Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Penicillin V Potassium TAB 250mg 999 0.1092 Penicillin V Potassium TAB 500mg 999 0.0870 Amoxicillin CAP 250mg 999 0.0792 Amoxicillin CAP 500mg 999 0.0724 Amoxicillin TAB 500mg 999 0.1481 Amoxicillin TAB 875mg 999 0.0752 Amoxicillin PDR 125mg / 5ml, 80ml 80 0.0350 Amoxicillin PDR 125mg / 5ml, 100ml 100 0.0274 Amoxicillin PDR 125mg / 5ml, 150ml 150 0.0239 Amoxicillin SUS 200/5ml, 50ml 50 0.0711 Amoxicillin SUS 200/5ml, 75ml 75 0.0506 Amoxicillin SUS 200/5ml, 100ml 100 0.0380 Amoxicillin PDR 250mg / 5ml, 80ml 80 0.0211 Amoxicillin PDR 250mg / 5ml, 100ml 100 0.0211 Amoxicillin PDR 250mg / 5ml, 150ml 150 0.0177 Amoxicillin SUS 400/5ml, 50ml 50 0.0501 Amoxicillin SUS 400/5ml, 75ml 75 0.0488 Amoxicillin SUS 400/5ml, 100ml 100 0.0399 Dicloxacillin Sodium CAP 250mg 999 0.2434 Dicloxacillin Sodium CAP 500mg 999 0.4610 Amoxicillin/Clavulanic Acid TAB 250mg 999 2.7350 Amoxicillin/Clavulanic Acid TAB 500mg 999 0.1896 Amoxicillin/Clavulanic Acid TAB 875mg 999 0.1824 Amoxicillin/Clavulanic Acid SUS 200mg, 50ml 50 0.2665 Amoxicillin/Clavulanic Acid SUS 200mg, 75ml 75 0.2372 Amoxicillin/Clavulanic Acid SUS 200mg, 100ml 100 0.2612 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 75 0.7844 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 100 0.7855 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 150 0.7695 Amoxicillin/Clavulanic Acid SUS 400mg, 50mg 50 0.0765 Amoxicillin/Clavulanic Acid SUS 400mg, 75mg 75 0.0765 Amoxicillin/Clavulanic Acid SUS 400mg, 100mg 100 0.0765 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 75 0.0351 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 125 0.0351 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 200 0.0351 Cefadroxil CAP 500mg 999 0.2445 Cefadroxil SUS 250mg/5ml 50 0.2918 Cefadroxil SUS 250mg/5ml 100 0.2918 Cefadroxil SUS 500mg/5ml 75 0.3706 Cefadroxil SUS 500mg/5ml 100 0.3706 Cephalexin CAP 250mg 999 0.1011 Cephalexin CAP 500mg 999 0.0744 Cephalexin PDR 125mg/5ml, 100ml 100 0.0616 Cephalexin PDR 125mg/5ml, 200ml 200 0.0616 Cephalexin PDR 250mg/5ml, 100ml 100 0.1018 Cephalexin PDR 250mg/5ml, 200ml 200 0.0752 Cefprozil TAB 250mg 999 1.1038 Cefprozil TAB 500mg 999 0.6838 Cefprozil SUS 125mg/5ml 50 0.2565 Cefprozil SUS 125mg/5ml 75 0.2565 Cefprozil SUS 125mg/5ml 100 0.2565 Cefprozil SUS 250mg/5ml 50 0.1032 Cefprozil SUS 250mg/5ml 75 0.1032 Cefprozil SUS 250mg/5ml 100 0.1032 Cefuroxime TAB 250mg 999 0.1968 Cefuroxime TAB 500mg 999 0.3591 Cefdinir CAP 300mg 999 0.3828 Cefdinir SUS 125mg/5ml 60 0.1641 Cefdinir SUS 125mg/5ml 100 0.1562 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Cefdinir SUS 250mg/5ml 60 0.3094 Cefdinir SUS 250mg/5ml 100 0.2914 Cefixime SUS 100mg/5ml 999 3.3003 Cefixime SUS 200mg/5ml 50 6.6338 Cefixime SUS 200mg/5ml 75 6.6338 Cefpodoxime Proxetil TAB 100mg 999 2.8541 Cefpodoxime Proxetil TAB 200mg 999 3.2948 Ceftriaxone Sodium INJ 1gm 999 2.3721 Erythromycin TAB 250mg 999 9.7854 Erythromycin TAB 500mg 999 14.7511 Erythromycin Ethylsuccinate SUS 200mg/5ml 100 2.9821 Erythromycin Ethylsuccinate SUS 200mg/5ml 200 2.6995 Erythromycin Ethylsuccinate SUS 400mg/5ml 100 5.2889 Azithromycin TAB 250 mg 999 0.4444 Azithromycin TAB 500 mg 999 0.8341 Azithromycin TAB 600 mg 999 2.0004 Azithromycin SUS, PDR 100mg / 5 ml 15 1.1088 Azithromycin SUS, PDR 200mg / 5 ml 15 0.3340 Azithromycin SUS, PDR 200mg / 5 ml 22.5 0.2228 Azithromycin SUS, PDR 200mg / 5 ml 30 0.1990 Clarithromycin TAB 250mg 999 1.0901 Clarithromycin TAB 500mg 999 0.6273 Clarithromycin XL TAB, ER 500mg 999 2.3942 Demeclocycline TAB 150mg 999 4.9063 Demeclocycline TAB 300mg 999 3.8884 Doxycycline Monohydrate CAP 50mg 999 0.2885 Doxycycline Monohydrate CAP 75mg 999 13.3106 Doxycycline Monohydrate CAP 100mg 999 0.2394 Doxycycline Monohydrate CAP 150mg 999 16.3295 Doxycycline Monohydrate TAB 50mg 999 0.5299 Doxycycline Monohydrate TAB 75mg 999 0.5831 Doxycycline Monohydrate TAB 100mg 999 0.2782 Doxycycline Monohydrate TAB 150mg 999 2.9874 Doxycycline Monohydrate SUSP 25mg/5ml 999 0.3292 Doxycycline Hyclate CAP 50mg 999 0.3653 Doxycycline Hyclate CAP 100mg 999 0.9821 Doxycycline TAB 20mg 999 0.4400 Doxycycline Hyclate TAB 75mg 999 23.1067 Doxycycline Hyclate TAB 100mg 999 0.5400 Doxycycline Hyclate TAB 150mg 999 23.1067 Doxycycline Hyclate TAB, DR 50mg 999 9.0192 Doxycycline Hyclate TAB, DR 75mg 999 8.4757 Doxycycline Hyclate TAB, DR 100mg 999 2.0358 Doxycycline Hyclate TAB, DR 150mg 999 4.1656 Doxycycline Hyclate TAB, DR 200mg 999 9.5994 Minocycline Hydrochloride CAP 50mg 999 0.1520 Minocycline Hydrochloride CAP 75mg 999 0.2753 Minocycline Hydrochloride CAP 100mg 999 0.2263 Minocycline Hydrochloride TAB 50 mg 999 1.7163 Minocycline Hydrochloride TAB 75 mg 999 2.4676 Minocycline Hydrochloride TAB 100 mg 999 0.3406 Minocycline Hydrochloride TAB, ER 45mg 999 15.6356 Minocycline HCl TAB, ER 55mg 999 30.4193 Minocycline Hydrochloride TAB, ER 65mg 999 33.0219 Minocycline HCl TAB, ER 80mg 999 9.8618 Minocycline Hydrochloride TAB, ER 90mg 999 2.7777 Minocycline HCl TAB, ER 105mg 999 9.8618 Minocycline Hydrochloride TAB, ER 115mg 999 33.0219 Minocycline Hydrochloride TAB, ER 135mg 999 2.7777 Tetracycline Hydrochloride CAP 250mg 999 1.8673 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Tetracycline Hydrochloride CAP 500mg 999 3.9214 Ciprofloxacin TAB 250mg 999 0.0634 Ciprofloxacin TAB 500mg 999 0.0732 Ciprofloxacin TAB 750mg 999 0.3104 Levofloxacin TAB 250mg 999 0.1977 Levofloxacin TAB 500MG 999 0.2344 Levofloxacin TAB 750MG 999 0.1450 Moxifloxacin TAB 400mg 999 7.1429 Neomycin Sulfate TAB 500mg 999 0.7083 Tobramycin NEB 300mg/5ml 999 12.0325 Ethambutol TAB 100mg 999 0.1903 Ethambutol TAB 400mg 999 1.0315 Isoniazid TAB 300mg 999 0.0687 Rifampin CAP 150mg 999 0.9245 Rifampin CAP 300mg 999 0.3950 Flucytosine CAP 250mg 999 56.1352 Flucytosine CAP 500mg 999 108.6226 Griseofulvin Microsize TAB 500mg 999 7.2928 Griseofulvin, microsize SUS 125 mg/5 ml 999 0.0854 Griseofulvin Ultramicrosize TAB 125mg 999 3.5821 Griseofulvin Ultramicrosize TAB 250mg 999 4.5705 Nystatin TAB 500,000 units 999 0.2256 Terbinafine TAB 250mg 999 0.1116 Ketoconazole TAB 200mg 999 0.2016 Fluconazole TAB 50mg 999 0.4304 Fluconazole TAB 100mg 999 0.1026 Fluconazole TAB 150mg 999 0.2442 Fluconazole TAB 200mg 999 1.2225 Fluconazole SUS 10mg/ml 999 0.2036 Fluconazole SUS 40mg/ml 999 0.5701 Itraconazole CAP 100 mg 999 1.2090 Itraconazole SOL 10mg/ml 999 1.5110 Posaconazole TAB, DR 100mg 999 26.5421 Voriconazole TAB 50mg 999 1.8240 Voriconazole TAB 200mg 999 2.5935 Voriconazole SUS 40mg/ml 999 11.0101 Atazanavir Sulfate CAP 150mg 999 4.2891 Atazanavir Sulfate CAP 200mg 999 4.2891 Atazanavir Sulfate CAP 300mg 999 8.4971 Ritonavir TAB 100mg 999 1.3776 Abacavir Sulfate TAB 300mg 999 4.2052 Lamivudine TAB 150mg 999 3.4347 Lamivudine TAB 300mg 999 6.8701 Lamivudine SOL 10mg/ml 999 0.2367 Zidovudine CAP 100mg 999 0.6716 Zidovudine TAB 300mg 999 0.2902 Zidovudine SYP 50mg/5ml 999 0.0917 Tenofovir disoproxil fumarate TAB 300mg 999 6.3112 Efavirenz TAB 600mg 999 13.1167 Nevirapine TAB 200mg 999 0.1497 Nevirapine TAB,ER 400mg 999 11.3027 Abacavir / Lamivudine TAB 600-300mg 999 7.4386 Emtricitabine / Tenofovir TAB 200mg-300mg 999 29.7529 Lamivudine / Zidovudine TAB 150mg - 300mg 999 2.4546 Efavirenz / Emtricitabine / Tenofovir TAB 600mg - 200mg - 300mg 999 48.3646 Valganciclovir TAB 450mg 999 2.9330 Entecavir TAB 0.5mg 999 19.9063 Entecavir TAB 1mg 999 19.9063 Lamivudine TAB 100mg 999 7.5270 Ribavirin CAP 200mg 999 0.7493 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Ribavirin TAB 200mg 999 0.5723 Acyclovir CAP 200mg 999 0.1223 Acyclovir TAB 400mg 999 0.0711 Acyclovir TAB 800mg 999 0.1419 Acyclovir SUS 200/5ml 999 0.3744 Valacyclovir TAB 500mg 999 0.3864 Valacyclovir TAB 1Gm 999 0.5719 Famciclovir TAB 125mg 999 0.8718 Famciclovir TAB 250mg 999 0.8604 Famciclovir TAB 500mg 999 1.5351 Oseltamivir Phosphate CAP 30mg 999 9.7359 Oseltamivir Phosphate CAP 45mg 999 9.7359 Oseltamivir Phosphate CAP 75mg 999 10.3127 Oseltamivir Phosphate SUS 6mg/ml 999 2.0243 Hydroxychloroquine Sulfate TAB 200mg 999 1.1296 Quinine Sulfate CAP 324mg 999 5.6598 Atovaquone / Proguanil HCL TAB 250-100mg 999 1.3922 Albendazole TAB 200mg 999 193.7874 Metronidazole TAB 250mg 999 0.0975 Metronidazole TAB 500mg 999 0.0820 Tinidazole TAB 250mg 999 0.7010 Tinidazole TAB 500mg 999 0.6204 Trimethoprim TAB 100mg 999 0.3242 Clindamycin Hydrochloride CAP 150mg 999 0.0897 Clindamycin Hydrochloride CAP 300mg 999 0.1275 Clindamycin Palmitate HCL SOL 75mg/5ml 999 0.1473 Linezolid TAB 600mg 999 1.5208 Vancomycin CAP 125mg 999 2.3336 Vancomycin CAP 250mg 999 2.4402 Dapsone TAB 25mg 999 1.8200 Dapsone TAB 100mg 999 2.2326 Atovaquone SUS 750mg/5ml 999 1.2490 Methenamine Hippurate TAB 1gm 999 1.4739 Nitrofurantoin SUS 25mg/5ml 999 1.5848 Nitrofurantoin Macrocrystal CAP 25mg 999 5.6631 Nitrofurantoin Macrocrystal CAP 50mg 999 0.3548 Nitrofurantoin Macrocrystal CAP 100mg 999 0.2833 Nitrofurantoin Monohydrate CAP 100mg 999 0.1742 Sulfamethoxazole / Trimethoprim TAB 400 / 80mg 999 0.0770 Sulfamethoxazole / Trimethoprim TAB 800 / 160mg 999 0.0389 Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 20 0.1131 Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 473 0.1131 Cyclophosphamide CAP 25mg 999 6.7430 Cyclophosphamide CAP 50mg 999 12.5780 Temozolomide CAP 5mg 999 5.9041 Temozolomide CAP 20mg 999 23.5965 Temozolomide CAP 100mg 999 117.9815 Temozolomide CAP 140mg 999 165.1730 Temozolomide CAP 180mg 999 212.3653 Temozolomide CAP 250mg 999 295.0319 Capecitabine TAB 150mg 999 5.6040 Capecitabine TAB 500mg 999 18.6764 Mercaptopurine TAB 50mg 999 0.4516 Methotrexate TAB 2.5mg 999 0.1671 Erlotinib TAB 25mg 999 32.6410 Erlotinib TAB 100mg 999 89.8740 Erlotinib TAB 150mg 999 101.6790 Bicalutamide TAB 50MG 999 0.4190 Flutamide CAP 125mg 999 0.6372 Tamoxifen TAB 10mg 999 0.1520 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Tamoxifen TAB 20mg 999 0.3192 Anastrozole TAB 1mg 999 0.1859 Exemestane TAB 25mg 999 5.8098 Letrozole TAB 2.5mg 999 0.1528 Megestrol Acetate TAB 20mg 999 0.1393 Megestrol Acetate TAB 40mg 999 0.1704 Megestrol Acetate SUS 40mg/ml 10 0.0684 Megestrol Acetate SUS 40mg/ml 240 0.0684 Megestrol Acetate SUS 40mg/ml 480 0.0684 Abiraterone TAB 250mg 999 39.1434 Imatinib Mesylate TAB 100mg 999 32.3610 Imatinib Mesylate TAB 400mg 999 116.6110 Everolimus TAB 2.5mg 999 187.3990 Everolimus TAB 5mg 999 196.0162 Everolimus TAB 7.5mg 999 196.0162 Hydroxyurea CAP 500mg 999 0.4125 Tretinoin CAP 10mg 999 21.1828 Bexarotene CAP 75mg 999 103.5487 Leucovorin Calcium TAB 5mg 999 0.7766 Leucovorin Calcium TAB 25mg 999 6.4838 Budesonide CAP, EC 3mg 999 6.6509 Budesonide TAB, ER 9mg 999 39.3152 Dexamethasone ELIX 0.5mg/5ml 999 0.1750 Hydrocortisone TAB 5mg 999 0.1118 Hydrocortisone TAB 10mg 999 0.2050 Hydrocortisone TAB 20mg 999 0.2420 Methylprednisolone TAB 4mg 999 0.3657 Methylprednisolone TAB 8mg 999 1.4898 Methylprednisolone TAB 16mg 999 2.5162 Methylprednisolone TAB 32mg 999 3.4270 Prednisolone Sodium Phosphate SOL 15 mg/5ml 999 0.0562 Prednisolone SOL 20mg/5ml 999 5.1994 Prednisone TAB 1mg 999 0.1199 Prednisone TAB 2.5mg 999 0.0561 Prednisone TAB 5mg 999 0.0351 Prednisone TAB 10mg 999 0.0441 Prednisone TAB 20mg 999 0.0659 Prednisone TAB 50mg 999 0.3016 Fludrocortisone TAB 0.1mg 999 0.4804 Danazol CAP 200mg 999 6.7513 Testosterone SOL 30mg/act 999 5.8816 Testosterone GEL, TD 1%, 25mg/2.5GM 999 4.9870 Testosterone GEL, TD 1%, 50mg/5GM 999 0.8296 Testosterone GEL, TD 1.62%, 20.25mg/1.25GM 999 10.9340 Testosterone GEL, TD 1.62%, 40.5mg/2.5GM 999 5.6195 Testosterone GEL, PUMP 1.62%, 20.25mg/ACT 999 2.7120 Oxandrolone TAB 2.5mg 999 2.7348 Oxandrolone TAB 10mg 999 5.0912 Estradiol TAB 0.5mg 999 0.0766 Estradiol TAB 1mg 999 0.0905 Estradiol TAB 2mg 999 0.1181 Estradiol DIS, Biweekly 0.025mg/24hr 999 11.1824 Estradiol DIS, Biweekly 0.0375mg/24hr 999 10.6392 Estradiol DIS, Biweekly 0.05mg/24hr 999 11.1378 Estradiol DIS, Biweekly 0.075mg/24hr 999 11.5264 Estradiol DIS, Biweekly 0.1mg/24hr 999 10.9237 Estradiol DIS, Weekly 0.025mg/24hr 999 17.1968 Estradiol DIS, Weekly 0.0375mg/24hr 999 17.1968 Estradiol DIS, Weekly 0.05mg/24hr 999 13.9524 Estradiol DIS, Weekly 0.06mg/24hr 999 17.1968 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Estradiol DIS, Weekly 0.075mg/24hr 999 17.1968 Estradiol DIS, Weekly 0.1mg/24hr 999 6.5177 Estradiol / Norethindrone Acetate TAB 0.5mg-0.1mg 999 4.6388 Estradiol / Norethindrone Acetate TAB 1mg-0.5mg 999 3.5796 Norethindrone / Ethinyl Estradiol TAB 0.5mg-2.5mcg 999 2.8135 Norethindrone / Ethinyl Estradiol TAB 1mg-5mcg 999 2.0014 Norethindrone TAB 0.35mg 999 0.1348 Medroxyprogesterone INJ 150mg/ml 999 49.5038 Etonogestrel-Ethinyl Estradiol VA RING 0.120-0.015mg/24HR 999 136.8998 Ethinyl Estradiol / Desogestrel TAB 30mcg - 15mg 999 0.5395 Drospirenone / Ethinyl Estradiol TAB 3mg- 0.02mg 999 1.9845 Drospirenone / Ethinyl Estradiol TAB 3mg/0.03mg 999 1.8758 Ethinyl Estradiol / Ethynodiol Diacetate TAB 35 mcg - 1 mg 999 0.6614 Ethinyl Estradiol / Levonorgestrel TAB 20mcg - 0.1mg, 28-day 999 0.3519 Ethinyl Estradiol / Levonorgestrel TAB 30mcg - 0.15mg, 28-day 999 0.5550 Ethinyl Estradiol / Norethindrone TAB 0.4 / 0.035 mg 999 0.8430 Ethinyl Estradiol / Norethindrone TAB 35/0.5 999 0.7785 Ethinyl Estradiol / Norethindrone TAB 35 mcg - 1 mg, 28-day 999 0.5510 Ethinyl Estradiol / Norethindrone TAB 20mcg-1mg 999 0.3828 Ethinyl Estradiol / Norethindrone TAB 30mcg-1.5mg 999 0.9240 Ethinyl Estradiol / Norgestrel TAB 30mcg-0.3mg, 28-day 999 0.6544 Ethinyl Estradiol / Norgestimate TAB 35mcg-0.25mg, 28-day 999 0.3862 Ethinyl Estradiol / Norethindrone FE TAB, CHEW 35mcg/0.4mg 999 2.1424 Norethindrone/Ethinyl Estradiol/FE TAB, CHEW 0.8mg-25mcg-75mg 999 3.6535 Ethinyl Estradiol / Norethindrone / Fe CAP 20mcg-1mg-75mg 999 5.2730 Ethinyl Estradiol / Norethindrone / Fe TAB 20mcg-1mg-75mg, 28-day 999 0.6230 Ethinyl Estradiol/Norethindrone FE TAB 20mcg-1mg-75mg 999 2.6783 Ethinyl Estradiol / Norethindrone / Fe TAB 30mcg-1.5mg-75mg, 28-day 999 0.6793 Ethinyl Estradiol / Norethindrone / Fe TAB, CHEW 20mcg-1mg-75mg 999 4.4186 Desogestrel / Ethinyl Estradiol TAB 28 day 999 0.9862 Desogestrel/Ethinyl Estradiol TAB 28 day 999 0.8019 Ethinyl Estradiol / Levonorgestrel TAB 28-day 999 0.5920 Ethinyl Estradiol / Norethindrone TAB 7/7/7-28- day 999 0.6410 Ethinyl Estradiol / Norgestimate TAB 25-0.18/0.215/0.25 mcg-mg 999 0.4276 Ethinyl Estradiol/Norgestimate TAB 28-day 999 0.3189 Levonorgestrel/Ethinyl Estradiol TAB 0.1-0.02mg 999 2.0753 Ethinyl Estradiol / Levonorgestrel TAB 0.03 / 0.15 mg 999 1.1304 Levonorgestrel/Ethinyl Estradiol TAB 0.15-0.03mg 999 2.2297 Levonorgestrel - Ethinyl Estradiol TAB 0.15-0.02/0.025/0.03mg&0.01mg 999 3.1234 Ethinyl Estradiol / Levonorgestrel TAB 20-90mg 999 1.2092 Medroxyprogesterone Acetate TAB 2.5mg 999 0.0692 Medroxyprogesterone Acetate TAB 5mg 999 0.0740 Medroxyprogesterone Acetate TAB 10mg 999 0.0363 Megestrol Acetate SUS 650mg/5ml 999 3.4234 Norethindrone Acetate TAB 5mg 999 0.4859 Progesterone CAP 100mg 999 1.3745 Progesterone CAP 200mg 999 0.7420 Progesterone INJ 50mg/ml 999 3.1531 Glimepiride TAB 1mg 999 0.0262 Glimepiride TAB 2mg 999 0.0413 Glimepiride TAB 4mg 999 0.0612 Glipizide TAB 5mg 999 0.0216 Glipizide TAB 10mg 999 0.0383 Glipizide TAB 2.5mg CR 999 0.2026 Glipizide TAB 5mg CR 999 0.1793 Glipizide TAB 10mg CR 999 0.3341 Glyburide TAB 1.25mg 999 0.1112 Glyburide TAB 2.5mg 999 0.1276 Glyburide TAB 5mg 999 0.1926 Glyburide TAB, MICRO 1.5mg 999 0.0415 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Glyburide TAB, MICRO 3mg 999 0.0621 Glyburide TAB, MICRO 6mg 999 0.0815 Metformin TAB 500mg 999 0.0233 Metformin TAB 850mg 999 0.0374 Metformin TAB 1000mg 999 0.0512 Metformin TAB, ER 500mg (GP) 999 0.0469 Metformin TAB, ER 750mg (GP) 999 0.1221 Metformin TAB, ER 500mg (F) 999 0.8930 Metformin TAB, ER 1000mg (F) 999 9.7119 Metformin TAB, ER 500mg (GZ) 999 2.3831 Metformin TAB, ER 1000mg (GZ) 999 7.4393 Nateglinide TAB 60mg 999 0.8813 Nateglinide TAB 120mg 999 0.7415 Repaglinide TAB 0.5mg 999 0.6097 Repaglinide TAB 1mg 999 0.1796 Repaglinide TAB 2mg 999 0.2606 Glucose GEL 40% 999 0.0971 Acarbose TAB 25mg 999 0.2380 Acarbose TAB 50mg 999 0.2851 Acarbose TAB 100mg 999 0.3087 Pioglitazone HCL TAB 15mg 999 0.1764 Pioglitazone HCL TAB 30mg 999 0.1905 Pioglitazone HCL TAB 45mg 999 0.3332 Glipizide/Metformin TAB 2.5/250mg 999 0.4866 Glipizide/Metformin TAB 2.5/500mg 999 0.4562 Glipizide/Metformin TAB 5/500mg 999 0.4329 Glyburide/Metformin TAB 1.25mg/250mg 999 0.0706 Glyburide/Metformin TAB 2.5mg/500mg 999 0.0772 Glyburide/Metformin TAB 5mg/500mg 999 0.0781 Pioglitazone HCL / Metformin TAB 15-500mg 999 2.3692 Pioglitazone HCL / Metformin TAB 15-850mg 999 2.3692 Levothyroxine TAB 0.025mg 999 0.1300 Levothyroxine-Levoxyl TAB 0.025mg 999 0.1238 Levothyroxine-Unithroid TAB 0.025mg 999 0.4905 Levothyroxine TAB 0.05mg 999 0.1694 Levothyroxine-Levoxyl TAB 0.05mg 999 0.1267 Levothyroxine-Unithroid TAB 0.05mg 999 0.5592 Levothyroxine TAB 0.075mg 999 0.1330 Levothyroxine-Levoxyl TAB 0.075mg 999 0.1267 Levothyroxine-Unithroid TAB 0.075mg 999 0.6188 Levothyroxine TAB 0.088mg 999 0.1330 Levothyroxine-Levoxyl TAB 0.088mg 999 0.1267 Levothyroxine-Unithroid TAB 0.088mg 999 0.6299 Levothyroxine TAB 0.1mg 999 0.1330 Levothyroxine-Levoxyl TAB 0.1mg 999 0.1267 Levothyroxine-Unithroid TAB 0.1mg 999 0.6343 Levothyroxine TAB 0.112mg 999 0.2328 Levothyroxine-Levoxyl TAB 0.112mg 999 0.2217 Levothyroxine-Unithroid TAB 0.112mg 999 0.7345 Levothyroxine TAB 0.125mg 999 0.3141 Levothyroxine-Levoxyl TAB 0.125mg 999 0.2062 Levothyroxine-Unithroid TAB 0.125mg 999 0.7448 Levothyroxine TAB 0.137mg 999 0.2838 Levothyroxine-Levoxyl TAB 0.137mg 999 0.2702 Levothyroxine-Unithroid TAB 0.137mg 999 0.7733 Levothyroxine TAB 0.15mg 999 0.2257 Levothyroxine-Levoxyl TAB 0.15mg 999 0.2150 Levothyroxine-Unithroid TAB 0.15mg 999 0.7673 Levothyroxine TAB 0.175mg 999 0.2348 Levothyroxine-Levoxyl TAB 0.175mg 999 0.2237 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Levothyroxine-Unithroid TAB 0.175mg 999 0.9149 Levothyroxine TAB 0.2mg 999 0.2329 Levothyroxine-Levoxyl TAB 0.2mg 999 0.2218 Levothyroxine-Unithroid TAB 0.2mg 999 0.9167 Levothyroxine TAB 0.3mg 999 0.3420 Levothyroxine-Unithroid TAB 0.3mg 999 1.2518 Liothyronine TAB 5mcg 999 0.5224 Liothyronine TAB 25mcg 999 0.7997 Liothyronine TAB 50mcg 999 1.0859 Methimazole TAB 5mg 999 0.1587 Methimazole TAB 10mg 999 0.0607 Methylergon TAB 0.2mg 999 41.7191 Alendronate TAB 10mg 999 0.1343 Alendronate TAB 35mg 999 0.7118 Alendronate TAB 70mg 999 0.7085 Ibandronate Sodium TAB 150mg 999 40.9015 Risedronate Sodium TAB 5mg 999 4.1016 Risedronate Sodium TAB 30mg 999 29.0190 Risedronate Sodium TAB 35mg 999 17.3247 Risedronate Sodium TAB 150mg 999 184.3208 Risedronate Sodium TAB, DR 35mg 999 42.1036 Zoledronic Acid INJ 5mg/100ml 999 4.4012 Calcitonin, Salmon SOL 200U 999 13.4956 Raloxifene TAB 60mg 999 1.7126 Desmopressin Acetate TAB 0.1mg 999 1.1100 Desmopressin Acetate TAB 0.2mg 999 0.3849 Desmopressin Acetate SPR 0.01%, 5ml 999 21.7766 Cabergoline TAB 0.5mg 999 2.6394 Levocarnitine SOL 100 mg/ml 999 0.2910 Calcitriol CAP 0.25mcg 999 0.3434 Calcitriol CAP 0.5mcg 999 0.7659 Calcitriol SOL 1mcg / ml 999 8.8425 Paricalcitol Cap 1mcg 999 6.4351 Paricalcitol Cap 2mcg 999 4.8550 Paricalcitol CAP 4mcg 999 31.4941 Cinacalcet TAB 30mg 999 12.7707 Cinacalcet TAB 60mg 999 25.5419 Cinacalcet TAB 90mg 999 38.3119 Digoxin TAB 0.125mg 999 0.2930 Digoxin TAB 0.25mg 999 0.2930 Isosorbide Dinitrate TAB 5mg 999 0.6108 Isosorbide Dinitrate TAB 10mg 999 0.7017 Isosorbide Dinitrate TAB 20mg 999 0.7620 Isosorbide Dinitrate TAB 30mg 999 1.0330 Isosorbide Mononitrate TAB 10mg 999 0.1943 Isosorbide Mononitrate TAB 20mg 999 0.1573 Isosorbide Mononitrate TAB, ER 30mg 999 0.2832 Isosorbide Mononitrate TAB, ER 60mg 999 0.2936 Isosorbide Mononitrate TAB, ER 120mg 999 0.6362 Nitroglycerin TAB, SL 0.3mg 999 0.3742 Nitroglycerin TAB, SL 0.4mg 25 0.8165 Nitroglycerin TAB, SL 0.4mg 100 0.3742 Nitroglycerin TAB, SL 0.6mg 999 0.3742 Nitroglycerin PMP 0.4mg/spray 4.9 33.9453 Nitroglycerin PMP 0.4mg/spray 12 20.6961 Nitroglycerin PATCH 0.1mg/hr 999 0.9016 Nitroglycerin PATCH 0.2mg/hr 999 0.6739 Nitroglycerin PATCH 0.4mg/hr 999 0.6552 Nitroglycerin PATCH 0.6mg/hr 999 0.9345 Ranolazine TAB, ER 500mg 999 1.5417 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Ranolazine TAB, ER 1000mg 999 2.5313 Nadolol TAB 20mg 999 2.0130 Nadolol TAB 40mg 999 2.8026 Nadolol TAB 80mg 999 4.2522 Pindolol TAB 5mg 999 0.9804 Pindolol TAB 10mg 999 1.3357 Propranolol TAB 10mg 999 0.0474 Propranolol TAB 20mg 999 0.1442 Propranolol TAB 40mg 999 0.0578 Propranolol TAB 60mg 999 1.0566 Propranolol TAB 80mg 999 0.0677 Propranolol CAP, LA 60mg 999 1.3198 Propranolol CAP, LA 80mg 999 1.4382 Propranolol CAP, LA 120mg 999 1.8471 Propranolol CAP, LA 160MG 999 2.7680 Sotalol TAB 80mg 999 0.1227 Sotalol TAB 120mg 999 0.1888 Sotalol TAB 160mg 999 0.1801 Sotalol TAB 240mg 999 0.2775 Sotalol AF TAB 80mg 999 0.1252 Sotalol AF TAB 120mg 999 0.1809 Sotalol AF TAB 160mg 999 0.5843 Acebutolol Hydrochloride CAP 200 mg 999 0.2114 Acebutolol Hydrochloride CAP 400 mg 999 0.2653 Atenolol TAB 25mg 999 0.0252 Atenolol TAB 50mg 999 0.0260 Atenolol TAB 100mg 999 0.0453 Betaxolol HCL TAB 10mg 999 0.9015 Betaxolol HCL TAB 20mg 999 1.2312 Bisoprolol TAB 5mg 999 0.4408 Bisoprolol TAB 10mg 999 0.4724 Metoprolol Succinate TAB, ER 25mg 999 0.5212 Metoprolol Succinate TAB, ER 50mg 999 0.5193 Metoprolol Succinate TAB, ER 100mg 999 0.7851 Metoprolol Succinate TAB, ER 200mg 999 1.2490 Metoprolol Tartrate TAB 25mg 999 0.0238 Metoprolol Tartrate TAB 50mg 999 0.0229 Metoprolol Tartrate TAB 100mg 999 0.0348 Carvedilol TAB 3.125mg 999 0.0426 Carvedilol TAB 6.25mg 999 0.0426 Carvedilol TAB 12.5mg 999 0.0426 Carvedilol TAB 25mg 999 0.0463 Labetalol TAB 100mg 999 0.2770 Labetalol TAB 200mg 999 0.4322 Labetalol TAB 300mg 999 0.5265 Amlodipine TAB 2.5mg 999 0.0282 Amlodipine TAB 5mg 999 0.0292 Amlodipine Besylate TAB 10mg 999 0.0459 Diltiazem TAB 30mg 999 0.0473 Diltiazem TAB 60mg 999 0.0698 Diltiazem TAB 90mg 999 0.1969 Diltiazem TAB 120mg 999 0.1804 Diltiazem CAP, ER 120mg 999 0.4928 Diltiazem CAP, ER 180mg 999 0.6356 Diltiazem CAP, ER 240mg 999 0.9060 Diltiazem CAP, ER 300mg 999 1.2535 Diltiazem CAP, ER 360mg 999 1.2054 Diltiazem CAP, CD 120mg 999 0.4207 Diltiazem CAP, CD 180mg 999 0.5373 Diltiazem CAP, CD 240mg 999 0.6773 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Diltiazem CAP, CD 300mg 999 0.9174 Diltiazem CAP, CD 360mg 999 7.4969 Felodipine TAB, ER 2.5mg 999 0.2423 Felodipine TAB, ER 5mg 999 0.2867 Felodipine TAB, ER 10mg 999 0.3393 Nicardipine CAP 20mg 999 0.4139 Nicardipine CAP 30mg 999 0.5929 Nifedipine CAP 10mg 999 0.5322 Nifedipine TAB, ER 30mg 999 0.4168 Nifedipine TAB, ER 60mg 999 0.1922 Nifedipine TAB, ER 90mg 999 0.7573 Nifedipine TAB, XL 30mg 999 0.2751 Nifedipine TAB, XL 60mg 999 0.2445 Nifedipine TAB, XL 90mg 999 0.6667 Nimodipine CAP 30mg 999 6.0366 Verapamil HCL TAB 40mg 999 0.1577 Verapamil HCL TAB 80mg 999 0.0568 Verapamil HCL TAB 120mg 999 0.0910 Verapamil HCL TAB, ER 120mg 999 0.3408 Verapamil HCL TAB, ER 180mg 999 0.3174 Verapamil HCL TAB, ER 240mg 999 0.1607 Disopyramide Phosphate CAP 100mg 999 0.2727 Disopyramide Phosphate CAP 150mg 999 0.3126 Mexiletine Hydrochoride CAP 150mg 999 1.4452 Mexiletine Hydrochoride CAP 200mg 999 1.7253 Mexiletine Hydrochoride CAP 250mg 999 1.9940 Flecainide TAB 50mg 999 0.2212 Flecainide TAB 100mg 999 0.5147 Flecainide TAB 150mg 999 0.8200 Propafenone HCL TAB 150mg 999 0.1757 Propafenone HCL TAB 225mg 999 0.3063 Propafenone HCL TAB 300mg 999 0.7703 Propafenone CAP, ER 225mg 999 6.9602 Propafenone CAP, ER 325mg 999 8.8179 Propafenone CAP, ER 425mg 999 8.3194 Amiodarone TAB 100mg 999 3.3395 Amiodarone TAB 200mg 999 0.1434 Amiodarone TAB 400mg 999 2.1605 Dofetilide CAP 125mcg 999 3.7247 Dofetilide CAP 250mcg 999 3.7247 Dofetilide CAP 500mcg 999 3.7247 Benazepril TAB 5mg 999 0.0662 Benazepril TAB 10mg 999 0.0689 Benazepril TAB 20mg 999 0.0808 Benazepril TAB 40mg 999 0.0795 Captopril TAB 12.5mg 999 0.0265 Captopril TAB 25mg 999 0.0285 Captopril TAB 50mg 999 0.0445 Captopril TAB 100mg 999 0.0634 Enalapril TAB 2.5mg 999 0.0817 Enalapril TAB 5mg 999 0.1695 Enalapril TAB 10mg 999 0.1049 Enalapril TAB 20mg 999 0.1242 Fosinopril TAB 10mg 999 0.0958 Fosinopril TAB 20mg 999 0.1463 Fosinopril TAB 40mg 999 0.1692 Lisinopril TAB 2.5mg 999 0.0205 Lisinopril TAB 5mg 999 0.0231 Lisinopril TAB 10mg 999 0.0373 Lisinopril TAB 20mg 999 0.0489 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Lisinopril TAB 30mg 999 0.0935 Lisinopril TAB 40mg 999 0.0862 Perindopril Erbumine TAB 2mg 999 0.4681 Perindopril Erbumine TAB 4mg 999 0.6392 Perindopril Erbumine TAB 8mg 999 0.6888 Quinapril TAB 5mg 999 0.1595 Quinapril TAB 10mg 999 0.1719 Quinapril TAB 20mg 999 0.1813 Quinapril TAB 40mg 999 0.1822 Ramipril CAP 1.25mg 999 0.1970 Ramipril CAP 2.5mg 999 0.0951 Ramipril CAP 5mg 999 0.0979 Ramipril CAP 10mg 999 0.1094 Trandolapril TAB 1mg 999 0.3120 Trandolapril TAB 2mg 999 0.2503 Trandolapril TAB 4mg 999 0.2505 Candesartan TAB 4mg 999 2.2195 Candesartan TAB 8 mg 999 2.1985 Candesartan TAB 16mg 999 2.1726 Candesartan TAB 32mg 999 3.0358 Irbesartan TAB 75mg 999 0.3301 Irbesartan TAB 150mg 999 0.6025 Irbesartan TAB 300mg 999 0.6752 Losartan TAB 25mg 999 0.0661 Losartan TAB 50mg 999 0.0917 Losartan TAB 100mg 999 0.1301 Olmesartan Medoxomil TAB 5mg 999 0.5625 Olmesartan Medoxomil TAB 20mg 999 0.6889 Olmesartan Medoxomil TAB 40mg 999 0.9650 Telmisartan TAB 20mg 999 0.7427 Telmisartan TAB 40mg 999 0.6210 Telmisartan TAB 80mg 999 1.1069 Valsartan TAB 40mg 999 0.1723 Valsartan TAB 80mg 999 0.2449 Valsartan TAB 160mg 999 0.1594 Valsartan TAB 320mg 999 0.3995 Clonidine HCL PATCH 0.1mg/24 hour 999 20.6465 Clonidine HCL PATCH 0.2mg/24 hour 999 32.0016 Clonidine HCL PATCH 0.3mg/24 hour 999 40.5170 Clonidine HCL TAB 0.1mg 999 0.0306 Clonidine HCL TAB 0.2mg 999 0.0579 Clonidine HCL TAB 0.3mg 999 0.0701 Guanfacine Hydrochloride TAB 1mg 999 0.0793 Guanfacine Hydrochloride TAB 2mg 999 0.1242 Methyldopa TAB 250mg 999 0.0853 Methyldopa TAB 500mg 999 0.1842 Doxazosin TAB 1mg 999 0.1386 Doxazosin TAB 2mg 999 0.1516 Doxazosin TAB 4mg 999 0.1485 Doxazosin TAB 8mg 999 0.1631 Prazosin Hydrochloride CAP 1mg 999 0.1254 Prazosin Hydrochloride CAP 2mg 999 0.1267 Prazosin Hydrochloride CAP 5mg 999 0.1267 Terazosin CAP 1mg 999 0.0583 Terazosin CAP 2mg 999 0.0673 Terazosin CAP 5mg 999 0.0601 Terazosin CAP 10mg 999 0.0780 Eplerenone TAB 25mg 999 2.8785 Eplerenone TAB 50mg 999 2.1897 Phenoxybenzamine HCL CAP 10mg 999 75.3637 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Hydralazine Hydrochloride TAB 10mg 999 0.0402 Hydralazine Hydrochloride TAB 25mg 999 0.1006 Hydralazine Hydrochloride TAB 50mg 999 0.1856 Hydralazine Hydrochloride TAB 100mg 999 0.1797 Minoxidil TAB 2.5mg 999 0.1124 Minoxidil TAB 10mg 999 0.2673 Amlodipine / Benazepril CAP 2.5/10mg 999 0.1354 Amlodipine / Benazepril CAP 5/10mg 999 0.0844 Amlodipine / Benazepril CAP 5/20mg 999 0.6198 Amlodipine / Benazepril CAP 5/40mg 999 0.7327 Amlodipine / Benazepril CAP 10/20mg 999 0.6474 Amlodipine / Benazepril CAP 10/40mg 999 0.7702 Benazepril/HCTZ TAB 5mg / 6.25mg 999 0.4432 Benazepril/HCTZ TAB 10mg / 12.5mg 999 0.4432 Benazepril/HCTZ TAB 20mg / 12.5mg 999 0.4432 Benazepril/HCTZ TAB 20 mg / 25mg 999 0.4876 Enalapril / HCTZ TAB 5mg / 12.5 mg 999 0.1393 Enalapril / HCTZ TAB 10mg / 25 mg 999 0.1835 Fosinopril / HCTZ TAB 10mg / 12.5mg 999 0.9522 Fosinopril / HCTZ TAB 20mg / 12.5mg 999 1.0211 Lisinopril / HCTZ TAB 10mg / 12.5mg 999 0.0233 Lisinopril / HCTZ TAB 20mg / 12.5mg 999 0.0355 Lisinopril / HCTZ TAB 20mg / 25mg 999 0.0344 Hydrochlorothiazide/Quinapril TAB 12.5mg / 10mg 999 0.1978 Hydrochlorothiazide/Quinapril TAB 12.5mg / 20mg 999 0.7474 Hydrochlorothiazide/Quinapril TAB 25mg / 20mg 999 0.7444 Atenolol / Chlorthalidone TAB 50 / 25mg 999 0.2331 Atenolol / Chlorthalidone TAB 100 / 25mg 999 0.1330 Bisoprolol / HCTZ TAB 2.5mg / 6.25mg 999 0.1014 Bisoprolol / HCTZ TAB 5mg / 6.25mg 999 0.0673 Bisoprolol / HCTZ TAB 10mg / 6.25mg 999 0.0813 Metoprolol / Hydrochlorothiazide TAB 50mg / 25mg 999 0.9301 Metoprolol / Hydrochlorothiazide TAB 100mg / 25mg 999 1.3605 Amlodipine / Olmesartan Medoxomil TAB 5-20mg 999 1.1137 Amlodipine / Olmesartan Medoxomil TAB 5-40mg 999 1.4068 Amlodipine / Olmesartan Medoxomil TAB 10-20mg 999 1.0126 Amlodipine / Olmesartan Medoxomil TAB 10-40mg 999 1.4068 Amlodipine / Valsartan TAB 5-160mg 999 0.9226 Amlodipine / Valsartan TAB 5-320mg 999 1.1712 Amlodipine / Valsartan TAB 10-160mg 999 1.0470 Amlodipine / Valsartan TAB 10-320mg 999 1.3290 Telmisartan/Amlodipine TAB 40-5mg 999 3.9043 Telmisartan/Amlodipine TAB 40-10mg 999 3.9043 Telmisartan/Amlodipine TAB 80-5mg 999 3.9043 Telmisartan/Amlodipine TAB 80-10mg 999 3.9043 Candesartan / HCTZ TAB 16-12.5mg 999 2.3941 Candesartan / HCTZ TAB 32-12.5mg 999 2.3253 Candesartan / HCTZ TAB 32-25mg 999 1.9296 Irbesartan/HCTZ TAB 150-12.5mg 999 0.3474 Irbesartan/HCTZ TAB 300-12.5mg 999 0.4663 Losartan/HCTZ TAB 50-12.5mg 999 0.5985 Losartan/HCTZ TAB 100-12.5mg 999 0.8154 Losartan/HCTZ TAB 100-25mg 999 0.8154 Olmesartan Medoxomil / HCTZ TAB 20-12.5mg 999 0.6947 Olmesartan Medoxomil / HCTZ TAB 40-12.5mg 999 0.9655 Olmesartan Medoxomil / HCTZ TAB 40-25mg 999 0.9655 Telmisartan / HCTZ TAB 40-12.5mg 999 3.3615 Telmisartan / HCTZ TAB 80-12.5mg 999 4.0992 Telmisartan / HCTZ TAB 80-25mg 999 4.5092 Valsartan / HCTZ TAB 80-12.5mg 999 0.3833 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Valsartan / HCTZ TAB 160-12.5mg 999 0.4160 Valsartan / HCTZ TAB 160-25mg 999 0.3712 Valsartan / HCTZ TAB 320-12.5mg 999 0.3708 Valsartan / HCTZ TAB 320-25mg 999 0.6264 Olmesartan Medoxomil / Amlodipine / HCTZ TAB 20-5-12.5mg 999 3.2786 Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-5-12.5mg 999 3.5577 Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-5-25mg 999 3.9083 Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-10-12.5mg 999 3.8064 Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-10-25mg 999 4.2624 Acetazolamide TAB 125mg 999 1.6153 Acetazolamide TAB 250mg 999 0.2348 Acetazolamide CAP, ER 500mg 999 0.5143 Methazolamide TAB 25mg 999 1.6590 Methazolamide TAB 50mg 999 3.3181 Bumetanide TAB 0.5mg 999 0.2966 Bumetanide TAB 1mg 999 0.3867 Bumetanide TAB 2mg 999 0.6571 Ethacrynic Acid TAB 25mg 999 20.4786 Furosemide TAB 20mg 999 0.0216 Furosemide TAB 40mg 999 0.0228 Furosemide TAB 80mg 999 0.0343 Furosemide SOL 10mg / ml, 60ml 60 0.1106 Furosemide SOL 10mg / ml, 120ml 120 0.0840 Torsemide TAB 5mg 999 0.0928 Torsemide TAB 10mg 999 0.1613 Torsemide TAB 20mg 999 0.1578 Torsemide TAB 100mg 999 0.2861 Amiloride TAB 5mg 999 0.4171 Spironolactone TAB 25mg 999 0.0705 Spironolactone TAB 50mg 999 0.2359 Spironolactone TAB 100mg 999 0.1833 Chlorthalidone TAB 25mg 999 0.8943 Chlorthalidone TAB 50mg 999 1.1030 Hydrochlorothiazide CAP 12.5mg 999 0.0707 Hydrochlorothiazide TAB 12.5mg 999 0.1367 Hydrochlorothiazide TAB 25mg 999 0.0292 Hydrochlorothiazide TAB 50mg 999 0.0523 Indapamide TAB 1.25mg 999 0.1003 Indapamide TAB 2.5mg 999 0.1204 Metolazone TAB 2.5mg 999 0.3952 Metolazone TAB 5mg 999 0.7949 Metolazone TAB 10mg 999 0.7749 Amiloride Hydrochloride / Hydrochlorothiazide TAB 5mg / 50mg 999 0.2331 Spironolactone / HCTZ TAB 25mg / 25mg 999 0.2613 Triamterene / Hydrochlorothiazide CAP 37.5mg / 25mg 999 0.2410 Triamterene / Hydrochlorothiazide TAB 37.5mg / 25mg 999 0.2289 Triamterene / Hydrochlorothiazide TAB 75mg / 50mg 999 0.1872 Midodrine TAB 2.5mg 999 0.4000 Midodrine TAB 5mg 999 0.4129 Midodrine TAB 10mg 999 1.1098 Droxidopa CAP 100mg 999 14.6407 Droxidopa CAP 200mg 999 29.2807 Droxidopa CAP 300mg 999 44.2519 Cholestyramine POW 4gm/scoop 999 0.0978 Cholestyramine POW 4gm, Packet 1 1.8412 Cholestyramine POW 4gm, Packet 60 1.8412 Cholestyramine POW, LITE 4gm/scoop, 210gm 210 0.1376 Cholestyramine POW, LITE 4gm/scoop, 231gm 231 0.1595 Cholestyramine POW, LITE 4gm/scoop, 239.4gm 239.4 0.2216 Cholestyramine POW, LITE 4gm, Packet 1 1.3942 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Cholestyramine POW, LITE 4gm, Packet 42 1.3942 Cholestyramine POW, LITE 4gm, Packet 60 1.3942 Colesevelam HCL TAB 625mg 999 2.8788 Colesevelam HCL PACK 3.75gm 999 16.6465 Fenofibrate CAP, DR 45mg 999 1.0089 Fenofibrate CAP, DR 135mg 999 3.4360 Fenofibrate TAB 48mg 999 0.4426 Fenofibrate TAB 54mg 999 0.6210 Fenofibrate TAB 145mg 999 0.7030 Fenofibrate TAB 160mg 999 0.5482 Fenofibrate CAP 43mg 999 1.7517 Fenofibrate CAP 67mg 999 0.7828 Fenofibrate CAP 130mg 999 5.1443 Fenofibrate CAP 134mg 999 1.2619 Fenofibrate CAP 200mg 999 2.0388 Gemfibrozil TAB 600mg 999 0.1301 Ezetimibe TAB 10mg 999 3.2143 Atorvastatin Calcium TAB 10mg 999 0.2425 Atorvastatin Calcium TAB 20mg 999 0.3494 Atorvastatin Calcium TAB 40mg 999 0.3525 Atorvastatin Calcium TAB 80mg 999 0.4185 Fluvastatin TAB, ER 80mg 999 7.3260 Lovastatin TAB 10mg 999 0.0781 Lovastatin TAB 20mg 999 0.0898 Lovastatin TAB 40mg 999 0.0824 Rosuvastatin Calcium TAB 5mg 999 1.0634 Rosuvastatin Calcium TAB 10mg 999 1.0603 Rosuvastatin Calcium TAB 20mg 999 1.0579 Rosuvastatin Calcium TAB 40mg 999 1.0574 Pravastatin TAB 10mg 999 0.1330 Pravastatin TAB 20mg 999 0.1330 Pravastatin TAB 40mg 999 0.1530 Pravastatin TAB 80mg 999 0.2779 Simvastatin TAB 5mg 999 0.0447 Simvastatin TAB 10mg 999 0.0322 Simvastatin TAB 20mg 999 0.0912 Simvastatin TAB 40mg 999 0.0537 Simvastatin TAB 80mg 999 0.0898 Niacin TAB, ER 500mg 999 1.1674 Niacin TAB, ER 750mg 999 4.5048 Niacin TAB, ER 1000mg 999 5.7880 Omega-3 Acid CAP 1GM 999 0.4823 Ezetimibe / Simvastatin TAB 10-10mg 999 3.6745 Ezetimibe / Simvastatin TAB 10-20mg 999 3.8582 Ezetimibe / Simvastatin TAB 10-40mg 999 3.8582 Ezetimibe / Simvastatin TAB 10-80mg 999 3.6745 Sildenafil Citrate TAB 20mg 999 2.1349 Sildenafil Citrate SUS 10mg/ml 999 25.4147 Tadalafil (A) TAB 20mg 999 24.2083 Ambrisentan TAB 5mg 999 105.8893 Ambrisentan TAB 10mg 999 105.8893 Bosentan monohydrate TAB 62.5mg 999 60.4408 Bosentan monohydrate TAB 125mg 999 60.4408 Sildenafil Citrate TAB 25mg 999 16.7070 Sildenafil Citrate TAB 50mg 999 16.7070 Sildenafil Citrate TAB 100mg 999 16.7070 Tadalafil TAB 2.5mg 999 3.0070 Tadalafil TAB 5mg 999 3.0070 Tadalafil TAB 10mg 999 17.7084 Tadalafil TAB 20mg 999 17.6812 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Vardenafil HCL TAB 2.5mg 999 41.9667 Vardenafil HCL TAB 5mg 999 41.9667 Vardenafil HCL TAB 10mg 999 41.9667 Vardenafil HCL TAB 20mg 999 41.9667 Amlodipine / Atorvastatin TAB 2.5mg - 10mg 999 4.4520 Amlodipine / Atorvastatin TAB 2.5mg - 20mg 999 6.8454 Amlodipine / Atorvastatin TAB 2.5mg - 40mg 999 7.2144 Amlodipine / Atorvastatin TAB 5mg - 10mg 999 4.4076 Amlodipine / Atorvastatin TAB 5mg - 20mg 999 6.8454 Amlodipine / Atorvastatin TAB 5mg - 40mg 999 7.7916 Amlodipine / Atorvastatin TAB 5mg - 80mg 999 7.2144 Amlodipine / Atorvastatin TAB 10mg - 10mg 999 5.0372 Amlodipine / Atorvastatin TAB 10mg - 20mg 999 6.9441 Amlodipine / Atorvastatin TAB 10mg - 40mg 999 5.1223 Amlodipine / Atorvastatin TAB 10mg - 80mg 999 4.4441 Chlorpheniramine TAB 4mg 999 0.0084 Chlorpheniramine Maleate SYP 2mg / 5ml 999 0.0197 Clemastine Fumarate TAB 1.34mg 999 0.2382 Diphenhydramine Hydrochloride CAP 25mg 999 0.0174 Diphenhydramine TAB 25mg 999 0.0464 Diphenhydramine Hydrochloride LIQ 12.5mg / 5ml 999 0.4304 Diphenhydramine Hydrochloride ELIX 12.5mg / 5ml 999 0.5773 Promethazine Hydrochloride TAB 12.5mg 999 0.1146 Promethazine Hydrochloride TAB 25mg 999 0.0271 Promethazine Hydrochloride TAB 50mg 999 0.0438 Promethazine Hydrochloride SYP 6.25mg / 5ml 999 0.0211 Promethazine SUPP 12.5mg 999 9.0949 Promethazine Hydrochloride SUPP 25mg 999 0.5458 Cyproheptadine Hydrochloride TAB 4mg 999 0.1148 Cyproheptadine HCL SYP 2mg / 5ml 999 0.0363 Cetirizine TAB 5mg 999 0.0748 Cetirizine TAB 10mg 999 0.0599 Cetirizine TAB, CHEW 5mg 999 3.8919 Cetirizine TAB, CHEW 10mg 999 3.5834 Cetirizine SYP 1mg/ml 999 0.0182 Desloratadine TAB 5mg 999 0.6744 Fexofenadine TAB 60mg 999 0.2122 Fexofenadine TAB 180mg 999 0.3062 Levocetirizine Dihydrochloride TAB 5mg 999 0.2848 Levocetirizine SOLUTION 2.5mg/5ml 999 0.5225 Loratadine TAB 10mg 999 0.0588 Loratadine SYP 5mg / 5ml 999 0.0444 Loratidine TAB, DIS 10mg 999 0.4772 Pseudoephedrine HCL TAB 30mg 999 0.0238 Pseudoephedrine HCL TAB 60mg 999 0.0355 Pseudoepherine HCL TAB, SR 120mg 999 0.3488 Oxymetazoline HCL SOL, NAS 0.05% 15 0.0601 Oxymetazoline HCL SOL, NAS 0.05% 20 0.0601 Oxymetazoline HCL SOL, NAS 0.05% 22 0.0601 Oxymetazoline HCL SOL, NAS 0.05% 30 0.0601 Oxymetazoline HCL SOL, NAS 0.05% 37 0.0601 Fluticasone Propionate SPY 0.05%, 9.9ml 9.9 0.2514 Fluticasone Propionate SPY 0.05%, 15.8ml 15.8 0.2514 Fluticasone Propionate SPY 0.05%, 16gm 16 0.2891 Mometasone SPR, NASAL 50mcg 999 5.7117 Triamcinolone Acetonide Nasal AER 55mcg/act 10.8 0.9234 Triamcinolone Acetonide Nasal AER 55mcg/act 16.9 0.9234 Ipratropium Bromide SPY, NASAL 0.03%, 30ml 999 0.6634 Ipratropium Bromide SPY, NASAL 0.06%, 15ml 999 1.5424 Azelastine Nasal SPR 137mcg 999 0.4424 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Azelastine SPRAY, NASAL 0.15% 999 1.0615 Olopatadine HCL SPRAY, Nasal 0.6% 999 7.5930 Saline SPY, NASAL 0.65%, 45ml 999 0.0284 Azelastine / Fluticasone Nasal SPR 137-50mcg/act 999 5.7299 Hydrocodone Bitartrate / Homatropine Methylbromide TAB 5mg/1.5mg 999 0.8662 Hydrocodone Bitartrate / Homatropine Methylbromide SYP 5-1.5mg / 5ml 999 0.0486 Benzonatate CAP 100mg 999 0.0629 Benzonatate CAP 150mg 999 2.2585 Benzonatate CAP 200mg 999 0.1387 Guaifenesin TAB 200mg 999 0.0586 Guaifenesin TAB 400mg 999 0.0975 Guaifenesin LIQ 100mg / 5ml 999 0.0140 Guaifenesin SYP 100mg / 5ml 999 0.0095 Guaifenesin TAB 600 mg 999 0.2454 Acetylcysteine SOL 10% Inhalation, 4ml 4 1.1149 Acetylcysteine SOL 10% Inhalation, 10ml 10 0.6170 Acetylcysteine SOL 10% Inhalation, 30ml 30 0.1703 Acetylcysteine SOL 20% Inhalation, 4ml 4 1.5262 Acetylcysteine SOL 20% Inhalation, 10ml 10 0.7695 Acetylcysteine SOL 20% Inhalation, 30ml 30 0.6232 Bromphenirmine / PE ELIX 1-2.5mg/5ml 999 0.0160 Brompheniramine / PSE SOL 1-15 mg / 5 ml 999 0.0160 Cetririzine / PSE TAB 5-120mg 999 0.6703 Chlorpheniramine / PE TAB 4-10mg 999 0.1493 Chlorpheniramine / PSE TAB 4-60mg 999 0.0748 Loratadine / PSE TAB 5mg / 120mg 999 0.6232 Loratadine / PSE TAB 10mg / 240mg 999 0.5173 Pseudoephedrine HCL / Triprolidine HCL TAB 60-2.5mg 999 0.0385 Promethazine HCL / Codeine Phosphate SYR 6.25-10mg / 5ml 999 0.0097 Brompheniramine/Dextromethorphan/PSE SYP 2-10-30mg/5ml 999 0.0609 Guaifenesin / PSE / SYP 100-30 / 5ml 999 0.0153 Dextromethorphan/Guaifenesin LIQ 10mg-100mg/5ml 999 0.0159 Dextromethorphan / Guaifenesin LIQ 10-200mg/5ml 999 0.0308 Dextromethorphan / Guaifenesin SYP 100-10mg/5ml 999 0.0075 Dextromethorphan/Guaifenesin TAB 60mg / 1200mg 999 0.5988 Phenylephrine / DM / GG LIQ 5-10-100mg/5ml 999 0.0223 Codeine Phosphate / Guaifenesin / Pseudoephedrine Hydrochloride SOL 10-100-30mg / 5ml 999 0.0718 Ipratropium Bromide INH SOL 0.02% 999 0.0576 Albuterol Sulfate TAB 2mg 999 0.1048 Albuterol Sulfate TAB 4mg 999 0.1462 Albuterol Sulfate SYR 2mg / 5ml 999 0.0097 Albuterol Sulfate SOL 0.083%, Inhalation, 3ml 999 0.0307 Albuterol Sulfate SOL 0.50% 999 0.4805 Albuterol NEB .63/3ml 999 0.0709 Albuterol NEB 1.25mg 999 0.0709 Albuterol Sulfate HFA INH 108mcg/Act, 6.7gm 6.7 5.9688 Albuterol Sulfate HFA INH 108mcg/Act, 8.5gm 8.5 4.7049 Albuterol Sulfate HFA INH 108mcg/Act, 18gm 18 2.2218 Levalbuterol HCL NEB 0.31mg/3ml 999 0.9601 Levalbuterol HCL NEB 0.63mg/3ml 999 0.1796 Levalbuterol HCL NEB 1.25mg/3ml 999 0.1796 Levalbuterol HCL NEB 1.25mg/5ml 1 4.9646 Levalbuterol HCL NEB 1.25mg/5ml 30 4.9646 Terbutaline Sulfate TAB 2.5mg 999 2.1235 Terbutaline Sulfate TAB 5mg 999 2.6518 Ipratropium Bromide / Albuterol INH SOL 0.5-3mg/3ml 999 0.0488 Theophylline SOL 80mg/15ml 999 0.1739 Theophylline TAB, ER 400mg 999 0.9957 Theophylline TAB, ER 600mg 999 1.4536 Budesonide INH SOL 0.25mg/2ml 999 1.7165 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Budesonide INH SOL 0.5mg/2ml 999 1.9170 Budesonide RES 1mg/2ml 999 7.8018 Zileuton TAB 600mg 999 24.4653 Montelukast Sodium TAB 10mg 999 0.4594 Montelukast Sodium TAB, CHEW 4mg 999 0.0726 Montelukast Sodium TAB, CHEW 5mg 999 0.0846 Montelukast GRA PKT 4mg 999 1.1252 Zafirlukast TAB 10mg 999 1.5782 Zafirlukast TAB 20mg 999 1.7785 Magnesium Hydroxide SUS 400mg / 5ml 999 0.0040 Magnesium Citrate SOL 1.745 GM / 30 ml 999 0.0037 Sodium Phosphate SOL, ENE 133 0.0068 Sodium Phosphate SOL, ENE 230 0.0068 Sodium Phosphate SOL, ENE 59 0.0068 Sodium Phosphate SOL, ENE 66 0.0068 Bisacodyl EC TAB 5mg 999 0.0196 Bisacodyl SUPP 10mg 999 0.1587 Sennosides TAB 8.6mg 999 0.0287 Sennosides SYP 8.8 mg / 5ml 999 0.0748 Calcium Polycarbophil TAB 625mg 999 0.0764 Psyllium Seed POW 999 0.0152 Docusate Calcium CAP 240mg 999 0.0772 Docusate Sodium CAP 100mg 999 0.0156 Docusate Sodium CAP 250mg 999 0.0464 Docusate Sodium LIQ 150mg / 15ml 999 0.0086 Docusate Sodium SYP 60mg / 15ml 999 0.0067 Lactulose SOL 10mg / 15ml 15 0.0120 Lactulose SOL 10mg / 15ml 30 0.0120 Lactulose SOL 10mg / 15ml 237 0.0120 Lactulose SOL 10mg / 15ml 473 0.0120 Lactulose SOL 10mg / 15ml 946 0.0120 Polyethylene Glycol POW 3350 999 0.0216 Senosides/Docusate Sodium TAB 8.6-50 MG 999 0.0456 Polyethylene Glycol SOL 999 0.0019 PEG 3350 SOL 999 0.0027 Diphenoxylate / Atropine TAB 2.5mg/0.025mg 999 0.1064 Loperamide HCL CAP 2mg 999 0.1487 Loperamide HCL TAB 2mg 999 0.1202 Loperimide HCL LIQ 1mg / 5ml 999 0.0222 Bismuth Subsalicylate TAB, CHEW 262mg 999 0.0637 Bismuth Subsalicylate SUS 262mg / 15ml 999 0.0083 Lactobacillus CAP 999 0.0274 Sodium Bicarbonate TAB 650mg 999 0.0117 Calcium Carbonate TAB, CHEW 500mg 999 0.0190 Calcium Carbonate TAB, CHEW 750mg 999 0.0342 Calcium Carbonate SUS 1250mg/5ml 999 0.0208 Magnesium Oxide TAB 400mg 999 0.0538 AlumOH / MagOH / Simethicone SUS 200-200-20 999 0.0059 Aluminum / Magnesium / Simethicone SUS 400-400-40 / 5 ml 999 0.0094 Glycopyrrolate TAB 1mg 999 0.3259 Glycopyrrolate TAB 2mg 999 0.1449 Dicyclomine Hydrochloride CAP 10mg 999 0.0444 Dicyclomine Hydrochloride TAB 20mg 999 0.0315 Chlordiazepoxide Hydrochloride / Clidinium Bromide CAP 5mg / 2.5mg 999 16.6528 Cimetidine TAB 200mg 999 0.6610 Cimetidine TAB 300mg 999 0.0964 Cimetidine TAB 400mg 999 0.1088 Cimetidine TAB 800mg 999 0.3020 Famotidine TAB 10mg 999 0.0903 Famotidine TAB 20mg 999 0.0325 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Famotidine TAB 40mg 999 0.0632 Misoprostol TAB 200mcg 999 0.8992 Esomeprazole Magnesium CAP 20mg 999 2.5876 Esomeprazole Magnesium CAP 40mg 999 2.5876 Lansoprazole CAP 15mg 999 0.4679 Lansoprazole CAP 30mg 999 1.0315 Omeprazole TAB 20mg 999 0.8544 Omeprazole CAP 10mg 999 0.2999 Omeprazole CAP 20mg 999 0.1555 Omeprazole CAP 40mg 999 0.2364 Omeprazole Magnesium CAP, DR 20.6mg 999 0.5651 Pantoprazole TAB 20mg 999 0.2489 Pantoprazole TAB 40mg 999 0.1896 Rabeprazole TAB 20mg 999 0.8838 Sucralfate TAB 1GM 999 0.1277 Amoxicillin/Clarithromycin/Lansoprazole KIT 500mg-500mg-30mg 14 days kit 999 3.9528 Omeprazole / Sod Bicarbonate CAP 20-1100mg 999 1.1065 Omeprazole / Sod Bicarbonate CAP 40-1100mg 999 1.1247 Omeprazole / Sod Bicarbonate POW PKT 20-1680mg 999 10.2875 Omeprazole / Sod Bicarbonate POW PKT 40-1680mg 999 16.7381 Dimenhydrinate TAB 50mg 999 0.0246 Meclizine Hydrochloride TAB 12.5mg 999 0.0531 Meclizine Hydrochloride TAB 25mg 999 0.0575 Scopolamine DIS 1mg/3Day 999 14.5010 Trimethobenzamide CAP 300mg 999 1.3119 Granisetron TAB 1mg 999 3.4644 Ondansetron TAB, ODT 4mg 999 0.2574 Ondansetron TAB, ODT 8mg 999 0.2052 Ondansetron TAB 4mg 999 0.1338 Ondansetron TAB 8mg 999 0.2019 Ondansetron INJ 4mg/2ml 999 0.3330 Ondansetron INJ 40mg/20ml 999 0.2907 Ondansetron SOL 4mg/5ml 999 0.3112 Aprepitant CAP 40mg 999 81.4627 Aprepitant CAP 80mg 999 150.9944 Aprepitant CAP 125mg 999 235.9246 Aprepitant CAP 125mg-80mg 999 178.1462 Dronabinol CAP 2.5mg 999 2.1791 Dronabinol CAP 5mg 999 4.1941 Dronabinol CAP 10mg 999 9.0595 Doxylamine / Pyridoxine TAB, DR 10-10mg 999 5.7068 Ursodiol CAP 300mg 999 3.1723 Ursodiol TAB 250mg 999 2.0804 Ursodiol TAB 500mg 999 3.7157 Cromolyn Sodium CONC 100mg/5ml 999 1.0240 Simethicone TAB, CHEW 80 MG 999 0.0322 Simethicone TAB, CHEW 125MG 999 0.0673 Simethicone Drop 20mg/0.3ml 999 0.2098 Simethicone DRO 40mg / 0.6ml 15 0.0669 Simethicone DRO 40mg / 0.6ml 30 0.0669 Simethicone DRO 40mg / 0.6ml 45 0.0669 Metoclopramide Hydrochloride TAB 5mg 999 0.0547 Metoclopramide Hydrochloride TAB 10mg 999 0.0600 Metoclopramide Hydrochloride SOL 5mg/5ml 999 0.0130 Lactulose SOL 10mg / 15ml 999 0.0147 Balsalazide CAP 750mg 999 0.2106 Mesalamine TAB, DR 1.2gm 999 8.6435 Mesalamine ENE 4gm 999 0.1214 Mesalamine SUP 1000mg 999 26.3171 Mesalamine CAP 400mg 999 3.2197 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Mesalamine CAP 0.375gm 999 3.4131 Sulfasalazine TAB 500mg 999 0.1853 Sulfasalazine TAB, EC 500mg 999 0.2147 Alosetron TAB 0.5mg 999 17.9574 Alosetron TAB 1mg 999 46.6478 Calcium Acetate CAP 667mg 999 0.1699 Calcium Acetate TAB 667mg 999 0.3605 Sevelamer TAB 800mg 999 3.7566 Sevelamer Carbonate POW 0.8 GM 999 12.7597 Sevelamer Carbonate POW 2.4 GM 999 12.9284 Darifenacin Hydrobromide TAB, ER 7.5mg 999 8.5717 Darifenacin Hydrobromide TAB, ER 15mg 999 8.5717 Oxybutynin Chloride TAB 5mg 999 0.1187 Oxybutynin Chloride SYP 5mg/5ml 999 0.0190 Oxybutynin Chloride TAB,ER 5mg 999 0.5970 Oxybutynin Chloride TAB,ER 10mg 999 0.6568 Oxybutynin Chloride TAB,ER 15mg 999 0.9419 Solifenacin Succinate TAB 5mg 999 3.2957 Solifenacin Succinate TAB 10mg 999 3.2957 Tolterodine Tartrate TAB 1mg 999 2.1113 Tolterodine Tartrate TAB 2mg 999 1.0284 Tolterodine Tartrate CAP, ER 2mg 999 4.0055 Tolterodine Tartrate CAP, ER 4mg 999 3.6194 Trospium Chloride TAB 20mg 999 2.0510 Trospium Chloride CAP,ER 60mg 999 5.0802 Bethanechol TAB 5mg 999 0.1723 Bethanechol TAB 10mg 999 0.2171 Bethanechol TAB 25mg 999 0.3620 Bethanechol TAB 50mg 999 0.6969 Flavoxate HCL TAB 100mg 999 0.7686 Metronidazole GEL, VAG 0.75% 999 1.4597 Clotrimazole CRE, VAG 1%, 45gm 999 0.1026 Miconazole Nitrate VAG, CRE 2%, 45gm 999 0.0992 Miconazole Nitrate VAG, SUPP 100mg, #7 999 0.6189 Miconazole Nitrate KIT 999 8.7850 Miconazole Nitrate VAG, KIT 999 8.4533 Terconazole CRE, VAG 0.40% 999 0.1484 Estradiol Hemihydrate TAB, VAG 10mcg 999 19.3497 Estradiol CRE, VAG 0.01% 999 5.8500 Potassium Citrate TAB, ER 5 meq 999 1.3514 Potassium Citrate TAB, ER 10 meq 999 1.9379 Potassium Citrate TAB, ER 15meq 999 2.1249 Sodium Chloride IRR SOL 0.9%, 250ml 250 0.0068 Sodium Chloride IRR SOL 0.9%, 500ml 500 0.0060 Sodium Chloride IRR SOL 0.9%, 1000ml 1000 0.0060 Dutasteride CAP 0.5mg 999 0.6372 Finasteride TAB 5mg 999 0.1108 Alfuzosin HCL TAB, ER 10mg 999 0.2630 Silodosin CAP 4mg 999 2.5229 Silodosin CAP 8mg 999 2.6536 Tamsulosin CAP 0.4mg 999 0.3137 Dutasteride/Tamsulosin CAP 0.5mg-0.4mg 999 3.9149 Alprazolam TAB 0.25mg 999 0.0129 Alprazolam TAB 0.5mg 999 0.0094 Alprazolam TAB 1mg 999 0.0119 Alprazolam TAB 2mg 999 0.0547 Alprazolam TAB, XR 0.5mg 999 0.0502 Alprazolam TAB, XR 1mg 999 0.0524 Alprazolam TAB, XR 2mg 999 0.1186 Alprazolam TAB, XR 3mg 999 0.5454 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Chlordiazepoxide Hydrochloride CAP 5mg 999 0.0838 Chlordiazepoxide Hydrochloride CAP 10mg 999 0.0836 Chlordiazepoxide Hydrochloride CAP 25mg 999 0.0941 Clorazepate Dipotassium TAB 3.75mg 999 0.1875 Clorazepate Dipotassium TAB 7.5mg 999 0.1816 Clorazepate Dipotassium TAB 15mg 999 0.3287 Diazepam TAB 2mg 999 0.0206 Diazepam TAB 5mg 999 0.0201 Diazepam TAB 10mg 999 0.0226 Lorazepam TAB 0.5mg 999 0.0108 Lorazepam TAB 1mg 999 0.0090 Lorazepam TAB 2mg 999 0.0471 Lorazepam CONC 2mg/ml 999 1.1356 Buspirone TAB 5mg 999 0.0555 Buspirone TAB 7.5mg 999 0.3410 Buspirone TAB 10mg 999 0.0710 Buspirone TAB 15mg 999 0.0876 Buspirone TAB 30mg 999 1.7997 Hydroxyzine Hydrochloride TAB 10mg 999 0.0171 Hydroxyzine Hydrochloride TAB 25mg 999 0.0266 Hydroxyzine Hydrochloride TAB 50mg 999 0.0290 Hydroxyzine Hydrochloride SYP 10mg / 5ml 999 0.0178 Hydroxyzine Pamoate CAP 25mg 999 0.0740 Hydroxyzine Pamoate CAP 50mg 999 0.0749 Meprobamate TAB 200 mg 999 1.7019 Meprobamate TAB 400mg 999 3.3526 Mirtazapine TAB 7.5mg 999 1.9417 Mirtazapine TAB 15mg 999 0.1281 Mirtazapine TAB 30mg 999 0.1552 Mirtazapine TAB 45mg 999 0.3560 Mirtazapine TAB, DISP 15mg 999 0.8298 Mirtazapine TAB, DISP 30mg 999 0.8020 Mirtazapine TAB, DISP 45mg 999 0.9393 Tranylcypromine TAB 10mg 999 2.6676 Trazodone Hydrochloride TAB 50mg 999 0.0178 Trazodone Hydrochloride TAB 100mg 999 0.0796 Trazodone Hydrochloride TAB 150mg 999 0.1267 Trazodone Hydrochloride TAB 300mg 999 3.9435 Citalopram TAB 10mg 999 0.0523 Citalopram TAB 20mg 999 0.0381 Citalopram TAB 40mg 999 0.0423 Citalopram SOL 10mg / 5ml 999 0.2645 Escitalopram Oxalate TAB 5mg 999 0.0491 Escitalopram Oxalate TAB 10MG 999 0.1542 Escitalopram Oxalate TAB 20mg 999 0.1983 Escitalopram SOL 5mg/5ml 999 0.0970 Fluoxetine CAP 10mg 999 0.0355 Fluoxetine CAP 20mg 999 0.0453 Fluoxetine CAP 40mg 999 0.2537 Fluoxetine TAB 10mg 999 0.4452 Fluoxetine TAB 20mg 999 3.1595 Fluoxetine TAB 60mg 999 7.7808 Fluoxetine LIQ 20mg/5ml 999 0.0415 Fluvoxamine TAB 25mg 999 0.2283 Fluvoxamine TAB 50mg 999 0.2895 Fluvoxamine TAB 100mg 999 0.3102 Paroxetine TAB 10mg 999 0.0334 Paroxetine TAB 20mg 999 0.1003 Paroxetine TAB 30mg 999 0.1420 Paroxetine TAB 40mg 999 0.1527 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Paroxetine TAB, ER 12.5mg 999 4.7673 Paroxetine TAB, ER 25mg 999 4.0055 Paroxetine TAB, ER 37.5mg 999 5.1243 Sertraline Hydrochloride TAB 25mg 999 0.0483 Sertraline Hydrochloride TAB 50mg 999 0.0888 Sertraline Hydrochloride TAB 100mg 999 0.0903 Sertraline Hydrochloride SOL 20mg/ml 999 0.8394 Desvenlafaxine TAB, ER 25mg 999 3.4811 Desvenlafaxine TAB, ER 50mg 999 1.4118 Desvenlafaxine TAB, ER 100mg 999 1.4118 Duloxetine HCL CAP 20mg 999 0.3883 Duloxetine HCL CAP 30mg 999 0.2964 Duloxetine HCL CAP 40mg 999 5.8189 Duloxetine HCL CAP 60mg 999 0.2641 Venlafaxine Hydrochloride TAB 25mg 999 0.3258 Venlafaxine Hydrochloride TAB 37.5mg 999 0.3047 Venlafaxine Hydrochloride TAB 50mg 999 0.3315 Venlafaxine Hydrochloride TAB 75mg 999 0.3048 Venlafaxine Hydrochloride TAB 100mg 999 0.3361 Venlafaxine Hydrochloride CAP, ER 37.5mg 999 0.2003 Venlafaxine Hydrochloride CAP, ER 75mg 999 0.2185 Venlafaxine Hydrochloride CAP, ER 150mg 999 0.1667 Venlafaxine Hydrochloride TAB, ER 37.5 mg 999 5.0843 Venlafaxine Hydrochloride TAB, ER 75mg 999 5.6928 Venlafaxine Hydrochloride TAB, ER 150mg 999 5.5869 Venlafaxine Hydrochloride TAB, ER 225mg 999 14.9951 Amitriptyline TAB 10mg 999 0.0543 Amitriptyline TAB 25mg 999 0.0274 Amitriptyline TAB 50mg 999 0.0478 Amitriptyline TAB 75mg 999 0.0594 Amitriptyline TAB 100mg 999 0.0762 Amitriptyline TAB 150mg 999 0.0809 Clomipramine Hydrochloride CAP 25mg 999 8.2788 Clomipramine Hydrochloride CAP 50mg 999 7.3310 Clomipramine Hydrochloride CAP 75mg 999 8.2626 Desipramine HCL TAB 10mg 999 0.8222 Desipramine HCL TAB 25mg 999 1.2321 Desipramine HCL TAB 50mg 999 1.9768 Desipramine HCL TAB 75mg 999 2.6601 Desipramine HCL TAB 100mg 999 3.8791 Desipramine HCL TAB 150mg 999 4.8878 Doxepin Hydrochloride CAP 10mg 999 0.4627 Doxepin Hydrochloride CAP 25mg 999 0.6090 Doxepin Hydrochloride CAP 50mg 999 0.8731 Doxepin Hydrochloride CAP 75mg 999 1.3413 Doxepin Hydrochloride CAP 100mg 999 1.4613 Doxepin Hydrochloride LIQ 10mg/ml, Conc 999 0.0642 Imipramine HCL TAB 10mg 999 0.1187 Imipramine HCL TAB 25mg 999 0.1167 Imipramine HCL TAB 50mg 999 0.2079 Imipramine Pamoate CAP 75mg 999 5.0148 Imipramine Pamoate CAP 100mg 999 5.0148 Imipramine Pamoate CAP 125mg 999 5.0148 Imipramine Pamoate CAP 150mg 999 5.0148 Nortriptyline Hydrochloride CAP 10mg 999 0.1058 Nortriptyline Hydrochloride CAP 25mg 999 0.1442 Nortriptyline Hydrochloride CAP 50mg 999 0.1645 Nortriptyline Hydrochloride CAP 75mg 999 0.2449 Protriptyline TAB 5mg 999 1.3314 Protriptyline TAB 10mg 999 0.3283 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Bupropion HCL TAB 75mg 999 0.0860 Bupropion TAB 100mg 999 0.4456 Bupropion HCL TAB, SR 100mg 999 0.2620 Bupropion HCL TAB, SR 150mg 999 0.2174 Bupropion HCL TAB, SR 200mg 999 0.4514 Bupropion HCL TAB, XL 150mg 999 0.5583 Bupropion HCL TAB, XL 300mg 999 0.6617 Paliperidone TAB, ER 1.5mg 999 20.3818 Paliperidone TAB, ER 3mg 999 20.3818 Paliperidone TAB, ER 6mg 999 13.1673 Paliperidone TAB, ER 9mg 999 30.5728 Risperidone TAB 0.25mg 999 0.0839 Risperidone TAB 0.5mg 999 0.0841 Risperidone TAB 1mg 999 0.1169 Risperidone TAB 2mg 999 0.1350 Risperidone TAB 3mg 999 0.0774 Risperidone TAB 4mg 999 0.1586 Risperidone SOL 1mg/ml 999 0.4689 Risperidone TAB, ODT 0.5mg 999 1.3645 Risperidone TAB, ODT 1mg 999 1.2512 Risperidone TAB, ODT 2mg 999 3.7734 Risperidone TAB, ODT 3mg 999 4.3781 Risperidone TAB, ODT 4mg 999 7.2469 Haloperidol TAB 0.5mg 999 0.0634 Haloperidol TAB 1mg 999 0.1031 Haloperidol TAB 2mg 999 0.1422 Haloperidol TAB 5mg 999 0.1267 Haloperidol TAB 10mg 999 0.8011 Haloperidol TAB 20mg 999 2.0005 Haloperidol Lactate CONC 2mg / ml 15 0.2523 Haloperidol Lactate CONC 2mg / ml 120 0.1020 Clozapine TAB 25mg 999 0.4390 Clozapine TAB 50mg 999 0.8292 Clozapine TAB 100mg 999 0.5998 Clozapine TAB 200mg 999 2.4977 Quetiapine Fumarate TAB 25mg 999 0.1093 Quetiapine Fumarate TAB 50mg 999 0.0438 Quetiapine Fumarate TAB 100mg 999 0.0531 Quetiapine Fumarate TAB 200mg 999 0.0977 Quetiapine Fumarate TAB 300mg 999 0.1417 Quetiapine Fumarate TAB 400mg 999 0.1695 Quetiapine Fumarate TAB, ER 50mg 999 4.6707 Quetiapine Fumarate TAB, ER 150mg 999 7.9879 Quetiapine Fumarate TAB, ER 200mg 999 8.3920 Quetiapine Fumarate TAB, ER 300mg 999 11.5270 Quetiapine Fumarate TAB, ER 400mg 999 15.2416 Loxapine Succinate CAP 5mg 999 0.3327 Loxapine Succinate CAP 10mg 999 0.4396 Loxapine Succinate CAP 25mg 999 0.6631 Loxapine Succinate CAP 50mg 999 0.8979 Asenapine Maleate TAB, SL 5mg 999 9.7017 Asenapine Maleate TAB, SL 10mg 999 6.5571 Olanzapine TAB 2.5mg 999 0.1962 Olanzapine TAB 5mg 999 0.1707 Olanzapine TAB 7.5mg 999 0.2581 Olanzapine TAB 10mg 999 0.1894 Olanzapine TAB 15mg 999 0.4155 Olanzapine TAB 20 mg 999 0.4203 Olanzapine ODT TAB 5 mg 999 1.0746 Olanzapine ODT TAB 10 mg 999 0.7934 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Olanzapine ODT TAB 15 mg 999 1.8071 Olanzapine ODT TAB 20 mg 999 2.5310 Chlorpromazine HCL TAB 10mg 999 2.4322 Chlorpromazine HCL TAB 25mg 999 4.0706 Chlorpromazine HCL TAB 50mg 999 5.6055 Chlorpromazine HCL TAB 100mg 999 8.0329 Chlorpromazine HCL TAB 200mg 999 12.0741 Fluphenazine Hydrochloride TAB 1mg 999 3.2545 Fluphenazine Hydrochloride TAB 2.5mg 999 5.0388 Fluphenazine Hydrochloride TAB 5mg 999 6.8172 Fluphenazine Hydrochloride TAB 10mg 999 8.5956 Perphenazine TAB 2mg 999 1.1498 Perphenazine TAB 4mg 999 1.5739 Perphenazine TAB 8mg 999 1.9090 Perphenazine TAB 16mg 999 2.5683 Prochlorperazine SUPP 25mg, #12 999 3.3770 Prochlorperazine TAB 5mg 999 0.0852 Prochlorperazine TAB 10mg 999 0.1267 Trifluoperazine HCL TAB 1mg 999 0.2149 Trifluoperazine HCL TAB 2mg 999 0.3385 Trifluoperazine HCL TAB 5mg 999 0.4258 Trifluoperazine HCL TAB 10mg 999 0.6418 Aripiprazole TAB, ER 2mg 999 3.3818 Aripiprazole TAB, ER 5mg 999 3.8884 Aripiprazole TAB, ER 10mg 999 3.2205 Aripiprazole TAB, ER 15mg 999 3.2202 Aripiprazole TAB, ER 20mg 999 4.5540 Aripiprazole TAB, ER 30mg 999 4.5537 Aripiprazole SOL 1mg/ml 999 4.7112 Aripiprazole TAB, ODT 10mg 999 31.0429 Aripiprazole TAB, ODT 15mg 999 31.0429 Ziprasidone Hydrochloride CAP 20mg 999 0.3225 Ziprasidone Hydrochloride CAP 40mg 999 0.7795 Ziprasidone Hydrochloride CAP 60mg 999 0.4419 Ziprasidone Hydrochloride CAP 80mg 999 0.4419 Lithium Carbonate CAP 150mg 999 0.0673 Lithium Carbonate CAP 300mg 999 0.0331 Lithium Carbonate CAP 600mg 999 0.0999 Lithium Carbonate TAB 300mg 999 0.1542 Lithium Carbonate TAB, ER 300mg 999 0.1989 Lithium Carbonate TAB, ER 450mg 999 0.3141 Estazolam TAB 1mg 999 0.3260 Estazolam TAB 2mg 999 0.5453 Midazolam SYP 2mg/ml 999 0.8678 Temazepam CAP 7.5mg 999 1.8604 Temazepam CAP 15mg 999 0.0356 Temazepam CAP 22.5mg 999 2.7964 Temazepam CAP 30mg 999 0.0490 Triazolam TAB 0.125mg 999 2.5406 Triazolam TAB 0.25mg 999 0.7106 Eszopiclone TAB 1mg 999 0.2668 Eszopiclone TAB 2mg 999 0.2801 Eszopiclone TAB 3mg 999 0.2941 Zaleplon CAP 5mg 999 0.2944 Zaleplon CAP 10mg 999 0.1728 Zolpidem TAB 5mg 999 0.0216 Zolpidem TAB 10mg 999 0.0226 Zolpidem TAB, ER 6.25mg 999 0.3016 Zolpidem TAB, ER 12.5mg 999 0.2873 Ramelteon TAB 8mg 999 3.4169 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Diphenhydramine Hydrochloride CAP 25mg 999 0.0174 Doxepin Hydrochloride TAB 3mg 999 12.4815 Doxepin Hydrochloride TAB 6mg 999 12.5124 Amphetamine sulfate TAB 5mg 999 5.7285 Amphetamine sulfate TAB 10mg 999 5.7280 Dextroamphetamine TAB 5mg 999 0.1990 Dextroamphetamine TAB 10mg 999 0.2667 Dextroamphetamine CAP, CR 5mg 999 2.2765 Dextroamphetamine CAP, CR 10mg 999 2.1814 Dextroamphetamine CAP, CR 15mg 999 3.5760 Amphetamine/Dextroamphetamine TAB 5mg 999 0.2104 Amphetamine/Dextroamphetamine TAB 7.5mg 999 0.8341 Amphetamine/Dextroamphetamine TAB 10mg 999 0.3868 Amphetamine/Dextroamphetamine TAB 12.5mg 999 0.7725 Amphetamine/Dextroamphetamine TAB 15mg 999 0.2335 Amphetamine/Dextroamphetamine TAB 20mg 999 0.3795 Amphetamine/Dextroamphetamine TAB 30mg 999 0.3795 Amphetamine/Dextroamphetamine CAP, ER 5mg 999 1.4499 Amphetamine/Dextroamphetamine CAP, ER 10mg 999 1.4499 Amphetamine/Dextroamphetamine CAP, ER 15mg 999 1.4499 Amphetamine/Dextroamphetamine CAP, ER 20mg 999 1.4202 Amphetamine/Dextroamphetamine CAP, ER 25mg 999 1.4499 Amphetamine/Dextroamphetamine CAP, ER 30mg 999 1.9373 Benzphetamine TAB 50mg 999 0.4033 Diethylpropion HCL TAB 25 MG 999 0.2309 Phendimetrazine TAB 35mg 999 0.1564 Phentermine CAP 15mg 999 0.2575 Phentermine CAP 30mg 999 0.2538 Phentermine CAP 37.5mg 999 0.8735 Phentermine TAB 37.5mg 999 0.1436 Caffeine Citrate SOL 20mg/ml 999 8.8170 Clonidine HCL TAB, ER 0.1mg 999 3.4492 Guanfacin TAB, ER 1mg 999 0.7213 Guanfacin TAB, ER 2mg 999 0.6734 Guanfacin TAB, ER 3mg 999 0.7786 Guanfacin TAB, ER 4mg 999 0.6805 Atomoxetine HCL CAP 10mg 999 4.4964 Atomoxetine HCL CAP 18mg 999 4.4964 Atomoxetine HCL CAP 25mg 999 4.4964 Atomoxetine HCL CAP 40mg 999 4.8854 Atomoxetine HCL CAP 60mg 999 5.3739 Atomoxetine HCL CAP 80mg 999 5.7982 Atomoxetine HCL CAP 100mg 999 5.7982 Armodafinil TAB 50mg 999 0.7288 Armodafinil TAB 150mg 999 2.4214 Armodafinil TAB 200mg 999 1.9958 Armodafinil TAB 250mg 999 2.4214 Dexmethylphenidate HCL TAB 2.5mg 999 0.4277 Dexmethylphenidate HCL TAB 5mg 999 0.3472 Dexmethylphenidate HCL TAB 10mg 999 0.5242 Dexmethylphenidate HCL CAP, ER 5mg 999 3.0130 Dexmethylphenidate HCL CAP, ER 10mg 999 2.3647 Dexmethylphenidate HCL CAP, ER 15mg 999 2.7871 Dexmethylphenidate HCL CAP, ER 20mg 999 3.6354 Dexmethylphenidate HCL CAP, ER 25mg 999 6.9577 Dexmethylphenidate HCL CAP, ER 30mg 999 1.6760 Dexmethylphenidate HCL CAP, ER 35mg 999 7.3059 Dexmethylphenidate HCL CAP, ER 40mg 999 6.2530 Methylphenidate CAP, CD 10mg 999 3.7026 Methylphenidate CAP, CD 20mg 999 3.9735 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Methylphenidate CAP, CD 30mg 999 3.7026 Methylphenidate CAP, CD 40mg 999 4.9043 Methylphenidate CAP, CD 50mg 999 6.3926 Methylphenidate CAP, CD 60mg 999 6.2404 Methylphenidate Hydrochloride TAB 5mg 999 0.0846 Methylphenidate Hydrochloride TAB 10mg 999 0.1570 Methylphenidate Hydrochloride TAB 20mg 999 0.1753 Methylphenidate Hydrochloride TAB, ER 10mg 999 5.2583 Methylphenidate Hydrochloride TAB, ER 20mg 999 2.7035 Methylphenidate Hydrochloride TAB, ER 18mg 999 7.9899 Methylphenidate Hydrochloride TAB, ER 27mg 999 8.1901 Methylphenidate Hydrochloride TAB, ER 36mg 999 1.2391 Methylphenidate Hydrochloride TAB, ER 54mg 999 1.1077 Methylphenidate Hydrochloride TAB, CHEW 2.5mg 999 2.3389 Methylphenidate Hydrochloride TAB, CHEW 5mg 999 3.3412 Methylphenidate Hydrochloride TAB, CHEW 10mg 999 4.7632 Methylphenidate SOL 5mg/5ml 999 0.7696 Methylphenidate HCL SOL 10mg/5ml 999 0.8996 Methylphenidate Hydrochloride CAP, ER 10mg 999 8.4596 Methylphenidate Hydrochloride CAP, ER 20mg 999 4.4451 Methylphenidate Hydrochloride CAP, ER 30mg 999 4.3303 Methylphenidate Hydrochloride CAP, ER 40mg 999 4.4425 Modafinil TAB 100mg 999 1.1148 Modafinil TAB 200mg 999 1.6838 Donepezil HCL TAB 5mg 999 0.2252 Donepezil HCL TAB 10mg 999 0.1145 Donepezil HCL TAB 23mg 999 7.5617 Donepezil HCL ODT 5mg 999 0.2143 Donepezil HCL ODT 10mg 999 0.2747 Galantamine TAB 4mg 999 0.7751 Galantamine TAB 8mg 999 1.6858 Galantamine TAB 12mg 999 0.7751 Galantamine ER CAP 8mg 999 2.7033 Galantamine ER CAP 16mg 999 3.8123 Galantamine ER CAP 24mg 999 2.5162 Rivastigmine DIS 4.6mg/24hr 999 12.4168 Rivastigmine DIS 9.5mg/24hr 999 12.4305 Rivastigmine DIS 13.3mg/24hr 999 12.4175 Rivastigmine CAP 1.5mg 999 1.4047 Rivastigmine CAP 3mg 999 1.0086 Rivastigmine CAP 4.5mg 999 1.3867 Rivastigmine CAP 6mg 999 1.5452 Memantine HCL TAB 5mg 999 0.6423 Memantine HCL TAB 10mg 999 0.6117 Memantine HCL SOL 10mg/5ml 999 1.6553 Memantine HCL CAP, ER 7mg 999 4.5546 Memantine HCL CAP, ER 14mg 999 4.5546 Memantine HCL CAP, ER 21mg 999 4.5546 Memantine HCL CAP, ER 28mg 999 4.7824 Bupropion HCL TAB, SR 150mg 999 0.5323 Nicotine DIS 7mg / 24hr 999 1.7366 Nicotine DIS 14mg / 24hr 999 1.7366 Nicotine DIS 21mg / 24 hr 999 1.7366 Nicotine Polacrilex GUM 2 mg 999 0.2024 Nicotine Polacrilex GUM 4 mg 999 0.2871 Nicotine LOZ 2mg 999 0.3736 Nicotine LOZ 4mg 999 0.3705 Tetrabenazine TAB 12.5mg 999 34.8227 Tetrabenazine TAB 25mg 999 69.6453 Dimethyl Fumarate CAP, DR 120mg & 240mg 999 35.7183 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Dimethyl Fumarate CAP, DR 120mg 999 35.9523 Dimethyl Fumarate CAP, DR 240mg 999 35.9540 Dalfampridine TAB, ER 10mg 999 7.7049 Acamprosate Calcium TAB 333mg 999 1.1662 Disulfiram TAB 250mg 999 1.0255 Olanzapine / Fluoxetine CAP 3-25mg 999 2.1738 Olanzapine / Fluoxetine CAP 6-25mg 999 12.4746 Olanzapine / Fluoxetine CAP 6-50mg 999 2.9718 Olanzapine / Fluoxetine CAP 12-25mg 999 16.7321 Olanzapine / Fluoxetine CAP 12-50mg 999 14.6642 Aspirin TAB 325mg 999 0.0112 Aspirin TAB, CHEW 81mg 999 0.0292 Aspirin TAB 81mg 999 0.0091 Aspirin TAB, EC 325mg 999 0.0088 Aspirin TAB, DR 500MG 999 0.0413 Diflunisal TAB 500mg 999 1.3788 Acetaminophen TAB 325mg 999 0.0171 Acetaminophen TAB 500mg 999 0.0149 Acetaminophen TAB, CR 650mg 999 0.0695 Acetaminophen TAB, CHEW 80mg 999 0.0506 Acetaminophen LIQ 160mg/5ml 999 0.0099 Acetaminophen ELIX 160mg/5ml 999 0.0078 Acetaminophen SUS 160MG/5ML 5 0.2348 Acetaminophen SUS 160MG/5ML 30 0.1071 Acetaminophen SUS 160MG/5ML 59 0.0534 Acetaminophen SUS 160MG/5ML 60 0.0534 Acetaminophen SUS 160MG/5ML 118 0.0192 Acetaminophen SUS 160MG/5ML 120 0.0192 Acetaminophen SUS 160MG/5ML 148 0.0192 Acetaminophen SUS 160MG/5ML 237 0.0192 Acetaminophen SOL 160mg/5ml 5 0.0147 Acetaminophen SOL 160mg/5ml 10.15 0.0147 Acetaminophen SOL 160mg/5ml 20.3 0.0147 Acetaminophen SUPP 120mg 999 0.3012 Acetaminophen SUPP 650mg 999 0.2845 Acetaminophen / Butalbital TAB 300mg/50mg 999 12.7896 Acetaminophen / Butalbital TAB 325mg/50mg 999 1.2151 Acetaminophen / Butalbital / Caffeine CAP 300-50-40mg 999 2.5427 Acetaminophen / Butalbital / Caffeine CAP 325-50-40mg 999 3.5879 Acetaminophen / Butalbital / Caffeine TAB 325/50/40mg 999 0.0524 Butalbital / Aspirin / Caffeine CAP 50/325/40mg 999 1.0502 Fentanyl PATCH 12mcg/hr 999 3.4474 Fentanyl PATCH 25 mcg/ hr 999 1.6806 Fentanyl PATCH 37.5mcg/hr 999 48.3977 Fentanyl PATCH 50 mcg/hr 999 3.0628 Fentanyl PATCH 75 mcg/hr 999 4.7443 Fentanyl PATCH 100 mcg/hr 999 6.1776 Fentanyl Citrate LOLLIPOP 200mcg 999 4.0862 Fentanyl Citrate LOLLIPOP 400mcg 999 5.1762 Fentanyl Citrate LOLLIPOP 600mcg 999 6.3405 Fentanyl Citrate LOLLIPOP 800mcg 999 7.5120 Fentanyl Citrate LOLLIPOP 1200mcg 999 9.7616 Fentanyl Citrate LOLLIPOP 1600mcg 999 12.0474 Hydromorphone TAB 2mg 999 0.0483 Hydromorphone TAB 4mg 999 0.0744 Hydromorphone TAB 8mg 999 0.1619 Hydromorphone TAB, ER 8mg 999 10.3610 Hydromorphone TAB, ER 12mg 999 4.2443 Hydromorphone TAB, ER 16mg 999 5.6582 Hydromorphone TAB, ER 32mg 999 41.9881 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Levorphanol Tartrate TAB 2mg 999 39.5694 Methadone Hydrochloride TAB 5mg 999 0.2021 Methadone Hydrochloride TAB 10mg 999 0.1194 Methadone Hydrochloride TAB 40mg 999 0.2564 Morphine Sulfate TAB 15mg 999 0.4733 Morphine Sulfate TAB 30mg 999 0.8060 Morphine Sulfate TAB, CR 15mg 999 0.1019 Morphine Sulfate TAB, CR 30mg 999 0.1936 Morphine Sulfate TAB, CR 60mg 999 0.2551 Morphine Sulfate TAB, CR 100mg 999 0.5597 Morphine Sulfate TAB, CR 200mg 999 4.2009 Morphine Sulfate CAP, ER 20mg 999 3.1318 Morphine Sulfate CAP, ER 30mg 999 3.4063 Morphine Sulfate CAP, ER 50mg 999 1.9502 Morphine Sulfate CAP, ER 60mg 999 2.3339 Morphine Sulfate CAP, ER 80mg 999 9.8126 Morphine Sulfate CAP, ER 100mg 999 13.8189 Oxycodone HCL CAP 5mg 999 1.3673 Oxycodone HCL TAB 5mg 999 0.0591 Oxycodone HCL TAB 10mg 999 0.0931 Oxycodone HCL TAB 15mg 999 0.0887 Oxycodone HCL TAB 20mg 999 0.1617 Oxycodone HCL TAB 30mg 999 0.1867 Oxycodone HCL CONC 20mg/ml 30 5.8051 Oxycodone HCL SOL 5mg/5ml 5 0.8017 Oxycodone HCL SOL 5mg/5ml 15 0.7661 Oxycodone HCL SOL 5mg/5ml 500 0.2367 Oxymorphone HCL TAB 5mg 999 1.1970 Oxymorphone HCL TAB 10mg 999 0.5190 Tramadol TAB 50mg 999 0.0153 Tramadol TAB, ER 100mg 999 0.7174 Tramadol TAB, ER 200MG 999 1.0805 Tramadol TAB, ER 300mg 999 1.4784 Tramadol TAB, ER Biphasic Release 100mg 999 0.9492 Tramadol TAB, ER Biphasic Release 200mg 999 1.5699 Tramadol TAB 300mg 999 2.1901 Buprenorphine PATCH 5mcg/hr 999 55.3719 Buprenorphine PATCH 10mcg/hr 999 83.0599 Buprenorphine PATCH 15mcg/hr 999 119.8123 Buprenorphine PATCH 20mcg/hr 999 147.0435 Buprenorphine TAB, SL 2mg 999 0.5187 Buprenorphine TAB, SL 8MG 999 0.7441 Buprenorphine / Naloxone TAB, SUB 2mg-0.5mg 999 1.1271 Buprenorphine / Naloxone TAB, SUB 8mg-2mg 999 1.3665 Buprenorphine HCl-Naloxone HCl FILM, SL 2-0.5mg 999 3.6893 Buprenorphine HCl-Naloxone HCl FILM, SL 4-1mg 999 6.6089 Buprenorphine HCl-Naloxone HCl FILM, SL 8-2mg 999 3.8514 Buprenorphine HCl-Naloxone HCl FILM, SL 12-3mg 999 13.3329 Butorphanol SOL 10mg/ml , 2.5ml 999 3.4911 Pentazocine / Naloxone TAB 50mg / 0.5mg 999 1.8792 Oxycodone HCL / Acetaminophen TAB 2.5-325mg 999 1.7684 Oxycodone HCL / Acetaminophen TAB 5-325 mg 999 0.1077 Oxycodone HCL / Acetaminophen TAB 7.5-325 mg 999 0.1614 Oxycodone HCL / Acetaminophen TAB 10-325 mg 999 0.2330 Acetaminophen / Codeine Phosphate TAB 300-15 mg 999 0.1430 Acetaminophen / Codeine Phosphate TAB 300-30 mg 999 0.0388 Acetaminophen / Codeine Phosphate TAB 300-60 mg 999 0.0854 Acetaminophen / Codeine Phosphate SOL 120-12mg / 5ml 999 0.0206 Acetaminophen / Butalbital / Caffeine / Codeine CAP 325/50/40/30mg 999 0.4398 Aspirin / Butalb / Caffeine / Codeine CAP 325-50-40-30mg 999 0.4184 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Acetaminophen / Hydrocodone Bitartrate TAB 325-10 mg 999 0.1051 Acetaminophen / Hydrocodone Bitartrate TAB 300-5 mg 999 1.2535 Acetaminophen / Hydrocodone Bitartrate TAB 300-7.5 mg 999 1.1319 Acetaminophen / Hydrocodone Bitartrate TAB 325-5mg 999 0.0310 Acetaminophen / Hydrocodone Bitartrate TAB 325-7.5mg 999 0.0422 Acetaminophen / Hydrocodone Bitartrate TAB 300-10 mg 999 1.7016 Acetaminophen / Hydrocodone Bitartrate SOL 325-7.5mg / 15ml 999 0.0243 Hydrocodone Bitartrate / Ibuprofen TAB 7.5mg/200mg 999 0.1304 Hydrocodone Bitartrate / Ibuprofen TAB 10-200mg 999 2.3417 Acetaminophen / Tramadol TAB 325 / 37.5 mg 999 0.0382 Diclofenac Potassium TAB 50mg 999 0.2496 Diclofenac Sodium TAB, EC 25mg 999 1.0780 Diclofenac Sodium TAB, EC 50mg 999 0.0790 Diclofenac Sodium TAB, EC 75mg 999 0.0773 Diclofenac Sodium TAB, SR 100mg 999 0.0784 Etodolac CAP 200mg 999 0.9192 Etodolac CAP 300mg 999 0.3425 Etodolac TAB 400mg 999 0.1647 Etodolac TAB 500mg 999 0.1712 Etodolac TAB, ER 400mg 999 0.4258 Etodolac TAB, ER 500mg 999 0.4756 Etodolac TAB, ER 600mg 999 0.7108 Flurbiprofen TAB 100mg 999 0.2849 Ibuprofen TAB 100mg 999 0.1440 Ibuprofen TAB 200mg 999 0.0169 Ibuprofen TAB 400mg 999 0.0327 Ibuprofen TAB 600mg 999 0.0327 Ibuprofen TAB 800mg 999 0.0267 Ibuprofen TAB, CHEW 100mg 999 0.1369 Ibuprofen DRO 40mg / ml 999 0.2234 Ibuprofen SUS 100mg / 5ml 999 0.0469 Indomethacin CAP 25mg 999 0.1306 Indomethacin CAP 50mg 999 0.0759 Indomethacin CAP, ER 75mg 999 0.1254 Ketorolac TAB 10mg 999 0.5073 Mefenamic Acid CAP 250mg 999 1.1400 Meloxicam TAB 7.5mg 999 0.0159 Meloxicam TAB 15mg 999 0.0228 Nabumetone TAB 500mg 999 0.1504 Nabumetone TAB 750mg 999 0.1770 Naproxen TAB 250mg 999 0.0485 Naproxen TAB 375mg 999 0.0634 Naproxen TAB 500mg 999 0.0579 Naproxen TAB, EC 375mg 999 0.1317 Naproxen TAB, EC 500mg 999 0.4013 Naproxen SUS 125mg/5ml 999 0.9837 Naproxen Sodium TAB 220mg 999 0.0725 Naproxen Sodium TAB 275mg 999 0.5387 Naproxen Sodium TAB 550mg 999 0.8499 Naproxen Sodium TAB,CR 375mg 999 13.4940 Oxaprozin TAB 600mg 999 0.8803 Piroxicam CAP 10mg 999 0.8994 Piroxicam CAP 20mg 999 0.6566 Sulindac TAB 150mg 999 0.1561 Sulindac TAB 200mg 999 0.2173 Celecoxib TAB 50mg 999 0.4949 Celecoxib TAB 100mg 999 0.4780 Celecoxib TAB 200mg 999 0.5206 Celecoxib TAB 400mg 999 3.3311 Diclofenac/Misoprostol TAB 50-0.2mg 999 2.4593 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Diclofenac/Misoprostol TAB 75-0.2mg 999 2.6445 Leflunomide TAB 10mg 999 2.1618 Leflunomide TAB 20mg 999 2.1622 Dihydroergotamine Mesylate Nasal SPR 4mg/ml 999 380.8966 Almotriptan Malate TAB 6.25mg 999 35.8367 Almotriptan Malate TAB 12.5mg 999 15.4724 Eletriptan Hydrobromide TAB 20mg 999 17.4836 Eletriptan Hydrobromide TAB 40mg 999 18.3578 Frovatriptan TAB 2.5mg 999 49.5048 Naratriptan TAB 1mg 999 4.6562 Naratriptan TAB 2.5mg 999 0.6304 Rizatriptan TAB 5mg 999 0.4900 Rizatriptan TAB 10mg 999 0.7360 Rizatriptan TAB, ODT 5mg 999 0.9814 Rizatriptan TAB, ODT 10mg 999 0.8047 Sumatriptan SPR, NASAL 5mg/ACT 999 37.5303 Sumatriptan SPR, NASAL 20mg/ACT 999 39.4068 Sumatriptan TAB 25mg 999 0.3343 Sumatriptan TAB 50mg 999 0.2095 Sumatriptan TAB 100mg 999 0.3830 Sumaptriptan INJ 6mg/0.5 999 98.5370 Zolmitriptan TAB 2.5mg 999 6.1437 Zolmitriptan TAB 5mg 999 5.9884 Zolmitriptan TAB, ODT 2.5mg 999 5.7196 Zolmitriptan TAB, ODT 5mg 999 2.9925 Sumatriptan/Naproxen TAB 85-500mg 999 72.6351 Allopurinol TAB 100mg 999 0.0575 Allopurinol TAB 300mg 999 0.1334 Colchicine TAB 0.6mg 999 5.0911 Febuxostat TAB 40mg 999 7.9248 Febuxostat TAB 80mg 999 7.9248 Probenecid TAB 500mg 999 0.4842 Probenecid / Colchicine TAB 500mg/0.5mg 999 0.6310 Clobazam TAB 10mg 999 4.9575 Clobazam TAB 20mg 999 9.9150 Clobazam SUS 2.5mg/ml 999 0.4884 Clonazepam TAB 0.5mg 999 0.0204 Clonazepam TAB 1mg 999 0.0135 Clonazepam TAB 2mg 999 0.0535 Clonazepam ODT TAB 0.125mg 999 0.9624 Clonazepam ODT TAB 0.25mg 999 0.9624 Clonazepam ODT TAB 0.5mg 999 0.9624 Clonazepam ODT TAB 1mg 999 1.0981 Clonazepam ODT TAB 2mg 999 1.5214 Felbamate TAB 400mg 999 4.4443 Felbamate TAB 600mg 999 5.0909 Felbamate SUS 600mg/5ml 999 2.1114 Tiagabine HCL TAB 2mg 999 5.9946 Tiagabine HCL TAB 4mg 999 5.9946 Vigabatrin POW 500mg 999 58.3572 Phenytoin TAB, CHEW 50mg 999 0.4377 Phenytoin SUS 125mg / 5ml 999 0.0993 Phenytoin CAP 100mg 999 0.2377 Ethosuximide CAP 250mg 999 1.2255 Ethosuximide SYP 250mg / 5ml 999 0.2377 Divalproex TAB, DR 125mg 999 0.0608 Divalproex TAB, DR 250mg 999 0.0568 Divalproex TAB, DR 500mg 999 0.3902 Divalproex TAB, ER 250mg 999 0.2111 Divalproex TAB, ER 500mg 999 0.3447 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Valproic Acid SYP 250mg / 5ml 999 0.0332 Valproic Acid CAP 250mg 999 0.2633 Carbamazepine TAB 200mg 999 0.5651 Carbamazepine TAB, CHEW 100mg 999 0.2622 Carbamazepine SUS 100mg / 5ml 999 0.1443 Carbamazepine CAP, ER 100mg 999 1.6064 Carbamazepine CAP, ER 200mg 999 1.3917 Carbamazepine CAP, ER 300mg 999 1.4297 Carbamazepine TAB, ER 100mg 999 0.6523 Carbamazepine TAB, ER 200mg 999 1.2441 Carbamazepine TAB, ER 400mg 999 2.4862 Gabapentin CAP 100mg 999 0.0554 Gabapentin CAP 300mg 999 0.0665 Gabapentin CAP 400mg 999 0.0781 Gabapentin TAB 600mg 999 0.1142 Gabapentin TAB 800mg 999 0.0907 Gabapentin SOL 250mg/5ml 999 0.1423 Lamotrigine TAB 25mg 999 0.0273 Lamotrigine TAB 100mg 999 0.0791 Lamotrigine TAB 150mg 999 0.1061 Lamotrigine TAB 200mg 999 0.1093 Lamotrigine TAB, DIS 5 mg 999 0.2152 Lamotrigine TAB, DIS 25 mg 999 0.2541 Lamotrigine TAB, ODT 25mg 999 6.6817 Lamotrigine TAB, ODT 50mg 999 8.0411 Lamotrigine TAB, ODT 100mg 999 8.5743 Lamotrigine TAB, ODT 200mg 999 9.1060 Lamotrigine TAB,ER 25mg 999 3.4355 Lamotrigine TAB,ER 50mg 999 3.4127 Lamotrigine TAB,ER 100mg 999 5.8710 Lamotrigine TAB,ER 200mg 999 5.7024 Lamotrigine TAB,ER 250mg 999 14.5315 Lamotrigine TAB,ER 300mg 999 5.9340 Levetiracetam TAB 250mg 999 0.0554 Levetiracetam TAB 500mg 999 0.1440 Levetiracetam TAB 750mg 999 0.2489 Levetiracetam TAB 1000mg 999 0.4164 Levetiracetam SOL 100mg/ml 999 0.0294 Levetiracetam TAB, ER 500mg 999 0.4846 Levetiracetam TAB, ER 750mg 999 0.2014 Oxcarbazepine TAB 150mg 999 0.0616 Oxcarbazepine TAB 300mg 999 0.1936 Oxcarbazepine TAB 600mg 999 0.2174 Oxcarbazepine SUS 300mg/5ml 999 0.2853 Pregabalin CAP 25mg 999 1.4353 Pregabalin CAP 50mg 999 1.4354 Pregabalin CAP 75mg 999 1.4733 Pregabalin CAP 100mg 999 1.4733 Pregabalin CAP 150mg 999 1.4757 Pregabalin CAP 200mg 999 1.4770 Pregabalin CAP 225mg 999 1.4787 Pregabalin CAP 300mg 999 1.4787 Primidone TAB 50mg 999 0.1002 Primidone TAB 250mg 999 0.2006 Rufinamide SUS 40mg/ml 999 3.0301 Topiramate TAB 25mg 999 0.0213 Topiramate TAB 50mg 999 0.0437 Topiramate TAB 100mg 999 0.0629 Topiramate TAB 200mg 999 0.1546 Topiramate CAP, Sprinkle 15mg 999 0.6513 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Topiramate CAP, Sprinkle 25mg 999 0.1908 Zonisamide CAP 25mg 999 0.0945 Zonisamide CAP 50mg 999 0.1617 Zonisamide CAP 100mg 999 0.0898 Benztropine Mesylate TAB 0.5mg 999 0.0732 Benztropine Mesylate TAB 1mg 999 0.0558 Benztropine Mesylate TAB 2mg 999 0.1259 Trihexyphenidyl Hydrochloride TAB 2mg 999 0.0698 Trihexyphenidyl Hydrochloride TAB 5mg 999 0.1031 Tolcapone TAB 100mg 999 64.7200 Entacapone TAB 200mg 999 2.7462 Amantadine Hydrochloride CAP 100mg 999 0.5366 Amantadine Hydrochloride TAB 100mg 999 1.6919 Amantadine Hydrochloride SYR 50mg / 5ml 999 0.0217 Bromocriptine CAP 5mg 999 4.8168 Bromocriptine Mesylate TAB 2.5mg 999 0.2052 Pramipexole Dihydrochloride TAB 0.125 mg 999 0.0933 Pramipexole Dihydrochloride TAB 0.25 mg 999 0.0672 Pramipexole Dihydrochloride TAB 0.5 mg 999 0.0617 Pramipexole Dihydrochloride TAB 0.75ng 999 0.1128 Pramipexole Dihydrochloride TAB 1 mg 999 0.1016 Pramipexole Dihydrochloride TAB 1.5 mg 999 0.1574 Pramipexole Dihydrochloride TAB, ER 0.375mg 999 12.6204 Pramipexole Dihydrochloride TAB, ER 0.75mg 999 12.8779 Pramipexole Dihydrochloride TAB, ER 1.5mg 999 12.6204 Pramipexole Dihydrochloride TAB, ER 2.25mg 999 11.9580 Pramipexole Dihydrochloride TAB, ER 3mg 999 12.8779 Pramipexole Dihydrochloride TAB, ER 4.5mg 999 11.4613 Ropinirole TAB 0.25mg 999 0.1089 Ropinirole TAB 0.5mg 999 0.0988 Ropinirole TAB 1mg 999 0.1027 Ropinirole TAB 2mg 999 0.1081 Ropinirole TAB 3mg 999 0.1255 Ropinirole TAB 4mg 999 0.1137 Ropinirole TAB 5mg 999 0.1503 Ropinirole TAB, ER 2mg 999 1.6399 Ropinirole TAB, ER 4mg 999 3.0326 Ropinirole TAB, ER 6mg 999 4.8946 Ropinirole TAB, ER 8mg 999 7.0326 Ropinirole TAB, ER 12mg 999 11.7205 Carbidopa / Levodopa TAB 10 / 100mg 999 0.1631 Carbidopa / Levodopa TAB 25 / 100mg 999 0.1075 Carbidopa / Levodopa TAB 25 / 250mg 999 0.1912 Carbidopa / Levodopa TAB, ER 25 / 100mg 999 0.3304 Carbidopa / Levodopa TAB, ER 50 / 200mg 999 0.6351 Carbidopa/Levodopa/Entacapone TAB 12.5-50-200mg 999 2.4430 Carbidopa/Levodopa/Entacapone TAB 18.75-75-200mg 999 2.8346 Carbidopa/Levodopa/Entacapone TAB 25-100-200mg 999 2.2110 Carbidopa/Levodopa/Entacapone TAB 31.25-125-200mg 999 2.2110 Carbidopa/Levodopa/Entacapone TAB 37.5-150-200mg 999 2.8346 Carbidopa/Levodopa/Entacapone TAB 50-200-200mg 999 2.8346 Rasagiline Mesylate TAB 0.5mg 999 18.5169 Rasagiline Mesylate TAB 1mg 999 18.5169 Selegiline Hydrochloride CAP 5mg 999 1.3120 Carbidopa TAB 25mg 999 7.3798 Riluzole TAB 50mg 999 2.3091 Baclofen TAB 10mg 999 0.1088 Baclofen TAB 20mg 999 0.2092 Carisoprodol TAB 250mg 999 2.5184 Carisoprodol TAB 350mg 999 0.0497 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Chlorzoxazone TAB 375mg 999 6.9109 Chlorzoxazone TAB 500mg 999 0.5120 Chlorzoxazone TAB 750mg 999 7.7276 Cyclobenzaprine Hydrochloride TAB 5mg 999 0.0203 Cyclobenzaprine Hydrochloride TAB 7.5mg 999 1.2561 Cyclobenzaprine Hydrochloride TAB 10mg 999 0.0156 Cyclobenzaprine HCL CAP, ER 15mg 999 15.0086 Cyclobenzaprine HCL CAP, ER 30mg 999 15.0086 Metaxalone TAB 800mg 999 2.2776 Methocarbamol TAB 500mg 999 0.0498 Methocarbamol TAB 750mg 999 0.0654 Orphenadrine Citrate TAB, ER 100mg 999 0.1702 Tizanidine CAP 2mg 999 0.5436 Tizanidine CAP 4mg 999 0.7184 Tizanidine CAP 6mg 999 1.0038 Tizanidine HCL TAB 2mg 999 0.0328 Tizanidine HCL TAB 4mg 999 0.0516 Dantrolene CAP 25 mg 999 0.5892 Dantrolene CAP 50 mg 999 0.9525 Dantrolene CAP 100 mg 999 1.1945 Pyridostigmine TAB 60mg 999 0.3177 Pyridostigmine TAB, ER 180mg 999 12.8220 Pyridostigmine SOL 60mg/5ml 999 2.0976 Niacin CAP, SA 500mg 999 0.0667 Niacin TAB 500mg 999 0.0356 Niacin TAB, CR 500mg 999 0.0493 Ascorbic Acid TAB 500mg 999 0.0261 Ergocalciferol CAP 50000 IU 999 0.1130 Ergocalciferol SOL 8000 unit/ml 999 0.8908 Cholecalciferol CAP 1000 unit 999 0.0379 Cholecalciferol TAB 1000 unit 999 0.0247 Cholecalciferol DROP 400units/ml 999 0.1239 Vitamin E CAP 400U 999 0.0505 Phytonadione TAB 5mg 999 49.9118 Multi-Vitamins TAB 999 0.0284 Multi-Vitamins w/ Minerals & FA CAP 999 0.3006 Multi-Vitamins w/fMinerals LIQ 999 0.0179 Pediatric Multiple Vitamin TAB CHEW 999 0.0280 Multi-Vitamins/Minerals TAB 999 0.0398 Multi-Vitamins/Minerals TAB 999 0.0398 Multi-Vitamins w/ Iron TAB 999 0.1427 Calcium Carbonate TAB 1.25gm 999 0.0459 Calcium Carbonate TAB 600mg 999 0.0431 Calcium, Oyster Shell TAB 500mg 999 0.0268 Calcium Carbonate / /Vit D2 TAB 250mg / 125mg 999 0.0152 Calcium Carbonate / Vitamin D TAB 500mg-200unit 999 0.0456 Calcium Carbonate / Vitamin D TAB 600mg-400unit 999 0.0331 Calcium Carbonate / Cholecalciferol TAB 500mg-200unit 999 0.0360 Calcium Citrate / Vitamin D3 TAB 250mg-200unit 999 0.0482 Potassium Chloride CAP, SA 8meq 999 0.5108 Potassium Chloride CAP, CR 10meq 999 0.4628 Potassium Chloride TAB, CR 8meq (600mg) 999 0.3156 Potassium Chloride TAB, CR 10meq 999 0.2751 Potassium Chloride TAB, CR 20meq 999 0.3442 Potassium Chloride SOL 10% 15 0.9825 Potassium Chloride SOL 10% 30 0.7062 Potassium Chloride SOL 10% 473 0.6018 Potassium Chloride SOL 20% 999 1.2036 Potassium Chloride POW 20meq 999 7.8784 Potassium Chloride TAB, ER 10meq 999 0.3379 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Potassium Chloride TAB, ER 20meq 999 0.3146 Zinc Sulfate CAP 220mg 999 0.1142 Electrolyte SOL 999 0.0037 Levocarnitine CAP 250mg 999 0.4102 Omega-3 Fatty Acids CAP 1000mg 999 0.0436 Folic Acid TAB 400mcg 999 0.0100 Folic Acid TAB 800mcg 999 0.0177 Folic Acid TAB 1mg 999 0.0389 Iron SUS 15mg/1.25ml 999 0.1300 Ferrous Sulfate TAB 325mg 999 0.0103 Ferrous Sulfate TAB, DR 325mg (65) 999 0.0432 Ferrous Sulfate ELIX 220mg / 5ml 999 0.0073 Ferrous Sulfate SOL 75mg/ml 999 0.0620 Ferrous Sulfate, Dried TAB 160mg 999 0.1615 Ferrous Gluconate TAB 240mg 999 0.0275 Ferrous Fumarate TAB 325mg 999 0.1395 Iron Polysaccharide Complex CAP 150mg 999 0.1142 Enoxaparin Sodium INJ 30mg/0.3ml 999 10.1841 Enoxaparin Sodium INJ 40mg/0.4ml 999 10.4391 Enoxaparin Sodium INJ 60mg/0.6ml 999 10.3756 Enoxaparin Sodium INJ 80mg/0.8ml 999 10.3277 Enoxaparin Sodium INJ 100mg/ml 999 10.4139 Enoxaparin Sodium INJ 120mg/0.8ml 999 28.5000 Enoxaparin Sodium INJ 150mg/ml 999 15.6194 Enoxaparin Sodium INJ 300mg/3ml 999 50.7747 Fondaparinux Sodium INJ 2.5mg/0.5ml 999 73.2858 Fondaparinux Sodium INJ 5mg/0.4ml 999 217.0884 Fondaparinux Sodium INJ 7.5mg/0.6ml 999 144.6638 Fondaparinux Sodium INJ 10mg/0.8ml 999 108.5441 Warfarin TAB 1mg 999 0.1267 Warfarin TAB 2mg 999 0.1267 Warfarin TAB 2.5mg 999 0.1267 Warfarin TAB 3mg 999 0.1267 Warfarin TAB 4mg 999 0.1267 Warfarin TAB 5mg 999 0.1027 Warfarin TAB 6mg 999 0.1393 Warfarin TAB 7.5mg 999 0.1393 Warfarin TAB 10mg 999 0.1393 Aminocaproic Acid TAB 500mg 999 17.7668 Aminocaproic Acid SOLN 0.25gm/ml 999 9.8080 Tranexamic Acid TAB 650mg 999 1.5057 Dipyridamole TAB 25mg 999 0.1685 Dipyridamole TAB 50mg 999 0.2669 Dipyridamole TAB 75mg 999 0.3651 Cilostazol TAB 50mg 999 0.1638 Cilostazol TAB 100mg 999 0.1436 Clopidogrel TAB 75mg 999 0.2052 Clopidogrel TAB 300mg 999 15.1790 Prasugrel TAB 5mg 999 4.7035 Prasugrel TAB 10mg 999 4.9387 Aspirin / Dipyridamole CAP 25mg-200mg 999 5.7591 Pentoxyphylline TAB 400mg 999 0.1840 Icatibant INJ 30mg/3ml 999 840.4321 Ciprofloxacin HCl SOL 0.3%, 2.5ml 2.5 0.7563 Ciprofloxacin HCl SOL 0.3%, 5ml 5 0.7563 Ciprofloxacin HCl SOL 0.3%, 10ml 10 0.7563 Erythromycin OIN, OPTH 5mg/gm, Ophth 1 1.1970 Erythromycin OIN, OPTH 5mg/gm, Ophth 3.5 3.0957 Gatifloxacin SOL, OPTH 2.50% 999 13.0562 Gentamicin Sulfate SOL, OPTH 0.30% 5 0.7600 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Levofloxacin OPTH SOL 0.50% 999 9.8619 Moxifloxacin SOL, OPTH 0.5% 999 16.1193 Ofloxacin SOL, OPTH 0.30% 5 0.6550 Ofloxacin SOL, OPTH 0.30% 10 0.6550 Tobramycin Sulfate SOL, OPTH 0.30% 999 0.5167 Sulfacetamide Sodium SOL, OPTH 10% 5 0.7481 Sulfacetamide Sodium SOL, OPTH 10% 15 0.7481 Bacitracin Zinc / Polymyxin B sulfate OIN, OPTH 500U-10000U / gm, 3.5gm 999 2.9275 Polymyxin B Sulf / Trimethoprim Sulf SOL, OPTH 10,000 units-1mg/ml 999 0.3693 Neomycin / Bacitracin / Polymyxin B Sulf OIN, OPTH 3.5mg/400U/10,000U 999 10.3396 Polyvinyl Alcohol DRO 999 0.1261 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 12 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 15 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 15 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 30 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 32 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 1 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 32 0.2907 Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 36 0.2907 Artificial Tears OPTH OIN 999 1.9484 Timolol Maleate SOL, OPTH 0.25% 5 0.6047 Timolol Maleate SOL, OPTH 0.25% 10 0.6047 Timolol Maleate SOL, OPTH 0.25% 15 0.6047 Timolol Maleate SOL, OPTH 0.5%, 5ml 5 1.1450 Timolol Maleate SOL, OPTH 0.5%, 10ml 10 0.8669 Timolol Maleate SOL, OPTH 0.5%, 15ml 15 0.8384 Timolol Maleate XE SOL, OPTH 0.25%, 5ml 999 21.1486 Dorzolamide / Timolol SOL, OPTH 2% - 0.5% 999 1.1821 Neomycin / Polymyxin B Sulf / Dexamethasone SUS, OPTH 0.35%-10,000U-0.1%, 5ml 999 0.6457 Neomycin / Polymyxin B Sulf / Dexamethasone OIN, OPTH 0.35%-10,000U-0.1% 999 2.1921 Bacitracin / Neomycin / Polymixin B Sulf / HC OIN, OPTH 400U/1%/5mg/10,000U 3.5gm 999 14.6522 Bimatoprost OPTH SOL 0.03% 2.5 39.3612 Bimatoprost OPTH SOL 0.03% 5 39.4383 Bimatoprost OPTH SOL 0.03% 7.5 39.2874 Latanoprost OPTH SOL 0.005% 999 2.4024 Travoprost SOL, OPTH 0.004%, 2.5ml 2.5 61.8948 Travoprost SOL, OPTH 0.004%, 5ml 5 61.8948 Cyclopentolate HCL SOL, OPTH 1%, 2ml 2 5.6977 Cyclopentolate HCL SOL, OPTH 1%, 15ml 15 1.7419 Tropicamide SOL, OPTH 0.5%, Ophthalmic 999 0.5458 Tropicamide SOL, OPTH 1%, Ophthalmic 2 4.6512 Tropicamide SOL, OPTH 1%, Ophthalmic 3 3.8727 Tropicamide SOL, OPTH 1%, Ophthalmic 15 1.9882 Tetrahydrozoline HCL SOL, OPTH 0.05% 999 0.0904 Pilocarpine SOL, OPTH 1% 15ml 999 4.7112 Pilocarpine SOL, OPTH 2% 15ml 999 4.8187 Pilocarpine SOL, OPTH 4% 15ml 999 4.8989 Brimonidine Tartrate SOL 0.20% 5 0.9750 Brimonidine Tartrate SOL 0.20% 10 0.9750 Brimonidine Tartrate SOL 0.20% 15 0.9750 Proparacaine Hydrochloride SOL, OPTH 0.50% 999 0.3966 Azelastine OPTH SOL 0.05% 999 1.7948 Cromolyn Sodium SOL, OPTH 4% 999 0.5302 Epinastine OPTH SOL 0.05% 999 7.5567 Ketotifen Fumarate SOL, OPTH 0.025% 5 2.0205 Ketotifen Fumarate SOL, OPTH 0.025% 10 2.0205 Olopatadine OPTH SOL 0.10% 999 4.1860 Olopatadine HCl OPTH SOL 0.2% 999 43.4595 Dorzolamide SOL, OPTH 2% 999 1.4933 Diclofenac Sodium SOL, OPTH 0.1%, 2.5ml 2.5 2.8257 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Diclofenac Sodium SOL, OPTH 0.1%, 5ml 5 1.4150 Ketorolac OPTH SOL 0.40% 999 9.6957 Ketorolac OPTH SOL 0.50% 3 0.5861 Ketorolac OPTH SOL 0.50% 5 0.5861 Ketorolac OPTH SOL 0.50% 10 0.5861 Ofloxacin SOL, OTIC 0.3% 5 1.2368 Ofloxacin SOL, OTIC 0.3% 10 1.2371 Fluocinolone Acetonide OTIC OIL 0.01% 999 7.6648 Acetic Acid / Hydrocortisone SOL 2% / 1%, Otic, 10ml 999 4.0187 Acetic Acid SOL 2%, Otic, 15ml 999 1.0913 Carbamide Peroxide DRO, OTIC 6.5% 999 0.1254 Hydrocortisone / Neomycin / Polymyxin B Sulf SUS, OTIC 1%, 10ml 999 0.5027 Hydrocortisone / Neomycin / Polymyxin B Sulf SOL, OTIC 1%, 10ml 999 0.4788 Nystatin SUS 100,000 units/ml 5 0.0387 Nystatin SUS 100,000 units/ml 60 0.0387 Nystatin SUS 100,000 units/ml 473 0.0387 Nystatin SUS 100,000 units/ml 480 0.0387 Chlorhexidine Gluconate SOL 0.12% Dental Sol 15 0.0058 Chlorhexidine Gluconate SOL 0.12% Dental Sol 118 0.0058 Chlorhexidine Gluconate SOL 0.12% Dental Sol 473 0.0058 Triamcinolone Acetonide PASTE 0.1%, Dental Paste 999 2.4075 Lidocaine HCL SOL 2% 15 0.0414 Lidocaine HCL SOL 2% 100 0.0414 Cevimeline CAP 30mg 999 2.3194 Pilocarpine TAB 5mg 999 1.2335 Pilocarpine TAB 7.5mg 999 1.2668 Hydrocortisone CRE, RECTAL 2.50% 999 0.6276 Adapalene GEL 0.10% 999 1.1044 Adapalene GEL 0.30% 999 2.4317 Isotretinoin CAP 10mg 999 5.7578 Isotretinoin CAP 20mg 999 1.7624 Isotretinoin CAP 30mg 999 3.6675 Isotretinoin CAP 40mg 999 2.0469 Tretinoin CRE 0.025%, 20gm 20 1.9715 Tretinoin CRE 0.025%, 45gm 45 1.6593 Tretinoin CRE 0.05%, 20gm 20 4.5492 Tretinoin CRE 0.05%, 45gm 45 3.7921 Tretinoin CRE 0.1%, 20gm 20 5.3097 Tretinoin CRE 0.1%, 45gm 45 4.4191 Tretinoin GEL 0.01%, 15gm 15 5.0851 Tretinoin GEL 0.01%, 45gm 45 3.9844 Tretinoin GEL 0.025%, 15gm 15 1.9023 Tretinoin GEL 0.025%, 20gm 20 1.9023 Tretinoin GEL 0.025%, 45gm 45 1.4961 Clindamycin Phosphate SOL 1%, 30ml 30 1.0599 Clindamycin Phosphate SOL 1%, 60ml 60 1.0599 Clindamycin Phosphate GEL 1% 30 0.8777 Clindamycin Phosphate GEL 1% 60 0.8777 Clindamycin Phosphate LOT 1% 999 0.8979 Clindamycin Phosphate TOP, SWAB 1% 60 0.4715 Clindamycin Phosphate TOP, SWAB 1% 69 0.4715 Dapsone GEL 5% 60 5.6680 Dapsone GEL 5% 90 4.9607 Erythromycin SOL 2%, Topical 999 0.1332 Erythromycin GEL 2%, Topical, 30gm 30 4.4569 Erythromycin GEL 2%, Topical, 60gm 60 3.1963 Sulfacetamide Sodium LOT 10% 999 0.4712 Adapalene / Benzoyl Peroxide GEL 0.1%-2.5% 999 6.4456 Erythromycin / Benzoyl Peroxide GEL 3%-5%, 23.3gm 23.3 6.9962 Erythromycin / Benzoyl Peroxide GEL 3%-5%, 46.6gm 46.6 6.9937 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 25 6.8912 Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 35 9.2179 Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 50 7.4051 Clindamycin / Benzoyl Peroxide GEL 1.2-2.5% 50 8.7527 Clindamycin / Benzoyl Peroxide Gel 1.2-5% 999 1.8399 Azelaic Acid GEL 15% 999 4.2372 Metronidazole CRE 0.75% 999 0.4211 Metronidazole GEL 0.75% 999 0.1039 Metronidazole GEL 1%, 55gm 55 4.0228 Metronidazole GEL 1%, 60gm 60 3.6876 Metronidazole LOT 0.75% 999 0.7165 Bacitracin OIN 500u / gram 1 0.0567 Bacitracin OIN 500u / gram 14 0.0567 Bacitracin OIN 500u / gram 15 0.0567 Bacitracin OIN 500u / gram 28 0.0567 Bacitracin OIN 500u / gram 28.35 0.0567 Bacitracin OIN 500u / gram 28.4 0.0567 Bacitracin OIN 500u / gram 30 0.0567 Bacitracin OIN 500u / gram 1 0.0567 Bacitracin OIN 500u / gram 14 0.0567 Bacitracin OIN 500u / gram 15 0.0567 Bacitracin OIN 500u / gram 28 0.0567 Bacitracin OIN 500u / gram 28.35 0.0567 Bacitracin OIN 500u / gram 28.4 0.0567 Gentamicin Sulfate CRE 0.10% 15 2.4394 Gentamicin Sulfate CRE 0.10% 30 2.4394 Gentamicin Sulfate OIN 0.10% 15 2.4394 Gentamicin Sulfate OIN 0.10% 30 2.4391 Mupirocin OIN 2%, 15gm 15 0.8384 Mupirocin OIN 2%, 22gm 22 0.1577 Mupirocin CRE 2% 15 12.1181 Mupirocin CRE 2% 30 10.7859 Bacitracin / Polymyxin OIN 1 0.2879 Bacitracin / Polymyxin OIN 14 0.2879 Bacitracin / Polymyxin OIN 14.17 0.2879 Bacitracin / Polymyxin OIN 28 0.2879 Bacitracin / Polymyxin OIN 28.3 0.2879 Bacitracin / Polymyxin OIN 28.35 0.2879 Bacitracin / Polymyxin OIN 28.4 0.2879 Neomycin / Bacitracin / Polymyxin B Sulf OIN 5mg/400U/5,000U 999 0.1041 Ciclopirox SOL 8% 999 0.5420 Ciclopirox GEL 0.77% 30 2.0622 Ciclopirox GEL 0.77% 45 2.0617 Ciclopirox GEL 0.77% 100 2.0598 Ciclopirox Shampoo 1% 999 0.1985 Ciclopirox SUS 0.77%, 30ml 30 1.1626 Ciclopirox SUS 0.77%, 60ml 60 1.2619 Ciclopirox CRE 0.77%, 15gm 15 0.2834 Ciclopirox CRE 0.77%, 30gm 30 0.2834 Ciclopirox CRE 0.77%, 90gm 90 0.2834 Naftifine HCL CRE 2%, 45gm 45 6.9922 Naftifine HCL CRE 2%, 60gm 60 7.0077 Nystatin POW 100,000 units/gm 15 0.1916 Nystatin POW 100,000 units/gm 30 0.1916 Nystatin POW 100,000 units/gm 60 0.1916 Nystatin CRE 100,000 units/gm 15 0.3152 Nystatin CRE 100,000 units/gm 30 0.3152 Nystatin OIN 100,000 units/gm 15 1.0853 Nystatin OIN 100,000 units/gm 30 0.8140 Tolnaftate POW 1% 45 0.0504 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Tolnaftate POW 1% 67.5 0.0504 Tolnaftate CRE 1% 999 0.0912 Terbinafine HCL CRE 1% 999 0.3010 Clotrimazole SOL 1% 30 1.8459 Clotrimazole CRE 1% 999 0.2928 Econazole CRE 1%, 15gm 15 0.2696 Econazole CRE 1%, 30gm 30 0.1896 Econazole CRE 1%, 85gm 85 0.1212 Ketoconazole CRE 2%, 15gm 15 0.6962 Ketoconazole CRE 2%, 30gm 30 0.7069 Ketoconazole CRE 2%, 60gm 60 0.5310 Ketoconazole SHAM 2% 999 0.0609 Miconazole Nitrate CRE 2% 999 0.0425 Tavaborole SOL 5% 999 95.3946 Betamethasone / Clotrimazole CRE 1%-0/05%, 15gm 15 0.3444 Betamethasone / Clotrimazole CRE 1%-0/05% 45gm 45 0.3444 Betamethazole / Clotrimazole LOT 1%-0/05% 999 0.9745 Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 15 6.1253 Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 30 4.5827 Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 60 3.4010 Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 15 5.7850 Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 30 4.1220 Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 60 3.2390 Diclofenac Sodium SOL 1.50% 999 0.2041 Diclofenac Sodium GEL 1% 999 0.3022 Calcipotriene SOL 0.01% 999 0.4236 Calcipotriene CRE 0.05% 60 1.0222 Calcipotriene CRE 0.05% 120 0.9398 Tazarotene CRE 0.10% 30 9.6336 Tazarotene CRE 0.10% 60 9.6336 Acitretin CAP 10mg 999 24.8920 Acitretin CAP 17.5mg 999 28.4983 Acitretin CAP 25mg 999 11.5755 Methoxsalen CAP 10mg 999 68.5197 Selenium Sulfide LOT 2.50% 999 0.0742 Acyclovir CRE 5% 999 124.5080 Acyclovir OIN 5% 5 7.7212 Acyclovir OIN 5% 15 7.7212 Acyclovir OIN 5% 30 7.7212 Fluorouracil CRE 5% 999 1.8180 Diclofenac Sodium GEL 3% 999 2.7654 Silver Sulfadiazine CRE 1% , 20gm 20 0.1783 Silver Sulfadiazine CRE 1%, 25gm 25 0.1441 Silver Sulfadiazine CRE 1%, 50gm 50 0.1196 Silver Sulfadiazine CRE 1% , 85gm 85 0.1180 Silver Sulfadiazine CRE 1%, 400gm 400 0.0641 Silver Sulfadiazine CRE 1%, 1000gm 1000 0.0723 Alclometasone CRE 0.05%, 15gm 15 0.8941 Alclometasone CRE 0.05%, 45gm 45 0.5520 Alclometasone CRE 0.05%, 60gm 60 0.5864 Alclometasone OIN 0.05%, 15gm 15 1.2922 Alclometasone OIN 0.05%, 45gm 45 0.8279 Alclometasone OIN 0.05%, 60gm 60 0.7201 Betamethasone Dipropionate CRE 0.05%, 15gm 15 0.6181 Betamethasone Dipropionate CRE 0.05%, 45gm 45 0.6181 Betamethasone Dipropionate LOT 0.05%, 60ml 999 0.1464 Betamethasone Dipropionate OIN 0.05%, 15gm 15 2.7921 Betamethasone Dipropionate OIN 0.05%, 45gm 45 1.8736 Betamethasone Augmented CRE 0.05%, 15gm 15 0.2107 Betamethasone Augmented CRE 0.05%, 50gm 50 0.2107 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Betamethasone Augmented LOT 0.05%, 30ml 30 2.1896 Betamethasone Augmented LOT 0.05%, 60ml 60 2.1578 Betamethasone Augmented OIN 0.05%, 15gm 15 3.5178 Betamethasone Augmented OIN 0.05%, 45gm 45 2.3085 Betamethasone Augmented OIN 0.05%, 50gm 50 2.3085 Betamethasone Valerate CRE 0.10% 15 0.3622 Betamethasone Valerate CRE 0.10% 45 0.1313 Betamethasone Valerate FOAM, AER 0.12%, 50gm 50 5.5159 Betamethasone Valerate FOAM, AER 0.12%, 100gm 100 5.1332 Betamethasone Valerate OIN 0.1%, 15gm 15 0.9915 Betamethasone Valerate OIN 0.1%, 45gm 45 0.6748 Clobetasol Propionate SPR 0.05%, 59ml 59 5.3419 Clobetasol Propionate SPR 0.05%, 125ml 125 4.5364 Clobetasol Propionate SOL 0.05%, 25ml 25 0.6042 Clobetasol Propionate SOL 0.05%, 50ml 50 0.6042 Clobetasol Propionate CRE 0.05%, 15gm 15 0.8779 Clobetasol Propionate CRE 0.05%, 30gm 30 1.1903 Clobetasol Propionate CRE 0.05%, 45gm 45 0.8779 Clobetasol Propionate CRE 0.05%, 60gm 60 0.7680 Clobetasol Propionate FOAM 0.05% 50 4.7984 Clobetasol Propionate FOAM 0.05% 100 4.3828 Clobetasol Propionate GEL 0.05%, 15gm 15 0.7481 Clobetasol Propionate GEL 0.05%, 30gm 30 0.7474 Clobetasol Propionate GEL 0.05%, 60gm 60 0.6537 Clobetasol Propionate LOT 0.05% 59 1.7105 Clobetasol Propionate LOT 0.05% 118 1.6104 Clobetasol Propionate OIN 0.05%, 15gm 15 0.8779 Clobetasol Propionate OIN 0.05%, 30gm 30 0.8779 Clobetasol Propionate OIN 0.05%, 45gm 45 0.8779 Clobetasol Propionate OIN 0.05%, 60gm 60 0.7680 Clobetasol Propionate SHAMPOO 0.05% 999 0.9843 Clobetasol Propionate CRE, EMOL 0.05%, 15gm 15 1.5603 Clobetasol Propionate CRE, EMOL 0.05%, 30gm 30 1.5603 Clobetasol Propionate CRE, EMOL 0.05%, 45gm 45 2.5891 Clobetasol Propionate CRE, EMOL 0.05%, 60gm 60 1.5603 Clobetasol Propionate AER EMOL 0.05% 50 5.1983 Clobetasol Propionate AER EMOL 0.05% 100 4.7480 Desonide CRE 0.05%, 15gm 15 0.9386 Desonide CRE 0.05%, 60gm 60 1.0434 Desonide LOT 0.05%, 59ml 59 2.2098 Desonide LOT 0.05%, 118ml 118 1.6360 Desonide OIN 0.05%, 15gm 15 0.7581 Desonide OIN 0.05%, 60gm 60 0.3613 Desoximetasone SPR 0.25% 100 3.3467 Desoximetasone CRE 0.25%, 15gm 15 0.4934 Desoximetasone CRE 0.25%, 60gm 60 0.3735 Desoximetasone OIN 0.05%, 60gm 60 4.8835 Desoximetasone OIN 0.05%, 100gm 100 4.8835 Desoximetasone OIN 0.25%, 15gm 15 5.8344 Desoximetasone OIN 0.25%, 60gm 60 4.7987 Diflorasone Diacetate OIN 0.05%, 15gm 15 4.1488 Diflorasone Diacetate OIN 0.05%, 30gm 30 5.1858 Diflorasone Diacetate OIN 0.05%, 60gm 60 5.7694 Fluocinolone Acetonide OIL 0.01% (Body Oil) 999 1.2455 Fluocinolone Acetonide OIL 0.01% (Scalp Oil) 999 1.2564 Fluocinolone Acetonide SOL 0.01% 999 2.0344 Fluocinolone Acetonide CRE 0.01%, 15gm 15 2.5163 Fluocinolone Acetonide CRE 0.01%, 60gm 60 1.8860 Fluocinolone Acetonide CRE 0.025%, 15gm 15 0.6869 Fluocinolone Acetonide CRE 0.025%, 60gm 60 0.5154 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Fluocinolone Acetonide OIN 0.025%, 15gm 15 0.6869 Fluocinolone Acetonide OIN 0.025%, 60gm 60 0.5154 Fluocinonide SOL 0.05% 20 0.8585 Fluocinonide SOL 0.05% 60 0.5262 Fluocinonide CRE 0.05% 15 0.7297 Fluocinonide CRE 0.05% 30 0.7297 Fluocinonide CRE 0.05% 60 0.7297 Fluocinonide CRE 0.05% 120 0.7297 Fluocinonide CRE 0.1% 30 0.2167 Fluocinonide CRE 0.1% 60 0.4498 Fluocinonide CRE 0.1% 120 0.5364 Fluocinonide GEL 0.05%, 15gm 15 1.3015 Fluocinonide GEL 0.05%, 30gm 30 1.3015 Fluocinonide GEL 0.05%, 60gm 60 1.0344 Fluocinonide OIN 0.05%, 15gm 15 0.4845 Fluocinonide OIN 0.05%, 30gm 30 0.3637 Fluocinonide OIN 0.05%, 60gm 60 0.2725 Fluocinonide Emollient CRE 0.05% 15 0.7781 Fluocinonide Emollient CRE 0.05% 30 0.7781 Fluocinonide Emollient CRE 0.05% 60 0.7781 Flurandrenolide CRE 0.05% 60 8.5288 Flurandrenolide CRE 0.05% 120 6.1155 Flurandrenolide LOT 0.05% 999 7.0576 Fluticasone Propionate CRE 0.05%, 15gm 15 0.4266 Fluticasone Propionate CRE 0.05%, 30gm 30 0.3092 Fluticasone Propionate CRE 0.05%, 60gm 60 0.2573 Fluticasone Propionate LOT 0.05% 60 2.0160 Fluticasone Propionate LOT 0.05% 120 2.0160 Fluticasone Propionate OIN 0.005%, 15gm 15 0.4266 Fluticasone Propionate OIN 0.005%, 30gm 30 0.3385 Fluticasone Propionate OIN 0.005%, 60gm 60 0.2550 Halobetasol Propionate CRE 0.05%, 15gm 15 1.0077 Halobetasol Propionate CRE 0.05%, 50gm 50 0.4285 Halobetasol Propionate OIN 0.05%, 15gm 15 0.9793 Halobetasol Propionate OIN 0.05%, 50gm 50 0.6310 Hydrocortisone CRE 0.50% 28.35 0.0418 Hydrocortisone CRE 0.50% 28.4 0.0418 Hydrocortisone CRE 0.50% 56 0.0418 Hydrocortisone CRE 0.50% 57 0.0418 Hydrocortisone CRE 1% 999 0.0465 Hydrocortisone CRE 2.50% 20 0.1267 Hydrocortisone CRE 2.50% 28 0.1267 Hydrocortisone CRE 2.50% 28.35 0.1267 Hydrocortisone CRE 2.50% 30 0.1267 Hydrocortisone CRE 2.50% 453.6 0.1267 Hydrocortisone CRE 2.50% 454 0.1267 Hydrocortisone LOT 1% 999 0.0367 Hydrocortisone LOT 2.50% 59 0.1732 Hydrocortisone LOT 2.50% 118 0.1732 Hydrocortisone OIN 0.5% 28.4 0.1243 Hydrocortisone OIN 0.5% 30 0.1243 Hydrocortisone OIN 0.5% 56 0.1243 Hydrocortisone Acetate CRE 1% 999 0.0416 Hydrocortison Valerate CRE 0.2%, 15gm 15 0.7132 Hydrocortison Valerate CRE 0.2%, 45gm 45 0.4933 Hydrocortison Valerate CRE 0.2%, 60gm 60 0.4451 Hydrocortison Valerate OIN 0.2%, 15gm 15 4.8610 Hydrocortison Valerate OIN 0.2%, 45gm 45 3.2664 Hydrocortison Valerate OIN 0.2%, 60gm 60 2.9467 Hydrocortisone Butyrate CRE 0.1%, 15gm 15 3.4764 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Hydrocortisone Butyrate CRE 0.1%, 45gm 45 3.4845 Hydrocortisone Butyrate LOT 0.1%, 59ml 59 6.4191 Hydrocortisone Butyrate LOT 0.1%, 118ml 118 6.3165 Hydrocortisone Butyrate OIN 0.1%, 15gm 15 3.0920 Hydrocortisone Butyrate OIN 0.1%, 45gm 45 3.0936 Hydrocortisone Butyrate CRE, LIPO 0.1%, 45gm 45 6.4379 Hydrocortisone Butyrate CRE, LIPO 0.1%, 60gm 60 6.6410 Mometasone Furoate SOL 0.1%, 30ml 30 0.8380 Mometasone Furoate SOL 0.1%, 60ml 60 0.7863 Mometasone Furoate CRE 0.1%, 15gm 15 0.1572 Mometasone Furoate CRE 0.1%, 45gm 45 0.1572 Mometasone Furoate OIN 0.10%, 15gm 15 0.9757 Mometasone Furoate OIN 0.10%, 45gm 45 0.6460 Triamcinolone AER SPR 63 3.1152 Triamcinolone AER SPR 100 3.1152 Triamcinolone Acetonide CRE 0.025% 15 0.2271 Triamcinolone Acetonide CRE 0.025% 80 0.1064 Triamcinolone Acetonide CRE 0.025% 454 0.0469 Triamcinolone Acetonide CRE 0.10% 15 0.2533 Triamcinolone Acetonide CRE 0.10% 28.4 0.2396 Triamcinolone Acetonide CRE 0.10% 30 0.2442 Triamcinolone Acetonide CRE 0.10% 80 0.1482 Triamcinolone Acetonide CRE 0.10% 453.6 0.0641 Triamcinolone Acetonide CRE 0.10% 454 0.0641 Triamcinolone Acetonide CRE 0.50% 15 0.1550 Triamcinolone Acetonide CRE 0.50% 454 0.1550 Triamcinolone Acetonide LOT 0.025%, 60ml 60 0.5807 Triamcinolone Acetonide LOT 0.10% 999 0.1254 Triamcinolone Acetonide OIN 0.025%, 15gm 15 0.1473 Triamcinolone Acetonide OIN 0.025%, 80gm 80 0.0373 Triamcinolone Acetonide OIN 0.025%, 454gm 454 0.0303 Triamcinolone OIN 0.05% 430 1.9744 Triamcinolone Acetonide OIN 0.10% 15 0.2533 Triamcinolone Acetonide OIN 0.10% 80 0.1330 Triamcinolone Acetonide OIN 0.10% 453.6 0.0505 Triamcinolone Acetonide OIN 0.10% 454 0.0505 Triamcinolone Acetonide OIN 0.50% 999 0.4709 Calcipotriene/Betamethasone SUS 0.005%-0.064% 999 13.4191 Calcipotriene/Betamethasone OIN 0.005%-0.064% 60 4.3540 Calcipotriene/Betamethasone OIN 0.005%-0.064% 100 3.7308 Hydrocortisone w/ Aloe CRE 1.00% 14 0.0595 Hydrocortisone w/ Aloe CRE 1.00% 28 0.0595 Hydrocortisone w/ Aloe CRE 1.00% 28.4 0.0595 Hydrocortisone w/ Aloe CRE 1.00% 56 0.0595 Hydrocortisone w/ Aloe CRE 1.00% 56.8 0.0595 Ammonium Lactate CRE 12% 140 0.0249 Ammonium Lactate CRE 12% 385 0.0249 Ammonium Lactate LOT 12% 999 0.0195 Finasteride TAB 1mg 999 0.4439 Minoxidil SOL 2% 999 0.1188 Minoxidil SOL 5% 999 0.2972 Podofilox Sol SOL 3.5ml 999 13.2172 Imiquimod CRE 5% 1 0.8139 Imiquimod CRE 5% 12 0.8139 Imiquimod CRE 5% 24 0.9450 Pimecrolimus CRE 1% 30 7.8019 Pimecrolimus CRE 1% 60 7.8019 Pimecrolimus CRE 1% 100 7.8019 Tacrolimus OIN 0.03% 30 6.6991 Tacrolimus OIN 0.03% 60 6.6991 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Tacrolimus OIN 0.03% 100 6.6991 Tacrolimus OIN 0.10% 30 6.4606 Tacrolimus OIN 0.10% 60 6.4607 Tacrolimus OIN 0.10% 100 6.4606 Capsaicin CRE 0.025% 25 0.0947 Capsaicin CRE 0.025% 50 0.0947 Capsaicin CRE 0.025 60 0.0822 Capsaicin CRE 0.025 118 0.0822 Capsaicin CRE 0.025% 120 0.0947 Capsaicin CRE 0.025% 237 0.0947 Lidocaine CRE 4% 5 0.6473 Lidocaine CRE 4% 15 0.7465 Lidocaine CRE 4% 30 0.6822 Lidocaine CRE 4% 120 0.2842 Lidocaine OIN 5% 30 0.2470 Lidocaine OIN 5% 35.44 0.1884 Lidocaine OIN 5% 50 0.1933 Lidocaine OIN 5% 2500 1.8583 Lidocaine PATCH 5% 1 3.1246 Lidocaine PATCH 5% 15 3.1246 Lidocaine PATCH 5% 30 3.1246 Lidocaine Hcl SOL 4% 999 0.0914 Lidocaine CRE 4% 15 0.7465 Lidocaine CRE 4% 120 0.2842 Lidocaine/Prilocaine CRE 2.5/2.5% 5 0.1927 Lidocaine/Prilocaine CRE 2.5/2.5% 30 0.1927 Lidocaine/Prilocaine CRE 2.5/2.5% 5800 0.1927 Lidocaine/Prilocaine CRE 2.5/2.5% 18000 0.1927 Lidocaine/Prilocaine KIT 2.5/2.5% 999 36.6604 Permethrin LIQ 1% 59 0.1006 Permethrin LIQ 1% 120 0.1006 Permethrin CRE 5% 999 0.2611 Permethrin LOT 1% 999 0.1140 Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 60 0.0522 Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 120 0.0522 Pyrethrine / Piperonyl Butoxide SHAMPOO 0.33-4% 999 0.0447 Zinc Oxide OIN 20% 999 0.0935 Zinc Oxide OIN 40% 999 0.0397 Zinc Oxide PASTE 40% 999 0.0524 Hydrogen Peroxide SOL 3% 999 0.0023 Deferasirox TAB 90mg 999 14.9407 Deferasirox TAB 180mg 999 22.5750 Deferasirox TAB 360mg 999 59.7606 Deferasirox TAB 125mg 999 11.2448 Deferasirox TAB 250mg 999 22.4890 Deferasirox TAB 500mg 999 44.9773 Naltrexone TAB 50mg 999 0.9390 Coenzyme Q10 CAP 30mg 999 0.1740 Coenzyme Q10 CAP 100mg 999 0.3471 Glucosamine / Chondroitin CAP 500-400mg 999 0.2182 Trientine HCL CAP 250mg 999 11.9699 Penicillamine CAP 250mg 999 209.7877 Cyclosporine Modified CAP 25mg 999 0.7217 Cyclosporine Modified CAP 100mg 999 2.5770 Mycophenolate Mofetil CAP 250mg 999 0.3462 Mycophenolate Mofetil TAB 500mg 999 0.6146 Mycophenolate Sodium TAB, DR 180mg 999 1.7544 Mycophenolate Sodium TAB, DR 360mg 999 3.5088 Sirolimus TAB 0.5mg 999 2.0481 Sirolimus TAB 1mg 999 4.0754 Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list.

Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021

Drug Name Dosage Form Strength Pkg Size MAC/unit Sirolimus TAB 2mg 999 7.9430 Sirolimus SOL 1mg/ml 999 12.5642 Tacrolimus CAP 0.5mg 999 0.5770 Tacrolimus CAP 1mg 999 1.0487 Tacrolimus CAP 5mg 999 6.1717 Azathioprine TAB 50mg 999 0.5349 Sod Poly Sul Pow POW 999 0.0565 Methylprednisolone TAB 4mg, DosePak 999 0.3844 Prednisone TAB 5mg PAK, #21 21 0.5957 Prednisone TAB 5mg PAK, #48 48 0.4307 Prednisone TAB 10mg, PAK, #21 21 1.0283 Prednisone TAB 10mg, PAK, #48 48 0.6391 Medroxyprogesterone INJ, SYR 150mg/ml 999 56.1593 Hydrocodone / Chlorpheniramine SUS, ER 10mg-8mg/5ml 999 0.2670 Lansoprazole ODT TAB 15mg 999 11.6882 Lansoprazole ODT TAB 30mg 999 11.6882 Sumaptriptan INJ, Auto-injector 6mg/0.5 999 56.5583 Divalproex CAP, SPR 125mg 999 0.5301