Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
8-MOP
10 MG CAPSULE(S) METHOXSALEN Valeant Patient Assistance Program $1,843.80 $2,120.37 ABACAVIR (BRAND: ZIAGEN)
300 MG TABLET(S) ABACAVIR Xubex Preferred Network Program $603.33 $693.83 ABACAVIR SULFATE, LAMIVUDINE AND ZIDOVUDINE (BRAND: TRIZIVIR) 300-150-300 MG-MG-MG TABLET(S) ABACAVIR SULFATE, Xubex Preferred Network Program $1,738.46 $1,999.23 LAMIVUDINE AND ZIDOVUDINE ABELCET
5 MG/ML (20 ML) MG AMPHOTERICIN B LIPID Sigma-Tau Patient Assistance Program $240.00 $276.00 COMPLEX ABILIFY
* 1 MG/ML (150 ML) ML ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $1,177.87 $1,354.55 Foundation, Inc. * 2 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $1,070.36 $1,230.91 Foundation, Inc. * 20 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $5,045.42 $5,802.23 Foundation, Inc. * 5 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $3,567.66 $4,102.81 Foundation, Inc. ABILIFY
* 10 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $3,567.66 $4,102.81 Foundation, Inc. * 15 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $3,567.66 $4,102.81 Foundation, Inc.
Report Run: 04/19/16 10:53 AM Page 1 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ABILIFY
* 30 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $5,045.42 $5,802.23 Foundation, Inc. ABILIFY DISCMELT
10 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $1,273.96 $1,465.05 Foundation, Inc. 15 MG TABLET(S) ARIPIPRAZOLE Bristol-Myers Squibb Patient Assistance $820.49 $943.56 Foundation, Inc. ABILIFY MAINTENA DUAL-CHAMBERED SYRINGE
300 MG SYRINGE(S) aripiprazole ASSURE Program for Abilify Maintena $1,481.63 $1,703.87 400 MG SYRINGE(S) aripiprazole ASSURE Program for Abilify Maintena $2,052.50 $2,360.38 ABRAXANE
100 MG MG PACLITAXEL PROTEIN-BOUND Abraxis Patient Assistance Program $1,241.47 $1,427.69 100 MG MG PACLITAXEL PROTEIN-BOUND Celgene Patient Support $1,241.47 $1,427.69 ABSTRAL
100 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $1,302.89 $1,498.32 200 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $1,636.42 $1,881.88 300 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $1,962.37 $2,256.73 400 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $2,360.71 $2,714.82 600 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $3,040.54 $3,496.62 800 MCG TABLET(S) fentanyl citrate Galena Patient Services (GPS) for Abstral $3,718.94 $4,276.78 ACAMPROSATE CALCIUM (BRAND: CAMPRAL)
333 MG TABLET(S) ACAMPROSATE CALCIUM Xubex Preferred Network Program $249.50 $286.93
Report Run: 04/19/16 10:53 AM Page 2 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ACARBOSE (BRAND: PRECOSE)
100 MG TABLET(S) ACARBOSE Xubex Preferred Network Program $117.28 $134.87 25 MG TABLET(S) ACARBOSE Xubex Preferred Network Program $90.95 $104.59 50 MG TABLET(S) ACARBOSE Xubex Preferred Network Program $102.88 $118.31 ACCOLATE
* 10 MG TABLET(S) ZAFIRLUKAST AZ&Me Prescription Savings for people with $136.55 $157.03 Medicare Part D * 20 MG TABLET(S) ZAFIRLUKAST AZ&Me Prescription Savings for people with $136.55 $157.03 Medicare Part D ACCURETIC
* 10/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Pfizer RxPathways $354.43 $407.59 APRIL HYDROCHLORIDE * 20/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Pfizer RxPathways $354.43 $407.59 APRIL HYDROCHLOR * 20/25 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Pfizer RxPathways $354.43 $407.59 APRIL HYDROCHLORIDE 10/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Welvista - South Carolina Residents Only $354.43 $407.59 APRIL HYDROCHLORIDE 20/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Welvista - South Carolina Residents Only $354.43 $407.59 APRIL HYDROCHLOR 20/25 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/QUIN Welvista - South Carolina Residents Only $354.43 $407.59 APRIL HYDROCHLORIDE ACEBUTOLOL (BRAND: SECTRAL)
200 MG CAPSULE(S) ACEBUTOLOL Xubex Preferred Network Program $100.73 $115.84 400 MG CAPSULE(S) ACEBUTOLOL Xubex Preferred Network Program $133.97 $154.07
Report Run: 04/19/16 10:53 AM Page 3 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ACETAZOLAMIDE (BRAND: DIAMOX)
125 MG TABLET(S) ACETAZOLAMIDE Xubex Preferred Network Program $217.99 $250.69 250 MG TABLET(S) ACETAZOLAMIDE Xubex Preferred Network Program $288.31 $331.56 ACETAZOLAMIDE ER (BRAND: DIAMOX)
500 MG CAPSULE(S) ACETAZOLAMIDE Xubex Preferred Network Program $429.35 $493.75 ACIPHEX
20 MG TABLET(S) RABEPRAZOLE SODIUM Johnson & Johnson Patient Assistance $419.88 $482.86 Foundation ACITRETIN (BRAND: SORIATANE)
10 MG TABLET(S) ACITRETIN Xubex Preferred Network Program $936.05 $1,076.46 17.5 MG TABLET(S) ACITRETIN Xubex Preferred Network Program $1,153.78 $1,326.85 25 MG TABLET(S) ACITRETIN Xubex Preferred Network Program $1,153.78 $1,326.85 ACTEMRA
20 MG/ML (4 ML) MG tocilizumab Genetech Rheumatology Access Solutions $414.24 $476.38 ACTIVASE
100 MG UNIT(S) ALTEPLASE, RECOMBINANT Genentech Access to Care Foundation $8,455.85 $9,724.23 (TNKase, Cathflo, Activase) 50 MG UNIT(S) ALTEPLASE, RECOMBINANT Genentech Access to Care Foundation $4,227.92 $4,862.11 (TNKase, Cathflo, Activase) ACTIVELLA
0.5/0.1 MG-MG TABLET(S) ESTRADIOL/NORETHINDRONE Welvista - South Carolina Residents Only $220.32 $253.37 ACETATE
Report Run: 04/19/16 10:53 AM Page 4 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ACTOPLUS MET
* 15/500 MG/MG TABLET(S) METFORMIN Takeda Patient Assistance Program $625.91 $719.80 HYDROCHLORIDE/PIOGLITAZON E HYDROCHLORIDE * 15/850 MG/MG TABLET(S) METFORMIN Takeda Patient Assistance Program $625.91 $719.80 HYDROCHLORIDE/PIOGLITAZON E HYDROCHLORIDE ACTOPLUS MET XR
* 1000/15 MG TABLET(S) METFORMIN Takeda Patient Assistance Program $338.87 $389.70 HYDROCHLORIDE/PIOGLITAZON E HYDROCHLORIDE * 1000/30 MG TABLET(S) METFORMIN Takeda Patient Assistance Program $671.69 $772.44 HYDROCHLORIDE/PIOGLITAZON E HYDROCHLORIDE ACTOS
* 15 MG TABLET(S) PIOGLITAZONE Takeda Patient Assistance Program $1,235.66 $1,421.01 HYDROCHLORIDE * 30 MG TABLET(S) PIOGLITAZONE Takeda Patient Assistance Program $1,888.44 $2,171.71 HYDROCHLORIDE * 45 MG TABLET(S) PIOGLITAZONE Takeda Patient Assistance Program $1,696.09 $1,950.50 HYDROCHLORIDE ACUVAIL
0.45 % (0.4 ML) DROP(S) KETOROLAC TROMETHAMINE Allergan Patient Assistance Program $252.36 $290.21 ACYCLOVIR (BRAND: ZOVIRAX)
200 MG CAPSULE(S) ACYCLOVIR Rx Outreach $97.70 $112.35 400 MG TABLET(S) ACYCLOVIR Rx Outreach $195.03 $224.28
Report Run: 04/19/16 10:53 AM Page 5 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ACYCLOVIR (BRAND: ZOVIRAX)
800 MG TABLET(S) ACYCLOVIR Rx Outreach $329.98 $379.48 200 MG CAPSULE(S) ACYCLOVIR Xubex Preferred Network Program $97.70 $112.35 400 MG TABLET(S) ACYCLOVIR Xubex Preferred Network Program $195.03 $224.28 800 MG TABLET(S) ACYCLOVIR Xubex Preferred Network Program $329.98 $379.48 ACZONE
5 % (30 GM) GEL/JELLY DAPSONE Allergan Patient Assistance Program $269.23 $309.61 ADACEL
2.5/0.5/2 MCG/ML LF U/O INJECTION(S) TDAP VACCINE Sanofi Patient Connection $506.83 $582.85 ADAGEN
250 U/ML INJECTION(S) PEGADEMASE BOVINE Accredo - Adagen Patient Assistance Program $4,410.00 $5,071.50 ADALAT CC
30 MG TABLET(S) NIFEDIPINE Bayer HealthCare Patient Assistance Program $169.40 $194.81 60 MG TABLET(S) NIFEDIPINE Bayer HealthCare Patient Assistance Program $3,017.95 $3,470.64 90 MG TABLET(S) NIFEDIPINE Bayer HealthCare Patient Assistance Program $353.69 $406.74 ADCETRIS
50 MG MG brentuximab vedotin SeaGen Secure Patient Assistance Program $6,770.40 $7,785.96 ADCIRCA
20 MG TABLET(S) TADALAFIL United Therapeutics Patient Assistance $3,299.76 $3,794.72 Program-Adcirca
Report Run: 04/19/16 10:53 AM Page 6 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ADEFOVIR DIPIVOXIL (BRAND: HEPSERA)
10 MG TABLET(S) adefovir dipivoxil Xubex Preferred Network Program $1,136.84 $1,307.37 ADEKS
60-3-0.5-10 MG-MG-MG-MG TABLET(S) MULTIVITAMIN AND MINERALS Axcan Comprehensive Care Program for CF $21.35 $24.55 ADEMPAS
0.5 MG TABLET(S) riociguat Bayer Adempas REMS Program $9,826.20 $11,300.13 1 MG TABLET(S) riociguat Bayer Adempas REMS Program $9,826.20 $11,300.13 ADEMPAS
1.5 MG TABLET(S) riociguat Bayer Adempas REMS Program $9,826.20 $11,300.13 2 MG TABLET(S) riociguat Bayer Adempas REMS Program $9,826.20 $11,300.13 2.5 MG TABLET(S) riociguat Bayer Adempas REMS Program $9,826.20 $11,300.13 ADENOSCAN
3 MG/ML (20ML) INJECTION(S) ADENOSINE Astellas Stock Replacement Program $261.29 $300.48 ADVAIR DISKUS 100/50
0.01/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Access $323.18 $371.66 MG/ACTUATION 0.01/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $323.18 $371.66 MG/ACTUATION 0.01/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $323.18 $371.66 MG/ACTUATION 0.01/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Xubex Free Trial 30 Day Medication Supply $323.18 $371.66 MG/ACTUATION
Report Run: 04/19/16 10:53 AM Page 7 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ADVAIR DISKUS 250/50
0.25/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Access $401.56 $461.79 MG/ACTUATION 0.25/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $401.56 $461.79 MG/ACTUATION 0.25/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $401.56 $461.79 MG/ACTUATION 0.25/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Xubex Free Trial 30 Day Medication Supply $401.56 $461.79 MG/ACTUATION ADVAIR DISKUS 500/50
0.5/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Access $528.13 $607.35 MG/ACTUATION 0.5/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $528.13 $607.35 MG/ACTUATION 0.5/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $528.13 $607.35 MG/ACTUATION 0.5/0.05 MG/ACTUATION- PUFF(S) FLUTICASONE PROPIONATE Xubex Free Trial 30 Day Medication Supply $528.13 $607.35 MG/ACTUATION ADVAIR HFA
115/21 MCT (12 GM) PUFF(S) FLUTICASONE GSK Access $401.56 $461.79 PROPIONATE/SALMETEROL XINAFOATE 230/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL GSK Access $528.13 $607.35 GM) 45/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL GSK Access $323.18 $371.66 GM)
Report Run: 04/19/16 10:53 AM Page 8 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ADVAIR HFA
115/21 MCT (12 GM) PUFF(S) FLUTICASONE GSK Bridges to Access $401.56 $461.79 PROPIONATE/SALMETEROL XINAFOATE 230/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL GSK Bridges to Access $528.13 $607.35 GM) 230/30.45 MCG (12 GM) PUFF(S) FLUTICASONE/SALMETEROL GSK Bridges to Access $528.13 $607.35 45/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL GSK Bridges to Access $323.18 $371.66 GM) 115/21 MCT (12 GM) PUFF(S) FLUTICASONE Nova ScriptsCentral-Northern Virginia Clinic $401.56 $461.79 PROPIONATE/SALMETEROL Partners & Northern VA Residents ONLY XINAFOATE 230/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Nova ScriptsCentral-Northern Virginia Clinic $528.13 $607.35 GM) Partners & Northern VA Residents ONLY 45/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Nova ScriptsCentral-Northern Virginia Clinic $323.18 $371.66 GM) Partners & Northern VA Residents ONLY 115/21 MCT (12 GM) PUFF(S) FLUTICASONE Welvista - South Carolina Residents Only $401.56 $461.79 PROPIONATE/SALMETEROL XINAFOATE 230/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Welvista - South Carolina Residents Only $528.13 $607.35 GM) 230/30.45 MCG (12 GM) PUFF(S) FLUTICASONE/SALMETEROL Welvista - South Carolina Residents Only $528.13 $607.35 45/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Welvista - South Carolina Residents Only $323.18 $371.66 GM) 115/21 MCT (12 GM) PUFF(S) FLUTICASONE Xubex Free Trial 30 Day Medication Supply $401.56 $461.79 PROPIONATE/SALMETEROL XINAFOATE
Report Run: 04/19/16 10:53 AM Page 9 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ADVAIR HFA
230/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Xubex Free Trial 30 Day Medication Supply $528.13 $607.35 GM) 45/21 MCG/ACTUATION (12 PUFF(S) FLUTICASONE/SALMETEROL Xubex Free Trial 30 Day Medication Supply $323.18 $371.66 GM) ADVICOR
1000/20 MG-MG TABLET(S) LOVASTATIN/NIACIN Welvista - South Carolina Residents Only $802.67 $923.07 1000/40 MG-MG TABLET(S) LOVASTATIN/NIACIN Welvista - South Carolina Residents Only $929.20 $1,068.58 500/20 MG TABLET(S) LOVASTATIN/NIACIN Welvista - South Carolina Residents Only $697.99 $802.69 750/20 MG-MG TABLET(S) LOVASTATIN/NIACIN Welvista - South Carolina Residents Only $748.68 $860.98 AEROCHAMBER
- - DEVICE SPACER, INHALATION Actavis U.S. Patient Assistance Program $49.18 $56.56 AEROCHAMBER w/MASK
LARGE - DEVICE SPACER, INHALATION Actavis U.S. Patient Assistance Program $44.71 $51.42 MEDIUM - DEVICE SPACER, INHALATION Actavis U.S. Patient Assistance Program $53.42 $61.43 SMALL - DEVICE SPACER, INHALATION Actavis U.S. Patient Assistance Program $59.16 $68.03 AFEDITAB CR (BRAND: ADALAT CC)
30 MG TABLET(S) NIFEDIPINE Rx Outreach $103.81 $119.38 60 MG TABLET(S) NIFEDIPINE Rx Outreach $195.11 $224.38 30 MG TABLET(S) NIFEDIPINE Xubex Preferred Network Program $103.81 $119.38 60 MG TABLET(S) NIFEDIPINE Xubex Preferred Network Program $195.11 $224.38
Report Run: 04/19/16 10:53 AM Page 10 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AFINITOR
10 MG TABLET(S) EVEROLIMUS Novartis Oncology Patient Assistance $13,517.51 $15,545.14 Program 5 MG TABLET(S) EVEROLIMUS Novartis Oncology Patient Assistance $13,517.51 $15,545.14 Program 7.5 MG TABLET(S) EVEROLIMUS Novartis Oncology Patient Assistance $13,517.51 $15,545.14 Program AFINITOR
2.5 MG TABLET(S) EVEROLIMUS Novartis Oncology Patient Assistance $12,923.26 $14,861.75 Program AFINITOR DISPERZ
2 MG TABLET(S) everolimus Novartis Oncology Patient Assistance $12,858.82 $14,787.64 Program 3 MG TABLET(S) everolimus Novartis Oncology Patient Assistance $12,987.62 $14,935.76 Program 5 MG TABLET(S) everolimus Novartis Oncology Patient Assistance $13,517.51 $15,545.14 Program AFREZZA
4 U CARTRIDGE(S) insulin human inhaled Sanofi Patient Connection $271.27 $311.96 AFREZZA (30-4 UNIT CARTRIDGES AND 60-8 UNIT CARTRIDGES) N/A N/A CARTRIDGE(S) insulin human inhaled;insulin Sanofi Patient Connection $334.31 $384.46 human inhaled
Report Run: 04/19/16 10:53 AM Page 11 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AFREZZA (60-4 UNIT CARTRIDGES AND 30-8 UNIT CARTRIDGES) N/A N/A CARTRIDGE(S) insulin human inhaled;insulin Sanofi Patient Connection $302.80 $348.22 human inhaled AGENERASE
150 mg CAP AMPRENAVIR GSK Access $302.40 $347.76 50 mg CAP AMPRENAVIR GSK Access $201.60 $231.84 AGGRENOX
* 25-200 MG CAPSULE(S) ASPIRIN/DIPYRIDAMOLE Boehringer Ingelheim Cares Foundation Inc. $507.38 $583.49 AKYNZEO
300-0.5 MG-MG CAPSULE(S) netupitant/palonosetron Eisai Patient Assistance Program-Akynzeo $599.76 $689.72 ALBUTEROL (BRAND: VENTOLIN/PROVENTIL)
2 MG TABLET(S) ALBUTEROL SULFATE Xubex Preferred Network Program $1,756.63 $2,020.12 4 MG TABLET(S) ALBUTEROL SULFATE Xubex Preferred Network Program $1,756.63 $2,020.12 8 MG TABLET(S) ALBUTEROL SULFATE Xubex Preferred Network Program $334.46 $384.63 ALBUTEROL INH (BRAND: PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA) 0.083 % (3 ML) PUFF(S) albuterol sulfate Nova ScriptsCentral-Northern Virginia Clinic $33.28 $38.27 Partners & Northern VA Residents ONLY 0.083 % (3 ML) PUFF(S) albuterol sulfate Rx Outreach $33.28 $38.27 0.083 (90 ML) % (3 ML X 30) PUFF(S) albuterol sulfate Rx Outreach $49.80 $57.27 0.083 % (3 ML) PUFF(S) albuterol sulfate Xubex Preferred Network Program $33.28 $38.27 0.083 (180ML) % (3 ML X 60) PUFF(S) albuterol sulfate Xubex Preferred Network Program $79.86 $91.84
Report Run: 04/19/16 10:53 AM Page 12 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ALBUTEROL INH (BRAND: PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA) 0.083 (90 ML) % (3 ML X 30) PUFF(S) albuterol sulfate Xubex Preferred Network Program $49.80 $57.27 ALBUTEROL INHALER (BRAND: VENTOLIN/PROVENTIL)
17 GM PUFF(S) ALBUTEROL Xubex Patient Assistance Program $42.82 $49.24 ALCLOMETASONE DIPROPIONATE (BRAND: ACLOVATE)
0.05 % (15 GM) GM ALCLOMETASONE Rx Outreach $19.05 $21.91 DIPROPIONATE ALDACTAZIDE
25-25 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/SPIRO Pfizer MAINTAIN $170.88 $196.51 NOLACTONE 50-50 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/SPIRO Pfizer MAINTAIN $315.14 $362.41 NOLACTONE ALENDRONATE SODIUM (BRAND: FOSAMAX)
35 MG TABLET(S) ALENDRONATE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $613.88 $705.96 Partners & Northern VA Residents ONLY 70 MG TABLET(S) ALENDRONATE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $613.88 $705.96 Partners & Northern VA Residents ONLY 70 MG TABLET(S) ALENDRONATE SODIUM Rx Outreach $613.88 $705.96 70 MG TABLET(S) ALENDRONATE SODIUM Welvista - South Carolina Residents Only $613.88 $705.96 10 MG TABLET(S) ALENDRONATE SODIUM Xubex Preferred Network Program $292.68 $336.58 35 MG TABLET(S) ALENDRONATE SODIUM Xubex Preferred Network Program $613.88 $705.96 5 MG TABLET(S) ALENDRONATE SODIUM Xubex Preferred Network Program $292.68 $336.58 70 MG TABLET(S) ALENDRONATE SODIUM Xubex Preferred Network Program $613.88 $705.96
Report Run: 04/19/16 10:53 AM Page 13 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ALFUZOSIN HYDROCHLORIDE (BRAND: UROXATRAL)
10 MG TABLET(S) ALFUZOSIN HYDROCHLORIDE Xubex Preferred Network Program $379.23 $436.11 ALIMTA
500 MG MG PEMETREXED Eli Lilly PatientOne $3,646.92 $4,193.96 ALIMTA
100 MG MG PEMETREXED Eli Lilly PatientOne $729.38 $838.79 ALINIA
100 MG/5 ML (60 ML) MG NITAZOXANIDE Romark Laboratories Patient Assistance $119.56 $137.49 Program 500 MG TABLET(S) NITAZOXANIDE Romark Laboratories Patient Assistance $1,106.40 $1,272.36 Program ALLOPURINOL (BRAND: ZYLOPRIM)
100 MG TABLET(S) ALLOPURINOL Nova ScriptsCentral-Northern Virginia Clinic $31.08 $35.74 Partners & Northern VA Residents ONLY 300 MG TABLET(S) ALLOPURINOL Nova ScriptsCentral-Northern Virginia Clinic $37.00 $42.55 Partners & Northern VA Residents ONLY 100 MG TABLET(S) ALLOPURINOL Rx Outreach $31.08 $35.74 300 MG TABLET(S) ALLOPURINOL Rx Outreach $37.00 $42.55 100 MG TABLET(S) ALLOPURINOL Xubex Preferred Network Program $31.08 $35.74 ALODOX
20 MG TABLET(S) DOXYCYCLINE HYCLATE OcuSoft Patient Assistance Program $113.76 $130.82 ALOMIDE
0.1 % (10 ML) DROP(S) LODOXAMIDE TROMETHAMINE Alcon Cares, Inc. $167.82 $192.99
Report Run: 04/19/16 10:53 AM Page 14 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ALOMIDE
0.1 % (10 ML) DROP(S) LODOXAMIDE TROMETHAMINE Alcon Charitable Clinic Program-For Free $167.82 $192.99 Clinics ALOXI
0.05 MG/ML (5 ML) MG PALONOSETRON Eisai Patient Assistance Program $493.20 $567.18 HYDROCHLORIDE ALPHAGAN P
0.1 % 15ml DROP(S) BRIMONIDINE TARTRATE Allergan Patient Assistance Program $364.37 $419.03 ALPRAZOLAM (BRAND: XANAX)
0.25 MG TABLET(S) ALPRAZOLAM Rx Outreach $72.00 $82.80 0.5 MG TABLET(S) ALPRAZOLAM Rx Outreach $135.55 $155.88 1 MG TABLET(S) ALPRAZOLAM Rx Outreach $215.24 $247.53 2 MG TABLET(S) ALPRAZOLAM Rx Outreach $195.00 $224.25 0.25 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $72.00 $82.80 0.5 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $135.55 $155.88 1 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $215.24 $247.53 2 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $195.00 $224.25 ALPRAZOLAM ER (BRAND: XANAX XR)
0.5 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $128.95 $148.29 1 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $160.44 $184.51 2 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $212.93 $244.87 3 MG TABLET(S) ALPRAZOLAM Xubex Preferred Network Program $319.38 $367.29
Report Run: 04/19/16 10:53 AM Page 15 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ALREX
0.2 % (10ML) DROP(S) LOTEPREDNOL ETABONATE Bausch & Lomb US Patient Assistance $447.83 $515.00 Program ALTABAX OINTMENT
1 % (15 GM) APPLICATION RETAPAMULIN GSK Access $165.42 $190.23 1 % (15 GM) APPLICATION RETAPAMULIN GSK Bridges to Access $165.42 $190.23 AMANTADINE HCL
100 MG CAPSULE(S) amantadine hydrochloride Rx Outreach $329.76 $379.22 100 MG CAPSULE(S) amantadine hydrochloride Xubex Preferred Network Program $329.76 $379.22 AMBISOME
50 MG INJECTION(S) AMPHOTERICIN B LIPOSOME Astellas Stock Replacement Program $207.71 $238.87 AMERGE
1 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE GSK Access $443.16 $509.63 2.5 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE GSK Access $443.16 $509.63 * 1 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE GSK Bridges to Access $443.16 $509.63 * 2.5 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE GSK Bridges to Access $443.16 $509.63 1 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE Welvista - South Carolina Residents Only $443.16 $509.63 2.5 mg TABLET(S) NARATRIPTAN HYDROCHLORIDE Welvista - South Carolina Residents Only $443.16 $509.63 AMETHYST
20-90 MCG-MCG TABLET(S) ethinyl estradiol/levonorgestrel Xubex Preferred Network Program $59.40 $68.31 AMILORIDE/HCTZ (BRAND: MODURETIC)
5-50 MG-MG TABLET(S) AMILORIDE/HCTZ Xubex Preferred Network Program $32.86 $37.79
Report Run: 04/19/16 10:53 AM Page 16 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMIODARONE (BRAND: CORDARONE, PACERONE)
200 MG TABLET(S) AMIODARONE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $178.34 $205.09 Partners & Northern VA Residents ONLY 200 MG TABLET(S) AMIODARONE HYDROCHLORIDE Rx Outreach $178.34 $205.09 200 MG TABLET(S) AMIODARONE HYDROCHLORIDE Welvista - South Carolina Residents Only $178.34 $205.09 200 MG TABLET(S) AMIODARONE HYDROCHLORIDE Xubex Preferred Network Program $178.34 $205.09 AMITIZA
24 MCG CAPSULE(S) LUBIPROSTONE Takeda Patient Assistance Program $396.32 $455.77 8 MCG CAPSULE(S) LUBIPROSTONE Takeda Patient Assistance Program $396.32 $455.77 24 MCG CAPSULE(S) LUBIPROSTONE Welvista - South Carolina Residents Only $396.32 $455.77 8 MCG CAPSULE(S) LUBIPROSTONE Welvista - South Carolina Residents Only $396.32 $455.77 AMITRIPTYLINE (BRAND: ELAVIL)
10 MG TABLET(S) AMITRIPTYLINE Nova ScriptsCentral-Northern Virginia Clinic $67.44 $77.56 Partners & Northern VA Residents ONLY 25 MG TABLET(S) AMITRIPTYLINE Nova ScriptsCentral-Northern Virginia Clinic $61.83 $71.10 HYDROCHLORIDE Partners & Northern VA Residents ONLY 10 MG TABLET(S) AMITRIPTYLINE Rx Outreach $67.44 $77.56 100 MG TABLET(S) AMITRIPTYLINE Rx Outreach $118.80 $136.62 HYDROCHLORIDE 150 MG TABLET(S) AMITRIPTYLINE Rx Outreach $99.99 $114.99 HYDROCHLORIDE 25 MG TABLET(S) AMITRIPTYLINE Rx Outreach $61.83 $71.10 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 17 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMITRIPTYLINE (BRAND: ELAVIL)
50 MG TABLET(S) AMITRIPTYLINE Rx Outreach $80.00 $92.00 HYDROCHLORIDE 75 MG TABLET(S) AMITRIPTYLINE Rx Outreach $80.64 $92.74 HYDROCHLORIDE 10 MG TABLET(S) AMITRIPTYLINE Xubex Preferred Network Program $67.44 $77.56 150 MG TABLET(S) AMITRIPTYLINE Xubex Preferred Network Program $99.99 $114.99 HYDROCHLORIDE 25 MG TABLET(S) AMITRIPTYLINE Xubex Preferred Network Program $61.83 $71.10 HYDROCHLORIDE 50 MG TABLET(S) AMITRIPTYLINE Xubex Preferred Network Program $80.00 $92.00 HYDROCHLORIDE 75 MG TABLET(S) AMITRIPTYLINE Xubex Preferred Network Program $80.64 $92.74 HYDROCHLORIDE AMLODIPINE (BRAND: NORVASC)
* 10 MG TABLET(S) AMLODIPINE BESYLATE Generic Assistance Program (NeedyMeds & $213.59 $245.63 Rx Outreach) * 2.5 MG TABLET(S) AMLODIPINE BESYLATE Generic Assistance Program (NeedyMeds & $155.00 $178.25 Rx Outreach) * 5 MG TABLET(S) AMLODIPINE BESYLATE Generic Assistance Program (NeedyMeds & $155.68 $179.03 Rx Outreach) 10 MG TABLET(S) AMLODIPINE BESYLATE Nova ScriptsCentral-Northern Virginia Clinic $213.59 $245.63 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) AMLODIPINE BESYLATE Nova ScriptsCentral-Northern Virginia Clinic $155.00 $178.25 Partners & Northern VA Residents ONLY 5 MG TABLET(S) AMLODIPINE BESYLATE Nova ScriptsCentral-Northern Virginia Clinic $155.68 $179.03 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 18 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMLODIPINE (BRAND: NORVASC)
10 MG TABLET(S) AMLODIPINE BESYLATE Rx Outreach $213.59 $245.63 2.5 MG TABLET(S) AMLODIPINE BESYLATE Rx Outreach $155.00 $178.25 5 MG TABLET(S) AMLODIPINE BESYLATE Rx Outreach $155.68 $179.03 10 MG TABLET(S) AMLODIPINE BESYLATE Welvista - South Carolina Residents Only $213.59 $245.63 5 MG TABLET(S) AMLODIPINE BESYLATE Welvista - South Carolina Residents Only $155.68 $179.03 10 MG TABLET(S) AMLODIPINE BESYLATE Xubex Preferred Network Program $213.59 $245.63 2.5 MG TABLET(S) AMLODIPINE BESYLATE Xubex Preferred Network Program $155.00 $178.25 5 MG TABLET(S) AMLODIPINE BESYLATE Xubex Preferred Network Program $155.68 $179.03 AMLODIPINE/BENAZEPRIL (BRAND: LOTREL)
* 10/20 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Generic Assistance Program (NeedyMeds & $298.89 $343.72 Rx Outreach) * 5/10 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Generic Assistance Program (NeedyMeds & $243.64 $280.19 Rx Outreach) * 5/20 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Generic Assistance Program (NeedyMeds & $257.28 $295.87 Rx Outreach) 10/20 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Rx Outreach $298.89 $343.72 5/10 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Rx Outreach $243.64 $280.19 5/20 MG CAPSULE(S) AMLODIPINE/BENAZEPRIL Rx Outreach $257.28 $295.87 AMLODIPINE/VALSARTAN (BRAND: EXFORGE)
10/160 MG/MG TABLET(S) amlodipine besylate/valsartan Rx Outreach $558.23 $641.96 10/320 MG/MG TABLET(S) amlodipine besylate/valsartan Rx Outreach $708.62 $814.91 5/160 MG/MG TABLET(S) amlodipine besylate/valsartan Rx Outreach $492.05 $565.86
Report Run: 04/19/16 10:53 AM Page 19 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMLODIPINE/VALSARTAN (BRAND: EXFORGE)
5/320 MG/MG TABLET(S) amlodipine besylate/valsartan Rx Outreach $624.16 $717.78 AMLODIPINE/VALSARTAN HCTZ (BRAND: EXFORGE HCT) 10/12.5/160 MG/MG/MG TABLET(S) amlodipine Rx Outreach $558.23 $641.96 besylate/hydrochlorothiazide/v alsartan 10/25/160 MG/MG/MG TABLET(S) amlodipine Rx Outreach $558.23 $641.96 besylate/hydrochlorothiazide/v alsartan 10/25/320 MG/MG/MG TABLET(S) amlodipine Rx Outreach $708.62 $814.91 besylate/hydrochlorothiazide/v alsartan 5/12.5/160 MG/MG/MG TABLET(S) amlodipine Rx Outreach $492.05 $565.86 besylate/hydrochlorothiazide/v alsartan 5/25/160 MG/MG/MG TABLET(S) amlodipine Rx Outreach $492.05 $565.86 besylate/hydrochlorothiazide/v alsartan AMOXAPINE (BRAND: ASENDIN)
100 MG TABLET(S) amoxapine Rx Outreach $148.80 $171.12 100 MG TABLET(S) amoxapine Xubex Preferred Network Program $148.80 $171.12 150 MG TABLET(S) amoxapine Xubex Preferred Network Program $74.28 $85.42 25 MG TABLET(S) amoxapine Xubex Preferred Network Program $56.38 $64.84 50 MG TABLET(S) amoxapine Xubex Preferred Network Program $86.81 $99.83
Report Run: 04/19/16 10:53 AM Page 20 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMPYRA
10 MG TABLET(S) dalfampridine Acorda - Ampyra Patient Assistance Program $2,132.22 $2,452.05 AMTURNIDE
150-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Novartis Patient Assistance Foundation, Inc. $142.98 $164.43 BESYLATE/HYDROCHLOROTHIAZ IDE 300-10-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Novartis Patient Assistance Foundation, Inc. $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 300-10-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Novartis Patient Assistance Foundation, Inc. $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 300-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Novartis Patient Assistance Foundation, Inc. $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 300-5-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Novartis Patient Assistance Foundation, Inc. $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 150-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Welvista - South Carolina Residents Only $142.98 $164.43 BESYLATE/HYDROCHLOROTHIAZ IDE 300-10-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Welvista - South Carolina Residents Only $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 300-10-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Welvista - South Carolina Residents Only $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE
Report Run: 04/19/16 10:53 AM Page 21 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AMTURNIDE
300-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Welvista - South Carolina Residents Only $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE 300-5-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE Welvista - South Carolina Residents Only $180.46 $207.53 BESYLATE/HYDROCHLOROTHIAZ IDE ANAFRANIL
25 MG CAPSULE(S) CLOMIPRAMINE Covidien/Mallinckrodt Patient Assistance $980.57 $1,127.66 HYDROCHLORIDE Program 50 MG CAPSULE(S) CLOMIPRAMINE Covidien/Mallinckrodt Patient Assistance $990.07 $1,138.58 HYDROCHLORIDE Program 75 MG CAPSULE(S) CLOMIPRAMINE Covidien/Mallinckrodt Patient Assistance $1,017.55 $1,170.18 HYDROCHLORIDE Program ANAGRELIDE HCL (BRAND: AGRYLIN)
0.5 MG TABLET(S) ANAGRELIDE HCL Xubex Preferred Network Program $585.70 $673.56 ANAGRELIDE HCL(BRAND: AGRYLIN)
1 MG TABLET(S) ANAGRELIDE HCL Xubex Preferred Network Program $1,171.35 $1,347.05 ANALPRAM-HC CREAM
1-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $74.16 $85.28 ACETATE/PRAMOXINE Program HYDROCHLORIDE 2.5-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $74.16 $85.28 ACETATE/PRAMOXINE Program HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 22 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ANALPRAM-HC LOTION
2.5-1 %-% (60 ML) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $90.95 $104.59 ACETATE/PRAMOXINE Program HYDROCHLORIDE ANASTROZOLE (BRAND: ARIMIDEX)
1 MG TABLET(S) ANASTROZOLE Rx Outreach $404.85 $465.58 1 MG TABLET(S) ANASTROZOLE Xubex Preferred Network Program $404.85 $465.58 ANCOBON
500 MG CAPSULE(S) FLUCYTOSINE Valeant Patient Assistance Program $18,586.72 $21,374.73 ANDROGEL
1.62 % (1.25 GM) PACKET(S) testosterone AbbVie Patient Assistance Foundation- $571.03 $656.68 Androgel ANDROXY
10 MG TABLET(S) fluoxymesterone Rx Outreach $577.84 $664.52 ANGELIQ
0.5-1 MG-MG TABLET(S) DROSPIRENONE/ESTRADIOL Bayer HealthCare Patient Assistance Program $398.15 $457.87 ANGIOMAX
250 MG MG BIVALIRUDIN The Medicine Company Hospital/Patient $6,912.00 $7,948.80 Assistance Program for Angiomax ANORO ELLIPTA
62.5/25 MCG/ACTUATION BLISTERS umeclidinium GSK Access $106.20 $122.13 bromide/vilanterol trifenatate 62.5/25 MCG/ACTUATION BLISTERS umeclidinium GSK Bridges to Access $106.20 $122.13 bromide/vilanterol trifenatate
Report Run: 04/19/16 10:53 AM Page 23 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ANORO ELLIPTA
62.5/25 MCG/ACTUATION BLISTERS umeclidinium Welvista - South Carolina Residents Only $106.20 $122.13 bromide/vilanterol trifenatate ANUCORT-HC (BRAND: ANUSOL-HC)
25 MG SUPPOSITORY HYDROCORTISONE ACETATE Xubex Patient Assistance Program $96.84 $111.37 ANUSOL-HC
2.5 % (30 GM) CREAM HYDROCORTISONE ACETATE Salix Patient Assistance Program $118.96 $136.80 25 MG SUPPOSITORY HYDROCORTISONE ACETATE Salix Patient Assistance Program $132.40 $152.26 APIDRA
100 U/ML UNIT(S) INSULIN GLULISINE Sanofi Patient Connection $283.45 $325.97 APIDRA SOLOSTAR
100 U/ML (3 ML) UNIT(S) INSULIN GLULISINE Sanofi Patient Connection $547.58 $629.72 APLIGRAF
n/a n/a SHEET GRAFTSKIN Organogenesis Apligraf Patient Assistance $1,900.80 $2,185.92 Program APRISO
0.375 GM CAPSULE(S) MESALAMINE Salix Patient Assistance Program $500.47 $575.54 APTIOM
600 MG TABLET(S) eslicarbazepine acetate Sunovion Support Prescription Assistance $1,823.04 $2,096.50 Program-Aptiom 800 MG TABLET(S) eslicarbazepine acetate Sunovion Support Prescription Assistance $911.52 $1,048.25 Program-Aptiom
Report Run: 04/19/16 10:53 AM Page 24 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
APTIOM
200 MG TABLET(S) eslicarbazepine acetate Sunovion Support Prescription Assistance $684.00 $786.60 Program-Aptiom 400 MG TABLET(S) eslicarbazepine acetate Sunovion Support Prescription Assistance $911.52 $1,048.25 Program-Aptiom APTIVUS
250 MG CAPSULE(S) TIPRANAVIR Boehringer Ingelheim Cares Foundation Inc. $1,590.18 $1,828.71 ARANESP
100 MCG/ML SYRINGES(S) DARBEPOETIN ALFA Amgen Safety Net Foundation $2,371.20 $2,726.88 200 MCG/ML SYRINGE(S) DARBEPOETIN ALFA Amgen Safety Net Foundation $4,533.12 $5,213.09 25 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $851.04 $978.70 300 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $1,778.40 $2,045.16 40 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $1,361.76 $1,566.02 60 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $2,042.40 $2,348.76 ARANESP-PRE FILLED SYRINGE
150/0.3 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $3,556.80 $4,090.32 500 MCG/ML MCG DARBEPOETIN ALFA Amgen Safety Net Foundation $2,964.00 $3,408.60 ARCAPTA NEOHALER
75 MCG CAPSULE(S) INDACATEROL MALEATE Novartis Patient Assistance Foundation, Inc. $256.33 $294.78 ARICEPT
10 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Rx Outreach $503.28 $578.77 * 23 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Rx Outreach $910.08 $1,046.59
Report Run: 04/19/16 10:53 AM Page 25 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ARICEPT
5 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Rx Outreach $1,509.84 $1,736.32 23 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Xubex Free Trial 30 Day Medication Supply $910.08 $1,046.59 ARIMIDEX
1 MG TABLET(S) ANASTROZOLE AZ&Me Prescription Savings for people with $572.84 $658.77 Medicare Part D 1 MG TABLET(S) ANASTROZOLE AZ&Me Prescription Savings Program $572.84 $658.77 1 MG TABLET(S) ANASTROZOLE Welvista - South Carolina Residents Only $572.84 $658.77 ARISTADA
441 MG/ML (1.6 ML) INJECTION aripiprazole lauroxil ARISTADA Care Support Patient Assistance $1,266.00 $1,455.90 Program 662 MG/ML (2.4 ML) INJECTION aripiprazole lauroxil ARISTADA Care Support Patient Assistance $1,899.60 $2,184.54 Program 882 MG/ML (3.2 ML) INJECTION aripiprazole lauroxil ARISTADA Care Support Patient Assistance $2,530.80 $2,910.42 Program ARIXTRA
10/0.8 MG/ML (0.8ML) MG FONDAPARINUX SODIUM GSK Access $1,429.02 $1,643.37 2.5/0.5 MG/ML (0.5ML) MG FONDAPARINUX SODIUM GSK Access $607.25 $698.34 5/0.4 MG/ML (0.4 ML) MG FONDAPARINUX SODIUM GSK Access $1,429.02 $1,643.37 7.5/0.6 MG/ML SYRINGE FONDAPARINUX SODIUM GSK Access $1,488.56 $1,711.84 ARMOUR THYROID
120 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $133.66 $153.71 15 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $55.90 $64.29
Report Run: 04/19/16 10:53 AM Page 26 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ARMOUR THYROID
180 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $126.00 $144.90 240 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $153.00 $175.95 30 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $65.62 $75.46 300 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $180.00 $207.00 60 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $72.90 $83.84 90 MG TABLET(S) THYROID Actavis U.S. Patient Assistance Program $114.22 $131.35 ARNUITY ELLIPTA
100 MCG/ACTUATION BLISTER(S) fluticasone furoate GSK Bridges to Access $179.95 $206.94 200 MCG/ACTUATION BLISTER(S) fluticasone furoate GSK Bridges to Access $240.92 $277.06 ARNUITY ELLIPTA (INSTITUTIONAL PACK)
100 MCG/ACTUATION BLISTER(S) fluticasone furoate GSK Bridges to Access $83.98 $96.58 200 MCG/ACTUATION BLISTER(S) fluticasone furoate GSK Bridges to Access $112.44 $129.31 AROMASIN
25 MG TABLET(S) EXEMESTANE Pfizer RxPathways $705.73 $811.59 ARRANON
5 MG/ML (50 ML) INJECTION(S) NELARABINE Commitment to Access $5,294.63 $6,088.82 ARTHROTEC
50-0.2 MG-MG TABLET(S) DICLOFENAC Pfizer RxPathways $564.52 $649.20 SODIUM/MISOPROSTOL 75-0.2 MG-MG TABLET(S) DICLOFENAC Pfizer RxPathways $376.37 $432.83 SOD/MISOPROSTOL
Report Run: 04/19/16 10:53 AM Page 27 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ARTHROTEC
50-0.2 MG-MG TABLET(S) DICLOFENAC Welvista - South Carolina Residents Only $564.52 $649.20 SODIUM/MISOPROSTOL 75-0.2 MG-MG TABLET(S) DICLOFENAC Welvista - South Carolina Residents Only $376.37 $432.83 SOD/MISOPROSTOL ARZERRA
20 MG/ML (5ML) INJECTION(S) OFATUMUMAB Commitment to Access $1,819.12 $2,091.99 ASMANEX HFA
100 MCG/ACTUATION (13 PUFF(S) mometasone furoate Merck Patient Assistance Program $200.46 $230.53 GM) 200 MCG/ACTUATION (13 PUFF(S) mometasone furoate Merck Patient Assistance Program $235.56 $270.89 GM) ASMANEX TWISTHALER
110 MCG (30) PUFF(S) MOMETASONE FUROATE Merck Patient Assistance Program $173.53 $199.56 220 MCG (120) PUFF(S) MOMETASONE FUROATE Merck Patient Assistance Program $337.58 $388.22 110 MCG (30) PUFF(S) MOMETASONE FUROATE Welvista - South Carolina Residents Only $173.53 $199.56 220 MCG (120) PUFF(S) MOMETASONE FUROATE Welvista - South Carolina Residents Only $337.58 $388.22 ASPIRIN
81 MG TABLET(S) aspirin Nova ScriptsCentral-Northern Virginia Clinic $3.62 $4.16 Partners & Northern VA Residents ONLY ATACAND
* 16 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings for people with $317.57 $365.21 Medicare Part D
Report Run: 04/19/16 10:53 AM Page 28 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ATACAND
* 32 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings for people with $429.58 $494.02 Medicare Part D * 4 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings for people with $105.77 $121.64 Medicare Part D * 8 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings for people with $105.77 $121.64 Medicare Part D * 16 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings Program $317.57 $365.21 * 32 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings Program $429.58 $494.02 * 4 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings Program $105.77 $121.64 * 8 MG TABLET(S) CANDESARTAN CILEXETIL AZ&Me Prescription Savings Program $105.77 $121.64 ATACAND HCT
* 16-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL/HCTZ AZ&Me Prescription Savings for people with $429.58 $494.02 Medicare Part D * 32-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL/HCTZ AZ&Me Prescription Savings for people with $438.13 $503.85 Medicare Part D * 16-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL/HCTZ AZ&Me Prescription Savings Program $429.58 $494.02 * 32-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL/HCTZ AZ&Me Prescription Savings Program $438.13 $503.85 * 32-25 MG-MG TABLET(S) CANDESARTAN AZ&Me Prescription Savings Program $474.25 $545.39 CILEXETIL/HYDROCHLOROTHIAZ IDE ATENOLOL (BRAND: TENORMIN)
100 MG TABLET(S) ATENOLOL Nova ScriptsCentral-Northern Virginia Clinic $133.20 $153.18 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 29 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ATENOLOL (BRAND: TENORMIN)
25 MG TABLET(S) ATENOLOL Nova ScriptsCentral-Northern Virginia Clinic $34.75 $39.96 Partners & Northern VA Residents ONLY 50 MG TABLET(S) ATENOLOL Nova ScriptsCentral-Northern Virginia Clinic $96.30 $110.75 Partners & Northern VA Residents ONLY 100 MG TABLET(S) ATENOLOL Rx Outreach $133.20 $153.18 25 MG TABLET(S) ATENOLOL Rx Outreach $34.75 $39.96 50 MG TABLET(S) ATENOLOL Rx Outreach $96.30 $110.75 100 MG TABLET(S) ATENOLOL Welvista - South Carolina Residents Only $133.20 $153.18 25 MG TABLET(S) ATENOLOL Welvista - South Carolina Residents Only $34.75 $39.96 50 MG TABLET(S) ATENOLOL Welvista - South Carolina Residents Only $96.30 $110.75 100 MG TABLET(S) ATENOLOL Xubex Preferred Network Program $133.20 $153.18 25 MG TABLET(S) ATENOLOL Xubex Preferred Network Program $34.75 $39.96 50 MG TABLET(S) ATENOLOL Xubex Preferred Network Program $96.30 $110.75 ATENOLOL/CHLORTHALIDONE (BRAND: TENORETIC)
100/25 MG-MG TABLET(S) ATENOLOL/CHLORTHALIDONE Rx Outreach $127.11 $146.18 50/25 MG-MG TABLET(S) ATENOLOL/CHLORTHALIDONE Rx Outreach $140.36 $161.41 100/25 MG-MG TABLET(S) ATENOLOL/CHLORTHALIDONE Xubex Preferred Network Program $127.11 $146.18 50/25 MG-MG TABLET(S) ATENOLOL/CHLORTHALIDONE Xubex Preferred Network Program $140.36 $161.41 ATORVASTATIN CALCIUM (BRAND: LIPITOR)
10 MG TABLET(S) ATORVASTATIN CALCIUM Nova ScriptsCentral-Northern Virginia Clinic $364.28 $418.92 Partners & Northern VA Residents ONLY 10 MG TABLET(S) ATORVASTATIN CALCIUM Rx Outreach $364.28 $418.92
Report Run: 04/19/16 10:53 AM Page 30 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ATORVASTATIN CALCIUM (BRAND: LIPITOR)
20 MG TABLET(S) ATORVASTATIN CALCIUM Rx Outreach $519.63 $597.57 40 MG TABLET(S) ATORVASTATIN CALCIUM Rx Outreach $519.63 $597.57 80 MG TABLET(S) ATORVASTATIN CALCIUM Rx Outreach $519.63 $597.57 10 MG TABLET(S) ATORVASTATIN CALCIUM Xubex Preferred Network Program $364.28 $418.92 20 MG TABLET(S) ATORVASTATIN CALCIUM Xubex Preferred Network Program $519.63 $597.57 40 MG TABLET(S) ATORVASTATIN CALCIUM Xubex Preferred Network Program $519.63 $597.57 80 MG TABLET(S) ATORVASTATIN CALCIUM Xubex Preferred Network Program $519.63 $597.57 ATRIPLA
600-200-300 MG-MG-MG TABLET(S) EFAVIRENZ/EMTRICITABINE/TEN Gilead Advancing Access $2,869.86 $3,300.34 OFOVIR ATROVENT HFA
0.017 MG/ACTUATION PUFF(S) IPRATROPIUM BROMIDE Boehringer Ingelheim Cares Foundation Inc. $311.87 $358.65 AUBAGIO
14 MG TABLET(S) teriflunomide MS One to One Patient Assistance Program $5,803.68 $6,674.23 7 MG TABLET(S) teriflunomide MS One to One Patient Assistance Program $5,803.68 $6,674.23 AURSTAT ANTI-ITCH HYDROGEL
N/A 225 ML GEL Onset Patient Assistance Program $364.94 $419.68 AURSTAT KIT
N/A N/A APPLICATION Onset Patient Assistance Program $220.32 $253.37 AURYXIA
1 GM TABLET(S) ferric citrate Keryx Patient Plus Program $1,010.40 $1,161.96
Report Run: 04/19/16 10:53 AM Page 31 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AVANDAMET
1000-2 MG TABLET(S) METFORMIN GSK Access $165.31 $190.11 HYDROCHLORIDE/ROSIGLITAZO NE MALEATE 1000-4 MG TABLET(S) METFORMIN GSK Access $280.07 $322.08 HYDROCHLORIDE/ROSIGLITAZO NE MALEATE 500;1 MG;MG TABLET(S) METFORMIN GSK Access $113.00 $129.95 HCL/ROSIGLITAZONE MALEATE 500-2 MG-MG TABLET(S) METFORMIN GSK Access $165.31 $190.11 HCL/ROSIGLITAZONE MALEATE 500-4 MG-MG TABLET(S) METFORMIN GSK Access $280.07 $322.08 HCL/ROSIGLITAZONE MALEATE 1000-2 MG TABLET(S) METFORMIN GSK Bridges to Access $165.31 $190.11 HYDROCHLORIDE/ROSIGLITAZO NE MALEATE 1000-4 MG TABLET(S) METFORMIN GSK Bridges to Access $280.07 $322.08 HYDROCHLORIDE/ROSIGLITAZO NE MALEATE 500;1 MG;MG TABLET(S) METFORMIN GSK Bridges to Access $113.00 $129.95 HCL/ROSIGLITAZONE MALEATE 500-2 MG-MG TABLET(S) METFORMIN GSK Bridges to Access $165.31 $190.11 HCL/ROSIGLITAZONE MALEATE 500-4 MG-MG TABLET(S) METFORMIN GSK Bridges to Access $280.07 $322.08 HCL/ROSIGLITAZONE MALEATE AVANDIA
2 MG TABLET(S) ROSIGLITAZONE MALEATE GSK Access $189.25 $217.64
Report Run: 04/19/16 10:53 AM Page 32 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AVANDIA
4 mg TABLET(S) ROSIGLITAZONE MALEATE GSK Access $140.45 $161.52 8 MG TABLET(S) ROSIGLITAZONE MALEATE GSK Access $255.17 $293.45 2 MG TABLET(S) ROSIGLITAZONE MALEATE GSK Bridges to Access $189.25 $217.64 4 mg TABLET(S) ROSIGLITAZONE MALEATE GSK Bridges to Access $140.45 $161.52 8 MG TABLET(S) ROSIGLITAZONE MALEATE GSK Bridges to Access $255.17 $293.45 AVAPRO
* 150 MG TABLET(S) IRBESARTAN Bristol-Myers Squibb Patient Assistance $169.27 $194.66 Foundation, Inc. * 300 MG TABLET(S) IRBESARTAN Bristol-Myers Squibb Patient Assistance $610.58 $702.17 Foundation, Inc. * 75 MG TABLET(S) IRBESARTAN Bristol-Myers Squibb Patient Assistance $482.58 $554.97 Foundation, Inc. AVASTIN
25 MG/ML (4 ML) MG BEVACIZUMAB Genentech BioOncology Access to Solutions- $814.42 $936.58 Infused Products AVELOX
400 MG TABLET(S) MOXIFLOXACIN Merck Patient Assistance Program $162.22 $186.55 HYDROCHLORIDE 400 MG TABLET(S) MOXIFLOXACIN Welvista - South Carolina Residents Only $162.22 $186.55 HYDROCHLORIDE AVODART
0.5 MG CAPSULE(S) DUTASTERIDE GSK Access $604.99 $695.74 0.5 MG CAPSULE(S) DUTASTERIDE GSK Bridges to Access $604.99 $695.74
Report Run: 04/19/16 10:53 AM Page 33 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AVODART
0.5 MG CAPSULE(S) DUTASTERIDE Nova ScriptsCentral-Northern Virginia Clinic $604.99 $695.74 Partners & Northern VA Residents ONLY 0.5 MG CAPSULE(S) DUTASTERIDE Welvista - South Carolina Residents Only $604.99 $695.74 AVONEX
30/0.5 MCG/ML INJECTION(S) INTERFERON BETA-1A Biogen Avonex Access Program $2,762.40 $3,176.76 AXERT
12.5 MG TABLET(S) ALMOTRIPTAN MALATE Johnson & Johnson Patient Assistance $533.40 $613.41 Foundation-Card Program 6.25 MG TABLET(S) ALMOTRIPTAN MALATE Johnson & Johnson Patient Assistance $266.65 $306.65 Foundation-Card Program 12.5 MG TABLET(S) ALMOTRIPTAN MALATE Welvista - South Carolina Residents Only $533.40 $613.41 6.25 MG TABLET(S) ALMOTRIPTAN MALATE Welvista - South Carolina Residents Only $266.65 $306.65 AXIRON
30/1.5 MG/ML (90 ML) PUMP(S) TESTOSTERONE Xubex Free Trial 30 Day Medication Supply $569.76 $655.22 AXONA
40 GM PACKET Axona Patient Assistance Program $88.99 $102.34 AZASAN
100 MG TABLET(S) AZATHIOPRINE Salix Patient Assistance Program $667.13 $767.20 75 MG TABLET(S) AZATHIOPRINE Salix Patient Assistance Program $498.60 $573.39 AZATHIOPRINE (BRAND: IMURAN)
50 MG TABLET(S) AZATHIOPRINE Rx Outreach $130.93 $150.57
Report Run: 04/19/16 10:53 AM Page 34 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AZATHIOPRINE (BRAND: IMURAN)
50 MG TABLET(S) AZATHIOPRINE Xubex Preferred Network Program $130.93 $150.57 AZELASTINE HCL (BRAND: ASTELIN OR ASTEPRO)
137 MCG/ACTUATION SPRAY(S) azelastine hydrochloride Rx Outreach $105.20 $120.98 137 MCG/ACTUATION SPRAY(S) azelastine hydrochloride Xubex Preferred Network Program $105.20 $120.98 AZILECT
0.5 MG TABLET(S) RASAGILINE Teva Azilect Patient Assistance Program $693.00 $796.95 1 MG TABLET(S) RASAGILINE Teva Azilect Patient Assistance Program $693.00 $796.95 AZITHROMYCIN (BRAND: ZITHROMAX)
250 MG TABLET(S) azithromycin Xubex Preferred Network Program $421.51 $484.74 500 MG TABLET(S) azithromycin Xubex Preferred Network Program $569.41 $654.82 AZOPT
1 % 15 ML DROP(S) BRINZOLAMIDE Alcon Cares, Inc. $449.94 $517.43 1 % (10 ML) DROP(S) BRINZOLAMIDE Alcon Cares, Inc. $300.00 $345.00 1 % 15 ML DROP(S) BRINZOLAMIDE Alcon Charitable Clinic Program-For Free $449.94 $517.43 Clinics AZOR
10-20 MG-MG TABLET(S) AMLODIPINE Daiichi Sankyo Open Care Program $653.40 $751.41 BESYLATE/OLMESARTAN MEDOXOMIL 10-40 MG-MG TABLET(S) AMLODIPINE Daiichi Sankyo Open Care Program $826.20 $950.13 BESYLATE/OLMESARTAN MEDOXOMIL
Report Run: 04/19/16 10:53 AM Page 35 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
AZOR
5-20 MG-MG TABLET(S) AMLODIPINE Daiichi Sankyo Open Care Program $653.40 $751.41 BESYLATE/OLMESARTAN MEDOXOMIL 5-40 MG-MG TABLET(S) AMLODIPINE Daiichi Sankyo Open Care Program $826.20 $950.13 BESYLATE/OLMESARTAN MEDOXOMIL BACLOFEN (BRAND: LIORESAL)
10 MG TABLET(S) BACLOFEN Nova ScriptsCentral-Northern Virginia Clinic $61.01 $70.16 Partners & Northern VA Residents ONLY 20 MG TABLET(S) BACLOFEN Nova ScriptsCentral-Northern Virginia Clinic $109.62 $126.06 Partners & Northern VA Residents ONLY 10 MG TABLET(S) BACLOFEN Rx Outreach $61.01 $70.16 20 MG TABLET(S) BACLOFEN Rx Outreach $109.62 $126.06 10 MG TABLET(S) BACLOFEN Xubex Preferred Network Program $61.01 $70.16 20 MG TABLET(S) BACLOFEN Xubex Preferred Network Program $109.62 $126.06 BACTROBAN
2 % 15gm CREAM MUPIROCIN CALCIUM GSK Access $98.76 $113.57 APPLICATION 2 % 15gm CREAM MUPIROCIN CALCIUM GSK Bridges to Access $98.76 $113.57 APPLICATION 2 % 15gm CREAM MUPIROCIN CALCIUM Welvista - South Carolina Residents Only $98.76 $113.57 APPLICATION BACTROBAN NASAL OINTMENT
2 % (1 GM) BOX MUPIROCIN CALCIUM GSK Bridges to Access $161.94 $186.23
Report Run: 04/19/16 10:53 AM Page 36 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BACTROBAN NASAL OINTMENT
2 % (1 GM) BOX MUPIROCIN CALCIUM Welvista - South Carolina Residents Only $161.94 $186.23 BALSALAZIDE DISODIUM (BRAND: COLAZAL)
750 MG CAPSULE(S) BALSALAZIDE DISODIUM Rx Outreach $447.82 $514.99 750 MG CAPSULE(S) BALSALAZIDE DISODIUM Xubex Preferred Network Program $447.82 $514.99 BANZEL
200 MG TABLET(S) RUFINAMIDE Eisai Banzel Patient Assistance Program $981.60 $1,128.84 400 MG TABLET(S) RUFINAMIDE Eisai Banzel Patient Assistance Program $1,963.20 $2,257.68 BARACLUDE
0.5 MG TABLET(S) ENTECAVIR Bristol-Myers Squibb Baraclude Patient $4,443.48 $5,110.00 Assistance Program 1 MG TABLET(S) ENTECAVIR Bristol-Myers Squibb Baraclude Patient $1,481.17 $1,703.35 Assistance Program BARACLUDE ORAL SOLUTION
0.05 MG/ML (210 ML) ML ENTECAVIR Bristol-Myers Squibb Baraclude Patient $1,036.80 $1,192.32 Assistance Program BECONASE AQ
0.042 MG/INH(25gm) PUFF(S) BECLOMETHASONE GSK Access $267.47 $307.59 DIPROPIONATE MONOHYDRATE 0.042 MG/INH(25gm) PUFF(S) BECLOMETHASONE GSK Bridges to Access $267.47 $307.59 DIPROPIONATE MONOHYDRATE 0.042 MG/INH(25gm) PUFF(S) BECLOMETHASONE Welvista - South Carolina Residents Only $267.47 $307.59 DIPROPIONATE MONOHYDRATE
Report Run: 04/19/16 10:53 AM Page 37 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BELSOMRA
10 MG TABLET(S) suvorexant Merck Patient Assistance Program $315.72 $363.08 15 MG TABLET(S) suvorexant Merck Patient Assistance Program $315.72 $363.08 20 MG TABLET(S) suvorexant Merck Patient Assistance Program $315.72 $363.08 5 MG TABLET(S) suvorexant Merck Patient Assistance Program $315.72 $363.08 BELVIQ
10 MG TABLET(S) lorcaserin hydrochloride Rx Outreach $239.40 $275.31 10 MG TABLET(S) lorcaserin hydrochloride Xubex Free Trial 30 Day Medication Supply $239.40 $275.31 BENAZEPRIL (BRAND: LOTENSIN)
10 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $59.40 $68.31 Partners & Northern VA Residents ONLY 20 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $58.75 $67.56 Partners & Northern VA Residents ONLY 40 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $72.40 $83.26 Partners & Northern VA Residents ONLY 10 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Rx Outreach $59.40 $68.31 20 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Rx Outreach $58.75 $67.56 40 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Rx Outreach $72.40 $83.26 5 MG TABLET(S) BENAZEPRIL Rx Outreach $105.11 $120.88 10 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Xubex Preferred Network Program $59.40 $68.31 20 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Xubex Preferred Network Program $58.75 $67.56 40 MG TABLET(S) BENAZEPRIL HYDROCHLORIDE Xubex Preferred Network Program $72.40 $83.26 5 MG TABLET(S) BENAZEPRIL Xubex Preferred Network Program $105.11 $120.88
Report Run: 04/19/16 10:53 AM Page 38 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BENAZEPRIL HCTZ (BRAND: LOTENSIN-HCT)
10-12.5 MG TABLET(S) BENAZEPRIL Rx Outreach $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 20-25 MG-MG TABLET(S) BENAZEPRIL Rx Outreach $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 10-12.5 MG TABLET(S) BENAZEPRIL Xubex Preferred Network Program $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 20-25 MG-MG TABLET(S) BENAZEPRIL Xubex Preferred Network Program $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE BENAZEPRIL/HCTZ (BRAND: LOTENSIN-HCT)
20-12.5 MG-MG TABLET(S) BENAZEPRIL Rx Outreach $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 5-6.25 MG TABLET(S) BENAZEPRIL Rx Outreach $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 20-12.5 MG-MG TABLET(S) BENAZEPRIL Xubex Preferred Network Program $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE 5-6.25 MG TABLET(S) BENAZEPRIL Xubex Preferred Network Program $115.50 $132.83 HYDROCHLORIDE/HYDROCHLOR OTHIAZIDE
Report Run: 04/19/16 10:53 AM Page 39 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BENEFIX
1 IU (1000 IU) INJECTION COAGULATION FACTOR IX Pfizer RxPathways $1.36 $1.56 RECOMBINANT 1 IU (500 IU) INJECTION COAGULATION FACTOR IX Pfizer RxPathways $1.36 $1.56 RECOMBINANT BENICAR
20 MG TABLET(S) OLMESARTAN MEDOXOMIL Daiichi Sankyo Open Care Program $571.32 $657.02 40 MG TABLET(S) OLMESARTAN MEDOXOMIL Daiichi Sankyo Open Care Program $794.88 $914.11 5 MG TABLET(S) OLMESARTAN MEDOXOMIL Daiichi Sankyo Open Care Program $155.88 $179.26 BENICAR HCT
20/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/OLME Daiichi Sankyo Open Care Program $571.32 $657.02 SARTAN MEDOXOMIL 40/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/OLME Daiichi Sankyo Open Care Program $794.88 $914.11 SARTAN MEDOXOMIL 40/25 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/OLME Daiichi Sankyo Open Care Program $794.88 $914.11 SARTAN MEDOXOMIL BENLYSTA
120 MG MG belimumab Benlysta Gateway Patient Assistance Program $556.12 $639.54 400 MG MG belimumab Benlysta Gateway Patient Assistance Program $1,853.69 $2,131.74 BENZONATATE (BRAND: TESSALON)
100 MG CAPSULE(S) BENZONATATE Rx Outreach $101.33 $116.53 200 MG CAPSULE(S) BENZONATATE Rx Outreach $197.73 $227.39 100 MG CAPSULE(S) BENZONATATE Xubex Preferred Network Program $101.33 $116.53
Report Run: 04/19/16 10:53 AM Page 40 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BENZTROPINE MESYLATE (BRAND: COGENTIN)
0.5 MG TABLET(S) BENZTROPINE MESYLATE Nova ScriptsCentral-Northern Virginia Clinic $38.65 $44.45 Partners & Northern VA Residents ONLY 1 MG TABLET(S) BENZTROPINE MESYLATE Nova ScriptsCentral-Northern Virginia Clinic $40.91 $47.05 Partners & Northern VA Residents ONLY 2 MG TABLET(S) BENZTROPINE MESYLATE Nova ScriptsCentral-Northern Virginia Clinic $51.86 $59.64 Partners & Northern VA Residents ONLY 0.5 MG TABLET(S) BENZTROPINE MESYLATE Rx Outreach $38.65 $44.45 1 MG TABLET(S) BENZTROPINE MESYLATE Rx Outreach $40.91 $47.05 2 MG TABLET(S) BENZTROPINE MESYLATE Rx Outreach $51.86 $59.64 0.5 MG TABLET(S) BENZTROPINE MESYLATE Xubex Preferred Network Program $38.65 $44.45 1 MG TABLET(S) BENZTROPINE MESYLATE Xubex Preferred Network Program $40.91 $47.05 2 MG TABLET(S) BENZTROPINE MESYLATE Xubex Preferred Network Program $51.86 $59.64 BEPREVE
15 MG/ML (10 ML) DROP(S) bepotastine besilate Bausch & Lomb US Patient Assistance $412.09 $473.90 Program BERINERT
500 U UNITS C1 ESTERASE INHIBITOR, CSL Behring Patient Assistance Program $2,276.40 $2,617.86 HUMAN BESIVANCE
0.6 % (5 ML) DROP(S) BESIFLOXACIN HYDROCHLORIDE Bausch & Lomb US Patient Assistance $168.10 $193.32 Program
Report Run: 04/19/16 10:53 AM Page 41 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BETAMETHASONE DIPROPIONATE AUGMENTED (BRAND: DIPROLENE AF) 0.05 % (50 GM) GM BETAMETHASONE Nova ScriptsCentral-Northern Virginia Clinic $81.65 $93.90 DIPROPIONATE AUGMENTED Partners & Northern VA Residents ONLY BETAMETHASONE DIPROPIONATE AUGMENTED (BRAND; DIPROLENE AF) 0.05 % (15 GM) GM BETAMETHASONE Nova ScriptsCentral-Northern Virginia Clinic $36.43 $41.89 DIPROPIONATE AUGMENTED Partners & Northern VA Residents ONLY 0.05 % (15 GM) GM BETAMETHASONE Rx Outreach $36.43 $41.89 DIPROPIONATE AUGMENTED BETASERON
0.3 MG BLISTER UNITS INTERFERON BETA-1B Bayer Betaseron Patient Assistance $3,187.56 $3,665.69 Foundation BETAXOLOL (BRAND: KERLONE)
10 MG TABLET(S) betaxolol hydrochloride Xubex Preferred Network Program $124.25 $142.89 20 MG TABLET(S) betaxolol hydrochloride Xubex Preferred Network Program $186.10 $214.02 BETHANECHOL
10 MG TABLET(S) bethanechol Rx Outreach $133.83 $153.90 25 MG TABLET(S) bethanechol Rx Outreach $178.41 $205.17 5 MG TABLET(S) bethanechol Rx Outreach $71.32 $82.02 50 MG TABLET(S) bethanechol Rx Outreach $285.46 $328.28 10 MG TABLET(S) bethanechol Xubex Preferred Network Program $133.83 $153.90 25 MG TABLET(S) bethanechol Xubex Preferred Network Program $178.41 $205.17 5 MG TABLET(S) bethanechol Xubex Preferred Network Program $71.32 $82.02
Report Run: 04/19/16 10:53 AM Page 42 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BETHANECHOL
50 MG TABLET(S) bethanechol Xubex Preferred Network Program $285.46 $328.28 BETHKIS
300/4 MG/ML AMPULE TOBRAMYCIN Chiesi CAREDIRECT $3,405.00 $3,915.75 BETIMOL
0.5 % (10ml) DROP(S) TIMOLOL Akorn Patient Assistance Program $167.84 $193.02 BETOPTIC S
0.25 % (10 ML) DROP(S) BETAXOLOL HYDROCHLORIDE Alcon Cares, Inc. $327.18 $376.26 0.25 % (15ML) DROP(S) BETAXOLOL HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $490.74 $564.35 Clinics BEYAZ
3-0.02-0.451 MG TABLET(S) drospirenone/ethinyl Bayer Patient Assistance Program-Beyaz, $371.54 $427.27 estradiol/levomefolate ca Safyral & Natazia BIAXIN FILMTAB
* 250 MG TABLET(S) CLARITHROMYCIN AbbVie Patient Assistance Program $364.90 $419.63 * 500 MG TABLET(S) CLARITHROMYCIN AbbVie Patient Assistance Program $364.90 $419.63 250 MG TABLET(S) CLARITHROMYCIN Welvista - South Carolina Residents Only $364.90 $419.63 500 MG TABLET(S) CLARITHROMYCIN Welvista - South Carolina Residents Only $364.90 $419.63 BIAXIN XL
* 500 MG TABLET(S) CLARITHROMYCIN AbbVie Patient Assistance Program $390.37 $448.93 500 MG TABLET(S) CLARITHROMYCIN Welvista - South Carolina Residents Only $390.37 $448.93
Report Run: 04/19/16 10:53 AM Page 43 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BICALUTAMIDE (BRAND: CASODEX)
* 50 MG TABLET(S) BICALUTAMIDE Generic Assistance Program (NeedyMeds & $1,856.06 $2,134.47 Rx Outreach) 50 MG TABLET(S) BICALUTAMIDE Rx Outreach $1,856.06 $2,134.47 50 MG TABLET(S) BICALUTAMIDE Xubex Preferred Network Program $1,856.06 $2,134.47 BIDIL
37.5-20 MG-MG TABLET(S) ISOSORBIDE Arbor Pharmaceuticals Patient Assistance $634.43 $729.59 DINITRATE/HYDRALAZINE HCL Program BILTRICIDE
600 MG TABLET(S) PRAZIQUANTEL Bayer HealthCare Patient Assistance Program $597.88 $687.56 BION TEARS
0.1-0.3 %-% DROP(S) dextran 70/hypromellose Alcon Cares, Inc. $11.88 $13.66 BISOPROLOL FUMARATE
10 MG TABLET(S) bisoprolol fumarate Nova ScriptsCentral-Northern Virginia Clinic $121.97 $140.27 Partners & Northern VA Residents ONLY 5 MG TABLET(S) bisoprolol fumarate Nova ScriptsCentral-Northern Virginia Clinic $121.97 $140.27 Partners & Northern VA Residents ONLY 10 MG TABLET(S) bisoprolol fumarate Xubex Preferred Network Program $121.97 $140.27 5 MG TABLET(S) bisoprolol fumarate Xubex Preferred Network Program $121.97 $140.27 BISOPROLOL/HCTZ (BRAND: ZIAC)
10-6.25 MG-MG TABLET(S) BISOPROLOL Nova ScriptsCentral-Northern Virginia Clinic $114.00 $131.10 FUMARATE/HYDROCHLOROTHI Partners & Northern VA Residents ONLY AZIDE
Report Run: 04/19/16 10:53 AM Page 44 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BISOPROLOL/HCTZ (BRAND: ZIAC)
2.5-6.25 MG-MG TABLET(S) BISOPROLOL Nova ScriptsCentral-Northern Virginia Clinic $114.00 $131.10 FUMARATE/HYDROCHLOROTHI Partners & Northern VA Residents ONLY AZIDE 5-6.25 MG-MG TABLET(S) BISOPROLOL Nova ScriptsCentral-Northern Virginia Clinic $114.00 $131.10 FUMARATE/HYDROCHLOROTHI Partners & Northern VA Residents ONLY AZIDE 10-6.25 MG-MG TABLET(S) BISOPROLOL Rx Outreach $114.00 $131.10 FUMARATE/HYDROCHLOROTHI AZIDE 2.5-6.25 MG-MG TABLET(S) BISOPROLOL Rx Outreach $114.00 $131.10 FUMARATE/HYDROCHLOROTHI AZIDE 5-6.25 MG-MG TABLET(S) BISOPROLOL Rx Outreach $114.00 $131.10 FUMARATE/HYDROCHLOROTHI AZIDE 10-6.25 MG-MG TABLET(S) BISOPROLOL Xubex Preferred Network Program $114.00 $131.10 FUMARATE/HYDROCHLOROTHI AZIDE BLEPH-10
10 % (5 ML) DROP(S) SULFACETAMIDE SODIUM Alcon Charitable Clinic Program-For Free $30.94 $35.58 Clinics BLINCYTO
35 MCG MCG blinatumomab Amgen Safety Net Foundation $3,814.28 $4,386.42 BOOSTRIX
18.5/0.5-2.5 MCG/ML-LF U (0.5 ML) VIAL(S) TDAP VACCINE GSK Vaccines Access Program $446.10 $513.02
Report Run: 04/19/16 10:53 AM Page 45 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BOSULIF
100 MG TABLET(S) bosutinib Pfizer RxPathways $11,277.36 $12,968.96 500 MG TABLET(S) bosutinib Pfizer RxPathways $11,277.36 $12,968.96 BOTOX
100 U INJECTION(S) BOTULINUM TOXIN TYPE A Allergan Botox Patient Assistance Program $669.60 $770.04 BRAVELLE
75 IU VIAL urofollitropin Heart Beat Program $750.92 $863.56 BREO ELLIPTA
100-25 MCG-MCG/ACTUATION PUFF(S) fluticasone furoate/vilanterol GSK Access $337.26 $387.85 trifenatate 200-25 MCG/ACTUATION PUFF(S) fluticasone furoate/vilanterol GSK Access $337.26 $387.85 trifenatate 100-25 MCG-MCG/ACTUATION PUFF(S) fluticasone furoate/vilanterol GSK Bridges to Access $337.26 $387.85 trifenatate 200-25 MCG/ACTUATION PUFF(S) fluticasone furoate/vilanterol GSK Bridges to Access $337.26 $387.85 trifenatate 100-25 MCG-MCG/ACTUATION PUFF(S) fluticasone furoate/vilanterol Welvista - South Carolina Residents Only $337.26 $387.85 trifenatate BRILINTA
90 MG TABLET(S) TICAGRELOR AZ&Me Prescription Savings for people with $543.71 $625.27 Medicare Part D 60 MG TABLET(S) ticagrelor AZ&Me Prescription Savings Program $369.95 $425.44 90 MG TABLET(S) TICAGRELOR AZ&Me Prescription Savings Program $543.71 $625.27 90 MG TABLET(S) TICAGRELOR Welvista - South Carolina Residents Only $543.71 $625.27
Report Run: 04/19/16 10:53 AM Page 46 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BRILINTA
90 MG TABLET(S) TICAGRELOR Xubex Free Trial 30 Day Medication Supply $543.71 $625.27 BRIMONIDINE TARTRATE
0.2 % (10 ML) DROP(S) brimonidine tartrate Nova ScriptsCentral-Northern Virginia Clinic $65.20 $74.98 Partners & Northern VA Residents ONLY 0.2 % (10 ML) DROP(S) brimonidine tartrate Rx Outreach $65.20 $74.98 BRINTELLIX
10 MG TABLET(S) VORTIOXETINE HYDROBROMIDE Takeda Patient Assistance Program $316.10 $363.52 20 MG TABLET(S) VORTIOXETINE HYDROBROMIDE Takeda Patient Assistance Program $316.10 $363.52 5 MG TABLET(S) VORTIOXETINE HYDROBROMIDE Takeda Patient Assistance Program $316.10 $363.52 BROVANA
15 MCG/2ML MCG ARFORMOTEROL TARTRATE Sepracor Patient Assistance Program $165.96 $190.85 BUDESONIDE INHALATION (BRAND: PULMICORT RESPULES) 0.25/2 MG/ML (2 ML) VIAL(S) budesonide Rx Outreach $282.42 $324.78 0.5/2 MG/ML (2 ML) VIAL(S) budesonide Rx Outreach $332.37 $382.23 0.25/2 MG/ML (2 ML) VIAL(S) budesonide Xubex Preferred Network Program $282.42 $324.78 0.5/2 MG/ML (2 ML) VIAL(S) budesonide Xubex Preferred Network Program $332.37 $382.23 BUDESONIDE NASAL SPRAY (BRAND: RHINOCORT)
0.032 MG/ACTUATION (8.6 SPRAY(S) BUDESONIDE Rx Outreach $160.52 $184.60 GM) BUMETANIDE (BRAND: BUMEX)
0.5 MG TABLET(S) BUMETANIDE Xubex Preferred Network Program $26.10 $30.02
Report Run: 04/19/16 10:53 AM Page 47 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BUMETANIDE (BRAND: BUMEX)
1 MG TABLET(S) BUMETANIDE Xubex Preferred Network Program $35.10 $40.36 2 MG TABLET(S) BUMETANIDE Xubex Preferred Network Program $67.80 $77.97 BUPAP
300-50 MG-MG TABLET(S) acetaminophen/butalbital Valeant Patient Assistance Program $922.74 $1,061.15 BUPHENYL
500 MG TABLET(S) SODIUM PHENYLBUTYRATE Hyperion UCD Support Services $3,398.06 $3,907.77 BUPROPION HCL (BRAND: WELLBUTRIN)
100 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $168.90 $194.23 75 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $79.43 $91.34 100 MG TABLET(S) BUPROPION HYDROCHLORIDE Xubex Preferred Network Program $168.90 $194.23 75 MG TABLET(S) BUPROPION HYDROCHLORIDE Xubex Preferred Network Program $79.43 $91.34 BUPROPION HYDROCHLORIDE SR (BRAND: WELLBUTRIN SR) 100 MG TABLET(S) BUPROPION HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $168.90 $194.23 Partners & Northern VA Residents ONLY 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $193.30 $222.30 Partners & Northern VA Residents ONLY 200 MG TABLET(S) BUPROPION HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $229.98 $264.48 Partners & Northern VA Residents ONLY 100 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $168.90 $194.23 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $193.30 $222.30 200 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $229.98 $264.48
Report Run: 04/19/16 10:53 AM Page 48 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BUPROPION HYDROCHLORIDE SR (BRAND: WELLBUTRIN SR) 100 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $168.90 $194.23 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $193.30 $222.30 200 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $229.98 $264.48 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Xubex Preferred Network Program $193.30 $222.30 BUPROPION HYDROCHLORIDE XL (BRAND: WELLBUTRIN XL) 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $469.80 $540.27 300 MG TABLET(S) BUPROPION HYDROCHLORIDE Rx Outreach $566.64 $651.64 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Xubex Preferred Network Program $469.80 $540.27 300 MG TABLET(S) BUPROPION HYDROCHLORIDE Xubex Preferred Network Program $566.64 $651.64 BUSPIRONE (BRAND: BUSPAR)
10 MG TABLET(S) BUSPIRONE Nova ScriptsCentral-Northern Virginia Clinic $155.71 $179.07 Partners & Northern VA Residents ONLY 15 MG TABLET(S) BUSPIRONE Nova ScriptsCentral-Northern Virginia Clinic $161.74 $186.00 Partners & Northern VA Residents ONLY 5 MG TABLET(S) BUSPIRONE Nova ScriptsCentral-Northern Virginia Clinic $74.13 $85.25 Partners & Northern VA Residents ONLY 10 MG TABLET(S) BUSPIRONE Rx Outreach $155.71 $179.07 15 MG TABLET(S) BUSPIRONE Rx Outreach $161.74 $186.00 30 MG TABLET(S) BUSPIRONE Rx Outreach $138.94 $159.78 5 MG TABLET(S) BUSPIRONE Rx Outreach $74.13 $85.25 10 MG TABLET(S) BUSPIRONE Xubex Preferred Network Program $155.71 $179.07
Report Run: 04/19/16 10:53 AM Page 49 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BUSPIRONE (BRAND: BUSPAR)
15 MG TABLET(S) BUSPIRONE Xubex Preferred Network Program $161.74 $186.00 30 MG TABLET(S) BUSPIRONE Xubex Preferred Network Program $138.94 $159.78 5 MG TABLET(S) BUSPIRONE Xubex Preferred Network Program $74.13 $85.25 BUSPIRONE HCL (BRAND: BUSPAR)
7.5 MG TABLET(S) BUSPIRONE HCL Xubex Preferred Network Program $158.03 $181.73 BUTRANS
5 MCG/HR PATCH BUPRENORPHINE Purdue Pharma Patient Assistance Program $245.36 $282.16 BUTRANS
10 MCG/HR PATCH BUPRENORPHINE Purdue Pharma Patient Assistance Program $368.04 $423.25 20 MCG/HR PATCH buprenorphine Purdue Pharma Patient Assistance Program $651.56 $749.29 BYDUREON PEN
2 MG INJECTION(S) exenatide AZ&Me Prescription Savings for people with $610.22 $701.75 Medicare Part D 2 MG INJECTION(S) exenatide AZ&Me Prescription Savings Program $610.22 $701.75 2 MG INJECTION(S) exenatide Welvista - South Carolina Residents Only $610.22 $701.75 BYDUREON VIAL
2 MG INJECTION(S) EXENATIDE AZ&Me Prescription Savings Program $610.22 $701.75 2 MG INJECTION(S) EXENATIDE Welvista - South Carolina Residents Only $610.22 $701.75 BYETTA
10 MCG/ML (2.4ML) INJECTION(S) EXENATIDE AZ&Me Prescription Savings Program $619.93 $712.92 5 MCG/ML (1.2ML) INJECTION(S) EXENATIDE AZ&Me Prescription Savings Program $619.93 $712.92
Report Run: 04/19/16 10:53 AM Page 50 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
BYETTA
10 MCG/ML (2.4ML) INJECTION(S) EXENATIDE Welvista - South Carolina Residents Only $619.93 $712.92 5 MCG/ML (1.2ML) INJECTION(S) EXENATIDE Welvista - South Carolina Residents Only $619.93 $712.92 BYSTOLIC
10 MG TABLET(S) NEBIVOLOL HYDROCHLORIDE Actavis U.S. Patient Assistance Program $361.97 $416.27 * 2.5 MG TABLET(S) NEBIVOLOL HYDROCHLORIDE Actavis U.S. Patient Assistance Program $409.84 $471.32 20 MG TABLET(S) NEBIVOLOL HYDROCHLORIDE Actavis U.S. Patient Assistance Program $367.58 $422.72 5 MG TABLET(S) NEBIVOLOL HYDROCHLORIDE Actavis U.S. Patient Assistance Program $361.97 $416.27 CADUET
10-10 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM 10-20 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 10-40 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 10-80 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 2.5-10 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM
Report Run: 04/19/16 10:53 AM Page 51 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CADUET
2.5-20 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 2.5-40 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-10 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM 5-20 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-40 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-80 MG-MG TABLET(S) AMLODIPINE Pfizer RxPathways $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 10-10 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM 10-20 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 10-40 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM
Report Run: 04/19/16 10:53 AM Page 52 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CADUET
10-80 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 2.5-10 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM 2.5-20 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 2.5-40 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-10 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $323.96 $372.55 BESYLATE/ATORVASTATIN CALCIUM 5-20 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-40 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM 5-80 MG-MG TABLET(S) AMLODIPINE Welvista - South Carolina Residents Only $443.20 $509.68 BESYLATE/ATORVASTATIN CALCIUM CAMPATH
30 MG/ML (1ml) INJECTION(S) ALEMTUZUMAB Genzyme Campath Distribution Program $5,780.46 $6,647.53
Report Run: 04/19/16 10:53 AM Page 53 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CAMPTOSAR
20 MG/ML (2ML) MG IRINOTECAN HYDROCHLORIDE Pfizer RxPathways $30.00 $34.50 CANASA
1000 MG SUPPOSITORY MESALAMINE Actavis U.S. Patient Assistance Program $850.99 $978.64 CANCIDAS
70 MG MG CASPOFUNGIN ACETATE Merck Hotline for Invanz, Primaxin and $421.06 $484.22 Cancidas CANCIDAS
50 MG MG CASPOFUNGIN ACETATE Merck Hotline for Invanz, Primaxin and $405.25 $466.04 Cancidas CANDESARTAN CILEXETIL (BRAND: ATACAND)
16 MG TABLET(S) CANDESARTAN CILEXETIL Rx Outreach $99.16 $114.03 32 MG TABLET(S) CANDESARTAN CILEXETIL Rx Outreach $134.27 $154.41 4 MG TABLET(S) CANDESARTAN CILEXETIL Rx Outreach $99.16 $114.03 8 MG TABLET(S) CANDESARTAN CILEXETIL Rx Outreach $99.16 $114.03 16 MG TABLET(S) CANDESARTAN CILEXETIL Xubex Preferred Network Program $99.16 $114.03 32 MG TABLET(S) CANDESARTAN CILEXETIL Xubex Preferred Network Program $134.27 $154.41 4 MG TABLET(S) CANDESARTAN CILEXETIL Xubex Preferred Network Program $99.16 $114.03 8 MG TABLET(S) CANDESARTAN CILEXETIL Xubex Preferred Network Program $99.16 $114.03 CANDESARTAN CILEXETIL-HCTZ (BRAND: ATACAND HCT) 16-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Rx Outreach $368.20 $423.43 32-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Rx Outreach $375.53 $431.86
Report Run: 04/19/16 10:53 AM Page 54 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CANDESARTAN CILEXETIL-HCTZ (BRAND: ATACAND HCT) 32-25 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Rx Outreach $406.48 $467.45 16-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Xubex Preferred Network Program $368.20 $423.43 32-12.5 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Xubex Preferred Network Program $375.53 $431.86 32-25 MG-MG TABLET(S) CANDESARTAN CILEXETIL-HCTZ Xubex Preferred Network Program $406.48 $467.45 CAPRELSA
100 MG TABLET(S) vandetanib AZ&Me Prescription Savings for people with $7,217.50 $8,300.13 Medicare Part D 300 MG TABLET(S) vandetanib AZ&Me Prescription Savings for people with $14,434.98 $16,600.23 Medicare Part D 100 MG TABLET(S) vandetanib AZ&Me Prescription Savings Program $7,217.50 $8,300.13 300 MG TABLET(S) vandetanib AZ&Me Prescription Savings Program $14,434.98 $16,600.23 CAPTOPRIL (BRAND: CAPOTEN)
100 MG TABLET(S) CAPTOPRIL Rx Outreach $253.99 $292.09 12.5 MG TABLET(S) CAPTOPRIL Rx Outreach $15.93 $18.32 25 MG TABLET(S) CAPTOPRIL Rx Outreach $61.07 $70.23 50 MG TABLET(S) CAPTOPRIL Rx Outreach $86.07 $98.98 100 MG TABLET(S) CAPTOPRIL Xubex Preferred Network Program $253.99 $292.09 12.5 MG TABLET(S) CAPTOPRIL Xubex Preferred Network Program $15.93 $18.32 25 MG TABLET(S) CAPTOPRIL Xubex Preferred Network Program $61.07 $70.23 50 MG TABLET(S) CAPTOPRIL Xubex Preferred Network Program $86.07 $98.98
Report Run: 04/19/16 10:53 AM Page 55 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CAPTOPRIL/HCTZ (BRAND: CAPOZIDE)
25-15 MG-MG TABLET(S) CAPTOPRIL/HYDROCHLOROTHIA Xubex Preferred Network Program $79.59 $91.53 ZIDE 25-25 MG-MG TABLET(S) CAPTOPRIL/HYDROCHLOROTHIA Xubex Preferred Network Program $79.59 $91.53 ZIDE 50-15 MG-MG TABLET(S) CAPTOPRIL/HYDROCHLOROTHIA Xubex Preferred Network Program $136.61 $157.10 ZIDE 50-25 MG-MG TABLET(S) CAPTOPRIL/HYDROCHLOROTHIA Xubex Preferred Network Program $136.61 $157.10 ZIDE CARBAMAZEPINE (BRAND: TEGRETOL)
* 200 MG TABLET(S) CARBAMAZEPINE Generic Assistance Program (NeedyMeds & $32.85 $37.78 Rx Outreach) 200 MG TABLET(S) CARBAMAZEPINE Rx Outreach $32.85 $37.78 200 MG TABLET(S) CARBAMAZEPINE Xubex Preferred Network Program $32.85 $37.78 CARBAMAZEPINE CHEWABLE (BRAND: CARBATROL, TEGRETOL) 100 MG TABLET(S) CARBAMAZEPINE Xubex Preferred Network Program $65.85 $75.73 CARBAMAZEPINE ER (BRAND: CARBATROL, TEGRETOL)
400 MG TABLET(S) CARBAMAZEPINE Rx Outreach $415.40 $477.71 400 MG TABLET(S) CARBAMAZEPINE Xubex Preferred Network Program $415.40 $477.71 CARBAMAZEPINE ER (BRAND: TEGRETOL XR)
200 MG CAPSULE(S) CARBAMAZEPINE Rx Outreach $229.76 $264.22
Report Run: 04/19/16 10:53 AM Page 56 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CARBATROL
100 MG CAPSULE(S) CARBAMAZEPINE Shire Cares Patient Assistance & Support $255.29 $293.58 Program 200 MG CAPSULE(S) CARBAMAZEPINE Shire Cares Patient Assistance & Support $255.29 $293.58 Program 300 MG CAPSULE(S) CARBAMAZEPINE Shire Cares Patient Assistance & Support $255.29 $293.58 Program CARBIDOPA/LEVODOPA (BRAND: SINEMET)
10/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Nova ScriptsCentral-Northern Virginia Clinic $70.88 $81.51 Partners & Northern VA Residents ONLY 25/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Nova ScriptsCentral-Northern Virginia Clinic $114.03 $131.13 Partners & Northern VA Residents ONLY 25/250 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Nova ScriptsCentral-Northern Virginia Clinic $101.97 $117.27 Partners & Northern VA Residents ONLY 10/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Rx Outreach $70.88 $81.51 25/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Rx Outreach $114.03 $131.13 25/250 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Rx Outreach $101.97 $117.27 10/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Xubex Preferred Network Program $70.88 $81.51 25/100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Xubex Preferred Network Program $114.03 $131.13 25/250 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Xubex Preferred Network Program $101.97 $117.27 CARBIDOPA/LEVODOPA SR (BRAND: SINEMET CR)
50/200 MG-MG TABLET(S) carbidopa/levodopa Rx Outreach $189.89 $218.37 50/200 MG-MG TABLET(S) carbidopa/levodopa Xubex Preferred Network Program $189.89 $218.37
Report Run: 04/19/16 10:53 AM Page 57 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CARDIZEM
* 120 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $1,279.36 $1,471.26 * 30 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $442.96 $509.40 * 60 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $695.01 $799.26 * 90 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $627.86 $722.04 CARDIZEM CD
* 120 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $1,043.75 $1,200.31 * 180 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $1,284.04 $1,476.65 * 240 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $1,821.52 $2,094.75 * 300 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $2,360.76 $2,714.87 * 360 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $3,485.27 $4,008.06 CARDIZEM LA
120 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $427.95 $492.14 180 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $452.14 $519.96 240 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $506.79 $582.81 300 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $659.27 $758.16 360 MG TABLET(S) DILTIAZEM HYDROCHLORIDE Valeant Patient Assistance Program $708.78 $815.10 CARDURA XL
4 MG TABLET(S) DOXAZOSIN MESYLATE Pfizer MAINTAIN $61.03 $70.18 8 MG TABLET(S) DOXAZOSIN MESYLATE Pfizer MAINTAIN $61.06 $70.22
Report Run: 04/19/16 10:53 AM Page 58 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CARIMUNE NF
12 GM INJECTION IMMUNE GLOBULIN CSL Behring Patient Assistance Program $1,272.00 $1,462.80 3 GM INJECTION IMMUNE GLOBULIN CSL Behring Patient Assistance Program $318.00 $365.70 6 GM INJECTION IMMUNE GLOBULIN CSL Behring Patient Assistance Program $636.00 $731.40 CARISOPRODOL (BRAND: SOMA)
350 MG TABLET(S) CARISOPRODOL Xubex Preferred Network Program $59.62 $68.56 CARNITOR
100 MG/ML MG LEVOCARNITINE Sigma-Tau Carnitor Drug Assistance Program $34.55 $39.73 200 MG/ML INJECTION(S) LEVOCARNITINE Sigma-Tau Carnitor Drug Assistance Program $192.00 $220.80 330 MG TABLET(S) LEVOCARNITINE Sigma-Tau Carnitor Drug Assistance Program $86.96 $100.00 CARTEOLOL HCL
1 % (10 ML) DROP(S) CARTEOLOL HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $40.10 $46.12 Clinics CARVEDILOL (BRAND: COREG)
12.5 MG TABLET(S) CARVEDILOL Nova ScriptsCentral-Northern Virginia Clinic $213.45 $245.47 Partners & Northern VA Residents ONLY 25 MG TABLET(S) CARVEDILOL Nova ScriptsCentral-Northern Virginia Clinic $213.45 $245.47 Partners & Northern VA Residents ONLY 3.125 MG TABLET(S) CARVEDILOL Nova ScriptsCentral-Northern Virginia Clinic $213.45 $245.47 Partners & Northern VA Residents ONLY 6.25 MG TABLET(S) CARVEDILOL Nova ScriptsCentral-Northern Virginia Clinic $213.45 $245.47 Partners & Northern VA Residents ONLY 12.5 MG TABLET(S) CARVEDILOL Rx Outreach $213.45 $245.47
Report Run: 04/19/16 10:53 AM Page 59 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CARVEDILOL (BRAND: COREG)
25 MG TABLET(S) CARVEDILOL Rx Outreach $213.45 $245.47 3.125 MG TABLET(S) CARVEDILOL Rx Outreach $213.45 $245.47 6.25 MG TABLET(S) CARVEDILOL Rx Outreach $213.45 $245.47 12.5 MG TABLET(S) CARVEDILOL Xubex Preferred Network Program $213.45 $245.47 25 MG TABLET(S) CARVEDILOL Xubex Preferred Network Program $213.45 $245.47 3.125 MG TABLET(S) CARVEDILOL Xubex Preferred Network Program $213.45 $245.47 6.25 MG TABLET(S) CARVEDILOL Xubex Preferred Network Program $213.45 $245.47 CATHFLO ACTIVASE
2 MG INJECTION(S) ALTEPLASE, RECOMBINANT Genentech Access to Care Foundation $139.58 $160.52 (TNKase, Cathflo, Activase) CAVERJECT
10 MCG INJECTION(S) ALPROSTADIL Pfizer RxPathways $140.53 $161.61 20 MCG INJECTION(S) ALPROSTADIL Pfizer RxPathways $389.38 $447.79 40 MCG INJECTION(S) ALPROSTADIL Pfizer RxPathways $513.64 $590.69 CAYSTON
75 MG/VIAL AMPULE(S) AZTREONAM Gilead Cayston Access Program $6,374.86 $7,331.09 CEFTIN
125 mg/5ml (100ml) PDS CEFUROXIME AXETIL GSK Access $31.00 $35.65 250 MG TABLET(S) CEFUROXIME AXETIL GSK Access $190.84 $219.47 500 MG TABLET(S) CEFUROXIME AXETIL GSK Access $347.74 $399.90
Report Run: 04/19/16 10:53 AM Page 60 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CELEBREX
50 MG CAPSULE(S) CELECOXIB Pfizer MAINTAIN $188.69 $216.99 100 MG CAPSULE(S) CELECOXIB Pfizer RxPathways $672.92 $773.86 200 MG CAPSULE(S) CELECOXIB Pfizer RxPathways $1,103.76 $1,269.32 400 MG CAPSULE(S) CELECOXIB Pfizer RxPathways $1,655.68 $1,904.03 50 MG CAPSULE(S) CELECOXIB Pfizer RxPathways $188.69 $216.99 100 MG CAPSULE(S) CELECOXIB Welvista - South Carolina Residents Only $672.92 $773.86 200 MG CAPSULE(S) CELECOXIB Welvista - South Carolina Residents Only $1,103.76 $1,269.32 400 MG CAPSULE(S) CELECOXIB Welvista - South Carolina Residents Only $1,655.68 $1,904.03 50 MG CAPSULE(S) CELECOXIB Welvista - South Carolina Residents Only $188.69 $216.99 CELECOXIB (BRAND: CELEBREX)
100 MG CAPSULE(S) celecoxib Rx Outreach $462.15 $531.47 200 MG CAPSULE(S) celecoxib Rx Outreach $758.04 $871.75 400 MG CAPSULE(S) celecoxib Rx Outreach $682.26 $784.60 50 MG CAPSULE(S) celecoxib Rx Outreach $129.59 $149.03 CELLCEPT
200 mg/ml (160ml) ML MYCOPHENOLATE MOFETIL Genentech Access to Care Foundation (HIV & $1,412.39 $1,624.25 Transplants)-CellCept & Valcyte 250 MG CAPSULE(S) MYCOPHENOLATE MOFETIL Genentech Access to Care Foundation (HIV & $857.17 $985.75 Transplants)-CellCept & Valcyte 500 MG TABLET(S) MYCOPHENOLATE MOFETIL Genentech Access to Care Foundation (HIV & $1,714.34 $1,971.49 Transplants)-CellCept & Valcyte
Report Run: 04/19/16 10:53 AM Page 61 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CELONTIN KAPSEALS
300 MG CAPSULE(S) METHSUXIMIDE Pfizer RxPathways $325.85 $374.73 CERVARIX
N/A N/A INJECTION(S) HUMAN PAPILLOMAVIRUS GSK Vaccines Access Program $154.35 $177.50 RECOMB VACCINE BIVALENT CETIRIZINE HYDROCHLORIDE (BRAND: ZYRTEC)
10 MG TABLET(S) CETIRIZINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $249.72 $287.18 Partners & Northern VA Residents ONLY 10 MG TABLET(S) CETIRIZINE HYDROCHLORIDE Rx Outreach $249.72 $287.18 10 MG TABLET(S) CETIRIZINE HYDROCHLORIDE Xubex Preferred Network Program $249.72 $287.18 5 MG TABLET(S) CETIRIZINE HYDROCHLORIDE Xubex Preferred Network Program $249.72 $287.18 CHANTIX
0.5 MG TABLET(S) VARENICLINE Nova ScriptsCentral-Northern Virginia Clinic $322.55 $370.93 Partners & Northern VA Residents ONLY 1 MG TABLET(S) VARENICLINE Nova ScriptsCentral-Northern Virginia Clinic $322.55 $370.93 Partners & Northern VA Residents ONLY 0.5 MG TABLET(S) VARENICLINE Pfizer RxPathways $322.55 $370.93 1 MG TABLET(S) VARENICLINE Pfizer RxPathways $322.55 $370.93 0.5 MG TABLET(S) VARENICLINE Welvista - South Carolina Residents Only $322.55 $370.93 1 MG TABLET(S) VARENICLINE Welvista - South Carolina Residents Only $322.55 $370.93 CHANTIX (STARTING MONTH BOX)
0.5 MG TABLET(S) VARENICLINE Nova ScriptsCentral-Northern Virginia Clinic $303.04 $348.50 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 62 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CHANTIX (STARTING MONTH BOX)
0.5 MG TABLET(S) VARENICLINE Pfizer RxPathways $303.04 $348.50 0.5 MG TABLET(S) VARENICLINE Welvista - South Carolina Residents Only $303.04 $348.50 CHLORDIAZEPOXIDE (BRAND: LIBRIUM)
10 MG CAPSULE(S) CHLORDIAZEPOXIDE Rx Outreach $19.96 $22.95 25 MG CAPSULE(S) CHLORDIAZEPOXIDE Rx Outreach $28.20 $32.43 10 MG CAPSULE(S) CHLORDIAZEPOXIDE Xubex Preferred Network Program $19.96 $22.95 25 MG CAPSULE(S) CHLORDIAZEPOXIDE Xubex Preferred Network Program $28.20 $32.43 CHLORDIAZEPOXIDE HCL (BRAND: LIBRIUM)
5 MG CAPSULE(S) chlordiazepoxide hydrochloride Rx Outreach $31.69 $36.44 5 MG CAPSULE(S) chlordiazepoxide hydrochloride Xubex Preferred Network Program $31.69 $36.44 CHLORDIAZEPOXIDE/CLIDINIUM (BRAND: LIBRAX)
5/2.5 MG-MG TABLET(S) CHLORDIAZEPOXIDE Rx Outreach $71.40 $82.11 HYDROCHLORIDE/CLIDINIUM BROMIDE 5/2.5 MG-MG TABLET(S) CHLORDIAZEPOXIDE Xubex Patient Assistance Program $71.40 $82.11 HYDROCHLORIDE/CLIDINIUM BROMIDE CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE
5/2.5 MG-MG CAPSULE(S) CHLORDIAZEPOXIDE/CLIDINIUM Valeant Patient Assistance Program $644.40 $741.06 BROMIDE 5/2.5 MG-MG CAPSULE(S) CHLORDIAZEPOXIDE/CLIDINIUM Xubex Preferred Network Program $644.40 $741.06 BROMIDE
Report Run: 04/19/16 10:53 AM Page 63 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CHLORPROMAZINE HCL (BRAND: THORAZINE)
10 MG TABLET(S) CHLORPROMAZINE Rx Outreach $420.14 $483.16 HYRDROCHLORIDE 100 MG TABLET(S) CHLORPROMAZINE Rx Outreach $1,488.69 $1,711.99 HYDROCHLORIDE 25 MG TABLET(S) CHLORPROMAZINE Rx Outreach $764.09 $878.70 HYDROCHLORIDE 50 MG TABLET(S) CHLORPROMAZINE Rx Outreach $1,037.47 $1,193.09 HYDROCHLORIDE 10 MG TABLET(S) CHLORPROMAZINE HCL Xubex Preferred Network Program $420.14 $483.16 100 MG TABLET(S) CHLORPROMAZINE Xubex Preferred Network Program $1,488.69 $1,711.99 HYDROCHLORIDE 25 MG TABLET(S) CHLORPROMAZINE HCL Xubex Preferred Network Program $764.09 $878.70 50 MG TABLET(S) CHLORPROMAZINE HCL Xubex Preferred Network Program $1,037.47 $1,193.09 CHLORPROMAZINE HCL (BRAND: THORZAINE)
200 MG TABLET(S) CHLORPROMAZINE Rx Outreach $2,284.21 $2,626.84 HYDROCHLORIDE 200 MG TABLET(S) CHLORPROMAZINE Xubex Preferred Network Program $2,284.21 $2,626.84 HYDROCHLORIDE CHLORPROPAMIDE (BRAND: DIABINESE)
250 MG TABLET(S) CHLORPROPAMIDE Xubex Patient Assistance Program $76.53 $88.01 CHLORTHALIDONE (BRAND: THALITONE)
25 MG TABLET(S) CHLORTHALIDONE Rx Outreach $55.17 $63.45 50 MG TABLET(S) CHLORTHALIDONE Rx Outreach $68.04 $78.25
Report Run: 04/19/16 10:53 AM Page 64 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CHLORTHALIDONE (BRAND: THALITONE)
25 MG TABLET(S) CHLORTHALIDONE Xubex Patient Assistance Program $55.17 $63.45 50 MG TABLET(S) CHLORTHALIDONE Xubex Patient Assistance Program $68.04 $78.25 25 MG TABLET(S) CHLORTHALIDONE Xubex Preferred Network Program $55.17 $63.45 50 MG TABLET(S) CHLORTHALIDONE Xubex Preferred Network Program $68.04 $78.25 CHLORZOXAZONE (BRAND: PARAFON-FORTE)
500 MG TABLET(S) CHLORZOXAZONE Xubex Patient Assistance Program $84.97 $97.72 CHOLINE MAGNESIUM TRISALICYLATE (BRAND: TRILISATE) 1000 MG TABLET(S) CHOLINE MAGNESIUM Xubex Patient Assistance Program $114.91 $132.15 TRISALICYLATE 500 MG TABLET(S) CHOLINE MAGNESIUM Xubex Patient Assistance Program $46.20 $53.13 TRISALICYLATE 750 MG TABLET(S) CHOLINE MAGNESIUM Xubex Patient Assistance Program $72.87 $83.80 TRISALICYLATE CIALIS
10 MG TABLET(S) TADALAFIL Eli Lilly Cares $1,501.20 $1,726.38 2.5 MG TABLET(S) TADALAFIL Eli Lilly Cares $256.32 $294.77 20 MG TABLET(S) TADALAFIL Eli Lilly Cares $1,501.20 $1,726.38 5 MG TABLET(S) TADALAFIL Eli Lilly Cares $256.32 $294.77 CILOSTAZOL (BRAND: PLETAL)
* 100 MG TABLET(S) CILOSTAZOL Generic Assistance Program (NeedyMeds & $182.45 $209.82 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 65 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CILOSTAZOL (BRAND: PLETAL)
* 50 MG TABLET(S) CILOSTAZOL Generic Assistance Program (NeedyMeds & $109.47 $125.89 Rx Outreach) 100 MG TABLET(S) CILOSTAZOL Rx Outreach $182.45 $209.82 50 MG TABLET(S) CILOSTAZOL Rx Outreach $109.47 $125.89 100 MG TABLET(S) CILOSTAZOL Xubex Preferred Network Program $182.45 $209.82 50 MG TABLET(S) CILOSTAZOL Xubex Preferred Network Program $109.47 $125.89 CILOXAN
0.3 % (3.5GM) APPLICATION CIPROFLOXACIN Alcon Cares, Inc. $210.30 $241.85 HYDROCHLORIDE 0.3 % (3.5GM) APPLICATION CIPROFLOXACIN Alcon Charitable Clinic Program-For Free $210.30 $241.85 HYDROCHLORIDE Clinics CIMETIDINE (BRAND: TEGAMET)
300 MG TABLET(S) CIMETIDINE Xubex Preferred Network Program $90.75 $104.36 400 MG TABLET(S) CIMETIDINE Xubex Preferred Network Program $142.89 $164.32 800 MG TABLET(S) CIMETIDINE Xubex Preferred Network Program $264.80 $304.52 CIMZIA
200 MG INJECTION CERTOLIZUMAB PEGOL UCB-Patient Assistance Program for Cimzia $3,651.96 $4,199.75 CINRYZE
500 U UNIT(S) c1 esterase inhibitor, human OnePath Patient Assistance Program $3,214.13 $3,696.25 CIPRO
250 MG TABLET(S) CIPROFLOXACIN Bayer HealthCare Patient Assistance Program $588.11 $676.33 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 66 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CIPRO
500 MG TABLET(S) CIPROFLOXACIN Bayer HealthCare Patient Assistance Program $688.36 $791.61 HYDROCHLORIDE CIPRO HC
0.2-1 %-% (10 ML) DROP(S) CIPROFLOXACIN Alcon Cares, Inc. $284.58 $327.27 HYDROCHLORIDE/HYDROCORTI SONE 0.2-1 %-% (10 ML) DROP(S) CIPROFLOXACIN Alcon Charitable Clinic Program-For Free $284.58 $327.27 HYDROCHLORIDE/HYDROCORTI Clinics SONE CIPRODEX
0.3-0.1 %-% (7.5 ML) DROP(S) CIPROFLOXACIN Alcon Cares, Inc. $210.60 $242.19 HYDROCHLORIDE/DEXAMETHAS ONE 0.3-0.1 %-% (7.5 ML) DROP(S) CIPROFLOXACIN Alcon Charitable Clinic Program-For Free $210.60 $242.19 HYDROCHLORIDE/DEXAMETHAS Clinics ONE CIPROFLOXACIN (BRAND: CIPRO)
250 MG TABLET(S) CIPROFLOXACIN Xubex Preferred Network Program $477.24 $548.83 500 MG TABLET(S) CIPROFLOXACIN Xubex Preferred Network Program $558.64 $642.44 750 MG TABLET(S) CIPROFLOXACIN Xubex Preferred Network Program $621.00 $714.15 CITALOPRAM (BRAND: CELEXA)
10 MG TABLET(S) CITALOPRAM HYDROBROMIDE Nova ScriptsCentral-Northern Virginia Clinic $244.50 $281.18 Partners & Northern VA Residents ONLY 20 MG TABLET(S) CITALOPRAM HYDROBROMIDE Nova ScriptsCentral-Northern Virginia Clinic $255.50 $293.83 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 67 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CITALOPRAM (BRAND: CELEXA)
40 MG TABLET(S) CITALOPRAM HYDROBROMIDE Nova ScriptsCentral-Northern Virginia Clinic $265.50 $305.33 Partners & Northern VA Residents ONLY 10 MG TABLET(S) CITALOPRAM HYDROBROMIDE Rx Outreach $244.50 $281.18 20 MG TABLET(S) CITALOPRAM HYDROBROMIDE Rx Outreach $255.50 $293.83 40 MG TABLET(S) CITALOPRAM HYDROBROMIDE Rx Outreach $265.50 $305.33 10 MG TABLET(S) CITALOPRAM HYDROBROMIDE Xubex Preferred Network Program $244.50 $281.18 20 MG TABLET(S) CITALOPRAM HYDROBROMIDE Xubex Preferred Network Program $255.50 $293.83 40 MG TABLET(S) CITALOPRAM HYDROBROMIDE Xubex Preferred Network Program $265.50 $305.33 CLARINEX
5 MG TABLET(S) DESLORATADINE Merck Patient Assistance Program $716.56 $824.04 CLARITHROMYCIN (BRAND: BIAXIN)
250 MG TABLET(S) CLARITHROMYCIN Xubex Preferred Network Program $452.12 $519.94 500 MG TABLET(S) CLARITHROMYCIN Xubex Preferred Network Program $452.12 $519.94 CLARITHROMYCIN ER (BRAND: BIAXIN)
500 MG TABLET(S) CLARITHROMYCIN Xubex Preferred Network Program $270.35 $310.90 CLEOCIN HCL
150 MG CAPSULE(S) CLINDAMYCIN HYDROCHLORIDE Pfizer RxPathways $555.24 $638.53 300 MG CAPSULE(S) CLINDAMYCIN HYDROCHLORIDE Pfizer RxPathways $1,127.80 $1,296.97 75 MG CAPSULE(S) CLINDAMYCIN HYDROCHLORIDE Pfizer RxPathways $282.82 $325.24
Report Run: 04/19/16 10:53 AM Page 68 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CLEOCIN PEDIATRIC
75/5 MG/ML (100 ML) MG/ML CLINDAMYCIN PALMITATE Pfizer MAINTAIN $82.21 $94.54 HYDROCHLORIDE 75/5 MG/ML (100 ML) MG/ML CLINDAMYCIN PALMITATE Pfizer RxPathways $82.21 $94.54 HYDROCHLORIDE CLEOCIN T GEL
1 % (60 ML) APPLICATION CLINDAMYCIN PHOSPHATE Pfizer MAINTAIN $137.17 $157.75 1 % (60 ML) APPLICATION CLINDAMYCIN PHOSPHATE Pfizer RxPathways $137.17 $157.75 CLEOCIN VAGINAL OVULES
100 MG SUPPOSITORY CLINDAMYCIN PHOSPHATE Pfizer MAINTAIN $115.84 $133.22 100 MG SUPPOSITORY CLINDAMYCIN PHOSPHATE Pfizer RxPathways $115.84 $133.22 CLIMARA
0.025/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 0.0375/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 0.05/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 0.06/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 0.075/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 0.1/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $124.72 $143.43 CLIMARA PRO
0.045 MG/24HR-0.015MG PATCH ESTRADIOL/LEVONORGESTREL Bayer HealthCare Patient Assistance Program $150.61 $173.20 CLINDAGEL
1 %, 75ml GEL/JELLY CLINDAMYCIN PHOSPHATE Onset Patient Assistance Program $1,196.70 $1,376.21
Report Run: 04/19/16 10:53 AM Page 69 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CLINDAMYCIN (BRAND: CLEOCIN)
150 MG CAPSULE(S) CLINDAMYCIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $119.20 $137.08 Partners & Northern VA Residents ONLY 150 MG CAPSULE(S) CLINDAMYCIN HYDROCHLORIDE Rx Outreach $119.20 $137.08 CLONAZEPAM (BRAND: KLONOPIN)
0.5 MG TABLET(S) CLONAZEPAM Rx Outreach $70.81 $81.43 1 MG TABLET(S) CLONAZEPAM Rx Outreach $80.78 $92.90 2 MG TABLET(S) CLONAZEPAM Rx Outreach $111.92 $128.71 0.5 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $70.81 $81.43 1 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $80.78 $92.90 2 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $111.92 $128.71 CLONAZEPAM ODT (BRAND: KLONOPIN)
0.125 MG TABLET(S) CLONAZEPAM ODT (BRAND: Xubex Preferred Network Program $77.93 $89.62 KLONOPIN) 0.25 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $77.93 $89.62 0.5 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $77.80 $89.47 1 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $88.91 $102.25 2 MG TABLET(S) CLONAZEPAM Xubex Preferred Network Program $123.19 $141.67 CLONIDINE (BRAND: CATAPRES)
0.1 MG TABLET(S) CLONIDINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $36.00 $41.40 Partners & Northern VA Residents ONLY 0.2 MG TABLET(S) CLONIDINE Nova ScriptsCentral-Northern Virginia Clinic $44.83 $51.55 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 70 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CLONIDINE (BRAND: CATAPRES)
0.3 MG TABLET(S) CLONIDINE Nova ScriptsCentral-Northern Virginia Clinic $30.75 $35.36 Partners & Northern VA Residents ONLY 0.1 MG TABLET(S) CLONIDINE HYDROCHLORIDE Rx Outreach $36.00 $41.40 0.2 MG TABLET(S) CLONIDINE Rx Outreach $44.83 $51.55 0.3 MG TABLET(S) CLONIDINE Rx Outreach $30.75 $35.36 0.1 MG TABLET(S) CLONIDINE HYDROCHLORIDE Welvista - South Carolina Residents Only $36.00 $41.40 0.2 MG TABLET(S) CLONIDINE Welvista - South Carolina Residents Only $44.83 $51.55 0.1 MG TABLET(S) CLONIDINE HYDROCHLORIDE Xubex Preferred Network Program $36.00 $41.40 0.2 MG TABLET(S) CLONIDINE Xubex Preferred Network Program $44.83 $51.55 0.3 MG TABLET(S) CLONIDINE Xubex Preferred Network Program $30.75 $35.36 CLONIDINE PATCH (BRAND: CATAPRES)
0.3/24 MG/HR PATCH CLONIDINE Rx Outreach $309.79 $356.26 0.1/24 MG/HR PATCH CLONIDINE Xubex Preferred Network Program $132.63 $152.52 0.2/24 MG/HR PATCH CLONIDINE Xubex Preferred Network Program $223.31 $256.81 0.3/24 MG/HR PATCH CLONIDINE Xubex Preferred Network Program $309.79 $356.26 CLOPIDOGREL (BRAND: PLAVIX)
75 MG TABLET(S) CLOPIDOGREL Nova ScriptsCentral-Northern Virginia Clinic $626.40 $720.36 Partners & Northern VA Residents ONLY 75 MG TABLET(S) CLOPIDOGREL Rx Outreach $626.40 $720.36 75 MG TABLET(S) CLOPIDOGREL Xubex Preferred Network Program $626.40 $720.36
Report Run: 04/19/16 10:53 AM Page 71 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CLORAZEPATE DIPOTASSIUM (BRAND: TRANXENE)
15 MG TABLET(S) clorazepate dipotassium Xubex Preferred Network Program $228.11 $262.33 3.75 MG TABLET(S) clorazepate dipotassium Xubex Preferred Network Program $134.84 $155.07 7.5 MG TABLET(S) clorazepate dipotassium Xubex Preferred Network Program $167.70 $192.86 CLOZAPINE
200 MG TABLET(S) CLOZAPINE Clozapine Patient Assistance Program $632.32 $727.17 50 MG TABLET(S) CLOZAPINE Clozapine Patient Assistance Program $165.00 $189.75 200 MG TABLET(S) CLOZAPINE Mylan Clozapine Patient Assistance Program $632.32 $727.17 (MCPAP) 50 MG TABLET(S) CLOZAPINE Mylan Clozapine Patient Assistance Program $165.00 $189.75 (MCPAP) CLOZAPINE
100 MG TABLET(S) CLOZAPINE Clozapine Patient Assistance Program $332.80 $382.72 25 MG TABLET(S) CLOZAPINE Clozapine Patient Assistance Program $128.47 $147.74 100 MG TABLET(S) CLOZAPINE Mylan Clozapine Patient Assistance Program $332.80 $382.72 (MCPAP) 25 MG TABLET(S) CLOZAPINE Mylan Clozapine Patient Assistance Program $128.47 $147.74 (MCPAP) COARTEM
20-120 MG-MG TABLET(S) ARTEMETHER/LUMEFANTRINE Novartis Patient Assistance Foundation, Inc. $133.90 $153.99 COLAZAL
750 MG CAPSULE(S) BALSALAZIDE DISODIUM Salix Patient Assistance Program $477.67 $549.32
Report Run: 04/19/16 10:53 AM Page 72 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
COLCHICINE (BRAND: COLCHICINE)
0.6 MG TABLET(S) COLCHICINE Xubex Patient Assistance Program $26.00 $29.90 COLCRYS
0.6 MG TABLET(S) COLCHICINE Takeda Patient Assistance Program-Colcrys & $718.54 $826.32 Uloric 0.6 MG TABLET(S) COLCHICINE Xubex Free Trial 30 Day Medication Supply $718.54 $826.32 COLESTID
5 GM/PACKET PACKET(S) COLESTIPOL HYDROCHLORIDE Pfizer MAINTAIN $132.04 $151.85 5 GM/PACKET PACKET(S) COLESTIPOL HYDROCHLORIDE Pfizer RxPathways $132.04 $151.85 COLESTID FLAVORED
5/7.5 GM/GM PACKET(S) COLESTIPOL HYDROCHLORIDE Pfizer MAINTAIN $289.69 $333.14 5/7.5 GM/GM PACKET(S) COLESTIPOL HYDROCHLORIDE Pfizer RxPathways $289.69 $333.14 COMBIGAN
0.2/0.5 % (10 ML) DROP(S) BRIMONIDINE Allergan Patient Assistance Program $267.85 $308.03 TARTRATE/TIMOLOL MALEATE COMBIVENT RESPIMAT
100-20 MCG/ACTUATION- PUFF(S) albuterol sulfate/ipratropium Boehringer Ingelheim Cares Foundation Inc. $334.76 $384.97 MCG/ACTUATION (4 bromide GM) COMBIVIR
150-300 MG-MG TABLET(S) LAMIVUDINE/ZIDOVUDINE ViiV Healthcare Patient Assistance Program $2,163.41 $2,487.92 COMPLERA
200-25-300 MG-MG-MG TABLET(S) ANTIVIRAL COMBINATION Gilead Advancing Access $2,815.04 $3,237.30
Report Run: 04/19/16 10:53 AM Page 73 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CONCERTA
18 MG TABLET(S) METHYLPHENIDATE Johnson & Johnson Patient Assistance $1,002.71 $1,153.12 HYDROCHLORIDE Foundation-Card Program 27 MG TABLET(S) METHYLPHENIDATE Johnson & Johnson Patient Assistance $1,027.85 $1,182.03 HYDROCHLORIDE Foundation-Card Program 36 MG TABLET(S) METHYLPHENIDATE Johnson & Johnson Patient Assistance $1,060.21 $1,219.24 HYDROCHLORIDE Foundation-Card Program 54 MG TABLET(S) METHYLPHENIDATE Johnson & Johnson Patient Assistance $1,153.62 $1,326.66 HYDROCHLORIDE Foundation-Card Program CONTRAVE
90-8 MG-MG TABLET(S) bupropion Takeda Patient Assistance Program $239.40 $275.31 hydrochloride/naltrexone hydrochloride COPAXONE
20 MG/ML SYRINGE(S) GLATIRAMER ACETATE Teva Copaxone Patient Assistance Program $7,332.60 $8,432.49 CORDARONE
* 200 MG TABLET(S) AMIODARONE HYDROCHLORIDE Pfizer RxPathways $295.42 $339.73 COREG
12.5 MG TABLET(S) CARVEDILOL GSK Access $503.02 $578.47 25 MG TABLET(S) CARVEDILOL GSK Access $503.02 $578.47 3.125 MG TABLET(S) CARVEDILOL GSK Access $503.02 $578.47 6.25 MG TABLET(S) CARVEDILOL GSK Access $503.02 $578.47 * 12.5 MG TABLET(S) CARVEDILOL GSK Bridges to Access $503.02 $578.47 * 25 MG TABLET(S) CARVEDILOL GSK Bridges to Access $503.02 $578.47
Report Run: 04/19/16 10:53 AM Page 74 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
COREG
* 3.125 MG TABLET(S) CARVEDILOL GSK Bridges to Access $503.02 $578.47 * 6.25 MG TABLET(S) CARVEDILOL GSK Bridges to Access $503.02 $578.47 COREG CR
10 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Access $303.05 $348.51 20 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Access $303.05 $348.51 40 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Access $303.05 $348.51 80 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Access $303.05 $348.51 10 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Bridges to Access $303.05 $348.51 20 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Bridges to Access $303.05 $348.51 40 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Bridges to Access $303.05 $348.51 80 MG TABLET(S) CARVEDILOL PHOSPHATE GSK Bridges to Access $303.05 $348.51 10 MG TABLET(S) CARVEDILOL PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $303.05 $348.51 Partners & Northern VA Residents ONLY 20 MG TABLET(S) CARVEDILOL PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $303.05 $348.51 Partners & Northern VA Residents ONLY 40 MG TABLET(S) CARVEDILOL PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $303.05 $348.51 Partners & Northern VA Residents ONLY 80 MG TABLET(S) CARVEDILOL PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $303.05 $348.51 Partners & Northern VA Residents ONLY 10 MG TABLET(S) CARVEDILOL PHOSPHATE Welvista - South Carolina Residents Only $303.05 $348.51 20 MG TABLET(S) CARVEDILOL PHOSPHATE Welvista - South Carolina Residents Only $303.05 $348.51 40 MG TABLET(S) CARVEDILOL PHOSPHATE Welvista - South Carolina Residents Only $303.05 $348.51
Report Run: 04/19/16 10:53 AM Page 75 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
COREG CR
80 MG TABLET(S) CARVEDILOL PHOSPHATE Welvista - South Carolina Residents Only $303.05 $348.51 CORLANOR
5 MG TABLET(S) ivabradine Amgen Safety Net Foundation $450.00 $517.50 7.5 MG TABLET(S) ivabradine Amgen Safety Net Foundation $450.00 $517.50 CORTEF
10 MG TABLET(S) HYDROCORTISONE Pfizer MAINTAIN $100.91 $116.05 20 MG TABLET(S) HYDROCORTISONE Pfizer MAINTAIN $191.28 $219.97 5 MG TABLET(S) HYDROCORTISONE Pfizer MAINTAIN $29.88 $34.36 10 MG TABLET(S) HYDROCORTISONE Pfizer RxPathways $100.91 $116.05 20 MG TABLET(S) HYDROCORTISONE Pfizer RxPathways $191.28 $219.97 5 MG TABLET(S) HYDROCORTISONE Pfizer RxPathways $29.88 $34.36 10 MG TABLET(S) HYDROCORTISONE Welvista - South Carolina Residents Only $100.91 $116.05 20 MG TABLET(S) HYDROCORTISONE Welvista - South Carolina Residents Only $191.28 $219.97 5 MG TABLET(S) HYDROCORTISONE Welvista - South Carolina Residents Only $29.88 $34.36 CORTISPORIN
1-0.35-10000 %-%-U/ML (10 ML) DROP(S) HC/NEOMYCIN Alcon Charitable Clinic Program-For Free $108.92 $125.26 SULF/POLYMYXIN B SULF Clinics COSOPT OCUMETER PLUS
2-0.5 % (10 ML) SOL DORZOLAMIDE Akorn Patient Assistance Program $168.89 $194.22 HYDROCHLORIDE/TIMOLOL MALEAT
Report Run: 04/19/16 10:53 AM Page 76 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
COSOPT OCUMETER PLUS
2-0.5 % (10 ML) SOL DORZOLAMIDE Nova ScriptsCentral-Northern Virginia Clinic $168.89 $194.22 HYDROCHLORIDE/TIMOLOL Partners & Northern VA Residents ONLY MALEAT COSOPT PF
2-05 % SOL DORZOLAMIDE Akorn Patient Assistance Program $102.72 $118.13 HYDROCHLORIDE/TIMOLOL MALEATE COUMADIN
* 1 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $120.14 $138.16 Foundation, Inc. * 10 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $186.38 $214.34 Foundation, Inc. * 2 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $125.35 $144.15 Foundation, Inc. * 2.5 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $129.34 $148.74 Foundation, Inc. * 3 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $129.84 $149.32 Foundation, Inc. * 4 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $130.19 $149.72 Foundation, Inc. * 5 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $134.80 $155.02 Foundation, Inc. * 6 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $173.66 $199.71 Foundation, Inc. * 7.5 MG TABLET(S) WARFARIN SODIUM Bristol-Myers Squibb Patient Assistance $179.68 $206.63 Foundation, Inc.
Report Run: 04/19/16 10:53 AM Page 77 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CREON 12000
60000-12000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE AbbVie Patient Assistance Foundation-Creon $300.11 $345.13 38000 CREON 24000
120000-24000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE AbbVie Patient Assistance Foundation-Creon $589.40 $677.81 76000 CREON 3000
15000-3000-9500 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE AbbVie Patient Assistance Foundation-Creon $88.36 $101.61 CREON 6000
30000-6000-19000 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE AbbVie Patient Assistance Foundation-Creon $153.49 $176.51 CRESEMBA
186 MG CAPSULE(S) isavuconazonium sulfate Astellas Access Program for Cresemba $1,176.00 $1,352.40 CRESEMBA
372 MG VIAL isavuconazonium sulfate Astellas Access Program for Cresemba $286.20 $329.13 CRESTOR
10 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings for people with $777.82 $894.49 Medicare Part D 20 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings for people with $777.82 $894.49 Medicare Part D 40 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings for people with $259.28 $298.17 Medicare Part D 5 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings for people with $777.82 $894.49 Medicare Part D 10 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings Program $777.82 $894.49
Report Run: 04/19/16 10:53 AM Page 78 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CRESTOR
20 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings Program $777.82 $894.49 40 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings Program $259.28 $298.17 5 MG TABLET(S) ROSUVASTATIN CALCIUM AZ&Me Prescription Savings Program $777.82 $894.49 10 MG TABLET(S) ROSUVASTATIN CALCIUM Nova ScriptsCentral-Northern Virginia Clinic $777.82 $894.49 Partners & Northern VA Residents ONLY 20 MG TABLET(S) ROSUVASTATIN CALCIUM Nova ScriptsCentral-Northern Virginia Clinic $777.82 $894.49 Partners & Northern VA Residents ONLY 40 MG TABLET(S) ROSUVASTATIN CALCIUM Nova ScriptsCentral-Northern Virginia Clinic $259.28 $298.17 Partners & Northern VA Residents ONLY 5 MG TABLET(S) ROSUVASTATIN CALCIUM Nova ScriptsCentral-Northern Virginia Clinic $777.82 $894.49 Partners & Northern VA Residents ONLY 10 MG TABLET(S) ROSUVASTATIN CALCIUM Welvista - South Carolina Residents Only $777.82 $894.49 20 MG TABLET(S) ROSUVASTATIN CALCIUM Welvista - South Carolina Residents Only $777.82 $894.49 40 MG TABLET(S) ROSUVASTATIN CALCIUM Welvista - South Carolina Residents Only $259.28 $298.17 5 MG TABLET(S) ROSUVASTATIN CALCIUM Welvista - South Carolina Residents Only $777.82 $894.49 10 MG TABLET(S) ROSUVASTATIN CALCIUM Xubex Free Trial 30 Day Medication Supply $777.82 $894.49 20 MG TABLET(S) ROSUVASTATIN CALCIUM Xubex Free Trial 30 Day Medication Supply $777.82 $894.49 5 MG TABLET(S) ROSUVASTATIN CALCIUM Xubex Free Trial 30 Day Medication Supply $777.82 $894.49 CRINONE
4 % (1.125 GM, 15s) GEL APPLICATION progesterone Actavis U.S. Patient Assistance Program $93.77 $107.84 8 % (1.125 GM, 15s) GEL APPLICATION progesterone Actavis U.S. Patient Assistance Program $390.86 $449.49
Report Run: 04/19/16 10:53 AM Page 79 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CRIXIVAN
200 MG CAPSULE(S) INDINAVIR SULFATE Merck SUPPORT Program for Crixivan & $548.11 $630.33 Isentress 400 MG CAPSULE(S) INDINAVIR SULFATE Merck SUPPORT Program for Crixivan & $274.06 $315.17 Isentress CUBICIN
500 MG VIAL(S) DAPTOMYCIN Cubicin Patient Assistance Program $486.46 $559.43 CUPRIMINE
250 MG CAPSULE(S) PENICILLAMINE Valeant Patient Assistance Program $31,426.37 $36,140.33 CYCLOBENZAPRINE HCL (BRAND: FLEXERIL)
10 MG TABLET(S) CYCLOBENZAPRINE Nova ScriptsCentral-Northern Virginia Clinic $145.05 $166.81 HYDROCHLORIDE Partners & Northern VA Residents ONLY 5 MG TABLET(S) CYCLOBENZAPRINE Nova ScriptsCentral-Northern Virginia Clinic $20.24 $23.28 HYDROCHLORIDE Partners & Northern VA Residents ONLY 10 MG TABLET(S) CYCLOBENZAPRINE Rx Outreach $145.05 $166.81 HYDROCHLORIDE 5 MG TABLET(S) CYCLOBENZAPRINE Rx Outreach $20.24 $23.28 HYDROCHLORIDE 10 MG TABLET(S) CYCLOBENZAPRINE Xubex Preferred Network Program $145.05 $166.81 HYDROCHLORIDE 5 MG TABLET(S) CYCLOBENZAPRINE Xubex Preferred Network Program $20.24 $23.28 HYDROCHLORIDE CYCLOGYL
1 % (15 ML) DROP(S) CYCLOPENTOLATE Alcon Cares, Inc. $87.78 $100.95 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 80 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CYCLOGYL
2 % (15 ML) DROP(S) CYCLOPENTOLATE Alcon Cares, Inc. $103.14 $118.61 HYDROCHLORIDE 1 % (15 ML) DROP(S) CYCLOPENTOLATE Alcon Charitable Clinic Program-For Free $87.78 $100.95 HYDROCHLORIDE Clinics 2 % (15 ML) DROP(S) CYCLOPENTOLATE Alcon Charitable Clinic Program-For Free $103.14 $118.61 HYDROCHLORIDE Clinics CYCLOMYDRIL
0.2-0.1 %-% (2 ML) DROP(S) CYCLOPENTOLATE Alcon Cares, Inc. $30.00 $34.50 HCL/PHENYLEPH HCL 0.2-0.1 %-% (2 ML) DROP(S) CYCLOPENTOLATE Alcon Charitable Clinic Program-For Free $30.00 $34.50 HCL/PHENYLEPH HCL Clinics CYCLOSET
0.8 MG TABLET(S) bromocriptine mesylate Salix Patient Assistance Program $799.19 $919.07 CYCLOSPORINE
100 MG CAPSULE(S) CYCLOSPORINE, MODIFIED Teva Cares Foundation Patient Assistance $164.89 $189.62 Program 25 MG CAPSULE(S) CYCLOSPORINE, MODIFIED Teva Cares Foundation Patient Assistance $41.25 $47.44 Program 50 MG CAPSULE(S) CYCLOSPORINE, MODIFIED Teva Cares Foundation Patient Assistance $82.15 $94.47 Program CYCLOSPORINE
100 MG/ML MG cyclosporine, modified Teva Cares Foundation Patient Assistance $299.55 $344.48 Program
Report Run: 04/19/16 10:53 AM Page 81 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
CYMBALTA
20 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Eli Lilly Cares $466.56 $536.54 30 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Eli Lilly Cares $261.72 $300.98 60 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Eli Lilly Cares $261.72 $300.98 20 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $466.56 $536.54 Partners & Northern VA Residents ONLY 30 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $261.72 $300.98 Partners & Northern VA Residents ONLY 60 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $261.72 $300.98 Partners & Northern VA Residents ONLY 20 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Welvista - South Carolina Residents Only $466.56 $536.54 30 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Welvista - South Carolina Residents Only $261.72 $300.98 60 MG CAPSULE(S) DULOXETINE HYDROCHLORIDE Welvista - South Carolina Residents Only $261.72 $300.98 CYRAMZA
10 MG/ML (10 ML) MG ramucirumab Eli Lilly PatientOne $1,224.00 $1,407.60 DACOGEN
50 MG INJECTION(S) DECITABINE Eisai Patient Assistance Program $2,053.20 $2,361.18 DAKLINZA
30 MG TABLET(S) daclatasvir Bristol-Myers Squibb Patient Assistance $25,200.00 $28,980.00 Foundation, Inc. 60 MG TABLET(S) daclatasvir Bristol-Myers Squibb Patient Assistance $25,200.00 $28,980.00 Foundation, Inc.
Report Run: 04/19/16 10:53 AM Page 82 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DALIRESP
500 MCG TABLET(S) roflumilast AZ&Me Prescription Savings Program $1,011.94 $1,163.73 DALVANCE
500 MG VIAL dalbavancin Actavis U.S. Patient Assistance Program $1,788.00 $2,056.20 DANAZOL (BRAND: DANOCRINE)
100 MG CAPSULE(S) danazol Xubex Preferred Network Program $544.26 $625.90 200 MG CAPSULE(S) danazol Xubex Preferred Network Program $906.93 $1,042.97 DANAZOL DANAZOL (BRAND: DANOCRINE)
50 MG CAPSULE(S) danazol Xubex Preferred Network Program $362.73 $417.14 DANTROLENE SODIUM (BRAND: DANTRIUM, REVONTO, RYANODEX) 100 MG CAPSULE(S) dantrolene Xubex Preferred Network Program $216.78 $249.30 25 MG CAPSULE(S) dantrolene Xubex Preferred Network Program $106.93 $122.97 50 MG CAPSULE(S) dantrolene Xubex Preferred Network Program $172.87 $198.80 DARAPRIM
25 MG TABLET(S) PYRIMETHAMINE Daraprim Direct Program $90,000.00 $103,500.00 DARZALEX
100/5 MG/ML MG daratumumab Johnson & Johnson Patient Assistance $540.00 $621.00 Foundation 400/20 MG/ML MG daratumumab Johnson & Johnson Patient Assistance $2,160.00 $2,484.00 Foundation
Report Run: 04/19/16 10:53 AM Page 83 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DECAVAC
2/0.5-5/0.5 LF U/ML-LF U/ML (0.5 INJECTION(S) DIPHTHERIA TOXOID, Sanofi Patient Connection $250.79 $288.41 ML) ADSORBED/TETANUS TOXOID DELZICOL
400 MG CAPSULE(S) mesalamine Actavis U.S. Patient Assistance Program $641.17 $737.35 DEMECLOCYCLINE HCL (BRAND: DECLOMYCIN)
150 MG TABLET(S) demeclocycline hydrochloride Xubex Preferred Network Program $942.34 $1,083.69 300 MG TABLET(S) demeclocycline hydrochloride Xubex Preferred Network Program $919.07 $1,056.93 DEMSER
250 MG CAPSULE(S) METYROSINE Valeant Patient Assistance Program $15,633.55 $17,978.58 DEPAKENE
* 250 MG TABLET(S) VALPROIC ACID AbbVie Patient Assistance Program $532.67 $612.57 * 250/5 MG/ML (480 ML) MG VALPROIC ACID AbbVie Patient Assistance Program $544.46 $626.13 DEPAKOTE
* 125 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $190.04 $218.55 * 250 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $373.32 $429.32 * 500 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $688.42 $791.68 DEPAKOTE DR
* 125 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $177.78 $204.45 * 250 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $349.21 $401.59 * 500 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $643.98 $740.58
Report Run: 04/19/16 10:53 AM Page 84 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DEPAKOTE DR
125 MG TABLET(S) DIVALPROEX SODIUM Nova ScriptsCentral-Northern Virginia Clinic $177.78 $204.45 Partners & Northern VA Residents ONLY 250 MG TABLET(S) DIVALPROEX SODIUM Nova ScriptsCentral-Northern Virginia Clinic $349.21 $401.59 Partners & Northern VA Residents ONLY 500 MG TABLET(S) DIVALPROEX SODIUM Nova ScriptsCentral-Northern Virginia Clinic $643.98 $740.58 Partners & Northern VA Residents ONLY 125 MG TABLET(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $177.78 $204.45 250 MG TABLET(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $349.21 $401.59 500 MG TABLET(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $643.98 $740.58 DEPAKOTE ER
* 250 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $339.49 $390.41 * 500 MG TABLET(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $597.16 $686.73 250 MG TABLET(S) DIVALPROEX SODIUM Nova ScriptsCentral-Northern Virginia Clinic $339.49 $390.41 Partners & Northern VA Residents ONLY 500 MG TABLET(S) DIVALPROEX SODIUM Nova ScriptsCentral-Northern Virginia Clinic $597.16 $686.73 Partners & Northern VA Residents ONLY 250 MG TABLET(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $339.49 $390.41 500 MG TABLET(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $597.16 $686.73 DEPAKOTE SPRINKLE
* 125 MG CAPSULE(S) DIVALPROEX SODIUM AbbVie Patient Assistance Program $181.19 $208.37 125 MG CAPSULE(S) DIVALPROEX SODIUM Welvista - South Carolina Residents Only $181.19 $208.37 DEPOCYT
10 MG/ML (5ML) MG CYTARABINE LIPOSOME Sigma-Tau Patient Assistance Program $2,940.00 $3,381.00
Report Run: 04/19/16 10:53 AM Page 85 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DEPO-ESTRADIOL
5 MG/ML (5 ML) MG/ML ESTRADIOL CYPIONATE Pfizer MAINTAIN $63.43 $72.94 5 MG/ML (5 ML) MG/ML ESTRADIOL CYPIONATE Pfizer RxPathways $63.43 $72.94 DEPO-MEDROL
40 MG/ML MG METHYLPREDNISOLONE Pfizer MAINTAIN $9.94 $11.43 ACETATE 80 MG/ML INJECTION(S) METHYLPREDNISOLONE Pfizer MAINTAIN $17.24 $19.83 ACETATE 40 MG/ML MG METHYLPREDNISOLONE Pfizer RxPathways $9.94 $11.43 ACETATE 80 MG/ML INJECTION(S) METHYLPREDNISOLONE Pfizer RxPathways $17.24 $19.83 ACETATE DEPO-PROVERA CONTRACEPTIVE
150 MG/ML INJECTION(S) MEDROXYPROGESTERONE Pfizer RxPathways $173.76 $199.82 ACETATE DEPO-SUBQ PROVERA 104
104/0.65 MG/ML (0.65 ML) MG/ML MEDROXYPROGESTERONE Pfizer RxPathways $152.99 $175.94 ACETATE DESCOVY
200-25 MG-MG TABLET(S) emtricitabine/tenofovir Gilead Advancing Access $1,759.73 $2,023.69 alafenamide DESFERAL
2 gm PDS DEFEROXAMINE MESYLATE Novartis Patient Assistance Foundation, Inc. $455.75 $524.11 500 mg PDS DEFEROXAMINE MESYLATE Novartis Patient Assistance Foundation, Inc. $117.24 $134.83
Report Run: 04/19/16 10:53 AM Page 86 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DESIPRAMINE HCL (BRAND: NORPRAMIN)
10 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $112.37 $129.23 100 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $425.04 $488.80 150 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $307.93 $354.12 25 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $135.00 $155.25 50 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $254.13 $292.25 75 MG TABLET(S) desipramine hydrochloride Xubex Preferred Network Program $323.46 $371.98 DESLORATADINE (BRAND: CLARINEX)
5 MG TABLET(S) desloratadine Xubex Preferred Network Program $506.93 $582.97 DESLORATADINE ODT (BRAND: CLARINEX)
2.5 MG TABLET(S) DESLORATADINE Xubex Preferred Network Program $174.75 $200.96 5 MG TABLET(S) DESLORATADINE Xubex Preferred Network Program $174.75 $200.96 DESONATE
0.05 % (60 GM) GEL desonide Bayer HealthCare Patient Assistance Program $480.60 $552.69 DETROL
1 MG TABLET(S) TOLTERODINE TARTRATE Pfizer RxPathways $343.55 $395.08 2 MG TABLET(S) TOLTERODINE TARTRATE Pfizer RxPathways $352.62 $405.51 1 MG TABLET(S) TOLTERODINE TARTRATE Welvista - South Carolina Residents Only $343.55 $395.08 2 MG TABLET(S) TOLTERODINE TARTRATE Welvista - South Carolina Residents Only $352.62 $405.51 DETROL LA
2 MG CAPSULE(S) TOLTERODINE TARTRATE Nova ScriptsCentral-Northern Virginia Clinic $875.88 $1,007.26 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 87 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DETROL LA
4 MG CAPSULE(S) TOLTERODINE TARTRATE Nova ScriptsCentral-Northern Virginia Clinic $875.88 $1,007.26 Partners & Northern VA Residents ONLY 2 MG CAPSULE(S) TOLTERODINE TARTRATE Pfizer RxPathways $875.88 $1,007.26 4 MG CAPSULE(S) TOLTERODINE TARTRATE Pfizer RxPathways $875.88 $1,007.26 2 MG CAPSULE(S) TOLTERODINE TARTRATE Welvista - South Carolina Residents Only $875.88 $1,007.26 4 MG CAPSULE(S) TOLTERODINE TARTRATE Welvista - South Carolina Residents Only $875.88 $1,007.26 DEXAMETHASONE (BRAND: DECADRON)
0.5 MG TABLET(S) dexamethasone Nova ScriptsCentral-Northern Virginia Clinic $26.72 $30.73 Partners & Northern VA Residents ONLY 0.75 MG TABLET(S) dexamethasone Nova ScriptsCentral-Northern Virginia Clinic $36.81 $42.33 Partners & Northern VA Residents ONLY 1.5 MG TABLET(S) dexamethasone Nova ScriptsCentral-Northern Virginia Clinic $38.85 $44.68 Partners & Northern VA Residents ONLY 4 MG TABLET(S) dexamethasone Nova ScriptsCentral-Northern Virginia Clinic $64.25 $73.89 Partners & Northern VA Residents ONLY 0.5 MG TABLET(S) dexamethasone Xubex Preferred Network Program $26.72 $30.73 0.75 MG TABLET(S) dexamethasone Xubex Preferred Network Program $36.81 $42.33 1 MG TABLET(S) dexamethasone Xubex Preferred Network Program $35.00 $40.25 1.5 MG TABLET(S) dexamethasone Xubex Preferred Network Program $38.85 $44.68 2 MG TABLET(S) dexamethasone Xubex Preferred Network Program $71.45 $82.17 4 MG TABLET(S) dexamethasone Xubex Preferred Network Program $64.25 $73.89 6 MG TABLET(S) dexamethasone Xubex Preferred Network Program $107.07 $123.13
Report Run: 04/19/16 10:53 AM Page 88 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DEXAMETHASONE SODIUM PHOSPHATE
0.1 % (5 ML) DROP(S) DEXAMETHASONE SODIUM Alcon Charitable Clinic Program-For Free $17.30 $19.89 PHOSPHATE Clinics 0.1 % (5 ML) DROP(S) DEXAMETHASONE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $17.30 $19.89 PHOSPHATE Partners & Northern VA Residents ONLY DEXEDRINE
5 MG TABLET(S) DEXTROAMPHETAMINE GSK Access $57.11 $65.68 SULFATE DEXEDRINE SPANSULES
10 MG CAPSULE(S) DEXTROAMPHETAMINE GSK Access $259.46 $298.38 SULFATE 15 MG CAPSULE(S) DEXTROAMPHETAMINE GSK Access $330.82 $380.44 SULFATE 5 MG CAPSULE(S) DEXTROAMPHETAMINE GSK Access $207.70 $238.85 SULFATE DEXILANT
30 MG CAPSULE(S) DEXLANSOPRAZOLE Takeda Patient Assistance Program $292.90 $336.84 60 MG CAPSULE(S) DEXLANSOPRAZOLE Takeda Patient Assistance Program $292.90 $336.84 30 MG CAPSULE(S) DEXLANSOPRAZOLE Welvista - South Carolina Residents Only $292.90 $336.84 60 MG CAPSULE(S) DEXLANSOPRAZOLE Welvista - South Carolina Residents Only $292.90 $336.84 DIASTAT
2.5 MG APPLICATION(S) DIAZEPAM Valeant Patient Assistance Program $325.91 $374.80 DIASTAT ACUDIAL
10 MG GEL DIAZEPAM Valeant Patient Assistance Program $386.61 $444.60
Report Run: 04/19/16 10:53 AM Page 89 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DIASTAT ACUDIAL
20 MG GEL/JELLY DIAZEPAM Valeant Patient Assistance Program $386.61 $444.60 DIAZEPAM (BRAND: VALIUM)
10 MG TABLET(S) DIAZEPAM Rx Outreach $136.51 $156.99 2 MG TABLET(S) DIAZEPAM Rx Outreach $37.02 $42.57 5 MG TABLET(S) DIAZEPAM Rx Outreach $60.81 $69.93 10 MG TABLET(S) DIAZEPAM Xubex Preferred Network Program $136.51 $156.99 2 MG TABLET(S) DIAZEPAM Xubex Preferred Network Program $37.02 $42.57 5 MG TABLET(S) DIAZEPAM Xubex Preferred Network Program $60.81 $69.93 DIBENZYLINE
10 MG CAPSULE(S) PHENOXYBENZAMINE Rx Outreach $14,398.80 $16,558.62 HYDROCHLORIDE DICLEGIS
10-10 MG-MG TABLET(S) doxylamine Duchesnay USA Patient Assistance Program $592.80 $681.72 succinate/pyridoxine hydrochloride DICLOFENAC POTASSIUM (BRAND: CATAFLAM)
50 MG TABLET(S) DICLOFENAC POTASSIUM Xubex Preferred Network Program $150.00 $172.50 DICLOFENAC SODIUM (BRAND: VOLTAREN)
50 MG TABLET(S) DICLOFENAC SODIUM Rx Outreach $116.44 $133.91 50 MG TABLET(S) DICLOFENAC SODIUM Xubex Preferred Network Program $116.44 $133.91
Report Run: 04/19/16 10:53 AM Page 90 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DICLOFENAC SODIUM DR (BRAND: VOLTAREN)
75 MG TABLET(S) diclofenac sodium Xubex Preferred Network Program $114.47 $131.64 DICLOFENAC SODIUM EC (BRAND: VOLTAREN)
75 MG TABLET(S) DICLOFENAC SODIUM Rx Outreach $177.39 $204.00 75 MG TABLET(S) DICLOFENAC SODIUM Xubex Preferred Network Program $177.39 $204.00 DICLOFENAC SODIUM ER (BRAND: VOLTAREN)
100 MG TABLET(S) DICLOFENAC SODIUM ER Rx Outreach $255.00 $293.25 100 MG TABLET(S) DICLOFENAC SODIUM ER Xubex Preferred Network Program $255.00 $293.25 DICYCLOMINE (BRAND: BENTYL)
10 MG CAPSULE(S) DICYCLOMINE Nova ScriptsCentral-Northern Virginia Clinic $12.57 $14.46 Partners & Northern VA Residents ONLY 20 MG TABLET(S) DICYCLOMINE Nova ScriptsCentral-Northern Virginia Clinic $15.99 $18.39 Partners & Northern VA Residents ONLY 10 MG CAPSULE(S) DICYCLOMINE Rx Outreach $12.57 $14.46 20 MG TABLET(S) DICYCLOMINE Rx Outreach $15.99 $18.39 10 MG CAPSULE(S) DICYCLOMINE Xubex Preferred Network Program $12.57 $14.46 20 MG TABLET(S) DICYCLOMINE Xubex Preferred Network Program $15.99 $18.39 DIETHYLPROPION HCL (BRAND: TENUATE)
25 MG TABLET(S) diethylpropion hydrochloride Xubex Preferred Network Program $52.10 $59.92 75 MG TABLET(S) diethylpropion hydrochloride Xubex Preferred Network Program $130.17 $149.70 DIFICID
200 MG TABLET(S) FIDAXOMICIN AccessDIFICID Program $4,187.50 $4,815.63
Report Run: 04/19/16 10:53 AM Page 91 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DIFICID
200 MG TABLET(S) FIDAXOMICIN Merck Patient Assistance Program $4,187.50 $4,815.63 DIGOXIN (BRAND: LANOXIN)
0.125 MG TABLET(S) DIGOXIN Rx Outreach $79.85 $91.83 0.25 MG TABLET(S) DIGOXIN Rx Outreach $28.99 $33.34 0.25 MG TABLET(S) DIGOXIN Welvista - South Carolina Residents Only $28.99 $33.34 0.125 MG TABLET(S) DIGOXIN Xubex Preferred Network Program $79.85 $91.83 0.25 MG TABLET(S) DIGOXIN Xubex Preferred Network Program $28.99 $33.34 DILANTIN EXTENDED
100 MG CAPSULE(S) PHENYTOIN SODIUM, Pfizer RxPathways $77.38 $88.99 EXTENDED 30 MG CAPSULE(S) PHENYTOIN SODIUM, Pfizer RxPathways $66.71 $76.72 EXTENDED DILANTIN INFATABS
50 MG TABLET(S) PHENYTOIN Pfizer RxPathways $72.50 $83.38 50 MG TABLET(S) PHENYTOIN Welvista - South Carolina Residents Only $72.50 $83.38 DILANTIN KAPSEALS
30 MG CAPSULE(S) PHENYTOIN SODIUM, Pfizer RxPathways $53.16 $61.13 EXTENDED 30 MG CAPSULE(S) PHENYTOIN SODIUM, Welvista - South Carolina Residents Only $53.16 $61.13 EXTENDED
Report Run: 04/19/16 10:53 AM Page 92 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DILANTIN KAPSEALS
100 MG CAPSULE(S) PHENYTOIN SODIUM, Nova ScriptsCentral-Northern Virginia Clinic $54.01 $62.11 EXTENDED Partners & Northern VA Residents ONLY 100 MG CAPSULE(S) PHENYTOIN SODIUM, Pfizer RxPathways $54.01 $62.11 EXTENDED 100 MG CAPSULE(S) PHENYTOIN SODIUM, Welvista - South Carolina Residents Only $54.01 $62.11 EXTENDED DILANTIN-125
125 mg/5ml (237ml) ML PHENYTOIN Pfizer RxPathways $96.46 $110.93 DILTIAZEM ER (BRAND: DILACOR XR)
* 120 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $35.88 $41.26 Rx Outreach) 120 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $35.88 $41.26 Partners & Northern VA Residents ONLY 120 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Rx Outreach $35.88 $41.26 120 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Xubex Preferred Network Program $35.88 $41.26 DILTIAZEM ER (BRAND: DILACOR XR)
* 180 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $105.92 $121.81 Rx Outreach) * 240 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $128.17 $147.40 Rx Outreach) 180 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Rx Outreach $105.92 $121.81 240 MG CAPSULE(S) DILTIAZEM HYDROCHLORIDE Rx Outreach $128.17 $147.40
Report Run: 04/19/16 10:53 AM Page 93 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DILTIAZEM HCL (BRAND: CARDIZEM CD)
180 MG CAPSULE(S) diltiazem hydrochloride Xubex Preferred Network Program $130.12 $149.64 240 MG CAPSULE(S) diltiazem hydrochloride Xubex Preferred Network Program $184.60 $212.29 300 MG CAPSULE(S) diltiazem hydrochloride Xubex Preferred Network Program $239.24 $275.13 DILTIAZEM HCL TABLETS (BRAND: CARDIZEM, CARDIZEM CD, CARDIZEM LA, CARTIA XT, DILACOR XR, DILT-CD, DILTIA XT, TAZTIA XT, TIAZAC) 30 MG TABLET(S) diltiazem hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $44.94 $51.68 Partners & Northern VA Residents ONLY 60 MG TABLET(S) diltiazem hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $70.30 $80.85 Partners & Northern VA Residents ONLY 90 MG TABLET(S) diltiazem hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $85.69 $98.54 Partners & Northern VA Residents ONLY 30 MG TABLET(S) diltiazem hydrochloride Xubex Preferred Network Program $44.94 $51.68 60 MG TABLET(S) diltiazem hydrochloride Xubex Preferred Network Program $70.30 $80.85 90 MG TABLET(S) diltiazem hydrochloride Xubex Preferred Network Program $85.69 $98.54 DIOVAN
* 160 MG TABLET(S) VALSARTAN Novartis Patient Assistance Foundation, Inc. $500.40 $575.46 * 320 MG TABLET(S) VALSARTAN Novartis Patient Assistance Foundation, Inc. $633.04 $728.00 * 40 MG TABLET(S) VALSARTAN Novartis Patient Assistance Foundation, Inc. $129.76 $149.22 * 80 MG TABLET(S) VALSARTAN Novartis Patient Assistance Foundation, Inc. $465.36 $535.16
Report Run: 04/19/16 10:53 AM Page 94 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DIPHENOXYLATE/ATROPINE (BRAND: LOMOTIL OR LONOX) 2.5/0.025 MG TABLET(S) ATROPINE Rx Outreach $60.00 $69.00 SULFATE/DIPHENOXYLATE HYDROCHLORIDE 2.5/0.025 MG TABLET(S) ATROPINE Xubex Preferred Network Program $60.00 $69.00 SULFATE/DIPHENOXYLATE HYDROCHLORIDE DIPROLENE
0.05 % 15gm OIN BETAMETHASONE Merck Patient Assistance Program $88.74 $102.05 DIPROPIONATE, AUGMENTED 0.05 % 15gm OIN BETAMETHASONE Welvista - South Carolina Residents Only $88.74 $102.05 DIPROPIONATE, AUGMENTED DIPROLENE AF
0.05 % 15gm Application BETAMETHASONE Merck Patient Assistance Program $62.92 $72.36 DIPROPIONATE, AUGMENTED DIPYRIDAMOLE (BRAND: PERSANTINE)
25 MG TABLET(S) dipyridamole Xubex Preferred Network Program $94.92 $109.16 50 MG TABLET(S) dipyridamole Xubex Preferred Network Program $152.92 $175.86 75 MG TABLET(S) dipyridamole Xubex Preferred Network Program $204.61 $235.30 DITROPAN XL
10 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Hospital Access Patient $694.58 $798.77 Assistance Program 15 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Hospital Access Patient $711.97 $818.77 Assistance Program
Report Run: 04/19/16 10:53 AM Page 95 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DITROPAN XL
5 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Hospital Access Patient $693.88 $797.96 Assistance Program 10 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Patient Assistance $694.58 $798.77 Foundation-Card Program 15 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Patient Assistance $711.97 $818.77 Foundation-Card Program 5 MG TABLET(S) OXYBUTYNIN CHLORIDE Johnson & Johnson Patient Assistance $693.88 $797.96 Foundation-Card Program 10 MG TABLET(S) OXYBUTYNIN CHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $694.58 $798.77 Partners & Northern VA Residents ONLY 15 MG TABLET(S) OXYBUTYNIN CHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $711.97 $818.77 Partners & Northern VA Residents ONLY 5 MG TABLET(S) OXYBUTYNIN CHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $693.88 $797.96 Partners & Northern VA Residents ONLY 10 MG TABLET(S) OXYBUTYNIN CHLORIDE Welvista - South Carolina Residents Only $694.58 $798.77 15 MG TABLET(S) OXYBUTYNIN CHLORIDE Welvista - South Carolina Residents Only $711.97 $818.77 5 MG TABLET(S) OXYBUTYNIN CHLORIDE Welvista - South Carolina Residents Only $693.88 $797.96 DIVALPROEX SODIUM DR (BRAND: DEPAKOTE)
125 MG TABLET(S) DIVALPROEX SODIUM Rx Outreach $89.72 $103.18 250 MG TABLET(S) DIVALPROEX SODIUM Rx Outreach $176.23 $202.66 500 MG TABLET(S) DIVALPROEX SODIUM Rx Outreach $324.97 $373.72 250 MG TABLET(S) DIVALPROEX SODIUM Xubex Preferred Network Program $176.23 $202.66 500 MG TABLET(S) DIVALPROEX SODIUM Xubex Preferred Network Program $324.97 $373.72
Report Run: 04/19/16 10:53 AM Page 96 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DIVALPROEX SODIUM ER (BRAND: DEPAKOTE ER)
250 MG TABLET(S) divalproex sodium Rx Outreach $220.93 $254.07 500 MG TABLET(S) DIVALPROEX SODIUM Rx Outreach $366.74 $421.75 250 MG TABLET(S) divalproex sodium Xubex Preferred Network Program $220.93 $254.07 500 MG TABLET(S) DIVALPROEX SODIUM Xubex Preferred Network Program $366.74 $421.75 DONEPEZIL HYDROCHLORIDE (BRAND: ARICEPT)
5 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Rx Outreach $778.72 $895.53 5 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Xubex Preferred Network Program $778.72 $895.53 DONEPEZIL HYDROCHLORIDE(BRAND: ARICEPT)
10 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Rx Outreach $778.72 $895.53 10 MG TABLET(S) DONEPEZIL HYDROCHLORIDE Xubex Preferred Network Program $778.72 $895.53 DONNATAL
0.0194-0.1037-16.2 MG-MG-MG-MG TABLET(S) atropine sulf/hyoscyamine Donnatal Patient Assistance Program $943.37 $1,084.88 -0.0065 sulf/pb/scop hydrobrom DORZOLAMIDE HYDROCHLORIDE (BRAND: TRUSOPT)
2 % (10 ML) DROP(S) dorzolamide hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $68.58 $78.87 Partners & Northern VA Residents ONLY 2 % (10 ML) DROP(S) dorzolamide hydrochloride Rx Outreach $68.58 $78.87 DORZOLAMIDE/TIMOLOL (BRAND: COSOPT)
2/0.5 % (10 ML) DROP(S) DORZOLAMIDE/TIMOLOL Rx Outreach $67.49 $77.61 DOXAZOSIN MESYLATE (BRAND: CARDURA)
1 MG TABLET(S) DOXAZOSIN MESYLATE Rx Outreach $134.86 $155.09
Report Run: 04/19/16 10:53 AM Page 97 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DOXAZOSIN MESYLATE (BRAND: CARDURA)
2 MG TABLET(S) DOXAZOSIN MESYLATE Rx Outreach $134.86 $155.09 4 MG TABLET(S) DOXAZOSIN MESYLATE Rx Outreach $141.55 $162.78 8 MG TABLET(S) DOXAZOSIN MESYLATE Rx Outreach $148.64 $170.94 1 MG TABLET(S) DOXAZOSIN MESYLATE Xubex Preferred Network Program $134.86 $155.09 2 MG TABLET(S) DOXAZOSIN MESYLATE Xubex Preferred Network Program $134.86 $155.09 4 MG TABLET(S) DOXAZOSIN MESYLATE Xubex Preferred Network Program $141.55 $162.78 8 MG TABLET(S) DOXAZOSIN MESYLATE Xubex Preferred Network Program $148.64 $170.94 DOXEPIN (BRAND: ADAPIN, SINEQUAN)
10 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Rx Outreach $32.70 $37.61 100 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Rx Outreach $89.85 $103.33 25 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Rx Outreach $31.43 $36.14 50 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Rx Outreach $61.50 $70.73 75 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Rx Outreach $82.80 $95.22 10 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Xubex Preferred Network Program $32.70 $37.61 100 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Xubex Preferred Network Program $89.85 $103.33 25 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Xubex Preferred Network Program $31.43 $36.14 50 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Xubex Preferred Network Program $61.50 $70.73 75 MG CAPSULE(S) DOXEPIN HYDROCHLORIDE Xubex Preferred Network Program $82.80 $95.22 DOXIL
2 MG/ML (25ML) MG DOXORUBICIN HYDROCHLORIDE Johnson & Johnson Hospital Access Patient $3,233.70 $3,718.75 LIPOSOME Assistance Program
Report Run: 04/19/16 10:53 AM Page 98 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DOXIL
2 MG/ML (25ML) MG DOXORUBICIN HYDROCHLORIDE Johnson & Johnson Patient Assistance $3,233.70 $3,718.75 LIPOSOME Foundation DOXIL
2 MG/ML (10ML) MG DOXORUBICIN HYDROCHLORIDE Johnson & Johnson Hospital Access Patient $1,293.48 $1,487.50 LIPOSOME Assistance Program 2 MG/ML (10ML) MG DOXORUBICIN HYDROCHLORIDE Johnson & Johnson Patient Assistance $1,293.48 $1,487.50 LIPOSOME Foundation DOXYCYCLINE (BRAND: VIBRAMYCIN)
100 MG CAPSULE(S) DOXYCYCLINE Nova ScriptsCentral-Northern Virginia Clinic $128.15 $147.37 Partners & Northern VA Residents ONLY 100 MG CAPSULE(S) DOXYCYCLINE Xubex Preferred Network Program $128.15 $147.37 150 MG TABLET(S) DOXYCYCLINE Xubex Preferred Network Program $1,479.01 $1,700.86 DOXYCYCLINE DR (BRAND: VIBRAMYCIN)
75 MG TABLET(S) DOXYCYCLINE HYCLATE Xubex Preferred Network Program $493.40 $567.41 DRONABINOL (BRAND: MARINOL)
10 MG CAPSULE(S) DRONABINOL Xubex Preferred Network Program $1,297.32 $1,491.92 2.5 MG CAPSULE(S) DRONABINOL Xubex Preferred Network Program $339.44 $390.36 5 MG CAPSULE(S) DRONABINOL Xubex Preferred Network Program $706.45 $812.42 DROXIA
400 MG CAPSULE(S) HYDROXYUREA Bristol-Myers Squibb Access Support $58.31 $67.06 Oncology Patient Assistance Program
Report Run: 04/19/16 10:53 AM Page 99 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DROXIA
200 MG CAPSULE(S) HYDROXYUREA Bristol-Myers Squibb Access Support $56.76 $65.27 Oncology Patient Assistance Program 300 MG CAPSULE(S) HYDROXYUREA Bristol-Myers Squibb Access Support $56.76 $65.27 Oncology Patient Assistance Program DUAC
5-1.2 %-% (45 GM) GEL/JELLY BENZOYL GSK Access $350.30 $402.85 PEROXIDE/CLINDAMYCIN PHOSPHATE 5-1.2 %-% (45 GM) GEL/JELLY BENZOYL GSK Bridges to Access $350.30 $402.85 PEROXIDE/CLINDAMYCIN PHOSPHATE DUAVEE
20-0.45 MG-MG TABLET(S) bazedoxifene Pfizer RxPathways $133.63 $153.67 acetate/conjugated estrogens 20-0.45 MG-MG TABLET(S) bazedoxifene Welvista - South Carolina Residents Only $133.63 $153.67 acetate/conjugated estrogens DUETACT
* 2-30 MG-MG TABLET(S) GLIMEPIRIDE/PIOGLITAZONE Takeda Patient Assistance Program $629.48 $723.90 HYDROCHLORIDE * 4-30 MG-MG TABLET(S) GLIMEPIRIDE/PIOGLITAZONE Takeda Patient Assistance Program $629.48 $723.90 HYDROCHLORIDE DUEXIS
26.6-800 MG-MG TABLET(S) famotidine/ibuprofen Horizon Patient Assistance Program $1,959.12 $2,252.99
Report Run: 04/19/16 10:53 AM Page 100 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DULERA
100/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Merck Patient Assistance Program $329.32 $378.72 200/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Merck Patient Assistance Program $329.32 $378.72 100/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Welvista - South Carolina Residents Only $329.32 $378.72 200/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Welvista - South Carolina Residents Only $329.32 $378.72 100/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Xubex Free Trial 30 Day Medication Supply $329.32 $378.72 200/5 MCG/ACTUATION PUFF(S) MOMETASONE/FOROMOTEROL Xubex Free Trial 30 Day Medication Supply $329.32 $378.72 DULOXETINE HYDROCHLORIDE (BRAND: CYMBALTA)
* 30 MG CAPSULE(S) duloxetine hydrochloride Generic Assistance Program (NeedyMeds & $706.64 $812.64 Rx Outreach) * 60 MG CAPSULE(S) duloxetine hydrochloride Generic Assistance Program (NeedyMeds & $235.55 $270.88 Rx Outreach) 30 MG CAPSULE(S) duloxetine hydrochloride Rx Outreach $706.64 $812.64 60 MG CAPSULE(S) duloxetine hydrochloride Rx Outreach $235.55 $270.88 30 MG CAPSULE(S) duloxetine hydrochloride Xubex Preferred Network Program $706.64 $812.64 60 MG CAPSULE(S) duloxetine hydrochloride Xubex Preferred Network Program $235.55 $270.88 DULOXETINE HYDROCHLORIDE BRAND: CYMBALTA)
* 20 MG CAPSULE(S) duloxetine hydrochloride Generic Assistance Program (NeedyMeds & $419.90 $482.89 Rx Outreach) 20 MG CAPSULE(S) duloxetine hydrochloride Rx Outreach $419.90 $482.89 20 MG CAPSULE(S) duloxetine hydrochloride Xubex Preferred Network Program $419.90 $482.89
Report Run: 04/19/16 10:53 AM Page 101 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DURAGESIC
100 MCG/HRS PATCH FENTANYL Johnson & Johnson Patient Assistance $735.42 $845.73 Foundation-Card Program 12 MCG/HRS PATCH FENTANYL Johnson & Johnson Patient Assistance $164.56 $189.24 Foundation-Card Program 25 MCG/HRS PATCH FENTANYL Johnson & Johnson Patient Assistance $198.70 $228.51 Foundation-Card Program 50 MCG/HRS PATCH FENTANYL Johnson & Johnson Patient Assistance $363.28 $417.77 Foundation-Card Program 75 MCG/HRS PATCH FENTANYL Johnson & Johnson Patient Assistance $554.11 $637.23 Foundation-Card Program DUREZOL
0.05 % (5 ML) DROP(S) difluprednate Alcon Cares, Inc. $183.06 $210.52 DUTOPROL (BRAND: METOPROLOL SUCCINATE ER/HCTZ) 100/12.5 MG TABLET(S) hydrochlorothiazide/metoprolol Rx Outreach $192.00 $220.80 succinate 25/12.5 MG TABLET(S) hydrochlorothiazide/metoprolol Rx Outreach $192.00 $220.80 succinate 50/12.5 MG TABLET(S) hydrochlorothiazide/metoprolol Rx Outreach $192.00 $220.80 succinate 50/12.5 MG TABLET(S) hydrochlorothiazide/metoprolol Xubex Preferred Network Program $192.00 $220.80 succinate DYAZIDE
37.5-25 MG-MG CAPSULE(S) TRIAMTERENE/HYDROCHLOROT Welvista - South Carolina Residents Only $239.08 $274.94 HIAZIDE
Report Run: 04/19/16 10:53 AM Page 102 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
DYRENIUM
100 MG CAPSULE(S) TRIAMTERENE Rx Outreach $1,149.60 $1,322.04 50 MG CAPSULE(S) TRIAMTERENE Rx Outreach $1,149.60 $1,322.04 ECONOPRED PLUS
1 % (10ML) DROP(S) PREDNISOLONE ACETATE Alcon Cares, Inc. $60.51 $69.59 1 % (10ML) DROP(S) PREDNISOLONE ACETATE Alcon Charitable Clinic Program-For Free $60.51 $69.59 Clinics EDARBI
40 MG TABLET(S) AZILSARTAN MEDOXOMIL Arbor Pharmaceuticals Patient Assistance $188.53 $216.81 Program 80 MG TABLET(S) AZILSARTAN MEDOXOMIL Arbor Pharmaceuticals Patient Assistance $204.92 $235.66 Program EDARBYCLOR
40/12.5 MG TABLET (S) AZILSARTAN Arbor Pharmaceuticals Patient Assistance $193.42 $222.43 MEDOXOMIL/CHLORTHALIDON Program E 40/25 MG TABLET (S) AZILSARTAN Arbor Pharmaceuticals Patient Assistance $193.42 $222.43 MEDOXOMIL/CHLORTHALIDON Program E EDECRIN
25 MG TABLET(S) ETHACRYNIC ACID Valeant Patient Assistance Program $1,174.86 $1,351.09 EDURANT
25 MG TABLET(S) RILPIVIRINE HYDROCHLORIDE Johnson & Johnson Hospital Access Patient $996.43 $1,145.89 Assistance Program
Report Run: 04/19/16 10:53 AM Page 103 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EDURANT
25 MG TABLET(S) RILPIVIRINE HYDROCHLORIDE Johnson & Johnson Patient Assistance $996.43 $1,145.89 Foundation 25 MG TABLET(S) RILPIVIRINE HYDROCHLORIDE Johnson & Johnson Patient Assistance $996.43 $1,145.89 Foundation-Card Program EEMT
1.25-2.5 MG-MG TABLET(S) esterified Xubex Preferred Network Program $192.95 $221.89 estrogens/methyltestosterone EFFEXOR-XR
150 MG CAPSULE(S) VENLAFAXINE HYDROCHLORIDE Pfizer RxPathways $1,154.08 $1,327.19 37.5 MG CAPSULE(S) VENLAFAXINE HYDROCHLORIDE Pfizer RxPathways $945.70 $1,087.56 75 MG CAPSULE(S) VENLAFAXINE HYDROCHLORIDE Pfizer RxPathways $1,059.61 $1,218.55 EFFIENT
10 MG TABLET(S) PRASUGREL HYDROCHLORIDE Eli Lilly Cares $1,164.24 $1,338.88 5 MG TABLET(S) PRASUGREL HYDROCHLORIDE Eli Lilly Cares $388.08 $446.29 10 MG TABLET(S) PRASUGREL HYDROCHLORIDE Welvista - South Carolina Residents Only $1,164.24 $1,338.88 5 MG TABLET(S) PRASUGREL HYDROCHLORIDE Welvista - South Carolina Residents Only $388.08 $446.29 ELIDEL
1 % 100gm CRE PIMECROLIMUS Valeant Patient Assistance Program $900.27 $1,035.31 ELIGARD
22.5 MG INJECTION(S) LEUPROLIDE ACETATE Eligard Patient Assistance Program $1,626.08 $1,869.99 45 MG INJECTION(S) leuprolide acetate Eligard Patient Assistance Program $3,252.16 $3,739.98
Report Run: 04/19/16 10:53 AM Page 104 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ELIGARD
30 MG INJECTION(S) leuprolide acetate Eligard Patient Assistance Program $2,168.11 $2,493.33 7.5 MG INJECTION(S) leuprolide acetate Eligard Patient Assistance Program $542.03 $623.33 ELIQUIS
2.5 MG TABLET(S) apixaban Bristol-Myers Squibb Patient Assistance $630.00 $724.50 Foundation, Inc. 5 MG TABLET(S) apixaban Bristol-Myers Squibb Patient Assistance $630.00 $724.50 Foundation, Inc. 2.5 MG TABLET(S) apixaban Xubex Free Trial 30 Day Medication Supply $630.00 $724.50 ELITEK
1.5 MG INJECTION(S) RASBURICASE Sanofi Patient Connection $2,119.07 $2,436.93 7.5 MG INJECTION(S) RASBURICASE Sanofi Patient Connection $3,531.85 $4,061.63 ELLENCE
2 MG/ML (100 ML) INJECTION EPIRUBICIN HYDROCHLORIDE Pfizer RxPathways $537.60 $618.24 ELMIRON
100 MG CAPSULE(S) PENTOSAN POLYSULFATE Johnson & Johnson Patient Assistance $814.98 $937.23 SODIUM Foundation-Card Program 100 MG CAPSULE(S) PENTOSAN POLYSULFATE Welvista - South Carolina Residents Only $814.98 $937.23 SODIUM ELOCON
0.1 % (50 GM) CRE mometasone furoate Merck Patient Assistance Program $113.41 $130.42 0.1 % 15gm CRE MOMETASONE FUROATE Welvista - South Carolina Residents Only $56.86 $65.39
Report Run: 04/19/16 10:53 AM Page 105 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ELOXATIN
* 100 MG INJECTION(S) OXALIPLATIN Sanofi Patient Connection $2,354.39 $2,707.55 * 50 MG INJECTION(S) OXALIPLATIN Sanofi Patient Connection $1,177.20 $1,353.78 EMADINE
0.05 % (5 ML) DROP(S) EMEDASTINE DIFUMARATE Alcon Cares, Inc. $130.14 $149.66 0.05 % (5 ML) DROP(S) EMEDASTINE DIFUMARATE Alcon Charitable Clinic Program-For Free $130.14 $149.66 Clinics EMCYT
140 MG CAPSULE(S) ESTRAMUSTINE PHOSPHATE Pfizer RxPathways $777.94 $894.63 SODIUM EMEND
150 MG MG FOSAPREPITANT Merck Access Program $308.35 $354.60 DIMEGLUMINE 125 MG CAPSULE(S) APREPITANT Nova ScriptsCentral-Northern Virginia Clinic $1,869.37 $2,149.78 Partners & Northern VA Residents ONLY 80 MG CAPSULE(S) APREPITANT Nova ScriptsCentral-Northern Virginia Clinic $1,097.59 $1,262.23 Partners & Northern VA Residents ONLY 125 MG CAPSULE(S) APREPITANT Welvista - South Carolina Residents Only $1,869.37 $2,149.78 40 MG CAPSULE(S) APREPITANT Welvista - South Carolina Residents Only $452.74 $520.65 80 MG CAPSULE(S) APREPITANT Welvista - South Carolina Residents Only $1,097.59 $1,262.23 EMEND TRI-FOLD PACK
125-80 MG CAPSULE(S) APREPITANT Merck Access Program $705.79 $811.66 125-80 MG CAPSULE(S) APREPITANT Nova ScriptsCentral-Northern Virginia Clinic $705.79 $811.66 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 106 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EMEND TRI-FOLD PACK
125-80 MG CAPSULE(S) APREPITANT Welvista - South Carolina Residents Only $705.79 $811.66 EMSAM
12/24 MG/HR PATCH, ER SELEGILINE Mylan EMSAM Transdermal System Patient $1,308.62 $1,504.91 Assistance Program 6/24 MG/HR PATCH, ER SELEGILINE Mylan EMSAM Transdermal System Patient $1,308.62 $1,504.91 Assistance Program 9/24 MG/HR PATCH, ER SELEGILINE Mylan EMSAM Transdermal System Patient $1,308.62 $1,504.91 Assistance Program EMTRIVA
200 MG CAPSULE(S) EMTRICITABINE Gilead Advancing Access $643.82 $740.39 EMTRIVA
10 MG/ML (170 ML) MG emtricitabine Gilead Advancing Access $152.04 $174.85 ENALAPRIL (BRAND: VASOTEC)
10 MG TABLET(S) ENALAPRIL MALEATE Nova ScriptsCentral-Northern Virginia Clinic $134.00 $154.10 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) ENALAPRIL MALEATE Nova ScriptsCentral-Northern Virginia Clinic $100.00 $115.00 Partners & Northern VA Residents ONLY 20 MG TABLET(S) ENALAPRIL MALEATE Nova ScriptsCentral-Northern Virginia Clinic $137.28 $157.87 Partners & Northern VA Residents ONLY 5 MG TABLET(S) ENALAPRIL MALEATE Nova ScriptsCentral-Northern Virginia Clinic $22.50 $25.88 Partners & Northern VA Residents ONLY 10 MG TABLET(S) ENALAPRIL MALEATE Rx Outreach $134.00 $154.10 2.5 MG TABLET(S) ENALAPRIL MALEATE Rx Outreach $100.00 $115.00
Report Run: 04/19/16 10:53 AM Page 107 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ENALAPRIL (BRAND: VASOTEC)
20 MG TABLET(S) ENALAPRIL MALEATE Rx Outreach $137.28 $157.87 5 MG TABLET(S) ENALAPRIL MALEATE Rx Outreach $22.50 $25.88 10 MG TABLET(S) ENALAPRIL MALEATE Xubex Preferred Network Program $134.00 $154.10 2.5 MG TABLET(S) ENALAPRIL MALEATE Xubex Preferred Network Program $100.00 $115.00 20 MG TABLET(S) ENALAPRIL MALEATE Xubex Preferred Network Program $137.28 $157.87 5 MG TABLET(S) ENALAPRIL MALEATE Xubex Preferred Network Program $22.50 $25.88 ENALAPRIL/HCTZ (BRAND: VASERETIC)
10/25 MG/MG TABLET(S) ENALAPRIL/HCTZ Rx Outreach $119.40 $137.31 5/12.25 MG/MG TABLET(S) ENALAPRIL/HCTZ Rx Outreach $107.20 $123.28 10/25 MG/MG TABLET(S) ENALAPRIL/HCTZ Xubex Preferred Network Program $119.40 $137.31 5/12.25 MG/MG TABLET(S) ENALAPRIL/HCTZ Xubex Preferred Network Program $107.20 $123.28 ENBREL
25 MG INJECTION ETANERCEPT Amgen Safety Net Foundation $2,073.41 $2,384.42 50 MG/ML (0.98 ML) INJECTION (SURECLICK AUTOINJECTOR,P Amgen Safety Net Foundation $4,146.82 $4,768.84 ENJUVIA
0.3 MG TABLET(S) CONJUGATED ESTROGENS Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.45 MG TABLET(S) CONJUGATED ESTROGENS Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.625 MG TABLET(S) CONJUGATED ESTROGENS Enjuvia Patient Assistance Program $238.97 $274.82 SYNTHETIC B
Report Run: 04/19/16 10:53 AM Page 108 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ENJUVIA
1.25 MG TABLET(S) CONJUGATED ESTROGENS Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.3 MG TABLET(S) CONJUGATED ESTROGENS Teva Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.45 MG TABLET(S) CONJUGATED ESTROGENS Teva Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.625 MG TABLET(S) CONJUGATED ESTROGENS Teva Enjuvia Patient Assistance Program $238.97 $274.82 SYNTHETIC B 1.25 MG TABLET(S) CONJUGATED ESTROGENS Teva Enjuvia Patient Assistance Program $298.90 $343.74 SYNTHETIC B 0.3 MG TABLET(S) CONJUGATED ESTROGENS Xubex Free Trial 30 Day Medication Supply $298.90 $343.74 SYNTHETIC B 0.45 MG TABLET(S) CONJUGATED ESTROGENS Xubex Free Trial 30 Day Medication Supply $298.90 $343.74 SYNTHETIC B 0.625 MG TABLET(S) CONJUGATED ESTROGENS Xubex Free Trial 30 Day Medication Supply $238.97 $274.82 SYNTHETIC B 0.9 MG TABLET(S) CONJUGATED ESTROGENS Xubex Free Trial 30 Day Medication Supply $238.97 $274.82 SYNTHETIC B 1.25 MG TABLET(S) CONJUGATED ESTROGENS Xubex Free Trial 30 Day Medication Supply $298.90 $343.74 SYNTHETIC B ENSURE (CHOCOLATE)
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $35.14 $40.41 ENSURE (COFFEE LATTE)
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $9.68 $11.13
Report Run: 04/19/16 10:53 AM Page 109 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ENSURE (PECAN)
n/a n/a CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $35.14 $40.41 ENSURE (STRAWBERRY)
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $9.68 $11.13 ENSURE (VANILLA)
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $35.14 $40.41 ENSURE HIGH CALCIUM (CHOCOLATE)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $12.22 $14.05 ENSURE HIGH CALCIUM (VANILLA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $12.22 $14.05 ENSURE HIGH PROTEIN (BANANA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $1.94 $2.23 ENSURE HIGH PROTEIN (CHOCOLATE)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $1.94 $2.23 ENSURE HIGH PROTEIN (VANILLA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $1.94 $2.23 ENSURE PLUS (CHOCOLATE)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.16 $2.48 ENSURE PLUS (COFFEE)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.16 $2.48
Report Run: 04/19/16 10:53 AM Page 110 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ENSURE PLUS (CREAMY MILK CHOCOLATE)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.26 $2.60 ENSURE PLUS (EGGNOG)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.16 $2.48 ENSURE PLUS (HOMEMADE VANILLA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.26 $2.60 ENSURE PLUS (STRAWBERRIES & CREAM)
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $40.61 $46.70 ENSURE PLUS (VANILLA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.16 $2.48 ENTEREG
12 MG CAPSULE(S) alvimopan Entereg Access Support and Education $4,115.38 $4,732.69 (E.A.S.E.) ENTRESTO
49/51 MG TABLET(S) sacubitril/valsartan Novartis Patient Assistance Foundation, Inc. $750.00 $862.50 97/103 MG TABLET(S) sacubitril/valsartan Novartis Patient Assistance Foundation, Inc. $750.00 $862.50 ENTRESTO
24/26 MG TABLET(S) sacubitril/valsartan Novartis Patient Assistance Foundation, Inc. $750.00 $862.50 ENTYVIO
300 MG VIAL vedolizumab Entyvio Connect $5,782.80 $6,650.22
Report Run: 04/19/16 10:53 AM Page 111 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EPIDUO
0.1-2.5 % (45 GM) GEL ADAPALENE/BENZOYL Galderma Patient Assistance Program $497.63 $572.27 PEROXIDE EPINEPHRINE
0.3/0.3 MG/ML INJECTION(S) epinephrine Rx Outreach $494.01 $568.11 0.15/0.15 MG/ML INJECTION(S) epinephrine Xubex Preferred Network Program $494.01 $568.11 0.3/0.3 MG/ML INJECTION(S) epinephrine Xubex Preferred Network Program $494.01 $568.11 EPIPEN AUTO-INJECTOR
0.3/0.3 MG/ML INJECTION EPINEPHRINE Mylan EpiPen 2-Pak Auto-Injector Patient $553.02 $635.97 Assistance Program 0.3/0.3 MG/ML INJECTION EPINEPHRINE Rx Outreach $553.02 $635.97 EPIPEN JR AUTO-INJECTOR
0.15/0.3 MG/ML INJECTION EPINEPHRINE Mylan EpiPen 2-Pak Auto-Injector Patient $553.20 $636.18 Assistance Program EPIVIR
10 mg/ml (240ml) SOL LAMIVUDINE ViiV Healthcare Patient Assistance Program $133.04 $153.00 150 MG TABLET(S) LAMIVUDINE ViiV Healthcare Patient Assistance Program $498.89 $573.72 300 MG TABLET(S) LAMIVUDINE ViiV Healthcare Patient Assistance Program $498.89 $573.72 EPIVIR HBV
100 MG TABLET(S) LAMIVUDINE GSK Access $1,074.08 $1,235.19 5 MG/ML MG LAMIVUDINE GSK Access $214.81 $247.03 100 MG TABLET(S) LAMIVUDINE GSK Bridges to Access $1,074.08 $1,235.19 5 MG/ML MG LAMIVUDINE GSK Bridges to Access $214.81 $247.03
Report Run: 04/19/16 10:53 AM Page 112 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EPLERENONE (BRAND: INSPRA)
25 MG TABLET(S) EPLERENONE Xubex Preferred Network Program $390.56 $449.14 50 MG TABLET(S) EPLERENONE Xubex Preferred Network Program $390.56 $449.14 EPOGEN
10000 u/ml, 1 ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $182.34 $209.69 2000 u/ml, 1 ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $36.47 $41.94 20000 u/ml, 1ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $364.68 $419.38 3000 u/ml, 1 ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $54.71 $62.92 4000 u/ml, 1 ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $72.94 $83.88 40000 u/ml, 1ml UNIT(S) EPOETIN ALFA Amgen Safety Net Foundation $601.80 $692.07 EPROSARTAN MESYLATE (BRAND: TEVETEN)
600 MG TABLET(S) eprosartan mesylate Xubex Preferred Network Program $342.59 $393.98 EPZICOM
600-300 MG-MG TABLET(S) ABACAVIR GSK Access $1,416.35 $1,628.80 SULFATE/LAMIVUDINE 600-300 MG-MG TABLET(S) ABACAVIR ViiV Healthcare Patient Assistance Program $1,416.35 $1,628.80 SULFATE/LAMIVUDINE EQUETRO
100 MG CAPSULE(S) CARBAMAZEPINE Equetro Patient Assistance Program $399.60 $459.54 200 MG CAPSULE(S) CARBAMAZEPINE Equetro Patient Assistance Program $519.84 $597.82 300 MG CAPSULE(S) CARBAMAZEPINE Equetro Patient Assistance Program $506.40 $582.36
Report Run: 04/19/16 10:53 AM Page 113 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ERBITUX
2 MG/ML (50 ML) MG CETUXIMAB Eli Lilly PatientOne $629.88 $724.36 ERIVEDGE
150 MG CAPSULE(S) VISMODEGIB Genentech BioOncology Access Solutions- $11,268.79 $12,959.11 Oral Products ERWINAZE
10000 IU VIAL asparaginase erwinia EUSA Pharma Community Access Patient $19,664.76 $22,614.47 chrysanthemi Program ESBRIET
267 MG CAPSULE(S) pirfenidone Genentech Access to Care Foundation-Esbriet $9,360.00 $10,764.00 ESCITALOPRAM (BRAND: LEXAPRO)
10 MG TABLET(S) escitalopram oxalate Rx Outreach $471.58 $542.32 20 MG TABLET(S) escitalopram oxalate Rx Outreach $492.09 $565.90 5 MG TABLET(S) escitalopram oxalate Rx Outreach $451.02 $518.67 10 MG TABLET(S) escitalopram oxalate Xubex Preferred Network Program $471.58 $542.32 20 MG TABLET(S) escitalopram oxalate Xubex Preferred Network Program $492.09 $565.90 5 MG TABLET(S) escitalopram oxalate Xubex Preferred Network Program $451.02 $518.67 ESOMEPRAZOLE MAGNESIUM (BRAND: NEXIUM)
20 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM Rx Outreach $767.00 $882.05 40 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM Rx Outreach $767.00 $882.05
Report Run: 04/19/16 10:53 AM Page 114 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ESTRADIOL (BRAND: ESTRACE, FEMTRACE, GYNODIOL)
0.5 MG TABLET(S) ESTRADIOL Nova ScriptsCentral-Northern Virginia Clinic $25.50 $29.33 Partners & Northern VA Residents ONLY 1 MG TABLET(S) ESTRADIOL Nova ScriptsCentral-Northern Virginia Clinic $34.50 $39.68 Partners & Northern VA Residents ONLY 2 MG TABLET(S) ESTRADIOL Nova ScriptsCentral-Northern Virginia Clinic $49.50 $56.93 Partners & Northern VA Residents ONLY 0.5 MG TABLET(S) ESTRADIOL Rx Outreach $25.50 $29.33 1 MG TABLET(S) ESTRADIOL Rx Outreach $34.50 $39.68 2 MG TABLET(S) ESTRADIOL Rx Outreach $49.50 $56.93 0.5 MG TABLET(S) ESTRADIOL Xubex Preferred Network Program $25.50 $29.33 1 MG TABLET(S) ESTRADIOL Xubex Preferred Network Program $34.50 $39.68 2 MG TABLET(S) ESTRADIOL Xubex Preferred Network Program $49.50 $56.93 ESTRING
2 MG INSERT ESTRADIOL Pfizer MAINTAIN $293.42 $337.43 2 MG INSERT ESTRADIOL Pfizer RxPathways $293.42 $337.43 ESTROGEL
0.06 % (50 GM PUMP PUMP(S) ESTRADIOL Ascend Therapeutics Patient Assistance $121.20 $139.38 STARTER UNITS) Program ESTROPIPATE (BRAND: OGEN)
0.75 MG TABLET(S) ESTROPIPATE Rx Outreach $47.00 $54.05 1.5 MG TABLET(S) ESTROPIPATE Rx Outreach $65.00 $74.75 0.75 MG TABLET(S) ESTROPIPATE Xubex Preferred Network Program $47.00 $54.05
Report Run: 04/19/16 10:53 AM Page 115 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ESTROPIPATE (BRAND: OGEN)
1.5 MG TABLET(S) ESTROPIPATE Xubex Preferred Network Program $65.00 $74.75 3 MG TABLET(S) ESTROPIPATE Xubex Preferred Network Program $150.19 $172.72 ESZOPICLONE (BRAND: LUNESTA)
1 MG TABLET(S) eszopiclone Rx Outreach $1,167.47 $1,342.59 2 MG TABLET(S) eszopiclone Rx Outreach $1,167.47 $1,342.59 3 MG TABLET(S) eszopiclone Rx Outreach $1,167.47 $1,342.59 ETHOSUXIMIDE (BRAND: ZARONTIN)
250 MG TABLET(S) ETHOSUXIMIDE Xubex Preferred Network Program $223.14 $256.61 ETODOLAC (BRAND: LODINE)
200 MG CAPSULE(S) ETODOLAC Rx Outreach $105.15 $120.92 300 MG CAPSULE(S) ETODOLAC Rx Outreach $150.23 $172.76 400 MG TABLET(S) ETODOLAC Rx Outreach $160.05 $184.06 500 MG TABLET(S) ETODOLAC Rx Outreach $160.20 $184.23 200 MG CAPSULE(S) ETODOLAC Xubex Preferred Network Program $105.15 $120.92 300 MG CAPSULE(S) ETODOLAC Xubex Preferred Network Program $150.23 $172.76 400 MG TABLET(S) ETODOLAC Xubex Preferred Network Program $160.05 $184.06 500 MG TABLET(S) ETODOLAC Xubex Preferred Network Program $160.20 $184.23 600 MG TABLET(S) ETODOLAC Xubex Preferred Network Program $327.41 $376.52 ETOPOPHOS
100 MG/VIAL MG ETOPOSIDE PHOSPHATE Bristol-Myers Squibb Access Support $169.13 $194.50 Oncology Patient Assistance Program
Report Run: 04/19/16 10:53 AM Page 116 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EVISTA
60 MG TABLET(S) RALOXIFENE HYDROCHLORIDE Eli Lilly Cares $237.60 $273.24 60 MG TABLET(S) RALOXIFENE HYDROCHLORIDE Welvista - South Carolina Residents Only $237.60 $273.24 EVOCLIN
1 % FOAM CLINDAMYCIN PHOSPHATE GSK Access $112.68 $129.58 1 % FOAM CLINDAMYCIN PHOSPHATE GSK Bridges to Access $112.68 $129.58 EVOTAZ
300-150 MG-MG TABLET(S) atazanavir/cobicistat BMS3assist Program $1,684.44 $1,937.11 EVZIO
0.4/0.4 MG/ML (0.4 ML) AUTO-INJECTOR(S) naloxone hydrochloride Kaleo Cares Patient Assistance Program $690.00 $793.50 EXALGO
12 MG TABLET(S) HYDROMORPHONE HCL Covidien/Mallinckrodt Patient Assistance $2,281.99 $2,624.29 Program 16 MG TABLET(S) HYDROMORPHONE HCL Covidien/Mallinckrodt Patient Assistance $3,042.65 $3,499.05 Program 32 MG TABLET(S) HYDROMORPHONE HCL Covidien/Mallinckrodt Patient Assistance $6,085.30 $6,998.10 Program 8 MG TABLET(S) HYDROMORPHONE HCL Covidien/Mallinckrodt Patient Assistance $1,521.32 $1,749.52 Program EXELON PATCH
13.3 MG/24 HR PATCH(ES) RIVASTIGMINE Novartis Patient Assistance Foundation, Inc. $450.96 $518.60 4.6 MG/24 HR PATCH(ES) RIVASTIGMINE Novartis Patient Assistance Foundation, Inc. $450.96 $518.60 9.5 MG/24 HR PATCH(ES) RIVASTIGMINE Novartis Patient Assistance Foundation, Inc. $450.96 $518.60
Report Run: 04/19/16 10:53 AM Page 117 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
EXELON PATCH
4.6 MG/24 HR PATCH(ES) RIVASTIGMINE Xubex Free Trial 30 Day Medication Supply $450.96 $518.60 9.5 MG/24 HR PATCH(ES) RIVASTIGMINE Xubex Free Trial 30 Day Medication Supply $450.96 $518.60 EXJADE
125 MG TABLET(S) DEFERASIROX EPASS Prescription and Reimbursement $1,090.27 $1,253.81 Hotline 250 MG TABLET(S) DEFERASIROX EPASS Prescription and Reimbursement $2,180.51 $2,507.59 Hotline 500 MG TABLET(S) DEFERASIROX EPASS Prescription and Reimbursement $4,360.93 $5,015.07 Hotline EXTAVIA
0.3 MG MG INTERFERON BETA-1B Novartis Patient Assistance Foundation, Inc. $6,481.87 $7,454.15 EYE-STREAM 120 ML
N/A N/A DROP(S) BALANCED SALT SOLUTION Alcon Charitable Clinic Program-For Free $23.64 $27.19 Clinics EYE-STREAM 30 ML
N/A N/A DROP(S) BALANCED SALT SOLUTION Alcon Charitable Clinic Program-For Free $15.42 $17.73 Clinics FABIOR
0.1 % (50 GM) FOAM tazarotene GSK Bridges to Access $498.19 $572.92 FAMCICLOVIR (BRAND: FAMVIR)
125 MG TABLET(S) FAMCICLOVIR Xubex Preferred Network Program $174.40 $200.56 250 MG TABLET(S) FAMCICLOVIR Xubex Preferred Network Program $189.62 $218.06
Report Run: 04/19/16 10:53 AM Page 118 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FAMCICLOVIR (BRAND: FAMVIR)
500 MG TABLET(S) FAMCICLOVIR Xubex Preferred Network Program $380.80 $437.92 FAMOTIDINE (BRAND: MYLANTA, PEPCID)
20 MG TABLET(S) FAMOTIDINE Nova ScriptsCentral-Northern Virginia Clinic $173.50 $199.53 Partners & Northern VA Residents ONLY 40 MG TABLET(S) FAMOTIDINE Nova ScriptsCentral-Northern Virginia Clinic $335.00 $385.25 Partners & Northern VA Residents ONLY 20 MG TABLET(S) FAMOTIDINE Rx Outreach $173.50 $199.53 40 MG TABLET(S) FAMOTIDINE Rx Outreach $335.00 $385.25 20 MG TABLET(S) FAMOTIDINE Xubex Preferred Network Program $173.50 $199.53 40 MG TABLET(S) FAMOTIDINE Xubex Preferred Network Program $335.00 $385.25 FANAPT
* 1 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $919.04 $1,056.90 * 10 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $1,810.93 $2,082.57 * 12 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $1,810.93 $2,082.57 * 2 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $919.04 $1,056.90 * 4 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $919.04 $1,056.90 * 6 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $1,130.81 $1,300.43 * 8 MG TABLET(S) ILOPERIDONE Novartis Patient Assistance Foundation, Inc. $919.04 $1,056.90 FARESTON
60 MG TABLET(S) TOREMIFENE CITRATE Fareston Patient Assistance Program $1,295.16 $1,489.43
Report Run: 04/19/16 10:53 AM Page 119 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FARXIGA
10 MG TABLET(S) dapagliflozin propanediol AZ&Me Prescription Savings Program $435.68 $501.03 5 MG TABLET(S) dapagliflozin propanediol AZ&Me Prescription Savings Program $435.68 $501.03 10 MG TABLET(S) dapagliflozin propanediol Xubex Free Trial 30 Day Medication Supply $435.68 $501.03 5 MG TABLET(S) dapagliflozin propanediol Xubex Free Trial 30 Day Medication Supply $435.68 $501.03 FARYDAK
10 MG CAPSULE(S) panobinostat Novartis Oncology Patient Assistance $8,800.01 $10,120.01 Program 15 MG CAPSULE(S) panobinostat Novartis Oncology Patient Assistance $8,800.01 $10,120.01 Program 20 MG CAPSULE(S) panobinostat Novartis Oncology Patient Assistance $8,800.01 $10,120.01 Program FASLODEX
50 MG/ML (2.5ML) INJECTION(S) FULVESTRANT AZ&Me Prescription Savings for people with $953.76 $1,096.82 Medicare Part D 50 MG/ML (2.5ML) INJECTION(S) FULVESTRANT AZ&Me Prescription Savings Program $953.76 $1,096.82 FELBAMATE (BRAND: FELBATOL)
400 MG TABLET(S) FELBAMATE Xubex Preferred Network Program $469.83 $540.30 600 MG TABLET(S0 FELBAMATE Xubex Preferred Network Program $538.46 $619.23 FELBATOL
400 MG TABLET(S) FELBAMATE Meda Patient Assistance Program $672.24 $773.08 600 MG TABLET(S) FELBAMATE Meda Patient Assistance Program $770.41 $885.97 600/5 MG/ML (237ML) ML FELBAMATE Meda Patient Assistance Program $826.19 $950.12
Report Run: 04/19/16 10:53 AM Page 120 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FELDENE
10 MG CAPSULE(S) PIROXICAM Pfizer RxPathways $506.16 $582.08 20 MG CAPSULE(S) PIROXICAM Pfizer RxPathways $866.20 $996.13 10 MG CAPSULE(S) PIROXICAM Welvista - South Carolina Residents Only $506.16 $582.08 20 MG CAPSULE(S) PIROXICAM Welvista - South Carolina Residents Only $866.20 $996.13 FELODIPINE ER (BRAND: PLENDIL ER)
* 2.5 MG TABLET(S) FELODIPINE Generic Assistance Program (NeedyMeds & $158.01 $181.71 Rx Outreach) * 5 MG TABLET(S) FELODIPINE Generic Assistance Program (NeedyMeds & $158.01 $181.71 Rx Outreach) 10 MG TABLET(S) FELODIPINE Rx Outreach $283.96 $326.55 2.5 MG TABLET(S) FELODIPINE Rx Outreach $158.01 $181.71 5 MG TABLET(S) FELODIPINE Rx Outreach $158.01 $181.71 10 MG TABLET(S) FELODIPINE Xubex Preferred Network Program $283.96 $326.55 2.5 MG TABLET(S) FELODIPINE Xubex Preferred Network Program $158.01 $181.71 5 MG TABLET(S) FELODIPINE Xubex Preferred Network Program $158.01 $181.71 FEMARA
* 2.5 MG TABLET(S) LETROZOLE Novartis Patient Assistance Foundation, Inc. $802.38 $922.74 FENOFIBRATE (BRAND: LOFIBRA, MICRONIZED)
134 MG CAPSULE(S) fenofibrate Rx Outreach $176.31 $202.76 130 MG CAPSULE(S) fenofibrate Xubex Preferred Network Program $623.37 $716.88 134 MG CAPSULE(S) fenofibrate Xubex Preferred Network Program $176.31 $202.76
Report Run: 04/19/16 10:53 AM Page 121 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FENOFIBRATE (BRAND: LOFIBRA, MICRONIZED)
200 MG CAPSULE(S) fenofibrate Xubex Preferred Network Program $283.56 $326.09 43 MG CAPSULE(S) fenofibrate Xubex Preferred Network Program $70.58 $81.17 67 MG CAPSULE(S) fenofibrate Xubex Preferred Network Program $95.09 $109.35 FENOFIBRATE (BRAND: TRICOR)
145 MG TABLET(S) fenofibrate Rx Outreach $515.58 $592.92 160 MG TABLET(S) fenofibrate Rx Outreach $213.88 $245.96 48 MG TABLET(S) fenofibrate Rx Outreach $171.86 $197.64 54 MG TABLET(S) fenofibrate Rx Outreach $71.29 $81.98 145 MG TABLET(S) fenofibrate Xubex Preferred Network Program $515.58 $592.92 160 MG TABLET(S) fenofibrate Xubex Preferred Network Program $213.88 $245.96 48 MG TABLET(S) fenofibrate Xubex Preferred Network Program $171.86 $197.64 54 MG TABLET(S) fenofibrate Xubex Preferred Network Program $71.29 $81.98 FENTORA
100 MCG TABLET(S) FENTANYL CITRATE Teva Cares Foundation Patient Assistance $1,237.20 $1,422.78 Program 200 MCG TABLET(S) FENTANYL CITRATE Teva Cares Foundation Patient Assistance $1,562.40 $1,796.76 Program 400 MCG TABLET(S) FENTANYL CITRATE Teva Cares Foundation Patient Assistance $2,268.00 $2,608.20 Program 600 MCG TABLET(S) FENTANYL CITRATE Teva Cares Foundation Patient Assistance $2,944.80 $3,386.52 Program 800 MCG TABLET(S) FENTANYL CITRATE Teva Cares Foundation Patient Assistance $3,627.60 $4,171.74 Program
Report Run: 04/19/16 10:53 AM Page 122 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FEROCON
75-0.015-110-0.5- MG-MG-MG-MG-MG CAPSULE(S) ferrous fum/folic acid/if/vit Xubex Preferred Network Program $43.95 $50.54 240 b12/vit c FERRIPROX
500 MG TABLET(S) deferiprone ApoPharma PAP-Ferriprox Total Care Support $4,954.07 $5,697.18 Program FERROUS SULFATE EC (BRAND: FEOSOL)
325 MG TABLET(S) ferrous sulfate Nova ScriptsCentral-Northern Virginia Clinic $2.90 $3.34 Partners & Northern VA Residents ONLY 325 MG TABLET(S) ferrous sulfate Rx Outreach $2.90 $3.34 325 MG TABLET(S) ferrous sulfate Xubex Preferred Network Program $2.90 $3.34 FETZIMA
120 MG CAPSULE(S) levomilnacipran hydrochloride Actavis U.S. Patient Assistance Program $359.02 $412.87 20 MG CAPSULE(S) levomilnacipran hydrochloride Actavis U.S. Patient Assistance Program $359.02 $412.87 40 MG CAPSULE(S) levomilnacipran hydrochloride Actavis U.S. Patient Assistance Program $359.02 $412.87 80 MG CAPSULE(S) levomilnacipran hydrochloride Actavis U.S. Patient Assistance Program $359.02 $412.87 FETZIMA TITRATION PACK
N/A N/A CAPSULE(S) levomilnacipran hydrochloride Actavis U.S. Patient Assistance Program $335.08 $385.34 FEXOFENADINE (BRAND: ALLEGRA)
180 MG TABLET(S) FEXOFENADINE Rx Outreach $261.00 $300.15 HYDROCHLORIDE 60 MG TABLET(S) FEXOFENADINE Rx Outreach $125.88 $144.76 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 123 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FEXOFENADINE (BRAND: ALLEGRA)
60 MG TABLET(S) FEXOFENADINE Xubex Preferred Network Program $125.88 $144.76 HYDROCHLORIDE FINACEA
15 % (50 GM) GEL azelaic acid Bayer HealthCare Patient Assistance Program $283.34 $325.84 FINASTERIDE (BRAND: PROSCAR)
* 5 MG TABLET(S) FINASTERIDE Generic Assistance Program (NeedyMeds & $281.76 $324.02 Rx Outreach) 5 MG TABLET(S) FINASTERIDE Nova ScriptsCentral-Northern Virginia Clinic $281.76 $324.02 Partners & Northern VA Residents ONLY 5 MG TABLET(S) FINASTERIDE Rx Outreach $281.76 $324.02 1 MG TABLET(S) finasteride Xubex Preferred Network Program $218.61 $251.40 5 MG TABLET(S) FINASTERIDE Xubex Preferred Network Program $281.76 $324.02 FLAGYL
250 MG TABLET(S) METRONIDAZOLE Pfizer MAINTAIN $424.68 $488.38 500 MG TABLET(S) METRONIDAZOLE Pfizer MAINTAIN $758.66 $872.46 FLAREX
0.1 % (5 ML) DROP(S) FLUOROMETHOLONE ACETATE Alcon Cares, Inc. $68.70 $79.01 0.1 % (5 ML) DROP(S) FLUOROMETHOLONE ACETATE Alcon Charitable Clinic Program-For Free $68.70 $79.01 Clinics FLECAINIDE ACETATE (BRAND: TAMBOCOR)
100 MG TABLET(S) flecainide acetate Rx Outreach $273.06 $314.02 150 MG TABLET(S) flecainide acetate Rx Outreach $375.81 $432.18
Report Run: 04/19/16 10:53 AM Page 124 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FLECAINIDE ACETATE (BRAND: TAMBOCOR)
100 MG TABLET(S) flecainide acetate Xubex Preferred Network Program $273.06 $314.02 150 MG TABLET(S) flecainide acetate Xubex Preferred Network Program $375.81 $432.18 FLOLAN
0.5 MG INJECTION(S) EPOPROSTENOL SODIUM Accredo - Flolan Patient Assistance Program $22.43 $25.79 1.5 MG INJECTION(S) EPOPROSTENOL SODIUM Accredo - Flolan Patient Assistance Program $54.17 $62.30 FLONASE
* 50 MCG SPRAY(S) FLUTICASONE PROPIONATE GSK Access $59.54 $68.47 * 50 MCG SPRAY(S) FLUTICASONE PROPIONATE GSK Bridges to Access $59.54 $68.47 50 MCG SPRAY(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $59.54 $68.47 FLOVENT DISKUS
100 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Access $190.49 $219.06 250 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Access $255.02 $293.27 50 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Access $180.64 $207.74 100 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $190.49 $219.06 250 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $255.02 $293.27 50 MCG/ACTUATION PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $180.64 $207.74 FLOVENT HFA
0.044 MG/INH (10.6gm) PUFF(S) FLUTICASONE PROPIONATE GSK Access $172.79 $198.71 0.11 mg/inh (7.9gm) PUFF(S) FLUTICASONE PROPIONATE GSK Access $39.97 $45.97 0.22 MG/INH (13 GM) PUFF(S) FLUTICASONE PROPIONATE GSK Access $196.58 $226.07
Report Run: 04/19/16 10:53 AM Page 125 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FLOVENT HFA
110 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE GSK Access $255.02 $293.27 GM) 220 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE GSK Access $396.11 $455.53 GM) 44 MCG/ACTUATION (10.6 PUFF(S) FLUTICASONE PROPIONATE GSK Access $190.49 $219.06 GM) 110 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $255.02 $293.27 GM) 220 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $396.11 $455.53 GM) 44 MCG/ACTUATION (10.6 PUFF(S) FLUTICASONE PROPIONATE GSK Bridges to Access $190.49 $219.06 GM) 110 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE Nova ScriptsCentral-Northern Virginia Clinic $255.02 $293.27 GM) Partners & Northern VA Residents ONLY 220 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE Nova ScriptsCentral-Northern Virginia Clinic $396.11 $455.53 GM) Partners & Northern VA Residents ONLY 44 MCG/ACTUATION (10.6 PUFF(S) FLUTICASONE PROPIONATE Nova ScriptsCentral-Northern Virginia Clinic $190.49 $219.06 GM) Partners & Northern VA Residents ONLY 110 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $255.02 $293.27 GM) 220 MCG/ACTUATION (12 PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $396.11 $455.53 GM) 44 MCG/ACTUATION (10.6 PUFF(S) FLUTICASONE PROPIONATE Welvista - South Carolina Residents Only $190.49 $219.06 GM)
Report Run: 04/19/16 10:53 AM Page 126 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FLOXIN
0.3 % (5 ML) DROP(S) OFLOXACIN Alcon Charitable Clinic Program-For Free $106.20 $122.13 Clinics FLUCONAZOLE (BRAND: DIFLUCAN)
100 MG TABLET(S) FLUCONAZOLE Nova ScriptsCentral-Northern Virginia Clinic $787.86 $906.04 Partners & Northern VA Residents ONLY 150 MG TABLET(S) FLUCONAZOLE Nova ScriptsCentral-Northern Virginia Clinic $181.67 $208.92 Partners & Northern VA Residents ONLY 100 MG TABLET(S) FLUCONAZOLE Rx Outreach $787.86 $906.04 200 MG TABLET(S) FLUCONAZOLE Rx Outreach $1,070.04 $1,230.55 100 MG TABLET(S) FLUCONAZOLE Xubex Patient Assistance Program $787.86 $906.04 150 MG TABLET(S) FLUCONAZOLE Xubex Patient Assistance Program $181.67 $208.92 200 MG TABLET(S) FLUCONAZOLE Xubex Patient Assistance Program $1,070.04 $1,230.55 FLUDROCORTISONE ACETATE (BRAND: FLORINEF)
0.1 MG TABLET(S) fludrocortisone acetate Xubex Preferred Network Program $74.77 $85.99 FLUNISOLIDE (BRAND: NASAREL)
0.025 MG/ACTUATION (25 SPRAY(S) flunisolide Xubex Preferred Network Program $66.00 $75.90 ML) FLUOXETINE (BRAND: PROZAC)
20 MG TABLET(S) FLUOXETINE Nova ScriptsCentral-Northern Virginia Clinic $266.55 $306.53 Partners & Northern VA Residents ONLY 40 MG TABLET(S) FLUOXETINE Nova ScriptsCentral-Northern Virginia Clinic $506.83 $582.85 Partners & Northern VA Residents ONLY 10 MG TABLET(S) FLUOXETINE Rx Outreach $259.89 $298.87
Report Run: 04/19/16 10:53 AM Page 127 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FLUOXETINE (BRAND: PROZAC)
20 MG TABLET(S) FLUOXETINE Rx Outreach $266.55 $306.53 40 MG TABLET(S) FLUOXETINE Rx Outreach $506.83 $582.85 10 MG TABLET(S) FLUOXETINE Welvista - South Carolina Residents Only $259.89 $298.87 20 MG TABLET(S) FLUOXETINE Welvista - South Carolina Residents Only $266.55 $306.53 20 MG TABLET(S) FLUOXETINE Xubex Preferred Network Program $266.55 $306.53 40 MG TABLET(S) FLUOXETINE Xubex Preferred Network Program $506.83 $582.85 FLUPHENAZINE HCL (BRAND: PROLIXIN)
1 MG TABLET(S) FLUPHENAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $62.99 $72.44 Partners & Northern VA Residents ONLY 10 MG TABLET(S) FLUPHENAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $38.39 $44.15 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) FLUPHENAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $75.75 $87.11 Partners & Northern VA Residents ONLY 5 MG TABLET(S) FLUPHENAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $33.53 $38.56 Partners & Northern VA Residents ONLY 10 MG TABLET(S) FLUPHENAZINE HCL Rx Outreach $38.39 $44.15 1 MG TABLET(S) FLUPHENAZINE HCL Xubex Preferred Network Program $62.99 $72.44 10 MG TABLET(S) FLUPHENAZINE HCL Xubex Preferred Network Program $38.39 $44.15 2.5 MG TABLET(S) FLUPHENAZINE HCL Xubex Preferred Network Program $75.75 $87.11 2.5/5 MG/ML (473 ML) ML FLUPHENAZINE HCL Xubex Preferred Network Program $192.00 $220.80 5 MG TABLET(S) FLUPHENAZINE HCL Xubex Preferred Network Program $33.53 $38.56
Report Run: 04/19/16 10:53 AM Page 128 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FLURAZEPAM HCL (BRAND: DALMANE)
15 MG CAPSULE(S) FLURAZEPAM HCL Xubex Preferred Network Program $72.76 $83.67 30 MG CAPSULE(S) flurazepam hydrochloride Xubex Preferred Network Program $87.70 $100.86 FLURBIPROFEN (BRAND: ANSAID)
100 MG TABLET(S) flurbiprofen Xubex Preferred Network Program $189.44 $217.86 50 MG TABLET(S) FLURBIPROFEN Xubex Preferred Network Program $82.74 $95.15 FLUTICASONE (BRAND: FLONASE)
50 MCG SPRAY(S) FLUTICASONE PROPIONATE Rx Outreach $96.84 $111.37 50 MCG SPRAY(S) FLUTICASONE PROPIONATE Xubex Preferred Network Program $96.84 $111.37 FLUVASTATIN (BRAND: ALTOPREV, MEVACOR)
20 MG CAPSULE(S) fluvastatin sodium Xubex Preferred Network Program $449.81 $517.28 40 MG CAPSULE(S) fluvastatin sodium Xubex Preferred Network Program $449.81 $517.28 FLUVOXAMINE CAPSULE (BRAND: LUVOX)
100 MG CAPSULE(S) FLUVOXAMINE Xubex Preferred Network Program $305.51 $351.34 150 MG CAPSULE(S) FLUVOXAMINE Xubex Preferred Network Program $327.87 $377.05 FLUVOXAMINE TABLET (BRAND: LUVOX)
100 MG TABLET(S) FLUVOXAMINE Rx Outreach $263.00 $302.45 100 MG TABLET(S) FLUVOXAMINE Xubex Preferred Network Program $263.00 $302.45 25 MG TABLET(S) FLUVOXAMINE Xubex Preferred Network Program $230.30 $264.85 50 MG TABLET(S) FLUVOXAMINE Xubex Preferred Network Program $257.35 $295.95
Report Run: 04/19/16 10:53 AM Page 129 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FOCALIN XR
10 MG CAPSULE(S) DEXMETHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $1,158.62 $1,332.41 HYDROCHLORIDE 15 MG CAPSULE DEXMETHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $1,191.50 $1,370.23 HYDROCHLORIDE 20 MG CAPSULE(S) DEXMETHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $1,191.50 $1,370.23 HYDROCHLORIDE 25 MG CAPSULE(S) dexmethylphenidate Novartis Patient Assistance Foundation, Inc. $1,251.11 $1,438.78 hydrochloride 40 MG CAPSULE(S) dexmethylphenidate Novartis Patient Assistance Foundation, Inc. $1,313.71 $1,510.77 hydrochloride 5 MG CAPSULE(S) DEXMETHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $1,141.72 $1,312.98 HYDROCHLORIDE FOCALIN XR
30 MG CAPSULE(S) dexmethylphenidate Novartis Patient Assistance Foundation, Inc. $1,147.80 $1,319.97 hydrochloride 35 MG CAPSULE(S) dexmethylphenidate Novartis Patient Assistance Foundation, Inc. $1,313.71 $1,510.77 hydrochloride FOLGARD
40-2000-120-800- MG-IU-MCG-MCG-MG- TABLET(S) multivitamin and minerals Rx Outreach $18.59 $21.38 31-12-0.32 MG-MG FOLGARD OS
1.5-500-0.25-1.1- MG-MG-MG-MG-MG- TABLET(S) boron/ca/folic acid/mg/vit Rx Outreach $24.75 $28.46 100-12.5-300 MG-IU b12/vit b6/vit d
Report Run: 04/19/16 10:53 AM Page 130 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FOLGARD RX
1-2.2-25 MG-MG-MG TABLET(S) cyanocobalamin/folic Rx Outreach $63.46 $72.98 acid/pyridoxine FOLIC ACID (BRAND: FOLVITE)
1 MG TABLET(S) FOLIC ACID Nova ScriptsCentral-Northern Virginia Clinic $37.50 $43.13 Partners & Northern VA Residents ONLY 1 MG TABLET(S) FOLIC ACID Rx Outreach $37.50 $43.13 1 MG TABLET(S) FOLIC ACID Xubex Preferred Network Program $37.50 $43.13 FOLOTYN
20 MG/ML (1 ML) INJECTION PRALATREXATE Allos Support for Assisting Patients (ASAP) $4,134.37 $4,754.53 20 MG/ML (1 ML) INJECTION PRALATREXATE STAR-Spectrum Therapy Access Resources $4,134.37 $4,754.53 FORADIL AEROLIZER
12 MCG CAPSULE(S) FORMOTEROL FUMARATE Merck Patient Assistance Program $241.39 $277.60 FORFIVO XL
450 MG TABLET(S) bupropion hydrochloride Xubex Free Trial 30 Day Medication Supply $332.64 $382.54 FORTAZ
1 GM PDS CEFTAZIDIME GSK Access $367.68 $422.83 1-2.2 gm/50ml (50ml) SOL CEFTAZIDIME GSK Access $406.24 $467.18 SODIUM/DEXTROSE 2 GM PDS CEFTAZIDIME GSK Access $284.53 $327.21 500 MG PDS CEFTAZIDIME GSK Access $367.68 $422.83 6 GM PDS CEFTAZIDIME GSK Access $496.80 $571.32
Report Run: 04/19/16 10:53 AM Page 131 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FORTEO
250 MCG/ML (2.4 ML) MCG TERIPARATIDE Eli Lilly Cares $2,424.96 $2,788.70 FORTICAL
2200 IU/ACTUATION (3.7ML) SPRAY(S) calcitonin (salmon) Rx Outreach $102.89 $118.32 FOSINOPRIL SODIUM (BRAND: MONOPRIL)
10 MG TABLET(S) fosinopril sodium Nova ScriptsCentral-Northern Virginia Clinic $182.04 $209.35 Partners & Northern VA Residents ONLY 20 MG TABLET(S) fosinopril sodium Nova ScriptsCentral-Northern Virginia Clinic $182.04 $209.35 Partners & Northern VA Residents ONLY 40 MG TABLET(S) fosinopril sodium Nova ScriptsCentral-Northern Virginia Clinic $182.04 $209.35 Partners & Northern VA Residents ONLY 10 MG TABLET(S) fosinopril sodium Xubex Preferred Network Program $182.04 $209.35 20 MG TABLET(S) fosinopril sodium Xubex Preferred Network Program $182.04 $209.35 40 MG TABLET(S) fosinopril sodium Xubex Preferred Network Program $182.04 $209.35 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE (BRAND: MONOPRIL HCT) 10-12.5 MG-MG TABLET(S) fosinopril Xubex Preferred Network Program $154.39 $177.55 sodium/hydrochlorothiazide 20-12.5 MG-MG TABLET(S) fosinopril Xubex Preferred Network Program $154.39 $177.55 sodium/hydrochlorothiazide FOSRENOL
1000 MG TABLET(S) LANTHANUM CARBONATE Shire Cares Patient Assistance & Support $1,090.21 $1,253.74 Program 500 MG TABLET(S) LANTHANUM CARBONATE Shire Cares Patient Assistance & Support $1,090.21 $1,253.74 Program
Report Run: 04/19/16 10:53 AM Page 132 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FOSRENOL
750 MG TABLET(S) LANTHANUM CARBONATE Shire Cares Patient Assistance & Support $1,090.21 $1,253.74 Program FRAGMIN
10000 iu/ml SOL DALTEPARIN SODIUM Rx Outreach-Fragmin $52.74 $60.65 2500/0.2 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $289.08 $332.44 25000 iu/ml SOL DALTEPARIN SODIUM Rx Outreach-Fragmin $453.26 $521.25 5000/0.2 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $469.01 $539.36 7500/0.3 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $703.57 $809.11 FRAGMIN
12500/0.5 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $1,172.58 $1,348.47 15000/0.6 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $1,407.01 $1,618.06 18000/0.72 IU/ML SYRINGE DALTEPARIN SODIUM Rx Outreach-Fragmin $1,688.41 $1,941.67 FROVA
2.5 MG TABLET(S) FROVATRIPTAN SUCCINATE Endo Patient Assistance Program $657.79 $756.46 FULYZAQ
125 MG TABLET(S) crofelemer Salix Patient Assistance Program $712.15 $818.97 FUROSEMIDE (BRAND: LASIX)
20 MG TABLET(S) FUROSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $29.88 $34.36 Partners & Northern VA Residents ONLY 40 MG TABLET(S) FUROSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $25.08 $28.84 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 133 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
FUROSEMIDE (BRAND: LASIX)
80 MG TABLET(S) FUROSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $35.25 $40.54 Partners & Northern VA Residents ONLY 20 MG TABLET(S) FUROSEMIDE Rx Outreach $29.88 $34.36 40 MG TABLET(S) FUROSEMIDE Rx Outreach $25.08 $28.84 80 MG TABLET(S) FUROSEMIDE Rx Outreach $35.25 $40.54 20 MG TABLET(S) FUROSEMIDE Welvista - South Carolina Residents Only $29.88 $34.36 40 MG TABLET(S) FUROSEMIDE Welvista - South Carolina Residents Only $25.08 $28.84 20 MG TABLET(S) FUROSEMIDE Xubex Preferred Network Program $29.88 $34.36 40 MG TABLET(S) FUROSEMIDE Xubex Preferred Network Program $25.08 $28.84 80 MG TABLET(S) FUROSEMIDE Xubex Preferred Network Program $35.25 $40.54 FUSILEV
50 MG INJECTION(S) LEVOLEUCOVORIN CALCIUM STAR-Spectrum Therapy Access Resources $273.60 $314.64 FYCOMPA
4 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $682.56 $784.94 FYCOMPA
10 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $682.56 $784.94 12 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $682.56 $784.94 2 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $341.28 $392.47 6 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $682.56 $784.94 8 MG TABLET(S) perampanel Eisai Fycompa CIII Patient Assistance Program $682.56 $784.94
Report Run: 04/19/16 10:53 AM Page 134 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GABAPENTIN (BRAND: NEURONTIN)
* 100 MG CAPSULE(S) GABAPENTIN Generic Assistance Program (NeedyMeds & $47.99 $55.19 Rx Outreach) * 300 MG CAPSULE(S) GABAPENTIN Generic Assistance Program (NeedyMeds & $119.88 $137.86 Rx Outreach) * 400 MG CAPSULE(S) GABAPENTIN Generic Assistance Program (NeedyMeds & $143.82 $165.39 Rx Outreach) 100 MG CAPSULE(S) GABAPENTIN Nova ScriptsCentral-Northern Virginia Clinic $47.99 $55.19 Partners & Northern VA Residents ONLY 300 MG CAPSULE(S) GABAPENTIN Nova ScriptsCentral-Northern Virginia Clinic $119.88 $137.86 Partners & Northern VA Residents ONLY 400 MG CAPSULE(S) GABAPENTIN Nova ScriptsCentral-Northern Virginia Clinic $143.82 $165.39 Partners & Northern VA Residents ONLY 100 MG CAPSULE(S) GABAPENTIN Rx Outreach $47.99 $55.19 300 MG CAPSULE(S) GABAPENTIN Rx Outreach $119.88 $137.86 400 MG CAPSULE(S) GABAPENTIN Rx Outreach $143.82 $165.39 600 MG TABLET(S) GABAPENTIN Rx Outreach $238.73 $274.54 800 MG TABLET(S) GABAPENTIN Rx Outreach $286.43 $329.39 100 MG CAPSULE(S) GABAPENTIN Welvista - South Carolina Residents Only $47.99 $55.19 300 MG CAPSULE(S) GABAPENTIN Welvista - South Carolina Residents Only $119.88 $137.86 400 MG CAPSULE(S) GABAPENTIN Welvista - South Carolina Residents Only $143.82 $165.39 600 MG TABLET(S) GABAPENTIN Welvista - South Carolina Residents Only $238.73 $274.54 800 MG TABLET(S) GABAPENTIN Welvista - South Carolina Residents Only $286.43 $329.39 100 MG CAPSULE(S) GABAPENTIN Xubex Preferred Network Program $47.99 $55.19
Report Run: 04/19/16 10:53 AM Page 135 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GABAPENTIN (BRAND: NEURONTIN)
300 MG CAPSULE(S) GABAPENTIN Xubex Preferred Network Program $119.88 $137.86 400 MG CAPSULE(S) GABAPENTIN Xubex Preferred Network Program $143.82 $165.39 600 MG TABLET(S) GABAPENTIN Xubex Preferred Network Program $238.73 $274.54 800 MG TABLET(S) GABAPENTIN Xubex Preferred Network Program $286.43 $329.39 GABITRIL
12 MG TABLET(S) TIAGABINE HYDROCHLORIDE Teva Cares Foundation Patient Assistance $302.40 $347.76 Program 16 MG TABLET(S) TIAGABINE HYDROCHLORIDE Teva Cares Foundation Patient Assistance $396.00 $455.40 Program 2 MG TABLET(S) TIAGABINE HYDROCHLORIDE Teva Cares Foundation Patient Assistance $234.00 $269.10 Program 4 MG TABLET(S) TIAGABINE HYDROCHLORIDE Teva Cares Foundation Patient Assistance $234.00 $269.10 Program GALZIN
50 MG CAPSULE(S) ZINC ACETATE Teva Cares Foundation Patient Assistance $654.42 $752.58 Program GALZIN
25 MG CAPSULE(S) ZINC ACETATE Teva Cares Foundation Patient Assistance $392.65 $451.55 Program GARDASIL (10 X 0.5ML,SDV,PF)
0.5 ML VIAL(S) HUMAN PAPILLOMAVIRUS Merck Vaccine Patient Assistance Program $1,762.56 $2,026.94 RECOMB VACCINE QUADRIVALENT
Report Run: 04/19/16 10:53 AM Page 136 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GARDASIL (10 X 0.5ML,SDV,PF)
0.5 ML VIAL(S) HUMAN PAPILLOMAVIRUS Welvista - South Carolina Residents Only $1,762.56 $2,026.94 RECOMB VACCINE QUADRIVALENT GARDASIL (6XSD PRE-FILLED SYRINGE)
0.5 ML ML HUMAN PAPILLOMAVIRUS Merck Vaccine Patient Assistance Program $1,068.49 $1,228.76 RECOMB VACCINE QUADRIVALENT 0.5 ML ML HUMAN PAPILLOMAVIRUS Welvista - South Carolina Residents Only $1,068.49 $1,228.76 RECOMB VACCINE QUADRIVALENT GARDASIL (SD PRE-FILLED SYRINGE,PF)
0.5 ML ML HUMAN PAPILLOMAVIRUS Merck Vaccine Patient Assistance Program $176.62 $203.11 RECOMB VACCINE QUADRIVALENT 0.5 ML ML HUMAN PAPILLOMAVIRUS Welvista - South Carolina Residents Only $176.62 $203.11 RECOMB VACCINE QUADRIVALENT GARDASIL (SDV,PF)
0.5 ML ML HUMAN PAPILLOMAVIRUS Merck Vaccine Patient Assistance Program $176.62 $203.11 RECOMB VACCINE QUADRIVALENT 0.5 ML ML HUMAN PAPILLOMAVIRUS Welvista - South Carolina Residents Only $176.62 $203.11 RECOMB VACCINE QUADRIVALENT
Report Run: 04/19/16 10:53 AM Page 137 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GAZYVA
25 MG/ML (40 ML) MG obinutuzumab Genentech BioOncology Access to Solutions- $6,192.00 $7,120.80 Infused Products GELNIQUE
100 MG/GM (1GM) PACKET OXYBUTYNIN CHLORIDE Gelnique Patient Assistance Program $186.68 $214.68 GEMFIBROZIL (BRAND: LOPID)
* 600 MG TABLET(S) GEMFIBROZIL Generic Assistance Program (NeedyMeds & $122.11 $140.43 Rx Outreach) 600 MG TABLET(S) GEMFIBROZIL Nova ScriptsCentral-Northern Virginia Clinic $122.11 $140.43 Partners & Northern VA Residents ONLY 600 MG TABLET(S) GEMFIBROZIL Rx Outreach $122.11 $140.43 600 MG TABLET(S) GEMFIBROZIL Welvista - South Carolina Residents Only $122.11 $140.43 600 MG TABLET(S) GEMFIBROZIL Xubex Preferred Network Program $122.11 $140.43 GEMZAR
1 GM MG GEMCITABINE HYDROCHLORIDE Eli Lilly PatientOne $889.14 $1,022.51 200 MG MG GEMCITABINE HYDROCHLORIDE Eli Lilly PatientOne $177.83 $204.50 GENGRAF
100 MG CAPSULE(S) CYCLOSPORINE AbbVie Patient Assistance Program $235.62 $270.96 25 MG CAPSULE(S) CYCLOSPORINE AbbVie Patient Assistance Program $58.98 $67.83 GENOTROPIN
13.8 MG INJECTION(S) SOMATROPIN, E-COLI DERIVED Pfizer RxPathways $902.81 $1,038.23 5.8 MG INJECTION(S) SOMATROPIN, E-COLI DERIVED Pfizer RxPathways $376.16 $432.58
Report Run: 04/19/16 10:53 AM Page 138 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GENVOYA
150-150-200-10 MG-MG-MG-MG TABLET(S) cobicistat/elvitegravir/emtricita Gilead Advancing Access $3,093.19 $3,557.17 bine/tenofovir GIAZO
1.1 GM TABLET(S) balsalazide disodium Salix Patient Assistance Program $1,139.45 $1,310.37 GILENYA
0.5 MG CAPSULE(S) FINGOLIMOD HYDROCHLORIDE Novartis Patient Assistance Foundation, Inc. $7,706.58 $8,862.57 GILOTRIF
20 MG TABLET(S) afatinib dimaleate Boehringer Ingelheim Cares Foundation Inc. $7,768.22 $8,933.45 30 MG TABLET(S) afatinib dimaleate Boehringer Ingelheim Cares Foundation Inc. $7,768.22 $8,933.45 40 MG TABLET(S) afatinib dimaleate Boehringer Ingelheim Cares Foundation Inc. $7,768.22 $8,933.45 GLATOPA
20 MG/ML (1 ML) SYRINGE(S) glatiramer acetate Novartis Patient Assistance Foundation, Inc. $6,492.41 $7,466.27 GLEEVEC
400 MG TABLET(S) IMATINIB MESYLATE Novartis Oncology Patient Assistance $12,146.92 $13,968.96 Program GLEEVEC
100 MG TABLET(S) IMATINIB MESYLATE Novartis Oncology Patient Assistance $10,112.93 $11,629.87 Program GLIADEL
7.7 MG IMPLANT CARMUSTINE Eisai Patient Assistance Program $34,841.40 $40,067.61
Report Run: 04/19/16 10:53 AM Page 139 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GLIMEPIRIDE (BRAND: AMARYL)
1 MG TABLET(S) GLIMEPIRIDE Nova ScriptsCentral-Northern Virginia Clinic $40.22 $46.25 Partners & Northern VA Residents ONLY 2 MG TABLET(S) GLIMEPIRIDE Nova ScriptsCentral-Northern Virginia Clinic $65.20 $74.98 Partners & Northern VA Residents ONLY 4 MG TABLET(S) GLIMEPIRIDE Nova ScriptsCentral-Northern Virginia Clinic $122.97 $141.42 Partners & Northern VA Residents ONLY 1 MG TABLET(S) GLIMEPIRIDE Rx Outreach $40.22 $46.25 2 MG TABLET(S) GLIMEPIRIDE Rx Outreach $65.20 $74.98 4 MG TABLET(S) GLIMEPIRIDE Rx Outreach $122.97 $141.42 1 MG TABLET(S) GLIMEPIRIDE Xubex Preferred Network Program $40.22 $46.25 2 MG TABLET(S) GLIMEPIRIDE Xubex Preferred Network Program $65.20 $74.98 4 MG TABLET(S) GLIMEPIRIDE Xubex Preferred Network Program $122.97 $141.42 GLIPIZIDE (BRAND: GLUCOTROL)
10 MG TABLET(S) GLIPIZIDE Nova ScriptsCentral-Northern Virginia Clinic $61.69 $70.94 Partners & Northern VA Residents ONLY 5 MG TABLET(S) GLIPIZIDE Nova ScriptsCentral-Northern Virginia Clinic $30.99 $35.64 Partners & Northern VA Residents ONLY 10 MG TABLET(S) GLIPIZIDE Rx Outreach $61.69 $70.94 5 MG TABLET(S) GLIPIZIDE Rx Outreach $30.99 $35.64 10 MG TABLET(S) GLIPIZIDE Welvista - South Carolina Residents Only $61.69 $70.94 5 MG TABLET(S) GLIPIZIDE Welvista - South Carolina Residents Only $30.99 $35.64 10 MG TABLET(S) GLIPIZIDE Xubex Preferred Network Program $61.69 $70.94 5 MG TABLET(S) GLIPIZIDE Xubex Preferred Network Program $30.99 $35.64
Report Run: 04/19/16 10:53 AM Page 140 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GLIPIZIDE ER (BRAND: GLUCOTROL XL)
* 10 MG TABLET(S) GLIPIZIDE Generic Assistance Program (NeedyMeds & $173.00 $198.95 Rx Outreach) * 2.5 MG TABLET(S) GLIPIZIDE Generic Assistance Program (NeedyMeds & $20.35 $23.40 Rx Outreach) * 5 MG TABLET(S) GLIPIZIDE Generic Assistance Program (NeedyMeds & $82.55 $94.93 Rx Outreach) 10 MG TABLET(S) GLIPIZIDE Rx Outreach $173.00 $198.95 2.5 MG TABLET(S) GLIPIZIDE Rx Outreach $20.35 $23.40 5 MG TABLET(S) GLIPIZIDE Rx Outreach $82.55 $94.93 5 MG TABLET(S) GLIPIZIDE Welvista - South Carolina Residents Only $82.55 $94.93 10 MG TABLET(S) GLIPIZIDE Xubex Preferred Network Program $173.00 $198.95 2.5 MG TABLET(S) GLIPIZIDE Xubex Preferred Network Program $20.35 $23.40 5 MG TABLET(S) GLIPIZIDE Xubex Preferred Network Program $82.55 $94.93 GLUCAGEN HYPOKIT
1 MG UNIT(S) GLUCAGON HYDROCHLORIDE Novo Nordisk Patient Assistance Program $153.00 $175.95 1 MG UNIT(S) GLUCAGON HYDROCHLORIDE Welvista - South Carolina Residents Only $153.00 $175.95 GLUCAGON EMERGENCY KIT
1 MG INJECTION(S) GLUCAGON HYDROCHLORIDE Eli Lilly Cares $258.54 $297.32 GLUCERNA
N/A N/A CAN NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $68.02 $78.22
Report Run: 04/19/16 10:53 AM Page 141 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GLUCOPHAGE
* 1000 MG TABLET(S) METFORMIN HYDROCHLORIDE Bristol-Myers Squibb Patient Assistance $230.23 $264.76 Foundation, Inc. * 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Bristol-Myers Squibb Patient Assistance $111.77 $128.54 Foundation, Inc. * 850 MG TABLET(S) METFORMIN HYDROCHLORIDE Bristol-Myers Squibb Patient Assistance $190.01 $218.51 Foundation, Inc. GLUCOPHAGE XR
* 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Bristol-Myers Squibb Patient Assistance $114.08 $131.19 Foundation, Inc. * 750 MG TABLET(S) METFORMIN HYDROCHLORIDE Bristol-Myers Squibb Patient Assistance $171.14 $196.81 Foundation, Inc. GLUCOTROL XL
2.5 MG TABLET(S) GLIPIZIDE Pfizer MAINTAIN $32.32 $37.17 GLUCOVANCE
* 1.25-250 MG-MG TABLET(S) GLYBURIDE/METFORMIN Bristol-Myers Squibb Patient Assistance $123.22 $141.70 HYDROCHLORIDE Foundation, Inc. * 2.5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Bristol-Myers Squibb Patient Assistance $146.99 $169.04 HYDROCHLORIDE Foundation, Inc. * 5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Bristol-Myers Squibb Patient Assistance $146.99 $169.04 HYDROCHLORIDE Foundation, Inc. GLUMETZA
1000 MG TABLET(S) metformin hydrochloride Salix Patient Assistance Program $1,335.96 $1,536.35 500 MG TABLET(S) metformin hydrochloride Salix Patient Assistance Program $686.40 $789.36
Report Run: 04/19/16 10:53 AM Page 142 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GLYBURIDE (BRAND: DIABETA/MICRONASE)
2.5 MG TABLET(S) GLYBURIDE Nova ScriptsCentral-Northern Virginia Clinic $41.34 $47.54 Partners & Northern VA Residents ONLY 5 MG TABLET(S) GLYBURIDE Nova ScriptsCentral-Northern Virginia Clinic $101.52 $116.75 Partners & Northern VA Residents ONLY 1.25 MG TABLET(S) GLYBURIDE Rx Outreach $24.81 $28.53 2.5 MG TABLET(S) GLYBURIDE Rx Outreach $41.34 $47.54 5 MG TABLET(S) GLYBURIDE Rx Outreach $101.52 $116.75 1.25 MG TABLET(S) GLYBURIDE Xubex Preferred Network Program $24.81 $28.53 5 MG TABLET(S) GLYBURIDE Xubex Preferred Network Program $101.52 $116.75 GLYBURIDE MICRONIZED (BRAND: GLYNASE PRESTAB)
1.5 MG TABLET(S) GLYBURIDE MICRONIZED Rx Outreach $37.78 $43.45 3 MG TABLET(S) GLYBURIDE MICRONIZED Rx Outreach $63.88 $73.46 6 MG TABLET(S) GLYBURIDE MICRONIZED Rx Outreach $107.32 $123.42 3 MG TABLET(S) GLYBURIDE MICRONIZED Welvista - South Carolina Residents Only $63.88 $73.46 6 MG TABLET(S) GLYBURIDE MICRONIZED Welvista - South Carolina Residents Only $107.32 $123.42 1.5 MG TABLET(S) GLYBURIDE MICRONIZED Xubex Preferred Network Program $37.78 $43.45 3 MG TABLET(S) GLYBURIDE MICRONIZED Xubex Preferred Network Program $63.88 $73.46 6 MG TABLET(S) GLYBURIDE MICRONIZED Xubex Preferred Network Program $107.32 $123.42 GLYBURIDE/METFORMIN (BRAND: GLUCOVANCE)
1.25-250 MG-MG TABLET(S) GLYBURIDE/METFORMIN Rx Outreach $79.74 $91.70 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 143 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GLYBURIDE/METFORMIN (BRAND: GLUCOVANCE)
2.5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Rx Outreach $143.93 $165.52 HYDROCHLORIDE 5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Rx Outreach $126.95 $145.99 HYDROCHLORIDE 2.5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Xubex Preferred Network Program $143.93 $165.52 HYDROCHLORIDE 5-500 MG-MG TABLET(S) GLYBURIDE/METFORMIN Xubex Preferred Network Program $126.95 $145.99 HYDROCHLORIDE GLYNASE PRES-TAB
1.5 MG TABLET(S) GLYBURIDE, MICRONIZED Pfizer MAINTAIN $117.18 $134.76 3 MG TABLET(S) GLYBURIDE, MICRONIZED Pfizer MAINTAIN $198.14 $227.86 6 MG TABLET(S) GLYBURIDE, MICRONIZED Pfizer MAINTAIN $312.43 $359.29 GLYSET
100 MG TABLET(S) MIGLITOL Pfizer MAINTAIN $233.47 $268.49 100 MG TABLET(S) MIGLITOL Pfizer RxPathways $233.47 $268.49 25 MG TABLET(S) MIGLITOL Pfizer RxPathways $179.96 $206.95 50 MG TABLET(S) MIGLITOL Pfizer RxPathways $197.89 $227.57 GLYXAMBI
10-5 MG-MG TABLET(S) empagliflozin/linagliptin Boehringer Ingelheim Cares Foundation Inc. $1,728.00 $1,987.20 25-5 MG-MG TABLET(S) empagliflozin/linagliptin Boehringer Ingelheim Cares Foundation Inc. $1,728.00 $1,987.20
Report Run: 04/19/16 10:53 AM Page 144 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
GRANIX
300/0.5 MCG/ML SYRINGE tbo-filgrastim TEVA-Comprehensive Oncology $2,954.04 $3,397.15 Reimbursement Expertise (CORE) 480/0.8 MCG/ML SYRINGE tbo-filgrastim TEVA-Comprehensive Oncology $4,727.70 $5,436.86 Reimbursement Expertise (CORE) GRANIX (SINGLE SYRINGE)
300/0.5 MCG/ML SYRINGE tbo-filgrastim TEVA-Comprehensive Oncology $295.40 $339.71 Reimbursement Expertise (CORE) 480/0.8 MCG/ML SYRINGE tbo-filgrastim TEVA-Comprehensive Oncology $472.78 $543.70 Reimbursement Expertise (CORE) GRASTEK
2800 bau TABLET(S) timothy grass pollen allergen Merck Patient Assistance Program $297.00 $341.55 extract GUAFENESIN (BRAND: LIQUIBID)
400 MG TABLET(S) GUAFENESIN Xubex Patient Assistance Program $75.36 $86.66 GUANFACINE (BRAND: TENEX)
1 MG TABLET(S) GUANFACINE Rx Outreach $87.20 $100.28 2 MG TABLET(S) GUANFACINE Rx Outreach $133.97 $154.07 1 MG TABLET(S) GUANFACINE Xubex Preferred Network Program $87.20 $100.28 2 MG TABLET(S) GUANFACINE Xubex Preferred Network Program $133.97 $154.07 HALAVEN
0.5 MG/ML (2 ML) MG ERIBULIN MESYLATE Eisai Patient Assistance Program $1,020.00 $1,173.00
Report Run: 04/19/16 10:53 AM Page 145 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HALDOL
5 MG/ML (1ML) VIAL HALOPERIDOL LACTATE Johnson & Johnson Patient Assistance $225.31 $259.11 Foundation HALDOL DECANOATE
100 MG/ML (1ML) VIAL HALOPERIDOL DECANOATE Johnson & Johnson Patient Assistance $906.24 $1,042.18 Foundation 50 mg/ml (1ml) ML HALOPERIDOL DECANOATE Johnson & Johnson Patient Assistance $523.70 $602.26 Foundation HALOPERIDOL (BRAND: HALDOL)
0.5 MG TABLET(S) HALOPERIDOL Rx Outreach $24.80 $28.52 1 MG TABLET(S) HALOPERIDOL Rx Outreach $35.15 $40.42 2 MG TABLET(S) HALOPERIDOL Rx Outreach $48.15 $55.37 5 MG TABLET(S) HALOPERIDOL Rx Outreach $78.00 $89.70 0.5 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $24.80 $28.52 1 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $35.15 $40.42 10 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $179.31 $206.21 2 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $48.15 $55.37 20 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $275.70 $317.06 5 MG TABLET(S) HALOPERIDOL Xubex Preferred Network Program $78.00 $89.70 HARVONI
90-400 MG-MG TABLET(S) ledipasvir/sofosbuvir Support Path Patient Assistance Program $37,800.00 $43,470.00
Report Run: 04/19/16 10:53 AM Page 146 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HAVRIX
1440 E U/ML (1ML) INJECTION(S) HEPATITIS A VACCINE, GSK Vaccines Access Program $377.85 $434.53 INACTIVATED HECORIA
0.5 MG CAPSULE(S) TACROLIMUS Novartis Patient Assistance Foundation, Inc. $218.06 $250.77 HECORIA
1 MG CAPSULE(S) TACROLIMUS Novartis Patient Assistance Foundation, Inc. $436.14 $501.56 5 MG CAPSULE(S) tacrolimus Novartis Patient Assistance Foundation, Inc. $2,180.70 $2,507.81 HECTOROL
2 MCG/ML (2ML 50s) MCG DOXERCALCIFEROL Genzyme Renassist $750.00 $862.50 HELIXATE FS
1 IU INJECTION(S) AHF VIII (RECOMBINANT) CSL Behring Patient Assistance Program $1.44 $1.66 SUCROSE FORMULATED HEMORRHOIDAL HC (BRAND: ANUCORT-HC)
25 MG SUPPOSITORY HYDROCORTISONE ACETATE Rx Outreach $89.50 $102.93 HEPSERA
10 MG TABLET(S) ADEFOVIR DIPIVOXIL Gilead Advancing Access $1,485.89 $1,708.77 HERCEPTIN
440 MG MG TRASTUZUMAB Genentech BioOncology Access to Solutions- $4,460.29 $5,129.33 Infused Products HETLIOZ
20 MG CAPSULE(S) tasimelteon HETLIOZSolutions $11,236.54 $12,922.02
Report Run: 04/19/16 10:53 AM Page 147 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HEXALEN
50 MG CAPSULE(S) ALTRETAMINE Eisai Patient Assistance Program $1,586.40 $1,824.36 50 MG CAPSULE(S) ALTRETAMINE Rx Outreach $1,586.40 $1,824.36 HIZENTRA
20 % (10 ML) GRAMS IMMUNE GLOBULIN CSL Behring Patient Assistance Program $302.40 $347.76 HIZENTRA
20 % (20 ML) GRAMS IMMUNE GLOBULIN CSL Behring Patient Assistance Program $604.80 $695.52 HUMALOG
100 U/ML (10 ML) UNIT(S) INSULIN LISPRO, HUMAN Eli Lilly Cares $284.40 $327.06 100 U/ML (10 ML) UNIT(S) INSULIN LISPRO, HUMAN Welvista - South Carolina Residents Only $284.40 $327.06 HUMALOG CARTRIDGE
100 U/ML (3ML) CARTRIDGE insulin lispro, recombinant Eli Lilly Cares $528.48 $607.75 HUMALOG KWIKPEN
100 U/ML (3 ML) UNIT(S) INSULIN LISPRO Eli Lilly Cares $549.18 $631.56 100 U/ML (3 ML) UNIT(S) INSULIN LISPRO Welvista - South Carolina Residents Only $549.18 $631.56 100 U/ML (3 ML) UNIT(S) INSULIN LISPRO Xubex Free Trial 30 Day Medication Supply $549.18 $631.56 HUMALOG MIX 50/50 KWIKPEN
50/50 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Eli Lilly Cares $549.18 $631.56 protamine 50/50 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Welvista - South Carolina Residents Only $549.18 $631.56 protamine
Report Run: 04/19/16 10:53 AM Page 148 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HUMALOG MIX 50/50 KWIKPEN
50/50 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Xubex Free Trial 30 Day Medication Supply $549.18 $631.56 protamine HUMALOG MIX 75/25
75-25 U/ML-U/ML UNIT(S) INSULIN LISPRO/INSULIN Eli Lilly Cares $294.72 $338.93 LISPRO PROTAMINE 75-25 U/ML-U/ML UNIT(S) INSULIN LISPRO/INSULIN Welvista - South Carolina Residents Only $294.72 $338.93 LISPRO PROTAMINE HUMALOG MIX 75/25 KWIKPEN
75/25 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Eli Lilly Cares $549.18 $631.56 protamine 75/25 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Welvista - South Carolina Residents Only $549.18 $631.56 protamine 75/25 U/ML (3ML) UNIT(S) insulin lispro/insulin lispro Xubex Free Trial 30 Day Medication Supply $549.18 $631.56 protamine HUMALOG U-200 KWIKPEN
200 U/ML (3ML) UNIT(S) insulin lispro, recombinant Eli Lilly Cares $439.34 $505.24 HUMATE-P
1 IU INJECTION(S) AHF HUMAN/VON WILLEBRAND CSL Behring Patient Assistance Program $1.00 $1.15 FACTOR HUMATROPE
12 MG MG SOMATROPIN, E-COLI DERIVED Eli Lilly Cares $1,383.41 $1,590.92 24 MG MG SOMATROPIN, E-COLI DERIVED Eli Lilly Cares $2,766.82 $3,181.84 5 MG MG SOMATROPIN, E-COLI DERIVED Eli Lilly Cares $576.42 $662.88
Report Run: 04/19/16 10:53 AM Page 149 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HUMATROPE
6 MG MG SOMATROPIN, E-COLI DERIVED Eli Lilly Cares $691.70 $795.46 HUMIRA PEN (PSORIASIS STARTER PACKAGE)
40/0.8 MG/ML PEN(S) adalimumab AbbVie Patient Assistance Foundation $9,113.05 $10,480.01 HUMIRA Patient Assistance Program HUMIRA PENS
40/0.8 MG/ML PEN(S) ADALIMUMAB AbbVie Patient Assistance Foundation $4,146.07 $4,767.98 HUMIRA Patient Assistance Program HUMIRA SYRINGE
40/0.8 MG/ML SYRINGE(S) ADALIMUMAB AbbVie Patient Assistance Foundation $4,146.07 $4,767.98 HUMIRA Patient Assistance Program HUMULIN 70/30
70-30 100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Eli Lilly Cares $144.72 $166.43 (NPH)/INSULIN HUMAN REGULAR 70-30 100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Welvista - South Carolina Residents Only $144.72 $166.43 (NPH)/INSULIN HUMAN REGULAR HUMULIN 70/30 KWIKPEN
70/30 U/ML UNIT(S) INSULIN HUMAN ISOPHANE Eli Lilly Cares $458.82 $527.64 (NPH)/INSULIN HUMAN REGULAR HUMULIN N
100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Eli Lilly Cares $144.72 $166.43 (NPH)
Report Run: 04/19/16 10:53 AM Page 150 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HUMULIN N
100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Welvista - South Carolina Residents Only $144.72 $166.43 (NPH) HUMULIN N KWIKPEN
100 U/ML UNIT(S) INSULIN HUMAN ISOPHANE Eli Lilly Cares $458.82 $527.64 (NPH) HUMULIN R
100 U/ML (10ML) UNIT(S) INSULIN HUMAN REGULAR Eli Lilly Cares $144.72 $166.43 100 U/ML (10ML) UNIT(S) INSULIN HUMAN REGULAR Welvista - South Carolina Residents Only $144.72 $166.43 HUMULIN R CONCENTRATED U-500
500 U/ML (20 ML) UNIT(S) INSULIN HUMAN REGULAR Eli Lilly Cares $1,447.20 $1,664.28 HYALGAN
10 MG/ML (2ML) UNIT(S) HYALURONATE SODIUM Fidia Hyalgan Reimbursement & Patient $228.00 $262.20 Assistance Program HYCAMTIN
0.25 MG CAPSULE(S) TOPOTECAN HYDROCHLORIDE Commitment to Access $1,170.79 $1,346.41 1 MG CAPSULE(S) TOPOTECAN HYDROCHLORIDE Commitment to Access $4,683.08 $5,385.54 4 MG INJECTION(S) TOPOTECAN HYDROCHLORIDE Commitment to Access $1,348.55 $1,550.83 HYDRALAZINE (BRAND: APRESOLINE)
10 MG TABLET(S) HYDRALAZINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $59.33 $68.23 Partners & Northern VA Residents ONLY 100 MG TABLET(S) hydralazine hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $101.28 $116.47 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 151 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HYDRALAZINE (BRAND: APRESOLINE)
25 MG TABLET(S) HYDRALAZINE Nova ScriptsCentral-Northern Virginia Clinic $50.83 $58.45 Partners & Northern VA Residents ONLY 50 MG TABLET(S) HYDRALAZINE Nova ScriptsCentral-Northern Virginia Clinic $56.32 $64.77 Partners & Northern VA Residents ONLY 10 MG TABLET(S) HYDRALAZINE HYDROCHLORIDE Rx Outreach $59.33 $68.23 100 MG TABLET(S) hydralazine hydrochloride Rx Outreach $101.28 $116.47 25 MG TABLET(S) HYDRALAZINE Rx Outreach $50.83 $58.45 50 MG TABLET(S) HYDRALAZINE Rx Outreach $56.32 $64.77 25 MG TABLET(S) HYDRALAZINE Welvista - South Carolina Residents Only $50.83 $58.45 50 MG TABLET(S) HYDRALAZINE Welvista - South Carolina Residents Only $56.32 $64.77 10 MG TABLET(S) HYDRALAZINE HYDROCHLORIDE Xubex Preferred Network Program $59.33 $68.23 25 MG TABLET(S) HYDRALAZINE Xubex Preferred Network Program $50.83 $58.45 HYDROCHLOROTHIAZIDE (BRAND: HYDRODIURIL, MICROZIDE) 12.5 MG CAPSULE(S) HYDROCHLOROTHIAZIDE Nova ScriptsCentral-Northern Virginia Clinic $82.43 $94.79 Partners & Northern VA Residents ONLY 25 MG TABLET(S) HYDROCHLOROTHIAZIDE Nova ScriptsCentral-Northern Virginia Clinic $22.13 $25.45 Partners & Northern VA Residents ONLY 50 MG TABLET(S) HYDROCHLOROTHIAZIDE Nova ScriptsCentral-Northern Virginia Clinic $20.49 $23.56 Partners & Northern VA Residents ONLY 12.5 MG CAPSULE(S) HYDROCHLOROTHIAZIDE Rx Outreach $82.43 $94.79 25 MG TABLET(S) HYDROCHLOROTHIAZIDE Rx Outreach $22.13 $25.45 50 MG TABLET(S) HYDROCHLOROTHIAZIDE Rx Outreach $20.49 $23.56
Report Run: 04/19/16 10:53 AM Page 152 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HYDROCHLOROTHIAZIDE (BRAND: HYDRODIURIL, MICROZIDE) 12.5 MG CAPSULE(S) HYDROCHLOROTHIAZIDE Welvista - South Carolina Residents Only $82.43 $94.79 25 MG TABLET(S) HYDROCHLOROTHIAZIDE Welvista - South Carolina Residents Only $22.13 $25.45 12.5 MG CAPSULE(S) HYDROCHLOROTHIAZIDE Xubex Preferred Network Program $82.43 $94.79 25 MG TABLET(S) HYDROCHLOROTHIAZIDE Xubex Preferred Network Program $22.13 $25.45 50 MG TABLET(S) HYDROCHLOROTHIAZIDE Xubex Preferred Network Program $20.49 $23.56 HYDROCORTISONE (BRAND: CORTEF)
10 MG TABLET(S) HYDROCORTISONE Rx Outreach $57.30 $65.90 5 MG TABLET(S) hydrocortisone Rx Outreach $16.95 $19.49 10 MG TABLET(S) HYDROCORTISONE Xubex Preferred Network Program $57.30 $65.90 20 MG TABLET(S) HYDROCORTISONE Xubex Preferred Network Program $42.50 $48.88 5 MG TABLET(S) hydrocortisone Xubex Preferred Network Program $16.95 $19.49 HYDROXYCHLOROQUINE (BRAND: PLAQUENIL)
* 200 MG TABLET(S) HYDROXYCHLOROQUINE Generic Assistance Program (NeedyMeds & $141.69 $162.94 Rx Outreach) 200 MG TABLET(S) HYDROXYCHLOROQUINE Rx Outreach $141.69 $162.94 200 MG TABLET(S) HYDROXYCHLOROQUINE Xubex Preferred Network Program $141.69 $162.94 HYDROXYUREA (BRAND: HYDREA)
* 500 MG CAPSULE(S) HYDROXYUREA Generic Assistance Program (NeedyMeds & $147.40 $169.51 Rx Outreach) 500 MG CAPSULE(S) HYDROXYUREA Nova ScriptsCentral-Northern Virginia Clinic $147.40 $169.51 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 153 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HYDROXYUREA (BRAND: HYDREA)
500 MG CAPSULE(S) HYDROXYUREA Rx Outreach $147.40 $169.51 500 MG CAPSULE(S) HYDROXYUREA Xubex Preferred Network Program $147.40 $169.51 HYDROXYZINE PAMOATE (BRAND: VISTARIL)
25 MG TABLET(S) HYDROXYZINE PAMOATE Nova ScriptsCentral-Northern Virginia Clinic $29.94 $34.43 Partners & Northern VA Residents ONLY 50 MG TABLET(S) HYDROXYZINE PAMOATE Nova ScriptsCentral-Northern Virginia Clinic $32.19 $37.02 Partners & Northern VA Residents ONLY 25 MG TABLET(S) HYDROXYZINE PAMOATE Rx Outreach $29.94 $34.43 50 MG TABLET(S) HYDROXYZINE PAMOATE Rx Outreach $32.19 $37.02 25 MG TABLET(S) HYDROXYZINE PAMOATE Welvista - South Carolina Residents Only $29.94 $34.43 50 MG TABLET(S) HYDROXYZINE PAMOATE Welvista - South Carolina Residents Only $32.19 $37.02 25 MG TABLET(S) HYDROXYZINE PAMOATE Xubex Preferred Network Program $29.94 $34.43 50 MG TABLET(S) HYDROXYZINE PAMOATE Xubex Preferred Network Program $32.19 $37.02 HYLATOPICPLUS CREAM
n/a 450 GM CREAM Onset Patient Assistance Program $357.74 $411.40 HYLATOPICPLUS FOAM
N/A 150 GM APPLICATION Onset Patient Assistance Program $357.74 $411.40 HYSINGLA ER
100 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $2,419.60 $2,782.54 120 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $2,681.35 $3,083.55 20 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $517.98 $595.68
Report Run: 04/19/16 10:53 AM Page 154 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
HYSINGLA ER
30 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $756.07 $869.48 40 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $1,018.61 $1,171.40 60 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $1,410.44 $1,622.01 80 MG TABLET(S) hydrocodone bitartrate Purdue Pharma Patient Assistance Program $1,901.62 $2,186.86 IBRANCE
100 MG CAPSULE(S) palbociclib Pfizer RxPathways $11,820.00 $13,593.00 125 MG CAPSULE(S) palbociclib Pfizer RxPathways $11,820.00 $13,593.00 75 MG CAPSULE(S) palbociclib Pfizer RxPathways $11,820.00 $13,593.00 IBUPROFEN (BRAND: MOTRIN)
400 MG TABLET(S) IBUPROFEN Nova ScriptsCentral-Northern Virginia Clinic $21.09 $24.25 Partners & Northern VA Residents ONLY 600 MG TABLET(S) IBUPROFEN Nova ScriptsCentral-Northern Virginia Clinic $26.17 $30.10 Partners & Northern VA Residents ONLY 800 MG TABLET(S) IBUPROFEN Nova ScriptsCentral-Northern Virginia Clinic $33.47 $38.49 Partners & Northern VA Residents ONLY 400 MG TABLET(S) IBUPROFEN Rx Outreach $21.09 $24.25 600 MG TABLET(S) IBUPROFEN Rx Outreach $26.17 $30.10 800 MG TABLET(S) IBUPROFEN Rx Outreach $33.47 $38.49 600 MG TABLET(S) IBUPROFEN Xubex Preferred Network Program $26.17 $30.10 800 MG TABLET(S) IBUPROFEN Xubex Preferred Network Program $33.47 $38.49
Report Run: 04/19/16 10:53 AM Page 155 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ICAPS AREDS
113-33-0.4-7160 MG-MG-MG TABLET(S) CA/CU/VIT A/VIT C/VIT E/ZINC Alcon Charitable Clinic Program-For Free $14.29 $16.43 Clinics ICAPS LUTEIN & ZEAXANTHIN
200-18.5-2-5 MG-MG-MG-MG TABLET(S) MULTIVITAMIN, MINERALS, Alcon Charitable Clinic Program-For Free $15.13 $17.40 AND NUTRICEUTICALS Clinics ICAPS MULTIVITAMIN
128-7.5-83.25 MG-MCG-MG TABLET(S) MULTIVITAMIN, MINERALS, Alcon Charitable Clinic Program-For Free $14.69 $16.89 AND NUTRICEUTICALS Clinics IDAMYCIN PFS
1 MG/ML (10ML) INJECTION IDARUBICIN HYDROCHLORIDE Pfizer RxPathways $600.00 $690.00 1 MG/ML (20 ML) INJECTION IDARUBICIN HYDROCHLORIDE Pfizer RxPathways $1,200.00 $1,380.00 ILARIS
180 MG INJECTION(S) CANAKINUMAB Novartis Patient Assistance Foundation, Inc. $19,266.01 $22,155.91 IMBRUVICA (Qty of 120)
140 MG CAPSULE(S) IBRUTINIB Johnson & Johnson Patient Assistance $14,670.12 $16,870.64 Foundation IMBRUVICA (Qty of 90)
140 MG CAPSULE(S) IBRUTINIB Johnson & Johnson Patient Assistance $11,002.60 $12,652.99 Foundation IMIPRAMINE HCL (BRAND: TOFRANIL)
10 MG TABLET(S) imipramine hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $42.96 $49.40 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 156 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
IMIPRAMINE HCL (BRAND: TOFRANIL)
25 MG TABLET(S) imipramine hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $71.75 $82.51 Partners & Northern VA Residents ONLY 50 MG TABLET(S) imipramine hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $121.65 $139.90 Partners & Northern VA Residents ONLY 10 MG TABLET(S) imipramine hydrochloride Xubex Preferred Network Program $42.96 $49.40 25 MG TABLET(S) imipramine hydrochloride Xubex Preferred Network Program $71.75 $82.51 50 MG TABLET(S) imipramine hydrochloride Xubex Preferred Network Program $121.65 $139.90 IMITREX
* 100 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Access $520.34 $598.39 20 MG SPRAY SUMATRIPTAN GSK Access $432.97 $497.92 * 25 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Access $299.23 $344.11 5 MG SPRAY SUMATRIPTAN GSK Access $432.97 $497.92 * 50 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Access $520.34 $598.39 * 6 MG/0.5ML INJECTION SUMATRIPTAN SUCCINATE GSK Access $842.87 $969.30 * 100 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Bridges to Access $520.34 $598.39 20 MG SPRAY SUMATRIPTAN GSK Bridges to Access $432.97 $497.92 * 25 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Bridges to Access $299.23 $344.11 5 MG SPRAY SUMATRIPTAN GSK Bridges to Access $432.97 $497.92 * 50 MG TABLET(S) SUMATRIPTAN SUCCINATE GSK Bridges to Access $520.34 $598.39 * 6 MG/0.5ML INJECTION SUMATRIPTAN SUCCINATE GSK Bridges to Access $842.87 $969.30 100 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $520.34 $598.39
Report Run: 04/19/16 10:53 AM Page 157 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
IMITREX
20 MG SPRAY SUMATRIPTAN Welvista - South Carolina Residents Only $432.97 $497.92 25 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $299.23 $344.11 5 MG SPRAY SUMATRIPTAN Welvista - South Carolina Residents Only $432.97 $497.92 50 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $520.34 $598.39 IMITREX STATDOSE
* 4 MG/0.5ML INJECTION(S) SUMATRIPTAN SUCCINATE GSK Bridges to Access $361.40 $415.61 IMITREX STATDOSE REFILL
* 6/0.5 MG/ML INJECTION SUMATRIPTAN SUCCINATE GSK Bridges to Access $342.29 $393.63 IMITREX STATDOSE SYSTEM
* 6 MG/0.5ML INJECTION(S) SUMATRIPTAN SUCCINATE GSK Bridges to Access $361.40 $415.61 IMOGAM RABIES-HT
150 IU/ML (10ML) UNIT(S) RABIES IMMUNE GLOBULIN Sanofi Patient Connection $2,151.01 $2,473.66 IMOVAX RABIES
2.5 IU VIAL RABIES VACCINE Sanofi Patient Connection $257.98 $296.68 INCIVEK
375 MG TABLET(S) TELAPREVIR Vertex GPS Patient Assistance Program- $26,462.04 $30,431.35 Incivek INCRUSE ELLIPTA
62.5 MCG/ACTUATION BLISTER(S) umeclidinium GSK Bridges to Access $269.71 $310.17
Report Run: 04/19/16 10:53 AM Page 158 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INCRUSE ELLIPTA (INSTITUTIONAL PACK)
62.5 MCG/ACTUATION BLISTER(S) umeclidinium GSK Bridges to Access $75.61 $86.95 INDAPAMIDE (BRAND: LOZOL)
1.25 MG TABLET(S) INDAPAMIDE Rx Outreach $67.95 $78.14 2.5 MG TABLET(S) INDAPAMIDE Rx Outreach $83.05 $95.51 1.25 MG TABLET(S) INDAPAMIDE Xubex Preferred Network Program $67.95 $78.14 2.5 MG TABLET(S) INDAPAMIDE Xubex Preferred Network Program $83.05 $95.51 INDERAL LA
120 MG CAPSULE(S) PROPRANOLOL Akrimax Patient Assistance Program $2,485.15 $2,857.92 HYDROCHLORIDE 160 MG CAPSULE(S) PROPRANOLOL Akrimax Patient Assistance Program $2,594.30 $2,983.45 HYDROCHLORIDE 60 MG CAPSULE(S) PROPRANOLOL Akrimax Patient Assistance Program $1,768.44 $2,033.71 HYDROCHLORIDE 80 MG CAPSULE(S) PROPRANOLOL Akrimax Patient Assistance Program $2,065.57 $2,375.41 HYDROCHLORIDE INFED
50 MG/ML (2ML, 10s) MG IRON DEXTRAN Actavis U.S. Patient Assistance Program $377.04 $433.60 INJECTAFER
50 MG/ML (15 ML) MG ferric carboxymaltose American Regent - IV Iron Patient Assistance $1,024.00 $1,177.60 Program INLYTA
1 MG TABLET(S) axitinib Pfizer RxPathways $13,635.58 $15,680.92
Report Run: 04/19/16 10:53 AM Page 159 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INLYTA
5 MG TABLET(S) axitinib Pfizer RxPathways $13,635.58 $15,680.92 INNOPRAN XL
120 MG CAPSULE PROPRANOLOL Akrimax Patient Assistance Program $2,083.75 $2,396.31 HYDROCHLORIDE 80 MG CAPSULE PROPRANOLOL Akrimax Patient Assistance Program $2,083.75 $2,396.31 HYDROCHLORIDE INSPRA
25 MG TABLET(S) EPLERENONE Pfizer MAINTAIN $672.42 $773.28 50 MG TABLET(S) EPLERENONE Pfizer MAINTAIN $672.42 $773.28 25 MG TABLET(S) EPLERENONE Pfizer RxPathways $672.42 $773.28 50 MG TABLET(S) EPLERENONE Pfizer RxPathways $672.42 $773.28 INTELENCE
100 MG TABLET(S) ETRAVIRINE Johnson & Johnson Hospital Access Patient $1,123.52 $1,292.05 Assistance Program 200 MG TABLET(S) ETRAVIRINE Johnson & Johnson Hospital Access Patient $1,123.52 $1,292.05 Assistance Program 100 MG TABLET(S) ETRAVIRINE Johnson & Johnson Patient Assistance $1,123.52 $1,292.05 Foundation 200 MG TABLET(S) ETRAVIRINE Johnson & Johnson Patient Assistance $1,123.52 $1,292.05 Foundation 100 MG TABLET(S) ETRAVIRINE Johnson & Johnson Patient Assistance $1,123.52 $1,292.05 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 160 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INTELENCE
25 MG TABLET(S) etravirine Johnson & Johnson Patient Assistance $280.88 $323.01 Foundation INTRON A
10 MILLION IU UNIT(S) INTERFERON ALFA-2B Merck Access Program $256.31 $294.76 18 MILLION IU UNIT(S) INTERFERON ALFA-2B Merck Access Program $461.36 $530.56 50 MILLION IU UNIT(S) INTERFERON ALFA-2B Merck Access Program $1,281.71 $1,473.97 INTUNIV
1 MG TABLET(S) GUANFACINE HYDROCHLORIDE Shire Cares Patient Assistance & Support $1,165.68 $1,340.53 Program 2 MG TABLET(S) GUANFACINE HYDROCHLORIDE Shire Cares Patient Assistance & Support $1,165.68 $1,340.53 Program 3 MG TABLET(S) GUANFACINE HYDROCHLORIDE Shire Cares Patient Assistance & Support $1,165.68 $1,340.53 Program 4 MG TABLET(S) GUANFACINE HYDROCHLORIDE Shire Cares Patient Assistance & Support $1,165.68 $1,340.53 Program INVANZ
1 GM GM ERTAPENEM SODIUM Merck Hotline for Invanz, Primaxin and $848.94 $976.28 Cancidas INVANZ, ADD-VANTAGE
1 GM GM ERTAPENEM SODIUM Merck Hotline for Invanz, Primaxin and $891.31 $1,025.01 Cancidas INVEGA
1.5 MG TABLET(S) PALIPERIDONE Johnson & Johnson Hospital Access Patient $1,019.87 $1,172.85 Assistance Program
Report Run: 04/19/16 10:53 AM Page 161 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INVEGA
3 MG TABLET(S) PALIPERIDONE Johnson & Johnson Hospital Access Patient $1,019.87 $1,172.85 Assistance Program 6 MG TABLET(S) PALIPERIDONE Johnson & Johnson Hospital Access Patient $1,019.87 $1,172.85 Assistance Program 9 MG TABLET(S) PALIPERIDONE Johnson & Johnson Hospital Access Patient $1,529.80 $1,759.27 Assistance Program 1.5 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation 3 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation 6 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation 9 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,529.80 $1,759.27 Foundation 1.5 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation-Card Program 3 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation-Card Program 6 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,019.87 $1,172.85 Foundation-Card Program 9 MG TABLET(S) PALIPERIDONE Johnson & Johnson Patient Assistance $1,529.80 $1,759.27 Foundation-Card Program 1.5 MG TABLET(S) PALIPERIDONE Welvista - South Carolina Residents Only $1,019.87 $1,172.85 3 MG TABLET(S) PALIPERIDONE Welvista - South Carolina Residents Only $1,019.87 $1,172.85 6 MG TABLET(S) PALIPERIDONE Welvista - South Carolina Residents Only $1,019.87 $1,172.85
Report Run: 04/19/16 10:53 AM Page 162 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INVEGA
9 MG TABLET(S) PALIPERIDONE Welvista - South Carolina Residents Only $1,529.80 $1,759.27 1.5 MG TABLET(S) PALIPERIDONE Xubex Free Trial 30 Day Medication Supply $1,019.87 $1,172.85 3 MG TABLET(S) PALIPERIDONE Xubex Free Trial 30 Day Medication Supply $1,019.87 $1,172.85 6 MG TABLET(S) PALIPERIDONE Xubex Free Trial 30 Day Medication Supply $1,019.87 $1,172.85 9 MG TABLET(S) PALIPERIDONE Xubex Free Trial 30 Day Medication Supply $1,529.80 $1,759.27 INVEGA SUSTENNA
117 MG (0.75 ML) INJECTION(S) PALIPERIDONE PALMITATE Johnson & Johnson Patient Assistance $1,205.69 $1,386.54 Foundation 156 MG (1 ML) INJECTION PALIPERIDONE PALMITATE Johnson & Johnson Patient Assistance $1,607.65 $1,848.80 Foundation 234 MG (1.5ML) INJECTION(S) PALIPERIDONE PALMITATE Johnson & Johnson Patient Assistance $2,411.42 $2,773.13 Foundation 39 MG (0.25 ML) INJECTION(S) PALIPERIDONE PALMITATE Johnson & Johnson Patient Assistance $401.87 $462.15 Foundation 78 MG (0.5ML) INJECTION(S) PALIPERIDONE PALMITATE Johnson & Johnson Patient Assistance $803.80 $924.37 Foundation INVEGA TRINZA
273 MG INJECTION(S) paliperidone palmitate Johnson & Johnson Patient Assistance $2,411.40 $2,773.11 Foundation 410 MG INJECTION(S) paliperidone palmitate Johnson & Johnson Patient Assistance $3,617.08 $4,159.64 Foundation 546 MG INJECTION(S) paliperidone palmitate Johnson & Johnson Patient Assistance $4,822.94 $5,546.38 Foundation
Report Run: 04/19/16 10:53 AM Page 163 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INVEGA TRINZA
819 MG INJECTION(S) paliperidone palmitate Johnson & Johnson Patient Assistance $7,234.27 $8,319.41 Foundation INVOKAMET
150-1000 MG-MG TABLET(S) canagliflozin/metformin Johnson & Johnson Patient Assistance $435.67 $501.02 hydrochloride Foundation 150-500 MG-MG TABLET(S) canagliflozin/metformin Johnson & Johnson Patient Assistance $435.67 $501.02 hydrochloride Foundation 50-1000 MG-MG TABLET(S) canagliflozin/metformin Johnson & Johnson Patient Assistance $435.67 $501.02 hydrochloride Foundation 50-500 MG-MG TABLET(S) canagliflozin/metformin Johnson & Johnson Patient Assistance $435.67 $501.02 hydrochloride Foundation 150-1000 MG-MG TABLET(S) canagliflozin/metformin Welvista - South Carolina Residents Only $435.67 $501.02 hydrochloride 150-500 MG-MG TABLET(S) canagliflozin/metformin Welvista - South Carolina Residents Only $435.67 $501.02 hydrochloride 50-1000 MG-MG TABLET(S) canagliflozin/metformin Welvista - South Carolina Residents Only $435.67 $501.02 hydrochloride 50-500 MG-MG TABLET(S) canagliflozin/metformin Welvista - South Carolina Residents Only $435.67 $501.02 hydrochloride INVOKANA
100 MG TABLET(S) canagliflozin Johnson & Johnson Hospital Access Patient $1,234.22 $1,419.35 Assistance Program 300 MG TABLET(S) canagliflozin Johnson & Johnson Hospital Access Patient $1,234.22 $1,419.35 Assistance Program 100 MG TABLET(S) canagliflozin Johnson & Johnson Patient Assistance $1,234.22 $1,419.35 Foundation
Report Run: 04/19/16 10:53 AM Page 164 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
INVOKANA
300 MG TABLET(S) canagliflozin Johnson & Johnson Patient Assistance $1,234.22 $1,419.35 Foundation 100 MG TABLET(S) canagliflozin Johnson & Johnson Patient Assistance $1,234.22 $1,419.35 Foundation-Card Program 300 MG TABLET(S) canagliflozin Johnson & Johnson Patient Assistance $1,234.22 $1,419.35 Foundation-Card Program 100 MG TABLET(S) canagliflozin Welvista - South Carolina Residents Only $1,234.22 $1,419.35 300 MG TABLET(S) canagliflozin Welvista - South Carolina Residents Only $1,234.22 $1,419.35 IOPIDINE
0.5 % (10 ML) DROP(S) APRACLONIDINE Alcon Cares, Inc. $324.78 $373.50 HYDROCHLORIDE 0.5 % (10 ML) DROP(S) APRACLONIDINE Alcon Charitable Clinic Program-For Free $324.78 $373.50 HYDROCHLORIDE Clinics IPRATROPIUM BROMIDE INHALED (BRAND: ATROVENT HFA) 0.02 % (2.5 ML) PUFF(S) ipratropium bromide Nova ScriptsCentral-Northern Virginia Clinic $53.40 $61.41 Partners & Northern VA Residents ONLY 0.02 % (2.5 ML) PUFF(S) ipratropium bromide Xubex Preferred Network Program $53.40 $61.41 IPRATROPIUM BROMIDE/ALBUTEROL (BRAND: COMBIVENT) 0.5/3 (90 ML) MG/ML (3 ML X 30) PUFF(S) albuterol sulfate/ipratropium Rx Outreach $14.40 $16.56 bromide 0.5/3 (180 ML) MG/ML (3 ML X 60) PUFF(S) albuterol sulfate/ipratropium Xubex Preferred Network Program $28.80 $33.12 bromide
Report Run: 04/19/16 10:53 AM Page 165 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
IPRATROPIUM BROMIDE/ALBUTEROL (BRAND: COMBIVENT) 0.5/3 (90 ML) MG/ML (3 ML X 30) PUFF(S) albuterol sulfate/ipratropium Xubex Preferred Network Program $14.40 $16.56 bromide IPRATROPIUM BROMIDE-ALBUTEROL SULFATE (BRAND: DuoNeb) 0.5-3 (2.5) MG/ML (3 ML) VIAL(S) albuterol sulfate/ipratropium Rx Outreach $65.21 $74.99 bromide IRBESARTAN (BRAND: AVAPRO)
150 MG TABLET(S) IRBESARTAN Rx Outreach $276.49 $317.96 300 MG TABLET(S) IRBESARTAN Rx Outreach $332.32 $382.17 75 MG TABLET(S) IRBESARTAN Rx Outreach $262.65 $302.05 150 MG TABLET(S) IRBESARTAN Xubex Preferred Network Program $276.49 $317.96 300 MG TABLET(S) IRBESARTAN Xubex Preferred Network Program $332.32 $382.17 75 MG TABLET(S) IRBESARTAN Xubex Preferred Network Program $262.65 $302.05 IRBESARTAN HYDROCHLOROTHIAZIDE (BRAND: AVALIDE) 150/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/IRBES Rx Outreach $364.32 $418.97 ARTAN 300/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE Rx Outreach $364.32 $418.97 IRBESARTAN 150/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/IRBES Xubex Preferred Network Program $364.32 $418.97 ARTAN 300/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE Xubex Preferred Network Program $364.32 $418.97 IRBESARTAN
Report Run: 04/19/16 10:53 AM Page 166 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
IRESSA
* 250 MG TABLET(S) GEFITINIB AZ&Me Prescription Savings Program $2,042.26 $2,348.60 ISENTRESS
100 MG TABLET(S) RALTEGRAVIR POTASSIUM Merck SUPPORT Program for Crixivan & $361.37 $415.58 Isentress 25 MG TABLET(S) RALTEGRAVIR POTASSIUM Merck SUPPORT Program for Crixivan & $90.35 $103.90 Isentress 400 MG TABLET(S) RALTEGRAVIR POTASSIUM Merck SUPPORT Program for Crixivan & $1,445.34 $1,662.14 Isentress ISONIAZID (BRAND: ISONIAZID)
100 MG TABLET(S) ISONIAZID Nova ScriptsCentral-Northern Virginia Clinic $6.67 $7.67 Partners & Northern VA Residents ONLY 300 MG TABLET(S) ISONIAZID Nova ScriptsCentral-Northern Virginia Clinic $10.96 $12.60 Partners & Northern VA Residents ONLY 300 MG TABLET(S) ISONIAZID Rx Outreach $10.96 $12.60 100 MG TABLET(S) ISONIAZID Xubex Preferred Network Program $6.67 $7.67 300 MG TABLET(S) ISONIAZID Xubex Preferred Network Program $10.96 $12.60 ISOPTO ATROPINE
1 % (15 ML) DROP(S) ATROPINE SULFATE Alcon Cares, Inc. $46.50 $53.48 OPHTHALMIC 1 % (15 ML) DROP(S) ATROPINE SULFATE Alcon Charitable Clinic Program-For Free $46.50 $53.48 OPHTHALMIC Clinics ISOPTO CARBACHOL
1.5 % (15 ML) DROP(S) CARBACHOL Alcon Cares, Inc. $48.42 $55.68
Report Run: 04/19/16 10:53 AM Page 167 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ISOPTO CARBACHOL
3 % (15 ML) DROP(S) CARBACHOL Alcon Cares, Inc. $55.38 $63.69 1.5 % (15 ML) DROP(S) CARBACHOL Alcon Charitable Clinic Program-For Free $48.42 $55.68 Clinics 3 % (15 ML) DROP(S) CARBACHOL Alcon Charitable Clinic Program-For Free $55.38 $63.69 Clinics ISOPTO CARPINE
2 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Cares, Inc. $30.84 $35.47 2 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $30.84 $35.47 Clinics ISOPTO CARPINE
1 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Cares, Inc. $100.32 $115.37 4 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Cares, Inc. $49.80 $57.27 1 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $100.32 $115.37 Clinics 4 % (15 ML) DROP(S) PILOCARPINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $49.80 $57.27 Clinics ISOPTO HOMATROPINE
2 % (5 ML) DROP(S) HOMATROPINE Alcon Cares, Inc. $29.22 $33.60 HYDROBROMIDE 5 % (5 ML) DROP(S) HOMATROPINE Alcon Cares, Inc. $33.66 $38.71 HYDROBROMIDE 2 % (5 ML) DROP(S) HOMATROPINE Alcon Charitable Clinic Program-For Free $29.22 $33.60 HYDROBROMIDE Clinics
Report Run: 04/19/16 10:53 AM Page 168 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ISOPTO HOMATROPINE
5 % (5 ML) DROP(S) HOMATROPINE Alcon Charitable Clinic Program-For Free $33.66 $38.71 HYDROBROMIDE Clinics ISOPTO HYOSCINE
0.25 % (5 ML) DROP(S) SCOPOLAMINE Alcon Cares, Inc. $29.34 $33.74 HYDROBROMIDE 0.25 % (5 ML) DROP(S) SCOPOLAMINE Alcon Charitable Clinic Program-For Free $29.34 $33.74 HYDROBROMIDE Clinics ISOPTO TEARS
0.5 % (15 ML) DROP(S) HYPROMELLOSE Alcon Charitable Clinic Program-For Free $29.28 $33.67 Clinics ISOSORBIDE DINITRATE (BRAND: ISORDIL)
10 MG TABLET(S) ISOSORBIDE DINITRATE Xubex Preferred Network Program $18.20 $20.93 20 MG TABLET(S) ISOSORBIDE DINITRATE Xubex Preferred Network Program $22.45 $25.82 30 MG TABLET(S) isosorbide dinitrate Xubex Preferred Network Program $131.11 $150.78 5 MG TABLET(S) ISOSORBIDE DINITRATE Xubex Preferred Network Program $14.95 $17.19 ISOSORBIDE DINITRATE ER (BRAND: ISORDIL)
40 MG TABLET(S) isosorbide dinitrate Xubex Preferred Network Program $237.61 $273.25 ISOSORBIDE MONONITRATE (BRAND: ISMO OR MONOKET) 10 MG TABLET(S) ISOSORBIDE MONONITRATE Rx Outreach $63.44 $72.96 20 MG TABLET(S) ISOSORBIDE MONONITRATE Rx Outreach $74.52 $85.70
Report Run: 04/19/16 10:53 AM Page 169 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ISOSORBIDE MONONITRATE ER (BRAND: IMDUR)
120 MG TABLET(S) ISOSORBIDE MONONITRATE ER Nova ScriptsCentral-Northern Virginia Clinic $76.08 $87.49 Partners & Northern VA Residents ONLY 30 MG TABLET(S) ISOSORBIDE MONONITRATE Nova ScriptsCentral-Northern Virginia Clinic $11.93 $13.72 Partners & Northern VA Residents ONLY 60 MG TABLET(S) ISOSORBIDE MONONITRATE ER Nova ScriptsCentral-Northern Virginia Clinic $137.18 $157.76 Partners & Northern VA Residents ONLY 120 MG TABLET(S) ISOSORBIDE MONONITRATE ER Rx Outreach $76.08 $87.49 30 MG TABLET(S) ISOSORBIDE MONONITRATE Rx Outreach $11.93 $13.72 60 MG TABLET(S) ISOSORBIDE MONONITRATE ER Rx Outreach $137.18 $157.76 30 MG TABLET(S) ISOSORBIDE MONONITRATE Xubex Preferred Network Program $11.93 $13.72 60 MG TABLET(S) ISOSORBIDE MONONITRATE ER Xubex Preferred Network Program $137.18 $157.76 ISRADIPINE (BRAND: DYNACIRC CR)
2.5 MG CAPSULE(S) isradipine Xubex Preferred Network Program $136.49 $156.96 5 MG CAPSULE(S) isradipine Xubex Preferred Network Program $199.59 $229.53 ISTALOL
0.5 % (5 ML) DROP(S) timolol maleate Bausch & Lomb US Patient Assistance $342.24 $393.58 Program JADENU
180 MG TABLET(S) deferasirox Novartis Oncology Patient Assistance $2,180.51 $2,507.59 Program 360 MG TABLET(S) deferasirox Novartis Oncology Patient Assistance $4,360.93 $5,015.07 Program
Report Run: 04/19/16 10:53 AM Page 170 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
JADENU
90 MG TABLET(S) deferasirox Novartis Oncology Patient Assistance $1,090.27 $1,253.81 Program JAKAFI
10 MG TABLET(S) ruxolitinib phosphate Incyte Jakafi Patient Assistance Program $10,502.40 $12,077.76 15 MG TABLET(S) ruxolitinib phosphate Incyte Jakafi Patient Assistance Program $10,502.40 $12,077.76 20 MG TABLET(S) ruxolitinib phosphate Incyte Jakafi Patient Assistance Program $10,502.40 $12,077.76 25 MG TABLET(S) ruxolitinib phosphate Incyte Jakafi Patient Assistance Program $10,502.40 $12,077.76 5 MG TABLET(S) ruxolitinib phosphate Incyte Jakafi Patient Assistance Program $10,502.40 $12,077.76 JALYN
0.5-0.4 MG-MG CAPSULE(S) DUTASTERIDE/TAMSULOSIN GSK Access $550.00 $632.50 HYDROCHLORIDE 0.5-0.4 MG-MG CAPSULE(S) DUTASTERIDE/TAMSULOSIN GSK Bridges to Access $550.00 $632.50 HYDROCHLORIDE 0.5-0.4 MG-MG CAPSULE(S) DUTASTERIDE/TAMSULOSIN Welvista - South Carolina Residents Only $550.00 $632.50 HYDROCHLORIDE JANTOVEN (BRAND: COUMADIN)
1 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $49.19 $56.57 10 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $75.96 $87.35 2 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $51.36 $59.06 2.5 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $52.81 $60.73 3 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $52.81 $60.73 4 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $52.81 $60.73
Report Run: 04/19/16 10:53 AM Page 171 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
JANTOVEN (BRAND: COUMADIN)
5 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $54.98 $63.23 6 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $70.89 $81.52 7.5 MG TABLET(S) WARFARIN SODIUM Xubex Patient Assistance Program $73.79 $84.86 JANUMET
1000-50 MG-MG TABLET(S) METFORMIN Merck Patient Assistance Program $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE 500-50 MG-MG TABLET(S) METFORMIN Merck Patient Assistance Program $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE 1000-50 MG-MG TABLET(S) METFORMIN Nova ScriptsCentral-Northern Virginia Clinic $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN Partners & Northern VA Residents ONLY PHOSPHATE 500-50 MG-MG TABLET(S) METFORMIN Nova ScriptsCentral-Northern Virginia Clinic $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN Partners & Northern VA Residents ONLY PHOSPHATE 1000-50 MG-MG TABLET(S) METFORMIN Welvista - South Carolina Residents Only $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE 500-50 MG-MG TABLET(S) METFORMIN Welvista - South Carolina Residents Only $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE 1000-50 MG-MG TABLET(S) METFORMIN Xubex Free Trial 30 Day Medication Supply $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE
Report Run: 04/19/16 10:53 AM Page 172 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
JANUMET
500-50 MG-MG TABLET(S) METFORMIN Xubex Free Trial 30 Day Medication Supply $1,308.10 $1,504.32 HYDROCHLORIDE/SITAGLIPTIN PHOSPHATE JANUMET XR
1000-100 MG TABLET(S) metformin Merck Patient Assistance Program $1,308.10 $1,504.32 hydrochloride/sitagliptin phosphate 1000-50 MG TABLET(S) metformin Merck Patient Assistance Program $436.08 $501.49 hydrochloride/sitagliptin phosphate 500-50 MG TABLET(S) metformin Merck Patient Assistance Program $436.08 $501.49 hydrochloride/sitagliptin phosphate 1000-100 MG TABLET(S) metformin Welvista - South Carolina Residents Only $1,308.10 $1,504.32 hydrochloride/sitagliptin phosphate 1000-50 MG TABLET(S) metformin Welvista - South Carolina Residents Only $436.08 $501.49 hydrochloride/sitagliptin phosphate 500-50 MG TABLET(S) metformin Welvista - South Carolina Residents Only $436.08 $501.49 hydrochloride/sitagliptin phosphate JANUVIA
100 MG TABLET(S) SITAGLIPTIN PHOSPHATE Merck Patient Assistance Program $1,190.26 $1,368.80 25 MG TABLET(S) SITAGLIPTIN PHOSPHATE Merck Patient Assistance Program $1,190.26 $1,368.80 50 MG TABLET(S) SITAGLIPTIN PHOSPHATE Merck Patient Assistance Program $1,190.26 $1,368.80
Report Run: 04/19/16 10:53 AM Page 173 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
JANUVIA
100 MG TABLET(S) SITAGLIPTIN PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $1,190.26 $1,368.80 Partners & Northern VA Residents ONLY 25 MG TABLET(S) SITAGLIPTIN PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $1,190.26 $1,368.80 Partners & Northern VA Residents ONLY 50 MG TABLET(S) SITAGLIPTIN PHOSPHATE Nova ScriptsCentral-Northern Virginia Clinic $1,190.26 $1,368.80 Partners & Northern VA Residents ONLY 100 MG TABLET(S) SITAGLIPTIN PHOSPHATE Welvista - South Carolina Residents Only $1,190.26 $1,368.80 25 MG TABLET(S) SITAGLIPTIN PHOSPHATE Welvista - South Carolina Residents Only $1,190.26 $1,368.80 50 MG TABLET(S) SITAGLIPTIN PHOSPHATE Welvista - South Carolina Residents Only $1,190.26 $1,368.80 100 MG TABLET(S) SITAGLIPTIN PHOSPHATE Xubex Free Trial 30 Day Medication Supply $1,190.26 $1,368.80 25 MG TABLET(S) SITAGLIPTIN PHOSPHATE Xubex Free Trial 30 Day Medication Supply $1,190.26 $1,368.80 50 MG TABLET(S) SITAGLIPTIN PHOSPHATE Xubex Free Trial 30 Day Medication Supply $1,190.26 $1,368.80 JARDIANCE
10 MG TABLET(S) empagliflozin Boehringer Ingelheim Cares Foundation Inc. $1,234.07 $1,419.18 25 MG TABLET(S) empagliflozin Boehringer Ingelheim Cares Foundation Inc. $1,234.07 $1,419.18 JENTADUETO
2.5-1000 MG TABLET(S) linagliptin/metformin Boehringer Ingelheim Cares Foundation Inc. $396.80 $456.32 hydrochloride 2.5-500 MG TABLET(S) linagliptin/metformin Boehringer Ingelheim Cares Foundation Inc. $396.80 $456.32 hydrochloride 2.5-850 MG TABLET(S) linagliptin/metformin Boehringer Ingelheim Cares Foundation Inc. $396.80 $456.32 hydrochloride
Report Run: 04/19/16 10:53 AM Page 174 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
JEVITY 1 CAL
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.38 $2.74 JEVITY 1.2 CAL
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $2.86 $3.29 JEVITY 1.5 CAL
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $3.01 $3.46 JEVTANA
60/1.5 MG/ML (1.5 ML) INJECTION CABAZITAXEL Sanofi Patient Connection $10,392.38 $11,951.24 JUXTAPID
10 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 20 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 30 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 40 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 5 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 60 MG CAPSULE(S) lomitapide mesylate Juxtapid REMS Program $34,662.00 $39,861.30 KADCYLA
160 MG MG ado-trastuzumab emtansine Genentech BioOncology Access to Solutions- $5,325.25 $6,124.04 Infused Products KADCYLA
100 MG MG ado-trastuzumab emtansine Genentech BioOncology Access to Solutions- $3,328.28 $3,827.52 Infused Products
Report Run: 04/19/16 10:53 AM Page 175 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
KALETRA
100-25 MG-MG TABLET(S) LOPINAVIR/RITONAVIR AbbVie Norvir Kaletra Patient Assistance $258.71 $297.52 Program 200-50 MG-MG TABLET(S) LOPINAVIR/RITONAVIR AbbVie Norvir Kaletra Patient Assistance $1,034.88 $1,190.11 Program 80/20 MG/ML SOL LOPINAVIR/RITONAVIR AbbVie Norvir Kaletra Patient Assistance $517.44 $595.06 Program KALYDECO
150 MG TABLET(S) IVACAFTOR Vertex GPS Patient Assistance Program- $29,400.00 $33,810.00 Kalydeco KAZANO
12.5-1000 MG-MG TABLET(S) alogliptin benzoate/metformin Takeda Patient Assistance Program $411.43 $473.14 hydrochloride 12.5-500 MG-MG TABLET(S) alogliptin benzoate/metformin Takeda Patient Assistance Program $411.43 $473.14 hydrochloride KEPIVANCE
6.25 MG INJECTION PALIFERMIN SOBI Kepivance Patient Assistance Program $9,900.00 $11,385.00 KEPPRA
1000 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $1,047.43 $1,204.54 250 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $857.00 $985.55 500 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $1,047.43 $1,204.54 750 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $1,419.06 $1,631.92 KEPPRA XR
500 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $474.77 $545.99
Report Run: 04/19/16 10:53 AM Page 176 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
KEPPRA XR
750 MG TABLET(S) LEVETIRACETAM UCB Patient Assistance Program $712.88 $819.81 KETOCONAZOLE (BRAND: NIZORAL)
200 MG TABLET(S) KETOCONAZOLE Nova ScriptsCentral-Northern Virginia Clinic $316.00 $363.40 Partners & Northern VA Residents ONLY 200 MG TABLET(S) KETOCONAZOLE Xubex Patient Assistance Program $316.00 $363.40 KETOPROFEN (BRAND: ORUDIS)
50 MG CAPSULE(S) KETOPROFEN Xubex Patient Assistance Program $96.50 $110.98 75 MG CAPSULE(S) KETOPROFEN Xubex Patient Assistance Program $107.30 $123.40 KETOROLAC TROMETHAMINE (BRAND: ACULAR)
0.4 % (5ML) DROP(S) KETOROLAC TROMETHAMINE Alcon Charitable Clinic Program-For Free $106.87 $122.90 Clinics 0.5 % (5 ML) DROP(S) KETOROLAC TROMETHAMINE Alcon Charitable Clinic Program-For Free $106.87 $122.90 Clinics 0.4 % (5ML) DROP(S) KETOROLAC TROMETHAMINE Nova ScriptsCentral-Northern Virginia Clinic $106.87 $122.90 Partners & Northern VA Residents ONLY 0.5 % (5 ML) DROP(S) KETOROLAC TROMETHAMINE Nova ScriptsCentral-Northern Virginia Clinic $106.87 $122.90 Partners & Northern VA Residents ONLY KETOTIFEN FUMARATE (BRAND: ALAWAY OTC)
0.025 % (5 ML) DROP(S) ketotifen fumarate Rx Outreach $12.19 $14.02 0.025 % (5 ML) DROP(S) ketotifen fumarate Xubex Preferred Network Program $12.19 $14.02 KEVEYIS
50 MG TABLET(S) dichlorphenamide Keys2Care $16,380.00 $18,837.00
Report Run: 04/19/16 10:53 AM Page 177 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
KEYTRUDA
50 MG MG pembrolizumab Merck Access Program $2,589.60 $2,978.04 KEYTRUDA
25/1 MG/ML MG pembrolizumab Merck Access Program $5,179.20 $5,956.08 KINERET
100 mg/0.67ml INJECTION(S) ANAKINRA Kineret Patient Assistance Program $61.80 $71.07 KOGENATE FS
1 IU (1000 IU) UNIT ANTIHEMOPHILIC FACTOR VIII Bayer Kogenate Factor Solutions $1.68 $1.93 (RECOMBINANT) KOMBIGLYZE XR
2.5/1000 MG-MG TABLET(S) METFORMIN AZ&Me Prescription Savings Program $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE 5/1000 MG-MG TABLET(S) METFORMIN AZ&Me Prescription Savings Program $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE 5/500 MG-MG TABLET(S) METFORMIN AZ&Me Prescription Savings Program $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE 2.5/1000 MG-MG TABLET(S) METFORMIN Welvista - South Carolina Residents Only $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE 5/1000 MG-MG TABLET(S) METFORMIN Welvista - South Carolina Residents Only $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 178 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
KOMBIGLYZE XR
5/500 MG-MG TABLET(S) METFORMIN Welvista - South Carolina Residents Only $389.88 $448.36 HYDROCHLORIDE/SAXAGLIPTIN HYDROCHLORIDE K-PHOS MF
155-350 MG-MG TABLET(S) K PHOS, MONOBASIC/NA PHOS, Beach Products $15.25 $17.54 MONOBASIC K-PHOS NO. 2
305-700 MG-MG TABLET(S) K PHOS, MONOBASIC/NA PHOS, Beach Products $23.75 $27.31 MONOBASIC K-PHOS ORIGINAL
500 MG TABLET(S) POTASSIUM PHOSPHATE, Beach Products $15.25 $17.54 MONOBASIC KRYSTEXXA
8 MG/ML (1 ML) MG pegloticase Krystexxa Connect Program $16,800.00 $19,320.00 K-TAB
* 10 MEQ TABLET(S) POTASSIUM CHLORIDE AbbVie Patient Assistance Program $100.61 $115.70 10 MEQ TABLET(S) POTASSIUM CHLORIDE Welvista - South Carolina Residents Only $100.61 $115.70 KUVAN
100 MG TABLET(S) SAPROPTERIN BioMarin Kuvan Patient Assistance Program $4,648.80 $5,346.12 DIHYDROCHLORIDE KYPROLIS
60 MG MG carfilzomib Amgen Safety Net Foundation $2,077.20 $2,388.78 60 MG MG carfilzomib Onyx 360 Patient Access $2,077.20 $2,388.78
Report Run: 04/19/16 10:53 AM Page 179 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LABETALOL (BRAND: TRANDATE)
* 100 MG TABLET(S) LABETALOL Generic Assistance Program (NeedyMeds & $100.00 $115.00 Rx Outreach) * 200 MG TABLET(S) LABETALOL Generic Assistance Program (NeedyMeds & $74.03 $85.13 Rx Outreach) * 300 MG TABLET(S) LABETALOL Generic Assistance Program (NeedyMeds & $101.23 $116.41 Rx Outreach) 100 MG TABLET(S) LABETALOL Nova ScriptsCentral-Northern Virginia Clinic $100.00 $115.00 Partners & Northern VA Residents ONLY 200 MG TABLET(S) LABETALOL Nova ScriptsCentral-Northern Virginia Clinic $74.03 $85.13 Partners & Northern VA Residents ONLY 300 MG TABLET(S) LABETALOL Nova ScriptsCentral-Northern Virginia Clinic $101.23 $116.41 Partners & Northern VA Residents ONLY 100 MG TABLET(S) LABETALOL Xubex Preferred Network Program $100.00 $115.00 200 MG TABLET(S) LABETALOL Xubex Preferred Network Program $74.03 $85.13 300 MG TABLET(S) LABETALOL Xubex Preferred Network Program $101.23 $116.41 LABETALOL HCL (BRAND: TRANDATE)
100 MG TABLET(S) LABETALOL HCL Rx Outreach $51.31 $59.01 200 MG TABLET(S) LABETALOL HCL Rx Outreach $72.79 $83.71 300 MG TABLET(S) LABETALOL HCL Rx Outreach $96.83 $111.35 LACRISERT
5 MG DEVICE (INSERT) HYDROXYPROPYL CELLULOSE Bausch & Lomb US Patient Assistance $497.62 $572.26 Program
Report Run: 04/19/16 10:53 AM Page 180 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LAMICTAL
100 MG TABLET(S) LAMOTRIGINE GSK Access $1,349.59 $1,552.03 150 MG TABLET(S) LAMOTRIGINE GSK Access $887.51 $1,020.64 200 MG TABLET(S) LAMOTRIGINE GSK Access $966.16 $1,111.08 25 MG TABLET(S) LAMOTRIGINE GSK Access $1,181.52 $1,358.75 100 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $1,349.59 $1,552.03 150 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $887.51 $1,020.64 200 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $966.16 $1,111.08 25 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $1,181.52 $1,358.75 100 MG TABLET(S) LAMOTRIGINE Nova ScriptsCentral-Northern Virginia Clinic $1,349.59 $1,552.03 Partners & Northern VA Residents ONLY 150 MG TABLET(S) LAMOTRIGINE Nova ScriptsCentral-Northern Virginia Clinic $887.51 $1,020.64 Partners & Northern VA Residents ONLY 200 MG TABLET(S) LAMOTRIGINE Nova ScriptsCentral-Northern Virginia Clinic $966.16 $1,111.08 Partners & Northern VA Residents ONLY 25 MG TABLET(S) LAMOTRIGINE Nova ScriptsCentral-Northern Virginia Clinic $1,181.52 $1,358.75 Partners & Northern VA Residents ONLY 100 MG TABLET(S) LAMOTRIGINE Welvista - South Carolina Residents Only $1,349.59 $1,552.03 150 MG TABLET(S) LAMOTRIGINE Welvista - South Carolina Residents Only $887.51 $1,020.64 200 MG TABLET(S) LAMOTRIGINE Welvista - South Carolina Residents Only $966.16 $1,111.08 25 MG TABLET(S) LAMOTRIGINE Welvista - South Carolina Residents Only $1,181.52 $1,358.75 LAMICTAL (GREEN) STARTER KIT (25MG AND 100MG)
N/A N/A TABLET(S) LAMOTRIGINE GSK Access $1,181.40 $1,358.61
Report Run: 04/19/16 10:53 AM Page 181 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LAMICTAL (GREEN) STARTER KIT (25MG AND 100MG)
N/A N/A TABLET(S) LAMOTRIGINE GSK Bridges to Access $1,181.40 $1,358.61 LAMICTAL (ORANGE) STARTER KIT
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $511.43 $588.14 LAMICTAL ODT
100 MG TABLET(S) LAMOTRIGINE GSK Access $374.63 $430.82 200 MG TABLET(S) LAMOTRIGINE GSK Access $447.04 $514.10 25 MG TABLET(S) LAMOTRIGINE GSK Access $328.02 $377.22 50 MG TABLET(S) LAMOTRIGINE GSK Access $351.34 $404.04 100 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $374.63 $430.82 200 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $447.04 $514.10 25 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $328.02 $377.22 50 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $351.34 $404.04 LAMICTAL ODT PATIENT TITRATION (BLUE)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $382.66 $440.06 LAMICTAL ODT PATIENT TITRATION (GREEN)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $1,093.18 $1,257.16 LAMICTAL ODT PATIENT TITRATION (ORANGE)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $546.60 $628.59 LAMICTAL XR
100 MG TABLET(S) LAMOTRIGINE GSK Access $734.58 $844.77
Report Run: 04/19/16 10:53 AM Page 182 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LAMICTAL XR
200 MG TABLET(S) LAMOTRIGINE GSK Access $783.35 $900.85 25 MG TABLET(S) LAMOTRIGINE GSK Access $342.94 $394.38 250 MG TABLET(S) lamotrigine GSK Access $1,068.23 $1,228.46 300 MG TABLET(S) LAMOTRIGINE GSK Access $1,175.05 $1,351.31 50 MG TABLET(S) LAMOTRIGINE GSK Access $685.79 $788.66 100 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $734.58 $844.77 200 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $783.35 $900.85 25 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $342.94 $394.38 250 MG TABLET(S) lamotrigine GSK Bridges to Access $1,068.23 $1,228.46 300 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $1,175.05 $1,351.31 50 MG TABLET(S) LAMOTRIGINE GSK Bridges to Access $685.79 $788.66 LAMICTAL XR PATIENT TITRATION (BLUE XR KIT)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $400.08 $460.09 LAMICTAL XR PATIENT TITRATION (GREEN XR KIT)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $1,142.89 $1,314.32 LAMICTAL XR PATIENT TITRATION (ORANGE XR KIT)
N/A N/A TABLET(S) lamotrigine GSK Bridges to Access $571.46 $657.18 LAMISIL
125 MG/PACKET PACKET(S) TERBINAFINE HYDROCHLORIDE Novartis Patient Assistance Foundation, Inc. $684.96 $787.70 187.5 MG/PACKET PACKET(S) TERBINAFINE HYDROCHLORIDE Novartis Patient Assistance Foundation, Inc. $1,027.46 $1,181.58
Report Run: 04/19/16 10:53 AM Page 183 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LAMOTRIGINE (BRAND: LAMICTAL)
* 100 MG TABLET(S) LAMOTRIGINE Generic Assistance Program (NeedyMeds & $475.12 $546.39 Rx Outreach) * 150 MG TABLET(S) LAMOTRIGINE Generic Assistance Program (NeedyMeds & $312.44 $359.31 Rx Outreach) * 200 MG TABLET(S) LAMOTRIGINE Generic Assistance Program (NeedyMeds & $340.15 $391.17 Rx Outreach) * 25 MG TABLET(S) LAMOTRIGINE Generic Assistance Program (NeedyMeds & $415.96 $478.35 Rx Outreach) 100 MG TABLET(S) LAMOTRIGINE Rx Outreach $475.12 $546.39 150 MG TABLET(S) LAMOTRIGINE Rx Outreach $312.44 $359.31 200 MG TABLET(S) LAMOTRIGINE Rx Outreach $340.15 $391.17 25 MG TABLET(S) LAMOTRIGINE Rx Outreach $415.96 $478.35 100 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $475.12 $546.39 150 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $312.44 $359.31 200 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $340.15 $391.17 25 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $415.96 $478.35 LAMOTRIGINE CHEWABLE (BRAND: LAMICTAL)
25 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $319.80 $367.77 5 MG TABLET(S) LAMOTRIGINE Xubex Preferred Network Program $305.33 $351.13 LANOXIN
0.0625 MG TABLET(S) digoxin Rx Outreach $288.00 $331.20 0.1875 MG TABLET(S) digoxin Rx Outreach $288.00 $331.20
Report Run: 04/19/16 10:53 AM Page 184 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LANOXIN
0.0625 MG TABLET(S) digoxin Welvista - South Carolina Residents Only $288.00 $331.20 0.1875 MG TABLET(S) digoxin Welvista - South Carolina Residents Only $288.00 $331.20 LANTUS
100 U/ML (10ML) UNIT(S) INSULIN HUMAN GLARGINE Sanofi Patient Connection $298.21 $342.94 LANTUS SOLOSTAR
100 U/ML UNIT(S) INSULIN GLARGINE, Sanofi Patient Connection $447.31 $514.41 RECOMBINANT LATANOPROST (BRAND: XALATAN)
0.005 % (2.5ML) DROP(S) LATANOPROST Rx Outreach $95.00 $109.25 0.005 % (2.5ML) DROP(S) LATANOPROST Xubex Preferred Network Program $95.00 $109.25 LATUDA
120 MG TABLET(S) LURASIDONE HYDROCHLORIDE Sunovion Support Prescription Assistance $1,651.32 $1,899.02 Program-Latuda 20 MG TABLET(S) LURASIDONE HYDROCHLORIDE Sunovion Support Prescription Assistance $1,106.28 $1,272.22 Program-Latuda 40 MG TABLET(S) LURASIDONE Sunovion Support Prescription Assistance $1,106.28 $1,272.22 Program-Latuda 60 MG TABLET(S) LURASIDONE HYDROCHLORIDE Sunovion Support Prescription Assistance $1,106.28 $1,272.22 Program-Latuda 80 MG TABLET(S) LURASIDONE Sunovion Support Prescription Assistance $1,106.28 $1,272.22 Program-Latuda LEFLUNOMIDE (BRAND: ARAVA)
10 MG TABLET(S) LEFLUNOMIDE Xubex Patient Assistance Program $492.17 $566.00
Report Run: 04/19/16 10:53 AM Page 185 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LEFLUNOMIDE (BRAND: ARAVA)
20 MG TABLET(S) LEFLUNOMIDE Xubex Patient Assistance Program $492.17 $566.00 LENVIMA
10 MG CAPSULE(S) lenvatinib Eisai Lenvima Patient Assistance Program $15,000.00 $17,250.00 LETAIRIS
10 MG TABLET(S) AMBRISENTAN Gilead Letairis Education and Access Program $8,842.73 $10,169.14 (LEAP) 5 MG TABLET(S) AMBRISENTAN Gilead Letairis Education and Access Program $9,718.16 $11,175.88 (LEAP) LETROZOLE (BRAND: FEMARA)
2.5 MG TABLET(S) LETROZOLE Rx Outreach $543.43 $624.94 2.5 MG TABLET(S) LETROZOLE Xubex Preferred Network Program $543.43 $624.94 LEVALBUTEROL INHALED (BRAND: XOPENEX)
1.25/3 MG/ML (3ML) VIAL(S) levalbuterol hydrochloride Rx Outreach $160.92 $185.06 1.25/3 MG/ML (3ML) VIAL(S) levalbuterol hydrochloride Xubex Preferred Network Program $160.92 $185.06 LEVAQUIN
750 MG TABLET(S) LEVOFLOXACIN Johnson & Johnson Hospital Access Patient $6,141.16 $7,062.33 Assistance Program 250 MG TABLET(S) LEVOFLOXACIN Johnson & Johnson Patient Assistance $2,861.54 $3,290.77 Foundation-Card Program 500 MG TABLET(S) LEVOFLOXACIN Johnson & Johnson Patient Assistance $3,279.59 $3,771.53 Foundation-Card Program 750 MG TABLET(S) LEVOFLOXACIN Johnson & Johnson Patient Assistance $6,141.16 $7,062.33 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 186 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LEVAQUIN
250 MG TABLET(S) LEVOFLOXACIN Welvista - South Carolina Residents Only $2,861.54 $3,290.77 500 MG TABLET(S) LEVOFLOXACIN Welvista - South Carolina Residents Only $3,279.59 $3,771.53 750 MG TABLET(S) LEVOFLOXACIN Welvista - South Carolina Residents Only $6,141.16 $7,062.33 LEVAQUIN
25 MG/ML (480 ML) ML levofloxacin Johnson & Johnson Patient Assistance $893.89 $1,027.97 Foundation LEVEMIR FLEXPEN
* 100 U/ML UNIT(S) INSULIN DETEMIR Novo Nordisk Patient Assistance Program $330.85 $380.48 LEVEMIR FLEXTOUCH
* 100 U/ML (3 ML) UNIT(S) insulin detemir Novo Nordisk Patient Assistance Program $484.20 $556.83 100 U/ML (3 ML) UNIT(S) insulin detemir Welvista - South Carolina Residents Only $484.20 $556.83 LEVEMIR VIAL
100 U/ML UNIT(S) INSULIN DETEMIR Novo Nordisk Patient Assistance Program $322.80 $371.22 100 U/ML UNIT(S) INSULIN DETEMIR Welvista - South Carolina Residents Only $322.80 $371.22 LEVETIRACETAM (BRAND: KEPPRA)
* 250 MG TABLET(S) LEVETIRACETAM Generic Assistance Program (NeedyMeds & $345.42 $397.23 Rx Outreach) * 500 MG TABLET(S) LEVETIRACETAM Generic Assistance Program (NeedyMeds & $422.18 $485.51 Rx Outreach) * 750 MG TABLET(S) LEVETIRACETAM Generic Assistance Program (NeedyMeds & $571.95 $657.74 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 187 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LEVETIRACETAM (BRAND: KEPPRA)
500 MG TABLET(S) LEVETIRACETAM Nova ScriptsCentral-Northern Virginia Clinic $422.18 $485.51 Partners & Northern VA Residents ONLY 750 MG TABLET(S) LEVETIRACETAM Nova ScriptsCentral-Northern Virginia Clinic $571.95 $657.74 Partners & Northern VA Residents ONLY 1000 MG TABLET(S) LEVETIRACETAM Rx Outreach $422.18 $485.51 250 MG TABLET(S) LEVETIRACETAM Rx Outreach $345.42 $397.23 500 MG TABLET(S) LEVETIRACETAM Rx Outreach $422.18 $485.51 750 MG TABLET(S) LEVETIRACETAM Rx Outreach $571.95 $657.74 250 MG TABLET(S) LEVETIRACETAM Welvista - South Carolina Residents Only $345.42 $397.23 500 MG TABLET(S) LEVETIRACETAM Welvista - South Carolina Residents Only $422.18 $485.51 750 MG TABLET(S) LEVETIRACETAM Welvista - South Carolina Residents Only $571.95 $657.74 1000 MG TABLET(S) LEVETIRACETAM Xubex Preferred Network Program $422.18 $485.51 250 MG TABLET(S) LEVETIRACETAM Xubex Preferred Network Program $345.42 $397.23 750 MG TABLET(S) LEVETIRACETAM Xubex Preferred Network Program $571.95 $657.74 LEVETIRACETAM ER (BRAND: KEPPRA XR)
500 MG TABLET(S) LEVETIRACETAM Rx Outreach $345.45 $397.27 750 MG TABLET(S) LEVETIRACETAM Rx Outreach $422.15 $485.47 500 MG TABLET(S) LEVETIRACETAM Xubex Preferred Network Program $345.45 $397.27 750 MG TABLET(S) LEVETIRACETAM Xubex Preferred Network Program $422.15 $485.47 LEVOCETIRIZINE (BRAND: XYZAL)
5 MG TABLET(S) LEVOCETIRIZINE Rx Outreach $276.90 $318.44
Report Run: 04/19/16 10:53 AM Page 188 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LEVOFLOXACIN (BRAND: LEVAQUIN)
250 MG TABLET(S) LEVOFLOXACIN Xubex Preferred Network Program $1,682.97 $1,935.42 500 MG TABLET(S) LEVOFLOXACIN Xubex Preferred Network Program $1,928.84 $2,218.17 750 MG TABLET(S) LEVOFLOXACIN Xubex Preferred Network Program $2,461.35 $2,830.55 LEVOTHYROXINE (BRAND: SYNTHROID)
0.025 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $43.69 $50.24 0.05 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $11.39 $13.10 0.075 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $12.52 $14.40 0.088 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $27.27 $31.36 0.1 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $56.18 $64.61 0.112 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $105.90 $121.79 0.125 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $15.83 $18.20 0.137 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $66.78 $76.80 0.15 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $18.92 $21.76 0.175 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $80.58 $92.67 0.2 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $63.42 $72.93 0.3 MG TABLET(S) LEVOTHYROXINE SODIUM Rx Outreach $97.63 $112.27 0.025 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $43.69 $50.24 0.05 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $11.39 $13.10 0.075 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $12.52 $14.40 0.088 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $27.27 $31.36 0.1 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $56.18 $64.61
Report Run: 04/19/16 10:53 AM Page 189 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LEVOTHYROXINE (BRAND: SYNTHROID)
0.112 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $105.90 $121.79 0.125 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $15.83 $18.20 0.137 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $66.78 $76.80 0.15 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $18.92 $21.76 0.175 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $80.58 $92.67 0.2 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $63.42 $72.93 0.3 MG TABLET(S) LEVOTHYROXINE SODIUM Xubex Preferred Network Program $97.63 $112.27 LEXISCAN
0.08 MG/ML (5ML) INJECTION(S) REGADENOSON Astellas Stock Replacement Program $247.68 $284.83 LEXIVA
700 MG TABLET(S) FOSAMPRENAVIR CALCIUM GSK Access $1,204.43 $1,385.09 50 MG/ML (225 ML) MG FOSAMPRENAVIR CALCIUM ViiV Healthcare Patient Assistance Program $184.54 $212.22 700 MG TABLET(S) FOSAMPRENAVIR CALCIUM ViiV Healthcare Patient Assistance Program $1,204.43 $1,385.09 LIALDA
1.2 GM TABLET(S) MESALAMINE Shire Cares Patient Assistance & Support $1,134.52 $1,304.70 Program LIDOCAINE (BRAND: LIDODERM)
5 % PATCH (ES) LIDOCAINE Rx Outreach $280.81 $322.93 5 % PATCH (ES) LIDOCAINE Xubex Preferred Network Program $280.81 $322.93 LIDODERM
5 % PATCH(ES) LIDOCAINE Endo Patient Assistance Program $312.01 $358.81
Report Run: 04/19/16 10:53 AM Page 190 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LILETTA
52 MG INSERT levonorgestrel Actavis U.S. Patient Assistance Program $750.00 $862.50 LINCOCIN
300 MG/ML (10ML) VIAL LINCOMYCIN HYDROCHLORIDE Pfizer MAINTAIN $108.62 $124.91 300 MG/ML (10ML) VIAL LINCOMYCIN HYDROCHLORIDE Pfizer RxPathways $108.62 $124.91 LINZESS
290 MCG CAPSULE(S) LINACLOTIDE Actavis U.S. Patient Assistance Program $365.45 $420.27 LINZESS
145 MCG CAPSULE(S) LINACLOTIDE Actavis U.S. Patient Assistance Program $365.45 $420.27 LIPOFEN
* 150 MG CAPSULE(S) FENOFIBRATE Kowa KPAssist Patient Assistance Program $682.20 $784.53 * 50 MG CAPSULE(S) FENOFIBRATE Kowa KPAssist Patient Assistance Program $311.40 $358.11 LISINOPRIL (BRAND: ZESTRIL OR PRINIVIL)
10 MG TABLET(S) LISINOPRIL Nova ScriptsCentral-Northern Virginia Clinic $86.09 $99.00 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) LISINOPRIL Nova ScriptsCentral-Northern Virginia Clinic $52.00 $59.80 Partners & Northern VA Residents ONLY 20 MG TABLET(S) LISINOPRIL Nova ScriptsCentral-Northern Virginia Clinic $90.05 $103.56 Partners & Northern VA Residents ONLY 40 MG TABLET(S) LISINOPRIL Nova ScriptsCentral-Northern Virginia Clinic $80.05 $92.06 Partners & Northern VA Residents ONLY 10 MG TABLET(S) LISINOPRIL Rx Outreach $86.09 $99.00 2.5 MG TABLET(S) LISINOPRIL Rx Outreach $52.00 $59.80
Report Run: 04/19/16 10:53 AM Page 191 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LISINOPRIL (BRAND: ZESTRIL OR PRINIVIL)
20 MG TABLET(S) LISINOPRIL Rx Outreach $90.05 $103.56 30 MG TABLET(S) LISINOPRIL Rx Outreach $134.93 $155.17 40 MG TABLET(S) LISINOPRIL Rx Outreach $80.05 $92.06 10 MG TABLET(S) LISINOPRIL Welvista - South Carolina Residents Only $86.09 $99.00 20 MG TABLET(S) LISINOPRIL Welvista - South Carolina Residents Only $90.05 $103.56 10 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $86.09 $99.00 2.5 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $52.00 $59.80 20 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $90.05 $103.56 30 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $134.93 $155.17 40 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $80.05 $92.06 LISINOPRIL (BRAND: ZESTRIL OR PRINVIL)
5 MG TABLET(S) LISINOPRIL Nova ScriptsCentral-Northern Virginia Clinic $88.71 $102.02 Partners & Northern VA Residents ONLY 5 MG TABLET(S) LISINOPRIL Rx Outreach $88.71 $102.02 5 MG TABLET(S) LISINOPRIL Welvista - South Carolina Residents Only $88.71 $102.02 5 MG TABLET(S) LISINOPRIL Xubex Preferred Network Program $88.71 $102.02 LISINOPRIL/HCTZ (BRAND: ZESTORETIC)
10/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Nova ScriptsCentral-Northern Virginia Clinic $136.29 $156.73 Partners & Northern VA Residents ONLY 20/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Nova ScriptsCentral-Northern Virginia Clinic $143.90 $165.48 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 192 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LISINOPRIL/HCTZ (BRAND: ZESTORETIC)
20/25 MG/MG TABLET(S) LISINOPRIL/HCTZ Nova ScriptsCentral-Northern Virginia Clinic $90.05 $103.56 Partners & Northern VA Residents ONLY 10/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Rx Outreach $136.29 $156.73 20/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Rx Outreach $143.90 $165.48 20/25 MG/MG TABLET(S) LISINOPRIL/HCTZ Rx Outreach $90.05 $103.56 10/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Welvista - South Carolina Residents Only $136.29 $156.73 20/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Welvista - South Carolina Residents Only $143.90 $165.48 20/25 MG/MG TABLET(S) LISINOPRIL/HCTZ Welvista - South Carolina Residents Only $90.05 $103.56 10/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Xubex Preferred Network Program $136.29 $156.73 20/12.5 MG/MG TABLET(S) LISINOPRIL/HCTZ Xubex Preferred Network Program $143.90 $165.48 20/25 MG/MG TABLET(S) LISINOPRIL/HCTZ Xubex Preferred Network Program $90.05 $103.56 LITHIUM CARBONATE
150 MG CAPSULE(S) LITHIUM CARBONATE Nova ScriptsCentral-Northern Virginia Clinic $18.77 $21.59 Partners & Northern VA Residents ONLY 300 MG CAPSULE(S) LITHIUM CARBONATE Nova ScriptsCentral-Northern Virginia Clinic $46.52 $53.50 Partners & Northern VA Residents ONLY 150 MG CAPSULE(S) LITHIUM CARBONATE Rx Outreach $18.77 $21.59 300 MG CAPSULE(S) LITHIUM CARBONATE Rx Outreach $46.52 $53.50 150 MG CAPSULE(S) LITHIUM CARBONATE Xubex Preferred Network Program $18.77 $21.59 LITHIUM CARBONATE (BRAND: LITHOBID ER)
300 MG TABLET(S) lithium carbonate Rx Outreach $46.52 $53.50 450 MG TABLET(S) lithium carbonate Rx Outreach $46.37 $53.33
Report Run: 04/19/16 10:53 AM Page 193 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LITHIUM CARBONATE (BRAND: LITHOBID ER)
300 MG TABLET(S) lithium carbonate Xubex Preferred Network Program $46.52 $53.50 450 MG TABLET(S) lithium carbonate Xubex Preferred Network Program $46.37 $53.33 LITHOSTAT
250 MG TABLET(S) ACETOHYDROXAMIC ACID Mission Pharmacal Patient Assistance $198.72 $228.53 Program LIVALO
* 1 MG TABLET(S) pitavastatin calcium Eli Lilly Cares $642.60 $738.99 * 2 MG TABLET(S) PITAVASTATIN CALCIUM Eli Lilly Cares $642.60 $738.99 * 4 MG TABLET(S) PITAVASTATIN CALCIUM Eli Lilly Cares $642.60 $738.99 1 MG TABLET(S) pitavastatin calcium Kowa KPAssist Patient Assistance Program $642.60 $738.99 2 MG TABLET(S) PITAVASTATIN CALCIUM Kowa KPAssist Patient Assistance Program $642.60 $738.99 4 MG TABLET(S) PITAVASTATIN CALCIUM Kowa KPAssist Patient Assistance Program $642.60 $738.99 LOCOID
0.1 % (118 ML) LOTION hydrocortisone butyrate Onset Patient Assistance Program $1,089.95 $1,253.44 LODOSYN
25 MG TABLET(S) CARBIDOPA Valeant Patient Assistance Program $2,531.70 $2,911.46 LONSURF
6.14-15 MG TABLET(S) tipiracil/trifluridine Taiho Oncology Patient Support Program $9,852.95 $11,330.89 8.19-20 MG TABLET(S) tipiracil/trifluridine Taiho Oncology Patient Support Program $13,137.26 $15,107.85 LOPID
600 MG TABLET(S) GEMFIBROZIL Pfizer MAINTAIN $264.34 $303.99
Report Run: 04/19/16 10:53 AM Page 194 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LORATADINE (BRAND: ALAVERT, CLARITIN)
10 MG TABLET(S) loratadine Nova ScriptsCentral-Northern Virginia Clinic $82.50 $94.88 Partners & Northern VA Residents ONLY 10 MG TABLET(S) loratadine Rx Outreach $82.50 $94.88 10 MG TABLET(S) loratadine Xubex Preferred Network Program $82.50 $94.88 LORAZEPAM (BRAND: ATIVAN)
0.5 MG TABLET(S) LORAZEPAM Rx Outreach $69.00 $79.35 1 MG TABLET(S) LORAZEPAM Rx Outreach $38.75 $44.56 2 MG TABLET(S) LORAZEPAM Rx Outreach $105.00 $120.75 0.5 MG TABLET(S) LORAZEPAM Xubex Preferred Network Program $69.00 $79.35 1 MG TABLET(S) LORAZEPAM Xubex Preferred Network Program $38.75 $44.56 2 MG TABLET(S) LORAZEPAM Xubex Preferred Network Program $105.00 $120.75 LOSARTAN POTASSIUM (BRAND: COZAAR)
100 MG TABLET(S) LOSARTAN POTASSIUM Nova ScriptsCentral-Northern Virginia Clinic $277.36 $318.96 Partners & Northern VA Residents ONLY 25 MG TABLET(S) LOSARTAN POTASSIUM Nova ScriptsCentral-Northern Virginia Clinic $151.43 $174.14 Partners & Northern VA Residents ONLY 50 MG TABLET(S) LOSARTAN POTASSIUM Nova ScriptsCentral-Northern Virginia Clinic $217.88 $250.56 Partners & Northern VA Residents ONLY 100 MG TABLET(S) LOSARTAN POTASSIUM Rx Outreach $277.36 $318.96 25 MG TABLET(S) LOSARTAN POTASSIUM Rx Outreach $151.43 $174.14 50 MG TABLET(S) LOSARTAN POTASSIUM Rx Outreach $217.88 $250.56 100 MG TABLET(S) LOSARTAN POTASSIUM Welvista - South Carolina Residents Only $277.36 $318.96
Report Run: 04/19/16 10:53 AM Page 195 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LOSARTAN POTASSIUM (BRAND: COZAAR)
50 MG TABLET(S) LOSARTAN POTASSIUM Welvista - South Carolina Residents Only $217.88 $250.56 100 MG TABLET(S) LOSARTAN POTASSIUM Xubex Preferred Network Program $277.36 $318.96 25 MG TABLET(S) LOSARTAN POTASSIUM Xubex Preferred Network Program $151.43 $174.14 50 MG TABLET(S) LOSARTAN POTASSIUM Xubex Preferred Network Program $217.88 $250.56 LOSARTAN POTASSIUM/HCTZ (BRAND: HYZAAR)
100/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Nova ScriptsCentral-Northern Virginia Clinic $306.70 $352.71 HYDROCHLOROTHIAZIDE Partners & Northern VA Residents ONLY 100/25 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Nova ScriptsCentral-Northern Virginia Clinic $306.70 $352.71 HYDROCHLOROTHIAZIDE Partners & Northern VA Residents ONLY 50/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Nova ScriptsCentral-Northern Virginia Clinic $225.16 $258.93 HYDROCHLOROTHIAZIDE Partners & Northern VA Residents ONLY 100/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Rx Outreach $306.70 $352.71 HYDROCHLOROTHIAZIDE 100/25 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Rx Outreach $306.70 $352.71 HYDROCHLOROTHIAZIDE 50/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Rx Outreach $225.16 $258.93 HYDROCHLOROTHIAZIDE 100/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Xubex Preferred Network Program $306.70 $352.71 HYDROCHLOROTHIAZIDE 100/25 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Xubex Preferred Network Program $306.70 $352.71 HYDROCHLOROTHIAZIDE 50/12.5 MG/MG TABLET(S) LOSARTAN POTASSIUM AND Xubex Preferred Network Program $225.16 $258.93 HYDROCHLOROTHIAZIDE
Report Run: 04/19/16 10:53 AM Page 196 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LOTEMAX GEL
0.5 % (5 GM) GM LOTEPREDNOL ETABONATE Bausch & Lomb US Patient Assistance $189.30 $217.70 Program LOTRISONE
0.05-1 % (15gm) CRE BETAMETHASONE Merck Patient Assistance Program $57.42 $66.03 DIPROPIONATE/CLOTRIMAZOLE 0.05-1 % (15gm) CRE BETAMETHASONE Welvista - South Carolina Residents Only $57.42 $66.03 DIPROPIONATE/CLOTRIMAZOLE LOTRONEX
1 MG TABLET(S) ALOSETRON HYDROCHLORIDE GSK Access $649.49 $746.91 LOVASTATIN (BRAND: MEVACOR)
10 MG TABLET(S) LOVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $134.51 $154.69 Partners & Northern VA Residents ONLY 20 MG TABLET(S) LOVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $237.25 $272.84 Partners & Northern VA Residents ONLY 40 MG TABLET(S) LOVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $427.11 $491.18 Partners & Northern VA Residents ONLY 10 MG TABLET(S) LOVASTATIN Rx Outreach $134.51 $154.69 20 MG TABLET(S) LOVASTATIN Rx Outreach $237.25 $272.84 40 MG TABLET(S) LOVASTATIN Rx Outreach $427.11 $491.18 10 MG TABLET(S) LOVASTATIN Xubex Preferred Network Program $134.51 $154.69 20 MG TABLET(S) LOVASTATIN Xubex Preferred Network Program $237.25 $272.84 40 MG TABLET(S) LOVASTATIN Xubex Preferred Network Program $427.11 $491.18
Report Run: 04/19/16 10:53 AM Page 197 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LOVAZA
1 GM CAPSULE(S) OMEGA-3-ACID ETHYL ESTERS GSK Access $348.76 $401.07 1 GM CAPSULE(S) OMEGA-3-ACID ETHYL ESTERS GSK Bridges to Access $348.76 $401.07 1 GM CAPSULE(S) OMEGA-3-ACID ETHYL ESTERS Nova ScriptsCentral-Northern Virginia Clinic $348.76 $401.07 Partners & Northern VA Residents ONLY 1 GM CAPSULE(S) OMEGA-3-ACID ETHYL ESTERS Welvista - South Carolina Residents Only $348.76 $401.07 LOVENOX
120 MG/0.8 ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $1,192.52 $1,371.40 30 MG/0.3 ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $297.70 $342.36 40 MG/0.4 ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $396.91 $456.45 80 MG/0.8 ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $794.77 $913.99 LOVENOX
100 MG/ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $993.44 $1,142.46 150 MG/ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $1,490.68 $1,714.28 60 MG/0.6 ML SYRINGE ENOXAPARIN SODIUM Sanofi Patient Connection $596.08 $685.49 LOXAPINE (BRAND: LOXITANE)
10 MG CAPSULE(S) LOXAPINE Rx Outreach $86.28 $99.22 25 MG CAPSULE(S) LOXAPINE Rx Outreach $131.24 $150.93 5 MG CAPSULE(S) LOXAPINE Rx Outreach $65.62 $75.46 50 MG CAPSULE(S) LOXAPINE Rx Outreach $174.94 $201.18 10 MG CAPSULE(S) LOXAPINE Xubex Preferred Network Program $86.28 $99.22 25 MG CAPSULE(S) LOXAPINE Xubex Preferred Network Program $131.24 $150.93
Report Run: 04/19/16 10:53 AM Page 198 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LOXAPINE (BRAND: LOXITANE)
5 MG CAPSULE(S) LOXAPINE Xubex Preferred Network Program $65.62 $75.46 50 MG CAPSULE(S) LOXAPINE Xubex Preferred Network Program $174.94 $201.18 LUCENTIS
0.5/0.05 MG/ML ML RANIBIZUMAB Genentech Access to Care-Lucentis $2,437.50 $2,803.13 LUCENTIS
0.3/0.05 MG/ML ML RANIBIZUMAB Genentech Access to Care-Lucentis $1,404.00 $1,614.60 LUMIGAN
0.01 % (7.5 ML) DROP(S) BIMATOPROST Allergan Patient Assistance Program $448.60 $515.89 LUPANETA PACK
11.25-5 MG-MG KIT leuprolide AbbVie Lupron Depot & Lupaneta Pack $3,525.96 $4,054.85 acetate;norethindrone acetate Patient Assistance Program 3.75-5 MG-MG KIT leuprolide AbbVie Lupron Depot & Lupaneta Pack $1,175.30 $1,351.60 acetate;norethindrone acetate Patient Assistance Program LUPRON DEPOT
11.25 MG PI3 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $3,298.37 $3,793.13 Patient Assistance Program 22.5 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $3,930.47 $4,520.04 Patient Assistance Program 3.75 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $1,099.44 $1,264.36 Patient Assistance Program 30 MG PI4 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $5,240.64 $6,026.74 Patient Assistance Program
Report Run: 04/19/16 10:53 AM Page 199 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LUPRON DEPOT
45 MG PI6 leuprolide acetate AbbVie Lupron Depot & Lupaneta Pack $7,861.08 $9,040.24 Patient Assistance Program 7.5 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $1,310.17 $1,506.70 Patient Assistance Program LUPRON DEPOT-PED
11.25 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $2,401.24 $2,761.43 Patient Assistance Program 15 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $2,644.72 $3,041.43 Patient Assistance Program 7.5 MG PI1 LEUPROLIDE ACETATE AbbVie Lupron Depot & Lupaneta Pack $1,322.63 $1,521.02 Patient Assistance Program LUXIQ
0.12 % FOAM BETAMETHASONE VALERATE GSK Access $167.98 $193.18 0.12 % FOAM BETAMETHASONE VALERATE GSK Bridges to Access $167.98 $193.18 LYNPARZA
50 MG CAPSULE(S) olaparib AZ&Me Prescription Savings Program $3,360.00 $3,864.00 LYRICA
100 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 150 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 200 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 225 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 25 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31
Report Run: 04/19/16 10:53 AM Page 200 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
LYRICA
300 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 50 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 75 MG CAPSULE(S) PREGABALIN Pfizer RxPathways $518.53 $596.31 LYSODREN
500 MG TABLET(S) MITOTANE Bristol-Myers Squibb Access Support $575.94 $662.33 Oncology Patient Assistance Program MACUGEN
0.3/0.09 MG/ML (0.09 ML) INJECTION(S) PEGAPTANIB OCTASODIUM Valeant Macugen Access Program $1,194.00 $1,373.10 MAGNESIUM OXIDE
400 MG TABLET(S) magnesium oxide Nova ScriptsCentral-Northern Virginia Clinic $14.75 $16.96 Partners & Northern VA Residents ONLY 400 MG TABLET(S) magnesium oxide Xubex Preferred Network Program $14.75 $16.96 MAG-TAB SR
84 MG TABLET(S) MAGNESIUM LACTATE Niche Pharmaceuticals Patient Assistance $17.50 $20.13 Program MAKENA
250 MG/ML (5ML) ML HYDROXYPROGESTERONE Ther-Rx Makena Patient Assistance Program $4,140.00 $4,761.00 CAPROATE MALARONE
250-100 MG-MG TABLET(S) ATOVAQUONE GSK Access $807.58 $928.72 250-100 MG-MG TABLET(S) ATOVAQUONE GSK Bridges to Access $807.58 $928.72
Report Run: 04/19/16 10:53 AM Page 201 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MALARONE PEDIATRIC
62.5-25 MG-MG TABLET(S) ATOVAQUONE/CHLOROGUANID GSK Bridges to Access $298.70 $343.51 E HYDROCHLORIDE MARINOL
10 MG CAPSULE(S) DRONABINOL AbbVie Patient Assistance Foundation- $3,004.58 $3,455.27 Marinol 2.5 MG CAPSULE(S) DRONABINOL AbbVie Patient Assistance Foundation- $786.14 $904.06 Marinol 5 MG CAPSULE(S) DRONABINOL AbbVie Patient Assistance Foundation- $1,636.16 $1,881.58 Marinol MARPLAN
10 MG TABLET(S) ISOCARBOXAZID Equetro Patient Assistance Program $472.80 $543.72 MATULANE
50 MG CAPSULE(S) procarbazine hydrochloride Matulane Patient Assistance Program $6,217.20 $7,149.78 MAVIK
* 1 MG TABLET(S) TRANDOLAPRIL AbbVie Patient Assistance Program $174.47 $200.64 * 2 MG TABLET(S) TRANDOLAPRIL AbbVie Patient Assistance Program $174.47 $200.64 * 4 MG TABLET(S) TRANDOLAPRIL AbbVie Patient Assistance Program $174.47 $200.64 1 MG TABLET(S) TRANDOLAPRIL Welvista - South Carolina Residents Only $174.47 $200.64 2 MG TABLET(S) TRANDOLAPRIL Welvista - South Carolina Residents Only $174.47 $200.64 4 MG TABLET(S) TRANDOLAPRIL Welvista - South Carolina Residents Only $174.47 $200.64 MAXALT
10 MG TABLET(S) RIZATRIPTAN BENZOATE Merck Patient Assistance Program $745.86 $857.74
Report Run: 04/19/16 10:53 AM Page 202 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MAXALT
5 MG TABLET(S) RIZATRIPTAN BENZOATE Merck Patient Assistance Program $745.86 $857.74 10 MG TABLET(S) RIZATRIPTAN BENZOATE Nova ScriptsCentral-Northern Virginia Clinic $745.86 $857.74 Partners & Northern VA Residents ONLY 5 MG TABLET(S) RIZATRIPTAN BENZOATE Nova ScriptsCentral-Northern Virginia Clinic $745.86 $857.74 Partners & Northern VA Residents ONLY 10 MG TABLET(S) RIZATRIPTAN BENZOATE Welvista - South Carolina Residents Only $745.86 $857.74 5 MG TABLET(S) RIZATRIPTAN BENZOATE Welvista - South Carolina Residents Only $745.86 $857.74 MAXALT-MLT
10 MG TABLET(S) RIZATRIPTAN BENZOATE Merck Patient Assistance Program $469.51 $539.94 5 MG TABLET(S) RIZATRIPTAN BENZOATE Merck Patient Assistance Program $469.51 $539.94 10 MG TABLET(S) RIZATRIPTAN BENZOATE Nova ScriptsCentral-Northern Virginia Clinic $745.86 $857.74 Partners & Northern VA Residents ONLY 5 MG TABLET(S) RIZATRIPTAN BENZOATE Nova ScriptsCentral-Northern Virginia Clinic $745.86 $857.74 Partners & Northern VA Residents ONLY 10 MG TABLET(S) RIZATRIPTAN BENZOATE Welvista - South Carolina Residents Only $469.51 $539.94 5 MG TABLET(S) RIZATRIPTAN BENZOATE Welvista - South Carolina Residents Only $469.51 $539.94 MAXIDEX
0.1 % (5 ML) DROP(S) DEXAMETHASONE Alcon Cares, Inc. $81.30 $93.50 0.1 % (5 ML) DROP(S) DEXAMETHASONE Alcon Charitable Clinic Program-For Free $81.30 $93.50 Clinics MAXITROL
1-3.5-10000 MG/ML-MG/ML (5 DROP(S) DEXAMETHASONE/NEOMYCIN Alcon Cares, Inc. $121.86 $140.14 ML) SULFATE/POLYMYXIN B SULFATE
Report Run: 04/19/16 10:53 AM Page 203 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MAXITROL
1-3.5-10000 MG/ML-MG/ML (5 DROP(S) DEXAMETHASONE/NEOMYCIN Alcon Charitable Clinic Program-For Free $121.86 $140.14 ML) SULFATE/POLYMYXIN B SULFATE Clinics MECLIZINE (BRAND: ANTIVERT)
12.5 MG TABLET(S) MECLIZINE HYDROCHLORIDE Rx Outreach $89.59 $103.03 25 MG TABLET(S) MECLIZINE HYDROCHLORIDE Rx Outreach $18.30 $21.04 12.5 MG TABLET(S) MECLIZINE HYDROCHLORIDE Xubex Preferred Network Program $89.59 $103.03 25 MG TABLET(S) MECLIZINE HYDROCHLORIDE Xubex Preferred Network Program $18.30 $21.04 MEDROL
16 MG TABLET(S) METHYLPREDNISOLONE Pfizer MAINTAIN $217.44 $250.06 2 MG TABLET(S) METHYLPREDNISOLONE Pfizer MAINTAIN $105.97 $121.87 32 MG TABLET(S) METHYLPREDNISOLONE Pfizer MAINTAIN $161.89 $186.17 4 MG TABLET(S) METHYLPREDNISOLONE Pfizer MAINTAIN $200.46 $230.53 8 MG TABLET(S) METHYLPREDNISOLONE Pfizer MAINTAIN $70.39 $80.95 MEDROXYPROGESTERONE (BRAND: PROVERA)
10 MG TABLET(S) MEDROXYPROGESTERONE Rx Outreach $49.14 $56.51 ACETATE 2.5 MG TABLET(S) MEDROXYPROGESTERONE Rx Outreach $31.29 $35.98 ACETATE 10 MG TABLET(S) MEDROXYPROGESTERONE Xubex Preferred Network Program $49.14 $56.51 ACETATE 2.5 MG TABLET(S) MEDROXYPROGESTERONE Xubex Preferred Network Program $31.29 $35.98 ACETATE
Report Run: 04/19/16 10:53 AM Page 204 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MEDROXYPROGESTERONE ACETATE (BRAND: PROVERA) 5 MG TABLET(S) medroxyprogesterone acetate Rx Outreach $47.25 $54.34 5 MG TABLET(S) medroxyprogesterone acetate Xubex Preferred Network Program $47.25 $54.34 MEFENAMIC ACID (BRAND: PONSTEL)
250 MG CAPSULE(S) mefenamic acid Xubex Preferred Network Program $522.37 $600.73 MEGACE ES
625/5 MG/ML (150ML) ML (S) MEGESTROL ACETATE Strativa Patient Assistance Program $998.46 $1,148.23 MEKINIST
0.5 MG TABLET(S) trametinib dimethyl sulfoxide Commitment to Access $3,081.84 $3,544.12 2 MG TABLET(S) trametinib dimethyl sulfoxide Commitment to Access $12,327.32 $14,176.42 MELOXICAM (BRAND: MOBIC)
15 MG TABLET(S) MELOXICAM Nova ScriptsCentral-Northern Virginia Clinic $483.96 $556.55 Partners & Northern VA Residents ONLY 7.5 MG TABLET(S) MELOXICAM Nova ScriptsCentral-Northern Virginia Clinic $316.84 $364.37 Partners & Northern VA Residents ONLY 15 MG TABLET(S) MELOXICAM Rx Outreach $483.96 $556.55 7.5 MG TABLET(S) MELOXICAM Rx Outreach $316.84 $364.37 15 MG TABLET(S) MELOXICAM Xubex Preferred Network Program $483.96 $556.55 7.5 MG TABLET(S) MELOXICAM Xubex Preferred Network Program $316.84 $364.37 MEMANTINE HCL (BRAND: NAMENDA)
10 MG TABLET(S) memantine hydrochloride Rx Outreach $365.77 $420.64 5 MG TABLET(S) memantine hydrochloride Rx Outreach $365.77 $420.64
Report Run: 04/19/16 10:53 AM Page 205 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MENACTRA
16/0.5 MCG/ML (5ML) INJECTION(S) MENINGOCOCCAL VACCINE, Sanofi Patient Connection $619.72 $712.68 DIPHTHERIA CONJUGATE MENOMUNE-A/C/Y/W-135
0.05 MG VIAL meningococcal polysaccharide Sanofi Patient Connection $140.66 $161.76 vaccine MENOPUR
75-75 IU-IU VIAL follicle stimulating Heart Beat Program $830.48 $955.05 hormone/luteinizing hormone MENOSTAR
0.014/24 MG/HR PATCH ESTRADIOL Bayer HealthCare Patient Assistance Program $133.49 $153.51 MEPHYTON
5 MG TABLET(S) PHYTONADIONE Valeant Patient Assistance Program $2,801.17 $3,221.35 MEPRON
750 mg/5ml (210 ml) SUS ATOVAQUONE GSK Access $1,533.04 $1,763.00 750 mg/5ml (210 ml) SUS ATOVAQUONE GSK Bridges to Access $1,533.04 $1,763.00 MERREM IV
1 GM VIAL MEROPENEM AZ&Me Prescription Savings Program $805.36 $926.16 500 MG VIAL MEROPENEM AZ&Me Prescription Savings Program $402.67 $463.07 MESTINON
60 MG TABLET(S) PYRIDOSTIGMINE BROMIDE Valeant Patient Assistance Program $864.08 $993.69
Report Run: 04/19/16 10:53 AM Page 206 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MESTINON TIMESPAN
180 MG TABLET(S) PYRIDOSTIGMINE BROMIDE Valeant Patient Assistance Program $491.66 $565.41 METFORMIN HCL (BRAND: GLUCOPHAGE)
1000 MG TABLET(S) METFORMIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $108.31 $124.56 Partners & Northern VA Residents ONLY 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $52.61 $60.50 Partners & Northern VA Residents ONLY 850 MG TABLET(S) METFORMIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $89.42 $102.83 Partners & Northern VA Residents ONLY 1000 MG TABLET(S) METFORMIN HYDROCHLORIDE Rx Outreach $108.31 $124.56 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Rx Outreach $52.61 $60.50 850 MG TABLET(S) METFORMIN HYDROCHLORIDE Rx Outreach $89.42 $102.83 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Welvista - South Carolina Residents Only $52.61 $60.50 850 MG TABLET(S) METFORMIN HYDROCHLORIDE Welvista - South Carolina Residents Only $89.42 $102.83 1000 MG TABLET(S) METFORMIN HYDROCHLORIDE Xubex Preferred Network Program $108.31 $124.56 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Xubex Preferred Network Program $52.61 $60.50 850 MG TABLET(S) METFORMIN HYDROCHLORIDE Xubex Preferred Network Program $89.42 $102.83 METFORMIN HCL ER (BRAND: GLUCOPHAGE)
750 MG TABLET(S) MEFORMIN HYDROCHLORIDE Rx Outreach $119.70 $137.65 750 MG TABLET(S) MEFORMIN HYDROCHLORIDE Xubex Preferred Network Program $119.70 $137.65 METFORMIN XR (BRAND: GLUCOPHAGE XR)
500 MG TABLET(S) METFORMIN HYDROCHLORIDE Rx Outreach $45.51 $52.34 500 MG TABLET(S) METFORMIN HYDROCHLORIDE Xubex Patient Assistance Program $45.51 $52.34
Report Run: 04/19/16 10:53 AM Page 207 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
METFORMIN XR (BRAND: GLUCOPHAGE XR)
500 MG TABLET(S) METFORMIN HYDROCHLORIDE Xubex Preferred Network Program $45.51 $52.34 METHAZOLAMIDE (BRAND: NEPTAZANE)
25 MG TABLET(S) methazolamide Xubex Preferred Network Program $383.09 $440.55 50 MG TABLET(S) methazolamide Xubex Preferred Network Program $766.21 $881.14 METHIMAZOLE (BRAND: TAPAZOLE)
10 TABLET(S) TABLET(S) methimazole Nova ScriptsCentral-Northern Virginia Clinic $76.78 $88.30 Partners & Northern VA Residents ONLY 5 MG TABLET(S) methimazole Nova ScriptsCentral-Northern Virginia Clinic $44.44 $51.11 Partners & Northern VA Residents ONLY 10 TABLET(S) TABLET(S) methimazole Rx Outreach $76.78 $88.30 5 MG TABLET(S) methimazole Rx Outreach $44.44 $51.11 10 TABLET(S) TABLET(S) methimazole Xubex Preferred Network Program $76.78 $88.30 5 MG TABLET(S) methimazole Xubex Preferred Network Program $44.44 $51.11 METHOCARBAMOL (BRAND: ROBAXIN)
500 MG TABLET(S) METHOCARBAMOL Nova ScriptsCentral-Northern Virginia Clinic $76.00 $87.40 Partners & Northern VA Residents ONLY 750 MG TABLET(S) METHOCARBAMOL Nova ScriptsCentral-Northern Virginia Clinic $94.99 $109.24 Partners & Northern VA Residents ONLY 500 MG TABLET(S) METHOCARBAMOL Rx Outreach $76.00 $87.40 750 MG TABLET(S) METHOCARBAMOL Rx Outreach $94.99 $109.24 750 MG TABLET(S) METHOCARBAMOL Xubex Preferred Network Program $94.99 $109.24
Report Run: 04/19/16 10:53 AM Page 208 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
METHOTREXATE
2.5 MG TABLET(S) METHOTREXATE DAVA Methotrexate Patient Assistance $356.40 $409.86 Program METHOTREXATE (BRAND: RHEUMATREX)
2.5 MG TABLET(S) METHOTREXATE Rx Outreach $356.40 $409.86 2.5 MG TABLET(S) METHOTREXATE Welvista - South Carolina Residents Only $356.40 $409.86 2.5 MG TABLET(S) METHOTREXATE Xubex Preferred Network Program $356.40 $409.86 METHYLDOPA (BRAND: ALDOMET)
250 MG TABLET(S) METHYLDOPA Nova ScriptsCentral-Northern Virginia Clinic $35.70 $41.06 Partners & Northern VA Residents ONLY 500 MG TABLET(S) METHYLDOPA Nova ScriptsCentral-Northern Virginia Clinic $63.30 $72.79 Partners & Northern VA Residents ONLY 250 MG TABLET(S) METHYLDOPA Xubex Preferred Network Program $35.70 $41.06 500 MG TABLET(S) METHYLDOPA Xubex Preferred Network Program $63.30 $72.79 METHYLPREDNISOLONE (BRAND: MEDROL)
4 MG TABLET(S) METHYLPREDNISOLONE Nova ScriptsCentral-Northern Virginia Clinic $142.92 $164.36 Partners & Northern VA Residents ONLY 4 MG TABLET(S) METHYLPREDNISOLONE Xubex Preferred Network Program $142.92 $164.36 8 MG TABLET(S) METHYLPREDNISOLONE Xubex Preferred Network Program $50.26 $57.80 METOCLOPRAMIDE HCL (BRAND: REGLAN)
10 MG TABLET(S) METOCLOPRAMIDE Nova ScriptsCentral-Northern Virginia Clinic $121.72 $139.98 HYDROCHLORIDE Partners & Northern VA Residents ONLY 5 MG TABLET(S) METOCLOPRAMIDE Nova ScriptsCentral-Northern Virginia Clinic $38.16 $43.88 HYDROCHLORIDE Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 209 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
METOCLOPRAMIDE HCL (BRAND: REGLAN)
10 MG TABLET(S) METOCLOPRAMIDE Rx Outreach $121.72 $139.98 HYDROCHLORIDE 5 MG TABLET(S) METOCLOPRAMIDE Rx Outreach $38.16 $43.88 HYDROCHLORIDE METOLAZONE (BRAND: ZAROXOLYN)
2.5 MG TABLET(S) METOLAZONE Rx Outreach $207.31 $238.41 5 MG TABLET(S) METOLAZONE Rx Outreach $235.56 $270.89 10 MG TABLET(S) metolazone Xubex Preferred Network Program $282.11 $324.43 2.5 MG TABLET(S) METOLAZONE Xubex Preferred Network Program $207.31 $238.41 5 MG TABLET(S) METOLAZONE Xubex Preferred Network Program $235.56 $270.89 METOPROLOL SUCCINATE ER (BRAND: TOPROL)
100 MG TABLET(S) METOPROLOL SUCCINATE ER Rx Outreach $135.14 $155.41 100 MG TABLET(S) METOPROLOL SUCCINATE ER Welvista - South Carolina Residents Only $135.14 $155.41 100 MG TABLET(S) METOPROLOL SUCCINATE ER Xubex Preferred Network Program $135.14 $155.41 METOPROLOL SUCCINATE ER (BRAND: TOPROL-XL)
200 MG TABLET(S) METOPROLOL SUCCINATE ER Rx Outreach $215.02 $247.27 25 MG TABLET(S) METOPROLOL SUCCINATE ER Rx Outreach $89.93 $103.42 50 MG TABLET(S) METOPROLOL SUCCINATE ER Rx Outreach $89.93 $103.42 200 MG TABLET(S) METOPROLOL SUCCINATE ER Welvista - South Carolina Residents Only $215.02 $247.27 25 MG TABLET(S) METOPROLOL SUCCINATE ER Welvista - South Carolina Residents Only $89.93 $103.42 50 MG TABLET(S) METOPROLOL SUCCINATE ER Welvista - South Carolina Residents Only $89.93 $103.42
Report Run: 04/19/16 10:53 AM Page 210 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
METOPROLOL SUCCINATE ER (BRAND: TOPROL-XL)
200 MG TABLET(S) METOPROLOL SUCCINATE ER Xubex Preferred Network Program $215.02 $247.27 25 MG TABLET(S) METOPROLOL SUCCINATE ER Xubex Preferred Network Program $89.93 $103.42 50 MG TABLET(S) METOPROLOL SUCCINATE ER Xubex Preferred Network Program $89.93 $103.42 METOPROLOL TARTRATE (BRAND: LOPRESSOR)
100 MG TABLET(S) METOPROLOL TARTRATE Nova ScriptsCentral-Northern Virginia Clinic $72.00 $82.80 Partners & Northern VA Residents ONLY 25 MG TABLET(S) METOPROLOL TARTRATE Nova ScriptsCentral-Northern Virginia Clinic $27.00 $31.05 Partners & Northern VA Residents ONLY 50 MG TABLET(S) METOPROLOL TARTRATE Nova ScriptsCentral-Northern Virginia Clinic $45.00 $51.75 Partners & Northern VA Residents ONLY 100 MG TABLET(S) METOPROLOL TARTRATE Rx Outreach $72.00 $82.80 25 MG TABLET(S) METOPROLOL TARTRATE Rx Outreach $27.00 $31.05 50 MG TABLET(S) METOPROLOL TARTRATE Rx Outreach $45.00 $51.75 100 MG TABLET(S) METOPROLOL TARTRATE Welvista - South Carolina Residents Only $72.00 $82.80 50 MG TABLET(S) METOPROLOL TARTRATE Welvista - South Carolina Residents Only $45.00 $51.75 100 MG TABLET(S) METOPROLOL TARTRATE Xubex Preferred Network Program $72.00 $82.80 25 MG TABLET(S) METOPROLOL TARTRATE Xubex Preferred Network Program $27.00 $31.05 50 MG TABLET(S) METOPROLOL TARTRATE Xubex Preferred Network Program $45.00 $51.75 METOPROLOL TARTRATE/HCTZ (BRAND: LOPRESSOR HCT) 25/100 MG TABLET(S) METOPROLOL TARTRATE/HCTZ Xubex Preferred Network Program $177.25 $203.84 25/50 MG TABLET(S) METOPROLOL TARTRATE/HCTZ Xubex Preferred Network Program $113.40 $130.41
Report Run: 04/19/16 10:53 AM Page 211 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
METOPROLOL TARTRATE/HCTZ (BRAND: LOPRESSOR HCT) 50/100 MG TABLET(S) METOPROLOL TARTRATE/HCTZ Xubex Preferred Network Program $187.95 $216.14 METOZOLV ODT
10 MG TABLET(S) METOCLOPRAMIDE Salix Patient Assistance Program $132.00 $151.80 HYDROCHLORIDE 5 MG TABLET(S) METOCLOPRAMIDE Salix Patient Assistance Program $264.00 $303.60 HYDROCHLORIDE METRONIDAZOLE (BRAND: FLAGYL)
250 MG TABLET(S) metronidazole Nova ScriptsCentral-Northern Virginia Clinic $62.63 $72.02 Partners & Northern VA Residents ONLY 500 MG TABLET(S) metronidazole Nova ScriptsCentral-Northern Virginia Clinic $114.01 $131.11 Partners & Northern VA Residents ONLY 250 MG TABLET(S) metronidazole Xubex Preferred Network Program $62.63 $72.02 500 MG TABLET(S) metronidazole Xubex Preferred Network Program $114.01 $131.11 METRONIDAZOLE VAGINAL (BRAND: FLAGYL)
0.75 % (70 GM) APPLICATION metronidazole Nova ScriptsCentral-Northern Virginia Clinic $65.90 $75.79 Partners & Northern VA Residents ONLY 0.75 % (70 GM) APPLICATION metronidazole Xubex Preferred Network Program $65.90 $75.79 MEXILETINE HCL (BRAND: MEXITIL)
150 MG CAPSULE(S) mexiletine hydrochloride Xubex Preferred Network Program $253.56 $291.59 200 MG CAPSULE(S) mexiletine hydrochloride Xubex Preferred Network Program $302.67 $348.07 250 MG CAPSULE(S) mexiletine hydrochloride Xubex Preferred Network Program $349.81 $402.28
Report Run: 04/19/16 10:53 AM Page 212 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MIDODRINE HCL (BRAND: PROAMATINE)
10 MG TABLET(S) midodrine hydrochloride Rx Outreach $972.04 $1,117.85 2.5 MG TABLET(S) midodrine hydrochloride Rx Outreach $169.15 $194.52 5 MG TABLET(S) midodrine hydrochloride Rx Outreach $415.55 $477.88 10 MG TABLET(S) midodrine hydrochloride Xubex Preferred Network Program $972.04 $1,117.85 2.5 MG TABLET(S) midodrine hydrochloride Xubex Preferred Network Program $169.15 $194.52 5 MG TABLET(S) midodrine hydrochloride Xubex Preferred Network Program $415.55 $477.88 MIGRANAL
4 MG/ML SPRAY(S) DIHYDROERGOTAMINE Valeant Patient Assistance Program $4,045.30 $4,652.10 MESYLATE MINOCIN
100 MG TABLET(S) MINOCYCLINE HYDROCHLORIDE Onset Patient Assistance Program $1,166.85 $1,341.88 50 MG TABLET(S) MINOCYCLINE HYDROCHLORIDE Onset Patient Assistance Program $1,944.88 $2,236.61 75 MG CAPSULE(S) MINOCYCLINE HYDROCHLORIDE Onset Patient Assistance Program $1,166.85 $1,341.88 MINOCYCLINE (BRAND: DYNACIN, MINOCIN)
100 MG CAPSULE(S) MINOCYCLINE HYDROCHLORIDE Rx Outreach $93.23 $107.21 100 MG CAPSULE(S) MINOCYCLINE HYDROCHLORIDE Xubex Preferred Network Program $93.23 $107.21 MIRAPEX
0.125 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $470.74 $541.35 DIHYDROCHLORIDE 0.25 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $568.56 $653.84 DIHYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 213 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MIRAPEX
0.5 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $568.56 $653.84 DIHYDROCHLORIDE 0.75 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $470.74 $541.35 DIHYDROCHLORIDE 1 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $568.56 $653.84 DIHYDROCHLORIDE 1.5 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $568.56 $653.84 DIHYDROCHLORIDE MIRAPEX ER
* 0.375 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 DIHYDROCHLORIDE * 0.75 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 DIHYDROCHLORIDE * 1.5 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 DIHYDROCHLORIDE * 4.5 MG TABLET(S) PRAMIPEXOLE Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 DIHYDROCHLORIDE MIRAPEX ER
* 2.25 MG TABLET(S) pramipexole dihydrochloride Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 * 3 MG TABLET(S) pramipexole dihydrochloride Boehringer Ingelheim Cares Foundation Inc. $537.96 $618.65 MIRENA
52 MG INSERT LEVONORGESTREL Arch Foundation Patient Assistance Program $972.61 $1,118.50 MIRTAZAPINE (BRAND: REMERON)
15 MG TABLET(S) MIRTAZAPINE Rx Outreach $233.40 $268.41
Report Run: 04/19/16 10:53 AM Page 214 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MIRTAZAPINE (BRAND: REMERON)
30 MG TABLET(S) MIRTAZAPINE Rx Outreach $240.45 $276.52 45 MG TABLET(S) MIRTAZAPINE Rx Outreach $256.59 $295.08 15 MG TABLET(S) MIRTAZAPINE Welvista - South Carolina Residents Only $233.40 $268.41 30 MG TABLET(S) MIRTAZAPINE Welvista - South Carolina Residents Only $240.45 $276.52 15 MG TABLET(S) MIRTAZAPINE Xubex Preferred Network Program $233.40 $268.41 30 MG TABLET(S) MIRTAZAPINE Xubex Preferred Network Program $240.45 $276.52 45 MG TABLET(S) MIRTAZAPINE Xubex Preferred Network Program $256.59 $295.08 MIRVASO
0.33 % (30 GM) APPLICATION brimonidine tartrate Galderma Patient Assistance Program $449.94 $517.43 M-M-R II
n/a n/a INJECTION(S) MEASLES, MUMPS, AND Merck Vaccine Patient Assistance Program $714.43 $821.59 RUBELLA VIRUS VACCINE, LIVE n/a n/a INJECTION(S) MEASLES, MUMPS, AND Welvista - South Carolina Residents Only $714.43 $821.59 RUBELLA VIRUS VACCINE, LIVE MODAFINIL (BRAND: PROVIGIL)
100 MG TABLET(S) MODAFINIL Rx Outreach $1,961.60 $2,255.84 200 MG TABLET(S) MODAFINIL Rx Outreach $2,963.20 $3,407.68 100 MG TABLET(S) MODAFINIL Xubex Preferred Network Program $1,961.60 $2,255.84 200 MG TABLET(S) MODAFINIL Xubex Preferred Network Program $2,963.20 $3,407.68 MODERIBA
* 200 MG TABLET(S) ribavirin AbbVie Patient Assistance Program-Moderiba $474.00 $545.10
Report Run: 04/19/16 10:53 AM Page 215 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MODERIBA 1000 DOSE PACK
* N/A MG TABLET(S) ribavirin AbbVie Patient Assistance Program-Moderiba $1,153.37 $1,326.38 MODERIBA 1200 DOSE PACK
* 600 MG TABLET(S) ribavirin AbbVie Patient Assistance Program-Moderiba $1,384.02 $1,591.62 MODERIBA 600 DOSE PACK
* N/A N/A TABLET(S) ribavirin AbbVie Patient Assistance Program-Moderiba $876.55 $1,008.03 MODERIBA 800 DOSE PACK
* 400 MG TABLET(S) ribavirin AbbVie Patient Assistance Program-Moderiba $922.68 $1,061.08 MOEXIPRIL HYDROCHLORIDE
15 MG TABLET(S) MOEXIPRIL HYDROCHLORIDE Xubex Preferred Network Program $145.54 $167.37 7.5 MG TABLET(S) MOEXIPRIL HYDROCHLORIDE Xubex Preferred Network Program $138.92 $159.76 MOEXIPRIL/HCT
12.5-15 MG-MG TABLET(S) hydrochlorothiazide/moexipril Xubex Preferred Network Program $133.57 $153.61 hydrochloride MOMETASONE FUROATE (BRAND: ELOCON OINTMENT) 0.1 % (15 GM) GM MOMETASONE FUROATE Rx Outreach $25.92 $29.81 MOMETASONE FUROATE (BRAND: ELOCON CREAM)
0.1 % (15 GM) GM MOMETASONE FUROATE Rx Outreach $29.16 $33.53 MOMETASONE FUROATE (BRAND: ELOCON OINTMENT) 0.1 % (45 GM) GM MOMETASONE FUROATE Rx Outreach $51.30 $58.99
Report Run: 04/19/16 10:53 AM Page 216 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MONOCLATE-P
1 IU INJECTION(S) ANTIHEMOPHILIC FACTOR VIII:C CSL Behring Patient Assistance Program $1.00 $1.15 HUMAN MONONINE
1 IU INJECTION(S) FACTOR IX HUMAN, PURIFIED CSL Behring Patient Assistance Program $1.18 $1.36 MONTELUKAST SODIUM (BRAND: SINGULAIR)
10 MG TABLET(S) MONTELUKAST SODIUM Nova ScriptsCentral-Northern Virginia Clinic $509.10 $585.47 Partners & Northern VA Residents ONLY 5 MG TABLET(S) MONTELUKAST SODIUM Nova ScriptsCentral-Northern Virginia Clinic $509.10 $585.47 Partners & Northern VA Residents ONLY 10 MG TABLET(S) MONTELUKAST SODIUM Rx Outreach $509.10 $585.47 5 MG TABLET(S) MONTELUKAST SODIUM Rx Outreach $509.10 $585.47 10 MG TABLET(S) MONTELUKAST SODIUM Welvista - South Carolina Residents Only $509.10 $585.47 10 MG TABLET(S) MONTELUKAST SODIUM Xubex Preferred Network Program $509.10 $585.47 5 MG TABLET(S) MONTELUKAST SODIUM Xubex Preferred Network Program $509.10 $585.47 MONUROL
3 GM SACHET fosfomycin tromethamine Actavis U.S. Patient Assistance Program $79.80 $91.77 MOVANTIK
12.5 MG TABLET(S) naloxegol AZ&Me Prescription Savings for people with $299.52 $344.45 Medicare Part D 25 MG TABLET(S) naloxegol AZ&Me Prescription Savings for people with $299.52 $344.45 Medicare Part D 12.5 MG TABLET(S) naloxegol AZ&Me Prescription Savings Program $299.52 $344.45
Report Run: 04/19/16 10:53 AM Page 217 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MOVANTIK
25 MG TABLET(S) naloxegol AZ&Me Prescription Savings Program $299.52 $344.45 12.5 MG TABLET(S) naloxegol Welvista - South Carolina Residents Only $299.52 $344.45 25 MG TABLET(S) naloxegol Welvista - South Carolina Residents Only $299.52 $344.45 MOVIPREP
4.7-100-1.015-5.9- GM PDS PEG ELECTROLYTE LAVAGE Salix Patient Assistance Program $94.68 $108.88 2.691 SOLUTION MUGARD
N/A N/A ML SOLUTION Access - Mugard Patient Center $1,512.00 $1,738.80 MULTAQ
400 MG TABLET(S) DRONEDARONE Sanofi Patient Connection $476.28 $547.72 HYDROCHLORIDE MYCAMINE
100 MG MG MICAFUNGIN SODIUM Astellas Stock Replacement Program $2,244.00 $2,580.60 50 MG MG MICAFUNGIN SODIUM Astellas Stock Replacement Program $1,122.00 $1,290.30 MYCOBUTIN
150 MG CAPSULE(S) RIFABUTIN Pfizer RxPathways $2,079.89 $2,391.87 MYCOPHENOLATE MOFETIL (BRAND: CELLCEPT)
250 MG CAPSULE(S) MYCOPHENOLATE MOFETIL Rx Outreach $392.32 $451.17 500 MG TABLET(S) MYCOPHENOLATE MOFETIL Rx Outreach $784.65 $902.35 250 MG CAPSULE(S) MYCOPHENOLATE MOFETIL Xubex Preferred Network Program $392.32 $451.17 500 MG TABLET(S) MYCOPHENOLATE MOFETIL Xubex Preferred Network Program $784.65 $902.35
Report Run: 04/19/16 10:53 AM Page 218 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
MYDFRIN
2.5 % (3 ML) DROP(S) PHENYLEPHRINE Alcon Charitable Clinic Program-For Free $16.62 $19.11 HYDROCHLORIDE Clinics MYDRIACYL
1 % (15 ML) DROP(S) TROPICAMIDE Alcon Cares, Inc. $90.30 $103.85 1 % (15 ML) DROP(S) TROPICAMIDE Alcon Charitable Clinic Program-For Free $90.30 $103.85 Clinics MYFORTIC
180 MG TABLET(S) MYCOPHENOLATE SODIUM Novartis Patient Assistance Foundation, Inc. $666.40 $766.36 360 MG TABLET(S) MYCOPHENOLATE SODIUM Novartis Patient Assistance Foundation, Inc. $1,332.79 $1,532.71 360 MG TABLET(S) MYCOPHENOLATE SODIUM Xubex Free Trial 30 Day Medication Supply $1,332.79 $1,532.71 MYRBETRIQ
25 MG TABLET(S) mirabegron Astellas Access Program for Myrbetriq $818.16 $940.88 50 MG TABLET(S) mirabegron Astellas Access Program for Myrbetriq $818.16 $940.88 MYSOLINE
250 MG TABLET(S) PRIMIDONE Valeant Patient Assistance Program $2,584.43 $2,972.09 50 MG TABLET(S) PRIMIDONE Valeant Patient Assistance Program $751.00 $863.65 NABUMETONE (BRAND: RELAFEN)
500 MG TABLET(S) NABUMETONE Nova ScriptsCentral-Northern Virginia Clinic $143.09 $164.55 Partners & Northern VA Residents ONLY 750 MG TABLET(S) NABUMETONE Nova ScriptsCentral-Northern Virginia Clinic $155.97 $179.37 Partners & Northern VA Residents ONLY 500 MG TABLET(S) NABUMETONE Rx Outreach $143.09 $164.55
Report Run: 04/19/16 10:53 AM Page 219 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NABUMETONE (BRAND: RELAFEN)
750 MG TABLET(S) NABUMETONE Rx Outreach $155.97 $179.37 500 MG TABLET(S) NABUMETONE Xubex Preferred Network Program $143.09 $164.55 750 MG TABLET(S) NABUMETONE Xubex Preferred Network Program $155.97 $179.37 NADOLOL (BRAND: CORGARD)
20 MG TABLET(S) NADOLOL Xubex Preferred Network Program $92.49 $106.36 40 MG TABLET(S) NADOLOL Xubex Preferred Network Program $108.15 $124.37 80 MG TABLET(S) NADOLOL Xubex Preferred Network Program $146.57 $168.56 NAMENDA
* 10 MG TABLET(S) MEMANTINE HYDROCHLORIDE Actavis U.S. Patient Assistance Program $406.86 $467.89 2 MG/ML MG memantine hydrochloride Actavis U.S. Patient Assistance Program $725.32 $834.12 * 5 MG TABLET(S) MEMANTINE HYDROCHLORIDE Actavis U.S. Patient Assistance Program $406.86 $467.89 NAMENDA TITRATION PAK
N/A N/A TABLET(S) MEMANTINE HYDROCHLORIDE Actavis U.S. Patient Assistance Program $306.18 $352.11 NAMENDA XR
28 MG CAPSULE(S) memantine hydrochloride Actavis U.S. Patient Assistance Program $386.53 $444.51 28 MG CAPSULE(S) memantine hydrochloride Xubex Free Trial 30 Day Medication Supply $386.53 $444.51 NAMENDA XR
14 MG CAPSULE(S) memantine hydrochloride Actavis U.S. Patient Assistance Program $386.53 $444.51 21 MG CAPSULE(S) memantine hydrochloride Actavis U.S. Patient Assistance Program $386.53 $444.51 7 MG CAPSULE(S) memantine hydrochloride Actavis U.S. Patient Assistance Program $386.53 $444.51
Report Run: 04/19/16 10:53 AM Page 220 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NAMENDA XR
14 MG CAPSULE(S) memantine hydrochloride Xubex Free Trial 30 Day Medication Supply $386.53 $444.51 21 MG CAPSULE(S) memantine hydrochloride Xubex Free Trial 30 Day Medication Supply $386.53 $444.51 7 MG CAPSULE(S) memantine hydrochloride Xubex Free Trial 30 Day Medication Supply $386.53 $444.51 NAMENDA XR TITRATION PACK
N/A N/A CAPSULE(S) memantine hydrochloride Actavis U.S. Patient Assistance Program $360.77 $414.89 NAMZARIC
10-14 MG-MG CAPSULE(S) donepezil Actavis U.S. Patient Assistance Program $386.53 $444.51 hydrochloride/memantine hydrochloride 10-28 MG-MG CAPSULE(S) donepezil Actavis U.S. Patient Assistance Program $386.53 $444.51 hydrochloride/memantine hydrochloride NAPHCON-A
0.025-0.3 %-% (15 ML) DROP(S) NAPHAZOLINE Alcon Charitable Clinic Program-For Free $8.04 $9.25 HYDROCHLORIDE/PHENIRAMIN Clinics E MALEATE 0.025-0.3 %-% (15 ML) DROP(S) NAPHAZOLINE Nova ScriptsCentral-Northern Virginia Clinic $8.04 $9.25 HYDROCHLORIDE/PHENIRAMIN Partners & Northern VA Residents ONLY E MALEATE NAPROXEN (BRAND: NAPROSYN)
250 MG TABLET(S) NAPROXEN Nova ScriptsCentral-Northern Virginia Clinic $77.70 $89.36 Partners & Northern VA Residents ONLY 500 MG TABLET(S) NAPROXEN Nova ScriptsCentral-Northern Virginia Clinic $129.90 $149.39 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 221 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NAPROXEN (BRAND: NAPROSYN)
250 MG TABLET(S) NAPROXEN Rx Outreach $77.70 $89.36 375 MG TABLET(S) NAPROXEN Rx Outreach $106.40 $122.36 500 MG TABLET(S) NAPROXEN Rx Outreach $129.90 $149.39 250 MG TABLET(S) NAPROXEN Xubex Preferred Network Program $77.70 $89.36 375 MG TABLET(S) NAPROXEN Xubex Preferred Network Program $106.40 $122.36 500 MG TABLET(S) NAPROXEN Xubex Preferred Network Program $129.90 $149.39 NAPROXEN SODIUM (BRAND: ANAPROX DS)
550 MG TABLET(S) NAPROXEN SODIUM Rx Outreach $141.99 $163.29 275 MG TABLET(S) NAPROXEN SODIUM Xubex Preferred Network Program $89.30 $102.70 550 MG TABLET(S) NAPROXEN SODIUM Xubex Preferred Network Program $141.99 $163.29 NARATRIPTAN (BRAND: AMERGE)
1 MG TABLET(S) naratriptan hydrochloride Xubex Preferred Network Program $265.41 $305.22 2.5 MG TABLET(S) naratriptan hydrochloride Xubex Preferred Network Program $265.41 $305.22 NARDIL
15 MG TABLET(S) PHENELZINE SULFATE Pfizer RxPathways $95.04 $109.30 NASCOBAL
500 MCG/0.1 ML SPRAY(S) CYANOCOBALAMIN Strativa Patient Assistance Program $433.36 $498.36 NASONEX
50 MCG SPRAY(S) MOMETASONE FUROATE Merck Patient Assistance Program $235.74 $271.10 50 MCG SPRAY(S) MOMETASONE FUROATE Nova ScriptsCentral-Northern Virginia Clinic $235.74 $271.10 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 222 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NASONEX
50 MCG SPRAY(S) MOMETASONE FUROATE Welvista - South Carolina Residents Only $235.74 $271.10 NATAZIA
3/2-2/2-3/1 MG TABLET(S) dienogest/estradiol valerate Bayer Patient Assistance Program-Beyaz, $371.54 $427.27 Safyral & Natazia NATEGLINIDE (BRAND: STARLIX)
120 MG TABLET(S) NATEGLINIDE Xubex Preferred Network Program $172.70 $198.61 60 MG TABLET(S) nateglinide Xubex Preferred Network Program $166.22 $191.15 NATRECOR
1.5 MG MG NESIRITIDE Johnson & Johnson Patient Assistance $1,270.21 $1,460.74 Foundation NEFAZODONE HCL (BRAND: SERZONE)
100 MG TABLET(S) nefazodone hydrochloride Xubex Preferred Network Program $230.36 $264.91 150 MG TABLET(S) nefazodone hydrochloride Xubex Preferred Network Program $234.71 $269.92 200 MG TABLET(S) nefazodone hydrochloride Xubex Preferred Network Program $239.12 $274.99 250 MG TABLET(S) nefazodone hydrochloride Xubex Preferred Network Program $243.54 $280.07 50 MG TABLET(S) nefazodone hydrochloride Xubex Preferred Network Program $374.89 $431.12 NEORAL
100 MG CAPSULE(S) CYCLOSPORINE Novartis Patient Assistance Foundation, Inc. $257.69 $296.34 25 MG CAPSULE(S) CYCLOSPORINE Novartis Patient Assistance Foundation, Inc. $64.69 $74.39 NEPRO WITH CARB STEADY (BUTTER PECAN)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $4.03 $4.63
Report Run: 04/19/16 10:53 AM Page 223 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NEPRO WITH CARB STEADY (MIXED BERRY)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $4.03 $4.63 NEPRO WITH CARB STEADY (VANILLA)
N/A N/A ML NUTRITIONAL SUPPLEMENT Abbott Nutrition Patient Assistance Program $4.03 $4.63 NESINA
12.5 MG TABLET(S) ALOGLIPTIN BENZOATE Takeda Patient Assistance Program $411.43 $473.14 25 MG TABLET(S) ALOGLIPTIN BENZOATE Takeda Patient Assistance Program $411.43 $473.14 6.25 MG TABLET(S) ALOGLIPTIN BENZOATE Takeda Patient Assistance Program $411.43 $473.14 NEULASTA
6/0.6 MG/ML MG PEGFILGRASTIM Amgen Safety Net Foundation $5,622.24 $6,465.58 NEUMEGA
5 MG INJECTION(S) OPRELVEKIN Pfizer RxPathways $386.64 $444.64 NEUPOGEN
300 MCG/1 ml MCG FILGRASTIM Amgen Safety Net Foundation $367.15 $422.22 480 MCG/0.8 ML MCG FILGRASTIM Amgen Safety Net Foundation $619.74 $712.70 NEUPOGEN
300 MCG/0.5 ML MCG FILGRASTIM Amgen Safety Net Foundation $389.16 $447.53 480 MCG/1.6ml MCG FILGRASTIM Amgen Safety Net Foundation $584.64 $672.34 NEUPRO
1/24 MG/HR PATCH rotigotine UCB Patient Assistance Program-Neupro $634.48 $729.65 2/24 MG/HR PATCH ROTIGOTINE UCB Patient Assistance Program-Neupro $634.48 $729.65
Report Run: 04/19/16 10:53 AM Page 224 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NEUPRO
3/24 MG/HR PATCH rotigotine UCB Patient Assistance Program-Neupro $634.48 $729.65 4/24 MG/HR PATCH rotigotine UCB Patient Assistance Program-Neupro $634.48 $729.65 6/24 MG/HR PATCH rotigotine UCB Patient Assistance Program-Neupro $634.48 $729.65 8/24 MG/HR PATCH rotigotine UCB Patient Assistance Program-Neupro $634.48 $729.65 NEURONTIN
250;5 MG/ML ML GABAPENTIN Pfizer MAINTAIN $251.50 $289.23 NEVANAC
0.1 % (3ML) DROP(S) NEPAFENAC Alcon Cares, Inc. $270.00 $310.50 0.1 % (3ML) DROP(S) NEPAFENAC Alcon Charitable Clinic Program-For Free $270.00 $310.50 Clinics NEVIRAPINE (BRAND: VIRAMUNE)
200 MG TABLET(S) nevirapine Xubex Preferred Network Program $650.05 $747.56 50/5 MG/ML (240 ML) ML nevirapine Xubex Preferred Network Program $189.28 $217.67 NEXAVAR
200 MG TABLET(S) SORAFENIB Bayer REACH Program $17,278.56 $19,870.34 NEXIUM CAPSULE
* 20 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings Program $852.22 $980.05 * 40 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings Program $903.35 $1,038.85 20 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM Welvista - South Carolina Residents Only $852.22 $980.05 40 MG CAPSULE(S) ESOMEPRAZOLE MAGNESIUM Welvista - South Carolina Residents Only $903.35 $1,038.85
Report Run: 04/19/16 10:53 AM Page 225 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NEXIUM I.V.
20 MG INJECTION(S) ESOMEPRAZOLE SODIUM AZ&Me Prescription Savings for people with $465.90 $535.79 Medicare Part D 40 MG INJECTION(S) ESOMEPRAZOLE SODIUM AZ&Me Prescription Savings for people with $535.79 $616.16 Medicare Part D 20 MG INJECTION(S) ESOMEPRAZOLE SODIUM AZ&Me Prescription Savings Program $465.90 $535.79 40 MG INJECTION(S) ESOMEPRAZOLE SODIUM AZ&Me Prescription Savings Program $535.79 $616.16 NEXIUM PACKETS
10 MG/PACKET PACKET(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings for people with $301.13 $346.30 Medicare Part D 20 MG/PACKET PACKET(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings for people with $301.13 $346.30 Medicare Part D 40 MG/PACKET PACKET(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings for people with $301.13 $346.30 Medicare Part D 20 MG/PACKET PACKET(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings Program $301.13 $346.30 40 MG/PACKET PACKET(S) ESOMEPRAZOLE MAGNESIUM AZ&Me Prescription Savings Program $301.13 $346.30 NIACIN ER
1000 MG TABLET(S) niacin Rx Outreach $674.40 $775.56 500 MG TABLET(S) niacin Rx Outreach $381.31 $438.51 1000 MG TABLET(S) niacin Xubex Preferred Network Program $674.40 $775.56 500 MG TABLET(S) niacin Xubex Preferred Network Program $381.31 $438.51 750 MG TABLET(S) niacin Xubex Preferred Network Program $543.89 $625.47 NIACOR (BRAND: NIACIN)
500 MG TABLET(S) NIACIN Rx Outreach $41.83 $48.10
Report Run: 04/19/16 10:53 AM Page 226 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NICARDIPINE HCL (BRAND: CARDENE)
20 MG CAPSULE(S) NICARDIPINE HYDROCHLORIDE Xubex Preferred Network Program $45.77 $52.64 30 MG CAPSULE(S) NICARDIPINE HYDROCHLORIDE Xubex Preferred Network Program $65.55 $75.38 NICOTROL INHALER
10 MG/ACTUATION CARTRIDGE NICOTINE Pfizer MAINTAIN $348.47 $400.74 10 MG/ACTUATION CARTRIDGE NICOTINE Pfizer RxPathways $348.47 $400.74 NICOTROL NS
10 MG/ML SPRAY(S) NICOTINE Pfizer RxPathways $365.89 $420.77 10 MG/ML SPRAY(S) NICOTINE Welvista - South Carolina Residents Only $365.89 $420.77 NIFEDIPINE ER
* 30 MG TABLET(S) nifedipine Generic Assistance Program (NeedyMeds & $110.21 $126.74 Rx Outreach) * 60 MG TABLET(S) nifedipine Generic Assistance Program (NeedyMeds & $182.76 $210.17 Rx Outreach) 30 MG TABLET(S) nifedipine Nova ScriptsCentral-Northern Virginia Clinic $110.21 $126.74 Partners & Northern VA Residents ONLY 60 MG TABLET(S) nifedipine Nova ScriptsCentral-Northern Virginia Clinic $182.76 $210.17 Partners & Northern VA Residents ONLY 90 MG TABLET(S) nifedipine Nova ScriptsCentral-Northern Virginia Clinic $230.88 $265.51 Partners & Northern VA Residents ONLY 30 MG TABLET(S) nifedipine Rx Outreach $110.21 $126.74 60 MG TABLET(S) nifedipine Rx Outreach $182.76 $210.17 30 MG TABLET(S) nifedipine Xubex Preferred Network Program $110.21 $126.74 60 MG TABLET(S) nifedipine Xubex Preferred Network Program $182.76 $210.17
Report Run: 04/19/16 10:53 AM Page 227 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NIFEDIPINE ER
90 MG TABLET(S) nifedipine Xubex Preferred Network Program $230.88 $265.51 NILANDRON
150 MG TABLET(S) NILUTAMIDE Rx Outreach $5,483.14 $6,305.61 NISOLDIPINE (BRAND: SULAR)
17 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $769.76 $885.22 20 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $1,645.22 $1,892.00 25.5 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $839.48 $965.40 30 MG TABLET(S) NISO' Xubex Preferred Network Program $1,794.20 $2,063.33 34 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $839.48 $965.40 40 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $1,794.20 $2,063.33 8.5 MG TABLET(S) NISOLDIPINE Xubex Preferred Network Program $618.18 $710.91 NITRO-DUR
0.1 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $128.32 $147.57 0.2 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $159.07 $182.93 0.3 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $178.26 $205.00 0.4 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $178.26 $205.00 0.6 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $193.28 $222.27 0.8 mg/hr PATCH NITROGLYCERIN Merck Patient Assistance Program $193.28 $222.27 NITROGLYCERIN (BRAND: NITROGLYCERIN )
6.5 MG CAPSULE(S) NITROGLYCERIN Rx Outreach $79.97 $91.97
Report Run: 04/19/16 10:53 AM Page 228 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NITROGLYCERIN (BRAND: NITROGLYCERIN)
2.5 MG CAPSULE(S) NITROGLYCERIN Rx Outreach $69.25 $79.64 9 MG CAPSULE(S) NITROGLYCERIN Rx Outreach $66.69 $76.69 NITROMIST
0.4 MG/ACTUATION (4.1 SPRAY(S) NITROGLYCERIN Akrimax Patient Assistance Program $441.74 $508.00 GM) NITROSTAT
0.3 MG TABLET(S) NITROGLYCERIN Pfizer MAINTAIN $25.56 $29.39 0.6 MG TABLET(S) NITROGLYCERIN Pfizer MAINTAIN $25.56 $29.39 0.3 MG TABLET(S) NITROGLYCERIN Pfizer RxPathways $25.56 $29.39 0.4 MG TABLET(S) NITROGLYCERIN Pfizer RxPathways $25.56 $29.39 0.6 MG TABLET(S) NITROGLYCERIN Pfizer RxPathways $25.56 $29.39 0.4 MG TABLET(S) NITROGLYCERIN Welvista - South Carolina Residents Only $25.56 $29.39 NORETHINDRONE (BRAND: ORTHO MICRONOR)
0.35 MG TABLET(S) NORETHINDRONE Rx Outreach $110.75 $127.36 NORETHINDRONE ACETATE (BRAND: AYGESTIN)
5 MG TABLET(S) NORETHINDRONE ACETATE Rx Outreach $132.43 $152.29 NORETHINDRONE/ETHINYL ESTRADIOL (BRAND: OVCON 35) 0.4/0.035 MG TABLET(S) NORETHINDRONE/ETHINYL Rx Outreach $296.38 $340.84 ESTRADIOL NORPACE
100 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer MAINTAIN $280.90 $323.04
Report Run: 04/19/16 10:53 AM Page 229 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NORPACE
150 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer MAINTAIN $331.90 $381.69 100 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer RxPathways $280.90 $323.04 150 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer RxPathways $331.90 $381.69 NORPACE CR
100 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer MAINTAIN $287.50 $330.63 150 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer MAINTAIN $339.79 $390.76 100 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer RxPathways $287.50 $330.63 150 MG CAPSULE(S) DISOPYRAMIDE PHOSPHATE Pfizer RxPathways $339.79 $390.76 NORTHERA
100 MG CAPSULE(S) droxidopa Northera Support Center $1,858.19 $2,136.92 200 MG CAPSULE(S) droxidopa Northera Support Center $3,716.38 $4,273.84 NORTHERA
300 MG CAPSULE(S) droxidopa Northera Support Center $5,574.56 $6,410.74 NORTRIPTYLINE HCL (BRAND: PAMELOR)
10 MG TABLET(S) NORTRIPTYLINE HCL Nova ScriptsCentral-Northern Virginia Clinic $31.59 $36.33 Partners & Northern VA Residents ONLY 25 MG TABLET(S) NORTRIPTYLINE HCL Nova ScriptsCentral-Northern Virginia Clinic $60.25 $69.29 Partners & Northern VA Residents ONLY 50 MG TABLET(S) NORTRIPTYLINE HCL Nova ScriptsCentral-Northern Virginia Clinic $111.50 $128.23 Partners & Northern VA Residents ONLY 10 MG TABLET(S) NORTRIPTYLINE HCL Rx Outreach $31.59 $36.33 25 MG TABLET(S) NORTRIPTYLINE HCL Rx Outreach $60.25 $69.29
Report Run: 04/19/16 10:53 AM Page 230 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NORTRIPTYLINE HCL (BRAND: PAMELOR)
50 MG TABLET(S) NORTRIPTYLINE HCL Rx Outreach $111.50 $128.23 75 MG TABLET(S) NORTRIPTYLINE HCL Rx Outreach $193.59 $222.63 10 MG TABLET(S) NORTRIPTYLINE HCL Xubex Preferred Network Program $31.59 $36.33 25 MG TABLET(S) NORTRIPTYLINE HCL Xubex Preferred Network Program $60.25 $69.29 50 MG TABLET(S) NORTRIPTYLINE HCL Xubex Preferred Network Program $111.50 $128.23 75 MG TABLET(S) NORTRIPTYLINE HCL Xubex Preferred Network Program $193.59 $222.63 NORVIR
100 MG CAPSULE(S) RITONAVIR AbbVie Norvir Kaletra Patient Assistance $308.60 $354.89 Program 80 MG/ML (240ml) ML RITONAVIR AbbVie Norvir Kaletra Patient Assistance $1,728.24 $1,987.48 Program NOVAREL
10000 U VIAL chorionic gonadotropin Heart Beat Program $264.96 $304.70 NOVOFINE 30G FLEXPEN NEEDLE
N/A N/A NEEDLE(S) INSULIN SYRINGE/NEEDLE Novo Nordisk Patient Assistance Program $36.47 $41.94 N/A N/A NEEDLE(S) INSULIN SYRINGE/NEEDLE Welvista - South Carolina Residents Only $36.47 $41.94 NOVOFINE 32 GAUGE NEEDLE
N/A N/A NEEDLE(S) INSULIN SYRINGE/NEEDLE Novo Nordisk Patient Assistance Program $42.02 $48.32 N/A N/A NEEDLE(S) INSULIN SYRINGE/NEEDLE Welvista - South Carolina Residents Only $42.02 $48.32 NOVOFINE TIP 32 G, 6MM
N/A N/A NEEDLE TIPS Novo Nordisk Patient Assistance Program $44.58 $51.27
Report Run: 04/19/16 10:53 AM Page 231 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NOVOFINE TIP 32 G, 6MM
N/A N/A NEEDLE TIPS Welvista - South Carolina Residents Only $44.58 $51.27 NOVOLIN 70/30
70-30 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Novo Nordisk Patient Assistance Program $144.54 $166.22 (NPH)/INSULIN HUMAN REGULAR 70-30 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Welvista - South Carolina Residents Only $144.54 $166.22 (NPH)/INSULIN HUMAN REGULAR NOVOLIN N
100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Novo Nordisk Patient Assistance Program $144.54 $166.22 (NPH) 100 U/ML (10ML) UNIT(S) INSULIN HUMAN ISOPHANE Welvista - South Carolina Residents Only $144.54 $166.22 (NPH) NOVOLIN R
100 U/ML (10ML) UNIT(S) INSULIN HUMAN REGULAR Novo Nordisk Patient Assistance Program $144.54 $166.22 100 U/ML (10ML) UNIT(S) INSULIN HUMAN REGULAR Welvista - South Carolina Residents Only $144.54 $166.22 NOVOLOG FLEXPEN
* 100 U/ML (3ML) UNIT(S) INSULIN ASPART, HUMAN Novo Nordisk Patient Assistance Program $517.92 $595.61 100 U/ML (3ML) UNIT(S) INSULIN ASPART, HUMAN Welvista - South Carolina Residents Only $517.92 $595.61 NOVOLOG MIX 70/30
70-30 U/ML (10 ML) UNIT(S) INSULIN ASPART/INSULIN Novo Nordisk Patient Assistance Program $278.10 $319.82 ASPART PROTAMINE
Report Run: 04/19/16 10:53 AM Page 232 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NOVOLOG MIX 70/30
70-30 U/ML (10 ML) UNIT(S) INSULIN ASPART/INSULIN Welvista - South Carolina Residents Only $278.10 $319.82 ASPART PROTAMINE NOVOLOG MIX 70/30 FLEXPEN
* 70-30 U/ML (3ML) UNIT(S) INSULIN ASPART/INSULIN Novo Nordisk Patient Assistance Program $517.92 $595.61 ASPART PROTAMINE 70-30 U/ML (3ML) UNIT(S) INSULIN ASPART/INSULIN Welvista - South Carolina Residents Only $517.92 $595.61 ASPART PROTAMINE NOVOLOG VIAL
100 U/ML (10 ML) UNIT(S) INSULIN ASPART, HUMAN Novo Nordisk Patient Assistance Program $268.14 $308.36 100 U/ML (10 ML) UNIT(S) INSULIN ASPART, HUMAN Welvista - South Carolina Residents Only $268.14 $308.36 NOVOTWIST 30 G NEEDLES
N/A N/A NEEDLE(S) NEEDLE Novo Nordisk Patient Assistance Program $36.82 $42.34 NOVOTWIST 32 G NEEDLES
N/A N/A NEEDLE(S) NEEDLE Novo Nordisk Patient Assistance Program $43.70 $50.26 NOXAFIL
100 MG TABLET(S) POSACONAZOLE Merck-The ACT Program $3,867.34 $4,447.44 40 MG/ML ML POSACONAZOLE Merck-The ACT Program $1,230.52 $1,415.10 NPLATE
250 MCG MCG ROMIPLOSTIM Amgen Safety Net Foundation $1,680.42 $1,932.48 500 MCG MCG ROMIPLOSTIM Amgen Safety Net Foundation $3,360.84 $3,864.97
Report Run: 04/19/16 10:53 AM Page 233 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NUCYNTA
100 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $744.00 $855.60 Foundation-Card Program 50 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $477.60 $549.24 Foundation-Card Program 75 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $559.20 $643.08 Foundation-Card Program NUCYNTA ER
100 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $570.96 $656.60 Foundation-Card Program 150 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $736.56 $847.04 Foundation-Card Program 200 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $935.28 $1,075.57 Foundation-Card Program 250 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $1,170.00 $1,345.50 Foundation-Card Program 50 MG TABLET(S) TAPENTADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $308.88 $355.21 Foundation-Card Program NUEDEXTA
20-10 MG CAPSULE(S) dextromethorphan Avanir Nuedexta Patient Assistance Program $813.60 $935.64 hydrobromide/quinidine sulfate NULOJIX
250 MG MG BELATACEPT Bristol-Myers Squibb Patient Assistance $1,107.60 $1,273.74 Foundation, Inc.
Report Run: 04/19/16 10:53 AM Page 234 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
NUVIGIL
150 MG TABLET(S) ARMODAFINIL Teva Cares Foundation Patient Assistance $663.60 $763.14 Program 200 MG TABLET(S) ARMODAFINIL Teva Cares Foundation Patient Assistance $663.60 $763.14 Program 250 MG TABLET(S) ARMODAFINIL Teva Cares Foundation Patient Assistance $663.60 $763.14 Program 50 MG TABLET(S) ARMODAFINIL Teva Cares Foundation Patient Assistance $220.80 $253.92 Program NYSTATIN
500000 U TABLET(S) NYSTATIN Rx Outreach $142.08 $163.39 NYSTATIN CREAM (BRAND: PEDIADERM AF)
100000 U/GM (15 GM) APPLICATION(S) nystatin Nova ScriptsCentral-Northern Virginia Clinic $17.50 $20.13 Partners & Northern VA Residents ONLY 100000 U/GM (15 GM) APPLICATION(S) nystatin Xubex Preferred Network Program $17.50 $20.13 ODEFSEY
200-25-25 MG-MG-MG TABLET(S) emtricitabine/rilpivirine/tenofo Gilead Advancing Access $2,815.04 $3,237.30 vir alafenamide OFEV
100 MG CAPSULE(S) nintedanib Boehringer Ingelheim Cares Foundation Inc. $9,600.00 $11,040.00 150 MG CAPSULE(S) nintedanib Boehringer Ingelheim Cares Foundation Inc. $9,600.00 $11,040.00 OLANZAPINE (BRAND: ZYPREXA)
* 10 MG TABLET(S) OLANZAPINE Generic Assistance Program (NeedyMeds & $1,991.52 $2,290.25 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 235 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OLANZAPINE (BRAND: ZYPREXA)
* 2.5 MG TABLET(S) OLANZAPINE Generic Assistance Program (NeedyMeds & $1,119.74 $1,287.70 Rx Outreach) * 5 MG TABLET(S) OLANZAPINE Generic Assistance Program (NeedyMeds & $1,319.76 $1,517.72 Rx Outreach) * 7.5 MG TABLET(S) OLANZAPINE Generic Assistance Program (NeedyMeds & $1,608.34 $1,849.59 Rx Outreach) 10 MG TABLET(S) OLANZAPINE Rx Outreach $1,991.52 $2,290.25 15 MG TABLET(S) OLANZAPINE Rx Outreach $2,987.28 $3,435.37 2.5 MG TABLET(S) OLANZAPINE Rx Outreach $1,119.74 $1,287.70 20 MG TABLET(S) olanzapine Rx Outreach $3,983.00 $4,580.45 5 MG TABLET(S) OLANZAPINE Rx Outreach $1,319.76 $1,517.72 7.5 MG TABLET(S) OLANZAPINE Rx Outreach $1,608.34 $1,849.59 10 MG TABLET(S) OLANZAPINE Welvista - South Carolina Residents Only $1,991.52 $2,290.25 2.5 MG TABLET(S) OLANZAPINE Welvista - South Carolina Residents Only $1,119.74 $1,287.70 10 MG TABLET(S) OLANZAPINE Xubex Preferred Network Program $1,991.52 $2,290.25 15 MG TABLET(S) OLANZAPINE Xubex Preferred Network Program $2,987.28 $3,435.37 2.5 MG TABLET(S) OLANZAPINE Xubex Preferred Network Program $1,119.74 $1,287.70 5 MG TABLET(S) OLANZAPINE Xubex Preferred Network Program $1,319.76 $1,517.72 7.5 MG TABLET(S) OLANZAPINE Xubex Preferred Network Program $1,608.34 $1,849.59 OLANZAPINE ODT (BRAND: ZYPREXA)
10 MG TABLET(S) olanzapine Xubex Preferred Network Program $622.22 $715.55 15 MG TABLET(S) olanzapine Xubex Preferred Network Program $917.63 $1,055.27
Report Run: 04/19/16 10:53 AM Page 236 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OLANZAPINE ODT (BRAND: ZYPREXA)
20 MG TABLET(S) olanzapine Xubex Preferred Network Program $1,213.03 $1,394.98 5 MG TABLET(S) olanzapine Xubex Preferred Network Program $423.47 $486.99 OLYSIO
150 MG CAPSULE(S) SIMEPREVIR Johnson & Johnson Patient Assistance $26,544.00 $30,525.60 Foundation-Card Program OMEPRAZOLE (BRAND: PRILOSEC)
20 MG CAPSULE(S) OMEPRAZOLE Nova ScriptsCentral-Northern Virginia Clinic $360.00 $414.00 Partners & Northern VA Residents ONLY 10 MG CAPSULE(S) OMEPRAZOLE Rx Outreach $369.99 $425.49 20 MG CAPSULE(S) OMEPRAZOLE Rx Outreach $360.00 $414.00 40 MG CAPSULE(S) OMEPRAZOLE Rx Outreach $69.31 $79.71 20 MG CAPSULE(S) OMEPRAZOLE Welvista - South Carolina Residents Only $360.00 $414.00 40 MG CAPSULE(S) OMEPRAZOLE Welvista - South Carolina Residents Only $69.31 $79.71 20 MG CAPSULE(S) OMEPRAZOLE Xubex Patient Assistance Program $360.00 $414.00 10 MG CAPSULE(S) OMEPRAZOLE Xubex Preferred Network Program $369.99 $425.49 20 MG CAPSULE(S) OMEPRAZOLE Xubex Preferred Network Program $360.00 $414.00 40 MG CAPSULE(S) OMEPRAZOLE Xubex Preferred Network Program $69.31 $79.71 OMEPRAZOLE/SODIUM BICARBONATE (BRAND: ZEGERID) 20-1100 MG-MG CAPSULE(S) omeprazole/sodium Xubex Preferred Network Program $413.61 $475.65 bicarbonate 40-1100 MG-MG CAPSULE(S) omeprazole/sodium Xubex Preferred Network Program $413.61 $475.65 bicarbonate
Report Run: 04/19/16 10:53 AM Page 237 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OMNIPRED
1 % (10 ML) DROP(S) PREDNISOLONE ACETATE Alcon Cares, Inc. $140.64 $161.74 1 % (10 ML) DROP(S) PREDNISOLONE ACETATE Alcon Charitable Clinic Program-For Free $140.64 $161.74 Clinics ONCASPAR
750 IU/ML (5ML) IU PEGASPARGASE Sigma-Tau Patient Assistance Program $3,280.00 $3,772.00 ONDANSETRON (BRAND: ZOFRAN)
4 MG TABLET(S) ONDANSETRON Rx Outreach $668.78 $769.10 8 MG TABLET(S) ONDANSETRON Rx Outreach $1,113.95 $1,281.04 4 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $668.78 $769.10 8 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $1,113.95 $1,281.04 4 MG TABLET(S) ONDANSETRON Xubex Preferred Network Program $668.78 $769.10 8 MG TABLET(S) ONDANSETRON Xubex Preferred Network Program $1,113.95 $1,281.04 ONDANSETRON ODT (BRAND: ZOFRAN ODT)
4 MG TABLET(S) ONDANSETRON Rx Outreach $2,006.34 $2,307.29 8 MG TABLET(S) ONDANSETRON Rx Outreach $104.82 $120.54 4 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $2,006.34 $2,307.29 8 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $104.82 $120.54 4 MG TABLET(S) ONDANSETRON Xubex Preferred Network Program $2,006.34 $2,307.29 8 MG TABLET(S) ONDANSETRON Xubex Preferred Network Program $104.82 $120.54 ONFI
10 MG TABLET(S) clobazam ONFI Patient Assistance Program $971.22 $1,116.90
Report Run: 04/19/16 10:53 AM Page 238 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ONFI
20 MG TABLET(S) clobazam ONFI Patient Assistance Program $1,942.42 $2,233.78 5 MG TABLET(S) clobazam ONFI Patient Assistance Program $443.47 $509.99 10 MG TABLET(S) clobazam Xubex Free Trial 30 Day Medication Supply $971.22 $1,116.90 20 MG TABLET(S) clobazam Xubex Free Trial 30 Day Medication Supply $1,942.42 $2,233.78 ONGLYZA
2.5 MG TABLET(S) SAXAGLIPTIN HYDROCHLORIDE AZ&Me Prescription Savings Program $1,169.62 $1,345.06 5 MG TABLET(S) SAXAGLIPTIN HYDROCHLORIDE AZ&Me Prescription Savings Program $1,169.62 $1,345.06 2.5 MG TABLET(S) SAXAGLIPTIN HYDROCHLORIDE Welvista - South Carolina Residents Only $1,169.62 $1,345.06 5 MG TABLET(S) SAXAGLIPTIN HYDROCHLORIDE Welvista - South Carolina Residents Only $1,169.62 $1,345.06 ONTAK
150 MCG/ML INJECTION(S) DENILEUKIN DIFTITOX Eisai Patient Assistance Program $1,863.60 $2,143.14 OPANA ER
* 10 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $435.08 $500.34 HYDROCHLORIDE * 15 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $498.46 $573.23 HYDROCHLORIDE * 20 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $771.66 $887.41 HYDROCHLORIDE * 30 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $1,110.68 $1,277.28 HYDROCHLORIDE * 40 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $1,449.72 $1,667.18 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 239 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OPANA ER
* 5 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $226.57 $260.56 HYDROCHLORIDE * 7.5 MG TABLET(S) OXYMORPHONE Endo Patient Assistance Program-Opana ER $273.30 $314.29 HYDROCHLORIDE OPDIVO
10 MG/ML (10 ML) MG nivolumab Bristol-Myers Squibb Access Support $2,920.76 $3,358.87 Oncology Patient Assistance Program OPDIVO
10 MG/ML (4 ML) MG nivolumab Bristol-Myers Squibb Access Support $1,168.31 $1,343.56 Oncology Patient Assistance Program OPSUMIT
10 MG TABLET(S) macitentan Actelion Pathways $9,054.00 $10,412.10 ORACEA
40 MG CAPSULE(S) DOXYCYCLINE Galderma Patient Assistance Program $755.88 $869.26 ORAP
1 MG TABLET(S) PIMOZIDE Teva Cares Foundation Patient Assistance $203.32 $233.82 Program 2 MG TABLET(S) PIMOZIDE Teva Cares Foundation Patient Assistance $271.07 $311.73 Program ORBACTIV
400 MG VIAL(S) oritavancin Orbactiv Support Program $3,480.00 $4,002.00
Report Run: 04/19/16 10:53 AM Page 240 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ORENCIA
250 MG MG ABATACEPT Bristol-Myers Squibb Patient Assistance $944.24 $1,085.88 Foundation, Inc. ORENCIA PREFILLED SYRINGE
125 MG/ML SYRINGE ABATACEPT Bristol-Myers Squibb Patient Assistance $2,529.35 $2,908.75 Foundation, Inc. ORTHOVISC
30 MG/ML (2 ML) INJECTION(S) HYALURONIC ACID Johnson & Johnson Patient Assistance $436.80 $502.32 Foundation OSENI
12.5-15 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride 12.5-30 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride 25-30 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride 25-45 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride OSENI
12.5-45 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride 25-15 MG-MG TABLET(S) alogliptin benzoate/pioglitazone Takeda Patient Assistance Program $411.43 $473.14 hydrochloride
Report Run: 04/19/16 10:53 AM Page 241 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OSMOPREP
0.398-1.102 GM-GM TABLET(S) NA PHOS, DIBASIC/NA PHOS, Salix Patient Assistance Program $542.40 $623.76 MONOBASIC OTEZLA
30 MG TABLET(S) apremilast Otezla SupportPlus Program $2,250.00 $2,587.50 OTEZLA TITRATION STARTER PACK
n/a N/A TABLET(S) apremilast Otezla SupportPlus Program $1,012.50 $1,164.38 OXANDROLONE (BRAND: OXANDRIN)
10 MG TABLET(S) oxandrolone Rx Outreach $1,875.05 $2,156.31 2.5 MG TABLET(S) oxandrolone Rx Outreach $552.95 $635.89 10 MG TABLET(S) oxandrolone Xubex Preferred Network Program $1,875.05 $2,156.31 2.5 MG TABLET(S) oxandrolone Xubex Preferred Network Program $552.95 $635.89 OXAPROZIN (BRAND: DAYPRO)
600 MG TABLET(S) OXAPROZIN Xubex Preferred Network Program $151.50 $174.23 OXAZEPAM (BRAND: SERAX)
10 MG CAPSULE(S) oxazepam Xubex Preferred Network Program $86.99 $100.04 15 MG CAPSULE(S) oxazepam Xubex Preferred Network Program $108.99 $125.34 30 MG CAPSULE(S) oxazepam Xubex Preferred Network Program $163.99 $188.59 OXCARBAZEPINE (BRAND: TRILEPTAL, OXTELLAR XR)
150 MG TABLET(S) oxcarbazepine Rx Outreach $145.36 $167.16 300 MG TABLET(S) oxcarbazepine Rx Outreach $278.73 $320.54 600 MG TABLET(S) oxcarbazepine Rx Outreach $512.31 $589.16
Report Run: 04/19/16 10:53 AM Page 242 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OXCARBAZEPINE (BRAND: TRILEPTAL, OXTELLAR XR)
150 MG TABLET(S) oxcarbazepine Xubex Preferred Network Program $145.36 $167.16 300 MG TABLET(S) oxcarbazepine Xubex Preferred Network Program $278.73 $320.54 300/5 MG/ML (250 ML) ML oxcarbazepine Xubex Preferred Network Program $273.01 $313.96 600 MG TABLET(S) oxcarbazepine Xubex Preferred Network Program $512.31 $589.16 OXSORALEN-ULTRA
10 MG CAPSULE(S) METHOXSALEN Valeant Patient Assistance Program $4,829.24 $5,553.63 OXTELLAR XR
150 MG TABLET(S) oxcarbazepine Oxtellar XR Patient Savings and Support $478.60 $550.39 Program 300 MG TABLET(S) oxcarbazepine Oxtellar XR Patient Savings and Support $664.91 $764.65 Program 600 MG TABLET(S) oxcarbazepine Oxtellar XR Patient Savings and Support $1,217.38 $1,399.99 Program OXYBUTYNIN (BRAND: DITROPAN)
5 MG TABLET(S) OXYBUTYNIN CHLORIDE Rx Outreach $8.13 $9.35 5 MG TABLET(S) OXYBUTYNIN CHLORIDE Xubex Preferred Network Program $8.13 $9.35 OXYBUTYNIN CHLORIDE (BRAND: DITROPAN XL)
10 MG TABLET(S) oxybutynin chloride Rx Outreach $328.75 $378.06 15 MG TABLET(S) oxybutynin chloride Rx Outreach $333.95 $384.04 5 MG TABLET(S) oxybutynin chloride Rx Outreach $328.40 $377.66 10 MG TABLET(S) oxybutynin chloride Xubex Preferred Network Program $328.75 $378.06 5 MG TABLET(S) oxybutynin chloride Xubex Preferred Network Program $328.40 $377.66
Report Run: 04/19/16 10:53 AM Page 243 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
OXYCONTIN
10 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $367.84 $423.02 EXTENDED RELEASE 15 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $541.54 $622.77 EXTENDED RELEASE 20 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $686.00 $788.90 EXTENDED RELEASE 30 MG TABLET, EXTENDED OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $954.07 $1,097.18 RELEASE 40 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $1,174.86 $1,351.09 EXTENDED RELEASE 60 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $1,663.40 $1,912.91 EXTENDED RELEASE 80 MG TABLET(S), OXYCODONE HYDROCHLORIDE Purdue Pharma Patient Assistance Program $2,050.09 $2,357.60 EXTENDED RELEASE OZURDEX
0.7 MG APPLICATOR dexamethasone Allergan Ozurdex Patient Assistance Program $1,559.60 $1,793.54 PAMELOR
10 MG CAPSULE(S) NORTRIPTYLINE Covidien/Mallinckrodt Patient Assistance $1,091.54 $1,255.27 HYDROCHLORIDE Program 25 MG CAPSULE(S) NORTRIPTYLINE Covidien/Mallinckrodt Patient Assistance $1,113.37 $1,280.38 HYDROCHLORIDE Program 50 MG CAPSULE(S) NORTRIPTYLINE Covidien/Mallinckrodt Patient Assistance $1,135.21 $1,305.49 HYDROCHLORIDE Program 75 MG CAPSULE(S) NORTRIPTYLINE Covidien/Mallinckrodt Patient Assistance $1,157.04 $1,330.60 HYDROCHLORIDE Program
Report Run: 04/19/16 10:53 AM Page 244 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PANCREAZE
17500-4200-10000 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $110.59 $127.18 Foundation 43750-10500- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $276.55 $318.03 25000 Foundation 61000-21000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $552.94 $635.88 37000 Foundation 70000-16800- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $443.95 $510.54 40000 Foundation 17500-4200-10000 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $110.59 $127.18 Foundation-Card Program 43750-10500- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $276.55 $318.03 25000 Foundation-Card Program 61000-21000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $552.94 $635.88 37000 Foundation-Card Program 70000-16800- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Johnson & Johnson Patient Assistance $443.95 $510.54 40000 Foundation-Card Program 17500-4200-10000 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Welvista - South Carolina Residents Only $110.59 $127.18 43750-10500- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Welvista - South Carolina Residents Only $276.55 $318.03 25000 61000-21000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Welvista - South Carolina Residents Only $552.94 $635.88 37000 70000-16800- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Welvista - South Carolina Residents Only $443.95 $510.54 40000 PANRETIN
0.1 % (60 GM) APPLICATION(S) ALITRETINOIN Eisai Patient Assistance Program $4,339.20 $4,990.08
Report Run: 04/19/16 10:53 AM Page 245 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PANRETIN
0.1 % (60 GM) APPLICATION(S) ALITRETINOIN Rx Outreach $4,339.20 $4,990.08 PANTOPRAZOLE (BRAND: PROTONIX)
20 MG TABLET(S) PANTOPRAZOLE Rx Outreach $368.22 $423.45 40 MG TABLET(S) PANTOPRAZOLE Rx Outreach $368.22 $423.45 20 MG TABLET(S) PANTOPRAZOLE Xubex Preferred Network Program $368.22 $423.45 40 MG TABLET(S) PANTOPRAZOLE Xubex Preferred Network Program $368.22 $423.45 PARAFON FORTE DSC
500 MG TABLET(S) CHLORZOXAZONE Johnson & Johnson Patient Assistance $405.31 $466.11 Foundation 500 MG TABLET(S) CHLORZOXAZONE Welvista - South Carolina Residents Only $405.31 $466.11 PARCOPA
10-100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Parcopa Patient Assistance Program $103.79 $119.36 25-100 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Parcopa Patient Assistance Program $117.19 $134.77 25-250 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Parcopa Patient Assistance Program $149.32 $171.72 PARNATE
10 MG TABLET(S) TRANYLCYPROMINE SULFATE Rx Outreach $765.60 $880.44 PAROXETINE HCL (BRAND: PAXIL (HCL)
10 MG TABLET(S) PAROXETINE HCL Nova ScriptsCentral-Northern Virginia Clinic $227.97 $262.17 Partners & Northern VA Residents ONLY 20 MG TABLET(S) PAROXETINE HCL Nova ScriptsCentral-Northern Virginia Clinic $237.84 $273.52 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 246 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PAROXETINE HCL (BRAND: PAXIL (HCL)
30 MG TABLET(S) PAROXETINE HCL Nova ScriptsCentral-Northern Virginia Clinic $245.01 $281.76 Partners & Northern VA Residents ONLY 40 MG TABLET(S) PAROXETINE HCL Nova ScriptsCentral-Northern Virginia Clinic $258.84 $297.67 Partners & Northern VA Residents ONLY 10 MG TABLET(S) PAROXETINE HCL Rx Outreach $227.97 $262.17 20 MG TABLET(S) PAROXETINE HCL Rx Outreach $237.84 $273.52 30 MG TABLET(S) PAROXETINE HCL Rx Outreach $245.01 $281.76 40 MG TABLET(S) PAROXETINE HCL Rx Outreach $258.84 $297.67 10 MG TABLET(S) PAROXETINE HCL Xubex Preferred Network Program $227.97 $262.17 20 MG TABLET(S) PAROXETINE HCL Xubex Preferred Network Program $237.84 $273.52 30 MG TABLET(S) PAROXETINE HCL Xubex Preferred Network Program $245.01 $281.76 40 MG TABLET(S) PAROXETINE HCL Xubex Preferred Network Program $258.84 $297.67 PATADAY
0.2 % (2.5ML) DROP(S) OLOPATADINE HYDROCHLORIDE Alcon Cares, Inc. $189.84 $218.32 0.2 % (2.5ML) DROP(S) OLOPATADINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $189.84 $218.32 Clinics PATANASE
0.6 % (30.5 GM) SPRAY(S) OLOPATADINE HYDROCHLORIDE Alcon Cares, Inc. $114.78 $132.00 0.6 % (30.5 GM) SPRAY(S) OLOPATADINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $114.78 $132.00 Clinics PATANOL
0.1 % (5 ML) DROP(S) OLOPATADINE HYDROCHLORIDE Alcon Cares, Inc. $285.00 $327.75
Report Run: 04/19/16 10:53 AM Page 247 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PATANOL
0.1 % (5 ML) DROP(S) OLOPATADINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $285.00 $327.75 Clinics PAXIL
* 10 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $132.90 $152.83 * 20 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $138.66 $159.46 * 30 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $142.85 $164.28 * 40 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $150.92 $173.56 * 10 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $132.90 $152.83 * 20 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $138.66 $159.46 * 30 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $142.85 $164.28 * 40 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $150.92 $173.56 PAXIL CR
12.5 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $136.88 $157.41 25 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $142.84 $164.27 37.5 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Access $147.14 $169.21 * 12.5 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $136.88 $157.41 * 25 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $142.84 $164.27 * 37.5 MG TABLET(S) PAROXETINE HYDROCHLORIDE GSK Bridges to Access $147.14 $169.21 PEGASYS (SYRINGE)
180/0.5 MCG/ML SYRINGE PEGINTERFERON ALFA-2A Access to Care-Pegasys $4,533.65 $5,213.70
Report Run: 04/19/16 10:53 AM Page 248 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PEGASYS (VIAL)
180 MCG/ML (1ML) MCG peginterferon alfa-2a Access to Care-Pegasys $1,133.41 $1,303.42 PEGASYS PROCLICK
135/0.5 MCG/ML (0.5 ML) AUTOINJECTOR peginterferon alfa-2a Access to Care-Pegasys $4,533.65 $5,213.70 180/0.5 MCG/ML (0.5ML) AUTOINJECTOR peginterferon alfa-2a Access to Care-Pegasys $4,533.65 $5,213.70 PEGINTRON
120 MCG KIT PEGINTERFERON ALFA-2B Merck-The ACT Program $995.06 $1,144.32 150 MCG KIT PEGINTERFERON ALFA-2B Merck-The ACT Program $1,044.84 $1,201.57 50 MCG KIT PEGINTERFERON ALFA-2B Merck-The ACT Program $902.60 $1,037.99 80 MCG KIT PEGINTERFERON ALFA-2B Merck-The ACT Program $947.63 $1,089.77 PENTASA
250 MG CAPSULE(S) MESALAMINE Shire Cares Patient Assistance & Support $674.46 $775.63 Program 500 MG CAPSULE(S) MESALAMINE Shire Cares Patient Assistance & Support $674.46 $775.63 Program PENTOXIFYLLINE (BRAND: TRENTAL)
400 MG TABLET(S) PENTOXIFYLLINE Rx Outreach $64.70 $74.40 400 MG TABLET(S) PENTOXIFYLLINE Xubex Patient Assistance Program $64.70 $74.40 400 MG TABLET(S) PENTOXIFYLLINE Xubex Preferred Network Program $64.70 $74.40 PERINDOPRIL (BRAND: ACEON)
2 MG TABLET(S) perindopril erbumine Xubex Preferred Network Program $189.77 $218.24 4 MG TABLET(S) perindopril erbumine Xubex Preferred Network Program $221.27 $254.46
Report Run: 04/19/16 10:53 AM Page 249 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PERINDOPRIL (BRAND: ACEON)
8 MG TABLET(S) perindopril erbumine Xubex Preferred Network Program $268.76 $309.07 PERJETA
30 MG/ML (14 ML) MG pertuzumab Genentech BioOncology Access to Solutions- $4,890.79 $5,624.41 Infused Products PERPHENAZINE (BRAND: TRILAFON)
16 MG TABLET(S) perphenazine Rx Outreach $259.95 $298.94 2 MG TABLET(S) perphenazine Rx Outreach $116.38 $133.84 4 MG TABLET(S) perphenazine Rx Outreach $159.30 $183.20 8 MG TABLET(S) perphenazine Rx Outreach $193.22 $222.20 16 MG TABLET(S) perphenazine Xubex Preferred Network Program $259.95 $298.94 2 MG TABLET(S) perphenazine Xubex Preferred Network Program $116.38 $133.84 4 MG TABLET(S) perphenazine Xubex Preferred Network Program $159.30 $183.20 8 MG TABLET(S) perphenazine Xubex Preferred Network Program $193.22 $222.20 PERTZYE (Qty: 100)
30250-8000-28750 U-U-U CAPSULE(S) amylase/lipase/protease Chiesi CAREDIRECT $198.75 $228.56 60500-16000- U-U-U CAPSULE(S) amylase/lipase/protease Chiesi CAREDIRECT $398.75 $458.56 57500 PERTZYE (Qty: 250)
30250-8000-28750 U-U-U CAPSULE(S) amylase/lipase/protease Chiesi CAREDIRECT $496.88 $571.41 60500-16000- U-U-U CAPSULE(S) amylase/lipase/protease Chiesi CAREDIRECT $996.88 $1,146.41 57500
Report Run: 04/19/16 10:53 AM Page 250 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PHENOBARBITAL (BRAND: PHENOBARBITAL)
16.2 MG TABLET(S) PHENOBARBITAL Xubex Preferred Network Program $22.95 $26.39 32.4 MG TABLET(S) PHENOBARBITAL Xubex Preferred Network Program $28.91 $33.25 64.8 MG TABLET(S) PHENOBARBITAL Xubex Preferred Network Program $36.23 $41.66 97.2 MG TABLET(S) PHENOBARBITAL Xubex Preferred Network Program $51.08 $58.74 PHENYTOIN SODIUM (BRAND: DILANTIN)
* 100 MG TABLET(S) PHENYTOIN SODIUM Generic Assistance Program (NeedyMeds & $33.88 $38.96 Rx Outreach) 100 MG TABLET(S) PHENYTOIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $33.88 $38.96 Partners & Northern VA Residents ONLY 100 MG TABLET(S) PHENYTOIN SODIUM Rx Outreach $33.88 $38.96 100 MG TABLET(S) PHENYTOIN SODIUM Xubex Preferred Network Program $33.88 $38.96 PHOSLO
667 MG CAPSULE(S) CALCIUM ACETATE PhosLo Patient Assistance Program $168.43 $193.69 PHOSLYRA
667 MG/5ML (473 ML) SOL Calcium Acetate Fresenius Phoslyra & Velphoro Patient $105.60 $121.44 Assistance Program PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION
0.125 % DROP(S) ECHOTHIOPHATE IODIDE Pfizer RxPathways $80.45 $92.52 PILOPINE-HS
4 % 4gm GEL/JELLY PILOCARPINE HYDROCHLORIDE Alcon Cares, Inc. $109.50 $125.93 4 % 4gm GEL/JELLY PILOCARPINE HYDROCHLORIDE Alcon Charitable Clinic Program-For Free $109.50 $125.93 Clinics
Report Run: 04/19/16 10:53 AM Page 251 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PIOGLITAZONE HCL (BRAND: ACTOS)
15 MG TABLET (S) PIOGLITAZONE HCL Rx Outreach $630.49 $725.06 30 MG TABLET (S) PIOGLITAZONE HCL Rx Outreach $963.57 $1,108.11 45 MG TABLET (S) PIOGLITAZONE HCL Rx Outreach $1,045.25 $1,202.04 15 MG TABLET (S) PIOGLITAZONE HCL Welvista - South Carolina Residents Only $630.49 $725.06 30 MG TABLET (S) PIOGLITAZONE HCL Welvista - South Carolina Residents Only $963.57 $1,108.11 45 MG TABLET (S) PIOGLITAZONE HCL Welvista - South Carolina Residents Only $1,045.25 $1,202.04 15 MG TABLET (S) PIOGLITAZONE HCL Xubex Preferred Network Program $630.49 $725.06 30 MG TABLET (S) PIOGLITAZONE HCL Xubex Preferred Network Program $963.57 $1,108.11 45 MG TABLET (S) PIOGLITAZONE HCL Xubex Preferred Network Program $1,045.25 $1,202.04 PIROXICAM (BRAND: FELDENE)
10 MG CAPSULE(S) PIROXICAM Xubex Preferred Network Program $260.48 $299.55 20 MG CAPSULE(S) PIROXICAM Xubex Preferred Network Program $448.63 $515.92 PLAQUENIL
200 MG TABLET(S) HYDROXYCHLOROQUINE Rx Outreach $765.60 $880.44 SULFATE PLAVIX
* 75 MG TABLET(S) CLOPIDOGREL HYDROGEN Bristol-Myers Squibb Patient Assistance $696.11 $800.53 SULFATE Foundation, Inc. PNEUMOVAX 23 (1 5-DOSE VIAL)
2.5 ML VIAL PNEUMOCOCCAL VACCINE Merck Vaccine Patient Assistance Program $434.28 $499.42 POLYVALENT
Report Run: 04/19/16 10:53 AM Page 252 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PNEUMOVAX 23 (10 5-DOSEVIALS)
2.5 ML ML PNEUMOCOCCAL VACCINE Merck Vaccine Patient Assistance Program $1,596.54 $1,836.02 POLYVALENT PNEUMOVAX 23 (10 VIALS)
0.5 ML VIAL PNEUMOCOCCAL VACCINE Merck Vaccine Patient Assistance Program $946.79 $1,088.81 POLYVALENT 0.5 ML VIAL PNEUMOCOCCAL VACCINE Welvista - South Carolina Residents Only $946.79 $1,088.81 POLYVALENT POMALYST
1 MG CAPSULE(S) pomalidomide Celgene Patient Support $69,866.55 $80,346.53 2 MG CAPSULE(S) pomalidomide Celgene Patient Support $69,866.55 $80,346.53 3 MG CAPSULE(S) pomalidomide Celgene Patient Support $69,866.55 $80,346.53 4 MG CAPSULE(S) pomalidomide Celgene Patient Support $69,866.55 $80,346.53 PORTRAZZA
16 MG VIAL necitumumab Eli Lilly PatientOne $4,800.00 $5,520.00 POTABA
0.5 GM CAPSULE(S) AMINOBENZOATE POTASSIUM Glenwood Compassionate Drug Program $170.16 $195.68 POTASSIUM CHLORIDE ER
8 MEQ TABLET(S) POTASSIUM CHLORIDE Rx Outreach $17.74 $20.40 POTASSIUM CHLORIDE ER (BRAND: K-DUR/KLOR-CON)
20 MEQ TABLET(S) POTASSIUM CHLORIDE Rx Outreach $48.00 $55.20 20 MEQ TABLET(S) POTASSIUM CHLORIDE Xubex Preferred Network Program $48.00 $55.20
Report Run: 04/19/16 10:53 AM Page 253 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
POTASSIUM CHLORIDE ER (BRAND: KLOR-CON)
10 MEQ TABLET(S) POTASSIUM CHLORIDE Rx Outreach $50.81 $58.43 10 MEQ TABLET(S) POTASSIUM CHLORIDE Welvista - South Carolina Residents Only $50.81 $58.43 10 MEQ TABLET(S) POTASSIUM CHLORIDE Xubex Preferred Network Program $50.81 $58.43 POTASSIUM CITRATE (BRAND: CYTRA-K)
1080 MG (10 MEQ) TABLET(S) POTASSIUM CITRATE Rx Outreach $153.33 $176.33 540 MG (5 MEQ) TABLET(S) POTASSIUM CITRATE Rx Outreach $109.40 $125.81 POTIGA
200 MG TABLET(S) ezogabine GSK Access $1,195.43 $1,374.74 50 MG TABLET(S) ezogabine GSK Access $597.73 $687.39 200 MG TABLET(S) ezogabine GSK Bridges to Access $1,195.43 $1,374.74 50 MG TABLET(S) ezogabine GSK Bridges to Access $597.73 $687.39 POTIGA
300 MG TABLET(S) ezogabine GSK Access $1,195.43 $1,374.74 400 MG TABLET(S) ezogabine GSK Access $1,195.43 $1,374.74 300 MG TABLET(S) ezogabine GSK Bridges to Access $1,195.43 $1,374.74 400 MG TABLET(S) ezogabine GSK Bridges to Access $1,195.43 $1,374.74 PRADAXA
150 MG CAPSULE(S) DABIGATRAN ETEXILATE Boehringer Ingelheim Cares Foundation Inc. $377.64 $434.29 MESYLATE 75 MG CAPSULE(S) DABIGATRAN ETEXILATE Boehringer Ingelheim Cares Foundation Inc. $377.64 $434.29 MESYLATE
Report Run: 04/19/16 10:53 AM Page 254 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PRAMIPEXOLE (BRAND: MIRAPEX)
0.125 MG TABLET(S) PRAMIPEXOLE Rx Outreach $265.47 $305.29 0.25 MG TABLET(S) PRAMIPEXOLE Rx Outreach $265.47 $305.29 0.5 MG TABLET(S) PRAMIPEXOLE Rx Outreach $265.47 $305.29 1 MG TABLET(S) PRAMIPEXOLE Rx Outreach $265.47 $305.29 1.5 MG TABLET(S) PRAMIPEXOLE Rx Outreach $265.47 $305.29 0.125 MG TABLET(S) PRAMIPEXOLE Xubex Preferred Network Program $265.47 $305.29 0.25 MG TABLET(S) PRAMIPEXOLE Xubex Preferred Network Program $265.47 $305.29 0.5 MG TABLET(S) PRAMIPEXOLE Xubex Preferred Network Program $265.47 $305.29 1.5 MG TABLET(S) PRAMIPEXOLE Xubex Preferred Network Program $265.47 $305.29 PRAMIPEXOLE DIHYDROCHLORIDE (BRAND: MIRAPEX)
0.75 MG TABLET(S) PRAMIPEXOLE Xubex Preferred Network Program $300.81 $345.93 DIHYDROCHLORIDE PRAMOSONE CREAM
1-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $58.61 $67.40 ACETATE/PRAMOXINE Program HYDROCHLORIDE 2.5-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $58.61 $67.40 ACETATE/PRAMOXINE Program HYDROCHLORIDE PRAMOSONE LOTION
1-1 %-% (60 ML) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $76.82 $88.34 ACETATE/PRAMOXINE Program HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 255 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PRAMOSONE LOTION
2.5-1 %-% (60 ML) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $76.82 $88.34 ACETATE/PRAMOXINE Program HYDROCHLORIDE PRAMOSONE OINTMENT
1-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $60.22 $69.25 ACETATE/PRAMOXINE Program HYDROCHLORIDE 2.5-1 %-% (30 GM) APPLICATION HYDROCORTISONE Ferndale Laboratories Patient Assistance $60.22 $69.25 ACETATE/PRAMOXINE Program HYDROCHLORIDE PRAVACHOL
* 10 MG TABLET(S) PRAVASTATIN SODIUM Bristol-Myers Squibb Patient Assistance $386.54 $444.52 Foundation, Inc. * 20 MG TABLET(S) PRAVASTATIN SODIUM Bristol-Myers Squibb Patient Assistance $416.36 $478.81 Foundation, Inc. * 40 MG TABLET(S) PRAVASTATIN SODIUM Bristol-Myers Squibb Patient Assistance $610.99 $702.64 Foundation, Inc. * 80 MG TABLET(S) PRAVASTATIN SODIUM Bristol-Myers Squibb Patient Assistance $610.99 $702.64 Foundation, Inc. PRAVASTATIN (BRAND: PRAVACHOL)
10 MG TABLET(S) PRAVASTATIN SODIUM Rx Outreach $289.39 $332.80 20 MG TABLET(S) PRAVASTATIN SODIUM Rx Outreach $294.01 $338.11 40 MG TABLET(S) PRAVASTATIN SODIUM Rx Outreach $431.50 $496.23 80 MG TABLET(S) PRAVASTATIN Rx Outreach $431.50 $496.23
Report Run: 04/19/16 10:53 AM Page 256 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PRAVASTATIN (BRAND: PRAVACHOL)
10 MG TABLET(S) PRAVASTATIN SODIUM Xubex Preferred Network Program $289.39 $332.80 20 MG TABLET(S) PRAVASTATIN SODIUM Xubex Preferred Network Program $294.01 $338.11 40 MG TABLET(S) PRAVASTATIN SODIUM Xubex Preferred Network Program $431.50 $496.23 80 MG TABLET(S) PRAVASTATIN Xubex Preferred Network Program $431.50 $496.23 PRAZOSIN HCL (BRAND: MINIPRESS)
1 MG CAPSULE(S) PRAZOSIN HCL Nova ScriptsCentral-Northern Virginia Clinic $74.62 $85.81 Partners & Northern VA Residents ONLY 2 MG TABLET(S) PRAZOSIN HCL Nova ScriptsCentral-Northern Virginia Clinic $110.20 $126.73 Partners & Northern VA Residents ONLY 1 MG CAPSULE(S) PRAZOSIN HCL Rx Outreach $74.62 $85.81 2 MG TABLET(S) PRAZOSIN HCL Rx Outreach $110.20 $126.73 5 MG TABLET(S) PRAZOSIN HCL Rx Outreach $181.90 $209.19 1 MG CAPSULE(S) PRAZOSIN HCL Xubex Preferred Network Program $74.62 $85.81 2 MG TABLET(S) PRAZOSIN HCL Xubex Preferred Network Program $110.20 $126.73 5 MG TABLET(S) PRAZOSIN HCL Xubex Preferred Network Program $181.90 $209.19 PRECOSE
100 MG TABLET(S) ACARBOSE Bayer HealthCare Patient Assistance Program $125.10 $143.86 25 MG TABLET(S) ACARBOSE Bayer HealthCare Patient Assistance Program $112.33 $129.18 50 MG TABLET(S) ACARBOSE Bayer HealthCare Patient Assistance Program $127.01 $146.06 PRED FORTE
1 % (10 ML) DROP (S) PREDNISOLONE ACETATE Allergan Patient Assistance Program $230.69 $265.29
Report Run: 04/19/16 10:53 AM Page 257 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PREDNISONE (BRAND: Meticorten, Sterapred, Sterapred DS) 10 MG TABLET(S) PREDNISONE Nova ScriptsCentral-Northern Virginia Clinic $26.70 $30.71 Partners & Northern VA Residents ONLY 5 MG TABLET(S) PREDNISONE Nova ScriptsCentral-Northern Virginia Clinic $22.61 $26.00 Partners & Northern VA Residents ONLY 1 MG TABLET(S) PREDNISONE Rx Outreach $25.49 $29.31 10 MG TABLET(S) PREDNISONE Rx Outreach $26.70 $30.71 2.5 MG TABLET(S) PREDNISONE Rx Outreach $16.48 $18.95 20 MG TABLET(S) PREDNISONE Rx Outreach $28.49 $32.76 5 MG TABLET(S) PREDNISONE Rx Outreach $22.61 $26.00 50 MG TABLET(S) PREDNISONE Rx Outreach $40.70 $46.81 1 MG TABLET(S) PREDNISONE Xubex Preferred Network Program $25.49 $29.31 10 MG TABLET(S) PREDNISONE Xubex Preferred Network Program $26.70 $30.71 2.5 MG TABLET(S) PREDNISONE Xubex Preferred Network Program $16.48 $18.95 20 MG TABLET(S) PREDNISONE Xubex Preferred Network Program $28.49 $32.76 5 MG TABLET(S) PREDNISONE Xubex Preferred Network Program $22.61 $26.00 PREMARIN
0.45 MG TABLET(S) CONJUGATED ESTROGENS Pfizer MAINTAIN $341.15 $392.32 0.45 MG TABLET(S) CONJUGATED ESTROGENS Pfizer RxPathways $341.15 $392.32 0.625 MG TABLET(S) CONJUGATED ESTROGENS Pfizer RxPathways $520.90 $599.04 0.9 MG TABLET(S) CONJUGATED ESTROGENS Pfizer RxPathways $520.90 $599.04 1.25 MG TABLET(S) CONJUGATED ESTROGENS Pfizer RxPathways $520.90 $599.04
Report Run: 04/19/16 10:53 AM Page 258 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PREMARIN
0.45 MG TABLET(S) CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $341.15 $392.32 0.625 MG TABLET(S) CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $520.90 $599.04 0.9 MG TABLET(S) CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $520.90 $599.04 1.25 MG TABLET(S) CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $520.90 $599.04 PREMARIN
0.3 MG TABLET(S) CONJUGATED ESTROGENS Pfizer RxPathways $520.90 $599.04 0.3 MG TABLET(S) CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $520.90 $599.04 PREMARIN VAGINAL
0.625 MG/GM (30 GM) GRAM CONJUGATED ESTROGENS Pfizer RxPathways $226.66 $260.66 0.625 MG/GM (30 GM) GRAM CONJUGATED ESTROGENS Welvista - South Carolina Residents Only $226.66 $260.66 PREMPHASE
0.625/5 MG/MG TABLET(S) CONJUGATED Pfizer RxPathways $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.625/5 MG/MG TABLET(S) CONJUGATED Welvista - South Carolina Residents Only $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE PREMPRO
0.3/1.5 MG/MG TABLET(S) CONJUGATED Pfizer MAINTAIN $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE
Report Run: 04/19/16 10:53 AM Page 259 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PREMPRO
0.45/1.5 MG/MG TABLET(S) CONJUGATED Pfizer MAINTAIN $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.3/1.5 MG/MG TABLET(S) CONJUGATED Pfizer RxPathways $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.45/1.5 MG/MG TABLET(S) CONJUGATED Pfizer RxPathways $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.625/2.5 MG/MG TABLET(S) CONJUGATED Pfizer RxPathways $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.625/5 MG/MG TABLET(S) CONJUGATED Pfizer RxPathways $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.3/1.5 MG/MG TABLET(S) CONJUGATED Welvista - South Carolina Residents Only $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.45/1.5 MG/MG TABLET(S) CONJUGATED Welvista - South Carolina Residents Only $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.625/2.5 MG/MG TABLET(S) CONJUGATED Welvista - South Carolina Residents Only $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE 0.625/5 MG/MG TABLET(S) CONJUGATED Welvista - South Carolina Residents Only $178.92 $205.76 ESTROGENS/MEDROXYPROGES TERONE ACETATE
Report Run: 04/19/16 10:53 AM Page 260 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PREVACID SOLUTAB
15 MG TABLET(S) LANSOPRAZOLE Takeda Patient Assistance Program $1,612.02 $1,853.82 30 MG TABLET(S) LANSOPRAZOLE Takeda Patient Assistance Program $1,612.02 $1,853.82 PREVNAR 13
n/a n/a (0.5 ML) SYRINGE pneumococcal 13-valent Pfizer RxPathways $196.56 $226.04 vaccine, diphtheria conjug PREZCOBIX
150-800 MG TABLET(S) cobicistat/darunavir Johnson & Johnson Patient Assistance $1,862.12 $2,141.44 Foundation 150-800 MG TABLET(S) cobicistat/darunavir Johnson & Johnson Patient Assistance $1,862.12 $2,141.44 Foundation-Card Program PREZISTA
300 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Hospital Access Patient $986.54 $1,134.52 Assistance Program 600 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Hospital Access Patient $1,509.79 $1,736.26 Assistance Program 800 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Hospital Access Patient $1,509.79 $1,736.26 Assistance Program 300 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $986.54 $1,134.52 Foundation 600 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation 800 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation 300 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $986.54 $1,134.52 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 261 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PREZISTA
600 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation-Card Program 800 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation-Card Program PREZISTA
150 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation 75 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation 150 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation-Card Program 75 MG TABLET(S) DARUNAVIR ETHANOLATE Johnson & Johnson Patient Assistance $1,509.79 $1,736.26 Foundation-Card Program PRIALT
100 MCG/ML (1ML) MCG ZICONOTIDE Jazz Express Pain Information Center for Prialt $834.05 $959.16 25 MCG/ML (20 ML) MCG ZICONOTIDE Jazz Express Pain Information Center for Prialt $4,170.25 $4,795.79 PRIFTIN
150 MG TABLET(S) RIFAPENTINE Sanofi Patient Connection $145.86 $167.74 PRIMAXIN IM
500/500 MG/MG MG CILASTATIN SODIUM/IMIPENEM Merck Hotline for Invanz, Primaxin and $391.79 $450.56 Cancidas PRIMAXIN IV
250/250 MG/MG MG CILASTATIN SODIUM/IMIPENEM Merck Hotline for Invanz, Primaxin and $520.39 $598.45 Cancidas
Report Run: 04/19/16 10:53 AM Page 262 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PRIMAXIN IV
500/500 MG/MG MG CILASTATIN SODIUM/IMIPENEM Merck Hotline for Invanz, Primaxin and $979.54 $1,126.47 Cancidas PRIMAXIN IV (ADD-VANTAGE)
250/250 MG/MG MG CILASTATIN SODIUM/IMIPENEM Merck Hotline for Invanz, Primaxin and $550.68 $633.28 Cancidas 500/500 MG/MG MG CILASTATIN SODIUM/IMIPENEM Merck Hotline for Invanz, Primaxin and $1,017.85 $1,170.53 Cancidas PRIMIDONE (BRAND: MYSOLINE)
250 MG TABLET(S) PRIMIDONE Nova ScriptsCentral-Northern Virginia Clinic $99.60 $114.54 Partners & Northern VA Residents ONLY 50 MG TABLET(S) PRIMIDONE Nova ScriptsCentral-Northern Virginia Clinic $49.75 $57.21 Partners & Northern VA Residents ONLY 250 MG TABLET(S) PRIMIDONE Rx Outreach $99.60 $114.54 50 MG TABLET(S) PRIMIDONE Rx Outreach $49.75 $57.21 250 MG TABLET(S) PRIMIDONE Xubex Preferred Network Program $99.60 $114.54 50 MG TABLET(S) PRIMIDONE Xubex Preferred Network Program $49.75 $57.21 PRIMLEV
300-10 MG-MG TABLET(S) acetaminophen/oxycodone Akrimax Patient Assistance Program $1,828.48 $2,102.75 hydrochloride 300-5 MG-MG TABLET(S) acetaminophen/oxycodone Akrimax Patient Assistance Program $1,828.48 $2,102.75 hydrochloride 300-7.5 MG-MG TABLET(S) acetaminophen/oxycodone Akrimax Patient Assistance Program $1,828.48 $2,102.75 hydrochloride
Report Run: 04/19/16 10:53 AM Page 263 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PRISTIQ
100 MG TABLET(S) DESVENLAFAXINE SUCCINATE Pfizer MAINTAIN $998.42 $1,148.18 50 MG TABLET(S) DESVENLAFAXINE SUCCINATE Pfizer MAINTAIN $998.42 $1,148.18 100 MG TABLET(S) DESVENLAFAXINE SUCCINATE Pfizer RxPathways $998.42 $1,148.18 50 MG TABLET(S) DESVENLAFAXINE SUCCINATE Pfizer RxPathways $998.42 $1,148.18 100 MG TABLET(S) DESVENLAFAXINE SUCCINATE Welvista - South Carolina Residents Only $998.42 $1,148.18 50 MG TABLET(S) DESVENLAFAXINE SUCCINATE Welvista - South Carolina Residents Only $998.42 $1,148.18 PRIVIGEN
10 % (50 ML) INJECTION IMMUNE GLOBULIN CSL Behring Patient Assistance Program $666.00 $765.90 PROAIR HFA
0.09 MG/ACTUATION PUFF(S) ALBUTEROL SULFATE Teva Cares Foundation Patient Assistance $53.42 $61.43 (8.5GM) Program PROCARDIA
10 MG CAPSULE(S) NIFEDIPINE Pfizer RxPathways $209.92 $241.41 10 MG CAPSULE(S) NIFEDIPINE Welvista - South Carolina Residents Only $209.92 $241.41 PROCARDIA XL
30 MG TABLET(S) NIFEDIPINE Nova ScriptsCentral-Northern Virginia Clinic $452.26 $520.10 Partners & Northern VA Residents ONLY 60 MG TABLET(S) NIFEDIPINE Nova ScriptsCentral-Northern Virginia Clinic $782.64 $900.04 Partners & Northern VA Residents ONLY 90 MG TABLET(S) NIFEDIPINE Nova ScriptsCentral-Northern Virginia Clinic $902.99 $1,038.44 Partners & Northern VA Residents ONLY 30 MG TABLET(S) NIFEDIPINE Pfizer RxPathways $452.26 $520.10
Report Run: 04/19/16 10:53 AM Page 264 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROCARDIA XL
60 MG TABLET(S) NIFEDIPINE Pfizer RxPathways $782.64 $900.04 90 MG TABLET(S) NIFEDIPINE Pfizer RxPathways $902.99 $1,038.44 30 MG TABLET(S) NIFEDIPINE Welvista - South Carolina Residents Only $452.26 $520.10 60 MG TABLET(S) NIFEDIPINE Welvista - South Carolina Residents Only $782.64 $900.04 90 MG TABLET(S) NIFEDIPINE Welvista - South Carolina Residents Only $902.99 $1,038.44 PROCHLORPERAZINE (BRAND: COMPAZINE)
10 MG TABLET(S) PROCHLORPERAZINE MALEATE Nova ScriptsCentral-Northern Virginia Clinic $92.08 $105.89 Partners & Northern VA Residents ONLY 5 MG TABLET(S) PROCHLORPERAZINE MALEATE Nova ScriptsCentral-Northern Virginia Clinic $56.60 $65.09 Partners & Northern VA Residents ONLY 10 MG TABLET(S) PROCHLORPERAZINE MALEATE Rx Outreach $92.08 $105.89 5 MG TABLET(S) PROCHLORPERAZINE MALEATE Rx Outreach $56.60 $65.09 10 MG TABLET(S) PROCHLORPERAZINE MALEATE Xubex Preferred Network Program $92.08 $105.89 5 MG TABLET(S) PROCHLORPERAZINE MALEATE Xubex Preferred Network Program $56.60 $65.09 PROCRIT
10000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $1,606.32 $1,847.27 Assistance Program 2000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $321.26 $369.45 Assistance Program 20000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $2,141.76 $2,463.02 Assistance Program 3000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $481.90 $554.19 Assistance Program
Report Run: 04/19/16 10:53 AM Page 265 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROCRIT
4000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $642.53 $738.91 Assistance Program 40000 u/ml (1 ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Hospital Access Patient $4,283.52 $4,926.05 Assistance Program 10000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $1,606.32 $1,847.27 Foundation 2000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $321.26 $369.45 Foundation 20000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $2,141.76 $2,463.02 Foundation 3000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $481.90 $554.19 Foundation 4000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $642.53 $738.91 Foundation 40000 u/ml (1 ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $4,283.52 $4,926.05 Foundation 10000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $1,606.32 $1,847.27 Foundation-Card Program 2000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $321.26 $369.45 Foundation-Card Program 20000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $2,141.76 $2,463.02 Foundation-Card Program 3000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $481.90 $554.19 Foundation-Card Program 4000 u/ml (1ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $642.53 $738.91 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 266 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROCRIT
40000 u/ml (1 ml) VIAL(S) EPOETIN ALFA Johnson & Johnson Patient Assistance $4,283.52 $4,926.05 Foundation-Card Program PROCTOCORT
1 % CRE HYDROCORTISONE Salix Patient Assistance Program $140.74 $161.85 30 MG SUPPOSITORY HYDROCORTISONE ACETATE Salix Patient Assistance Program $136.04 $156.45 PROCYSBI
25 MG CAPSULE(S) cysteamine bitartrate RaptorCares $5,130.00 $5,899.50 75 MG CAPSULE(S) cysteamine bitartrate RaptorCares $21,375.00 $24,581.25 PROGLYCEM
50 MG/ML (30 ML) ML DIAZOXIDE Teva Cares Foundation Patient Assistance $300.05 $345.06 Program PROGRAF
0.5 MG CAPSULE(S) TACROLIMUS Astellas Access Program for Prograf $287.27 $330.36 1 MG CAPSULE(S) TACROLIMUS Astellas Access Program for Prograf $574.52 $660.70 5 MG CAPSULE(S) TACROLIMUS Astellas Access Program for Prograf $2,872.63 $3,303.52 PROLENSA
0.07 % (3 ML) DROP(S) bromfenac sodium Bausch & Lomb US Patient Assistance $264.69 $304.39 Program PROLIA
60 MG/ML (1 ML) INJECTION DENOSUMAB Amgen Safety Net Foundation $1,141.92 $1,313.21
Report Run: 04/19/16 10:53 AM Page 267 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROMACTA
12.5 MG TABLET(S) eltrombopag olamine Commitment to Access $4,124.09 $4,742.70 25 MG TABLET(S) ELTROMBOPAG OLAMINE Commitment to Access $4,124.09 $4,742.70 50 MG TABLET(S) ELTROMBOPAG OLAMINE Commitment to Access $7,672.72 $8,823.63 PROMETHAZINE (BRAND: PHENERGAN)
25 MG TABLET(S) promethazine hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $50.64 $58.24 Partners & Northern VA Residents ONLY 25 MG TABLET(S) promethazine hydrochloride Welvista - South Carolina Residents Only $50.64 $58.24 25 MG TABLET(S) promethazine hydrochloride Xubex Preferred Network Program $50.64 $58.24 50 MG TABLET(S) promethazine hydrochloride Xubex Preferred Network Program $77.62 $89.26 PROMETRIUM
* 100 MG CAPSULE(S) PROGESTERONE AbbVie Patient Assistance Program $253.20 $291.18 PROPAFENONE HCL (BRAND: RYTHMOL)
* 150 MG TABLET(S) PROPAFENONE HCL Generic Assistance Program (NeedyMeds & $163.58 $188.12 Rx Outreach) * 225 MG TABLET(S) PROPAFENONE HCL Generic Assistance Program (NeedyMeds & $232.94 $267.88 Rx Outreach) * 300 MG TABLET(S) PROPAFENONE HCL Generic Assistance Program (NeedyMeds & $296.99 $341.54 Rx Outreach) 150 MG TABLET(S) PROPAFENONE HCL Rx Outreach $163.58 $188.12 225 MG TABLET(S) PROPAFENONE HCL Rx Outreach $232.94 $267.88 300 MG TABLET(S) PROPAFENONE HCL Rx Outreach $296.99 $341.54 150 MG TABLET(S) PROPAFENONE HCL Xubex Patient Assistance Program $163.58 $188.12
Report Run: 04/19/16 10:53 AM Page 268 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROPAFENONE HCL (BRAND: RYTHMOL)
225 MG TABLET(S) PROPAFENONE HCL Xubex Patient Assistance Program $232.94 $267.88 150 MG TABLET(S) PROPAFENONE HCL Xubex Preferred Network Program $163.58 $188.12 225 MG TABLET(S) PROPAFENONE HCL Xubex Preferred Network Program $232.94 $267.88 300 MG TABLET(S) PROPAFENONE HCL Xubex Preferred Network Program $296.99 $341.54 PROPRANOLOL (BRAND: INDERAL)
10 MG TABLET(S) PROPRANOLOL Rx Outreach $24.75 $28.46 20 MG TABLET(S) PROPRANOLOL Rx Outreach $26.75 $30.76 40 MG TABLET(S) PROPRANOLOL Rx Outreach $50.95 $58.59 80 MG TABLET(S) PROPRANOLOL Rx Outreach $63.10 $72.57 10 MG TABLET(S) PROPRANOLOL Xubex Preferred Network Program $24.75 $28.46 20 MG TABLET(S) PROPRANOLOL Xubex Preferred Network Program $26.75 $30.76 40 MG TABLET(S) PROPRANOLOL Xubex Preferred Network Program $50.95 $58.59 80 MG TABLET(S) PROPRANOLOL Xubex Preferred Network Program $63.10 $72.57 PROPRANOLOL HCL (BRAND: INDERAL LA)
120 MG CAPSULE(S) propranolol hydrochloride Rx Outreach $192.09 $220.90 160 MG TABLET(S) propranolol hydrochloride Rx Outreach $251.47 $289.19 60 MG TABLET(S) propranolol hydrochloride Rx Outreach $127.23 $146.31 80 MG TABLET(S) propranolol hydrochloride Rx Outreach $96.85 $111.38 120 MG CAPSULE(S) propranolol hydrochloride Xubex Preferred Network Program $192.09 $220.90 60 MG TABLET(S) propranolol hydrochloride Xubex Preferred Network Program $127.23 $146.31
Report Run: 04/19/16 10:53 AM Page 269 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROPYLTHIOURACIL
50 MG TABLET(S) PROPYLTHIOURACIL Rx Outreach $74.68 $85.88 PROSTIGMIN BROMIDE
15 MG TABLET(S) NEOSTIGMINE BROMIDE Valeant Patient Assistance Program $265.32 $305.12 PROTONIX
* 20 MG TABLET(S) PANTOPRAZOLE SODIUM Pfizer RxPathways $987.02 $1,135.07 * 40 MG TABLET(S) PANTOPRAZOLE SODIUM Pfizer RxPathways $987.02 $1,135.07 PROTRIPTYLINE HYDROCHLORIDE (BRAND: VIVACTIL)
10 MG TABLET(S) protriptyline hydrochloride Xubex Preferred Network Program $408.31 $469.56 5 MG TABLET(S) protriptyline hydrochloride Xubex Preferred Network Program $408.31 $469.56 PROVENTIL HFA
0.09 MG PUFF(S) ALBUTEROL SULFATE Merck Patient Assistance Program $85.39 $98.20 0.09 MG PUFF(S) ALBUTEROL SULFATE Welvista - South Carolina Residents Only $85.39 $98.20 PROVERA
10 MG TABLET(S) MEDROXYPROGESTERONE Pfizer MAINTAIN $410.93 $472.57 ACETATE 5 MG TABLET(S) MEDROXYPROGESTERONE Pfizer MAINTAIN $314.99 $362.24 ACETATE * 10 MG TABLET(S) MEDROXYPROGESTERONE Pfizer RxPathways $410.93 $472.57 ACETATE * 5 MG TABLET(S) MEDROXYPROGESTERONE Pfizer RxPathways $314.99 $362.24 ACETATE
Report Run: 04/19/16 10:53 AM Page 270 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PROVIGIL
* 100 MG TABLET(S) MODAFINIL Teva Cares Foundation Patient Assistance $1,020.60 $1,173.69 Program * 200 MG TABLET(S) MODAFINIL Teva Cares Foundation Patient Assistance $1,542.24 $1,773.58 Program PROZAC
10 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Eli Lilly Cares $1,252.80 $1,440.72 20 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Eli Lilly Cares $385.92 $443.81 20/5 MG/ML (120ML) SOL FLUOXETINE HYDROCHLORIDE Eli Lilly Cares $256.26 $294.70 LIQUID 40 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Eli Lilly Cares $771.84 $887.62 10 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $1,252.80 $1,440.72 Partners & Northern VA Residents ONLY 20 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $385.92 $443.81 Partners & Northern VA Residents ONLY 40 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $771.84 $887.62 Partners & Northern VA Residents ONLY PROZAC WEEKLY
90 MG CAPSULE(S) FLUOXETINE HYDROCHLORIDE Eli Lilly Cares $174.24 $200.38 PULMICORT FLEXHALER
180 MCG PUFF(S) BUDESONIDE INHALATION AZ&Me Prescription Savings for people with $240.56 $276.64 POWDER Medicare Part D 90 MCG PUFF(S) BUDESONIDE INHALATION AZ&Me Prescription Savings for people with $179.65 $206.60 POWDER Medicare Part D
Report Run: 04/19/16 10:53 AM Page 271 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PULMICORT FLEXHALER
180 MCG PUFF(S) BUDESONIDE INHALATION AZ&Me Prescription Savings Program $240.56 $276.64 POWDER 90 MCG PUFF(S) BUDESONIDE INHALATION AZ&Me Prescription Savings Program $179.65 $206.60 POWDER 180 MCG PUFF(S) BUDESONIDE INHALATION Nova ScriptsCentral-Northern Virginia Clinic $240.56 $276.64 POWDER Partners & Northern VA Residents ONLY 180 MCG PUFF(S) BUDESONIDE INHALATION Welvista - South Carolina Residents Only $240.56 $276.64 POWDER 90 MCG PUFF(S) BUDESONIDE INHALATION Welvista - South Carolina Residents Only $179.65 $206.60 POWDER PULMICORT RESPULES
0.25 mg/2 ml VIAL(S) BUDESONIDE Nova ScriptsCentral-Northern Virginia Clinic $313.75 $360.81 Partners & Northern VA Residents ONLY 0.5 mg/2 ml VIAL(S) BUDESONIDE Nova ScriptsCentral-Northern Virginia Clinic $369.26 $424.65 Partners & Northern VA Residents ONLY 0.25 mg/2 ml VIAL(S) BUDESONIDE Welvista - South Carolina Residents Only $313.75 $360.81 0.5 mg/2 ml VIAL(S) BUDESONIDE Welvista - South Carolina Residents Only $369.26 $424.65 PULMOZYME
2.5/2.5 mg/ml (2.5ml) SOL DORNASE ALFA Genentech Access to Care-Pulmozyme $34.38 $39.54 PURINETHOL
* 50 MG TABLET(S) MERCAPTOPURINE Teva Cares Foundation Patient Assistance $365.49 $420.31 Program
Report Run: 04/19/16 10:53 AM Page 272 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
PYLERA
140-125-125 MG-MG-MG CAPSULE(S) bi subcitrate Actavis U.S. Patient Assistance Program $803.68 $924.23 k/metronidazole/tetracycline hcl QNASL
80 MCG/ACTUATION SPRAY(S) beclomethasone dipropionate Teva Cares Foundation Patient Assistance $192.66 $221.56 Program QNASL CHILDREN'S
40 MCG/ACTUATION (4.9 PUFF(S) beclomethasone dipropionate Teva Cares Foundation Patient Assistance $192.66 $221.56 GM) Program QUALAQUIN
324 MG CAPSULE(S) QUININE SULFATE Rx Outreach $198.10 $227.82 QUETIAPINE FUMARATE (BRAND: SEROQUEL)
* 100 MG TABLET(S) QUETIAPINE FUMARATE Generic Assistance Program (NeedyMeds & $685.75 $788.61 Rx Outreach) * 25 MG TABLET(S) QUETIAPINE FUMARATE Generic Assistance Program (NeedyMeds & $399.61 $459.55 Rx Outreach) 50 MG TABLET(S) QUETIAPINE FUMARATE Generic Assistance Program (NeedyMeds & $656.66 $755.16 Rx Outreach) 100 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $685.75 $788.61 200 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $1,293.69 $1,487.74 25 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $399.61 $459.55 300 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $1,017.74 $1,170.40 400 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $1,993.47 $2,292.49
Report Run: 04/19/16 10:53 AM Page 273 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
QUETIAPINE FUMARATE (BRAND: SEROQUEL)
50 MG TABLET(S) QUETIAPINE FUMARATE Rx Outreach $656.66 $755.16 100 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $685.75 $788.61 200 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $1,293.69 $1,487.74 25 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $399.61 $459.55 300 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $1,017.74 $1,170.40 400 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $1,993.47 $2,292.49 50 MG TABLET(S) QUETIAPINE FUMARATE Xubex Preferred Network Program $656.66 $755.16 QUILLIVANT XR (CII)
5 MG/ML (150 ML) MG methylphenidate hydrochloride Pfizer RxPathways $220.50 $253.58 QUILLIVANT XR (CII)
5 MG/ML (120 ML) MG methylphenidate hydrochloride Pfizer RxPathways $220.50 $253.58 QUINAPRIL (BRAND: ACCUPRIL)
10 MG TABLET(S) QUINAPRIL Nova ScriptsCentral-Northern Virginia Clinic $110.08 $126.59 Partners & Northern VA Residents ONLY 20 MG TABLET(S) QUINAPRIL Nova ScriptsCentral-Northern Virginia Clinic $110.08 $126.59 Partners & Northern VA Residents ONLY 40 MG TABLET(S) QUINAPRIL Nova ScriptsCentral-Northern Virginia Clinic $110.08 $126.59 Partners & Northern VA Residents ONLY 5 MG TABLET(S) QUINAPRIL Nova ScriptsCentral-Northern Virginia Clinic $110.08 $126.59 Partners & Northern VA Residents ONLY 10 MG TABLET(S) QUINAPRIL Rx Outreach $110.08 $126.59 20 MG TABLET(S) QUINAPRIL Rx Outreach $110.08 $126.59
Report Run: 04/19/16 10:53 AM Page 274 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
QUINAPRIL (BRAND: ACCUPRIL)
40 MG TABLET(S) QUINAPRIL Rx Outreach $110.08 $126.59 5 MG TABLET(S) QUINAPRIL Rx Outreach $110.08 $126.59 10 MG TABLET(S) QUINAPRIL Xubex Preferred Network Program $110.08 $126.59 20 MG TABLET(S) QUINAPRIL Xubex Preferred Network Program $110.08 $126.59 40 MG TABLET(S) QUINAPRIL Xubex Preferred Network Program $110.08 $126.59 QUINAPRIL HCL/HCTZ (BRAND: ACCURETIC)
10/12.5 MG TABLET(S) hydrochlorothiazide/quinapril Rx Outreach $110.10 $126.62 hydrochloride 20/12.5 MG TABLET(S) hydrochlorothiazide/quinapril Rx Outreach $110.10 $126.62 hydrochloride 20/25 MG TABLET(S) hydrochlorothiazide/quinapril Rx Outreach $110.10 $126.62 hydrochloride 10/12.5 MG TABLET(S) hydrochlorothiazide/quinapril Xubex Preferred Network Program $110.10 $126.62 hydrochloride 20/12.5 MG TABLET(S) hydrochlorothiazide/quinapril Xubex Preferred Network Program $110.10 $126.62 hydrochloride 20/25 MG TABLET(S) hydrochlorothiazide/quinapril Xubex Preferred Network Program $110.10 $126.62 hydrochloride QUINIDINE GLUCONATE
80 MG/ML (10 ML) UNIT(S) QUINIDINE GLUCONATE Eli Lilly Cares $21.56 $24.79 QUTENZA (1 PATCH)
8 % PATCH CAPSAICIN NeurogesX Qutenza Patient Assistance $810.00 $931.50 Program
Report Run: 04/19/16 10:53 AM Page 275 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
QUTENZA (2 PATCHES)
8 % PATCH CAPSAICIN NeurogesX Qutenza Patient Assistance $1,620.00 $1,863.00 Program QVAR
40 MCG (8.7 GM) PUFF(S) BECLOMETHASONE Teva Cares Foundation Patient Assistance $177.44 $204.06 DIPROPIONATE Program 80 MCG (8.7GM) PUFF(S) BECLOMETHASONE Teva Cares Foundation Patient Assistance $237.59 $273.23 DIPROPIONATE Program RABAVERT
2.5 IU INJECTION(S) RABIES VACCINE GSK Vaccines Access Program $363.70 $418.26 RABEPRAZOLE SODIUM (BRAND: ACIPHEX)
20 MG TABLET(S) RABEPRAZOLE SODIUM Rx Outreach $1,030.29 $1,184.83 RAGWITEK
N/A N/A TABLET(S) short ragweed pollen allergen Merck Patient Assistance Program $891.00 $1,024.65 extract RALOXIFENE (BRAND: EVISTA)
60 MG TABLET(S) raloxifene Rx Outreach $712.80 $819.72 RAMIPRIL (BRAND: ALTACE)
1.25 MG CAPSULE(S) RAMIPRIL Rx Outreach $152.99 $175.94 10 MG CAPSULE(S) RAMIPRIL Rx Outreach $221.70 $254.96 2.5 MG CAPSULE(S) RAMIPRIL Rx Outreach $180.59 $207.68 5 MG CAPSULE(S) RAMIPRIL Rx Outreach $189.46 $217.88 1.25 MG CAPSULE(S) RAMIPRIL Xubex Preferred Network Program $152.99 $175.94
Report Run: 04/19/16 10:53 AM Page 276 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RAMIPRIL (BRAND: ALTACE)
10 MG CAPSULE(S) RAMIPRIL Xubex Preferred Network Program $221.70 $254.96 2.5 MG CAPSULE(S) RAMIPRIL Xubex Preferred Network Program $180.59 $207.68 5 MG CAPSULE(S) RAMIPRIL Xubex Preferred Network Program $189.46 $217.88 RANEXA
1000 MG TABLET(S) RANOLAZINE Gilead Ranexa Connect Patient Assistance $598.44 $688.21 Program 500 MG TABLET(S) RANOLAZINE Gilead Ranexa Connect Patient Assistance $364.51 $419.19 Program RANITIDINE (BRAND: ZANTAC)
150 MG TABLET(S) RANITIDINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $288.23 $331.46 Partners & Northern VA Residents ONLY 300 MG TABLET(S) RANITIDINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $297.97 $342.67 Partners & Northern VA Residents ONLY 150 MG TABLET(S) RANITIDINE HYDROCHLORIDE Rx Outreach $288.23 $331.46 300 MG TABLET(S) RANITIDINE HYDROCHLORIDE Rx Outreach $297.97 $342.67 150 MG TABLET(S) RANITIDINE HYDROCHLORIDE Xubex Preferred Network Program $288.23 $331.46 300 MG TABLET(S) RANITIDINE HYDROCHLORIDE Xubex Preferred Network Program $297.97 $342.67 RANITIDINE HCL CAPSULE (BRAND: ZANTAC)
150 MG CAPSULE(S) ranitidine hydrochloride Xubex Preferred Network Program $91.27 $104.96 300 MG CAPSULE(S) ranitidine hydrochloride Xubex Preferred Network Program $266.12 $306.04 RAPAFLO
4 MG CAPSULE SILODOSIN Actavis U.S. Patient Assistance Program $249.47 $286.89
Report Run: 04/19/16 10:53 AM Page 277 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RAPAFLO
8 MG CAPSULE SILODOSIN Actavis U.S. Patient Assistance Program $748.37 $860.63 RAPAMUNE
1 MG TABLET(S) SIROLIMUS Pfizer RxPathways $2,271.78 $2,612.55 2 MG TABLET(S) SIROLIMUS Pfizer RxPathways $4,543.55 $5,225.08 RASUVO
10/0.2 MG/ML (0.2 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 12.5/0.25 MG/ML (0.25 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 15 MG/ML (0.3 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 17.5/0.35 MG/ML (0.35 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 20/0.4 MG/ML (0.4 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 22.5/0.45 MG/ML (0.45 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 25/0.5 MG/ML (0.5ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 27.5/0.55 MG/ML (0.55ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 30/0.6 MG/ML (0.6 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 7.5/0.15 MG/ML (0.15 ML) AUTOINJECTOR methotrexate Core Connections - Rasuvo $537.60 $618.24 RAYOS
1 MG TABLET(S) prednisone Horizon Patient Assistance Program $1,974.96 $2,271.20 2 MG TABLET(S) prednisone Horizon Patient Assistance Program $1,974.96 $2,271.20 5 MG TABLET(S) prednisone Horizon Patient Assistance Program $1,974.96 $2,271.20
Report Run: 04/19/16 10:53 AM Page 278 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RAZADYNE
12 MG TABLET(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program 4 MG TABLET(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program 8 MG TABLET(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program RAZADYNE
4 MG/ML (100 ML) ML galantamine hydrobromide Johnson & Johnson Patient Assistance $353.44 $406.46 Foundation RAZADYNE ER
16 MG CAPSULE(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program 24 MG CAPSULE(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program 8 MG CAPSULE(S) GALANTAMINE Johnson & Johnson Patient Assistance $349.61 $402.05 HYDROBROMIDE Foundation-Card Program RECLAST
5 MG/100ML MG ZOLEDRONIC ACID Novartis Patient Assistance Foundation, Inc. $1,300.60 $1,495.69 RECOMBINATE
1 iu, 1000 PDS ANTIHEMOPHILIC FACTOR VIII Baxter The CARE Program $1.18 $1.36 (RECOMBINANT) RECOMBIVAX HB
10 MCG/ML ML HEPATITIS B VACCINE Merck Vaccine Patient Assistance Program $71.64 $82.39 RECOMBINANT
Report Run: 04/19/16 10:53 AM Page 279 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RECOMBIVAX HB (10 VIALS)
10 MCG/ML ML HEPATITIS B VACCINE Merck Vaccine Patient Assistance Program $708.12 $814.34 RECOMBINANT RECTIV
0.4 % (30 GM) APPLICATION(S) nitroglycerin Actavis U.S. Patient Assistance Program $464.28 $533.92 0.4 % (30 GM) APPLICATION(S) nitroglycerin Aptalis Patient Assistance Program $464.28 $533.92 0.4 % (30 GM) APPLICATION(S) nitroglycerin Aptalis Uninsured Patient Assistance Program $464.28 $533.92 RELENZA
5 MG/ACTUATION DISK ZANAMIVIR GSK Access $70.80 $81.42 5 MG/ACTUATION DISK ZANAMIVIR GSK Bridges to Access $70.80 $81.42 RELISTOR
12/0.6 MG/ML SYRINGE(S) METHYLNALTREXONE BROMIDE Salix Patient Assistance Program $839.98 $965.98 8/0.4 MG/ML SYRINGE(S) METHYLNALTREXONE BROMIDE Salix Patient Assistance Program $839.98 $965.98 RELPAX
20 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Pfizer MAINTAIN $245.04 $281.80 40 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Pfizer MAINTAIN $490.06 $563.57 20 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Pfizer RxPathways $245.04 $281.80 40 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Pfizer RxPathways $490.06 $563.57 20 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Welvista - South Carolina Residents Only $245.04 $281.80 40 MG TABLET(S) ELETRIPTAN HYDROBROMIDE Welvista - South Carolina Residents Only $490.06 $563.57 REMERON
15 MG TABLET(S) MIRTAZAPINE Merck Patient Assistance Program $179.56 $206.49
Report Run: 04/19/16 10:53 AM Page 280 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
REMERON
30 MG TABLET(S) MIRTAZAPINE Merck Patient Assistance Program $184.96 $212.70 45 MG TABLET(S) MIRTAZAPINE Merck Patient Assistance Program $188.45 $216.72 REMICADE
100 MG MG INFLIXIMAB Johnson & Johnson Patient Assistance $1,225.72 $1,409.58 Foundation RENVELA
2.4 GM/PACKET PACKET SEVELAMER CARBONATE Genzyme Renassist $1,513.07 $1,740.03 800 MG TABLET(S) SEVELAMER CARBONATE Genzyme Renassist $1,513.07 $1,740.03 REOPRO
2 MG/ML (5ML) MG ABCIXIMAB Eli Lilly Cares $1,362.96 $1,567.40 REPAGLINIDE (BRAND: PRANDIN)
0.5 MG TABLET(S) repaglinide Rx Outreach $333.02 $382.97 1 MG TABLET(S) repaglinide Rx Outreach $365.95 $420.84 2 MG TABLET(S) repaglinide Rx Outreach $365.95 $420.84 0.5 MG TABLET(S) repaglinide Xubex Preferred Network Program $333.02 $382.97 1 MG TABLET(S) repaglinide Xubex Preferred Network Program $365.95 $420.84 2 MG TABLET(S) repaglinide Xubex Preferred Network Program $365.95 $420.84 REPATHA SURECLICK AUTOINJECTOR
140/1 MG/ML (1 ML) INJECTION(S) evolocumab Amgen Safety Net Foundation $650.77 $748.39 REPATHA PREFILLED SYRINGE
140/1 MG/ML (1 ML) INJECTION(S) evolocumab Amgen Safety Net Foundation $650.77 $748.39
Report Run: 04/19/16 10:53 AM Page 281 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
REQUIP
* 0.25 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $507.67 $583.82 * 0.5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $507.67 $583.82 * 1 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $507.67 $583.82 * 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $507.67 $583.82 * 3 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $526.58 $605.57 * 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $526.58 $605.57 * 5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $526.58 $605.57 * 0.25 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $507.67 $583.82 * 0.5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $507.67 $583.82 * 1 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $507.67 $583.82 * 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $507.67 $583.82 * 3 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $526.58 $605.57 * 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $526.58 $605.57 * 5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $526.58 $605.57 0.25 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $507.67 $583.82 0.5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $507.67 $583.82 1 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $507.67 $583.82 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $507.67 $583.82 3 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $526.58 $605.57 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $526.58 $605.57 5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $526.58 $605.57
Report Run: 04/19/16 10:53 AM Page 282 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
REQUIP XL
12 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $612.08 $703.89 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $367.25 $422.34 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $734.52 $844.70 6 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $367.25 $422.34 8 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Access $1,101.77 $1,267.04 12 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $612.08 $703.89 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $367.25 $422.34 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $734.52 $844.70 6 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $367.25 $422.34 8 MG TABLET(S) ROPINIROLE HYDROCHLORIDE GSK Bridges to Access $1,101.77 $1,267.04 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $367.25 $422.34 Partners & Northern VA Residents ONLY 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $734.52 $844.70 Partners & Northern VA Residents ONLY 8 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $1,101.77 $1,267.04 Partners & Northern VA Residents ONLY 12 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $612.08 $703.89 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $367.25 $422.34 4 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $734.52 $844.70 6 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $367.25 $422.34 8 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Welvista - South Carolina Residents Only $1,101.77 $1,267.04
Report Run: 04/19/16 10:53 AM Page 283 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RESCRIPTOR
100 MG TABLET(S) DELAVIRDINE MESYLATE GSK Access $462.52 $531.90 200 MG TABLET(S) DELAVIRDINE MESYLATE GSK Access $462.52 $531.90 100 MG TABLET(S) DELAVIRDINE MESYLATE ViiV Healthcare Patient Assistance Program $462.52 $531.90 RESTASIS
0.05 % (30 x .4ML) DROP(S) CYCLOSPORINE Allergan Patient Assistance Program $232.98 $267.93 RESTORIL
15 MG CAPSULE(S) TEMAZEPAM Covidien/Mallinckrodt Patient Assistance $1,665.14 $1,914.91 Program 30 MG CAPSULE(S) TEMAZEPAM Covidien/Mallinckrodt Patient Assistance $1,760.27 $2,024.31 Program 7.5 MG CAPSULE(S) TEMAZEPAM Covidien/Mallinckrodt Patient Assistance $1,573.50 $1,809.53 Program RETROVIR
100 MG CAPSULE(S) ZIDOVUDINE ViiV Healthcare Patient Assistance Program $323.83 $372.40 50 MG/5ML (240ML) SYR ZIDOVUDINE ViiV Healthcare Patient Assistance Program $77.71 $89.37 REVATIO
20 MG TABLET(S) SILDENAFIL CITRATE Pfizer RxPathways $2,750.52 $3,163.10 REVLIMID
10 MG CAPSULE(S) LENALIDOMIDE Celgene Patient Support $54,673.20 $62,874.18 15 MG CAPSULE(S) LENALIDOMIDE Celgene Patient Support $54,673.20 $62,874.18 25 MG CAPSULE(S) LENALIDOMIDE Celgene Patient Support $54,673.20 $62,874.18 5 MG CAPSULE(S) LENALIDOMIDE Celgene Patient Support $54,673.20 $62,874.18
Report Run: 04/19/16 10:53 AM Page 284 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
REVLIMID
20 MG CAPSULE(S) lenalidomide Celgene Patient Support $54,673.20 $62,874.18 REXULTI
0.25 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 0.5 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 1 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 2 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 3 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 4 MG TABLET(S) brexpiprazole ASSURE Program-Rexulti $1,121.69 $1,289.94 REYATAZ
150 MG CAPSULE(S) ATAZANAVIR SULFATE BMS3assist Program $1,535.23 $1,765.51 200 MG CAPSULE(S) ATAZANAVIR SULFATE BMS3assist Program $1,535.23 $1,765.51 300 MG CAPSULE(S) ATAZANAVIR SULFATE BMS3assist Program $1,520.72 $1,748.83 RHINOCORT AQUA
* 32 MCG SPRAY(S) BUDESONIDE AZ&Me Prescription Savings for people with $162.16 $186.48 Medicare Part D * 32 MCG SPRAY(S) BUDESONIDE AZ&Me Prescription Savings Program $162.16 $186.48 RIASTAP
1 MG INJECTION FIBRINOGEN CSL Behring Patient Assistance Program $1.09 $1.25 RISPERDAL
0.25 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $507.22 $583.30 Assistance Program
Report Run: 04/19/16 10:53 AM Page 285 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RISPERDAL
0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $556.58 $640.07 Assistance Program 1 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $591.72 $680.48 Assistance Program 2 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $988.87 $1,137.20 Assistance Program 3 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $1,161.48 $1,335.70 Assistance Program 4 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $1,560.02 $1,794.02 Assistance Program 0.25 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $507.22 $583.30 Foundation 0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $556.58 $640.07 Foundation 1 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $591.72 $680.48 Foundation 2 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $988.87 $1,137.20 Foundation 3 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $1,161.48 $1,335.70 Foundation 4 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $1,560.02 $1,794.02 Foundation 0.25 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $507.22 $583.30 Foundation-Card Program 0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $556.58 $640.07 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 286 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RISPERDAL
1 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $591.72 $680.48 Foundation-Card Program 2 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $988.87 $1,137.20 Foundation-Card Program 3 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $1,161.48 $1,335.70 Foundation-Card Program 4 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $1,560.02 $1,794.02 Foundation-Card Program 0.25 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $507.22 $583.30 Partners & Northern VA Residents ONLY 0.5 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $556.58 $640.07 Partners & Northern VA Residents ONLY 1 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $591.72 $680.48 Partners & Northern VA Residents ONLY 2 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $988.87 $1,137.20 Partners & Northern VA Residents ONLY 3 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $1,161.48 $1,335.70 Partners & Northern VA Residents ONLY 4 MG TABLET(S) RISPERIDONE Nova ScriptsCentral-Northern Virginia Clinic $1,560.02 $1,794.02 Partners & Northern VA Residents ONLY 0.25 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $507.22 $583.30 0.5 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $556.58 $640.07 1 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $591.72 $680.48 2 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $988.87 $1,137.20 3 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $1,161.48 $1,335.70
Report Run: 04/19/16 10:53 AM Page 287 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RISPERDAL
4 MG TABLET(S) RISPERIDONE Welvista - South Carolina Residents Only $1,560.02 $1,794.02 RISPERDAL CONSTA
12.5 MG INJECTION(S) RISPERIDONE Johnson & Johnson Patient Assistance $204.85 $235.58 Foundation 25 MG INJECTION RISPERIDONE Johnson & Johnson Patient Assistance $409.66 $471.11 Foundation 37.5 MG INJECTION RISPERIDONE Johnson & Johnson Patient Assistance $614.51 $706.69 Foundation 50 MG INJECTION RISPERIDONE Johnson & Johnson Patient Assistance $819.36 $942.26 Foundation RISPERDAL M-TAB
0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $290.78 $334.40 Assistance Program 1 MG TABLET(S) RISPERIDONE Johnson & Johnson Hospital Access Patient $339.80 $390.77 Assistance Program 0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $290.78 $334.40 Foundation 1 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $339.80 $390.77 Foundation 0.5 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $290.78 $334.40 Foundation-Card Program 1 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $339.80 $390.77 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 288 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RISPERDAL M-TAB
2 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $515.56 $592.89 Foundation 3 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $650.40 $747.96 Foundation 4 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $873.62 $1,004.66 Foundation 2 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $515.56 $592.89 Foundation-Card Program 3 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $650.40 $747.96 Foundation-Card Program 4 MG TABLET(S) RISPERIDONE Johnson & Johnson Patient Assistance $873.62 $1,004.66 Foundation-Card Program RISPERIDONE (BRAND: RISPERDAL)
* 0.25 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $234.10 $269.22 Rx Outreach) * 0.5 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $256.89 $295.42 Rx Outreach) * 1 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $273.11 $314.08 Rx Outreach) * 2 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $456.42 $524.88 Rx Outreach) * 3 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $536.08 $616.49 Rx Outreach) * 4 MG TABLET(S) RISPERIDONE Generic Assistance Program (NeedyMeds & $720.03 $828.03 Rx Outreach) 0.25 MG TABLET(S) RISPERIDONE Rx Outreach $234.10 $269.22
Report Run: 04/19/16 10:53 AM Page 289 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RISPERIDONE (BRAND: RISPERDAL)
0.5 MG TABLET(S) RISPERIDONE Rx Outreach $256.89 $295.42 1 MG TABLET(S) RISPERIDONE Rx Outreach $273.11 $314.08 2 MG TABLET(S) RISPERIDONE Rx Outreach $456.42 $524.88 3 MG TABLET(S) RISPERIDONE Rx Outreach $536.08 $616.49 4 MG TABLET(S) RISPERIDONE Rx Outreach $720.03 $828.03 0.25 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $234.10 $269.22 0.5 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $256.89 $295.42 1 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $273.11 $314.08 2 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $456.42 $524.88 3 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $536.08 $616.49 4 MG TABLET(S) RISPERIDONE Xubex Preferred Network Program $720.03 $828.03 RITALIN LA
* 10 MG CAPSULE(S) METHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $832.34 $957.19 HYDROCHLORIDE * 20 MG CAPSULE(S) METHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $832.34 $957.19 HYDROCHLORIDE * 30 MG CAPSULE(S) METHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $851.30 $979.00 HYDROCHLORIDE * 40 MG CAPSULE(S) METHYLPHENIDATE Novartis Patient Assistance Foundation, Inc. $874.94 $1,006.18 HYDROCHLORIDE RITUXAN
10 MG/ML (10ML) MG RITUXIMAB Genentech BioOncology Access to Solutions- $869.22 $999.60 Infused Products
Report Run: 04/19/16 10:53 AM Page 290 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RIVASTIGMINE TARTRATE (BRAND: EXELON)
1.5 MG CAPSULE(S) rivastigmine tartrate Rx Outreach $254.61 $292.80 3 MG CAPSULE(S) rivastigmine tartrate Rx Outreach $254.61 $292.80 4.5 MG CAPSULE(S) rivastigmine tartrate Rx Outreach $254.61 $292.80 6 MG CAPSULE(S) rivastigmine tartrate Rx Outreach $254.61 $292.80 1.5 MG CAPSULE(S) rivastigmine tartrate Xubex Preferred Network Program $254.61 $292.80 3 MG CAPSULE(S) rivastigmine tartrate Xubex Preferred Network Program $254.61 $292.80 4.5 MG CAPSULE(S) rivastigmine tartrate Xubex Preferred Network Program $254.61 $292.80 RIZATRIPTAN BENZOATE (BRAND: MAXALT, MAXALT- MLT) 10 MG TABLET(S) RIZATRIPTAN BENZOATE Xubex Preferred Network Program $598.55 $688.33 RIZATRIPTAN BENZOATE (BRAND: MAXALT, MAXALT- MLT) 5 MG TABLET(S) rizatriptan benzoate Xubex Preferred Network Program $598.55 $688.33 RIZATRIPTAN BENZOATE ODT (BRAND: MAXALT, MAXALT-MLT) 10 MG TABLET(S) RIZATRIPTAN BENZOATE Xubex Preferred Network Program $996.43 $1,145.89 5 MG TABLET(S) RIZATRIPTAN BENZOATE Xubex Preferred Network Program $996.43 $1,145.89 ROPINIROLE HCL (BRAND: REQUIP)
0.25 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Rx Outreach $250.52 $288.10 0.5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Rx Outreach $250.52 $288.10 1 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Rx Outreach $250.52 $288.10 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Rx Outreach $165.00 $189.75
Report Run: 04/19/16 10:53 AM Page 291 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ROPINIROLE HCL (BRAND: REQUIP)
0.25 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Xubex Preferred Network Program $250.52 $288.10 0.5 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Xubex Preferred Network Program $250.52 $288.10 1 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Xubex Preferred Network Program $250.52 $288.10 2 MG TABLET(S) ROPINIROLE HYDROCHLORIDE Xubex Preferred Network Program $165.00 $189.75 3 MG TABLET(S) ropinirole hydrochloride Xubex Preferred Network Program $259.86 $298.84 5 MG TABLET(S) ropinirole hydrochloride Xubex Preferred Network Program $259.86 $298.84 ROXICODONE
15 MG TABLET(S) OXYCODONE HYDROCHLORIDE Covidien/Mallinckrodt Patient Assistance $529.51 $608.94 Program 30 MG TABLET(S) OXYCODONE HYDROCHLORIDE Covidien/Mallinckrodt Patient Assistance $1,038.92 $1,194.76 Program ROZEREM
8 MG TABLET(S) RAMELTEON Takeda Patient Assistance Program $333.98 $384.08 8 MG TABLET(S) RAMELTEON Welvista - South Carolina Residents Only $333.98 $384.08 RYTARY
23.75-95 MG-MG CAPSULE(S) carbidopa/levodopa Impax Patient Assistance Program $276.00 $317.40 48.75-195 MG-MG CAPSULE(S) carbidopa/levodopa Impax Patient Assistance Program $276.00 $317.40 61.25-245 MG-MG CAPSULE(S) carbidopa/levodopa Impax Patient Assistance Program $346.80 $398.82 RYTARY
36.25-145 MG-MG CAPSULE(S) carbidopa/levodopa Impax Patient Assistance Program $276.00 $317.40
Report Run: 04/19/16 10:53 AM Page 292 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RYTHMOL
150 MG TABLET(S) PROPAFENONE GSK Access $602.99 $693.44 HYDROCHLORIDE 225 MG TABLET(S) PROPAFENONE GSK Access $792.84 $911.77 HYDROCHLORIDE * 150 MG TABLET(S) PROPAFENONE GSK Bridges to Access $602.99 $693.44 HYDROCHLORIDE * 225 MG TABLET(S) PROPAFENONE GSK Bridges to Access $792.84 $911.77 HYDROCHLORIDE 150 MG TABLET(S) PROPAFENONE Welvista - South Carolina Residents Only $602.99 $693.44 HYDROCHLORIDE 225 MG TABLET(S) PROPAFENONE Welvista - South Carolina Residents Only $792.84 $911.77 HYDROCHLORIDE RYTHMOL SR
225 MG CAPSULE(S) PROPAFENONE GSK Access $765.52 $880.35 HYDROCHLORIDE 325 MG CAPSULE(S) PROPAFENONE GSK Access $969.80 $1,115.27 HYDROCHLORIDE 425 MG CAPSULE(S) PROPAFENONE GSK Access $969.80 $1,115.27 HYDROCHLORIDE 225 MG CAPSULE(S) PROPAFENONE GSK Bridges to Access $765.52 $880.35 HYDROCHLORIDE 325 MG CAPSULE(S) PROPAFENONE GSK Bridges to Access $969.80 $1,115.27 HYDROCHLORIDE 425 MG CAPSULE(S) PROPAFENONE GSK Bridges to Access $969.80 $1,115.27 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 293 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
RYTHMOL SR
225 MG CAPSULE(S) PROPAFENONE Welvista - South Carolina Residents Only $765.52 $880.35 HYDROCHLORIDE 325 MG CAPSULE(S) PROPAFENONE Welvista - South Carolina Residents Only $969.80 $1,115.27 HYDROCHLORIDE 425 MG CAPSULE(S) PROPAFENONE Welvista - South Carolina Residents Only $969.80 $1,115.27 HYDROCHLORIDE SABRIL
500 MG/PACKET PACKET VIGABATRIN Lundbeck SHARE Patient Assistance Program $6,604.80 $7,595.52 SABRIL
500 MG TABLET(S) VIGABATRIN Lundbeck SHARE Patient Assistance Program $13,209.61 $15,191.05 SAFYRAL
3-0.03-0.451 MG TABLET(S) drospirenone/ethinyl Bayer Patient Assistance Program-Beyaz, $493.18 $567.16 estradiol/levomefolate ca Safyral & Natazia SAIZEN
5 mg PDS SOMATROPIN, MAMMALIAN EMD Connections for Growth $210.00 $241.50 DERIVED 8.8 MG PDS SOMATROPIN, MAMMALIAN EMD Connections for Growth $718.66 $826.46 DERIVED SALSALATE (BRAND: DISALCID)
500 MG TABLET(S) SALSALATE Xubex Patient Assistance Program $67.60 $77.74 750 MG TABLET(S) SALSALATE Xubex Patient Assistance Program $80.60 $92.69 SAMSCA
15 MG TABLET(S) TOLVAPTAN ASSURE Program for Samsca $4,012.80 $4,614.72
Report Run: 04/19/16 10:53 AM Page 294 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SAMSCA
30 MG TABLET(S) TOLVAPTAN ASSURE Program for Samsca $4,012.80 $4,614.72 SANCUSO
3.1/24 MG/HR PATCH granisetron Sancuso Patient Assistance Program $522.60 $600.99 SANDIMMUNE
100 MG CAPSULE(S) CYCLOSPORINE Novartis Patient Assistance Foundation, Inc. $442.06 $508.37 25 MG CAPSULE(S) CYCLOSPORINE Novartis Patient Assistance Foundation, Inc. $110.76 $127.37 50 MG/ML (5ML) UNIT(S) CYCLOSPORINE Novartis Patient Assistance Foundation, Inc. $574.31 $660.46 SANDOSTATIN LAR DEPOT
10 MG MG OCTREOTIDE ACETATE Novartis Oncology Patient Assistance $3,026.10 $3,480.02 Program 20 MG MG OCTREOTIDE ACETATE Novartis Oncology Patient Assistance $3,964.73 $4,559.44 Program 30 MG MG OCTREOTIDE ACETATE Novartis Oncology Patient Assistance $5,936.89 $6,827.42 Program SAPHRIS
10 MG TABLET(S) ASENAPINE Actavis U.S. Patient Assistance Program $1,830.88 $2,105.51 5 MG TABLET(S) ASENAPINE Actavis U.S. Patient Assistance Program $1,830.88 $2,105.51 SAPHRIS (BLACK CHERRY)
10 MG TABLET(S) ASENAPINE Actavis U.S. Patient Assistance Program $1,098.54 $1,263.32 2.5 MG TABLET(S) asenapine Actavis U.S. Patient Assistance Program $1,098.54 $1,263.32 5 MG TABLET(S) ASENAPINE Actavis U.S. Patient Assistance Program $1,098.54 $1,263.32
Report Run: 04/19/16 10:53 AM Page 295 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SAVAYSA
15 MG TABLET(S) edoxaban Daiichi Sankyo Open Care Program $332.64 $382.54 30 MG TABLET(S) edoxaban Daiichi Sankyo Open Care Program $997.92 $1,147.61 60 MG TABLET(S) edoxaban Daiichi Sankyo Open Care Program $997.92 $1,147.61 SAVELLA
100 MG TABLET(S) MILNACIPRAN HCL Actavis U.S. Patient Assistance Program $271.06 $311.72 12.5 MG TABLET(S) MILNACIPRAN HCL Actavis U.S. Patient Assistance Program $271.06 $311.72 25 MG TABLET(S) MILNACIPRAN HCL Actavis U.S. Patient Assistance Program $271.06 $311.72 50 MG TABLET(S) MILNACIPRAN HCL Actavis U.S. Patient Assistance Program $271.06 $311.72 SAVELLA TITRATION PACK
N/A N/A TABLET(S) MILNACIPRAN HYDROCHLORIDE Actavis U.S. Patient Assistance Program $248.47 $285.74 SCANDICAL
N/A N/A POWDER NUTRITIONAL SUPPLEMENT Axcan Comprehensive Care Program for CF $6.63 $7.62 SCANDISHAKE-BERRY
N/A N/A POWDER NUTRITIONAL SUPPLEMENT Axcan Comprehensive Care Program for CF $7.67 $8.82 SCANDISHAKE-CHOCOLATE
N/A N/A POWDER NUTRITIONAL SUPPLEMENT Axcan Comprehensive Care Program for CF $7.67 $8.82 SCANDISHAKE-VANILLA
N/A N/A POWDER NUTRITIONAL SUPPLEMENT Axcan Comprehensive Care Program for CF $7.67 $8.82 SELEGILINE HCL (BRAND: ELDEPRYL)
5 MG TABLET(S) SELEGILINE HYDROCHLORIDE Xubex Patient Assistance Program $122.45 $140.82
Report Run: 04/19/16 10:53 AM Page 296 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SELZENTRY
150 MG TABLET(S) MARAVIROC ViiV Healthcare Patient Assistance Program $1,455.13 $1,673.40 300 MG TABLET(S) MARAVIROC ViiV Healthcare Patient Assistance Program $1,455.13 $1,673.40 SENSIPAR
30 MG TABLET(S) CINACALCET HYDROCHLORIDE Amgen Safety Net Foundation $768.24 $883.48 60 MG TABLET(S) CINACALCET HYDROCHLORIDE Amgen Safety Net Foundation $1,536.48 $1,766.95 90 MG TABLET(S) CINACALCET HYDROCHLORIDE Amgen Safety Net Foundation $2,304.72 $2,650.43 SEREVENT DISKUS
0.046 MCG PUFF(S) SALMETEROL XINAFOATE GSK Access $387.12 $445.19 0.046 MCG PUFF(S) SALMETEROL XINAFOATE GSK Bridges to Access $387.12 $445.19 0.046 MCG PUFF(S) SALMETEROL XINAFOATE Welvista - South Carolina Residents Only $387.12 $445.19 SEROQUEL
* 100 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $800.04 $920.05 Medicare Part D * 200 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $1,509.30 $1,735.70 Medicare Part D * 25 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $466.21 $536.14 Medicare Part D * 300 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $1,187.38 $1,365.49 Medicare Part D * 400 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $2,325.72 $2,674.58 Medicare Part D * 50 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $766.10 $881.02 Medicare Part D
Report Run: 04/19/16 10:53 AM Page 297 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SEROQUEL
* 100 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $800.04 $920.05 * 200 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,509.30 $1,735.70 * 25 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $466.21 $536.14 * 300 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,187.38 $1,365.49 * 400 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $2,325.72 $2,674.58 * 50 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $766.10 $881.02 SEROQUEL XR
200 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $1,168.56 $1,343.84 Medicare Part D 300 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $1,532.14 $1,761.96 Medicare Part D 400 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings for people with $1,800.65 $2,070.75 Medicare Part D 150 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,061.71 $1,220.97 200 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,168.56 $1,343.84 300 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,532.14 $1,761.96 400 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $1,800.65 $2,070.75 50 MG TABLET(S) QUETIAPINE FUMARATE AZ&Me Prescription Savings Program $591.26 $679.95 150 MG TABLET(S) QUETIAPINE FUMARATE Welvista - South Carolina Residents Only $1,061.71 $1,220.97 200 MG TABLET(S) QUETIAPINE FUMARATE Welvista - South Carolina Residents Only $1,168.56 $1,343.84 300 MG TABLET(S) QUETIAPINE FUMARATE Welvista - South Carolina Residents Only $1,532.14 $1,761.96 400 MG TABLET(S) QUETIAPINE FUMARATE Welvista - South Carolina Residents Only $1,800.65 $2,070.75
Report Run: 04/19/16 10:53 AM Page 298 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SEROQUEL XR
50 MG TABLET(S) QUETIAPINE FUMARATE Welvista - South Carolina Residents Only $591.26 $679.95 SEROSTIM
4 MG INJECTION SOMATROPIN, MAMMALIAN EMD SeroCare-Serostim Patient Assistance $1,553.33 $1,786.33 DERIVED Program 5 MG INJECTION SOMATROPIN, MAMMALIAN EMD SeroCare-Serostim Patient Assistance $1,941.66 $2,232.91 DERIVED Program 6 MG INJECTION SOMATROPIN, MAMMALIAN EMD SeroCare-Serostim Patient Assistance $2,329.99 $2,679.49 DERIVED Program 8.8 MG INJECTION SOMATROPIN, MAMMALIAN EMD SeroCare-Serostim Patient Assistance $1,674.62 $1,925.81 DERIVED Program SERTRALINE (BRAND: ZOLOFT)
100 MG TABLET(S) SERTRALINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $273.06 $314.02 Partners & Northern VA Residents ONLY 50 MG TABLET(S) SERTRALINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $272.75 $313.66 Partners & Northern VA Residents ONLY 100 MG TABLET(S) SERTRALINE HYDROCHLORIDE Rx Outreach $273.06 $314.02 25 MG TABLET(S) SERTRALINE HYDROCHLORIDE Rx Outreach $241.43 $277.64 50 MG TABLET(S) SERTRALINE HYDROCHLORIDE Rx Outreach $272.75 $313.66 100 MG TABLET(S) SERTRALINE HYDROCHLORIDE Welvista - South Carolina Residents Only $273.06 $314.02 25 MG TABLET(S) SERTRALINE HYDROCHLORIDE Welvista - South Carolina Residents Only $241.43 $277.64 50 MG TABLET(S) SERTRALINE HYDROCHLORIDE Welvista - South Carolina Residents Only $272.75 $313.66 100 MG TABLET(S) SERTRALINE HYDROCHLORIDE Xubex Preferred Network Program $273.06 $314.02 25 MG TABLET(S) SERTRALINE HYDROCHLORIDE Xubex Preferred Network Program $241.43 $277.64
Report Run: 04/19/16 10:53 AM Page 299 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SERTRALINE (BRAND: ZOLOFT)
50 MG TABLET(S) SERTRALINE HYDROCHLORIDE Xubex Preferred Network Program $272.75 $313.66 SEVELAMER CARBONATE (BRAND: RENVELA)
800 MG TABLET(S) sevelamer carbonate Rx Outreach $1,114.14 $1,281.26 SIMBRINZA
0.2-1 % (8 ml) DROP(S) brimonidine Alcon Cares, Inc. $145.08 $166.84 tartrate/brinzolamide SIMCOR
1000/20 MG-MG TABLET(S) NIACIN/SIMVASTATIN Welvista - South Carolina Residents Only $863.87 $993.45 1000/40 MG-MG TABLET(S) NIACIN/SIMVASTATIN Welvista - South Carolina Residents Only $863.87 $993.45 500/20 MG-MG TABLET(S) NIACIN/SIMVASTATIN Welvista - South Carolina Residents Only $488.45 $561.72 500/40 MG-MG TABLET(S) NIACIN/SIMVASTATIN Welvista - South Carolina Residents Only $488.45 $561.72 750/20 MG-MG TABLET(S) NIACIN/SIMVASTATIN Welvista - South Carolina Residents Only $696.70 $801.21 SIMPLY SALINE
0.9 % (ML) SPRAY(S) SODIUM CHLORIDE Blairex Laboratories, Inc $4.22 $4.85 SIMPONI ARIA
50/4 MG/ML (4 ML) MG golimumab Johnson & Johnson Patient Assistance $1,592.96 $1,831.90 Foundation SIMPONI PREFILLED SYRINGE
50/0.5 MG/ML (0.5 ML) INJECTION GOLIMUMAB Johnson & Johnson Patient Assistance $3,928.58 $4,517.87 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 300 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SIMVASTATIN (BRAND: ZOCOR)
10 MG TABLET(S) SIMVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $253.81 $291.88 Partners & Northern VA Residents ONLY 20 MG TABLET(S) SIMVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $442.85 $509.28 Partners & Northern VA Residents ONLY 40 MG TABLET(S) SIMVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $442.85 $509.28 Partners & Northern VA Residents ONLY 80 MG TABLET(S) SIMVASTATIN Nova ScriptsCentral-Northern Virginia Clinic $442.85 $509.28 Partners & Northern VA Residents ONLY 10 MG TABLET(S) SIMVASTATIN Rx Outreach $253.81 $291.88 20 MG TABLET(S) SIMVASTATIN Rx Outreach $442.85 $509.28 40 MG TABLET(S) SIMVASTATIN Rx Outreach $442.85 $509.28 5 MG TABLET(S) SIMVASTATIN Rx Outreach $189.39 $217.80 80 MG TABLET(S) SIMVASTATIN Rx Outreach $442.85 $509.28 10 MG TABLET(S) SIMVASTATIN Welvista - South Carolina Residents Only $253.81 $291.88 20 MG TABLET(S) SIMVASTATIN Welvista - South Carolina Residents Only $442.85 $509.28 40 MG TABLET(S) SIMVASTATIN Welvista - South Carolina Residents Only $442.85 $509.28 10 MG TABLET(S) SIMVASTATIN Xubex Preferred Network Program $253.81 $291.88 20 MG TABLET(S) SIMVASTATIN Xubex Preferred Network Program $442.85 $509.28 40 MG TABLET(S) SIMVASTATIN Xubex Preferred Network Program $442.85 $509.28 5 MG TABLET(S) SIMVASTATIN Xubex Preferred Network Program $189.39 $217.80 80 MG TABLET(S) SIMVASTATIN Xubex Preferred Network Program $442.85 $509.28
Report Run: 04/19/16 10:53 AM Page 301 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SINEMET 10-100
* 10;100 MG;MG TABLET(S) CARBIDOPA/LEVODOPA Bristol-Myers Squibb Patient Assistance $109.49 $125.91 Foundation, Inc. SINEMET 25-100
* 25;100 MG;MG TABLET(S) CARBIDOPA/LEVODOPA Bristol-Myers Squibb Patient Assistance $123.62 $142.16 Foundation, Inc. SINEMET 25-250
* 25;250 MG;MG TABLET(S) CARBIDOPA/LEVODOPA Bristol-Myers Squibb Patient Assistance $157.52 $181.15 Foundation, Inc. SINEMET CR
* 50-200 MG-MG TABLET(S) CARBIDOPA/LEVODOPA Bristol-Myers Squibb Patient Assistance $266.38 $306.34 Foundation, Inc. SINGULAIR GRANULES
4 MG/PACKET PACKET(S) montelukast sodium Merck Patient Assistance Program $223.97 $257.57 SIROLIMUS (BRAND: RAPAMUNE)
0.5 MG TABLET(S) sirolimus Xubex Preferred Network Program $830.76 $955.37 SIVEXTRO
200 MG TABLET(S) tedizolid phosphate Access Sivextro Patient Assistance Program $2,124.00 $2,442.60 SKELAXIN
800 MG TABLET(S) METAXALONE Pfizer RxPathways $777.11 $893.68 800 MG TABLET(S) METAXALONE Welvista - South Carolina Residents Only $777.11 $893.68 SKYLA
13.5 MG DEVICE (INSERT) levonorgestrel Arch Foundation Patient Assistance Program $780.38 $897.44
Report Run: 04/19/16 10:53 AM Page 302 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SODIUM BICARBONATE (BRAND: ALKA-SELTZER)
325 MG TABLET(S) sodium bicarbonate Xubex Preferred Network Program $5.00 $5.75 650 MG TABLET(S) sodium bicarbonate Xubex Preferred Network Program $5.50 $6.33 SOLIRIS
10 MG/ML (30 ML) MG ECULIZUMAB Alexion Complement Foundation $6,451.20 $7,418.88 SOOLANTRA
1 % (30 GM) GM ivermectin Galderma Patient Assistance Program $343.75 $395.31 SORIATANE
10 MG KIT ACITRETIN GSK Access $700.30 $805.34 25 MG KIT ACITRETIN GSK Access $863.20 $992.68 10 MG KIT ACITRETIN GSK Bridges to Access $700.30 $805.34 25 MG KIT ACITRETIN GSK Bridges to Access $863.20 $992.68 SORILUX FOAM
0.005 % (120 gm) APPLICATION(S) CALCIPOTRIENE GSK Bridges to Access $1,176.46 $1,352.93 SORINE (BRAND: SOTALOL HCL)
120 MG TABLET(S) sotalol hydrochloride Rx Outreach $346.39 $398.35 160 MG TABLET(S) sotalol hydrochloride Rx Outreach $430.98 $495.63 240 MG TABLET(S) sotalol hydrochloride Rx Outreach $559.97 $643.97 80 MG TABLET(S) sotalol hydrochloride Rx Outreach $260.89 $300.02 SOTALOL HCL (BRAND: BETAPACE)
120 MG TABLET(S) sotalol hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $430.19 $494.72 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 303 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SOTALOL HCL (BRAND: BETAPACE)
80 MG TABLET(S) SOTALOL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $322.48 $370.85 Partners & Northern VA Residents ONLY 120 MG TABLET(S) sotalol hydrochloride Xubex Preferred Network Program $430.19 $494.72 80 MG TABLET(S) SOTALOL HYDROCHLORIDE Xubex Preferred Network Program $322.48 $370.85 SOTALOL HCL AF (BRAND: BETAPACE AF)
160 MG TABLET(S) sotalol hydrochloride Xubex Preferred Network Program $537.92 $618.61 80 MG TABLET(S) sotalol hydrochloride Xubex Preferred Network Program $322.48 $370.85 SOTYLIZE
5 MG/ML (250 ML) ML sotalol hydrochloride Arbor Pharmaceuticals Patient Assistance $432.00 $496.80 Program SOVALDI
400 MG TABLET(S) sofosbuvir Support Path Patient Assistance Program $33,600.00 $38,640.00 SPIRIVA
18 MCG CAPSULE/HANDIHAL TIOTROPIUM BROMIDE Boehringer Ingelheim Cares Foundation Inc. $1,136.45 $1,306.92 ER SPIRIVA RESPIMAT
2.5 MG/ACTUATION SPRAY(S) tiotropium bromide Boehringer Ingelheim Cares Foundation Inc. $378.82 $435.64 SPIRONOLACTONE (BRAND: ALDACTONE)
100 MG TABLET(S) spironolactone Nova ScriptsCentral-Northern Virginia Clinic $142.43 $163.79 Partners & Northern VA Residents ONLY 25 MG TABLET(S) SPIRONOLACTONE Nova ScriptsCentral-Northern Virginia Clinic $45.90 $52.79 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 304 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SPIRONOLACTONE (BRAND: ALDACTONE)
50 MG TABLET(S) spironolactone Nova ScriptsCentral-Northern Virginia Clinic $81.57 $93.81 Partners & Northern VA Residents ONLY 25 MG TABLET(S) SPIRONOLACTONE Rx Outreach $45.90 $52.79 100 MG TABLET(S) spironolactone Xubex Preferred Network Program $142.43 $163.79 25 MG TABLET(S) SPIRONOLACTONE Xubex Preferred Network Program $45.90 $52.79 50 MG TABLET(S) spironolactone Xubex Preferred Network Program $81.57 $93.81 SPIRONOLACTONE/HCTZ (BRAND: ALDACTAZIDE)
25/25 MG/MG TABLET(S) spironolactone/hctz Rx Outreach $46.01 $52.91 25/25 MG/MG TABLET(S) spironolactone/hctz Xubex Preferred Network Program $46.01 $52.91 SPORANOX
10 MG/ML (150ML) SOL ITRACONAZOLE Johnson & Johnson Patient Assistance $322.98 $371.43 Foundation 100 MG CAPSULE(S) ITRACONAZOLE Johnson & Johnson Patient Assistance $730.66 $840.26 Foundation 10 MG/ML (150ML) SOL ITRACONAZOLE Johnson & Johnson Patient Assistance $322.98 $371.43 Foundation-Card Program 100 MG CAPSULE(S) ITRACONAZOLE Johnson & Johnson Patient Assistance $730.66 $840.26 Foundation-Card Program 100 MG CAPSULE(S) ITRACONAZOLE Nova ScriptsCentral-Northern Virginia Clinic $730.66 $840.26 Partners & Northern VA Residents ONLY 10 MG/ML (150ML) SOL ITRACONAZOLE Welvista - South Carolina Residents Only $322.98 $371.43 100 MG CAPSULE(S) ITRACONAZOLE Welvista - South Carolina Residents Only $730.66 $840.26
Report Run: 04/19/16 10:53 AM Page 305 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SPRINTEC (BRAND: ORTHO-CYCLEN)
35-0.25 MG-MG TABLET(S) ETHINYL Rx Outreach $193.38 $222.39 ESTRADIOL/NORGESTIMATE SPRYCEL
100 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $12,428.33 $14,292.58 Oncology Patient Assistance Program 140 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $12,428.33 $14,292.58 Oncology Patient Assistance Program 20 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $6,895.70 $7,930.06 Oncology Patient Assistance Program 50 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $13,791.38 $15,860.09 Oncology Patient Assistance Program 70 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $13,791.38 $15,860.09 Oncology Patient Assistance Program 80 MG TABLET(S) DASATINIB Bristol-Myers Squibb Access Support $12,428.33 $14,292.58 Oncology Patient Assistance Program SSKI (BRAND: POTASSIUM IODIDE)
1 GM/ML (30 ML) ML potassium iodide Rx Outreach $22.57 $25.96 STALEVO 100
25-200-100 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA STALEVO 125
31.25-200-125 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA
Report Run: 04/19/16 10:53 AM Page 306 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
STALEVO 150
37.5-200-150 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA STALEVO 200
50-200-200 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA STALEVO 50
12.5-200-50 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA STALEVO 75
18.75-200-75 MG-MG-MG TABLET(S) CARBIDOPA/ENTACAPONE/LEV Novartis Patient Assistance Foundation, Inc. $663.85 $763.43 ODOPA STARLIX
* 120 MG TABLET(S) NATEGLINIDE Novartis Patient Assistance Foundation, Inc. $244.54 $281.22 * 60 MG TABLET(S) NATEGLINIDE Novartis Patient Assistance Foundation, Inc. $235.37 $270.68 STAVUDINE (BRAND: ZERIT)
15 MG CAPSULE(S) stavudine Xubex Preferred Network Program $365.08 $419.84 20 MG CAPSULE(S) stavudine Xubex Preferred Network Program $379.64 $436.59 30 MG CAPSULE(S) stavudine Xubex Preferred Network Program $403.25 $463.74 40 MG CAPSULE(S) stavudine Xubex Preferred Network Program $410.70 $472.31 STELARA
45/0.5 MG/ML (0.5ML) SYRINGE USTEKINUMAB Johnson & Johnson Patient Assistance $8,848.31 $10,175.56 Foundation
Report Run: 04/19/16 10:53 AM Page 307 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
STELARA
90 MG/ML (1 ML) SYRINGE ustekinumab Johnson & Johnson Patient Assistance $17,696.57 $20,351.06 Foundation STIMATE
0.15 MG/ACTUATION (2.5 SPRAY(S) DESMOPRESSIN ACETATE CSL Behring Patient Assistance Program $682.80 $785.22 ML) STIOLTO RESPIMAT
2.5-2.5 MCG/ACTUATION PUFF(S) olodaterol/tiotropium bromide Boehringer Ingelheim Cares Foundation Inc. $378.82 $435.64 STIVARGA
40 MG TABLET(S) regorafenib Bayer REACH Program $15,896.56 $18,281.04 STRATTERA
10 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $367.56 $422.69 HYDROCHLORIDE 100 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $430.92 $495.56 HYDROCHLORIDE 18 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $367.56 $422.69 HYDROCHLORIDE 25 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $367.56 $422.69 HYDROCHLORIDE 40 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $399.24 $459.13 HYDROCHLORIDE 60 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $399.24 $459.13 HYDROCHLORIDE 80 MG CAPSULE(S) ATOMOXETINE Eli Lilly Cares $430.92 $495.56 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 308 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
STRATTERA
10 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $367.56 $422.69 HYDROCHLORIDE 100 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $430.92 $495.56 HYDROCHLORIDE 18 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $367.56 $422.69 HYDROCHLORIDE 25 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $367.56 $422.69 HYDROCHLORIDE 40 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $399.24 $459.13 HYDROCHLORIDE 60 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $399.24 $459.13 HYDROCHLORIDE 80 MG CAPSULE(S) ATOMOXETINE Welvista - South Carolina Residents Only $430.92 $495.56 HYDROCHLORIDE STRIBILD
150-150-200-300 MG-MG-MG-MG TABLET(S) antiviral combination Gilead Advancing Access $3,244.76 $3,731.47 STRIVERDI RESPIMAT (28 METERED ACTUATIONS)
2.5 MCG/ACTUATION (4 PUFF(S) olodaterol Boehringer Ingelheim Cares Foundation Inc. $87.19 $100.27 GM) STRIVERDI RESPIMAT (60 METERED ACTUATIONS)
2.5 MCG/ACTUATION (4 PUFF(S) olodaterol Boehringer Ingelheim Cares Foundation Inc. $186.84 $214.87 GM) STROMECTOL
3 MG TABLET(S) IVERMECTIN Merck Patient Assistance Program $111.66 $128.41
Report Run: 04/19/16 10:53 AM Page 309 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SUBOXONE
2-0.5 MG-MG FILM buprenorphine Suboxone Here to Help Patient Assistance $141.42 $162.63 hydrochloride/naloxone Program hydrochloride 8-2 MG-MG FILM buprenorphine Suboxone Here to Help Patient Assistance $253.38 $291.39 hydrochloride/naloxone Program hydrochloride SUCRALFATE
1 GM TABLET(S) sucralfate Rx Outreach $70.92 $81.56 1 GM TABLET(S) sucralfate Xubex Preferred Network Program $70.92 $81.56 SULFAMETHOXAZOLE/TRIMETHOPRIM DS (BRAND: BACTRIM DS/SEPTRA DS) 800-160 MG-MG TABLET(S) SULFAMETHOXAZOLE AND Nova ScriptsCentral-Northern Virginia Clinic $144.11 $165.73 TRIMETHOPRIM DS Partners & Northern VA Residents ONLY 800-160 MG-MG TABLET(S) SULFAMETHOXAZOLE AND Rx Outreach $144.11 $165.73 TRIMETHOPRIM DS 800-160 MG-MG TABLET(S) SULFAMETHOXAZOLE AND Xubex Patient Assistance Program $144.11 $165.73 TRIMETHOPRIM DS SULFASALAZINE (BRAND: AZULFIDINE)
500 MG TABLET(S) SULFASALAZINE Nova ScriptsCentral-Northern Virginia Clinic $38.42 $44.18 Partners & Northern VA Residents ONLY 500 MG TABLET(S) SULFASALAZINE Rx Outreach $38.42 $44.18 500 MG TABLET(S) SULFASALAZINE Xubex Patient Assistance Program $38.42 $44.18 500 MG TABLET(S) SULFASALAZINE Xubex Preferred Network Program $38.42 $44.18
Report Run: 04/19/16 10:53 AM Page 310 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SULINDAC (BRAND: CLINORIL)
150 MG TABLET(S) SULINDAC Nova ScriptsCentral-Northern Virginia Clinic $98.20 $112.93 Partners & Northern VA Residents ONLY 200 MG TABLET(S) SULINDAC Nova ScriptsCentral-Northern Virginia Clinic $120.60 $138.69 Partners & Northern VA Residents ONLY 150 MG TABLET(S) SULINDAC Xubex Preferred Network Program $98.20 $112.93 200 MG TABLET(S) SULINDAC Xubex Preferred Network Program $120.60 $138.69 SUMATRIPTAN SUCCINATE (BRAND: IMITREX)
100 MG TABLET(S) SUMATRIPTAN SUCCINATE Rx Outreach $2,262.57 $2,601.96 25 MG TABLET(S) SUMATRIPTAN SUCCINATE Rx Outreach $2,434.68 $2,799.88 50 MG TABLET(S) SUMATRIPTAN SUCCINATE Rx Outreach $2,262.57 $2,601.96 100 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $2,262.57 $2,601.96 25 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $2,434.68 $2,799.88 50 MG TABLET(S) SUMATRIPTAN SUCCINATE Welvista - South Carolina Residents Only $2,262.57 $2,601.96 100 MG TABLET(S) SUMATRIPTAN SUCCINATE Xubex Preferred Network Program $2,262.57 $2,601.96 25 MG TABLET(S) SUMATRIPTAN SUCCINATE Xubex Preferred Network Program $2,434.68 $2,799.88 50 MG TABLET(S) SUMATRIPTAN SUCCINATE Xubex Preferred Network Program $2,262.57 $2,601.96 SUPRENZA
30 MG TABLET(S) phentermine hydrochloride Akrimax Patient Assistance Program $132.96 $152.90 SUPRENZA
15 MG TABLET(S) phentermine hydrochloride Akrimax Patient Assistance Program $132.96 $152.90 37.5 MG TABLET(S) phentermine hydrochloride Akrimax Patient Assistance Program $132.96 $152.90
Report Run: 04/19/16 10:53 AM Page 311 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SUSTIVA
600 MG TABLET(S) EFAVIRENZ BMS3assist Program $1,011.97 $1,163.77 SUSTIVA
200 MG CAPSULE(S) EFAVIRENZ BMS3assist Program $1,011.97 $1,163.77 50 MG CAPSULE(S) EFAVIRENZ BMS3assist Program $84.38 $97.04 SUTENT
12.5 MG CAPSULE(S) SUNITINIB MALATE Pfizer RxPathways $4,130.12 $4,749.64 25 MG CAPSULE(S) SUNITINIB MALATE Pfizer RxPathways $8,260.24 $9,499.28 50 MG CAPSULE(S) SUNITINIB MALATE Pfizer RxPathways $14,379.92 $16,536.91 SYLVANT
400 MG VIAL(S) siltuximab Johnson & Johnson Patient Assistance $4,118.35 $4,736.10 Foundation SYMBICORT
160/4.5 MCG (10.2 GM) PUFF(S) BUDESONIDE/FORMOTEROL AZ&Me Prescription Savings for people with $329.66 $379.11 FUMARATE Medicare Part D 80/4.5 MCG (10.2GM) PUFF(S) BUDESONIDE/FORMOTEROL AZ&Me Prescription Savings for people with $288.41 $331.67 FUMARATE Medicare Part D 160/4.5 MCG (10.2 GM) PUFF(S) BUDESONIDE/FORMOTEROL AZ&Me Prescription Savings Program $329.66 $379.11 FUMARATE 80/4.5 MCG (10.2GM) PUFF(S) BUDESONIDE/FORMOTEROL AZ&Me Prescription Savings Program $288.41 $331.67 FUMARATE 160/4.5 MCG (10.2 GM) PUFF(S) BUDESONIDE/FORMOTEROL Welvista - South Carolina Residents Only $329.66 $379.11 FUMARATE
Report Run: 04/19/16 10:53 AM Page 312 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SYMBICORT
80/4.5 MCG (10.2GM) PUFF(S) BUDESONIDE/FORMOTEROL Welvista - South Carolina Residents Only $288.41 $331.67 FUMARATE SYMBYAX
25-12 MG CAPSULE(S) FLUOXETINE Eli Lilly Cares $727.56 $836.69 HYDROCHLORIDE/OLANZAPINE 25-3 MG CAPSULE(S) FLUOXETINE Eli Lilly Cares $353.16 $406.13 HYDROCHLORIDE/OLANZAPINE 25-6 MG CAPSULE(S) FLUOXETINE Eli Lilly Cares $1,609.20 $1,850.58 HYDROCHLORIDE/OLANZAPINE 50-12 MG CAPSULE(S) FLUOXETINE Eli Lilly Cares $2,425.20 $2,788.98 HYDROCHLORIDE/OLANZAPINE 50-6 MG CAPSULE(S) FLUOXETINE Eli Lilly Cares $1,609.20 $1,850.58 HYDROCHLORIDE/OLANZAPINE 25-12 MG CAPSULE(S) FLUOXETINE Welvista - South Carolina Residents Only $727.56 $836.69 HYDROCHLORIDE/OLANZAPINE 25-3 MG CAPSULE(S) FLUOXETINE Welvista - South Carolina Residents Only $353.16 $406.13 HYDROCHLORIDE/OLANZAPINE 25-6 MG CAPSULE(S) FLUOXETINE Welvista - South Carolina Residents Only $1,609.20 $1,850.58 HYDROCHLORIDE/OLANZAPINE 50-12 MG CAPSULE(S) FLUOXETINE Welvista - South Carolina Residents Only $2,425.20 $2,788.98 HYDROCHLORIDE/OLANZAPINE 50-6 MG CAPSULE(S) FLUOXETINE Welvista - South Carolina Residents Only $1,609.20 $1,850.58 HYDROCHLORIDE/OLANZAPINE SYMLINPEN
120 MCG (2.7ML) INJECTION PRAMLINTIDE ACETATE AZ&Me Prescription Savings Program $714.70 $821.91
Report Run: 04/19/16 10:53 AM Page 313 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SYMLINPEN
60 MCG (1.5 ML) INJECTION PRAMLINTIDE ACETATE AZ&Me Prescription Savings Program $585.13 $672.90 SYNAGIS
50 MG VIAL PALIVIZUMAB AZ&Me Prescription Savings Program $1,670.81 $1,921.43 SYNAGIS
100 MG VIAL PALIVIZUMAB AZ&Me Prescription Savings Program $3,154.97 $3,628.22 SYNAREL
0.2 MG/ACTUATION (8ML) SPRAY(S) NAFARELIN ACETATE Pfizer MAINTAIN $1,858.84 $2,137.67 0.2 MG/ACTUATION (8ML) SPRAY(S) NAFARELIN ACETATE Pfizer RxPathways $1,858.84 $2,137.67 SYNJARDY
12.5/1000 MG/MG TABLET(S) empagliflozin/metformin Boehringer Ingelheim Cares Foundation Inc. $1,306.88 $1,502.91 hydrochloride 12.5/500 MG/MG TABLET(S) empagliflozin/metformin Boehringer Ingelheim Cares Foundation Inc. $1,306.88 $1,502.91 hydrochloride 5/1000 MG/MG TABLET(S) empagliflozin/metformin Boehringer Ingelheim Cares Foundation Inc. $1,306.88 $1,502.91 hydrochloride 5/500 MG/MG TABLET(S) empagliflozin/metformin Boehringer Ingelheim Cares Foundation Inc. $1,306.88 $1,502.91 hydrochloride SYNRIBO
3.5 MG INJECTION omacetaxine mepesuccinate TEVA-Comprehensive Oncology $1,002.00 $1,152.30 Reimbursement Expertise (CORE) SYNTHROID
100 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $110.40 $126.96
Report Run: 04/19/16 10:53 AM Page 314 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SYNTHROID
112 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $110.52 $127.10 125 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $110.80 $127.42 137 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $110.83 $127.45 150 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $111.61 $128.35 175 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $121.16 $139.33 200 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $121.42 $139.63 25 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $105.16 $120.93 300 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $130.04 $149.55 50 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $106.46 $122.43 75 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $107.84 $124.02 88 MCG TABLET(S) LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $109.64 $126.09 100 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $110.40 $126.96 Partners & Northern VA Residents ONLY 112 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $110.52 $127.10 Partners & Northern VA Residents ONLY 125 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $110.80 $127.42 Partners & Northern VA Residents ONLY 137 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $110.83 $127.45 Partners & Northern VA Residents ONLY 150 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $111.61 $128.35 Partners & Northern VA Residents ONLY 175 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $121.16 $139.33 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 315 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SYNTHROID
200 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $121.42 $139.63 Partners & Northern VA Residents ONLY 25 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $105.16 $120.93 Partners & Northern VA Residents ONLY 50 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $106.46 $122.43 Partners & Northern VA Residents ONLY 75 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $107.84 $124.02 Partners & Northern VA Residents ONLY 88 MCG TABLET(S) LEVOTHYROXINE SODIUM Nova ScriptsCentral-Northern Virginia Clinic $109.64 $126.09 Partners & Northern VA Residents ONLY 100 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $110.40 $126.96 112 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $110.52 $127.10 125 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $110.80 $127.42 137 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $110.83 $127.45 150 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $111.61 $128.35 175 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $121.16 $139.33 200 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $121.42 $139.63 25 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $105.16 $120.93 300 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $130.04 $149.55 50 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $106.46 $122.43 75 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $107.84 $124.02 88 MCG TABLET(S) LEVOTHYROXINE SODIUM Welvista - South Carolina Residents Only $109.64 $126.09
Report Run: 04/19/16 10:53 AM Page 316 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
SYNTHROID
0.5 mg POW LEVOTHYROXINE SODIUM AbbVie Patient Assistance Program $56.43 $64.89 SYNVISC
8 MG/ML (2ML) SYRINGE HYLAN G-F 20 Sanofi Synvisc Connection $1,334.88 $1,535.11 SYNVISC-ONE
8 MG/ML (6 ML) SYRINGE HYLAN POLYMERS A AND B Sanofi Synvisc Connection $1,334.88 $1,535.11 SYPRINE
250 MG CAPSULE(S) TRIENTINE HYDROCHLORIDE Valeant Patient Assistance Program $25,520.16 $29,348.18 SYSTANE
0.4-0.3 %-% DROP(S) PEG-400/PROPYLENE GLYCOL Alcon Cares, Inc. $9.54 $10.97 0.4-0.3 %-% DROP(S) PEG-400/PROPYLENE GLYCOL Alcon Charitable Clinic Program-For Free $9.54 $10.97 Clinics SYSTANE BALANCE
0.6 % (10 ML) DROP(S) propylene glycol Alcon Cares, Inc. $10.44 $12.01 TACROLIMUS (BRAND: PROGRAF)
0.5 MG CAPSULE(S) tacrolimus Rx Outreach $222.98 $256.43 1 MG CAPSULE(S) tacrolimus Rx Outreach $445.95 $512.84 1 MG CAPSULE(S) tacrolimus Xubex Preferred Network Program $445.95 $512.84 TAFINLAR
50 MG CAPSULE(S) dabrafenib mesylate Commitment to Access $7,038.83 $8,094.65 75 MG CAPSULE(S) dabrafenib mesylate Commitment to Access $10,557.54 $12,141.17
Report Run: 04/19/16 10:53 AM Page 317 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TAMOXIFEN CITRATE
20 MG TABLET(S) TAMOXIFEN CITRATE Rx Outreach $379.24 $436.13 20 MG TABLET(S) TAMOXIFEN CITRATE Welvista - South Carolina Residents Only $379.24 $436.13 20 MG TABLET(S) TAMOXIFEN CITRATE Xubex Preferred Network Program $379.24 $436.13 TAMOXIFEN CITRATE
10 MG TABLET(S) TAMOXIFEN CITRATE Rx Outreach $113.77 $130.84 10 MG TABLET(S) TAMOXIFEN CITRATE Welvista - South Carolina Residents Only $113.77 $130.84 10 MG TABLET(S) TAMOXIFEN CITRATE Xubex Preferred Network Program $113.77 $130.84 TAMSULOSIN (BRAND: FLOMAX)
0.4 MG CAPSULE(S) TAMSULOSIN Nova ScriptsCentral-Northern Virginia Clinic $421.35 $484.55 Partners & Northern VA Residents ONLY 0.4 MG CAPSULE(S) TAMSULOSIN Rx Outreach $421.35 $484.55 0.4 MG CAPSULE(S) TAMSULOSIN Xubex Preferred Network Program $421.35 $484.55 TANZEUM
30 MG PEN(S) albiglutide GSK Access $527.24 $606.33 50 MG PEN(S) albiglutide GSK Access $527.24 $606.33 30 MG PEN(S) albiglutide GSK Bridges to Access $527.24 $606.33 50 MG PEN(S) albiglutide GSK Bridges to Access $527.24 $606.33 30 MG PEN(S) albiglutide Welvista - South Carolina Residents Only $527.24 $606.33 50 MG PEN(S) albiglutide Welvista - South Carolina Residents Only $527.24 $606.33
Report Run: 04/19/16 10:53 AM Page 318 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TARCEVA
100 MG TABLET(S) ERLOTINIB Genentech BioOncology Access Solutions- $7,117.85 $8,185.53 Oral Products 150 MG TABLET(S) ERLOTINIB Genentech BioOncology Access Solutions- $8,050.79 $9,258.41 Oral Products 25 MG TABLET(S) ERLOTINIB Genentech BioOncology Access Solutions- $2,591.45 $2,980.17 Oral Products TARGRETIN
75 MG CAPSULE(S) BEXAROTENE Eisai Patient Assistance Program $8,753.30 $10,066.30 75 MG CAPSULE(S) BEXAROTENE Rx Outreach $8,753.30 $10,066.30 TARGRETIN GEL
1 % APPLICATION BEXAROTENE Eisai Patient Assistance Program $4,322.50 $4,970.88 1 % APPLICATION BEXAROTENE Rx Outreach $4,322.50 $4,970.88 TARKA
1-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL AbbVie Patient Assistance Program $587.81 $675.98 HYDROCHLORIDE 2-180 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL AbbVie Patient Assistance Program $587.81 $675.98 HYDROCHLORIDE 2-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL AbbVie Patient Assistance Program $587.81 $675.98 HYDROCHLORIDE 4-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL AbbVie Patient Assistance Program $587.81 $675.98 HYDROCHLORIDE 1-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL Welvista - South Carolina Residents Only $587.81 $675.98 HYDROCHLORIDE
Report Run: 04/19/16 10:53 AM Page 319 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TARKA
2-180 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL Welvista - South Carolina Residents Only $587.81 $675.98 HYDROCHLORIDE 2-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL Welvista - South Carolina Residents Only $587.81 $675.98 HYDROCHLORIDE 4-240 MG TABLET(S) TRANDOLAPRIL/VERAPAMIL Welvista - South Carolina Residents Only $587.81 $675.98 HYDROCHLORIDE TASIGNA
200 MG CAPSULE(S) NILOTINIB HYDROCHLORIDE Novartis Oncology Patient Assistance $2,736.84 $3,147.37 Program TASMAR
100 MG TABLET(S) TOLCAPONE Valeant Patient Assistance Program $4,113.75 $4,730.81 TAZORAC CREAM
0.05 % (60 GM) APPLICATION TAZAROTENE Allergan Patient Assistance Program $658.49 $757.26 0.1 % (60 GM) APPLICATION TAZAROTENE Allergan Patient Assistance Program $699.58 $804.52 TAZORAC GEL
0.05 % (100 GM) APPLICATION TAZAROTENE Allergan Patient Assistance Program $1,097.41 $1,262.02 0.1 % (100 GM) APPLICATION TAZAROTENE Allergan Patient Assistance Program $1,166.05 $1,340.96 TEARS AGAIN HYDRATE
40-500-1000 MG-MG-MG CAPSULE(S) BILBERRY EXTRACT/EVENING OcuSoft Patient Assistance Program $57.60 $66.24 PRIMROSE OIL/FLAXSEED OIL TECFIDERA
120 MG CAPSULE(S) dimethyl fumarate Biogen MS Active Source-Tecfidera $1,528.80 $1,758.12
Report Run: 04/19/16 10:53 AM Page 320 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TECFIDERA
240 MG CAPSULE(S) dimethyl fumarate Biogen MS Active Source-Tecfidera $6,552.00 $7,534.80 TEGRETOL
200 MG TABLET(S) CARBAMAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $180.61 $207.70 Partners & Northern VA Residents ONLY 100 MG TABLET(S) CARBAMAZEPINE Novartis Patient Assistance Foundation, Inc. $0.77 $0.89 200 MG TABLET(S) CARBAMAZEPINE Novartis Patient Assistance Foundation, Inc. $180.61 $207.70 TEGRETOL-XR
100 MG TABLET(S) CARBAMAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $111.08 $127.74 Partners & Northern VA Residents ONLY 200 MG TABLET(S) CARBAMAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $221.71 $254.97 Partners & Northern VA Residents ONLY 100 MG TABLET(S) CARBAMAZEPINE Novartis Patient Assistance Foundation, Inc. $111.08 $127.74 200 MG TABLET(S) CARBAMAZEPINE Novartis Patient Assistance Foundation, Inc. $221.71 $254.97 400 MG TABLET(S) CARBAMAZEPINE Novartis Patient Assistance Foundation, Inc. $443.09 $509.55 100 MG TABLET(S) CARBAMAZEPINE Welvista - South Carolina Residents Only $111.08 $127.74 200 MG TABLET(S) CARBAMAZEPINE Welvista - South Carolina Residents Only $221.71 $254.97 400 MG TABLET(S) CARBAMAZEPINE Welvista - South Carolina Residents Only $443.09 $509.55 TEKTURNA
150 MG TABLET(S) ALISKIREN Novartis Patient Assistance Foundation, Inc. $137.11 $157.68 300 MG TABLET(S) ALISKIREN Novartis Patient Assistance Foundation, Inc. $172.97 $198.92 150 MG TABLET(S) ALISKIREN Welvista - South Carolina Residents Only $137.11 $157.68 300 MG TABLET(S) ALISKIREN Welvista - South Carolina Residents Only $172.97 $198.92
Report Run: 04/19/16 10:53 AM Page 321 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TEKTURNA HCT
150-12.5 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Novartis Patient Assistance Foundation, Inc. $137.11 $157.68 ZIDE 150-25 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Novartis Patient Assistance Foundation, Inc. $137.11 $157.68 ZIDE 300-12.5 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Novartis Patient Assistance Foundation, Inc. $172.97 $198.92 ZIDE 300-25 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Novartis Patient Assistance Foundation, Inc. $172.97 $198.92 ZIDE 150-12.5 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Welvista - South Carolina Residents Only $137.11 $157.68 ZIDE 150-25 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Welvista - South Carolina Residents Only $137.11 $157.68 ZIDE 300-12.5 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Welvista - South Carolina Residents Only $172.97 $198.92 ZIDE 300-25 MG-MG TABLET(S) ALISKIREN/HYDROCHLOROTHIA Welvista - South Carolina Residents Only $172.97 $198.92 ZIDE TELMISARTAN (BRAND: MICARDIS)
20 MG TABLET(S) TELMISARTAN Rx Outreach $469.89 $540.37 40 MG TABLET(S) TELMISARTAN Rx Outreach $496.89 $571.42 80 MG TABLET(S) TELMISARTAN Rx Outreach $496.89 $571.42 20 MG TABLET(S) TELMISARTAN Xubex Preferred Network Program $469.89 $540.37 40 MG TABLET(S) TELMISARTAN Xubex Preferred Network Program $496.89 $571.42 80 MG TABLET(S) TELMISARTAN Xubex Preferred Network Program $496.89 $571.42
Report Run: 04/19/16 10:53 AM Page 322 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TELMISARTAN/AMLODIPINE (BRAND: TWYNSTA)
10-40 MG-MG TABLET(S) amlodipine Xubex Preferred Network Program $171.24 $196.93 besylate/telmisartan 5-40 MG-MG TABLET(S) amlodipine Xubex Preferred Network Program $171.24 $196.93 besylate/telmisartan TEMAZEPAM (BRAND: RESTORIL)
15 MG TABLET(S) TEMAZEPAM Rx Outreach $72.18 $83.01 30 MG TABLET(S) TEMAZEPAM Rx Outreach $80.01 $92.01 15 MG TABLET(S) TEMAZEPAM Xubex Preferred Network Program $72.18 $83.01 22.5 MG CAPSULE(S) temazepam Xubex Preferred Network Program $299.45 $344.37 30 MG TABLET(S) TEMAZEPAM Xubex Preferred Network Program $80.01 $92.01 TEMODAR
100 MG CAPSULE(S) TEMOZOLOMIDE Merck Patient Assistance Program $1,901.48 $2,186.70 140 MG CAPSULE(S) TEMOZOLOMIDE Merck Patient Assistance Program $2,442.29 $2,808.63 20 MG CAPSULE(S) TEMOZOLOMIDE Merck Patient Assistance Program $414.59 $476.78 250 MG CAPSULE(S) TEMOZOLOMIDE Merck Patient Assistance Program $4,362.42 $5,016.78 5 MG CAPSULE(S) TEMOZOLOMIDE Merck Patient Assistance Program $94.42 $108.58 TERAZOL 3
80 MG SUPPOSITORY TERCONAZOLE Johnson & Johnson Patient Assistance $52.79 $60.71 Foundation 80 MG SUPPOSITORY TERCONAZOLE Welvista - South Carolina Residents Only $52.79 $60.71
Report Run: 04/19/16 10:53 AM Page 323 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TERAZOL 3 CREAM
0.8 % 20 GM APPLICATION TERCONAZOLE Johnson & Johnson Patient Assistance $52.79 $60.71 Foundation 0.8 % 20 GM APPLICATION TERCONAZOLE Welvista - South Carolina Residents Only $52.79 $60.71 TERAZOL 7 CREAM
0.4 % (45GM) APPLICATION TERCONAZOLE Johnson & Johnson Patient Assistance $52.79 $60.71 Foundation 0.4 % (45GM) APPLICATION TERCONAZOLE Nova ScriptsCentral-Northern Virginia Clinic $52.79 $60.71 Partners & Northern VA Residents ONLY 0.4 % (45GM) APPLICATION TERCONAZOLE Welvista - South Carolina Residents Only $52.79 $60.71 TERAZOSIN (BRAND: HYTRIN)
1 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $160.50 $184.58 Partners & Northern VA Residents ONLY 10 MG CAPSULE(S) terazosin hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $160.50 $184.58 Partners & Northern VA Residents ONLY 2 MG CAPSULE(S) terazosin hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $160.50 $184.58 Partners & Northern VA Residents ONLY 5 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $160.50 $184.58 Partners & Northern VA Residents ONLY 1 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Rx Outreach $160.50 $184.58 5 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Rx Outreach $160.50 $184.58 1 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Xubex Preferred Network Program $160.50 $184.58 10 MG CAPSULE(S) terazosin hydrochloride Xubex Preferred Network Program $160.50 $184.58 2 MG CAPSULE(S) terazosin hydrochloride Xubex Preferred Network Program $160.50 $184.58
Report Run: 04/19/16 10:53 AM Page 324 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TERAZOSIN (BRAND: HYTRIN)
5 MG CAPSULE(S) TERAZOSIN HYDROCHLORIDE Xubex Preferred Network Program $160.50 $184.58 TERBINAFINE (BRAND: LAMISIL)
250 MG TABLET(S) TERBINAFINE Nova ScriptsCentral-Northern Virginia Clinic $30.48 $35.05 Partners & Northern VA Residents ONLY 250 MG TABLET(S) TERBINAFINE Xubex Patient Assistance Program $30.48 $35.05 TESSALON PERLES
* 100 MG CAPSULE(S) BENZONATATE Pfizer RxPathways $132.43 $152.29 * 200 MG CAPSULE(S) BENZONATATE Pfizer RxPathways $259.91 $298.90 TEV-TROPIN
5 MG MG SOMATROPIN, E-COLI DERIVED Teva Cares Foundation Patient Assistance $323.02 $371.47 Program THALOMID
100 MG CAPSULE(S) THALIDOMIDE Celgene Patient Support $46,604.45 $53,595.12 150 MG CAPSULE(S) THALIDOMIDE Celgene Patient Support $39,865.34 $45,845.14 200 MG CAPSULE(S) THALIDOMIDE Celgene Patient Support $31,836.59 $36,612.08 50 MG CAPSULE(S) THALIDOMIDE Celgene Patient Support $5,742.30 $6,603.65 THEOPHYLLINE (BRAND: THEO-DUR)
100 MG TABLET(S) THEOPHYLLINE Rx Outreach $25.60 $29.44 200 MG TABLET(S) THEOPHYLLINE Rx Outreach $41.04 $47.20 300 MG TABLET(S) THEOPHYLLINE Rx Outreach $48.73 $56.04 100 MG TABLET(S) THEOPHYLLINE Xubex Patient Assistance Program $25.60 $29.44
Report Run: 04/19/16 10:53 AM Page 325 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
THEOPHYLLINE (BRAND: THEO-DUR)
200 MG TABLET(S) THEOPHYLLINE Xubex Patient Assistance Program $41.04 $47.20 300 MG TABLET(S) THEOPHYLLINE Xubex Patient Assistance Program $48.73 $56.04 THERACYS
81 MG POWDER BACILLUS OF CALMETTE AND Sanofi Patient Connection $204.79 $235.51 GUERIN VACCINE, LIVE THIOLA
100 MG TABLET(S) TIOPRONIN Thiola Total Care Hub $3,385.10 $3,892.87 THIORIDAZINE HCL (BRAND: MELLARIL)
10 MG TABLET(S) THIORIDAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $54.19 $62.32 Partners & Northern VA Residents ONLY 100 MG TABLET(S) THIORIDAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $108.56 $124.84 Partners & Northern VA Residents ONLY 25 MG TABLET(S) THIORIDAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $76.23 $87.66 Partners & Northern VA Residents ONLY 50 MG TABLET(S) THIORIDAZINE HCL Nova ScriptsCentral-Northern Virginia Clinic $95.33 $109.63 Partners & Northern VA Residents ONLY 10 MG TABLET(S) THIORIDAZINE HCL Xubex Preferred Network Program $54.19 $62.32 100 MG TABLET(S) THIORIDAZINE HCL Xubex Preferred Network Program $108.56 $124.84 25 MG TABLET(S) THIORIDAZINE HCL Xubex Preferred Network Program $76.23 $87.66 50 MG TABLET(S) THIORIDAZINE HCL Xubex Preferred Network Program $95.33 $109.63 THYROID (BRAND: THYROID)
120 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $14.25 $16.39
Report Run: 04/19/16 10:53 AM Page 326 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
THYROID (BRAND: THYROID)
15 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $8.40 $9.66 180 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $12.00 $13.80 30 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $9.00 $10.35 60 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $9.60 $11.04 90 MG CAPSULE(S) THYROID Xubex Patient Assistance Program $10.20 $11.73 TIAGABINE HYDROCHLORIDE (BRAND: GABITRIL)
2 MG TABLET(S) TIAGABINE HYDROCHLORIDE Xubex Preferred Network Program $200.00 $230.00 4 MG TABLET(S) TIAGABINE HYDROCHLORIDE Xubex Preferred Network Program $200.00 $230.00 TICLOPIDINE HCL (BRAND: TICLID)
250 MG TABLET(S) TICLOPIDINE HYDROCHLORIDE Xubex Patient Assistance Program $186.00 $213.90 TIKOSYN
0.125 MG CAPSULE(S) DOFETILIDE Pfizer RxPathways $396.44 $455.91 0.25 MG CAPSULE(S) DOFETILIDE Pfizer RxPathways $396.44 $455.91 0.5 MG CAPSULE(S) DOFETILIDE Pfizer RxPathways $396.44 $455.91 TIMENTIN
1-30 gm-gm PDS CLAVULANATE GSK Access $114.31 $131.46 POTASSIUM/TICARCILLIN DISODIUM TIMENTIN
100/100-3/100 mg/ml-g/m SOL CLAVULANATE GSK Access $15.00 $17.25 POTASSIUM/TICARCILLIN DISODIUM
Report Run: 04/19/16 10:53 AM Page 327 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TIMENTIN (ADD-VANTAGE)
100-3 mg-g PDS CLAVULANATE GSK Access $11.72 $13.48 POTASSIUM/TICARCILLIN DISODIUM TIMENTIN (VIAL)
100-3 mg-g PDS CLAVULANATE GSK Access $11.44 $13.16 POTASSIUM/TICARCILLIN DISODIUM TIMOLOL
0.5 % (5ml) DROP(S) TIMOLOL MALEATE Alcon Charitable Clinic Program-For Free $94.15 $108.27 Clinics TIMOPTIC IN OCUDOSE
0.5 % (60 units) DROP(S) TIMOLOL MALEATE Bausch & Lomb US Patient Assistance $473.41 $544.42 Program TIROSINT
100 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $31.99 $36.79 112 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 125 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 13 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 137 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 150 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 25 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 50 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 75 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77
Report Run: 04/19/16 10:53 AM Page 328 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TIROSINT
88 MCG CAPSULE(S) levothyroxine sodium Akrimax Patient Assistance Program $111.10 $127.77 TIVICAY
50 MG TABLET(S) dolutegravir sodium ViiV Healthcare Patient Assistance Program $1,581.68 $1,818.93 TIZANIDINE HCL (BRAND: ZANAFLEX)
2 MG TABLET(S) TIZANIDINE HCL Rx Outreach $122.17 $140.50 4 MG TABLET(S) TIZANIDINE HCL Rx Outreach $146.50 $168.48 2 MG TABLET(S) TIZANIDINE HCL Xubex Preferred Network Program $122.17 $140.50 4 MG TABLET(S) TIZANIDINE HCL Xubex Preferred Network Program $146.50 $168.48 TNKASE
50 MG KIT TENECTEPLASE Genentech Access to Care Foundation $4,983.24 $5,730.73 (TNKase, Cathflo, Activase) TOBI
300/5 MG/ML (5ML) SOL TOBRAMYCIN Novartis Tobi Patient Assistance Program $8,805.37 $10,126.18 TOBRADEX
0.1-0.3 %-% (10 ML) DROP(S) DEXAMETHASONE/TOBRAMYCI Alcon Cares, Inc. $359.10 $412.97 N 0.1-0.3 %-% (10 ML) DROP(S) DEXAMETHASONE/TOBRAMYCI Alcon Charitable Clinic Program-For Free $359.10 $412.97 N Clinics TOFRANIL
10 MG TABLET(S) IMIPRAMINE HYDROCHLORIDE Covidien/Mallinckrodt Patient Assistance $294.36 $338.51 Program
Report Run: 04/19/16 10:53 AM Page 329 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TOFRANIL
25 MG TABLET(S) IMIPRAMINE HYDROCHLORIDE Covidien/Mallinckrodt Patient Assistance $310.42 $356.98 Program 50 MG TABLET(S) IMIPRAMINE HYDROCHLORIDE Covidien/Mallinckrodt Patient Assistance $327.04 $376.10 Program TOFRANIL-PM
100 MG CAPSULE(S) IMIPRAMINE PAMOATE Covidien/Mallinckrodt Patient Assistance $698.72 $803.53 Program 125 MG CAPSULE(S) IMIPRAMINE PAMOATE Covidien/Mallinckrodt Patient Assistance $726.13 $835.05 Program 150 MG CAPSULE(S) IMIPRAMINE PAMOATE Covidien/Mallinckrodt Patient Assistance $754.06 $867.17 Program 75 MG CAPSULE(S) IMIPRAMINE PAMOATE Covidien/Mallinckrodt Patient Assistance $671.86 $772.64 Program TOLMETIN SODIUM
400 MG CAPSULE(S) tolmetin sodium Xubex Preferred Network Program $288.24 $331.48 TOLMETIN SODIUM
200 MG TABLET(S) tolmetin sodium Xubex Preferred Network Program $75.00 $86.25 TOLTERODINE TARTRATE (BRAND: DETROL)
1 MG TABLET(S) tolterodine tartrate Rx Outreach $198.55 $228.33 2 MG TABLET(S) tolterodine tartrate Rx Outreach $203.79 $234.36 2 MG TABLET(S) tolterodine tartrate Xubex Preferred Network Program $203.79 $234.36 4 MG CAPSULE(S) tolterodine tartrate Xubex Preferred Network Program $723.20 $831.68
Report Run: 04/19/16 10:53 AM Page 330 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TOPAMAX
100 MG TABLET(S) TOPIRAMATE Johnson & Johnson Hospital Access Patient $856.74 $985.25 Assistance Program 15 MG CAPSULE(S) TOPIRAMATE Johnson & Johnson Hospital Access Patient $297.29 $341.88 Assistance Program 200 MG TABLET(S) TOPIRAMATE Johnson & Johnson Hospital Access Patient $1,002.97 $1,153.42 Assistance Program 25 MG CAPSULE(S) TOPIRAMATE Johnson & Johnson Hospital Access Patient $359.39 $413.30 Assistance Program 50 MG TABLET(S) TOPIRAMATE Johnson & Johnson Hospital Access Patient $627.35 $721.45 Assistance Program 100 MG TABLET(S) TOPIRAMATE Johnson & Johnson Patient Assistance $856.74 $985.25 Foundation-Card Program 15 MG CAPSULE(S) TOPIRAMATE Johnson & Johnson Patient Assistance $297.29 $341.88 Foundation-Card Program 200 MG TABLET(S) TOPIRAMATE Johnson & Johnson Patient Assistance $1,002.97 $1,153.42 Foundation-Card Program 25 MG CAPSULE(S) TOPIRAMATE Johnson & Johnson Patient Assistance $359.39 $413.30 Foundation-Card Program 50 MG TABLET(S) TOPIRAMATE Johnson & Johnson Patient Assistance $627.35 $721.45 Foundation-Card Program 100 MG TABLET(S) TOPIRAMATE Welvista - South Carolina Residents Only $856.74 $985.25 15 MG CAPSULE(S) TOPIRAMATE Welvista - South Carolina Residents Only $297.29 $341.88 200 MG TABLET(S) TOPIRAMATE Welvista - South Carolina Residents Only $1,002.97 $1,153.42 25 MG CAPSULE(S) TOPIRAMATE Welvista - South Carolina Residents Only $359.39 $413.30 50 MG TABLET(S) TOPIRAMATE Welvista - South Carolina Residents Only $627.35 $721.45
Report Run: 04/19/16 10:53 AM Page 331 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TOPIRAMATE (BRAND: TOPAMAX)
* 100 MG TABLET(S) TOPIRAMATE Generic Assistance Program (NeedyMeds & $677.10 $778.67 Rx Outreach) * 200 MG TABLET(S) TOPIRAMATE Generic Assistance Program (NeedyMeds & $795.90 $915.29 Rx Outreach) * 25 MG TABLET(S) TOPIRAMATE Generic Assistance Program (NeedyMeds & $247.80 $284.97 Rx Outreach) * 50 MG TABLET(S) TOPIRAMATE Generic Assistance Program (NeedyMeds & $509.88 $586.36 Rx Outreach) 100 MG TABLET(S) TOPIRAMATE Nova ScriptsCentral-Northern Virginia Clinic $677.10 $778.67 Partners & Northern VA Residents ONLY 200 MG TABLET(S) TOPIRAMATE Nova ScriptsCentral-Northern Virginia Clinic $795.90 $915.29 Partners & Northern VA Residents ONLY 25 MG TABLET(S) TOPIRAMATE Nova ScriptsCentral-Northern Virginia Clinic $247.80 $284.97 Partners & Northern VA Residents ONLY 50 MG TABLET(S) TOPIRAMATE Nova ScriptsCentral-Northern Virginia Clinic $509.88 $586.36 Partners & Northern VA Residents ONLY 100 MG TABLET(S) TOPIRAMATE Rx Outreach $677.10 $778.67 200 MG TABLET(S) TOPIRAMATE Rx Outreach $795.90 $915.29 25 MG TABLET(S) TOPIRAMATE Rx Outreach $247.80 $284.97 50 MG TABLET(S) TOPIRAMATE Rx Outreach $509.88 $586.36 100 MG TABLET(S) TOPIRAMATE Xubex Preferred Network Program $677.10 $778.67 200 MG TABLET(S) TOPIRAMATE Xubex Preferred Network Program $795.90 $915.29 25 MG TABLET(S) TOPIRAMATE Xubex Preferred Network Program $247.80 $284.97 50 MG TABLET(S) TOPIRAMATE Xubex Preferred Network Program $509.88 $586.36
Report Run: 04/19/16 10:53 AM Page 332 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TOPROL XL
* 100 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings for people with $215.60 $247.94 Medicare Part D * 200 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings for people with $343.02 $394.47 Medicare Part D * 25 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings for people with $143.46 $164.98 Medicare Part D * 50 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings for people with $143.36 $164.86 Medicare Part D * 100 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings Program $215.60 $247.94 * 200 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings Program $343.02 $394.47 * 25 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings Program $143.46 $164.98 * 50 MG TABLET(S) METOPROLOL SUCCINATE AZ&Me Prescription Savings Program $143.36 $164.86 TORISEL
25 MG/ML (1ML) INJECTION(S) TEMSIROLIMUS Pfizer RxPathways $1,735.02 $1,995.27 TORSEMIDE
100 MG TABLET(S) torsemide Nova ScriptsCentral-Northern Virginia Clinic $304.15 $349.77 Partners & Northern VA Residents ONLY 100 MG TABLET(S) torsemide Xubex Preferred Network Program $304.15 $349.77 TORSEMIDE (BRAND: DEMADEX)
10 MG TABLET(S) TORSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $70.27 $80.81 Partners & Northern VA Residents ONLY 20 MG TABLET(S) TORSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $82.08 $94.39 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 333 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TORSEMIDE (BRAND: DEMADEX)
5 MG TABLET(S) TORSEMIDE Nova ScriptsCentral-Northern Virginia Clinic $63.41 $72.92 Partners & Northern VA Residents ONLY 10 MG TABLET(S) TORSEMIDE Xubex Preferred Network Program $70.27 $80.81 20 MG TABLET(S) TORSEMIDE Xubex Preferred Network Program $82.08 $94.39 5 MG TABLET(S) TORSEMIDE Xubex Preferred Network Program $63.41 $72.92 TOUJEO SOLOSTAR PEN
300 U/ML (1.5 ML) UNIT(S) insulin glargine, recombinant Sanofi Patient Connection $402.58 $462.97 TOVIAZ
4 MG TABLET(S) FESOTERODINE FUMARATE Pfizer MAINTAIN $297.36 $341.96 8 MG TABLET(S) FESOTERODINE FUMARATE Pfizer MAINTAIN $297.36 $341.96 4 MG TABLET(S) FESOTERODINE FUMARATE Pfizer RxPathways $297.36 $341.96 8 MG TABLET(S) FESOTERODINE FUMARATE Pfizer RxPathways $297.36 $341.96 4 MG TABLET(S) FESOTERODINE FUMARATE Welvista - South Carolina Residents Only $297.36 $341.96 8 MG TABLET(S) FESOTERODINE FUMARATE Welvista - South Carolina Residents Only $297.36 $341.96 4 MG TABLET(S) FESOTERODINE FUMARATE Xubex Free Trial 30 Day Medication Supply $297.36 $341.96 8 MG TABLET(S) FESOTERODINE FUMARATE Xubex Free Trial 30 Day Medication Supply $297.36 $341.96 TRACLEER
125 MG TABLET(S) BOSENTAN Actelion Pathways $11,098.80 $12,763.62 62.5 MG TABLET(S) BOSENTAN Actelion Pathways $11,098.80 $12,763.62 TRADJENTA
5 MG TABLET(S) linagliptin Boehringer Ingelheim Cares Foundation Inc. $1,190.30 $1,368.85
Report Run: 04/19/16 10:53 AM Page 334 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRAMADOL (BRAND: ULTRAM)
50 MG TABLET(S) TRAMADOL HYDROCHLORIDE Rx Outreach $157.50 $181.13 50 MG TABLET(S) TRAMADOL HYDROCHLORIDE Xubex Preferred Network Program $157.50 $181.13 TRANDOLAPRIL (BRAND: MAVIK)
1 MG TABLET(S) TRANDOLAPRIL Rx Outreach $123.93 $142.52 2 MG TABLET(S) TRANDOLAPRIL Rx Outreach $105.93 $121.82 4 MG TABLET(S) TRANDOLAPRIL Rx Outreach $105.93 $121.82 1 MG TABLET(S) TRANDOLAPRIL Xubex Preferred Network Program $123.93 $142.52 2 MG TABLET(S) TRANDOLAPRIL Xubex Preferred Network Program $105.93 $121.82 4 MG TABLET(S) TRANDOLAPRIL Xubex Preferred Network Program $105.93 $121.82 TRANYLCYPROMINE SULFATE (BRAND: PARNATE)
10 MG TABLET(S) tranylcypromine sulfate Xubex Preferred Network Program $360.89 $415.02 TRAVATAN
0.004 % 2.5 ML DROP(S) TRAVOPROST Alcon Cares, Inc. $91.74 $105.50 0.004 % 2.5 ML DROP(S) TRAVOPROST Alcon Charitable Clinic Program-For Free $91.74 $105.50 Clinics TRAVATAN Z
0.004 % (2.5ml) DROP(S) TRAVOPROST Alcon Cares, Inc. $151.44 $174.16 0.004 % (2.5ml) DROP(S) TRAVOPROST Alcon Charitable Clinic Program-For Free $151.44 $174.16 Clinics 0.004 % (2.5ml) DROP(S) TRAVOPROST Nova ScriptsCentral-Northern Virginia Clinic $151.44 $174.16 Partners & Northern VA Residents ONLY
Report Run: 04/19/16 10:53 AM Page 335 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRAZODONE (BRAND: DESYREL)
100 MG TABLET(S) TRAZODONE Nova ScriptsCentral-Northern Virginia Clinic $180.00 $207.00 Partners & Northern VA Residents ONLY 150 MG TABLET(S) TRAZODONE Nova ScriptsCentral-Northern Virginia Clinic $170.78 $196.40 Partners & Northern VA Residents ONLY 50 MG TABLET(S) TRAZODONE Nova ScriptsCentral-Northern Virginia Clinic $153.00 $175.95 Partners & Northern VA Residents ONLY 100 MG TABLET(S) TRAZODONE Rx Outreach $180.00 $207.00 150 MG TABLET(S) TRAZODONE Rx Outreach $170.78 $196.40 50 MG TABLET(S) TRAZODONE Rx Outreach $153.00 $175.95 100 MG TABLET(S) TRAZODONE Welvista - South Carolina Residents Only $180.00 $207.00 50 MG TABLET(S) TRAZODONE Welvista - South Carolina Residents Only $153.00 $175.95 100 MG TABLET(S) TRAZODONE Xubex Preferred Network Program $180.00 $207.00 150 MG TABLET(S) TRAZODONE Xubex Preferred Network Program $170.78 $196.40 300 MG TABLET(S) TRAZODONE Xubex Preferred Network Program $543.52 $625.05 50 MG TABLET(S) TRAZODONE Xubex Preferred Network Program $153.00 $175.95 TREANDA
100 MG INJECTION BENDAMUSTINE TEVA-Comprehensive Oncology $3,069.58 $3,530.02 HYDROCHLORIDE Reimbursement Expertise (CORE) 25 MG INJECTION BENDAMUSTINE TEVA-Comprehensive Oncology $767.40 $882.51 HYDROCHLORIDE Reimbursement Expertise (CORE) TRECATOR
250 MG TABLET(S) ETHIONAMIDE Pfizer RxPathways $422.09 $485.40
Report Run: 04/19/16 10:53 AM Page 336 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRELSTAR
11.25 MG MG triptorelin pamoate Actavis U.S. Patient Assistance Program $2,927.66 $3,366.81 22.5 MG MG triptorelin pamoate Actavis U.S. Patient Assistance Program $5,855.33 $6,733.63 3.75 MG MG triptorelin pamoate Actavis U.S. Patient Assistance Program $975.89 $1,122.27 TREXIMET
* 500-85 MG-MG TABLET(S) NAPROXEN GSK Access $750.60 $863.19 SODIUM/SUMATRIPTAN SUCCINATE * 500-85 MG-MG TABLET(S) NAPROXEN GSK Bridges to Access $750.60 $863.19 SODIUM/SUMATRIPTAN SUCCINATE 500-85 MG-MG TABLET(S) NAPROXEN Pernix Therapeutics Patient Assistance $750.60 $863.19 SODIUM/SUMATRIPTAN Program SUCCINATE TRIAMTERENE/HCTZ (BRAND: DYAZIDE, MAXZIDE)
25/37.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Nova ScriptsCentral-Northern Virginia Clinic $39.27 $45.16 MTERENE Partners & Northern VA Residents ONLY 50-75 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Nova ScriptsCentral-Northern Virginia Clinic $111.32 $128.02 MTERENE Partners & Northern VA Residents ONLY 25/37.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Rx Outreach $39.27 $45.16 MTERENE 50-75 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Rx Outreach $111.32 $128.02 MTERENE 25/37.5 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Xubex Preferred Network Program $39.27 $45.16 MTERENE
Report Run: 04/19/16 10:53 AM Page 337 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRIAMTERENE/HCTZ (BRAND: DYAZIDE, MAXZIDE)
25-50 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Xubex Preferred Network Program $72.09 $82.90 MTERENE 50-75 MG-MG TABLET(S) HYDROCHLOROTHIAZIDE/TRIA Xubex Preferred Network Program $111.32 $128.02 MTERENE TRIBENZOR
20/5/12.5 MG-MG-MG TABLET(S) OLMESARTAN Daiichi Sankyo Open Care Program $653.40 $751.41 MEDOXOMIL/AMLODIPINE BESYLATE/HCTZ 40/10/12.5 MG-MG-MG TABLET(S) OLMESARTAN Daiichi Sankyo Open Care Program $826.20 $950.13 MEDOXOMIL/AMLODIPINE BESYLATE/HCTZ 40/10/25 MG-MG-MG TABLET(S) OLMESARTAN Daiichi Sankyo Open Care Program $702.00 $807.30 MEDOXOMIL/AMLODIPINE BESYLATE/HCTZ 40/5/12.5 MG-MG-MG TABLET(S) OLMESARTAN Daiichi Sankyo Open Care Program $826.20 $950.13 MEDOXOMIL/AMLODIPINE BESYLATE/HCTZ 40/5/25 MG-MG-MG TABLET(S) OLMESARTAN Daiichi Sankyo Open Care Program $826.20 $950.13 MEDOXOMIL/AMLODIPINE BESYLATE/HCTZ TRIFLUOPERAZINE HCL (BRAND: STELAZINE)
1 MG TABLET(S) TRIFLUOPERAZINE HCL Xubex Preferred Network Program $87.45 $100.57 10 MG TABLET(S) TRIFLUOPERAZINE HCL Xubex Preferred Network Program $244.65 $281.35 2 MG TABLET(S) TRIFLUOPERAZINE HCL Xubex Preferred Network Program $128.85 $148.18 5 MG TABLET(S) TRIFLUOPERAZINE HCL Xubex Preferred Network Program $162.30 $186.65
Report Run: 04/19/16 10:53 AM Page 338 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRIHEXYPHENIDYL HCL (BRAND: ARTANE)
2 MG TABLET(S) TRIHEXYPHENIDYL Xubex Patient Assistance Program $18.02 $20.72 HYDROCHLORIDE TRILEPTAL
150 MG TABLET(S) OXCARBAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $377.39 $434.00 Partners & Northern VA Residents ONLY 300 MG TABLET(S) OXCARBAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $689.27 $792.66 Partners & Northern VA Residents ONLY 600 MG TABLET(S) OXCARBAZEPINE Nova ScriptsCentral-Northern Virginia Clinic $1,266.83 $1,456.85 Partners & Northern VA Residents ONLY 150 MG TABLET(S) OXCARBAZEPINE Novartis Patient Assistance Foundation, Inc. $377.39 $434.00 300 MG TABLET(S) OXCARBAZEPINE Novartis Patient Assistance Foundation, Inc. $689.27 $792.66 600 MG TABLET(S) OXCARBAZEPINE Novartis Patient Assistance Foundation, Inc. $1,266.83 $1,456.85 150 MG TABLET(S) OXCARBAZEPINE Welvista - South Carolina Residents Only $377.39 $434.00 300 MG TABLET(S) OXCARBAZEPINE Welvista - South Carolina Residents Only $689.27 $792.66 600 MG TABLET(S) OXCARBAZEPINE Welvista - South Carolina Residents Only $1,266.83 $1,456.85 TRISENOX
1 MG/ML (10 ML) INJECTION (ML) ARSENIC TRIOXIDE TEVA-Comprehensive Oncology $6,767.64 $7,782.79 Reimbursement Expertise (CORE) TRI-SPRINTEC (BRAND: ORTHO-TRI-CYCLEN)
N/A N/A TABLET(S) ETHINYL Rx Outreach $235.94 $271.33 ESTRADIOL/NORGESTIMATE
Report Run: 04/19/16 10:53 AM Page 339 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TRIUMEQ
600-50-300 MG-MG-MG TABLET(S) abacavir/dolutegravir/lamivudin ViiV Healthcare Patient Assistance Program $2,648.84 $3,046.17 e TRIZIVIR
300-150-300 MG-MG-MG TABLET(S) ABACAVIR SULFATE ViiV Healthcare Patient Assistance Program $1,931.64 $2,221.39 TROKENDI XR
100 MG CAPSULE(S) topiramate Supernus Support $534.24 $614.38 200 MG CAPSULE(S) topiramate Supernus Support $730.80 $840.42 25 MG CAPSULE(S) topiramate Supernus Support $207.00 $238.05 50 MG CAPSULE(S) topiramate Supernus Support $269.64 $310.09 TRULICITY
0.75/0.5 MG/ML PEN dulaglutide Eli Lilly Cares $638.16 $733.88 1.5/0.5 MG/ML PEN dulaglutide Eli Lilly Cares $638.16 $733.88 TRUMENBA
120/0.5 MCG/ML (10s) SYRINGE(S) meningococcal vaccine, group b Pfizer RxPathways $1,387.50 $1,595.63 TRUSOPT OCUMETER PLUS
2 % (10 ml) DROP(S) DORZOLAMIDE Merck Patient Assistance Program $92.04 $105.85 HYDROCHLORIDE TRUVADA
200-300 MG-MG TABLET(S) EMTRICITABINE/TENOFOVIR Gilead Advancing Access $1,759.73 $2,023.69 DISOPROXIL FUMARATE
Report Run: 04/19/16 10:53 AM Page 340 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
TUDORZA PRESSAIR
400 MCG/ACTUATION PUFF(S) ACLIDINIUM BROMIDE AZ&Me Prescription Savings Program $361.32 $415.52 TWINRIX
720-20 EL U/ML-MCG/ML INJECTION(S) HEP A VAC, INACTIVATED/HEP B GSK Vaccines Access Program $1,107.01 $1,273.06 VAC RECOMBINANT TYBOST
150 MG TABLET(S) cobicistat Gilead Advancing Access $230.90 $265.54 TYGACIL
50 MG INJECTION(S) TIGECYCLINE Pfizer RxPathways $1,216.01 $1,398.41 TYKERB
250 MG TABLET(S) LAPATINIB DITOSYLATE Commitment to Access $6,328.46 $7,277.73 TYZEKA
600 MG TABLET(S) TELBIVUDINE Novartis Patient Assistance Foundation, Inc. $1,169.48 $1,344.90 UCERIS
9 MG TABLET(S) budesonide Salix Patient Assistance Program $1,935.07 $2,225.33 ULORIC
40 MG TABLET(S) FEBUXOSTAT Takeda Patient Assistance Program-Colcrys & $310.39 $356.95 Uloric 80 MG TABLET(S) FEBUXOSTAT Takeda Patient Assistance Program-Colcrys & $310.39 $356.95 Uloric 40 MG TABLET(S) FEBUXOSTAT Welvista - South Carolina Residents Only $310.39 $356.95 80 MG TABLET(S) FEBUXOSTAT Welvista - South Carolina Residents Only $310.39 $356.95
Report Run: 04/19/16 10:53 AM Page 341 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ULTRACET
325-37.5 MG-MG TABLET(S) APAP/TRAMADOL HCL Johnson & Johnson Hospital Access Patient $301.28 $346.47 Assistance Program 325-37.5 MG-MG TABLET(S) APAP/TRAMADOL HCL Johnson & Johnson Patient Assistance $301.28 $346.47 Foundation-Card Program ULTRAM
50 MG TABLET(S) TRAMADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $295.85 $340.23 Foundation-Card Program ULTRAM ER
100 MG TABLET(S) TRAMADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $224.20 $257.83 Foundation-Card Program 200 MG TABLET(S) TRAMADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $370.78 $426.40 Foundation-Card Program 300 MG TABLET(S) TRAMADOL HYDROCHLORIDE Johnson & Johnson Patient Assistance $517.32 $594.92 Foundation-Card Program ULTRESA
27600-13800- U-U-U CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $301.10 $346.27 27600 41400-20700- U-U-U CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $445.54 $512.37 41400 46000-23000- U-U-U CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $547.13 $629.20 46000 UPTRAVI
200 MCG TABLET(S) selexipag Actelion Pathways $26,136.00 $30,056.40
Report Run: 04/19/16 10:53 AM Page 342 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
UPTRAVI TITRATION PACK
800 MCG TABLET(S) selexipag Actelion Pathways $26,136.00 $30,056.40 URIBEL
0.12-118-10-36- MG CAPSULE(S) belladonna alkaloids and Mission Pharmacal Patient Assistance $255.67 $294.02 40.8 analgesics Program UROCIT-K 10
10 MEQ TABLET(S) POTASSIUM CITRATE Mission Pharmacal Patient Assistance $244.46 $281.13 Program UROCIT-K 15
15 MEQ TABLET(S) potassium Mission Pharmacal Patient Assistance $396.41 $455.87 Program UROCIT-K 5
5 MEQ TABLET(S) POTASSIUM CITRATE Mission Pharmacal Patient Assistance $174.42 $200.58 Program UROXATRAL
10 MG TABLET(S) ALFUZOSIN HYDROCHLORIDE Rx Outreach $1,407.60 $1,618.74 URSODIOL (BRAND: URSO FORTE)
250 MG TABLET(S) ursodiol Xubex Preferred Network Program $268.24 $308.48 300 MG CAPSULE(S) ursodiol Xubex Preferred Network Program $735.10 $845.37 500 MG TABLET(S) ursodiol Xubex Preferred Network Program $475.34 $546.64 UVADEX
0.02 MG/ML (10ML 12s) INJECTION(S) METHOXSALEN Johnson & Johnson Patient Assistance $755.00 $868.25 Foundation
Report Run: 04/19/16 10:53 AM Page 343 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VAGIFEM 18
10 MCG TABLET(S) ESTRADIOL Novo Nordisk Hormone Therapy Patient $459.43 $528.34 Assistance Program 10 MCG TABLET(S) ESTRADIOL Welvista - South Carolina Residents Only $459.43 $528.34 VAGIFEM 8
10 MCG TABLET(S) ESTRADIOL Novo Nordisk Hormone Therapy Patient $204.19 $234.82 Assistance Program 10 MCG TABLET(S) ESTRADIOL Welvista - South Carolina Residents Only $204.19 $234.82 VALACYCLOVIR HCL (BRAND: VALTREX)
1 GM TABLET(S) valacyclovir hydrochloride Rx Outreach $379.68 $436.63 500 MG TABLET(S) valacyclovir hydrochloride Rx Outreach $650.83 $748.45 1 GM TABLET(S) valacyclovir hydrochloride Xubex Preferred Network Program $379.68 $436.63 500 MG TABLET(S) valacyclovir hydrochloride Xubex Preferred Network Program $650.83 $748.45 VALCYTE
450 MG TABLET(S) VALGANCICLOVIR Genentech Access to Care Foundation (HIV & $5,054.03 $5,812.13 HYDROCHLORIDE Transplants)-CellCept & Valcyte VALPROIC ACID (BRAND: DEPAKENE)
250 MG CAPSULE(S) valproic acid Rx Outreach $79.40 $91.31 250 MG CAPSULE(S) valproic acid Xubex Preferred Network Program $79.40 $91.31 VALSARTAN (BRAND: DIOVAN)
* 160 MG TABLET(S) VALSARTAN Generic Assistance Program (NeedyMeds & $593.47 $682.49 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 344 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VALSARTAN (BRAND: DIOVAN)
* 320 MG TABLET(S) VALSARTAN Generic Assistance Program (NeedyMeds & $569.10 $654.47 Rx Outreach) * 40 MG TABLET(S) VALSARTAN Generic Assistance Program (NeedyMeds & $116.65 $134.15 Rx Outreach) * 80 MG TABLET(S) VALSARTAN Generic Assistance Program (NeedyMeds & $418.36 $481.11 Rx Outreach) 160 MG TABLET(S) VALSARTAN Nova ScriptsCentral-Northern Virginia Clinic $593.47 $682.49 Partners & Northern VA Residents ONLY 160 MG TABLET(S) VALSARTAN Rx Outreach $593.47 $682.49 320 MG TABLET(S) VALSARTAN Rx Outreach $569.10 $654.47 40 MG TABLET(S) VALSARTAN Rx Outreach $116.65 $134.15 80 MG TABLET(S) VALSARTAN Rx Outreach $418.36 $481.11 160 MG TABLET(S) VALSARTAN Welvista - South Carolina Residents Only $593.47 $682.49 320 MG TABLET(S) VALSARTAN Welvista - South Carolina Residents Only $569.10 $654.47 40 MG TABLET(S) VALSARTAN Welvista - South Carolina Residents Only $116.65 $134.15 80 MG TABLET(S) VALSARTAN Welvista - South Carolina Residents Only $418.36 $481.11 160 MG TABLET(S) VALSARTAN Xubex Preferred Network Program $593.47 $682.49 320 MG TABLET(S) VALSARTAN Xubex Preferred Network Program $569.10 $654.47 40 MG TABLET(S) VALSARTAN Xubex Preferred Network Program $116.65 $134.15 80 MG TABLET(S) VALSARTAN Xubex Preferred Network Program $418.36 $481.11 VALSARTAN/HCTZ (BRAND: DIOVAN HCT)
* 160/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Generic Assistance Program (NeedyMeds & $384.64 $442.34 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 345 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VALSARTAN/HCTZ (BRAND: DIOVAN HCT)
* 160/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Generic Assistance Program (NeedyMeds & $436.20 $501.63 Rx Outreach) * 320/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Generic Assistance Program (NeedyMeds & $487.33 $560.43 Rx Outreach) * 320/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Generic Assistance Program (NeedyMeds & $552.87 $635.80 Rx Outreach) * 80/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Generic Assistance Program (NeedyMeds & $353.52 $406.55 Rx Outreach) 160/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Rx Outreach $384.64 $442.34 160/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Rx Outreach $436.20 $501.63 320/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Rx Outreach $487.33 $560.43 320/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Rx Outreach $552.87 $635.80 80/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Rx Outreach $353.52 $406.55 160/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Welvista - South Carolina Residents Only $384.64 $442.34 160/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Welvista - South Carolina Residents Only $436.20 $501.63 320/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Welvista - South Carolina Residents Only $487.33 $560.43 320/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Welvista - South Carolina Residents Only $552.87 $635.80 80/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Welvista - South Carolina Residents Only $353.52 $406.55 160/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Xubex Preferred Network Program $384.64 $442.34 160/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Xubex Preferred Network Program $436.20 $501.63 320/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Xubex Preferred Network Program $487.33 $560.43 320/25 MG-MG TABLET(S) hydrochlorothiazide/valsartan Xubex Preferred Network Program $552.87 $635.80
Report Run: 04/19/16 10:53 AM Page 346 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VALSARTAN/HCTZ (BRAND: DIOVAN HCT)
80/12.5 MG-MG TABLET(S) hydrochlorothiazide/valsartan Xubex Preferred Network Program $353.52 $406.55 VALSTAR
40 MG/ML (5 ML) VIAL VALRUBICIN Endo Patient Assistance Program for Valstar $4,809.22 $5,530.60 VALTREX
1 GM TABLET(S) VALACYCLOVIR GSK Access $519.12 $596.99 HYDROCHLORIDE 500 MG TABLET(S) VALACYCLOVIR GSK Access $296.63 $341.12 HYDROCHLORIDE * 1 GM TABLET(S) VALACYCLOVIR GSK Bridges to Access $519.12 $596.99 HYDROCHLORIDE * 500 MG TABLET(S) VALACYCLOVIR GSK Bridges to Access $296.63 $341.12 HYDROCHLORIDE 1 GM TABLET(S) VALACYCLOVIR Welvista - South Carolina Residents Only $519.12 $596.99 HYDROCHLORIDE 500 MG TABLET(S) VALACYCLOVIR Welvista - South Carolina Residents Only $296.63 $341.12 HYDROCHLORIDE VANTAS
50 MG IMPLANT HISTRELIN ACETATE Endo Patient Assitance Program for Vantas $3,840.00 $4,416.00 VANTIN
200 MG TABLET(S) CEFPODOXIME PROXETIL Pfizer RxPathways $273.66 $314.71 VAPRISOL
20 MG/100 ML MG CONIVAPTAN HYDROCHLORIDE Astellas Stock Replacement Program $687.02 $790.07
Report Run: 04/19/16 10:53 AM Page 347 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VAQTA
50 U/ML ML HEPATITIS A VACCINE, Merck Vaccine Patient Assistance Program $76.21 $87.64 INACTIVATED VAQTA (10 VIALS)
50 U/ML ML HEPATITIS A VACCINE, Merck Vaccine Patient Assistance Program $719.86 $827.84 INACTIVATED VARIVAX
1350 PFU ML VARICELLA VIRUS VACCINE Merck Vaccine Patient Assistance Program $126.57 $145.56 VARIVAX (10 VIALS)
1350 PFU ML VARICELLA VIRUS VACCINE Merck Vaccine Patient Assistance Program $1,206.64 $1,387.64 VARUBI
90 MG TABLET(S) rolapitant Together with Tesaro Patient Assistance $636.00 $731.40 Program VASERETIC
* 10-25 MG-MG TABLET(S) ENALAPRIL Valeant Patient Assistance Program $492.15 $565.97 MALEATE/HYDROCHLOROTHIAZ IDE * 5-12.5 MG-MG TABLET(S) ENALAPRIL Valeant Patient Assistance Program $131.20 $150.88 MALEATE/HYDROCHLOROTHIAZ IDE VASOTEC
* 10 MG TABLET(S) ENALAPRIL MALEATE Valeant Patient Assistance Program $327.09 $376.15 * 2.5 MG TABLET(S) ENALAPRIL MALEATE Valeant Patient Assistance Program $355.99 $409.39 * 20 MG TABLET(S) ENALAPRIL MALEATE Valeant Patient Assistance Program $646.15 $743.07
Report Run: 04/19/16 10:53 AM Page 348 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VASOTEC
* 5 MG TABLET(S) ENALAPRIL MALEATE Valeant Patient Assistance Program $412.86 $474.79 VECTIBIX
20 MG/ML (20 ML) VIAL panitumumab Amgen Safety Net Foundation $4,754.88 $5,468.11 VELCADE
3.5 MG MG BORTEZOMIB Millennium Velcade Reimbursement $1,934.40 $2,224.56 Assistance Program VELETRI
1.5 MG ML epoprostenol sodium Actelion Pathways $45.50 $52.33 VELPHORO
500 MG TABLET(S) sucroferric oxyhydroxide Fresenius Phoslyra & Velphoro Patient $1,026.00 $1,179.90 Assistance Program VELTASSA
16.8 GM/PACKET PACKET(S) patiromer VeltassaKonnect $714.00 $821.10 25.2 GM/PACKET PACKET(S) patiromer VeltassaKonnect $714.00 $821.10 8.4 GM/PACKET PACKET(S) patiromer VeltassaKonnect $714.00 $821.10 VELTIN
1.2-0.025 % (30 GM) GEL APPLICATION clindamycin GSK Bridges to Access $265.16 $304.93 phosphate/tretinoin VENLAFAXINE (BRAND: EFFEXOR)
* 37.5 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $279.72 $321.68 Rx Outreach)
Report Run: 04/19/16 10:53 AM Page 349 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VENLAFAXINE (BRAND: EFFEXOR)
* 50 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $185.49 $213.31 Rx Outreach) * 75 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $313.20 $360.18 Rx Outreach) 37.5 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $279.72 $321.68 Partners & Northern VA Residents ONLY 75 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $313.20 $360.18 Partners & Northern VA Residents ONLY 37.5 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Rx Outreach $279.72 $321.68 50 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Rx Outreach $185.49 $213.31 75 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Rx Outreach $313.20 $360.18 37.5 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Xubex Preferred Network Program $279.72 $321.68 50 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Xubex Preferred Network Program $185.49 $213.31 75 MG TABLET(S) VENLAFAXINE HYDROCHLORIDE Xubex Preferred Network Program $313.20 $360.18 VENOFER
20 MG/5 ML MG IRON SUCROSE American Regent - IV Iron Patient Assistance $600.00 $690.00 Program VENTAVIS
10 MCG/ML MCG ILOPROST Actelion Pathways $4,237.20 $4,872.78 20 MCG/ML MCG ILOPROST Actelion Pathways $4,237.20 $4,872.78 VENTOLIN HFA
0.09 MG/ACTUATION (8 PUFF(S) albuterol sulfate GSK Access $21.64 $24.89 GM)
Report Run: 04/19/16 10:53 AM Page 350 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VENTOLIN HFA
0.09 MG/ACTUATION (8 PUFF(S) albuterol sulfate GSK Bridges to Access $21.64 $24.89 GM) 0.09 MG/INH (18GM) PUFF(S) ALBUTEROL SULFATE Nova ScriptsCentral-Northern Virginia Clinic $60.79 $69.91 Partners & Northern VA Residents ONLY 0.09 MG/ACTUATION (8 PUFF(S) albuterol sulfate Welvista - South Carolina Residents Only $21.64 $24.89 GM) VERAMYST
27.5 MCG SPRAY(S) FLUTICASONE FUROATE GSK Access $196.85 $226.38 27.5 MCG SPRAY(S) FLUTICASONE FUROATE GSK Bridges to Access $196.85 $226.38 27.5 MCG SPRAY(S) FLUTICASONE FUROATE Nova ScriptsCentral-Northern Virginia Clinic $196.85 $226.38 Partners & Northern VA Residents ONLY 27.5 MCG SPRAY(S) FLUTICASONE FUROATE Welvista - South Carolina Residents Only $196.85 $226.38 VERAPAMIL (BRAND: CALAN, ISOPTIN)
80 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $57.00 $65.55 Partners & Northern VA Residents ONLY 80 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Rx Outreach $57.00 $65.55 80 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Xubex Preferred Network Program $57.00 $65.55 VERAPAMIL ER (BRAND: CALAN, ISOPTIN)
300 MG CAPSULE(S) verapamil hydrochloride Xubex Preferred Network Program $367.20 $422.28 VERAPAMIL HCL (BRAND: CALAN, ISOPTIN)
120 MG TABLET(S) verapamil hydrochloride Nova ScriptsCentral-Northern Virginia Clinic $39.35 $45.25 Partners & Northern VA Residents ONLY 120 MG TABLET(S) verapamil hydrochloride Rx Outreach $39.35 $45.25
Report Run: 04/19/16 10:53 AM Page 351 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VERAPAMIL HCL (BRAND: CALAN, ISOPTIN)
100 MG CAPSULE(S) verapamil hydrochloride Xubex Preferred Network Program $195.84 $225.22 120 MG TABLET(S) verapamil hydrochloride Xubex Preferred Network Program $39.35 $45.25 200 MG CAPSULE(S) verapamil hydrochloride Xubex Preferred Network Program $252.55 $290.43 VERAPAMIL SR (BRAND: CALAN SR, ISOPTIN SR)
* 120 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $213.36 $245.36 Rx Outreach) * 180 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $99.00 $113.85 Rx Outreach) * 240 MG TABLET (S) VERAPAMIL HYDROCHLORIDE Generic Assistance Program (NeedyMeds & $105.00 $120.75 Rx Outreach) 120 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $213.36 $245.36 Partners & Northern VA Residents ONLY 180 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $99.00 $113.85 Partners & Northern VA Residents ONLY 240 MG TABLET (S) VERAPAMIL HYDROCHLORIDE Nova ScriptsCentral-Northern Virginia Clinic $105.00 $120.75 Partners & Northern VA Residents ONLY 120 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Rx Outreach $213.36 $245.36 180 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Rx Outreach $99.00 $113.85 240 MG TABLET (S) VERAPAMIL HYDROCHLORIDE Rx Outreach $105.00 $120.75 120 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Xubex Preferred Network Program $213.36 $245.36 180 MG TABLET(S) VERAPAMIL HYDROCHLORIDE Xubex Preferred Network Program $99.00 $113.85 240 MG TABLET (S) VERAPAMIL HYDROCHLORIDE Xubex Preferred Network Program $105.00 $120.75
Report Run: 04/19/16 10:53 AM Page 352 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VERDESO
0.05 % FOAM DESONIDE GSK Access $194.92 $224.16 VESICARE
10 MG TABLET(S) SOLIFENACIN SUCCINATE Astellas Vesicare Access Program $614.76 $706.97 5 MG TABLET(S) SOLIFENACIN SUCCINATE Astellas Vesicare Access Program $670.15 $770.67 VESTURA
3-0.2 MG-MG TABLET(S) drospirenone/ ethinyl estradiol Xubex Preferred Network Program $203.94 $234.53 VEXOL
1 % (10ml) DROP(S) RIMEXOLONE Alcon Cares, Inc. $140.64 $161.74 1 % (10ml) DROP(S) RIMEXOLONE Alcon Charitable Clinic Program-For Free $140.64 $161.74 Clinics VEXOL
1 % (5 ML) DROP(S) RIMEXOLONE Alcon Cares, Inc. $93.06 $107.02 VFEND
200 MG TABLET(S) VORICONAZOLE Pfizer RxPathways $2,348.22 $2,700.45 50 MG TABLET(S) VORICONAZOLE Pfizer RxPathways $587.04 $675.10 VIAGRA
100 MG TABLET(S) SILDENAFIL CITRATE Pfizer RxPathways $1,363.60 $1,568.14 25 MG TABLET(S) SILDENAFIL CITRATE Pfizer RxPathways $1,363.60 $1,568.14 50 MG TABLET(S) SILDENAFIL CITRATE Pfizer RxPathways $1,363.60 $1,568.14 100 MG TABLET(S) SILDENAFIL CITRATE Welvista - South Carolina Residents Only $1,363.60 $1,568.14 25 MG TABLET(S) SILDENAFIL CITRATE Welvista - South Carolina Residents Only $1,363.60 $1,568.14
Report Run: 04/19/16 10:53 AM Page 353 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VIAGRA
50 MG TABLET(S) SILDENAFIL CITRATE Welvista - South Carolina Residents Only $1,363.60 $1,568.14 VIBERZI
100 MG TABLET(S) eluxadoline Actavis U.S. Patient Assistance Program $1,152.00 $1,324.80 75 MG TABLET(S) eluxadoline Actavis U.S. Patient Assistance Program $1,152.00 $1,324.80 VICTOZA
6 MG/ML (2x3 ML) MG LIRAGLUTIDE Novo Nordisk Patient Assistance Program $512.78 $589.70 6 MG/ML (2x3 ML) MG LIRAGLUTIDE Welvista - South Carolina Residents Only $512.78 $589.70 VIDAZA
100 MG INJECTION AZACITIDINE Celgene Patient Support $633.46 $728.48 VIGAMOX
0.5 % (3ML) DROP(S) MOXIFLOXACIN Alcon Cares, Inc. $167.10 $192.17 HYDROCHLORIDE 0.5 % (3ML) DROP(S) MOXIFLOXACIN Alcon Charitable Clinic Program-For Free $167.10 $192.17 HYDROCHLORIDE Clinics VIIBRYD
10 MG TABLET(S) vilazodone hydrochloride Actavis U.S. Patient Assistance Program $197.78 $227.45 20 MG TABLET(S) vilazodone hydrochloride Actavis U.S. Patient Assistance Program $197.78 $227.45 40 MG TABLET(S) vilazodone hydrochloride Actavis U.S. Patient Assistance Program $197.78 $227.45 VIIBRYD TITRATION PACK
N/A N/A TABLET(S) vilazodone hydrochloride Actavis U.S. Patient Assistance Program $197.78 $227.45
Report Run: 04/19/16 10:53 AM Page 354 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VIMOVO
20-375 MG-MG TABLET(S) ESOMEPRAZOLE AZ&Me Prescription Savings for people with $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN Medicare Part D 20-500 MG-MG TABLET(S) ESOMEPRAZOLE AZ&Me Prescription Savings for people with $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN Medicare Part D 20-375 MG-MG TABLET(S) ESOMEPRAZOLE AZ&Me Prescription Savings Program $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN 20-500 MG-MG TABLET(S) ESOMEPRAZOLE AZ&Me Prescription Savings Program $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN 20-375 MG-MG TABLET(S) ESOMEPRAZOLE Horizon Patient Assistance Program $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN 20-500 MG-MG TABLET(S) ESOMEPRAZOLE Horizon Patient Assistance Program $1,959.12 $2,252.99 MAGNESIUM/NAPROXEN VIMPAT
100 MG TABLET(S) LACOSAMIDE UCB Patient Assistance Program $824.32 $947.97 150 MG TABLET(S) LACOSAMIDE UCB Patient Assistance Program $873.00 $1,003.95 200 MG TABLET(S) LACOSAMIDE UCB Patient Assistance Program $873.25 $1,004.24 50 MG TABLET(S) LACOSAMIDE UCB Patient Assistance Program $527.26 $606.35 VIOKACE
39150-10440- U-U-U TABLET(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $291.72 $335.48 39150 78300-20880- U-U-U TABLET(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $575.52 $661.85 78300 VIRACEPT
250 MG TABLET(S) NELFINAVIR MESYLATE ViiV Healthcare Patient Assistance Program $1,169.22 $1,344.60
Report Run: 04/19/16 10:53 AM Page 355 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VIRACEPT
625 MG TABLET(S) NELFINAVIR MESYLATE ViiV Healthcare Patient Assistance Program $1,169.22 $1,344.60 VIRACEPT
50 MG/GM MG NELFINAVIR MESYLATE ViiV Healthcare Patient Assistance Program $75.71 $87.07 VIRAMUNE
50 MG/5ML (240ML) SUS NEVIRAPINE Boehringer Ingelheim Cares Foundation Inc. $156.59 $180.08 VIRAMUNE XR
400 MG TABLET(S) nevirapine Boehringer Ingelheim Cares Foundation Inc. $798.73 $918.54 VIREAD
300 MG TABLET(S) TENOFOVIR DISOPROXIL Gilead Advancing Access $1,197.32 $1,376.92 FUMARATE VITEKTA
150 MG TABLET(S) elvitegravir Gilead Advancing Access $1,445.34 $1,662.14 85 MG TABLET(S) elvitegravir Gilead Advancing Access $1,445.34 $1,662.14 VOTRIENT
200 MG TABLET(S) PAZOPANIB HYDROCHLORIDE Commitment to Access $9,980.21 $11,477.24 VSL#3-DS
900 BILLION ORG/PACKET PACKET lactobacillus combination Sigma-Tau VSL#3 DS Medical Food Patient $108.00 $124.20 Assistance Program VYTORIN
10/10 MG TABLET(S) EZETIMIBE/SIMVASTATIN Merck Patient Assistance Program $843.72 $970.28 10/20 MG TABLET(S) EZETIMIBE/SIMVASTATIN Merck Patient Assistance Program $843.72 $970.28
Report Run: 04/19/16 10:53 AM Page 356 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
VYTORIN
10/40 MG TABLET(S) EZETIMIBE/SIMVASTATIN Merck Patient Assistance Program $843.72 $970.28 10/80 MG TABLET(S) EZETIMIBE/SIMVASTATIN Merck Patient Assistance Program $843.72 $970.28 10/10 MG TABLET(S) EZETIMIBE/SIMVASTATIN Welvista - South Carolina Residents Only $843.72 $970.28 10/20 MG TABLET(S) EZETIMIBE/SIMVASTATIN Welvista - South Carolina Residents Only $843.72 $970.28 10/40 MG TABLET(S) EZETIMIBE/SIMVASTATIN Welvista - South Carolina Residents Only $843.72 $970.28 10/80 MG TABLET(S) EZETIMIBE/SIMVASTATIN Welvista - South Carolina Residents Only $843.72 $970.28 10/10 MG TABLET(S) EZETIMIBE/SIMVASTATIN Xubex Free Trial 30 Day Medication Supply $843.72 $970.28 10/20 MG TABLET(S) EZETIMIBE/SIMVASTATIN Xubex Free Trial 30 Day Medication Supply $843.72 $970.28 10/40 MG TABLET(S) EZETIMIBE/SIMVASTATIN Xubex Free Trial 30 Day Medication Supply $843.72 $970.28 10/80 MG TABLET(S) EZETIMIBE/SIMVASTATIN Xubex Free Trial 30 Day Medication Supply $843.72 $970.28 VYVANSE
20 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program 30 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program 40 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program 50 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program 60 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program 70 MG CAPSULE(S) LISDEXAMFETAMINE Shire Cares Patient Assistance & Support $867.74 $997.90 DIMESYLATE Program
Report Run: 04/19/16 10:53 AM Page 357 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
WARFARIN (BRAND: COUMADIN)
10 MG TABLET(S) WARFARIN Nova ScriptsCentral-Northern Virginia Clinic $83.74 $96.30 Partners & Northern VA Residents ONLY 4 MG TABLET(S) WARFARIN Nova ScriptsCentral-Northern Virginia Clinic $59.11 $67.98 Partners & Northern VA Residents ONLY 10 MG TABLET(S) WARFARIN Rx Outreach $83.74 $96.30 4 MG TABLET(S) WARFARIN Rx Outreach $59.11 $67.98 10 MG TABLET(S) WARFARIN Xubex Preferred Network Program $83.74 $96.30 WARFARIN SODIUM (BRAND: COUMADIN)
1 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $128.66 $147.96 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $130.30 $149.85 Partners & Northern VA Residents ONLY 3 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $63.07 $72.53 Partners & Northern VA Residents ONLY 6 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $90.30 $103.85 Partners & Northern VA Residents ONLY 7.5 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $93.44 $107.46 Partners & Northern VA Residents ONLY 1 MG TABLET(S) WARFARIN SODIUM Rx Outreach $128.66 $147.96 2.5 MG TABLET(S) WARFARIN SODIUM Rx Outreach $130.30 $149.85 3 MG TABLET(S) WARFARIN SODIUM Rx Outreach $63.07 $72.53 6 MG TABLET(S) WARFARIN SODIUM Rx Outreach $90.30 $103.85 7.5 MG TABLET(S) WARFARIN SODIUM Rx Outreach $93.44 $107.46 1 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $128.66 $147.96
Report Run: 04/19/16 10:53 AM Page 358 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
WARFARIN SODIUM (BRAND: COUMADIN)
2.5 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $130.30 $149.85 3 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $63.07 $72.53 6 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $90.30 $103.85 7.5 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $93.44 $107.46 WARFARIN SODIUM (BRAND: COUMADIN, JANTOVEN)
2 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $90.66 $104.26 Partners & Northern VA Residents ONLY 5 MG TABLET(S) WARFARIN SODIUM Nova ScriptsCentral-Northern Virginia Clinic $141.24 $162.43 Partners & Northern VA Residents ONLY 2 MG TABLET(S) WARFARIN SODIUM Rx Outreach $90.66 $104.26 5 MG TABLET(S) WARFARIN SODIUM Rx Outreach $141.24 $162.43 2 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $90.66 $104.26 5 MG TABLET(S) WARFARIN SODIUM Xubex Preferred Network Program $141.24 $162.43 WELCHOL
3.75 GM/PACKET PACKET COLESEVELAM Daiichi Sankyo Open Care Program $622.08 $715.39 HYDROCHLORIDE 625 MG TABLET(S) COLESEVELAM Daiichi Sankyo Open Care Program $622.08 $715.39 HYDROCHLORIDE WELLBUTRIN
* 100 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Access $354.85 $408.08 * 75 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Access $266.08 $305.99 * 100 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Bridges to Access $354.85 $408.08
Report Run: 04/19/16 10:53 AM Page 359 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
WELLBUTRIN
* 75 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Bridges to Access $266.08 $305.99 WELLBUTRIN SR
* 100 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Access $334.32 $384.47 * 150 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Access $358.31 $412.06 * 200 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Access $665.36 $765.16 * 100 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Bridges to Access $334.32 $384.47 * 150 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Bridges to Access $358.31 $412.06 * 200 MG TABLET(S) BUPROPION HYDROCHLORIDE GSK Bridges to Access $665.36 $765.16 100 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $334.32 $384.47 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $358.31 $412.06 200 MG TABLET(S) BUPROPION HYDROCHLORIDE Welvista - South Carolina Residents Only $665.36 $765.16 WELLBUTRIN XL
* 150 MG TABLET(S) BUPROPION HYDROCHLORIDE Valeant Patient Assistance Program $301.94 $347.23 * 300 MG TABLET(S) BUPROPION HYDROCHLORIDE Valeant Patient Assistance Program $398.59 $458.38 WINRHO SDF
1500 IU PDS RHO(D) IMMUNE GLOBULIN Baxter WinRho Reimbursement Support and $387.89 $446.07 Patient Assistance Program 5000 IU PDS RHO(D) IMMUNE GLOBULIN Baxter WinRho Reimbursement Support and $1,301.32 $1,496.52 Patient Assistance Program 600 IU PDS RHO(D) IMMUNE GLOBULIN Baxter WinRho Reimbursement Support and $106.13 $122.05 Patient Assistance Program
Report Run: 04/19/16 10:53 AM Page 360 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
WOUND WASH SALINE
0.9 % (210 ML) SPRAY(S) SODIUM CHLORIDE Blairex Laboratories, Inc $5.00 $5.75 XALATAN
0.005 % (2.5ml) DROP(S) LATANOPROST Nova ScriptsCentral-Northern Virginia Clinic $142.90 $164.34 Partners & Northern VA Residents ONLY 0.005 % (2.5ml) DROP(S) LATANOPROST Pfizer MAINTAIN $142.90 $164.34 0.005 % (2.5ml) DROP(S) LATANOPROST Pfizer RxPathways $142.90 $164.34 0.005 % (2.5ml) DROP(S) LATANOPROST Welvista - South Carolina Residents Only $142.90 $164.34 XALKORI
200 MG CAPSULE(S) CRIZOTINIB Pfizer RxPathways $14,382.53 $16,539.91 250 MG CAPSULE(S) CRIZONTINIB Pfizer RxPathways $14,382.53 $16,539.91 XARELTO
10 MG TABLET(S) RIVAROXABAN Johnson & Johnson Hospital Access Patient $1,258.80 $1,447.62 Assistance Program 10 MG TABLET(S) RIVAROXABAN Johnson & Johnson Patient Assistance $1,258.80 $1,447.62 Foundation-Card Program 10 MG TABLET(S) RIVAROXABAN Welvista - South Carolina Residents Only $1,258.80 $1,447.62 XARELTO
15 MG TABLET(S) RIVAROXABAN Johnson & Johnson Hospital Access Patient $1,258.80 $1,447.62 Assistance Program 20 MG TABLET(S) RIVAROXABAN Johnson & Johnson Hospital Access Patient $1,132.92 $1,302.86 Assistance Program 15 MG TABLET(S) RIVAROXABAN Johnson & Johnson Patient Assistance $1,258.80 $1,447.62 Foundation-Card Program
Report Run: 04/19/16 10:53 AM Page 361 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
XARELTO
20 MG TABLET(S) RIVAROXABAN Johnson & Johnson Patient Assistance $1,132.92 $1,302.86 Foundation-Card Program 15 MG TABLET(S) RIVAROXABAN Welvista - South Carolina Residents Only $1,258.80 $1,447.62 20 MG TABLET(S) RIVAROXABAN Welvista - South Carolina Residents Only $1,132.92 $1,302.86 XARTEMIS XR
325-7.5 MG-MG TABLET(S) acetaminophen/oxycodone Covidien/Mallinckrodt Patient Assistance $276.00 $317.40 hydrochloride Program XELJANZ
5 MG TABLET(S) tofacitinib citrate Xelsource Patient Assistance Program-Xeljanz $3,220.56 $3,703.64 XENAZINE
12.5 MG TABLET(S) TETRABENAZINE Lundbeck Xenazine Patient Assistance $6,620.05 $7,613.06 Program 25 MG TABLET(S) TETRABENAZINE Lundbeck Xenazine Patient Assistance $13,240.09 $15,226.10 Program XGEVA
120/1.7 MG/ML MG DENOSUMAB Amgen Safety Net Foundation $2,198.22 $2,527.95 XIAFLEX
0.9 MG POWDER COLLAGENASE, CLOSTRIDIUM Xiaflex Patient Assistance Program $3,397.50 $3,907.13 HISTOLYTICUM XIFAXAN
550 MG TABLET(S) RIFAXIMIN Salix Patient Assistance Program $2,199.01 $2,528.86
Report Run: 04/19/16 10:53 AM Page 362 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
XIGDUO XR
5/500 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings for people with $435.68 $501.03 propanediol/metformin Medicare Part D hydrochlorid 5/500 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings Program $435.68 $501.03 propanediol/metformin hydrochlorid XIGDUO XR
10/1000 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings for people with $435.68 $501.03 propanediol/metformin Medicare Part D hydrochloride 10/500 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings for people with $435.68 $501.03 propanediol/metformin Medicare Part D hydrochloride 5/1000 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings for people with $435.68 $501.03 propanediol/metformin Medicare Part D hydrochloride 10/1000 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings Program $435.68 $501.03 propanediol/metformin hydrochloride 10/500 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings Program $435.68 $501.03 propanediol/metformin hydrochloride 5/1000 MG-MG TABLET(S) dapagliflozin AZ&Me Prescription Savings Program $435.68 $501.03 propanediol/metformin hydrochloride
Report Run: 04/19/16 10:53 AM Page 363 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
XIGDUO XR
10/1000 MG-MG TABLET(S) dapagliflozin Welvista - South Carolina Residents Only $435.68 $501.03 propanediol/metformin hydrochloride 10/500 MG-MG TABLET(S) dapagliflozin Welvista - South Carolina Residents Only $435.68 $501.03 propanediol/metformin hydrochloride 5/1000 MG-MG TABLET(S) dapagliflozin Welvista - South Carolina Residents Only $435.68 $501.03 propanediol/metformin hydrochloride XOLAIR
150 MG MG OMALIZUMAB Genetech Access to Care Foundation-Xolair $1,008.49 $1,159.76 XOPENEX
0.63/3 MG/ML VIAL LEVALBUTEROL Sepracor Patient Assistance Program $75.00 $86.25 HYDROCHLORIDE 1.25/3 MG/ML VIAL LEVALBUTEROL Sepracor Patient Assistance Program $75.00 $86.25 HYDROCHLORIDE XOPENEX HFA
45 MCG/INHALATION PUFF(S) LEVALBUTEROL TARTRATE Sepracor Patient Assistance Program $49.75 $57.21 XTANDI
40 MG CAPSULE(S) enzalutamide Astellas Access Program-Xtandi $10,026.04 $11,529.95 XYNTHA
1 IU (1000 IU) INJECTION ANTIHEMOPHILIC FACTOR Pfizer RxPathways $1.74 $2.00 (RECOMB) PLASMA/ALBUMIN- FREE
Report Run: 04/19/16 10:53 AM Page 364 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
YERVOY
5 MG/ML (10 ML) MG ipilimumab Bristol-Myers Squibb Access Support $7,872.79 $9,053.71 Oncology Patient Assistance Program ZADITOR
0.025 % (5ml) Drop(s) KETOTIFEN FUMARATE Alcon Cares, Inc. $11.70 $13.46 0.025 % (5ml) Drop(s) KETOTIFEN FUMARATE Xubex Preferred Network Program $11.70 $13.46 ZAFIRLUKAST (BRAND: ACCOLATE)
10 MG TABLET(S) ZAFIRLUKAST Rx Outreach $107.36 $123.46 20 MG TABLET(S) ZAFIRLUKAST Rx Outreach $107.36 $123.46 10 MG TABLET(S) ZAFIRLUKAST Xubex Preferred Network Program $107.36 $123.46 20 MG TABLET(S) ZAFIRLUKAST Xubex Preferred Network Program $107.36 $123.46 ZALEPLON (BRAND: SONATA)
10 MG CAPSULE(S) ZALEPLON Rx Outreach $374.58 $430.77 5 MG CAPSULE(S) ZALEPLON Rx Outreach $364.64 $419.34 10 MG CAPSULE(S) ZALEPLON Xubex Preferred Network Program $374.58 $430.77 5 MG CAPSULE(S) ZALEPLON Xubex Preferred Network Program $364.64 $419.34 ZALTRAP
25 MG/ML (4 ML) VIAL ziv-aflibercept Sanofi Patient Connection $1,920.00 $2,208.00 ZARAH
3-0.03 MG-MG TABLET(S) drospirenone/ethinyl Xubex Preferred Network Program $198.76 $228.57 estradiol;placebo
Report Run: 04/19/16 10:53 AM Page 365 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZARONTIN
250 MG CAPSULE(S) ETHOSUXIMIDE Pfizer RxPathways $265.28 $305.07 ZAVESCA
100 MG CAPSULE(S) miglustat Actelion - Zavesca Financial Support $32,184.00 $37,011.60 ZELAPAR
1.25 MG TABLET(S) SELEGILINE HYDROCHLORIDE Valeant Patient Assistance Program $1,940.16 $2,231.18 ZELBORAF
240 MG TABLET(S) VEMURAFENIB Genentech BioOncology Access Solutions- $6,510.48 $7,487.05 Oral Products ZEMAIRA
1 MG INJECTION(S) ALPHA-1 PROTEINASE CSL Behring Patient Assistance Program $0.43 $0.49 INHIBITOR HUMAN ZENPEP
10500-25000- U-U-U CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $632.04 $726.85 79000 109000-20000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Actavis U.S. Patient Assistance Program $510.76 $587.37 68000 218000-40000- U-U-U CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $1,008.00 $1,159.20 136000 27000-5000-17000 U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Actavis U.S. Patient Assistance Program $131.70 $151.46 55000-10000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Actavis U.S. Patient Assistance Program $260.34 $299.39 34000 82000-15000- U-U-U CAPSULE(S) AMYLASE/LIPASE/PROTEASE Actavis U.S. Patient Assistance Program $376.01 $432.41 51000
Report Run: 04/19/16 10:53 AM Page 366 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZENPEP
16000-3000-10000 MG CAPSULE(S) amylase/lipase/protease Actavis U.S. Patient Assistance Program $138.04 $158.75 ZEPATIER
50-100 MG-MG TABLET(S) elbasvir/grazoprevir Merck Access Program $21,840.00 $25,116.00 ZERBAXA
1-0.5 GM-GM VIAL(S) ceftolozane/tazobactam AccessZerbaxa $996.00 $1,145.40 ZETIA
10 MG TABLET(S) EZETIMIBE Merck Patient Assistance Program $774.85 $891.08 10 MG TABLET(S) EZETIMIBE Welvista - South Carolina Residents Only $774.85 $891.08 10 MG TABLET(S) EZETIMIBE Xubex Free Trial 30 Day Medication Supply $774.85 $891.08 ZEVALIN Y-90
3.2/2-50/2 MG/ML MMOLE/ML SOLUTION ibritumomab tiuxetan/sodium STAR-Spectrum Therapy Access Resources $45,360.00 $52,164.00 acetate ZIAGEN
20 MG/ML (240 ML) SOL ABACAVIR SULFATE GSK Access $176.23 $202.66 300 MG TABLET(S) ABACAVIR SULFATE GSK Access $670.37 $770.93 20 MG/ML (240 ML) SOL ABACAVIR SULFATE ViiV Healthcare Patient Assistance Program $176.23 $202.66 300 MG TABLET(S) ABACAVIR SULFATE ViiV Healthcare Patient Assistance Program $670.37 $770.93 ZIDOVUDINE (BRAND: RETROVIR)
300 MG TABLET(S) zidovudine Rx Outreach $365.04 $419.80 100 MG CAPSULE(S) zidovudine Xubex Preferred Network Program $201.94 $232.23 300 MG TABLET(S) zidovudine Xubex Preferred Network Program $365.04 $419.80
Report Run: 04/19/16 10:53 AM Page 367 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZINACEF
1.5 GM PDS CEFUROXIME SODIUM GSK Access $134.52 $154.70 7.5 GM PDS CEFUROXIME SODIUM GSK Access $395.66 $455.01 750 MG PDS CEFUROXIME SODIUM GSK Access $181.10 $208.27 750/50 MG/ML (50ml) SOL CEFUROXIME SODIUM GSK Access $227.12 $261.19 ZINECARD
250 MG INJECTION DEXRAZOXANE Pfizer RxPathways $281.86 $324.14 HYDROCHLORIDE 500 MG INJECTION DEXRAZOXANE Pfizer RxPathways $563.72 $648.28 HYDROCHLORIDE ZIOPTAN
0.0015 % (0.3 ML) DROP(S) TAFLUPROST Akorn Patient Assistance Program $373.64 $429.69 0.0015 % (0.3 ML) DROP(S) TAFLUPROST Welvista - South Carolina Residents Only $373.64 $429.69 ZIOPTAN
0.0015 % (0.3 ML) DROP(S) TAFLUPROST Akorn Patient Assistance Program $124.55 $143.23 0.0015 % (0.3 ML) DROP(S) TAFLUPROST Welvista - South Carolina Residents Only $124.55 $143.23 ZIPRASIDONE HYDROCHLORIDE (BRAND: GEODON)
20 MG CAPSULE(S) ziprasidone hydrochloride Rx Outreach $531.83 $611.60 40 CAPSULE(S) CAPSULE(S) ziprasidone hydrochloride Rx Outreach $531.83 $611.60 60 MG CAPSULE(S) ziprasidone hydrochloride Rx Outreach $645.41 $742.22 80 MG CAPSULE(S) ziprasidone hydrochloride Rx Outreach $645.51 $742.34 20 MG CAPSULE(S) ziprasidone hydrochloride Xubex Preferred Network Program $531.83 $611.60
Report Run: 04/19/16 10:53 AM Page 368 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZIPRASIDONE HYDROCHLORIDE (BRAND: GEODON)
40 CAPSULE(S) CAPSULE(S) ziprasidone hydrochloride Xubex Preferred Network Program $531.83 $611.60 60 MG CAPSULE(S) ziprasidone hydrochloride Xubex Preferred Network Program $645.41 $742.22 80 MG CAPSULE(S) ziprasidone hydrochloride Xubex Preferred Network Program $645.51 $742.34 ZIRGAN
0.15 % (5 GM) GM ganciclovir Bausch & Lomb US Patient Assistance $348.65 $400.95 Program ZOFRAN
* 4 MG TABLET(S) ONDANSETRON GSK Bridges to Access $797.34 $916.94 HYDROCHLORIDE * 8 MG TABLET(S) ONDANSETRON GSK Bridges to Access $1,328.09 $1,527.30 HYDROCHLORIDE 4 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $797.34 $916.94 HYDROCHLORIDE 8 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $1,328.09 $1,527.30 HYDROCHLORIDE ZOFRAN ODT
* 4 MG TABLET(S) ONDANSETRON GSK Bridges to Access $752.17 $865.00 4 MG TABLET(S) ONDANSETRON Welvista - South Carolina Residents Only $752.17 $865.00 ZOLADEX
10.8 MG IMPLANT (MG) GOSERELIN ACETATE AZ&Me Prescription Savings for people with $1,637.83 $1,883.50 Medicare Part D 3.6 MG IMPLANT (MG) GOSERELIN ACETATE AZ&Me Prescription Savings for people with $545.94 $627.83 Medicare Part D
Report Run: 04/19/16 10:53 AM Page 369 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZOLADEX
10.8 MG IMPLANT (MG) GOSERELIN ACETATE AZ&Me Prescription Savings Program $1,637.83 $1,883.50 3.6 MG IMPLANT (MG) GOSERELIN ACETATE AZ&Me Prescription Savings Program $545.94 $627.83 ZOLMITRIPTAN
5 MG TABLET(S) zolmitriptan Xubex Preferred Network Program $166.25 $191.19 ZOLMITRIPTAN
2.5 MG TABLET(S) zolmitriptan Xubex Preferred Network Program $300.77 $345.89 ZOLMITRIPTAN ODT
2.5 MG TABLET(S) zolmitriptan Xubex Preferred Network Program $300.77 $345.89 5 MG TABLET(S) zolmitriptan Xubex Preferred Network Program $166.25 $191.19 ZOLPIDEM (BRAND: AMBIEN)
10 MG TABLET(S) ZOLPIDEM TARTRATE Rx Outreach $415.80 $478.17 5 MG TABLET(S) ZOLPIDEM TARTRATE Rx Outreach $25.85 $29.73 10 MG TABLET(S) ZOLPIDEM TARTRATE Xubex Preferred Network Program $415.80 $478.17 5 MG TABLET(S) ZOLPIDEM TARTRATE Xubex Preferred Network Program $25.85 $29.73 ZOLPIDEM TARTRATE ER (BRAND: AMBIEN CR)
12.5 MG TABLET(S) zolpidem tartrate Rx Outreach $611.63 $703.37 6.25 MG TABLET(S) zolpidem tartrate Rx Outreach $611.63 $703.37 6.25 MG TABLET(S) zolpidem tartrate Xubex Preferred Network Program $611.63 $703.37 ZOMETA
4 MG/100 ML MG zoledronic acid Novartis Oncology Patient Assistance $1,074.73 $1,235.94 Program
Report Run: 04/19/16 10:53 AM Page 370 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZOMIG
2.5 MG TABLET(S) ZOLMITRIPTAN Impax Patient Assistance Program $546.86 $628.89 5 MG TABLET(S) ZOLMITRIPTAN Impax Patient Assistance Program $273.42 $314.43 ZOMIG NASAL SPRAY
5 MG SPRAY(S) ZOLMITRIPTAN Impax Patient Assistance Program $376.03 $432.43 ZOMIG-ZMT
2.5 MG TABLET(S) ZOLMITRIPTAN Impax Patient Assistance Program $546.86 $628.89 5 MG TABLET(S) ZOLMITRIPTAN Impax Patient Assistance Program $273.42 $314.43 ZONISAMIDE (BRAND: ZONEGRAN)
100 MG CAPSULE(S) ZONISAMIDE Rx Outreach $239.20 $275.08 25 MG CAPSULE(S) ZONISAMIDE Rx Outreach $59.81 $68.78 50 MG CAPSULE(S) ZONISAMIDE Rx Outreach $107.41 $123.52 100 MG CAPSULE(S) ZONISAMIDE Xubex Patient Assistance Program $239.20 $275.08 25 MG CAPSULE(S) ZONISAMIDE Xubex Patient Assistance Program $59.81 $68.78 50 MG CAPSULE(S) ZONISAMIDE Xubex Patient Assistance Program $107.41 $123.52 100 MG CAPSULE(S) ZONISAMIDE Xubex Preferred Network Program $239.20 $275.08 25 MG CAPSULE(S) ZONISAMIDE Xubex Preferred Network Program $59.81 $68.78 50 MG CAPSULE(S) ZONISAMIDE Xubex Preferred Network Program $107.41 $123.52 ZONTIVITY
2.08 MG TABLET(S) vorapaxar Merck Patient Assistance Program $962.28 $1,106.62
Report Run: 04/19/16 10:53 AM Page 371 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZORTRESS
0.25 MG TABLET(S) EVEROLIMUS Novartis Patient Assistance Foundation, Inc. $476.75 $548.26 0.5 MG TABLET(S) EVEROLIMUS Novartis Patient Assistance Foundation, Inc. $953.50 $1,096.53 0.75 MG TABLET(S) EVEROLIMUS Novartis Patient Assistance Foundation, Inc. $1,430.23 $1,644.76 0.75 MG TABLET(S) EVEROLIMUS Xubex Free Trial 30 Day Medication Supply $1,430.23 $1,644.76 ZOSTAVAX
19400 PFU ML VARICELLA VIRUS VACCINE Merck Vaccine Patient Assistance Program $236.56 $272.04 19400 PFU ML VARICELLA VIRUS VACCINE Welvista - South Carolina Residents Only $236.56 $272.04 ZOSTAVAX
19400 PFU (10 VIALS) ML VARICELLA VIRUS VACCINE Merck Vaccine Patient Assistance Program $2,254.73 $2,592.94 19400 PFU (10 VIALS) ML VARICELLA VIRUS VACCINE Welvista - South Carolina Residents Only $2,254.73 $2,592.94 ZOVIA 1/35E
35-1 MCG-MG TABLET(S) ethinyl estradiol/ethynodiol Xubex Preferred Network Program $179.27 $206.16 diacetate;placebo ZOVIA 1/50E
50-1 MCG-MG TABLET(S) ethinyl estradiol/ethynodiol Xubex Preferred Network Program $199.74 $229.70 diacetate;placebo ZOVIRAX
200 MG CAPSULE(S) ACYCLOVIR GSK Access $380.15 $437.17 400 MG TABLET(S) ACYCLOVIR GSK Access $737.77 $848.44 800 MG TABLET(S) ACYCLOVIR GSK Access $1,328.27 $1,527.51
Report Run: 04/19/16 10:53 AM Page 372 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZOVIRAX CREAM
5 % (5 GM) APPLICATION(S) ACYCLOVIR Valeant Patient Assistance Program $762.50 $876.88 ZOVIRAX OINTMENT
5 % (30 GM) APPLICATION(S) ACYCLOVIR Valeant Patient Assistance Program $1,262.70 $1,452.11 ZUBSOLV
1.4-0.36 MG-MG TABLET(S) buprenorphine/naloxone Zubsolv Patient Assistance Program $126.60 $145.59 5.7-1.4 MG-MG TABLET(S) buprenorphine/naloxone Zubsolv Patient Assistance Program $253.38 $291.39 ZYDELIG
100 MG TABLET(S) idelalisib Zydelig AccessConnect $9,495.36 $10,919.66 150 MG TABLET(S) idelalisib Zydelig AccessConnect $9,495.36 $10,919.66 ZYFLO
600 MG TABLET(S) ZILEUTON Critical Therapeutics Care Assist Program $3,753.65 $4,316.70 600 MG TABLET(S) ZILEUTON Zyflo Connect Patient Assistance Program $3,753.65 $4,316.70 ZYFLO CR
600 MG TABLET(S) ZILEUTON Zyflo Connect Patient Assistance Program $3,753.65 $4,316.70 ZYKADIA
150 MG CAPSULE(S) ceritinib Novartis Oncology Patient Assistance $7,558.80 $8,692.62 Program ZYLET
0.5-0.3 %-% (10ML) DROP(S) LOTEPREDNOL Bausch & Lomb US Patient Assistance $491.11 $564.78 ETABONATE/TOBRAMYCIN Program
Report Run: 04/19/16 10:53 AM Page 373 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZYPREXA
10 MG TABLET(S) OLANZAPINE Eli Lilly Cares $663.84 $763.42 15 MG TABLET(S) OLANZAPINE Eli Lilly Cares $995.76 $1,145.12 2.5 MG TABLET(S) OLANZAPINE Eli Lilly Cares $373.25 $429.24 20 MG TABLET(S) OLANZAPINE Eli Lilly Cares $1,327.68 $1,526.83 5 MG TABLET(S) OLANZAPINE Eli Lilly Cares $440.53 $506.61 7.5 MG TABLET(S) OLANZAPINE Eli Lilly Cares $536.11 $616.53 10 MG TABLET(S) OLANZAPINE Nova ScriptsCentral-Northern Virginia Clinic $663.84 $763.42 Partners & Northern VA Residents ONLY 15 MG TABLET(S) OLANZAPINE Nova ScriptsCentral-Northern Virginia Clinic $995.76 $1,145.12 Partners & Northern VA Residents ONLY 2.5 MG TABLET(S) OLANZAPINE Nova ScriptsCentral-Northern Virginia Clinic $373.25 $429.24 Partners & Northern VA Residents ONLY 20 MG TABLET(S) OLANZAPINE Nova ScriptsCentral-Northern Virginia Clinic $1,327.68 $1,526.83 Partners & Northern VA Residents ONLY 5 MG TABLET(S) OLANZAPINE Nova ScriptsCentral-Northern Virginia Clinic $440.53 $506.61 Partners & Northern VA Residents ONLY ZYPREXA RELPREVV
210 MG MG olanzapine pamoate Eli Lilly Cares $707.62 $813.76 300 MG MG olanzapine pamoate Eli Lilly Cares $1,010.88 $1,162.51 405 MG MG olanzapine pamoate Eli Lilly Cares $1,364.69 $1,569.39 ZYPREXA ZYDIS
10 MG TABLET(S) OLANZAPINE Eli Lilly Cares $699.12 $803.99 15 MG TABLET(S) OLANZAPINE Eli Lilly Cares $1,031.04 $1,185.70
Report Run: 04/19/16 10:53 AM Page 374 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Medications
ZYPREXA ZYDIS
20 MG TABLET(S) OLANZAPINE Eli Lilly Cares $1,362.96 $1,567.40 5 MG TABLET(S) OLANZAPINE Eli Lilly Cares $475.81 $547.18 ZYTIGA
250 MG TABLET(S) abiraterone acetate Johnson & Johnson Patient Assistance $9,595.58 $11,034.92 Foundation-Card Program ZYVOX
600 MG TABLET(S) LINEZOLID Zyvox Assist $4,880.74 $5,612.85 Supply
ACCU-CHECK ACTIVE TEST STRIPS
n/a n/a n/a n/a Xubex Free Diabetes Kit $32.82 $37.74 ACCU-CHECK LANCETS
n/a n/a n/a n/a Xubex Free Diabetes Kit $14.86 $17.09 ACCU-CHECK NANO
n/a n/a n/a n/a Xubex Free Blood Glucose Meter $28.74 $33.05 n/a n/a n/a n/a Xubex Free Diabetes Kit $28.74 $33.05 BD HOME SHARPS CONTAINER
n/a n/a n/a n/a BD Diabetes $2.44 $2.81 BD ULTRA-FINE II (31GX5/16,1CC)
n/a n/a n/a n/a BD Diabetes $24.57 $28.26 BD ULTRA-FINE II (31GX5/16,3/10CC)
n/a n/a n/a n/a BD Diabetes $24.57 $28.26
Report Run: 04/19/16 10:53 AM Page 375 of 377 Available Medications and Supplies
* Denotes "Restricted n/a n/a n/a n/a BD Diabetes $24.57 $28.26 BD ULTRA-FINE III MINI (31G X 3/16)
n/a n/a n/a n/a BD Diabetes $28.04 $32.25 BD ULTRA-FINE NANO PEN NEEDLE 32GX5/32"
n/a n/a n/a n/a BD Diabetes $37.18 $42.76 CPAP Equipment
n/a n/a n/a n/a CPAP Assistance Program $100.00 $115.00 Eligiblity
n/a n/a n/a n/a LFM Eligibility Check $0.01 $0.01 EYEGLASSES
n/a n/a n/a n/a New Eyes Voucher Program $60.00 $69.00 FREESTYLE FREEDOM BLOOD GLUCOSE MONITORING SYSTEM METER n/a n/a n/a n/a FreeStyle Promise Program $18.00 $20.70 FREESTYLE INSULINX BLOOD GLUC MONITORING SYSTEM n/a n/a n/a n/a FreeStyle Promise Program $45.60 $52.44 FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM METER n/a n/a n/a n/a FreeStyle Promise Program $18.00 $20.70 HEARING AIDS
n/a n/a n/a n/a Hear Now Program $125.00 $143.75 HUMAPEN LUXURA HD
n/a n/a n/a n/a Eli Lilly Cares-Supplies $56.25 $64.69 NEBULIZER
Report Run: 04/19/16 10:53 AM Page 376 of 377 Available Medications and Supplies
* Denotes "Restricted
Name Strength Units Dosage Form Generic Name Program Name AWP ARP
Supply
NEBULIZER
n/a n/a n/a n/a Global Links-Nebulizers $55.00 $63.25 PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM n/a n/a n/a n/a Rx Outreach Diabetic Supplies $96.75 $111.26 PRODIGY INSULIN SYRINGES (28G)
n/a n/a n/a n/a Rx Outreach Diabetic Supplies $15.00 $17.25 PRODIGY INSULIN SYRINGES (31G)
n/a n/a n/a n/a Rx Outreach Diabetic Supplies $15.00 $17.25 PRODIGY INSULIN SYRINGES (31G, SHORT NEEDLE)
n/a n/a n/a n/a Rx Outreach Diabetic Supplies $15.00 $17.25 PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS
n/a n/a n/a n/a Rx Outreach Diabetic Supplies $69.08 $79.44 PRODIGY TWIST TOP LANCETS 28G
n/a n/a n/a n/a Rx Outreach Diabetic Supplies $11.88 $13.66
Report Run: 04/19/16 10:53 AM Page 377 of 377