAL 04/06/2016 0.04824

PRASUGREL HCL 5 MG TABLET ORAL 01/16/2019 0.87055

PRASUGREL HCL 10 MG TABLET ORAL 01/16/2019 0.66107

PRAVASTATIN SODIUM 10 MG TABLET ORAL 02/27/2019 0.07221

PRAVASTATIN SODIUM 20 MG TABLET ORAL 01/16/2019 0.07272

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019148

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PRAVASTATIN SODIUM 40 MG TABLET ORAL 11/21/2018 0.10928

PRAVASTATIN SODIUM 80 MG TABLET ORAL 01/09/2019 0.18304

PRAZIQUANTEL 600 MG TABLET ORAL 04/22/2018 68.09075

PRAZOSIN HCL 1 MG CAPSULE ORAL 09/08/2015 0.54283

PRAZOSIN HCL 2 MG CAPSULE ORAL 11/21/2018 0.36850

PRAZOSIN HCL 5 MG CAPSULE ORAL 11/28/2018 1.00500

PREDNICARBATE 0.1 % OINT. (G) TOPICAL 03/22/2017 2.02608

PREDNISOLONE 15 MG/5 ML SOLUTION ORAL 11/21/2018 0.04746

PREDNISOLONE ACETATE 1 % DROPS SUSP OPHTHALMIC 04/19/2016 7.51713

PREDNISOLONE SODIUM PHOSPHATE 5 MG/5 ML SOLUTION ORAL 07/03/2018 0.87614

PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML SOLUTION ORAL 02/27/2019 0.16214

PREDNISOLONE SODIUM PHOSPHATE 10 MG/5 ML SOLUTION ORAL 03/01/2017 2.57271

PREDNISOLONE SODIUM PHOSPHATE 20 MG/5 ML SOLUTION ORAL 12/05/2018 3.60132

PREDNISOLONE SODIUM PHOSPHATE 10 MG TAB RAPDIS ORAL 04/11/2016 11.39210

PREDNISOLONE SODIUM PHOSPHATE 15 MG TAB RAPDIS ORAL 03/28/2016 18.12388

PREDNISOLONE SODIUM PHOSPHATE 30 MG TAB RAPDIS ORAL 02/10/2016 23.30213

PREDNISONE 1 MG TABLET ORAL 12/05/2018 0.14727

PREDNISONE 10 MG TABLET ORAL 04/19/2016 0.08013

PREDNISONE 2.5 MG TABLET ORAL 08/15/2018 0.13038

PREDNISONE 20 MG TABLET ORAL 01/12/2016 0.18034

PREDNISONE 5 MG TABLET ORAL 12/19/2018 0.10921

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019149

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PREDNISONE 5 MG TAB DS PK ORAL 10/31/2018 0.62282

PREDNISONE 10 MG TAB DS PK ORAL 12/05/2018 1.07982

PRENAT VIT 17/IRON/FOLIC/OM3,6 35-5-1.2MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL 12/IRON/FOLIC/DSS/OM3 29-1-50 MG CMBPKGDRCP ORAL 01/22/2013 0.04250

PRENATAL 2/IRON/FOLIC ACID/OM3 29-1-250MG COMBO. PKG ORAL 01/22/2013 0.04250

PRENATAL 21/IRON FU/FOLIC ACID 14 MG-400 TABLET ORAL 01/22/2013 0.08500

PRENATAL 25/IRON/FOLATE 6/DHA 30-1-200MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL 26/IRON PS/FOLIC/DHA 29-1-200MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL 34/IRON/FOLIC/DSS/DHA 30-1-50 MG CAPSULE ORAL 09/01/2015 0.08500

PRENATAL 47/IRON/FOLATE 1/DHA 27-1-300MG CAPSULE ORAL 09/15/2015 0.08500

PRENATAL 48/IRON/FOLIC ACID/B6 20-1-25 MG TABLET SEQ ORAL 03/05/2014 0.48061

PRENATAL 53/IRON/FOLIC AC/OMG3 29-1-400MG COMBO. PKG ORAL 01/22/2013 0.04250

PRENATAL 68/IRON/FOLIC NO1/DHA 28-1-300MG CAPSULE ORAL 11/11/2015 0.08500

PRENATAL 87/IRON BIS/FOLIC/DHA 32-1-230MG COMBO. PKG ORAL 01/22/2013 0.04250

PRENATAL NO.123/IRON/FOLIC AC 50-1.25 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL NO35/IRON/FOLATE6/DHA 29-1-300MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL NO4/IRON FUM,PS/FOLIC 106 MG-1MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL VIT 10/IRON FUM/FOLIC 65 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT 10/IRON/FOLIC/DHA 65-1-250MG COMBO. PKG ORAL 01/22/2013 0.04250

PRENATAL VIT 14/IRON FUM/FOLIC 29 MG-1 MG TAB CHEW ORAL 01/22/2013 0.08500

PRENATAL VIT 28/IRON FUM/FOLIC 27 MG-1 MG TABLET ORAL 01/22/2013 0.08500

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019150

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PRENATAL VIT 32/IRON/FOLIC/DHA 27-1-150MG COMBO. PKG ORAL 01/22/2013 0.02833

PRENATAL VIT 33/IRON/FOLIC/DHA 29-1-250MG COMBO. PKG ORAL 01/22/2013 0.04250

PRENATAL VIT 36/IRON/FOLATE 6 26 MG-1 MG TABLET ORAL 03/20/2013 0.08500

PRENATAL VIT 40/IRON/FOLIC/DHA 27-0.8-250 CAPSULE ORAL 04/13/2017 0.08500

PRENATAL VIT 55/IRON/FOLIC/OM3 29-1-430MG CMBPKGDRCP ORAL 01/22/2013 0.04250

PRENATAL VIT 75/IRON/FOLIC/OM3 28-800-440 COMBO. PKG ORAL 05/29/2013 0.04250

PRENATAL VIT 91/IRON/FOLIC/DHA 28-975-200 COMBO. PKG ORAL 01/22/2013 0.02125

PRENATAL VIT 93/IRON FUM/FOLIC 9MG-267MCG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT 98/IRON FUM/FOLIC 9MG-267MCG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT NO.127/IRON/FOLIC 15 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT NO.130/IRON/FOLIC 27MG-0.8MG TABLET ORAL 04/26/2017 0.03573

PRENATAL VIT,CALC78/IRON/FOLIC 29 MG-1 MG TABLET ORAL 09/15/2015 0.08500

PRENATAL VIT/IRON FUM/FOLIC AC 65 MG-1 MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL VIT/IRON FUM/FOLIC AC 65 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT100/IRON/FOLIC/OM3 27-1-374MG CMBPKGDRCP ORAL 01/22/2013 0.04250

PRENATAL VIT101/IRON/FOLIC/DHA 27-800-200 COMBO. PKG ORAL 01/22/2013 0.08500

PRENATAL VIT103/IRON FUM/FOLIC 27 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT127/IRON/FOLIC/DSS 29-1-50 MG TABLET DR ORAL 01/22/2013 0.04250

PRENATAL VIT128/IRON/FOLIC ACD 29 MG-1 MG TAB CHEW ORAL 01/22/2013 0.08500

PRENATAL VIT136/IRON/FOLIC ACD 27 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT22/IRON/FOLIC/OM3S 28-6-1-203 COMBO. PKG ORAL 01/22/2013 0.04250

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019151

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PRENATAL VIT27,CALCIUM/IRON/FA 60 MG-1 MG TABLET ORAL 01/22/2013 0.08500

PRENATAL VIT37/IRON/FOLIC ACID 29 MG-1 MG TAB CHEW ORAL 01/22/2013 0.08500

PRENATAL VIT86/IRON/FOLIC ACID 32 MG-1 MG TABLET ORAL 06/17/2014 0.08500

PRENATAL VITS15/IRON/FOLIC/DSS 90-1-50 MG TABLET ORAL 08/15/2014 0.08500

PRENATAL VITS16/IRON/FOLIC/DSS 90-1-50 MG TABLET ORAL 08/15/2014 0.08500

PRENATAL VITS96/IRON FUM/FOLIC 27MG-0.8MG TABLET ORAL 11/28/2018 0.03806

PRENATAL,CALC NO.65/IRON/FOLIC 60 MG-1 MG CAPSULE ORAL 01/22/2013 0.08500

PRENATAL,CALC.40/IRON/FOLATE 1 27 MG-1 MG TABLET ORAL 09/01/2015 0.08500

PRIMAQUINE PHOSPHATE 26.3 MG TABLET ORAL 03/06/2019 2.14869

PRIMIDONE 250 MG TABLET ORAL 11/21/2018 0.18787

PRIMIDONE 50 MG TABLET ORAL 03/06/2019 0.09605

PROBENECID 500 MG TABLET ORAL 09/12/2018 0.69696

PROBENECID/COLCHICINE 500-0.5 MG TABLET ORAL 10/03/2018 1.13739

PROCAINAMIDE HCL 100 MG/ML VIAL INJECTION 01/09/2019 7.86000

PROCAINAMIDE HCL 500 MG/ML VIAL INJECTION 12/12/2018 28.70000

PROCHLORPERAZINE 25 MG SUPP.RECT RECTAL 04/28/2015 5.18927

PROCHLORPERAZINE EDISYLATE 5 MG/ML VIAL INJECTION 11/21/2018 2.91555

PROCHLORPERAZINE EDISYLATE 10 MG/2 ML VIAL INJECTION 02/27/2019 5.28000

PROCHLORPERAZINE MALEATE 10 MG TABLET ORAL 01/09/2019 0.25165

PROCHLORPERAZINE MALEATE 5 MG TABLET ORAL 09/12/2018 0.23222

PROGESTERONE 50 MG/ML VIAL INTRAMUSC 02/27/2019 2.96208

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019152

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PROGESTERONE, MICRONIZED 100 MG CAPSULE ORAL 02/13/2019 0.64387

PROGESTERONE, MICRONIZED 200 MG CAPSULE ORAL 02/13/2019 1.25169

PROMETHAZINE HCL 6.25MG/5ML SYRUP ORAL 02/27/2019 0.02208

PROMETHAZINE HCL 12.5 MG TABLET ORAL 02/06/2019 0.10117

PROMETHAZINE HCL 25 MG TABLET ORAL 01/30/2019 0.04208

PROMETHAZINE HCL 50 MG TABLET ORAL 01/30/2019 0.11149

PROMETHAZINE HCL 25 MG/ML AMPUL INJECTION 08/03/2016 1.06932

PROMETHAZINE HCL 50 MG/ML AMPUL INJECTION 02/06/2019 2.38520

PROMETHAZINE HCL 25 MG/ML VIAL INJECTION 12/20/2017 1.09478

PROMETHAZINE HCL 50 MG/ML VIAL INJECTION 01/22/2013 2.35505

PROMETHAZINE HCL 12.5 MG SUPP.RECT RECTAL 03/06/2019 7.21600

PROMETHAZINE HCL 25 MG SUPP.RECT RECTAL 01/30/2019 7.55968

PROMETHAZINE HCL 50 MG SUPP.RECT RECTAL 12/06/2017 52.67419

PROMETHAZINE HCL/CODEINE 6.25-10/5 SYRUP ORAL 03/07/2018 0.01963

PROMETHAZINE/DEXTROMETHORPHAN 6.25-15/5 SYRUP ORAL 10/03/2018 0.01709

PROPAFENONE HCL 225 MG CAP ER 12H ORAL 02/06/2019 2.42406

PROPAFENONE HCL 325 MG CAP ER 12H ORAL 02/06/2019 3.40538

PROPAFENONE HCL 425 MG CAP ER 12H ORAL 02/06/2019 3.02500

PROPAFENONE HCL 150 MG TABLET ORAL 01/23/2019 0.20113

PROPAFENONE HCL 300 MG TABLET ORAL 01/23/2019 1.80887

PROPAFENONE HCL 225 MG TABLET ORAL 01/23/2019 0.38726

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019153

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

PROPARACAINE HCL 0.5 % DROPS OPHTHALMIC 02/13/2019 2.64248

PROPRANOLOL HCL 120 MG CAP SA 24H ORAL 07/07/2015 1.91017

PROPRANOLOL HCL 160 MG CAP SA 24H ORAL 09/22/2015 2.07084

PROPRANOLOL HCL 60 MG CAP SA 24H ORAL 07/07/2015 0.65111

PROPRANOLOL HCL 80 MG CAP SA 24H ORAL 04/11/2016 1.45430

PROPRANOLOL HCL 10 MG TABLET ORAL 10/17/2017 0.14995

PROPRANOLOL HCL 20 MG TABLET ORAL 01/30/2018 0.22194

PROPRANOLOL HCL 40 MG TABLET ORAL 01/16/2018 0.32227

PROPRANOLOL HCL 60 MG TABLET ORAL 08/18/2015 1.07401

PROPRANOLOL HCL 80 MG TABLET ORAL 10/04/2017 0.46900

PROPRANOLOL HCL 1 MG/ML VIAL INTRAVEN 04/24/2018 5.03100

PROPYLENE GLYCOL 99.5 % LIQUID MISCELL 02/13/2019 0.02373

PROPYLENE GLYCOL/PEG 400 0.3 %-0.4% DROPS OPHTHALMIC 01/16/2019 0.40915

PROPYLPARABEN 100 % POWDER MISCELL 12/26/2018 0.12060

PROPYLTHIOURACIL 50 MG TABLET ORAL 07/18/2018 2.27800

PROTECTIVES, O.U. MED. SWAB TOPICAL 06/17/2015 1.77011

PROTRIPTYLINE HCL 10 MG TABLET ORAL 10/10/2018 2.00477

PROTRIPTYLINE HCL 5 MG TABLET ORAL 02/15/2017 1.81315

PSEUDOEPHED/CODEINE/GUAIFEN 30-10-100 SYRUP ORAL 05/19/2015 0.21395

PSEUDOEPHEDRINE HCL 30 MG TABLET ORAL 10/24/2018 0.14712

PSEUDOEPHEDRINE HCL 15 MG/5 ML LIQUID ORAL 03/25/2015 0.01306

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019154

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

Date MAC Price

PSEUDOEPHEDRINE HCL 30 MG TABLET ORAL 02/20/2019 0.01332

PSEUDOEPHEDRINE HCL 120 MG TABLET ER ORAL 01/02/2019 0.33098

PSYLLIUM HUSK 0.52G CAPSULE ORAL 09/12/2018 0.09983

PSYLLIUM HUSK 0.4 G CAPSULE ORAL 12/19/2018 0.05609

PSYLLIUM HUSK 3.4 G/5.4G POWDER ORAL 01/31/2018 0.03600

PSYLLIUM HUSK (WITH SUGAR) 3.4 G POWD PACK ORAL 07/03/2018 0.49669

PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER ORAL 07/03/2018 0.01347

PSYLLIUM HUSK (WITH SUGAR) 3.4 G/12 G POWDER ORAL 07/03/2018 0.01642

PSYLLIUM HUSK/ASPARTAME 3.4G/5.8G POWDER ORAL 01/30/2019 0.03059

PSYLLIUM SEED POWDER ORAL 07/03/2018 0.02095

PSYLLIUM SEED (WITH SUGAR) POWDER ORAL 07/03/2018 0.01347

PYRAZINAMIDE 500 MG TABLET ORAL 10/02/2018 2.74652

PYRIDOSTIGMINE BROMIDE 60 MG TABLET ORAL 05/26/2015 0.87904

PYRIDOSTIGMINE BROMIDE 180 MG TABLET ER ORAL 01/09/2019 12.18177

PYRIDOXINE HCL (VITAMIN B6) 100 MG TABLET ORAL 02/27/2019 0.02211

PYRIDOXINE HCL (VITAMIN B6) 25 MG TABLET ORAL 11/14/2018 0.01474

PYRIDOXINE HCL (VITAMIN B6) 250 MG TABLET ORAL 08/22/2018 0.12283

PYRIDOXINE HCL (VITAMIN B6) 50 MG TABLET ORAL 03/06/2019 0.01221

PYRIDOXINE HCL (VITAMIN B6) 100 MG/ML VIAL INJECTION 04/18/2017 7.59264

PYRITHIONE ZINC 0.25 % SPRAY TOPICAL 09/11/2013 0.10412

PYRITHIONE ZINC 2 % BAR TOPICAL 09/11/2013 4.62000

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019155

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

Date MAC Price

PYRITHIONE ZINC 2 % SHAMPOO TOPICAL 10/15/2014 0.02737

QUETIAPINE FUMARATE 25 MG TABLET ORAL 11/07/2018 0.03626

QUETIAPINE FUMARATE 100 MG TABLET ORAL 12/12/2018 0.05876

QUETIAPINE FUMARATE 200 MG TABLET ORAL 12/12/2018 0.11457

QUETIAPINE FUMARATE 300 MG TABLET ORAL 12/12/2018 0.17179

QUETIAPINE FUMARATE 50 MG TABLET ORAL 12/12/2018 0.03511

QUETIAPINE FUMARATE 400 MG TABLET ORAL 12/12/2018 0.21841

QUETIAPINE FUMARATE 200 MG TAB ER 24H ORAL 01/23/2019 0.39887

QUETIAPINE FUMARATE 300 MG TAB ER 24H ORAL 03/06/2019 0.52997

QUETIAPINE FUMARATE 400 MG TAB ER 24H ORAL 12/12/2018 0.78144

QUETIAPINE FUMARATE 50 MG TAB ER 24H ORAL 01/23/2019 0.22333

QUETIAPINE FUMARATE 150 MG TAB ER 24H ORAL 12/26/2018 0.34550

QUINAPRIL HCL 10 MG TABLET ORAL 01/16/2019 0.12075

QUINAPRIL HCL 20 MG TABLET ORAL 01/16/2019 0.12656

QUINAPRIL HCL 5 MG TABLET ORAL 03/21/2017 0.11911

QUINAPRIL HCL 40 MG TABLET ORAL 01/16/2019 0.13400

QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET ORAL 08/16/2017 0.23286

QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET ORAL 03/20/2018 0.52800

QUINAPRIL/HYDROCHLOROTHIAZIDE 20 MG-25MG TABLET ORAL 03/20/2018 0.57400

QUININE SULFATE 324 MG CAPSULE ORAL 12/19/2018 3.20760

RABEPRAZOLE SODIUM 20 MG TABLET DR ORAL 03/06/2019 0.42329

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019156

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

Date MAC Price

RALOXIFENE HCL 60 MG TABLET ORAL 01/02/2019 0.81380

RAMIPRIL 1.25 MG CAPSULE ORAL 11/21/2018 0.14517

RAMIPRIL 2.5 MG CAPSULE ORAL 12/12/2018 0.04918

RAMIPRIL 5 MG CAPSULE ORAL 03/06/2019 0.06097

RAMIPRIL 10 MG CAPSULE ORAL 01/23/2019 0.06298

RANITIDINE HCL 150 MG CAPSULE ORAL 12/26/2018 0.91568

RANITIDINE HCL 300 MG CAPSULE ORAL 12/26/2018 1.20600

RANITIDINE HCL 15 MG/ML SYRUP ORAL 02/13/2019 0.21982

RANITIDINE HCL 150 MG TABLET ORAL 02/13/2019 0.06681

RANITIDINE HCL 300 MG TABLET ORAL 11/14/2018 0.16080

RANITIDINE HCL 75 MG TABLET ORAL 02/13/2019 0.07013

RANITIDINE HCL 25 MG/ML VIAL INJECTION 02/27/2019 5.75733

RANITIDINE HCL 50 MG/2 ML VIAL INJECTION 02/27/2019 5.75501

RANOLAZINE 500 MG TAB ER 12H ORAL 03/06/2019 6.52590

RANOLAZINE 1000 MG TAB ER 12H ORAL 03/06/2019 9.70198

RASAGILINE MESYLATE 1 MG TABLET ORAL 12/12/2018 10.72605

RASAGILINE MESYLATE 0.5 MG TABLET ORAL 12/12/2018 10.72605

RASPBERRY FLAVOR SYRUP ORAL 06/03/2015 0.08534

REMIFENTANIL HCL 5 MG VIAL INTRAVEN 08/29/2018 251.53603

REMIFENTANIL HCL 2 MG VIAL INTRAVEN 08/29/2018 118.22043

REMIFENTANIL HCL 1 MG VIAL INTRAVEN 08/29/2018 59.10970

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019157

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

Date MAC Price

REPAGLINIDE 0.5 MG TABLET ORAL 07/25/2018 0.32562

REPAGLINIDE 1 MG TABLET ORAL 01/23/2019 0.24897

REPAGLINIDE 2 MG TABLET ORAL 08/22/2018 0.27671

RIBAVIRIN 200 MG CAPSULE ORAL 01/23/2019 1.64469

RIBAVIRIN 200 MG TABLET ORAL 08/08/2018 0.81748

RIBAVIRIN 600-600 MG TAB DS PK ORAL 01/09/2019 25.30172

RIBAVIRIN 600-600(7) TAB DS PK ORAL 12/16/2015 25.30162

RIBAVIRIN 6 G VIAL-NEB INHALATION 07/11/2018 23574.99744

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET ORAL 05/14/2018 0.02727

RIBOFLAVIN (VITAMIN B2) 25 MG TABLET ORAL 03/21/2018 0.04717

RIBOFLAVIN (VITAMIN B2) 50 MG TABLET ORAL 01/22/2013 0.05219

RIFABUTIN 150 MG CAPSULE ORAL 04/24/2017 17.19333

RIFAMPIN 150 MG CAPSULE ORAL 07/25/2018 0.82772

RIFAMPIN 300 MG CAPSULE ORAL 07/05/2016 0.70229

RIFAMPIN 600 MG VIAL INTRAVEN 08/01/2018 69.54625

RILUZOLE 50 MG TABLET ORAL 02/27/2019 1.44452

RIMANTADINE HCL 100 MG TABLET ORAL 07/03/2018 1.75781

RINGER'S SOLUTION IV SOLN INTRAVEN 07/08/2015 0.00537

RINGER'S SOLUTION IRRIG SOLN IRRIGATION 11/18/2015 0.00668

RINGER'S SOLUTION,LACTATED IV SOLN INTRAVEN 06/14/2017 0.00276

RINGER'S SOLUTION,LACTATED IRRIG SOLN IRRIGATION 02/07/2018 0.00427

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019158

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

RISEDRONATE SODIUM 30 MG TABLET ORAL 12/19/2018 24.00965

RISEDRONATE SODIUM 5 MG TABLET ORAL 12/19/2018 4.51836

RISEDRONATE SODIUM 35 MG TABLET ORAL 02/20/2019 7.48170

RISEDRONATE SODIUM 150 MG TABLET ORAL 11/14/2018 28.11575

RISEDRONATE SODIUM 35 MG TABLET DR ORAL 03/06/2019 26.80503

RISPERIDONE 1 MG/ML SOLUTION ORAL 02/13/2019 0.31713

RISPERIDONE 1 MG TABLET ORAL 01/09/2019 0.04444

RISPERIDONE 2 MG TABLET ORAL 02/20/2018 0.05248

RISPERIDONE 3 MG TABLET ORAL 02/13/2019 0.06588

RISPERIDONE 4 MG TABLET ORAL 02/20/2018 0.06789

RISPERIDONE 0.25 MG TABLET ORAL 05/23/2017 0.02345

RISPERIDONE 0.5 MG TABLET ORAL 07/25/2017 0.03238

RISPERIDONE 1 MG TAB RAPDIS ORAL 02/06/2019 0.91790

RISPERIDONE 2 MG TAB RAPDIS ORAL 02/06/2019 1.97841

RISPERIDONE 0.5 MG TAB RAPDIS ORAL 02/27/2019 0.68519

RISPERIDONE 3 MG TAB RAPDIS ORAL 02/06/2019 5.78757

RISPERIDONE 4 MG TAB RAPDIS ORAL 06/20/2017 7.26471

RISPERIDONE 0.25 MG TAB RAPDIS ORAL 06/19/2017 3.16823

RITONAVIR 100 MG TABLET ORAL 02/06/2019 3.61108

RIVASTIGMINE 4.6MG/24HR PATCH TD24 TRANSDERM 08/29/2018 7.66440

RIVASTIGMINE 9.5MG/24HR PATCH TD24 TRANSDERM 08/15/2018 6.93589

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019159

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

RIVASTIGMINE 13.3MG/24H PATCH TD24 TRANSDERM 08/15/2018 7.42680

RIVASTIGMINE TARTRATE 1.5 MG CAPSULE ORAL 12/12/2018 0.39919

RIVASTIGMINE TARTRATE 3 MG CAPSULE ORAL 12/12/2018 0.42867

RIVASTIGMINE TARTRATE 4.5 MG CAPSULE ORAL 12/12/2018 0.46887

RIVASTIGMINE TARTRATE 6 MG CAPSULE ORAL 12/12/2018 0.50907

RIZATRIPTAN BENZOATE 5 MG TABLET ORAL 12/26/2018 0.75636

RIZATRIPTAN BENZOATE 10 MG TABLET ORAL 03/06/2019 0.74147

RIZATRIPTAN BENZOATE 5 MG TAB RAPDIS ORAL 08/04/2015 1.18218

RIZATRIPTAN BENZOATE 10 MG TAB RAPDIS ORAL 12/13/2016 1.52760

ROCURONIUM BROMIDE 10 MG/ML VIAL INTRAVEN 02/13/2019 0.56320

ROMIDEPSIN 10 MG/2 ML VIAL INTRAVEN 08/15/2018 3114.68544

ROPINIROLE HCL 0.25 MG TABLET ORAL 12/26/2018 0.06700

ROPINIROLE HCL 1 MG TABLET ORAL 02/06/2019 0.07164

ROPINIROLE HCL 2 MG TABLET ORAL 10/31/2018 0.07035

ROPINIROLE HCL 5 MG TABLET ORAL 10/10/2018 0.09367

ROPINIROLE HCL 0.5 MG TABLET ORAL 10/31/2018 0.06700

ROPINIROLE HCL 3 MG TABLET ORAL 09/20/2016 0.07678

ROPINIROLE HCL 4 MG TABLET ORAL 10/10/2018 0.09367

ROPINIROLE HCL 2 MG TAB ER 24H ORAL 07/03/2018 0.91924

ROPINIROLE HCL 4 MG TAB ER 24H ORAL 07/03/2018 1.57584

ROPINIROLE HCL 8 MG TAB ER 24H ORAL 07/03/2018 2.77200

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019160

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ROPINIROLE HCL 12 MG TAB ER 24H ORAL 10/26/2016 5.40173

ROPINIROLE HCL 6 MG TAB ER 24H ORAL 09/06/2016 2.75000

ROPIVACAINE HCL/PF 2 MG/ML INFUS. BTL INJECTION 01/30/2019 0.42880

ROPIVACAINE HCL/PF 2 MG/ML VIAL INJECTION 04/25/2018 0.22043

ROPIVACAINE HCL/PF 5 MG/ML VIAL INJECTION 02/27/2019 0.26733

ROPIVACAINE HCL/PF 10 MG/ML VIAL INJECTION 12/19/2018 0.41460

ROPIVACAINE HCL/PF 7.5 MG/ML VIAL INJECTION 07/03/2018 1.08540

ROPIVACAINE HCL/PF 2 MG/ML PLAST. BAG INJECTION 02/27/2019 0.47431

ROSUVASTATIN CALCIUM 10 MG TABLET ORAL 02/27/2019 0.11468

ROSUVASTATIN CALCIUM 20 MG TABLET ORAL 02/27/2019 0.11078

ROSUVASTATIN CALCIUM 40 MG TABLET ORAL 02/27/2019 0.14516

ROSUVASTATIN CALCIUM 5 MG TABLET ORAL 02/06/2019 0.08174

SACCHARIN POWDER MISCELL 02/11/2015 1.34181

SACCHAROMYCES BOULARDII 250 MG CAPSULE ORAL 11/15/2017 0.88440

SALICYLIC ACID 17 % GEL (GRAM) TOPICAL 01/23/2019 0.99998

SALICYLIC ACID 10 % CREAM (G) TOPICAL 04/25/2018 0.22333

SALICYLIC ACID 2 % CLEANSER TOPICAL 04/11/2018 0.02938

SALICYLIC ACID 40 % ADH. PATCH TOPICAL 01/09/2019 0.40602

SALICYLIC ACID 2 % LOTION TOPICAL 04/09/2014 0.42433

SALICYLIC ACID 17 % LIQUID TOPICAL 12/19/2018 0.42731

SALICYLIC ACID 3 % SHAMPOO TOPICAL 09/19/2018 0.02635

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019161

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 TRANSDERM 07/18/2018 16.85294

SELEGILINE HCL 5 MG CAPSULE ORAL 07/11/2017 0.71087

SELEGILINE HCL 5 MG TABLET ORAL 09/29/2015 1.12471

SELENIUM 200 MCG TABLET ORAL 01/30/2019 0.06151

SELENIUM 50 MCG TABLET ORAL 11/14/2018 0.02365

SELENIUM SULFIDE 2.5 % LOTION TOPICAL 08/15/2018 0.08219

SELENIUM SULFIDE 1 % SHAMPOO TOPICAL 04/18/2016 0.02318

SENNOSIDES 8.8MG/5ML SYRUP ORAL 12/12/2018 0.05600

SENNOSIDES 8.6 MG TABLET ORAL 02/20/2019 0.02191

SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG TABLET ORAL 02/27/2019 0.01654

SERTRALINE HCL 20 MG/ML ORAL CONC ORAL 03/21/2017 0.74917

SERTRALINE HCL 25 MG TABLET ORAL 01/16/2019 0.03455

SERTRALINE HCL 50 MG TABLET ORAL 02/06/2019 0.04580

SERTRALINE HCL 100 MG TABLET ORAL 01/16/2019 0.06492

SESAME OIL OIL MISCELL 03/06/2019 0.02003

SEVELAMER CARBONATE 0.8 G POWD PACK ORAL 01/23/2019 13.85977

SEVELAMER CARBONATE 2.4 G POWD PACK ORAL 01/23/2019 14.08470

SEVELAMER CARBONATE 800 MG TABLET ORAL 02/20/2019 1.42973

SEVELAMER HCL 800 MG TABLET ORAL 02/27/2019 7.23900

SILDENAFIL CITRATE 25 MG TABLET ORAL 01/16/2019 0.58067

SILDENAFIL CITRATE 50 MG TABLET ORAL 02/27/2019 0.58067

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019162

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SILDENAFIL CITRATE 100 MG TABLET ORAL 02/27/2019 0.58067

SILDENAFIL CITRATE 20 MG TABLET ORAL 03/06/2019 0.12358

SILDENAFIL CITRATE 10 MG/12.5 VIAL INTRAVEN 02/21/2018 12.95272

SILODOSIN 4 MG CAPSULE ORAL 02/13/2019 1.56780

SILODOSIN 8 MG CAPSULE ORAL 02/13/2019 0.93800

SILVER GEL ER(ML) TOPICAL 12/28/2016 0.60300

SILVER SULFADIAZINE 1 % CREAM (G) TOPICAL 06/20/2017 0.12177

SIMETHICONE 125 MG CAPSULE ORAL 03/06/2019 0.10407

SIMETHICONE 180 MG CAPSULE ORAL 03/06/2019 0.08219

SIMETHICONE 40MG/0.6ML DROPS SUSP ORAL 05/02/2018 0.09023

SIMETHICONE 125 MG TAB CHEW ORAL 10/10/2018 0.04837

SIMETHICONE 80 MG TAB CHEW ORAL 01/16/2019 0.02533

SIMPLE SYRUP SYRUP ORAL 03/06/2019 0.01295

SIMVASTATIN 5 MG TABLET ORAL 03/06/2019 0.02602

SIMVASTATIN 10 MG TABLET ORAL 11/07/2018 0.02345

SIMVASTATIN 20 MG TABLET ORAL 02/27/2019 0.03317

SIMVASTATIN 40 MG TABLET ORAL 08/18/2015 0.04604

SIMVASTATIN 80 MG TABLET ORAL 10/31/2018 0.06845

SIROLIMUS 1 MG/ML SOLUTION ORAL 02/27/2019 29.89566

SIROLIMUS 1 MG TABLET ORAL 09/19/2018 10.01535

SIROLIMUS 2 MG TABLET ORAL 03/15/2016 17.01966

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019163

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SIROLIMUS 0.5 MG TABLET ORAL 10/04/2016 9.44000

SKIN CLEANSER CLEANSER TOPICAL 12/06/2017 0.00946

SKIN CLEANSER COMB NO.31 SPRAY TOPICAL 07/15/2015 0.01798

SOAP BAR TOPICAL 09/13/2017 2.53260

SOD BORATE/BORIC AC/WATER/NACL IRRIG SOLN OPHTHALMIC 11/14/2018 0.03372

SOD CHLOR,BICARB/SQUEEZ BOTTLE PACK W/DEV NASAL 09/19/2018 0.17474

SOD CHLOR,SOD BICARB/NETI POT PACK W/DEV NASAL 10/25/2017 0.29078

SOD PHOS DI, MONO/K PHOS MONO 250 MG TABLET ORAL 09/15/2015 1.29980

SOD PHOSPHATE,MONOBASIC-DIBAS 3MMOL/ML VIAL INTRAVEN 06/19/2017 2.31820

SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLUTION ORAL 06/13/2018 0.04983

SODIUM ACETATE 4 MEQ/ML VIAL INTRAVEN 05/06/2015 0.11792

SODIUM BENZOATE/SOD PHENYLACET 10 %-10 % VIAL INTRAVEN 01/30/2019 209.10000

SODIUM BICARBONATE 325 MG TABLET ORAL 01/30/2018 0.01138

SODIUM BICARBONATE 650 MG TABLET ORAL 12/12/2018 0.01079

SODIUM BICARBONATE 1 MEQ/ML SYRINGE INTRAVEN 01/12/2016 0.25621

SODIUM BICARBONATE 1 MEQ/ML VIAL INTRAVEN 10/11/2017 0.22965

SODIUM BISULFITE 100 % POWDER MISCELL 05/21/2014 0.14070

SODIUM CHLORIDE 5 % OINT. (G) OPHTHALMIC 06/20/2018 2.80971

SODIUM CHLORIDE 5 % DROPS OPHTHALMIC 06/20/2018 0.66553

SODIUM CHLORIDE 0.65 % SPRAY NASAL 02/20/2019 0.02561

SODIUM CHLORIDE 2.5 MEQ/ML VIAL INTRAVEN 04/28/2015 0.11357

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019164

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SODIUM CHLORIDE 4 MEQ/ML VIAL INTRAVEN 07/11/2017 0.10097

SODIUM CHLORIDE 1000 MG TABLET SOL MISCELL 02/20/2019 0.13367

SODIUM CHLORIDE 0.45 % 0.45 % IV SOLN INTRAVEN 02/06/2019 0.00402

SODIUM CHLORIDE 3 % 3 % IV SOLN INTRAVEN 01/10/2018 0.01708

SODIUM CHLORIDE 5 % 5 % IV SOLN INTRAVEN 06/13/2018 0.01879

SODIUM CHLORIDE FOR INHALATION 0.9 % VIAL-NEB INHALATION 05/22/2018 0.06271

SODIUM CHLORIDE FOR INHALATION 3 % VIAL-NEB INHALATION 05/22/2018 0.08632

SODIUM CHLORIDE FOR INHALATION 7 % VIAL-NEB INHALATION 05/16/2017 0.08632

SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G SOLN RECON ORAL 08/28/2018 0.00448

SODIUM CHLORIDE/SODIUM BICARB PACKET NASAL 12/05/2018 0.08211

SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL INTRAVEN 01/23/2019 2.29622

SODIUM HYPOCHLORITE 0.25 % SOLUTION MISCELL 01/23/2019 0.02931

SODIUM HYPOCHLORITE 0.5 % SOLUTION MISCELL 01/23/2019 0.02931

SODIUM HYPOCHLORITE 0.125 % SOLUTION MISCELL 01/23/2019 0.02931

SODIUM METABISULFITE POWDER MISCELL 11/21/2018 0.06504

SODIUM PHENYLBUTYRATE 0.94 G/G POWDER ORAL 01/09/2019 17.94157

SODIUM PHENYLBUTYRATE 500 MG TABLET ORAL 01/10/2018 27.94150

SODIUM PHOSPHATE,MONO-DIBASIC 19G-7G/118 ENEMA RECTAL 09/19/2018 0.00856

SODIUM POLYSTYRENE SULFONATE POWDER ORAL 02/20/2019 0.08855

SODIUM POLYSTYRENE SULFONATE 15 G/60 ML ORAL SUSP ORAL 01/30/2019 0.16144

SODIUM,POTASSIUM PHOSPHATES 280-250MG POWD PACK ORAL 10/17/2018 0.58116

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019165

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SORBITOL POWDER MISCELL 02/06/2019 0.04516

SORBITOL SOLUTION 70 % SOLUTION MISCELL 07/05/2017 0.00858

SOTALOL HCL 160 MG TABLET ORAL 12/05/2018 0.22749

SOTALOL HCL 240 MG TABLET ORAL 06/13/2018 0.69023

SOTALOL HCL 80 MG TABLET ORAL 01/30/2019 0.08348

SOTALOL HCL 120 MG TABLET ORAL 10/31/2018 0.12355

SPEARMINT OIL OIL MISCELL 05/21/2014 1.50750

SPINOSAD 0.9 % SUSPENSION TOPICAL 01/23/2019 2.75693

SPIRONOLACT/HYDROCHLOROTHIAZID 25 MG-25MG TABLET ORAL 04/21/2015 0.95006

SPIRONOLACTONE 100 MG TABLET ORAL 07/12/2016 0.35644

SPIRONOLACTONE 25 MG TABLET ORAL 01/16/2019 0.06332

SPIRONOLACTONE 50 MG TABLET ORAL 03/06/2019 0.18157

ST. JOHN'S WORT 300 MG CAPSULE ORAL 06/07/2017 0.04139

STAVUDINE 15 MG CAPSULE ORAL 03/29/2018 1.71274

STAVUDINE 20 MG CAPSULE ORAL 03/29/2018 1.78131

STAVUDINE 30 MG CAPSULE ORAL 04/25/2017 1.89163

STAVUDINE 40 MG CAPSULE ORAL 01/30/2018 2.04082

STEARIC ACID POWDER MISCELL 02/13/2019 0.04092

STEARYL ALCOHOL FLAKES MISCELL 03/06/2019 0.08234

SUB-Q INFUSION PUMP ACCESSORY EACH MISCELL 01/07/2015 5.71500

SUCCINYLCHOLINE CHLORIDE 20 MG/ML VIAL INJECTION 02/27/2019 2.19562

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019166

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SUCRALFATE 1 G TABLET ORAL 02/27/2019 0.30565

SUFENTANIL CITRATE 50 MCG/ML AMPUL INTRAVEN 08/30/2017 2.57280

SULFACETAMIDE SODIUM 10 % SUSPENSION TOPICAL 10/04/2016 0.98021

SULFACETAMIDE SODIUM 10 % DROPS OPHTHALMIC 01/09/2019 3.30616

SULFACETAMIDE SODIUM/SULFUR 10 %-4 % MED. PAD TOPICAL 02/20/2019 3.76156

SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % CLEANSER TOPICAL 01/23/2019 1.89566

SULFACETAMIDE SODIUM/SULFUR 9 %-4 % CLEANSER TOPICAL 02/27/2019 0.73530

SULFACETAMIDE SODIUM/SULFUR 8 %-4 % SUSPENSION TOPICAL 05/07/2014 0.22158

SULFACETAMIDE/SULFUR/CLEANSR23 9 %-4.5 % KIT TOPICAL 01/23/2019 658.31650

SULFACT SOD/SULUR/AVOB/OTN/OCT 9 %-4.5 % CMB CLN CR TOPICAL 02/20/2019 1.52388

SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP ORAL 05/22/2018 0.30742

SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160/20 ORAL SUSP ORAL 12/05/2018 0.16549

SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG TABLET ORAL 11/07/2018 0.06097

SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG TABLET ORAL 03/06/2019 0.06202

SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL INTRAVEN 11/08/2017 1.21297

SULFASALAZINE 500 MG TABLET ORAL 07/21/2015 0.21721

SULFASALAZINE 500 MG TABLET DR ORAL 08/25/2015 2.51014

SULINDAC 150 MG TABLET ORAL 01/09/2019 0.16075

SULINDAC 200 MG TABLET ORAL 02/06/2019 0.21614

SUMATRIPTAN 5 MG SPRAY NASAL 07/20/2017 54.46338

SUMATRIPTAN 20 MG SPRAY NASAL 01/17/2018 54.74013

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019167

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SUMATRIPTAN SUCC/NAPROXEN SOD 85MG-500MG TABLET ORAL 09/11/2018 65.82664

SUMATRIPTAN SUCCINATE 100 MG TABLET ORAL 01/16/2019 0.72807

SUMATRIPTAN SUCCINATE 50 MG TABLET ORAL 02/13/2019 0.65511

SUMATRIPTAN SUCCINATE 25 MG TABLET ORAL 01/23/2019 0.71504

SUMATRIPTAN SUCCINATE 6 MG/0.5ML CARTRIDGE SUBCUT 01/23/2019 188.65125

SUMATRIPTAN SUCCINATE 4 MG/0.5ML CARTRIDGE SUBCUT 01/09/2019 376.53939

SUMATRIPTAN SUCCINATE 6 MG/0.5ML VIAL SUBCUT 03/06/2019 13.93140

SUMATRIPTAN SUCCINATE 6 MG/0.5ML PEN INJCTR SUBCUT 01/30/2019 81.95900

SUMATRIPTAN SUCCINATE 4 MG/0.5ML PEN INJCTR SUBCUT 07/20/2017 215.00400

SYRGE-NDL,INS 0.3 ML HALF MARK 31 GX5/16" DISP SYRIN MISCELL 09/24/2018 0.15008

SYRGE-NDL,INS 0.3 ML HALF MARK 31GX15/64" DISP SYRIN MISCELL 06/06/2018 0.29601

SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" DISP SYRIN MISCELL 01/09/2019 0.13239

SYRING-NEEDL,DISP,INSUL,0.3 ML 30 GX5/16" DISP SYRIN MISCELL 12/12/2018 0.12596

SYRING-NEEDL,DISP,INSUL,0.3 ML 30GX1/2" DISP SYRIN MISCELL 02/13/2019 0.14137

SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" DISP SYRIN MISCELL 02/13/2019 0.13239

SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" DISP SYRIN MISCELL 02/06/2019 0.23427

SYRING-NEEDL,DISP,INSUL,0.3 ML 31 G X1/4" DISP SYRIN MISCELL 01/30/2019 0.21554

SYRINGE ACCESSORY EACH MISCELL 02/13/2019 0.07272

SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" DISP SYRIN MISCELL 06/06/2018 0.11658

SYRINGE AND NEEDLE,INSULIN,1ML DISP SYRIN MISCELL 01/22/2013 0.11776

SYRINGE AND NEEDLE,INSULIN,1ML 30 GX5/16" DISP SYRIN MISCELL 12/12/2018 0.12583

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019168

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SYRINGE AND NEEDLE,INSULIN,1ML 25GX5/8" DISP SYRIN MISCELL 06/21/2017 0.14054

SYRINGE AND NEEDLE,INSULIN,1ML 27GX1/2" DISP SYRIN MISCELL 05/23/2018 0.07598

SYRINGE AND NEEDLE,INSULIN,1ML 27GX5/8" DISP SYRIN MISCELL 07/18/2018 0.41912

SYRINGE AND NEEDLE,INSULIN,1ML 29 GAUGE DISP SYRIN MISCELL 02/27/2019 0.14733

SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" DISP SYRIN MISCELL 02/07/2017 0.11658

SYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE DISP SYRIN MISCELL 02/27/2019 0.14733

SYRINGE AND NEEDLE,INSULIN,1ML 30GX1/2" DISP SYRIN MISCELL 02/13/2019 0.14137

SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" DISP SYRIN MISCELL 02/13/2019 0.13239

SYRINGE AND NEEDLE,INSULIN,1ML 31GX15/64" DISP SYRIN MISCELL 02/06/2019 0.29601

SYRINGE AND NEEDLE,INSULIN,1ML 31 G X1/4" DISP SYRIN MISCELL 01/30/2019 0.21554

SYRINGE DISPOSABLE IRRIGATION DISP SYRIN MISCELL 01/22/2013 0.05427

SYRINGE FILTER 25 MM-0.22 EACH MISCELL 05/17/2017 10.32700

SYRINGE W-NEEDLE,DISPOSAB,3 ML 20GX1" DISP SYRIN MISCELL 05/17/2017 0.08424

SYRINGE W-NEEDLE,DISPOSAB,3 ML 20GX1 1/2" DISP SYRIN MISCELL 02/10/2016 0.08424

SYRINGE W-NEEDLE,DISPOSAB,3 ML 21 G X 1" DISP SYRIN MISCELL 01/23/2019 0.14070

SYRINGE W-NEEDLE,DISPOSAB,3 ML 21GX1 1/2" DISP SYRIN MISCELL 05/23/2018 0.14130

SYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX3/4" DISP SYRIN MISCELL 01/03/2018 0.11558

SYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1" DISP SYRIN MISCELL 06/28/2017 0.08424

SYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1 1/2" DISP SYRIN MISCELL 06/28/2017 0.08424

SYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1" DISP SYRIN MISCELL 06/21/2017 0.12690

SYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1 1/2" DISP SYRIN MISCELL 06/21/2017 0.06271

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019169

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX5/8" DISP SYRIN MISCELL 06/28/2017 0.06479

SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX1" DISP SYRIN MISCELL 06/21/2017 0.06546

SYRINGE W-NEEDLE,DISPOSAB,3 ML 27GX1.25" DISP SYRIN MISCELL 05/17/2017 0.08208

SYRINGE WITH NEEDLE, 1 ML 25GX5/8" DISP SYRIN MISCELL 12/12/2018 0.15638

SYRINGE WITH NEEDLE, 1 ML 25GX1" DISP SYRIN MISCELL 01/03/2018 0.21768

SYRINGE WITH NEEDLE, 1 ML 26GX3/8" DISP SYRIN MISCELL 06/28/2017 0.17639

SYRINGE WITH NEEDLE, 1 ML 27GX0.375" DISP SYRIN MISCELL 09/23/2015 0.11390

SYRINGE WITH NEEDLE, 1 ML 27GX1/2" DISP SYRIN MISCELL 06/21/2017 0.15658

SYRINGE WITH NEEDLE, 1 ML 28GX1/2" DISP SYRIN MISCELL 04/19/2017 0.23705

SYRINGE WITH NEEDLE, 12 ML 18GX1" DISP SYRIN MISCELL 10/05/2016 3.40214

SYRINGE WITH NEEDLE, 5 ML 20GX1" DISP SYRIN MISCELL 06/21/2017 0.19309

SYRINGE WITH NEEDLE, 5 ML 20GX1 1/2" DISP SYRIN MISCELL 06/21/2017 0.19309

SYRINGE WITH NEEDLE, 5 ML 21 G X 1" DISP SYRIN MISCELL 06/21/2017 0.22566

SYRINGE WITH NEEDLE, 5 ML 21GX1 1/2" DISP SYRIN MISCELL 06/21/2017 0.24696

SYRINGE WITH NEEDLE, 5 ML 22GX1" DISP SYRIN MISCELL 06/21/2017 0.22566

SYRINGE WITH NEEDLE, 5 ML 22GX1 1/2" DISP SYRIN MISCELL 07/05/2017 0.24696

SYRINGE WITH NEEDLE, 6 ML 20GX1 1/2" DISP SYRIN MISCELL 01/22/2013 0.18425

SYRINGE WITH NEEDLE, 6 ML 21 G X 1" DISP SYRIN MISCELL 01/22/2013 0.18425

SYRINGE WITH NEEDLE, 6 ML 21GX1 1/2" DISP SYRIN MISCELL 01/22/2013 0.18425

SYRINGE, DISPOSABLE, 1 ML DISP SYRIN MISCELL 12/27/2017 0.10800

SYRINGE, DISPOSABLE, 10 ML DISP SYRIN MISCELL 01/24/2018 0.12596

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019170

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SYRINGE, DISPOSABLE, 12 ML DISP SYRIN MISCELL 03/19/2013 0.11521

SYRINGE, DISPOSABLE, 20 ML DISP SYRIN MISCELL 01/24/2018 0.44304

SYRINGE, DISPOSABLE, 3 ML DISP SYRIN MISCELL 06/21/2017 0.07879

SYRINGE, DISPOSABLE, 30 ML DISP SYRIN MISCELL 05/17/2017 0.30364

SYRINGE, DISPOSABLE, 35 ML DISP SYRIN MISCELL 01/22/2013 0.32767

SYRINGE, DISPOSABLE, 5 ML DISP SYRIN MISCELL 02/17/2016 0.09085

SYRINGE, DISPOSABLE, 6 ML DISP SYRIN MISCELL 04/06/2016 0.11474

SYRINGE, DISPOSABLE, 60 ML DISP SYRIN MISCELL 05/24/2017 0.38385

SYRINGE,ENFIT 60ML,NON-STERILE DISP SYRIN MISCELL 11/15/2017 1.90950

SYRINGE,INSULIN,NEEDLESS 1 ML DISP SYRIN MISCELL 03/02/2016 0.08429

SYRINGE,NEEDLE,INSULN,SAFE,1ML 30 GX5/16" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,NEEDLE,INSULN,SAFE,1ML 29 G X1/2" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,NEEDLE,INSULN,SF 0.5ML 30 GX5/16" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,NEEDLE,INSULN,SF 0.5ML 29 G X1/2" DISP SYRIN MISCELL 02/07/2018 0.16415

SYRINGE,SAFETY NEEDLE,10 ML 21GX1 1/2" DISP SYRIN MISCELL 01/11/2017 0.32133

SYRINGE,SAFETY NEEDLE,10 ML 20GX1" DISP SYRIN MISCELL 01/27/2016 0.29453

SYRINGE,SAFETY NEEDLE,10 ML 20GX1 1/2" DISP SYRIN MISCELL 01/27/2016 0.29453

SYRINGE,SAFETY WITH NEEDLE,1ML 25GX1" SYRINGE MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,1ML 25GX5/8" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,1ML 27GX1/2" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,1ML 28GX1/2" DISP SYRIN MISCELL 05/16/2018 0.29467

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019171

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SYRINGE,SAFETY WITH NEEDLE,1ML 26GX3/8" DISP SYRIN MISCELL 11/09/2016 0.32307

SYRINGE,SAFETY WITH NEEDLE,3ML 21GX1 1/2" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 22GX1" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 22GX1 1/2" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 23GX1" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 25GX5/8" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 25GX1" DISP SYRIN MISCELL 07/18/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 21 G X 1" DISP SYRIN MISCELL 03/01/2016 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 20GX1" DISP SYRIN MISCELL 05/16/2018 0.29467

SYRINGE,SAFETY WITH NEEDLE,3ML 20GX1 1/2" DISP SYRIN MISCELL 01/19/2016 0.24288

SYRINGE,SAFETY WITH NEEDLE,5ML 21GX1 1/2" DISP SYRIN MISCELL 01/11/2017 0.32133

SYRINGE,SAFETY WITH NEEDLE,5ML 20GX1 1/2" DISP SYRIN MISCELL 01/27/2016 0.29453

SYRINGE,SAFETY WITH NEEDLE,5ML 20GX1" DISP SYRIN MISCELL 01/27/2016 0.29453

SYRINGE,SAFETY WITH NEEDLE,5ML 22GX1 1/2" DISP SYRIN MISCELL 03/30/2016 0.32133

SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" DISP SYRIN MISCELL 06/06/2018 0.11658

SYRINGE-NEEDLE,INSULIN,0.5 ML 28 GAUGE DISP SYRIN MISCELL 02/27/2019 0.14733

SYRINGE-NEEDLE,INSULIN,0.5 ML 27GX1/2" DISP SYRIN MISCELL 05/04/2016 0.18057

SYRINGE-NEEDLE,INSULIN,0.5 ML 29 GAUGE DISP SYRIN MISCELL 02/27/2019 0.14733

SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" DISP SYRIN MISCELL 07/03/2018 0.11658

SYRINGE-NEEDLE,INSULIN,0.5 ML 30 GX5/16" DISP SYRIN MISCELL 12/12/2018 0.12583

SYRINGE-NEEDLE,INSULIN,0.5 ML 30GX1/2" DISP SYRIN MISCELL 02/13/2019 0.14137

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019172

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" DISP SYRIN MISCELL 03/01/2016 0.13239

SYRINGE-NEEDLE,INSULIN,0.5 ML 31GX15/64" DISP SYRIN MISCELL 12/26/2018 0.23427

SYRINGE-NEEDLE,INSULIN,0.5 ML 31 G X1/4" DISP SYRIN MISCELL 01/30/2019 0.21554

TACROLIMUS 1 MG CAPSULE ORAL 03/06/2019 0.35845

TACROLIMUS 5 MG CAPSULE ORAL 05/17/2016 3.10873

TACROLIMUS 0.5 MG CAPSULE ORAL 09/24/2018 0.28703

TACROLIMUS 0.03 % OINT. (G) TOPICAL 06/09/2015 4.88199

TACROLIMUS 0.1 % OINT. (G) TOPICAL 10/10/2018 5.10356

TADALAFIL 10 MG TABLET ORAL 10/10/2018 69.21518

TADALAFIL 20 MG TABLET ORAL 01/30/2019 69.21518

TADALAFIL 5 MG TABLET ORAL 01/30/2019 10.48800

TADALAFIL 2.5 MG TABLET ORAL 10/10/2018 12.67640

TADALAFIL 20 MG TABLET ORAL 03/06/2019 3.45400

TAMOXIFEN CITRATE 10 MG TABLET ORAL 09/19/2018 0.23941

TAMOXIFEN CITRATE 20 MG TABLET ORAL 09/29/2015 0.38369

TAMSULOSIN HCL 0.4 MG CAPSULE ORAL 01/02/2019 0.13836

TAZAROTENE 0.1 % CREAM (G) TOPICAL 01/23/2019 7.18820

TEA TREE OIL 100 % OIL TOPICAL 11/07/2018 0.20033

TELMISARTAN 40 MG TABLET ORAL 01/23/2019 0.33634

TELMISARTAN 80 MG TABLET ORAL 02/06/2019 0.33634

TELMISARTAN 20 MG TABLET ORAL 02/06/2019 0.33634

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019173

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TELMISARTAN/AMLODIPINE 40 MG-5 MG TABLET ORAL 01/23/2019 4.88708

TELMISARTAN/AMLODIPINE 40 MG-10MG TABLET ORAL 01/12/2016 5.09312

TELMISARTAN/AMLODIPINE 80 MG-5 MG TABLET ORAL 01/23/2019 5.22520

TELMISARTAN/AMLODIPINE 80 MG-10MG TABLET ORAL 01/23/2019 5.50037

TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG TABLET ORAL 10/27/2015 2.17929

TELMISARTAN/HYDROCHLOROTHIAZID 40-12.5 MG TABLET ORAL 10/27/2015 2.67062

TELMISARTAN/HYDROCHLOROTHIAZID 80 MG-25MG TABLET ORAL 04/25/2017 2.57503

TEMAZEPAM 15 MG CAPSULE ORAL 11/21/2018 0.06215

TEMAZEPAM 30 MG CAPSULE ORAL 01/30/2019 0.07906

TEMAZEPAM 7.5 MG CAPSULE ORAL 10/24/2018 2.54064

TEMAZEPAM 22.5 MG CAPSULE ORAL 02/14/2018 3.35280

TEMOZOLOMIDE 5 MG CAPSULE ORAL 02/13/2019 2.38520

TEMOZOLOMIDE 20 MG CAPSULE ORAL 02/13/2019 8.37686

TEMOZOLOMIDE 100 MG CAPSULE ORAL 01/19/2016 31.84265

TEMOZOLOMIDE 250 MG CAPSULE ORAL 02/13/2019 80.23905

TEMOZOLOMIDE 140 MG CAPSULE ORAL 02/13/2019 47.82240

TEMOZOLOMIDE 180 MG CAPSULE ORAL 02/13/2019 52.79775

TEMSIROLIMUS FDN 30MG/3 VIAL INTRAVEN 02/13/2019 1175.23425

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET ORAL 01/30/2019 3.14028

TERAZOSIN HCL 1 MG CAPSULE ORAL 11/15/2017 0.13216

TERAZOSIN HCL 2 MG CAPSULE ORAL 07/03/2018 0.13216

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019174

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TERAZOSIN HCL 5 MG CAPSULE ORAL 11/21/2018 0.11524

TERAZOSIN HCL 10 MG CAPSULE ORAL 11/28/2018 0.13216

TERBINAFINE HCL 250 MG TABLET ORAL 02/27/2019 0.14204

TERBINAFINE HCL 1 % CREAM (G) TOPICAL 11/07/2018 0.58156

TERBUTALINE SULFATE 2.5 MG TABLET ORAL 02/20/2019 5.23182

TERBUTALINE SULFATE 5 MG TABLET ORAL 02/20/2019 6.25869

TERBUTALINE SULFATE 1 MG/ML VIAL SUBCUT 07/25/2018 1.80900

TERCONAZOLE 0.4 % CREAM/APPL VAGINAL 12/05/2018 0.92617

TERCONAZOLE 80 MG SUPP.VAG VAGINAL 03/06/2019 31.37867

TESTOSTERONE 30MG/1.5ML SOL MD PMP TRANSDERM 02/20/2019 4.35468

TESTOSTERONE 50 MG (1%) GEL (GRAM) TRANSDERM 11/07/2018 2.16222

TESTOSTERONE 25MG(1%) GEL PACKET TRANSDERM 07/11/2018 3.91600

TESTOSTERONE 50 MG (1%) GEL PACKET TRANSDERM 09/12/2018 2.02376

TESTOSTERONE 1.25G-1.62 GEL PACKET TRANSDERM 10/24/2018 10.31764

TESTOSTERONE 2.5G-1.62% GEL PACKET TRANSDERM 02/27/2019 9.40470

TESTOSTERONE 12.5/1.25G GEL MD PMP TRANSDERM 04/07/2015 1.63703

TESTOSTERONE 10 MG (2%) GEL MD PMP TRANSDERM 02/27/2019 7.88500

TESTOSTERONE 20.25/1.25 GEL MD PMP TRANSDERM 02/27/2019 9.45904

TESTOSTERONE CYPIONATE 100 MG/ML VIAL INTRAMUSC 08/01/2018 4.92756

TESTOSTERONE CYPIONATE 200 MG/ML VIAL INTRAMUSC 01/23/2019 5.21928

TESTOSTERONE ENANTHATE 200 MG/ML VIAL INTRAMUSC 08/29/2018 13.55802

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019175

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TETRABENAZINE 25 MG TABLET ORAL 11/28/2018 12.27679

TETRABENAZINE 12.5 MG TABLET ORAL 12/12/2018 12.65625

TETRACAINE HCL 0.5 % DROPS OPHTHALMIC 06/20/2018 0.48240

TETRACYCLINE HCL 250 MG CAPSULE ORAL 02/27/2019 2.56767

TETRACYCLINE HCL 500 MG CAPSULE ORAL 02/27/2019 9.08990

TETRAHYDROZOLINE HCL 0.05 % DROPS OPHTHALMIC 05/16/2018 0.10184

THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION ORAL 02/13/2019 0.08794

THEOPHYLLINE ANHYDROUS 400 MG TAB ER 24H ORAL 12/06/2017 1.29256

THEOPHYLLINE ANHYDROUS 600 MG TAB ER 24H ORAL 12/06/2017 1.86756

THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H ORAL 02/14/2018 0.28939

THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H ORAL 07/03/2018 0.36274

THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H ORAL 05/22/2018 5.41376

THIAMINE HCL 100 MG TABLET ORAL 01/02/2019 0.01132

THIAMINE HCL 250 MG TABLET ORAL 07/29/2015 0.03330

THIAMINE HCL 100 MG/ML VIAL INJECTION 02/06/2019 3.69600

THIAMINE MONONITRATE (VIT B1) 100 MG TABLET ORAL 07/03/2018 0.02124

THIORIDAZINE HCL 10 MG TABLET ORAL 01/30/2018 0.57459

THIORIDAZINE HCL 100 MG TABLET ORAL 03/28/2017 1.15093

THIORIDAZINE HCL 25 MG TABLET ORAL 10/24/2017 0.77063

THIORIDAZINE HCL 50 MG TABLET ORAL 02/07/2017 0.99508

THIOTEPA 15 MG VIAL INJECTION 11/07/2018 701.64325

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019176

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

THIOTHIXENE 10 MG CAPSULE ORAL 04/24/2017 4.49500

THIOTHIXENE 2 MG CAPSULE ORAL 04/07/2015 2.66767

THIOTHIXENE 5 MG CAPSULE ORAL 09/05/2018 3.57284

TIAGABINE HCL 4 MG TABLET ORAL 07/10/2018 5.42830

TIAGABINE HCL 12 MG TABLET ORAL 04/03/2018 9.21100

TIAGABINE HCL 16 MG TABLET ORAL 03/21/2018 9.04700

TIAGABINE HCL 2 MG TABLET ORAL 07/10/2018 5.42830

TIGECYCLINE 50 MG VIAL INTRAVEN 06/06/2018 75.95250

TIMOLOL MALEATE 0.25 % SOL-GEL OPHTHALMIC 06/13/2018 32.17475

TIMOLOL MALEATE 0.5 % SOL-GEL OPHTHALMIC 01/30/2019 29.64505

TIMOLOL MALEATE 0.5 % DROP DAILY OPHTHALMIC 07/25/2018 44.52600

TIMOLOL MALEATE 0.25 % DROPS OPHTHALMIC 02/27/2019 0.62444

TIMOLOL MALEATE 0.5 % DROPS OPHTHALMIC 02/13/2019 0.61551

TINIDAZOLE 500 MG TABLET ORAL 01/16/2019 1.13342

TINIDAZOLE 250 MG TABLET ORAL 01/17/2018 1.91419

TIZANIDINE HCL 2 MG CAPSULE ORAL 02/06/2019 0.54324

TIZANIDINE HCL 4 MG CAPSULE ORAL 02/06/2019 0.97329

TIZANIDINE HCL 6 MG CAPSULE ORAL 01/16/2019 1.37484

TIZANIDINE HCL 2 MG TABLET ORAL 03/06/2019 0.11229

TIZANIDINE HCL 4 MG TABLET ORAL 09/08/2015 0.10148

TOBRAMYCIN 0.3 % DROPS OPHTHALMIC 02/27/2019 2.66660

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019177

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TOBRAMYCIN IN 0.225% SOD CHLOR 300 MG/5ML AMPUL-NEB INHALATION 02/13/2019 7.26446

TOBRAMYCIN SULFATE 1.2 G VIAL INJECTION 12/05/2018 76.55213

TOBRAMYCIN SULFATE 40 MG/ML VIAL INJECTION 06/13/2018 0.59273

TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% DROPS SUSP OPHTHALMIC 03/06/2019 16.10385

TOBRAMYCIN/NEBULIZER 300 MG/5ML AMPUL-NEB INHALATION 02/27/2019 15.81255

TOLCAPONE 100 MG TABLET ORAL 10/30/2018 79.49410

TOLNAFTATE 1 % AERO POWD TOPICAL 02/13/2019 0.04402

TOLNAFTATE 1 % CREAM (G) TOPICAL 10/17/2018 0.02820

TOLNAFTATE 1 % POWDER TOPICAL 11/28/2018 0.05371

TOLNAFTATE 1 % SOLUTION TOPICAL 09/05/2018 0.20234

TOLTERODINE TARTRATE 4 MG CAP ER 24H ORAL 02/20/2019 2.77537

TOLTERODINE TARTRATE 2 MG CAP ER 24H ORAL 02/20/2019 3.11960

TOLTERODINE TARTRATE 1 MG TABLET ORAL 12/14/2016 4.08848

TOLTERODINE TARTRATE 2 MG TABLET ORAL 04/21/2015 1.15575

TOPICAL CREAM METERED-DOSE DEV EACH MISCELL 01/14/2015 1.33665

TOPIRAMATE 15 MG CAP SPRINK ORAL 08/25/2015 0.49424

TOPIRAMATE 25 MG CAP SPRINK ORAL 04/19/2016 0.60032

TOPIRAMATE 50 MG TABLET ORAL 02/13/2019 0.04958

TOPIRAMATE 100 MG TABLET ORAL 01/30/2019 0.06544

TOPIRAMATE 200 MG TABLET ORAL 03/06/2019 0.08956

TOPIRAMATE 25 MG TABLET ORAL 01/30/2019 0.03350

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019178

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TOPOTECAN HCL 4 MG VIAL INTRAVEN 08/08/2018 86.10000

TOPOTECAN HCL 4 MG/4 ML VIAL INTRAVEN 01/23/2019 11.20963

TOREMIFENE CITRATE 60 MG TABLET ORAL 02/06/2019 39.14543

TORSEMIDE 5 MG TABLET ORAL 03/06/2018 0.08670

TORSEMIDE 10 MG TABLET ORAL 11/14/2018 0.10117

TORSEMIDE 20 MG TABLET ORAL 01/16/2019 0.11725

TORSEMIDE 100 MG TABLET ORAL 01/30/2018 0.35028

TRAMADOL HCL 50 MG TABLET ORAL 05/14/2018 0.01520

TRAMADOL HCL 200 MG TAB ER 24H ORAL 12/12/2018 3.18208

TRAMADOL HCL 300 MG TAB ER 24H ORAL 12/12/2018 4.43608

TRAMADOL HCL 100 MG TAB ER 24H ORAL 12/12/2018 2.25611

TRAMADOL HCL 100 MG TBMP 24HR ORAL 12/12/2018 2.01000

TRAMADOL HCL 200 MG TBMP 24HR ORAL 02/14/2017 3.08000

TRAMADOL HCL 300 MG TBMP 24HR ORAL 01/23/2019 3.96000

TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG TABLET ORAL 12/05/2018 0.14941

TRANDOLAPRIL 1 MG TABLET ORAL 07/11/2018 0.23959

TRANDOLAPRIL 2 MG TABLET ORAL 07/11/2018 0.24602

TRANDOLAPRIL 4 MG TABLET ORAL 08/29/2018 0.24415

TRANDOLAPRIL/VERAPAMIL HCL 2 MG-180MG TAB BP 24H ORAL 05/10/2017 5.01600

TRANDOLAPRIL/VERAPAMIL HCL 1MG-240 MG TAB BP 24H ORAL 03/06/2018 3.49160

TRANDOLAPRIL/VERAPAMIL HCL 2MG-240 MG TAB BP 24H ORAL 05/10/2017 5.01600

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019179

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TRANDOLAPRIL/VERAPAMIL HCL 4MG-240 MG TAB BP 24H ORAL 05/10/2017 5.01600

TRANEXAMIC ACID 650 MG TABLET ORAL 10/06/2015 2.99156

TRANEXAMIC ACID 1000 MG/10 AMPUL INTRAVEN 01/23/2019 1.19662

TRANEXAMIC ACID 1000 MG/10 VIAL INTRAVEN 12/19/2018 0.81740

TRANYLCYPROMINE SULFATE 10 MG TABLET ORAL 02/20/2019 1.99955

TRAZODONE HCL 50 MG TABLET ORAL 11/21/2018 0.04663

TRAZODONE HCL 100 MG TABLET ORAL 02/06/2019 0.06981

TRAZODONE HCL 150 MG TABLET ORAL 01/26/2019 0.15197

TRAZODONE HCL 300 MG TABLET ORAL 03/06/2019 2.64101

TREPROSTINIL SODIUM 1 MG/ML VIAL INJECTION 03/06/2019 37.77125

TREPROSTINIL SODIUM 2.5 MG/ML VIAL INJECTION 03/06/2019 94.42813

TREPROSTINIL SODIUM 5 MG/ML VIAL INJECTION 03/06/2019 188.85625

TREPROSTINIL SODIUM 10 MG/ML VIAL INJECTION 03/06/2019 377.71250

TRETINOIN 10 MG CAPSULE ORAL 05/19/2015 19.34552

TRETINOIN 0.01 % GEL (GRAM) TOPICAL 09/15/2015 3.52293

TRETINOIN 0.025 % GEL (GRAM) TOPICAL 03/06/2019 3.55139

TRETINOIN 0.05 % GEL (GRAM) TOPICAL 11/21/2018 6.04731

TRETINOIN 0.025 % CREAM (G) TOPICAL 04/19/2016 2.65291

TRETINOIN 0.05 % CREAM (G) TOPICAL 07/21/2015 2.84651

TRETINOIN 0.1 % CREAM (G) TOPICAL 01/06/2015 4.60592

TRETINOIN MICROSPHERES 0.1 % GEL (GRAM) TOPICAL 01/02/2019 9.50667

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019180

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TRETINOIN MICROSPHERES 0.04 % GEL (GRAM) TOPICAL 12/19/2018 11.33000

TRETINOIN MICROSPHERES 0.04 % GEL W/PUMP TOPICAL 09/29/2015 7.55940

TRETINOIN MICROSPHERES 0.1 % GEL W/PUMP TOPICAL 05/26/2015 7.55940

TRIAMCINOLONE ACETONIDE 40 MG/ML VIAL INJECTION 01/23/2019 6.47700

TRIAMCINOLONE ACETONIDE 0.147MG/G AEROSOL TOPICAL 01/02/2019 3.83366

TRIAMCINOLONE ACETONIDE 0.025 % CREAM (G) TOPICAL 01/30/2019 0.04534

TRIAMCINOLONE ACETONIDE 0.1 % CREAM (G) TOPICAL 03/06/2019 0.05142

TRIAMCINOLONE ACETONIDE 0.5 % CREAM (G) TOPICAL 03/06/2019 0.47347

TRIAMCINOLONE ACETONIDE 0.025 % OINT. (G) TOPICAL 01/04/2019 0.26353

TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G) TOPICAL 02/27/2019 0.03748

TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) TOPICAL 02/20/2019 0.35733

TRIAMCINOLONE ACETONIDE 0.025 % LOTION TOPICAL 08/09/2016 0.64767

TRIAMCINOLONE ACETONIDE 0.1 % LOTION TOPICAL 03/06/2019 0.60278

TRIAMCINOLONE ACETONIDE 55 MCG SPRAY NASAL 06/13/2018 0.77835

TRIAMCINOLONE ACETONIDE 0.1 % PASTE (G) DENTAL 05/12/2015 8.79600

TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG CAPSULE ORAL 12/19/2018 0.06003

TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG TABLET ORAL 11/14/2018 0.06955

TRIAMTERENE/HYDROCHLOROTHIAZID 75 MG-50MG TABLET ORAL 11/28/2018 0.09273

TRIAZOLAM 0.125 MG TABLET ORAL 11/14/2018 2.45689

TRIAZOLAM 0.25 MG TABLET ORAL 02/06/2019 1.72686

TRIENTINE HCL 250 MG CAPSULE ORAL 11/28/2018 208.78584

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019181

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TRIFLUOPERAZINE HCL 1 MG TABLET ORAL 01/30/2019 0.73687

TRIFLUOPERAZINE HCL 10 MG TABLET ORAL 01/30/2019 1.81865

TRIFLUOPERAZINE HCL 2 MG TABLET ORAL 01/30/2019 0.96480

TRIFLUOPERAZINE HCL 5 MG TABLET ORAL 01/30/2019 1.23320

TRIFLURIDINE 1 % DROPS OPHTHALMIC 01/16/2018 13.07386

TRIHEXYPHENIDYL HCL 2 MG/5 ML ELIXIR ORAL 03/06/2019 0.05486

TRIHEXYPHENIDYL HCL 2 MG TABLET ORAL 02/27/2019 0.05816

TRIHEXYPHENIDYL HCL 5 MG TABLET ORAL 02/06/2019 0.12368

TRIMETHOBENZAMIDE HCL 300 MG CAPSULE ORAL 05/06/2015 1.61917

TRIMETHOPRIM 100 MG TABLET ORAL 09/18/2018 0.34693

TRIMIPRAMINE MALEATE 100 MG CAPSULE ORAL 10/18/2017 3.73342

TRIMIPRAMINE MALEATE 25 MG CAPSULE ORAL 07/03/2018 1.59366

TRIMIPRAMINE MALEATE 50 MG CAPSULE ORAL 07/03/2018 2.60697

TRIPROLIDINE HCL 0.625MG/ML DROPS ORAL 05/23/2018 1.33955

TRIPROLIDINE HCL 0.313MG/ML DROPS ORAL 02/20/2019 1.31776

TRIPROLIDINE/PSEUDOEPHEDRINE 2.5MG-60MG TABLET ORAL 12/12/2018 0.06842

TROLAMINE SALICYLATE 10 % CREAM (G) TOPICAL 05/14/2018 0.03320

TROPICAMIDE 0.5 % DROPS OPHTHALMIC 07/25/2018 0.57173

TROPICAMIDE 1 % DROPS OPHTHALMIC 07/25/2018 0.57173

TROSPIUM CHLORIDE 60 MG CAP ER 24H ORAL 05/12/2015 5.61552

TROSPIUM CHLORIDE 20 MG TABLET ORAL 01/30/2019 0.41696

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019182

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

TYROSINE 500 MG CAPSULE ORAL 10/26/2016 0.08308

UBIDECARENONE 200 MG CAPSULE ORAL 02/20/2019 0.30016

UBIDECARENONE POWDER MISCELL 11/21/2018 26.71663

UNDECYLENIC ACID 25 % SOLUTION TOPICAL 02/21/2018 0.40423

UREA 45 % GEL/PF APP TOPICAL 04/25/2017 5.08299

UREA 45 % GEL (ML) TOPICAL 04/19/2017 5.12445

UREA 20 % CREAM (G) TOPICAL 05/05/2015 0.06560

UREA 45 % CREAM (G) TOPICAL 12/22/2014 0.61729

UREA 10 % LOTION TOPICAL 11/03/2015 0.04020

UREA 45 % LOTION TOPICAL 04/19/2017 0.37353

URINE ALBUMIN TEST STRIP MISCELL 06/11/2014 3.16580

URSODIOL 300 MG CAPSULE ORAL 11/14/2018 3.13487

URSODIOL 250 MG TABLET ORAL 09/29/2015 1.00500

URSODIOL 500 MG TABLET ORAL 12/19/2018 1.40874

VALACYCLOVIR HCL 500 MG TABLET ORAL 01/16/2019 0.24116

VALACYCLOVIR HCL 1000 MG TABLET ORAL 11/07/2018 0.46930

VALGANCICLOVIR HCL 50 MG/ML SOLN RECON ORAL 09/07/2016 10.22542

VALGANCICLOVIR HCL 450 MG TABLET ORAL 02/20/2019 8.00000

VALPROIC ACID 250 MG CAPSULE ORAL 03/06/2019 0.23584

VALPROIC ACID (AS SODIUM SALT) 250 MG/5ML SOLUTION ORAL 05/14/2018 0.01778

VALPROIC ACID (AS SODIUM SALT) 250 MG/5ML SOLUTION ORAL 07/25/2018 0.13831

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019183

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

VALPROIC ACID (AS SODIUM SALT) 500MG/10ML SOLUTION ORAL 03/06/2019 0.09597

VALPROIC ACID (AS SODIUM SALT) 500 MG/5ML VIAL INTRAVEN 02/06/2019 0.52528

VALSARTAN 320 MG TABLET ORAL 08/01/2018 0.17581

VALSARTAN 160 MG TABLET ORAL 11/21/2018 0.11668

VALSARTAN 80 MG TABLET ORAL 01/30/2018 0.14874

VALSARTAN 40 MG TABLET ORAL 12/05/2018 0.10720

VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG TABLET ORAL 11/14/2018 0.17107

VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG TABLET ORAL 12/05/2018 0.20234

VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG TABLET ORAL 12/05/2018 0.20978

VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET ORAL 10/24/2018 0.35272

VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG TABLET ORAL 11/14/2018 0.31093

VANCOMYCIN HCL 125 MG CAPSULE ORAL 01/23/2019 5.58800

VANCOMYCIN HCL 250 MG CAPSULE ORAL 11/28/2018 8.40600

VANCOMYCIN HCL 1 G VIAL INTRAVEN 01/09/2019 5.08200

VANCOMYCIN HCL 10 G VIAL INTRAVEN 10/21/2014 41.64575

VANCOMYCIN HCL 5 G VIAL INTRAVEN 11/03/2014 19.64078

VANCOMYCIN HCL 500 MG VIAL INTRAVEN 01/16/2019 3.18120

VANCOMYCIN HCL 750 MG VIAL INTRAVEN 11/21/2018 10.09125

VARDENAFIL HCL 5 MG TABLET ORAL 01/16/2019 28.50815

VARDENAFIL HCL 10 MG TABLET ORAL 03/06/2019 28.50815

VARDENAFIL HCL 20 MG TABLET ORAL 03/06/2019 28.50815

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019184

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

VARDENAFIL HCL 2.5 MG TABLET ORAL 01/16/2019 28.50815

VARDENAFIL HCL 10 MG TAB RAPDIS ORAL 12/12/2018 29.66863

VECURONIUM BROMIDE 10 MG VIAL INTRAVEN 01/30/2019 6.53796

VECURONIUM BROMIDE 20 MG VIAL INTRAVEN 01/16/2019 7.14375

VENLAFAXINE HCL 37.5 MG CAP ER 24H ORAL 01/30/2018 0.08231

VENLAFAXINE HCL 75 MG CAP ER 24H ORAL 12/05/2018 0.10735

VENLAFAXINE HCL 150 MG CAP ER 24H ORAL 07/12/2016 0.16988

VENLAFAXINE HCL 37.5 MG TAB ER 24 ORAL 05/09/2018 2.28470

VENLAFAXINE HCL 75 MG TAB ER 24 ORAL 12/12/2017 5.08409

VENLAFAXINE HCL 150 MG TAB ER 24 ORAL 12/12/2017 4.73822

VENLAFAXINE HCL 225 MG TAB ER 24 ORAL 07/03/2018 12.70353

VENLAFAXINE HCL 25 MG TABLET ORAL 01/23/2019 0.16080

VENLAFAXINE HCL 37.5 MG TABLET ORAL 12/12/2018 0.17688

VENLAFAXINE HCL 50 MG TABLET ORAL 12/12/2018 0.10934

VENLAFAXINE HCL 75 MG TABLET ORAL 02/06/2019 0.18948

VENLAFAXINE HCL 100 MG TABLET ORAL 05/19/2015 0.20368

VERAPAMIL HCL 100 MG CAP24H PCT ORAL 07/03/2018 1.47440

VERAPAMIL HCL 200 MG CAP24H PCT ORAL 05/06/2015 1.89905

VERAPAMIL HCL 300 MG CAP24H PCT ORAL 05/06/2015 2.71828

VERAPAMIL HCL 120 MG CAP24H PEL ORAL 01/10/2017 4.46107

VERAPAMIL HCL 240 MG CAP24H PEL ORAL 01/23/2019 8.64300

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019185

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

VERAPAMIL HCL 180 MG CAP24H PEL ORAL 01/23/2019 7.65876

VERAPAMIL HCL 360 MG CAP24H PEL ORAL 04/18/2017 11.64647

VERAPAMIL HCL 120 MG TABLET ORAL 11/14/2018 0.07544

VERAPAMIL HCL 40 MG TABLET ORAL 01/30/2018 0.24267

VERAPAMIL HCL 80 MG TABLET ORAL 01/12/2016 0.05824

VERAPAMIL HCL 240 MG TABLET ER ORAL 01/23/2019 0.14298

VERAPAMIL HCL 180 MG TABLET ER ORAL 01/23/2019 0.12127

VERAPAMIL HCL 120 MG TABLET ER ORAL 01/23/2019 0.15611

VERAPAMIL HCL 2.5 MG/ML VIAL INTRAVEN 12/26/2018 6.61353

VIGABATRIN 500 MG POWD PACK ORAL 07/03/2018 64.90751

VIGABATRIN 500 MG TABLET ORAL 02/20/2019 77.67886

VINCRISTINE SULFATE 1 MG/ML VIAL INTRAVEN 08/22/2018 6.82879

VINCRISTINE SULFATE 2 MG/2 ML VIAL INTRAVEN 02/14/2018 6.35222

VINORELBINE TARTRATE 10 MG/ML VIAL INTRAVEN 01/23/2019 14.23800

VINORELBINE TARTRATE 50 MG/5 ML VIAL INTRAVEN 02/06/2019 11.41140

VIT A PALMITATE/VIT C/VIT D3 750-35/ML DROPS ORAL 04/11/2018 0.11109

VIT A/VIT C/VIT E/ZINC/COPPER 14320-226 CAPSULE ORAL 12/19/2018 0.24221

VIT A/VIT C/VIT E/ZINC/COPPER 7160-113 TABLET ORAL 09/03/2014 0.12110

VIT B COMP NO.3/FOLIC/C/BIOTIN 1MG-60MG TABLET ORAL 01/09/2019 0.19792

VIT B COMP/C/FOLIC/IRON/VIT E 500-400-18 TABLET ORAL 01/22/2013 0.07203

VIT B COMPLX/FOLIC AC/C/BIOTIN 1-100-300 TABLET ORAL 10/31/2018 32.06541

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019186

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

VIT B12/LEVOMEFOLATE/VIT B6/B2 1-6-50-5MG TABLET ORAL 02/07/2017 3.09291

VIT E ACET/GLY/DIMETH/WATER LOTION TOPICAL 11/15/2017 0.02680

VITAMIN A 10000 UNIT CAPSULE ORAL 12/05/2018 0.02003

VITAMIN A 8000 UNIT CAPSULE ORAL 01/30/2019 0.03551

VITAMIN A/VIT C/ZINC/PROPOLIS 15 MG LOZENGE ORAL 01/09/2014 0.02673

VITAMIN B COMPLEX CAPSULE ORAL 03/14/2018 0.02184

VITAMIN B COMPLEX TABLET ORAL 04/01/2015 0.01973

VITAMIN B COMPLEX TABLET ER ORAL 10/09/2013 0.08991

VITAMIN B COMPLEX/FOLIC ACID 0.4 MG TABLET ORAL 10/18/2017 0.09405

VITAMIN B COMPLEX/FOLIC ACID 0.4 MG TABLET ER ORAL 09/19/2018 0.13020

VITAMIN B COMPLEX/LYSINE 790MG/15ML LIQUID ORAL 09/14/2016 0.02092

VITAMIN D3/FOLIC ACID 3775 UNIT CAPSULE ORAL 06/12/2018 13.07955

VITAMIN D3/FOLIC ACID 5750 UNIT CAPSULE ORAL 06/13/2018 20.74800

VITAMIN D3/FOLIC ACID 5000 UNIT TABLET ORAL 06/13/2018 12.50865

VITAMIN D3/FOLIC ACID 3775 UNIT TABLET ORAL 10/31/2018 17.46500

VITAMIN E 1000 UNIT CAPSULE ORAL 05/22/2018 0.15097

VITAMIN E 200 UNIT CAPSULE ORAL 08/21/2014 0.02526

VITAMIN E 400 UNIT CAPSULE ORAL 11/29/2017 0.02295

VITAMIN E CREAM (G) TOPICAL 08/05/2015 0.04456

VITAMIN E OIL TOPICAL 01/31/2013 0.21105

VITAMIN E (DL,TOCOPHERYL ACET) 1000 UNIT CAPSULE ORAL 11/21/2018 0.10043

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019187

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT CAPSULE ORAL 03/06/2019 0.05923

VITAMIN E (DL,TOCOPHERYL ACET) 200 UNIT CAPSULE ORAL 12/05/2018 0.03317

VITAMIN E ACETATE 400 UNIT CAPSULE ORAL 02/15/2017 0.05595

VITAMIN E MIXED 400 UNIT CAPSULE ORAL 07/29/2015 0.04174

VITAMINS B1,B2,B3,B5,AND B6 100-2MG/ML VIAL INJECTION 08/01/2018 7.41341

VITS A AND D/WHITE PET/LANOLIN OINT PACK TOPICAL 03/20/2018 0.00905

VITS A AND D/WHITE PET/LANOLIN OINT. (G) TOPICAL 11/13/2017 0.02513

VITS A,C,E/LUTEIN/MINERALS 1000-60-2 TABLET ORAL 01/30/2019 0.06700

VORICONAZOLE 200 MG/5ML SUSP RECON ORAL 05/23/2017 8.44240

VORICONAZOLE 50 MG TABLET ORAL 08/01/2018 3.34356

VORICONAZOLE 200 MG TABLET ORAL 03/06/2019 7.40833

VORICONAZOLE 200 MG VIAL INTRAVEN 01/23/2019 29.27400

WARFARIN SODIUM 10 MG TABLET ORAL 11/28/2018 0.18050

WARFARIN SODIUM 2.5 MG TABLET ORAL 12/05/2018 0.12998

WARFARIN SODIUM 2 MG TABLET ORAL 04/19/2016 0.12603

WARFARIN SODIUM 5 MG TABLET ORAL 02/27/2019 0.12998

WARFARIN SODIUM 7.5 MG TABLET ORAL 07/07/2015 0.18680

WARFARIN SODIUM 1 MG TABLET ORAL 01/23/2019 0.12603

WARFARIN SODIUM 3 MG TABLET ORAL 07/07/2015 0.12603

WARFARIN SODIUM 4 MG TABLET ORAL 11/21/2018 0.12998

WARFARIN SODIUM 6 MG TABLET ORAL 04/05/2016 0.18680

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019188

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

WATER LIQUID ORAL 01/14/2015 0.02153

WATER FOR INJECTION,STERILE VIAL INJECTION 01/10/2017 0.05446

WATER FOR INJECTION,STERILE IV SOLN INTRAVEN 10/31/2018 0.00335

WATER FOR IRRIGATION,STERILE IRRIG SOLN IRRIGATION 04/25/2017 0.00208

WITCH HAZEL 50 % MED. PAD TOPICAL 08/30/2017 0.09993

ZAFIRLUKAST 20 MG TABLET ORAL 12/19/2018 2.03278

ZAFIRLUKAST 10 MG TABLET ORAL 12/14/2016 2.03278

ZALEPLON 5 MG CAPSULE ORAL 12/26/2018 0.22445

ZALEPLON 10 MG CAPSULE ORAL 01/09/2019 0.22445

ZIDOVUDINE 100 MG CAPSULE ORAL 01/23/2019 1.96524

ZIDOVUDINE 10 MG/ML SYRUP ORAL 07/03/2018 0.15750

ZIDOVUDINE 300 MG TABLET ORAL 06/13/2018 0.39731

ZILEUTON 600 MG TBMP 12HR ORAL 02/14/2018 27.49093

ZINC AMINO ACID CHELATE 50 MG TABLET ORAL 02/27/2019 0.06298

ZINC GLUCONATE 30 MG TABLET ORAL 04/13/2016 0.05253

ZINC GLUCONATE 50 MG TABLET ORAL 02/13/2019 0.02084

ZINC GLUCONATE 100 MG TABLET ORAL 02/13/2019 0.03008

ZINC OXIDE 20 % OINT. (G) TOPICAL 11/21/2017 0.03111

ZINC OXIDE 40 % OINT. (G) TOPICAL 02/06/2019 0.01735

ZINC SULFATE 220(50) MG CAPSULE ORAL 05/22/2018 0.02948

ZINC SULFATE 220 MG TABLET ORAL 07/03/2018 0.02653

Any disclosure, reproduction, distribution, or other use of the NE MAC Pricing Information is strictly prohibited.You are to keep the NE MAC Pricing Information confidential and not disclose it to any third party and you are not to use the NE MAC Pricing Information for any other purpose.

NE MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.

** Confidential and Proprietary ** March 2019189

Nebraska Medicaid ProgramMonthly Maximum Allowable Cost (MAC) Listing

Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted monthly.

Generic Name Strength Form RouteEffective

DateMACPrice

ZIPRASIDONE HCL 20 MG CAPSULE ORAL 11/14/2018 0.52707

ZIPRASIDONE HCL 40 MG CAPSULE ORAL 11/14/2018 0.48664

ZIPRASIDONE HCL 60 MG CAPSULE ORAL 11/14/2018 0.56682

ZIPRASIDONE HCL 80 MG CAPSULE ORAL 01/16/2019 0.60747

ZOLEDRONIC AC/MANNITOL/0.9NACL 4 MG/100ML PIGGYBACK INTRAVEN 10/04/2017 0.76380

ZOLEDRONIC ACID 4 MG/5 ML VIAL INTRAVEN 01/23/2019 4.18440

ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML PIGGYBACK INTRAVEN 08/01/2018 1.12560

ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML PGGYBK BTL INTRAVEN 06/27/2018 1.44720

ZOLMITRIPTAN 2.5 MG TABLET ORAL 12/12/2018 2.61300

ZOLMITRIPTAN 5 MG TABLET ORAL 12/12/2018 6.94267

ZOLMITRIPTAN 2.5 MG TAB RAPDIS ORAL 01/30/2019 4.78500

ZOLMITRIPTAN 5 MG TAB RAPDIS ORAL 01/30/2019 5.46100

ZOLPIDEM TARTRATE 5 MG TABLET ORAL 03/06/2019 0.02680

ZOLPIDEM TARTRATE 10 MG TABLET ORAL 03/06/2019 0.02961

ZOLPIDEM TARTRATE 6.25 MG TAB MPHASE ORAL 02/07/2017 1.00487

ZOLPIDEM TARTRATE 12.5 MG TAB MPHASE ORAL 02/13/2019 0.88319

ZOLPIDEM TARTRATE 1.75 MG TAB SUBL SUBLINGUAL 11/28/2018 10.59840

ZOLPIDEM TARTRATE 3.5 MG TAB SUBL SUBLINGUAL 11/28/2018 10.59840

ZONISAMIDE 100 MG CAPSULE ORAL 01/16/2019 0.15772

ZONISAMIDE 25 MG CAPSULE ORAL 01/30/2019 0.10720

ZONISAMIDE 50 MG CAPSULE ORAL 10/03/2018 0.23182