Walgreens Plus Drug List

Home , Acebutolol, Benzonatate, Bimatoprost, Darifenacin, Diphenoxylate, Docusate

Medication List Walgreens Plus™ members receive discounts on thousands of generic and brand-name medications included on this Medication List, which is divided into four sections: Value-Priced Generics, Brand-Name, Lifestyle and Discounted Medications.*

Up to 85% off Cash Prices on Atorvastatin (generic Lipitor) and Rosuvastatin Up to (generic Crestor)* % off Saving at Walgreens just got easier with Walgreens Plus™, a 60 * new program launching in your Cash Prices area! With 20% off storewide every day,# discounts on eligible prescription purchases* and free prescription delivery,§ we’re adding more value to the Walgreens experience you already enjoy.

* Savings apply only to prescription purchased by Walgreens Plus Members from Walgreens stores in Florida. Cannot be combined with any form of insurance or other pharmacy benefit programs. Actual savings will vary.

# Only valid in a Walgreens store located in Florida or on Walgreens.com. Excludes prescriptions, clinic services, pharmacy items and services, sales tax, shipping and membership fees. Other restrictions apply.

§ Not available in all areas and excludes orders for perishable, age - restricted and other sensitive products as well as orders billed to Medicare Part B. Other restrictions and limitations apply.

Learn more about the Walgreens Plus program at Walgreens.com/Plus. Table of contents Value-Priced Generics 3-12 Antifungal 3 Antiviral 3 Arthritis or Pain 3 Asthma 4 Blood Pressure/Heart Health 4-6 Cholesterol 6 Cough/Cold/Allergy 7 Diabetes 7-8 Ear Care 8 Eye Care 8 Gastrointestinal Health 8 Gout 9 Infections 9-10 Medical Devices 10 Mental Health 10-11 Mouth/Throat/Dental 11 Skin Conditions 11-12 Thyroid Conditions 12 Urinary Health 12 Vitamins and Nutritional Health 12-13 Women’s Health 13-14 Other 14

Brand-Name Medications 15 Insulins 15 Diabetic Supplies 15

Lifestyle Medications 16 Birth Control 16 Erectile Dysfunction 16

Discounted Medications 17-80 A-C 17-31 D-E 31-38 F-J 38-46 K-O 46-60 P-T 60-76 U-Z 76-80 Medication List

The price for a medication identified as “Value-Priced” is listed below: • 30-day-supply drugs cost $5 (tier 1), $10 (tier 2) or $15 (tier 3) • 90-day-supply drugs cost $10 (tier 1), $20 (tier 2) or $30 (tier 3)

The Discounted Medications section lists the discounts offered to Walgreens Plus members on other generic and brand-name medications not included in the Value-Priced Medication section.

The price for a medication is based on its tier and whether it is a 30-day or 90-day supply.† There may be an additional cost for quantities greater than those listed. This discount prescription pricing applies only to Walgreen Plus members on prescriptions purchased in select Walgreens stores that are not billed to insurance and/or used in combination with other health or pharmacy benefit programs. For further details, see your pharmacist or Walgreens.com/Plus.

Value-Priced Generics Antifungal Quantity Drug Name Tier 30-day 90-day FLUCONAZOLE 150MG TAB 2 1 3 TERBINAFINE 250MG TAB 2 30 90

Antiviral Quantity Drug Name Tier 30-day 90-day ACYCLOVIR 200MG CAPS 3 60 180

Arthritis or Pain Quantity Drug Name Tier 30-day 90-day BACLOFEN 10MG TAB 3 30 90 CYCLOBENZAPRINE 5MG TAB 2 30 90 CYCLOBENZAPRINE 10MG TAB 2 30 90 DICLOFENAC SODIUM 75MG EC TAB 3 60 180 IBUPROFEN 100MG/5ML ORAL SUSP 2 120 360 IBUPROFEN 400MG TAB 2 90 270 IBUPROFEN 600MG TAB 2 60 180 IBUPROFEN 800MG TAB 2 60 180 INDOMETHACIN 25MG CAP 2 60 180 INDOMETHACIN 50MG CAP 1 30 90 KETOPROFEN 50MG CAP 3 90 270 KETOPROFEN 75MG CAP 3 60 180 KETOROLAC 30MG/ML INJ, 2ML 3 15 45 MELOXICAM 7.5MG TAB 2 30 90 MELOXICAM 15MG TAB 2 30 90 NAPROXEN 250MG TAB 2 60 180 NAPROXEN 500MG TAB 2 60 180 NAPROXEN 375MG TAB 2 60 180 NAPROXEN DR 500MG TAB 3 60 180

This Program is NOT insurance. Membership fee required. Discounted price applies only to prescription purchased by Walgreens Plus Members from Walgreens stores in Florida. Cannot be combined with any form of insurance or other pharmacy benefit programs. Amount of the discount may vary based on type of item Member purchases but provider will not charge Member more than the discounted rate. Program does not make any payments to providers. Member is entirely responsible for paying discounted price to provider at time of service.

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Asthma Quantity Drug Name Tier 30-day 90-day ALBUTEROL 0.083% INH SOLN 25X3ML 2 75 225 AMINOPHYLLINE 100MG TAB 2 60 180 AMINOPHYLLINE 200MG TAB 2 60 180 DYPHYLLINE-GG 100-100 ELIXIR 2 240 720 DYPHYLLIN-GG TAB 3 30 90 IPRATROPIUM INHAL SOLN 60 X 2.5ML 2 75 225

Blood Pressure/Heart Health Quantity Drug Name Tier 30-day 90-day AMILORIDE 5MG / HCTZ 50MG TAB 2 30 90 AMIODARONE 200MG TAB 2 30 90 AMLODIPINE BESYLATE 2.5MG TAB 2 30 90 AMLODIPINE BESYLATE 5MG TAB 2 30 90 AMLODIPINE BESYLATE 10MG TAB 3 30 90 ATENOLOL 100MG TAB 1 30 90 ATENOLOL 25MG TAB 2 60 180 ATENOLOL 50MG TAB 2 60 180 ATENOLOL/CHLORTHALIDONE 50/25 TAB 3 30 90 BENAZEPRIL 5MG TAB 2 30 90 BENAZEPRIL 10MG TAB 2 30 90 BENAZEPRIL 20MG TAB 2 30 90 BENAZEPRIL 40MG TAB 2 30 90 BISOPROLOL FUMARATE 5MG TAB 2 30 90 BISOPROLOL/HCTZ 2.5MG/6.25MG TAB 2 30 90 BISOPROLOL/HCTZ 5MG/6.25MG TAB 2 30 90 BISOPROLOL/HCTZ 10MG/6.25MG TAB 2 30 90 CARVEDILOL 3.125MG TAB 2 60 180 CARVEDILOL 6.25MG TAB 2 60 180 CARVEDILOL 12.5MG TAB 2 60 180 CARVEDILOL 25MG TAB 2 60 180 CLONIDINE 0.1MG TAB 2 60 180 CLONIDINE 0.2MG TAB 2 60 180 CLONIDINE 0.3MG TAB 2 60 180 DILTIAZEM 30MG TAB 2 60 180 DILTIAZEM 60MG TAB 3 60 180 DILTIAZEM 120MG TAB 2 30 90 DOXAZOSIN 1MG TAB 3 30 90 DOXAZOSIN 2MG TAB 3 30 90 DOXAZOSIN 4MG TAB 3 30 90 ENALAPRIL 2.5MG TAB 2 60 180 ENALAPRIL 5MG TAB 2 60 180 ENALAPRIL-HCTZ 5-12.5MG TAB 2 60 180 ENALAPRIL-HCTZ 10-25MG TAB 2 30 90 FOSINOPRIL 10MG TAB 2 30 90 FOSINOPRIL 20MG TAB 2 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Blood Pressure/Heart Health, continued Quantity Drug Name Tier 30-day 90-day FOSINOPRIL 40MG TAB 3 30 90 FUROSEMIDE 10MG/ML ORAL SOLN 60ML 3 90 270 FUROSEMIDE 20MG TAB 1 60 180 FUROSEMIDE 40MG TAB 1 60 180 FUROSEMIDE 80MG TAB 1 30 90 GUANFACINE 1MG TAB 2 30 90 GUANFACINE 2MG TAB 2 30 90 HYDRALAZINE 10MG TAB 1 60 90 HYDRALAZINE 25MG TAB 2 60 180 HYDROCHLOROTHIAZIDE 12.5MG CAP 2 30 90 YDROCHLOROTHIAZIDE 12.5MG TAB 3 30 90 HYDROCHLOROTHIAZIDE 25MG TAB 1 30 90 HYDROCHLOROTHIAZIDE 50MG TAB 1 30 90 INDAPAMIDE 1.25MG TAB 2 30 90 INDAPAMIDE 2.5MG TAB 2 30 90 ISOSORBIDE DINITRATE 2.5MG SL TAB 2 30 90 ISOSORBIDE DINITRATE 5MG SUBL TAB 3 120 360 ISOSORBIDE MONONITRATE 30MG ER TAB 2 30 90 ISOSORBIDE MONONITRATE 60MG ER TAB 2 30 90 LISINOPRIL 2.5MG TAB 2 30 90 LISINOPRIL 5MG TAB 2 30 90 LISINOPRIL 10MG TAB 1 30 90 LISINOPRIL 20MG TAB 1 30 90 LISINOPRIL 30MG TAB 2 30 90 LISINOPRIL 40MG TAB 2 30 90 LISINOPRIL-HCTZ 10/12.5MG TAB 2 30 90 LISINOPRIL-HCTZ 20/12.5MG TAB 2 30 90 LISINOPRIL-HCTZ 20/25MG TAB 2 30 90 METHYLDOPA 250MG TAB 3 60 180 METHYLDOPA 500MG TAB 3 60 180 METOPROLOL TARTRATE 25MG TAB 2 60 180 METOPROLOL TARTRATE 50MG TAB 2 60 180 METOPROLOL TARTRATE 100MG TAB 2 60 180 PRAZOSIN 1MG CAP 3 30 90 PROPRANOLOL 60MG TAB 3 60 180 QUINAPRIL 5MG TAB 2 30 90 QUINAPRIL 10MG TAB 2 30 90 QUINAPRIL 20MG TAB 3 30 90 QUINAPRIL 40MG TAB 2 30 90 RAMIPRIL 1.25MG CAP 3 30 90 SOTALOL 120MG TAB 2 60 180 SPIRONOLACTONE 25MG TAB 2 30 90 SPIRONOLACTONE 50MG TAB 2 30 90 TERAZOSIN 1MG CAP 2 30 90 TERAZOSIN 2MG CAP 2 30 90 TERAZOSIN 5MG CAP 2 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Blood Pressure/Heart Health, continued Quantity Drug Name Tier 30-day 90-day TERAZOSIN 10MG CAP 2 30 90 TICLOPIDINE 250MG TAB 3 60 180 TORSEMIDE 5MG TAB 3 30 90 TORSEMIDE 10MG TAB 3 30 90 TORSEMIDE 20MG TAB 3 30 90 TRANDOLAPRIL 1MG TAB 2 30 90 TRANDOLAPRIL 2MG TAB 2 30 90 TRANDOLAPRIL 4MG TAB 2 30 90 TRIAMTERENE 37.5MG/ HCTZ 25MG CAP 2 30 90 TRIAMTERENE 37.5MG/ HCTZ 25MG TAB 3 30 90 TRIAMTERENE 75MG/ HCTZ 50MG TAB 1 30 90 VERAPAMIL 40MG TAB 3 60 180 VERAPAMIL 80MG TAB 1 30 90 VERAPAMIL 120MG TAB 2 30 90 WARFARIN SOD 1MG TAB 2 30 90 WARFARIN SOD 2.5MG TAB 2 30 90 WARFARIN SOD 2MG TAB 2 30 90 WARFARIN SOD 3MG TAB 2 30 90 WARFARIN SOD 4MG TAB 2 30 90 WARFARIN SOD 5MG TAB 2 30 90 WARFARIN SOD 6MG TAB 2 30 90 WARFARIN SOD 7.5MG TAB 2 30 90 WARFARIN SOD 10MG** TAB 2 30 90

Cholesterol Quantity Drug Name Tier 30-day 90-day ATORVASTATIN 10MG TAB 3 30 90 ATORVASTATIN 20MG TAB 3 30 90 ATORVASTATIN 40MG TAB 3 30 90 ATORVASTATIN 80MG TAB 3 30 90 FENOFIBRATE 54MG TAB 3 30 90 GEMFIBROZIL 600MG TAB 3 60 180 LOVASTATIN 10MG TAB 2 30 90 LOVASTATIN 20MG TAB 2 30 90 LOVASTATIN 40MG TAB 2 30 90 PRAVASTATIN 10MG TAB 2 30 90 PRAVASTATIN 20MG TAB 2 30 90 PRAVASTATIN 40MG TAB 2 30 90 PRAVASTATIN 80MG TAB 2 30 90 ROSUVASTATIN 5MG TAB 3 30 90 ROSUVASTATIN 10MG TAB 3 30 90 ROSUVASTATIN 20MG TAB 3 30 90 ROSUVASTATIN 40MG TAB 3 30 90 SIMVASTATIN 5MG TAB 2 30 90 SIMVASTATIN 10MG TAB 2 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Cholesterol, continued Quantity Drug Name Tier 30-day 90-day SIMVASTATIN 20MG TAB 2 30 90 SIMVASTATIN 40MG TAB 2 30 90 SIMVASTATIN 80MG TAB 2 30 90

Cough/Cold/Allergy Quantity Drug Name Tier 30-day 90-day ALLER-CHLOR 4MG TAB 1 100 300 BENZONATATE 100MG CAP 2 30 90 BENZONATATE 200MG CAP 3 30 90 CETIRIZINE 1MG/ML SYRUP 3 120 360 CYPROHEPTADINE 2MG/5ML SYRUP 3 120 360 DE-CHLOR DM LIQUID 2 120 360 DE-CHLOR DR SYRUP 2 180 540 DEHISTINE SYRUP 3 240 720 DIPHENHYDRAMINE 50MG CAP 2 30 90 FLUTICASONE NASAL SP (120INH) 16GM 3 16 48 LORATADINE 10MG TAB 1 30 90 NOHIST TAB 3 30 90 ORGAN-I NR 200MG TAB 3 120 360 PBM ALLERGY SYRUP 3 120 360 PHENYLTOLOXAMINE PE CPM SYRUP 2 240 720 PROMETHAZINE 12.5MG TAB 2 30 90 PROMETHAZINE 25MG TAB 1 12 36 PROMETHAZINE 50MG TAB 2 60 180 PROMETHAZINE DM SYRUP 2 180 540 QUARTUSS DM DROPS 30ML 3 30 90 QV-ALLERGY SYRUP 3 240 720 REME TUSSIN DM SYRUP 3 150 450 SILDEC PE-DM SYRUP 1 120 360 SILDEC-PE SYRUP 1 120 360 SUPRESS-DX PED DROPS 30ML 3 30 90

TRIPOHIST LIQUID 3 120 360

Diabetes Quantity Drug Name Tier 30-day 90-day GLIMEPIRIDE 1MG TAB 1 30 90 GLIMEPIRIDE 2MG TAB 1 30 90 GLIMEPIRIDE 4MG TAB 2 30 90 GLIPIZIDE 5MG TAB 1 30 90 GLIPIZIDE 10MG TAB 2 60 180 GLIPIZIDE ER 10MG TAB 3 30 90 GLIPIZIDE XL 2.5MG TAB 3 60 180 GLIPIZIDE XL 5MG TAB 3 30 90 GLYBURIDE 1.25MG TAB 1 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Diabetes, continued Quantity Drug Name Tier 30-day 90-day GLYBURIDE 2.5MG TAB 2 30 90 GLYBURIDE 5MG TAB 2 30 90 GLYBURIDE MICRO 1.5MG TAB 1 30 90 GLYBURIDE MICRO 3MG TAB 1 30 90 GLYBURIDE MICRO 6MG TAB 2 30 90 GLYBURIDE/METFORMIN 1.25/250MG TAB 2 60 180 GLYBURIDE/METFORMIN 2.5/500MG TAB 2 60 180 METFORMIN 500MG TAB 1 90 270 METFORMIN 850MG TAB 1 90 270 METFORMIN 1000MG TAB 1 60 180 METFORMIN ER 500MG 24HR TAB 1 60 180

Ear Care Quantity Drug Name Tier 30-day 90-day ANTIPYRINE BENZOCAINE OTIC SOL 15ML 2 15 45

Eye Care Quantity Drug Name Tier 30-day 90-day BACITRACIN/POLYMYX OPHTHOINT 3.5GM 3 3.5 10.5 ERYTHROMYCIN OPHTH OINT 3.5GM 2 3.5 10.5 GENTAMICIN 0.3% OPHTH SOLN 5ML 2 5 15 LEVOBUNOLOL 0.5% OPTH SOLN 5ML 2 5 15 PILOCARPINE 0.5% OPHTH SOLN 3 15 45 POLYMYXIN-B/TRIMETHOPRIMOPHTH SOLN 2 10 30 SULFACETAMIDE NA 10% OPH SOL 15ML 2 15 45 TIMOLOL MALEATE .25% OPHTH SOL 5ML 2 5 15 TIMOLOL MALEATE 0.5% OPHTH SOLN 5ML 2 5 15 TOBRAMYCIN 0.3% OPH SOL 5ML 2 5 15

Gastrointestinal Health Quantity Drug Name Tier 30-day 90-day CIMETIDINE ORAL LIQ 300MG/5ML 3 240 720 DICYCLOMINE 10MG CAP 2 90 270 DICYCLOMINE 20MG TAB 2 60 180 DOC-Q-LACE 100MG CAP 2 60 180 FAMOTIDINE 20MG TAB 1 60 180 FAMOTIDINE 40MG TAB 1 30 90 METOCLOPRAMIDE 5MG TAB 2 60 180 METOCLOPRAMIDE 10MG TAB 2 60 180 METOCLOPRAMIDE HCL 5MG/5ML SOLN 1 60 180 NIZATIDINE 150MG CAP 3 60 180 RANITIDINE 150MG TAB 2 60 180 RANITIDINE 300MG TAB 2 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Gout Quantity Drug Name Tier 30-day 90-day ALLOPURINOL 100MG TAB 2 60 180 ALLOPURINOL 300MG TAB 3 60 180

Infections Quantity Drug Name Tier 30-day 90-day AMOX-CLAV 200MG/5ML SUSP 100ML 3 100 300 AMOX-CLAV 400MG/5ML SUSP 100ML 3 100 300 AMOXICILLIN 250MG CAP 1 30 90 AMOXICILLIN 500MG CAP 1 30 90 AMOXICILLIN 125MG CHEWABLE TAB 2 30 90 AMOXICILLIN 250MG CHEW TAB 3 40 120 AMOXICILLIN 125MG/5ML SUSP 80ML 2 150 450 AMOXICILLIN 125MG/5ML SUSP 100ML 2 150 450 AMOXICILLIN 125MG/5ML SUSP 150ML 2 150 450 AMOXICILLIN 200MG/5ML SUSP 75ML 1 100 300 AMOXICILLIN 200MG/5ML SUSP 100ML 1 100 300 AMOXICILLIN 250MG/5ML SUSP 80ML 1 150 450 AMOXICILLIN 250MG/5ML SUSP 100ML 1 150 450 AMOXICILLIN 250MG/5ML SUSP 150ML 1 150 450 AMOXICILLIN 400MG/5ML SUSP 50ML 1 100 300 AMOXICILLIN 400MG/5ML SUSP 75ML 1 100 300 AMOXICILLIN 400MG/5ML SUSP 100ML 1 100 300 AMOXICILLIN 500MG TAB 3 30 90 AMOXICILLIN 875MG TAB 3 20 60 AMPICILLIN 250MG CAP 2 40 120 AMPICILLIN 500MG CAP 3 60 180 CEFPROZIL 125MG/5ML SUSP 50ML 3 100 300 CEFPROZIL 125MG/5ML SUSP 75ML 3 100 300 CEFPROZIL 125MG/5ML SUSP 100ML 3 100 300 CEPHALEXIN 250MG CAP 1 28 84 CEPHALEXIN 500MG CAP 2 30 90 CIPROFLOXACIN 250MG TAB 1 14 42 CIPROFLOXACIN 500MG TAB 1 20 60 CIPROFLOXACIN 750MG TAB 3 20 60 CLINDAMYCIN 150MG CAP 3 30 90 LINDAMYCIN 300MG CAP 3 28 84 METRONIDAZOLE 250MG TAB 2 28 84 METRONIDAZOLE 500MG TAB 3 14 42 PENICILLIN VK 125MG/5ML SOLN 100ML 2 200 600 PENICILLIN VK 125MG/5ML SOLN 200ML 2 200 600 PENICILLIN VK 250MG/5ML SOLN 100ML 2 100 300 PENICILLIN VK 250MG/5ML SOLN 200ML 2 100 300 PENICILLIN VK 250MG TAB 1 30 90 PENICILLIN VK 500MG TAB 1 20 60 SMZ/TMP REGULAR STRENGTH TAB 2 28 84

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Infections, continued Quantity Drug Name Tier 30-day 90-day SULFAMETH/TRIMETHOPRIM 800/160 TAB 2 28 84 TRIMETHOPRIM 100MG TAB 3 30 90

Medical Devices Quantity Drug Name Tier 30-day 90-day PROCHAMBER AERO SPACER 3 1 3

Mental Health Quantity Drug Name Tier 30-day 90-day AMITRIPTYLINE 10MG TAB 1 30 90 AMITRIPTYLINE 25MG TAB 1 30 90 AMITRIPTYLINE 50MG TAB 1 30 90 BENZTROPINE 0.5MG TAB 2 30 90 BENZTROPINE 1MG TAB 3 60 180 BENZTROPINE 2MG TAB 2 30 90 BUSPIRONE 5MG TAB 2 60 180 BUSPIRONE 10MG TAB 2 60 180 CITALOPRAM 10MG TAB 1 30 90 CITALOPRAM 20MG TAB 1 30 90 CITALOPRAM 40MG TAB 1 30 90 CLOZAPINE 25MG TAB 3 30 90 DOXEPIN 10MG CAP 3 30 90 DOXEPIN 25MG CAP 3 30 90 DOXEPIN HCL 10MG/ML CONC 118ML 3 90 270 FLUOXETINE 10MG CAP 2 30 90 FLUOXETINE 20MG CAP 1 30 90 FLUOXETINE 40MG CAP 2 30 90 FLUPHENAZINE 2.5MG TAB 3 30 90 FLUVOXAMINE 25MG TAB 3 30 90 GABAPENTIN 100MG CAP 1 90 270 GABAPENTIN 250MG/5ML SOLN 3 236 708 HALOPERIDOL 0.5MG TAB 3 60 180 HALOPERIDOL 1MG TAB 2 30 90 HALOPERIDOL 2MG TAB 3 30 90 HYDROXYZINE 10MG/5ML SYRUP 3 240 720 HYDROXYZINE HCL 25MG TAB 2 30 90 HYDROXYZINE HCL 50MG TAB 3 30 90 HYDROXYZINE PAMOATE 25MG CAP 3 90 270 IMIPRAMINE 10MG TAB 3 60 180 IMIPRAMINE 25MG TAB 3 60 180 IMIPRAMINE 50MG TAB 3 30 90 LITHIUM CARBONATE 150MG CAP 3 60 180 LITHIUM CARBONATE 300MG CAP 2 90 270

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Mental Health, continued Quantity Drug Name Tier 30-day 90-day LITHIUM CARBONATE 300MG TAB 3 60 180 LITHIUM CARBONATE 600MG CAP 3 60 180 METHOCARBAMOL 500MG TAB 2 30 90 METHOCARBAMOL 750MG TAB 3 60 180 MIRTAZAPINE 15MG TAB 1 30 90 NORTRIPTYLINE 10MG CAP 2 30 90 NORTRIPTYLINE 75MG CAP 1 30 90 PAROXETINE 10MG TAB 2 30 90 PAROXETINE 20MG TAB 2 30 90 PAROXETINE 30MG TAB 2 30 90 PRAMIPEXOLE 0.25MG TAB 3 30 90 PRIMIDONE 50MG TAB 3 60 180 PROCHLORPERAZINE 5MG TAB 2 30 90 PROCHLORPERAZINE 10MG TAB 2 30 90 SERTRALINE 25MG TAB 2 30 90 SERTRALINE 50MG TAB 2 30 90 SERTRALINE 100MG TAB 2 30 90 TRAZODONE 50MG TAB 1 30 90 TRAZODONE 100MG TAB 1 30 90 TRAZODONE 150MG TAB 2 30 90 TRIHEXYPHENIDYL 2MG TAB 2 60 180 TRIHEXYPHENIDYL 5MG TAB 3 90 270

Mouth/Throat/Dental Quantity Drug Name Tier 30-day 90-day CHLORHEXIDINE ORAL RINSE 473ML 2 473 1419 LIDOCAINE VISCOUS 2% ORAL SOL 100ML 2 100 300 SF 5000 PLUS 1.1% CREAM 51GM 3 60 180 SOD FLUORIDE 0.2% MINT SOLUTION 2 473 1419 STANNOUS FLUORIDE 0.63% RINSE 3 300 900

Skin Conditions Quantity Drug Name Tier 30-day 90-day BENZOYL PEROXIDE 5% AQ GEL 60GM 3 60 180 BETAMETHASONE VAL 0.1% CRM 15GM 3 15 45 HYDROCORTISONE 1% CREAM 28.35GM 2 28.35 85.05 HYDROCORTISONE 2.5% CREAM 30GM 2 30 90 HYDROCORTISONE 2.5% OINT 28.35GM 3 60 180 HYPERCARE 20% SOL DAB-O-MATIC 60ML 3 60 180 MOMETASONE 0.1% OINT 15GM 3 15 45 MOMETASONE 0.1% OINT 45GM 3 45 135 MOMETASONE 0.1% TOPICAL SOLN 60ML 3 60 180 NYSTATIN OINT 15GM 3 15 45

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Skin Conditions, continued Quantity Drug Name Tier 30-day 90-day SALICYLIC AC 6% SHAMPOO 177ML 3 177 531 SELENIUM SULFIDE 2.5% SHAMPOO (LOTN) 2 118 354 TRIAMCINOLONE 0.025% CREAM 15GM 1 15 45 TRIAMCINOLONE 0.5% CREAM 15GM 2 15 45 TRIAMCINOLONE 0.1% CREAM 80GM 2 80 240 TRIAMCINOLONE 0.1% OINT 80GM 3 80 240 UREA 40% LOTION 236.6ML 3 236.6 709.8 UREA 50% NAIL GEL 18ML 3 18 54

Thyroid Conditions Quantity Drug Name Tier 30-day 90-day LEVOTHROID 0.1MG TAB 2 30 90 LEVOTHYROXINE 0.025MG (25MCG) TAB 2 30 90 LEVOTHYROXINE 0.05MG (50MCG) TAB 2 30 90 LEVOTHYROXINE 0.075MG (75MCG) TAB 2 30 90 LEVOTHYROXINE 0.088MG (88MCG) TAB 2 30 90 LEVOTHYROXINE 0.100MG (100MCG) TAB 2 30 90 LEVOTHYROXINE 0.112MG (112MCG) TAB 2 30 90 LEVOTHYROXINE 0.125MG (125MCG) TAB 2 30 90 LEVOTHYROXINE 0.137MG (137MCG) TAB 2 30 90 LEVOTHYROXINE 0.150MG (150MCG) TAB 2 30 90 LEVOTHYROXINE 0.175MG (175MCG) TAB 2 30 90 LEVOTHYROXINE 0.2MG (200MCG) TAB 2 30 90 LEVOTHYROXINE 0.3MG (300MCG) TAB 2 30 90 METHIMAZOLE 5MG TAB 2 30 90 METHIMAZOLE 10MG TAB 3 30 90 NATURE-THROID 0.5GR (32.5MG) TAB 3 60 180

Urinary Health Quantity Drug Name Tier 30-day 90-day OXYBUTYNIN 5MG/5ML SYRUP 3 240 720

Vitamins and Nutritional Health Quantity Drug Name Tier 30-day 90-day FABB TAB 3 30 90 FE C PLUS TAB 3 30 90 FEROTRIN CAP 3 60 180 FERREX 150 FORTE CAP 2 45 135 FLUORIDE 0.25MG F CHEWABLE TAB 2 120 360 FLUORIDE 0.5MG F CHEWABLE TAB 1 30 90 FLUORIDE 1.0MG F CHEWABLE TAB 2 30 90 FOLBECAL TAB 3 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Vitamins and Nutritional Health, continued Quantity Drug Name Tier 30-day 90-day FOLBEE PLUS TAB 3 30 90 FOLBEE TAB 3 30 90 FOLIC ACID 1MG TAB 1 30 90 HEMATINIC/ FA TAB 2 30 90 HEMATINIC PLUS TAB 10 X 10 3 30 90 KLOR-CON 10MEQ TAB 3 30 90 MULTIVIT/F 0.25MG CHEWABLE TAB 2 30 90 MULTI-VITA-F 0.5MG CHEW TAB 1 30 90 MULTI-VIT/FLUORIDE 1MG CHEW TAB 2 30 90 MULTIVITAMINS W/ FL 1.0MG CHEW TAB 3 30 90 MULTIVITS W/FL 1MG & IRON CHEW TAB 1 30 90 NATALCARE PLUS TAB (1MG FOLIC ACID) 1 30 90 POLY-IRON 150 CAP 3 60 180 POLY-IRON 150 FORTE CAP 3 45 135 POTASSIUM CL 10MEQ ER TAB 3 30 90 PRENAFIRST TAB 3 30 90 PRENATAB FA TAB 3 30 90 PRENATAL 19 TAB 2 30 90 PRENATAL PLUS TAB 3 30 90 RE DUALVIT F CAP 3 30 90 RE PRENATAL MULTIVIT W/IRON CHEW TB 3 30 90 RENA-VITE RX TAB 2 30 90 RENAL SOFTGEL CAP 3 30 90 THEROBEC PLUS TAB 3 30 90 VINATE AZ TAB 3 30 90 VINATE CARE CHEWABLE TAB 3 30 90 VINATE C TAB 3 30 90 VINATE GT TAB 2 30 90 VINATE M TAB 2 30 90 VINATE ONE TAB 2 30 90 VITAMIN B-12 100MCG TAB 1 100 300 VITAMIN D 50,000IU CAP 1 4 12

Women’s Health Quantity Drug Name Tier 30-day 90-day ALENDRONATE 10MG TAB 3 30 90 ALENDRONATE 35MG TAB 3 4 12 ALENDRONATE 70MG TAB 3 4 12 CLOMIPHENE CITRATE 50MG TAB 3 5 15 ESTRADIOL 0.5MG TAB 1 30 90 ESTRADIOL 1MG TAB 1 30 90 ESTRADIOL 2MG TAB 1 30 90 ESTROPIPATE 0.625MG (0.75MG) TAB 3 30 90 MEDROXYPROGESTERONE 2.5MG TAB 2 30 90

Prescription drug coverage and cost are subject to change.

Value-Priced Generics Women’s Health, continued Quantity Drug Name Tier 30-day 90-day MEDROXYPROGESTERONE 5MGTAB 1 30 90 MEDROXYPROGESTERONE 10MGTAB 1 10 30 MEGESTROL ACETATE 20MG TAB 2 30 90

Other Quantity Drug Name Tier 30-day 90-day DEXAMETHASONE 0.5MG TAB 2 60 180 DEXAMETHASONE 0.75MG TAB 2 12 36 DEXAMETHASONE 1MG TAB 3 30 90 DEXAMETHASONE 1.5MG TAB 3 45 135 DEXAMETHASONE 4MG TAB 2 30 90 FINASTERIDE 5MG TAB 2 30 90 HYDROCORTISONE 5MG TAB 3 50 150 ISONIAZID 100MG TAB 2 100 300 LIDOCAINE 4% TOP SOLN 50ML 2 50 150 PREDNISOLONE 15MG/5ML SOLN 3 60 180 PREDNISOLONE SOD PHOS 15MG/5ML SOL 2 30 90 PREDNISONE 1MG TAB 3 90 270 PREDNISONE 2.5MG TAB 2 60 180 PREDNISONE 5MG TAB 2 30 90 PREDNISONE 10MG** TAB 1 30 90 PREDNISONE 20MG TAB 2 30 90

Prescription drug coverage and cost are subject to change.

Brand-Name Medications Insulins Drug Name Qty Price LEVEMIR FLEXTOUCH PEN 1 BOX $367.19 LEVEMIR 100 UNITS/ML VIAL 1 VIAL $244.79 NOVOLIN N 100 UNITS/ML VIAL 1 VIAL $104.68 NOVOLIN R 100 UNITS/ML VIAL 1 VIAL $104.68 NOVOLIN 70/30 100 UNIT/ML VIAL 1 VIAL $104.68 NOVOLOG MIX 70/30 VIAL 1 VIAL $240.26 NOVOLOG MIX 70/30 FLEXPEN 1 BOX $426.00 NOVOLOG FLEXPEN 1 BOX $426.00 NOVOLOG PENFILL 3 ML 1 BOX $418.83 NOVOLOG 100 UNIT/ML VIAL 1 VIAL $241.68

Diabetic Supplies Drug Name Qty Price WALGREENS TRUE METRIX METER 1 METER FREE WALGREENS TRUE METRIX STRIPS 25’S 1 BOX $19.99 WALGREENS TRUE METRIX STRIPS 50’S 1 BOX $29.99 WALGREENS TRUE METRIX STRIPS 100’S 1 BOX $52.99 CONTOUR NEXT METER 1 METER FREE CONTOUR NEXT EZ METER 1 METER FREE CONTOUR NEXT ONE 1 METER FREE CONTOUR NEXT STRIPS 25’S 1 BOX $23.99 CONTOUR NEXT STRIPS 50’S 1 BOX $39.99 CONTOUR NEXT STRIPS 100’S 1 BOX $78.99 CONTOUR TEST STRIPS 50’S 1 BOX $47.99 CONTOUR TEST STRIPS 100’S 1 BOX $93.99 BREEZE 2 TEST DISCS 100'S 1 BOX $93.99

Prescription drug coverage and cost are subject to change.

Lifestyle Medications Birth Control - 1-month supply Qty Price MONONESSA TAB 28 $15 MICROGESTIN 1.5/30 FE TAB 28 $18.99 MICROGESTIN 1/20 FE TAB 28 $18.99 LEVORA 0.15/30 TAB 28 $24.99 RECLIPSEN 0.15MG-30MCG TAB 28 $24.99 LOW-OGESTREL TAB 28 $26.99 NECON 1/35 TAB 28 $26.99 JOLIVETTE 0.35MG TAB 28 $29.99 LUTERA TAB 28 $29.99

Erectile Dysfunction Qty Price CIALIS 2.5MG TAB 6 $74.99 CIALIS 5MG TAB 6 $74.99 CIALIS 10MG TAB 6 $439.99 CIALIS 20MG TAB 6 $439.99

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ABACAVIR 300MG TABLETS 59 $547.86 173 $1,606.73 ABACAVIR/LAMVUDINE 600-300MG TABLET 30 $875.20 89 $2,613.07 ACAMPROSATE CAL DR 333MG TABLETS 145 $241.71 430 $708.37 ACANYA 1.2-2.5% GEL 50GM 50 $518.59 110 $1,128.18 ACARBOSE 100MG TABLETS 86 $78.35 247 $216.70 ACARBOSE 25MG TABLETS 90 $64.98 243 $169.04 ACARBOSE 50MG TABLETS 87 $65.78 245 $177.98 ACEBUTOLOL 200MG CAPSULES 50 $30.53 141 $78.09 ACEBUTOLOL 400MG CAPSULES 48 $36.44 128 $89.78 ACETAMINOPHEN/COD #2 (300/15MG) TAB 35 $19.36 163 $74.47 ACETAMINOPHEN/COD #3 (300/30MG) TAB 31 $14.42 194 $68.67 ACETAMINOPHEN/COD #4 (300/60MG) TAB 67 $73.32 228 $239.37 ACETAMINOPHEN/COD 120-12MG/5ML ELXR 199 $22.19 788 $76.14 ACETAZOLAMIDE 125MG TABLETS 32 $53.49 159 $253.04 ACETAZOLAMIDE 500MG ER CAPSULES 53 $196.43 172 $634.43 ACETIC ACID 0.25% IRR SOL, 250ML 1999 $10.00 6889 $24.67 ACETIC ACID-HC OTIC SOLUTION 10ML 10 $213.20 15 $303.90 ACETYLCYST 20% SOL , 30ML 142 $164.54 492 $561.41 ACETYLCYSTEINE 10% SOLUTION 4ML 156 $139.55 443 $387.34 ACITRETIN 10MG CAPSULES 36 $719.13 98 $1,949.33 ACITRETIN 17.5MG CAPSULES 33 $764.91 96 $2,190.59 ACITRETIN 25MG CAPSULES 33 $946.25 87 $2,459.91 ACTHIB INJ, 1 VIAL 1 $104.83 2 $107.49 ACTICIN 5% CREAM 60GM 68 $180.12 326 $850.79 ACTOPLUS MET XR 15MG/1000MG TABLETS 52 $612.70 156 $1,837.28 ACTOPLUS MET XR 30MG/1000MG TABLETS 32 $737.72 89 $2,079.60 ACUVAIL 0.45% OPHT SOL 30SINGLE USE 36 $374.74 124 $1,267.28 ACYCLOVIR 200MG/5ML ORAL SUSP 204 $152.91 1006 $739.61 ACYCLOVIR 400MG TABLETS 44 $27.67 149 $83.49 ACYCLOVIR 5% OINTMENT 5GM 20 $454.54 63 $1,427.22 ACYCLOVIR 800MG TABLETS 37 $43.19 123 $135.52 ACZONE 7.5% GEL (PUMP) 60GM 60 $628.68 113 $1,173.98 ADACEL INJECTION, 0.5ML VIAL 1 $55.47 1 $55.69 ADAPAL/BENZ 0.1-2.5% GEL (PMP) 45G 45 $270.89 138 $822.43 ADAPALENE 0.1% CREAM 45GM 45 $207.40 123 $554.89 ADAPALENE 0.1% GEL 45GM 45 $174.60 116 $439.81 ADAPALENE PMP 0.3% GEL 45GM 45 $282.17 122 $752.24 ADCIRCA 20MG TABLETS 52 $3,462.97 139 $9,304.33 ADDYI 100MG TABLETS 30 $867.82 87 $2,509.24 ADEFOVIR DIPIVOXIL 10MG TABLETS 29 $978.01 88 $2,934.15 ADVAIR DISKUS 100/50MCG 28'S 60 $305.19 173 $867.54 ADVAIR DISKUS 250/50MCG 14'S 61 $371.46 176 $1,072.81 ADVAIR DISKUS 500/50MCG (RED) 60'S 61 $484.03 174 $1,384.72 ADVAIR HFA 115/21MCG ORAL INH 60'S 12 $403.96 34 $1,117.06 ADVAIR HFA 230/21MCG (120PUFFS)12GM 12 $531.04 34 $1,478.45 ADVAIR HFA 45/21MCG (120PUFFS) 12GM 12 $325.45 33 $893.38 AEROCHAMBER PLUS W/MASK (LARGE) 1 $60.22 1 $60.50 AEROSPAN 80MCG ORAL INHALER 120'S 9 $230.77 20 $509.71 AFEDITAB 30MG CR (CC) TABLETS 35 $46.00 102 $126.10 AFINITOR 10MG TABLETS 28 $14,594.37 84 $43,686.52

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price AFINITOR 5MG TABLETS 28 $14,701.41 69 $35,890.21 AK-DEX 0.1% OPHTH SOLN 5ML 6 $17.40 8 $22.85 AK-PRED 1% OPHTH SOLN 5ML 10 $20.71 10 $21.13 AK-ZOL 250MG TABLETS 61 $111.34 178 $317.82 ALBA-3 OPHTH SOLUTION 10ML 10 $42.19 10 $41.99 ALBENZA 200MG TABLETS 6 $1,116.19 184 $37,020.20 ALBUTEROL 0.021%(0.63MG/3ML) 25X3ML 133 $57.22 692 $280.70 ALBUTEROL 0.042%(1.25MG/3ML) 25X3ML 129 $24.06 678 $109.38 ALBUTEROL 0.5%(5MG/ML) CONC 20ML 33 $17.34 152 $66.34 ALBUTEROL 2MG TABLETS 56 $239.97 211 $887.17 ALBUTEROL 4MG TABLETS 60 $299.65 196 $970.03 ALBUTEROL SULF ER 4MG TABLETS 59 $109.70 198 $357.13 ALBUTEROL SULF ER 8MG TABLETS 57 $137.88 166 $395.02 ALCLOMETASONE 0.05% CREAM 15GM 38 $46.25 161 $182.54 ALCLOMETASONE 0.05% OINTMENT 60GM 42 $176.47 84 $349.38 ALDACTAZIDE 50/50 TABLET 30 $149.71 85 $415.55 ALENDRONATE 40MG TABLETS 13 $119.07 37 $329.48 ALENDRONATE 5MG TABLETS 28 $17.26 82 $42.00 ALENDRONATE 70MG/75ML SOLUTION 293 $104.48 852 $296.53 ALFUZOSIN ER 10MG TABLETS 31 $77.52 92 $221.71 ALINIA 100MG/5ML ORAL SUSP 60ML 96 $927.34 4500 $43,084.75 ALINIA 500MG TABLETS 14 $1,373.41 144 $13,810.96 ALMOTRIPTAN 12.5MG TABLETS 10 $415.66 36 $1,465.08 ALMOTRIPTAN 6.25MG TABLETS 9 $366.87 37 $1,529.14 ALOCRIL 2% OPHTH SOLN 5ML 5 $220.60 8 $317.49 ALOGLIPTIN/METFORMIN 12.5/1000MG TB 59 $206.54 170 $591.93 ALOMIDE 0.1% OPHTH DROP 10ML 10 $223.08 14 $302.19 ALOSETRON 0.5MG TABLETS 56 $1,199.50 139 $2,983.19 ALOSETRON 1MG TABLETS 52 $2,508.54 160 $7,747.84 ALPHAGAN P 0.1% OPHTH SOLN 10ML 7 $190.86 15 $406.84 ALPRAZOLAM 0.25MG ODT TABLETS 42 $56.64 144 $182.92 ALPRAZOLAM 0.25MG TABLETS 46 $14.14 140 $35.22 ALPRAZOLAM 0.5MG ODT TABLETS 46 $77.94 167 $275.14 ALPRAZOLAM 0.5MG TABLETS 53 $17.79 149 $42.87 ALPRAZOLAM 1MG ODT TABLETS 50 $115.23 154 $344.69 ALPRAZOLAM 1MG TABLETS 64 $20.37 161 $45.16 ALPRAZOLAM 2MG ODT TABLETS 59 $330.37 117 $644.49 ALPRAZOLAM 2MG TABLETS 67 $35.92 168 $84.28 ALPRAZOLAM CON 1MG/ML SOLUTION 37 $122.73 30 $100.99 ALPRAZOLAM ER 1MG TABLETS 45 $97.63 120 $255.14 ALPRAZOLAM ER 2MG TABLETS 41 $108.37 114 $296.61 ALPRAZOLAM ER 3MG TABLETS 36 $177.32 106 $512.25 ALPRAZOLAM XR 0.5MG TABLETS 45 $53.01 127 $143.49 ALPROSTADIL 500MCG INJ, 1ML 3 $321.97 18 $1,911.82 ALREX 0.2% OPHTHALMIC SUSP 5ML 6 $243.30 10 $404.22 ALTOCOR 20MG TABLETS 29 $823.86 90 $2,556.97 ALTOCOR 60MG TABLETS 30 $1,000.79 87 $2,889.15 ALTOPREV 40MG ER TABLETS 32 $1,106.35 88 $3,013.97

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ALURIA QIV PFS 2018-2019 1 $40.99 1 $40.99 ALVESCO HFA 160MCG ORAL INH (60INH) 8 $319.57 25 $1,020.17 ALVESCO HFA 80MCG ORAL INH (60 INH) 7 $275.24 19 $799.83 AMANTADINE 100MG CAPSULES 58 $92.37 183 $284.80 AMANTADINE 100MG TABLETS 53 $105.82 168 $328.16 AMANTADINE 50MG/5ML SYRUP 394 $23.66 1239 $65.81 AMCINONIDE 0.1% CREAM 30GM 54 $312.88 180 $1,041.97 AMETHIA LO TABLETS 91 $169.99 91 $170.24 AMETHYST 90-20MCG TABLETS 29 $51.25 83 $141.07 AMIKACIN 250MG/ML INJ, 4ML 70 $235.29 60 $202.60 AMIKACIN SULFATE 500/2MLINJ, 2ML 49 $305.32 91 $560.27 AMILORIDE 5MG TABLETS 51 $63.50 134 $160.12 AMIODARONE 100MG TABLETS 33 $200.71 92 $544.91 AMIODARONE 400MG TABLETS 33 $119.91 96 $343.33 AMITIZA 24MCG CAPSULES 55 $356.20 160 $1,026.02 AMITIZA 8MCG CAPSULES 58 $373.85 165 $1,061.10 AMITRIPTYLINE 100MG (HUNDRED MG)TAB 35 $33.50 101 $89.27 AMITRIPTYLINE 150MG TABLETS 32 $41.63 95 $115.46 AMITRIPTYLINE 75MG TABLETS 33 $22.69 96 $58.57 AMLO/VAL/HCTZ 10/160/12.5MG TABLETS 30 $115.93 89 $334.88 AMLOD/VAL/HCTZ 10/160/25MG TABLETS 30 $114.76 89 $335.62 AMLOD/VAL/HCTZ 10/320/25MG TABLETS 30 $215.01 89 $633.68 AMLOD/VAL/HCTZ 5/160/12.5MG TABLETS 30 $103.33 90 $297.57 AMLOD/VAL/HCTZ 5/160/25MG TABLETS 30 $102.37 90 $297.26 AMLODIPINE/OLMES MEDOXOM 5-20MG T 30 $213.48 90 $628.19 AMLODIPINE/OLMES MEDOXOM 10-40MG T 30 $266.41 89 $787.13 AMLODIPINE/OLMES MEDOXOM 5-40MG T 30 $267.29 89 $785.30 AMLODIPINE/OLMES MEDOXOM10-20MG T 29 $208.45 89 $620.37 AMLODIPINE-ATORVASTAT 2.5/10MG TABS 30 $95.09 91 $285.86 AMLODIPINE-ATORVASTAT 2.5/40MG TABS 30 $252.66 90 $749.99 AMLODIPINE-ATORVASTATIN 10/10MG TAB 30 $128.17 89 $375.88 AMLODIPINE-ATORVASTATIN 10/20MG TAB 30 $177.66 89 $521.55 AMLODIPINE-ATORVASTATIN 10/40MG TAB 30 $178.25 89 $519.25 AMLODIPINE-ATORVASTATIN 10/80MG TAB 30 $180.20 89 $517.96 AMLODIPINE-ATORVASTATIN 5/10MG TABS 30 $245.18 90 $722.65 AMLODIPINE-ATORVASTATIN 5/20MG TABS 30 $180.59 89 $521.61 AMLODIPINE-ATORVASTATIN 5/40MG TABS 30 $182.61 89 $532.43 AMLODIPINE-ATORVASTATIN 5/80MG TABS 29 $176.74 90 $539.20 AMLODIPINE-BENAZ 10/20MG CAPSULES 30 $18.11 90 $46.19 AMLODIPINE-BENAZ 10/40MG CAPSULES 30 $124.10 90 $364.41 AMLODIPINE-BENAZ 2.5/10MG CAPSULES 31 $18.68 93 $47.55 AMLODIPINE-BENAZ 5/10MG CAPSULES 31 $18.50 93 $47.30 AMLODIPINE-BENAZ 5/20MG CAPSULES 33 $19.34 98 $49.87 AMLODIPINE-BENAZ 5/40MG CAPSULES 31 $106.82 92 $310.32 AMLODIPINE-VALSARTAN 10-160MG TABS 30 $184.82 88 $536.52 AMLODIPINE-VALSARTAN 10-320MG TABS 30 $219.93 89 $645.70 AMLODIPINE-VALSARTAN 5-160MG TABS 31 $163.51 90 $472.90 AMLODIPINE-VALSARTAN 5-320MG TABS 30 $189.71 89 $555.82

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

AMMONIUM LAC 12% LOTION 225GM 302 $42.94 827 $110.47 AMMONIUM LACTATE 12% CREAM 140GM 309 $38.16 835 $96.42 AMNESTEEM 40MG CAPSULES 48 $1,005.63 53 $1,111.50 AMOXAPINE 100MG TABLETS 36 $49.62 140 $179.76 AMOXAPINE 150MG TABLETS 30 $65.99 90 $189.97 AMOXAPINE 25MG TABLETS 49 $25.73 132 $62.07 AMOXAPINE 50MG TABLETS 40 $34.52 137 $107.74 AMOX-CLAV 200/28.5MG CHEW TABS 28 $55.05 90 $165.96 AMOX-CLAV 250MG TABLETS 21 $86.66 101 $396.19 AMOX-CLAV 250MG/5ML SUSP 100ML 152 $135.63 100 $90.65 AMOX-CLAV 400MG CHEWABLETABLETS 24 $73.21 85 $245.43 AMOX-CLAV 500MG TABLETS 20 $52.10 109 $260.48 AMOX-CLAV 875MG TABLETS 19 $51.97 128 $329.86 AMOX-CLAV ES 600MG/5ML SUSP 200ML 133 $18.92 298 $37.37 AMOX-CLAV XR 1000/62.5MG TABLETS 26 $87.42 90 $294.23 AMPHOCIN 50MG INJ, 1 VIAL 13 $617.38 90 $4,143.10 ANADROL-50 50MG TAB 50 $2,238.00 90 $4,030.82 ANAGRELIDE 0.5MG CAPSULES 83 $75.49 220 $194.36 ANAGRELIDE 1MG CAPSULES 70 $133.95 175 $330.07 ANASTROZOLE 1MG TABLETS 24 $15.06 78 $40.60 ANDRODERM 4MG TRANSDERMAL30'S 32 $609.12 94 $1,776.42 ANDROGEL 1.62% (20.25MG/1.25GM)PUMP 98 $757.77 289 $2,228.82 ANGELIQ 0.5-1MG TABLETS 28'S 28 $182.58 83 $527.10 ANOLOR 300MG CAPSULES 43 $80.39 156 $277.96 ANORO ELLIPTA 62.5-25MCG ORAL INH 7 60 $444.21 174 $1,269.65 ANTI-DIARRHEAL SOFTGELS 24S 56 $22.50 272 $94.44 ANUSOL-HC 2.5% CREAM 33 $55.94 123 $196.21 APIDRA SOLOSTAR PEN INJ 3ML 18 $689.44 38 $1,459.63 APIDRA U-100 INJECTION 10ML 21 $627.25 70 $2,073.09 APRACLONIDINE 0.5% OPTH SOL 5ML 6 $100.08 12 $183.51 APREPITANT 80MG CAPSULES 4 $734.84 36 $6,584.14 APREPITANT 80MG/125MG CAPS TRI-PACK 3 $757.35 15 $3,243.95 APRISO 0.375GM CAPSULES 116 $559.47 336 $1,612.00 ARANELLE TABLETS 28 30 $36.19 84 $93.39 ARANESP 100MCG INJ , 1ML 2 $1,555.34 4 $3,235.96 ARANESP 100MCG/0.5ML SGJCT ALB FREE 2 $2,444.54 4 $6,144.49 ARANESP 150MCG/0.3ML INJ ALB FREE 1 $2,210.69 2 $9,372.77 ARANESP 25MCG INJ, 0.42ML 1 $575.44 3 $1,461.18 ARANESP 25MCG/ML INJ, 1ML 2 $303.65 2 $284.49 ARANESP 300MCG/0.6ML INJ ALB FREE 2 $7,959.75 2 $7,669.39 ARANESP 40MCG/0.4ML INJ ALB FREE 1 $1,041.12 2 $2,025.39 ARANESP 60MCG/0.3ML SGJCT ALB FREE 1 $1,471.23 2 $3,146.81 ARANESP 60MCG/ML VL ALBUMIN FREE 2 $970.84 3 $1,413.97 ARIPIPRAZOLE 10MG TABLETS 30 $840.98 89 $2,522.67 ARIPIPRAZOLE 15MG (FIFTEEN MG) TABS 28 $806.03 85 $2,432.86 ARIPIPRAZOLE 1MG/ML ORAL SOLUTION 157 $932.76 492 $2,911.03 ARIPIPRAZOLE 20MG (TWENTY MG) TABS 29 $1,130.47 88 $3,405.28

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

ARIPIPRAZOLE 2MG TABLETS 32 $877.65 93 $2,554.11 ARIPIPRAZOLE 30MG TABLETS 29 $1,133.85 88 $3,388.42 ARIPIPRAZOLE 5MG TABLETS 30 $831.78 89 $2,452.51 ARIPIPRAZOLE ODT 10MG TABLETS 32 $1,267.48 95 $3,807.14 ARIPIPRAZOLE ODT 15MG TABLETS 34 $1,376.99 90 $3,606.97 ARMODAFINIL 150MG TABLETS 30 $301.21 91 $900.80 ARMODAFINIL 200MG TABLETS 30 $299.80 93 $915.82 ARMODAFINIL 250MG TABLETS 30 $301.31 91 $903.17 ARZOL SILVER NITRATE APPLICATORS 88 $57.64 100 $65.07 ASCENSIA AUTO DISC 100S 125 $116.25 195 $179.82 ASCORBIC ACID 500MG/ML INJ, 50ML 57 $51.99 75 $66.99 ASPIRIN-DIPYRIDAMOLE ER 25/200MG C 61 $360.92 176 $1,036.65 ASSESS PEAK FLOW METER FULL RANGE 1 $23.00 1 $24.61 ATABEX EC TABLETS 29 $15.91 73 $34.37 ATENOLOL 100MG/CHLORTHAL 25MG TABS 30 $14.56 87 $35.08 ATOMOXETINE 100MG CAPSULES 30 $312.36 89 $921.63 ATOMOXETINE 10MG CAPSULES 36 $324.54 113 $999.77 ATOMOXETINE 18MG CAPSULES 33 $297.12 107 $950.11 ATOMOXETINE 25MG CAPSULES 35 $309.87 113 $1,005.15 ATOMOXETINE 40MG CAPSULES 33 $317.33 100 $966.29 ATOMOXETINE 60MG CAPSULES 30 $293.74 92 $887.85 ATOMOXETINE 80MG CAPSULES 30 $311.69 89 $925.76 ATOVAQUONE 750MG/5ML SUSPENSION 257 $1,069.79 802 $3,334.22 ATOVAQUONE-PROGUANIL 250/100 TABS 23 $139.14 102 $604.40 ATRIPLA (EFV600/FTC200/TDF300) TAB 30 $2,689.73 89 $7,992.51 ATROPINE SULF 1% OPH SOLN 5ML 5 $34.94 7 $42.68 ATROPINE SULFATE 1% OPHTH OINTMENT 4 $20.25 4 $19.99 ATROVENT HFA ORAL INHALER (200 INH) 14 $401.43 25 $723.53 AUBRA TABS 28S 29 $28.60 85 $76.63 AUVI-Q 0.3MG INJ, 2 AUTO INJECTORS 2 $748.91 4 $1,353.98 A-Z ADVANTAGE TABLETS 45'S 33 $76.08 150 $335.17 AZASAN 100MG TABLETS 37 $270.98 106 $757.18 AZASAN 75MG TABLETS 39 $629.02 112 $1,791.99 AZATHIOPRINE 50MG TABLETS 66 $65.51 187 $178.51 AZELASTINE 0.05% OPHTH SOLUTION 6ML 6 $131.27 17 $354.48 AZELASTINE 0.1%(137MCG) NASAL-200SP 31 $94.07 60 $176.03 AZELASTINE 0.15% NASAL SP(200 DOSE) 31 $135.77 53 $226.06 AZELEX 20% CREAM 50GM 38 $531.06 96 $1,333.15 AZITHROMYCIN 100MG/5ML SUSP 15ML 24 $55.81 235 $505.18 AZITHROMYCIN 1GM PAK POWDER 1 $29.21 6 $145.98 AZITHROMYCIN 200MG/5ML SUSP 22.5ML 28 $66.87 319 $726.91 AZITHROMYCIN 250MG TABLETS 6 $31.50 52 $236.14 AZITHROMYCIN 500MG TABLET 4 $55.77 41 $501.60 AZITHROMYCIN 600MG TABLETS 9 $160.91 25 $429.44 AZOPT 1% OPHTH SUSP 5ML 11 $327.46 16 $484.64 AZURETTE TABLETS 28S 29 $36.82 85 $100.96 BACITRACIN OPHTH OINTMENT 3.5GM 4 $116.94 14 $450.34

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

BACLOFEN 20MG TABLETS 80 $56.39 262 $175.42 BACTERIOSTATIC WATER FORINJECTION 192 $12.97 30 $5.40 BALSALAZIDE 750MG CAPSULES 217 $157.35 600 $428.20 BANZEL 400MG TABLETS 142 $3,427.15 463 $11,153.32 BANZEL 40MG/ML SUSPENSION 460ML 741 $2,587.17 1499 $5,229.52 BARACLUDE 0.05MG/ML ORALSOLUTION 199 $961.51 260 $1,253.22 B-D #1603 SYRINGE 5ML W/SLIP TIP 56 $12.60 7 $5.13 B-D #3405 SYRINGE 10ML W/CANNULA 46 $8.57 24 $6.40 B-D #5106 NEEDLES 30GX1/2 12 $7.60 17 $9.02 B-D #5109 NEEDLES 27GX1/2 11 $4.84 15 $5.10 B-D #5128 NEEDLES 30GX1 20 $8.81 59 $18.05 B-D #5136 NEEDLES 27GX1-1/4 18 $6.03 35 $8.02 B-D #5143 NEEDLES 23GX3/4 9 $4.31 15 $4.55 B-D #5155 NEEDLES 22GX1 13 $4.99 17 $5.28 B-D #5156 NEEDLES 22GX1-1/2 18 $5.42 19 $5.50 B-D #5167 NEEDLES 21GX1-1/2 10 $4.75 20 $5.49 B-D #5175 NEEDLES 20GX1 17 $5.73 26 $6.55 B-D #5176 NEEDLES 20GX1-1/2 14 $4.50 20 $4.70 B-D #5180 NEEDLE 18GX1.5" 9 $4.75 16 $5.30 B-D #5186 NEEDLES 19GX1 10 $4.72 16 $5.14 B-D #5187 NEEDLES 19GX1-1/2 17 $4.61 15 $4.53 B-D #5195 NEEDLES 18GX1 11 $5.69 16 $6.61 B-D #5197 NEEDLES 16GX1 PG 17 $7.20 17 $7.12 B-D #5572 SYR/NDL 3ML 22GX1 10 $5.16 13 $5.62 B-D #5787 SYR/NDL 3ML 25GX1 LL 10 $5.15 12 $5.45 B-D #5906 SAFETY GLD 3ML 22GX1-1/2 9 $9.09 14 $11.66 B-D #5915 SAFETYGLIDE 21GX1" NEEDLE 10 $4.75 19 $5.38 B-D #5945 SYR/NDL 1ML 27GX1/2 SG TB 17 $12.50 20 $14.50 B-D #9464 SYR/NDL 1ML 29GX1/2 80 $38.64 136 $63.14 B-D #9575 SYR/NDL 3ML 21GX1 LL 10 $5.18 15 $5.75 B-D #9577 SYR/NDL 3ML 21GX1-1/2 LL 11 $5.27 10 $5.26 B-D #9578 SYR/NDL 3ML 20GX1 LL 15 $5.76 20 $6.36 B-D #9579 SYR/NDL 3ML 20GX1-1/2 LL 16 $5.95 19 $6.27 B-D #9580 SYR/NDL 3ML 18GX1-1/2 LL 13 $5.55 17 $6.07 B-D #9582 SYR/NDL 3ML 25GX1-1/2 LL 12 $5.61 13 $5.74 B-D #9585 SYRINGE 3ML W/LL 17 $4.69 21 $4.83 B-D #9588 SYR/NDL 3ML 23GX1 LL TW 10 $5.20 14 $5.69 B-D #9589 SYR/NDL 3ML 23GX1-1/2 LL 10 $5.23 15 $5.74 B-D #9592 SYR/NDL 3ML 25GX5/8 LL 12 $11.32 12 $10.90 B-D #9602 SYRINGE 1ML W/SLIP TIP TB 12 $5.49 24 $7.08 B-D #9606 SYRINGE 3ML W/LL 16 $6.66 15 $6.61 B-D #9620 SYRINGE 60ML CATHETER TIP 31 $63.48 200 $383.96 B-D #9622 SYR/NDL 1ML 25GX1 10 $7.32 13 $8.41 B-D #9626 SYR/NDL 1ML 25GX5/8 TB 14 $8.76 18 $10.51 B-D #9630 SYR/NDL 5ML 22GX1 LL 25 $12.43 32 $14.71 B-D #9631 SYR/NDL 5ML 22GX1-1/2 LL 28 $10.59 21 $8.81 B-D #9632 SYR/NDL 5ML 21GX1 LL 50 $17.49 59 $19.92 B-D #9634 SYR/NDL 5ML 20GX1 LL 44 $14.37 8 $5.88

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

B-D #9635 SYR/NDL 5ML 20GX1-1/2 LL 25 $11.04 6 $5.68 B-D #9637 SYR/NDL 1ML 20GX1 LL 19 $14.61 19 $14.59 B-D #9640 SYR/NDL 10ML 22GX1 LL 14 $7.48 62 $19.51 B-D #9642 SYR/NDL 10ML 21GX1 LL 30 $11.44 30 $11.59 B-D #9644 SYR/NDL 10ML 20GX1 LL 47 $15.68 51 $16.76 B-D #9651 SYR/NDL 1ML 25GX5/8 14 $7.81 22 $9.91 B-D #9661 SYRINGE 20ML W/LL 36 $12.05 10 $6.26 B-D 1ML TB SLIP-TIP SYRINGE 12 $7.48 19 $9.41 B-D ALLERGIST KIT 1CC, 27G 0.5" 32 $6.50 45 $7.52 B-D ECLIPSE 23GX1" SYRINGE 10 $4.77 18 $5.38 B-D ECLIPSE 25GX5/8" NEEDLES 15 $6.15 21 $6.99 B-D ECLIPSE NEEDLE 25GX1 13 $4.95 19 $5.38 B-D ECLIPSE NEEDLE 25GX1.5 11 $4.85 13 $4.96 B-D FILTER NEEDLE 19GX 1-1/2" 22 $6.99 36 $8.86 BECONASE-AQ NASAL (180 SPRAYS) 25GM 26 $320.80 59 $727.97 BELLADONNA 16.2MG / OPIUM 60MG SUPP 22 $674.95 54 $1,623.96 BELLADONNA ALKALOIDS W/PB TABLETS 56 $471.15 219 $1,833.07 BELVIQ 10MG TABLETS 59 $277.02 175 $818.83 BELVIQ XR 20MG TABLETS 30 $296.05 89 $869.69 BENAZEPRIL/HCTZ 10/12.5MG TABLETS 31 $61.99 92 $175.53 BENAZEPRIL/HCTZ 20/12.5MG TABLETS 37 $32.72 108 $86.52 BENAZEPRIL/HCTZ 20/25MG TABLETS 31 $46.94 93 $130.56 BENAZEPRIL/HCTZ 5/6.25MGTABLETS 31 $61.77 91 $173.88 BENZOYL PEROXIDE 10% GEL 90GM 55 $15.97 196 $46.49 BENZOYL PEROXIDE 10% WASH 148ML 198 $63.16 303 $94.81 BENZOYL PEROXIDE 5% WASH 227GM 188 $21.78 299 $32.29 BENZOYL PEROXIDE 6% CLEANSER LOTN 214 $49.25 170 $39.97 BENZOYL PEROXIDE 7% WASHLIQ 180GM 477 $131.19 473 $130.01 BENZOYL PEROXIDE 9.8% FOAM 100GM 100 $116.60 300 $341.80 BENZPHETAMINE 50MG TABLETS 74 $75.63 167 $165.70 BEPREVE 1.5% OPTH DROPS 10ML 6 $235.39 13 $458.06 BESIVANCE 0.6% OPTH SUSP 5ML 5 $155.67 7 $203.47 BETAMETHASON DIP AUG 0.05% LOT 30ML 57 $141.69 259 $633.28 BETAMETHASONE DIP 0.05% CRM 15GM 40 $59.33 135 $189.34 BETAMETHASONE DIP 0.05% OINT 45GM 43 $57.61 158 $201.13 BETAMETHASONE DIP AUG .05% OINT 50G 42 $81.42 165 $304.19 BETAMETHASONE DIP AUG 0.05%GEL 15GM 39 $55.78 124 $167.33 BETAMETHASONE DIP AUG CREAM 15GM 44 $45.56 178 $171.54 BETAMETHASONE DP 0.05% LOTION 64 $38.15 188 $104.04 BETAMETHASONE VAL 0.1% LOTN 60ML 63 $50.55 178 $134.51 BETAMETHASONE VAL 0.1% OINT 45GM 40 $29.39 126 $84.35 BETAMETHASONE VAL 0.12% FOAM 100GM 79 $317.90 285 $1,133.30 BETASERON 0.3MG VIAL FOR INJ KIT 14 $8,414.08 44 $26,190.31 BETAXOLOL 0.5% OPHTH SOLN 5ML 7 $75.78 12 $124.01 BETAXOLOL 10MG TABLETS 31 $41.11 91 $111.95 BETAXOLOL 20MG TABLETS 33 $56.28 90 $148.04 BETHANECHOL 10MG TABLETS 83 $95.91 230 $259.21 BETHANECHOL 25MG TABLETS 83 $125.76 232 $342.46

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

BETHANECHOL 50MG TABLETS 83 $103.92 233 $285.41 BETHANECHOL 5MG TABLETS 73 $30.14 222 $84.01 BETIMOL 0.25% OPHTH SOLN 5ML 6 $136.90 8 $200.70 BETIMOL 0.5% OPHTHALMIC SOLN 5ML 7 $186.58 11 $287.60 BETOPTIC-S 0.25% OPHTH SUSP 5ML 11 $367.64 15 $487.86 BEXSERO PFS SINGLE DOSE INJ, 0.5ML 1 $190.37 1 $189.99 BICALUTAMIDE 50MG TABLETS 31 $163.82 92 $477.12 BICILLIN L-A 1200000U/2ML SYR 5 $369.31 13 $1,002.07 BICILLIN LA 2400000 UNITS/4ML SYR 7 $592.13 33 $2,662.77 BIDEX 400MG TABLETS 42 $16.27 230 $70.68 BIFERARX TABLETS 34 $59.04 113 $187.59 BILTRICIDE 600MG TABLETS 10 $841.91 30 $2,613.95 BIMATOPROST 0.03% OPH SOL W/BRUSHES 4 $137.66 6 $194.05 BIMATOPROST 0.03% OPHTH SOLN 5ML 4 $129.49 7 $266.92 BIOCEF 250MG/5ML SUSP 100ML 195 $37.19 527 $93.58 BIONECT 0.2% GEL 100GM 100 $764.99 300 $2,286.97 BISOPROLOL FUMARATE 10MG TABLETS 34 $33.69 102 $92.07 BLEPHAMIDE OPHTH SUSPENSION 5ML 8 $234.44 8 $246.40 BLISOVI FE 1.5/30 TABLETS 28S 29 $19.39 85 $49.49 BOOSTRIX INJ, 0.5ML (VIAL) 1 $55.37 1 $55.34 BOTOX 100UNIT INJECTION 2 $1,133.76 2 $1,498.59 BOTOX 200UNIT INJ, 1 VIAL 1 $1,427.64 1 $1,426.36 BP VIT 3 CAPSULES 43 $49.38 93 $103.62 BREO ELLIPTA 100-25MCG ORAL INH(30) 60 $360.39 174 $1,030.21 BREO ELLIPTA 200-25MCG ORAL INH(30) 60 $381.57 173 $1,084.23 BRILINTA 90MG TABLETS 59 $333.44 174 $981.12 BRIMONIDINE 0.15% OPHTH SOL 5ML 8 $177.95 16 $371.70 BRIMONIDINE 0.2% OPHTH SOLN 5ML 8 $32.15 15 $59.02 BRINTELLIX 20MG TABLETS 30 $352.30 89 $1,047.37 BROMFENAC 0.09% OPTH SOL1.7ML 2 $154.61 6 $477.83 BROMOCRIPTINE 5MG CAPSULES 48 $503.53 133 $1,375.97 BROMOCRIPTINE MESYLATE 2.5MG TABS 42 $132.73 119 $368.49 BROMPHEN/PSEUDO/DEXTRO HBR SYRUP 163 $37.06 243 $53.36 BROMSITE 0.075% EYE DROPS 5 $280.45 5 $283.35 BROVANA 15MCG/2ML INH SOL 30X2ML 119 $1,018.03 348 $2,967.31 BUDESONIDE 0.25MG/2ML VIALS 30X2ML 89 $280.81 306 $956.64 BUDESONIDE 0.5MG/2ML VIALS 30X2ML 97 $379.99 314 $1,222.03 BUDESONIDE 1MG/2ML RESPULES 30X2ML 81 $712.08 241 $2,117.10 BUDESONIDE 32MCG NS SP (120INH) RX 9 $139.87 22 $350.63 BUDESONIDE 3MG CAPSULES 75 $960.20 182 $2,335.06 BUMETANIDE 0.5MG TABLETS 38 $20.65 106 $49.92 BUMETANIDE 1MG TABLETS 50 $30.71 132 $74.56 BUMETANIDE 2MG TABLETS 52 $52.88 142 $136.83 BUPIVACAINE 0.5% INJ, 30ML 1071 $30.66 250 $10.23 BUPRENORPHINE 10MCG/HR TD PATCH 4 $159.40 11 $433.55 BUPRENORPHINE 15MCG/HR TDPATCH 4 $511.42 11 $1,415.85 BUPRENORPHINE 20MCG/HR TD PATCH 4 $705.94 12 $2,060.22

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

BUPRENORPHINE 2MG SL TABLETS 48 $127.95 130 $342.09 BUPRENORPHINE 8MG SL TABLETS 34 $163.00 88 $416.92 BUPRENORPHINE/NALOX 2MG/0.5MG SL TB 41 $205.17 164 $817.43 BUPRENORPHINE/NALOX 8MG/2MG SL TAB 26 $225.90 129 $1,129.63 BUPROPION 100MG TABLETS 57 $36.51 169 $99.97 BUPROPION 75MG TABLETS 50 $30.85 150 $83.93 BUPROPION SR 100MG TABLETS (12 H) 45 $47.16 139 $135.94 BUPROPION SR 150MG TABLET 53 $70.86 150 $193.54 BUPROPION SR 150MG TABLETS (12 H) 52 $51.70 156 $145.60 BUPROPION SR 200MG TABLETS (12 HR) 47 $118.16 144 $354.89 BUPROPION XL 150MG TABLETS (24 H) 36 $129.29 109 $386.72 BUPROPION XL 300MG TABLETS 30 $85.91 90 $250.44 BUSPIRONE 15MG TABLETS 68 $19.84 197 $49.99 BUSPIRONE 30MG TABLETS 59 $59.96 175 $170.11 BUSPIRONE 7.5MG TABLETS 61 $75.39 184 $217.71 BUT/ACETAMI/CAFF COD 50-300-40-30 C 50 $257.84 180 $913.06 BUT/ACETAMINOPHEN CAFF 50-300-40 CP 41 $97.58 193 $441.23 BUT/APAP/CAF COD CAPSULES 58 $61.16 204 $204.28 BUTALB/ACETAMINOPHEN 325MG TABS 52 $48.66 211 $186.52 BUTALB/ASPIRIN 325MG/CAFFEINE TAB 40 $18.09 110 $43.04 BUTALB/ASPIRIN/CAFF/CODEINE 30MG CP 61 $122.40 188 $366.60 BUTALBITAL/ACETAMINOPHEN/CAFF TABS 50 $47.34 209 $185.26 BUTISOL SOD 30MG TABLETS 73 $321.10 293 $1,281.85 BUTORPHANOL 2MG/ML INJ, 2ML 131 $868.21 90 $597.73 BUTORPHANOL NS NASAL SPRAY 2.5ML 4 $113.97 11 $285.56 BYDUREON 2MG VIAL(ONCE WEEKLY)4TRAY 4 $698.56 12 $1,992.80 BYSTOLIC 10MG TABLETS 33 $132.34 97 $377.68 BYSTOLIC 2.5MG TABLETS 31 $140.07 92 $405.03 BYSTOLIC 20MG TABLETS 33 $139.79 97 $406.37 BYSTOLIC 5MG TABLETS 31 $123.38 90 $353.76 CABERGOLINE 0.5MG TABLETS 9 $245.72 21 $603.59 CALCIPOTRIEN/BETAMET DIP OINT 60GM 78 $517.15 237 $1,565.95 CALCIPOTRIENE 0.005% CREAM 120GM 84 $538.50 300 $1,915.82 CALCIPOTRIENE 0.005% OINTMENT 60GM 81 $440.32 268 $1,454.10 CALCIPOTRIENE 0.005% SCALP SOLUTION 65 $217.29 199 $654.69 CALCITONIN 200IU/NASAL SPR 30 DOSES 4 $86.82 11 $239.20 CALCITRENE 0.005% OINTMEN 120GM 103 $609.14 360 $2,111.01 CALCITRIOL 0.25MCG CAPSULES 32 $36.12 81 $84.51 CALCITRIOL 0.5MCG CAPSULES 43 $73.16 101 $165.15 CALCITRIOL 1MCG/ML SOLUTION 15ML 21 $274.22 46 $604.34 CALCITRIOL 3MCG/GM OINTMENT 100GM 102 $529.87 420 $2,171.16 CALCIUM ACETATE 667MG CAPSULES 175 $122.28 462 $316.07 CALCIUM ACETATE 667MG TABLETS 154 $70.09 394 $173.59 CALCIUM W/D 600-400MG TABLETS 220'S 56 $5.44 160 $8.14 CAMBIA 50MG POWDER 10 $463.44 32 $1,431.96 CAMRESE TABLETS 91S 91 $170.63 91 $170.24 CANASA 1000MG SUPPOSITORIES 29 $1,040.03 92 $3,281.14

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CANDESARTAN 16MG TABLETS 32 $111.51 95 $321.10 CANDESARTAN 32MG TABLETS 30 $144.21 89 $420.78 CANDESARTAN 4MG TABLETS 37 $122.27 93 $304.68 CANDESARTAN 8MG TABLETS 35 $131.53 98 $358.45 CANDESARTAN HCT 16-12.5MG TABLETS 31 $117.97 92 $337.89 CANDESARTAN HCT 32/25MG TABLETS 30 $124.38 89 $360.43 CANDESARTAN HCT 32-12.5MG TABLETS 30 $114.82 90 $338.43 CAPECITABINE 150MG TABLETS 52 $278.59 56 $299.86 CAPECITABINE 500MG TABLETS 83 $2,854.27 383 $13,196.40 CAPEX SHAMPOO 120ML 124 $439.08 480 $1,687.98 CAPHOSOL SOLUTION 397 $121.62 89 $30.23 CAPTOPRIL 100MG TABLETS 66 $99.72 183 $268.98 CAPTOPRIL 12.5MG TABLETS 52 $41.56 146 $108.61 CAPTOPRIL 25MG TABLETS 59 $49.89 170 $136.93 CAPTOPRIL 50MG TABLETS 64 $87.62 186 $248.33 CAPTOPRIL/HCTZ 25/15 TABLETS 39 $32.77 131 $99.89 CAPTOPRIL/HCTZ 25/25 TABLETS 37 $27.28 102 $68.79 CAPTOPRIL/HCTZ 50/15 TABLETS 49 $66.47 153 $197.34 CAPTOPRIL/HCTZ 50/25 TABLETS 37 $46.78 111 $133.89 CARAFATE 1GM/10ML SUSPENSION 549 $244.54 2476 $1,088.59 CARB/LEV/ENTAC 37.5-150-200MG TABS 122 $400.57 334 $1,091.65 CARBAMAZEPINE 100MG CHEWABLE TABS 115 $27.05 313 $66.50 CARBAMAZEPINE 100MG ER CPASULES 89 $156.78 250 $432.84 CARBAMAZEPINE 100MG/5ML SHAKE WELL 756 $123.29 2323 $370.54 CARBAMAZEPINE 200MG ER CAPSULES 93 $193.64 276 $570.69 CARBAMAZEPINE 200MG TABLETS 91 $76.68 268 $218.70 CARBAMAZEPINE 300MG ER CAPSULES 78 $178.54 227 $510.05 CARBAMAZEPINE ER 100MG TABLETS 79 $84.91 245 $253.62 CARBAMAZEPINE ER 200MG TABLETS 88 $114.24 263 $335.09 CARBAMAZEPINE ER 400MG TABLETS 64 $155.41 192 $459.58 CARBI/LEVO/ENTOCAP 100 TABS 117 $383.87 336 $1,098.20 CARBIDOPA 25MG TABLETS 110 $524.89 307 $1,452.64 CARBIDOPA/LEV/ENTAC 18.75-75-200MG 108 $187.04 335 $569.22 CARBIDOPA/LEV/ENTAC 31.25-125-200MG 120 $562.50 345 $1,610.44 CARBIDOPA/LEV/ENTAC 50-200-200MG 112 $372.13 348 $1,150.20 CARBIDOPA/LEVODOPA 10-100MG DIS TAB 104 $137.48 286 $370.23 CARBIDOPA/LEVODOPA 10-100MG TABS 87 $31.82 244 $82.02 CARBIDOPA/LEVODOPA 25-100MG CR TABS 93 $57.04 253 $147.93 CARBIDOPA/LEVODOPA 25-100MG DIS TAB 130 $128.92 362 $351.75 CARBIDOPA/LEVODOPA 25-100MG TABS 137 $60.32 403 $169.03 CARBIDOPA/LEVODOPA 25-250MG DIS TAB 122 $169.97 317 $435.16 CARBIDOPA/LEVODOPA 25-250MG TABS 113 $47.10 323 $126.68 CARBIDOPA/LEVODOPA 50-200MG CR TABS 80 $98.46 208 $249.16 CARBINOXAMIN 4MG/5ML LIQUID 139 $19.87 268 $34.61 CARBINOXAMINE 4MG TABLETS 45 $29.47 156 $92.83 CARDIOTEK-RX TABLETS 33 $38.26 90 $96.74 CARDURA XL 4MG TABLETS 33 $180.94 93 $507.19 CARISOPRODOL 250MG TABLETS 47 $140.88 141 $410.80

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CARISOPRODOL 350MG TABLETS 71 $32.40 199 $83.46 CARISOPRODOL/ASA/CODEINE TABLETS 95 $212.24 293 $647.41 CARTEOLOL HCL 1% OPH SOL 10ML 8 $21.75 13 $32.13 CARVEDILOL ER 40MG CAPSULES 31 $293.61 90 $839.30 CAVERJECT 20MCG VIAL INJ 5 $424.73 12 $1,089.98 CAVERJECT 40MCG INJ VIAL 5 $639.38 23 $2,756.46 CEFACLOR 250MG CAPSULES 29 $38.41 91 $112.69 CEFACLOR 500MG CAPSULES 24 $50.35 131 $262.02 CEFADROXIL 1GM TABLETS 20 $93.78 121 $561.93 CEFADROXIL 500MG CAPSULES 20 $18.17 158 $114.57 CEFDINIR 125MG/5ML SUSPENSION 60ML 85 $56.56 73 $49.46 CEFDINIR 250MG/5ML SUSPENSION 100ML 76 $97.49 168 $211.47 CEFDINIR 300MG CAPSULES 19 $68.88 108 $374.14 CEFPODOXIME PRO 100MG TABLETS 14 $63.61 111 $469.33 CEFPODOXIME PRO 200MG TABLETS 17 $113.43 121 $799.76 CEFPROZIL 250MG TABLETS 20 $55.40 90 $233.46 CEFPROZIL 250MG/5ML SUSP 100ML 108 $35.32 100 $32.99 CEFPROZIL 500MG TABLETS 19 $100.95 152 $795.07 CEFTRIAXONE 1GM INJ, 1 VIAL 3 $64.03 1 $24.70 CEFTRIAXONE 250MG INJ, 1 VIAL 1 $11.35 1 $10.60 CEFTRIAXONE 2GM INJ 8 $358.16 90 $3,783.10 CEFUROXIME 250MG TABLETS 20 $39.36 110 $201.27 CEFUROXIME 500MG TABLETS 19 $65.64 127 $422.22 CELECOXIB 100MG CAPSULES 50 $208.17 145 $602.14 CELECOXIB 200MG CAPSULES 39 $260.70 113 $756.18 CELECOXIB 400MG CAPSULES 30 $312.60 96 $978.78 CELECOXIB 50MG CAPSULES 51 $99.43 151 $285.65 CELONTIN 300MG CAPSULES 73 $317.09 223 $961.25 CEPHALEXIN 125MG/5ML SUSP 100ML 177 $23.51 533 $62.67 CEPHALEXIN 250MG TAB 27 $73.32 73 $188.07 CEPHALEXIN 500MG TABLETS 24 $67.80 137 $375.03 CEPHALEXIN 750MG CAPSULES 20 $73.25 149 $520.12 CEVIMELINE 30MG CAPSULES 84 $271.13 250 $794.90 CHANTIX 0.5MG TABLETS 45 $316.52 161 $1,114.22 CHANTIX 1MG CONTINUING MONTH PAK 56 $391.32 160 $1,101.55 CHANTIX STARTING MONTH PAK 53'S 53 $396.05 58 $434.10 CHLORDIAZEPOX 5MG/AMITRP 12.5MG TAB 48 $54.39 116 $126.45 CHLORDIAZEPOXIDE/AMIT 10-25MG TABS 43 $60.81 111 $149.85 CHLORDIAZEPOXIDE/CLIDINIUM CAPS 64 $225.00 185 $639.55 CHLOROQUINE 250MG TABLETS 19 $46.57 72 $161.53 CHLOROQUINE PHOSPHATE 500MG TABLETS 7 $86.46 21 $264.35 CHLOROTHIAZIDE 250MG TABLETS 37 $18.14 100 $41.81 CHLOROTHIAZIDE 500MG TABLETS 39 $32.49 95 $74.45 CHLORPROMAZINE 100MG TABLETS 61 $545.20 190 $1,698.94 CHLORPROMAZINE 10MG TABS 57 $188.20 212 $690.95 CHLORPROMAZINE 200MG TABLETS 56 $692.74 167 $2,070.16 CHLORPROMAZINE 25MG TABLETS 50 $222.13 188 $830.66 CHLORPROMAZINE 50MG TABLETS 59 $377.60 183 $1,170.30

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CHLORPROPAMIDE 100MG TABLETS 49 $46.84 192 $170.64 CHLORPROPAMIDE 250MG TABLETS 48 $93.95 114 $215.82 CHLORTHALIDONE 25MG TABLETS 29 $20.38 83 $51.11 CHLORTHALIDONE 50MG TABLETS 31 $20.41 91 $52.37 CHLORZOXAZONE500MG TABLETS 64 $19.64 224 $58.67 CHOLESTYRAMINE 4G PWD (CAN) 378GM 411 $64.87 894 $136.37 CHOLESTYRAMINE 4GM PACKETS 60'S 51 $107.83 139 $284.85 CHOLESTYRAMINE LIGHT POWDER 210GM 278 $78.30 758 $206.67 CHOR GONADOT 10000UNT INJ, 1VIAL 2 $460.16 2 $542.00 CIALIS 10MG TABLETS 6 $470.68 26 $1,864.39 CIALIS 2.5MG BLISTER PAK TABLETS 26 $309.71 88 $1,047.30 CIALIS 20MG TABLETS 6 $434.04 20 $1,482.44 CIALIS 5MG TABLETS 22 $265.84 85 $1,007.26 CICLOPIROX 0.77% CREAM 90GM 55 $77.80 159 $216.35 CICLOPIROX 0.77% GEL 45GM 50 $100.43 143 $279.45 CICLOPIROX 1% SHAMPOO 120ML 124 $165.49 304 $399.60 CICLOPIROX 8% NAIL LACQUER TOP SOLN 7 $44.34 18 $110.99 CICLOPIROX TOPICAL SUSPENSION 30ML 51 $86.26 103 $169.16 CILOXAN 0.3% OPHTH OINT (EYE) 3.5GM 4 $237.20 9 $597.44 CIMETIDINE 200MG TABLETS 77 $27.15 232 $73.53 CIMETIDINE 300MG TABLETS 54 $26.79 159 $70.81 CIMETIDINE 400MG TABLETS 44 $49.33 151 $159.63 CIMETIDINE 800MG TABLETS 43 $28.47 122 $73.70 CIMZIA 200MG/ML PRF SYR KIT (2 SYR) 1 $4,119.29 3 $12,342.45 CIPRODEX OTIC SUSPENSION (EAR) 8 $226.33 13 $390.73 CIPROFLOXACIN 0.3% OP SOL5ML-EYE 5 $71.03 7 $101.42 CIPROFLOXACIN 100MG PACK 22 $226.17 86 $865.28 CIPROFLOXACIN ER 1000MG TABLETS 10 $96.24 88 $836.98 CIPROFLOXCN 0.2% PF OTIC SOL (EAR) 14 $107.26 15 $108.16 CIPRO-HC OTIC SUSPENSION 10ML (EAR) 10 $324.16 11 $340.32 CITALOPRAM 10MG/5ML SOLUTION 235 $88.35 683 $248.82 CITRANATAL DHA PAK 60 $80.34 173 $222.47 CITRANATAL HARMONY CAPSULES 30 $124.10 89 $360.83 CLARAVIS 20MG CAPSULES 49 $975.05 90 $1,771.27 CLARINEX 2.5MG/5ML SYRUP 97 $108.38 758 $822.20 CLARINEX-D 12 HOUR TABLETS 43 $310.02 169 $1,214.23 CLARITHROMYCIN 250MG TABLETS 24 $127.91 103 $542.58 CLARITHROMYCIN 500MG ER TABLETS 20 $74.88 118 $421.19 CLARITHROMYCIN 500MG TABLETS 23 $76.04 130 $414.49 CLEMASTINE 2.68MG TABLETS 53 $27.84 143 $68.18 CLEOCIN 100MG VAGINAL OVULE 3'S 3 $202.06 8 $451.17 CLEOCIN T 1% GEL 60GM 74 $1,569.85 175 $3,685.98 CLIMARA PRO 0.045MG/DAY PATCHES 4'S 4 $188.76 12 $531.64 CLINDAMYCIN 1% FOAM 100GM 81 $483.04 267 $1,582.61 CLINDAMYCIN 1% GEL 30GM 46 $94.44 145 $290.06 CLINDAMYCIN 1% LOTION 60ML 62 $106.06 193 $319.09 CLINDAMYCIN 1% PLEDGETS 60'S 62 $36.80 177 $98.42

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CLINDAMYCIN 1% TOPICAL SOLN 30ML 54 $63.68 179 $200.63 CLINDAMYCIN 2% VAGINAL CREAM 40GM 41 $82.39 139 $268.16 CLINDAMYCIN PED 75MG/5MLSOL 100ML 287 $150.31 717 $369.43 CLINDAMYCIN/BENZ PER 1/5% GEL 50GM 44 $438.86 128 $1,269.33 CLINDAMYCIN/BPO 1.2-5% GEL 45GM 45 $193.63 125 $526.01 CLINDETS 1% PLEDGETS 60'S 69 $577.96 199 $1,664.69 CLOBETASOL 0.05% EMOLLIENT CRM 60GM 42 $119.61 178 $491.06 CLOBETASOL 0.05% EMOLLNT FOAM 100GM 84 $431.87 250 $1,278.95 CLOBETASOL 0.05% FOAM 100GM 80 $361.70 255 $1,139.10 CLOBETASOL 0.05% SHAMPOO 118ML 123 $184.30 374 $553.03 CLOBETASOL 0.05% SOLUTION 25ML 50 $87.61 175 $297.64 CLOBETASOL 0.05% SPRAY 59ML 92 $543.53 290 $1,710.24 CLOBETASOL PROP 0.05% CREAM 30GM 44 $112.31 144 $358.02 CLOBETASOL PROP 0.05% GEL 60GM 41 $279.49 213 $1,454.52 CLOBETASOL PROP 0.05% LOTION 59ML 85 $175.93 316 $641.88 CLOBETASOL PROP 0.05% OINT 60GM 46 $299.36 139 $895.54 CLOCORTOLONE PIV 0.1% CRM 75GM PUMP 61 $398.04 195 $1,267.58 CLOMIPRAMINE 25MG CAPSULES 48 $340.71 139 $970.53 CLOMIPRAMINE 50MG CAPSULES 65 $490.05 189 $1,416.18 CLOMIPRAMINE 75MG CAPSULES 53 $420.25 157 $1,231.91 CLONAZEPAM 0.5MG TABLETS 51 $25.98 140 $64.58 CLONAZEPAM 1MG TABLETS 57 $22.12 143 $49.41 CLONAZEPAM 2MG TABLETS 56 $25.34 136 $55.94 CLONAZEPAM ODT 0.125MG TABLETS 56 $62.84 143 $153.60 CLONAZEPAM ODT 0.25MG TABLETS 47 $57.70 146 $169.82 CLONAZEPAM ODT 0.5MG TABLETS 49 $53.39 145 $151.01 CLONAZEPAM ODT 1MG TABLETS 47 $63.44 151 $194.78 CLONAZEPAM ODT 2MG TABLETS 40 $76.16 134 $244.53 CLONIDINE 0.1MG EXTENDEDRELEASE TB 66 $267.15 201 $804.79 CLONIDINE 0.1MG/24H WEEKLY PATCH 4 $146.09 12 $404.79 CLONIDINE 0.2MG/24H WEEKLY PATCHES 4 $200.79 12 $549.62 CLONIDINE 0.3MG/24H WEEKLY PATCH 4 $231.52 12 $634.57 CLOPIDOGREL 300MG TABLETS 6 $133.24 23 $523.02 CLOPIDOGREL 75MG TABLETS 30 $65.11 90 $186.31 CLORAZEPATE 15MG TABLETS 49 $107.27 140 $297.65 CLORAZEPATE 3.75MG TABLETS 58 $56.56 157 $147.67 CLORAZEPATE 7.5MG TABLETS 52 $70.66 148 $193.31 CLOTRIMAZOLE 1% CREAM 15GM 36 $25.49 134 $84.30 CLOTRIMAZOLE 1% SOLUTION 10ML 33 $70.55 65 $136.44 CLOTRIMAZOLE 10MG LOZENGE 53 $80.78 244 $356.39 CLOTRIMAZOLE-BETAMETHASONE CRM 45GM 34 $59.13 131 $213.59 CLOTRIMAZOLE-BETAMETHASONE LOT 30ML 35 $127.64 153 $550.41 CLOZAPINE 100MG TABLETS 76 $192.59 174 $434.11 CLOZAPINE 200MG TABLETS 45 $267.08 68 $399.98 CLOZAPINE 50MG TABLETS 39 $32.90 68 $54.13 COAL TAR 465 $31.53 473 $32.00 COARTEM 20-120MG TABLETS 34 $193.77 241 $1,359.12

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CODEINE SULF 30MG TABLETS 89 $61.65 300 $199.25 CODEINE SULFATE 15MG TABLETS 54 $28.99 99 $49.53 CODEINE SULFATE 60MG TABLETS 103 $79.20 214 $160.02 COLCHICINE 0.6MG CAPSULES 29 $164.84 103 $576.09 COLCHICINE 0.6MG TABLETS 29 $155.97 105 $550.33 COLESTID 7.5GM FLAVORED PACKS 60'S 51 $383.67 113 $837.42 COLESTIPOL 1GM TABLETS 79 $64.28 224 $174.15 COLESTIPOL 5GM GRANULE PACKETS 90'S 47 $168.31 139 $488.86 COLESTIPOL HCL 5GM GRANULES 500GM 510 $210.16 615 $252.62 COLISTIMETHATE 150MG INJ, 1 VIAL 44 $1,311.41 81 $2,423.17 COMBIGAN 0.2/0.5% OPTH SOLN 5ML 7 $201.57 14 $412.17 COMBIPATCH .05MG/.14MG/DAY PATCHES 8 $179.99 23 $504.30 COMBIVENT RESPIMAT ORAL 120SPRAY 4G 4 $402.22 11 $1,068.16 CONDYLOX 0.5% GEL 3.5GM 4 $591.17 9 $1,361.48 CONTRAVE ER 8-90MG TABLETS 110 $220.35 301 $598.33 CORDRAN 80X3 4MCG/CM TAPE 1 $663.14 4 $2,387.96 COREG CR 10MG CAPSULES 32 $296.76 92 $846.63 COREG CR 80MG CAPSULES 30 $307.51 90 $911.03 CORTIFOAM RECTAL FOAM (14 DOSES) 20 $506.05 105 $2,626.06 CORTISONE ACETATE 25MG TABLETS 48 $141.60 136 $391.53 CORVITA 150 TABLETS 30 $34.22 93 $97.66 CORVITE FE TABLETS 34 $124.96 89 $321.60 CORVITE TABLETS 32 $28.08 91 $73.04 COSOPT PF OPHTH SOLN 64 $168.76 172 $446.42 COUMADIN 10MG (TEN MG) TABS (WHITE) 33 $111.05 89 $295.84 COUMADIN 3MG TABLETS (TAN) 34 $80.97 94 $216.85 COUMADIN 6MG TABLETS (BLUE/GREEN) 30 $96.00 90 $280.44 CREON 12,000 CAPSULES 225 $683.19 470 $1,419.58 CREON 24,000U CAPSULES 243 $1,457.64 533 $3,186.68 CREON 6,000 CAPSULES 239 $365.21 405 $615.19 CRINONE 4% GEL PREFILLED APPLIC 16 $254.78 27 $408.45 CRINONE 8% (90MG)VAG GEL15X1.125GM 26 $583.43 82 $1,828.27 CRIXIVAN 400MG CAPSULES 155 $450.37 540 $1,563.57 CROMOLYN SOD 100/5ML ORAL CONC 5ML 880 $530.00 2852 $1,709.35 CROMOLYN SOD 20/2ML INH SOLN 60X2ML 156 $156.36 525 $516.22 CROMOLYN SODIUM 4% OPHTH SOLN 10ML 10 $18.29 19 $30.64 CUPRIMINE 250MG CAPSULES 92 $26,495.28 153 $44,117.68 CYANOCOBALAMIN 1000MCG/ML INJ 10ML 3 $34.77 5 $65.01 CYCLAFEM 7/7/7 TABLETS 28'S 28 $29.40 84 $79.31 CYCLOBENZAPRINE 7.5MG TABLETS 36 $164.79 172 $772.13 CYCLOGYL 1% OPHTH SOLUTION 15ML 10 $27.99 14 $39.69 CYCLOGYL 2% OPHTH SOLN 2ML 5 $36.40 13 $91.73 CYCLOMYDRIL OPHTH SOLUTION 2ML 4 $44.68 5 $53.38 CYCLOPENTOLATE 0.5% OPHTH SOLN 15ML 15 $71.99 15 $71.99 CYCLOPENTOLATE 1% OPHTH SOL 15ML 5 $8.70 15 $18.02 CYCLOPHOSPHAMIDE 25MG CAPSULES 55 $513.65 124 $1,161.53 CYCLOPHOSPHAMIDE 50MG CAPSULES 42 $724.83 123 $2,108.24 CYCLOSET 0.8MG TABLETS 104 $418.19 346 $1,387.84

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CYCLOSPORINE 100MG (MOD) CAPS 58 $167.46 159 $453.52 CYCLOSPORINE 100MG CAPSULES 62 $548.97 169 $1,496.49 CYCLOSPORINE 100MG/ML MOD ORAL SOLN 68 $340.97 55 $276.07 CYCLOSPORINE 25MG (MOD) CAPS 134 $173.46 375 $478.58 CYCLOSPORINE 25MG CAPSULES 128 $333.35 351 $903.81 CYCLOSPORINE 50MG (MOD) CAPS 65 $157.68 175 $418.43 CYPROHEPTADINE HCL 4MG TABLETS 50 $32.33 148 $88.07 CYTARABINE 20MG/ML INJ, 5ML 27 $22.48 20 $17.52 DALIRESP 500MCG TABLETS 30 $284.97 89 $841.30 D-AMPHETAMINE ER 10MG SALT COMBO CP 33 $151.95 100 $459.43 D-AMPHETAMINE ER 15MG SALT COMBO CP 32 $150.94 96 $449.77 D-AMPHETAMINE ER 20MG SALT COMBO CP 36 $62.00 110 $179.75 D-AMPHETAMINE ER 25MG SALT COMBO CP 33 $178.12 101 $530.86 D-AMPHETAMINE ER 30MG SALT COMBO CP 34 $183.01 103 $538.59 D-AMPHETAMINE ER 5MG SALT COMBO CP 32 $165.61 103 $522.51 D-AMPHETAMINE SALT COMBO 15MG TABS 53 $75.42 142 $195.51 D-AMPHETAMINE SALT COMBO 20MG TABS 60 $79.10 164 $209.50 D-AMPHETAMINE SALT COMBO 10MG TAB 52 $69.49 142 $183.92 D-AMPHETAMINE SALT COMBO 12.5MG TB 57 $63.18 185 $195.14 D-AMPHETAMINE SALT COMBO 30MG TABS 57 $82.58 157 $221.28 D-AMPHETAMINE SALT COMBO 5MG TABS 43 $74.49 124 $208.42 D-AMPHETAMINE SALT COMBO 7.5MG TAB 45 $46.59 158 $153.59 DANAZOL 100MG CAPSULES 56 $276.03 137 $671.74 DANAZOL 200MG CAPSULES 62 $572.68 157 $1,455.26 DANAZOL 50MG CAPSULES 50 $165.71 142 $461.28 DANTROLENE 100MG CAPSULES 84 $169.06 265 $524.31 DANTROLENE 25MG CAPSULES 105 $100.30 259 $241.01 DANTROLENE 50MG CAPSULES 94 $124.03 270 $349.24 DAPSONE 100MG TABLETS 29 $39.82 84 $106.46 DAPSONE 25MG TABLETS 62 $65.77 179 $181.39 DAPTACEL INJ, 0.5ML 1 $42.99 1 $62.49 DARIFENACIN ER 7.5MG TABLETS 31 $160.72 91 $455.79 DARPAZ TABLETS 52 $439.97 175 $1,476.19 DAYTRANA 10MG TRANSDERMAL PATCHES 30 $345.55 90 $1,029.97 DAYTRANA 15MG TRANSDERMAL PATCHES 30 $359.48 88 $1,037.97 DAYTRANA 20MG TRANSDERMAL PATCHES 31 $370.96 104 $1,222.43 DAYTRANA 30MG TRANSDERMAL PATCHES 31 $363.23 97 $1,139.17 DEBACTEROL 0.2ML SWAB KIT 8 $47.28 11 $62.41 DEMECLOCYCLINE 150MG TABLETS 58 $412.11 146 $1,027.58 DEMECLOCYCLINE 300MG TABLETS 52 $653.91 173 $2,154.88 DEMSER 250MG CAPSULES 87 $31,539.98 255 $92,025.72 DENAVIR 1% CREAM 5GM 5 $395.48 19 $1,455.72 DEPEN TITRA 250MG TAB 66 $4,434.40 259 $17,264.10 DEPO-ESTRADIOL 5MG/ML 5ML 5 $125.25 5 $130.60 DEPO-PROVERA *104MG* SUBQ SYRINGE 1 $256.99 1 $256.99 DESIPRAMINE 100*MG TABLETS 42 $156.25 128 $463.35 DESIPRAMINE 10MG TABLETS 55 $45.54 147 $115.57 DESIPRAMINE 150MG TABLETS 34 $137.01 104 $412.16

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DESIPRAMINE 25MG TABLETS 51 $45.11 142 $117.57 DESIPRAMINE 50MG TABLETS 55 $116.52 162 $338.03 DESIPRAMINE 75MG TABLETS 38 $141.68 102 $376.32 DESLORATADINE 5MG TABLETS 29 $83.91 91 $251.62 DESMOPRESSIN 0.01%(0.1ML/NASAL SPR) 8 $277.30 29 $980.41 DESMOPRESSIN 0.01%(0.1ML/NASAL SPR) 8 $274.05 30 $999.42 DESMOPRESSIN 0.1MG TABLETS 62 $190.49 174 $528.30 DESMOPRESSIN 0.2MG TABLETS 64 $285.01 185 $813.14 DESMOPRESSIN 4MCG/ML INJ SINGLE USE 23 $1,114.30 47 $2,276.62 DESONIDE 0.05% CREAM 60GM 37 $188.80 123 $614.12 DESONIDE 0.05% LOTION 118ML 84 $312.99 231 $853.09 DESONIDE 0.05% OINTMENT 60GM 37 $120.06 121 $378.56 DESOXIMETAS 0.05% CRE 63 $327.83 210 $1,075.06 DESOXIMETASONE 0.05% GEL 15GM 44 $186.26 200 $830.54 DESOXIMETASONE 0.05% OINTMENT 60GM 71 $364.53 100 $514.99 DESOXIMETASONE 0.25% CRM 15GM 49 $80.31 187 $297.10 DESOXIMETASONE 0.25% OINTMENT 15GM 57 $257.44 223 $991.13 DESVENLAFAXINE ER SUCCINATE 100MG T 31 $222.61 93 $664.96 DESVENLAFAXINE ER SUCCINATE 25MG T 32 $210.99 94 $618.38 DESVENLAFAXINE ER SUCCINATE 50MG T 31 $208.49 93 $620.68 DESVENLAFAXINE ER TABS 100MG 31 $163.78 90 $472.91 DESVENLAFAXINE ER TABS 50MG 31 $83.68 92 $245.15 DEXAMETH SOD PHO 4MG/ML INJECTION 7 $10.80 16 $19.77 DEXAMETHASONE 0.5MG/5ML ELIXIR 203 $45.99 644 $137.09 DEXAMETHASONE 0.5MG/5ML ORAL SOLN 275 $15.42 874 $40.35 DEXAMETHASONE 2MG TABLETS 22 $16.26 103 $61.94 DEXAMETHASONE 6MG TAB 6 $9.18 66 $57.27 DEXAMETHASONE INTENSOL 1MG/ML SOLN 39 $32.56 180 $135.94 DEXAMETHASONE PHOS 120MG/30ML INJ 34 $37.21 30 $32.99 DEXAMETHASONE SOD PHOS 10MG/ML INJ 4 $13.24 14 $36.47 DEXAMETHASONE SOD PHOS 4MG/ML INJ 18 $21.62 20 $22.84 DEXILANT 30MG CAP(FORMERLY KAPIDEX) 32 $283.71 91 $808.75 DEXMETHYLPHENIDATE 10MG TABLETS 52 $58.50 139 $148.71 DEXMETHYLPHENIDATE 15MG ER CAPSULES 31 $174.73 92 $517.97 DEXMETHYLPHENIDATE 2.5MG TABLETS 44 $22.31 122 $54.59 DEXMETHYLPHENIDATE 30MG ER CAPSULES 31 $189.20 91 $548.06 DEXMETHYLPHENIDATE 35MG ER CAPSULES 30 $181.56 97 $572.89 DEXMETHYLPHENIDATE 40MG ER CAPSULES 31 $238.65 93 $715.32 DEXMETHYLPHENIDATE 5MG TABLETS 44 $35.35 129 $95.50 DEXMETHYLPHENIDATE ER 10MG CAPSULES 31 $239.02 96 $730.76 DEXMETHYLPHENIDATE ER 20MG CAPSULES 31 $251.13 95 $752.46 DEXMETHYLPHENIDATE ER 5MG CAPSULES 32 $304.54 107 $1,018.88 DEXTROAMPHETAMINE 10MG ER CAPSULES 64 $238.32 174 $637.85 DEXTROAMPHETAMINE 10MG TABLETS 82 $208.71 205 $518.75 DEXTROAMPHETAMINE 15MG ERCAPSULES 64 $644.46 170 $1,697.22 DEXTROAMPHETAMINE 5MG ER CAPSULES 46 $237.47 174 $891.50 DEXTROAMPHETAMINE 5MG TABLETS 57 $104.98 182 $326.38 DIALYVITE 3000 TABLETS 30 $14.65 90 $35.99

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DIALYVITE SUPREM D TABLETS 31 $14.33 90 $33.80 DIALYVITE WITH ZINC TABLETS 31 $9.54 91 $20.32 DIAZEPAM 10MG RECTAL GEL(2 PACK) 1 $468.28 2 $737.98 DIAZEPAM 10MG TABLETS 45 $16.64 145 $45.17 DIAZEPAM 2.5MG RECTAL GEL (2 PACK) 1 $385.90 3 $951.17 DIAZEPAM 20MG RECTAL GEL(2 PACK) 1 $569.98 4 $1,451.46 DIAZEPAM 2MG TABLETS 41 $10.90 151 $29.10 DIAZEPAM 5MG TABLETS 37 $11.59 138 $32.42 DIAZEPAM 5MG/1ML ORAL CONCENTRATE 60 $87.75 220 $311.93 DIAZEPAM 5MG/5ML (1MG/1ML) ORAL SOL 176 $56.85 699 $213.59 DICLEGIS 10-10MG TABLETS 72 $545.21 157 $1,191.55 DICLOFENAC 1% GEL 100GM 155 $75.26 565 $263.69 DICLOFENAC 1.5% TOPICAL SOL 150ML 173 $261.23 512 $764.79 DICLOFENAC 3% GEL 100GM 111 $702.06 298 $1,883.82 DICLOFENAC POTASSIUM 50MG TABLETS 44 $35.02 179 $129.10 DICLOFENAC SOD 0.1% OPHTH SOLN 5ML 5 $59.29 6 $78.97 DICLOFENAC SODIUM 100MG ER TABLETS 31 $18.52 97 $49.44 DICLOFENAC SODIUM 25MG DR TABLETS 53 $47.16 186 $154.25 DICLOFENAC SODIUM 50MG DRTABLETS 52 $16.10 181 $46.22 DICLOFENAC/MISOPROSTOL 50-0.2MG TAB 57 $173.39 170 $506.49 DICLOFENAC/MISOPROSTOL 75-0.2MG TAB 55 $165.61 165 $489.29 DICLOXACILLIN 250MG CAPSULES 37 $16.83 183 $67.85 DICLOXACILLIN 500MG CAPSULES 34 $34.83 195 $179.84 DICYCLOMINE 10MG/5ML SOLUTION 177 $56.79 1528 $459.52 DIDANOSINE (DDI) 200MG DR CAPSULES 35 $183.66 113 $581.46 DIDANOSINE (DDI) 400MG DR CAPSULES 30 $314.56 89 $922.10 DIETHYLPROPION 25MG TABLETS 63 $30.35 169 $74.86 DIETHYLPROPION 75MG ER TABLETS 30 $32.58 92 $92.45 DIFICID 200MG TABLETS 18 $3,490.06 74 $14,211.96 DIFLORASONE DIACETATE .05% CRM 30GM 62 $765.39 120 $1,469.98 DIFLORASONE DIACETATE .05% ONT 30GM 53 $696.53 165 $2,159.89 DIFLUNISAL 500MG TABLETS 37 $57.50 171 $249.23 DIGOXIN 0.125MG TABLETS 30 $26.04 87 $67.78 DIGOXIN 0.25MG TABLETS (WHITE) 31 $23.02 89 $59.06 DIGOXIN 50 MCG/ML (0.05 MG/ML) DRP 64 $42.65 124 $78.52 DIHYDROERGOTAMINE (1MG/ML) 1ML AMP 11 $1,516.04 27 $3,703.37 DILANTIN 30MG CAPSULES 59 $67.31 147 $161.91 DILTIAZEM 300MG CD CAP 30 $62.32 90 $178.27 DILTIAZEM 90MG TABLETS 74 $20.89 198 $49.19 DILTIAZEM CD 120MG CAPSULES (24 HR) 33 $19.49 99 $50.21 DILTIAZEM CD 180MG CAPSULES (24 HR) 34 $37.86 101 $105.34 DILTIAZEM CD 240MG CAPSULES (24 HR) 32 $46.45 95 $129.98 DILTIAZEM ER 120MG CAPSULES (24 HR) 33 $36.96 98 $101.66 DILTIAZEM ER 180MG CAPS (XR-24H) 35 $22.48 102 $58.41 DILTIAZEM ER 240MG CAPSULES (24 HR) 32 $46.32 95 $130.28 DILTIAZEM ER 240MG TABS (LA 24HR) 31 $88.18 92 $251.94 DILTIAZEM ER 300MG CAPSULES (24 HR) 30 $71.29 90 $204.93 DILTIAZEM ER 360MG (24 HR/CD) CAPS 30 $259.21 90 $768.08

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DILTIAZEM ER 360MG TABLETS (LA 24H) 30 $128.66 89 $377.65 DILTIAZEM ER 420MG CAPSULES (24 HR) 30 $50.93 89 $145.03 DILTIAZEM ER 60MG CAPSULES (12 HR) 54 $73.67 159 $208.22 DILTIAZEM ER 90MG CAPSULES (12 HR) 55 $68.83 152 $183.85 DILTIAZEM SR 120MG CAPSULES (12 HR) 48 $83.09 141 $235.37 DILTIAZEM XR 120MG CAPSULES (24 HR) 33 $19.49 98 $49.55 DILTIAZEM XR 240MG CAPSULES (24 HR) 33 $26.76 95 $70.17 DILTZAC ER 180MG CAPSULES(24 HR) 34 $49.72 102 $140.03 DILTZAC ER 360MG CAPSULES(24 HR) 30 $65.08 90 $186.18 DIPHENHYDRAMINE 25MG CAPSULES 40 $4.45 123 $5.37 DIPHENHYDRAMINE 50MG/ML INJ, 1ML 29 $128.70 131 $567.98 DIPHENOXYLATE/ATROP 2.5MG TABLETS 65 $38.73 282 $154.46 DIPHENOXYLATE/ATROPINE LIQUID 165 $36.67 246 $52.74 DIPYRIDAMOLE 25MG TABLETS 65 $31.30 179 $79.16 DIPYRIDAMOLE 50MG TABLETS 91 $25.02 248 $61.11 DIPYRIDAMOLE 75MG TABLETS 74 $32.84 207 $84.78 DISOPYRAMIDE 100MG CAPSULES 97 $137.00 270 $373.70 DISOPYRAMIDE 150MG CAPSULES 80 $178.17 225 $492.59 DISULFIRAM 250MG TABLETS 30 $116.30 89 $337.69 DISULFIRAM 500MG TABLETS 27 $163.52 86 $513.82 DIURIL 250/5ML SUSPENSION 97 $33.00 229 $72.69 DIVALPROEX 125MG SPRINKLES 160 $109.84 436 $291.92 DIVALPROEX DELAYED RELEASE 125MG TB 81 $17.43 217 $40.10 DIVALPROEX DELAYED RELEASE 250MG TB 77 $95.27 228 $274.36 DIVALPROEX DELAYED RELEASE 500MG TB 69 $131.88 208 $388.90 DIVALPROEX EXTENDED RELEASE 250MG T 66 $124.60 192 $356.28 DIVALPROEX EXTENDED RELEASE 500MG T 66 $259.08 198 $768.25 DIVIGEL 0.1% (1MG/DAY) TOP GEL 32 $128.00 92 $366.89 DOCUSATE SODIUM 250MG CAPSULES 52 $5.53 136 $8.04 DOFETILIDE 125MCG CAPSULES 74 $566.59 212 $1,614.67 DOFETILIDE 250MCG CAPSULES 60 $456.40 179 $1,367.07 DOFETILIDE 500MCG CAPSULES 59 $451.42 178 $1,354.08 DOLOGESIC DYE FREE TABLETS 33 $10.71 37 $11.48 DONEPEZIL 10MG TABLETS 32 $94.87 94 $273.67 DONEPEZIL 23MG TABLETS 30 $295.52 89 $868.79 DONEPEZIL 5MG TABLETS 31 $93.84 92 $267.08 DONEPEZIL ODT 10MG TABLETS 32 $130.21 91 $359.89 DONEPEZIL ODT 5MG TABLETS 32 $127.48 90 $355.69 DORZOLAMIDE 2% OPHTH SOLN 10ML 10 $18.20 15 $25.26 DORZOLAMIDE-TIMOLOL OPHTH SOLN 10ML 10 $81.89 15 $122.45 DOXAZOSIN 8MG TABLETS 34 $16.49 97 $39.68 DOXEPIN 100MG (HUNDRED MG) CAPSULES 40 $26.40 117 $68.84 DOXEPIN 150MG CAPSULES 34 $47.67 102 $132.95 DOXEPIN 50MG CAPSULES 43 $26.79 125 $70.46 DOXEPIN 75MG CAPSULES 37 $21.75 110 $56.98 DOXERCALCIFEROL 0.5MCG CAPSULES 30 $224.62 97 $714.88 DOXYCYCLINE 100MG DR TABLETS 24 $292.34 115 $1,410.86 DOXYCYCLINE 150MG CAPSULES 27 $602.97 104 $2,303.25

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

DOXYCYCLINE 40MG CAPSULES 30 $615.46 90 $1,831.31 DOXYCYCLINE 75MG DR TABLETS 37 $175.51 98 $455.80 DOXYCYCLINE HYC 150MG DR TABLETS 29 $249.65 82 $704.74 DOXYCYCLINE HYC 200MG DR TABLETS 22 $441.23 89 $1,739.51 DOXYCYCLINE HYCLATE 100MG CAPSULES 25 $121.87 123 $594.10 DOXYCYCLINE HYCLATE 100MG TABLETS 23 $61.20 116 $288.36 DOXYCYCLINE HYCLATE 20MGTABLETS 57 $33.32 167 $89.77 DOXYCYCLINE HYCLATE 50MG CAPSULES 40 $68.47 106 $174.00 DOXYCYCLINE MONOHYD 25MG/5ML SUSP 276 $91.41 240 $79.96 DOXYCYCLINE MONOHYDRATE 100MG CAPS 27 $43.75 122 $186.91 DOXYCYCLINE MONOHYDRATE 100MG TABS 24 $93.47 120 $445.90 DOXYCYCLINE MONOHYDRATE 150MG TABS 26 $186.31 93 $656.29 DOXYCYCLINE MONOHYDRATE 50MG CAPS 43 $60.19 107 $144.99 DOXYCYCLINE MONOHYDRATE 50MG TABS 41 $122.14 105 $308.79 DOXYCYCLINE MONOHYDRATE 75MG CAPS 39 $483.77 120 $1,467.96 DOXYCYCLINE MONOHYDRATE 75MG TABS 39 $159.18 96 $392.24 DRONABINOL 10MG CAPSULES 63 $2,016.18 169 $5,427.47 DRONABINOL 2.5MG CAPSULES 57 $322.37 175 $976.03 DRONABINOL 5MG CAPSULES 60 $722.62 179 $2,140.16 DROSPIRENONE-ETHINYL 3-0.03MG T 28 29 $56.49 85 $158.72 DROXIA 200MG CAPSULES 42 $39.30 106 $92.36 DROXIA 300MG CAPS 52 $47.57 105 $91.52 DROXIA 400MG CAPS 60 $57.42 167 $153.24 DUAVEE 0.45-20 TABLETS 30 $190.87 89 $552.01 DULERA 100-5MCG ORAL INHALER 120INH 13 $324.01 36 $885.76 DULERA 200-5MCG ORAL INHALER 120INH 13 $324.49 36 $900.44 DULOXETINE DR 20MG CAPSULES 42 $305.78 122 $887.69 DULOXETINE DR 30MG CAPSULES 40 $253.45 119 $740.00 DULOXETINE DR 40MG CAPSULES 34 $137.23 99 $391.54 DULOXETINE DR 60MG CAPSULES 36 $229.84 106 $663.58 DUREZOL 0.05% OPHTH EMULSION 5ML 5 $206.94 7 $267.04 DUTASTERIDE 0.5MG CAPSULES 30 $160.80 89 $467.91 DUTASTERIDE/TAMSULOSIN 0.5-0.4MG CP 30 $170.81 89 $497.51 DUTOPROL 100MG/12.5MG TABLETS 35 $211.18 96 $567.81 DYMISTA 137/50 MCG NASAL SPR 120SPR 23 $201.75 66 $565.77 DYRENIUM 100MG CAPSULES 39 $424.90 123 $1,326.74 DYRENIUM 50MG CAPSULES 38 $415.82 107 $1,160.90 EASY TOUCH PEN NEEDLE 31GX3/16 100S 120 $56.74 162 $75.09 EC-NAPROXEN 375MG TABLETS 43 $13.83 166 $42.17 ECONAZOLE NITRATE 1% CREAM 85GM 52 $190.79 176 $637.19 EDARBI 40MG TABLETS 30 $156.45 90 $455.38 EDARBYCLOR 40/25MG TABLETS 30 $205.61 89 $592.22 EDEX 10MCG KIT ( 2 PACK ) 3 $260.37 10 $790.02 EDEX 20MCG KIT ( 6 PACK) 3 $200.64 11 $693.95 EDEX 40MCG KIT (2 PACK) 2 $1,072.58 4 $2,457.10 EEMT HS 0.625/1.25MG TABLETS 30 $96.20 87 $273.66 EFFER-K 10MEQ TABLETS 46 $20.74 118 $47.18 EFFER-K 20MEQ TABLETS 49 $25.42 134 $62.95

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

EFLONE 0.1% OPH SUSP 5ML 5 $99.45 6 $107.99 ELESTRIN 0.06% GEL PUMP 26GM 52 $226.65 133 $572.83 ELETRIPTAN 20MG TABLETS 9 $240.87 29 $807.35 ELETRIPTAN 40MG TABLETS 9 $245.73 29 $810.78 ELIDEL 1% CREAM 60GM 57 $483.98 148 $1,245.40 ELIQUIS 2.5MG TABLETS U/D 57 $363.90 174 $1,094.07 ELIQUIS 5MG TABLETS 59 $427.80 177 $1,277.67 ELITE-OB TABLETS 30 $45.01 90 $127.05 ELLA 30MG TABLETS 1 $47.07 15 $603.94 ELMIRON 100MG CAPSULES 85 $671.20 252 $1,978.40 EMCYT 140MG CAPSULES 77 $1,249.52 90 $1,454.89 EMOQUETTE TABETS 28S (6X28) 29 $25.77 85 $67.80 EMSAM 12MG/24H PATCH 30 $1,719.47 89 $4,992.42 EMSAM 6MG/24HR PATCH 30 $1,704.19 89 $5,112.57 EMSAM 9MG/24HR PATCH 31 $1,728.77 98 $5,502.97 EMTRIVA 10MG/ML ORAL SOLUTION 342 $284.29 720 $594.47 E-MYCIN 250MG EC TABLETS 49 $397.34 137 $1,115.09 E-MYCIN 333MG EC TABLETS 38 $376.67 148 $1,442.88 ENALAPRIL 10MG TABLETS 40 $13.22 114 $30.66 ENALAPRIL 20MG TABLETS 44 $21.46 129 $55.67 ENBREL 25MG VIAL FOR INJ (4 VIALS) 6 $3,551.56 20 $10,983.95 ENBREL 25MG/0.5ML INJ (1 SYRINGE) 3 $3,362.15 10 $11,057.15 ENBREL 50MG/ML INJ (1 SYRINGE) 4 $4,557.85 12 $13,053.98 ENBREL SURECLICK 50MG/ML(1 SYRINGE) 4 $4,444.79 12 $12,918.88 ENDOMETRIN 100MG VAGINAL INSERT 38 $449.20 150 $1,746.79 ENGERIX-B 10MCG/0.5ML INJ, (PED) 1 $54.25 1 $53.99 ENGERIX-B 20MCG/ML INJ, 1ML (ADULT) 1 $81.26 1 $82.00 ENOXAPARIN 100MG/1ML SYR (10 X 1ML) 21 $1,785.53 112 $9,370.48 ENOXAPARIN 120MG/0.8ML SYR 10X0.8ML 16 $1,992.73 79 $9,925.96 ENOXAPARIN 150MG/1ML SYR(10X1ML) 18 $1,395.66 106 $8,148.08 ENOXAPARIN 300MG/3ML INJ, 3ML 12 $988.32 26 $2,124.71 ENOXAPARIN 30MG/0.3ML SYR(10X0.3ML) 7 $519.22 27 $2,036.70 ENOXAPARIN 40MG/0.4ML SYR(10X0.4ML) 8 $643.24 35 $2,780.41 ENOXAPARIN 60MG/0.6ML SYR(10X0.6ML) 15 $605.23 83 $3,359.26 ENOXAPARIN 80MG/0.8ML SYR(10X0.8ML) 18 $1,512.55 96 $7,911.23 ENTACAPONE 200MG TABLETS 104 $410.51 320 $1,251.34 ENTECAVIR 0.5MG TABLETS 29 $854.84 85 $2,490.48 ENTECAVIR 1MG TABLETS 28 $830.98 81 $2,367.07 ENTRESTO 24-26MG TABLETS 58 $496.62 170 $1,444.16 ENTRESTO 49-51MG TABLETS 59 $504.82 174 $1,486.25 EPIDUO GEL 45GM 45 $430.88 116 $1,099.40 EPINASTINE 0.05% OPHTH SOL 5ML 5 $120.29 15 $338.09 EPINEPHRINE 0.15MG AUTO-INJECTOR 2 $151.60 2 $132.99 EPINEPHRINE 0.1MG/ML INJ, 10ML 55 $32.59 100 $55.98 EPINEPHRINE 0.3MG PRE-FILLED(1 SYR) 2 $141.74 3 $228.15 EPIPEN-JR 0.15MG INJ 2 PACK (GREEN) 2 $803.79 6 $2,028.97 EPIVIR HBV 5MG/ML ORAL SOLN 240ML 198 $180.78 457 $412.53 EPLERENONE 25MG TABLETS 34 $106.63 95 $293.44

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

EPLERENONE 50MG TABLETS 44 $170.72 128 $486.13 EPOGEN 10,000 U/ML 1ML SDV VIALS 4 $687.19 7 $1,274.95 EPOGEN 40,000U/ML 1ML SDV VIALS 4 $3,475.85 7 $6,416.23 EPROSARTAN MESYLATE 600MG TABLETS 31 $51.05 87 $137.60 EQUETRO 100MG CAPSULES 63 $226.11 200 $711.80 EQUETRO 200MG CAPSULES 71 $265.90 263 $978.10 EQUETRO 300MG CAPSULES 64 $293.04 252 $1,135.23 ERGOLOID MES 1MG ORAL TABLETS 88 $642.26 228 $1,651.38 ERGOTAMINE TARTRATE CAFFEINE TABS 33 $53.48 100 $153.22 ERY-TAB 500MG EC TABLETS 28 $353.39 155 $1,908.93 ERYTH-BENZ PEROX GEL 46.6GM 39 $63.97 123 $190.79 ERYTHROMYCIN 2% GEL 60GM 45 $54.15 105 $121.23 ERYTHROMYCIN 2% TOPICAL SOLN 60ML 62 $31.04 207 $93.67 ERYTHROMYCIN 250MG TABLETS 46 $536.75 139 $1,607.34 ERYTHROMYCIN BASE 250MG TABLETS 42 $420.46 145 $1,423.91 ERYTHROMYCIN BASE 500MGTABLETS 21 $329.54 149 $2,353.89 ERYTHROMYCIN DR 250MG CAPSULES 54 $372.65 219 $1,496.26 ERYTHROMYCIN E.S 400MG TABLETS 39 $512.66 144 $1,877.91 ERYTHROMYCIN PLEDGETS 60'S 60 $71.39 150 $171.48 ESCITALOPRAM 10MG TABLETS 31 $109.16 93 $316.24 ESCITALOPRAM 20MG TABLETS 31 $99.24 93 $287.18 ESCITALOPRAM 5MG TABLETS 32 $102.30 94 $291.85 ESOMEPRAZOLE MAGNESIUM 20MG DR CAPS 35 $251.72 97 $695.92 ESOMEPRAZOLE MAGNESIUM 40MG DR CAPS 34 $243.47 97 $686.80 EST ESTRGN METHTEST 1.25/2.5MG TAB 30 $100.10 88 $288.75 ESTAZOLAM 1MG TABLETS 32 $25.46 104 $74.45 ESTAZOLAM 2MG TABLETS 30 $25.03 93 $69.09 ESTRA 0.5MG/NORETH 0.1MG TB LOW STR 28 $63.76 83 $179.24 ESTRADIOL 0.01% VAG CREAM 42.5GM 43 $282.00 49 $322.49 ESTRADIOL 0.025MG PATCH (ONCE WK) 4 $58.89 12 $157.32 ESTRADIOL 0.025MG PATCH (TWICE WK) 9 $65.70 24 $172.33 ESTRADIOL 0.0375MG PATCH (TWICE WK 8 $63.76 24 $172.82 ESTRADIOL 0.05MG PATCH (ONCE WK) 4 $74.41 12 $201.83 ESTRADIOL 0.05MG PATCH (TWICE WK) 8 $76.44 24 $209.54 ESTRADIOL 0.075MG PATCH (ONCE WK) 4 $59.33 12 $159.04 ESTRADIOL 0.075MG PATCH (TWICE WK) 9 $65.44 24 $173.25 ESTRADIOL 0.1MG PATCH (ONCE WK) 4 $75.87 12 $205.87 ESTRADIOL 0.1MG PATCH (TWICE WK) 10 $86.22 24 $214.17 ESTRADIOL TDS 0.0375MG PATCHES 4'S 4 $62.23 12 $166.45 ESTRADIOL TDS 0.06MG PATCH 4'S 4 $48.84 12 $134.76 ESTRADIOL VAL 40MG/ML 10ML 5 $115.68 5 $119.03 ESTRADIOL VALERATE 20MG/ML INJ, 5ML 5 $127.06 5 $129.58 ESTRATAB 0.625MG TABLETS 26 $69.44 82 $209.63 ESTRING 2MG VAGINAL RING 1 $441.56 1 $441.56 ESTROGEL 0.06% GEL 93GM 55 $142.32 158 $401.73 ESTROPIPATE 1.5MG (1.25MG) TABS 32 $15.77 92 $37.67 ESTROPIPATE 2.5MG (3MG) TABLETS 31 $40.24 94 $112.53 ESZOPICLONE 1MG TABLETS 30 $300.83 92 $917.21

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

ESZOPICLONE 2MG TABLETS 29 $303.92 90 $944.25 ESZOPICLONE 3MG TABLETS 29 $320.37 90 $982.63 ETHAMBUTOL 100MG TABLETS 73 $23.57 142 $41.88 ETHAMBUTOL 400MG TABLETS 62 $95.73 158 $239.17 ETHOSUXIMIDE 250MG CAPSULES 104 $155.15 301 $443.85 ETHOSUXIMIDE 250MG/5ML SYRUP 366 $121.26 1083 $351.16 ETHYL CHLORIDE 88.70 112 $43.11 373 $133.55 ETIDRONATE DISODIUM 200MGTABLETS 47 $140.84 59 $177.06 ETIDRONATE DISODIUM 400MGTABLETS 70 $639.93 118 $1,079.75 ETODOLAC 200MG CAPSULES 48 $47.30 192 $176.35 ETODOLAC 300MG CAPSULES 46 $58.76 191 $229.85 ETODOLAC 400MG TABLETS 46 $39.24 174 $137.17 ETODOLAC 500MG ER TABLETS 38 $79.86 139 $283.48 ETODOLAC 500MG TABLETS 49 $47.34 169 $152.94 ETODOLAC 600MG ER TABLETS 34 $70.38 115 $225.94 ETODOLAC ER 400MG TABLETS 40 $88.44 131 $279.77 EUCRISA 2% OINTMENT 60GM 61 $695.04 119 $1,340.15 EVAMIST 1.53MG TOPICAL SP/56 SPRAYS 9 $146.65 26 $412.33 EXELDERM 1% CREAM 15GM 62 $258.32 60 $249.84 EXELDERM 1% SOLUTION 30ML 33 $369.47 90 $996.97 EXEMESTANE 25MG TABLETS 30 $333.24 89 $984.61 EXJADE 125MG TABLETS 73 $3,838.71 180 $9,507.95 EXJADE 500MG TABLETS 69 $14,128.68 90 $18,435.97 EZETIMIBE 10MG TABLETS 30 $56.31 89 $158.92 EZETIMIBE/SIMVASTATIN 10-10MG TABS 30 $293.52 87 $848.81 EZETIMIBE/SIMVASTATIN 10-20MG TABS 30 $294.53 88 $863.54 EZETIMIBE/SIMVASTATIN 10-40MG TABS 30 $295.90 89 $866.52 EZETIMIBE/SIMVASTATIN 10-80MG TABS 30 $298.18 88 $856.51 FA/B12/B6 TABLETS 35 $9.47 96 $18.90 FAMCICLOVIR 125MG TABLETS 27 $106.82 121 $463.67 FAMCICLOVIR 250MG TABLETS 43 $186.24 147 $622.25 FAMCICLOVIR 500MG TABLETS 24 $177.05 126 $912.20 FAMOTIDINE 40MG/5ML SUSPENSION 50ML 82 $264.65 252 $801.66 FARXIGA 10MG TABLETS 30 $507.41 88 $1,487.67 FARXIGA 5MG TABLETS 30 $480.34 89 $1,407.71 FELBAMATE 400MG TABLETS 137 $547.67 406 $1,611.90 FELBAMATE 600MG TABLETS 128 $573.50 400 $1,789.08 FELBAMATE OS 600MG/5ML SUSPENSION 390 $318.90 1318 $1,067.84 FELODIPINE 10MG ER TABLETS 31 $69.55 92 $197.58 FELODIPINE 2.5MG ER TABLETS 35 $20.23 101 $51.17 FELODIPINE 5MG ER TABLETS 33 $43.55 98 $121.02 FEMRING 0.05MG/DAY 1 $471.62 1 $473.17 FEMRING 0.1MG/DAY 1 $505.06 1 $504.06 FENOFIBRATE 120MG TABLETS 30 $858.59 89 $2,516.67 FENOFIBRATE 130MG CAPSULES 30 $140.67 89 $409.00 FENOFIBRATE 134MG CAPSULES 30 $50.12 90 $140.65 FENOFIBRATE 145MG TABLETS 30 $143.30 90 $419.04

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price FENOFIBRATE 150MG CAPSULES 30 $167.22 89 $491.60 FENOFIBRATE 160MG TABLETS 30 $72.47 90 $207.55 FENOFIBRATE 200MG CAPSULES 30 $78.61 90 $224.41 FENOFIBRATE 40MG TABLETS 32 $304.70 95 $890.81 FENOFIBRATE 43MG CAPSULES 31 $71.55 92 $203.38 FENOFIBRATE 48MG TABLETS 31 $65.53 93 $186.39 FENOFIBRATE 50MG CAPSULES 32 $82.69 97 $242.19 FENOFIBRATE 67MG CAPSULES 31 $41.73 92 $114.57 FENOFIBRIC 105MG TABLETS 30 $82.78 90 $237.30 FENOFIBRIC 135MG DR CAPSULES 30 $119.70 90 $347.51 FENOFIBRIC 45MG DR CAPSULES 32 $43.91 94 $123.35 FENOPROFEN 600MG TABLETS 73 $323.68 209 $917.76 FENTANYL 100MCG/HR PATCH 12 $516.39 36 $1,556.08 FENTANYL 12MCG/HR PATCH 10 $155.66 32 $499.71 FENTANYL 25MCG/HR PATCH 10 $124.22 33 $387.07 FENTANYL 50MCG/HR PATCH 11 $238.54 32 $717.57 FENTANYL 75MCG/HR PATCH 11 $328.72 37 $1,076.22 FEOGEN FORTE CAPSULES U/D 10 X 10 38 $37.07 114 $101.98 FERRAPLUS 90 TABLETS 32 $24.88 94 $65.30 FERREX 150 PLUS CAPSULES 42 $44.29 104 $103.67 FERRO-PLEX TABLETS 30 $18.74 30 $18.99 FERROUS SULFATE 325MG (5GR) TABS 51 $22.52 129 $50.51 FERROUS SULFATE 325MG EC TABS RED 49 $21.64 107 $42.62 FEXOFENADINE 180MG TABLETS 30 $14.87 91 $37.43 FEXOFENADINE 60MG TABLETS (OTC) 44 $52.44 147 $165.60 FIASP FLEXTOUCH PEN INJ 3ML 19 $676.35 41 $1,414.55 FINACEA 15% GEL 30GM 51 $334.78 135 $885.89 FINASTERIDE 1MG TABLETS 31 $59.00 90 $166.53 FIRST-MAGIC MOUTHWASH BLM SUSP KIT 216 $46.82 119 $27.60 FIRST-PROGESTERONE 100MG VAG SUP KT 35 $180.17 30 $157.19 FIRST-VANCOMYCIN 25MG/ML SOL 150ML 301 $139.73 900 $409.99 FLAVOXATE 100MG TABLETS 56 $72.85 250 $309.25 FLECAINIDE 100MG TABLETS 59 $86.38 177 $251.70 FLECAINIDE 150MG TABLETS 52 $94.68 157 $277.88 FLECAINIDE 50MG TABLETS 63 $66.69 184 $188.24 FLECTOR 1.3% PATCH 40 $533.86 156 $2,048.65 FLOVENT 100MCG DISKUS (28 ORAL INH) 61 $195.51 175 $555.11 FLOVENT 250MCG DISKUS (60 ORAL INH) 63 $267.60 178 $755.27 FLOVENT HFA 110 MCG ORAL INH 120INH 12 $232.63 31 $591.10 FLOVENT HFA 220MCG INH 12GM 12 $404.50 31 $1,024.82 FLOVENT HFA 44MCG ORAL INH 120INH 11 $177.08 28 $458.74 FLOVENT ROTADISK 50MCG 61 $187.09 175 $526.80 FLUAD PFS 2018-2019 1 $69.99 1 $69.99 FLUARIX QIV PFS 2018-2019 1 $40.99 1 $40.99 FLUCONAZOLE 100MG TABLETS 11 $43.27 63 $237.79 FLUCONAZOLE 10MG/ML ORAL SUSP 35ML 50 $51.11 105 $102.97 FLUCONAZOLE 200MG TABLETS 14 $43.82 60 $178.58

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price FLUCONAZOLE 40MG/ML ORALSUSP 35ML 45 $114.59 78 $195.09 FLUCONAZOLE 50MG TABLETS 17 $24.79 75 $94.35 FLUCYTOSINE 250MG CAPSULES 69 $2,563.32 90 $3,327.79 FLUCYTOSINE 500MG CAPSULES 85 $6,072.94 88 $6,256.95 FLUDROCORTISONE 0.1MG TABLETS 46 $30.02 113 $68.13 FLUMAZENIL 0.5MG/5ML INJ, 5ML 5 $37.78 5 $37.99 FLUNISOLIDE 0.025% NASALSOLN 25ML 27 $74.84 48 $129.64 FLUOCINOLONE 0.01% OIL DROPS (EAR) 20 $203.05 22 $219.66 FLUOCINOLONE ACET 0.01% CRM 15GM 37 $80.02 242 $499.03 FLUOCINOLONE ACET 0.01% SOLN 60ML 63 $156.14 127 $310.46 FLUOCINOLONE ACET 0.025% OINT 15GM 46 $93.30 363 $704.60 FLUOCINOLONE ACET 0.025%CRM 60GM 41 $86.90 60 $125.24 FLUOCINOLONE ACETONIDE BODY OIL 122 $260.50 270 $571.47 FLUOCINOLONE ACETONIDE SCALP OIL 121 $275.76 243 $551.26 FLUOCINONIDE 0.05% CREAM 60GM 51 $58.44 181 $196.64 FLUOCINONIDE 0.05% GEL 15GM 38 $81.52 151 $315.72 FLUOCINONIDE 0.05% OINTMENT 30GM 48 $94.44 171 $322.29 FLUOCINONIDE 0.05% SOLN 60ML 62 $89.06 172 $238.38 FLUOCINONIDE 0.1% CREAM 60GM 68 $568.57 288 $2,394.37 FLUOCINONIDE -E 0.05% CREAM 60GM 47 $122.45 225 $573.97 FLUORABON DROPS 60ML 60 $11.99 62 $12.19 FLUOROMETHOLONE 0.1% OPTH SUSP 10ML 6 $88.96 8 $117.09 FLUOROURACIL 0.5% CREAM 30GM 32 $1,436.35 60 $2,709.98 FLUOROURACIL 2% SOLUTION 10ML 11 $71.84 29 $178.26 FLUOROURACIL 5% CREAM 40GM 41 $197.82 79 $379.03 FLUOROURACIL 5% SOLUTION10ML 11 $110.08 27 $259.97 FLUOROURACIL 500MG/10ML INJ, 10ML 94 $41.57 10 $7.99 FLUOXETINE 10MG (PMDD) TABLETS 32 $13.30 91 $30.25 FLUOXETINE 10MG TABLETS 35 $14.02 96 $31.84 FLUOXETINE 20MG TABLETS 40 $38.24 115 $103.54 FLUOXETINE 90MG CAPSULES 4 $138.95 12 $381.70 FLUOXETINE HCL 20MG/5ML SOLUTION 141 $16.95 433 $43.64 FLUPHENAZINE 10MG** TABLETS 59 $37.06 164 $96.05 FLUPHENAZINE 1MG TABLETS 62 $19.12 172 $46.11 FLUPHENAZINE 5MG TABLETS 55 $277.13 161 $801.16 FLUPHENAZINE DEC 25MG/ML INJ, 5ML 5 $190.46 6 $204.94 FLURANDRENOLIDE 0.05% CREAM 120GM 120 $448.74 240 $895.31 FLURANDRENOLIDE 0.05% LOTION 127 $665.77 240 $1,249.98 FLURAZEPAM 30MG CAPSULES 29 $18.71 92 $50.22 FLURAZEPAM 15MG CAPSULES 38 $20.20 103 $47.66 FLURBIPROFEN 0.03% OPHTHSOLN 2.5ML 3 $19.02 7 $34.89 FLURBIPROFEN 100MG TABLETS 43 $14.11 170 $43.73 FLURBIPROFEN 50MG TABLETS 50 $29.21 146 $77.18 FLUTAMIDE 125MG CAPSULES 101 $214.55 250 $524.47 FLUTICASONE 0.005% OINTMENT 30GM 43 $78.54 110 $193.89 FLUTICASONE 0.05% CREAM 30GM 43 $30.95 119 $79.06 FLUTICASONE 0.05% LOTION 60ML 80 $504.93 180 $1,125.99 FLUVASTATIN 20MG CAPSULES 31 $95.19 90 $269.04

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

FLUVASTATIN 40MG CAPSULES 34 $104.90 101 $301.05 FLUVASTATIN ER 80MG TABLETS 30 $120.30 88 $345.91 FLUVOXAMINE 100MG ER CAPSULES 44 $397.62 133 $1,184.13 FLUVOXAMINE 150MG ER CAPSULES 42 $402.35 123 $1,181.25 FLUVOXAMINE 50MG TABLETS 46 $93.63 138 $270.78 FLUZONE HD PFS 2018-2019 1 $69.99 1 $69.99 FLUZONE QIV PFS 2018-2019 1 $40.99 1 $40.99 FML FORTE (0.25%) OPHTHSUSP 15ML 6 $196.10 8 $260.89 FOCALGIN CA PAK 60 $123.97 174 $351.05 FOLBEE PLUS CZ TABLETS 32 $24.52 92 $62.20 FOLBIC TB (FOLIC2.5/PYRID25/CYAN2) 34 $28.85 95 $73.82 FOLGARD OS TABLETS 42 $18.09 117 $42.75 FOLIC ACID 5MG/ML INJ 11 $54.99 13 $61.49 FOLITAB 500MG TABLETS 36 $21.98 94 $51.06 FOLIVANE-OB CAPSULES 30 $28.67 90 $77.21 FOLLISTIM AQ 900IU INJ, 1.200ML 2 $4,110.23 1 $1,999.99 FOLTRATE TABLETS 32 $28.81 91 $74.12 FONDAPARINUX 10MG/0.8ML SL 10X0.8ML 20 $2,782.32 71 $9,733.83 FONDAPARINUX 2.5MG/.5ML SL 10X0.5ML 9 $453.05 45 $2,315.33 FONDAPARINUX 7.5MG/.6ML SL 10X0.6ML 15 $2,785.43 51 $9,728.87 FORMALDEHYDE 10% SOLUTION 92 $25.97 89 $25.07 FORTEO 600MCG PEN(20MCG/DOSE)28DOSE 2 $3,063.37 7 $8,821.82 FOSAMAX PLUS D TABLETS (2800) 4 $197.87 12 $570.26 FOSAMAX PLUS D TABLETS (5600) 4 $198.44 11 $548.91 FOSINOPRIL-HCTZ 10MG/12.5MG TABLETS 37 $48.17 101 $124.04 FOSINOPRIL-HCTZ 20MG/12.5MG TABLETS 39 $52.94 111 $145.21 FOSTEUM PLUS CAPSULES 41 $211.47 130 $657.75 FRAGMIN 12,500IU/0.5ML INJ, 0.5ML 14 $2,681.36 45 $8,781.70 FRAGMIN 15,000IU/0.6ML INJ, 0.6ML 16 $3,135.73 72 $13,922.80 FRESHKOTE DROPS 15 $40.42 23 $60.27 FROVATRIPTAN 2.5MG TABLETS 10 $641.43 31 $2,024.86 FUROSEMIDE 10MG/ML INJ, 4ML AMPULE 50 $88.45 70 $122.97 FUROSEMIDE 8MG/ML SOLUTION 125 $18.52 324 $41.83 GABAPENTIN 300MG CAPSULES 93 $31.98 243 $76.90 GABAPENTIN 400MG CAPSULES 103 $19.97 263 $44.89 GABAPENTIN 600MG TABLETS 94 $135.06 256 $361.87 GABAPENTIN 800MG TABLETS 91 $212.95 250 $577.91 GABITRIL 12MG TABLETS 66 $736.73 187 $2,084.25 GABITRIL 16MG TABLETS 64 $891.41 158 $2,216.39 GALANTAMINE ER 16MG CAPSULES 30 $111.79 89 $320.99 GALANTAMINE ER 24MG CAPSULES 30 $195.52 89 $576.51 GALANTAMINE ER 8MG CAPSULES 32 $118.68 94 $338.29 GALANTAMINE HBR 12MG TABLETS 57 $158.68 171 $466.08 GALANTAMINE HBR 4MG TABLETS 56 $154.55 163 $442.37 GALANTAMINE HBR 8MG TABLETS 52 $144.92 154 $421.46 GALZIN 25MG CAPSULES 69 $107.57 166 $253.29 GALZIN 50MG CAPSULES 77 $195.63 194 $488.43 GAMMAKED 10GM/100ML INJ, 100ML 460 $5,652.62 400 $4,915.84

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price GARDASIL 9 PREFILLED SYRINGE, 0.5ML 1 $207.03 1 $210.18 GARDASIL INJ, 0.5ML VIAL 1 $189.99 1 $189.99 GATIFLOXACIN 0.5% OPTH SOL 2.5ML 3 $107.58 6 $245.75 GAVILYTE-C SOLUTION 4000ML 4033 $16.10 4131 $16.39 GELNIQUE 10% PUMP GEL 30GM 33 $422.57 96 $1,220.78 GENORA 0.5/35 TABLETS 21'S 30 $26.12 88 $68.03 GENOTROPIN 0.2MG PREFILLED SYRINGES 23 $504.27 56 $1,235.44 GENOTROPIN 0.4MG PREFILLED SYRINGES 25 $1,222.41 74 $3,573.26 GENOTROPIN 0.6MG PREFILLED SYRINGES 28 $2,126.97 91 $6,919.09 GENOTROPIN 0.8MG PREFILLED SYRINGES 29 $3,079.44 86 $9,314.19 GENOTROPIN 1.4MG PREFILLED SYRINGES 28 $5,043.72 84 $15,123.16 GENOTROPIN 12MG(13.8MG OVERFILL)1'S 4 $6,123.01 11 $15,367.64 GENTAMICIN 0.1% CREAM 30GM 25 $61.32 102 $234.04 GENTAMICIN 0.1% OINTMENT 15GM 25 $64.90 113 $274.98 GENTAMICIN 40MG/ML INJ, 2ML 27 $49.40 62 $108.89 GENTAMICIN SULFATE 10MG/ML INJ, 2ML 41 $86.45 180 $363.78 GERITOL COMPLETE TABLETS 31 $128.08 89 $360.14 GG/DM NR 100-10/5ML LIQUID 190 $11.36 138 $9.37 GIANVI 3MG/0.02MG TABLETS 28'S 29 $66.24 84 $188.02 GILDESS 1.5/30 TABLETS 21 26 $25.09 81 $69.37 GILDESS 1/20 TABLETS 21S 25 $22.16 77 $58.96 GILENYA 0.5MG CAPSULES 30 $8,120.12 89 $24,190.94 GILPHEX TR 10-388MG TABLETS 20 $23.28 20 $23.20 GLATOPA 20MG/ML SOL FOR INJ 30X1ML 30 $5,829.55 90 $17,394.97 GLIPIZIDE-METFORMIN 2.5MG/250MG TAB 64 $53.20 170 $134.84 GLIPIZIDE-METFORMIN 2.5MG/500MG TAB 79 $47.21 229 $129.78 GLIPIZIDE-METFORMIN 5MG/500MG TABS 89 $45.61 256 $124.07 GLUCAGEN HYPOKIT INJ/EMERGENCY USE 1 $405.88 3 $887.75 GLUCAGON 1MG EMERGENCY KIT RDNA 1 $436.68 3 $804.57 GLYBURIDE/METFORMIN 5/500MG TABLETS 92 $19.28 272 $49.22 GLYCOPYRROLATE 1MG TABLETS 78 $72.20 204 $183.33 GLYCOPYRROLATE 2MG TABLETS 64 $79.54 173 $208.49 GLYXAMBI 10MG/5MG TABLETS 30 $579.79 89 $1,708.58 GLYXAMBI 25MG/5MG TABLETS 30 $579.68 89 $1,708.84 GOLYTELY PACKET 1 $22.40 1 $17.96 GONAL-F RFF 900IU INJ, 1.5ML 3 $3,187.64 5 $5,091.97 GRALISE 600MG (GABAPENTIN ER)TABLET 77 $609.11 220 $1,738.14 GRANISETRON 1MG TABLETS 28 $1,259.78 77 $3,438.21 GRISEOFULVIN 125MG/5ML ORAL SUSP 355 $160.57 424 $191.24 GRISEOFULVIN MICRO 500MGTABS 30 $152.27 108 $540.19 GRISEOFULVIN ULTR 125 TABLETS 56 $147.68 90 $236.88 GRISEOFULVIN UM 250MG TABLETS 44 $288.76 99 $644.02 GUAIFENESIN 100/5ML SOLUTION 168 $9.93 120 $8.22 GUAIFENESIN AC LIQUID 166 $27.05 318 $48.13 GUAIFENEX LA 600MG TABLETS 32 $12.01 138 $38.59 GUANFACINE ER 1MG TABLETS 33 $250.31 103 $769.70 GUANFACINE ER 2MG TABLETS 31 $275.33 94 $824.64 GUANFACINE ER 3MG TABLETS 30 $268.61 91 $802.74

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price GUANFACINE ER 4MG TABLETS 30 $266.51 90 $797.09 GYNEX 1/35 E TABS 28'S 30 $25.06 85 $64.88 HALOBETASOL 0.05% CREAM 15GM 45 $113.97 135 $335.65 HALOBETASOL 0.05% OINTMENT 50GM 46 $202.73 142 $616.31 HALOG 0.1% CREAM 216GM 64 $869.65 180 $2,421.98 HALOG 0.1% OINTMENT 15GM 54 $723.78 240 $3,227.97 HALOPERIDOL 10MG (TEN MG) TABLETS 50 $54.12 151 $156.12 HALOPERIDOL 20MG (TWENTYMG) TABLET 46 $123.61 126 $333.74 HALOPERIDOL 2MG/ML CONCENTRATE 35 $7.81 215 $27.25 HALOPERIDOL 5MG (FIVE MG) TABS 50 $27.86 151 $76.07 HALOPERIDOL DEC 50MG/ML INJ 3X1ML 1 $48.42 3 $102.23 HALOPERIDOL DECANOATE 100MG/ML INJ 2 $47.42 4 $121.17 HAVRIX 1440 U/ML VIAL (ADULT) 1 $109.07 1 $109.15 HAVRIX 720 U/0.5ML INJ (PEDIATRIC) 1 $60.96 1 $59.99 HC PRAMOXINE 1-1% CREAM 28.35GM 32 $74.26 130 $289.96 HC PRAMOXINE 2.5-1% CREAM 120GM 34 $91.88 105 $276.69 HEMATOGEN CAPSULES 35 $13.57 89 $28.53 HEMATOGEN FA CAPSULES 32 $15.54 90 $36.39 HEMENATAL OB + DHA 59 $49.49 173 $136.22 HEMOCYTE-F TABLETS 33 $15.74 90 $35.49 HEMORRHOIDAL HC 25MG RECT SUPP 12'S 20 $167.76 101 $826.46 HEPARIN LOCK 100/ML INJ, 1ML VIAL 138 $154.14 46 $53.50 HEPARIN SOD 10,000U/ML INJ, 1ML 39 $324.69 140 $1,143.62 HEPARIN SOD 1000/ML INJ, 2ML 84 $651.04 90 $698.78 HEPARIN SOD 20,000 UNITS/ML VIAL 25 $495.08 37 $730.13 HEPARIN SOD 5000/ML INJ, 10ML 42 $119.42 194 $532.51 HEPARIN SOD LOCK FLUSH 10U/ML, 5ML 163 $56.81 225 $76.90 HEP-LOCK 10UNT/ML INJ , 10ML 179 $80.63 325 $143.43 HOMATROPINE HBR 5% OPHTH SOL 5ML 5 $20.26 6 $24.32 HORIZANT 600MG TABLETS 45 $638.87 121 $1,728.91 HUMALOG 100/ML INJ, 3ML 21 $550.69 64 $1,659.18 HUMALOG CARTRIDGE 3ML 17 $667.51 41 $1,562.77 HUMALOG DISPENSER INSULIN PEN 3ML 19 $705.45 39 $1,481.45 HUMALOG MIX 50/50 INJ, 10ML 26 $812.63 80 $2,498.03 HUMALOG MIX 50/50 PEN INJ 5X3ML 25 $1,243.17 63 $3,168.70 HUMALOG MIX 75/25 DISP PEN 5X3ML 23 $1,140.98 58 $2,932.50 HUMALOG MIX 75/25 VIAL 10ML 22 $702.89 64 $1,996.50 HUMATROPE 12MG INJECTION 2 $3,523.81 4 $6,808.97 HUMATROPE 6MG CARTRIGE KIT INJ 2 $1,592.88 5 $4,014.61 HUMIRA 40MG/0.8ML PED CRO STRT-6SYR 2 $5,487.40 6 $15,351.85 HUMIRA PEN 40MG/0.8ML KIT(2 PENS) 2 $5,342.76 7 $14,772.02 HUMULIN 70/30 U-100 KWIKPEN INJ 3ML 22 $778.91 55 $1,956.50 HUMULIN N U-100 KWIKPEN INJ 3ML 17 $616.43 34 $1,202.65 HUMULIN R U-500 (CONCEN) VL 20ML 24 $1,950.83 49 $3,916.78 HYDRALAZINE 100MG (HUNDRED MG) TABS 82 $47.52 235 $128.66 HYDRALAZINE 50MG TABLETS (ORANGE) 85 $17.25 237 $40.90 HYDRISALIC 6% GEL 28.35GM 49 $236.91 207 $995.96 HYDROCOD/ACETAMINOPHEN 7.5-325/15ML 284 $93.05 2780 $875.40

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price HYDROCODONE/ACETAMINOPHEN 10-325 T 93 $67.58 261 $182.35 HYDROCODONE/ACETAMINOPHEN 5-300 TAB 31 $29.42 188 $159.45 HYDROCODONE/ACETAMINOPHEN 5-325 TB 36 $31.78 171 $134.66 HYDROCODONE/ACETAMINOPHEN 7.5-300 T 52 $90.60 223 $374.46 HYDROCODONE/ACETAMINOPHEN 7.5-325 T 61 $15.13 222 $44.72 HYDROCODONE/CHLORPHEN ER SUSPENSION 119 $72.60 409 $238.89 HYDROCODONE/HOMATROPINE 5/1.5MG TAB 49 $44.74 104 $91.02 HYDROCODONE/HOMATROPINE SYRUP 155 $28.07 344 $57.43 HYDROCODONE/IBUPROF 7.5-200MG TB 55 $64.94 170 $190.48 HYDROCODONE/IBUPROFEN 10-200MG TAB 92 $388.27 270 $1,127.17 HYDROCORT ACET/PRAMOX 2.5%-1% CREAM 37 $193.48 128 $660.96 HYDROCORT BUTYRATE 0.1% SOLN 60ML 60 $112.33 540 $975.73 HYDROCORTISONE /IODOQUINOL 1% CREAM 32 $53.61 85 $135.97 HYDROCORTISONE 0.5% CREAM 56GM 35 $5.81 42 $6.17 HYDROCORTISONE 1% LOTION 120 $7.70 236 $11.29 HYDROCORTISONE 100MG ENEMA 7 X 60ML 1210 $136.45 4721 $520.94 HYDROCORTISONE 10MG TABLETS 78 $38.38 206 $94.68 HYDROCORTISONE 2.5% LOTION 118ML 77 $57.81 306 $216.77 HYDROCORTISONE 2.5% RECTAL CREAM 34 $19.41 127 $60.81 HYDROCORTISONE 20MG TABLETS 52 $31.01 135 $73.96 HYDROCORTISONE 5MG TABLETS 102 $24.41 281 $60.23 HYDROCORTISONE BUT 0.1% CREAM 15GM 34 $109.75 77 $239.06 HYDROCORTISONE BUT 0.1% OINT 45GM 33 $105.45 135 $417.91 HYDROCORTISONE BUTYR 0.1% CRM 60GM 52 $645.48 83 $1,026.98 HYDROCORTISONE VAL 0.2% CREAM 15GM 39 $163.71 130 $540.04 HYDROCORTISONE VAL 0.2% ONT 45GM 38 $214.09 189 $1,037.07 HYDROMORPHONE 12MG ER TABLETS 38 $672.39 83 $1,455.99 HYDROMORPHONE 16MG ER TABLETS 39 $929.75 90 $2,122.59 HYDROMORPHONE 1MG/ML LIQUID 202 $76.32 1887 $678.05 HYDROMORPHONE 32MG ER TABLETS 38 $1,806.38 90 $4,228.59 HYDROMORPHONE 4MG TABLETS 92 $58.27 249 $151.20 HYDROMORPHONE 8MG ER TABLETS 35 $402.57 90 $1,020.99 HYDROMORPHONE 8MG TABLETS 111 $123.75 291 $318.21 HYDROMORPHONE HCL 2MG TABLETS 55 $23.97 169 $65.84 HYDROQUINONE 4% CREAM 28.35GM 30 $75.24 34 $84.45 HYDROXOCOBALAM 1000MCG/ML INJ, 30ML 32 $47.99 31 $46.63 HYDROXYCHLOROQUINE 200MGTABLETS 53 $151.07 153 $428.30 HYDROXYUREA 500MG CAPSULES 61 $43.32 133 $90.54 HYDROXYZINE 50MG/ML 2ML 31 $23.24 24 $18.88 HYDROXYZINE HCL 10MG TABLETS 56 $16.98 150 $38.88 HYDROXYZINE PAMOATE 100MG CAPSULES 57 $28.59 155 $71.10 HYDROXYZINE PAMOATE 50MG CAPSULES 62 $18.55 179 $45.66 HYFIBER WITH FOS LIQUID 946ML 945 $16.00 1072 $17.62 HYOSCYAMINE 0.125MG ORAL DIS TABS 54 $27.20 260 $116.38 HYOSCYAMINE 0.125MG SUBLINGUAL TABS 49 $29.17 278 $145.67 HYOSCYAMINE 0.375MG ER TABLETS 55 $58.86 165 $168.49 HYOSCYAMINE ORAL DROPS 0.125MG/ML 20 $28.05 45 $57.97 HYOSCYAMINE SULFATE 0.125MG TABLETS 55 $33.51 256 $140.27

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price HYOSYNE 0.125/5ML ELXIR 157 $15.28 1014 $77.01 HYSINGLA ER 40MG TABLETS 30 $562.52 90 $1,683.96 IBANDRONATE 3MG/3ML INJ, 3ML 3 $231.34 3 $231.34 IBANDRONATE SODIUM 150MG TABLETS 1 $145.16 3 $418.75 IBUPROFEN 200MG TABLETS 58 $5.44 226 $9.59 ILEVRO 0.3% OPHTH DROPS 2 $370.59 4 $683.24 IMATINIB MESYLATE 100MG TABLETS 74 $7,069.11 156 $15,020.66 IMATINIB MESYLATE 400MG TABLETS 30 $4,963.52 90 $14,755.66 IMIPRAMINE PAMOATE 100MG CAPSULES 40 $753.36 113 $2,101.39 IMIPRAMINE PAMOATE 125MG CAPSULES 36 $474.85 114 $1,514.42 IMIPRAMINE PAMOATE 150MG CAPSULES 34 $447.40 103 $1,367.97 IMIPRAMINE PAMOATE 75MG CAPSULES 34 $460.66 102 $1,364.93 IMIQUIMOD 5% CREAM 24'S 16 $293.58 26 $496.26 IMOVAX AMPULE 2.5IU/ML 1ML 1 $349.95 1 $332.99 INDOMETHACIN 75MG ER CAPSULES 37 $77.27 131 $261.15 INDPA-SYR/ND MJ .5ML 30'S 53 $17.60 154 $43.77 INFED 50MG/ML INJ 8 $146.87 7 $130.86 INNOPRAN XL 80MG CAPSULES 32 $720.81 97 $2,166.63 INSULIN SYRG U-100 0.3ML 30X 1/2 106 $35.73 230 $72.91 INSULIN SYRINGES 1ML 31G X 5/16 99 $33.69 189 $60.79 INSULIN SYRINGES 29G, 0.3ML 95 $24.75 128 $31.99 INTEGRA F CAPSULES 32 $22.52 90 $55.72 INTEGRA PLUS CAPSULES 31 $20.04 90 $49.98 INTELENCE 100MG TABLETS 115 $1,158.69 338 $3,378.90 INVANZ 1GM INJ, 1 VIAL 7 $731.93 90 $9,363.10 INVEGA SUSTENNA 117MG/0.75ML INJ 1 $1,689.70 2 $4,045.12 INVEGA SUSTENNA 234MG/1.5ML INJ 2 $2,527.97 4 $7,048.77 INVIRASE 500MG TABLETS 116 $1,256.07 348 $3,759.48 INVOKAMET 150MG/500MG TABLETS 56 $481.82 164 $1,398.30 INVOKAMET XR 150-1000MG TABLETS 52 $448.67 162 $1,387.57 INVOKANA 100MG TABLETS 31 $427.71 90 $1,248.24 INVOKANA 300MG TABLETS 30 $421.20 89 $1,231.73 IODOFLEX 0.9% GEL PADS 5'S 43 $140.83 240 $759.95 IPOL INACTIVATED IPV INJ, 0.5ML 1 $64.12 1 $62.99 IPRATROPI/ALB 0.5/3MG INH SL 30X3ML 248 $115.79 957 $434.54 IPRATROPIUM 0.03% NASAL SPRAY 30ML 30 $23.15 60 $41.96 IPRATROPIUM 0.06% NAS SP 15ML (165) 19 $36.69 62 $112.06 IRBESARTAN 150MG TABLETS 31 $80.61 93 $229.14 IRBESARTAN 300MG TABLETS 30 $90.17 90 $260.76 IRBESARTAN 75MG TABLETS 31 $76.36 92 $215.38 IRBESARTAN/HCTZ 150-12.5MG TABLETS 33 $98.53 96 $279.62 IRBESARTAN/HCTZ 300-12.5MG TABLETS 30 $99.21 89 $287.13 IRO-PLEX TABLETS 31 $18.98 61 $33.26 IROSPAN 24/6 TABLETS 30 $163.18 90 $476.38 ISENTRESS 400MG TABLETS 57 $1,365.81 178 $4,254.08 ISOLLYL CAPSULES 52 $48.81 184 $163.24 ISOMETH/CAFF/ACETAMINOPHEN TABS 35 $103.59 79 $229.38 ISONIAZID 300MG TABLETS 30 $24.96 88 $65.66

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ISONIAZID 50MG/5ML SYRUP 498 $189.13 1393 $522.47 ISOSORBIDE 40MG ORAL TABLETS 37 $75.37 126 $247.91 ISOSORBIDE DINITRATE 10MG ORAL TABS 76 $64.00 210 $169.84 ISOSORBIDE DINITRATE 20MG ORAL TAB 84 $71.57 227 $185.86 ISOSORBIDE DINITRATE 30MG ORAL TABS 53 $46.89 136 $113.87 ISOSORBIDE DINITRATE 5MG ORAL TABS 70 $49.67 187 $125.68 ISOSORBIDE MONONITRATE 10MG TABS 55 $16.74 147 $38.39 ISOSORBIDE MONONITRATE 120MG ER TAB 33 $20.05 98 $51.20 ISOSORBIDE MONONITRATE 20MG TABS 54 $16.71 155 $40.04 ISOXSUPRINE 10MG TABLETS 61 $36.70 265 $145.91 ISRADIPINE 2.5MG CAPSULES 59 $73.12 168 $200.49 ISRADIPINE 5MG CAPSULES 54 $95.20 164 $280.44 ISTALOL 0.5% OPHTH SOLUTION 2.5ML 4 $220.24 8 $470.15 ITRACONAZOLE 100MG CAPSULES 51 $415.97 175 $1,424.93 IVERMECTIN 3MG TABLETS 9 $53.15 35 $191.50 IXIARO 0.5ML INJECTION 1 $316.97 1 $313.99 JANTOVEN 1MG TABLETS (PINK) 49 $106.50 117 $250.15 JANTOVEN 2.5MG TABLETS (GREEN) 43 $102.16 105 $242.29 JANTOVEN 2MG TABLETS (PURPLE) 48 $109.61 122 $272.87 JANTOVEN 4MG TABLETS (BLUE) 34 $82.70 97 $227.39 JANTOVEN 5MG TABLETS (PEACH) 41 $102.64 102 $249.13 JANTOVEN 7.5MG TABLETS (YELLOW) 30 $98.57 84 $270.57 JANUMET 50/1000MG TABLETS 58 $465.56 171 $1,351.05 JANUMET 50/500MG TABLETS 56 $409.20 161 $1,178.43 JANUMET XR 100MG/1000MG TABLETS 31 $449.63 90 $1,312.87 JANUMET XR 50MG/1000MG TABLETS 55 $402.96 158 $1,154.91 JANUVIA 100MG TABLETS 30 $455.48 89 $1,339.93 JANUVIA 25MG TABLETS 30 $453.17 88 $1,308.82 JANUVIA 50MG TABLETS 31 $454.49 89 $1,308.45 JARDIANCE 10MG TABLETS 30 $478.80 88 $1,398.12 JARDIANCE 25MG TABLETS 30 $516.20 88 $1,509.35 JENTADUETO 2.5MG/850MG TABLETS 56 $425.31 166 $1,255.65 JENTADUETO XR 2.5MG-1000MG TABLETS 55 $421.48 165 $1,247.64 JOBST ULSR PTHS 15-20MM BLK MED 3 $152.82 1 $53.52 JUBLIA 10% TOPICAL NAIL SOL 8ML 6 $872.92 12 $1,768.25 KALETRA 100-25MG TABLETS 141 $630.46 405 $1,799.77 KAPIDEX 60MG DR CAPS (NOW DEXILANT) 31 $277.03 90 $802.78 KARIGEL-N 1.1% GEL 125ML 64 $10.83 213 $26.76 KETOCONAZOLE 2% CREAM 30GM 45 $117.14 155 $396.76 KETOCONAZOLE 2% SHAMPOO 120ML 128 $31.80 405 $91.80 KETOCONAZOLE 200MG TABLETS 18 $26.35 75 $98.40 KETONE (URINE) TEST STRIP100'S 72 $7.62 121 $10.07 KETOPROFEN 200MG E.R. CAPSULES 29 $172.25 90 $522.03 KETOPROFEN 50MG CAPSULES 43 $8.79 163 $22.09 KETOPROFEN 75MG CAPSULES 40 $10.72 175 $33.17 KETOROLAC 0.4% OPTH SOLN5ML 5 $56.99 7 $78.38 KETOROLAC 0.5% OPHTH SOLN 10ML 6 $22.02 9 $28.42 KETOROLAC 10MG TABLETS 17 $22.23 61 $67.58

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price KETOROLAC 15MG/ML INJ, 1ML 10 $39.09 11 $42.39 KETOROLAC 30MG/ML INJ, 1ML 7 $16.51 15 $30.29 KINRIX INJ, 0.5ML 1 $59.99 1 $59.99 KIONEX POWDER 414 $109.68 683 $178.58 K-LOR 20MEQ POWDER 23 $260.48 90 $999.88 KLOR-CON POWDER PKTS 20MEQ 30S 41 $59.53 124 $173.67 KLOR-CON/EF 25MEQ TABLETS 49 $30.21 151 $84.62 K-LYTE-ORANGE TABLETS 68 $19.61 156 $39.87 KOMBIGLYZE XR 5-1000MG TABLETS 31 $339.64 91 $986.38 KOMBIGLYZE XR 5-500MG TABLETS 31 $446.80 90 $1,280.49 K-PHOS 500MG TABLETS 79 $44.61 231 $122.41 K-PHOS-2 TABLETS 94 $96.30 210 $209.86 KRISTALOSE 10GM PACKETS 31 $209.70 143 $934.95 KRISTALOSE 20GM PACKETS 37 $303.55 137 $1,103.01 LABETALOL 100MG TABLETS 64 $33.64 182 $88.79 LABETALOL 200MG TABLETS 78 $50.80 216 $133.72 LABETALOL 300MG TABLETS 75 $45.02 209 $119.06 LABETALOL 5MG/ML INJ, 20ML 20 $5.67 20 $5.67 LACTATED RINGERS INJ, 1000ML 8762 $53.94 12324 $74.25 LACTIC ACID 10% E CREAM 113.4GM 113 $22.97 340 $60.92 LAMISIL ANTI-FUNGAL PUMP SPRAY 30ML 124 $369.30 188 $556.06 LAMIVUDINE 100MG TABLETS 28 $305.24 85 $915.07 LAMIVUDINE 150MG TABLETS 39 $214.05 117 $642.25 LAMOTRIGINE 100MG TABLETS 54 $130.79 169 $403.98 LAMOTRIGINE 150MG TABLETS 49 $114.24 152 $348.80 LAMOTRIGINE 200MG TABLETS 45 $117.53 138 $354.52 LAMOTRIGINE 25MG CHEW/DISPRSBL TAB 176 $18.01 530 $46.18 LAMOTRIGINE 25MG TABLETS 73 $148.86 233 $465.92 LAMOTRIGINE 300MG ER TABLETS 37 $574.90 112 $1,733.16 LAMOTRIGINE 5MG CHEW/DISPRSBL TAB 138 $17.77 345 $38.45 LAMOTRIGINE ER 100MG TABLETS 51 $528.15 160 $1,653.67 LAMOTRIGINE ER 200MG TABLETS 46 $506.85 136 $1,496.94 LAMOTRIGINE ER 250MG TABLETS 43 $794.65 127 $2,331.61 LAMOTRIGINE ER 25MG TABLETS 60 $349.88 170 $984.05 LAMOTRIGINE ER 50MG TABLETS 46 $442.09 146 $1,382.96 LAMOTRIGINE ODT 100MG TABLETS 64 $510.91 178 $1,412.10 LAMOTRIGINE ODT 200MG TABLETS 48 $474.78 139 $1,360.60 LAMOTRIGINE ODT 25MG TABLETS 106 $756.10 349 $2,471.51 LAMOTRIGINE ODT 50MG TABLETS 63 $478.60 173 $1,299.53 LANSO/AMOX/CLAR PACK CARD 112 $680.27 112 $679.99 LANSOPRAZOLE 15MG DR CAPSULES 35 $117.21 102 $329.70 LANSOPRAZOLE 30MG DR CAPSULES 35 $160.83 102 $461.27 LANTHANUM 1000MG CHEWABLE TABLETS 115 $672.26 332 $1,943.39 LANTHANUM 500MG CHEWABLE TABLETS 134 $785.76 344 $2,006.92 LANTUS SOLOSTAR PEN INJ 5 X 3ML 17 $457.41 33 $874.47 LANTUS U-100 INSULIN 10ML 16 $423.26 43 $1,123.77 LASTACAFT 0.25% OPHTH SOLN 3ML 3 $228.65 10 $721.79 LATANOPROST 0.005% OPHTH SOLN 2.5ML 3 $72.26 8 $164.55

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price LATUDA 120MG TABLETS 29 $1,779.99 88 $5,341.29 LATUDA 20MG TABLETS 30 $1,223.58 92 $3,748.03 LATUDA 40MG TABLETS 30 $1,035.99 90 $3,128.00 LATUDA 60MG TABLETS 30 $1,215.60 90 $3,688.06 LATUDA 80MG TABLETS 32 $1,178.58 97 $3,562.51 LEFLUNOMIDE 10MG TABLETS 32 $140.29 91 $393.98 LEFLUNOMIDE 20MG TABLETS 30 $158.11 88 $452.20 LETROZOLE 2.5MG TABLETS 23 $191.09 88 $706.27 LEUCOVORIN CALCIUM 10MG TABLETS 28 $177.00 27 $171.27 LEUCOVORIN CALCIUM 15MG TABLETS 33 $178.71 31 $170.42 LEUCOVORIN CALCIUM 25MG TABLETS 47 $509.32 82 $888.70 LEUCOVORIN CALCIUM 5MG TABLETS 24 $35.90 29 $42.35 LEUKERAN 2MG TABS 24 $586.84 54 $1,300.45 LEUPROLIDE 1MG/0.2 ML 2-WK INJ KIT 1 $619.26 3 $1,537.97 LEVALBUTEROL 0.31MG/3ML NEB 24X3ML 123 $213.17 818 $1,389.94 LEVALBUTEROL 0.63MG/3ML NEB 24X3ML 166 $365.62 762 $1,665.97 LEVALBUTEROL 1.25MG/3ML NEB 24X3ML 173 $337.27 808 $1,563.09 LEVALBUTEROL CONC 1.25MG/0.5ML 30VL 53 $339.94 204 $1,305.11 LEVALBUTEROL HFA INH (200PF) 15GM 18 $77.84 46 $195.94 LEVBID 0.375MG ER TABLETS 55 $58.79 167 $170.63 LEVEMIR FLEX TOUCH PEN INJ 3ML 19 $469.68 38 $918.47 LEVEMIR SOLUTION FOR INJ, 10ML 18 $433.34 44 $1,055.06 LEVETIRACETAM 1000MG TABLTS 71 $124.04 207 $355.71 LEVETIRACETAM 100MG/ML SOLUTION 334 $142.47 1016 $425.18 LEVETIRACETAM 250MG TABLETS 77 $75.88 207 $196.98 LEVETIRACETAM 500MG TABLETS 78 $122.45 225 $344.22 LEVETIRACETAM 750MG TABLETS 78 $121.76 227 $346.57 LEVETIRACETAM ER 500MG TABLETS 88 $313.92 244 $860.68 LEVETIRACETAM ER 750MG TABLETS 78 $455.40 219 $1,266.36 LEVITRA 10MG TABLETS 7 $325.86 23 $1,091.78 LEVITRA 2.5MG TABLETS 11 $636.01 30 $1,663.95 LEVITRA 20MG TABLETS 6 $295.86 27 $1,278.60 LEVITRA 5MG TABLETS 11 $535.22 63 $3,021.19 LEVO PYRIDOX PHOSPHA PWD CAPS 46 $94.23 143 $282.64 LEVOCARNITINE 10% ORAL SOLUTION 318 $74.08 947 $212.59 LEVOCARNITINE 330MG TABLETS 106 $73.52 297 $198.79 LEVOCETIRIZINE 2.5MG/5ML ORAL SOL 135 $68.56 444 $217.00 LEVOCETIRIZINE 5MG TABLETS 29 $65.52 90 $193.98 LEVOFLOXACIN 0.5% OPHTH SOLN 5ML 5 $76.06 5 $73.99 LEVOFLOXACIN 250MG TABLETS 8 $107.62 81 $1,012.54 LEVOFLOXACIN 500MG TABLETS 9 $114.62 74 $942.05 LEVOFLOXACIN 750MG TABLETS 7 $163.07 66 $1,419.83 LEVONOR/ETHINYL ESTRADIOL TABS 28S 28 $22.29 84 $57.86 LEVORA 0.15/30 TABLETS 28 29 $25.88 86 $68.18 LEVOTHYROXIN/LIOTHYRONINE 15MG TABS 44 $21.60 115 $49.86 LEVOTHYROXIN/LIOTHYRONINE 90MG TABS 33 $17.48 94 $42.35 LEVOXINE 0.175MG TABLETS 30 $39.66 86 $107.70 LEVOXINE 0.3MG TABLETS 30 $40.30 89 $110.63

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price LEVOXYL 0.05MG (50MCG) TABLETS 31 $44.82 90 $120.75 LEVOXYL 0.075MG (75MCG) TABLETS 30 $42.01 87 $115.80 LEVOXYL 0.088MG (88MCG) TABLETS 30 $41.40 87 $113.90 LIDAZONE HC RECTAL CREAM 38 $38.18 170 $155.00 LIDOCAINE 1% INJ, 2ML 31 $6.69 20 $5.79 LIDOCAINE 1% INJ, 5ML 28 $10.50 21 $8.98 LIDOCAINE 10MG/ML INJ, 5ML 13 $16.67 500 $503.00 LIDOCAINE 2% INJ, 10ML 36 $13.63 403 $110.72 LIDOCAINE 2% TOPICAL JELLY 30ML 36 $30.57 252 $189.19 LIDOCAINE 20MG/ML INJ 50ML VIAL 254 $17.21 215 $15.16 LIDOCAINE 20MG/ML INJECTION 5ML 146 $46.86 360 $109.84 LIDOCAINE 3% CREAM 85GM 46 $45.90 193 $180.88 LIDOCAINE 5% PATCH 34 $275.47 118 $955.98 LIDOCAINE 5% TOPICAL OINTMENT 50GM 51 $355.94 210 $1,464.36 LIDOCAINE/PRILOCAINE CREAM 30GM 35 $39.85 151 $159.85 LIMBREL 250MG CAPSULES 50 $108.99 180 $381.96 LIMBREL 500-50MG CAPSULES 57 $736.29 180 $2,311.55 LIMBREL 500MG CAPSULES 57 $694.79 165 $1,989.48 LINEZOLID 600MG TABLETS 20 $3,198.93 115 $18,334.56 LINZESS 145MCG CAPSULES 31 $403.73 89 $1,153.77 LINZESS 290MCG CAPSULES 30 $399.01 88 $1,142.10 LIOTHYRONINE 25MCG TABLETS 36 $33.85 96 $83.63 LIOTHYRONINE 50MCG** TABLETS 39 $65.65 109 $177.85 LIOTHYRONINE 5MCG TABLETS 52 $54.25 138 $137.02 LIPOCHOL PLUS TABLETS 28 $25.47 90 $73.29 LITE TOUCH PEN NDL 29GX12.7MM 116 $53.77 159 $72.27 LITHIUM CARBONATE ER 300MG TABLETS 78 $40.22 217 $105.20 LITHIUM CARBONATE ER 450MG TABLETS 55 $16.75 155 $40.04 LITHIUM CITRATE 8MEQ/5ML SOLUTION 343 $59.64 598 $100.90 LIVALO 1MG TABLETS 29 $281.20 86 $817.99 LIVALO 2MG TABLETS 30 $280.52 87 $814.65 LIVALO 4MG TABLETS 30 $284.14 87 $830.97 L-METHYLFOLATE 15MG TABLETS 30 $82.83 91 $241.90 L-METHYLFOLATE 7.5MG TABLETS 31 $56.98 88 $156.77 L-METHYLFOLATE CA/ME-CBL/NAC TABS 33 $46.83 92 $122.32 L-METHYLFOLATE FORTE 15MG CAPSULES 30 $117.18 90 $342.91 L-METHYLFOLATE W/B6-B12 TABLETS 45 $51.66 116 $127.55 LO LOESTRIN FE TABLETS 28S 28 $116.32 84 $336.24 LOCHOLEST LIGHT PWDR PKTS(BOX) 60'S 50 $78.72 141 $212.60 LOCOID 0.1% LOTION 59ML 100 $783.60 354 $2,775.93 LOESTRIN FE 1/20 TABLETS28S 29 $31.19 85 $83.58 LOPREEZA 1MG/0.5MG TABLETS 28'S 28 $111.60 83 $319.97 LORAZEPAM 0.5MG TABLETS 45 $16.62 141 $43.97 LORAZEPAM 1MG TABLETS 50 $25.15 145 $65.05 LORAZEPAM 2MG TABLETS 54 $38.79 145 $97.65 LORAZEPAM 2MG/ML DROPS 30ML 34 $50.69 67 $95.57 LORAZEPAM 2MG/ML DROPS 30ML 33 $49.30 50 $72.32 LOSARTAN 100MG TABLETS 30 $61.54 90 $175.05

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

LOSARTAN 25MG TABLETS 32 $38.87 93 $106.51 LOSARTAN 50MG TABLETS 33 $54.62 99 $155.79 LOSARTAN/HCTZ 100/12.5MG TABLETS 30 $18.06 90 $45.88 LOSARTAN/HCTZ 100/25MG TABLETS 30 $67.11 90 $192.47 LOSARTAN/HCTZ 50/12.5MG TABLETS 31 $56.82 92 $160.97 LOTEMAX 0.5% OPHTH OINTMENT 4 $243.58 12 $809.77 LOTEMAX 0.5% OPHTHALMIC SUSP 15ML 6 $233.90 8 $331.39 LOTEMAX 0.5% OPTH GEL DROPS 5GM 5 $178.52 7 $239.43 LOUTREX CREAM 30GM 37 $148.53 113 $442.72 LOW-OGESTREL TABLETS 28 29 $27.79 85 $74.01 LOXAPINE 10MG CAPSULES 61 $77.21 166 $203.34 LOXAPINE 25MG CAPSULES 53 $54.03 151 $147.12 LOXAPINE 50MG (FIFTY MG) CAPSULES 64 $82.86 167 $210.87 LOXAPINE 5MG CAPSULES 58 $59.92 143 $140.94 LUGOLS (STRONG IODINE) SOLUTION 100 $19.63 473 $78.17 LUMIGAN 0.01% OPHTH SOLN 2.5ML 3 $227.55 8 $491.62 LUPRON DEPOT 11.25MG INJ/3 MTH KIT 1 $3,456.99 1 $3,456.99 LUPRON DEPOT 22.5MG INJ KIT (3MTH) 1 $4,111.99 1 $4,111.99 LUPRON DEPOT 3.75MG KIT 1 $1,164.36 3 $2,901.48 LUPRON DEPOT 45MG INJ/6 MTH KIT 1 $8,316.99 1 $8,316.99 LUPRON DEPOT-PED 11.25MGINJ/1 MTH 1 $2,517.99 1 $2,517.99 LUZU 1% CREAM 60GM 61 $466.67 150 $1,143.97 LYRICA 100MG CAPSULES 73 $529.65 198 $1,430.77 LYRICA 150MG CAPSULES 68 $497.06 189 $1,366.08 LYRICA 200MG CAPSULES 70 $470.32 197 $1,305.53 LYRICA 225MG** CAPSULES 57 $433.02 166 $1,261.15 LYRICA 25MG CAPSULES 63 $480.77 167 $1,269.79 LYRICA 300MG CAPSULES 55 $424.06 162 $1,233.40 LYRICA 50MG CAPSULES 67 $489.34 179 $1,298.51 LYRICA 75MG CAPSULES 65 $503.51 179 $1,380.20 LYSODREN 500MG TABLETS 41 $230.52 32 $177.98 MACNATAL CN DHA CAPSULES 30 $30.86 94 $87.59 MAGNEBIND 400 TABLETS 48 $17.43 113 $35.47 MAGNESIUM CHLORIDE 20% INJ , 50ML 67 $31.99 50 $24.99 MAGNESIUM SULFATE 50% INJ, 20ML 54 $7.30 58 $7.53 MAG-OXIDE 400MG TABLETS 58 $7.80 154 $14.03 MAPROTILINE 25MG TABLETS 72 $98.00 139 $186.72 MAPROTILINE 50MG TABLETS 74 $148.05 192 $380.36 MAPROTILINE 75MG TABLETS 49 $105.65 118 $247.98 MARPLAN 10MG TABLETS 97 $464.68 242 $1,152.35 MATZIM LA 180MG TABLETS 32 $96.59 98 $283.63 MAXIDEX OPHTH SUSP 15ML 6 $90.85 10 $166.58 M-CLEAR WC LIQUID 195 $15.93 240 $18.71 MECLIZINE 12.5MG (RX) TABLETS 45 $17.41 175 $56.55 MECLIZINE 25MG (RX) TABLETS 42 $16.68 179 $57.74 MECLOFENAMATE 100MG CAPSULES 51 $356.65 199 $1,372.12 MEDROXYPROGESTERONE 150MG/ML PF SYR 1 $76.97 1 $76.53 MEDROXYPROGESTERONE 150MG/ML VIAL 1 $75.03 1 $73.22

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

MEFENAMIC ACID 250MG CAPSULES 30 $330.59 182 $1,985.85 MEFLOQUINE HCL 250MG TABLETS 5 $27.21 10 $53.27 MEGESTROL 625MG/5ML SUSPENSION 158 $421.93 475 $1,263.61 MEGESTROL ACETATE 40MG TABLETS 64 $42.34 163 $101.49 MEGESTROL ACETATE 40MG/ML SUSP 349 $105.63 788 $233.22 MEMANTINE 10MG TABLETS 56 $300.94 166 $875.63 MEMANTINE 2MG/ML SOLUTION 301 $552.87 728 $1,331.00 MEMANTINE 5MG TABLETS 54 $279.65 147 $755.63 MENEST 0.3MG TABLETS 28 $53.28 85 $153.99 MENEST 1.25MG TABLETS 29 $105.43 92 $326.56 MENOPUR 75 UNIT INJ, 1VIAL 10 $1,928.68 64 $12,031.46 MENOSTAR 14MCG PATCHES 4 $177.61 12 $484.78 MEPERIDINE 100MG TABLETS 62 $159.60 315 $791.41 MEPERIDINE 100MG/ML VIAL5X20 30 $25.86 30 $26.20 MEPERIDINE 50MG/ML INJ, 30ML 2 $12.64 7 $36.93 MEPHYTON 5MG TABLETS 27 $1,745.53 79 $5,086.25 MEPROBAMATE 200MG TABLETS 77 $129.26 154 $253.76 MEPROBAMATE 400MG TABLETS 64 $121.00 176 $325.01 MERCAPTOPURINE (6-MP) 50MG TABLETS 44 $109.77 124 $301.67 MESALAMINE 1.2GM TABLETS 92 $842.83 256 $2,323.58 MESALAMINE 4GM KIT 3 $477.34 10 $1,464.08 MESALAMINE 800MG DR TABLETS 135 $474.56 329 $1,153.50 MESALAMINE RECTAL SUSP 7X60ML 1469 $465.77 4686 $1,476.76 MESTINON SYRUP 331 $831.82 1053 $2,633.94 METAPROTERENOL 10MG TABLETS 115 $99.37 260 $219.77 METAPROTERENOL 20MG TABLETS 56 $74.62 216 $275.78 METAXALONE 400MG TABLETS 51 $270.06 211 $1,093.99 METAXALONE 800MG TABLETS 50 $197.18 201 $774.13 METFORMIN ER 1000MG MODIFIED TABS 46 $2,479.23 137 $7,404.64 METFORMIN ER 1000MG OSMOTIC TABS 49 $695.50 145 $2,052.94 METFORMIN ER 500MG MODIFIED TABS 59 $1,479.24 183 $4,576.47 METFORMIN ER 500MG OSMOTIC TABS 62 $478.14 183 $1,395.48 METFORMIN ER 750MG 24HR TABS 50 $15.71 145 $37.82 METHADONE 10MG TABLETS 124 $50.74 261 $102.67 METHADONE 10MG/5ML SOLN 442 $64.97 500 $73.00 METHADONE 10MG/ML CONCENTRATE SOLN 78 $64.47 120 $97.00 METHADONE 5MG TABLETS 74 $21.04 208 $51.82 METHADONE 5MG/5ML SOLN 232 $23.50 260 $25.86 METHADOSE 10MG/ML CONCENTRATE SOLN 56 $47.61 30 $27.25 METHAMPHETAMINE 5MG TABLETS 127 $648.55 388 $1,966.97 METHAZOLAMIDE 25MG TABLETS 65 $321.94 204 $1,005.99 METHAZOLAMIDE 50MG TABLETS 60 $582.26 186 $1,802.27 METHENAMINE HIPPURATE 1GM TABLETS 54 $98.76 146 $262.42 METHENAMINE MANDELATE 0.5GM TABS 63 $29.22 163 $68.99 METHENAMINE MANDELATE 1GM TABLETS 56 $84.94 159 $232.69 METHOTREXATE 100MG/4ML PF SINGLE U 5 $11.56 16 $30.40 METHOTREXATE 2.5MG TABLETS - YELLOW 27 $73.20 76 $199.05 METHOTREXATE 25MG/ML PF SINGLE USE 7 $15.54 18 $33.74

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price METHOTREXATE 25MG/ML PF SINGLE USE 13 $25.97 10 $20.75 METHOTREXATE 25MG/ML PF SINGLE USE 80 $136.00 40 $70.00 METHOTREXATE 25MG/ML PRESV MULT USE 10 $25.16 10 $25.54 METHOTREXATE 25MG/ML PRESV MULT USE 4 $19.72 10 $41.18 METHSCOPOLAMINE 2.5MG TABLETS 60 $140.84 188 $431.06 METHSCOPOLAMINE BR 5MG TABLETS 56 $157.99 168 $470.02 METHYCL/DESER 5MG/.25MG TABLETS 33 $73.09 86 $184.71 METHYLDOPA/HCT 250-25MG TABLETS 47 $116.17 145 $352.93 METHYLDOPA/HCTZ 250/15MG TABS 68 $114.05 158 $261.16 METHYLPHENIDATE 10MG ER TABLETS 37 $171.13 122 $558.23 METHYLPHENIDATE 10MG TABLETS 60 $56.04 170 $150.90 METHYLPHENIDATE 10MG/5ML ORAL SOLN 314 $292.75 659 $609.95 METHYLPHENIDATE 18MG ER TABLETS 31 $223.89 98 $710.58 METHYLPHENIDATE 20MG ER (LA) CAPS 33 $133.36 109 $426.40 METHYLPHENIDATE 20MG TABLETS 70 $98.82 194 $266.55 METHYLPHENIDATE 27MG ER TABLETS 30 $225.14 92 $682.70 METHYLPHENIDATE 27MG ER TABLETS 30 $222.96 90 $666.97 METHYLPHENIDATE 30MG ER (LA) CAPS 33 $169.68 99 $492.82 METHYLPHENIDATE 36MG ER TABLETS 37 $283.94 115 $868.24 METHYLPHENIDATE 36MG ER TABLETS 36 $278.84 90 $681.97 METHYLPHENIDATE 40MG ER (LA) CAPS 32 $131.89 96 $395.17 METHYLPHENIDATE 54MG ER TABLETS 30 $248.77 92 $744.73 METHYLPHENIDATE 54MG ER TABLETS 31 $250.95 99 $799.27 METHYLPHENIDATE 5MG TABLETS 52 $40.14 159 $115.02 METHYLPHENIDATE 5MG/5ML ORAL SOLN 324 $209.08 483 $309.05 METHYLPHENIDATE CD 10MG CAPSULES 32 $162.69 102 $512.11 METHYLPHENIDATE CD 20MG CAPSULES 31 $165.59 99 $509.96 METHYLPHENIDATE CD 30MG CAPSULES 31 $167.26 98 $520.59 METHYLPHENIDATE CD 40MG CAPSULES 30 $213.40 96 $662.64 METHYLPHENIDATE CD 50MG CAPSULES 30 $258.96 90 $764.19 METHYLPHENIDATE CD 60MG CAPSULES 30 $269.38 92 $806.47 METHYLPHENIDATE S.R. 20MG TABS 44 $158.11 138 $490.87 METHYLPRED ACE 40MG/ML INJ, 1ML 4 $42.61 6 $61.59 METHYLPRED ACE 80MG/ML INJ, 1ML 2 $43.18 5 $118.95 METHYLPREDNISOLONE 16MG TABLETS 10 $32.71 77 $217.59 METHYLPREDNISOLONE 32MG TABS 4 $22.19 32 $143.19 METHYLPREDNISOLONE 4MG DOSPAK 21'S 21 $29.05 32 $41.49 METHYLPREDNISOLONE 4MG TABLETS 33 $37.81 108 $116.04 METHYLPREDNISOLONE 8MG TABLETS 25 $41.98 113 $175.64 METOLAZONE 10MG TABLETS 29 $44.99 91 $134.77 METOLAZONE 2.5MG TABLETS 23 $27.50 63 $68.93 METOLAZONE 5MG TABLETS 25 $33.61 74 $92.96 METOPROLOL ER SUCCINATE 100MG TABS 34 $49.01 100 $137.08 METOPROLOL ER SUCCINATE 200MG TABS 32 $61.61 95 $174.25 METOPROLOL ER SUCCINATE 25MG TABS 33 $32.45 96 $86.87 METOPROLOL ER SUCCINATE 50MG TABS 34 $38.17 101 $105.20 METOPROLOL HCT 100/25MG TABLETS 31 $69.16 93 $199.02 METOPROLOL HCT 100/50MG TABLETS 31 $58.59 89 $161.35

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price METOPROLOL HCT 50/25MG TABLETS 32 $47.55 93 $129.73 METRONIDAZOLE 0.75% TOPICAL CRM 45G 46 $138.12 113 $336.40 METRONIDAZOLE 0.75% TOPICAL GEL 45G 46 $69.13 119 $173.16 METRONIDAZOLE 0.75% TOPICAL LOTION 61 $149.20 168 $406.24 METRONIDAZOLE 0.75% VAGINAL GEL 70G 71 $96.68 149 $197.93 METRONIDAZOLE 1% TOPICAL GEL PUMP 60 $245.88 144 $586.34 MEXILETINE 150MG CAPSULES 81 $55.65 234 $152.76 MEXILETINE 200MG CAPSULES 78 $188.73 230 $549.10 MEXILETINE 250MG CAPSULES 79 $208.57 219 $571.91 MICONAZOLE 3 DS VAG SUPP 3'S 3 $59.37 6 $105.98 MICOTREX 2% VAG CREAM 45GM OTC 45 $10.05 45 $9.99 MICROGESTIN 1.5/30 FE TAB 28 29 $19.40 84 $49.22 MICROGESTIN 1/20 FE TABS 28S 29 $21.33 85 $55.43 MICRO-K 10MEQ EXTENCAPS 55 $36.92 141 $88.33 MIDAZOLAM 5MG/ML INJ , 5ML 2 $4.87 2 $5.23 MIDODRINE 10MG TABLETS 74 $272.61 206 $753.05 MIDODRINE 2.5MG TABLETS 81 $67.55 221 $176.18 MIDODRINE 5MG TABLETS 84 $134.36 222 $350.85 MIGRAZONE CAPSULES 35 $143.31 124 $505.17 MINIMED SOF-SET 24" MIS 23 $676.10 36 $1,049.67 MINITRAN 0.1MG/HR PATCHES 30'S 31 $26.55 88 $68.42 MINITRAN 0.4MG/HR PATCHES 30'S 31 $34.29 91 $91.53 MINOCYCLINE 100MG CAPSULES 44 $24.36 124 $61.75 MINOCYCLINE 100MG TABLETS 40 $219.11 115 $625.11 MINOCYCLINE 50MG CAPSULES 47 $15.07 120 $31.87 MINOCYCLINE 50MG TABLETS 44 $206.89 115 $533.49 MINOCYCLINE 75MG CAPSULES 46 $81.02 113 $194.51 MINOCYCLINE 75MG TABLETS 42 $368.45 113 $987.76 MINOCYCLINE ER 135MG TABLETS 30 $671.99 90 $2,007.97 MINOCYCLINE ER 45MG TABLETS 33 $731.19 89 $1,980.13 MINOCYCLINE ER 90MG TABLETS 29 $613.84 93 $1,946.30 MINOXIDIL 10MG TABLETS 50 $29.04 140 $74.01 MINOXIDIL 2.5MG TABLETS 70 $25.09 199 $63.59 MIRENA IUD SYSTEM 1 $891.99 1 $891.99 MIRTAZAPINE 15MG ORAL DSNTGRT TABS 30 $60.20 90 $171.89 MIRTAZAPINE 30MG ORAL DSNTGRT TABS 31 $31.06 94 $85.10 MIRTAZAPINE 30MG TABLETS 31 $18.66 93 $47.46 MIRTAZAPINE 45MG ORAL DSNTGRT TABS 29 $61.81 89 $179.01 MIRTAZAPINE 45MG TABLETS 30 $37.90 90 $105.66 MIRTAZAPINE 7.5MG TABLETS 31 $82.19 92 $236.77 MIRVASO 0.33% GEL 30GM 31 $491.45 85 $1,359.30 MISOPROSTOL 100MCG TABLETS 30 $21.19 191 $112.36 MISOPROSTOL 200MCG TABLETS 10 $15.00 188 $217.40 M-M-R II LIVE VACCINE W/DILUENT INJ 1 $89.99 1 $89.99 MODAFINIL 100MG TABLETS 39 $759.52 118 $2,276.36 MODAFINIL 200MG TABLETS 39 $1,084.14 117 $3,231.52 MOEXIPRIL 15MG TABLETS 37 $23.56 107 $61.00 MOEXIPRIL 7.5MG TABLETS 35 $17.98 98 $43.28

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

MOEXIPRIL/HCTZ 15-12.5MG TABLETS 33 $29.05 99 $79.92 MOEXIPRIL/HCTZ 15-25MG TABLETS 31 $27.98 90 $72.86 MOEXIPRIL/HCTZ 7.5-12.5MG TABLETS 38 $24.96 97 $57.45 MOMETASONE 0.1% CREAM 15GM 37 $38.71 126 $121.44 MOMETASONE 0.1% OINTMENT 15GM 40 $35.84 123 $102.05 MOMETASONE 0.1% TOP SOLN/LOT 60ML 52 $28.49 89 $45.35 MOMETASONE 50MCG NASAL SPRAY (120) 17 $197.44 50 $564.44 MONOJECT 1ML TB SYRNG 28G X 1/2 42 $15.01 67 $21.36 MONOJECT SYR/NDL, 28G, 0.5ML, 100'S 75 $12.03 158 $21.02 MONOJECT SYR/NDL, 28G, 1ML 67 $11.21 111 $15.93 MONOJECT SYR/NDL, 29G, 0.5ML, 100'S 100 $22.06 188 $37.77 MONOJECT SYR/NDL, 30G, 1ML 93 $54.45 187 $104.79 MONOJECT SYRINGE 60ML CATHETER TIP 34 $67.71 90 $174.98 MONOJECT TUBERCULIN SYR 1ML 26GX3/8 18 $7.59 23 $8.62 MONTELUKAST 10MG TABLETS 30 $86.94 90 $253.09 MONTELUKAST 4MG CHEW TABS 30 $66.87 90 $192.27 MONTELUKAST 4MG ORAL GRANULES 30 $154.06 89 $453.34 MONTELUKAST 5MG CHEW TABS 30 $60.54 92 $174.95 MONUROL 3GM SINGLE DOSE PACKET 2 $162.17 10 $804.98 MORPHINE SUL 20MG/5ML(4MG/ML) SOL 226 $25.91 1048 $105.50 MORPHINE SUL 100MG/5ML(20MG/ML) SOL 39 $22.12 103 $52.27 MORPHINE SUL 10MG ER CAPS (24H) 48 $105.89 144 $311.18 MORPHINE SUL 15MG ER TABS (12H) 59 $53.22 171 $146.74 MORPHINE SUL 15MG IMM REL TAB 76 $24.19 192 $55.08 MORPHINE SUL 20MG ER CAPS(24H) 55 $265.14 110 $524.29 MORPHINE SUL 30MG ER CAPS (24H) 43 $215.33 120 $599.19 MORPHINE SUL 30MG IMM REL TAB 101 $41.08 299 $113.46 MORPHINE SUL 60MG ER CAPS (24H) 38 $424.65 203 $2,223.38 MORPHINE SUL 60MG ER CAPS(24H) 50 $581.42 160 $1,869.58 MORPHINE SUL 80MG ER CAPS (24H) 54 $542.67 158 $1,574.26 MORPHINE SULF 100MG ER CAPS (24H) 59 $717.53 180 $2,187.38 MORPHINE SULF 100MG ER TABS (12H) 72 $334.59 201 $923.71 MORPHINE SULF 120MG ER CAPS (24H) 43 $771.64 90 $1,599.69 MORPHINE SULF 200MG ER TABS (12H) 77 $481.45 189 $1,175.27 MORPHINE SULF 60MG ER TABS (12H) 68 $199.03 211 $610.93 MORPHINE SULF ER 30MG CAPS (24H) 52 $278.65 193 $1,032.51 MORPHINE SULF ER 50MG CAPS (24H) 54 $775.32 105 $1,493.24 MORPHINE SULFATE 30MG ER TABS (12H) 65 $133.19 184 $369.01 MOVIPREP SOLUTION 1 $104.50 1 $103.99 MOXIFLOXACIN 0.5% OPHTH SOLN 3ML 3 $160.50 7 $368.20 MOXIFLOXACIN 400MG TABLETS 9 $123.30 78 $989.90 MPB - ACCU-CHEK MULTICLIX L/DEVICE 2 $29.24 3 $54.67 MS/L MORPHINE SO4 10MG/5ML (2MG/ML) 247 $19.26 321 $23.90 MULTAQ 400MG TABLETS 58 $576.02 171 $1,707.12 MULTIGEN TABLETS 35 $20.12 96 $47.68 MULTI-VIT/FE FL 0.25MG DROPS 50ML 50 $31.77 100 $59.33 MULTIVITAMIN W/FL .5MG/MLORAL DROP 51 $12.11 85 $17.60 MUPIROCIN 2% CREAM 30GM 23 $234.35 120 $1,203.92

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

MUPIROCIN 2% OINTMENT 22GM 24 $49.31 118 $230.01 MUSE 1000MCG TRANSURETHRAL SYSTEM 6 $500.59 19 $1,461.89 MUSE 500MCG TRANSURETHRAL SYSTEM 5 $397.01 14 $1,023.13 MYCOPHENOLATE 200MG/ML SUSP 160ML 196 $1,016.58 255 $1,318.07 MYCOPHENOLATE 250MG CAPSULES 140 $224.06 371 $585.12 MYCOPHENOLATE 500MG TABLETS 102 $299.34 294 $851.35 MYCOPHENOLIC 180MG DR TABLETS 132 $490.86 361 $1,333.55 MYCOPHENOLIC ACID 360MG DR TABLETS 88 $572.55 258 $1,677.22 MYRBETRIQ 25MG TABLETS 30'S 30 $397.84 89 $1,155.30 MYRBETRIQ 50MG TABLETS 30'S 30 $393.44 88 $1,144.66 NABUMETONE 500MG TABLETS 53 $16.37 183 $46.77 NABUMETONE 750MG TABLETS 50 $61.71 168 $197.35 NADOLOL 20MG TABLETS 35 $76.14 99 $207.69 NADOLOL 40MG TABLETS 36 $78.45 104 $219.65 NADOLOL 80MG TABLETS 38 $111.54 111 $321.08 NADOLOL/BEND 40-5MG TABLETS 29 $126.03 86 $360.09 NAFTIFINE 2% CREAM 45GM 55 $436.22 228 $1,807.69 NAFTIFINE HCL 1% CREAM 90GM 67 $255.18 113 $423.99 NAFTIN 1% GEL 40GM 59 $591.43 90 $894.98 NALBUPHINE 10MG/ML INJECTION 10X1ML 32 $102.73 152 $475.05 NALBUPHINE 20MG/ML INJ, 1ML 41 $182.99 366 $1,614.03 NALTREXONE 50MG TABLETS 30 $84.83 90 $247.53 NAMENDA XR 28MG CAPSULES 30 $431.68 87 $1,246.25 NAPROXEN 125MG/5ML SUSPENSION 296 $346.75 1840 $2,130.73 NAPROXEN DR/EC 500MG TABLETS 42 $13.85 167 $42.93 NAPROXEN SOD 500MG CR TABLETS 40 $398.08 150 $1,495.39 NAPROXEN SODIUM 275MG TABLETS 35 $7.86 183 $24.32 NAPROXEN SODIUM 550MG TABLETS 34 $79.79 169 $376.23 NARATRIPTAN 1MG TABLETS 9 $301.69 42 $1,380.62 NARATRIPTAN 2.5MG TABLETS 9 $186.94 31 $603.59 NASAL ALLERGY 24 HOUR SPRAY 16.9ML 17 $88.64 46 $230.36 NATACYN 5% OPHTH SUSP 15ML 15 $346.90 15 $345.72 NATALVIRT FLT TABLETS 31 $71.98 90 $201.04 NATATAB RX TABLETS 30 $19.47 90 $50.21 NATAZIA TABLETS 28 28 $189.64 82 $537.50 NATEGLINIDE 120MG TABLETS 83 $133.39 241 $379.57 NATEGLINIDE 60MG TABLETS 86 $129.06 232 $342.16 NATURE-THROID 2.5GR (162.5MG) TB 23 $14.77 71 $36.48 NATURE-THROID 1/4 GR (16.25MG) TABS 34 $10.09 92 $20.58 NATURE-THROID 113.75MG TABLETS 26 $12.98 87 $33.72 NATURE-THROID 2GR (130MG) TABLETS 33 $16.20 101 $41.50 NATURE-THROID 3GR (195MG) TABLETS 25 $13.44 77 $33.20 NATURE-THROID 97.5MG TABLETS 33 $14.29 98 $34.46 NEBULIZER MASK ADULT 1 $7.88 1 $7.59 NEBULIZER POCKET 1 $60.47 1 $60.94 NEBUPENT 300MG INHALATION SOLN 1 $197.96 3 $554.95 NECON 1/35 TABLETS 28 (GREEN) 29 $28.06 86 $74.66 NECON 1/50 TABLETS 28'S (PINK) 29 $24.00 85 $61.32

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

NEFAZODONE 50MG TABLETS 55 $52.57 168 $152.79 NEFAZODONE 100MG TABLETS 66 $67.54 191 $188.82 NEFAZODONE 150MG TABLETS 63 $68.07 183 $190.02 NEFAZODONE 200MG TABLETS 62 $68.52 171 $180.45 NEFAZODONE 250MG TABLETS 51 $57.56 150 $161.48 NELOVA 0.5/35 E TABS 28'S 29 $34.77 86 $94.52 NEO/POLY/BAC OPHTH OINT 3.5GM 4 $31.05 11 $80.89 NEO/POLY/BAC/HC OPHTH OINT 3.5GM 4 $32.99 4 $31.76 NEO/POLY/DEX OPHTH SUSP 5ML 5 $19.61 7 $25.97 NEO/POLY/DEXAMETH OPHTH OINT 3.5GM 4 $20.39 13 $63.96 NEOMYCIN 500MG TABLETS 12 $17.09 188 $213.80 NEOMYCIN/POLY/HC OTIC SOL(EAR) 10 $50.40 11 $54.86 NEOMYCIN/POLY/HC OTIC SUSP (EAR) 10 $40.33 11 $43.05 NEOMYCIN/POLYMY IRRIGATION ONLY SOL 14 $110.26 240 $1,791.88 NEOSALUS CREAM 180GM 209 $448.09 455 $969.97 NEPHRON FA TABLETS 31 $19.97 95 $53.82 NEPHRO-VITE RX TABLETS 30 $8.38 89 $17.07 NESTABS TABLETS 30 $69.77 90 $201.51 NEUPOGEN 300MCG/0.5ML, PRFL SRYGE 4 $2,755.40 21 $15,753.58 NEURIN-SL TABLETS 29 $15.92 77 $35.51 NEVANAC 0.1% OPHT SUSP 3ML 3 $296.43 9 $834.87 NEVIRAPINE 200MG TABLETS 59 $520.68 177 $1,557.12 NEVIRAPINE 400MG ER TABLETS 30 $632.89 90 $1,887.59 NEXIUM 10MG DR PWDR PKT FOR SUSP-30 32 $376.31 103 $1,192.54 NEXIUM 20MG DR PWDR PKT FOR SUSP-30 33 $345.34 106 $1,102.50 NEXIUM 40MG DR PWDR PKT FOR SUSP-30 34 $353.55 103 $1,061.18 NIACIN 1000MG ER TABLETS 40 $226.62 113 $631.47 NIACIN 500MG ER TABLETS 43 $129.03 120 $354.20 NIACIN 750MG ER TABLETS 46 $230.34 137 $679.77 NICARDIPINE 20MG CAPSULES 87 $125.72 238 $336.88 NICARDIPINE 30MG CAPSULES 70 $156.47 194 $427.25 NICOTINE 14MG/24H PATCH 14S 24 $58.01 80 $186.86 NICOTINE 7MG/24H PATCH 22 $43.95 78 $148.75 NICOTINE TD 21MG/24H PATCH CLR 14'S 25 $61.29 76 $178.76 NICOTROL INHALER 10MG/CARTRIDGE 178 $446.95 394 $987.25 NICOTROL NS 10MG/ML NASAL SPRAY 52 $580.86 78 $856.91 NIFEDICAL XL (OSM) 30MG TABLETS 34 $40.42 100 $110.87 NIFEDIPINE 10MG CAPSULES 62 $46.70 171 $122.04 NIFEDIPINE 20MG CAPSULES 59 $118.65 169 $330.96 NIFEDIPINE 60MG ER (CC) TABLETS 37 $58.82 105 $161.16 NIFEDIPINE 60MG ER (XL/OSM) TABLET 36 $76.26 104 $215.01 NIFEDIPINE 90MG ER (CC) TABLETS 32 $83.93 93 $240.19 NIFEDIPINE 90MG ER (XL/OSM) TABLET 31 $74.90 93 $213.68 NIMODIPINE 30MG CAPSULES 101 $1,746.14 171 $2,955.15 NISOLDIPINE ER 17MG TABLETS 32 $158.19 97 $472.13 NISOLDIPINE ER 20MG TABLETS 27 $201.90 97 $704.51 NISOLDIPINE ER 25.5MG TABLETS 29 $114.49 96 $367.99 NISOLDIPINE ER 30MG TABLETS 31 $295.92 99 $941.86

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price NISOLDIPINE ER 34MG TABLETS 30 $117.62 91 $346.96 NISOLDIPINE ER 40MG TABLETS 29 $237.12 88 $717.82 NISOLDIPINE ER 8.5MG TABLETS 34 $129.38 103 $387.39 NITREK 0.2MG/HR PATCHES 30 $36.41 88 $97.34 NITREK 0.6MG/HR PATCHES 31 $37.67 91 $103.63 NITRODISC 0.3MG/HR PATCH 30'S 30 $189.82 83 $508.76 NITROFURANT MAC 25MG CAPSULES 30 $170.79 94 $525.10 NITROFURANTOIN 25MG/5ML ORAL SUSP 240 $520.76 520 $1,125.07 NITROFURANTOIN MACRO 100MG CAPSULES 20 $49.09 89 $200.70 NITROFURANTOIN MACRO 50MG CAPSULES 30 $34.85 88 $95.13 NITROFURANTOIN MONO/MAC 100MG CAPS 15 $39.55 89 $220.62 NITROGLYCERIN 0.3MG SL TABS 100 101 $18.14 117 $20.42 NITROGLYCERIN 0.4MG SUB TAB 25 38 $19.07 111 $48.58 NITROGLYCERIN 0.6MG SUB TABS 100 103 $18.03 132 $22.08 NITROGLYCERIN 2.5MG S.R.CAPSULES 62 $26.34 176 $67.32 NITROGLYCERIN 400MCG AERO 200 DOSES 6 $102.48 12 $212.24 NITROGLYCERIN 400MCG SPRAY 200 DOSE 8 $315.59 18 $725.46 NITROGLYCERIN 400MCG SPRAY 60 DOSES 6 $225.39 72 $2,883.86 NITROGLYCERIN 6.5MG ER CAPSULES 58 $35.13 182 $101.11 NITROGLYN 9MG SR CAP 73 $39.11 170 $85.21 NITROL 2% OINTMENT 30GM 41 $52.06 144 $174.54 NIZATIDINE 15MG/ML SOLUTION 133 $82.42 588 $351.84 NORDITROPIN NORDFLEX 15MG/1.5ML PEN 5 $6,584.53 5 $6,613.87 NORETH/ETHIN 1MG-5MCG TABLETS 28'S 29 $63.50 84 $178.23 NORETH/ETHIN EST 0.5-2.5MCG TABLETS 29 $92.12 83 $260.35 NORETHINDRONE 5MG TABLETS 35 $68.59 94 $179.34 NORETHINDRONE/ETH 24 FE TABS 28'S 28 $66.99 84 $189.71 NORETHINDRONE-ETH EST FE CHEW TABS 29 $81.39 83 $229.96 NORITATE 1% CREAM 60GM 60 $1,862.87 140 $4,311.31 NORLYDA 0.35MG TABLETS 28S 28 $28.26 84 $76.16 NORMOSOL -R INJ SOLUTION 1000ML 7250 $40.25 12000 $64.00 NORPACE CR 100MG CAPSULES 89 $438.59 245 $1,194.68 NORTRIPTYLINE 10MG/5ML SOLN 287 $97.80 697 $231.86 NORTRIPTYLINE 50MG CAPSULES 43 $14.01 123 $32.67 NORVIR 100MG TABLETS 37 $352.04 115 $1,091.64 NOVAGESIC TABLETS 26 $6.37 20 $5.79 NOVOFINE 31G 6MM DISP PEN NEEDLES 111 $36.64 153 $48.81 NOVOLIN 70/30 PREFILLED,1.5ML, 5'S 23 $359.61 62 $976.35 NOVOLIN INSULIN NPH U-100 HUMAN 16 $259.71 45 $708.33 NOVOLIN R PENFILL 7.5ML 16 $249.88 41 $643.05 NOVOLOG MIX 70/30 FLXPEN 3ML (BLUE) 24 $909.65 61 $2,305.97 NOVOLOG MIX 70/30 SUS VL10ML(BLUE) 23 $660.43 67 $1,901.85 NOVOLOG PENFILL 3ML CARTRIDGE(ORNG) 18 $828.48 40 $1,866.81 NOVOLOG U-100 INSULIN VL10ML(ORANG) 24 $666.31 68 $1,916.12 NOVOPEN 3 INSULIN DELIVERY SYSTEM 1 $39.84 2 $58.84 NOXAFIL 40MG/ML SUSPENSION 346 $4,722.72 862 $11,745.67 NUCYNTA 100MG TABLETS 95 $858.18 214 $1,936.28 NUCYNTA 50MG TABLETS 72 $423.93 213 $1,239.56

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price NUCYNTA 75MG TABLETS 84 $570.66 206 $1,401.47 NUEDEXTA 20-10MG CAPSULES 54 $821.29 161 $2,432.06 NUTRADERM ADVANCED FORMULA 473ML 382 $495.47 1050 $1,355.84 NUVARING 1 $154.17 3 $443.39 NYSTATIN 500,000 UNITS ORAL TABLETS 90 $95.39 260 $266.14 NYSTATIN CREAM 15GM 32 $21.27 162 $90.51 NYSTATIN ORAL SUSP 100000UNIT/ML 186 $43.50 833 $181.05 NYSTATIN/TRIAMCINOLONE CREAM 30GM 33 $117.64 141 $481.92 NYSTATIN/TRIAMCINOLONE OINT 15GM 30 $111.72 125 $454.86 OB COMPLETE ONE CAPSULE 30 $161.21 89 $467.44 OB COMPLETE PREMIER TABLETS 30 $112.15 90 $333.94 OB-NATAL ONE CAPSULES 30 $18.17 93 $47.59 OBSTETRIX EC TABLETS 28 $29.52 89 $85.83 OBTREX DHA PAK 60 $45.99 152 $110.37 O-CAL PRENATAL TABLETS 30 $10.29 90 $22.94 OCTREOTIDE 0.2MG/ML INJ,5ML 46 $988.16 114 $2,424.33 OCTREOTIDE 100MCG INJ, 1ML 59 $1,123.14 146 $2,781.29 OCTREOTIDE 1MG/ML INJ, 5ML 16 $430.83 20 $522.40 OCTREOTIDE 50MCG/ML INJ,1ML 63 $504.92 192 $1,534.39 OFLOXACIN 0.3% OPH SOLN 5ML (EYE) 6 $37.77 8 $51.45 OFLOXACIN 0.3% OTIC SOLN10ML (EAR) 7 $213.11 11 $324.37 OFLOXACIN 400MG TABLETS 14 $79.82 3 $21.72 OGESTREL TABLETS 28 29 $47.01 85 $128.46 OLANZAPINE 10MG TABLETS 32 $211.96 94 $617.65 OLANZAPINE 15MG TABLETS 34 $671.49 99 $1,973.55 OLANZAPINE 2.5MG TABLETS 33 $127.08 97 $361.98 OLANZAPINE 20MG TABLETS 31 $772.29 95 $2,336.55 OLANZAPINE 5MG TABLETS 33 $303.78 95 $873.21 OLANZAPINE 7.5MG TABLETS 31 $371.15 90 $1,087.69 OLANZAPINE ODT 10MG TABLETS 33 $554.04 98 $1,626.20 OLANZAPINE ODT 15MG TABLETS 34 $478.78 103 $1,439.76 OLANZAPINE ODT 20MG TABLETS 32 $864.79 92 $2,433.57 OLANZAPINE ODT 5MG TABLETS 34 $430.49 94 $1,181.73 OLANZAPINE/FLUOXETINE 12-25MG CAPS 30 $525.94 98 $1,719.97 OLANZAPINE/FLUOXETINE 12-50MG CAPS 30 $603.02 88 $1,786.45 OLANZAPINE/FLUOXETINE 3-25MG CAPS 30 $145.66 88 $421.17 OLANZAPINE/FLUOXETINE 6-25MG CAPS 32 $426.63 95 $1,275.36 OLANZAPINE/FLUOXETINE 6-50MG CAPS 30 $403.79 88 $1,178.07 OLMESARTAN MEDOX/HCTZ 20-12.5MG TAB 30 $124.41 89 $361.43 OLMESARTAN MEDOX/HCTZ 40-12.5MG TAB 30 $164.70 89 $481.36 OLMESARTAN MEDOX/HCTZ 40-25MG TAB 30 $170.83 89 $501.75 OLMESARTAN MEDOXOMIL 20MG TABLETS 30 $132.41 89 $382.47 OLMESARTAN MEDOXOMIL 40MG TABLETS 30 $171.19 89 $501.63 OLMESARTAN MEDOXOMIL 5MG TABLETS 41 $135.89 115 $374.60 OLMESARTAN/AMLO/HCTZ 40-10-12.5MG T 30 $137.16 89 $400.63 OLMESARTAN/AMLOD/HCTZ 20-5-12.5MG T 30 $109.11 91 $323.64 OLMESARTAN/AMLOD/HCTZ 40-10-25MG T 30 $136.57 88 $399.12 OLOPATADINE 0.1% OPTH SOLN 5ML 5 $187.34 14 $495.17

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price OLOPATADINE 0.6% NASAL SPR (240 SP) 31 $252.00 71 $582.10 OMEGA-3-ACID 1GM CAPSULES (RX) 102 $178.94 288 $498.65 OMEPRAZOL 20MG/SOD BICARB1100MG CP 36 $542.10 98 $1,456.17 OMEPRAZOL 40MG/SOD BICARB 1100MG CP 36 $2,580.41 104 $7,375.05 OMEPRAZOLE 10MG CAPSULES 34 $68.09 100 $190.78 OMEPRAZOLE 20MG CAPSULES 36 $20.75 105 $52.99 OMEPRAZOLE 40MG CAPSULES 33 $88.71 98 $251.56 OMNARIS 50MCG NASAL SPR (120 SPR) 13 $266.16 37 $771.87 OMNITROPE 10MG/1.5ML INJ, 1.5ML 5 $4,652.89 17 $14,522.79 OMNITROPE 5.8MG INJ, 1 VIAL 3 $945.37 7 $2,402.13 OMNITROPE 5MG/1.5ML INJ, 1.5ML 5 $2,158.44 12 $5,220.17 ONDANSETRON 40/20ML INJ, 20ML 69 $729.14 60 $636.97 ONDANSETRON 4MG TABLETS 23 $78.70 165 $547.73 ONDANSETRON 4MG/2ML INJ, 2ML 35 $21.45 1086 $541.57 ONDANSETRON 4MG/5ML SOLUTION 39 $205.36 889 $4,626.25 ONDANSETRON 8MG TABLETS 26 $117.92 161 $698.11 ONDANSETRON ODT 4MG TABLETS 16 $71.53 126 $543.79 ONDANSETRON ODT 8MG TABLETS 20 $87.55 128 $540.30 ONE-A-DAY MENS PRO EDGE TABLETS 35 $30.58 99 $80.10 ONEXTON 1.2% - 3.75% GEL 50GM 50 $483.28 120 $1,152.31 ONFI 10MG TABLETS 66 $1,210.15 178 $3,268.31 ONFI 20MG TABLETS 58 $2,147.55 174 $6,386.86 ONGLYZA 5MG TABLETS 30 $453.53 88 $1,325.10 OPIUM 10MG/ML (1%) TINCTURE 107 $818.34 166 $1,269.90 ORACIT SOLUTION 853 $42.72 2050 $97.07 ORASEP SOLUTION 30 $13.03 30 $12.99 ORPHENADRINE 30MG/ML INJ, 2ML 11 $96.39 19 $160.39 ORPHENADRINE CITRATE 100MG ER TABS 30 $46.07 149 $212.10 ORTHO-TRI-CYCLEN LO TABS28(ORANGE) 28 $25.20 84 $66.93 ORTHOVISC 15MG/ML INJ, 2ML 8 $2,121.13 9 $2,532.96 OSELTAMIVIR 30MG CAPSULES 14 $178.47 10 $127.99 OSELTAMIVIR 45MG CAPSULES 10 $127.17 10 $127.99 OSELTAMIVIR 6MG/ML SUSPENSION 60ML 98 $161.33 87 $143.62 OSELTAMIVIR 75MG CAPSULES 10 $97.57 18 $170.87 OVIDREL 250MCG/0.5ML INJ(1 SYRINGE) 1 $173.85 6 $1,799.64 OXANDROLONE 10MG TABLETS 62 $972.91 138 $2,168.28 OXANDROLONE 2.5MG TABLETS 48 $193.34 119 $474.63 OXAPROZIN 600MG TABLETS 51 $154.29 163 $481.64 OXAZEPAM 10MG CAPSULES 58 $59.49 155 $153.23 OXAZEPAM 15MG CAPSULES 63 $82.74 168 $215.29 OXAZEPAM 30MG CAPSULES 59 $113.51 161 $300.96 OXCARBAZEPINE 150MG TABLETS 71 $35.88 229 $106.91 OXCARBAZEPINE 300MG TABLETS 77 $86.07 238 $257.39 OXCARBAZEPINE 300MG/5ML ORAL SUSP 389 $239.21 1305 $792.09 OXCARBAZEPINE 600MG TABLETS 67 $101.67 202 $296.36 OXICONAZOLE NITRATE 1% CREAM 60GM 54 $256.27 105 $495.21 OXISTAT 1% LOTION 30ML 49 $547.58 135 $1,499.33 OXSORALEN-ULTRA 10MG CAPSULES 27 $2,495.81 30 $2,807.29

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price OXTELLAR XR 600MG TABLETS 60 $1,030.63 189 $3,250.93 OXYBUTYNIN 5MG TABLETS 59 $29.54 170 $77.56 OXYBUTYNIN ER 10MG TABLETS 32 $62.33 96 $177.20 OXYBUTYNIN ER 15MG TABLETS 33 $19.54 98 $49.85 OXYBUTYNIN ER 5MG TABLETS 32 $18.97 94 $48.03 OXYCODONE 10MG ER TABLETS 43 $151.30 270 $938.17 OXYCODONE 10MG IMMEDIATE TABS 97 $66.06 251 $164.60 OXYCODONE 15MG* IMMEDIATE REL TABS 109 $106.28 270 $258.15 OXYCODONE 20MG IMMEDIATE REL TABS 111 $117.61 326 $336.18 OXYCODONE 20MG/ML SOLUTION 30ML 85 $613.94 675 $4,826.40 OXYCODONE 30MG IMMEDIATE REL TABS 120 $164.80 336 $454.72 OXYCODONE 40MG ER TABLETS 59 $528.71 216 $1,922.06 OXYCODONE 5MG IMMEDIATE REL CAPS 48 $69.78 90 $126.99 OXYCODONE 5MG IMMEDIATE REL TABS 57 $29.62 209 $98.23 OXYCODONE 5MG/5ML SOLUTION 220 $57.21 661 $163.87 OXYCODONE 80MG ER TABLETS 76 $540.97 205 $1,451.88 OXYCODONE/ACETAMINOPHEN 10-325MG TB 94 $208.37 266 $582.90 OXYCODONE/ACETAMINOPHEN 5-325MG TAB 43 $28.13 169 $99.48 OXYCODONE/ACETAMINOPHN 7.5-325MG TB 73 $112.49 217 $327.35 OXYCODONE/ASA 4.5/325MG TABS 81 $88.82 252 $268.47 OXYCONTIN 10MG CONTROLLED REL TABS 54 $190.66 179 $622.02 OXYCONTIN 15MG TABLETS 58 $298.00 197 $1,002.82 OXYCONTIN 30MG TABLETS 61 $553.11 208 $1,862.11 OXYCONTIN 60MG CONTROLLED REL TABS 67 $1,063.25 215 $3,399.43 OXYMORPHONE 10MG TABLETS 101 $283.06 345 $959.62 OXYMORPHONE 5MG TABLETS 85 $150.56 540 $932.75 OXYMORPHONE ER 10MG TABLETS 56 $198.66 180 $626.78 OXYMORPHONE ER 15MG TABLETS 61 $282.40 131 $604.27 OXYMORPHONE ER 20MG TABLETS 59 $355.29 225 $1,344.98 OXYMORPHONE ER 40MG TABLETS 64 $462.42 203 $1,457.08 OXYTROL FOR WOMEN 3.9MG PATCH (OTC) 9 $714.63 24 $1,981.52 PALIPERIDONE ER 1.5MG TABLETS 32 $885.44 96 $2,639.68 PALIPERIDONE ER 3MG TABLETS 31 $865.28 93 $2,563.08 PALIPERIDONE ER 6MG TABLETS 35 $974.75 111 $3,047.84 PALIPERIDONE ER 9MG TABLETS 29 $1,208.28 89 $3,664.70 PANCREAZE 10,500 CAPSULES 171 $521.68 491 $1,493.21 PANCREAZE 16,800 CAPSULES 245 $1,199.30 437 $2,130.89 PANCREAZE 21,000 CAPSULES 312 $1,895.59 941 $5,716.34 PANCREAZE 4,200 CAPSULES 143 $177.35 371 $454.59 PANTOPRAZOLE 20MG TABLETS 34 $71.82 101 $201.86 PANTOPRAZOLE 40MG TABLETS 35 $80.31 101 $225.67 PAPAVERINE HCL 30MG/ML 10ML 16 $46.28 10 $30.99 PAREGORIC LIQUID 367 $194.67 225 $121.02 PARI BABY MASK CONVERSION PACK 1 $5.39 1 $5.49 PARI TREK S COMBO KIT 1 $133.34 1 $129.99 PARICALCITOL 1MCG CAPSULES 25 $249.82 70 $681.60 PARICALCITOL 2MCG CAPSULES 27 $530.48 74 $1,435.59 PARICALCITOL 4MCG CAPSULES 33 $1,307.44 78 $3,108.38

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PAROXETINE 40MG TABLETS 31 $33.12 93 $90.35 PAROXETINE 7.5MG CAPSULES 30 $181.24 89 $528.85 PAROXETINE ER 12.5MG TABLETS 31 $127.18 92 $374.89 PAROXETINE ER 25MG TABLETS 36 $125.73 105 $361.31 PAROXETINE ER 37.5MG TABLETS 32 $151.65 95 $437.96 PAZEO 0.7% OPHTH SOLUTION 2.5ML 3 $190.67 8 $617.19 PEDIARIX 0.5ML INJ, 0.5ML 1 $84.99 1 $84.99 PEDI-DRI 100000U POWDER60GM 44 $76.11 197 $325.24 PEG-3350 & ELECTROLYTES FLAVORED 4065 $25.55 4037 $25.40 PEG-3350/KCL /SOD LEMON-LIME 4000ML 4022 $22.10 4000 $22.00 PEGASYS 180MCG/ML INJ 1ML VIAL 4 $3,948.03 8 $8,734.48 PENICILLIN G 5,000,000U/ VIAL 2 $84.66 3 $126.97 PENNSAID 2% TOPICAL SOLUTION 112GM 126 $2,801.11 400 $8,909.74 PENTASA 250MG CAPSULES 218 $569.44 682 $1,772.28 PENTASA 500MG CAPSULES 172 $894.85 526 $2,730.56 PENTAZOCINE/NALOXONE TABLETS 74 $167.07 242 $537.34 PENTOXIFYLLINE 400MG ER TABLETS 73 $21.01 199 $50.32 PERFOROMIST 20MCG INH SOL 30X2ML 116 $1,064.70 346 $3,171.74 PERINDOPRIL 2MG TABLETS 33 $59.77 101 $172.26 PERINDOPRIL 4MG TABLETS 34 $50.74 97 $136.78 PERINDOPRIL 8MG TABLETS 33 $76.85 99 $222.67 PERPHENAZINE 16MG TABLETS 54 $178.43 152 $498.89 PERPHENAZINE 2MG TABLETS 61 $48.27 177 $131.52 PERPHENAZINE 4MG TABLETS 60 $63.10 162 $163.87 PERPHENAZINE 8MG TABLETS 61 $77.98 164 $203.63 PERPHENAZINE/AMITRIPT 2-10MG TAB 49 $70.55 137 $190.64 PERPHENAZINE/AMITRIPT 2-25MG TAB 63 $116.88 152 $276.08 PERPHENAZINE/AMITRIPTYLINE 4-10 TAB 60 $92.28 100 $149.43 PERPHENAZINE/AMITRIPTYLINE 4-25 TAB 57 $110.12 160 $302.39 PERPHENAZINE/AMITRIPTYLINE 4-50 TAB 44 $140.21 151 $466.53 PHENADOZ 12.5MG SUPPOSITORIES 13 $89.59 124 $818.04 PHENADOZ 25MG SUPPOSITORIES 15 $97.68 123 $782.49 PHENAZOPYRIDINE 100MG TABLETS 13 $21.22 131 $178.24 PHENAZOPYRIDINE 200MG TABLETS 11 $28.92 157 $369.56 PHENDIMETRAZINE 105MG CR CAPSULES 30 $26.47 95 $76.23 PHENDIMETRAZINE 35MG TABLETS 62 $20.54 159 $46.46 PHENELZINE SULFATE 15MG TABLETS 112 $86.01 319 $238.25 PHENOBARBITAL 100MG TABLETS 70 $26.37 151 $51.93 PHENOBARBITAL 15MG TABLETS 76 $18.96 178 $39.27 PHENOBARBITAL 16.2MG TABLETS 78 $32.70 172 $67.67 PHENOBARBITAL 30MG TABLETS 82 $24.93 215 $58.99 PHENOBARBITAL 32.4MG TABLETS 85 $44.09 224 $109.30 PHENOBARBITAL 60MG TABLETS 79 $29.89 184 $64.28 PHENOBARBITAL 64.8MG TABLETS 81 $51.44 182 $111.29 PHENOBARBITAL 97.2MG TABLETS 67 $56.45 147 $119.05 PHENOBARBITAL ELIXIR 20MG/5ML 464 $68.06 1143 $161.87 PHENOXYBENZAMINE 10MG CAPSULES 94 $10,600.44 177 $20,092.89 PHENTERMINE 37.5MG CAPSULES 30 $29.25 88 $77.59

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PHENTERMINE 37.5MG TABLETS 30 $29.36 89 $78.19 PHENTERMINE HCL 15MG CAPSULES 32 $35.17 97 $97.93 PHENYLEPHRINE 10% OPHTH SOLN 5ML 5 $49.41 5 $46.99 PHENYLEPHRINE 2.5% OPH 15ML 11 $72.55 21 $134.19 PHENYTOIN 100MG/4ML SUSPENSION 311 $162.65 975 $501.41 PHENYTOIN 200MG ER CAPSULES 57 $62.10 167 $173.83 PHENYTOIN 50MG CHEW TABLETS 90 $40.98 197 $84.88 PHENYTOIN SOD 300MG ER CAPSULES 35 $42.95 103 $117.04 PHENYTOIN SODIUM 100MG EXT CAPSULES 109 $28.27 305 $71.79 PHOSPHOLINE IODIDE 0.125% OPH SOLN 5 $106.58 11 $218.65 PHYTONADIONE 1MG/0.5ML INJ, 0.5ML 2 $14.46 20 $99.60 PILOCARPINE 1% OPHTH SOLN 15ML 15 $87.31 17 $96.70 PILOCARPINE 2% OPHTH SOLN 15ML 15 $90.68 18 $107.44 PILOCARPINE 5MG TABLETS 93 $18.84 271 $47.38 PILOCARPINE 7.5MG TABLETS 88 $147.07 257 $423.96 PILOCARPINE HCL 4% OPHTH SOLN 16 $107.39 22 $148.44 PIMOZIDE 1MG TABLETS 58 $94.57 155 $245.80 PIMOZIDE 2MG TABLETS 58 $128.01 178 $382.16 PINDOLOL 10MG TABLETS 61 $119.37 165 $317.68 PINDOLOL 5MG TABLETS 49 $73.53 137 $200.99 PIOGLITAZONE 15MG TABLETS 31 $114.60 91 $329.84 PIOGLITAZONE 30MG TABLETS 30 $168.61 90 $491.07 PIOGLITAZONE 45MG TABLETS 30 $177.35 89 $515.80 PIOGLITAZONE/GLIMEPIRIDE 30-2MG TAB 32 $304.05 86 $816.83 PIOGLITAZONE/GLIMEPIRIDE 30-4MG TAB 30 $300.69 89 $873.17 PIOGLITAZONE/METFORMIN 15-500MG TAB 57 $262.69 163 $738.27 PIOGLITAZONE/METFORMIN 15-850MG TB 60 $241.32 174 $689.48 PIROXICAM 10MG CAPSULES 37 $29.24 116 $84.10 PIROXICAM 20MG CAPSULES 29 $79.92 90 $237.83 PNU-IMUNE 0.5ML SYRINGE 1 $120.34 1 $120.27 PNV-DHA+DOCUSATE CAPSULES 30 $43.48 89 $120.11 PODIAPN CAPSULES 54 $40.52 139 $98.85 PODOFILOX 0.5% SOLUTION 3.5ML 4 $98.46 8 $212.76 POLYETH GLYC 3350 NF POWPACKS 14'S 25 $41.31 93 $142.79 POLYETH GLYCOL 3350 NF POWDER 255GM 468 $31.53 1668 $102.09 POLYVITAMIN/FLU 0.25MG 50ML 50 $13.02 99 $21.89 PORTABLE ULTRASONICE NEBULIZER 1 $61.40 1 $59.99 POT BICAR/CL 25MEQ EF TABLETS 49 $50.08 163 $156.26 POT CHLORIDE 8MEQ CR CAPSULES 46 $36.85 124 $93.53 POT CITRATE-CITRIC ACID CRYSTAL PAK 57 $58.74 163 $160.22 POTASSIUM CHLOR 10% LIQ(20MEQ/15ML) 549 $263.89 1567 $746.05 POTASSIUM CHLOR 20% LIQ(40MEQ/15ML) 504 $691.80 1571 $2,146.26 POTASSIUM CHLORIDE 20MEQ ER TABLETS 41 $25.23 120 $66.31 POTASSIUM CHLORIDE ER 8MEQ TABLETS 48 $21.41 130 $51.74 POTASSIUM CIT 1080MG (10MEQ) TABS 87 $116.79 233 $304.91 POTASSIUM CIT 540MG (5MEQ) TABLETS 92 $88.47 227 $212.54 POTASSIUM CIT ER 1620MG (15MEQ) TAB 68 $157.68 190 $436.09

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price POTASSIUM CITRATE CITRIC ACID SOL 727 $87.32 1697 $198.52 POTASSIUM CITRATE CITRIC ACID SOL 918 $124.38 2329 $309.27 POTASSIUM CL 10MEQ ER CAPSULES 51 $34.54 140 $88.16 POTASSIUM CL 20MEQ ER TABLETS 45 $25.00 131 $65.18 PRADAXA 150MG CAPS (BLISTER PACK) 59 $402.92 173 $1,167.86 PRADAXA 75MG CAPSULES(BLISTER PACK) 59 $406.33 172 $1,172.93 PRAMIPEXOLE 0.125MG TABLETS 58 $30.52 161 $77.13 PRAMIPEXOLE 0.5MG TABLETS 55 $16.80 152 $39.47 PRAMIPEXOLE 0.75MG TABLETS 51 $71.20 141 $191.24 PRAMIPEXOLE 1.5MG TABLETS 60 $17.96 168 $43.07 PRAMIPEXOLE 1MG TABLETS 58 $17.63 161 $41.65 PRAMIPEXOLE ER 0.375MG TABLETS 40 $563.66 120 $1,676.16 PRAMIPEXOLE ER 0.75MG TABLETS 36 $511.03 114 $1,631.09 PRAMIPEXOLE ER 1.5MG TABLETS 36 $519.17 105 $1,497.95 PRAMIPEXOLE ER 2.25MG TABLETS 33 $481.90 95 $1,372.43 PRAMIPEXOLE ER 3MG TABLETS 31 $436.66 95 $1,321.74 PRAMIPEXOLE ER 4.5MG TABLETS 32 $420.50 90 $1,188.47 PRASUGREL 10MG TABLETS 30 $317.18 89 $919.56 PRASUGREL 5MG TABLETS 31 $117.41 89 $328.89 PRAZOSIN 2MG CAPSULES 44 $30.32 146 $91.68 PRAZOSIN HCL 5MG CAPSULES 42 $43.40 143 $137.28 PRECISION SURE DOSE 28G,1ML, 100'S 58 $19.11 109 $32.12 PRED MILD 0.12% OPHTH SUS 10ML 6 $201.45 8 $242.05 PREDNICARBATE-E 0.1% CREAM 61 $84.80 210 $280.47 PREDNISOLONE 25MG/5ML SOLUTION 32 $39.85 41 $50.61 PREDNISOLONE AC 1% OPHTH SUSP 10ML 7 $63.54 9 $82.60 PREDNISOLONE ODT 10MG TABLETS 17 $238.35 80 $1,123.61 PREDNISOLONE ODT 15MG TABLETS 9 $190.55 58 $1,275.17 PREDNISOLONE ODT 30MG TABLETS 8 $220.10 135 $3,817.72 PREDNISOLONE SOD PHOS 5MG/5ML SOL 54 $33.26 142 $81.08 PREDNISONE 10MG TABS PACK 21'S 21 $22.02 42 $39.98 PREDNISONE 50MG (FIFTY MG) TABLETS 6 $9.63 59 $62.49 PREDNISONE 5MG TABLETS PACK 21'S 21 $11.00 53 $21.49 PREDNISONE INTENSOL 5MG/1ML CONC. 56 $92.43 368 $579.62 PREDNISONE SOLN 5MG/5ML (1MG/1ML) 88 $23.13 275 $63.62 PREFERAOB ONE CAPSULES 30 $118.32 90 $348.97 PREFEST TABLETS (NEW MANUFACTURER) 30 $133.94 88 $383.68 PREMARIN 0.3MG TABLETS 29 $141.73 84 $403.07 PREMARIN 0.45MG TABLETS 29 $143.40 88 $418.67 PREMARIN 0.625MG (DF) TABS 29 $144.75 87 $422.37 PREMARIN 0.9MG TABLETS 30 $143.62 88 $421.68 PREMARIN 1.25MG TABS 31 $154.42 93 $457.60 PREMARIN VAGINAL CREAM 30GM 30 $388.07 35 $441.93 PREMPHASE SINGLE TABLETS28'S 28 $202.25 86 $606.97 PREMPRO 0.3MG/1.5MG TABS 28'S 28 $169.03 80 $471.34 PREMPRO 0.45MG/1.5MG TABS 28'S 28 $169.02 81 $476.31 PREMPRO 0.625MG/2.5MG TAB 28 PEACH 28 $209.63 81 $586.16

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PREMPRO 0.625MG/5MG TABS28 (BLUE) 28 $202.56 82 $582.72 PRENATAL - U CAPSULES 30 $17.03 89 $42.63 PRENATAL PLUS TABLETS 30 $12.87 91 $30.69 PRENATE ESSENTIAL CAPSULES 30 $64.51 90 $183.06 PREPOPIK PAK (ORANGE FLAVOR) 2 $146.01 2 $145.80 PREVALITE POWDER PACKETS(BOX)42S 48 $114.42 142 $328.57 PREVIDENT 5000 BOOSTER GEL (SPRMNT) 103 $12.86 235 $24.27 PREVIDENT 5000 SENSITIVE PASTE/MINT 102 $23.82 244 $51.40 PREVNAR 13 INJ, 0.5ML (1 SYRINGE) 1 $219.87 1 $219.31 PREZISTA 150MG TABLETS 124 $777.68 90 $564.25 PREZISTA 600MG TABLETS 59 $1,483.89 177 $4,427.64 PRIFTIN 150MG TABLETS 24 $102.94 64 $273.49 PRILOSEC 10MG POWDER PACKS 30'S 45 $331.04 155 $1,120.56 PRIMAQUINE PHOSPHATE 26.3MG TABS 28 $29.06 87 $83.14 PRIMIDONE 250MG TABLETS 66 $33.64 176 $82.69 PRIMSOL 50MG/5ML SOLUTION 103 $206.05 185 $365.53 PROAIR RESPICLICK ORAL PWD INH(200) 1 $65.38 2 $116.46 PROBENECID 500MG TABLETS 53 $37.11 142 $93.67 PROBENECID/COLCHICINE TABLETS 41 $35.93 121 $98.70 PROCHLORPERAZINE 25MG SUPPOSITORIES 14 $140.92 100 $1,012.46 PROCHLORPERAZINE 5MG/ML INJ 2ML 15 $35.72 532 $1,154.61 PROCRIT 2,000 U/ML 1ML SD VIAL 4 $128.25 7 $230.81 PROCRIT 20,000U/ML, 1ML VIAL 3 $1,559.20 5 $2,340.95 PROCRIT 3,000 U/ML 1ML SD VIAL 7 $489.86 6 $445.99 PROCRIT 4,000 U/ML 1ML SD VIAL 5 $356.86 7 $505.43 PROCTOFOAM-HC 1-1% SPRAY10GM 11 $139.86 82 $990.53 PROCTOSERT 30MG SUP 12S 19 $291.98 87 $1,316.18 PRODIGY INS SYR U100/0.3ML/31GX5/16 118 $55.39 231 $104.29 PROFERRIN FORTE TABLETS 44 $31.53 155 $101.62 PROGESTERONE 100MG CAPSULES 33 $54.75 94 $148.37 PROGESTERONE 200MG CAPSULES 31 $100.13 92 $284.68 PROGESTERONE/OIL 50MG/MLMDV 10ML 23 $63.39 41 $110.13 PROGLYCEM 50MG/ML SUSPENSION 94 $980.82 237 $2,476.36 PROLENSA 0.07% OPTH SOLUTION 3ML 3 $235.11 8 $619.66 PROMETHAZINE 25MG/ML INJ, 1ML 22 $19.52 75 $57.46 PROMETHAZINE 50MG/ML INJ 25X1ML 22 $62.53 42 $117.69 PROMETHAZINE PE W/CODEINE SYRUP 155 $61.00 148 $58.35 PROMETHAZINE VC PLAIN SYRUP 165 $44.27 413 $104.82 PROMETHAZINE W/ CODEINE SYRUP 168 $19.88 469 $48.31 PROPAFENONE 150MG TABLETS 79 $16.34 233 $40.18 PROPAFENONE 225MG TABLETS 75 $82.38 220 $234.89 PROPAFENONE 300MG TABLETS 69 $103.35 217 $316.23 PROPAFENONE 425MG SR CAPSULES 58 $855.82 172 $2,532.94 PROPAFENONE SR 225MG CAPSULES 59 $459.85 176 $1,372.07 PROPAFENONE SR 325MG CAPSULES 58 $543.81 176 $1,632.37 PROPANTHELINE BROMIDE 15MG TABS 79 $53.58 268 $172.50 PROPARACAINE 0.5% OPHTH SOLN 15ML 15 $34.11 24 $52.32 PROPRANOLOL 10MG TABLETS 63 $15.60 184 $37.80

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PROPRANOLOL 20MG TABLETS 62 $19.87 179 $49.67 PROPRANOLOL 20MG/5ML SOLN 175 $25.10 449 $58.25 PROPRANOLOL 40MG TABLETS 59 $23.63 170 $60.76 PROPRANOLOL 40MG/5ML SOLN 186 $29.69 589 $85.22 PROPRANOLOL 80MG TABLETS 56 $32.36 157 $83.26 PROPRANOLOL ER 120MG CAPSULES 34 $65.06 101 $185.92 PROPRANOLOL ER 160MG CAPSULES 33 $76.80 97 $221.47 PROPRANOLOL ER 60MG CAPSULES 33 $46.57 98 $130.94 PROPRANOLOL ER 80MG CAPSULES 32 $51.50 97 $146.67 PROPRANOLOL/HCTZ 40/25 MG TABS 36 $41.96 108 $118.03 PROPRANOLOL/HCTZ 80/25MG TABS 36 $49.03 105 $137.32 PROPYLTHIOURACIL 50MG TABLETS 89 $60.31 194 $126.80 PROQUAD LIVE VACCINE W/DILUENT INJ 1 $218.99 1 $218.99 PROSED/DS (ATROPINE FREE) TABLETS 57 $171.81 193 $575.13 PROTECT CARDIO CAPSULES 31 $21.56 86 $52.86 PROTECT PLUS NR CAPSULES 52 $29.05 127 $65.33 PROTONIX 40MG GRANULE FOR SUSP 30PK 33 $482.53 107 $1,542.18 PROTRIPTYLINE 10MG TABLETS 70 $160.54 182 $408.85 PROTRIPTYLINE 5MG TABLETS 64 $194.08 184 $549.85 PRUET DHA PACK 60 $38.00 180 $106.01 PULMICORT 180MCG FLEXHALR(120PUFFS) 1 $246.45 2 $568.19 PULMICORT 90MCG FLEXHALER(60 PUFFS) 1 $196.90 3 $601.58 PYLERA CAPSULES 121 $800.32 120 $791.99 PYRAZINAMIDE 500MG TABLETS 70 $165.88 178 $414.41 PYRIDOSTIGMINE 180MG TABLETS 43 $711.57 124 $2,056.72 PYRIDOSTIGMINE 60MG TABLETS 116 $52.64 309 $133.89 PYRIDOXINE 100MG/ML INJ 1ML VIAL 4 $67.12 8 $137.84 QNASL 80MCG NASAL AEROSOL 120SPRAYS 9 $201.19 25 $564.01 QSYMIA 11.25/69MG CAPSULES 29 $219.68 88 $647.25 QSYMIA 15-92MG CAPSULES 30 $221.80 89 $657.26 QSYMIA 3.75-23MG CAPSULES 19 $127.25 93 $620.56 QSYMIA 7.5-46MG CAPSULES 30 $229.88 87 $665.33 QUASENSE TABLETS 91S 91 $109.99 91 $110.22 QUETIAPINE 100MG TABLETS 42 $124.67 123 $356.34 QUETIAPINE 20MG TABLETS 39 $247.81 118 $732.92 QUETIAPINE 25MG TABLETS 48 $69.17 132 $184.19 QUETIAPINE 300MG TABLETS 39 $367.57 117 $1,098.37 QUETIAPINE 400MG TABLETS 40 $396.72 122 $1,205.61 QUETIAPINE 50MG ER TABLETS 42 $238.13 121 $683.72 QUETIAPINE 50MG TABLETS 44 $116.91 127 $329.73 QUETIAPINE ER 150MG TABLETS 31 $318.24 94 $946.01 QUETIAPINE ER 200MG TABLETS 32 $356.89 93 $1,040.69 QUETIAPINE ER 300MG TABLETS 38 $551.84 113 $1,646.13 QUETIAPINE ER 400MG TABLETS 38 $680.74 112 $1,998.54 QUINAPRIL/HCTZ 20-12.5MG TABLETS 42 $63.23 119 $169.90 QUINAPRIL/HCTZ 20-25MG TABLETS 33 $24.62 96 $64.57 QUINARETIC 10-12.5MG TABLETS 32 $18.88 92 $47.11 QUINIDINE GL 324MG CR TAB 74 $671.44 244 $2,188.86

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price QUINIDINE SULFATE 200MG (3GR) TABS 72 $15.49 190 $34.39 QUINIDINE SULFATE 300MG TABS 72 $26.38 201 $66.22 QUININE SULFATE 324MG CAPSULES 35 $190.88 103 $558.19 QVAR 40MCG AEROSOL (100PUFFS) 7.3GM 9 $165.86 22 $405.55 QVAR 80MCG ORAL INHALER 120 DOSES 9 $223.84 22 $555.91 RABAVERT FOR INJECTION 1VL 1 $357.69 2 $497.49 RABEPRAZOLE DR 20MG TABLETS 36 $350.05 104 $992.05 RAJANI TABLETS 28S 29 $144.54 83 $415.43 RALOXIFENE 60MG TABLETS 30 $171.46 90 $501.01 RAMIPRIL 10MG CAPSULES 38 $51.45 113 $142.95 RAMIPRIL 2.5MG CAPSULES 33 $58.49 96 $163.87 RAMIPRIL 5MG CAPSULES 34 $45.85 101 $128.58 RANEXA 1000MG TABLETS 58 $628.08 172 $1,850.53 RANEXA 500MG TABLETS 59 $343.95 172 $998.15 RANITIDINE 150MG CAPSULES 51 $37.87 151 $104.48 RANITIDINE 15MG/ML (75MG/5ML) SYRUP 135 $19.35 487 $59.60 RANITIDINE 300MG CAPSULES 35 $58.53 103 $165.61 RAPAFLO 4MG CAPSULES 31 $263.60 93 $777.31 RAPAFLO 8MG CAPSULES 30 $253.63 89 $743.30 RAPAMUNE 1MG/ML SOL (60ML KIT) 67 $2,077.19 75 $2,315.44 RASAGILINE 1MG TABLETS 30 $471.30 89 $1,393.99 RASAGILINE MESYLATE 0.5MG TABLETS 32 $509.45 95 $1,491.38 RE DUALVIT PLUS CAPSULES 33 $20.96 91 $50.62 REBIF 22MCG/0.5 ML SYR (6ML/PKG) 6 $7,780.09 18 $21,991.57 REBIF 44MCG/0.5 ML SYR (6ML/PKG) 6 $7,971.91 18 $22,472.48 RECAL D 1342-1MG WAFERS 57 $35.39 124 $72.27 RECOMBIVAX HB 10MCG/ML INJ, 1ML 1 $80.99 1 $80.99 RECOMBIVAX HB 5MCG/0.5 INJ, 0.5ML 1 $53.99 1 $53.99 RENACIDIN IRRIGATION SOLN 500ML 1278 $96.17 2790 $205.16 RENAGEL 400MG TABLETS 146 $571.71 251 $978.43 RENAGEL 800MG TABLETS 184 $1,411.83 460 $3,521.70 REPAGLINIDE 0.5MG TABLETS 85 $252.54 231 $677.89 REPAGLINIDE 1MG TABLETS 89 $286.63 250 $796.92 REPAGLINIDE 2MG TABLETS 108 $351.00 299 $959.65 REPATHA SURE CLICK 140MG/ML, 2ML 2 $1,242.60 6 $3,654.24 REPLIVA 21/7 TABLETS 29 $31.36 73 $73.32 RESTASIS 0.05% OPHTH SINGLE USE 30 44 $4,463.59 143 $14,551.73 RESTIZAN GEL 28GM 26 $356.72 36 $483.30 RETIN-A MICRO 0.08% GEL PUMP 50GM 50 $1,032.21 139 $2,863.18 REVLIMID 10MG CAPSULES 28'S 21 $15,621.82 63 $45,922.21 REXULTI 1MG TABLETS 30 $1,100.57 89 $3,306.56 REXULTI 2MG TABLETS 29 $1,092.68 89 $3,288.64 REYATAZ 150MG CAPSULES 54 $1,405.59 120 $3,103.98 RHOGAM PLUS 300MCG INJ 1 $155.46 1 $153.99 RIBAVIRIN 200MG CAPSULES 84'S 82 $488.70 252 $1,497.98 RIBAVIRIN 200MG TABLETS 94 $141.48 270 $399.33 RIDAURA 3MG CAPSULES 55 $1,335.39 152 $3,671.71 RIFABUTIN 150MG CAPSULES 44 $711.69 124 $1,989.41

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price RIFAMATE CAPSULES 54 $319.58 24 $144.26 RIFAMPIN 150MG CAPSULES 55 $161.04 167 $482.39 RIFAMPIN 300MG CAPSULES 46 $82.83 126 $217.50 RILUZOLE 50MG TABLETS 59 $272.12 176 $799.91 RIMANTADINE 100MG TABLETS 30 $53.39 145 $238.13 RIMSO-50 50% SOLUTION 80 $999.81 150 $1,880.92 RIOMET 500MG/5ML SOLUTION 365 $515.00 1163 $1,631.15 RISEDRONATE SOD 150MG TABLETS 1 $137.33 3 $393.52 RISEDRONATE SOD 30MG TABLETS 11 $564.05 23 $1,131.81 RISEDRONATE SOD 35MG DELAYED REL TB 4 $200.42 12 $571.19 RISEDRONATE SOD 35MG IMM REL TB PK 4 $195.99 12 $554.04 RISEDRONATE SOD 5MG TABLETS 29 $217.34 89 $660.37 RISPERDAL CONSTA 12.5MG INJ, 1 VIAL 1 $341.52 5 $1,193.30 RISPERDAL CONSTA 25MG KIT 1 $706.28 6 $2,858.11 RISPERDAL CONSTA 37.5MG KIT 2 $1,076.04 6 $4,155.59 RISPERDAL CONSTA 50MG KIT 2 $1,435.61 6 $5,273.38 RISPERIDONE 0.25MG TABLETS 50 $124.28 141 $344.89 RISPERIDONE 0.5MG TABLETS 48 $105.01 134 $284.58 RISPERIDONE 1MG TABLETS 46 $132.93 128 $361.54 RISPERIDONE 1MG/ML ORAL SOLN 30ML 62 $310.38 167 $831.81 RISPERIDONE 2MG TABLETS 41 $218.47 119 $622.71 RISPERIDONE 3MG TABLETS 41 $237.96 121 $696.22 RISPERIDONE 4MG ODT TABLETS 41 $603.52 128 $1,859.38 RISPERIDONE 4MG TABLETS 40 $184.31 119 $544.94 RISPERIDONE ODT 0.25MG TABLETS 49 $202.51 156 $632.66 RISPERIDONE ODT 0.5MG TABLETS 48 $215.07 133 $581.55 RISPERIDONE ODT 1MG TABLETS 48 $194.14 130 $522.56 RISPERIDONE ODT 2MG TABLETS 43 $350.42 134 $1,089.29 RISPERIDONE ODT 3MG TABLETS 38 $395.94 124 $1,269.32 RITALIN LA 10MG CAPSULES 33 $350.20 106 $1,113.66 RIVASTIGMINE 1.5MG CAPSULES 61 $201.87 179 $582.67 RIVASTIGMINE 13.3MG/24H PATCH 30 $414.62 88 $1,197.63 RIVASTIGMINE 3MG CAPSULES 58 $181.48 171 $527.59 RIVASTIGMINE 4.5MG CAPSULES 56 $174.33 166 $508.52 RIVASTIGMINE 4.6MG/24H PATCH 30 $409.39 88 $1,178.75 RIVASTIGMINE 6MG CAPSULES 57 $180.43 172 $532.95 RIVASTIGMINE 9.5MG/24H PATCH 30 $419.73 88 $1,209.65 RIZATRIPTAN 10MG TABLETS 10 $193.79 34 $631.95 RIZATRIPTAN 5MG TABLETS 10 $283.18 36 $999.07 RIZATRIPTAN ODT 10MG TABLETS 10 $310.68 32 $935.60 RIZATRIPTAN ODT 5MG TABLETS 10 $297.87 26 $786.11 ROBAFEN DM 100-10/5 SYRUP 188 $6.38 228 $6.90 ROBITUSSIN HEAD AND CHEST PE SYRUP 119 $13.18 120 $13.22 ROPINIROLE 0.25MG TABLETS 58 $17.45 159 $41.10 ROPINIROLE 0.5MG TABLETS 52 $89.14 151 $251.04 ROPINIROLE 1MG TABLETS 55 $93.07 157 $260.91 ROPINIROLE 2MG TABLETS 52 $65.92 150 $183.76 ROPINIROLE 3MG TABLETS 50 $27.22 149 $73.50

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

ROPINIROLE 4MG TABLETS 50 $85.03 146 $242.18 ROPINIROLE 5MG TABLETS 51 $88.10 153 $254.43 ROPINIROLE ER 12MG TABLETS 35 $441.74 107 $1,353.42 ROPINIROLE ER 2MG TABLETS 48 $111.49 131 $295.43 ROPINIROLE ER 4MG TABLETS 38 $124.48 111 $358.51 ROPINIROLE ER 6MG TABLETS 35 $259.23 112 $830.70 ROPINIROLE ER 8MG TABLETS 37 $285.25 116 $879.64 ROTATEQ ORAL SOLUTION, 2ML 2 $104.99 2 $104.99 ROZEREM 8MG TABLETS 29 $383.77 89 $1,177.22 RU-LETS 500 TABLETS 30 $4.43 93 $5.31 RYTARY ER 23.75-95MG CAPSULES 204 $583.19 600 $1,709.06 SALICYLIC AC 6% LOTION 400GM 417 $52.64 1242 $148.94 SALICYLIC ACID 26% LIQUID 11 $45.76 30 $120.40 SALICYLIC ACID 6% CREAM 400GM 400 $58.15 667 $94.20 SALICYLIC ACID 6% FOAM 200GM 150 $268.88 300 $535.39 SALICYLIC ACID POWDER 454GM 80 $11.77 120 $15.63 SALICYLIC ACID WART REMOVER LIQ 10 $91.48 10 $89.99 SALSALATE 500MG TABLETS 85 $93.42 303 $322.59 SALSALATE 750MG TABLETS 85 $126.05 252 $364.58 SANCUSO TRANSDERMAL SYSTEM 2 $1,352.57 12 $7,108.88 SANDIMMUNE 100MG/ML ORALSOLN 66 $918.07 129 $1,801.97 SANDOSTATIN LAR DEPOT 20MG INJ KIT 1 $4,619.80 3 $10,378.56 SANTYL 250U/GM OINTMENT 30GM 48 $357.76 194 $1,431.06 SAVELLA 100MG TABLETS 56 $364.95 167 $1,075.28 SAVELLA 12.5MG TABLETS 55 $357.67 141 $903.11 SAVELLA 25MG TABLETS 59 $348.23 164 $960.26 SAVELLA 50MG TABLETS 59 $351.18 174 $1,022.22 SAXENDA 6MG/ML PEN INJ 3ML 15 $1,271.15 40 $3,386.40 SCOPOLAMINE TRANSDERMAL PATCHES 4 $50.43 28 $293.99 SE BPO 6% FOAMING CLOTHS 60 $267.10 180 $793.30 SECONAL SODIUM 100MG CAPSULES 37 $1,170.72 59 $1,889.63 SELEGILINE 5MG CAPSULES 57 $85.06 161 $235.45 SELEGILINE 5MG TABLETS 54 $133.18 155 $376.64 SELENIUM SULFIDE 2.25% SHAMPOO 184 $128.64 321 $221.83 SEMPREX-D CAPSULES 57 $287.18 189 $941.87 SE-NATAL 19 TABLETS 30 $17.08 91 $43.49 SENSIPAR 30MG TABLETS 32 $951.57 92 $2,728.09 SENSIPAR 60MG TABLETS 33 $1,794.24 96 $5,137.83 SENSIPAR 90MG TABLETS 35 $3,085.66 103 $9,190.40 SEREVENT DISKUS 50MCG ORAL INH (60) 61 $385.56 172 $1,081.64 SEROSTIM 4MG FOR INJECTION 28 $10,617.85 84 $31,503.16 SEROSTIM 6MG FOR INJECTION 28 $14,309.68 84 $43,395.88 SERTRALINE 20MG/ML CONCENTRATE 73 $70.76 240 $223.67 SEVELAMER 800MG TABLETS 192 $740.46 528 $2,025.98 SHINGRIX 50MCG INJ(IM)SNGL DSE 1VL 1 $162.11 1 $162.18 SILDENAFIL 100MG TABLETS 6 $246.88 18 $740.44 SILDENAFIL 20MG TABLETS 39 $128.70 196 $632.16

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

SILDENAFIL 25MG TABLETS 7 $392.76 20 $1,087.64 SILDENAFIL 50MG TABLETS 6 $340.30 18 $972.44 SILENOR 6MG TABLETS 30 $419.54 89 $1,252.09 SILVADENE 1% CREAM 1000GM 62 $16.47 1000 $203.80 SILVER SULFADIAZINE CREAM 50GM 104 $24.76 671 $137.99 SILVERMED GEL 44GM 112 $16.71 213 $28.06 SIMBRINZA 1-0.2% SUSPENSION 8ML 8 $173.36 21 $426.99 SIMPONI 50MG/0.5ML PF SYR, 0.5ML 1 $4,348.31 2 $11,991.97 SIMPONI 50MG/0.5ML SMTJTAUTO INJ 1 $4,066.12 2 $11,991.66 SIROLIMUS 0.5MG TABLETS 52 $409.46 140 $1,089.24 SIROLIMUS 1MG TABLETS 56 $918.05 150 $2,450.39 SIROLIMUS 2MG TABLETS 40 $1,117.55 97 $2,715.83 SOD CHLORIDE 0.9% BACT INJ, 30ML 373 $31.86 2700 $205.69 SOD CHLORIDE 0.9% INJ, 10ML 545 $37.81 882 $58.68 SOD CHLORIDE 0.9% INJ, 250ML 1738 $52.15 3688 $106.14 SOD CHLORIDE 0.9% NEB SOL 30X15ML 282 $29.68 479 $47.71 SOD CHLORIDE 23.4% INJ, 200ML 231 $19.98 319 $26.08 SOD FLUORIDE 1.1 (.5MG)/ML DRP 50ML 51 $12.08 53 $12.42 SOD POLYSTY SULF 15GM/60ML SUSP 377 $148.65 1781 $686.32 SOD SUL/SULF 10-5% EMU WASH 170.3GM 244 $58.40 638 $146.34 SOD SUL/SULFUR 9-4.5% WASH 454GM 455 $217.28 1180 $557.73 SOD SULFA/SULFUR 10-2% CREAM 57GM 58 $207.13 171 $603.41 SOD SULFACET 10% OP SOL 15 $30.00 15 $30.29 SOD SULFACET 9%/SULF 4% WASH 473ML 474 $280.66 1419 $831.99 SOD SULFACETAMIDE 10% WSH GL 340.2G 355 $238.67 355 $238.83 SODIUM BICARBONATE 8.4% INJ 50ML 721 $90.39 575 $72.89 SODIUM CHLORIDE 0.45% INJ, 1000ML 14500 $19.95 37500 $45.25 SODIUM CHLORIDE 0.9% INJ, 20ML 152 $12.49 65 $7.64 SODIUM CHLORIDE 0.9% IRR SOLN 250ML 4030 $24.15 7944 $43.72 SODIUM CHLORIDE 3% NEB SOL 15ML 282 $11.59 762 $24.50 SODIUM CHLORIDE 7% NEB SOLUTION 4ML 251 $46.86 640 $113.30 SODIUM SULF/SULFUR IN UREA CLEANSER 355 $283.99 355 $283.99 SODIUM SULF-10%/SULFUR-5% SUSP 30GM 38 $71.49 428 $773.37 SODIUM SULFACETAM 10% LOTN(TOPICAL) 120 $101.29 285 $235.79 SODIUM SULFACETAMIDE 10% WASH LIQ 350 $79.19 795 $174.59 SODIUM SULFACETAMIDE/SULF 10-2% SOL 230 $201.22 681 $587.62 SODIUM THIOSULFATE 25% INJ, 50ML 50 $39.99 1800 $1,299.64 SOLIQUA 100/33MCG PEN INJ 3ML 15 $683.07 29 $1,309.74 SOLODYN 105MG ER TABLETS 30 $1,135.03 88 $3,337.08 SOLODYN 115MG ER TABLETS 30 $1,143.77 90 $3,429.97 SOLODYN 55MG ER TABLETS 30 $1,128.27 83 $3,114.74 SOLODYN 80MG ER TABLETS 30 $1,129.56 87 $3,263.44 SOLODYN ER 65MG TABLETS 30 $1,100.89 90 $3,291.97 SOLU-CORTEF 100MG INJ 25 VIALS 3 $42.82 18 $267.58 SOLU-CORTEF 250MG INJ, 1VIAL 2 $57.30 6 $153.88 SOLU-MEDROL 500MG INJ, 1VIAL 3 $66.83 6 $145.36 SOMATULINE 90MG/0.3ML INJ, 0.3ML 0 $4,906.85 1 $13,731.97

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

SORBITRATE 40MG TABLETS 71 $192.02 225 $598.18 SOTALOL 160MG TABLETS 56 $17.10 167 $43.02 SOTALOL 240MG TABLETS 51 $206.69 168 $670.40 SOTALOL 80MG TABLETS 55 $36.96 159 $99.38 SOTALOL AF 160MG TABLETS 60 $18.04 169 $43.44 SOTALOL AF 80MG TABLETS 56 $37.88 160 $100.26 SOTRET 30MG CAPSULES 55 $589.61 170 $1,828.61 SPINOSAD 0.9% TOPICAL SUSP 120ML 126 $250.88 120 $239.99 SPIRIVA 18MCG CAPS 90S & HANDIHALER 30 $382.08 87 $1,092.21 SPIRIVA RESPIMAT 2.5MCG INH 4GM 60D 4 $445.66 11 $1,238.03 SPIRONOLACTONE 100MG TABLETS 39 $34.91 111 $93.01 SPIRONOLACTONE 25MG W/ HCTZ 25MG TB 32 $25.64 89 $63.63 SPORANOX 100MG/10ML SOLN 150ML 560 $1,216.66 2196 $4,762.78 STALEVO 50 TABLETS 104 $835.85 324 $2,602.90 STAVUDINE 30MG CAPSULES 60 $174.99 180 $516.96 STAVUDINE 40MG CAPSULES 58 $356.19 175 $1,062.55 STAXYN 10MG ODT TABLETS 6 $162.25 16 $448.23 STENDRA 100MG TABLETS 5 $377.03 15 $1,038.62 STENDRA 200MG TABLETS 6 $383.56 17 $1,167.79 STERILE WATER INJ, 5ML 265 $29.40 484 $50.49 STERILE WATER/IRRIGATION 250ML 7105 $131.89 13208 $241.75 STORZ H-P-N 0.1% OPHTH SUSP 7.5ML 8 $143.29 8 $141.99 SUBOXONE 2MG/0.5MG SUBL/BUCC FILM 29 $154.78 152 $792.77 SUBOXONE 8MG/2MG SUBL/BUCC FILM 30 $275.57 115 $1,064.30 SUCRALFATE 1GM TABLETS 83 $35.91 262 $104.45 SUCRALFATE 1GM/10ML SUSP 30X10ML 579 $411.13 1725 $1,216.68 SULFACETAMIDE 10%/SULFUR5% LOTION 47 $357.63 184 $1,391.33 SULFACLEANSE 8-4% SUSPENSION 475 $256.93 699 $376.47 SULFADIAZINE 500MG TABLETS 140 $441.86 311 $978.44 SULFALONE OPHTH SOLN 10ML 7 $19.19 13 $30.24 SULFAMETH-TRIMETH SUSP(CHERRY) 168 $40.86 351 $81.13 SULFAMYLON 85MG CRM 113.4GM 126 $152.45 397 $470.12 SULFASALAZINE 500MG TABLETS 125 $31.12 356 $81.03 SULFASALAZINE EC 500MG DR TABLETS 123 $45.79 366 $128.29 SULINDAC 150MG TABLETS 51 $15.88 164 $42.21 SULINDAC 200MG TABLETS 50 $21.44 164 $61.29 SUMATRIPTAN 100MG TABLETS 10 $142.71 30 $427.95 SUMATRIPTAN 20MG NASAL SPRAY(6 SPR) 7 $370.00 21 $1,106.91 SUMATRIPTAN 25MG TABLETS 10 $125.56 30 $355.17 SUMATRIPTAN 4MG/0.5ML INJ, 2X0.5ML 3 $453.04 10 $1,633.98 SUMATRIPTAN 50MG TABLETS 10 $140.20 32 $431.49 SUMATRIPTAN 5MG NASAL SPRAY (6 SPR) 7 $339.79 17 $861.11 SUMATRIPTAN 6MG REFILL INJECTION 4 $768.71 12 $2,334.19 SUMATRIPTAN 6MG/0.5ML PF INJ2X0.5ML 3 $546.37 10 $1,802.04 SUMATRIPTAN 6MG/0.5ML VIAL FOR INJ 3 $515.63 9 $1,366.92 SUPARTZ 25MG INJECTION 2.5ML 9 $1,047.26 16 $1,862.94 SUPER B COMPLEX TABLETS 34 $12.90 96 $29.07 SUPRAX 400MG CAPSULES 7 $177.70 63 $1,599.94

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

SUPREP BOWEL PREP SOLN 355 $126.19 354 $125.99 SUSTIVA 200MG CAPSULES 58 $683.54 90 $1,049.99 SYMBICORT 160/4.5MCG (120 ORAL INH) 10 $326.98 29 $923.35 SYMBICORT 80/4.5MCG (120 ORAL INH) 10 $303.22 28 $827.47 SYNAREL 2MG/ML NASAL SOLN(60 SPR) 24 $9,825.39 67 $26,951.12 SYNTHROID 0.025MG (25MCG)TABLETS 31 $52.72 90 $143.74 SYNTHROID 0.112MG (112MCG) TABLETS 31 $42.63 89 $115.84 SYNTHROID 0.137MG (137MCG) TABLETS 30 $47.64 87 $131.65 SYNTHROID 0.1MG (100MCG)TABLETS 30 $41.56 88 $114.06 SYNVISC ONE 8MG/ML INJ, 6ML 7 $1,530.27 7 $1,488.35 TACLONEX SUSPENSION 60GM 82 $1,305.56 212 $3,349.84 TACROLIMUS 0.03% OINTMENT 60GM 51 $307.10 125 $738.78 TACROLIMUS 0.1% OINTMENT 60GM 55 $329.71 164 $971.69 TACROLIMUS 0.5MG (HALF MG) CAPSULES 80 $160.86 209 $414.09 TACROLIMUS 1MG CAPSULES 145 $556.50 348 $1,326.15 TACROLIMUS 5MG (FIVE MG) CAPSULES 63 $1,228.09 175 $3,421.13 TAMIFLU 6MG/ML SUSPENSION 100 $253.16 132 $331.78 TAMOXIFEN 10MG TABLETS 50 $59.40 149 $170.03 TAMOXIFEN 20MG TABLETS 30 $44.34 90 $123.68 TAMSULOSIN 0.4MG CAPSULES 33 $76.17 105 $234.40 TANZEUM 30MG ONCE WEEKLY INJ 4 PENS 4 $579.98 12 $1,720.57 TARCEVA 100MG TABLETS 30 $8,600.69 90 $25,911.97 TARCEVA 150MG TABLETS 29 $8,399.87 90 $25,911.97 TARCEVA 25MG TABLETS 67 $6,641.76 225 $22,455.40 TARON FORTE CAPSULES 32 $26.91 91 $68.25 TARON-C DHA CAPSULES 30 $28.10 89 $74.87 TARON-PREX CAPSULES 30 $51.02 90 $145.06 TASIGNA 200MG CAPSULES 88 $10,049.34 98 $11,160.88 TAZAROTENE 0.1% CREAM 30GM 44 $259.87 128 $752.29 TAZORAC 0.05% CREAM 15GM 41 $520.64 186 $2,324.20 TAZORAC 0.05% GEL 30GM 43 $539.63 218 $2,723.22 TAZORAC 0.1% GEL 30GM 46 $619.49 108 $1,439.83 T-DIET 30MG CAPSULES 27 $32.24 90 $97.24 TECHLITE INSULIN SYR 30GX12MM, 1ML 95 $32.45 186 $59.76 TECHLITE INSULIN SYR 30GX12MM,0.5ML 104 $35.27 209 $66.65 TECHLITE PEN NEEDLES 29GX12MM 109 $59.14 158 $84.11 TEKTURNA 150MG TABLETS 31 $193.26 92 $562.01 TEKTURNA 300MG TABLETS 29 $225.94 89 $683.41 TEKTURNA HCT 150-12.5MG TABLETS 29 $193.95 92 $608.38 TEKTURNA HCT 300-12.5 TABLETS 30 $233.41 88 $679.15 TEKTURNA HCT 300MG-25MG TABLETS 30 $232.60 89 $683.18 TELMISARTAN 20MG TABLETS 31 $135.21 90 $383.94 TELMISARTAN 40MG TABLETS 31 $135.32 91 $391.00 TELMISARTAN 80MG TABLETS 31 $133.88 91 $387.33 TELMISARTAN/AMLODIPINE 40-10MG TABS 29 $152.22 89 $453.08 TELMISARTAN/AMLODIPINE 40-5MG TABS 31 $158.86 91 $464.86 TELMISARTAN/AMLODIPINE 80-10MG TABS 30 $156.43 90 $457.84 TELMISARTAN/AMLODIPINE 80-5MG TABS 30 $157.04 90 $460.17

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

TELMISARTAN/HCTZ 40-12.5MG TABS 30 $150.94 89 $437.46 TELMISARTAN/HCTZ 80-12.5MG TABS 31 $157.81 92 $457.93 TELMISARTAN/HCTZ 80-25MG TABS 30 $152.76 89 $442.61 TEMAZEPAM 22.5MG CAPSULES 29 $228.11 93 $710.56 TEMAZEPAM 30MG CAPSULES 30 $14.34 91 $35.26 TEMAZEPAM 7.5MG CAPSULES 30 $187.90 99 $602.31 TEMOZOLOMIDE 100MG CAPSULES 15 $2,093.09 56 $7,698.29 TEMOZOLOMIDE 140MG CAPSULES 14 $2,470.70 15 $2,685.97 TEMOZOLOMIDE 180MG CAPSULES 9 $1,920.05 15 $3,291.97 TEMOZOLOMIDE 20MG CAPSULES 19 $586.48 15 $471.97 TEMOZOLOMIDE 250MG CAPSULES 5 $1,534.95 15 $4,191.97 TENIVAC INJ, 0.5ML VIAL 1 $47.18 1 $46.99 TENOFOVIR 300MG TABLETS 29 $735.79 84 $2,141.15 TERBUTALINE 2.5MG TABLETS 36 $119.15 119 $390.67 TERBUTALINE 5MG TABLETS 55 $226.46 191 $767.95 TERBUTALINE SULFATE 1MG/ML INJ, 1ML 38 $923.62 25 $603.75 TERCONAZOLE 0.4% VAGINAL CRM 45GM 45 $41.20 70 $61.33 TERCONAZOLE 0.8% VAGINAL CRM 20GM 21 $45.27 71 $146.54 TERCONAZOLE 80MG VAGINAL SUPP 3'S 3 $81.55 15 $363.95 TESTOSTERONE 1% (12.5MG/1.25GM)PUMP 167 $400.88 396 $944.54 TESTOSTERONE 1% GEL(25MG)30X2.5GM 103 $522.35 277 $1,395.36 TESTOSTERONE 1%(50MG) GEL 30X5GM PK 183 $476.03 523 $1,348.89 TESTOSTERONE 10MG/ACT GEL(120PUMPS) 69 $426.14 168 $1,033.78 TESTOSTERONE CYP 100MG/ML INJ, 10ML 10 $50.20 10 $50.64 TESTOSTERONE CYP 200MG/ML 1ML 4 $35.55 8 $75.33 TESTOSTERONE ENAN 200MG/ML INJ, 5ML 5 $82.47 7 $102.37 TETANUS/DIPH TOX 2-2 LF INJ. O.5ML 1 $23.31 1 $22.99 TETRABENAZINE 12.5MG TABLETS 75 $4,817.88 200 $12,853.98 TETRABENAZINE 25MG TABLETS 82 $5,891.43 218 $15,650.92 TETRACAINE HCL .5% OPHTHSOLN 14 $8.57 17 $9.31 TETRACYCLINE 250MG CAPSULES 45 $331.07 144 $1,051.99 TETRACYCLINE 500MG CAPSULES 41 $620.13 138 $2,063.48 THEO-24 100MG CR CAPSULES 44 $92.17 143 $289.52 THEO-24 300MG ER CAPSULES 39 $137.95 115 $402.89 THEOPHYLLINE 200MG ER TABLETS 43 $17.54 45 $18.24 THEOPHYLLINE 300MG CR TABLETS 50 $68.50 146 $193.97 THEOPHYLLINE 400MG ER TABLETS 33 $40.03 96 $108.43 THEOPHYLLINE 450MG ER TABLETS 44 $37.75 136 $107.66 THEOPHYLLINE 600MG ER TABLETS 33 $79.22 98 $224.95 THEOPHYLLINE 80MG/15ML ORAL SOLN 689 $77.26 1760 $191.08 THERA-FLUR GEL DROPS 24ML 89 $24.89 219 $55.31 THIAMINE 100MG/ML INJ, 2ML 12 $76.51 8 $50.03 THIORIDAZINE 100MG** TABLETS 57 $30.71 181 $88.82 THIORIDAZINE 25MG TABLETS 53 $25.05 176 $74.19 THIOTHIXENE 10MG** CAPSULES 64 $88.16 198 $264.79 THIOTHIXENE 1MG CAPSULES 69 $35.83 181 $87.42 THIOTHIXENE 2MG CAPSULES 48 $29.00 146 $79.29 THIOTHIXENE 5MG CAPSULES 53 $62.51 152 $172.23

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

THYROID (ARMOUR) 2GR (120MG) TABS 31 $41.51 90 $112.81 THYROID (ARMOUR) 0.25GR (15MG) TABS 42 $25.62 111 $60.68 THYROID (ARMOUR) 1.5GR (90MG) TABS 30 $37.23 88 $100.00 THYROID (ARMOUR) 1/2GRN30MG TABS 39 $27.39 106 $67.36 THYROID (ARMOUR) 1GR (60MG) TABS 35 $25.20 99 $63.11 THYROID (ARMOUR) 3GR (180MG) TABS 30 $38.99 89 $106.57 THYROID (ARMOUR) 4GR (240MG) TABS 30 $41.50 86 $112.76 THYROID (ARMOUR) 5GR (300MG) TABS 23 $41.87 63 $107.96 THYROID TABS USP 1/2GR 39 $11.87 110 $26.06 THYROID TABS USP 1GR 38 $12.92 109 $29.48 THYROID TABS USP 1GR (65MG) 33 $7.31 94 $13.35 TIAGABINE 2MG TABLETS 69 $455.14 177 $1,154.59 TIAGABINE 4MG TABLETS 75 $493.50 232 $1,512.74 TILIA FE TABLETS 28'S 28 $43.64 84 $120.31 TIMOLOL 0.25% GF OPHTH SOLN 5ML 5 $81.70 8 $123.65 TIMOLOL 0.5% GF OPHTH SOLN 2.5ML 5 $103.17 8 $163.10 TIMOLOL MALEATE 10MG TABLETS 58 $106.81 153 $272.67 TIMOLOL MALEATE 20MG TABLETS 51 $145.20 154 $430.28 TIMOLOL MALEATE 5MG TABLETS 54 $64.83 132 $151.70 TIMOPTIC 0.25% OCUDOSE 60'S 61 $400.81 156 $1,012.77 TIMOPTIC 0.5% OCUDOSE 60S 63 $511.26 174 $1,406.60 TINIDAZOLE 250MG TABLETS 33 $155.24 134 $611.83 TINIDAZOLE 500MG TABLETS 10 $99.21 76 $745.78 TIROSINT 137 MCG CAPSULES 29 $117.56 85 $337.53 TIROSINT 100MCG CAPSULES 31 $143.19 90 $403.94 TIROSINT 112MCG CAPSULES 29 $134.45 89 $396.31 TIROSINT 125MCG CAPSULES 30 $136.34 87 $389.33 TIROSINT 13MCG CAPSULES 33 $152.32 103 $458.07 TIROSINT 150MCG CAPSULES 31 $141.22 89 $395.92 TIROSINT 25MCG CAPSULES 29 $128.37 86 $369.11 TIROSINT 50MCG CAPSULES 29 $130.61 84 $374.09 TIROSINT 75MCG CAPSULES 28 $129.72 83 $372.44 TIROSINT 88MCG CAPSULES 30 $137.41 88 $392.33 TIZANIDINE 2MG CAPSULES 54 $135.97 199 $493.53 TIZANIDINE 2MG TABLETS 62 $18.37 209 $52.71 TIZANIDINE 4MG CAPSULES 59 $95.07 188 $295.54 TIZANIDINE 4MG TABLETS 65 $56.30 213 $174.16 TIZANIDINE 6MG CAPSULES 70 $165.26 206 $482.98 TL-CERMIDE EMULSION 90GM 172 $230.99 386 $514.33 TL-HEM 150 TABLETS 32 $21.17 87 $51.61 TOBRADEX OPHTH OINT 3.5GM 4 $269.36 14 $1,047.96 TOBRADEX ST 0.3/0.05% OPTH SUSP 5ML 5 $227.02 8 $333.97 TOBRAMYCIN 1.2/30ML INJ, 30ML 107 $161.64 330 $492.33 TOBRAMYCIN 300MG/5ML INH SOL 56X5ML 258 $5,146.65 389 $7,748.45 TOBRAMYCIN 80MG/2ML INJ,2ML 82 $125.94 168 $252.61 TOBRAMYCIN/DEXAMETHASONESUSP 2.5ML 5 $91.27 9 $163.93 TOBREX 0.3% OPTH OINT 3.5GM 4 $216.96 12 $697.30 TOLAZAMIDE 250MG TABLETS 38 $80.85 90 $186.69

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

TOLAZAMIDE 500MG TABLETS 55 $174.49 180 $561.98 TOLBUTAMIDE 500MG TABLETS 80 $85.21 190 $198.05 TOLCAPONE 100MG TABLETS 121 $12,587.38 306 $31,936.78 TOLMETIN SODIUM 400MG CAPSULES 72 $231.02 220 $702.10 TOLMETIN SODIUM 600MG TABLETS 62 $228.16 197 $713.46 TOLTERODINE TART 2MG ER CAPSULES 32 $178.69 94 $521.66 TOLTERODINE TART ER 4MG CAPSULES 31 $203.93 91 $598.13 TOLTERODINE TARTRATE 1MG TABLETS 54 $139.69 160 $406.53 TOLTERODINE TARTRATE 2MG TABLETS 54 $86.08 156 $242.79 TOPIRAMATE 100MG TABLETS 56 $187.69 164 $540.52 TOPIRAMATE 15MG SPRINKLE CAPSULES 91 $202.19 236 $514.67 TOPIRAMATE 200MG TABLETS 54 $246.96 156 $710.52 TOPIRAMATE 25MG SPRINKLE CAPSULES 101 $283.04 249 $692.88 TOPIRAMATE 25MG TABLETS 71 $88.86 201 $244.89 TOPIRAMATE 50MG TABLETS 60 $109.51 176 $314.82 TOPIRAMATE ER 150MG CAPSULES 36 $523.13 107 $1,548.83 TOPIRAMATE ER 25MG CAPSULES 48 $224.75 148 $681.02 TOPIRAMATE ER 50MG CAPSULES 38 $229.07 109 $656.53 TORSEMIDE 100MG (HUNDREDMG) TABLET 36 $20.68 98 $49.52 TOUJEO MAX SOLOSTAR 300U/ML PEN 3ML 7 $580.73 14 $1,232.88 TOVIAZ 4MG TABLETS 31 $338.06 90 $982.82 TOVIAZ 8MG TABLETS 30 $316.04 89 $924.38 TRADJENTA 5MG TABLETS 30 $406.28 88 $1,188.41 TRAMADOL 50MG TABLETS 67 $21.85 259 $72.95 TRAMADOL ER 100MG CAPSULES 34 $297.19 106 $907.72 TRAMADOL ER 100MG TABLETS 35 $105.22 105 $305.00 TRAMADOL ER 200MG CAPSULES 30 $336.41 88 $992.72 TRAMADOL ER 200MG TABLETS 30 $154.39 91 $457.66 TRAMADOL ER 300MG CAPSULES 29 $453.85 89 $1,392.26 TRAMADOL ER 300MG TABLETS 29 $186.76 89 $554.64 TRAMADOL HCL ER 100MG (BIPHASIC) TB 38 $84.74 113 $242.28 TRAMADOL HCL ER 200MG TABLETS 31 $192.55 86 $534.99 TRAMADOL HCL ER 300MG TABLETS 30 $148.36 90 $442.33 TRAMADOL/APAP 37.5MG/325MG TABS 56 $59.59 264 $267.64 TRANDOLAPRIL-VERAPAMIL ER 1-240MG T 29 $140.64 83 $395.64 TRANDOLAPRIL-VERAPAMIL ER 2-180MG T 34 $144.32 97 $406.29 TRANDOLAPRIL-VERAPAMIL ER2-240MG T 32 $138.66 95 $399.99 TRANDOLAPRIL-VERAPAMIL ER4-240MG T 31 $133.69 94 $396.16 TRANEXAMIC ACID 650MG TABLETS 31 $76.70 103 $245.71 TRANSDERM-SCOP PATCHES 5 $97.12 29 $574.03 TRANYLCYPROMINE 10MG TABLETS 139 $290.14 429 $887.83 TRAVATAN Z 0.004% OPHTH SOLN 5ML 3 $274.60 8 $631.57 TRAZODONE 300MG TABLETS 30 $134.07 91 $392.10 TRESIBA FLEXTOUCH PEN (U-100)INJ3ML 16 $509.52 27 $863.59 TRESIBA FLEXTOUCH PEN(U-200)INJ 3ML 12 $807.95 27 $1,748.64 TRETINOIN 0.01% GEL 15GM 35 $146.77 107 $444.50 TRETINOIN 0.025% CREAM 45GM 36 $155.49 89 $378.22

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

TRETINOIN 0.025% GEL 45GM 36 $151.37 98 $406.98 TRETINOIN 0.05% CREAM 20GM 37 $163.89 90 $395.04 TRETINOIN 0.05% EMOLLIENT CRM 60GM 41 $138.65 50 $168.99 TRETINOIN 0.05% GEL 45GM 45 $362.06 113 $893.98 TRETINOIN 0.1% CREAM 20GM 37 $188.69 101 $511.06 TRETINOIN MICRO 0.04% GEL 45GM 41 $445.29 128 $1,375.30 TRETINOIN MICRO 0.1% GEL PUMP 50GM 41 $564.54 105 $1,433.41 TREXALL 10MG TABLETS 7 $213.00 18 $533.47 TREXALL 15MG TABLETS 5 $186.33 12 $508.69 TREXALL 5MG TABLETS 14 $202.36 37 $544.72 TREXALL 7.5MG TABLETS 6 $130.79 14 $305.31 TRIAMCIN/ORABAS 0.1% DENT-PAST 5GM 6 $59.88 29 $285.94 TRIAMCINOLONE 0.025% LOTION 60ML 64 $57.38 154 $132.55 TRIAMCINOLONE 0.025% OINTMENT 454GM 71 $41.94 294 $160.74 TRIAMCINOLONE 0.1% LOTION60ML 66 $42.44 235 $141.13 TRIAMCINOLONE 0.5% OINT 15GM 32 $14.79 157 $56.14 TRIAMCINOLONE TOPICAL SPRAY 63GM 89 $310.36 267 $928.61 TRIAMTERENE 50MG/ HCTZ 25MG CAPS 21 $37.24 89 $146.51 TRIANEX 0.05% OINTMENT 430GM 434 $2,275.47 430 $2,252.64 TRIAZOLAM 0.125MG TABLETS 16 $31.89 106 $189.45 TRIAZOLAM 0.25MG TABLETS 21 $42.76 107 $201.52 TRICARE PRENATAL DHA ONE CAPSULES 30 $69.41 90 $201.96 TRIFLUOPERAZINE 10MG TABLETS 60 $66.40 167 $176.76 TRIFLUOPERAZINE 1MG TABLETS 55 $22.02 149 $53.03 TRIFLUOPERAZINE 2MG TABLETS 55 $50.48 144 $126.18 TRIFLUOPERAZINE 5MG TABS 54 $47.27 149 $122.85 TRIFLURIDINE 1% OPHTH SOLN 7.5ML 8 $167.74 8 $180.74 TRIGLIDE 160MG TABLETS 30 $289.03 89 $852.22 TRIHEXYPHENIDYL 0.4MG/ML ELIXIR 530 $56.65 1795 $182.26 TRI-LO SPRINTEC TABLETS 28'S 28 $25.20 84 $67.17 TRI-LUMA CREAM 30GM 30 $198.61 33 $216.29 TRIMAGEN FA TABLETS 34 $43.40 93 $112.73 TRIMAGEN FORTE TABLETS 34 $35.01 96 $90.80 TRIMETHOBENZAMIDE 300MG CAPSULES 35 $55.57 217 $324.61 TRIMIPRAMINE 100MG CAPSULES 50 $413.36 162 $1,321.55 TRIMIPRAMINE 25MG CAPSULES 37 $127.95 150 $503.95 TRIMIPRAMINE 50MG CAPSULES 57 $324.37 163 $919.36 TRINATE TABLETS 30 $17.69 90 $45.39 TRINTELLIX 10MG TB (WAS BRINTELLIX) 30 $423.95 90 $1,256.53 TRITAL DM LIQUID 138 $22.31 4021 $539.13 TRI-VIT/FLUO 0.5MG DROPS 50ML 50 $25.18 55 $27.07 TROKENDI XR 100MG CAPSULES 33 $839.00 98 $2,458.10 TROPICACYL 1% OPHTH SOLN 2ML 11 $14.09 18 $20.36 TROPICAMIDE 0.5% OPHTH SOLN 15ML 17 $22.55 15 $19.99 TROSPIUM CL 60MG ER CAPSULES 30 $191.54 89 $555.48 TRUE TEST TEST STRIPS 25'S 110 $177.77 211 $337.57 TRULANCE 3MG TABLETS 30 $433.86 88 $1,253.28

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

TRULICITY 0.75MG/0.5ML SDP 4X0.5ML 2 $763.12 6 $2,143.13 TRUMENBA PRE-FILLED INJ, 0.5ML SYR 1 $168.86 1 $167.99 TRUVADA 200MG-300MG TABLETS 30 $1,682.43 89 $5,051.77 TUDORZA PRESSAIR 400MCG ORAL INH 60 1 $204.29 3 $556.98 TUSNEL PEDIATRIC DROPS 60 $15.00 60 $15.00 TUSNEL PEDIATRIC LIQUID 119 $13.07 118 $12.99 TWINRIX INJ, 1ML 1 $143.20 1 $145.02 TX-APTIVUS 250MG CAPSULES 115 $1,554.27 360 $4,836.96 TX-DIDANOSINE (DDI) 250MG DR CAPS 30 $202.56 87 $580.01 TX-EDURANT 25MG TABLETS 30 $998.45 90 $2,990.67 TX-EMTRIVA 200MG CAPSULES 25 $506.45 70 $1,401.40 TX-INTELENCE 200MG TABLETS 60 $1,292.01 178 $3,844.38 TX-INVIRASE 200MG CAPSULES 99 $454.61 540 $2,463.97 TX-KALETRA 200-50MG TABLETS 118 $1,125.30 347 $3,299.79 TX-LAMIVUD/ZIDOVUD 150MG/300MG TABS 59 $419.66 178 $1,269.15 TX-LAMIVUDINE 300MG TABLETS 30 $196.52 93 $603.20 TX-NORVIR 80MG/ML SOL 71 $496.86 227 $1,568.00 TX-ODEFSEY (FTC200/RPV25//TAF25)TAB 30 $2,953.56 89 $8,795.48 TX-REYATAZ 200MG CAPSULES 59 $1,527.74 177 $4,580.17 TX-REYATAZ 300MG CAPSULES 30 $1,569.35 90 $4,672.91 TX-STAVUDINE 20MG CAPSULES 52 $92.27 104 $179.73 TX-SUSTIVA 600MG TABLETS 30 $1,049.24 89 $3,117.92 TX-VIRACEPT 250MG TABLETS 253 $954.98 660 $2,487.78 TX-VIRACEPT 625MG TABLETS 119 $1,193.34 341 $3,421.80 TX-ZIDOVUDINE 100MG CAPSULES 109 $218.56 293 $577.72 TX-ZIDOVUDINE 300MG TABLETS 56 $121.22 162 $344.23 TYDEMY TABLETS 28S 29 $208.33 82 $588.51 TYPHIM VI INJECTION, 0.5ML 1 $90.60 1 $90.34 UD MEPERIDINE 50MG TABLETS 34 $37.58 101 $104.77 UD THIORIDAZINE 10MG TABLETS 98 $31.62 222 $66.58 UD THIORIDAZINE 50MG TABLETS 60 $30.10 169 $77.16 ULORIC 40MG TABLETS 30 $321.69 88 $929.58 ULORIC 80MG TABLETS 30 $316.95 88 $923.96 ULTIGUARD INS SYR 0.5ML, 31G X 5/16 102 $34.60 208 $66.22 ULTILET LANCETS 100S 116 $23.68 176 $34.03 UNIFINE PENTIPS PLUS 31GX8MM 118 $56.07 166 $77.10 UNIFINE PENTIPS PLUS 32GX4MM(5/32") 125 $63.84 166 $83.39 UNISTIK 2 NORMAL LANCETS 123 $33.73 227 $58.64 UNITHROID 125MCG TABLETS 30 $42.11 88 $114.41 UNITHROID 150MCG TABLETS 30 $41.44 87 $113.10 UNITHROID 200MCG TABLETS 30 $40.37 88 $109.92 UREA 20% CREAM 85GM 93 $17.18 293 $45.31 UREA 39% CREAM 226.8GM 229 $200.45 454 $393.96 UREA 40% CREAM 85GM 109 $97.37 269 $235.20 UREA POWDER 933 $43.20 1500 $67.00 URETRON D-S TABLETS 18 $26.58 217 $277.61 UROAV-B CAPSULES 44 $54.91 225 $265.77

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

URO-BLUE TABLETS 48 $190.71 224 $877.08 URSODIOL 250MG TABLETS 58 $135.90 196 $446.97 URSODIOL 300MG CAPSULES 75 $374.18 236 $1,165.85 URSODIOL 500MG TABLETS 62 $251.01 186 $739.55 UTA CAPSULES 49 $113.29 233 $519.52 VALACYCLOVIR 1GM TAB 21 $207.81 94 $905.69 VALACYCLOVIR 500MG TABLETS 29 $167.18 98 $544.94 VALGANCICLOVIR 450MG TABLETS 48 $2,969.94 127 $7,813.64 VALPROIC ACID 250/5ML SYRUP 527 $17.38 1604 $44.74 VALPROIC ACID 250MG CAPSULES 106 $41.16 300 $108.80 VALSARTAN 160MG TABLETS 33 $139.03 100 $410.16 VALSARTAN 320MG TABLETS 30 $158.24 90 $464.32 VALSARTAN 40MG TABLETS 34 $110.67 98 $309.20 VALSARTAN 80MG TABLETS 33 $124.54 98 $361.61 VALSARTAN/HCTZ 160MG/12.5MG TABLETS 31 $121.14 92 $349.98 VALSARTAN/HCTZ 160MG/25MGTABLETS 30 $134.23 90 $392.08 VALSARTAN/HCTZ 320MG/12.5MG TABLETS 30 $149.00 90 $436.94 VALSARTAN/HCTZ 320MG/25MG TABLETS 30 $159.83 90 $470.15 VALSARTAN/HCTZ 80MG/12.5MG TABLETS 31 $101.84 90 $293.37 VANACOF LIQUID 154 $23.84 95 $16.25 VANCOMYCIN 125MG CAPSULES 42 $1,148.18 118 $3,229.89 VANCOMYCIN 250MG CAPSULES 48 $2,355.50 142 $6,956.68 VANIQA TWINPACK CREAM 2X30GM 45 $171.18 45 $169.99 VAQTA 25U/0.5ML INJ, 0.5ML (PED) 1 $61.16 1 $59.99 VAQTA 50U/1ML INJ, 1ML (ADULT) 1 $109.05 1 $108.99 VARIVAX INJ VIAL 1 $143.04 1 $142.99 VASCEPA 1GM CAPSULES 111 $263.42 313 $737.93 VAYARIN CAPSULES 60 $72.80 172 $201.32 VELIVET TABLETS 28 28 $25.88 84 $68.79 VENLAFAXINE ER 37.5MG CAPSULES 35 $129.78 101 $372.64 VENLAFAXINE 100MG TABLETS 62 $18.39 176 $45.13 VENLAFAXINE 25MG TABLETS 46 $14.69 132 $34.76 VENLAFAXINE 37.5MG TABLETS 47 $14.89 132 $34.71 VENLAFAXINE 50MG TABLETS 51 $15.87 147 $38.22 VENLAFAXINE 75MG TABLETS 57 $17.19 158 $40.78 VENLAFAXINE ER 150MG CAPSULES 35 $146.06 103 $424.09 VENLAFAXINE ER 150MG TABLETS 33 $150.10 100 $442.15 VENLAFAXINE ER 225MG TABLETS 29 $294.35 89 $885.09 VENLAFAXINE ER 37.5MG TABLETS 34 $126.57 102 $373.54 VENLAFAXINE ER 75MG CAPSULES 40 $152.60 117 $438.32 VENLAFAXINE ER 75MG TABLETS 36 $197.40 108 $587.34 VENTOLIN HFA INH W/DOS CTR 60PUFFS 14 $142.07 46 $465.73 VERAMYST 27.5MCG NASAL SP (120 INH) 12 $245.08 33 $669.17 VERAPAMIL 120MG SR CAPSULES 34 $34.72 101 $95.23 VERAPAMIL 180MG SR CAPSULES 33 $43.97 101 $125.68 VERAPAMIL 2.5MG/ML INJ, 5X2ML VIAL 11 $183.67 21 $344.29 VERAPAMIL 240MG ER CAPSULES 33 $41.69 99 $115.81 VERAPAMIL 360MG SR CAPSULES 30 $99.66 90 $290.43

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

VERAPAMIL ER 100MG CAPSULES (24 HR) 32 $19.14 97 $49.07 VERAPAMIL ER 120MG TABLETS 36 $24.53 108 $65.66 VERAPAMIL ER 180MG TABLETS 36 $11.23 110 $25.82 VERAPAMIL ER 200MG CAPSULES (24 HR) 33 $74.06 98 $212.06 VERAPAMIL ER 240MG TABLETS 35 $22.12 104 $57.30 VERAPAMIL ER 300MG CAPSULES (24 HR) 30 $88.10 89 $253.92 VEREGEN 15% OINTMENT 30GM 31 $841.32 30 $825.54 VESICARE 10MG TABLETS 30 $383.87 88 $1,113.26 VESICARE 5MG TABLETS 30 $371.59 89 $1,081.26 VFC-GARDASIL 9 INJ, 0.5ML1 VIAL 1 $206.82 1 $214.68 VFC-MENACTRA INJ 0.5ML VIAL 1 $128.74 1 $131.25 VFC-MENVEO INJ, 1 VIAL 1 $129.37 1 $128.43 VIAGRA 100MG TABLETS 6 $411.02 24 $1,543.72 VIAGRA 25MG TABLETS 9 $579.11 26 $1,715.63 VIAGRA 50MG TABLETS 7 $457.05 26 $1,699.24 VIBERZI 100MG TABLETS 57 $1,195.60 168 $3,536.42 VIBRAMYCIN 50MG/5ML SYRUP 149 $148.27 380 $372.47 VICA FORTE CAPSULES 37 $8.76 97 $16.62 VICODIN HP 10-300MG TABLETS (NEW) 91 $213.95 251 $585.81 VICTOZA 18MG/3ML INJ PEN 3ML 8 $741.22 23 $2,030.36 VIIBRYD 10MG TABLETS 32 $269.35 98 $817.99 VIIBRYD 20MG TABLETS 31 $259.92 92 $767.02 VIIBRYD 40MG TABLETS 30 $227.76 89 $676.37 VIMOVO 375-20MG TABLETS 54 $2,260.53 156 $6,484.84 VIMOVO 500-20MG TABLETS 56 $2,334.11 169 $7,018.53 VIMPAT 100MG TABLETS 67 $931.55 196 $2,711.88 VIMPAT 50MG TABLETS 73 $649.61 204 $1,814.81 VINATE II TABLETS (REFORMULATED) 27 $10.16 90 $24.37 VINCASAR PFS 1MG/ML INJ, 1ML 2 $49.23 3 $62.49 VIRTRATE-2 SOLUTION 912 $73.39 2751 $213.34 VISBIOME ORAL PACKETS 30S 33 $94.10 83 $228.40 VISICOL TABLETS 32 $217.07 32 $219.45 VIS-PHOS N TABLETS 99 $30.81 280 $79.45 VIT ACD & FLUORIDE 0.25MGDROPS 50 $14.05 97 $23.33 VITAFOL-OB +DHA CAPSULES 60 $128.25 176 $367.66 VITAL-D RX TABLETS 30 $13.53 91 $33.06 VITAMIN D 400UNITS/ML DROPS 50ML 61 $10.07 115 $15.49 VITAMIN K1 10MG/ML FOR INJ, 1ML 6 $243.68 15 $608.95 VIVA DHA CAPSULES 30 $114.21 90 $333.63 VIVOTIF TYPHOID ORAL VACCINE 4 $86.09 4 $85.99 VOL-NATE TABLETS 30 $17.98 91 $46.06 VORICONAZOLE 200MG TABLETS 54 $1,229.15 174 $3,939.22 VORICONAZOLE 50MG TABLETS 117 $1,192.40 296 $3,023.65 VOTRIENT 200MG TABLETS 99 $9,113.08 315 $29,130.98 VP-GSTN CAPSULES 59 $42.52 144 $97.51 VSL#3 DS POWDER PAK FOR SOLUTION 34 $190.88 129 $713.75 VYVANSE 20MG CAPSULES 30 $295.87 95 $914.48 VYVANSE 30MG CAPSULES 30 $295.37 93 $896.91

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price

VYVANSE 40MG CAPSULES 30 $294.02 93 $899.02 VYVANSE 50MG CAPSULES 30 $293.61 92 $891.55 VYVANSE 60MG CAPSULES 30 $292.68 91 $880.08 VYVANSE 70MG CAPSULES 30 $293.28 91 $884.53 WALG FIRST AID ANTIBIOTIC OINT 28GM 26 $10.03 294 $71.00 WAL-ITIN D 24 HOUR TABLETS 15'S 24 $10.18 89 $26.93 WELCHOL 625MG TABLETS 132 $482.51 382 $1,392.14 WP THYROID 48.75MG TABLETS 35 $12.28 99 $27.79 WP THYROID 65MG TABLETS 44 $12.28 118 $26.43 WP THYROID 81.25MG TABLETS 25 $11.03 87 $28.52 XADAGO 50MG TABLETS 31 $842.44 90 $2,414.50 XARELTO 20MG TABLETS 30 $369.22 89 $1,097.90 XARELTO 10MG TABLETS 25 $306.03 89 $1,091.12 XARELTO 15MG TABLETS 32 $480.79 90 $1,334.99 XENICAL 120MG CAPSULES 78 $518.36 241 $1,602.20 XERAC-AC SOLUTION 60ML 51 $27.30 53 $27.99 XEROFORM PETROLATUM DRESSING 50 $50.84 60 $60.39 XIFAXAN 200MG TABLETS 33 $595.30 209 $3,778.34 XIFAXAN 550MG TABLETS 47 $1,619.15 173 $5,975.66 XIGDUO XR 10MG/1000MG TABLETS 30 $521.65 90 $1,542.00 XIGDUO XR 5MG/1000MG TABLETS 52 $445.11 156 $1,329.45 XIIDRA 5% OP SOL SINGLES 5S 60 $304.23 176 $882.43 XTAMPZA ER 18MG CAPSULES 57 $475.83 113 $941.07 XULANE PATCHES 3 $132.24 9 $378.15 YUVAFEM 10MCG VAGINAL TABS 18S 10 $160.23 26 $398.50 ZAFIRLUKAST 20MG TABLETS 57 $107.86 169 $310.11 ZALEPLON 10MG CAPSULES 33 $40.27 99 $112.71 ZALEPLON 5MG CAPSULES 30 $31.22 96 $89.59 ZATEAN-PN DHA CAPSULES 30 $66.81 89 $189.67 ZELAPAR 1.25MG ORAL DISTINTGRT TABS 63 $4,693.73 180 $13,439.43 ZENCHENT TABLETS 28 29 $31.29 85 $83.36 ZEOSA 0.4MG/0.035MG TABLETS 28'S 29 $62.05 85 $173.50 ZIANA GEL 60GM 55 $728.03 132 $1,755.18 ZIDOVUDINE 10MG/ML SYRUP 559 $99.49 2462 $424.26 ZINC SULFATE 220MG CAPSULES 39 $11.77 113 $26.57 ZIOPTAN 0.0015% DROPS 30VIALS 30 $120.40 85 $330.82 ZIPRASIDONE HCL 20MG CAPSULES 46 $157.66 135 $453.18 ZIPRASIDONE HCL 40MG CAPSULES 44 $151.27 129 $432.49 ZIPRASIDONE HCL 60MG CAPSULES 47 $276.66 143 $827.90 ZIPRASIDONE HCL 80MG CAPSULES 49 $193.42 147 $571.90 ZIRGAN 0.15% OPHTH GEL 5GM 5 $312.13 8 $520.14 ZOLEDRONIC 4MG/5ML INJ, 5ML 5 $466.00 7 $608.80 ZOLEDRONIC 5MG/100ML INJ, 100ML 100 $451.34 100 $451.34 ZOLMITRIPTAN 2.5MG ODT TABLETS 9 $387.14 35 $1,493.03 ZOLMITRIPTAN 2.5MG TABLETS 9 $397.95 29 $1,212.90 ZOLMITRIPTAN 5MG ODT TABLETS 9 $427.16 28 $1,373.95 ZOLMITRIPTAN 5MG TABLETS 9 $443.21 31 $1,569.66 ZOLPIDEM 10MG TABLETS 29 $36.93 89 $105.25

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ZOLPIDEM 5MG TABLETS 28 $39.98 89 $117.31 ZOLPIDEM ER 12.5MG TABLETS 29 $140.77 90 $426.70 ZOLPIDEM ER 6.25MG TABLETS 29 $122.88 91 $370.74 ZONISAMIDE 100MG CAPSULES 89 $131.73 263 $380.56 ZONISAMIDE 25MG CAPSULES 86 $30.55 223 $73.08 ZONISAMIDE 50MG CAPSULES 71 $51.13 199 $135.64 ZORTRESS 0.25MG TABLETS 137 $1,238.14 360 $3,257.75 ZORTRESS 0.5MG TABLETS 175 $3,167.66 417 $7,539.66 ZORTRESS 0.75MG TABLETS 118 $3,346.55 291 $8,271.50 ZORVOLEX 35MG CAPSULES 71 $280.86 199 $777.95 ZOSTAVAX INJ (SQ) SINGL DSE VL 10PK 1 $237.99 1 $237.99 ZOVIA 1/35 TABLETS 21'S 29 $24.84 85 $64.96 ZOVIA 1/50 TABLETS 28 29 $26.35 86 $69.34 ZOVIRAX 5% CREAM 2GM 6 $762.94 26 $3,480.52 ZUBSOLV 5.7-1.4MG SUBLINGUAL TAB 32 $282.12 84 $728.08 ZYCLARA 3.75% CREAM 11 $1,646.21 23 $3,511.26 ZYFLO 600MG TABLETS 94 $3,032.04 303 $9,747.01 ZYLET OPHTHALMIC SUSPENSION 2.5ML 6 $264.22 9 $405.10 ZYTIGA 250MG TABLETS 116 $10,009.23 360 $31,021.71

Prescription drug coverage and cost are subject to change.