Walgreens Plus Drug List

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

Up to 85% off Cash Prices on Atorvastatin (generic Lipitor) and Rosuvastatin Up to (generic Crestor)* %

Saving at Walgreens is easier off TM with Walgreens Plus , an 60 * exclusive program available Cash Prices at 17 select stores. With 20% off storewide every day,# discounts on eligible prescription purchases* and free prescription delivery,§ we’re adding more value to the Walgreens experience you already enjoy.

* Savings apply only to prescriptions purchased by Walgreens Plus members from 17 select stores listed at Walgreens.com/Plus. Cannot be combined with any form of insurance or other pharmacy benefit programs. Actual savings will vary.

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

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

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

Brand-Name Medications 15 Insulins 15 Diabetic Supplies 15

Lifestyle Medications 16 Birth Control 16 Erectile Dysfunction 16

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

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

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

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

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

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

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

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

TRIPOHIST LIQUID 3 120 360

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

Prescription drug coverage and cost are subject to change.

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

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

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

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

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

Prescription drug coverage and cost are subject to change.

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

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

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

Prescription drug coverage and cost are subject to change.

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

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

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

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

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

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ACAMPROSATE CAL DR 333MG TABLETS 147 $244.47 432 $710.78 ACARBOSE 100MG TABLETS 86 $77.60 250 $218.70 ACARBOSE 50MG TABLETS 87 $66.08 244 $177.41 AMITRIPTYLINE 100MG (HUNDRED MG)TAB 35 $33.40 101 $89.68 AMITRIPTYLINE 75MG TABLETS 33 $22.68 97 $58.90 AMLO/VAL/HCTZ 10/160/12.5MG TABLETS 30 $185.43 90 $547.53 AMLODIPINE/OLMES MEDOXOM 10-40MG T 30 $265.37 90 $794.31 AMLODIPINE/OLMES MEDOXOM 5-20MG T 30 $213.69 91 $632.72 AMLODIPINE/OLMES MEDOXOM 5-40MG T 30 $267.00 90 $792.58 AMLODIPINE/OLMES MEDOXOM10-20MG T 29 $207.75 90 $627.41 AMLODIPINE-ATORVASTATIN 10/40MG TAB 30 $178.39 90 $525.17 AMLODIPINE-ATORVASTATIN 5/20MG TABS 30 $179.77 90 $526.16 AMLODIPINE-ATORVASTATIN 5/40MG TABS 30 $183.54 90 $537.39 AMLODIPINE-BENAZ 10/20MG CAPSULES 30 $18.07 91 $46.21 AMLODIPINE-BENAZ 10/40MG CAPSULES 30 $123.75 90 $364.65 AMLODIPINE-BENAZ 2.5/10MG CAPSULES 31 $18.61 94 $47.60 AMLODIPINE-BENAZ 5/10MG CAPSULES 31 $18.48 93 $47.28 AMLODIPINE-BENAZ 5/20MG CAPSULES 33 $19.26 98 $49.79 AMLODIPINE-BENAZ 5/40MG CAPSULES 31 $106.78 92 $310.45 AMNESTEEM 10MG CAPSULES 41 $619.43 124 $1,850.29 AMNESTEEM 20MG CAPSULES 50 $451.48 149 $1,346.43 AMNESTEEM 40MG CAPSULES 48 $1,005.48 85 $1,789.47 ANAGRELIDE 0.5MG CAPSULES 84 $76.83 218 $192.66 ATOMOXETINE 100MG CAPSULES 30 $311.77 90 $938.61 ATOMOXETINE 10MG CAPSULES 37 $328.14 115 $1,021.11 ATOMOXETINE 25MG CAPSULES 35 $310.80 112 $997.58 ATOMOXETINE 60MG CAPSULES 30 $294.03 93 $898.14 ATOMOXETINE 80MG CAPSULES 30 $311.64 90 $939.32 BACLOFEN 20MG TABLETS 80 $56.22 261 $174.92 BALSALAZIDE 750MG CAPSULES 219 $158.65 598 $426.61 BENAZEPRIL/HCTZ 20/25MG TABLETS 31 $46.79 93 $130.74 BETHANECHOL 25MG TABLETS 83 $124.86 233 $343.76 BISOPROLOL FUMARATE 10MG TABLETS 34 $33.85 102 $92.62 BUDEPRION SR 100MG TABLETS (12 H) 45 $46.96 139 $135.73 BUDESONIDE 3MG CAPSULES 76 $976.13 182 $2,325.44 BUMETANIDE 1MG TABLETS 50 $30.72 134 $75.31 BUPROPION 75MG TABLETS 50 $30.75 151 $84.29 BUPROPION XL 150MG TABLETS (24 H) 36 $129.10 109 $384.98 BUPROPION 100MG TABLETS 57 $36.44 169 $99.71 BUPROPION SR 150MG TABLETS (12 H) 52 $51.56 156 $145.57 BUPROPION SR 200MG TABLETS (12 HR) 47 $118.15 144 $355.50 BUSPIRONE 15MG TABLETS 68 $19.84 198 $50.21 BUSPIRONE 7.5MG TABLETS 62 $75.85 186 $219.93 CABERGOLINE 0.5MG TABLETS 9 $249.04 21 $594.44 CALCITRIOL 0.25MCG CAPSULES 32 $36.12 81 $84.66 CALCITRIOL 0.5MCG CAPSULES 44 $73.67 101 $166.16 CARBAMAZEPINE 100MG CHEWABLE TABS 116 $27.17 315 $66.91

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CARTIA (DILTIAZEM) 240MGXT CAPS 32 $46.33 95 $130.01 CARTIA (DILTIAZEM) 180MGXT CAPS 34 $37.65 101 $105.22 CARTIA (DILTIAZEM) 300MGXT CAPS 30 $62.22 90 $178.53 CEFACLOR 500MG ER TABLETS 18 $215.89 53 $639.68 CEFPROZIL 250MG TABLETS 20 $56.07 90 $233.46 CEFPROZIL 500MG TABLETS 19 $103.01 150 $784.50 CELECOXIB 400MG CAPSULES 30 $305.92 97 $989.13 CIPROFLOXACIN 100MG PACK 23 $230.73 84 $841.98 DEMECLOCYCLINE 300MG TABLETS 55 $683.26 178 $2,211.68 DESVENLAFAXINE ER SUCCINATE 50MG T 31 $207.72 93 $624.05 DESVENLAFAXINE SUCCINATE 100MG ER T 31 $222.04 94 $670.82 DESVENLAFAXINE SUCCINATE 25MG ER T 32 $212.89 95 $629.89 DILTIAZEM 90MG TABLETS 73 $20.52 200 $49.44 DILTIAZEM ER 180MG CAPSULES 34 $49.60 102 $140.45 DILTIAZEM ER 360MG (24 HR/CD) CAPS 30 $258.54 90 $773.03 DILTIAZEM ER 360MG CAPSULES (24 HR) 30 $65.12 90 $187.16 DIVALPROEX DELAYED RELEASE 125MG TB 82 $17.65 213 $39.50 DIVALPROEX DELAYED RELEASE 250MG TB 78 $95.75 231 $277.36 DIVALPROEX EXTENDED RELEASE 250MG T 66 $125.70 195 $360.99 DONEPEZIL 23MG TABLETS 30 $295.16 90 $876.93 DOXAZOSIN 8MG TABLETS 34 $16.55 98 $39.82 DOXYCYCLINE HYCLATE 20MG TABLETS 57 $33.26 167 $90.05 DOXYCYCLINE HYCLATE 50MG CAPSULES 40 $68.40 107 $174.57 DOXYCYCLINE MONOHYDRATE 150MG TABS 26 $185.20 91 $644.66 DOXYCYCLINE MONOHYDRATE 75MG TABS 38 $156.66 97 $392.82 DULOXETINE DR 20MG CAPSULES 42 $305.95 123 $893.22 DUTASTERIDE 0.5MG CAPSULES 30 $160.26 89 $468.82 EC-NAPROXEN 375MG TABLETS 43 $13.88 172 $43.65 ELETRIPTAN 20MG TABLETS 9 $240.30 31 $860.20 ELETRIPTAN 40MG TABLETS 9 $243.51 30 $824.40 ENTACAPONE 200MG TABLETS 107 $421.22 324 $1,265.83 EPLERENONE 50MG TABLETS 44 $171.32 128 $485.85 ESCITALOPRAM 10MG TABLETS 31 $108.98 93 $316.50 ESCITALOPRAM 20MG TABLETS 31 $98.95 93 $286.96 ESCITALOPRAM 5MG TABLETS 32 $102.18 94 $293.03 ESOMEPRAZOLE MAGNESIUM 40MG DR CAPS 34 $244.21 98 $693.53 ESTROPIPATE 1.5MG (1.25MG) TABS 30 $14.97 92 $37.58 EXEMESTANE 25MG TABLETS 30 $333.95 90 $994.55 EZETIMIBE 10MG TABLETS 30 $56.23 89 $159.03 EZETIMIBE/SIMVASTATIN 10-10MG TABS 30 $204.32 88 $597.68 EZETIMIBE/SIMVASTATIN 10-20MG TABS 30 $205.94 89 $604.21 EZETIMIBE/SIMVASTATIN 10-40MG TABS 30 $206.95 89 $607.11 EZETIMIBE/SIMVASTATIN 10-80MG TABS 30 $205.64 88 $600.02 FAMCICLOVIR 125MG TABLETS 27 $105.30 122 $468.40 FELODIPINE 10MG ER TABLET 31 $69.28 92 $198.10 FELODIPINE 2.5MG ER TABLETS 35 $20.14 101 $51.29

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price FELODIPINE 5MG ER TABLETS 33 $43.61 98 $121.01 FENOFIBRATE 145MG TABLETS 30 $110.88 90 $322.39 FENOFIBRATE 200MG CAPSULES 30 $78.81 90 $225.45 FENOFIBRATE 48MG TABLETS 31 $65.59 93 $186.45 FENOFIBRATE 67MG CAPSULES 31 $41.56 93 $115.46 FENOFIBRIC 135MG DR CAPSULES 30 $119.65 90 $348.41 FLUVOXAMINE 50MG TABLETS 46 $93.77 139 $273.49 FOLCAL DHA CAPSULES 30 $43.50 90 $121.45 GABAPENTIN 300MG CAPSULES 93 $31.80 241 $76.32 GABAPENTIN 600MG TABLETS 93 $134.84 255 $360.84 GALANTAMINE ER 16MG CAPSULES 30 $111.96 90 $325.48 GALANTAMINE ER 24MG CAPSULES 30 $196.39 90 $579.74 GLIPIZIDE-METFORMIN 5MG/500MG TABS 88 $45.39 256 $124.40 GLYCOPYRROLATE 1MG TABLETS 77 $71.20 203 $182.03 GUANFACINE ER 1MG TABLETS 33 $250.97 104 $777.79 GUANFACINE ER 2MG TABLETS 31 $275.77 94 $828.85 GUANFACINE ER 3MG TABLETS 30 $268.76 91 $805.64 GUANFACINE ER 4MG TABLETS 30 $266.18 90 $797.14 HYDRALAZINE 100MG (HUNDRED MG) TABS 82 $47.40 236 $129.19 HYDRALAZINE 50MG TABLETS 85 $17.21 238 $40.99 HYDROXYCHLOROQUINE 200MG TABLETS 53 $120.21 153 $339.25 IBANDRONATE SODIUM 150MG TABLETS 1 $145.24 3 $420.24 IRBESARTAN 150MG TABLETS 32 $80.67 93 $230.85 IRBESARTAN 300MG TABLETS 30 $89.21 90 $260.94 IRBESARTAN 75MG TABLETS 31 $75.11 92 $215.17 ISOSORBIDE DINITRATE 20MG ORAL TAB 85 $72.33 231 $189.03 ISOSORBIDE DINITRATE 5MG ORAL TABS 71 $50.04 190 $127.41 ISOSORBIDE MONONITRATE 10MG TABS 54 $16.60 149 $38.64 ISOSORBIDE MONONITRATE 120MG ER TAB 33 $20.04 98 $51.38 ISOSORBIDE MONONITRATE 20MG TABS 54 $16.60 155 $40.20 KLOR-CON 8MEQ ER TABLETS 47 $21.21 130 $51.66 LABETALOL 200MG TABLETS 78 $50.57 218 $134.63 LABETALOL 300MG TABLETS 75 $45.15 211 $119.87 LAMOTRIGINE 100MG TABLETS 54 $130.77 169 $403.28 LAMOTRIGINE 200MG TABLETS 45 $118.25 139 $357.30 LAMOTRIGINE 300MG ER TABLETS 38 $461.23 114 $1,368.73 LAMOTRIGINE ER 100MG TABLETS 54 $563.26 165 $1,703.76 LAMOTRIGINE ER 200MG TABLETS 48 $533.60 144 $1,578.56 LEFLUNOMIDE 10MG TABLETS 32 $140.42 93 $399.07 LEVETIRACETAM 1000MG TABLETS 71 $124.36 207 $356.67 LEVETIRACETAM 750MG TABLETS 78 $121.44 228 $347.96 LEVOCETIRIZINE 5MG TABLET 30 $66.49 91 $194.67 LINEZOLID 600MG TABLETS 22 $3,456.70 137 $21,836.01 LOSARTAN 25MG TABLETS 32 $38.79 93 $106.55 LOSARTAN 50-12.5MG TABLETS 31 $56.63 92 $161.03 LOSARTAN 50MG TABLETS 33 $54.45 99 $155.75 LOSARTAN/HCTZ 100/12.5MG TABLETS 30 $18.02 90 $45.88

Prescription drug coverage and cost are subject to change.

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

LOSARTAN/HCTZ 100/25MG TABLETS 30 $66.95 90 $192.50 MEMANTINE 5MG TABLETS 54 $281.31 150 $766.45 MEMANTINE ER 28MG CAPSULES 30 $212.06 90 $625.00 MEMANTINE ER 7MG CAPSULES 30 $420.76 94 $1,286.71 MERCAPTOPURINE (6-MP) 50MG TABLETS 44 $109.78 124 $302.13 METFORMIN ER 1000MG OSMOTIC TABS 49 $699.10 148 $2,084.57 METFORMIN ER 500MG OSMOTIC TABS 63 $483.72 190 $1,446.32 METFORMIN ER 750MG 24HR TABS 50 $16.50 145 $40.19 METOLAZONE 5MG TABLETS 25 $33.63 74 $93.00 METOPROLOL ER SUCCINATE 200MG TABS 32 $61.41 95 $174.35 MINOXIDIL 2.5MG TABLETS 69 $24.81 196 $62.81 MOEXIPRIL 7.5MG TABLETS 35 $18.15 98 $43.33 MONTELUKAST 10MG TABLETS 30 $86.95 90 $253.11 MONTELUKAST 4MG CHEW TABS 30 $66.87 90 $193.10 MONTELUKAST 5MG CHEW TABS 30 $60.58 92 $175.36 MOXIFLOXACIN 400MG TABLETS 10 $126.09 81 $1,027.98 MULTIGEN FOLIC TABLETS 33 $42.21 97 $116.68 MYCOPHENOLIC 180MG DR TABLETS 136 $505.49 373 $1,378.50 NALTREXONE 50MG TABLETS 30 $84.75 90 $247.88 NARATRIPTAN 2.5MG TABLETS 9 $112.11 33 $382.61 NATEGLINIDE 120MG TABLETS 85 $135.73 244 $384.01 NIACIN 1000MG ER TABLETS 40 $227.66 113 $634.06 NIACIN 500MG ER TABLETS 43 $129.11 121 $355.28 NIACIN 750MG ER TABLETS 45 $227.32 137 $675.25 NIFEDICAL XL (OSM) 30MG TABLETS 34 $40.42 101 $111.35 NIFEDICAL XL (OSM) 60MG TABLETS 36 $76.31 104 $215.89 NIFEDIPINE 90MG ER (CC) TABLETS 31 $83.56 93 $240.80 OLANZAPINE 7.5MG TABLETS 31 $371.60 91 $1,102.70 OLMESARTAN MEDOX/HCTZ 20-12.5MG TAB 30 $123.87 90 $364.16 OLMESARTAN MEDOX/HCTZ 40-12.5MG TAB 30 $163.90 90 $484.58 OLMESARTAN MEDOX/HCTZ 40-25MG TAB 30 $170.14 89 $505.03 OLMESARTAN MEDOXOMIL 20MG TABLETS 30 $131.80 90 $385.24 OLMESARTAN MEDOXOMIL 40MG TABLETS 30 $170.31 90 $503.88 OLMESARTAN MEDOXOMIL 5MG TABLETS 40 $133.02 117 $381.96 OLMESARTAN/AMLOD/HCTZ 40-10-25MG T 30 $136.41 90 $404.31 OLMESARTAN/AMLOD/HCTZ 40-5-12.5MG T 30 $268.60 90 $800.18 OLMESARTAN/AMLOD/HCTZ 40-5-25MG T 29 $264.14 90 $794.87 OMEPRAZOLE 10MG CAPSULES 34 $68.36 101 $192.25 OMEPRAZOLE 40MG CAPSULES 33 $88.62 98 $251.91 OXAPROZIN 600MG TABLETS 52 $155.51 163 $482.90 OXCARBAZEPINE 600MG TABLETS 68 $102.10 203 $298.11 PANTOPRAZOLE 20MG TABLETS 34 $71.62 101 $201.82 PAROXETINE 40MG TABLETS 31 $33.05 93 $90.41 PERINDOPRIL 4MG TABLETS 34 $49.96 98 $137.73 PERPHENAZINE 16MG TABLETS 54 $128.98 158 $368.56 PERPHENAZINE 4MG TABLETS 60 $63.61 165 $167.18

Prescription drug coverage and cost are subject to change.

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

PERPHENAZINE 8MG TABLETS 61 $78.15 165 $205.12 PHENYTOIN SODIUM 100MG EXT CAPSULES 108 $27.95 305 $71.67 PIOGLITAZONE 30MG TABLETS 30 $168.48 90 $491.63 PIOGLITAZONE/METFORMIN 15-500MG TAB 58 $263.73 163 $739.26 PIOGLITAZONE/METFORMIN 15-850MG TB 60 $241.40 175 $690.93 PRAZOSIN HCL 5MG CAPSULES 42 $43.50 141 $136.04 PROPAFENONE 225MG TABLETS 74 $81.78 221 $235.73 PROPAFENONE 425MG SR CAPSULES 59 $864.92 175 $2,574.95 PROPAFENONE SR 225MG CAPSULES 59 $465.02 179 $1,397.67 PROPAFENONE SR 325MG CAPSULES 59 $547.38 178 $1,651.96 PROPRANOLOL ER 160MG CAPSULES 33 $76.99 98 $223.47 PROPRANOLOL ER 60MG CAPSULES 33 $46.45 98 $131.33 QUETIAPINE 25MG TABLETS 48 $69.04 132 $183.84 QUETIAPINE 300MG TABLETS 39 $367.14 118 $1,107.42 QUETIAPINE 50MG ER TABLETS 42 $240.46 125 $706.29 QUETIAPINE 50MG TABLETS 44 $116.11 127 $330.62 QUETIAPINE ER 200MG TABLETS 32 $355.86 96 $1,068.78 QUETIAPINE ER 300MG TABLETS 38 $491.53 113 $1,458.05 QUETIAPINE ER 400MG TABLETS 38 $602.91 114 $1,793.56 QUINAPRIL/HCTZ 20-12.5MG TABLETS 42 $62.69 119 $170.88 RABEPRAZOLE DR 20MG TABLES 37 $352.80 105 $1,007.46 RAMIPRIL 10MG CAPSULES 38 $51.35 113 $143.16 RAMIPRIL 2.5MG CAPSULES 33 $58.49 96 $164.52 RAMIPRIL 5MG CAPSULES 34 $45.83 101 $128.74 REPAGLINIDE 0.5MG TABLETS 85 $253.51 231 $678.43 REPAGLINIDE 1MG TABLETS 89 $287.31 252 $802.55 REPAGLINIDE 2MG TABLETS 108 $349.15 300 $965.38 RILUZOLE 50MG TABLETS 59 $272.38 178 $808.33 RISEDRONATE 35MG TABLETS 4 $196.33 12 $558.40 RISEDRONATE SOD 150MG TABLETS 1 $137.42 3 $397.01 RISPERIDONE 0.25MG TABLET 50 $124.21 141 $344.49 RISPERIDONE 0.5MG TABLETS 48 $104.73 134 $285.30 RISPERIDONE 1MG TABLETS 46 $133.01 128 $363.13 RISPERIDONE 2MG TABLETS 41 $116.15 119 $327.90 RISPERIDONE 4MG TABLETS 40 $184.80 119 $542.30 RIZATRIPTAN ODT 10MG TABLETS 10 $310.25 32 $936.02 RIZATRIPTAN ODT 5MG TABLETS 10 $298.93 29 $849.83 ROPINIROLE 1MG TABLETS 54 $92.93 158 $261.61 ROPINIROLE 2MG TABLETS 51 $65.45 151 $185.59 SEVELAMER 800MG TABLETS 210 $805.58 573 $2,196.44 SILDENAFIL 20MG TABLETS 36 $119.07 197 $633.96 SPIRONOLACTONE 25MG W/ HCTZ 25MG TB 33 $25.70 90 $64.00 SULINDAC 200MG TABLETS 50 $21.38 166 $62.02 SUMATRIP/NAPROXEN 85/500MG TABLETS 10 $628.94 31 $1,874.99 SUMATRIPTAN 25MG TABLETS 10 $125.43 31 $372.02 TELMISARTAN 80MG TABLETS 30 $132.98 91 $388.72

Prescription drug coverage and cost are subject to change.

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

TELMISARTAN/HCTZ 40-12.5MG TABS 30 $150.70 90 $442.14 TELMISARTAN/HCTZ 80-12.5MG TABS 31 $157.17 92 $460.09 TENOFOVIR 300MG TABLETS 29 $735.06 85 $2,164.72 TOLTERODINE TART 2MG ER CAPSULES 32 $179.06 95 $526.93 TOLTERODINE TART ER 4MG CAPSULES 31 $204.05 91 $601.45 TOLTERODINE TARTRATE 1MG TABLETS 54 $140.41 161 $408.68 TOLTERODINE TARTRATE 2MG TABLETS 54 $86.07 158 $246.14 TOPIRAMATE 25MG TABLETS 70 $88.57 201 $245.02 TOPIRAMATE 50MG TABLETS 60 $109.46 176 $314.35 VERAPAMIL ER 120MG TABLETS 36 $24.44 108 $65.58 VERAPAMIL ER 180MG TABLETS 36 $11.21 110 $25.86 VERAPAMIL ER 240MG TABLETS 35 $21.99 103 $57.20 VP-GSTN CAPSULES 58 $41.54 148 $100.21 ZOLMITRIPTAN 2.5MG ODT TABLETS 9 $387.93 33 $1,412.94 ZOLMITRIPTAN 2.5MG TABLET 9 $398.41 31 $1,308.01 ZOLMITRIPTAN 5MG ODT TABLETS 9 $428.23 27 $1,329.35 ZOLMITRIPTAN 5MG TABLETS 9 $446.71 32 $1,597.21 ZONISAMIDE 100MG CAPSULES 90 $132.36 266 $384.53 ZONISAMIDE 50MG CAPSULES 71 $51.02 200 $135.96 BENAZEPRIL/HCTZ 10/12.5MG TABLETS 31 $61.74 92 $176.33 BLISOVI 24 FE TABLETS 28'S 29 $67.10 84 $190.92 BUPROPION SR 150MG TABLET 53 $70.60 150 $194.51 DESIPRAMINE 10MG TABLETS 55 $46.02 152 $119.22 OLMESARTAN/AMLOD/HCTZ 20-5-12.5MG T 30 $109.99 91 $324.04 POTASSIUM CIT ER 1620MG (15MEQ) TAB 69 $160.06 191 $437.35 TOPIRAMATE 25MG SPRINKLE CAPSULES 105 $295.42 253 $702.91 ABACAVIR (ABC) 300MG TABLETS 59 $545.17 175 $1,627.27 ABACAVIR 20MG/ML ORAL SOLUTION 668 $388.27 2,700 $1,556.50 ABACAVIR/LAMVUDINE 600-300MG TABLET 30 $875.82 90 $2,635.70 ABIRATERONE 250MG TABLETS 115 $3,057.16 360 $9,522.98 ACAPELLA DEVICE 2 $104.00 6 $304.01 ACARBOSE 25MG TABLETS 90 $65.37 245 $170.25 ACCU-CHEK ACTIVE TEST STRIPS 50'S 108 $174.76 209 $333.88 ACEBUTOLOL 200MG CAPSULES 49 $30.09 141 $78.49 ACEBUTOLOL 400MG CAPSULES 48 $36.26 130 $90.88 ACETAM-CAFF-DIHYDRO CAPSULES 69 $108.23 75 $116.64 ACETAMINOPHEN/COD #2 (300/15MG) TAB 35 $15.37 177 $62.30 ACETAMINOPHEN/COD #3 (300/30MG) TAB 30 $14.08 186 $65.90 ACETAMINOPHEN/COD #4 (300/60MG) TAB 66 $72.65 231 $242.79 ACETAMINOPHEN/COD 120-12MG/5ML SOL 198 $22.16 1,082 $103.15 ACETAZOLAMIDE 125MG TABLETS 32 $53.77 160 $255.70 ACETAZOLAMIDE 250MG TABLETS 62 $112.76 181 $323.72 ACETAZOLAMIDE 500MG ER CAPSULES 54 $202.76 179 $666.02 ACETIC ACID .25% IRR. 1000ML 1,866 $9.60 5,496 $20.49 ACETIC ACID 2% AL ACTATE60ML (EAR) 65 $64.66 195 $185.97 ACETIC ACID 2% OTIC SOLN 15ML (EAR) 15 $30.72 20 $38.27

Prescription drug coverage and cost are subject to change.

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

ACETYLCYST 20% SOL , 30ML 143 $165.81 400 $456.99 ACETYLCYSTEINE 10% INH SOL 3 X 10ML 165 $146.52 486 $425.30 ACITRETIN 10MG CAPSULES 37 $739.25 101 $2,009.98 ACITRETIN 17.5MG CAPSULES 33 $768.78 100 $2,299.42 ACITRETIN 25MG CAPSULES 34 $956.52 91 $2,577.59 ACLARO PD 4% EMULSION 30 $100.86 90 $294.57 ACTEMRA 200MG/10ML INJ, 10ML 20 $1,905.72 59 $5,709.16 ACTEMRA 400MG/20ML INJ, 20ML 27 $2,661.15 82 $7,975.46 ACTEMRA 80MG/4ML INJ, 4ML 13 $1,301.80 40 $3,897.41 ACTHIB INJ, 1 VIAL 1 $90.11 4 $262.33 ACTICIN 5% CREAM 60GM 68 $180.13 219 $573.07 ACTOPLUS MET XR 15MG/1000MG TABLETS 50 $593.27 156 $1,829.30 ACTOPLUS MET XR 30MG/1000MG TABLETS 31 $732.96 90 $2,095.63 ACUVAIL 0.45% OPHT SOL 30SINGLE USE 37 $381.71 103 $1,047.18 ACYCLOVIR 200MG/5ML ORAL SUSP 210 $157.33 988 $727.02 ACYCLOVIR 400MG TABLETS 44 $27.58 149 $83.58 ACYCLOVIR 5% OINTMENT 15GM 20 $463.58 81 $1,825.60 ACYCLOVIR 800MG TABLETS 37 $43.11 124 $136.18 ACZONE 7.5% GEL (PUMP) 60GM 70 $730.63 101 $1,049.99 ADACEL INJ, 0.5ML 1 $55.56 2 $158.68 ADAPAL/BENZ 0.1-2.5% GEL (PMP) 45G 45 $271.02 134 $795.19 ADAPALENE 0.1% CREAM 45GM 45 $207.32 125 $566.93 ADAPALENE 0.1% GEL 45GM 38 $147.29 97 $369.29 ADAPALENE 0.3% GEL (PUMP) 45GM 45 $282.25 123 $756.01 ADCIRCA 20MG TABLETS 48 $3,881.41 143 $11,555.07 ADDYI 100MG TABLETS 30 $868.48 90 $2,583.85 ADEFOVIR DIPIVOXIL 10MG TABLETS 29 $977.24 88 $2,938.99 ADRENALIN 1:1000 (0.1%) NASAL SOLN 35 $147.44 105 $434.32 ADRIAMYCIN 10MG INJ, 1VIAL 1 $18.60 3 $47.80 ADRIAMYCIN 20MG INJ, 1 VIAL 1 $15.88 3 $39.64 ADRIAMYCIN 50MG INJ, 1VIAL 1 $74.00 3 $214.00 ADRUCIL 50MG/ML INJ , 10ML 56 $26.32 168 $70.95 ADRUCIL 5GM/100ML INJ, 100ML 181 $70.41 544 $203.23 ADULT MASK (14F20-PVC) 1 $5.34 1 $5.47 ADVAIR DISKUS 250/50MCG 14'S 61 $371.44 180 $1,094.72 ADVAIR HFA 115/21MCG ORAL INH 120'S 12 $404.30 35 $1,162.30 ADVAIR HFA 230/21MCG ORAL INH 120'S 12 $530.93 35 $1,540.90 ADVAIR HFA 45/21MCG ORAL INH 120'S 12 $325.63 34 $906.27 ADVATE 1500IU FOR INJ 3,000 $4,928.20 9,000 $14,776.60 ADVATE 3000IU FOR INJ 1 $5.64 3 $8.92 AEROCHAMBER MAX W/ MASK (MEDIUM) 1 $20.49 1 $20.73 AEROSPAN 80MCG ORAL INHALER 120'S 9 $230.54 20 $498.47 AFEDITAB 30MG CR (CC) TABLETS 35 $45.84 102 $126.62 AFEDITAB 60MG CR (CC) TABLETS 36 $58.56 105 $162.11 AFINITOR 10MG TABLETS 28 $14,585.86 84 $43,686.52 AFINITOR 2.5MG TABLETS 38 $19,025.69 115 $57,069.08

Prescription drug coverage and cost are subject to change.

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

AFINITOR 5MG TABLETS 29 $14,917.25 68 $35,181.00 A-HYDROCORT 100MG INJ, 1VIAL 1 $5.08 3 $7.24 AIMOVIG SURECLICK 70MG/ML INJ 1 $445.46 4 $1,237.42 AK-CIDE OPHTH OINTMENT 30 $89.63 90 $260.89 ALA-QUIN CREAM 28.4GM 53 $808.29 160 $2,416.87 ALBAFORT INJ, 10ML 1 $21.50 3 $56.49 ALBATUSSIN NN LIQUID 30 $9.06 90 $19.19 ALBENZA 200MG TABLETS 6 $1,174.50 67 $13,415.67 ALBUMIN HUM 25% INJ, 100ML 180 $178.96 540 $528.88 ALBUMIN HUM 5% INJ, 250ML 1 $4.31 3 $4.92 ALBUTEROL SULFATE SYRP (2MG/5ML) 136 $17.60 805 $84.55 ALBUTEROL 0.021%(0.63MG/3ML) 25X3ML 130 $55.99 671 $272.28 ALBUTEROL 0.042%(1.25MG/3ML) 25X3ML 127 $23.70 633 $102.34 ALBUTEROL 0.5% NEB SOLUTION 30'S 33 $17.35 174 $75.42 ALBUTEROL 2MG TABLETS 62 $265.10 220 $926.17 ALBUTEROL 4MG TABLETS 64 $317.68 193 $952.13 ALBUTEROL SULF ER 4MG TABLETS 60 $111.01 195 $351.15 ALBUTEROL SULF ER 8MG TABLETS 54 $131.22 172 $407.69 ALCLOMETASONE 0.05% CREAM 15GM 38 $46.33 160 $181.53 ALCLOMETASONE 0.05% OINTMENT 15GM 42 $179.19 84 $352.70 ALCOHOL 98% INJ, 1ML 5 $32.15 15 $88.45 ALDACTAZIDE 50/50 TABLET 33 $162.83 85 $416.93 ALDEX AN 5MG CHEWABLE TABLETS 30 $72.56 90 $209.67 ALENDRONATE 40MG TABLETS 14 $125.41 37 $331.11 ALENDRONATE 5MG TABLETS 29 $17.38 82 $42.19 ALENDRONATE 70MG/75ML SOLUTION 293 $104.76 856 $298.20 ALFERON N 5MU/ML VIAL FOR INJECTION 1 $679.99 3 $2,031.97 ALFUZOSIN 10MG TABLETS 31 $77.38 92 $221.74 ALINIA 100MG/5ML ORAL SUSP 60ML 113 $1,087.21 2,340 $22,405.99 ALINIA 500MG TABLETS 15 $1,424.17 135 $12,908.55 ALLANZYME 650 OINTMENT 30GM 30 $44.97 90 $126.91 ALLERGY RELIEF & NASAL DEC TABS 26 $10.81 90 $27.13 ALMOTRIPTAN 12.5MG TABLETS 10 $413.76 35 $1,452.00 ALMOTRIPTAN 6.25MG TABLETS 9 $366.38 41 $1,676.73 ALOCRIL 2% OPHTH SOLN 5ML 5 $220.96 15 $630.97 ALOGLIPTIN/METFORMIN 12.5/1000MG TB 59 $206.95 170 $591.91 ALOMIDE 0.1% OPHTH DROP 10ML 10 $222.99 13 $275.08 ALOSETRON 0.5MG TABLETS 57 $1,225.60 153 $3,293.35 ALOSETRON 1MG TABLETS 53 $2,576.31 162 $7,849.61 ALPHAGAN P 0.1% OPHTH SOLN 5ML 7 $192.43 16 $418.14 ALPHAQUIN HP 4% CREAM 56.7GM 35 $47.07 106 $133.22 ALPRAZOLAM 0.25MG ODT TABLETS 41 $55.42 138 $174.75 ALPRAZOLAM 0.25MG TABLETS 45 $14.00 139 $34.87 ALPRAZOLAM 0.5MG ODT TABLETS 46 $78.09 160 $262.87 ALPRAZOLAM 0.5MG TABLETS 52 $17.65 147 $42.48 ALPRAZOLAM 1MG ODT TABLETS 52 $118.10 153 $342.57 ALPRAZOLAM 1MG TABLETS 63 $20.15 159 $44.64

Prescription drug coverage and cost are subject to change.

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

ALPRAZOLAM 2MG ODT TABLETS 58 $322.93 136 $747.88 ALPRAZOLAM 2MG TABLETS 66 $35.37 166 $83.42 ALPRAZOLAM CON 1MG/ML SOLUTION 39 $129.60 117 $380.79 ALPRAZOLAM ER 0.5MG TABLETS 44 $34.76 128 $93.60 ALPRAZOLAM ER 1MG TABLETS 44 $96.98 119 $253.14 ALPRAZOLAM ER 2MG TABLETS 40 $107.26 114 $295.40 ALPRAZOLAM ER 3MG TABLETS 36 $156.37 107 $458.37 ALPROSTADIL 500MCG INJ, 1ML 4 $379.78 18 $1,911.82 ALREX 0.2% OPHTHALMIC SUSP 10ML 6 $314.84 10 $517.76 ALTABAX 1% OINTMENT 15GM 21 $402.39 63 $1,199.16 ALTAVERA TABLETS 28S 29 $25.89 86 $68.43 ALTOPREV 20MG ER TABLETS 29 $839.23 90 $2,556.97 ALTOPREV 40MG ER TABLETS 31 $1,068.24 90 $3,099.97 ALTOPREV 60MG ER TABLETS 30 $1,003.33 90 $2,994.37 ALURIA QIV PFS 2018-2019 1 $33.00 1 $33.14 ALVESCO HFA 160MCG ORAL INH (60INH) 8 $321.35 24 $1,013.23 ALYACEN 7/7/7 TABLETS 28S 28 $29.42 85 $79.47 AMANTADINE 100MG CAPSULES 58 $41.75 184 $123.50 AMANTADINE 100MG TABLETS 53 $105.77 169 $331.42 AMANTADINE 50MG/5ML SYRUP 387 $23.31 1,300 $68.87 AMBI 10PEH/400GFN 10-400MG TABLETS 28 $28.17 90 $81.39 AMBI 40PSE/400GFN TABLETS 39 $45.69 68 $76.22 AMBI 60PSE/400GFN TABLETS 30 $34.39 90 $95.16 AMBI 60PSE/400GFN/20DM TABLETS 30 $36.10 90 $100.29 AMBISOME 50MG INJ , 1VIAL 15 $2,616.75 44 $7,842.26 AMCINONIDE 0.1% CREAM 15GM 53 $308.56 180 $1,041.97 AMCINONIDE 0.1% LOTION 96 $509.58 288 $1,520.75 AMCINONIDE 0.1% OINTMENT 60GM 30 $34.50 90 $95.49 AMETHIA LO TABLETS 91 $114.29 91 $114.55 AMETHIA TABLETS 91S 91 $170.28 91 $170.30 AMETHYST 90-20MCG TABLETS 29 $51.13 85 $143.35 AMIBID LA 600MG CR TABLETS 29 $11.25 130 $36.40 AMICAR 1000MG TABLETS 54 $375.66 162 $1,118.97 AMIKACIN 1GM VIAL FOR INJECTION 74 $250.02 130 $435.62 AMIKACIN 500MG/2ML INJ, 2ML 49 $302.77 95 $584.47 AMILORIDE 5MG TABLETS 51 $63.52 135 $161.24 AMINOBENZOATE POTASSIUM POWDER PKTS 30 $43.59 90 $122.78 AMINOPHYLLIN 25MG/ML INJ, 20ML 135 $94.44 405 $275.31 AMINOPHYLLINE ANHYD POWDER 30 $37.75 90 $105.25 AMIODARONE 100MG TABLETS 34 $157.35 93 $427.59 AMIODARONE 400MG TABLETS 34 $123.33 98 $350.35 AMIODARONE 50MG/ML INJ, 3ML 1 $4.65 3 $5.96 AMITIZA 24MCG CAPSULES 55 $358.64 163 $1,045.17 AMITIZA 8MCG CAPSULES 58 $377.94 167 $1,078.06 AMITRIPTYLINE 150MG TABLETS 32 $41.61 96 $116.54 AMLOD/VAL/HCTZ 10/160/25MG TABLETS 30 $114.53 90 $338.39 AMLOD/VAL/HCTZ 10/320/25MG TABLETS 30 $202.24 90 $603.48

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price AMLOD/VAL/HCTZ 5/160/12.5MG TABLETS 31 $177.87 91 $521.86 AMLOD/VAL/HCTZ 5/160/25MG TABLETS 30 $118.82 90 $349.25 AMLODIPINE-ATORVASTAT 2.5/10MG TABS 30 $95.52 89 $277.00 AMLODIPINE-ATORVASTAT 2.5/40MG TABS 29 $242.91 90 $749.99 AMLODIPINE-ATORVASTATIN 10/10MG TAB 30 $129.02 90 $377.88 AMLODIPINE-ATORVASTATIN 10/20MG TAB 30 $178.15 90 $525.76 AMLODIPINE-ATORVASTATIN 10/80MG TAB 30 $179.08 89 $520.28 AMLODIPINE-ATORVASTATIN 5/10MG TABS 30 $245.69 91 $728.52 AMLODIPINE-ATORVASTATIN 5/80MG TABS 30 $182.30 90 $538.59 AMLODIPINE-VALSARTAN 10-160MG TABS 30 $184.09 89 $542.07 AMLODIPINE-VALSARTAN 10-320MG TABS 30 $219.37 90 $650.59 AMLODIPINE-VALSARTAN 5-160MG TABS 31 $163.17 91 $478.60 AMLODIPINE-VALSARTAN 5-320MG TABS 30 $189.17 90 $561.34 AMMONIUM LAC 12% CREAM 280GM 300 $37.18 823 $95.09 AMMONIUM LAC 12% LOTION 225GM 305 $43.30 854 $113.98 AMMONIUM MOLYBD 25MCG/MLINJ , 10ML 1 $4.28 3 $4.85 AMOXAPINE 100MG TABLETS 42 $56.59 139 $179.15 AMOXAPINE 150MG TABLETS 34 $73.35 90 $189.97 AMOXAPINE 25MG TABLETS 54 $27.76 147 $68.70 AMOXAPINE 50MG TABLETS 59 $48.89 146 $115.18 AMOX-CLAV 200/28.5MG CHEW TABS 28 $54.88 86 $159.48 AMOX-CLAV 250MG TABLETS 22 $90.62 102 $397.30 AMOX-CLAV 250MG/5ML SUSP 100ML 156 $139.41 469 $410.24 AMOX-CLAV 400MG CHEW TABLETS 26 $77.30 79 $230.00 AMOX-CLAV 500MG TABLETS 20 $51.79 109 $261.00 AMOX-CLAV 875MG TABLETS 19 $51.66 127 $328.17 AMOX-CLAV ES 600MG/5ML SUSP 125ML 134 $18.96 428 $51.84 AMOX-CLAV XR 1000/62.5MG TABLETS 27 $92.59 67 $218.99 AMPHADASE 150UNIT/ML INJ, 1ML 2 $126.80 6 $372.41 AMPHETAMINE 30MG TABLETS 57 $82.35 155 $218.04 AMPHOTERICIN B 50MG INJ 17 $763.05 90 $4,143.10 AMPICILLIN 10GM VIAL FOR INJECTION 1 $78.99 3 $228.97 AMPICILLIN 125/5ML SUSP 200ML 220 $12.21 660 $28.62 AMPICILLIN 1GM INJ 5 $20.47 15 $53.40 AMPICILLIN 1GM INJ, 1 VIAL 3 $18.93 10 $48.80 AMPICILLIN 250/5ML SUSP 100 ML 147 $17.19 440 $43.56 AMPICILLIN 250MG INJ , 1VIAL 1 $5.22 3 $7.66 AMPICILLIN 2GM INJ, 1 VIAL 1 $21.52 4 $56.57 AMPICILLIN 2GM INJ, 1 VIAL 42 $843.58 126 $2,522.74 AMPICILLIN 500MG INJ, 1 VIAL 40 $167.60 120 $494.80 AMPICILLIN-SULBACT 2-1GMINJ,1 VIAL 70 $773.30 210 $2,311.90 AMPICILLIN-SULBACTAM 1.5GM INJ, 1VL 5 $21.78 15 $57.33 AMPICILLIN-SULBACTAM 15GM INJ, 1VL 1 $75.99 3 $219.97 AMTURNIDE 150/5/12.5MG TABLETS 30 $135.11 90 $397.33 AMTURNIDE 300/10/12.5MG TABLETS 30 $169.48 90 $500.44 AMTURNIDE 300/5/12.5MG TABLETS 30 $169.48 90 $500.44

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price AMTURNIDE 300/5/25MG TABLETS 30 $169.48 90 $500.44 ANADROL-50 50MG TABLETS 58 $2,599.54 90 $4,030.82 ANAGRELIDE 1MG CAPSULES 72 $137.99 175 $329.90 ANALPRAM ADVANCED KIT (30GM TUBE) 30 $7,078.90 90 $21,228.70 ANALPRAM-HC 2.5% LOTION 59ML 61 $235.69 183 $699.06 ANANA FORTE NR TABLETS 13 $32.37 39 $89.10 ANASTROZOLE 1MG TABLETS 23 $14.90 78 $40.27 ANDEHIST NR 4-45 SYRUP 30 $5.67 90 $9.00 ANDEHIST SYRUP 30 $7.75 90 $15.24 ANDRODERM 4MG TRANSDERMAL30'S 32 $610.53 97 $1,831.90 ANDROXY 10MG TABLETS 30 $173.00 90 $510.99 ANGELIQ 0.5-1MG TABLETS 28'S 28 $183.54 83 $532.95 ANORO ELLIPTA 62.5-25MCG ORAL INH30 60 $444.62 180 $1,316.36 ANTHRALIN 1% CREAM 50GM 52 $60.48 157 $173.43 ANTIPY/BENZ 5.5-1.4% OTIC SOL (EAR) 30 $353.26 90 $1,051.79 ANUCORT-HC 25MG RECTAL SUPP 20 $167.23 91 $748.99 ANZEMET 100MG TABLETS 30 $3,156.88 90 $9,462.64 ANZEMET 20MG/ML INJ , 0.625ML 1 $45.34 3 $128.03 ANZEMET 50MG TABLETS 30 $2,382.64 90 $7,139.92 APEXICON E 0.05% CREAM 30GM 48 $779.16 180 $2,919.95 APIDRA SOLOSTAR PEN INJ,5 X 3ML 17 $669.05 40 $1,555.58 APIDRA U-100 INJECTION 10ML 21 $624.98 69 $2,048.37 APLISOL 5TU MDV (10 DOSESX 0.1ML) 1 $93.26 3 $271.78 APRACLONIDINE 0.5% OPHTH SOL 10ML 6 $97.70 12 $185.58 APREPITANT 125MG CAPSULES 4 $1,224.27 13 $3,664.80 APREPITANT 40MG CAPSULES 2 $167.63 4 $396.79 APREPITANT 80MG CAPSULES 4 $760.24 76 $13,862.18 APREPITANT 80MG/125MG CAPS TRI-PACK 4 $772.03 14 $3,008.32 APRI TABS 28 29 $25.81 86 $68.15 APRISO 0.375GM CAPSULES 117 $592.28 342 $1,722.79 APTIVUS 250MG CAPSULES 116 $1,564.43 360 $4,836.96 APTIVUS SOLUTION 30 $176.46 90 $521.37 ARANELLE TABLETS 28 30 $35.63 85 $94.67 ARANESP 100MCG INJ , 1ML 2 $1,546.53 8 $6,265.92 ARANESP 100MCG/0.5ML SGJCT ALB FREE 2 $2,484.30 3 $4,939.14 ARANESP 150MCG/0.3ML INJ ALB FREE 1 $3,268.88 2 $7,669.36 ARANESP 200MCG/0.4ML INJ ALB FREE 1 $4,012.77 3 $12,030.30 ARANESP 200MCG/ML VL ALBUMIN FREE 1 $2,304.65 4 $6,905.96 ARANESP 25MCG INJ, 0.42ML 1 $618.32 3 $1,652.12 ARANESP 25MCG/ML INJ, 1ML 1 $284.27 2 $290.72 ARANESP 300MCG/0.6ML INJ ALB FREE 2 $7,505.60 2 $7,669.39 ARANESP 300MCG/ML VL ALBUMIN FREE 2 $4,546.45 5 $13,631.36 ARANESP 40MCG/0.4ML INJ ALB FREE 1 $1,062.07 2 $2,037.02 ARANESP 40MCG/ML INJ SRCLK ALB FREE 2 $696.28 2 $706.31 ARANESP 500MCG/ML INJ ALB FREE 1 $4,932.39 4 $14,789.16 ARANESP 60MCG INJ, 1ML 2 $1,032.53 4 $1,789.96

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ARANESP 60MCG/0.3ML SGJCT ALB FREE 1 $1,618.34 2 $2,919.07 ARIPIPRAZOLE 10MG TABLETS 30 $845.00 90 $2,531.98 ARIPIPRAZOLE 15MG (FIFTEEN MG) TABS 28 $808.88 86 $2,458.52 ARIPIPRAZOLE 1MG/ML ORAL SOLUTION 183 $1,082.91 440 $2,604.51 ARIPIPRAZOLE 20MG (TWENTY MG) TAB 29 $1,136.08 90 $3,447.65 ARIPIPRAZOLE 2MG TABLETS 32 $879.75 93 $2,573.08 ARIPIPRAZOLE 30MG TABLETS 29 $1,136.76 89 $3,438.44 ARIPIPRAZOLE 5MG TABLETS 30 $834.96 89 $2,463.18 ARIPIPRAZOLE ODT 10MG TABLETS 31 $1,263.62 96 $3,828.21 ARIPIPRAZOLE ODT 15MG TABLETS 34 $1,370.29 96 $3,832.16 ARISTOSPAN 20MG/ML INJ, 5ML 1 $11.85 3 $27.54 ARMODAFINIL 150MG TABLETS 30 $302.44 93 $914.16 ARMODAFINIL 200MG TABLETS 30 $300.11 93 $922.07 ARMODAFINIL 250MG TABLETS 30 $299.98 92 $914.46 ARMODAFINIL 50MG TABLETS 42 $274.16 117 $756.78 ARZOL SILVER NITRATE APPLICATORS 78 $51.36 95 $61.72 ASCOMP W/CODEINE 30MG CAPSULES 62 $123.63 181 $353.66 ASCORBIC ACID 500MG/ML INJ, 50ML 64 $57.99 64 $57.99 ASPIRIN-DIPYRIDAMOLE ER 25/200MG C 61 $363.99 179 $1,056.25 ASSESS METER FLOW METER 1 $22.96 1 $23.08 ATABEX EC TABLETS 29 $15.88 68 $32.31 ATABEX PRENATAL TABLETS 27 $14.04 82 $34.13 ATAZANAVIR 150MG CAPSULES 56 $1,394.19 167 $4,179.76 ATAZANAVIR 200MG CAPSULES 59 $1,468.38 176 $4,405.52 ATAZANAVIR 300MG CAPSULES 30 $988.77 90 $2,962.14 ATENOLOL 100MG/CHLORTHAL 25MG TABS 30 $18.20 88 $46.08 ATOMOXETINE 18MG CAPSULES 33 $299.58 108 $955.10 ATOMOXETINE 40MG CAPSULES 33 $318.42 102 $987.66 ATOVAQUONE 750MG/5ML SUSPENSION 262 $1,089.86 840 $3,490.03 ATOVAQUONE-PROGUANIL 250/100 TABS 23 $140.67 104 $615.40 ATRIPLA (EFV600/FTC200/TDF300) TAB 30 $2,692.53 90 $8,080.36 ATROPINE SUL 0.4MG/ML INJ , 1ML 2 $10.24 5 $22.72 ATROPINE SUL 1MG/ML INJ , 1ML 5 $8.74 16 $18.21 ATROPINE SULF 1% OPH SOLN 15ML 5 $34.69 7 $43.83 ATROPINE SULF 1% OPHTH OINTMENT 4 $20.27 11 $52.82 ATROVENT HFA ORAL INHALER (200 INH) 14 $407.49 25 $726.82 AUGMENTIN 125MG/5ML SUSP 150ML 149 $174.49 446 $515.47 AUTOPEN 1-21UNIT 1 $39.42 1 $46.65 AVAILNEX 750MG CHEWABLE TABLETS 30 $24.06 90 $64.18 AVASTIN SOL FOR INJ 16ML (400MG) 47 $10,216.88 142 $30,642.64 AVIANE-28 TABLETS 28 29 $28.65 85 $76.92 AVITA 0.025% CREAM 20GM 36 $155.23 83 $352.12 AVITA 0.025% GEL 45GM 36 $150.79 102 $426.28 AXONA POWDER 33 $94.28 84 $233.50 AZASAN 100MG TABLETS 40 $286.69 109 $779.64 AZASAN 75MG TABLETS 41 $653.58 109 $1,745.46 AZATHIOPRINE 50MG TABLETS 66 $65.17 185 $176.43

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price AZELASTINE 0.05% OPHTH SOLUTION 6ML 6 $131.25 17 $367.00 AZELASTINE 0.1%(137MCG) NASAL-200SP 31 $94.03 57 $168.76 AZELASTINE 0.15% NASAL SP(200 DOSE) 31 $135.76 51 $216.59 AZELEX 20% CREAM 30GM 39 $542.44 110 $1,526.98 AZITHROMYCIN 100MG/5ML SUSP 15ML 25 $56.33 65 $143.59 AZITHROMYCIN 1GM PAK POWDER 1 $29.38 3 $67.10 AZITHROMYCIN 200MG/5ML SUSP 15ML 28 $66.67 281 $640.48 AZITHROMYCIN 250MG TABLETS 6 $31.62 52 $235.98 AZITHROMYCIN 500MG INJ, 1 VIAL 9 $217.91 27 $645.73 AZITHROMYCIN 500MG TABLET 4 $54.51 41 $495.86 AZITHROMYCIN 600MG TABLETS 9 $163.93 26 $441.82 AZITHROMYCIN POWDER 1 $12.96 3 $30.88 AZOPT 1% OPHTH SUSP 10ML 11 $329.17 17 $503.49 AZURETTE TABLETS 28S 29 $36.88 85 $101.26 BACIIM 50000UNT INJ , 1VIAL 23 $366.44 68 $1,091.32 BACITRACIN OPHTH OINTMENT3.5GM 4 $102.84 14 $384.00 BACMIN TABLETS 34 $30.04 105 $85.24 BACTERIOSTATIC WATER INJ, 30ML 126 $8.78 368 $17.93 BACTROBAN NASAL 2% OINTMENT 18 $342.15 54 $1,018.44 BALZIVA TABLETS 28S 29 $31.34 86 $83.84 BANOPHEN (DIPHENHYDRAMINE) 25MG CP 37 $4.42 123 $5.36 BANZEL 400MG TABLETS 147 $3,539.13 445 $10,704.24 BANZEL 40MG/ML SUSPENSION 460ML 758 $2,647.45 1,679 $5,855.99 BARACLUDE 0.05MG/ML ORALSOLUTION 205 $989.63 615 $2,960.89 BASAGLAR 100 U/ML KWIKPEN INJ 5X3ML 16 $418.58 33 $869.20 B-COMPLEX INJ, 30ML 30 $195.99 30 $195.99 B-D #000 ALLERGY SYR/NDL1ML 28GX1/2 38 $13.96 62 $20.10 B-D #1603 SYRINGE 5ML W/SLIP TIP 46 $11.07 138 $25.20 B-D #1604 SYRINGE 10ML W/SLIP TIP 76 $11.58 117 $15.63 B-D #1625 SYRINGE 20ML W/LL SLIPTIP 74 $38.17 222 $106.50 B-D #1627 SYRINGE 50-60ML W/ LS 32 $37.37 103 $110.40 B-D #5106 NEEDLES 30GX1/2 25 $11.57 44 $17.08 B-D #5109 NEEDLES 27GX1/2 22 $5.65 28 $6.08 B-D #5110 NEEDLES 26GX3/8 21 $5.51 62 $8.53 B-D #5122 NEEDLES 25GX5/8 16 $6.26 21 $6.98 B-D #5125 NEEDLES 25GX1 HYPO 14 $5.02 21 $5.50 B-D #5127 NEEDLES 25GX1-1/2 15 $5.08 21 $5.57 B-D #5128 NEEDLES 30GX1 17 $7.91 40 $13.53 B-D #5136 NEEDLES 27GX1-1/4 19 $6.14 30 $7.42 B-D #5143 NEEDLES 23GX3/4 13 $4.46 21 $4.75 B-D #5145 NEEDLES 23GX1 PG 10 $4.78 19 $5.41 B-D #5155 NEEDLES 22GX1 12 $4.92 18 $5.35 B-D #5156 NEEDLES 22GX1-1/2 14 $5.16 16 $5.28 B-D #5157 NEEDLES 22GX1-1/4 20 $4.71 60 $6.14 B-D #5165 NEEDLES 21GX1 13 $4.91 20 $5.44 B-D #5167 NEEDLES 21GX1-1/2 11 $4.81 19 $5.39 B-D #5175 NEEDLES 20GX1 18 $5.79 24 $6.35

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price B-D #5176 NEEDLES 20GX1-1/2 16 $4.59 19 $4.69 B-D #5185 NEEDLES 18GX1-1/2 PG 10 $4.81 17 $5.36 B-D #5186 NEEDLES 19GX1 9 $4.66 17 $5.25 B-D #5187 NEEDLES 19GX1-1/2 15 $4.54 21 $4.75 B-D #5195 NEEDLES 18GX1 11 $5.81 17 $6.78 B-D #5197 NEEDLES 16GX1 PG 13 $6.45 19 $7.59 B-D #5269 SYR/NDL 3ML 25GX5/8 INT 13 $11.53 38 $26.58 B-D #5272 SYR/NDL 3ML 22GX1-1/2 10 $9.52 14 $11.54 B-D #5554 SYR/NDL 1ML 25GX5/8 SL TB 13 $8.65 17 $9.95 B-D #5930 SYR/NDL 1ML 29GX1/2 SG 87 $41.86 150 $68.99 B-D #5937 SAFE GL SYR 0.3ML31GX5/16 107 $50.25 169 $77.22 B-D #5945 SYR/NDL 1ML 27GX1/2 SG TB 16 $12.33 19 $13.61 B-D #8278 SYR/NDL 1ML 30GX1/2 UF 93 $32.00 178 $57.48 B-D #8279 SYR/NDL 0.5ML 30GX1/2 UF 105 $35.49 206 $65.69 B-D #8280 SYR/NDL 0.3ML 29GX1/2 UF 107 $35.94 195 $62.38 B-D #8281 SYR/NDL 1ML 28GX1/2 MF 56 $18.50 86 $26.21 B-D #8282 SYR/NDL 0.5ML 28GX1/2 MF 77 $23.89 124 $36.21 B-D #8289 SYR/NDL 1ML 31GX5/16 UF 97 $33.21 175 $56.51 B-D #8290 SYR/NDL 0.5ML 31GX5/16 UF 102 $34.60 181 $58.30 B-D #9571 SYR/NDL 3ML 23GX1 LL 10 $5.22 14 $5.70 B-D #9572 SYR/NDL 3ML 22GX1 LL 11 $5.29 15 $5.76 B-D #9573 SYR/NDL 3ML 22GX1-1/4 LL 11 $5.37 34 $8.11 B-D #9575 SYR/NDL 3ML 21GX1 LL 10 $5.20 15 $5.77 B-D #9577 SYR/NDL 3ML 21GX1-1/2 LL 10 $5.18 14 $5.64 B-D #9578 SYR/NDL 3ML 20GX1 LL 15 $5.79 19 $6.25 B-D #9579 SYR/NDL 3ML 20GX1-1/2 LL 14 $5.65 18 $6.19 B-D #9580 SYR/NDL 3ML 18GX1-1/2 LL 11 $5.38 16 $5.88 B-D #9581 SYR/NDL 3ML 25GX1 LL 10 $5.15 11 $5.34 B-D #9582 SYR/NDL 3ML 25GX1-1/2 LL 12 $5.58 14 $5.85 B-D #9585 SYRINGE 3ML W/LL 15 $4.59 19 $4.76 B-D #9589 SYR/NDL 3ML 23GX1-1/2 LL 11 $5.32 15 $5.78 B-D #9602 SYRINGE 1ML W/SLIP TIP TB 13 $5.67 19 $6.52 B-D #9620 SYRINGE 60ML CATHETER TIP 34 $68.75 99 $191.37 B-D #9622 SYR/NDL 1ML 25GX1 10 $7.34 13 $8.38 B-D #9625 SYR/NDL 1ML 26GX3/8 TB 17 $7.28 20 $7.92 B-D #9630 SYR/NDL 5ML 22GX1 LL 23 $11.90 70 $27.70 B-D #9631 SYR/NDL 5ML 22GX1-1/2 LL 24 $9.57 71 $20.70 B-D #9632 SYR/NDL 5ML 21GX1 LL 37 $14.10 112 $34.29 B-D #9633 SYR/NDL 5ML 21GX1-1/2 LL 23 $9.51 70 $20.52 B-D #9634 SYR/NDL 5ML 20GX1 LL 48 $15.30 144 $37.89 B-D #9635 SYR/NDL 5ML 20GX1-1/2 LL 22 $10.09 65 $22.27 B-D #9637 SYR/NDL 1ML 20GX1 LL 18 $14.01 20 $14.99 B-D #9640 SYR/NDL 10ML 22GX1 LL 22 $9.48 60 $19.08 B-D #9642 SYR/NDL 10ML 21GX1 LL 32 $11.97 57 $18.35 B-D #9643 SYR/NDL 10ML 21GX1-1/2 LL 15 $7.80 46 $15.40 B-D #9644 SYR/NDL 10ML 20GX1 LL 38 $13.43 113 $32.29 B-D #9650 SYRINGE 30ML W/LL 26 $12.66 90 $33.46 B-D #9651 SYR/NDL 1ML 25GX5/8 13 $7.61 17 $8.66

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price B-D 1CC ALLERGI TRAY SYR KIT 29 $5.13 43 $5.66 B-D ALLERGIST KIT 1CC, 27G 0.5" 30 $6.37 40 $7.18 B-D AUTOSHIELD 29GX1/2" PEN NEEDLES 112 $60.76 155 $82.67 B-D FILTER NEEDLE 19GX 1-1/2" 17 $6.27 41 $9.59 B-D INJECT-EASE AUTO INJECTOR 2 $49.74 7 $141.21 B-D PEN NDL MINI 31GX5MM(3/16)PRPL 121 $57.36 164 $75.93 B-D PEN NDL NANO 32GX4MM(5/32) GRN 127 $64.54 167 $83.89 B-D PEN NDL ORIG29GX12.7MM(1/2) RED 117 $54.41 161 $73.40 B-D PEN NDL SHRT 31GX8MM(5/16) BLU 120 $56.75 167 $77.60 BECONASE-AQ NASAL (180 SPRAYS) 25GM 26 $320.33 45 $552.64 BELLADONNA 16.2MG / OPIUM 30MG SUPP 17 $412.02 113 $2,778.90 BELLADONNA 16.2MG / OPIUM 60MG SUPP 20 $614.11 40 $1,203.97 BELLADONNA ALKALOIDS W/PB TABLETS 61 $510.79 211 $1,772.62 BELVIQ 10MG TABLETS 57 $313.15 176 $966.67 BELVIQ XR 20MG TABLETS 30 $294.93 90 $878.62 BENAZEPRIL/HCTZ 20/12.5MG TABLETS 37 $32.70 108 $86.50 BENAZEPRIL/HCTZ 5/6.25MG TABLETS 31 $62.29 91 $174.00 BENSAL HP OINTMENT 30GM 31 $1,031.01 93 $3,085.03 BENZAMYCIN PAK GEL 23 $127.49 70 $374.46 BENZOIC ACID CRYSTALS 30 $5.92 90 $9.76 BENZONATATE 150MG CAPSULES 32 $78.99 180 $425.97 BENZOYL PER 4% CRM WASH COMP KIT 30 $2,103.70 90 $6,303.10 BENZOYL PER 8% CRM WASH COMP KIT 30 $2,253.70 90 $6,753.10 BENZOYL PER-4 ACNE WASH KIT 30 $1,593.70 90 $4,773.10 BENZOYL PEROX 4.5%-10% CLNSER 400ML 30 $9.55 90 $20.65 BENZOYL PEROX 6.5%-10% CLNSER 400ML 30 $6.16 90 $10.47 BENZOYL PEROX 8.5%-10% CLNSER 400ML 30 $7.60 90 $14.80 BENZOYL PEROXIDE 10% AQ GEL 60GM 54 $15.64 95 $24.65 BENZOYL PEROXIDE 10% WASH 142GM 193 $27.15 285 $38.14 BENZOYL PEROXIDE 4% GEL 42.5GM 43 $266.11 130 $790.33 BENZOYL PEROXIDE 5% WASH 142GM 189 $21.81 256 $28.22 BENZOYL PEROXIDE 5.75% WASH LIQUID 30 $9.84 90 $21.51 BENZOYL PEROXIDE 6% CLEANSER LOTN 30 $10.34 90 $23.01 BENZOYL PEROXIDE 7% WASH LIQ 480ML 419 $115.65 946 $256.01 BENZOYL PEROXIDE 8% GEL 42.5GM 43 $236.69 128 $702.08 BENZOYL PEROXIDE 8.5-10% PADS 30 $79.99 90 $231.97 BENZOYL PEROXIDE 9.8% FOAM 100GM 103 $119.42 300 $341.80 BENZPHETAMINE 50MG TABLETS 72 $73.53 161 $159.95 BEPREVE 1.5% OPTH DROPS 10ML 6 $295.22 13 $584.09 BESIVANCE 0.6% OPTH SUSP 5ML 5 $199.40 6 $242.89 BETAINE CAPSULES 42 $7.81 84 $11.53 BETAMETHASON DIP AUG 0.05% LOT 30ML 57 $141.88 258 $631.10 BETAMETHASONE DIP 0.05% CRM 15GM 41 $59.89 149 $209.58 BETAMETHASONE DIP 0.05% LOTN 60ML 64 $38.24 199 $110.27 BETAMETHASONE DIP 0.05% OINT 15GM 43 $105.13 164 $389.36 BETAMETHASONE DIP AUG .05% GEL 50GM 39 $56.12 135 $182.17 BETAMETHASONE DIP AUG .05% OIN 15GM 43 $81.78 190 $349.43 BETAMETHASONE DIP AUG CREAM 15GM 45 $46.06 161 $155.04

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price BETAMETHASONE VAL 0.1% LOTN 60ML 64 $50.68 207 $155.97 BETAMETHASONE VAL 0.1% OINT 15GM 40 $29.70 141 $93.86 BETAMETHASONE VAL 0.12% FOAM 100GM 79 $351.86 290 $1,284.44 BETASERON 0.3MG VIAL FOR INJ KIT 14 $8,369.52 44 $26,252.92 BETAVENT SYRUP 30 $7.50 90 $14.49 BETAXOLOL 0.5% OPHTH SOLN 5ML 7 $75.92 12 $122.55 BETAXOLOL 10MG TABLETS 31 $40.77 90 $110.06 BETAXOLOL 20MG TABLETS 33 $57.46 88 $144.41 BETHANECHOL 10MG TABLETS 81 $93.91 232 $261.41 BETHANECHOL 50MG TABLETS 82 $103.39 236 $289.42 BETHANECHOL 5MG TABLETS 68 $28.63 204 $77.40 BETIMOL 0.25% OPHTH SOLN 5ML 6 $99.77 8 $146.33 BETIMOL 0.5% OPHTHALMIC SOLN 10ML 7 $171.54 10 $271.30 BETOPTIC-S 0.25% OPHTH SUSP 10ML 11 $368.05 15 $486.15 BEXAROTENE 75MG CAPSULES 111 $29,868.08 218 $58,700.46 BEXSERO PFS SINGL DOSE INJ 0.5MLX10 1 $191.46 1 $198.85 BICALUTAMIDE 50MG TABLETS 31 $163.19 92 $477.92 BICILLIN CR 1200000 UNITS/2ML SYR 4 $234.17 6 $382.39 BICILLIN C-R 900/300 INJ, 2ML 2 $140.64 7 $413.92 BICILLIN LA 1200000 UNITS/2ML SYR 5 $373.16 18 $1,390.84 BICILLIN LA 2400000 UNITS/4ML SYR 7 $565.14 16 $1,320.03 BIDEX 400MG TABLETS 38 $15.10 113 $36.82 BIKTARVY TABLETS 30 $3,186.05 90 $9,535.64 BIMATOP 0.03% OPHTH SOLN 5ML 4 $131.37 7 $264.65 BIMATOPROST 0.03% OPH SOL W/BRUSHES 4 $135.92 6 $190.01 BIO GLO 1MG OPTH TEST STRIPS 300 100 $14.33 300 $34.99 BIONECT 0.2% CREAM 100GM 92 $556.94 100 $607.96 BIOTUSS LIQUID 134 $6.44 139 $6.53 BLEPHAMIDE S.O.P. OPHTH OINTMENT 4 $143.09 11 $421.27 BLISOVI FE 1.5/30 TABLETS 28S 29 $19.42 85 $49.61 BOOSTRIX INJ, 0.5ML 1 $55.38 2 $158.15 BOTOX 100UNIT INJECTION 2 $1,071.01 2 $1,515.32 BOTOX 200UNIT INJ, 1 VIAL 1 $1,414.99 1 $1,430.22 BOTOX COSMETIC 100UNIT INJECTION 1 $761.11 3 $2,275.34 BP 10-1 EMULSION 175 $518.92 524 $1,548.76 BP VIT 3 CAPSULES 42 $48.62 93 $103.35 BP WASH 2.5% LIQUID 227GM 228 $224.42 681 $660.96 BPM PSEUDO 6-45MG TABLETS 30 $16.97 90 $42.91 BPO 6% FOAMING CLOTHS 60S 61 $363.70 140 $834.65 BRAVELLE 75IU FOR INJECTION 1 $133.60 3 $392.80 BREEZE 2 TEST DISCS 100'S 118 $110.48 195 $179.55 BREO ELLIPTA 100-25MCG ORAL INH(30) 60 $383.66 180 $1,133.97 BREO ELLIPTA 200-25MCG ORAL INH(30) 60 $381.75 180 $1,129.58 BRILINTA 90MG TABLETS 59 $384.02 178 $1,155.37 BRIMONIDINE 0.15% OPHTH SOL 10ML 8 $177.44 17 $382.09 BRIMONIDINE 0.2% OPHTH SOLN 10ML 8 $32.04 15 $58.99

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price BRINTELLIX 20MG TABLETS 30 $352.70 91 $1,061.70 BROMFENAC 0.09% OPHTH SOLN 2.5ML 5 $375.98 15 $1,119.94 BROMFENAC 0.09% OPTH SOL 1.7ML 2 $155.13 6 $482.96 BROMHIST DM PEDIATRIC DROPS 30ML 30 $26.10 90 $70.29 BROMHIST PEDIATRIC DROPS 30ML 30 $13.68 90 $33.04 BROMOCRIPTINE 2.5MG TABLETS 43 $134.59 120 $372.10 BROMOCRIPTINE 5MG CAPSULES 50 $515.72 133 $1,374.90 BROMPHEN/PSE 9/90MG CAPSULES 30 $19.86 90 $51.58 BROMPHEN/PSEUDO/DEXTRO HBR SYRUP 160 $36.46 200 $44.66 BROMPHENIRAMINE TANN 12MG CHEW TABS 30 $41.99 90 $117.96 BROMSITE 0.075% EYE DROPS 5 $281.92 5 $290.44 BRONCODUR SOLUTION 30 $6.25 90 $10.74 BRONKIDS DROPS 30 $18.99 90 $48.97 BROVANA 15MCG/2ML INH SOL 30X2ML 118 $1,011.01 354 $3,014.55 BROVEX PEB LIQUID 30 $15.23 90 $37.69 BROVEX PSB LIQUID 30 $14.90 90 $36.69 BUCALSEP SOLUTION 30 $25.99 90 $69.97 BUCALSEP SPRAY 30 $24.99 90 $66.97 BUDESONIDE 0.25MG/2ML VIALS 30X2ML 89 $249.56 296 $818.71 BUDESONIDE 0.5MG/2ML VIALS 30X2ML 96 $377.24 308 $1,198.19 BUDESONIDE 1MG/2ML RESPULES 30X2ML 86 $754.32 264 $2,317.52 BUDESONIDE 32MCG NS SP (120INH) RX 9 $138.85 20 $315.54 BUDESONIDE ER 9MG TABLETS 29 $1,600.32 89 $4,821.71 BUMETANIDE 0.25/ML INJ, 10ML 69 $15.66 206 $38.97 BUMETANIDE 0.5MG TABLETS 38 $20.59 106 $50.04 BUMETANIDE 2MG TABLETS 53 $70.51 145 $187.01 BUPIVACAINE 0.25% INJ , 10ML 129 $33.45 386 $92.35 BUPIVACAINE 0.5% INJ, 10 ML 355 $110.53 1,217 $368.64 BUPIVACAINE 0.5% INJ, 50ML 594 $18.78 1,781 $48.35 BUPIVACAINE 0.75% INJ, 30ML 30 $8.00 90 $16.00 BUPIVACAINE HCL POWDER 30 $507.94 90 $1,515.82 BUPRENEX 0.324MG/ML 1ML AMPS 78 $1,023.43 235 $3,062.30 BUPRENORPHINE 10MCG/HR TD PATCH 4 $287.71 12 $845.92 BUPRENORPHINE 15MCG/HR TDPATCH 4 $413.09 12 $1,216.97 BUPRENORPHINE 20MCG/HR TD PATCH 4 $511.24 12 $1,524.94 BUPRENORPHINE 2MG SL TABLETS 47 $103.32 140 $297.73 BUPRENORPHINE 8MG SL TABLETS 34 $162.10 88 $418.38 BUPRENORPHINE HCL POWDER 0.5GM 30 $32,763.40 90 $98,282.20 BUPRENORPHINE/NALOX 2MG/0.5MG SL TB 40 $204.66 160 $797.16 BUPRENORPHINE/NALOX 8MG/2MG SL TAB 26 $227.20 119 $1,043.52 BUPROPION XL 300MG TABLETS 30 $85.78 90 $250.45 BUSPIRONE 30MG TABLETS 59 $59.68 175 $170.33 BUT/ACETAMI/CAFF COD 50-300-40-30 C 52 $264.91 143 $729.53 BUT/ACETAMINOPHEN CAFF 50-300-40 CP 41 $96.38 185 $423.60 BUT/APAP/CAF COD CAPSULES 58 $60.68 203 $203.01 BUTALB/ACETA 50-300MG TABLETS 46 $604.91 237 $3,103.75

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price BUTALB/ACETAMINOPHEN 325MG TABS 51 $48.29 186 $165.52 BUTALB/ACETAMINOPHEN/CAFFCAPSULES 44 $82.08 155 $276.07 BUTALB/ASPIRIN 325MG/CAFFEINE TAB 45 $19.94 190 $71.43 BUTALBITAL/ACETAMINOPHEN/CAFF TABS 49 $46.53 207 $183.64 BUTALBITAL/ASPIRIN/CAFFEINE CAPS 51 $48.50 174 $154.50 BUTISOL SOD 30MG TABLETS 73 $312.94 234 $998.50 BUTISOL SOD 50MG TABLETS 30 $166.65 90 $491.95 BUTORPHANOL 2MG/ML INJ, 10ML 1VL 105 $517.19 314 $1,543.57 BUTORPHANOL NS NASAL SPRAY 2.5ML 4 $113.06 9 $248.51 B-VEX 12MG/5ML SUSPENSION 30 $10.09 90 $22.28 BYDUREON 2MG VIAL(ONCE WEEKLY)4TRAY 4 $698.48 12 $2,058.97 BYSTOLIC 10MG TABLETS 33 $156.99 97 $455.19 BYSTOLIC 2.5MG TABLETS 31 $141.39 93 $411.87 BYSTOLIC 20MG TABLETS 33 $139.98 99 $412.78 BYSTOLIC 5MG TABLETS 31 $152.17 92 $443.31 CALCIFOL WAFERS 30 $35.39 90 $98.17 CALCIPOTRIEN/BETAMET DIP OINT 100GM 78 $519.00 229 $1,515.45 CALCIPOTRIENE 0.005% CREAM 120GM 83 $533.62 305 $1,953.18 CALCIPOTRIENE 0.005% OINTMENT 120GM 81 $443.89 304 $1,648.12 CALCIPOTRIENE 0.005% SCALP SOLUTION 66 $219.97 229 $752.33 CALCITONIN 200IU/NASAL SPR 30 DOSES 4 $86.81 11 $243.87 CALCITRIOL 1MCG/ML SOL 15ML 21 $283.50 47 $612.66 CALCITRIOL 3MCG/GM OINTMENT 100GM 102 $529.11 323 $1,669.24 CALCIUM 600+D (400U) TABLETS 56 $5.45 158 $8.08 CALCIUM ACETATE 667MG CAPSULES 179 $124.80 479 $327.62 CALCIUM ACETATE 667MG TABLETS 160 $72.64 420 $184.39 CALCIUM CHLORIDE 10% INJ, 10ML 13 $6.50 38 $11.51 CALCIUM GLUC 10% INJ, 100ML 92 $18.66 275 $47.97 CALCIUM-FA PLUS D CHEW WAFERS 68 $41.44 140 $80.97 CAL-NATE TABLETS 30 $8.80 90 $18.40 CAMBIA 50MG POWDER 11 $469.32 39 $1,699.89 CAMILA 0.35MG TABLETS 28S 28 $28.27 84 $76.31 CANASA 1000MG SUPPOSITORIES 30 $1,060.80 92 $3,289.38 CANDESARTAN 16MG TABLETS 32 $110.71 96 $324.48 CANDESARTAN 32MG TABLETS 30 $143.62 89 $423.33 CANDESARTAN 4MG TABLETS 36 $119.22 95 $310.17 CANDESARTAN 8MG TABLETS 34 $128.22 98 $361.50 CANDESARTAN HCT 16-12.5MG TABLETS 31 $115.99 92 $337.73 CANDESARTAN HCT 32/25MG TABLETS 30 $123.23 90 $362.73 CANDESARTAN HCT 32-12.5MG TABLETS 30 $114.90 90 $339.29 CANTIL TABLETS 30 $74.80 90 $216.39 CAPECITABINE 150MG TABLETS 53 $285.14 56 $299.86 CAPECITABINE 500MG TABLETS 85 $2,934.08 264 $9,117.91 CAPEX 0.01% SHAMPOO 120ML 126 $446.34 504 $1,772.18 CAPHOSOL SOLUTION 232 $72.73 1,587 $473.87 CAPITAL W/ CODEINE SUSPENSION 30 $142.25 90 $418.75

Prescription drug coverage and cost are subject to change.

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

CAPSULES SIZE 3 VEGGIE CLEAR 100CT 20 $5.00 228 $15.35 CAPTOPRIL 100MG TABLETS 67 $226.22 184 $613.66 CAPTOPRIL 12.5MG TABLETS 54 $42.45 146 $108.89 CAPTOPRIL 25MG TABLETS 59 $49.84 171 $137.69 CAPTOPRIL 50MG TABLETS 65 $88.85 188 $249.92 CAPTOPRIL/HCTZ 25/15 TABLETS 40 $33.41 132 $101.04 CAPTOPRIL/HCTZ 25/25 TABLETS 37 $27.13 101 $68.17 CAPTOPRIL/HCTZ 50/15 TABLETS 52 $69.57 146 $189.34 CAPTOPRIL/HCTZ 50/25 TABLETS 37 $47.36 114 $136.62 CARAFATE 1GM/10ML SUSPENSION 570 $253.89 2,513 $1,105.08 CARB/LEV/ENTAC 37.5-150-200MG TABS 123 $406.51 343 $1,122.05 CARBAMAZEPINE 100MG ER CAPSULES 89 $156.39 251 $435.72 CARBAMAZEPINE 100MG/5ML SHAKE WELL 789 $128.44 2,374 $378.62 CARBAMAZEPINE 200MG ER CAPSULES 95 $198.04 281 $579.85 CARBAMAZEPINE 200MG TABLETS 91 $77.03 270 $220.22 CARBAMAZEPINE 300MG ER CAPSULES 80 $181.48 233 $523.37 CARBAMAZEPINE ER 100MG TABLETS 88 $93.81 256 $265.54 CARBAMAZEPINE ER 200MG TABLETS 92 $119.88 272 $346.18 CARBAMAZEPINE ER 400MG TABLETS 65 $158.81 196 $469.63 CARBAMAZEPINE POWDER 30 $53.95 90 $153.85 CARBI/LEVO/ENTOCAP 100 TABS 121 $399.86 340 $1,113.12 CARBIDOPA 25MG TABLETS 113 $537.01 314 $1,489.39 CARBIDOPA/LEV/ENTAC 18.75-75-200MG 112 $193.02 338 $574.43 CARBIDOPA/LEV/ENTAC 31.25-125-200MG 121 $568.77 355 $1,659.52 CARBIDOPA/LEV/ENTAC 50-200-200MG 118 $391.05 351 $1,159.10 CARBIDOPA/LEVODOPA 10-100MG DIS TAB 103 $135.84 308 $398.20 CARBIDOPA/LEVODOPA 10-100MG TABS 88 $32.03 250 $83.82 CARBIDOPA/LEVODOPA 25-100MG CR TABS 93 $57.27 259 $151.51 CARBIDOPA/LEVODOPA 25-100MG DIS TAB 130 $128.81 352 $341.84 CARBIDOPA/LEVODOPA 25-100MG TABS 138 $60.70 407 $170.87 CARBIDOPA/LEVODOPA 25-250MG DIS TAB 128 $177.70 325 $445.78 CARBIDOPA/LEVODOPA 25MG-250MG TABS 113 $46.91 327 $128.42 CARBIDOPA/LEVODOPA 50-200MG CR TABS 80 $98.91 209 $250.52 CARBINOXAMIN 4MG/5ML LIQUID 136 $19.55 358 $44.89 CARBINOXAMINE 4MG TABLETS 45 $29.88 151 $90.17 CARBOPLATIN 10MG/ML INJ MDV 5ML 55 $319.30 165 $949.90 CARBOPLATIN 10MG/ML INJ,15ML 68 $394.37 204 $1,175.12 CARBOPLATIN 450/45ML INJ, 45ML 68 $390.96 203 $1,164.88 CARBOPLATIN 600MG/60ML INJ, 60ML 67 $387.65 201 $1,154.96 CARB-PE-GFN SYRUP 30 $6.33 90 $10.98 CARDEC DM DROPS 30ML 30 $46.99 90 $132.97 CARDIOTEK-RX TABLETS 33 $38.49 91 $97.64 CARDIOVID PLUS CAPSULES 10 $7.83 30 $15.50 CARDURA XL 4MG TABLETS 33 $182.61 93 $502.03 CARIMUNE NF 12GM INJ, 1 VIAL 3 $3,806.98 9 $11,412.94 CARIMUNE NF 6GM INJ, 1 VIAL 6 $3,806.98 18 $11,412.94

Prescription drug coverage and cost are subject to change.

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

CARISOPRODOL 250MG TABLETS 47 $140.52 136 $396.17 CARISOPRODOL 350MG TABLETS 70 $31.83 194 $81.65 CARISOPRODOL/ASA/CODEINE TABLETS 86 $192.63 289 $639.16 CARISOPRODOL/ASPIRIN TABLETS 32 $63.63 95 $182.90 CARTEOLOL HCL 1% OPH SOL 10ML 8 $21.38 13 $31.85 CARTIA (DILTIAZEM) 120MGXT CAPS 33 $19.47 99 $50.27 CARVEDILOL ER 10MG CAPSULES 32 $284.59 93 $822.74 CARVEDILOL ER 20MG CAPSULES 31 $282.00 93 $828.01 CARVEDILOL ER 40MG CAPSULES 31 $291.15 92 $855.26 CARVEDILOL ER 80MG CAPSULES 30 $270.21 91 $808.94 CAVERJECT 20MCG VIAL INJ 5 $439.00 11 $1,029.65 CAVERJECT 40MCG INJ VIAL 5 $617.75 16 $1,912.37 CAVERJECT IMPULSE 10MCG KIT (2 SYR) 3 $242.57 8 $623.96 CAVERJECT IMPULSE 20MCG KIT (2 SYR) 3 $202.96 11 $711.04 CAZIANT TABLETS 28 28 $25.93 85 $69.19 CEFACLOR 250MG CAPSULES 29 $38.86 91 $112.80 CEFACLOR 500MG CAPSULES 24 $34.05 113 $144.50 CEFADROXIL 1GM TABLETS 20 $97.18 139 $642.86 CEFADROXIL 250MG/5ML SUSP 100ML 124 $89.78 373 $261.35 CEFADROXIL 500MG CAPSULES 20 $18.14 164 $118.71 CEFADROXIL 500MG/5ML SUSP 100ML 101 $95.15 302 $277.46 CEFAZOLIN 10GM INJ, 1 VIAL 10 $112.00 30 $328.00 CEFAZOLIN 1GM INJ, 1 VIAL 4 $7.94 12 $15.81 CEFAZOLIN 1GM INJ, 1 VIAL 8 $39.70 23 $111.10 CEFAZOLIN 1GM/50ML INJ, 50ML 1 $4.10 3 $4.30 CEFDINIR 125MG/5ML SUSPENSION 100ML 85 $56.78 146 $94.33 CEFDINIR 250MG/5ML SUSPENSION 100ML 76 $97.61 126 $159.64 CEFDINIR 300MG CAPSULES 19 $68.55 110 $381.49 CEFEPIME 1GM INJ, 1 VIAL 15 $275.50 45 $818.50 CEFEPIME 2GM INJ, 1 VIAL 27 $986.93 82 $2,952.78 CEFIXIME 100MG/5ML SUSP 50ML 70 $263.25 350 $1,305.93 CEFIXIME 200MG/5ML SUSP 50ML 64 $497.72 191 $1,485.15 CEFOTAXIME 10GM INJ, 1 VIAL 1 $42.31 3 $118.93 CEFOTAXIME SOD 2GM INJ, 1 VIAL 1 $13.50 3 $32.50 CEFOTETAN 1GM/10ML INJ, 1VIAL 7 $164.93 21 $486.79 CEFOXITIN 10GM INJ , 1VIAL 1 $54.51 3 $155.53 CEFOXITIN 1GM INJ, 1 VIAL 1 $9.05 3 $19.15 CEFOXITIN 2GM INJ, 1 VIAL 6 $59.72 17 $171.15 CEFPODOXIM PROX 100MG/5ML SUS 100ML 142 $183.90 425 $543.71 CEFPODOXIME 200MG TABLETS 17 $118.99 130 $861.56 CEFPODOXIME PRO 100MG TABLETS 15 $66.25 111 $471.89 CEFPODOXIME PROX 50MG/5ML SUSP 50ML 30 $16.30 90 $40.89 CEFPROZIL 250MG/5ML SUSP 100ML 110 $35.90 330 $99.69 CEFTIBUTEN 180MG/5ML ORAL SUSP 60ML 30 $242.00 90 $717.99 CEFTIN 125MG/5ML 100ML -NEW-REFRIG 139 $225.85 416 $669.56 CEFTIN 250MG/5ML 100ML -NEW-REFRIG 128 $351.01 383 $1,045.02

Prescription drug coverage and cost are subject to change.

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

CEFTRIAXONE 10GM INJ, 1 VIAL 2 $22.42 6 $59.26 CEFTRIAXONE 1GM INJ, 1 VIAL 3 $44.19 4 $56.47 CEFTRIAXONE 250MG INJ, 1 VIAL 1 $11.76 4 $27.28 CEFTRIAXONE 2GM INJ 9 $387.92 90 $3,783.10 CEFTRIAXONE/ DEX 2GM INJ, 50ML 1 $4.36 3 $5.09 CEFTRIAXONE/DEX 1GM INJ, 50ML 1 $4.15 3 $4.46 CEFUROXIME 1.5GM INJ , 1VIAL 1 $10.05 3 $22.15 CEFUROXIME 250MG TABLETS 20 $39.21 109 $199.54 CEFUROXIME 500MG TABLETS 19 $65.57 127 $423.15 CEFUROXIME 750MG INJ 1 $7.04 3 $13.12 CELECOXIB 100MG CAPSULES 49 $207.67 146 $605.25 CELECOXIB 200MG CAPSULES 39 $260.42 113 $759.08 CELECOXIB 50MG CAPSULES 51 $99.42 158 $298.61 CELONTIN 300MG CAPSULES 79 $343.63 230 $989.36 CEPHALEXIN 125MG/5ML SUSP 100ML 183 $24.09 417 $49.83 CEPHALEXIN 250MG TABLETS 27 $72.36 68 $176.00 CEPHALEXIN 250MG/5ML SUSP 100ML 195 $37.12 425 $76.27 CEPHALEXIN 500MG TABLETS 24 $67.65 115 $314.32 CEPHALEXIN 750MG CAPSULES 21 $77.87 172 $598.59 CERACADE EXTERNAL EMULSION 270GM 169 $226.62 411 $547.18 CEREZYME 200U VIAL FOR INJECTION 1 $902.13 3 $2,698.39 CEREZYME 400U INJ, 1VL 1 $1,743.99 3 $5,223.97 CEROVEL 40% GEL 25ML 30 $119.92 90 $351.76 CEROVEL 40% LOTION 325ML 229 $13.70 428 $22.12 CERVARIX INJ, 0.5ML 1 $375.98 3 $1,119.94 CETROTIDE 0.25MG VIAL FOR INJ KIT 3 $780.32 9 $2,332.95 CEVIMELINE 30MG CAPSULES 85 $169.43 250 $493.47 CHANTIX 0.5MG TABLETS 47 $481.84 159 $1,618.21 CHANTIX 1MG CONT 2 PACK (2X28) 57 $487.23 166 $1,414.02 CHANTIX STARTING MONTH PAK 53'S 53 $486.97 60 $552.74 CHEMSTRIP 2 LN TEST STRIPS 100'S 51 $25.20 152 $67.61 CHENODAL 250MG TABLETS 30 $15,618.68 90 $46,848.03 CHERATUSSIN AC SYRUP 163 $26.66 268 $41.20 CHERATUSSIN DAC SYRUP 183 $32.43 500 $81.75 CHLORAMPHEN 1GM INJ, 1VIAL 1 $51.99 3 $147.97 CHLORDIAZEPOX 10MG/AMITRIP 25MG TAB 44 $61.73 115 $154.59 CHLORDIAZEPOX 5MG/AMITRP 12.5MG TAB 49 $55.75 118 $129.03 CHLORDIAZEPOXIDE/CLIDINIUM CAPS 65 $226.26 191 $660.12 CHLOROBUTAN ANHYDROU POWDER 25GM 30 $29.19 90 $79.56 CHLOROBUTAN HEMIHYDR POW NF 25ML 30 $27.99 90 $75.96 CHLOROQUINE 250MG TABLETS 21 $49.52 68 $154.19 CHLOROQUINE PHOSPHATE 500MG TABLETS 7 $89.77 23 $277.80 CHLOROTHIAZIDE 250MG TABLETS 35 $17.48 98 $41.20 CHLOROTHIAZIDE 500MG TABLETS 39 $32.70 97 $76.11 CHLORPHENIR MALEATE POWDER 25GM 30 $38.79 90 $108.36 CHLORPHENIRAMINE/PSE 8-120 CR CAPS 30 $35.59 90 $98.77

Prescription drug coverage and cost are subject to change.

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

CHLORPROMAZINE 100MG TABLETS 62 $560.01 192 $1,714.96 CHLORPROMAZINE 10MG TABLETS 57 $188.81 223 $726.59 CHLORPROMAZINE 200MG TABLETS 57 $703.93 177 $2,185.12 CHLORPROMAZINE 25MG TABLETS 52 $189.76 198 $719.36 CHLORPROMAZINE 25MG/ML AMPULES 1ML 11 $158.26 34 $466.79 CHLORPROMAZINE 25MG/ML AMPULES 2ML 8 $117.54 23 $344.63 CHLORPROMAZINE 50MG TABLETS 60 $334.25 180 $988.51 CHLORPROMAZINE HCL USP POW 30 $32.80 90 $90.39 CHLORPROPAMIDE 100MG TABLETS 63 $58.61 182 $161.96 CHLORPROPAMIDE 250MG TABLETS 44 $85.43 118 $223.81 CHLORTHALIDONE 100MG TABLETS 30 $17.67 90 $45.00 CHLORTHALIDONE 25MG TABLETS 29 $20.36 83 $51.26 CHLORTHALIDONE 50MG TABLETS 31 $20.53 92 $52.90 CHLORZOXAZONE 500MG TABLETS 64 $19.61 225 $58.88 CHO MAG TRIS 500/5ML LIQUID 30 $9.50 90 $20.49 CHOLESTYRAMINE 4G PWD (CAN) 378GM 416 $65.59 924 $140.82 CHOLESTYRAMINE 4GM LGHT POW PK 60S 51 $79.53 142 $214.22 CHOLESTYRAMINE 4GM PACKETS 60'S 51 $107.51 139 $285.23 CHOLESTYRAMINE LIGHT POWDER (CAN) 279 $78.55 772 $210.38 CHOLESTYRAMINE RESIN POWDER 100 $303.99 300 $903.97 CHOLINE/MAG TRISALICYLATE 1000MG TB 30 $10.60 90 $23.79 CHORIONIC GONADOTROPIN 10,000 U/VL 1 $370.83 2 $602.74 CHROMIUM CL 4MCG/ML INJ, 10ML 1 $5.06 3 $7.17 CIALIS 10MG TABLETS 6 $468.66 26 $1,888.91 CIALIS 2.5MG BLISTER PAK TABLETS 25 $303.12 88 $1,050.78 CIALIS 20MG TABLETS 6 $432.09 20 $1,433.93 CIALIS 5MG BLISTER PAK TABLETS 22 $264.00 87 $1,027.60 CICLODAN 8% NAIL KIT SOL/FRESHENER 35 $392.53 105 $1,169.59 CICLOPIROX 0.77% CREAM 15GM 56 $78.56 156 $211.59 CICLOPIROX 0.77% GEL 100GM 51 $102.09 131 $257.78 CICLOPIROX 1% SHAMPOO 120ML 124 $139.50 326 $359.86 CICLOPIROX 8% NAIL LACQUER TOP SOLN 7 $44.37 18 $113.50 CICLOPIROX 8% TOPICAL SOL KIT 30 $4,623.70 90 $13,863.10 CICLOPIROX TOPICAL SUSPENSION 30ML 52 $87.37 121 $196.83 CICLOPIROXOLAMINE POWDER 30 $254.79 90 $756.36 CILOSTAZOL 100MG TABLETS 58 $17.60 170 $43.53 CILOSTAZOL 50MG TABLETS 59 $17.71 170 $43.67 CILOXAN 0.3% OPHTH OINT (EYE) 3.5GM 4 $237.92 11 $671.62 CIMETIDINE 200MG TABLETS 68 $24.31 233 $73.99 CIMETIDINE 300MG TABLETS 52 $25.91 162 $71.98 CIMETIDINE 400MG TABLETS 45 $50.10 152 $160.94 CIMETIDINE 800MG TABLETS 43 $28.66 124 $74.63 CIMZIA 200MG/ML INJ KIT (2 VIALS) 1 $4,212.73 3 $12,630.18 CIMZIA 200MG/ML PRF SYR KIT (2 SYR) 1 $4,147.30 3 $12,099.62 CIPRODEX OTIC SUSPENSION (EAR) 8 $282.52 14 $507.76 CIPROFLOX 0.3% OPHTH SOLN 5ML-EYE 5 $43.92 8 $64.49

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CIPROFLOXACIN 0.2% OTIC SOL (EAR) 15 $108.19 44 $316.56 CIPROFLOXACIN 10GM/100ML SUSP 117 $153.06 352 $451.19 CIPROFLOXACIN 400MG INJ , 40ML 1 $4.08 3 $4.24 CIPROFLOXACIN ER 1000MG TABLETS 9 $92.44 90 $860.78 CIPROFLOXACIN ER 500MG TABLETS 9 $87.55 26 $254.65 CIPROFLOXACN 250MG/5ML SUSP 131 $144.13 500 $538.95 CIPRO-HC OTIC SUSPENSION 10ML (EAR) 10 $323.56 11 $351.64 CISPLATIN AQ INJ, 100ML 260 $118.87 780 $348.62 CISPLATIN AQ INJ, 50ML 293 $133.39 879 $392.17 CITALOPRAM 10MG/5ML SOLUTION 243 $91.09 694 $252.51 CITRANATAL ASSURE PAK 60 $124.08 179 $360.94 CITRANATAL HARMONY CAPSULES 30 $124.29 90 $364.59 CITRIC ACID (ANHYDROUS)POWDER 500GM 1,000 $40.00 3,000 $112.00 CITRIC ACID SODIUM CITRATE SOLUTION 892 $71.85 2,676 $207.63 CLADRIBINE 1MG/ML INJ , 10ML 30 $1,551.97 90 $4,647.91 CLARAVIS 30MG CAPSULES 55 $591.28 135 $1,452.96 CLARINEX 2.5MG/5ML SYRUP 95 $106.07 758 $822.20 CLARINEX-D 12 HOUR TABLETS 44 $318.40 173 $1,243.75 CLARITHROMYCIN 125MG/5ML SUSP 100ML 118 $52.31 354 $148.92 CLARITHROMYCIN 250MG TABLETS 24 $132.89 105 $559.69 CLARITHROMYCIN 250MG/5ML SUSP 100ML 121 $118.96 363 $348.87 CLARITHROMYCIN 500MG ER TABLETS 21 $78.05 120 $431.35 CLARITHROMYCIN 500MG TABLETS 23 $77.31 134 $427.07 CLEMASTINE 2.68MG TABLETS 52 $27.26 132 $63.59 CLEOCIN 100MG VAGINAL OVULE 3'S 4 $206.94 10 $553.41 CLIMARA PRO 0.045MG/DAY PATCHES 4'S 4 $189.40 12 $543.32 CLINDACIN ETZ 1% PLEDGETS 60'S 62 $517.88 180 $1,505.41 CLINDACIN PAC 1% KIT 1 $524.78 3 $1,566.34 CLINDAMAX 1% GEL 30GM 46 $94.61 146 $291.87 CLINDAMYC/BENZ PER 1/5%GEL PMP 50GM 44 $439.15 131 $1,298.74 CLINDAMYCIN 1% FOAM 100GM 81 $482.03 209 $1,240.19 CLINDAMYCIN 1% LOTION 60ML 62 $93.19 194 $281.27 CLINDAMYCIN 1% TOPICAL SOLN 30ML 55 $64.18 184 $206.00 CLINDAMYCIN 2% VAGINAL CREAM 40GM 41 $82.41 123 $237.40 CLINDAMYCIN 900MG INJ, 50ML 1 $4.24 3 $4.72 CLINDAMYCIN 900MG INJ, 6ML 17 $11.42 50 $26.26 CLINDAMYCIN PED 75MG/5ML 100ML 298 $156.01 400 $207.96 CLINDAMYCIN PHOSP CRY POWDER 5GM 30 $279.94 90 $831.82 CLINDAMYCIN/BPO 1.2-5% GEL 45GM 45 $122.55 132 $347.37 CLINIMIX E 4.25/D25 INJ, 2000ML 1 $4.15 3 $4.46 CLINPRO 5000 1.1% PASTE 113GM 102 $12.83 237 $24.42 CLIOQUINOL/HYDROCORT CREAM 20GM 30 $14.05 90 $34.15 CLOBAZAM 10MG TABLETS 69 $855.05 185 $2,302.89 CLOBAZAM 20MG TABLETS 61 $1,412.93 177 $4,082.84 CLOBETASOL 0.05% EMOLLIENT CRM 15GM 43 $120.23 150 $414.45 CLOBETASOL 0.05% EMOLLNT FOAM 100GM 83 $428.08 250 $1,278.95

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CLOBETASOL 0.05% FOAM 100GM 81 $365.37 252 $1,123.48 CLOBETASOL 0.05% SHAMPOO 118ML 123 $184.84 447 $660.36 CLOBETASOL 0.05% SOLUTION 25ML 50 $87.59 174 $296.55 CLOBETASOL 0.05% SPRAY 125ML 92 $542.78 338 $1,990.43 CLOBETASOL PROP 0.05% CREAM 15GM 44 $111.73 154 $383.33 CLOBETASOL PROP 0.05% GEL 15GM 41 $279.74 146 $993.30 CLOBETASOL PROP 0.05% LOTION 118ML 85 $175.00 391 $791.18 CLOBETASOL PROP 0.05% OINT 30GM 46 $140.15 137 $410.48 CLOBETASOL PROPIONATE POWDER 1 $67.69 2 $195.08 CLOCORTOLONE PIV 0.1% CRM 75GM PUMP 63 $411.77 124 $809.36 CLOMIPRAMINE 25MG CAPSULES 49 $344.51 140 $977.73 CLOMIPRAMINE 50MG CAPSULES 66 $411.53 190 $1,173.70 CLOMIPRAMINE 75MG CAPSULES 54 $316.29 160 $922.77 CLONAZEPAM 0.5MG TABLETS 50 $23.31 139 $57.18 CLONAZEPAM 1MG TABLETS 56 $21.82 142 $48.87 CLONAZEPAM 2MG TABLETS 55 $25.16 134 $55.18 CLONAZEPAM ODT 0.125MG TABLETS 55 $62.17 141 $151.78 CLONAZEPAM ODT 0.25MG TABLETS 47 $57.42 143 $166.48 CLONAZEPAM ODT 0.5MG TABLETS 48 $52.53 143 $149.54 CLONAZEPAM ODT 1MG TABLETS 46 $62.36 147 $190.47 CLONAZEPAM ODT 2MG TABLETS 39 $74.49 143 $259.80 CLONIDINE 0.1MG EXTENDED RELEASE TB 66 $265.77 199 $797.28 CLONIDINE 0.1MG/24H WEEKLY PATCH 30 $1,023.93 90 $3,063.78 CLONIDINE 0.2MG/24H WEEKLY PATCHES 30 $1,376.43 90 $4,121.28 CLONIDINE 0.3MG/24H WEEKLY PATCH 30 $1,563.93 90 $4,683.78 CLONIDINE HCL POWDER 30 $1,416.97 90 $4,242.91 CLOPIDOGREL 300MG TABLETS 5 $108.96 38 $861.52 CLOPIDOGREL 75MG TABLETS 30 $64.99 90 $186.35 CLORAZEPATE 15MG TABLETS 49 $106.86 142 $302.23 CLORAZEPATE 3.75MG TABLETS 57 $55.75 158 $148.57 CLORAZEPATE 7.5MG TABLETS 53 $72.18 150 $195.71 CLOTRIMAZOLE 1% CREAM 15GM 35 $25.21 135 $84.76 CLOTRIMAZOLE 1% SOLUTION 32 $68.86 71 $148.26 CLOTRIMAZOLE 10MG LOZENGE 55 $82.76 238 $346.86 CLOTRIMAZOLE POWDER 63 $252.29 189 $748.86 CLOTRIMAZOLE-BETAMETHASONE CRM 15GM 34 $58.88 135 $219.80 CLOTRIMAZOLE-BETAMETHASONE LOT 30ML 35 $128.29 151 $542.05 CLOZAPINE 100MG ODT TABLETS 83 $309.46 180 $666.17 CLOZAPINE 100MG TABLETS 78 $196.89 179 $444.56 CLOZAPINE 200MG TABLETS 46 $275.55 87 $516.98 CLOZAPINE 25MG ODT TABLETS 71 $120.78 213 $354.34 CLOZAPINE 50MG TABLETS 41 $34.12 122 $94.39 COAL TAR 161 $13.56 484 $32.67 COAL TAR 20% SOLUTION 392 $27.19 402 $27.82 COARTEM 20-120MG TABLETS 36 $207.99 146 $824.94 CODAL-DM SYRUP 30 $4.51 90 $5.54

Prescription drug coverage and cost are subject to change.

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

CODEINE SULF 30MG TABLETS 81 $56.81 254 $168.98 CODEINE SULFATE 15MG TABLETS 47 $25.50 113 $55.74 CODEINE SULFATE 60MG TABLETS 99 $76.47 204 $152.73 CODEINE/GUAI 10-300MG LIQUID 30 $12.33 90 $29.00 COLCHICINE 0.6MG CAPSULES 30 $173.00 108 $603.32 COLCHICINE 0.6MG TABLETS 29 $156.22 107 $559.66 COLDMIST JR 12HR 45MG/600MG TABS 30 $18.99 90 $48.97 COLESEVELAM 625MG TABLETS 132 $310.57 382 $887.90 COLESTID 7.5GM FLAVORED PACKS 60'S 48 $356.43 139 $1,036.05 COLESTIPOL 1GM TABLETS 80 $64.45 226 $175.64 COLESTIPOL HCL 5GM GRANULES 501 $206.59 681 $278.94 COLISTIMETH 150MG INJ, 1VL 1 $33.87 3 $93.60 COLYTE FLAVOR PACKS SOLN 3,785 $56.99 11,355 $162.97 COMBIGAN 0.2/0.5% OPTH SOLN 5ML 7 $202.94 14 $419.69 COMBIPATCH .05MG/.14MG/DAY PATCHES 8 $180.59 24 $513.69 COMBIVENT RESPIMAT ORAL 120SPRAY 4G 4 $404.26 12 $1,131.35 COMP AIR COMPRESSOR NEBULIZER 1 $60.73 1 $61.48 COMPLETENATE CHEWABLE TABLETS 30 $23.87 92 $64.52 COMPRO (PROCHLOPERAZINE) 25MG SUPP 14 $147.47 106 $1,065.62 CONCEPTION KIT 1 $353.93 1 $353.93 CONDYLOX 0.5% GEL 3.5GM 4 $599.64 11 $1,632.97 CONISON CAPSULES 44 $19.72 118 $46.41 CONTOUR METER 1 $4.00 1 $4.00 CONTOUR NEXT ONE METER 1 $4.00 3 $4.00 CONTRAVE 8-90MG ER TABLETS 100 $201.74 292 $580.19 COPPER SULF 0.4MG/ML INJ, 10ML 1 $4.40 3 $5.20 CORDRAN 24X3 4MCG/CM TAPE 1 $675.94 2 $1,195.98 CORDRON NR LIQUID 30 $7.00 90 $12.99 CORTIC-ND OTIC DROPS 15ML(EAR) 30 $184.88 90 $546.64 CORTIFOAM RECTAL FOAM 15GM 20 $511.16 113 $2,813.35 CORTISONE ACETATE 25MG TABLETS 48 $141.85 142 $409.57 CORTISPORIN TOPICAL CREAM7.5GM 10 $166.98 31 $492.95 CORTISPORIN TOPICAL OINTMENT 15GM 17 $189.07 52 $559.20 CORVITA 150 TABLETS 30 $34.59 94 $99.39 CORVITE FE TABLETS 34 $123.73 93 $335.55 CORVITE TABLETS 32 $28.21 91 $73.08 COSYNTROPIN 0.25MG INJ, 1ML 1 $113.95 3 $333.85 COUMADIN 10MG (TEN MG) TABS (WHITE) 32 $108.46 90 $298.79 COUMADIN 1MG TABLETS (PINK) 55 $120.07 136 $288.84 COUMADIN 2.5MG TABLETS (GREEN) 47 $109.42 116 $267.42 COUMADIN 2MG TABLETS (PURPLE) 52 $119.43 131 $292.67 COUMADIN 3MG TABLETS (TAN) 38 $89.04 100 $231.59 COUMADIN 4MG TABLETS (BLUE) 38 $90.28 101 $235.53 COUMADIN 5MG TABLET (PEACH) 41 $102.70 105 $255.63 COUMADIN 6MG TABLETS (BLUE/GREEN) 32 $102.66 92 $285.30 COUMADIN 7.5MG TABLETS (YELLOW) 31 $101.55 87 $277.98

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CP DEC-DM SYRUP 30 $4.83 90 $6.50 CPM 8/PE 20/MSC 1.25 TABLETS 30 $30.47 90 $83.41 CRANTEX ER CAPSULES 30 $25.99 90 $69.97 CREON 12,000 CAPSULES 230 $696.65 454 $1,373.36 CREON 24,000U CAPSULES 250 $1,495.30 519 $3,103.40 CREON 6,000 CAPSULES 240 $365.45 401 $609.15 CRINONE 4% (45MG)VAG GEL 6 X1.125GM 16 $249.65 38 $583.49 CRINONE 8% (90MG)VAG GEL 15X1.125GM 26 $586.80 74 $1,647.09 CRIXIVAN 200MG CAPSULES 30 $45.89 90 $129.66 CRIXIVAN 400MG CAPSULES 155 $452.52 540 $1,563.57 CROMOLYN SOD 100/5ML ORAL CONC 5ML 896 $540.10 2,739 $1,641.92 CROMOLYN SOD 20/2ML INH SOLN 60X2ML 154 $154.62 543 $533.15 CROMOLYN SODIUM 4% OPHTH SOLN 10ML 10 $18.33 19 $30.26 CRYSELLE TABLETS 28 29 $27.84 85 $74.15 CUPRIC CHLORIDE 0.4MG/ML INJ, 10ML 30 $86.68 90 $252.04 CUPRIMINE 250MG CAPSULES 95 $27,478.65 183 $52,714.71 CYANOCOBALAMIN 1000MCG INJ 1ML VIAL 2 $33.22 5 $61.77 CYCLAFEM 1/35 TABLETS 28S 29 $28.12 86 $74.81 CYCLOBENZAPRINE 7.5MG TABLETS 37 $167.45 160 $719.71 CYCLOMYDRIL OPHTH SOLUTION 2ML 4 $39.62 7 $68.19 CYCLOPENTOLATE 0.5% OPHTH SOLN 15ML 15 $71.99 15 $71.99 CYCLOPENTOLATE 1% OPHTH SOL 15ML 5 $8.79 15 $17.81 CYCLOPHOSPHA 1GM INJ, 1 VIAL 2 $1,501.20 3 $2,313.97 CYCLOPHOSPHAMIDE 25MG CAPSULES 52 $486.03 142 $1,327.64 CYCLOPHOSPHAMIDE 25MG TABLETS 30 $78.00 90 $225.99 CYCLOPHOSPHAMIDE 2GM VIAL FOR INJ 1 $1,677.56 3 $5,024.68 CYCLOPHOSPHAMIDE 500MG INJ 1 VIAL 3 $1,240.92 10 $3,714.76 CYCLOPHOSPHAMIDE 50MG CAPSULES 43 $743.42 135 $2,299.29 CYCLOPHOSPHAMIDE 50MG TABLETS 30 $73.03 90 $211.08 CYCLOSET 0.8MG TABLETS 106 $429.05 330 $1,322.28 CYCLOSPORINE 100MG (MOD) CAPS 58 $169.45 162 $462.50 CYCLOSPORINE 100MG CAPSULES 61 $542.02 173 $1,527.11 CYCLOSPORINE 100MG/ML MOD ORAL SOLN 65 $324.31 195 $964.93 CYCLOSPORINE 25MG (MOD) CAPS 129 $167.33 374 $477.93 CYCLOSPORINE 25MG CAPSULES 122 $316.10 337 $869.56 CYCLOSPORINE 50MG (MOD) CAPS 63 $152.94 174 $416.89 CYCLOSPORINE 50MG/ML INJ, 5ML 50 $343.90 150 $1,023.70 CYPEX LA TABLETS 30 $26.49 90 $71.46 CYPROHEPTADINE 4MG TABLETS 50 $32.34 147 $87.42 CYSTEINE HCL 50MG/ML INJ, 10ML 1 $4.38 3 $5.15 CYTARABIN 100MG/ML INJ, 20ML 143 $148.50 429 $437.50 CYTARABINE 100MG INJECTION 1 $6.16 3 $10.48 CYTARABINE 20MG/ML INJ ,5ML 30 $24.41 91 $65.22 CYTARABINE 500MG INJECTION 1 $8.59 3 $17.77 CYTRA K CRYSTALS POWDER PACKETS 58 $60.02 161 $158.75 CYTRA-3 SYRUP 775 $105.58 2,477 $328.69

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price CYTRA-K ORAL SOLUTION 712 $85.57 1,432 $168.10 D5W/NACL 0.45% INJ, 1000ML 8,600 $55.60 25,800 $158.80 D5W/NACL 0.9% INJ , 500ML 28,000 $116.00 84,000 $340.00 DACARBAZINE 100MG INJ, 1VIAL 1 $15.23 3 $37.70 DACARBAZINE 200MG INJ, 1VIAL 8 $221.43 23 $656.28 DALFAMPRIDINE 10MG ER TABLETS 59 $2,588.09 177 $7,701.63 DALIRESP 500MCG TABLETS 30 $285.25 90 $853.61 DALLERGY DROPS 30ML 30 $21.06 90 $55.18 D-AMPHETAMINE ER 20MG SALT COMBO CP 36 $61.86 110 $179.19 D-AMPHETAMINE SALT COMBO7.5MG TAB 45 $46.58 146 $142.64 D-AMPHETAMINE SALT COM ER(XR)10MG C 32 $150.95 102 $464.32 D-AMPHETAMINE SALT COM ER(XR)15MG C 32 $150.64 96 $449.15 D-AMPHETAMINE SALT COM ER(XR)25MG C 33 $177.76 100 $524.38 D-AMPHETAMINE SALT COM ER(XR)30MG C 34 $182.63 103 $537.49 D-AMPHETAMINE SALT COM ER(XR)5MG C 32 $165.03 100 $506.95 D-AMPHETAMINE SALT COMBO 10MG TAB 52 $69.34 141 $182.01 D-AMPHETAMINE SALT COMBO 15MG TABS 53 $75.54 142 $196.15 D-AMPHETAMINE SALT COMBO 5MG TABS 43 $74.45 124 $207.87 D-AMPHETAMINE SALT COMBO 20MG TABS 60 $78.87 163 $208.02 D-AMPHETAMINE SALT COMBO12.5MG TB 57 $63.28 185 $195.19 DANAZOL 100MG CAPSULES 62 $303.64 141 $688.82 DANAZOL 200MG CAPSULES 62 $572.07 156 $1,442.65 DANAZOL 50MG CAPSULES 50 $164.49 136 $443.92 DANTROLENE 100MG CAPSULES 88 $176.79 268 $528.99 DANTROLENE 25MG CAPSULES 110 $104.82 272 $252.42 DANTROLENE 50MG CAPSULES 96 $126.75 271 $351.36 DAPSONE 100MG TABLETS 30 $74.89 86 $208.77 DAPSONE 25MG TABLETS 63 $127.71 176 $350.07 DAPSONE 5% GEL 60GM 67 $609.54 145 $1,305.57 DAPTACEL INJ, 0.5ML 1 $45.55 1 $48.56 DARIFENACIN ER 15MG TABLETS 30 $421.89 91 $1,257.33 DARIFENACIN ER 7.5MG TABLETS 32 $438.18 93 $1,277.46 DAYTRANA 10MG TRANSDERMAL PATCHES 30 $345.42 90 $1,029.97 DAYTRANA 15MG TRANSDERMAL PATCHES 30 $361.09 102 $1,205.62 DAYTRANA 20MG TRANSDERMALPATCHES 31 $371.08 97 $1,139.67 DAYTRANA 30MG TRANSDERMAL PATCHES 31 $362.66 103 $1,208.89 DEBACTEROL 0.2ML SWAB KIT 7 $41.79 10 $54.98 DE-CHLOR DR SYRUP 30 $5.11 90 $7.33 DEFEROXAMIN 2GM INJ, 1VIAL 13 $875.07 40 $2,617.20 DEFEROXAMINE 500MG INJ 8 $147.92 24 $435.76 DEMECLOCYCLINE 150MG TABLETS 58 $412.40 147 $1,034.52 DEMSER 250MG CAPSULES 98 $36,714.43 270 $101,377.71 DENAVIR 1% CREAM 1.5GM 5 $394.53 21 $1,556.93 DEPEN TITRA 250MG TAB 70 $4,654.23 270 $18,004.87 DEPO-ESTRADIOL 5MG/ML 5ML 5 $125.82 5 $129.76 DEPO-PROVERA *104MG* SUBQ SYRINGE 1 $266.13 2 $790.40

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DESIPRAMINE 100MG** TABLETS 43 $141.43 129 $421.62 DESIPRAMINE 150MG TABLETS 34 $137.46 103 $406.07 DESIPRAMINE 25MG TABLETS 51 $44.83 142 $117.42 DESIPRAMINE 50MG TABLETS 55 $117.83 162 $337.86 DESIPRAMINE 75MG TABLETS 38 $143.45 103 $381.42 DESLORATADINE 5MG TABLET 29 $83.73 91 $252.43 DESLORATADINE ODT 2.5MG TABLETS 30 $159.06 89 $466.23 DESLORATADINE ODT 5MG TABLETS 30 $163.63 91 $491.35 DESMOPRESSIN 0.01% RHINAL TUBE SOL 6 $371.05 28 $1,770.14 DESMOPRESSIN 0.01%(0.1ML/NASAL SPR) 8 $283.98 31 $1,048.24 DESMOPRESSIN 0.01%(0.1ML/NASAL SPR) 8 $276.97 31 $1,038.60 DESMOPRESSIN 0.1MG TABLETS 61 $188.90 173 $527.58 DESMOPRESSIN 0.2MG TABLETS 64 $284.30 185 $813.89 DESMOPRESSIN 4MCG/ML INJ SINGLE USE 22 $1,341.25 53 $3,179.94 DESONIDE 0.05% CREAM 15GM 38 $190.02 128 $635.98 DESONIDE 0.05% LOTION 118ML 85 $315.49 269 $991.88 DESONIDE 0.05% OINTMENT 15GM 38 $121.89 139 $434.60 DESOXIMETASONE 0.05% CREAM 100GM 63 $277.19 226 $979.44 DESOXIMETASONE 0.05% GEL 15GM 44 $185.60 165 $685.90 DESOXIMETASONE 0.05% OINTMENT 100GM 70 $362.24 167 $855.65 DESOXIMETASONE 0.25% CREAM 100GM 49 $80.57 212 $335.66 DESOXIMETASONE 0.25% OINTMENT 100GM 57 $258.28 212 $942.57 DESPEC LIQUID 154 $28.35 462 $77.05 DESVENLAFAXINE ER 100MG TABLETS 30 $162.04 91 $479.10 DESVENLAFAXINE ER 50MG TABLETS 30 $82.92 90 $238.59 DESVENLAFAXINE FUMARATE ER 100MG TB 30 $164.99 90 $486.97 DESVENLAFAXINE FUMARATE ER 50MG TAB 30 $82.36 90 $239.08 DEXAMETH PHO 4MG/ML INJ 7 $10.43 13 $16.53 DEXAMETHASONE 0.1% OPHTH SOLN 5ML 6 $66.29 8 $88.01 DEXAMETHASONE 0.5MG/5ML ELIXIR 211 $47.59 578 $123.53 DEXAMETHASONE 0.5MG/5ML ORAL SOLN 285 $64.58 885 $192.03 DEXAMETHASONE 2MG TABLETS 23 $16.66 94 $56.71 DEXAMETHASONE 6MG TABLETS 7 $13.53 57 $87.14 DEXAMETHASONE INTENSOL 1MG/ML SOLN 38 $31.91 103 $79.39 DEXAMETHASONE PHO 4MG/ML INJECTION 33 $35.98 39 $41.41 DEXAMETHASONE PHO 4MG/MLINJ , 5ML 17 $20.89 48 $50.66 DEXAMETHASONE SOD PHOS 10MG/ML INJ 4 $12.26 20 $50.86 DEXCHLORPHENIRAMINE 2MG/5ML SYRUP 30 $8.82 90 $18.46 DEXCON-DM SYRUP 30 $5.65 90 $8.96 DEXILANT 30MG CAP(FORMERLY KAPIDEX) 32 $284.55 93 $828.99 DEXILANT 60MG CAP(FORMERLY KAPIDEX) 31 $277.01 92 $815.91 DEXMETHYLPHENIDATE 10MG TABLETS 52 $57.65 136 $145.80 DEXMETHYLPHENIDATE 15MG ER CAPSULES 31 $174.61 93 $523.13 DEXMETHYLPHENIDATE 2.5MG TABLETS 44 $22.22 121 $54.26 DEXMETHYLPHENIDATE 25MG ER CAPSULES 31 $328.61 98 $1,033.22 DEXMETHYLPHENIDATE 30MG ER CAPSULES 31 $188.55 92 $552.90

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DEXMETHYLPHENIDATE 35MG ER CAPSULES 30 $337.84 97 $1,074.02 DEXMETHYLPHENIDATE 40MG ER CAPS 31 $116.95 94 $351.30 DEXMETHYLPHENIDATE 5MG TABLETS 43 $34.82 130 $96.56 DEXMETHYLPHENIDATE ER 10MG CAPSULES 31 $237.77 97 $735.43 DEXMETHYLPHENIDATE ER 20MG CAPSULES 31 $251.10 96 $757.61 DEXMETHYLPHENIDATE ER 5MG CAPSULES 31 $302.23 104 $994.88 DEXPANTHENOL 250MG/ML INJ , 2ML 1 $4.88 3 $6.64 DEXRAZOXANE 250MG INJ, 1 VIAL 1 $114.83 3 $336.49 DEXRAZOXANE 500MG INJ, 1 VIAL 1 $599.99 3 $1,791.97 DEXTROAMPHETAMINE 10MG ER CAPSULES 65 $240.11 164 $603.48 DEXTROAMPHETAMINE 10MG TABLETS 82 $208.77 201 $509.30 DEXTROAMPHETAMINE 15MG ER CAPSULES 64 $461.03 164 $1,184.02 DEXTROAMPHETAMINE 5MG ER CAPSULES 46 $241.02 150 $772.31 DEXTROAMPHETAMINE 5MG TABLETS 57 $105.47 188 $335.82 DEXTROSE 10% INJ, 1000ML 1 $4.00 3 $4.01 DEXTROSE 5% INJ , 100ML 4,800 $61.12 14,400 $175.36 DEXTROSE 5%/NACL 0.2% 1000ML 30 $4.08 90 $4.23 DEXTROSE 50% INJ , 50ML 54 $10.28 163 $22.85 DEXTROSE 70% INJ , 2000ML 1 $4.00 3 $4.01 DIALYVITE 3000 TABLETS 30 $14.79 90 $36.04 DIALYVITE SUPREM D TABLETS 32 $14.60 89 $33.62 DIALYVITE TABLETS 30 $8.45 91 $17.30 DIALYVITE WITH ZINC TABLETS 31 $9.51 92 $20.48 DIAZEPAM 10MG RECTAL GEL (2 PACK) 1 $482.06 12 $4,512.73 DIAZEPAM 10MG TABLETS 43 $16.29 145 $45.17 DIAZEPAM 2.5MG RECTAL GEL (2 PACK) 1 $416.74 3 $914.74 DIAZEPAM 20MG RECTAL GEL 1 $575.63 4 $1,547.96 DIAZEPAM 2MG TABLETS 40 $10.67 148 $28.59 DIAZEPAM 5MG TABLETS 36 $11.37 136 $31.97 DIAZEPAM 5MG/1ML ORAL CONCENTRATE 51 $75.14 103 $148.23 DIAZEPAM 5MG/5ML (1MG/1ML) ORAL SOL 173 $55.99 724 $221.24 DIAZEPAM 5MG/ML INJ, 10ML 39 $142.56 118 $419.68 DIBUCAINE 1% OINTMENT 28GM 36 $8.54 47 $9.99 DICLEGIS 10-10MG TABLETS 70 $529.53 146 $1,103.39 DICLOFENAC 1% GEL 100GM 155 $75.36 562 $262.46 DICLOFENAC 1.5% TOPICAL SOL 150ML 170 $256.19 492 $735.20 DICLOFENAC 3% GEL 100GM 112 $708.98 290 $1,833.87 DICLOFENAC POTASSIUM 50MG TABLETS 44 $34.55 180 $130.02 DICLOFENAC SOD 0.1% OPHTH SOL 2.5ML 5 $61.37 7 $84.63 DICLOFENAC SODIUM 100MG ER TABLETS 31 $121.82 97 $373.93 DICLOFENAC SODIUM 25MG DR TABLETS 52 $46.13 191 $158.69 DICLOFENAC SODIUM 50MG DR TABLETS 51 $15.94 182 $46.37 DICLOFENAC/MISOPROSTOL 50-0.2MG TAB 57 $173.50 172 $513.86 DICLOFENAC/MISOPROSTOL 75-0.2MG TAB 55 $165.31 167 $493.13 DICLOXACILLIN 250MG CAPSULES 39 $17.49 174 $64.85 DICLOXACILLIN 500MG CAPSULES 36 $36.06 198 $181.79

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DICYCLOMINE 10MG/5ML SOLUTION 192 $61.21 1,461 $439.60 DICYCLOMINE 10MG/ML INJ, 2ML 20 $167.18 60 $493.54 DICYCLOMINE POWDER 25GM 30 $37.59 90 $104.76 DIDANOSINE (DDI) 200MG DR CAPSULES 40 $210.41 105 $542.97 DIDANOSINE (DDI) 250MG DR CAPSULES 30 $203.19 90 $602.17 DIDANOSINE (DDI) 400MG DR CAPSULES 30 $313.92 90 $936.91 DIDANOSINE 125MG CAPSULES 32 $100.05 95 $292.14 DIETHYLPROPION 25MG TABLETS 60 $29.22 157 $69.73 DIETHYLPROPION 75MG ER TABLETS 29 $31.86 90 $91.18 DIFFERIN 0.1% LOTION 59ML 61 $554.32 177 $1,604.93 DIFICID 200MG TABLETS 19 $3,633.65 47 $9,027.98 DIFIL G FORT 300-300 LIQ 30 $7.87 90 $15.62 DIFLORASONE DIACETATE .05% CRM 15GM 63 $769.25 105 $1,286.73 DIFLORASONE DIACETATE .05% ONT 15GM 53 $696.48 178 $2,323.22 DIFLUNISAL 500MG TABLETS 37 $56.72 172 $250.87 DIGITEK 0.125MG TABLETS (YELLOW) 30 $25.96 87 $67.72 DIGITEK 0.25MG TABLETS 30 $22.94 88 $59.00 DIGOXIN 0.25MG/ML INJ, 1ML 50 $158.95 150 $468.85 DIGOXIN 50 MCG/ML (0.05 MG/ML) DRP 69 $45.09 128 $80.68 DIHYDROERGOTAMINE (1MG/ML) 1ML AMP 11 $1,563.28 30 $4,191.97 DIHYDROERGOTAMINE 4MG/ML 1X8ML SP 8 $2,617.07 25 $7,917.15 DILANTIN 30MG CAPSULES 61 $69.28 152 $166.51 DILEX-G 200-200 TABLETS 30 $14.00 90 $34.00 DILTIAZEM 5MG/ML INJ, 5ML 1 $4.24 3 $4.71 DILTIAZEM ER 120MG CAPSULES (24 HR) 33 $19.53 98 $49.80 DILTIAZEM ER 120MG CAPSULES (24 HR) 33 $37.00 99 $102.54 DILTIAZEM ER 180MG CAPS (XR-24H) 35 $22.44 102 $58.47 DILTIAZEM ER 180MG TABLETS 32 $97.05 99 $286.76 DILTIAZEM ER 240MG CAPSULES (24 HR) 32 $26.70 95 $70.36 DILTIAZEM ER 240MG CAPSULES (24 HR) 32 $46.19 95 $130.43 DILTIAZEM ER 240MG TABS (LA 24HR) 31 $88.17 93 $255.81 DILTIAZEM ER 300MG CAPSULES (24 HR) 30 $71.01 90 $205.61 DILTIAZEM ER 360MG TABLET (LA 24H) 30 $128.98 90 $382.38 DILTIAZEM ER 420MG CAPSULES (24 HR) 30 $51.08 90 $145.98 DILTIAZEM ER 60MG CAPSULES (12 HR) 51 $56.63 160 $168.93 DILTIAZEM ER 90MG CAPSULES (12 HR) 51 $63.94 152 $184.02 DILTIAZEM SR 120MG CAPSULES (12 HR) 45 $78.57 142 $236.57 DIMENHYDRINATE 50MG/ML INJ, 1ML 1 $9.42 3 $20.26 DIPHENHYDRAMINE 12.5MG/5ML ELIXIR 135 $44.20 405 $124.60 DIPHENHYDRAMINE 50MG/ML INJ 1ML 26 $40.47 112 $161.12 DIPHENMAX D 25/10MG CHW TABLETS 30 $36.00 90 $99.99 DIPHENOXYLATE/ATROPINE LIQUID 167 $37.16 257 $54.97 DIPHENOXYLATE/ATROPINE TABLETS 66 $39.16 280 $153.47 DIPHTHERIA/TETANUS PED INJ, 0.5ML 1 $55.99 2 $159.97 DIPIVEFRIN 0.1% OPH SOLN 5ML 30 $41.98 90 $117.94 DIPYRIDAMOLE 25MG TABLETS 66 $31.88 182 $80.47 DIPYRIDAMOLE 50MG TABLETS 91 $24.86 254 $62.32

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DIPYRIDAMOLE 75MG TABLETS 75 $33.43 211 $86.38 DISOPYRAMIDE 100MG CAPSULES 97 $137.49 269 $372.98 DISOPYRAMIDE 150MG CAPSULES 79 $176.31 227 $496.74 DISPAS 0.25MG TABLETS 30 $9.10 90 $19.29 DISULFIRAM 250MG TABLETS 30 $116.86 91 $344.02 DISULFIRAM 500MG TABLETS 27 $165.92 87 $520.80 DIURIL 250MG/5ML SUSPENSION 97 $33.11 206 $65.66 DIVALPROEX 125MG SPRINKLES 167 $114.37 460 $307.26 DIVALPROEX DELAYED RELEASE 500MG TB 69 $131.82 210 $391.59 DIVALPROEX EXTENDED RELEASE 500MG T 66 $261.10 200 $777.18 DIVIGEL 0.1% (1MG/DAY) TOP GEL 31 $127.74 92 $366.87 DIVISTA CAPSULES 30 $32.20 90 $88.60 DNZ-2 250MG CAPSULES 30 $12.70 90 $30.09 DOBUTAMINE 12.5MG/ML INJ, 20ML 1 $4.10 3 $4.31 DOBUTAMINE 4MG/ML INJ, 250ML 1 $4.05 3 $4.15 DOBUTAMINE 5%/DEXTROSE 2MG/ML INJ 1 $4.03 3 $4.08 DOCETAXEL 160MG/16ML INJ, 16ML 16 $2,699.99 48 $8,091.97 DOCETAXEL 20MG/2ML INJ, 2ML 1 $174.00 3 $513.99 DOCETAXEL 80MG/8ML INJ, 8ML 11 $1,871.59 34 $5,606.76 DOFETILIDE 125MCG CAPSULES 74 $565.40 211 $1,610.78 DOFETILIDE 250MCG CAPSULES 60 $456.78 181 $1,383.25 DOFETILIDE 500MCG CAPSULES 59 $450.89 179 $1,367.68 DOLOGESIC DYE FREE TABLETS 26 $9.40 79 $20.19 DONEPEZIL 10MG TABLETS 32 $94.78 94 $273.54 DONEPEZIL 5MG TABLETS 31 $93.83 92 $267.51 DONEPEZIL ODT 10MG TABLETS 32 $129.91 93 $365.77 DONEPEZIL ODT 5MG TABLETS 32 $127.83 91 $360.26 DONNATAL EXTENTABS 30 $67.80 90 $195.39 DOPAMINE 80MG/ML INJ , 5ML 1 $5.20 3 $7.60 DOPAMINE/D5W 1.6MG/ML INJ , 500ML 1 $4.02 3 $4.06 DORAL 15MG TABLETS 25 $119.43 90 $426.97 DORZOLAMIDE 2% OPHTH SOLN 10ML 10 $44.56 16 $66.66 DORZOLAMIDE-TIMOLOL OPHTH SOLN 10ML 10 $81.96 16 $125.17 DOXEPIN 100MG (HUNDRED MG) CAPSULES 41 $26.59 119 $70.07 DOXEPIN 150MG CAPSULES 35 $48.42 104 $135.55 DOXEPIN 50MG CAPSULES 43 $26.84 125 $70.75 DOXEPIN 75MG CAPSULES 37 $21.96 111 $57.85 DOXERCALCIFEROL 0.5MCG CAPSULES 32 $237.11 100 $743.28 DOXORUBICIN 2MG/ML INJ 100ML VIAL 74 $120.29 222 $352.88 DOXYCYCLINE 100MG DR TABLETS 24 $298.51 110 $1,349.40 DOXYCYCLINE 150MG CAPSULES 27 $604.94 103 $2,293.67 DOXYCYCLINE 150MG TABLETS 29 $804.52 84 $2,351.07 DOXYCYCLINE 40MG CAPSULES 30 $491.11 90 $1,466.69 DOXYCYCLINE 75MG DR TABLETS 35 $167.13 97 $450.76 DOXYCYCLINE HYC 150MG DR TABLETS 29 $251.71 86 $732.07 DOXYCYCLINE HYC 200MG DR TABLETS 22 $437.99 90 $1,762.49

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price DOXYCYCLINE HYCLATE 100MG CAPSULES 25 $84.25 123 $404.35 DOXYCYCLINE HYCLATE 100MG TABLETS 23 $61.40 116 $289.29 DOXYCYCLINE HYCLATE DR 50MG TABLETS 30 $320.00 90 $952.00 DOXYCYCLINE HYCLATE POWDER 30 $268.10 90 $796.29 DOXYCYCLINE HYDRATE 100MGINJ, 1 VL 11 $283.20 32 $841.59 DOXYCYCLINE MONOHYD 25MG/5ML SUSP 281 $92.78 540 $174.91 DOXYCYCLINE MONOHYDRATE 100MG CAPS 27 $43.86 123 $188.77 DOXYCYCLINE MONOHYDRATE 100MG TABS 25 $94.37 123 $456.60 DOXYCYCLINE MONOHYDRATE 50MG CAPS 43 $60.26 108 $146.91 DOXYCYCLINE MONOHYDRATE 50MG TABS 41 $121.74 106 $311.25 DOXYCYCLINE MONOHYDRATE 75MG CAPS 39 $479.25 124 $1,520.25 DRONABINOL 10MG CAPSULES 64 $576.23 176 $1,573.89 DRONABINOL 2.5MG CAPSULES 58 $145.44 178 $436.08 DRONABINOL 5MG CAPSULES 61 $355.19 185 $1,065.62 DROPERIDOL 2.5MG/ML INJ, 2ML 1 $4.65 3 $5.96 DROSPIRE/ETH ESTR/LEV TABS 28 $144.39 84 $420.37 DROSPIRENONE/ETH-EST/L-MEFOLATE 28S 29 $120.67 85 $349.74 DROSPIRENONE/ETHY EST 3/0.02MG T 28 29 $66.32 85 $188.80 DROSPIRENONE-ETHINYL 3-0.03MG T 28 29 $61.55 85 $174.19 DROXIA 200MG CAPSULES 43 $40.02 100 $87.40 DROXIA 300MG CAPS 53 $48.50 106 $92.67 DROXIA 400MG CAPS 60 $57.47 156 $143.28 DRYSEC CR TABLETS 30 $14.37 90 $35.11 DUAVEE 0.45-20 TABLETS 30 $190.95 90 $561.50 DULERA 100-5MCG ORAL INHALER 120INH 13 $323.92 38 $930.06 DULERA 200-5MCG ORAL INHALER 120INH 13 $324.60 38 $946.28 DULOXETINE DR 30MG CAPSULES 40 $252.67 119 $738.96 DULOXETINE DR 40MG CAPSULES 34 $137.74 101 $397.23 DULOXETINE DR 60MG CAPSULES 36 $230.08 107 $665.78 DUOTAN PD SUSPENSION 30 $11.25 90 $25.74 DURAXIN CAPSULES 30 $15.29 90 $37.87 DUREZOL 0.05% OPHTH EMULSION 5ML 5 $222.40 7 $280.40 DUTASTERIDE/TAMSULOSIN 0.5-0.4MG CP 30 $170.63 90 $502.49 DUTOPROL 100MG/12.5MG TABLETS 37 $219.58 90 $532.18 DYMISTA 137/50 MCG NASAL SPR 120SPR 23 $201.86 68 $581.50 DYRENIUM 100MG CAPSULES 41 $440.23 118 $1,271.15 DYRENIUM 50MG CAPSULES 38 $417.16 107 $1,156.74 EC-NAPROXEN 500MG TABLETS 41 $13.62 168 $43.08 ECONAZOLE NITRATE 1% CREAM 15GM 52 $191.17 185 $668.59 ED CYTE F TABLETS 30 $8.95 90 $18.86 EDARBI 40MG TABLETS 30 $156.48 92 $466.99 EDARBYCLOR 40/25MG TABLETS 30 $205.81 90 $604.45 ED-BRON G SYRUP 30 $5.90 90 $9.71 EDEX 40MCG INJ CARTRIDGE KIT (6 PK) 2 $1,068.02 4 $2,229.97 EDURANT 25MG TABLETS 30 $998.93 90 $2,991.97 EEMT 1.25/2.5MG TABLETS 30 $100.10 88 $290.84 EEMT HS 0.625/1.25MG TABLETS 30 $96.39 88 $275.63 EFAVIRENZ 200MG CAPSULES 61 $646.60 218 $2,299.80

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price EFAVIRENZ 50MG CAPSULES 105 $272.77 314 $810.30 EFAVIRENZ 600MG TABLETS 30 $698.25 90 $2,093.57 EFFER-K 10MEQ TABLETS 42 $19.47 119 $47.47 EFFER-K 20MEQ TABLETS 46 $24.22 140 $65.43 EFFER-K 25MEQ EFFERVESC TABS ORANGE 50 $15.50 152 $38.84 ELESTRIN 0.06% GEL PUMP 2 X 26GM 51 $222.29 137 $590.80 ELIQUIS 2.5MG TABLETS 58 $365.54 178 $1,120.19 ELIQUIS 5MG TABLETS 59 $427.20 178 $1,286.95 ELITE-OB TABLETS 30 $45.18 91 $127.78 ELLA 30MG TABLETS 1 $47.68 10 $413.14 ELMIRON 100MG CAPSULES 87 $687.10 254 $1,996.24 EMADINE 0.05% OPHTH SOLN 5ML 5 $157.99 15 $465.97 EMCYT 140MG CAPSULES 77 $1,245.32 90 $1,454.89 EMEND 150MG I.V. SOLN, 1VL 2 $532.56 5 $1,589.67 EMSAM 12MG/24H PATCH 30 $1,710.42 90 $5,076.97 EMSAM 6MG/24HR PATCH 30 $1,706.87 90 $5,169.97 EMSAM 9MG/24HR PATCH 30 $1,786.45 93 $5,476.41 EMTRIVA 10MG/ML ORAL SOLUTION 323 $268.87 720 $594.47 EMTRIVA 200MG CAPSULES 25 $499.28 69 $1,367.71 ENALAPRIL 10MG TABLETS 39 $13.17 114 $30.65 ENALAPRIL 20MG TABLETS 43 $21.36 129 $55.56 ENALAPRILAT 1.25/ML INJ, 2ML 1 $11.00 3 $24.99 ENBREL 25MG VIAL FOR INJ (4 VIALS) 7 $4,828.12 22 $15,971.55 ENBREL 25MG/0.5ML INJ (1 SYRINGE) 3 $6,082.61 10 $19,793.99 ENBREL 50MG/ML INJ (1 SYRINGE) 4 $6,607.15 12 $19,755.39 ENBREL SURECLICK 50MG/ML(1 SYRINGE) 4 $7,452.62 12 $22,115.11 ENDACOF-DH LIQUID 30 $8.19 90 $16.56 ENDOCET 10/325MG TABLETS (YELLOW) 93 $205.74 238 $521.25 ENDOCET 5/325MG (OXYCOD/APAP) TAB 41 $27.18 167 $98.33 ENDOCET 7.5/325MG TABLETS (PEACH) 72 $110.99 211 $318.82 ENDODAN TABLETS 79 $87.06 223 $237.51 ENDOMETRIN 100MG VAGINAL INSERT 39 $453.43 107 $1,252.27 ENGERIX-B 10MCG/0.5ML INJ, (PED) 1 $54.63 2 $155.89 ENGERIX-B 20MCG/ML INJ, 1ML (ADULT) 1 $81.21 1 $82.13 ENJUVIA 0.3MG TABLETS 30 $86.23 90 $250.68 ENJUVIA 0.45MG TABLETS 30 $86.23 90 $250.68 ENJUVIA 0.625MG TABLETS 30 $80.80 90 $234.39 ENJUVIA 0.9MG TABLETS 30 $86.80 90 $252.39 ENJUVIA 1.25MG TABLETS 30 $89.80 90 $261.39 ENOXAPARIN 100MG/1ML SYR (10 X 1ML) 22 $1,841.77 126 $10,509.72 ENOXAPARIN 120MG/0.8ML SYR 10X0.8ML 17 $2,111.13 82 $10,233.85 ENOXAPARIN 150MG/1ML SYR(10X1ML) 20 $1,516.62 103 $7,918.60 ENOXAPARIN 300MG/3ML INJ, 3ML 13 $1,024.13 69 $5,581.20 ENOXAPARIN 30MG/0.3ML SYR(10X0.3ML) 7 $534.00 29 $2,191.44 ENOXAPARIN 40MG/0.4ML SYR(10X0.4ML) 8 $646.09 36 $2,927.43 ENOXAPARIN 60MG/0.6ML SYR(10X0.6ML) 16 $642.26 85 $3,470.89 ENOXAPARIN 80MG/0.8ML SYR(10X0.8ML) 19 $1,580.32 104 $8,562.94 ENPRESSE TABLETS 28 29 $22.31 84 $58.24

Prescription drug coverage and cost are subject to change.

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

ENTECAVIR 0.5MG TABLETS 29 $853.32 86 $2,515.17 ENTECAVIR 1MG TABLETS 28 $831.97 81 $2,373.70 ENTRESTO 24-26MG TABLETS 58 $496.44 173 $1,473.08 ENTRESTO 49-51MG TABLETS 59 $550.15 178 $1,649.93 EPIFOAM 1% AEROSOL 10GM 11 $60.53 32 $173.60 EPINASTINE 0.05% OPHTH SOL 5ML 5 $142.83 15 $392.15 EPINEPHRINE 0.15MG INJ 2 PACK 2 $149.97 2 $161.65 EPINEPHRINE 0.1MG/ML INJ, 10ML 21 $8.79 100 $26.91 EPINEPHRINE 0.3MG INJ 2 PACK 2 $142.05 4 $257.85 EPINEPHRINE 1MG/ML INJ, 1ML 4 $8.58 10 $15.34 EPINEPHRINE 1MG/ML INJ, 30ML 30 $69.99 90 $201.97 EPIPEN-JR 0.15MG INJ 2 PACK (GREEN) 2 $772.51 4 $1,460.85 EPIRUBICIN 200/100M INJ,100ML 1 $6.06 3 $10.17 EPIRUBICIN 200MG INJ, 25ML 1 $6.06 3 $10.18 EPIRUBICIN 50MG INJ , 1VIAL 1 $87.99 3 $255.97 EPIVIR HBV 5MG/ML ORAL SOLN 240ML 206 $188.14 470 $424.46 EPLERENONE 25MG TABLETS 34 $107.68 96 $296.33 EPOGEN 10,000 U/ML 2ML MDV VIALS 4 $676.52 8 $1,383.24 EPOGEN 2,000 U/ML 1ML SDV VIALS 4 $123.77 7 $249.78 EPOGEN 20,000 U/ML 1ML MDV VIAL 3 $1,571.50 6 $2,816.11 EPOGEN 3,000 U/ML 1ML SDV VIALS 6 $440.22 8 $572.27 EPOGEN 4,000 U/ML 1ML SDV VIALS 5 $376.84 8 $572.20 EPOPROSTENOL 0.5MG INJ, 1 VIAL 1 $12.75 3 $30.25 EPOPROSTENOL 1.5MG INJ, 1 VIAL 1 $25.12 3 $67.36 EPROSARTAN MESYLATE 600MG TABLETS 29 $48.98 88 $140.33 EQUAGESIC 200-325MG TABLETS 30 $61.32 90 $175.95 EQUETRO 100MG CAPSULES 65 $235.33 200 $711.97 EQUETRO 200MG CAPSULES 71 $267.51 260 $964.65 EQUETRO 300MG CAPSULES 65 $296.94 247 $1,111.11 ERGOLOID MES 1MG ORAL TAB 89 $645.02 242 $1,752.54 ERGOTAMINE TARTRATE CAFFEINE TABS 32 $51.77 134 $205.25 ERTACZO 2% CREAM 60GM 63 $421.47 180 $1,191.96 ERY 2% PADS 60S 60 $71.48 180 $204.97 ERY-TAB 250MG EC TABLETS 52 $422.55 135 $1,098.89 ERY-TAB 333MG EC TABLETS 41 $397.89 150 $1,461.85 ERY-TAB 500MG EC TABLETS 31 $381.31 144 $1,773.75 ERYTH-BENZ PEROX GEL 23.3GM 39 $63.93 125 $194.91 ERYTHROCIN 250MG TABLETS 46 $539.37 159 $1,836.78 ERYTHROM LAC 500MG INJ, 1VIAL 9 $680.02 27 $2,032.05 ERYTHROMYCIN 2% GEL 30GM 44 $53.65 128 $146.35 ERYTHROMYCIN 2% TOPICAL SOLN 60ML 63 $31.25 183 $83.48 ERYTHROMYCIN 250MG ER CAPSULES 56 $383.46 210 $1,431.27 ERYTHROMYCIN BASE 250MG TABLETS 45 $442.36 153 $1,504.36 ERYTHROMYCIN BASE 500MG TABLETS 21 $334.25 147 $2,319.35 ERYTHROMYCIN ETH 400MG TABLETS 41 $537.25 157 $2,039.90 ERYTHROMYCIN/SULFISOX SUSP 100ML 30 $6.40 90 $11.19

Prescription drug coverage and cost are subject to change.

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

ESOMEPRAZOLE MAGNESIUM 20MG DR CAPS 35 $257.97 99 $716.25 ESTAZOLAM 1MG TABLETS 33 $26.29 105 $75.19 ESTAZOLAM 2MG TABLETS 30 $72.11 94 $217.51 ESTRA 0.5MG/NORETH 0.1MG TB LOW STR 28 $63.82 84 $181.16 ESTRA 1MG/NORETH 0.5MG TB REG STR 28 $111.69 84 $322.65 ESTRADIOL 0.01% VAG CREAM 42.5GM 43 $214.39 49 $243.99 ESTRADIOL 0.025MG PATCH (ONCE WK) 4 $59.15 12 $160.19 ESTRADIOL 0.025MG PATCH (TWICE WK) 9 $65.49 24 $174.13 ESTRADIOL 0.0375MG PATCH (TWICE WK) 8 $63.73 24 $174.94 ESTRADIOL 0.05MG PATCH (ONCE WK) 4 $74.68 12 $206.16 ESTRADIOL 0.05MG PATCH (TWICE WK) 8 $76.17 24 $211.39 ESTRADIOL 0.075MG PATCH (ONCE WK) 4 $59.28 12 $162.42 ESTRADIOL 0.075MG PATCH (TWICE WK) 9 $64.78 24 $175.50 ESTRADIOL 0.1MG PATCH (ONCE WK) 4 $76.55 12 $211.40 ESTRADIOL 0.1MG PATCH (TWICE WK) 9 $84.42 25 $217.45 ESTRADIOL 10MCG VAGINAL TABS 18S 10 $158.51 26 $397.26 ESTRADIOL TDS 0.0375MG PATCHES 4'S 4 $62.47 12 $169.62 ESTRADIOL TDS 0.06MG PATCH 4'S 4 $49.08 12 $136.91 ESTRADIOL VALERATE 20MG/ML INJ, 5ML 5 $129.50 6 $140.22 ESTRADIOL VALERATE 40MG/ML INJ, 5ML 5 $114.69 5 $117.99 ESTRING 2MG VAGINAL RING 1 $573.26 1 $573.28 ESTROGEL 0.06% GEL 50GM 55 $142.11 153 $390.66 ESTRONE POWDER USP 5GM 30 $549.94 90 $1,641.82 ESTROPIPATE 2.5MG (3MG) TABLETS 29 $37.91 91 $108.94 ESZOPICLONE 1MG TABLETS 30 $301.67 95 $947.23 ESZOPICLONE 2MG TABLETS 29 $303.80 90 $947.54 ESZOPICLONE 3MG TABLETS 29 $319.99 90 $984.49 ETHACRYNIC ACD 25MG TABLETS 58 $882.24 155 $2,340.89 ETHAMBUTOL 100MG TABLETS 74 $23.78 166 $48.11 ETHAMBUTOL 400MG TABLETS 62 $97.10 158 $239.72 ETHEDENT 1MG CHEW TABS 31 $8.30 93 $17.05 ETHOSUXIMIDE 250MG CAPSULES 103 $154.56 302 $444.88 ETHOSUXIMIDE 250MG/5ML SYRUP 370 $122.64 1,099 $356.50 ETHYL CHLORIDE FINE STREAM SPRAY 116 $44.39 419 $149.75 ETHYNODIOL-ETH EST 1/35 TABLETS 28S 29 $24.92 86 $65.48 ETIDRONATE DISODIUM 200MG TABLETS 61 $183.43 184 $542.28 ETIDRONATE DISODIUM 400MG TABLETS 65 $600.23 107 $974.91 ETODOLAC 200MG CAPSULES 46 $45.83 196 $180.33 ETODOLAC 300MG CAPSULES 45 $57.69 192 $231.30 ETODOLAC 400MG TABLETS 45 $38.73 175 $137.82 ETODOLAC 500MG ER TABLETS 38 $80.26 137 $279.39 ETODOLAC 500MG TABLETS 49 $47.40 171 $154.34 ETODOLAC 600MG ER TABLETS 34 $47.94 115 $151.59 ETODOLAC ER 400MG TABLETS 40 $88.62 131 $278.76 ETOPOSIDE (VP-16) 50MG CAPSULES 20 $1,446.20 60 $4,330.60 EUCALYPTUS OIL 30 $8.20 90 $16.59

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price EUCRISA 2% OINTMENT 60GM 62 $697.84 149 $1,686.34 EUFLEXXA 10MG/ML INJ, 2ML SYRINGE 7 $1,356.55 22 $4,061.65 EURAX 10% CREAM 60GM 30 $272.00 90 $807.99 EURAX 10% LOTION 454GM 60 $539.99 180 $1,611.98 EVAMIST 1.53MG TOPICAL SP/56 SPRAYS 9 $146.46 27 $420.18 EXELDERM 1% CREAM 15GM 60 $249.84 60 $249.84 EXELDERM 1% SOLUTION 30ML 33 $364.32 60 $665.98 EXETUSS-DM TABLETS 30 $25.30 90 $67.89 FA/B12/B6 TABLETS 35 $9.39 95 $18.80 FABRAZYME 35MG INJ, 1VIAL 4 $25,428.76 12 $76,278.28 FABRAZYME 5MG INJ, 1VIAL 2 $1,820.06 6 $5,452.18 FAMCICLOVIR 250MG TABLETS 43 $185.03 150 $633.25 FAMCICLOVIR 500MG TABLETS 25 $180.83 126 $908.94 FAMOTIDINE 10MG/ML INJ , 2ML 11 $16.48 34 $41.44 FAMOTIDINE 10MG/ML INJ, 20ML 20 $8.95 60 $18.85 FAMOTIDINE 10MG/ML INJ, 4ML 1 $4.25 3 $4.74 FAMOTIDINE 40MG/5ML SUSPENSION 50ML 84 $268.97 295 $936.62 FARXIGA 10MG TABLETS 30 $507.82 90 $1,512.06 FARXIGA 5MG TABLETS 30 $373.92 91 $1,111.62 FAZACLO 150MG ORAL DISINGRTING TAB 37 $897.93 112 $2,685.80 FELBAMATE 400MG TABLETS 140 $556.50 425 $1,687.52 FELBAMATE 600MG TABLETS 132 $594.82 410 $1,832.57 FELBAMATE OS 600MG/5ML SUSPENSION 432 $352.43 1,291 $1,046.16 FEMRING 0.05MG/DAY 1 $472.37 3 $1,409.11 FEMRING 0.1MG/DAY 1 $503.34 1 $506.07 FENOFIBRATE 120MG TABLETS 30 $744.73 90 $2,202.89 FENOFIBRATE 130MG CAPSULES 30 $140.81 90 $411.73 FENOFIBRATE 134MG CAPSULES 30 $50.08 90 $140.76 FENOFIBRATE 150MG CAPSULES 30 $167.33 90 $494.59 FENOFIBRATE 160MG TABLETS 30 $53.93 90 $152.62 FENOFIBRATE 40MG TABLETS 32 $186.36 96 $553.97 FENOFIBRATE 43MG CAPSULES 31 $71.55 93 $204.92 FENOFIBRATE 50MG CAPSULES 32 $82.88 96 $240.70 FENOFIBRIC 105MG TABLETS 30 $82.81 90 $237.63 FENOFIBRIC 45MG DR CAPSULES 32 $43.95 94 $122.66 FENOPROFEN 600MG TABLETS 75 $333.33 215 $942.29 FENTANYL 100MCG/HR PATCH 12 $515.35 35 $1,488.67 FENTANYL 12MCG/HR PATCH 10 $154.87 33 $506.70 FENTANYL 25MCG/HR PATCH 10 $123.50 31 $372.34 FENTANYL 37.5MCG/HR PATCH 10 $616.30 30 $1,761.94 FENTANYL 50MCG/HR PATCH 11 $237.08 33 $725.38 FENTANYL 62.5MCG/HR PATCH 11 $935.31 45 $3,837.91 FENTANYL 75MCG/HR PATCH 11 $327.23 35 $1,033.10 FENTANYL 87.5MCG/HR PATCH 11 $1,253.88 32 $3,753.65 FENTANYL CIT 0.05MG/ML INJ, 20ML 1 $4.17 3 $4.51 FENTANYL CIT 0.05MG/ML INJ, 2ML 2 $4.87 7 $6.60

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price FENTANYL CIT 0.05MG/ML INJ, 50ML 1 $4.19 3 $4.58 FENTANYL CIT 0.05MG/ML INJ, 5ML 6 $5.20 17 $7.61 FENTANYL CIT 1200MCG ORAL TRANSMCSL 80 $2,670.72 239 $8,004.17 FENTANYL CIT 1600MCG ORAL TRANSMCSL 130 $5,831.01 390 $17,485.03 FENTANYL CIT 200MCG ORAL TRANSMCSL 56 $835.70 168 $2,499.10 FENTANYL CIT 400MCG ORAL TRANSMCSL 73 $1,498.69 220 $4,488.08 FENTANYL CIT 600MCG ORAL TRANSMCSL 99 $2,452.31 180 $4,461.93 FENTANYL CIT 800MCG ORAL TRANSMCSL 94 $2,439.54 281 $7,310.62 FENTORA 100MCG BUCCAL TABLETS 58 $2,756.09 173 $8,260.27 FENTORA 200MCG BUCCAL TABLETS 86 $5,148.12 259 $15,436.36 FENTORA 400MCG BUCCAL TABLETS 81 $7,021.68 243 $21,057.04 FENTORA 600MCG BUCCAL TABLETS 112 $13,611.30 336 $40,825.89 FENTORA 800MCG BUCCAL TABLETS 67 $9,812.82 201 $29,430.46 FERAHEME 510MG/17ML INJ, 17ML 24 $1,284.54 71 $3,845.62 FERRALET 90 TABS (NEW FORMULA) 31 $72.26 91 $201.39 FERRAPLUS 90 TABLETS 31 $24.64 93 $64.84 FERREX 150 PLUS CAPSULES 30 $32.66 90 $89.99 FERREX TABLETS 28S 29 $31.14 63 $64.17 FERRO-PLEX TABLETS 29 $18.69 44 $26.19 FERROUS SULFATE 300MG/5ML SYRUP 174 $42.56 521 $119.67 FERROUS SULFATE 325MG EC TABS RED 51 $8.28 124 $14.34 FERROUS SULFATE 325MG EC TABS RED 47 $20.93 108 $42.69 FEXOFENADINE 180MG TABLETS 30 $14.90 91 $37.35 FEXOFENADINE 30MG TABLETS 30 $23.60 91 $62.81 FEXOFENADINE 60MG TABLETS 41 $49.05 141 $158.64 FINACEA 15% GEL 50GM 50 $333.91 146 $958.37 FINASTERIDE 1MG TABLETS 30 $58.71 90 $166.69 FINGERSTIX LANCETS 115 $23.57 168 $32.58 FIRMAGON 80MG INJ, 1 VIAL 1 $504.94 3 $1,506.81 FIRST-MAGIC MOUTHWASH BLM SUSP KIT 212 $45.95 222 $48.07 FIRST-PROGESTERONE 100MG VAG SUP KT 35 $183.10 105 $541.29 FIRST-PROGESTERONE 25MG VAG SUPP KT 30 $120.00 90 $352.00 FIRST-TESTOSTERONE 2% CREAM 60GM KT 30 $44.00 90 $123.99 FIRST-TESTOSTERONE 2% OINT 60GM KIT 30 $42.13 90 $118.39 FIRST-VANCOMYCIN 25MG/ML SOL 150ML 30 $19.20 90 $49.59 FLAREX 0.1% OPHTH SUSPENSION 5 $121.93 6 $135.98 FLAVOXATE 100MG TABLETS 54 $69.68 259 $319.73 FLEBOGAMMA DIF 5% INJ, 100ML 1 $8.60 3 $17.80 FLEBOGAMMA DIF 5% INJ, 10ML 1 $8.60 3 $17.80 FLEBOGAMMA DIF 5% INJ, 200ML 978 $4,500.80 2,933 $13,494.40 FLEBOGAMMA DIF 5% INJ, 400ML 1 $8.60 3 $17.80 FLEBOGAMMA DIF 5% INJ, 50ML 1 $8.60 3 $17.80 FLECAINIDE 100MG TABLETS 59 $86.21 177 $251.89 FLECAINIDE 150MG TABLETS 52 $94.48 158 $278.84 FLECAINIDE 50MG TABLETS 62 $66.34 184 $188.30 FLECTOR 1.3% PATCH 41 $545.01 162 $2,127.53

Prescription drug coverage and cost are subject to change.

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

FLOVENT 250MCG DISKUS (60 ORAL INH) 63 $270.10 183 $774.12 FLOVENT 50MCG DISKUS (60 ORAL INH) 62 $187.65 180 $540.67 FLOVENT HFA 110 MCG ORAL INH 120INH 12 $232.68 32 $615.41 FLOVENT HFA 220 MCG ORAL INH 120INH 12 $405.36 33 $1,076.36 FLOVENT HFA 44MCG ORAL INH 120INH 11 $177.13 29 $477.53 FLOVENT100MCG DISKUS (60 ORAL INH) 61 $195.92 180 $570.68 FLOXURIDINE 0.5GM INJ, 1VIAL 1 $140.00 3 $412.00 FLUAD PFS 2018-2019 1 $56.07 2 $160.20 FLUCONAZOLE 100MG TABLETS 11 $43.33 63 $237.83 FLUCONAZOLE 10MG/ML ORAL SUSP 35ML 51 $51.95 58 $58.99 FLUCONAZOLE 200MG TABLETS 13 $42.63 58 $174.85 FLUCONAZOLE 40MG/ML ORAL SUSP 35ML 47 $118.61 116 $289.13 FLUCONAZOLE 50MG TABLETS 17 $24.58 73 $91.90 FLUCONAZOLE/DEX 200MG INJ, 100ML 1 $4.07 3 $4.20 FLUCONAZOLE/NACL 200MG INJ, 100ML 1,000 $503.90 3,000 $1,503.70 FLUCONAZOLE/NACL 400MG INJ, 200ML 1 $4.21 3 $4.63 FLUCYTOSINE 250MG CAPSULES 68 $2,505.24 90 $3,327.79 FLUCYTOSINE 500MG CAPSULES 92 $6,586.42 276 $19,751.25 FLUDARABINE 50MG INJ, 1 VIAL 3 $351.07 9 $1,045.21 FLUDROCORTISONE 0.1MG TABLETS 45 $39.38 113 $92.02 FLUMAZENIL 0.1MG/ML INJ,10ML 9 $14.19 26 $34.58 FLUMAZENIL 0.5MG/5ML INJ, 5ML 5 $9.85 5 $10.11 FLUNISOLIDE 0.025% NASALSOLN 25ML 27 $75.17 49 $133.17 FLUOCINOLONE 0.01% CREAM 60GM 38 $80.97 196 $405.76 FLUOCINOLONE 0.01% OIL DROPS (EAR) 20 $202.94 22 $214.89 FLUOCINOLONE ACET 0.01% SOLN 60ML 63 $157.26 126 $310.04 FLUOCINOLONE ACET 0.025% CRM 15GM 42 $89.21 150 $307.11 FLUOCINOLONE ACET 0.025% OINT 15GM 47 $95.01 251 $489.59 FLUOCINOLONE ACETONIDE BODY OIL 122 $261.05 301 $638.03 FLUOCINOLONE ACETONIDE SCALP OIL 121 $276.42 249 $564.73 FLUOCINONIDE 0.05% CREAM 15GM 51 $44.75 175 $144.75 FLUOCINONIDE 0.05% GEL 15GM 37 $80.80 148 $308.87 FLUOCINONIDE 0.05% OINT 60GM 49 $94.81 166 $313.83 FLUOCINONIDE 0.05% SOLN 20ML 62 $89.07 172 $239.35 FLUOCINONIDE 0.1% CREAM 120GM 68 $571.43 280 $2,330.83 FLUOCINONIDE -E 0.05% CREAM 15GM 46 $121.75 249 $633.68 FLUORABON DROPS 60ML 60 $11.99 61 $12.10 FLUOR-A-DAY 0.125MG DROPS 30 $118.26 90 $346.78 FLUOR-A-DAY 0.25MG CHEW TABLETS 30 $39.71 90 $111.13 FLUORIDEX SENSITIVE PASTE 102 $21.29 228 $42.64 FLUOROMETHOLONE 0.1% OPHTSUSP 5ML 6 $88.99 8 $116.46 FLUOROURACIL 0.5% CREAM 30GM 32 $1,436.01 50 $2,258.99 FLUOROURACIL 2% SOLUTION 10ML 11 $71.57 30 $186.97 FLUOROURACIL 5% CREAM 40GM 41 $197.93 64 $307.22 FLUOROURACIL 5% SOLUTION 10ML 11 $111.21 43 $411.96 FLUOROURACIL 50MG/ML INJ, 50ML 129 $21.96 388 $57.89

Prescription drug coverage and cost are subject to change.

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

FLUOXETINE 20MG/5ML LIQUID 143 $17.13 433 $43.68 FLUOXETINE 10MG TABLETS 34 $13.76 93 $30.83 FLUOXETINE 10MG TABLETS 31 $453.69 92 $1,341.15 FLUOXETINE 20MG (PMDD) TABLETS 39 $38.17 115 $103.72 FLUOXETINE 60MG TABLETS 29 $187.78 90 $565.10 FLUOXETINE 90MG CAPSULES 4 $138.08 13 $409.68 FLUPHENAZINE 10MG** TABLETS 60 $56.84 171 $154.23 FLUPHENAZINE 1MG TABLETS 64 $19.65 169 $45.34 FLUPHENAZINE 2.5MG/5ML ELIXIR 416 $170.48 1,249 $503.45 FLUPHENAZINE 5MG TABLETS 56 $29.63 164 $79.24 FLUPHENAZINE DEC 25MG/ML INJ 5 $155.88 6 $175.42 FLURANDRENOLIDE 0.05% CREAM 120GM 120 $451.03 180 $672.48 FLURANDRENOLIDE 0.05% LOTION 126 $655.86 390 $2,028.72 FLURAZEPAM 15MG CAPSULES 38 $19.84 104 $47.95 FLURAZEPAM 30MG CAPSULES 29 $18.56 93 $50.29 FLURBIPROFEN 0.03% OPHTH SOLN 2.5M 3 $18.60 7 $34.27 FLURBIPROFEN 100MG TABLETS 43 $14.03 173 $44.27 FLURBIPROFEN 50MG TABLETS 50 $28.74 164 $85.99 FLUTAMIDE 125MG CAPSULES 100 $212.88 249 $521.72 FLUTICASONE 0.005% OINTMENT 15GM 44 $79.30 105 $185.26 FLUTICASONE 0.05% CREAM 30GM 43 $30.98 145 $95.77 FLUTICASONE 0.05% LOTION 120ML 81 $509.89 150 $939.00 FLUVASTATIN 20MG CAPSULES 31 $94.31 91 $271.40 FLUVASTATIN 40MG CAPSULES 34 $104.90 102 $303.74 FLUVASTATIN ER 80MG TABLETS 30 $119.76 89 $348.22 FLUVOXAMINE 100MG ER CAPSULES 45 $398.80 135 $1,204.69 FLUVOXAMINE 100MG TABLETS 56 $17.96 167 $45.60 FLUVOXAMINE 150MG ER CAPSULES 42 $400.36 126 $1,205.69 FLUZONE HD PFS 2018-2019 1 $56.01 1 $56.25 FML FORTE (0.25%) OPHTH SUSP 10ML 6 $195.85 8 $256.65 FML OPHTH OINTMENT 3.5GM 4 $140.79 11 $414.38 FOLBEE PLUS CZ TABLETS 32 $24.13 92 $62.16 FOLBIC TB (FOLIC2.5/PYRID25/CYAN2) 33 $28.44 95 $73.30 FOLGARD OS TABLETS 41 $17.74 116 $42.58 FOLIC ACID 5MG/ML INJ, 10ML 11 $54.24 33 $154.71 FOLITAB 500MG TABLETS 34 $20.98 90 $49.12 FOLIVANE-F CAPSULES 32 $22.35 90 $56.00 FOLIVANE-OB CAPSULES 30 $28.62 90 $77.70 FOLIVANE-PLUS CAPSULES 31 $19.91 91 $50.41 FOLLISTIM AQ VIAL 150IU/0.5ML 1 $597.98 3 $1,785.94 FOLLISTIM AQ VIAL 75IU/0.5ML 1 $327.98 3 $975.94 FOLTRATE TABLETS 31 $28.03 90 $73.63 FOLYSINE SOLUTION 30 $6.29 90 $10.86 FONDAPARINUX 10MG/0.8ML SL 2X0.8ML 21 $2,866.22 72 $9,813.10 FONDAPARINUX 2.5MG/0.5ML SL 2X0.5ML 9 $467.26 48 $2,490.19 FONDAPARINUX 5.0MG/0.4ML SL 2X0.4ML 10 $1,513.46 36 $5,503.90

Prescription drug coverage and cost are subject to change.

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

FONDAPARINUX 7.5MG/.6ML SL 10X0.6ML 15 $2,884.60 52 $10,013.79 FORADIL 12MCG INH CAP/AEROLIZR 12'S 30 $169.15 90 $499.45 FORMADON 10% SOLUTION 78 $49.67 82 $52.25 FORTAVIT CAPSULES 48 $27.23 106 $55.30 FORTEO 600MCG PEN(20MCG/DOSE)28DOSE 2 $3,920.04 7 $11,663.22 FOSAMAX PLUS D TABLETS (2800) 4 $197.26 12 $576.16 FOSAMAX PLUS D TABLETS (5600) 4 $195.60 12 $576.16 FOSCARNET 24MG/ML INJ , 500ML 1 $4.16 3 $4.49 FOSINOPRIL-HCTZ 10MG/12.5MG TABLETS 37 $47.78 102 $124.80 FOSINOPRIL-HCTZ 20MG/12.5MG TABLETS 38 $52.35 112 $146.36 FOVEX CAPSULES 44 $222.42 133 $673.18 FRAGMIN 12,500IU/0.5ML INJ, 0.5ML 15 $2,869.97 44 $8,601.92 FRAGMIN 15,000IU/0.6ML INJ, 0.6ML 16 $3,170.92 90 $17,402.50 FRAGMIN 2500/0.2 INJ, 0.2ML 2 $278.00 7 $825.99 FRAGMIN 7500/0.3ML INJ, 0.3ML 11 $2,099.75 32 $6,291.24 FREAMINE III 10% INJ, 1000ML 1 $4.02 3 $4.05 FRESHKOTE DROPS 15 $40.38 21 $54.00 FROVATRIPTAN 2.5MG TABLETS 10 $652.03 32 $2,099.73 FUROSEMIDE 10MG/ML INJ 25X10ML 61 $106.92 182 $312.75 FUROSEMIDE 8MG/ML SOLUTION 117 $17.64 330 $42.47 FYAVOLV 1/0.005MG TABLETS 29 $63.68 85 $180.25 GABAPENTIN 400MG CAPSULES 102 $19.83 261 $44.58 GABAPENTIN 800MG TABLETS 91 $212.58 249 $577.80 GALANTAMINE ER 8MG CAPSULES 32 $118.48 95 $341.91 GALANTAMINE HBR 12MG TABLETS 57 $158.98 173 $469.92 GALANTAMINE HBR 4MG TABLETS 56 $155.14 163 $442.44 GALANTAMINE HBR 8MG TABLETS 52 $146.21 155 $425.17 GALZIN 25MG CAPSULES 63 $98.93 211 $320.64 GALZIN 50MG CAPSULES 76 $194.91 177 $444.85 GAMMAGARD 10GM/100ML INJECTION 489 $8,109.35 1,466 $24,320.05 GAMMAGARD 1G/10ML INJ, 10ML 138 $2,285.11 413 $6,847.33 GAMMAGARD 2.5GM/25ML INJ, 25ML 1 $20.59 3 $53.77 GAMMAGARD 20GM/200ML INJECTION 333 $5,533.97 1,000 $16,593.90 GAMMAGARD 5GM/50ML INJ, 50ML 133 $2,215.99 400 $6,639.96 GAMMAGARD SD 10GM HU INJ 1 $1,399.99 3 $4,191.97 GAMMAGARD SD 2.5GM HU INJ 1 $307.79 3 $915.37 GANIDIN NR 100MG/5ML LIQUID 199 $11.02 210 $11.39 GARDASIL 9 INJ SINGLE DOSE VL,0.5ML 1 $223.23 1 $286.96 GARDASIL 9 PREFILLED SYRINGE, 0.5ML 1 $223.05 1 $233.44 GARDASIL INJ, 0.5ML SYRINGE 1 $189.99 1 $189.99 GASTROGRAFIN SOLUTION 120ML 113 $76.32 340 $220.97 GATIFLOXACIN 0.5% OPTH SOL 2.5ML 3 $107.97 6 $250.17 GAVILYTE-C SOLUTION 4000ML 4,038 $16.11 4,224 $16.67 GAVILYTE-G SOLUTION 4000ML 4,069 $25.56 4,122 $25.85 GAVILYTE-N FLAVOR PACK SOLUTION 4,028 $22.12 12,083 $58.37 GEBAUERS SPRAY AND STRETCH 103.5ML 116 $40.84 325 $107.73

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price GELFOAM SPONGE 12-7MM 12 $117.50 36 $344.50 GELNIQUE 10% GEL 30 X 1GM 33 $426.49 95 $1,198.39 GEMFIBROZIL 600MG TABLETS 57 $17.24 164 $42.15 GENOTROPIN 0.2MG PREFILLED SYRINGES 24 $1,027.91 73 $3,172.77 GENOTROPIN 0.4MG PREFILLED SYRINGES 25 $1,560.91 78 $4,913.57 GENOTROPIN 0.6MG PREFILLED SYRINGES 26 $2,452.23 88 $8,341.25 GENOTROPIN 0.8MG PREFILLED SYRINGES 28 $3,063.78 85 $9,138.05 GENOTROPIN 1.2MG PREFILLED SYRINGES 26 $4,865.69 78 $14,589.07 GENOTROPIN 1.4MG PREFILLED SYRINGES 27 $5,887.07 84 $18,455.44 GENOTROPIN 1.6MG PREFILLED SYRINGES 16 $3,966.86 47 $11,892.57 GENOTROPIN 1.8MG PREFILLED SYRINGES 27 $7,788.80 81 $23,358.39 GENOTROPIN 12MG(13.8MG OVERFILL)1'S 4 $7,385.89 12 $20,686.63 GENOTROPIN 1MG PREFILLED SYRINGES 30 $4,114.21 91 $12,271.71 GENOTROPIN 2MG PREFILLED SYRINGES 25 $7,734.00 74 $23,193.99 GENOTROPIN 5MG CARTRIDGE 4 $3,195.22 6 $4,377.16 GENTAMICIN - GENTAK 0.3%OPHTH OINT 4 $20.08 11 $52.25 GENTAMICIN 0.1% CREAM 15GM 26 $62.18 109 $251.28 GENTAMICIN 0.1% OINT (TOPICAL) 26 $66.17 99 $241.53 GENTAMICIN 40MG/ML INJ, 20ML 24 $45.49 71 $124.02 GENTAMICIN SULF POWDER 5GM 35 $143.93 105 $423.79 GENTAMICIN SULFATE 10MG/ML INJ, 2ML 47 $97.89 131 $265.84 GENTAMICIN SULFATE 10MG/ML INJ, 8ML 1 $4.10 3 $4.30 GENTAMICIN/NACL 100MG INJ , 100ML 938 $18.45 2,815 $47.36 GENTAMICIN/NACL 80MG INJ , 50ML 1,373 $91.31 4,118 $265.92 GENTAMICIN/NACL 80MG PB INJ , 100ML 200 $8.94 600 $18.82 GENTIAN VIOLET 2% SOLUTION 59ML 59 $10.93 178 $24.79 GESTICARE DHA PAK (NEW FORMULA) 30 $51.00 90 $144.99 GFN 800 / PE 25 EXT RELEASE TABLETS 30 $34.99 90 $96.97 GFN-DM-PE TABLETS 30 $21.99 90 $57.97 GFN-PSE 1200MG-75MG ER TABLETS 30 $37.99 90 $105.97 GFN-PSE 595-48 ER TABLETS 30 $13.99 90 $33.97 GFN-PSE 800MG-60MG ER TABLETS 30 $16.00 90 $39.99 GFN-PSE-DM 800MG-60MG-30MG TABLETS 30 $9.28 90 $19.84 GILDESS 1.5/30 TABLETS 21 26 $25.25 81 $69.78 GILDESS 1/20 TABLETS 21S 26 $22.47 79 $60.24 GILDESS FE 1/20 TABLETS 28S 29 $21.37 85 $55.57 GILENYA 0.5MG CAPSULES 30 $8,155.65 89 $24,274.13 GILPHEX TR 10-388MG TABLETS 20 $22.82 59 $60.45 GILTUSS C PEDIATRIC LIQUID 30 $18.50 90 $47.49 GILTUSS LIQUID 137 $17.82 410 $45.46 GILTUSS PED LIQUID 80 $36.56 240 $101.68 GILTUSS TR 7-14-288 CAPSULES 20 $21.09 25 $25.49 GLATIRAMER 20MG/ML SOL INJ 1ML 30 $5,813.13 90 $17,394.97 GLATOPA 40MG/ML PF SYR, 12X1ML 12 $5,668.20 36 $16,754.98 GLEOSTINE 40MG CAPSULES 2 $755.34 7 $2,258.02 GLIPIZIDE-METFORMIN 2.5MG/250MG TAB 64 $53.14 175 $138.60

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price GLIPIZIDE-METFORMIN 2.5MG/500MG TAB 79 $47.18 229 $129.75 GLUCAGEN HYPOKIT INJ/EMERGENCY USE 1 $420.80 3 $732.31 GLUCAGON 1MG EMERGENCY KIT RDNA 1 $450.05 3 $840.98 GLUCOSAMINE ACETYL-D POWDER 30 $27.70 90 $75.09 GLYB/METFORMIN 5/500MG TABLETS 91 $19.22 269 $48.80 GLYCOPYRROLATE 0.2MG/ML INJ, 1ML 76 $540.55 227 $1,613.65 GLYCOPYRROLATE 0.2MG/ML INJ, 20ML 299 $2,123.61 897 $6,362.83 GLYCOPYRROLATE 0.2MG/ML INJ, 5ML 172 $1,220.75 515 $3,654.26 GLYCOPYRROLATE 2MG TABLETS 64 $79.26 177 $212.85 GLYXAMBI 10MG/5MG TABLETS 30 $579.01 90 $1,732.22 GLYXAMBI 25MG/5MG TABLETS 30 $580.00 90 $1,732.54 GOLYTELY PACKET 1 $21.44 3 $48.67 GONAL-F 1050UNIT INJ, 1 VIAL 2 $5,427.02 6 $16,273.07 GONAL-F 450IU VIAL 3 $3,912.90 8 $11,730.69 GONAL-F RFF 300IU INJ, 0.5ML 1 $1,168.11 3 $3,496.34 GONAL-F RFF 450IU INJ, 0.75ML 2 $1,826.57 5 $5,471.72 GONAL-F RFF 75IU INJ, 1 VIAL 5 $1,270.74 14 $3,804.21 GONAL-F RFF 900IU INJ, 1.5ML 3 $3,198.73 8 $9,588.19 GRALISE 600MG (GABAPENTIN ER)TABLET 78 $617.56 222 $1,754.29 GRANISETRON 1MG TABLETS 29 $1,289.92 77 $3,418.99 GRANISETRON 1MG/ML INJ, 1ML (PF) 5 $429.88 11 $894.89 GRANISETRON 1MG/ML INJ, 4ML 17 $157.70 52 $465.09 GRANIX 300MGG/0.5ML INJ, 0.5ML 4 $2,626.32 18 $12,135.64 GRANIX 480MCG/0.8ML INJ, 0.8ML 6 $3,819.37 18 $11,450.10 GRILLED TUNA FLAVOR 6 $7.34 18 $14.03 GRISEOFULVIN 125MG/5ML ORAL SUSP 363 $164.18 512 $230.31 GRISEOFULVIN MICR 500MG TABLETS 30 $151.08 104 $519.66 GRISEOFULVIN ULTR 125 TABLETS 57 $151.91 156 $407.67 GRISEOFULVIN ULTR 250MG TABLETS 46 $297.39 114 $735.04 GUAIFENESIN DM SYRUP 196 $6.49 225 $6.85 HALOBETASOL 0.05% CREAM 15GM 45 $114.43 161 $399.92 HALOBETASOL 0.05% OINTMENT 15GM 46 $204.62 162 $705.06 HALOG 0.1% CREAM 216GM 68 $911.01 203 $2,724.22 HALOG 0.1% OINTMENT 30GM 58 $789.07 240 $3,227.97 HALOPERIDOL 10MG (TEN MG) TABLETS 49 $53.56 153 $158.22 HALOPERIDOL 20MG (TWENTY MG) TABLET 46 $123.82 135 $358.83 HALOPERIDOL 2MG/ML CONCENTRATE 37 $8.02 194 $24.97 HALOPERIDOL 5MG (FIVE MG) TABS 49 $27.61 148 $74.83 HALOPERIDOL DEC 100MG/ML INJ, 1ML 2 $47.41 4 $121.28 HALOPERIDOL DEC 50MG/ML INJ 1 $48.67 3 $111.15 HALOPERIDOL LACTATE 5MG/ML INJ 10ML 12 $110.65 29 $251.22 HALOTIN 1% CREAM 20GM 30 $42.99 90 $120.96 HAVRIX 1440 U/ML SYRINGE (ADULT) 1 $109.06 1 $109.07 HAVRIX 720 U/0.5ML SYR (PEDIATRIC) 1 $60.77 2 $174.31 HC PRAMOXINE 1-1% CREAM 30GM 32 $74.21 160 $356.94 HC PRAMOXINE 2.5-1% CREAM 120GM 35 $94.19 178 $464.17

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price HECTOROL 4MCG/2ML INJ, 2ML 18 $251.00 54 $744.99 HELIXATE FS 1000 UNIT SOL, 1 VIAL 1 $5.43 3 $8.29 HELIXATE FS 2000 UNIT INJ, 1 VIAL 1 $5.43 3 $8.29 HELIXATE FS 500 UNIT SOL, 1 VIAL 4,000 $5,726.00 12,000 $17,170.00 HEMATOGEN CAPSULES 34 $13.44 90 $28.64 HEMATOGEN FA CAPSULES 35 $16.62 121 $47.49 HEMATRON LIQUID 237ML 30 $7.00 90 $12.99 HEMENATAL OB + DHA 59 $48.96 172 $135.97 HEMETAB TABLETS 34 $58.55 99 $164.25 HEMOCYTE-F ELIXIR 30 $7.71 90 $15.12 HEMOCYTE-F TABLETS 35 $16.40 96 $37.82 HEP FLUSH-10 10UNT/ML INJ , 10ML 168 $76.09 228 $101.60 HEPARIN LOCK 100/ML INJ 10ML 144 $160.26 431 $472.77 HEPARIN SOD 10,000U/ML INJ, 0.5ML 32 $219.48 97 $650.43 HEPARIN SOD 10,000U/ML INJ, 1ML 39 $324.17 116 $948.93 HEPARIN SOD 1000/ML INJ, 2ML 64 $497.77 90 $698.78 HEPARIN SOD 20,000/ML INJECTION,1ML 25 $497.10 53 $1,048.55 HEPARIN SOD 5,000U/ML INJ, 1ML 44 $123.67 183 $500.76 HEPARIN SOD LOCK FLUSH 10U/ML, 5ML 30 $13.72 90 $33.16 HERCEPTIN 440MG INJ, 1 VIAL 1 $4,686.99 3 $14,052.97 HISTACOL DM SYRUP 30 $6.41 90 $11.23 HOMATROPINE (HOMATROPAIRE)5% OP SOL 5 $20.24 6 $24.65 HORIZANT 600MG(GABAPENTIN ENA ER)TB 46 $665.45 124 $1,774.26 HUMALOG 100 U/ML KWIKPEN INJ 5X3ML 18 $664.87 41 $1,552.38 HUMALOG 100/ML INJ, 3ML 21 $549.00 64 $1,647.99 HUMALOG 200 U/ML KWIKPEN INJ 3ML 13 $1,054.71 35 $2,866.44 HUMALOG CARTRIDGE 5 X 3ML 17 $669.01 44 $1,660.22 HUMALOG MIX 50/50 INJ, 10ML 27 $831.47 80 $2,513.41 HUMALOG MIX 50/50 KWIKPEN INJ 5X3ML 25 $1,271.92 65 $3,268.17 HUMALOG MIX 75/25 KWIKPEN INJ 5X3ML 23 $1,143.73 60 $3,023.54 HUMALOG MIX 75/25 VIAL 10ML 23 $720.81 66 $2,068.10 HUMATROPE 12MG CARTRIGE KIT INJ 2 $3,634.29 4 $6,808.97 HUMATROPE 24MG CARTRIGE KIT INJ 2 $5,601.16 5 $16,795.47 HUMATROPE 5MG INJ, VIAL 6 $3,916.17 19 $11,740.50 HUMATROPE 6MG CARTRIGE KIT INJ 2 $1,961.35 5 $4,198.86 HUMIRA 20MG/0.4ML KIT (2PRF SYR) 2 $4,891.14 6 $14,665.42 HUMIRA 40MG/0.8ML KIT (2PRF SYR) 2 $5,555.93 6 $15,549.57 HUMIRA PEN 40MG CROHN STRKIT-6PEN 2 $5,346.16 7 $14,941.45 HUMULIN 70/30 INSULIN (HI-710) 23 $366.48 63 $985.51 HUMULIN 70/30 U-100 KWIKPEN 5X3ML 22 $773.55 56 $1,999.46 HUMULIN N INSULIN (HI-310) 16 $262.05 45 $710.08 HUMULIN N U-100 KWIKPEN 5X3ML 16 $564.88 35 $1,240.64 HUMULIN R U-100 3ML 16 $255.55 41 $655.48 HUMULIN R U-500 (CONCEN) VL 20ML 25 $1,966.61 48 $3,836.16 HYDROCOD /ACETAMINOPHEN 2.5-325 TB 43 $44.76 85 $84.74 HYDROCOD/ACETAMINOPHEN 7.5-325 SOL 275 $90.23 2,045 $645.23

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price HYDROCODONE BITAR/CHLORPH/PSE LIQ 164 $161.40 493 $476.19 HYDROCODONE BITARTRATE POWDER 30 $489.94 90 $1,461.82 HYDROCODONE/ACETAMINOPHEN 10-300 T 88 $208.20 189 $443.44 HYDROCODONE/ACETAMINOPHEN 10-325 T 92 $66.52 248 $173.27 HYDROCODONE/ACETAMINOPHEN 5-300 TAB 29 $27.70 164 $138.90 HYDROCODONE/ACETAMINOPHEN 5-325 TB 35 $30.74 163 $128.87 HYDROCODONE/ACETAMINOPHEN 7.5-300 T 49 $85.88 195 $327.27 HYDROCODONE/ACETAMINOPHEN 7.5-325 T 60 $14.93 210 $42.51 HYDROCODONE/CHLORPHEN ER SUSPENSION 118 $72.09 424 $247.87 HYDROCODONE/HOMATROPINE 5/1.5MG TAB 42 $39.13 96 $83.96 HYDROCODONE/HOMATROPINE ORAL SOLN 151 $27.46 271 $46.17 HYDROCODONE/IBUPROF 7.5-200MG TB 54 $63.25 167 $187.92 HYDROCODONE/IBUPROFEN 10-200MG TAB 91 $381.98 160 $669.58 HYDROCODONE/IBUPROFEN 5-200MG TAB 42 $135.04 127 $397.13 HYDROCORT ACET/PRAMOX 2.5%-1% CREAM 38 $198.24 165 $850.95 HYDROCORT BUTYRATE 0.1% SOLN 20ML 61 $113.06 84 $155.96 HYDROCORT/ACETIC ACID OTIC SOL(EAR) 10 $148.97 12 $173.83 HYDROCORTISON BUT 0.1% LOTION 118ML 92 $671.08 266 $1,920.99 HYDROCORTISONE /IODOQUINOL 1% CREAM 31 $52.54 68 $109.57 HYDROCORTISONE 0.5% CREAM 36 $5.88 49 $6.53 HYDROCORTISONE 1% CREAM 28.4GM 36 $7.10 130 $15.32 HYDROCORTISONE 1% IN ABSOBASE OINT 46 $6.97 195 $16.68 HYDROCORTISONE 1% LOTION 118 $7.66 145 $8.48 HYDROCORTISONE 100MG ENEMA 7 X 60ML 1,239 $139.63 4,719 $520.76 HYDROCORTISONE 10MG TABLETS 78 $38.37 206 $94.63 HYDROCORTISONE 2.5% LOTION 118ML 78 $58.17 302 $213.70 HYDROCORTISONE 2.5% RECTAL CREAM 34 $56.55 132 $210.70 HYDROCORTISONE 2.5% RECTAL CREAM 34 $56.55 132 $210.70 HYDROCORTISONE 20MG TABLETS 52 $31.02 137 $75.00 HYDROCORTISONE 5MG TABLETS 103 $24.58 284 $60.88 HYDROCORTISONE ACE 30MG SUPPOSITORY 21 $314.50 84 $1,264.47 HYDROCORTISONE BUT 0.1% CREAM 15GM 35 $111.66 98 $302.94 HYDROCORTISONE BUT 0.1% OINT 15GM 34 $107.88 150 $463.90 HYDROCORTISONE BUTYR 0.1% CRM 45GM 53 $246.24 79 $367.11 HYDROCORTISONE POWDER 10 $39.99 30 $111.97 HYDROCORTISONE VAL 0.2% CREAM 15GM 39 $164.16 149 $619.48 HYDROCORTISONE VAL 0.2% OINT 15GM 39 $150.46 191 $724.68 HYDROMORPHONE 12MG ER TABLETS 38 $674.79 101 $1,778.07 HYDROMORPHONE 16MG ER TABLETS 40 $658.96 104 $1,720.46 HYDROMORPHONE 1MG/ML LIQUID 196 $56.83 473 $131.66 HYDROMORPHONE 2MG/ML INJ, 1ML (PF) 31 $49.55 92 $140.66 HYDROMORPHONE 32MG ER TABLETS 38 $1,594.32 90 $3,737.73 HYDROMORPHONE 3MG RECTAL SUPP 30 $346.29 91 $1,030.86 HYDROMORPHONE 4MG TABLETS 90 $57.45 222 $135.25 HYDROMORPHONE 4MG/ML INJ, 1ML 10 $17.34 29 $44.02 HYDROMORPHONE 8MG ER TABLETS 36 $407.76 90 $1,020.99

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price HYDROMORPHONE 8MG TABLETS 109 $121.98 285 $311.77 HYDROMORPHONE HCL 2MG TABLETS 53 $23.40 148 $58.39 HYDROMORPHONE HCL POWDER 30 $5,699.19 90 $17,089.56 HYDROQUINONE 4% CREAM 28.35GM 30 $74.88 32 $81.70 HYDROXOCOBALAM 1000MCG/ML INJ, 30ML 1 $5.37 3 $8.10 HYDROXYPROGES CAP 250MG/ML INJ, 1ML 4 $2,158.75 12 $6,468.26 HYDROXYUREA 500MG CAPSULES 60 $43.16 133 $90.21 HYDROXYZINE 50MG/ML INJ, 1ML 21 $17.24 64 $43.72 HYDROXYZINE HCL 10MG TABLETS 55 $16.86 148 $38.51 HYDROXYZINE HCL 25MG/ML INJ 1ML 30 $23.09 90 $61.26 HYDROXYZINE PAMOATE 100MG CAPSULES 57 $28.67 154 $70.74 HYDROXYZINE PAMOATE 25MG CAPSULES 58 $10.42 183 $24.36 HYDROXYZINE PAMOATE 50MG CAPSULES 62 $18.50 179 $45.79 HYFIBER WITH FOS LIQUID 946ML 30 $4.38 90 $5.14 HYLATOPIC EMOLLIENT FOAM100GM 171 $505.18 513 $1,507.54 HYOMAX-SL 0.125MG SUB TABLETS 48 $28.53 281 $147.28 HYOPHEN TABLETS 55 $165.54 205 $609.96 HYOSCYAMINE 0.125/5ML ELIXIR 139 $13.98 952 $72.55 HYOSCYAMINE 0.125MG ORAL DIS TABS 54 $27.34 260 $116.72 HYOSCYAMINE 0.125MG TABLETS 53 $32.33 263 $143.99 HYOSCYAMINE 0.375MG ER TABLETS 55 $58.55 166 $169.76 HYOSCYAMINE SULFATE ORAL DROPS 15ML 19 $26.72 52 $66.15 HYPERHEP B S/D INJ , 1ML 4 $715.22 12 $2,137.65 HYPERRHO S/D 300MCG INJ,1VIAL 1 $154.54 3 $455.61 HYSINGLA ER 40MG TABLETS 30 $562.95 90 $1,683.96 IBANDRONATE 3MG/3ML INJ, 3ML 3 $231.34 3 $231.34 IBUPROFEN 200MG TABLETS 58 $5.43 247 $10.11 IDARUBICIN 10MG/10ML INJ, 10ML 1 $12.89 3 $30.68 IDARUBICIN 5MG/5ML INJ 20ML 1 $12.89 3 $30.68 IFOSFAMIDE 1GM INJ , 1VIAL 1 $35.35 3 $98.05 IFOSFAMIDE 1GM/20ML INJ,20ML 1 $7.55 3 $14.65 IFOSFAMIDE 3GM/60ML INJ,60ML 540 $2,037.91 1,620 $6,105.73 ILEVRO 0.3% OPHTH DROPS 2 $410.60 5 $799.12 IMATINIB MESYLATE 100MG TABLETS 75 $7,193.61 186 $17,860.66 IMATINIB MESYLATE 400MG TABLETS 30 $10,836.11 93 $33,048.79 IMIPRAMINE PAMOATE 100MG CAPSULES 41 $762.58 112 $2,076.01 IMIPRAMINE PAMOATE 125MG CAPSULES 35 $461.14 129 $1,701.10 IMIPRAMINE PAMOATE 150MG CAPSULES 34 $457.84 105 $1,386.37 IMIPRAMINE PAMOATE 75MG CAPSULES 35 $466.99 106 $1,425.07 IMIQUIMOD 5% CREAM 16 $292.60 26 $484.40 IMOGAM RABIES-HT 150IU/ML INJ, 10ML 10 $3,651.12 30 $10,945.36 IMOVAX RABIES VACCINE INJ, 2.5U/ML 1 $350.58 1 $365.89 INATAL ADVANCE TABLETS 30 $9.25 90 $19.75 INCRELEX 40MG/4ML INJ, 4ML 1 $840.75 3 $2,514.24 INDERAL XL 80MG CAPSULES 32 $711.99 98 $2,197.30 INDOMETHACIN 75MG ER CAPSULES 37 $76.40 132 $264.30

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price INFANRIX INJ, 0.5ML 1 $39.99 2 $111.97 INFED 50MG/ML INJ 7 $121.75 7 $122.37 INFUVITE ADULT INJ, 10ML 10 $9.46 30 $20.38 INFUVITE INJ, 5ML 1 $7.60 3 $14.79 INOVA 4/1 ACNE CONTROL THERAPY 30 $111.38 90 $326.15 INS SYR ULT THIN 0.5ML 29GX1/2 97 $21.40 163 $33.39 INSPIREASE REPLACEMENT BAGS 3 $18.65 9 $47.95 INTELENCE 100MG TABLETS 114 $1,146.14 334 $3,339.19 INTELENCE 200MG TABLETS 60 $1,293.68 181 $3,899.48 INTRALIPID 20% EMUL FOR INJ, 1000ML 750 $61.00 2,250 $175.00 INTRON A 10 MIL IU POWDERSDV 11 $3,424.89 33 $10,266.67 INTRON A 18 MIL IU POWDERSDV 1 $606.99 3 $1,812.97 INTRON A 18 MIL IU/3ML SOLN MDV 7 $1,310.91 21 $3,924.73 INTRON A 25 MIL IU/2.5ML SOLN MDV 10 $2,974.24 29 $8,914.72 INTRON A 50 MIL IU POWDERSDV 10 $13,023.90 30 $39,063.70 INTROVALE TABLETS 91 $109.99 91 $110.23 INVANZ 1GM INJ, 1 VIAL 8 $833.06 79 $8,193.21 INVANZ 1GM INJ, 1 VIAL 7 $883.13 20 $2,641.38 INVEGA SUSTENNA 117MG/0.75ML INJ 1 $2,222.65 3 $6,659.96 INVEGA SUSTENNA 234MG/1.5ML INJ 1 $1,681.33 3 $5,035.98 INVIRASE 200MG CAPSULES 96 $439.20 287 $1,309.61 INVIRASE 500MG TABLETS 114 $1,230.86 355 $3,837.86 INVOKAMET 150MG/500MG TABLETS 56 $482.57 165 $1,408.25 INVOKAMET XR 150-1000MG TABLETS 52 $450.69 163 $1,390.43 INVOKANA 100MG TABLETS 31 $428.63 91 $1,268.36 INVOKANA 300MG TABLETS 30 $421.22 90 $1,248.37 IODOSORB 0.9% GEL 40GM 42 $136.59 107 $339.98 IOPHEN DM-NR 10-100/5ML LIQUID 170 $10.61 511 $23.83 IOPIDINE 1% OPHTH SOLN 16 $463.49 48 $1,382.46 IPOL INACTIVATED IPV INJ, 0.5ML 1 $64.25 2 $184.76 IPRATROPI/ALB 0.5/3MG INH SL 30X3ML 238 $111.15 978 $443.78 IPRATROPIUM 0.03% NAS SP 30ML (345) 30 $23.19 61 $42.41 IPRATROPIUM 0.06% NAS SP 15ML (165) 19 $37.67 63 $113.14 IRBESARTAN/HCTZ 150-12.5MG TABLETS 33 $97.29 96 $278.43 IRBESARTAN/HCTZ 300-12.5MG TABLETS 30 $98.77 90 $288.14 IRINOTECAN 100MG/5ML INJ, 5ML 31 $121.43 92 $356.30 IRINOTECAN 20MG/ML SOL, 2ML 28 $681.72 83 $2,037.17 IROFOL LIQ 120 $12.26 360 $28.77 IROFOL TAB 31 $16.90 94 $42.69 IRO-PLEX TABLETS 30 $18.40 90 $47.19 IROSPAN 24/6 TABLETS 30 $163.23 92 $485.47 ISENTRESS 400MG TABLETS 57 $1,361.36 180 $4,298.05 ISOMETH/ACETAMINOPHEN/DICHLOR CAPS 33 $138.32 107 $436.13 ISOMETH/CAFF/ACETAMINOPHEN TABS 32 $95.42 44 $129.11 ISONIAZID 300MG TABLETS 30 $24.78 88 $65.52 ISONIAZID 50MG/5ML SYRUP 518 $196.91 1,308 $490.81 ISOPTO CARBACHOL 1.5% 15ML SOLN 30 $127.02 90 $373.06

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ISOPTO CARBACHOL 3% 15ML 30 $144.86 90 $426.58 ISOPTO HOMATROPINE 2% OPH SOLN 5ML 30 $223.84 90 $663.52 ISOPTO HYOSCINE 0.25% OPH SOLN 5ML 30 $216.58 90 $641.74 ISORDIL TITRADOSE 40MG TABLETS 72 $193.25 217 $578.37 ISOSORBIDE DINITRATE 10MG ORAL TABS 76 $64.18 212 $171.50 ISOSORBIDE DINITRATE 30MG ORAL TABS 53 $47.14 138 $115.52 ISOSORBIDE DINITRATE 40MGER TABS 37 $75.37 127 $249.40 ISOXSUPRINE 10MG TABLETS 64 $38.42 271 $148.89 ISRADIPINE 2.5MG CAPSULES 60 $74.33 171 $202.93 ISRADIPINE 5MG CAPSULES 55 $96.88 165 $281.61 ITRACONAZOLE 100MG 7 DAY PACK 51 $416.54 170 $1,385.87 ITRACONAZOLE 10MG/ML SOLN 150ML 550 $825.50 1,779 $2,662.72 IVERMECTIN 3MG TABLETS 9 $54.38 38 $208.23 IXIARO 0.5ML INJECTION 1 $316.09 2 $940.28 JANUMET 50/1000MG TABLETS 58 $465.80 173 $1,371.99 JANUMET 50/500MG TABLETS 56 $410.66 164 $1,200.77 JANUMET XR 100MG/1000MG TABLETS 31 $450.05 91 $1,336.16 JANUMET XR 50MG/1000MG TABLETS 55 $403.80 160 $1,169.26 JANUVIA 100MG TABLETS 30 $455.03 90 $1,346.24 JANUVIA 25MG TABLETS 30 $453.84 90 $1,338.90 JANUVIA 50MG TABLETS 31 $454.04 91 $1,333.40 JARDIANCE 10MG TABLETS 30 $479.70 90 $1,426.60 JARDIANCE 25MG TABLETS 30 $516.96 90 $1,534.73 JENTADUETO 2.5MG/850MG TABLETS 56 $428.99 169 $1,278.53 JENTADUETO XR 2.5MG-1000MG TABLETS 55 $422.33 166 $1,257.90 JEVANTIQUE LO 0.5MG-2.5MCG TABLETS 29 $92.84 85 $263.61 JUBLIA 10% TOPICAL NAIL SOL 4ML 6 $831.90 10 $1,380.51 JULUCA 50-25MG TABLETS 30 $2,843.08 90 $8,517.79 KALETRA 100-25MG TABLETS 140 $623.28 381 $1,695.25 KALETRA 200-50MG TABLETS 118 $1,124.80 352 $3,347.61 KARIGEL-N 1.1% GEL 125ML 74 $11.94 223 $27.89 KCL/D5W/LR 0.15% INJ, 1000ML 1 $4.00 3 $4.01 KCL/D5W/NAC .15-.45% INJ,, 500ML 1 $4.00 3 $4.01 KCL/D5W/NACL .075/.45 INJ, 1000ML 1 $4.00 3 $4.01 KCL/D5W/NACL 0.15/0.2 INJ, 1000ML 1 $4.00 3 $4.01 KCL/D5W/NACL 0.15/0.9 INJ , 1000ML 1 $4.00 3 $4.01 KCL/D5W/NACL 0.3/0.45 INJ, 1000ML 1 $4.00 3 $4.01 KELNOR 1/50 TABLETS 28S 29 $26.43 87 $70.42 KEPIVANCE 6.25MG INJ, 1 VIAL 1 $1,517.05 3 $4,543.15 KERAFOAM 30% AER 60GM 30 $82.50 90 $239.49 KERAFOAM 42 42% AEROSOL FOAM 30 $68.49 90 $197.48 KERALYT SCALP 6% KIT 1 $84.33 3 $244.99 KETAMINE 100MG/ML INJ, 10ML 16 $32.05 70 $130.69 KETAMINE 50MG/ML INJ, 10ML 13 $6.57 37 $11.08 KETEK 400MG TABLETS 30 $540.85 90 $1,614.55 KETOCONAZOLE 2% CREAM 30GM 45 $117.52 165 $421.16 KETOCONAZOLE 2% SHAMPOO 120ML 128 $31.80 410 $92.86

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price KETOCONAZOLE 200MG TABLETS 17 $25.57 73 $96.20 KETONE (URINE) TEST STRIP100'S 69 $7.44 114 $9.73 KETOPROFEN 200MG E.R. CAPSULES 30 $173.21 91 $526.72 KETOPROFEN 50MG CAPSULES 42 $8.69 154 $21.10 KETOPROFEN 75MG CAPSULES 40 $10.63 179 $33.84 KETOROLAC 0.4% OPTH SOLN5ML 5 $57.25 7 $78.99 KETOROLAC 0.5% OPHTH SOL 5ML 6 $21.30 9 $28.00 KETOROLAC 10MG TABLETS 17 $22.04 52 $58.83 KETOROLAC 15MG/ML INJ, 1ML 9 $37.73 28 $105.20 KETOROLAC 30MG/ML INJ 1ML 7 $15.94 18 $34.34 KETOROLAC 30MG/ML INJ, CARPUJECT LL 10 $24.60 23 $51.07 KEVZARA 150MG/1.14ML INJ(2 PF PENS) 2 $3,412.99 7 $10,230.97 KEVZARA 150MG/1.14ML INJ(2 PF PENS) 2 $3,412.99 7 $10,230.97 KEVZARA 200MG/1.14ML INJ(2 PF PENS) 2 $3,412.99 7 $10,230.97 KEVZARA 200MG/1.14ML INJ(2 PF PENS) 2 $3,501.64 5 $8,185.58 KEYTRUDA 100MG/4ML INJ, 4ML 8 $10,289.91 25 $30,861.73 KEYTRUDA 50MG SOLUTION 30 $71,253.70 90 $213,753.10 KINRIX INJ, 0.5ML 1 $59.99 1 $59.99 KIONEX 15GM/60ML SUSPENSION 340 $134.12 1,598 $616.43 KIONEX POWDER 405 $107.45 701 $183.04 KLOR-CON 20MEQ POWDER PACK 41 $458.13 127 $1,409.49 KLOR-CON POWDER PKTS 25MEQ 30 $415.09 90 $1,237.27 KOMBIGLYZE XR 5-1000MG TABLETS 31 $340.29 92 $998.76 KOMBIGLYZE XR 5-500MG TABLETS 31 $341.76 92 $998.20 K-PHOS 500MG TABLETS 75 $42.54 204 $108.81 K-PHOS-2 TABLETS 86 $88.01 194 $194.38 KRISTALOSE 10GM PACKETS 32 $252.58 140 $1,099.32 KRISTALOSE 20GM PACKETS 38 $308.27 155 $1,246.81 LABETALOL 100MG TABLETS 64 $33.63 182 $89.02 LABETALOL 5MG/ML INJ, 20ML 20 $5.67 20 $5.67 LACTATED RINGER SOL FOR INJ, 1000ML 8,087 $50.09 11,718 $70.79 LACTATED RINGERS DEXTROS 5%, 500ML 8,000 $46.40 13,000 $72.90 LACTATED RINGERS IRRIGATION SOLN 5,864 $33.32 12,000 $64.00 LACTIC ACID 10% E CREAM 113.4GM 113 $22.97 340 $60.92 LACTIC ACID 10% LOTION 354.84ML 367 $14.91 1,065 $35.62 L-ALL 12 SUSPENSION 30 $12.13 90 $28.40 LAMICTAL BLUE STARTER KIT 25MG 37 $471.82 110 $1,407.45 LAMICTAL ORANGE STRT KIT25MG/100MG 49 $642.71 147 $1,920.12 LAMISIL 1% SOLUTION 30ML 125 $372.16 167 $494.72 LAMISIL 187.5MG GRANULES 30 $743.63 90 $2,222.89 LAMIVUD/ZIDOVUD 150MG/300MG TABS 58 $418.52 179 $1,273.89 LAMIVUDINE 100MG TABLETS 28 $303.45 86 $926.90 LAMIVUDINE 150MG TABLETS 39 $216.27 117 $642.81 LAMIVUDINE 300MG TABLETS 30 $197.21 93 $602.66 LAMOTRIGINE 150MG TABLETS 49 $114.60 153 $351.74 LAMOTRIGINE 25MG CHEW/DISPRSBL TAB 181 $18.40 545 $47.38

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price LAMOTRIGINE 25MG TABLETS 73 $148.90 234 $468.08 LAMOTRIGINE 5MG CHEW/DISPRSBL TAB 144 $18.34 331 $37.02 LAMOTRIGINE ER 250MG TABLETS 44 $809.58 129 $2,358.02 LAMOTRIGINE ER 25MG TABLETS 59 $341.48 169 $980.96 LAMOTRIGINE ER 50MG TABLETS 48 $456.37 148 $1,406.98 LAMOTRIGINE ODT 100MG TABLETS 71 $561.80 169 $1,338.51 LAMOTRIGINE ODT 200MG TABLETS 51 $497.66 152 $1,493.06 LAMOTRIGINE ODT 25-50-100MG TB KIT 35 $225.86 105 $669.57 LAMOTRIGINE ODT 25-50MG TB KIT BLUE 29 $163.53 86 $482.58 LAMOTRIGINE ODT 25MG TABLETS 126 $895.02 394 $2,788.71 LAMOTRIGINE ODT 50-100MG TB KIT GRN 56 $446.71 168 $1,332.12 LAMOTRIGINE ODT 50MG TABLETS 72 $547.17 176 $1,323.91 LANSO/AMOX/CLAR PACK CARD 112 $680.50 336 $2,033.51 LANSOPRAZOLE 15MG DR CAPSULES 36 $118.94 103 $334.56 LANSOPRAZOLE 30MG DR CAPS 35 $160.97 102 $463.07 LANTHANUM 1000MG CHEWABLE TABLETS 114 $668.78 346 $2,021.24 LANTHANUM 500MG CHEWABLE TABLETS 137 $803.73 354 $2,064.64 LANTHANUM 750MG CHEWABLE TABLETS 131 $769.61 568 $3,320.91 LANTUS U-100 INSULIN 10ML 16 $450.26 43 $1,181.68 LASTACAFT 0.25% OPHTH SOLN 3ML 3 $229.69 10 $719.23 LATANOPROST 0.005% OPHTH SOLN 2.5ML 4 $72.62 8 $165.84 LATRIX 50% SUSPENSION 30 $14.14 90 $34.42 LATUDA 120MG TABLETS 29 $1,799.82 89 $5,458.83 LATUDA 20MG TABLETS 30 $1,247.50 94 $3,852.70 LATUDA 40MG TABLETS 30 $1,048.62 92 $3,214.73 LATUDA 60MG TABLETS 30 $1,216.71 92 $3,708.68 LATUDA 80MG TABLETS 33 $1,194.76 99 $3,622.55 LAVOCLEN-4% CREAMY WASH 170.1GM 172 $50.39 515 $143.18 LAVOCLEN-8 ACNE WASH KIT 30 $1,683.70 90 $5,043.10 LAYOLIS FE CHEW TABLETS 29 $81.71 85 $233.35 LEFLUNOMIDE 20MG TABLETS 30 $157.94 89 $454.83 LETAIRIS 5MG TABLETS 30 $7,799.99 90 $23,391.97 LETROZOLE 2.5MG TABLETS 23 $189.66 88 $707.03 LEUCOVOR CA 100MG INJ, 1ML 9 $237.10 27 $705.73 LEUCOVORIN CALCIUM 10MG TABLETS 28 $177.31 83 $523.93 LEUCOVORIN CALCIUM 15MG TABLETS 34 $185.02 40 $216.07 LEUCOVORIN CALCIUM 25MG TABLETS 49 $529.69 76 $828.03 LEUCOVORIN CALCIUM 350MGINJ, 1 VL 4 $49.91 13 $141.73 LEUCOVORIN CALCIUM 5MG TABLETS 23 $34.56 31 $44.26 LEUCOVORIN CALCIUM INJ, 1 VIAL 1 $46.50 3 $131.50 LEUKERAN 2MG TABLETS 24 $569.36 49 $1,169.80 LEUKINE 250MCG INJ, 1 VIAL 15 $4,218.41 46 $12,647.24 LEUPROLIDE 1MG/0.2 ML 2-WK INJ KIT 1 $619.81 1 $717.22 LEVALBUTEROL 0.31MG/3ML NEB 24X3ML 120 $207.38 757 $1,285.89 LEVALBUTEROL 0.63MG/3ML NEB 24X3ML 159 $351.22 765 $1,673.05 LEVALBUTEROL 1.25MG/3ML NEB 24X3ML 164 $321.25 792 $1,535.04

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price LEVALBUTEROL CONC 1.25MG/0.5ML 30VL 53 $342.52 211 $1,347.08 LEVALBUTEROL HFA INH (200PF) 15GM 18 $62.43 48 $159.89 LEVEMIR FLEX TOUCH PEN INJ 5X3ML 18 $435.96 37 $908.85 LEVEMIR SOLUTION FOR INJ, 10ML 18 $436.56 45 $1,081.89 LEVETIRACETAM 100MG/ML SOLUTION 340 $144.95 1,047 $437.94 LEVETIRACETAM 250MG TABLETS 79 $77.67 212 $202.26 LEVETIRACETAM 500MG TABLETS 78 $122.35 225 $344.60 LEVETIRACETAM ER 500MG TABLETS 92 $348.58 249 $934.68 LEVETIRACETAM ER 750MG TABLETS 81 $495.76 223 $1,362.94 LEVITRA 10MG TABLETS 6 $274.66 16 $772.60 LEVITRA 2.5MG TABLETS 6 $333.98 18 $993.93 LEVITRA 20MG TABLETS 6 $268.59 19 $892.82 LEVITRA 5MG TABLETS 6 $290.99 18 $861.97 LEVO CAL/ACETYL/MECO PWD TABLETS 30 $103.82 92 $304.96 LEVO PYRIDOX PHOSPHA PWD CAPS 43 $88.58 123 $244.71 LEVOBUNOLOL 0.25% OPHTH SOLN 5ML 30 $46.72 90 $132.16 LEVOCARNITINE 10% ORAL SOLUTION 325 $75.59 950 $213.28 LEVOCARNITINE 200MG/ML INJ, 5ML 15 $116.80 45 $342.39 LEVOCARNITINE 330MG TABLETS 109 $75.59 301 $201.55 LEVOCETIRIZINE 2.5MG/5ML ORAL SOL 136 $69.25 439 $214.56 LEVOFLOXACIN 0.5% OPHTH SOLN 5ML 5 $76.69 8 $108.99 LEVOFLOXACIN 250MG TABLETS 8 $107.98 80 $1,002.33 LEVOFLOXACIN 500MG TABLET 9 $114.78 74 $940.68 LEVOFLOXACIN 750MG TABLETS 8 $165.50 69 $1,470.47 LEVONORGSTRL/ETHNYL EST TABLETS 91S 91 $374.99 91 $375.33 LEVOTHROID 0.075MG TABS (REFORM) 30 $42.51 89 $117.91 LEVOTHROID 0.088MG TABS (REFORM) 30 $41.84 89 $116.15 LEVOTHYROXIN/LIOTHYRONINE 15MG TABS 42 $20.86 111 $48.52 LEVOTHYROXIN/LIOTHYRONINE 30MG TABS 39 $11.71 107 $25.29 LEVOTHYROXIN/LIOTHYRONINE 60MG TABS 36 $19.52 101 $47.67 LEVOTHYROXIN/LIOTHYRONINE 90MG TABS 31 $16.72 90 $41.00 LEVOTHYROXINE SODIUM POWDER 30 $5,673.70 90 $17,013.10 LEVOXYL 0.025MG (25MCG) TABLETS 31 $52.73 91 $145.75 LEVOXYL 0.05MG (50MCG) TABLETS 31 $44.13 90 $121.22 LEVOXYL 0.100MG (100MCG)TABLETS 30 $42.07 89 $116.10 LEVOXYL 0.112MG (112MCG)TABLETS 31 $42.73 90 $117.38 LEVOXYL 0.125MG (125MCG)TABLETS 31 $42.22 90 $116.38 LEVOXYL 0.137MG (137MCG)TABLETS 30 $48.12 89 $134.22 LEVOXYL 0.15MG (150MCG) TABLETS 30 $41.89 89 $115.50 LEVOXYL 0.175MG (175MCG)TABLETS 30 $40.03 88 $110.11 LEVOXYL 0.2MG (200MCG) TABLETS 31 $41.13 90 $112.05 LIDAZONE HC RECTAL CREAM 36 $36.22 111 $102.14 LIDOCAINE 1% INJ, 10ML 28 $10.53 36 $12.49 LIDOCAINE 1% INJ, 30ML 28 $6.50 37 $7.26 LIDOCAINE 1% INJ, 5ML 1 $5.00 3 $6.99 LIDOCAINE 1%/EPINE:100000 INJ, 20ML 380 $52.53 437 $59.76

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price LIDOCAINE 2% INJ , 5ML 34 $12.95 135 $39.74 LIDOCAINE 2% INJ, 50ML 179 $13.32 538 $31.97 LIDOCAINE 2% INJ, 5ML 1 $4.29 3 $4.88 LIDOCAINE 2% TOPICAL JELLY 30 $23.44 90 $62.32 LIDOCAINE 2%/EPINEPHRINE 0.001% INJ 220 $35.68 660 $99.04 LIDOCAINE 3% CREAM 28.35GM 43 $43.88 148 $139.57 LIDOCAINE 4% INJECTION, 5ML 131 $29.85 392 $81.56 LIDOCAINE 5% PATCH 33 $270.54 119 $964.44 LIDOCAINE 5% TOP/ORAL OINT (SPRMT) 51 $359.36 215 $1,493.82 LIDOCAINE/EPINEPHRINE 2% INJ, 20ML 20 $6.23 60 $10.69 LIDOCAINE/PRILOCAINE CREAM 30GM 35 $39.82 150 $159.43 LIDOCAINE-HYDROCORTISONEW/ALOE GEL 102 $135.71 306 $399.12 LIMBREL 250-50MG CAPSULES 28 $358.68 83 $1,068.04 LIMBREL 250MG CAPSULES 50 $108.99 180 $381.96 LIMBREL 500-50MG CAPSULES 57 $736.63 180 $2,311.55 LIMBREL 500MG CAPSULES 58 $702.55 142 $1,711.00 LINCOCIN VIAL 300MG/ML2ML 9 $205.13 27 $607.40 LINDANE 1% LOTION 60ML 30 $61.40 90 $176.19 LINDANE 1% SHAMPOO 67 $143.07 201 $421.22 LINEZOLID 100MG/5ML ORALSUSP 150ML 382 $1,880.42 1,146 $5,633.25 LINZESS 145MCG CAPSULES 31 $405.03 91 $1,185.99 LINZESS 290MCG CAPSULES 31 $399.93 90 $1,177.19 LIOTHYRONINE 25MCG TABLETS 36 $33.88 97 $84.44 LIOTHYRONINE 50MCG** TABLETS 39 $66.73 108 $176.94 LIOTHYRONINE 5MCG TABLETS 52 $54.41 139 $137.86 LIOTHYRONINE SODIUM POWDER 30 $3,123.94 90 $9,363.82 LIPOCHOL PLUS TABLETS 28 $25.53 59 $49.51 LIPOSYN III 10% INJ, 500ML 1 $4.03 3 $4.09 LIPRAM UL 20 CAPSULES 30 $32.80 90 $90.39 LITHIUM CARBONATE ER 300MG TABLETS 77 $39.96 219 $106.07 LITHIUM CARBONATE ER 450MG TABLETS 55 $16.71 154 $39.83 LITHIUM CITRATE 8MEQ/5ML SOLUTION 354 $61.39 642 $108.06 LITHOSTAT 250MG TABLETS 30 $665.49 90 $1,988.48 LIVALO 1MG TABLETS 29 $283.07 87 $824.30 LIVALO 2MG TABLETS 30 $281.10 87 $819.03 LIVALO 4MG TABLETS 30 $285.31 88 $837.45 L-METHYLFOLATE 15MG TABLETS 30 $82.65 91 $243.22 L-METHYLFOLATE 7.5MG TABLETS 30 $56.74 88 $156.39 L-METHYLFOLATE FORTE 15MG CAPSULES 30 $116.99 90 $345.39 L-METHYLFOLATE W/B6-B12 TABLETS 44 $51.00 115 $126.93 L-METHYL-MC NAC TABLETS 33 $46.11 91 $121.62 L-M-X 4% CREAM 15GM 42 $68.88 113 $177.06 LO LOESTRIN FE TABLETS 28S 28 $116.26 84 $338.25 LOHIST-D LIQUID 179 $18.43 536 $47.28 LOHIST-DM 5-2-10MG SYRUP 146 $21.28 438 $55.84 LOPERAMIDE 2MG CAPSULES 57 $22.91 270 $93.96

Prescription drug coverage and cost are subject to change.

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

LOPERAMIDE HCL POWDER 25GM 30 $237.99 90 $705.96 LORAZEPAM 0.5MG TABLETS 44 $16.39 139 $43.27 LORAZEPAM 1MG TABLETS 49 $24.55 142 $63.80 LORAZEPAM 2MG TABLETS 53 $37.99 142 $95.64 LORAZEPAM 2MG/ML DROPS 30ML 34 $51.06 59 $84.51 LORAZEPAM 2MG/ML INJ 10ML 19 $11.74 58 $27.23 LORAZEPAM 4MG/ML INJ , 10ML 13 $10.68 40 $24.04 LOSARTAN 100MG TABLETS 30 $61.38 90 $175.09 LOTEMAX 0.5% OPHTH OINTMENT 4 $310.19 11 $935.95 LOTEMAX 0.5% OPHTHALMIC SUSP 10ML 6 $298.22 8 $413.50 LOTEMAX 0.5% OPTH GEL DROPS 5GM 5 $225.95 7 $296.01 LOXAPINE 10MG CAPSULES 63 $79.43 166 $203.72 LOXAPINE 25MG CAPSULES 54 $55.37 161 $156.78 LOXAPINE 50MG (FIFTY MG) CAPSULES 65 $84.28 170 $215.37 LOXAPINE 5MG CAPSULES 57 $58.95 141 $139.06 LOZI-FLUR 2.2MG LOZENGE 30 $11.49 90 $26.47 LUFYLLIN 200MG TABLETS 30 $147.40 90 $434.20 LUFYLLIN 400MG TABLETS 30 $225.10 90 $667.30 LUGOLS (STRONG IODINE) SOLUTION 104 $17.64 227 $33.82 LUMIGAN 0.01% OPHTH SOLN 2.5ML 4 $228.08 8 $498.19 LUPRON DEPOT 11.25MG INJ/3 MTH KIT 1 $3,456.99 1 $3,456.99 LUPRON DEPOT 22.5MG INJ KIT (3MTH) 1 $4,111.99 1 $4,111.99 LUPRON DEPOT 3.75MG INJ/1MTH KIT 1 $1,165.54 3 $2,965.86 LUPRON DEPOT 45MG INJ/6 MTH KIT 1 $8,316.99 1 $8,316.99 LUPRON DEPOT 7.5MG INJ/1MTH KIT 1 $1,388.31 3 $4,156.94 LUPRON DEPOT-PED 11.25MGINJ/1 MTH 1 $2,539.48 3 $7,610.43 LUPRON DEPOT-PED 15MG INJ/1 MTH KIT 1 $2,773.99 3 $8,313.97 LUPRON DEPOT-PED 7.5MG INJ/1MTH KIT 1 $1,442.06 3 $4,318.19 LYRICA 100MG CAPSULES 73 $683.15 201 $1,869.48 LYRICA 150MG CAPSULES 69 $611.86 193 $1,706.07 LYRICA 200MG CAPSULES 71 $634.55 200 $1,769.12 LYRICA 225MG** CAPSULES 58 $440.48 168 $1,278.81 LYRICA 25MG CAPSULES 64 $491.47 170 $1,295.07 LYRICA 300MG CAPSULES 56 $430.71 166 $1,262.79 LYRICA 50MG CAPSULES 68 $584.83 181 $1,554.17 LYRICA 75MG CAPSULES 65 $523.73 181 $1,447.43 LYSODREN 500MG TABLETS 32 $182.11 97 $538.32 MACNATAL CN DHA CAPSULES 30 $30.75 95 $88.32 MACUGEN 0.3MG /0.09ML SYRINGE 30 $34,219.60 90 $102,650.80 MACUTEK TABLETS 30 $154.69 90 $456.08 MAGNEBIND 400 TABLETS 46 $16.94 101 $32.12 MAGNESIUM CHLORIDE 20% INJ, 50ML 54 $26.82 163 $72.45 MAGNESIUM OXIDE 400MG TABLETS 53 $7.47 129 $12.45 MAGNESIUM SU 50% INJ, 50ML 59 $7.62 178 $14.85 MALATHION 0.5% LOTION 59ML 64 $275.35 177 $756.98 MANGANESE CL 0.1MG/ML INJ , 10ML 1 $5.24 3 $7.72

Prescription drug coverage and cost are subject to change.

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

MANGANESE SULF 0.1MG/ML INJ , 10ML 1 $6.62 3 $11.86 MANNITOL 25% INJ , 50ML 285 $10.16 855 $22.47 MAPROTILINE 25MG TABLETS 68 $93.70 167 $222.83 MAPROTILINE 50MG TABLETS 69 $139.28 186 $368.18 MAPROTILINE 75MG TABLETS 52 $110.77 129 $270.62 MAR-COF BP LIQUID 60 $13.77 180 $33.30 MAR-COF CG EXPECTORANT LIQUID 147 $26.33 440 $70.99 MARNATAL-F CAPSULES 30 $64.99 90 $186.97 MARPLAN 10MG TABLETS 98 $468.74 212 $1,011.19 MAXIDEX OPHTH SUSP 5ML 6 $91.20 7 $114.74 MAXIFED DM TABLETS (NEW) 30 $29.99 90 $81.97 MAXIFED-G TABLETS (NEW) 30 $24.99 90 $66.97 M-CLEAR WC LIQUID 189 $15.61 240 $18.71 MECLIZINE 12.5MG (O-T-C) TABLETS 44 $17.04 173 $55.96 MECLIZINE 25MG (RX) TABLETS 41 $16.21 178 $57.40 MECLOFENAMATE 100MG CAPSULES 50 $344.16 201 $1,384.60 MECLOFENAMATE 50MG CAPSULES 39 $148.28 180 $666.38 MEDROXYPR AC 150MG/ML INJ , 1ML 1 $74.80 3 $216.39 MEDROXYPROGESTERONE 150MG/ML PF SYR 1 $77.05 3 $223.14 MEFENAMIC ACID 250MG CAPSULES 31 $335.99 177 $1,926.03 MEFLOQUINE 250MG TABLETS 5 $27.21 10 $52.96 MEGESTROL 625MG/5ML SUSPENSION 160 $428.56 456 $1,211.90 MEGESTROL ACET MICRO POW100GM 30 $143.20 90 $421.59 MEGESTROL ACETATE 40MG TABLETS 64 $42.50 161 $100.41 MEGESTROL ACETATE 40MG/ML SUSP 353 $106.80 833 $246.15 MELODETTA 24 FE CHEW TABLETS 28S 28 $114.53 84 $332.59 MELOXICAM 7.5MG/5ML SUSPENSION 31 $30.96 94 $84.88 MEMANTINE 10MG TABLETS 56 $300.86 166 $877.93 MEMANTINE 2MG/ML SOLUTION 307 $562.68 778 $1,422.57 MEMANTINE ER 14MG CAPSULES 29 $204.71 90 $628.09 MEMANTINE ER 21MG CAPSULES 28 $198.39 90 $626.57 MEMANTINE TABLETS TITRATION PAK 49 $139.08 147 $409.24 MENACTRA INJ 0.5ML VIAL 1 $68.41 2 $197.22 M-END PE LIQUID 194 $16.30 581 $40.90 M-END WC LIQUID 120 $19.73 360 $51.20 MENEST 0.3MG TABLETS 29 $55.93 87 $156.81 MENEST 0.625MG TABLETS 29 $77.59 87 $222.34 MENEST 1.25MG TABLETS 30 $108.17 95 $337.14 MENEST 2.5MG TABLETS 30 $167.27 90 $493.80 MENOPUR 75 UNIT INJ, 1VIAL 9 $1,621.02 77 $14,531.28 MENOSTAR 14MCG PATCHES 4 $180.62 12 $491.41 MENVEO INJ, 1 VIAL 1 $129.13 3 $379.38 MEPERIDINE 100MG TABLETS 61 $157.35 165 $416.45 MEPERIDINE 100MG/ML INJ, 1ML 23 $20.86 68 $54.57 MEPERIDINE 50MG TABLETS 31 $35.41 76 $80.13 MEPERIDINE 50MG/ML INJ, 1ML 2 $11.68 3 $17.31

Prescription drug coverage and cost are subject to change.

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

MEPERIDINE HCL 50MG/5ML SYRUP 14 $6.03 42 $10.10 MEPHYTON 5MG TABLETS 17 $1,075.80 85 $5,476.70 MEPROBAMATE 200MG TABLETS 73 $430.53 150 $879.01 MEPROBAMATE 400MG TABLETS 65 $431.04 170 $1,112.18 MESALAMINE 1.2GM TABLETS 93 $552.60 257 $1,515.26 MESALAMINE 4GM KIT (4 KITS) 3 $494.50 11 $1,582.44 MESALAMINE 800MG DR TABLETS 136 $477.29 328 $1,148.62 MESALAMINE RECTAL SUSP 28 X 60ML 1,496 $474.20 4,803 $1,513.73 MESNA 100MG/M INJ, 10ML 24 $91.26 73 $265.79 MESNEX 400MG TABLETS 14 $1,255.12 43 $3,757.36 MESTINON SYRUP 337 $846.30 1,111 $2,779.24 METAPROTERENOL 10MG TABLETS 111 $96.27 178 $151.51 METAPROTERENOL 10MG/5ML SYRUP 30 $4.91 90 $6.73 METAPROTERENOL 20MG TABLETS 60 $79.94 244 $311.78 METAXALONE 400MG TABLETS 52 $274.37 198 $1,026.90 METAXALONE 800MG TABLETS 51 $197.96 200 $772.25 METFORMIN ER 1000MG MODIFIED TABS 47 $2,542.38 143 $7,739.28 METFORMIN ER 500MG MODIFIED TABS 66 $1,648.74 198 $4,968.92 METHADONE 10MG TABLETS 121 $49.59 238 $93.99 METHADONE 10MG/5ML SOLN 420 $61.93 500 $73.00 METHADONE 10MG/ML CONCENTRATE SOLN 69 $57.39 207 $164.16 METHADONE 5MG TABLETS 73 $20.88 194 $48.62 METHADONE 5MG/5ML SOLN 215 $22.06 244 $24.52 METHAMPHETAMINE 5MG TABLETS 130 $661.14 299 $1,515.76 METHAZOLAMIDE 25MG TABLETS 66 $329.72 208 $1,025.81 METHAZOLAMIDE 50MG TABLETS 62 $605.80 191 $1,851.75 METHENAMINE HIPPURATE 1GM TABLETS 54 $99.48 147 $264.35 METHENAMINE MANDELATE 0.5GM TABS 60 $27.92 170 $71.96 METHENAMINE MANDELATE 1GM TABLETS 56 $84.57 165 $242.06 METHOTREXATE 1GM/40ML PF SINGLE USE 7 $15.36 18 $32.96 METHOTREXATE 2.5MG TABLETS - ORANGE 27 $73.19 76 $199.29 METHOTREXATE 250MG/10ML PF SINGLE U 13 $25.70 39 $69.10 METHOTREXATE 25MG/ML PF SINGLE USE 5 $11.49 13 $24.90 METHOTREXATE 25MG/ML PF SINGLE USE 9 $18.03 26 $46.08 METHOTREXATE 25MG/ML PF SINGLE USE 73 $124.00 218 $364.00 METHOTREXATE 25MG/ML PRESV MULT USE 4 $19.79 10 $41.20 METHOTREXATE 25MG/ML PRESV MULT USE 10 $25.13 10 $25.39 METHSCOPOLAMINE BR 2.5MG TABLETS 61 $142.88 189 $431.87 METHSCOPOLAMINE BR 5MG TABLETS 55 $156.69 173 $482.04 METHYCLOTHIAZIDE 5MG TABS 33 $72.34 85 $181.45 METHYLCOBALAMIN POWDER 30 $2,039.19 90 $6,109.56 METHYLDOPA/HCTZ 250/15MG TABS 67 $112.91 147 $244.04 METHYLDOPA/HCTZ 250/25MGTABLETS 48 $118.92 148 $359.72 METHYLENE BLUE 1% INJ, 10ML 54 $52.95 163 $150.84 METHYLPHENIDATE 10MG ER (LA) CAPS 32 $316.63 106 $1,023.64 METHYLPHENIDATE 10MG ER TABLETS 37 $172.16 125 $571.96 METHYLPHENIDATE 10MG TABLETS 60 $56.05 168 $149.75 METHYLPHENIDATE 10MG/5ML ORAL SOLN 319 $297.58 601 $557.31

Prescription drug coverage and cost are subject to change.

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

METHYLPHENIDATE 18MG ER OSM TABLET 32 $232.75 90 $651.97 METHYLPHENIDATE 18MG ER TABLETS 31 $223.95 98 $707.13 METHYLPHENIDATE 20MG ER (LA) CAPS 34 $134.49 110 $427.49 METHYLPHENIDATE 20MG ER TABLETS 44 $158.56 137 $486.42 METHYLPHENIDATE 20MG TABLETS 70 $98.55 192 $264.19 METHYLPHENIDATE 27MG ER OSM TABLET 30 $225.32 92 $682.72 METHYLPHENIDATE 27MG ER TABLETS 30 $224.85 100 $740.63 METHYLPHENIDATE 30MG ER (LA) CAPS 34 $170.67 99 $496.21 METHYLPHENIDATE 36MG ER OSM TABLET 37 $284.57 114 $864.77 METHYLPHENIDATE 36MG ER TABLETS 36 $275.63 96 $727.17 METHYLPHENIDATE 40MG ER (LA) CAPS 32 $132.10 95 $391.54 METHYLPHENIDATE 54MG ER OSM TABLET 30 $249.00 92 $746.95 METHYLPHENIDATE 54MG ER TABLETS 30 $248.87 100 $804.43 METHYLPHENIDATE 5MG TABLETS 52 $40.08 153 $111.28 METHYLPHENIDATE 5MG/5ML ORAL SOLN 320 $206.45 701 $446.83 METHYLPHENIDATE CD 10MG CAPSULES 32 $162.57 103 $513.89 METHYLPHENIDATE CD 20MG CAPSULES 31 $165.62 98 $508.41 METHYLPHENIDATE CD 30MG CAPSULES 31 $166.83 95 $504.44 METHYLPHENIDATE CD 40MG CAPSULES 30 $213.06 95 $655.50 METHYLPHENIDATE CD 50MG CAPSULES 30 $259.28 90 $764.55 METHYLPHENIDATE CD 60MG CAPSULES 30 $268.90 91 $803.34 METHYLPR ACE 40MG/ML INJ, 10ML 2 $19.12 5 $51.10 METHYLPRED ACE 80MG/ML INJ , 1ML 2 $41.46 3 $69.69 METHYLPRED ACETATE MICROPOW 5GM 30 $447.94 90 $1,335.82 METHYLPREDNISOLONE 16MG TABLETS 11 $33.71 77 $216.09 METHYLPREDNISOLONE 32MG TABS 4 $22.27 39 $173.37 METHYLPREDNISOLONE 4MG DOSPAK 21'S 21 $29.02 63 $79.05 METHYLPREDNISOLONE 4MG DOSPAK 21'S 21 $29.05 28 $36.90 METHYLPREDNISOLONE 4MG TABLETS 34 $39.37 108 $115.98 METHYLPREDNISOLONE 8MG TABLETS 27 $44.59 110 $171.21 METHYLPREDNISOLONE SOD 125MG INJ 3 $20.23 8 $52.68 METIPRANOLOL 0.3% OPTH SOLN 10ML 30 $105.97 90 $309.91 METOCLOPRAM 5MG/ML INJ, 2ML 15 $9.95 36 $18.39 METOLAZONE 10MG TABLETS 29 $45.95 93 $137.21 METOLAZONE 2.5MG TABLETS 23 $27.31 64 $69.64 METOPROLOL ER SUCCINATE 50MG TABS 34 $38.15 101 $105.31 METOPROLOL ER SUCCINATE 100MG TABS 34 $48.93 100 $137.39 METOPROLOL ER SUCCINATE 25MG TABS 33 $32.38 96 $86.92 METOPROLOL HCT 100/25MG TABLETS 31 $69.63 94 $200.76 METOPROLOL HCT 100/50MG TABLETS 31 $58.76 90 $162.90 METOPROLOL HCT 50/25MG TABLETS 33 $47.92 94 $131.56 METRON/NACL 500MG PB INJ, 100ML 200 $5.98 600 $9.94 METRONIDAZOLE 0.75% TOPICAL CRM 45G 46 $138.10 120 $354.72 METRONIDAZOLE 0.75% TOPICAL GEL 45G 46 $69.12 127 $184.60 METRONIDAZOLE 0.75% TOPICAL LOTION 61 $149.54 200 $482.27 METRONIDAZOLE 0.75% VAGINAL GEL 70G 71 $96.70 148 $196.69 METRONIDAZOLE 1% TOPICAL GEL PUMP 60 $245.81 162 $656.77 MEXILETINE 150MG CAPSULES 82 $56.04 238 $155.25

Prescription drug coverage and cost are subject to change.

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

MEXILETINE 200MG CAPSULES 79 $192.15 233 $555.09 MEXILETINE 250MG CAPSULES 80 $211.24 223 $582.26 MICONAZOLE 3 DS VAG SUPP 3'S 3 $60.21 6 $105.98 MICONAZOLE 2% VAGINAL CREAM 45GM 45 $10.04 136 $22.12 MICONAZOLE POWDER 36 $67.35 108 $194.04 MIDAZOLAM 10MG/2ML INJ, 2ML 3 $5.06 9 $7.17 MIDAZOLAM 1MG/ML INJ, 10ML 14 $5.44 42 $8.33 MIDAZOLAM 1MG/ML INJ, 2ML 4 $8.07 11 $16.20 MIDAZOLAM 2MG/ML SYRUP 15 $13.04 65 $42.15 MIDAZOLAM 50MG/10ML INJ, 10ML 28 $14.11 83 $34.34 MIDAZOLAM 5MG/5ML INJ, 5ML 5 $4.71 16 $6.12 MIDAZOLAM 5MG/ML INJ, 1ML 2 $4.89 2 $5.01 MIDODRINE 10MG TABLETS 75 $278.21 211 $772.23 MIDODRINE 2.5MG TABLETS 82 $67.89 226 $180.32 MIDODRINE 5MG TABLETS 84 $135.72 228 $358.94 MIGRALAM CAPSULES 4 $25.18 11 $67.55 MILRINONE 1MG/ML INJ , 10ML 1 $6.16 3 $10.48 MILRINONE 1MG/ML INJ , 50ML 1 $4.63 3 $5.88 MILRINONE 1MG/ML INJ, 20ML 1 $6.13 3 $10.40 MILRINONE DW5 INJ, 100ML 1 $4.91 3 $6.73 MILRINONE DW5 INJ, 200ML 6,400 $987.68 19,200 $2,955.04 MINOCYCLINE 100MG CAPSULES 43 $24.25 125 $62.17 MINOCYCLINE 100MG TABLETS 41 $223.64 117 $634.11 MINOCYCLINE 115MG ER TABLETS 30 $1,172.42 90 $3,522.97 MINOCYCLINE 50MG CAPSULES 47 $15.05 120 $31.94 MINOCYCLINE 50MG TABLETS 45 $209.76 117 $539.92 MINOCYCLINE 65MG ER TABLETS 30 $765.45 91 $2,317.22 MINOCYCLINE 75MG CAPSULES 46 $81.17 117 $200.10 MINOCYCLINE 75MG TABLETS 43 $380.22 129 $1,129.77 MINOCYCLINE ER 135MG TABLETS 29 $659.04 90 $2,007.97 MINOCYCLINE ER 45MG TABLETS 32 $713.36 90 $2,007.97 MINOCYCLINE ER 90MG TABLETS 29 $617.70 92 $1,933.52 MINOXIDIL 10MG TABLETS 50 $29.04 140 $74.04 MI-OMEGA CAPSULES 30 $31.50 90 $86.49 MIRENA IUD SYSTEM 1 $891.99 1 $891.99 MIRTAZAPINE 15MG ORAL DSNTGRT TABS 30 $59.99 92 $174.89 MIRTAZAPINE 30MG ORAL DSNTGRT TABS 31 $31.17 95 $86.31 MIRTAZAPINE 30MG TABLETS 31 $18.63 93 $47.54 MIRTAZAPINE 45MG ORAL DSNTGRT TABS 30 $62.34 90 $181.52 MIRTAZAPINE 45MG TABLETS 30 $37.81 90 $106.36 MIRTAZAPINE 7.5MG TABLETS 31 $81.36 93 $238.86 MIRVASO 0.33% GEL 30GM 31 $492.79 104 $1,654.28 MISOPROSTOL 100MCG TABLETS 30 $21.11 193 $113.24 MISOPROSTOL 200MCG TABLETS 9 $14.53 193 $222.82 MITOMYCIN 20MG INJ, 1VIAL 2 $433.00 7 $1,291.00 MITOMYCIN 40MG INJ 1VIAL 2 $747.09 7 $2,233.26

Prescription drug coverage and cost are subject to change.

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

MITOMYCIN 5MG INJ, 1 VIAL 1 $99.99 3 $291.97 MITOXANTRON 2MG/ML INJ ,10ML PLX 1 $147.60 3 $434.80 MITOXANTRONE 2MG/ML INJ,12.5ML 13 $1,798.99 38 $5,388.96 MITOXANTRONE 2MG/ML INJ,15ML 1 $147.60 3 $434.80 MIXED VESPID 300MCG KIT 30 $1,317.70 90 $3,945.10 M-M-R II LIVE VACCINE W/DILUENT INJ 1 $90.00 3 $262.01 MODAFINIL 100MG TABLETS 39 $667.49 119 $2,007.16 MODAFINIL 200MG TABLETS 39 $1,090.69 119 $3,282.09 MOEXIPRIL 15MG TABLETS 37 $23.92 110 $62.81 MOEXIPRIL/HCTZ 15-12.5MG TABLETS 32 $28.56 99 $79.76 MOEXIPRIL/HCTZ 15-25MG TABLETS 31 $27.84 91 $73.47 MOEXIPRIL/HCTZ 7.5-12.5MG TABLETS 34 $22.42 97 $57.24 MOMETASONE 0.1% CREAM 15GM 37 $38.73 122 $117.94 MOMETASONE 0.1% OINTMENT 15GM 40 $36.22 137 $113.31 MOMETASONE 0.1% TOP SOLN 60ML 53 $28.80 99 $50.40 MOMETASONE 50MCG NASAL SPRAY (120) 17 $160.65 51 $463.88 MONOCLATE-P 250 UNIT INJKIT 1VIAL 1 $4.97 3 $6.91 MONOCLATE-P 500 UNIT INJKIT 1VIAL 1 $5.14 3 $7.41 MONOJECT SYR/NDL, 29G, 0.3ML, 100'S 95 $24.91 128 $32.06 MONOJECT SYR/NDL, 30G, 1ML 94 $54.80 168 $94.51 MONONINE 500IU INJ 1 $5.17 3 $7.52 MONTELUKAST 4MG ORAL GRANULES 30 $91.48 91 $270.71 MONUROL 3GM SINGLE DOSE PACKET 2 $167.93 11 $908.61 MORGIDOX 100MG KIT 1 (30 CAPS&WASH) 1 $682.65 3 $2,039.95 MORPHINE SUL 100MG ER TABLETS 72 $332.25 201 $922.18 MORPHINE SUL 100MG/5ML(20MG/ML SOL) 39 $22.15 95 $48.40 MORPHINE SUL 10MG RECT SUPPOSITORY 17 $96.11 50 $280.33 MORPHINE SUL 10MG/5ML(2MG/ML) SOL 232 $18.39 332 $24.52 MORPHINE SUL 1MG/ML INJ , 10ML 10 $7.65 30 $14.95 MORPHINE SUL 20MG/5ML(4MG/ML) SOL 212 $24.56 997 $100.62 MORPHINE SUL 25MG/ML INJ , 10ML 1 $4.38 3 $5.14 MORPHINE SUL 50MG ER CAPS(24H) 55 $535.74 105 $1,019.45 MORPHINE SUL 50MG/ML INJ , 20ML 50 $26.48 150 $71.43 MORPHINE SUL 80MG ER CAPS (24H) 53 $537.11 120 $1,200.39 MORPHINE SULF 10MG/ML SYR, 1ML 10 $17.99 30 $45.97 MORPHINE SULF 15MG ER TABLETS 59 $52.81 174 $148.75 MORPHINE SULF 200MG ER TABS (12H) 78 $486.39 154 $957.98 MORPHINE SULF 60MG ER TABS (12H) 67 $197.59 206 $595.29 MORPHINE SULF 8MG/ML INJ, 1ML 1 $4.61 3 $5.82 MORPHINE SULF ER 100MG CAPS (24H) 58 $702.54 180 $2,187.38 MORPHINE SULF ER 20MG CAPS (24H) 54 $261.16 122 $579.47 MORPHINE SULF ER 30MG CAPS (24H) 51 $277.22 135 $723.96 MORPHINE SULF RECT 5MG SUPPOSITORY 25 $102.89 74 $300.67 MORPHINE SULF RECT 20MG SUPPOSITORY 70 $446.72 210 $1,332.17 MORPHINE SULF RECT 30MG SUPPOSITORY 59 $475.95 177 $1,419.86 MORPHINE SULFATE 120MG ER CAP (24H) 43 $768.26 90 $1,599.69

Prescription drug coverage and cost are subject to change.

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

MORPHINE SULFATE 30MG ER TABS (12H 65 $132.21 180 $360.83 MORPHINE SULFATE 30MG ER CAPS (24H) 42 $213.59 100 $499.99 MORPHINE SULFATE 60MG ER CAPS (24H) 38 $424.96 180 $1,976.78 MORPHINE SULFATE ER 10MG CAPS (24H) 47 $104.76 117 $253.58 MORPHINE SULFATE ER 60MG CAPS (24H) 51 $492.24 150 $1,438.48 MORPHINE SULFATE IMM REL 15MG TAB 73 $23.44 182 $52.60 MORPHINE SULFATE IMM REL 30MG TAB 99 $40.34 287 $109.38 MOTOFEN TABLETS 78 $584.32 323 $2,413.04 MOVIPREP SOLUTION 1 $133.73 3 $393.19 MOXEZA 0.5% OPHTH SOLN 3ML 3 $197.18 9 $583.54 MOXIFLOXACIN 0.5% OPHTH SOLN 3ML 3 $68.74 7 $155.30 MULTAQ 400MG TABLETS 58 $576.76 174 $1,736.30 MULTIGEN PLUS TABLETS 34 $35.19 96 $91.22 MULTIGEN TABLETS 35 $19.78 97 $48.19 MULTI-NATE DHA EXTR PAK 30 $21.99 90 $57.98 MULTIRET-FOLIC-500 TABS UD-PACK 30 $12.44 90 $29.32 MULTITRACE-4 CONC INJ , 1ML 30 $239.19 90 $709.56 MULTITRACE-4 INJ, 10ML 1 $5.93 3 $9.78 MULTITRACE-4 NEONATAL INJ, 2ML 1 $5.69 3 $9.07 MULTITRACE-5 INJ, 10ML 1 $4.68 3 $6.03 MULTITRACE-5 REGULAR INJ, 10ML 1 $5.18 3 $7.53 MULTIVIT/F 0.25MG CHEWABLE TABS 31 $8.10 92 $16.25 MULTI-VIT/FE /FL 0.25MG DROPS 50ML 50 $31.79 98 $58.47 MULTI-VIT/FL 0.25MG DROPS 50ML 50 $13.02 99 $21.87 MULTIVITAMIN W/FL .5MG/ML ORAL DROP 51 $12.08 88 $18.12 MUPIROCIN 2% CREAM 15GM 23 $237.20 137 $1,374.24 MUPIROCIN 2% OINTMENT 15GM 24 $49.18 112 $216.89 MUSE 1000MCG SUPPOSITORIES 6 $478.16 22 $1,733.46 MUSE 500MCG SUPPOSITORIES 6 $408.72 13 $964.89 M-VIT TABLETS 30 $12.87 91 $30.70 MYCOPHENOLATE 200MG/ML SUSP 160ML 192 $995.29 360 $1,862.46 MYCOPHENOLATE 250MG CAPSULES 139 $221.32 363 $572.98 MYCOPHENOLATE 500MG TABLETS 105 $307.36 293 $848.93 MYCOPHENOLIC ACID 360MG DR TABLETS 92 $596.54 264 $1,716.26 MYRBETRIQ 25MG TABLETS 30'S 31 $399.09 91 $1,184.14 MYRBETRIQ 50MG TABLETS 30'S 30 $393.85 90 $1,171.73 NABUMETONE 500MG TABLETS 53 $16.27 184 $46.86 NABUMETONE 750MG TABLETS 50 $61.32 169 $197.85 NADOLOL 20MG TABLETS 35 $75.87 100 $208.67 NADOLOL 40MG TABLETS 36 $78.47 105 $220.65 NADOLOL 80MG TABLETS 38 $111.75 111 $323.15 NADOLOL/BEND 40/5MG TABLETS 30 $127.52 86 $362.69 NADOLOL/BEND 80/5MG TABLETS 37 $205.30 90 $498.09 NAFCILLIN 10GM INJ, 1VIAL 1 $139.99 3 $411.97 NAFCILLIN 1GM INJ, 1VIAL 1 $10.57 3 $23.71 NAFCILLIN 2GM INJ, 1VIAL 1 $25.99 3 $69.97

Prescription drug coverage and cost are subject to change.

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

NAFTIFINE 2% CREAM 45GM 55 $436.07 168 $1,334.02 NAFTIFINE HCL 1% CREAM 60GM 67 $255.80 141 $531.98 NALBUPHINE 10MG/ML INJ , 10ML 35 $113.13 116 $364.81 NALBUPHINE 20MG/ML INJ, 10ML 37 $167.95 217 $958.95 NAPHAZOLINE 0.1% OPTH SOL 15ML 15 $9.21 45 $19.63 NAPHAZOLINE HCL CRY POWDER 25GM 30 $84.39 90 $245.16 NAPROXEN 125MG/5ML SUSPENSION 312 $390.12 1,700 $2,107.55 NAPROXEN SOD 500MG CR TABLETS 41 $414.58 146 $1,456.79 NAPROXEN SODIUM 275MG TABLETS 34 $7.82 207 $26.94 NAPROXEN SODIUM 550MG TABLETS 34 $79.05 171 $379.43 NAPROXEN SODIUM CR 375MG TABS (24H) 46 $4,482.00 164 $15,896.35 NARATRIPTAN 1MG TABLETS 9 $305.79 38 $1,263.85 NASATAB LA TAB 30 $16.00 90 $39.99 NATACYN 5% OPHTH SUSP 15ML 15 $349.57 18 $418.95 NATAZIA TABLETS 28 28 $189.82 84 $555.23 NATEGLINIDE 60MG TABLETS 87 $130.19 236 $348.08 NATURE-THROID 2.5GR (162.5MG) TB 23 $14.56 72 $36.88 NATURE-THROID (81.25MG) TABS 25 $10.98 88 $28.85 NATURE-THROID 1/4 GR (16.25MG) TABS 33 $9.90 92 $20.64 NATURE-THROID 113.75MG TABLETS 26 $12.91 87 $33.72 NATURE-THROID 1GR (65MG)TABLETS 43 $12.22 117 $26.19 NATURE-THROID 2GR (130MG) TABLETS 33 $16.14 99 $40.52 NATURE-THROID 3/4GR (48.75MG) TABS 37 $12.99 104 $29.04 NATURE-THROID 3GR (195MG) TABLETS 25 $13.41 78 $33.80 NATURE-THROID 97.5MG TABLETS 34 $14.49 99 $34.80 NEBULIZER MASK ADULT 1 $7.72 3 $15.16 NEBULIZER REPLACEMENT KIT 1 $61.69 3 $177.07 NEBUPENT 300MG INHALATION SOLN 1 $188.81 3 $554.95 NECON 0.5/35 TABLETS 28 (BLUE) 29 $25.46 86 $67.28 NECON 1/50 TABLETS 28S 30 $24.12 87 $62.91 NECON 10/11 TABLETS 28 30 $26.49 90 $71.46 NEFAZODONE 50MG TABLETS 56 $53.68 176 $159.09 NEFAZODONE 100MG TABLETS 67 $68.74 190 $187.24 NEFAZODONE 150MG TABLETS 63 $68.48 188 $194.77 NEFAZODONE 200MG TABLETS 62 $68.15 175 $184.55 NEFAZODONE 250MG TABLETS 51 $58.01 141 $152.43 NEO/POLY/BAC OPHTH OINT 3.5GM 4 $30.89 14 $106.52 NEO/POLY/BAC/HC OPHTH OINT 3.5GM 4 $32.88 9 $73.40 NEO/POLY/DEX OPHTH SUSP 5ML 5 $19.60 7 $24.12 NEO/POLY/DEX 0.1% OPTH OINT 3.5GM 4 $20.42 12 $60.13 NEO/POLY/GRAM OPHTH SOLN10ML 10 $42.18 30 $118.53 NEO/POLY/HC 1% OTIC SOL BLUE (EAR) 10 $50.37 11 $53.91 NEO/POLY/HC 1% OTIC SUSPGREEN(EAR) 10 $40.32 11 $44.99 NEO/POLY/HC OPTH SUSP 7.5ML 8 $143.71 13 $233.98 NEOMYCIN 500MG TABLETS 11 $16.57 216 $244.38 NEOMYCIN/POLYMY IRRIGATION ONLY SOL 17 $129.76 105 $784.96

Prescription drug coverage and cost are subject to change.

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

NEOSALUS CREAM 100GM 235 $503.96 505 $1,076.67 NEOSTIG METH 1MG/ML INJ, 10ML 1 $4.77 3 $6.30 NEOTUSS-D LIQUID 115 $16.93 346 $42.80 NEPHRON FA TABLETS 32 $20.78 92 $52.28 NERVIDOX-6 NR TABLETS 156 $348.99 344 $764.22 NESTABS TABLETS 30 $70.29 90 $202.01 NEULASTA 6MG/0.6ML SYR FOR INJ 1 $6,883.57 4 $39,027.94 NEUPOGEN 300MCG/0.5ML, 0.5ML 4 $2,654.71 24 $18,003.52 NEUPOGEN 300MCG/ML 1ML VIAL 10 $3,738.45 31 $11,207.35 NEUPOGEN 300MCG/ML (480MCG/1.6ML) 8 $2,934.84 152 $58,998.04 NEUPOGEN 480MCG/0.8ML(600MCG/ML)PFS 6 $4,508.62 8 $5,993.90 NEURIN-SL TABLETS 28 $15.67 73 $33.78 NEVANAC 0.1% OPHT SUSP 3ML 3 $302.08 11 $1,033.18 NEVIRAPINE 200MG TABLETS 59 $521.03 178 $1,562.90 NEVIRAPINE 400MG ER TABLETS 30 $632.98 90 $1,887.97 NEVIRAPINE 50MG/5ML SUSPENSION 351 $128.64 1,054 $377.93 NEXIUM 10MG DR PWDR PKT FOR SUSP-30 33 $380.46 100 $1,157.74 NEXIUM 20MG DR PWDR PKT FOR SUSP-30 33 $348.85 110 $1,141.02 NEXIUM 40MG DR PWDR PKT FOR SUSP-30 34 $355.42 100 $1,030.00 NIC 750MG TABLETS 30 $24.14 90 $64.41 NICARDIPINE 20MG CAPSULES 87 $125.46 245 $347.29 NICARDIPINE 30MG CAPSULES 71 $158.28 193 $423.99 NICOTINE 14MG/24H PATCH 24 $57.82 80 $187.06 NICOTINE 21MG/24H PATCH 14'S 25 $61.82 81 $189.60 NICOTINE 7MG/24H PATCH 22 $44.23 81 $154.54 NICOTROL NS 10MG/ML NASAL SPRAY 54 $597.88 79 $877.85 NICOTROL ORAL INH 10MG/CRTDG (168) 179 $450.08 378 $947.17 NIFEDIPINE 10MG CAPSULES 63 $47.41 177 $126.37 NIFEDIPINE 20MG CAPSULES 61 $120.88 173 $337.72 NIFEDIPINE 90MG ER (XL/OSM) TABLET 31 $74.71 93 $214.74 NIMODIPINE 30MG CAPSULES 102 $1,761.42 179 $3,088.48 NISOLDIPINE ER 17MG TABLETS 32 $159.85 99 $483.23 NISOLDIPINE ER 20MG TABLETS 28 $202.27 100 $722.94 NISOLDIPINE ER 25.5MG TABLETS 28 $110.42 97 $370.60 NISOLDIPINE ER 30MG TABLETS 29 $277.32 103 $980.64 NISOLDIPINE ER 34MG TABLETS 30 $117.07 93 $354.44 NISOLDIPINE ER 40MG TABLETS 28 $230.52 90 $730.16 NISOLDIPINE ER 8.5MG TABLETS 35 $136.20 104 $392.00 NITRO-BID 2% OINTMENT 30GM 41 $52.04 118 $143.96 NITRO-DUR 0.3MG/HR PATCH30'S 30 $188.60 87 $535.33 NITROFURANT MAC 25MG CAPSULES 30 $171.81 96 $533.46 NITROFURANTOIN 25MG/5ML ORAL SUSP 249 $2,074.40 454 $3,775.63 NITROFURANTOIN MACRO 100MG CAPSULES 20 $48.76 90 $201.54 NITROFURANTOIN MACRO 50MG CAPSULES 30 $34.83 89 $95.66 NITROFURANTOIN MONO/MAC 100MG CAPS 14 $39.11 89 $220.30 NITROGLYCER 0.4MG/HR PATCHES 30'S 31 $34.32 92 $93.03

Prescription drug coverage and cost are subject to change.

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

NITROGLYCER 6.5MG ER CAPSULES 58 $35.10 177 $98.20 NITROGLYCERIN 0.1 MG/HR PATCH 30'S 31 $26.64 90 $70.24 NITROGLYCERIN 0.2 MG/HR PATCH 30S 30 $36.48 89 $98.99 NITROGLYCERIN 0.3MG SL TABS 100 101 $18.17 117 $20.33 NITROGLYCERIN 0.4MG SUB TAB 25 38 $19.09 113 $49.04 NITROGLYCERIN 0.6 MG/HR PATCH 30'S 31 $38.04 93 $106.56 NITROGLYCERIN 0.6MG SUB TABS 100 101 $17.80 133 $22.19 NITROGLYCERIN 2.5MG ER CAPSULES 61 $25.92 175 $67.05 NITROGLYCERIN 400MCG AERO 200 DOSES 6 $101.53 13 $226.76 NITROGLYCERIN 400MCG SPRAY 200 DOSE 8 $304.97 19 $748.45 NITROGLYCERIN 9MG ER CAPSULES 72 $38.29 183 $91.58 NITROGLYCERIN/D5W 25MG INJ , 250ML 1 $4.03 3 $4.10 NIZATIDINE 15MG/ML SOLUTION 141 $87.65 613 $366.88 NIZATIDINE 300MG CAPSULES 35 $20.16 102 $51.58 NOHIST-DM LIQUID 139 $22.54 2,918 $392.39 NORDITROPIN FLEXPRO 10MG/1.5ML INJ 5 $4,574.46 17 $14,588.79 NORDITROPIN FLEXPRO 15MG/1.5ML INJ 5 $6,560.07 6 $8,212.34 NORDITROPIN FLEXPRO 5MG/1.5ML INJ 5 $2,063.72 13 $5,439.64 NORETHINDRONE 5MG TABLETS 35 $68.69 95 $181.62 NORETHINDRONE ACETATE POWDER 0.1GM 30 $15,301.00 90 $45,895.00 NORGEST/ETHI ESTRADIOL TABLETS 28S 28 $25.22 84 $67.26 NORITATE 1% CREAM 60GM 61 $1,869.98 150 $4,618.98 NORMAL SALINE 0.9% FLUSH INJ, 10ML 459 $32.43 824 $55.08 NORMOSOL -R INJ SOLUTION 1000ML 9,625 $52.13 12,000 $64.00 NORPACE CR 100MG CAPSULES 91 $444.00 287 $1,397.17 NORTRIPTYLINE 10MG/5ML SOLN 292 $99.41 685 $228.08 NORTRIPTYLINE 50MG CAPSULES 43 $13.96 123 $32.65 NORTUSS-EX LIQUID 126 $11.46 378 $26.38 NORVIR 80MG/ML ORAL SOLUTION 74 $514.70 222 $1,533.10 NOVACORT GEL 29GM 30 $3,975.69 90 $11,919.07 NOVOLOG FLEXPEN INJ 5X3ML (ORANGE) 18 $644.12 40 $1,404.45 NOVOLOG MIX 70/30 FLEXPEN SYR(BLUE) 24 $898.14 60 $2,268.17 NOVOLOG MIX 70/30 SUS VL10ML(BLUE) 24 $681.32 66 $1,854.80 NOVOLOG PENFILL 3ML (ORANGE) 17 $807.61 38 $1,756.10 NOVOLOG U-100 INSULIN VL10ML(ORANG) 24 $670.03 67 $1,869.39 NOXAFIL 40MG/ML SUSPENSION 363 $4,943.89 905 $12,325.11 NUCYNTA 75MG TABLETS 84 $572.56 184 $1,252.49 NUEDEXTA 20-10MG CAPSULES 55 $831.10 164 $2,488.03 NUMOISYN LOZENGES 93 $21.62 100 $22.99 NUOX GEL 30 $80.74 90 $234.21 NUQUIN HP 4% GEL 28.40GM 30 $20.99 90 $54.97 NUTRILYTE INJ , 20ML 1 $4.35 3 $5.05 NUTROPIN AQ 10MG/2ML PEN CARTRIDGE 30 $22,443.85 90 $67,323.55 NUTROPIN AQ NUSPIN 5MG/2ML INJ, 2ML 1 $349.89 3 $1,041.67 NUTROPIN AQ PEN 20MG/2ML INJ, 2ML 1 $1,168.53 3 $3,497.59 NUVARING 1 $154.43 3 $446.95

Prescription drug coverage and cost are subject to change.

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

NYAMYC 100000 POWDER 45 $77.15 212 $349.70 NYSTATIN 500,000 UNITS ORAL TABLETS 91 $96.06 262 $268.34 NYSTATIN CREAM 15GM 32 $21.20 162 $90.35 NYSTATIN ORAL SUSP 1000000UNIT/ML 181 $42.46 846 $183.85 NYSTATIN PWDR FOR ORAL SUSP 2BU 1 $768.99 3 $2,298.97 NYSTATIN/TRIAMCINOLONE CREAM 15GM 34 $118.73 153 $523.61 NYSTATIN/TRIAMCINOLONE OINT 15GM 30 $113.70 127 $461.92 OB COMPLETE ONE CAPSULE 30 $161.35 90 $475.34 OB COMPLETE PREMIER TABLETS 30 $113.20 90 $333.94 OBSTETRIX DHA PAK 60 $46.00 162 $117.65 OBSTETRIX EC TABLETS 29 $30.77 90 $86.23 O-CAL PRENATAL TABLETS 30 $10.30 91 $23.00 OCTREOTIDE 0.2MG/ML INJ,5ML 47 $997.66 109 $2,318.33 OCTREOTIDE 100MCG INJ , 1ML 62 $1,190.86 158 $2,994.93 OCTREOTIDE 1MG/ML INJ , 5ML 19 $493.49 24 $619.60 OCTREOTIDE 500MCG INJ, 1ML 34 $652.00 103 $1,948.00 OCTREOTIDE 50MCG/ML INJ, 1ML 61 $491.43 190 $1,522.10 ODEFSEY (FTC200/RPV25/TAF25) TAB 30 $2,954.06 90 $8,862.26 OFLOXACIN 0.3% OPH SOL 10ML (EYE) 6 $37.45 8 $51.41 OFLOXACIN 0.3% OTIC SOLN 10ML (EAR) 7 $211.74 11 $312.02 OFLOXACIN 400MG TABLETS 14 $82.23 42 $238.70 OGESTREL TABLETS 28 29 $47.19 87 $132.48 OLANZAPINE 10MG TABLETS 32 $211.66 95 $625.98 OLANZAPINE 15MG TABLETS 34 $672.61 101 $2,011.42 OLANZAPINE 2.5MG TABLETS 33 $127.23 98 $366.20 OLANZAPINE 20MG TABLETS 31 $772.70 96 $2,368.87 OLANZAPINE 5MG TABLETS 33 $304.13 96 $879.67 OLANZAPINE ODT 10MG TABLETS 34 $559.19 103 $1,705.42 OLANZAPINE ODT 15MG TABLETS 34 $479.05 108 $1,504.87 OLANZAPINE ODT 20MG TABLETS 33 $877.98 93 $2,475.90 OLANZAPINE ODT 5MG TABLET 34 $426.87 96 $1,209.75 OLANZAPINE/FLUOXETINE 12-25MG CAPS 30 $524.01 99 $1,746.37 OLANZAPINE/FLUOXETINE 12-50MG CAPS 30 $608.00 91 $1,844.70 OLANZAPINE/FLUOXETINE 3-25MG CAPS 29 $144.30 90 $433.09 OLANZAPINE/FLUOXETINE 6-25MG CAPS 32 $429.37 95 $1,279.02 OLANZAPINE/FLUOXETINE 6-50MG CAPS 30 $407.85 89 $1,199.92 OLEPTRO 150MG 24HR TABLETS 30 $109.64 90 $320.92 OLEPTRO 300MG 24HR TABLETS 30 $132.75 90 $390.25 OLMESARTAN/AMLO/HCTZ 40-10-12.5MG T 30 $137.60 90 $403.90 OLOPATADINE 0.1% OPTH SOLN 5ML 5 $187.88 14 $487.34 OLOPATADINE 0.2% OPHTH SOLN 2.5ML 3 $126.39 9 $404.54 OLOPATADINE 0.6% NASAL SPR (240 SP) 31 $252.01 73 $591.22 OMEGA-3-ACID 1GM CAPSULES (RX) 102 $179.07 288 $497.71 OMEPRAZOL 20MG/SOD BICARB 1100MG CP 35 $517.15 101 $1,492.26 OMEPRAZOL 40MG/SOD BICARB 1100MG CP 36 $2,569.00 107 $7,595.01 OMEPRAZOLE 20MG CAPSULES 36 $20.68 105 $52.96

Prescription drug coverage and cost are subject to change.

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

OMNARIS 50MCG NASAL SPR (120 SPR) 13 $266.03 38 $785.63 OMNITROPE 5.8MG INJ, 1 VIAL 4 $1,260.18 8 $2,648.56 ONDANSETRON 2MG/ML INJ, 20ML 76 $29.70 177 $63.99 ONDANSETRON 2MG/ML INJ, 2ML 32 $19.63 686 $343.35 ONDANSETRON 4MG TABLETS 23 $79.41 168 $557.86 ONDANSETRON 4MG/5ML SOLUTION 40 $212.22 724 $3,769.60 ONDANSETRON 8MG TABLETS 27 $119.55 167 $723.81 ONDANSETRON ODT 4MG TABLETS 16 $73.57 141 $608.12 ONDANSETRON ODT 8MG TABLETS 21 $90.56 142 $599.78 ONE TOUCH PENLET PLUS 1 $28.21 4 $76.62 ONEXTON 1.2% - 3.75% GEL 50GM 50 $610.49 140 $1,697.67 ONGLYZA 5MG TABLETS 30 $454.17 90 $1,351.42 OPIUM 10MG/ML (1%) TINCTURE 106 $496.56 172 $804.45 ORACIT SOLUTION 867 $43.35 3,941 $182.92 ORASEP SOLUTION 30 $13.01 90 $31.03 ORENCIA 250MG INJ, 1 VIAL 3 $3,181.13 10 $9,535.39 ORPHENADRINE 30MG/ML INJ, 2ML 11 $91.78 18 $152.72 ORPHENADRINE CITRATE 100MG ER TABS 29 $44.71 147 $209.96 ORPHENADRINE/ASA/CAFF 25/385/30 TAB 30 $28.43 90 $77.28 ORTHOVISC 15MG/ML INJ, 2ML 1 $285.00 3 $846.99 OSCION 3% CLEANSER 170.3GM 30 $10.34 90 $23.01 OSCION 9% CLEANSER 340.2GM 30 $10.83 90 $24.49 OSELTAMIVIR 30MG CAPSULES 15 $131.57 44 $386.70 OSELTAMIVIR 45MG CAPSULES 10 $91.33 10 $91.79 OSELTAMIVIR 6MG/ML SUSPENSION 60ML 100 $163.33 100 $163.98 OSELTAMIVIR 75MG CAPSULES 10 $91.47 18 $166.22 OSMOPREP TABLETS 32 $217.69 59 $402.58 OTICAINE 20% OTIC DROPS15ML (EAR) 30 $15.16 90 $37.48 OTICIN OTIC DROPS 10ML (EAR) 30 $138.97 90 $408.91 OTOZIN OTIC DROPS (EAR) 10 $64.99 30 $186.97 OVIDREL 250MCG/0.5ML INJ(1 SYRINGE) 1 $172.38 1 $211.27 OXACILLIN 10GM INJ , 1VIAL 1 $129.99 3 $381.97 OXACILLIN 1GM INJ, 1VIAL 1 $12.99 3 $30.97 OXACILLIN 2GM INJ , 1VIAL 1 $33.99 3 $93.97 OXACILLIN 2GM VIAL FOR INJECTION 240 $5,521.60 720 $16,556.80 OXALIPLATIN 100MG INJ, 20ML 82 $246.77 245 $732.30 OXANDROLONE 10MG TABLETS 61 $967.17 142 $2,228.40 OXANDROLONE 2.5MG TABLETS 48 $192.78 119 $475.75 OXAZEPAM 10MG CAPSULES 58 $60.02 155 $152.33 OXAZEPAM 15MG CAPSULES 63 $82.78 167 $214.07 OXAZEPAM 30MG CAPSULES 61 $116.80 152 $285.76 OXCARBAZEPINE 150MG TABLETS 71 $35.95 230 $107.59 OXCARBAZEPINE 300MG TABLETS 77 $86.22 238 $257.63 OXCARBAZEPINE 300MG/5ML ORAL SUSP 409 $251.01 1,397 $847.82 OXICONAZOLE NITRATE 1% CREAM 30GM 54 $257.75 101 $474.57 OXISTAT 1% LOTION 60ML 50 $563.00 158 $1,748.55

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price OXSORALEN 1% LOTION 30 $954.56 90 $2,855.67 OXSORALEN-ULTRA 10MG CAPSULES 29 $2,733.69 38 $3,539.26 OXTELLAR XR 600MG TABLETS 61 $1,057.85 191 $3,285.51 OXYBUTYNIN 5MG TABLETS 59 $29.38 170 $77.62 OXYBUTYNIN 5MG/5ML SYRUP 246 $14.27 926 $42.61 OXYBUTYNIN ER 10MG TABLETS 32 $62.21 96 $177.39 OXYBUTYNIN ER 15MG TABLETS 33 $19.55 99 $49.97 OXYBUTYNIN ER 5MG TABLETS 32 $18.95 95 $48.08 OXYCODONE 10MG ER TABLETS 52 $184.56 172 $597.37 OXYCODONE 10MG IMMEDIATE REL TABS 96 $65.12 230 $151.34 OXYCODONE 15MG* IMMEDIATE REL TABS 108 $105.32 245 $234.49 OXYCODONE 20MG ER TABLETS 61 $172.96 178 $499.00 OXYCODONE 20MG IMMEDIATE REL TABS 110 $115.93 309 $318.84 OXYCODONE 20MG/ML SOLUTION 84 $601.69 660 $4,719.24 OXYCODONE 30MG IMM REL TABLETS 118 $162.14 279 $378.81 OXYCODONE 40MG ER TABLETS 66 $588.23 202 $1,799.40 OXYCODONE 5MG IMMEDIATE REL CAPS 44 $63.86 104 $146.12 OXYCODONE 5MG IMMEDIATE REL TABS 54 $28.14 189 $89.16 OXYCODONE 5MG/5ML SOLUTION 205 $53.57 613 $152.29 OXYCODONE 80MG ER TABLETS 79 $562.12 231 $1,641.73 OXYCODONE HCL POWDER 30 $683.19 90 $2,041.56 OXYCODONE/ACETAMINOPHEN 2.5-325 TAB 33 $68.67 178 $352.86 OXYCODONE/IBU 5/400MG TABLETS 50 $68.52 151 $197.56 OXYCONTIN 15MG CONTROLLED REL TABS 58 $295.59 176 $895.67 OXYCONTIN 30MG CONTROLLED REL TABS 62 $553.78 193 $1,726.12 OXYCONTIN 60MG CONTROLLED REL TABS 67 $1,059.30 197 $3,108.03 OXYMORPHONE 10MG TABLETS 100 $279.74 240 $668.78 OXYMORPHONE 5MG TABLETS 85 $149.79 300 $519.97 OXYMORPHONE ER 10MG TABLETS 56 $198.76 180 $626.78 OXYMORPHONE ER 15MG TABLETS 60 $277.77 167 $772.82 OXYMORPHONE ER 20MG TABLETS 59 $355.02 234 $1,398.62 OXYMORPHONE ER 30MG TABLETS 61 $595.95 182 $1,779.84 OXYMORPHONE ER 40MG TABLETS 64 $463.10 198 $1,424.79 OXYMORPHONE ER 5MG TABLETS 54 $119.99 163 $351.96 OXYMORPHONE ER 7.5MG TABLETS 54 $179.45 163 $530.35 OXYTOCIN 10UNT/ML INJ , 10ML 14 $64.72 43 $186.17 OXYTROL 3.9MG/ DAY PATCH 9 $713.68 25 $2,017.96 PACLITAXEL 300MG/50ML INJ, 50ML 77 $274.44 232 $815.32 PACLITAXEL 30MG/5ML INJ,5ML 27 $97.33 80 $283.98 PACLITAXEL 6MG/ML INJ, 16.7ML 95 $336.03 401 $1,406.72 PALIPERIDONE ER 1.5MG TABLETS 32 $890.28 98 $2,687.54 PALIPERIDONE ER 3MG TABLETS 32 $878.20 97 $2,671.31 PALIPERIDONE ER 6MG TABLETS 36 $985.84 113 $3,102.24 PALIPERIDONE ER 9MG TABLETS 30 $1,218.44 91 $3,768.31 PALONOSETRON 0.25MG/5ML INJ, 5ML 8 $744.53 25 $2,225.58 PAMIDRONATE 30MG INJ, 1 VIAL 1 $54.38 3 $155.14

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PAMIDRONATE 3MG/ML SOL 10ML 23 $130.93 68 $384.80 PAMIDRONATE 90MG INJ, 1 VIAL 1 $599.99 3 $1,791.97 PAMIDRONATE 9MG/ML SOL FOR INJ 10ML 10 $55.30 30 $157.90 PANATUSS DXP LIQUID 118ML 106 $20.12 118 $22.00 PANATUSS DXP PEDIATRIC DROPS 60ML 60 $21.99 60 $21.99 PANCREAZE 10,500 CAPSULES 180 $549.61 492 $1,496.30 PANCREAZE 16,800 CAPSULES 253 $1,310.66 466 $2,411.57 PANCREAZE 21,000 CAPSULES 317 $1,926.28 780 $4,736.85 PANCREAZE 4,200 CAPSULES 144 $178.97 391 $478.43 PANGESTYME EC CAPSULES 30 $14.68 90 $36.03 PANGESTYME UL 18 CAPSULES 30 $38.80 90 $108.39 PANOKASE-16 TABLETS 30 $19.33 90 $50.00 PANTOPRAZOLE 40MG TABLETS 35 $80.18 101 $226.16 PAPAVERINE 30MG/ML SOL 15 $45.33 46 $127.99 PAREGORIC LIQUID 398 $210.79 659 $346.49 PARICALCITOL 1MCG CAPSULES 26 $254.61 70 $688.88 PARICALCITOL 2MCG CAPSULES 28 $535.63 76 $1,460.73 PARICALCITOL 4MCG CAPSULES 32 $1,284.41 69 $2,760.13 PAROMOMYCIN 250MG CAPSULES 51 $288.26 90 $504.39 PAROXETINE 7.5MG CAPSULES 30 $181.31 90 $534.01 PAROXETINE ER 12.5MG TABLETS 31 $127.95 93 $379.88 PAROXETINE ER 25MG TABLETS 36 $126.25 107 $366.86 PAROXETINE ER 37.5MG TABLETS 32 $152.21 96 $442.53 PAZEO 0.7% OPHTH SOLUTION 2.5ML 3 $191.76 9 $622.25 PCM CHEWABLE TABLETS 30 $11.00 90 $24.99 PEDIADERM HC KIT 30 $6,448.00 90 $19,336.00 PEDIARIX 0.5ML INJ, 0.5ML 1 $87.69 2 $255.07 PEDVAX HIB INJ, 0.5ML 1 $44.99 2 $126.97 PEGASYS 180MCG/ML INJ 1ML VIAL 3 $3,520.44 8 $9,171.00 PEG-INTRON 120MCG INJ KIT(1 VIAL) 1 $929.99 3 $2,781.97 PEG-INTRON 150MCG INJ KIT(1 VIAL) 1 $959.99 3 $2,871.97 PEG-INTRON 80MCG INJ KIT(1 VIAL) 1 $869.99 3 $2,601.97 PEN G PROC 600000 INJ, 2ML 2 $58.99 6 $168.97 PENICILL GK/ DEX 3MU INJ, 50ML 1 $4.22 3 $4.66 PENICILLIN G SODIUM 5 MILLION UNITS 2 $124.73 7 $366.18 PENICILLIN GK 20MU INJ ,1 VIAL 1 $76.12 3 $220.36 PENICILLIN GK 5MU INJ , 1 VIAL 2 $105.27 3 $126.97 PENNSAID 2% TOPICAL SOLUTION 112GM 124 $2,762.58 377 $8,386.96 PENTACEL INJ, 1VL 1 $94.99 3 $276.97 PENTASA 250MG CAPSULES 219 $572.24 682 $1,772.47 PENTASA 500MG CAPSULES 176 $916.34 526 $2,731.66 PENTAZOCINE/NALOXONE TABLETS 74 $165.73 246 $544.31 PENTOXIFYLLINE 400MG E.R. TABLETS 72 $20.88 199 $50.33 PERFOROMIST 20MCG INH SOL60X2ML 114 $1,050.42 348 $3,188.92 PERINDOPRIL 2MG TABLETS 34 $59.94 100 $171.07 PERINDOPRIL 8MG TABLETS 33 $77.29 102 $228.19

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PERPHENAZINE 2MG TABLETS 61 $47.68 174 $129.19 PERPHENAZINE/AMITRIPT 2-10MG TAB 49 $71.30 144 $200.22 PERPHENAZINE/AMITRIPT 2-25MG TAB 63 $116.48 153 $277.24 PERPHENAZINE/AMITRIPT 4-25MG TABS 56 $107.78 164 $309.92 PERPHENAZINE/AMITRIPTYLINE 4-10 TAB 57 $86.62 111 $165.47 PERPHENAZINE/AMITRIPTYLINE 4-50 TAB 45 $143.49 149 $462.84 PHEN/GUAI 25-900 TABLETS 30 $39.99 90 $111.97 PHENADOZ 25MG SUPPOSITORIES 15 $99.44 99 $631.84 PHENAVENT PED ER CAPSULES 30 $41.99 90 $117.97 PHENAZOPYRID 200MG TABLETS 10 $27.99 130 $307.36 PHENAZOPYRIDINE 100MG TABLETS 12 $20.55 114 $155.93 PHENDIMETRAZINE 105MG CR CAPSULES 28 $25.39 94 $75.38 PHENDIMETRAZINE 35MG TABLETS 61 $20.32 158 $46.23 PHENELZINE SULFATE 15MG TABLETS 111 $85.18 325 $242.47 PHENOBARB 130MG/ML INJ, 1ML 3 $101.17 10 $295.52 PHENOBARB 32.4MG TABLETS 83 $42.95 218 $106.29 PHENOBARB 64.8MG TABLETS 79 $50.60 179 $109.64 PHENOBARBITAL 100MG TABLETS 70 $26.39 152 $52.25 PHENOBARBITAL 15MG TABLETS 70 $17.86 171 $37.76 PHENOBARBITAL 16.2MG TABLETS 72 $30.53 165 $64.91 PHENOBARBITAL 20MG/5ML SOLUTION 423 $62.46 909 $129.51 PHENOBARBITAL 30MG TABLETS 79 $24.26 205 $56.46 PHENOBARBITAL 60MG TABLETS 78 $29.53 184 $64.25 PHENOBARBITAL 97.2MG TABLETS 66 $55.90 145 $117.50 PHENOBARBITAL SOD 65MG/ML INJ 7 $179.84 21 $531.51 PHENOXYBENZAMINE 10MG CAPSULES 87 $9,905.22 180 $20,394.98 PHENTERMINE 37.5MG CAPSULES 30 $29.10 90 $78.63 PHENTERMINE 37.5MG TABLETS 30 $29.10 88 $77.09 PHENTERMINE HCL 15MG CAPS 32 $34.50 95 $95.96 PHENTERMINE HCL 30MG CAPSULES 28 $33.10 90 $97.04 PHENTOLAMINE MESYLATE INJ, 1 VIAL 1 $183.99 3 $543.97 PHENYDEX LIQUID 30 $6.54 90 $11.62 PHENYDEX PEDIATRIC DROPS 30ML 30 $9.49 90 $20.47 PHENYLEPHRIN 2.5% OPHTH SOL 15ML 11 $69.58 19 $124.47 PHENYLEPHRINE 10% OPHTH SOLN 5ML 5 $50.63 7 $61.32 PHENYLEPHRINE CRYSTAL 100GM 30 $62.80 90 $180.39 PHENYLEPHRINE/GUAIFENESIN DROP 30ML 30 $28.79 90 $78.37 PHENYLHISTINE DH ELIXIR 30 $8.00 90 $16.00 PHENYTOIN 100MG/4ML SUSPENSION 307 $160.38 982 $504.93 PHENYTOIN 200MG ER CAPSULES 56 $61.13 166 $173.19 PHENYTOIN 50MG CHEW TABLETS 91 $41.19 195 $83.93 PHENYTOIN 50MG/ML INJ, 5ML 84 $79.58 252 $230.75 PHENYTOIN POWDER 30 $38.79 90 $108.36 PHENYTOIN SOD 300MG ER CAPSULES 36 $43.07 105 $119.65 PHENYTOIN SODIUM POWDER 30 $25.90 90 $69.70 P-HIST DM DROPS 30ML 30 $21.99 90 $57.97

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PHOSPHA 250 NEUTRAL TABLETS 85 $26.81 260 $74.12 PHOSPHOLINE IODIDE 0.125% OPH SOLN 5 $107.29 12 $247.27 PHYTONADIONE 1MG/0.5ML INJ, 0.5ML 2 $11.28 11 $55.39 PILOCARPINE 1% OPHTH SOLN 15ML 15 $87.41 18 $98.93 PILOCARPINE 2% OPHTH SOLN 15ML 16 $90.81 18 $107.38 PILOCARPINE 4% OPHTH SOLN 15ML 16 $108.25 22 $145.52 PILOCARPINE 5MG TABLETS 93 $18.85 273 $47.68 PILOCARPINE 7.5MG TABLETS 88 $148.48 260 $428.61 PIMECROLIMUS 1% EXT CREAM 60GM 57 $411.76 165 $1,190.44 PIMOZIDE 1MG TABLETS 60 $97.34 151 $239.94 PIMOZIDE 2MG TABLETS 59 $128.17 183 $392.17 PINDOLOL 10MG TABLETS 62 $122.63 169 $324.25 PINDOLOL 5MG TABLETS 49 $73.61 138 $202.49 PIOGLITAZONE 15MG TABLETS 31 $114.48 92 $330.40 PIOGLITAZONE 45MG TABLETS 30 $177.22 89 $516.93 PIOGLITAZONE/GLIMEPIRIDE 30-2MG TAB 32 $305.44 87 $820.63 PIOGLITAZONE/GLIMEPIRIDE 30-4MG TAB 31 $302.02 90 $878.52 PIPERACILLIN 2GM INJ 1 $7.76 3 $15.28 PIROXICAM 10MG CAPSULES 35 $27.88 117 $84.34 PIROXICAM 20MG CAPSULES 29 $80.03 91 $239.69 PIROXICAM POWDER 30 $139.59 90 $410.76 PNEUMOVAX 23 INJ 25MCG/0.5ML PF SYR 1 $120.69 2 $354.08 PNV 29-1MG TABLETS 30 $19.46 91 $50.30 PNV OB+DHA PAK 60 $80.23 177 $228.32 PNV-DHA CAPSULES 30 $66.81 90 $192.24 PNV-SELECT TABLETS 30 $73.27 90 $210.07 PODIAPN CAPSULES 52 $39.30 136 $97.08 PODOCON-25 LIQUID 16 $125.28 48 $367.83 PODOFILOX 0.5% SOLUTION 3.5ML 4 $98.65 9 $244.16 PODOPHYLLUM RESIN POWDER 30 $92.80 90 $270.39 POLYETH GLYCOL 3350 NF POWDER 255GM 461 $31.09 1,657 $101.41 POLYETHYLENE GLYCOL 3350POW 14'S 25 $40.91 95 $145.76 POLYMYXIN B 500000 INJ, 1 VIAL 1 $10.86 3 $24.58 POT ACETATE 2MEQ/ML INJ, 20ML 1 $4.09 3 $4.28 POT ACETATE 4MEQ/ML INJ , 50ML 1 $4.19 3 $4.57 POT BICAR/CL 25MEQ EF TABLETS 45 $46.33 145 $139.42 POT CHL/DEXTROSE 5%/NACL0.45% INJ 1 $4.00 3 $4.00 POT CHLORIDE 20MEQ INJ, 100ML 1 $4.02 3 $4.05 POT CHLORIDE 2MEQ/ML INJ, 250ML 293 $10.33 879 $22.99 POT CHLORIDE 8MEQ CR CAPSULES 46 $36.77 126 $94.54 POT PHOSPHAT 3MM/ML INJ, 50ML 181 $22.06 542 $58.18 POTASSIUM CHLOR 10% LIQ(20MEQ/15ML) 562 $180.48 1,602 $506.94 POTASSIUM CHLOR 20% LIQ(40MEQ/15ML) 522 $715.55 1,560 $2,130.74 POTASSIUM CHLORIDE 20MEQ ER TABLETS 40 $24.77 119 $65.82 POTASSIUM CIT 1080MG (10MEQ) TABS 87 $116.55 230 $300.95 POTASSIUM CIT 540MG (5MEQ) TABLETS 93 $89.22 226 $212.12

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price POTASSIUM CL 10MEQ ER CAPSULES 51 $34.58 142 $88.98 POTASSIUM CL 20MEQ CR TABLETS 45 $24.87 131 $65.21 POTASSIUM PHOSPHATE 3MM/ML INJ 15ML 326 $52.94 979 $150.81 PRADAXA 150MG CAPS (BLISTER PACK) 60 $404.16 179 $1,205.23 PRADAXA 75MG CAPSULES(BLISTER PACK) 59 $408.57 178 $1,215.18 PRAMIPEXOLE 0.125MG TABLETS 58 $30.35 161 $77.44 PRAMIPEXOLE 0.5MG TABLETS 55 $16.73 153 $39.74 PRAMIPEXOLE 0.75MG TABLETS 51 $71.30 143 $193.30 PRAMIPEXOLE 1.5MG TABLETS 59 $17.70 168 $43.25 PRAMIPEXOLE 1MG TABLETS 58 $17.53 163 $42.01 PRAMIPEXOLE ER 0.375MG TABLETS 41 $576.46 123 $1,715.66 PRAMIPEXOLE ER 0.75MG TABLETS 36 $523.40 116 $1,649.80 PRAMIPEXOLE ER 1.5MG TABLETS 36 $518.04 106 $1,518.89 PRAMIPEXOLE ER 2.25MG TABLETS 33 $480.72 93 $1,343.63 PRAMIPEXOLE ER 3MG TABLETS 32 $447.77 95 $1,323.47 PRAMIPEXOLE ER 4.5MG TABLETS 31 $413.88 92 $1,213.35 PRAMOXINE HCL POWDER 25GM 30 $44.79 90 $126.36 PRASCION CLEANSER 170.3GM 238 $57.16 617 $141.52 PRASCION FC FACIAL CLENS CLOTH 30'S 30 $186.70 90 $552.10 PRASCION RA W/SUNSRN CREAM 45GM 30 $54.66 90 $155.98 PRASUGREL 10MG TABLETS 30 $317.83 90 $930.89 PRASUGREL 5MG TABLETS 32 $118.50 91 $334.17 PRAVASTATIN 40MG TABLETS 30 $17.88 90 $45.12 PRAVASTATIN 80MG TABLETS 30 $18.03 89 $45.62 PRAZOSIN 2MG CAPSULES 44 $30.35 145 $90.80 PRED MILD 0.12% OPHTH SUS 10ML 6 $190.89 8 $237.04 PRED-G OPHTH OINT 3.5GM 4 $145.45 11 $428.35 PRED-G OPHTH SUSP 5ML 5 $151.54 16 $446.63 PREDNICARBATE 0.1% OINT 15GM 42 $48.13 126 $136.39 PREDNICARBATE-E 0.1% CREAM 15GM 61 $84.86 210 $280.47 PREDNISOLONE 25MG/5ML SOLUTION 31 $45.55 41 $57.48 PREDNISOLONE AC 1% OPHTH SUSP 5ML 7 $62.63 9 $81.18 PREDNISOLONE ANHYDROUS POWDER 25GM 30 $143.19 90 $421.56 PREDNISOLONE ODT 10MG TABLETS 17 $238.82 70 $982.78 PREDNISOLONE ODT 15MG TABLETS 9 $197.40 54 $1,180.74 PREDNISOLONE ODT 30MG TABLETS 8 $219.80 73 $2,071.89 PREDNISOLONE SOD 1% OPHTH SOLN 10ML 10 $20.81 10 $21.44 PREDNISOLONE SOD PHOS 20MG/5ML SOL 37 $143.05 110 $421.15 PREDNISOLONE SOD PHOS 5MG/5ML SOL 56 $34.20 130 $74.16 PREDNISOLONE SOD PHOS POW 5GM 30 $609.94 90 $1,821.82 PREDNISONE 10MG TABS PACK 21'S 21 $22.02 63 $58.05 PREDNISONE 10MG TABS PACK 48'S 48 $45.13 144 $127.36 PREDNISONE 50MG (FIFTY MG) TABLETS 6 $9.67 56 $59.50 PREDNISONE 5MG PAK 48 48 $19.99 144 $51.97 PREDNISONE 5MG TABLETS PACK 21'S 21 $11.00 63 $25.00 PREDNISONE INTENSOL 5MG/1ML CONC. 59 $96.06 223 $352.50

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PREDNISONE SOLN 5MG/5ML (1MG/1ML) 92 $23.93 200 $47.41 PREFERAOB ONE CAPSULES 30 $119.19 90 $348.97 PREFEST TABLETS 31 $135.51 88 $383.88 PREGNENOLONE POWDER 25GM 30 $95.19 90 $277.56 PREMARIN 0.3MG TABLETS 29 $197.17 85 $565.08 PREMARIN 0.45MG TABS 30 $200.07 88 $586.72 PREMARIN 0.625MG TABS 29 $201.29 88 $590.59 PREMARIN 0.9MG TABS 30 $200.11 89 $591.84 PREMARIN 1.25MG TABLETS 31 $220.59 93 $656.09 PREMARIN VAGINAL CREAM 30GM 30 $388.60 34 $440.36 PREMASOL 6% SOLUTION, 500ML 30 $56.14 90 $160.42 PREMPHASE SINGLE TABLETS 28'S 28 $203.30 87 $612.16 PREMPRO 0.3MG/1.5MG TABS28'S 28 $234.88 83 $679.63 PREMPRO 0.45MG/1.5MG TABS 28'S 28 $234.60 84 $685.18 PREMPRO 0.625MG/2.5MG TAB28 PEACH 28 $209.52 84 $610.88 PREMPRO 0.625MG/5MG TABS 28 (BLUE) 28 $202.95 84 $595.35 PRENATAL - U CAPSULES 30 $17.10 90 $42.93 PRENATAL 19 TABLETS 30 $17.08 91 $43.57 PRENATAL 1MG W/IRON TABS(U-D PACK) 30 $14.20 90 $34.59 PREPOPIK PAK (ORANGE FLAVOR) 2 $146.21 6 $430.64 PREVNAR 13 INJ, 0.5ML 1 $220.40 2 $653.20 PREZISTA 150MG TABLETS 130 $811.59 389 $2,426.77 PREZISTA 600MG TABLETS 59 $1,484.35 178 $4,448.57 PREZISTA 75MG TABLETS 60 $191.00 90 $284.50 PRIFTIN 150MG TABLETS 24 $104.17 68 $289.44 PRILOCAINE HCL POWDER 100G 100 $350.99 300 $1,044.97 PRILOSEC 10MG POWDER PACKS 30'S 47 $344.60 166 $1,196.34 PRIMAQUINE PHOSPHATE 26.3MG TABS 27 $28.57 93 $88.90 PRIMIDONE 250MG TABLETS 66 $33.56 176 $82.88 PRIMSOL 50MG/5ML SOLUTION 102 $204.20 166 $327.42 PRIVIGEN 10% 20G/200ML INJ, 1 VIAL 375 $5,616.06 1,125 $16,840.19 PRIVIGEN 10GM INJ, 100ML 545 $8,167.00 1,636 $24,493.00 PRIVIGEN 5GM INJ, 50ML 1 $18.97 3 $48.90 PROAIR RESPICLICK ORAL PWD INH(200) 1 $75.21 2 $135.10 PROBENECID 500MG TABLETS 53 $37.50 144 $94.53 PROBENECID/COLCHICINE TABLETS 42 $36.45 125 $101.16 PROCHLORPERAZINE 5MG/ML INJ 2ML 20 $47.26 60 $133.77 PROCORT CREAM 60GM 60 $306.89 180 $912.68 PROCRIT 40,000 U/ML 1ML SD VIAL 3 $3,381.94 7 $6,777.95 PROCTOFOAM-HC 1-1% AERO FOAM 10GM 11 $141.17 33 $402.56 PROFERRIN ES 12MG TABLETS 38 $30.62 180 $129.06 PROFERRIN FORTE TABLETS 41 $29.97 141 $93.01 PROGESTERONE 100MG CAPSULES 33 $47.93 95 $130.01 PROGESTERONE 200MG CAPSULES 31 $34.68 92 $94.46 PROGESTERONE MICRO POWDER 500GM 30 $236.88 90 $702.63 PROGESTERONE/OIL 50MG/ML MDV 10ML 22 $61.95 24 $66.72

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PROGLYCEM 50MG/ML SUSPENSION 94 $983.75 267 $2,793.91 PROLENSA 0.07% OPTH SOLUTION 3ML 3 $297.63 8 $771.35 PROLEUKIN 22MU INJ, 1 VIAL 12 $15,538.12 36 $46,606.36 PROMETHAZINE 12.5MG SUPPOSITORIES 14 $94.22 97 $644.15 PROMETHAZINE 25MG/ML INJ 1ML AMPS 18 $17.08 66 $50.85 PROMETHAZINE 50MG SUPPOSITORIES 18 $384.20 225 $4,803.81 PROMETHAZINE 50MG/ML INJ 25X1ML 19 $54.26 25 $69.73 PROMETHAZINE 6.25MG/5ML SYRUP 216 $11.30 1,677 $60.67 PROMETHAZINE PE W/CODEINE SYRUP 156 $61.13 207 $79.95 PROMETHAZINE VC PLAIN SYRUP 165 $44.22 437 $110.72 PROMETHAZINE W/ CODEINE SYRUP 168 $19.88 358 $37.77 PROMISEB CREAM 30GM 41 $164.24 90 $354.97 PROPAFENONE 150MG TABLETS 79 $16.21 234 $40.38 PROPAFENONE 300MG TABLETS 69 $102.86 219 $318.64 PROPANTHELINE BROMIDE 15MG TABS 75 $50.95 252 $162.93 PROPARACAINE 0.5% OPHTH SOLN 15ML 15 $34.59 19 $41.02 PROPOFOL 10MG/ML INJ, 20ML 1,250 $196.50 3,750 $581.50 PROPRANOLOL 10MG TABLETS 63 $35.39 185 $96.35 PROPRANOLOL 20MG TABLETS 62 $19.79 180 $49.97 PROPRANOLOL 20MG/5ML SOLN 173 $24.94 475 $61.42 PROPRANOLOL 40MG TABLETS 59 $63.77 171 $178.40 PROPRANOLOL 40MG/5ML SOLN 185 $29.52 585 $84.68 PROPRANOLOL 80MG TABLETS 56 $32.33 158 $84.12 PROPRANOLOL ER 120MG CAPSULES 34 $64.76 101 $186.09 PROPRANOLOL ER 80MG CAPSULES 32 $51.31 97 $146.95 PROPRANOLOL HCL POWDER 30 $366.83 90 $1,092.48 PROPRANOLOL/HCTZ 40/25 MG TABS 36 $42.53 107 $117.68 PROPRANOLOL/HCTZ 80/25MG TABS 36 $50.12 107 $139.72 PROPYLTHIOURACIL 50MG TABLETS 92 $62.28 200 $130.69 PROQUAD LIVE VACCINE W/DILUENT INJ 1 $218.99 3 $648.97 PROTAMINE SULF 10MG/ML INJ , 25ML 1 $5.64 3 $8.92 PROTID CR TABLETS 30 $26.80 90 $72.39 PROTONIX 40MG GRANULE FOR SUSP 30PK 33 $480.51 107 $1,551.33 PROTRIPTYLINE 10MG TABLETS 72 $163.66 187 $420.39 PROTRIPTYLINE 5MG TABLETS 66 $218.87 188 $617.69 PROVENTIL HFA INH (200 PUFFS) 6.7GM 14 $143.77 32 $328.22 PRUTECT EMULSION 45GM 59 $66.54 71 $79.41 PSE/DM/GG SYRUP 30 $6.66 90 $11.98 PSE-GFN 120MG-1200MG ER TABLETS 28 $18.34 120 $65.84 PSE-GFN 90MG-800MG ER TABLETS 30 $22.99 90 $60.97 PSEUDACARB 75-25MG CHEWABLE TABLETS 30 $44.99 90 $126.97 PSEUDOEPHEDRINE GG/GRAPE SYRUP 120 $14.48 360 $35.43 PSEUDOVENT 120-400MG ER CAPSULES 30 $33.99 90 $93.96 PSEUDOVENT PED ER CAPSULES 30 $10.11 90 $22.33 PSORIZIDE FORTE TABLETS 101 $105.26 304 $307.77 P-TANN 8MG/5ML SUSPENSION 473ML 30 $9.77 90 $21.32

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price PULMICORT 180MCG FLEXHALR(120PUFFS) 1 $246.61 2 $593.52 PULMICORT 90MCG FLEXHALER(60 PUFFS) 1 $198.32 3 $611.83 PYLERA CAPSULES 122 $808.29 367 $2,416.87 PYRAZINAMIDE 500MG TABLETS 74 $174.50 190 $441.66 PYRIDOSTIGMINE 180MG TABLETS 45 $745.81 125 $2,073.78 PYRIDOSTIGMINE 60MG TABLETS 115 $52.42 312 $135.14 PYRIDOXINE 100MG/ML INJ 1ML VIAL 3 $57.02 7 $108.10 QNASL 80MCG NASAL AEROSOL 120SPRAYS 9 $201.26 26 $589.25 QSYMIA 11.25/69MG CAPSULES 29 $213.40 89 $658.22 QSYMIA 15-92MG CAPSULES 29 $219.67 90 $662.33 QSYMIA 3.75-23MG CAPSULES 21 $143.80 99 $654.69 QSYMIA 7.5-46MG CAPSULES 29 $226.43 89 $687.05 QUAL-TUSSIN SYRUP 30 $4.36 90 $5.07 QUETIAPINE 100MG TABLETS 42 $124.29 123 $357.94 QUETIAPINE 200MG TABLETS 39 $246.52 119 $739.17 QUETIAPINE 400MG TABLETS 40 $397.38 122 $1,209.05 QUETIAPINE ER 150MG TABLETS 31 $281.88 95 $845.71 QUICK-SERTER INSERTION DEVICE 16 $459.94 34 $977.01 QUINACRINE HYDROCHLORIDEPOWDER 30 $51.10 90 $145.29 QUINAPRIL/HCTZ 10-12.5MG TABLETS 32 $18.77 93 $47.40 QUINAPRIL/HCTZ 20-25MG TABLETS 32 $24.51 96 $64.78 QUINDAL CR 20-300MG TABLETS 30 $9.70 90 $21.09 QUINIDINE GLUCONATE 324MG CR TABS 74 $663.74 226 $2,034.19 QUINIDINE SULFATE 200MG (3GR) TABS 73 $15.74 218 $38.78 QUINIDINE SULFATE 300MG TABLETS 75 $27.12 189 $62.58 QUINIDINE SULFATE 300MG(E.R.) TAB 30 $29.80 90 $81.39 QUININE SULFATE 324MG CAPSULES 34 $188.87 105 $568.38 QVAR 40MCG ORAL INHALER 120 DOSES 9 $165.92 22 $418.23 QVAR 80MCG ORAL INHALER 120 DOSES 9 $223.89 22 $566.33 RABAVERT FOR INJECTION 1VL 1 $348.58 1 $364.32 RADIAPLEX RX GEL 170GM 102 $15.52 150 $20.96 RALOXIFENE 60MG TABLETS 30 $171.61 90 $501.45 RANEXA 1000MG TABLETS 58 $631.55 176 $1,890.20 RANITIDINE 150MG CAPSULES 50 $37.60 150 $104.30 RANITIDINE 15MG/ML (75MG/5ML) SYRUP 131 $19.00 485 $59.33 RANITIDINE 300MG CAPSULES 35 $58.77 105 $167.79 RANITIDINE 50MG/2ML INJ, 2ML 10 $14.44 27 $30.53 RAPAMUNE 1MG/ML SOL (60ML KIT) 68 $2,091.48 77 $2,366.81 RASAGILINE 1MG TABLETS 30 $468.90 90 $1,410.69 RASAGILINE MESYLATE 0.5MG TABLETS 32 $505.37 98 $1,525.33 RE DUALVIT PLUS CAPSULES 32 $20.26 90 $49.99 RE UREA 50% EMULSION 300 $91.33 900 $265.99 REA LO 40% CREAM 198.4GM 107 $96.09 268 $234.36 REBETOL 40MG/ML SOLUTION 162 $350.69 487 $1,044.07 REBIF 22MCG/0.5 ML SYR (6ML/PKG) 6 $8,604.88 18 $24,340.57 REBIF 44MCG/0.5 ML SYR (6ML/PKG) 6 $8,258.82 18 $24,145.99

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price REBIF TITRATION PACK (4.2ML/PKG) 4 $8,977.49 13 $26,924.47 RECEDO GEL 20GM 26 $349.32 78 $1,039.97 RECOMBIVAX HB 10MCG/ML INJ, 1ML 1 $80.99 2 $119.49 RECOMBIVAX HB 5MCG/0.5 INJ, 0.5ML 1 $53.99 1 $53.99 RECOMBIVAX-HB 40MCG/ML INJ, 1ML 1 $208.99 3 $618.97 RE-DRYLEX SYRUP 473ML 30 $6.92 90 $12.75 REGENECARE WOUND GEL 30 $8.96 90 $18.89 RELAGARD GEL 50GM 51 $54.69 61 $65.10 RELCOF PE TABLETS 30 $14.97 90 $36.90 RELENZA DISKHALER 5MG/INH (20 INH) 20 $70.14 61 $202.43 RELERA TABLETS 30 $14.00 90 $34.00 REMEVEN 50% CREAM 142GM 199 $64.09 596 $184.26 REMICADE 100MG INJ VIAL 6 $7,269.76 17 $21,801.29 REMODULIN 10MG/ML INJ., 20ML 1 $653.80 3 $1,953.40 RENACIDIN IRRIGATION SOLN 500ML 1,310 $98.45 2,695 $198.28 RENAGEL 400MG TABLETS 142 $554.33 229 $893.38 RENAGEL 800MG TABLETS 204 $1,561.00 527 $4,037.24 RENATABS TABLETS 30 $15.99 90 $39.97 RENOVA 0.02% CREAM 40GM 46 $322.54 86 $601.68 REPATHA SURE CLICK 140MG/ML, 2ML 2 $1,244.17 6 $3,690.09 REPRONEX 75IU FOR INJECTION 1 $153.80 3 $453.40 RESCON-JR SUST REL TABLETS 30 $40.91 90 $114.73 RESCON-MX SUST REL TABLETS 30 $92.54 90 $269.62 RESCRIPTOR 100MG TABLETS 30 $44.80 90 $126.39 RESERPINE 0.1MG TABS 30 $34.30 90 $94.89 RESERPINE 0.25MG TABLETS 30 $46.60 90 $131.79 RESPA C&C IR TABLETS 30 $35.80 90 $99.39 RESPA-BR TABLETS 30 $36.00 90 $99.99 RESPAHIST CAPSULES 30 $32.00 90 $87.99 RESPAIRE-30 CAPSULES 25 $24.00 75 $63.99 RESTASIS 0.05% OPHTH MULTDOSE 5.5ML 42 $4,332.86 140 $14,244.75 RETIN-A MICRO 0.08% GEL PUMP 50GM 50 $1,034.33 129 $2,658.46 REVLIMID 10MG CAPSULES 100'S 21 $15,572.41 63 $45,922.21 REVLIMID 15MG CAPSULES 21'S 19 $14,008.95 58 $42,018.84 REXULTI 1MG TABLETS 30 $1,106.90 91 $3,382.25 REXULTI 2MG TABLETS 29 $1,095.06 90 $3,346.41 RHOPHYLAC 1500IU/2ML SYRINGE 2 $180.49 6 $533.47 RIBASPHERE 600MG TABLETS 17 $761.09 52 $2,275.28 RIBAVIRIN 200MG CAPSULES 82 $490.44 246 $1,463.33 RIBAVIRIN 200MG TABLETS 96 $144.76 268 $396.41 RIDAURA 3MG CAPSULES 55 $1,323.46 151 $3,636.35 RIFABUTIN 150MG CAPSULES 45 $716.09 127 $2,025.08 RIFAMATE CAPSULES 52 $309.40 157 $920.21 RIFAMPIN 150MG CAPSULES 55 $161.12 172 $497.95 RIFAMPIN 300MG CAPSULES 47 $84.22 127 $219.53 RIFAMPIN 600MG VIAL FOR INJECTION 16 $565.60 48 $1,688.80

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price RIFATER TABLETS 83 $369.74 90 $402.99 RIMANTADINE 100MG TABLETS 35 $60.53 141 $232.18 RIMSO-50 50% SOLUTION 79 $998.56 150 $1,880.92 RIOMET 500MG/5ML SOLUTION 389 $547.86 1,239 $1,737.80 RISEDRONATE SOD 30MG TABLETS 11 $558.85 20 $1,015.36 RISEDRONATE SOD 35MG DELAYED REL TB 4 $200.36 12 $579.72 RISEDRONATE SOD 5MG TABLETS 29 $214.74 90 $663.43 RISPERDAL CONSTA 12.5MG INJ, 1 VIAL 1 $342.41 5 $1,261.26 RISPERDAL CONSTA 25MG KIT 1 $708.16 6 $2,858.11 RISPERDAL CONSTA 37.5MG KIT 2 $1,086.69 6 $4,142.62 RISPERDAL CONSTA 50MG KIT 2 $1,460.59 6 $5,374.89 RISPERIDONE 1MG/ML ORAL SOL 30ML 64 $319.88 180 $900.07 RISPERIDONE 3MG TABLETS 41 $238.89 122 $698.63 RISPERIDONE 4MG ODT TABLETS 43 $622.63 116 $1,688.09 RISPERIDONE M TAB 1MG TABLETS 47 $190.57 137 $551.85 RISPERIDONE M TAB 3MG TABLETS 40 $408.97 134 $1,376.85 RISPERIDONE ODT 0.25MG TABLETS 53 $219.60 164 $664.79 RISPERIDONE ODT 0.5MG TABLETS 49 $218.76 139 $609.87 RISPERIDONE ODT 2MG TABLETS 42 $344.95 146 $1,185.45 RITONAVIR 100MG TABLETS 37 $212.21 115 $646.15 RITUXAN 100MG INJ, 10ML 77 $8,822.68 100 $11,523.90 RIVASTIGMINE 1.5MG CAPSULES 61 $201.71 181 $587.80 RIVASTIGMINE 13.3MG/24H PATCH 30 $414.26 90 $1,221.40 RIVASTIGMINE 3MG CAPSULES 58 $181.66 174 $537.51 RIVASTIGMINE 4.5MG CAPSULES 56 $173.94 168 $515.09 RIVASTIGMINE 4.6MG/24H PATCH 30 $409.47 90 $1,210.63 RIVASTIGMINE 6MG CAPSULES 58 $181.39 173 $537.33 RIVASTIGMINE 9.5MG/24H PATCH 30 $300.87 90 $883.34 RIZATRIPTAN 10MG TABLETS 10 $193.95 34 $623.00 RIZATRIPTAN 5MG TABLETS 10 $285.63 36 $995.04 ROPINIROLE 0.25MG TABLETS 58 $17.46 160 $41.26 ROPINIROLE 0.5MG TABLETS 52 $88.72 151 $250.79 ROPINIROLE 3MG TABLETS 49 $26.92 149 $73.48 ROPINIROLE 4MG TABLETS 49 $84.38 145 $241.06 ROPINIROLE 5MG TABLETS 52 $89.09 152 $252.51 ROPINIROLE ER 12MG TABLETS 35 $441.06 106 $1,345.09 ROPINIROLE ER 2MG TABLETS 48 $112.14 136 $307.46 ROPINIROLE ER 4MG TABLETS 37 $123.37 115 $372.86 ROPINIROLE ER 6MG TABLETS 35 $262.71 110 $814.95 ROPINIROLE ER 8MG TABLETS 37 $287.08 115 $875.56 ROPIVACAINE 10MG/ML INJ, 20ML 1 $4.80 3 $6.40 ROPIVACAINE 5MG/ML INJ, 30ML 30 $24.99 90 $66.97 ROTARIX POWDER FOR SUSP(ORAL),1ML 1 $135.99 3 $399.97 ROTATEQ ORAL SOLUTION, 2ML 2 $105.00 2 $105.00 ROXICET 5/325 ORAL SOLUTION 30 $9.28 90 $19.84 ROZEREM 8MG TABLETS 29 $387.03 91 $1,207.50

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price R-TANNA PEDIATRIC SUSPENSION 30 $11.74 90 $27.23 RU-TUSS TABLETS 30 $9.67 90 $21.01 RY-T-12 SUSPENSION 30 $9.75 90 $21.24 RYTARY ER 23.75-95MG CAPSULES 209 $597.37 599 $1,706.85 SABRIL 500MG TABLETS 30 $3,997.73 90 $11,985.19 SAIZEN 5MG VIAL FOR INJECTION 4 $3,073.13 12 $9,211.40 SAIZEN 8.8MG CLICK EASY CARTRIDGE 14 $13,449.62 41 $40,340.86 SALICYLIC AC 6% CREAM KIT 1 $159.99 3 $471.97 SALICYLIC AC 6% LOTION 400GM 416 $52.58 825 $100.22 SALICYLIC ACID 26% LIQUID 11 $45.77 30 $120.40 SALICYLIC ACID 27.5% LIQUID 10 $92.12 27 $237.40 SALICYLIC ACID 6% CREAM 400GM 401 $58.20 800 $112.24 SALICYLIC ACID 6% FOAM 200GM 142 $256.25 300 $535.39 SALICYLIC ACID 6% GEL 40GM 57 $276.57 206 $991.39 SALICYLIC ACID 6% LOTION KIT 597 $112.88 1,791 $330.65 SALICYLIC ACID POWDER 454GM 147 $18.23 440 $46.68 SALKERA 6% EMMOLIENT FOAM 100GM 30 $64.14 90 $184.41 SALSALATE 500MG TABLETS 83 $91.34 287 $305.81 SALSALATE 750MG TABLETS 85 $126.21 253 $365.92 SAMSCA 30MG TABLETS 23 $11,656.23 90 $45,465.61 SANCUSO TRANSDERMAL SYSTEM 2 $1,413.54 11 $6,634.50 SANDIMMUNE 100MG/ML ORALSOLN 72 $1,074.34 114 $1,702.52 SANDOSTATIN LAR DEPOT 20MG INJ KIT 1 $4,562.32 3 $11,675.38 SANTYL COLLAGNS 250U/GM OINT 30GM 52 $387.35 222 $1,639.05 SAVELLA 100MG TABLETS 57 $368.11 170 $1,089.40 SAVELLA 12.5MG TABLETS 56 $362.03 144 $926.82 SAVELLA 25MG TABLETS 59 $351.26 173 $1,015.43 SAVELLA 50MG TABLETS 60 $354.18 177 $1,039.54 SAVELLA TITRATION PACK 55 $318.44 165 $947.32 SAXENDA 6MG/ML PEN INJ 5 X 3ML 14 $1,211.74 41 $3,449.07 SCOPOLAMINE 0.4MG/ML INJ 1ML 1 $8.29 3 $16.87 SCOPOLAMINE TRANSDERMAL PATCHES 5 $50.97 30 $310.89 SEB-PREV 10% WASH 340ML 355 $80.30 740 $162.90 SECONAL SODIUM 100MG CAPSULES 35 $1,137.84 43 $1,367.62 SELEGILINE 5MG CAPSULES 56 $84.30 162 $236.38 SELEGILINE 5MG TABLETS 53 $131.31 156 $378.83 SELENIUM 40MCG/ML INJ 10ML 1 $5.00 3 $6.99 SELENIUM SULFIDE 2.25% SHAMPOO 184 $137.64 393 $289.79 SEMPREX-D CAPSULES 58 $290.15 205 $1,021.59 SENSIPAR 30MG TABLETS 32 $953.12 94 $2,799.71 SENSIPAR 60MG TABLETS 34 $1,824.79 99 $5,300.34 SENSIPAR 90MG TABLETS 34 $3,058.97 104 $9,240.45 SE-PLETE DHA CAPSULES 30 $44.49 90 $125.48 SERADEX-LA TABLETS 30 $28.30 90 $76.89 SEREVENT DISKUS 50MCG ORAL INH (60) 61 $385.73 177 $1,115.75 SEROSTIM 4MG FOR INJECTION 28 $11,131.69 76 $29,603.67

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price SEROSTIM 5MG FOR INJECTION 25 $19,771.84 76 $59,307.52 SEROSTIM 6MG FOR INJECTION 28 $16,001.47 84 $48,620.67 SERTRALINE 20MG/ML CONCENTRATE 75 $72.53 233 $217.83 SEVELAMER CARB 2.4GM POWDER POUCHES 108 $1,780.65 271 $4,458.24 SHINGRIX 50MCG INJ, 1 VIAL 1 $162.09 1 $163.01 SILDENAFIL 100MG TABLETS 6 $244.22 17 $725.87 SILDENAFIL 25MG TABLETS 7 $299.29 22 $894.53 SILDENAFIL 50MG TABLETS 6 $256.89 19 $788.06 SILENOR 6MG TABLETS 30 $423.20 91 $1,277.02 SILODOSIN 4MG CAPSULES 32 $178.57 94 $523.16 SILODOSIN 8MG CAPSULES 30 $169.54 90 $502.93 SILVER NITRATE 0.5% SOLUTION 960ML 760 $33.93 2,279 $93.79 SILVER SULFADIAZINE 1% CREAM 25 GM 101 $24.18 634 $130.61 SIMBRINZA 1-0.2% SUSPENSION 8ML 9 $175.20 22 $443.35 SIMCOR 1000-20 TABLETS 30 $277.66 90 $824.99 SIMCOR 1000-40MG TABLETS 30 $268.06 90 $796.17 SIMCOR 500-20MG TABLETS 30 $156.00 90 $459.99 SIMCOR 500-40MG TABLETS 30 $153.30 90 $451.91 SIMCOR 750-20MG TABLETS 30 $228.00 90 $675.99 SIMPONI 50MG/0.5ML PF SYR, 0.5ML 1 $4,345.22 2 $11,991.97 SIMPONI 50MG/0.5ML SMTJTAUTO INJ 1 $4,037.37 2 $11,804.08 SIROLIMUS 0.5MG TABLETS 57 $442.80 131 $1,019.18 SIROLIMUS 1MG TABLETS 58 $952.85 147 $2,408.16 SIROLIMUS 2MG TABLETS 41 $1,142.28 101 $2,818.70 SOD ACETATE 2MEQ/ML INJ , 20ML 375 $38.28 1,125 $106.83 SOD CHLORIDE 0.45% INJ, 1000ML 15,857 $21.44 34,667 $42.13 SOD CHLORIDE 0.9% BACT INJ , 10ML 259 $23.37 1,103 $86.38 SOD CHLORIDE 0.9% INJ , 2ML 103 $9.76 507 $32.36 SOD CHLORIDE 0.9% INJ , 50ML 1,384 $42.32 4,151 $118.97 SOD CHLORIDE 0.9% NEB SOL 100 X 3ML 270 $28.65 401 $40.56 SOD CHLORIDE 0.9% W/ 20MEQ KCL 30 $4.12 90 $4.37 SOD CHLORIDE 2.5/ML INJ, 40ML 369 $55.69 1,108 $159.07 SOD CHLORIDE 23.4% INJ ,100ML 225 $19.61 324 $26.47 SOD FLUORIDE 0.2% GRAPE SOLUTION 479 $10.18 797 $14.29 SOD FLUORIDE 1.1 (.5MG)/ML DRP 50ML 51 $12.11 53 $12.44 SOD SUL/SULF 10-5% AER FOAM 60GM 64 $82.68 193 $240.04 SOD SUL/SULFUR 9-4.5% LIQUID 454 $217.19 1,176 $555.44 SOD SULFA/SULFUR 10-2% CREAM 57GM 58 $206.79 171 $603.41 SOD SULFA/SULFUR 10-5% CREAM 28GM 49 $222.74 171 $761.22 SOD SULFACET 9%/SULF 4% WASH 473ML 473 $280.25 1,419 $831.99 SOD SULFACET&SULFUR WASH 473ML 473 $124.99 1,419 $366.98 SOD SULFACETAMIDE 10% WSH GL 340.2G 356 $239.29 876 $583.74 SOD SULFACETAMIDE/SULFUR8-4% SUSP 474 $256.55 764 $411.02 SODIUM ACETATE 4MEQ/ML INJ 50ML 1 $4.07 3 $4.20 SODIUM BICARBONATE 8.4% INJ 50ML 541 $68.77 542 $68.97 SODIUM CHLORIDE .9% VIAL30ML 1 $4.07 3 $4.22

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price SODIUM CHLORIDE 0.9% IRR SOL 1000ML 3,879 $23.40 7,830 $43.15 SODIUM CHLORIDE 3% NEB SOL 15ML 273 $11.33 698 $22.76 SODIUM CHLORIDE 7% NEB SOL 30X4ML 252 $47.07 653 $115.60 SODIUM LAURYL SULFATE POWDER 30 $6.00 90 $9.99 SODIUM PHOSPHATE 3MM/ML INJ 5ML 46 $18.24 90 $31.84 SODIUM PHOSPHATE 3MM/ML 50ML 30 $6.03 90 $10.08 SODIUM PHOSPHATE 3MM/ML INJ 15ML 146 $80.71 439 $234.12 SODIUM SULF/SULFUR IN UREA CLEANSER 356 $284.74 533 $423.98 SODIUM SULF-10%/SULFUR-5% SUSP 30GM 38 $73.16 140 $255.96 SODIUM SULFACETAM 10% LOTN(TOPICAL) 120 $101.42 262 $217.03 SODIUM SULFACETAMIDE/SULF 10-2% LIQ 229 $200.41 551 $476.45 SODIUM THIOSULFATE 25% INJ, 50ML 50 $39.99 3,000 $2,163.40 SOLIQUA 100/33MCG INJ PEN 5 X 3ML 14 $628.07 30 $1,356.29 SOLU-CORTEF 500MG INJ, 1 VIAL 1 $53.96 3 $153.88 SOLU-CORTEF ACT-O-VIAL 100MG INJ 3 $42.45 22 $325.88 SOLU-CORTEF ACT-O-VIAL 250MG INJ 2 $53.75 8 $196.70 SOLU-MEDROL 500MG INJ, 1VIAL 3 $66.83 6 $145.36 SOMATULINE 90MG/0.3ML INJ, 0.3ML 1 $15,257.30 3 $45,763.90 SORBIC ACID POWDER 30 $14.58 90 $35.75 SORINE 80MG TABLETS 55 $37.04 160 $99.80 SOTALOL 160MG TABLETS 57 $17.23 170 $43.67 SOTALOL 240MG TABLETS 53 $212.41 169 $672.50 SOTALOL 80MG TABLETS 55 $37.04 160 $99.80 SOTALOL AF 160MG TABLETS 60 $18.10 173 $44.41 SOTALOL AF 80MG TABLETS 57 $38.05 161 $100.75 SPACOL LIQUID 30 $5.65 90 $8.94 SPINOSAD 0.9% TOPICAL SUSP 120ML 125 $250.71 376 $744.13 SPIRIVA 18MCG CAPS 30S &HANDIHALER 30 $382.23 90 $1,126.00 SPIRIVA RESPIMAT 2.5MCG INH 4GM 60D 4 $445.75 12 $1,312.86 SPIRONOLACTONE 100MG TABLETS 38 $34.62 111 $92.39 SPRIX 15.75MG NASAL SPR (40 SPRAYS) 30 $6,223.48 90 $18,662.44 STALEVO 50 TABLETS 100 $805.88 284 $2,281.02 STAVUDINE 15MG CAPSULES 36 $99.99 107 $291.98 STAVUDINE 20MG CAPSULES 48 $85.63 68 $119.13 STAVUDINE 30MG CAPSULES 59 $170.98 180 $516.96 STAVUDINE 40MG CAPSULES 57 $349.05 178 $1,079.33 STAVZOR 125MG CAPSULES 30 $46.17 90 $130.52 STAVZOR 250MG CAPSULES 30 $86.83 90 $252.49 STAVZOR 500MG CAPSULES 30 $156.73 90 $462.20 STAXYN 10MG ODT TABLETS 6 $164.54 15 $436.41 STENDRA 100MG TABLETS 6 $382.70 12 $794.61 STENDRA 200MG TABLETS 6 $386.74 18 $1,241.02 STENDRA 50MG TABLETS 5 $372.45 24 $1,643.78 STERIL WATER INJ , 250ML 13,756 $149.82 41,269 $441.45 STERIL WATER IRRIG SOLUTION, 500ML 7,095 $131.71 10,342 $190.16 STERILE WATER FOR INJECTION 188 $22.09 217 $24.79

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price STOOL SOFTENER 250MG CAPSULES 50 $5.48 134 $7.96 SUCRALFATE 1GM TABLETS 83 $36.00 269 $107.09 SUFENTANIL 50MCG/ML INJ, 1ML AMPULE 1 $9.60 3 $20.79 SUFENTANIL 50MCG/ML INJ, 2ML AMPULE 1 $9.60 3 $20.79 SUFENTANIL 50MCG/ML INJ, 5ML VIAL 1 $8.60 3 $17.79 SUFENTANIL CITRATE POWDER 30 $34,083.70 90 $102,243.10 SULFACET/PREDNISOLONE OPH SOL 10ML 7 $19.39 12 $29.56 SULFACETAMIDE 10%/SULFUR 5% LOTION 47 $360.04 247 $1,865.28 SULFACETAMIDE NA 10% OPH SOLN 15ML 15 $29.77 15 $30.81 SULFACETAMIDE SOD 10% OPHTH OINT 4 $35.46 11 $98.37 SULFADIAZINE 500MG TABLETS 143 $452.09 327 $1,028.67 SULFAMETHOX/TMP 400-80MG/5ML INJ 10 $9.98 30 $21.94 SULFAMETH-TRIMETH 200-40MG/5ML SUSP 170 $41.35 341 $78.91 SULFAMYLON 85MG/GM CREAM 136 $164.27 454 $536.71 SULFASALAZINE 500MG TABLETS 125 $31.03 354 $80.73 SULFASALAZINE DR 500MG TABLETS 123 $45.80 364 $127.73 SULINDAC 150MG TABLETS 50 $15.72 165 $42.42 SUMATRIPTAN 100MG TABLETS 10 $142.17 30 $423.66 SUMATRIPTAN 20MG NASAL SP (1 DOSE) 7 $370.34 21 $1,116.88 SUMATRIPTAN 4MG/0.5ML INJ, 2X0.5ML 3 $467.42 11 $1,865.47 SUMATRIPTAN 50MG TABLETS 10 $139.61 31 $427.65 SUMATRIPTAN 5MG NASAL SPRAY (6 SPR) 7 $342.67 19 $963.55 SUMATRIPTAN 6MG REFILL INJECTION 4 $783.86 14 $2,815.46 SUMATRIPTAN 6MG/0.5 INJ 2X 0.5ML 3 $556.13 10 $1,744.35 SUMATRIPTAN 6MG/0.5ML VIAL FOR INJ 3 $518.77 12 $1,842.17 SUMYCIN 125/5ML SYRUP 30 $9.75 90 $21.24 SUPARTZ 25MG INJECTION 2.5ML 9 $1,064.15 13 $1,529.28 SUPERVITE EC TABLETS 30 $17.99 90 $45.97 SUPERVITE LIQUID 237 $20.33 711 $52.99 SUPPORT-500 CAPSULES 30 $21.02 71 $44.25 SUPRAX 400MG CAPSULES 6 $130.92 64 $1,285.53 SUPRAX 400MG TABLETS 2 $50.08 7 $142.23 SUPREP BOWEL PREP SOLN 355 $126.19 1,064 $370.57 SUPRESS-PE PEDIATRIC DROPS 30ML 31 $22.40 92 $59.21 SUTAN-DM SUSPENSION 30 $7.80 90 $15.40 SUTENT 12.5MG CAPSULES 46 $10,655.50 137 $31,958.51 SUTENT 25MG CAPSULES 24 $8,742.42 71 $26,219.25 SUTENT 50MG CAPSULES 23 $13,664.03 70 $40,984.09 SYLATRON 200 MCG VIAL FORINJ KIT 4 $6,254.74 12 $18,756.22 SYLATRON 300 MCG VIAL FORINJ KIT 4 $9,633.40 12 $28,892.20 SYMBICORT 160/4.5MCG (120 ORAL INH) 10 $326.83 30 $949.24 SYMBICORT 80/4.5MCG (120 ORAL INH) 10 $332.20 30 $952.63 SYNAGIS 100MG/ML INJ (LIQUID) 1 $3,813.18 4 $11,431.53 SYNAGIS 50MG INJ (LIQUID) 1 $1,756.42 2 $5,261.27 SYNAREL 2MG/ML NASAL SOLN(60 SPR) 11 $4,471.57 32 $12,835.96 SYNTHROID 0.3MG (300MCG)TABLETS 35 $45.54 95 $118.27

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price SYNVISC 8MG/ML INJ, 2ML SYRINGE 7 $1,592.37 10 $2,408.21 SYNVISC ONE 8MG/ML INJ, 6ML 7 $1,545.34 7 $1,547.82 TAB-A-VITE TABLETS 30 $4.42 93 $5.30 TACLONEX SUSPENSION 60GM 80 $1,272.87 222 $3,515.07 TACROLIMUS 0.03% OINTMENT 52 $311.66 142 $840.68 TACROLIMUS 0.1% OINTMENT 100GM 56 $334.65 175 $1,036.91 TACROLIMUS 0.5MG (HALF MG) CAPSULES 83 $166.11 209 $413.99 TACROLIMUS 1MG CAPSULES 146 $559.92 347 $1,321.98 TACROLIMUS 5MG (FIVE MG) CAPSULES 63 $1,225.79 179 $3,510.28 TAMOXIFEN 10MG TABLETS 50 $59.12 151 $171.52 TAMOXIFEN 20MG TABLETS 30 $44.30 90 $123.85 TAMSULOSIN 0.4MG CAPSULES 33 $75.69 105 $234.96 TANABID SR 6-30MG TABLETS 30 $62.80 90 $180.39 TANNATE 12 S SUSPENSION 30 $10.87 90 $24.60 TANNATE-12 SUSPENSION 30 $10.25 90 $22.75 TANNATE-V DM (V-TAN DM)SUSPENSION 30 $10.50 90 $23.49 TANZEUM 30MG ONCE WEEKLY INJ 4 PENS 4 $580.96 12 $1,727.26 TARCEVA 100MG TABLETS 30 $8,598.35 90 $25,911.97 TARCEVA 150MG TABLETS 29 $8,414.47 90 $25,911.97 TARCEVA 25MG TABLETS 64 $6,385.30 244 $24,379.81 TARON FORTE CAPSULES 32 $26.89 92 $69.36 TARON-C DHA CAPSULES 30 $28.10 90 $76.09 TARON-PREX CAPSULES 30 $51.40 92 $147.58 TASIGNA 200MG CAPSULES 87 $9,935.70 96 $10,933.19 TAZAROTENE 0.1% CREAM 30GM 44 $260.11 127 $746.14 TAZICEF 2GM INJ, 1 VIAL 1 $29.99 3 $81.97 TAZORAC 0.05% CREAM 60GM 41 $515.23 127 $1,584.07 TAZORAC 0.05% GEL 100GM 44 $550.26 95 $1,188.98 TAZORAC 0.1% GEL 100GM 46 $609.04 109 $1,449.87 TBC AEROSOL 113.4GM 30 $6.07 90 $10.20 TEARS AGAIN HYDRATE CAPSULES 102 $50.75 135 $65.87 TEKAMLO 150-10MG TABLETS 30 $148.11 90 $436.33 TEKAMLO 150-5MG TABLETS 30 $148.11 90 $436.33 TEKAMLO 300-10MG TABLETS 30 $185.86 90 $549.58 TEKAMLO 300-5MG TABLETS 30 $185.86 90 $549.58 TEKTURNA 150MG TABLETS 31 $194.24 94 $570.09 TEKTURNA 300MG TABLETS 29 $228.07 90 $690.13 TEKTURNA HCT 150-12.5 TABLETS 29 $192.70 92 $613.74 TEKTURNA HCT 300-12.5 TABLETS 30 $231.54 90 $688.47 TEKTURNA HCT 300MG-25MG TABLETS 30 $231.12 90 $689.21 TELMISARTAN 20MG TABLETS 30 $132.88 90 $385.18 TELMISARTAN 40MG TABLETS 31 $135.33 92 $393.55 TELMISARTAN/AMLODIPINE 40-10MG TABS 29 $153.10 89 $457.20 TELMISARTAN/AMLODIPINE 40-5MG TABS 31 $158.56 92 $472.43 TELMISARTAN/AMLODIPINE 80-10MG TABS 30 $154.86 90 $459.55 TELMISARTAN/AMLODIPINE 80-5MG TABS 30 $156.87 90 $461.78

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price TELMISARTAN/HCTZ 80-25MG TABS 30 $59.45 90 $169.36 TEMAZEPAM 22.5MG CAPSULES 30 $272.44 92 $836.81 TEMAZEPAM 30MG CAPSULES 30 $14.29 91 $35.28 TEMAZEPAM 7.5MG CAPSULES 31 $192.99 100 $605.00 TEMOZOLOMIDE 100MG CAPES 15 $2,037.78 56 $7,698.29 TEMOZOLOMIDE 140MG CAPSULES 14 $2,497.02 15 $2,685.97 TEMOZOLOMIDE 180MG CAPSULES 9 $2,079.26 15 $3,291.97 TEMOZOLOMIDE 20MG CAPSULES 19 $604.81 58 $1,806.44 TEMOZOLOMIDE 250MG CAPSULES 5 $1,508.37 15 $4,191.97 TEMOZOLOMIDE 5MG CAPSULES 27 $283.21 80 $841.63 TENIVAC INJ, 0.5ML SYRINGE 1 $47.18 1 $47.44 TERBUTALINE 1MG/ML INJ, 1ML 35 $851.15 106 $2,545.44 TERBUTALINE 2.5MG TABLETS 34 $113.48 123 $403.03 TERBUTALINE 5MG TABLETS 55 $224.51 183 $738.21 TERCONAZOLE 0.4% VAGINAL CRM 45GM 45 $41.21 79 $69.21 TERCONAZOLE 0.8% VAGINAL CRM 20GM 21 $45.55 76 $156.94 TERCONAZOLE 80MG VAGINAL SUPP 3'S 3 $82.43 14 $338.54 TERSI FOAM 2.25% AEROSOL70GM 30 $96.57 90 $281.70 TESTOSTERONE 1% (12.5MG/1.25GM)PUMP 167 $400.59 390 $930.63 TESTOSTERONE 1% GEL 150GM (30X5GM) 185 $480.67 531 $1,369.78 TESTOSTERONE 1% GEL(25MG)30 X 2.5GM 104 $526.75 286 $1,439.92 TESTOSTERONE 1.62% GEL PKTS 52 $716.84 154 $2,099.43 TESTOSTERONE 1.62% GEL PKTS 101 $590.53 294 $1,707.92 TESTOSTERONE 1.62% GEL PUMP 99 $473.70 294 $1,398.73 TESTOSTERONE 10MG/ACT GEL(120PUMPS) 70 $348.30 173 $849.50 TESTOSTERONE 30MG/ACT SOLUTION 107 $663.94 293 $1,809.80 TESTOSTERONE CYP 100MG/ML INJ, 10ML 10 $50.09 10 $50.77 TESTOSTERONE CYP 200MG/ML INJ, 10ML 4 $34.77 8 $74.38 TESTOSTERONE CYPIONATE POWDER 30 $159.94 90 $471.82 TESTOSTERONE ENAN 200MG/ML INJ, 5ML 5 $82.59 7 $100.19 TESTOSTERONE PROPIONATE POWDER 5GM 30 $159.94 90 $471.82 TETANUS TOXOID ADSORBED INJ, 0.5ML 1 $123.98 3 $363.94 TETANUS/DIPH TOX 2-2 LF INJ, 0.5ML 1 $23.37 2 $62.10 TETRABENAZIN 25MG TABLETS 82 $5,910.18 218 $15,690.84 TETRABENAZINE 12.5MG TABLETS 74 $4,776.27 199 $12,808.09 TETRACAINE 0.5% OPTH SOLUTION 15ML 14 $8.52 15 $8.78 TETRACAINE HCL POWDER 30 $49.00 90 $138.99 TETRACYCLINE 250MG CAPSULES 47 $345.37 139 $1,011.41 TETRACYCLINE 500MG CAPSULES 43 $648.26 142 $2,122.78 TETRIX KIT 370 $268.96 1,110 $798.87 TEVETEN HCT 600MG/12.5MG 30 $158.82 90 $468.46 TEVETEN HCT 600MG/25MG TABLETS 30 $158.82 90 $468.46 THALOMID 100MG CAPSULES 28'S 29 $9,287.86 87 $27,855.59 THALOMID 50MG CAPSULES 28'S 35 $6,930.45 106 $20,783.36 THEO-24 100MG CR CAPSULES 43 $89.29 146 $296.88 THEO-24 300MG ER CAPSULES 38 $136.51 118 $414.09

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price THEOCHRON 100MG CR TABLETS 11 $6.99 32 $12.96 THEOCHRON 200MG CR TABLETS 40 $16.61 68 $25.36 THEOCHRON 300MG CR TABLETS 50 $212.34 147 $618.74 THEOPHYLLINE 400MG ER TABLETS 33 $39.99 96 $108.38 THEOPHYLLINE 450MG ER TABLETS 46 $38.66 135 $106.37 THEOPHYLLINE 600MG ER TABLETS 34 $80.42 101 $231.93 THEOPHYLLINE 80/15ML SOLUTION 640 $72.02 1,639 $178.23 THEOPHYLLINE ANHYDROUS POWDER 100GM 30 $17.82 90 $45.45 THEROBEC TABLETS 35 $13.02 103 $30.73 THIAMINE 100MG/ML INJ, 2ML 11 $67.16 13 $79.78 THIORIDAZINE 100MG TABLETS 61 $32.45 176 $86.60 THIORIDAZINE 10MG TABLETS 112 $35.43 233 $69.60 THIORIDAZINE 25MG TABLETS 57 $26.79 196 $82.40 THIORIDAZINE 50MG TABLETS 61 $30.49 175 $80.02 THIOTHIXENE 10MG CAPSULES 59 $81.79 188 $252.19 THIOTHIXENE 1MG CAPSULES 64 $33.51 190 $91.35 THIOTHIXENE 2MG CAPSULES 51 $30.26 154 $83.38 THIOTHIXENE 5MG CAPSULES 53 $47.10 155 $131.31 THYMOGLOBULIN 25MG INJ, 1 VIAL 1 $834.30 3 $2,494.90 THYROGEN 1.1MG INJECTION 2 $3,395.98 6 $10,179.94 THYROID (ARMOUR) 2GR (120MG) TABS 31 $41.76 92 $114.98 THYROID (ARMOUR) 3GR (180MG) TABS 30 $39.06 89 $107.31 THYROID (ARMOUR) 4GR (240MG) TABS 30 $42.03 88 $115.63 THYROID (ARMOUR) 5GR (300MG) TABS 23 $41.79 63 $107.71 THYROLAR-1 TABLETS 30 $24.93 90 $66.78 THYROLAR-1/2 TABLETS 30 $20.74 90 $54.22 THYROLAR-1/4 TABLETS 30 $19.08 90 $49.25 THYROLAR-2 TABLETS 30 $28.61 90 $77.82 THYROLAR-3 TABLETS 30 $34.08 90 $94.23 TIAGABINE 12MG TABLETS 65 $676.00 195 $2,007.85 TIAGABINE 2MG TABLETS 71 $466.50 195 $1,274.15 TIAGABINE 4MG TABLETS 86 $563.71 229 $1,492.12 TILIA FE TABLETS 28S 29 $43.69 85 $121.80 TIMOLOL 0.25% GF OPHTH SOLN 5ML 5 $164.44 8 $259.01 TIMOLOL 0.5% GF OPHTH SOLN 2.5ML 5 $103.91 8 $166.77 TIMOLOL MAL 0.5% OP SOL-ONCE DAILY 4 $225.37 8 $467.64 TIMOLOL MALEATE 10MG TABLETS 52 $96.37 148 $264.96 TIMOLOL MALEATE 20MG TABLETS 50 $142.74 154 $429.49 TIMOLOL MALEATE 5MG TABLETS 52 $61.82 139 $159.96 TIMOPTIC 0.25% OCUDOSE 60'S 60 $394.61 166 $1,076.68 TIMOPTIC 0.5% OCUDOSE 60S 63 $536.81 178 $1,515.43 TINIDAZOLE 250MG TABLETS 33 $151.53 113 $514.26 TINIDAZOLE 500MG TABLETS 10 $99.83 70 $691.65 TIROSINT 137 MCG CAPSULES 29 $118.68 87 $346.55 TIROSINT 100MCG CAPSULES 32 $145.39 91 $408.88 TIROSINT 112MCG CAPSULES 30 $135.89 89 $396.76

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price TIROSINT 125MCG CAPSULES 30 $136.55 88 $393.16 TIROSINT 13 MCG CAPSULES 34 $155.41 98 $439.82 TIROSINT 150MCG CAPSULES 31 $141.08 91 $406.08 TIROSINT 25MCG CAPSULES 30 $130.03 88 $375.91 TIROSINT 50MCG CAPSULES 29 $132.33 84 $377.10 TIROSINT 75MCG CAPSULES 29 $130.62 84 $374.77 TIROSINT 88MCG CAPSULES 30 $138.80 87 $388.96 TIZANIDINE 2MG CAPSULES 53 $134.74 198 $491.25 TIZANIDINE 2MG TABLETS 61 $18.12 211 $53.25 TIZANIDINE 4MG CAPSULES 58 $94.41 192 $301.52 TIZANIDINE 4MG TABLETS 65 $55.77 214 $175.20 TIZANIDINE 6MG CAPSULES 71 $168.82 210 $491.70 TL-HIST DM LIQUID 68 $12.70 203 $30.10 TOBRADEX OPHTH OINT 3.5GM 4 $283.97 11 $825.73 TOBRADEX ST 0.3/0.05% OPTH SUSP 5ML 5 $229.29 7 $289.97 TOBRAMYCIN 10MG/ML INJ, 2ML 143 $151.63 430 $446.90 TOBRAMYCIN 300MG/5ML INH SOL 56X5ML 262 $5,224.48 348 $6,941.59 TOBRAMYCIN 40MG/ML 2ML INJ 79 $120.77 136 $205.01 TOBRAMYCIN 40MG/ML INJ 30ML 118 $178.56 330 $492.33 TOBRAMYCIN 40MG/ML INJ, 50ML 1 $5.48 3 $8.44 TOBRAMYCIN/DEXAMETHASONESUSP 10ML 5 $92.55 8 $148.74 TOBREX 0.3% OPTH OINT 3.5GM 4 $217.82 16 $974.62 TOLAZAMIDE 250MG TABLETS 34 $72.34 70 $146.09 TOLAZAMIDE 500MG TABLETS 50 $159.00 180 $561.98 TOLBUTAMIDE 500MG TABLETS 81 $86.17 193 $200.58 TOLCAPONE 100MG TABLETS 111 $11,619.82 315 $32,875.98 TOLMETIN SOD 200MG TABLETS 30 $23.79 90 $63.37 TOLMETIN SODIUM 400MG CAPSULES 70 $225.04 235 $750.12 TOLMETIN SODIUM 600MG TABLETS 65 $236.64 209 $755.26 TOPIRAMATE 100MG TABLETS 56 $188.03 164 $541.17 TOPIRAMATE 15MG SPRINKLE CAPSULES 96 $211.45 228 $498.51 TOPIRAMATE 200MG TABLETS 54 $248.86 159 $723.41 TOPIRAMATE ER 150MG CAPSULES 36 $903.69 110 $2,755.63 TOPIRAMATE ER 25MG CAPSULES 50 $394.41 139 $1,093.65 TOPIRAMATE ER 50MG CAPSULES 36 $377.97 113 $1,158.07 TOPOSAR 20MG/ML INJ, 5ML 38 $93.93 113 $273.78 TORSEMIDE 100MG (HUNDRED MG) TABLET 36 $20.88 98 $49.74 TOUJEO SOLOSTAR 300U/ML PEN 3X1.5ML 7 $615.22 15 $1,336.72 TOVIAZ 4MG TABLETS 31 $339.13 91 $1,001.51 TOVIAZ 8MG TABLETS 30 $395.38 90 $1,178.77 TRADJENTA 5MG TABLETS 30 $406.71 90 $1,208.54 TRAMADOL 50MG TABLETS 65 $21.31 252 $71.08 TRAMADOL ER 100MG CAPSULES 35 $300.61 119 $1,023.22 TRAMADOL ER 100MG TABLETS 35 $103.19 106 $309.20 TRAMADOL ER 200MG BIPHASIC TAB 30 $191.27 88 $545.56 TRAMADOL ER 200MG CAPSULES 30 $338.14 91 $1,027.58

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price TRAMADOL ER 200MG TABLETS 30 $152.54 91 $457.77 TRAMADOL ER 300MG CAPSULES 29 $453.83 90 $1,401.97 TRAMADOL ER 300MG TABLETS 29 $186.40 90 $563.24 TRAMADOL HCL ER 100MG (BIPHASIC) TB 38 $83.64 103 $221.85 TRAMADOL HCL ER 300MG TABLETS 29 $146.80 90 $443.86 TRAMADOL/APAP 37.5MG/325MG TABS 54 $57.88 259 $262.71 TRANDOLAPRIL-VERAPAMIL ER 1-240MG T 30 $144.37 88 $418.16 TRANDOLAPRIL-VERAPAMIL ER 2-180MG T 33 $141.69 96 $405.91 TRANDOLAPRIL-VERAPAMIL ER 2-240MG T 32 $135.90 98 $410.44 TRANDOLAPRIL-VERAPAMIL ER 4-240MG T 31 $133.61 95 $398.60 TRANEXAMIC ACID 650MG TABLETS 31 $77.24 107 $255.52 TRANYLCYPROMINE 10MG TABLETS 136 $283.14 422 $872.29 TRAVATAN Z 0.004% OPHTH SOL 2.5ML 3 $295.12 8 $693.88 TRAZODONE 300MG TABLETS 31 $134.28 92 $397.87 TRAZODONE 50MG TABLETS 40 $12.78 114 $29.41 TRECATOR 250MG TABLETS 56 $316.26 169 $940.78 TRELEGY ELLIPTA ORAL INH(30 PUFFS) 59 $566.00 179 $1,704.08 TRESIBA FLEXTOUCH PEN (U-100) 5X3ML 14 $455.21 27 $873.89 TRESIBA FLEXTOUCH PEN (U-200) 3X3ML 12 $801.82 28 $1,802.29 TRETINOIN 0.01% GEL 15GM 35 $148.85 98 $410.58 TRETINOIN 0.05% CREAM 20GM 36 $162.57 92 $404.50 TRETINOIN 0.05% EMOLLIENT CRM 60GM 37 $126.67 63 $212.99 TRETINOIN 0.05% GEL 45GM 45 $362.07 107 $852.90 TRETINOIN 0.1% CREAM 20GM 36 $187.92 95 $485.17 TRETINOIN 10MG CAPSULES 145 $3,197.43 436 $9,584.30 TRETINOIN MICRO 0.04% GEL 20GM 41 $447.46 175 $1,889.17 TRETINOIN MICRO 0.1% GEL 20GM 41 $565.04 116 $1,593.67 TRETIN-X 0.025% CREAM KIT 30 $6,606.10 90 $19,810.30 TRETIN-X 0.1% CREAM KIT 30 $7,998.40 90 $23,987.20 TREXALL 10MG TABLETS 7 $215.94 18 $525.24 TREXALL 15MG TABLETS 5 $188.06 12 $502.67 TREXALL 5MG TABLETS 14 $207.15 32 $479.29 TREXALL 7.5MG TABLETS 6 $135.55 17 $379.51 TRI FEMYNOR TABLETS 28S 28 $18.14 84 $46.16 TRIAMCIN/ORABAS 0.1% DENT-PAST 5GM 6 $60.58 34 $334.04 TRIAMCINOLONE 0.025% LOTION 60ML 65 $58.29 255 $216.47 TRIAMCINOLONE 0.025% OINTMENT 15GM 71 $41.63 328 $178.70 TRIAMCINOLONE 0.1% LOTION 60ML 66 $42.78 262 $156.69 TRIAMCINOLONE 0.5% OINT 15GM 33 $14.82 188 $66.60 TRIAMCINOLONE NASAL SPRAY (120 SPR) 16 $83.51 41 $207.26 TRIAMCINOLONE TOPICAL SPRAY 100GM 88 $306.84 269 $935.27 TRIAMCINOLONE USP POWDER 5GM 30 $831.94 90 $2,487.82 TRIAMTERENE 50MG / HCTZ 25MG CAPS 22 $38.59 87 $143.73 TRIANEX 0.05% OINTMENT 17GM 432 $2,261.22 538 $2,814.80 TRIAZ 3% GEL 42.5GM 30 $44.94 90 $126.81 TRIAZOLAM 0.125MG TABLETS 14 $28.72 103 $184.77

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price TRIAZOLAM 0.25MG TABLETS 19 $38.56 108 $202.55 TRICARE PRENATAL DHA ONE CAPSULES 30 $70.34 90 $201.96 TRICHLOR ACID 20% SOLUTION 29.57ML 30 $18.19 90 $46.58 TRI-CHLOR LIQUID 15ML 16 $77.51 49 $224.53 TRIFLUOPERAZINE 10MG TABLETS 56 $61.76 163 $171.91 TRIFLUOPERAZINE 1MG TABLETS 51 $20.97 141 $50.51 TRIFLUOPERAZINE 2MG TABLETS 51 $47.55 144 $126.36 TRIFLUOPERAZINE 5MG TABLETS 49 $43.38 142 $117.50 TRIFLURIDINE 1% OPHTH SOLN 7.5ML 8 $168.13 9 $190.80 TRIGELS-F FORTE CAPSULES 37 $35.79 102 $91.89 TRIHEXYPHENIDYL 0.4MG/ML ELIXIR 532 $56.83 1,655 $168.35 TRI-LUMA CREAM 30GM 30 $198.94 33 $213.07 TRIMETHOBENZAMIDE 300MG CAPSULES 32 $52.02 224 $334.89 TRIMIPRAMINE 100MG CAPSULES 54 $443.83 158 $1,284.95 TRIMIPRAMINE 25MG CAPSULES 48 $163.43 155 $520.62 TRIMIPRAMINE 50MG CAPSULES 60 $342.77 144 $815.15 TRI-NASAL 50MCG SPRAY 30 $83.98 90 $243.94 TRINATE TABLETS 30 $17.75 91 $45.82 TRINTELLIX 10MG TB (WAS BRINTELLIX) 30 $425.39 92 $1,273.45 TRIPLE ANTIBIOTIC OINTMENT 14GM 26 $9.92 75 $21.20 TRIVEEN-DUO DHA PAK 60 $38.17 180 $106.01 TRIVIT W /FLUOR 0.5MG DROPS 50ML 50 $25.12 55 $27.07 TRI-VIT/FE FL .25MG DROPS 51 $42.45 92 $73.65 TRI-VIT/FLUORIDE 0.25MG DROPS 50ML 50 $14.05 98 $23.64 TROKENDI XR 100MG CAPSULES 33 $836.81 99 $2,487.13 TROPAZONE LOTION 378 $490.56 752 $972.53 TROPICAMIDE 0.5% OPHTH SOLN 15ML 17 $21.87 50 $57.61 TROPICAMIDE 1% OPHTH SOLN 15ML 12 $14.97 18 $21.04 TROSPIUM CL 60MG ER CAPSULES 30 $192.22 90 $564.73 TRULANCE 3MG TABLETS 30 $434.05 90 $1,291.18 TRULICITY 0.75MG/0.5ML SDP 4X0.5ML 2 $762.67 6 $2,233.75 TRUMENBA PRE-FILLED INJ, 0.5ML SYR 1 $169.26 2 $499.77 TRUVADA 200MG-300MG TABLETS 30 $1,685.14 90 $5,087.59 TRYPTOPHAN 500MG CAPSULES 56 $38.97 120 $78.39 TUDORZA PRESSAIR 400MCG ORAL INH 30 1 $206.15 3 $580.94 TUSNEL PEDIATRIC DROPS 60 $15.01 180 $37.04 TUSNEL PEDIATRIC LIQUID 112 $12.54 114 $12.72 TUSNEL-DM LIQUID PEDIATRIC DROPS 61 $16.12 182 $40.37 TUSSAFED EX LIQUID 118 $11.93 131 $12.82 TUSSI-PRES PEDIATRIC LIQUID 99 $11.45 298 $26.35 TWINRIX INJ, 1ML 1 $143.31 1 $151.59 TYPHIM VI INJECTION, 0.5ML 1 $90.39 2 $263.16 TYVASO 0.6MG/ML INH SOL 2.9ML 30 $6,108.38 90 $18,317.14 TYZEKA 600MG TABLETS 30 $1,059.99 90 $3,171.97 TYZINE 0.1% NASAL SOLN.30ML 30 $88.69 90 $258.07 ULORIC 40MG TABLETS 30 $322.71 90 $949.29

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ULORIC 80MG TABLETS 30 $318.02 89 $940.60 ULTIMATECARE ONE CAPSULE 30 $18.00 93 $47.52 UMECTA 40% MOUSSE 113.4GM 114 $297.86 342 $885.58 UMECTA PD 40% EMULSION 198.5GM 30 $47.22 90 $133.67 UMECTA PD 40% SUSPENSION 255.1GM 30 $38.81 90 $108.43 UNIFINE PENTIPS 31GX6MM 112 $36.84 145 $46.60 UNISTIK 3 COMFORT LANCETS28G 126 $34.35 215 $55.84 UNI-TANN CS CHEWABLE TABLETS 30 $34.50 90 $95.49 UNI-TEX ER CAPSULES 30 $25.60 90 $68.79 UNIVERT 32MG TABLETS 20 $14.75 60 $36.24 UREA 20% CREAM 85GM 90 $16.63 209 $33.47 UREA 35% LOTION 325ML 30 $7.65 90 $14.94 UREA 39% CREAM 226.8GM 229 $200.81 421 $366.30 UREA 41% CREAM 227GM 228 $738.81 2,724 $8,799.80 UREA 45% CREAM 255GM 258 $81.93 765 $235.03 UREA 50% OINTMENT 45GM 30 $26.98 90 $72.94 UREA POWDER 981 $45.21 1,500 $67.00 UREA TOPICAL 40% SUSPENSION 283.4GM 30 $16.49 90 $41.47 URELLE TABLETS 51 $429.84 222 $1,866.30 URETRON D/S TABLETS 29 $45.13 139 $200.66 URETRON D-S TABLETS 18 $26.26 162 $208.67 URITACT-EC TABLETS 30 $37.66 90 $104.97 UROGESIC-BLUE TABLETS 44 $176.74 197 $770.86 URO-MP CAPSULES 36 $45.71 209 $247.61 URSODIOL 250MG TABLETS 55 $127.83 191 $436.02 URSODIOL 300MG CAPSULES 75 $376.26 235 $1,161.48 URSODIOL 500MG TABLETS 63 $251.49 187 $745.38 USTELL CAPSULES 51 $116.21 215 $481.51 VALACYCLOVIR 1GM TAB 21 $209.12 95 $912.02 VALACYCLOVIR 500MG TABLET 29 $167.05 98 $543.92 VALGANCICLOVIR 450MG TABLETS 49 $2,995.24 127 $7,821.18 VALPROATE 100MG/ML INJ, 5ML 257 $103.76 771 $303.27 VALPROIC ACID 250/5ML SYRUP 532 $17.52 1,682 $46.73 VALPROIC ACID 250MG CAPSULES 106 $41.17 302 $109.78 VALSARTAN 160MG TABLETS 33 $138.65 100 $411.28 VALSARTAN 320MG TABLETS 30 $157.46 90 $464.41 VALSARTAN 40MG TABLETS 35 $113.12 100 $313.68 VALSARTAN 80MG TABLETS 33 $124.64 98 $363.09 VALSARTAN/HCTZ 160MG/12.5MG TABLETS 31 $120.81 92 $350.31 VALSARTAN/HCTZ 160MG/25MG TABLETS 30 $133.75 90 $392.24 VALSARTAN/HCTZ 320MG/12.5MG TABLETS 30 $148.65 90 $437.09 VALSARTAN/HCTZ 320MG/25MG TABLETS 30 $159.51 90 $470.32 VALSARTAN/HCTZ 80MG/12.5MG TABLETS 31 $101.67 90 $293.52 VANACOF CD LIQUID 30 $7.63 90 $14.88 VANACOF DX LIQUID 30 $7.87 90 $15.60 VANACOF LIQUID 149 $23.19 447 $61.57

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price VANCOMYCIN 1000MG INJ 1 $15.99 3 $39.97 VANCOMYCIN 10GM INJ 1 $249.99 3 $741.97 VANCOMYCIN 125MG CAPSULES 30 $822.99 90 $2,460.96 VANCOMYCIN 250MG CAPSULES 30 $1,473.99 90 $4,413.96 VANCOMYCIN 500MG INJ, 1 VIAL 1 $8.34 3 $17.02 VANCOMYCIN 5GM INJ 1 $53.99 3 $153.97 VANIQA 13.9% CREAM 45GM 45 $171.52 136 $506.56 VAQTA 25U/0.5ML INJ, 0.5ML (PED) 1 $62.85 2 $180.55 VAQTA 50U/1ML INJ, 1ML (ADULT) 1 $109.04 3 $319.12 VARIVAX INJ , 1 VIAL 1 $143.18 3 $421.54 VASCEPA 1GM CAPSULES 111 $264.25 319 $751.29 VASOLEX OINTMENT 30GM 30 $16.67 90 $42.01 VASOPRESSIN 20U/ML INJ 1 $39.99 3 $111.97 VAXCHORA SUSPENSION 100ML 30 $99.40 90 $290.20 VAYARIN CAPSULES 59 $71.21 173 $202.32 VENA-BAL DHA TABLETS 30 $36.99 90 $102.98 VENLAFAXINE ER 37.5MG CAPSULES 34 $129.22 101 $373.80 VENLAFAXINE 100MG TABLETS 62 $18.37 177 $45.29 VENLAFAXINE 150MG ER CAPSULES 35 $145.48 103 $424.10 VENLAFAXINE 25MG TABLETS 46 $14.64 130 $34.40 VENLAFAXINE 37.5MG TABLETS 46 $14.84 132 $34.69 VENLAFAXINE 50MG TABLETS 50 $15.77 150 $38.93 VENLAFAXINE 75MG TABLETS 56 $17.07 158 $40.93 VENLAFAXINE ER 150MG TABLETS 33 $149.30 101 $443.54 VENLAFAXINE ER 225MG TABLETS 29 $294.64 90 $898.60 VENLAFAXINE ER 37.5MG TABLETS 34 $126.20 102 $375.16 VENLAFAXINE ER 75MG CAPSULES 40 $152.05 117 $437.79 VENLAFAXINE ER 75MG TABLETS 36 $197.90 109 $595.11 VERAMYST 27.5MCG NASAL SP (120 INH) 9 $193.45 25 $515.43 VERAPAMIL 120MG ER CAPSULES 34 $34.76 102 $96.05 VERAPAMIL 180MG ER CAPSULES 34 $44.41 103 $127.03 VERAPAMIL 2.5MG/ML INJ 5X 4ML VIAL 9 $154.66 14 $230.36 VERAPAMIL 240MG ER CAPSULES 33 $41.44 99 $116.48 VERAPAMIL 360MG SR CAPSULES 30 $99.68 90 $293.24 VERAPAMIL ER 100MG CAPSULES (24 HR) 33 $19.26 97 $49.46 VERAPAMIL ER 200MG CAPSULES (24 HR) 33 $74.88 99 $215.11 VERAPAMIL ER 300MG CAPSULES (24 HR) 30 $88.56 91 $257.54 VERAPAMIL HCL POWDER 25 $22.95 75 $60.85 VEREGEN 15% OINTMENT 15GM 31 $841.99 92 $2,517.98 VERSICLEAR LOTION 120ML 121 $26.14 363 $70.43 VERTIGOHEEL TABLETS 61 $19.11 182 $49.34 VESICARE 5MG TABLETS 30 $372.68 91 $1,102.58 VESICARE 10MG TABLETS 30 $384.46 90 $1,136.35 VEXOL 1% OPHTH SUSPENSION 10ML 5 $74.87 15 $216.60 VIBERZI 100MG TABLETS 57 $1,202.24 171 $3,598.05 VIBRAMYCIN 50MG/5ML SYRUP 140 $139.49 213 $210.54

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price VICTOZA 18MG/3ML INJ PEN 2 X 3ML 8 $734.13 23 $2,077.24 VICTRELIS 200MG CAPSULES 30 $655.43 90 $1,958.29 VIIBRYD 10MG TABLETS 32 $271.23 96 $803.51 VIIBRYD 20MG TABLETS 31 $260.18 92 $774.01 VIIBRYD 40MG TABLETS 30 $227.78 90 $684.44 VIMOVO 375-20MG TABLETS 54 $2,241.56 147 $6,087.67 VIMOVO 500-20MG TABLETS 56 $2,344.76 166 $6,894.59 VIMPAT 100MG TABLETS 69 $953.76 200 $2,768.35 VIMPAT 50MG TABLETS 75 $671.41 210 $1,867.52 VINATE II TABLETS (REFORMULATED) 28 $10.32 90 $24.37 VINBLASTINE 10MG INJ, 1 VIAL 10 $159.99 30 $471.97 VINBLASTINE 1MG/ML INJ, 10ML 13 $64.31 38 $184.94 VINCASAR PFS 1MG/ML INJ, 2ML 2 $50.24 3 $62.49 VINORELBINE 10MG/ML INJ 5ML 18 $283.66 55 $842.97 VINORELBINE 10MG/ML INJ, 1 VIAL 11 $191.66 34 $566.97 VIRACEPT 250MG TABLETS 269 $1,016.97 875 $3,298.60 VIRACEPT 625MG TABLETS 119 $1,200.06 352 $3,538.81 VIRT-NATE DHA CAPSULES 30 $114.21 90 $334.51 VIRT-PN PLUS CAPSULES 30 $64.58 90 $183.72 VIRTPREX CAPSULES 30 $52.96 90 $150.88 VIRTRATE-3 SOLUTION 945 $127.88 2,379 $315.91 VIRT-SELECT CAPSULES 31 $82.31 90 $235.57 VIRT-VITE PLUS TABLETS 32 $16.96 91 $41.42 VISQID A/A TABLETS 30 $11.80 90 $27.39 VITAFOL TABLETS 31 $128.57 94 $378.91 VITAFOL-OB +DHA CAPSULES 60 $128.53 179 $374.88 VITAL-D RX TABLETS 30 $13.63 87 $31.81 VITAMIN D AQ INFANTS LIQUID 50ML 57 $9.71 104 $14.35 VITAMIN K1 10MG/ML FOR INJ, 1ML 7 $280.55 15 $608.95 VIVOTIF TYPHOID ORAL VACCINE 4 $86.10 12 $250.30 VORICONAZOLE 200MG TABLETS 55 $1,252.05 185 $4,196.18 VORICONAZOLE 40MG/ML SUSP 75ML 170 $2,124.06 325 $4,064.29 VORICONAZOLE 50MG TABLETS 122 $1,248.21 346 $3,534.09 VOTRIENT 200MG TABLETS 98 $11,524.47 277 $32,598.29 VP-CH-PNV CAPSULES 30 $34.37 90 $95.11 VSL#3 DS POWDER PAK FOR SOLUTION 34 $189.69 132 $728.48 VYVANSE 20MG CAPSULES 30 $296.62 94 $907.66 VYVANSE 30MG CAPSULES 30 $295.61 93 $896.94 VYVANSE 40MG CAPSULES 30 $293.99 93 $895.27 VYVANSE 50MG CAPSULES 30 $293.47 92 $893.04 VYVANSE 60MG CAPSULES 30 $292.61 91 $878.64 VYVANSE 70MG CAPSULES 30 $293.16 91 $885.15 WELLBID-D 600MG/40MG TABLETS 30 $15.99 90 $39.97 WELLTUSS EXPECTORANT SYRUP 30 $6.66 90 $11.99 WINRHO SDF 5000 UNITS INJ 1 $285.71 3 $849.13 WYMZYA FE CHEWABLE TABLETS 29 $62.38 86 $175.91

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price XADAGO 50MG TABLETS 32 $862.79 90 $2,414.50 XARELTO 20MG TABLETS 30 $467.86 90 $1,404.65 XARELTO 10MG TABLETS 26 $317.82 91 $1,112.95 XARELTO 15MG TABLETS 32 $483.12 91 $1,355.64 XATMEP 2.5MG/ML SOLUTION 32 $547.62 76 $1,296.73 XENICAL 120MG CAPSULES 78 $518.44 233 $1,548.39 XERAC AC SOLUTION 35ML 48 $25.82 75 $38.40 XERESE 5-1% CREAM 5GM 5 $1,173.85 15 $3,291.97 XEROFORM PETROLATUM DRESSING 35 $37.09 64 $63.77 XIAFLEX 0.9MG INJ, 1 VIAL 1 $4,330.73 3 $12,984.19 XIFAXAN 200MG TABLETS 31 $689.50 203 $4,456.14 XIFAXAN 550MG TABLETS 48 $2,059.03 178 $7,599.30 XIGDUO XR 10MG/1000MG TABLETS 30 $522.21 91 $1,556.14 XIGDUO XR 5MG/1000MG TABLETS 52 $331.47 157 $992.28 XIIDRA 5% OPHTH SOL (60 SINGLE USE) 60 $303.30 180 $901.25 XIRATUSS TABLETS 30 $54.48 90 $155.45 XOLAIR 150MG INJECTION 3 $3,049.70 8 $9,141.09 XTAMPZA ER 18MG CAPSULES 57 $475.92 119 $995.21 XULANE PATCHES 3 $132.52 9 $379.49 YELLOW FEVER VACCINE INJ, 1 VIAL 1 $151.99 1 $151.99 YODEFAN-NF 200MG/5ML LIQUID 118ML 100 $14.16 300 $34.48 YODOXIN 210MG TABLETS 30 $36.61 90 $101.84 ZACLIR 8% CLEANSING LOTION 30 $9.72 90 $21.17 ZAFIRLUKAST 20MG TABLETS 57 $108.24 169 $311.52 ZALEPLON 10MG CAPSULES 33 $40.19 100 $113.95 ZALEPLON 5MG CAPSULES 30 $30.94 97 $90.89 ZATEAN-CH CAPSULES 30 $64.50 90 $185.49 ZAVESCA 100MG CAPSULES 30 $9,841.58 90 $29,516.73 ZELAPAR 1.25MG ORAL DISTINTGRT TABS 61 $4,552.45 180 $13,439.43 ZEMPLAR 2MCG/ML INJ , 1ML 12 $75.88 36 $219.64 ZEMPLAR 5MCG/ML INJ 1ML 13 $220.73 39 $654.18 ZIDOVUDINE 100MG CAPSULES 113 $226.02 259 $511.22 ZIDOVUDINE 10MG/ML SYRUP 516 $92.09 981 $171.40 ZIDOVUDINE 300MG TABLETS 55 $119.75 165 $349.50 ZILEUTON ER 600MG TABLETS 109 $2,204.75 311 $6,301.94 ZINC 1MG/ML INJ 1 $5.44 3 $8.31 ZINC SULFATE 220MG CAPSULES 40 $11.90 108 $25.54 ZINC SULFATE 5MG/ML INJ 25X5ML 75 $399.55 225 $1,190.65 ZIOPTAN 0.0015% DROPS 30 VIALS 30 $120.60 87 $337.95 ZIPRASIDONE 80MG CAPSULES 49 $193.83 149 $580.67 ZIPRASIDONE HCL 20MG CAPSULES 46 $157.48 138 $460.78 ZIPRASIDONE HCL 40MG CAPSULES 44 $151.22 133 $444.19 ZIPRASIDONE HCL 60MG CAPSULES 47 $276.61 145 $839.10 ZIRGAN 0.15% OPHTH GEL 5GM 5 $397.51 9 $687.97 ZMAX ER 2 GRAM ORAL SUSPENSION 1 $180.99 3 $534.97 ZOLEDRONIC 4MG/5ML INJ, 5ML 5 $453.70 6 $559.43

Prescription drug coverage and cost are subject to change.

Discounted Medications Drug Name Avg 30-day Avg 30-day Avg 90-day Avg 90-day Qty Price Qty Price ZOLEDRONIC 5MG/100ML INJ, 100ML 100 $451.34 100 $451.34 ZOLINZA 100MG CAPSULES 55 $6,854.44 164 $20,555.31 ZOLPIDEM 10MG TABLETS 29 $36.83 89 $105.25 ZOLPIDEM 5MG TABLETS 28 $39.78 89 $117.32 ZOLPIDEM ER 12.5MG TABLETS 29 $140.21 90 $427.30 ZOLPIDEM ER 6.25MG TABLETS 29 $122.35 92 $373.40 ZONISAMIDE 25MG CAPSULES 84 $29.97 221 $72.42 ZORBTIVE 8.8MG INJ 7X1 VIALS 28 $30,895.28 84 $92,677.84 ZORTRESS 0.25MG TABLETS 135 $1,224.58 386 $3,490.16 ZORTRESS 0.5MG TABLETS 177 $3,199.62 433 $7,823.97 ZORTRESS 0.75MG TABLETS 113 $3,320.30 318 $9,363.80 ZORVOLEX 35MG CAPSULES 71 $280.53 198 $774.62 ZOSTAVAX INJ (SQ) SINGL DSE VL 10PK 1 $237.99 1 $237.99 ZUBSOLV 5.7-1.4MG SUBLINGUAL TAB 38 $327.87 76 $661.81 ZYCLARA 2.5% CREAM (PUMP) 8 $1,163.99 23 $3,363.97 ZYCLARA 3.75% CREAM (PUMP) 11 $1,633.83 21 $3,206.77 ZYFLO 600MG TABLETS 98 $3,174.36 288 $9,279.99 ZYLET OPHTHALMIC SUSPENSION 10ML 6 $333.39 9 $498.34 ZYTAZE 25-500MG CAPSULES 30 $119.53 90 $350.59 ZYVOX 2MG/ML SOLN FOR IV INJ 1 $4.57 3 $5.70 ZYVOX 2MG/ML SOLUTION, 100ML 30 $32.20 90 $88.59 8-MOP 10MG CAPSULES 30 $977.88 90 $2,925.65

Prescription drug coverage and cost are subject to change.