State and Specialty Pharmacy Drug Reimbursement Rates

State and Specialty Pharmacy Drug Reimbursement

The following table lists specialty pharmacy drug reimbursement rates.

ForwardHealth defines specialty drugs as drugs requiring comprehensive patient care services, clinical management, and product support services. Drugs that meet ForwardHealth’s definition of specialty drugs will be reimbursed using the following rates. However, these rates do not apply to specialty drugs purchased through the federal 340B Drug Discount Program, which will be reimbursed according to the 340B ingredient cost reimbursement methodology.

If ForwardHealth uses State Maximum Allowable Cost (SMAC) reimbursement in the future, the SMAC reimbursement rates will be published in this table.

Effective 10/01/2020 EAC* EAC* Label Generic Name - Label - Generic ANEMIA/NEUTROPENIA DRUGS ARANESP DARBEPOETIN ALFA IN POLYSORBAT -1.0% EPOGEN EPOETIN ALFA -1.6% FULPHILA PEGFILGRASTIM-JMDB -1.0% GRANIX TBO-FILGRASTIM -1.0% MIRCERA METHOXY PEG-EPOETIN BETA -0.4% NEULASTA PEGFILGRASTIM -1.0% NEUPOGEN FILGRASTIM -1.0% NIVESTYM FILGRASTIM-AAFI -1.0% PROCRIT EPOETIN ALFA -1.6% RETACRIT EPOETIN ALFA-EPBX -1.0% UDENYCA PEGFILGRASTIM-CBQV -1.0% ZARXIO FILGRASTIM-SNDZ -1.0% ZIEXTENZO PEGFILGRASTIM-BMEZ -1.0% ANTICOAGULANT DRUGS ARIXTRA FONDAPARINUX SODIUM -3.0% -50.0% FONDAPARINUX SODIUM FONDAPARINUX SODIUM -50.0% FRAGMIN DALTEPARIN SODIUM,PORCINE -0.4% THROMBATE III ANTITHROMBIN III (PLASMA DER) -0.4% ANTI-INFECTIVE DRUGS ABELCET AMPHOTERICIN B LIPID COMPLEX -0.4% AMBISOME AMPHOTERICIN B LIPOSOME -0.4% ANCOBON FLUCYTOSINE -0.4% -1.0% AVYCAZ CEFTAZIDIME/AVIBACTAM -0.4% CRESEMBA ISAVUCONAZONIUM SULFATE -0.4% CUBICIN DAPTOMYCIN -0.4% -1.0% CUBICIN RF DAPTOMYCIN -0.4% -1.0% DALVANCE DALBAVANCIN HCL -0.4% DAPTOMYCIN DAPTOMYCIN -1.0% FLUCYTOSINE FLUCYTOSINE -1.0% IMPAVIDO MILTEFOSINE -0.4% LINEZOLID IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% -40.0% LINEZOLID ORAL LINEZOLID ORAL -40.0% LINEZOLID-0.9% SODIUM CHLORIDE LINEZOLID-0.9% SODIUM CHLORIDE -0.4% ORBACTIV ORITAVANCIN DIPHOSPHATE -0.4% PENTAM 300 PENTAMIDINE ISETHIONATE -0.4% -1.0% PENTAMIDINE ISETHIONATE PENTAMIDINE ISETHIONATE -1.0% SIVEXTRO TEDIZOLID PHOSPHATE -0.4% SYNERCID QUINUPRISTIN/DALFOPRISTIN -0.4% VIBATIV TELAVANCIN HCL -0.4% ZYVOX IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% -0.4% -40.0% ZYVOX ORAL LINEZOLID ORAL -0.4% -40.0% BLOOD CELL DEFICIENCY DRUGS DOPTELET AVATROMBOPAG MALEATE -0.4% LEUKINE SARGRAMOSTIM -0.4% MULPLETA LUSUTROMBOPAG -0.4% NPLATE ROMIPLOSTIM -0.4% PROMACTA ELTROMBOPAG OLAMINE -0.4% ENDOCRINE DISORDER DRUGS BYNFEZIA OCTREOTIDE ACETATE -0.4% MYALEPT METRELEPTIN -0.4% MYCAPSSA OCTREOTIDE ACETATE -0.4% OCTREOTIDE ACETATE OCTREOTIDE ACETATE -30.0% SANDOSTATIN OCTREOTIDE ACETATE -30.0% SIGNIFOR PASIREOTIDE DIASPARTATE -0.4% SOMATULINE DEPOT LANREOTIDE ACETATE -0.4% SOMAVERT PEGVISOMANT -0.4% ENZYME DEFICIENCY DRUGS ADAGEN PEGADEMASE BOVINE 1.0% ALDURAZYME LARONIDASE 1.0% AMMONUL SODIUM BENZOATE/SOD PHENYLACET 1.0% -10.0% CARBAGLU CARGLUMIC ACID 1.0% CERDELGA ELIGLUSTAT TARTRATE 1.0% FABRAZYME AGALSIDASE BETA 1.0% GALAFOLD MIGALASTAT HCL 1.0% KUVAN SAPROPTERIN DIHYDROCHLORIDE -0.7% MEPSEVII VESTRONIDASE ALFA-VJBK 1.0% MIGLUSTAT MIGLUSTAT -10.0% NAGLAZYME GALSULFASE 1.0% NITYR NITISINONE 1.0% ORFADIN NITISINONE 1.0% PALYNZIQ PEGVALIASE-PQPZ 1.0% SODIUM BENZOATE/SOD PHENYLACET SODIUM BENZOATE/SOD PHENYLACET -10.0% STRENSIQ ASFOTASE ALFA 1.0% ZAVESCA MIGLUSTAT 1.0% -10.0% State and Specialty Pharmacy Drug Reimbursement

GROWTH HORMONE DRUGS EGRIFTA SV TESAMORELIN ACETATE -1.6% GENOTROPIN SOMATROPIN -1.6% HUMATROPE SOMATROPIN -1.6% INCRELEX MECASERMIN -1.6% NORDITROPIN FLEXPRO SOMATROPIN -1.6% NUTROPIN AQ NUSPIN SOMATROPIN -1.6% OMNITROPE SOMATROPIN -1.6% SAIZEN SOMATROPIN -1.6% SAIZEN-SAIZENPREP SOMATROPIN -1.6% SEROSTIM SOMATROPIN -1.6% ZOMACTON SOMATROPIN -1.6% ZORBTIVE SOMATROPIN -1.6% HEMOPHILIA DRUGS ADVATE ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% ADYNOVATE ANTIHEMO.FVIII,FULL LENGTH PEG -12.0% AFSTYLA ANTIHEM.FVIII,SIN-CHN,B-DM TRU -15.0% ALPHANATE ANTIHEMOPHILIC FACTOR/VWF -20.0% ALPHANINE SD FACTOR IX -20.0% ALPROLIX FACTOR IX REC, FC FUSION PROTN -4.0% BENEFIX FACTOR IX HUMAN RECOMBINANT -15.0% COAGADEX COAGULATION FACTOR X -10.0% CORIFACT FACTOR XIII -10.0% ELOCTATE ANTIHEMOPH.FVIII REC,FC FUSION -9.0% ESPEROCT FVIII REC,B-DOM TRUNC PEG-EXEI -10.0% FEIBA NF ANTI-INHIBITOR COAGULANT COMP. -15.0% HELIXATE FS ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% HEMLIBRA EMICIZUMAB-KXWH -6.0% HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN -20.0% HUMATE-P ANTIHEMOPHILIC FACTOR/VWF -15.0% IDELVION FACTOR IX RECOM,ALBUMIN FUSION -3.0% IXINITY FACTOR IX HUMAN RECOMB,THR 148 -5.0% JIVI FVIII REC,B-DOM DELET PEG-AUCL -10.0% KOATE ANTIHEMOPHILIC FACTOR, HUMAN -15.0% KOGENATE FS ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% KOVALTRY ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% MONONINE FACTOR IX -20.0% NOVOEIGHT ANTIHEMOPH.FVIII,B-DOM TRUNCAT -15.0% NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB -12.0% NUWIQ ANTIHEMOPH.FVIII,HEK B-DELETE -12.0% OBIZUR ANTIHEMOPHILIC FVIII,REC PORC 0.0% PROFILNINE FACTOR IX CPLX(PCC)NO4,3FACTOR -10.0% REBINYN FACTOR IX HUMAN REC,PEGYLATED -5.0% RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC -15.0% RIASTAP FIBRINOGEN -10.0% RIXUBIS FACTOR IX HUMAN RECOMBINANT -15.0% STIMATE DESMOPRESSIN ACETATE 0.0% TRETTEN FACTOR XIII A-SUBUNIT,RECOMB -10.0% VONVENDI VON WILLEBRAND FACTOR -10.0% WILATE ANTIHEMOPHILIC FACTOR/VWF -15.0% XYNTHA ANTIHEMOPH.FVIII,B-DOMAIN DEL -20.0% XYNTHA SOLOFUSE ANTIHEMOPH.FVIII,B-DOMAIN DEL -20.0% HEPATITIS DRUGS ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL -10.0% BARACLUDE SOLUTION ENTECAVIR SOLUTION -0.4% BARACLUDE TABLET ENTECAVIR TABLET -0.4% -40.0% ENTECAVIR TABLET ENTECAVIR TABLET -40.0% EPCLUSA SOFOSBUVIR/VELPATASVIR -1.6% EPIVIR HBV SOLUTION LAMIVUDINE SOLUTION -0.4% EPIVIR HBV TABLET LAMIVUDINE TABLET -2.5% -60.0% HARVONI LEDIPASVIR/SOFOSBUVIR -1.6% HEPSERA ADEFOVIR DIPIVOXIL -0.4% -10.0% INTRON A INTERFERON ALFA-2B,RECOMB. -0.4% LAMIVUDINE TABLET LAMIVUDINE TABLET -60.0% LEDIPASVIR-SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR -1.6% MAVYRET GLECAPREVIR/PIBRENTASVIR -3.0% MODERIBA RIBAVIRIN -50.0% PEGASYS PEGINTERFERON ALFA-2A -1.6% PEGINTRON PEGINTERFERON ALFA-2B -1.6% RIBASPHERE RIBAVIRIN -50.0% SOFOSBUVIR-VELPATASVIR SOFOSBUVIR/VELPATASVIR -1.6% SOVALDI SOFOSBUVIR -1.6% VEMLIDY TENOFOVIR ALAFENAMIDE -0.4% VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV -3.0% ZEPATIER ELBASVIR/GRAZOPREVIR -1.6% HEREDITARY ANGIOEDEMA DRUGS BERINERT C1 ESTERASE INHIBITOR -0.4% CINRYZE C1 ESTERASE INHIBITOR -0.4% FIRAZYR ICATIBANT ACETATE -0.4% -1.0% HAEGARDA C1 ESTERASE INHIBITOR -0.4% ICATIBANT ACETATE ICATIBANT ACETATE -1.0% RUCONEST C1 ESTERASE INHIBITOR, RECOMB -0.4% TAKHZYRO LANADELUMAB-FLYO -0.4% IMMUNE DEFICIENCY DRUGS ACTIMMUNE INTERFERON GAMMA-1B,RECOMB. -0.4% ASCENIV IMMUNE GLOBULIN,GAMMA(IGG)SLRA -20.0% BIVIGAM IMMUN GLOB G(IGG)/GLY/IGA OV50 -0.4% CUTAQUIG IMMUN GLOB G(IGG)-HIPP/MALTOSE -0.4% State and Specialty Pharmacy Drug Reimbursement

IMMUNE DEFICIENCY DRUGS CONT. CUVITRU IMMUN GLOB G(IGG)/GLY/IGA OV50 -5.0% FLEBOGAMMA DIF IMM GLOB G (IGG)/SORB/IGA 0-50 -5.0% GAMMAGARD LIQUID IMMUN GLOB G(IGG)/GLY/IGA OV50 -20.0% GAMMAKED IMMUNE GLOBUL G/GLY/IGA AVG 46 -20.0% GAMMAPLEX IMMUN GLOB G(IGG)/GLY/IGA 0-50 -20.0% GAMMAPLEX IMMUN GLOB G/SORB/GLY/IGA 0-50 -20.0% GAMUNEX-C IMMUNE GLOBUL G/GLY/IGA AVG 46 -20.0% HIZENTRA IMMUN GLOB G(IGG)/PRO/IGA 0-50 -20.0% HYQVIA IGG/HYALURONIDASE,RECOMBINANT -20.0% OCTAGAM IMMUN GLOBG(IGG)/MALT/IGA OV50 -20.0% PANZYGA IMMUN GLOB G(IGG)-IFAS/GLYCINE -0.4% PRIVIGEN IMMUN GLOB G(IGG)/PRO/IGA 0-50 -20.0% XEMBIFY IMMUNE GLOBULIN,GAMMA(IGG)KLHW -5.0% LIPITROPICS, OTHER DRUGS JUXTAPID LOMITAPIDE MESYLATE -0.4% PRALUENT PEN ALIROCUMAB -0.4% REPATHA PUSHTRONEX EVOLOCUMAB -0.4% REPATHA SURECLICK EVOLOCUMAB -0.4% REPATHA SYRINGE EVOLOCUMAB -0.4% MISC.: IRON DEFICIENCY DRUGS FERAHEME FERUMOXYTOL -0.4% MISC: HYPOCALCEMIA DRUGS CALCITRIOL CALCITRIOL -10.0% MISC: IRON OVERLOAD DRUGS DEFERASIROX DEFERASIROX -1.0% EXJADE DEFERASIROX -0.4% -1.0% FERRIPROX DEFERIPRONE -0.4% FERRIPROX (2 TIMES A DAY) DEFERIPRONE -0.4% JADENU DEFERASIROX -0.4% -1.0% JADENU SPRINKLE DEFERASIROX -0.4% MISCELLANEOUS: INJECTABLE & OTHER ROUTE DRUGS GATTEX TEDUGLUTIDE -0.4% RAVICTI GLYCEROL PHENYLBUTYRATE -0.4% MULTIPLE SCLEROSIS DRUGS AMPYRA DALFAMPRIDINE -1.6% -30.0% AUBAGIO TERIFLUNOMIDE -1.0% AVONEX INTERFERON BETA-1A -1.6% AVONEX INTERFERON BETA-1A/ALBUMIN -1.6% AVONEX PEN INTERFERON BETA-1A -1.6% BAFIERTAM MONOMETHYL FUMARATE -1.6% BETASERON INTERFERON BETA-1B -1.6% COPAXONE GLATIRAMER ACETATE -2.6% -30.0% DALFAMPRIDINE DALFAMPRIDINE -30.0% EXTAVIA INTERFERON BETA-1B -1.6% GILENYA FINGOLIMOD HCL -2.6% GLATIRAMER ACETATE GLATIRAMER ACETATE -30.0% GLATOPA GLATIRAMER ACETATE -2.6% -30.0% MAVENCLAD CLADRIBINE -1.6% MAYZENT SIPONIMOD -1.6% PLEGRIDY PEGINTERFERON BETA-1A -1.6% PLEGRIDY PEN PEGINTERFERON BETA-1A -1.6% REBIF INTERFERON BETA-1A/ALBUMIN -1.6% REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN -1.6% TECFIDERA DIMETHYL FUMARATE -1.6% VUMERITY DIROXIMEL FUMARATE -1.6% ZEPOSIA OZANIMOD HYDROCHLORIDE -1.6% ONCOLOGY - ADJUNCT THERAPY DRUGS ANZEMET DOLASETRON MESYLATE -0.4% LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM -1.0% MESNEX MESNA -0.4% VARUBI ROLAPITANT HCL -0.4% ZOLEDRONIC ACID ZOLEDRONIC ACID -20.0% ZOMETA ZOLEDRONIC ACID -0.4% -20.0% ZUPLENZ ONDANSETRON -0.4% ONCOLOGY - ORAL DRUGS ABIRATERONE ACETATE ABIRATERONE ACETATE -10.0% AFINITOR EVEROLIMUS -0.4% AFINITOR EVEROLIMUS -0.4% -1.0% AFINITOR DISPERZ EVEROLIMUS -0.4% ALECENSA ALECTINIB HCL -0.4% ALKERAN MELPHALAN -0.4% -10.0% ALUNBRIG BRIGATINIB -0.4% AYVAKIT AVAPRITINIB -0.4% BALVERSA ERDAFITINIB -0.4% BEXAROTENE BEXAROTENE -10.0% BOSULIF BOSUTINIB -0.4% BRAFTOVI ENCORAFENIB -0.4% BRUKINSA ZANUBRUTINIB -0.4% CABOMETYX CABOZANTINIB S-MALATE -0.4% CALQUENCE ACALABRUTINIB -0.4% CAPECITABINE CAPECITABINE -10.0% CAPRELSA VANDETANIB -0.4% COMETRIQ CABOZANTINIB S-MALATE -0.4% COPIKTRA DUVELISIB -0.4% COTELLIC COBIMETINIB FUMARATE -0.4% CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE -10.0% DAURISMO GLASDEGIB MALEATE -0.4% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY - ORAL DRUGS CONT. EMCYT ESTRAMUSTINE PHOSPHATE SODIUM -0.4% ERIVEDGE VISMODEGIB -0.4% ERLEADA APALUTAMIDE -0.4% ERLOTINIB HCL ERLOTINIB HCL -10.0% ETOPOSIDE ETOPOSIDE -10.0% EVEROLIMUS EVEROLIMUS -1.0% FARESTON TOREMIFENE CITRATE -0.4% -1.0% FARYDAK PANOBINOSTAT LACTATE -0.4% FLUTAMIDE FLUTAMIDE -10.0% GILOTRIF AFATINIB DIMALEATE -0.4% GLEEVEC IMATINIB MESYLATE -0.4% -40.0% HYCAMTIN TOPOTECAN HCL -0.4% IBRANCE PALBOCICLIB -0.4% ICLUSIG PONATINIB HCL -0.4% IDHIFA ENASIDENIB MESYLATE -0.4% IMATINIB MESYLATE IMATINIB MESYLATE -40.0% IMBRUVICA IBRUTINIB -0.4% INLYTA AXITINIB -0.4% INQOVI DECITABINE/CEDAZURIDINE -0.4% INREBIC FEDRATINIB DIHYDROCHLORIDE -0.4% IRESSA GEFITINIB -0.4% JAKAFI RUXOLITINIB PHOSPHATE -0.4% KISQALI RIBOCICLIB SUCCINATE -0.4% KISQALI FEMARA CO-PACK RIBOCICLIB SUCCINATE/LETROZOLE -0.4% KOSELUGO SELUMETINIB/VITAMIN E TPGS -0.4% LENVIMA LENVATINIB MESYLATE -0.4% LEUKERAN CHLORAMBUCIL -0.4% LONSURF TRIFLURIDINE/TIPIRACIL HCL -0.4% LORBRENA LORLATINIB -0.4% LYNPARZA OLAPARIB -0.4% LYSODREN MITOTANE -0.4% MATULANE PROCARBAZINE HCL -0.4% MEKINIST TRAMETINIB DIMETHYL SULFOXIDE -0.4% MEKTOVI BINIMETINIB -0.4% MELPHALAN MELPHALAN -10.0% MERCAPTOPURINE MERCAPTOPURINE -40.0% MYLERAN BUSULFAN -0.4% NERLYNX NERATINIB MALEATE -0.4% NEXAVAR SORAFENIB TOSYLATE -0.4% NILANDRON NILUTAMIDE -0.4% -10.0% NILUTAMIDE NILUTAMIDE -10.0% NINLARO IXAZOMIB CITRATE -0.4% NUBEQA DAROLUTAMIDE -0.4% ODOMZO SONIDEGIB PHOSPHATE -0.4% PEMAZYRE PEMIGATINIB -0.4% PIQRAY ALPELISIB -0.4% POMALYST POMALIDOMIDE -0.4% PURIXAN MERCAPTOPURINE -0.4% QINLOCK RIPRETINIB -0.4% RETEVMO SELPERCATINIB -0.4% REVLIMID LENALIDOMIDE -0.4% ROZLYTREK ENTRECTINIB -0.4% RUBRACA RUCAPARIB CAMSYLATE -0.4% RYDAPT MIDOSTAURIN -0.4% SPRYCEL DASATINIB -0.4% STIVARGA REGORAFENIB -0.4% SUTENT SUNITINIB MALATE -0.4% TABLOID THIOGUANINE -0.4% TABRECTA CAPMATINIB HYDROCHLORIDE -0.4% TAFINLAR DABRAFENIB MESYLATE -0.4% TAGRISSO OSIMERTINIB MESYLATE -0.4% TALZENNA TALAZOPARIB TOSYLATE -0.4% TARCEVA ERLOTINIB HCL -0.4% -10.0% TARGRETIN BEXAROTENE -0.4% -10.0% TASIGNA NILOTINIB HCL -0.4% TAZVERIK TAZEMETOSTAT HYDROBROMIDE -0.4% TEMODAR TEMOZOLOMIDE -0.4% -10.0% TEMOZOLOMIDE TEMOZOLOMIDE -10.0% THALOMID THALIDOMIDE -0.4% TIBSOVO IVOSIDENIB -0.4% TOREMIFENE CITRATE TOREMIFENE CITRATE -1.0% TRETINOIN TRETINOIN -10.0% TREXALL METHOTREXATE SODIUM -0.4% TUKYSA TUCATINIB -0.4% TURALIO PEXIDARTINIB HYDROCHLORIDE -0.4% TYKERB LAPATINIB DITOSYLATE -0.4% VENCLEXTA VENETOCLAX -0.4% VENCLEXTA STARTING PACK VENETOCLAX -0.4% VERZENIO ABEMACICLIB -0.4% VITRAKVI LAROTRECTINIB SULFATE -0.4% VIZIMPRO DACOMITINIB -0.4% VOTRIENT PAZOPANIB HCL -0.4% XALKORI CRIZOTINIB -0.4% XELODA CAPECITABINE -0.4% -10.0% XOSPATA GILTERITINIB FUMARATE -0.4% XPOVIO SELINEXOR -0.4% XTANDI ENZALUTAMIDE -0.4% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY - ORAL DRUGS CONT. YONSA ABIRATERONE ACET,SUBMICRONIZED -0.4% ZEJULA NIRAPARIB TOSYLATE -0.4% ZELBORAF VEMURAFENIB -0.4% ZOLINZA VORINOSTAT -0.4% ZYDELIG IDELALISIB -0.4% ZYKADIA CERITINIB -0.4% ZYTIGA ABIRATERONE ACETATE -0.4% ZYTIGA ABIRATERONE ACETATE -0.4% -10.0% ONCOLOGY DRUGS ABRAXANE PACLITAXEL PROTEIN-BOUND 0.0% ADRUCIL FLUOROURACIL 0.0% -10.0% ALIMTA PEMETREXED DISODIUM 0.0% ALKERAN MELPHALAN HCL -3.1% -10.0% ARRANON NELARABINE 0.0% AVASTIN BEVACIZUMAB 0.0% BLEOMYCIN SULFATE BLEOMYCIN SULFATE -10.0% BUSULFAN BUSULFAN -10.0% BUSULFEX BUSULFAN -8.8% -10.0% CAMPTOSAR IRINOTECAN HCL 0.0% -10.0% CARBOPLATIN CARBOPLATIN -10.0% CISPLATIN CISPLATIN -10.0% CLOFARABINE CLOFARABINE -10.0% CLOLAR CLOFARABINE -2.0% -10.0% COSMEGEN DACTINOMYCIN -2.0% -10.0% CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE -10.0% CYTARABINE CYTARABINE -10.0% CYTARABINE/PF 100 MG/5 ML VIAL CYTARABINE/PF 100 MG/5 ML VIAL -10.0% CYTARABINE/PF 2 G/20 ML VIAL CYTARABINE/PF 2 G/20 ML VIAL -10.0% DACARBAZINE DACARBAZINE -10.0% DACTINOMYCIN DACTINOMYCIN -10.0% EPIRUBICIN HCL EPIRUBICIN HCL -10.0% ERBITUX CETUXIMAB -0.9% ETOPOPHOS ETOPOSIDE PHOSPHATE 0.0% ETOPOSIDE ETOPOSIDE -10.0% FLOXURIDINE FLOXURIDINE -10.0% FLUOROURACIL FLUOROURACIL -10.0% FOLOTYN PRALATREXATE -0.4% IFEX IFOSFAMIDE 0.0% -10.0% IFOSFAMIDE IFOSFAMIDE -10.0% IFOSFAMIDE/MESNA IFOSFAMIDE/MESNA -10.0% IRINOTECAN HCL IRINOTECAN HCL -10.0% IXEMPRA IXABEPILONE 0.0% KYMRIAH TISAGENLECLEUCEL 0.0% LEUPROLIDE ACETATE LEUPROLIDE ACETATE -10.0% LUPRON DEPOT LEUPROLIDE ACETATE -0.4% MELPHALAN HCL MELPHALAN HCL -10.0% METHOTREXATE SODIUM METHOTREXATE SODIUM/PF -20.0% MITOMYCIN MITOMYCIN -10.0% MUTAMYCIN MITOMYCIN 0.0% -10.0% NIPENT PENTOSTATIN 0.0% ONCASPAR PEGASPARGASE -1.0% OXALIPLATIN OXALIPLATIN -1.0% PACLITAXEL PACLITAXEL -10.0% SYLATRON PEGINTERFERON ALFA-2B -1.6% SYNRIBO OMACETAXINE MEPESUCCINATE -5.0% TARGRETIN BEXAROTENE -1.6% TECARTUS BREXUCABTAGENE AUTOLEUCEL 0.0% TEMSIROLIMUS TEMSIROLIMUS -1.0% TENIPOSIDE TENIPOSIDE -10.0% TOPOSAR ETOPOSIDE -10.0% -10.0% TORISEL TEMSIROLIMUS -0.9% -1.0% TRELSTAR TRIPTORELIN PAMOATE -6.0% VALCHLOR MECHLORETHAMINE HCL -0.4% VALRUBICIN VALRUBICIN -1.0% VALSTAR VALRUBICIN 0.0% -1.0% VANTAS HISTRELIN ACETATE -0.4% VECTIBIX PANITUMUMAB -0.9% VELCADE BORTEZOMIB 0.0% XGEVA DENOSUMAB -0.4% YESCARTA AXICABTAGENE CILOLEUCEL 0.0% ZANOSAR STREPTOZOCIN 0.0% ZOLADEX GOSERELIN ACETATE -10.0% OPHTHALMIC CONDITIONS DRUGS CYSTARAN CYSTEAMINE HCL -0.4% LUXTURNA VORETIGENE NEPARVOVEC-RZYL -0.4% MACUGEN PEGAPTANIB SODIUM -0.4% OXERVATE CENEGERMIN-BKBJ -0.4% OTHER SPECIALTY CONDITION DRUGS ACTHAR CORTICOTROPIN -0.4% ACTHREL CORTICORELIN OVINE TRIFLUTATE -0.4% ALFERON N INTERFERON ALFA-N3 -0.4% APOKYN APOMORPHINE HCL -0.4% ARCALYST RILONACEPT -0.4% AUSTEDO DEUTETRABENAZINE -0.4% BENLYSTA BELIMUMAB -0.4% BUPHENYL SODIUM PHENYLBUTYRATE -0.4% -10.0% State and Specialty Pharmacy Drug Reimbursement

OTHER SPECIALTY CONDITION DRUGS CONT. CEPROTIN PROTEIN C, HUMAN -0.4% CHENODAL CHENODIOL -0.4% CHOLBAM CHOLIC ACID -0.4% CLOVIQUE TRIENTINE HCL -0.4% -10.0% CRYSVITA BUROSUMAB-TWZA 0.0% CYSTADANE BETAINE -0.4% CYSTAGON CYSTEAMINE BITARTRATE -2.2% DIBENZYLINE PHENOXYBENZAMINE HCL 1.0% -1.0% DUPIXENT PEN DUPILUMAB -1.0% DUPIXENT SYRINGE DUPILUMAB -1.0% EMFLAZA DEFLAZACORT -0.4% ENDARI GLUTAMINE -0.4% ENSPRYNG SATRALIZUMAB-MWGE 0.0% EXONDYS-51 ETEPLIRSEN 0.0% FIRDAPSE AMIFAMPRIDINE PHOSPHATE 0.0% GAMIFANT EMAPALUMAB-LZSG -0.4% GRASTEK GRASS POLLEN-TIMOTHY, STANDARD -0.4% HETLIOZ TASIMELTEON -0.4% INGREZZA VALBENAZINE TOSYLATE -0.4% INGREZZA INITIATION PACK VALBENAZINE TOSYLATE -0.4% ISTURISA OSILODROSTAT PHOSPHATE 0.0% JYNARQUE TOLVAPTAN -0.4% KEVEYIS DICHLORPHENAMIDE -0.4% KORLYM MIFEPRISTONE -0.4% LUPRON DEPOT LEUPROLIDE ACETATE -0.4% LUPRON DEPOT (LUPANETA) LEUPROLIDE ACETATE -0.4% LUPRON DEPOT-PED LEUPROLIDE ACETATE -0.4% NATPARA PARATHYROID HORMONE 1.0% NORTHERA DROXIDOPA -0.4% NYMALIZE NIMODIPINE -0.4% OCALIVA OBETICHOLIC ACID -0.4% ONPATTRO PATISIRAN SODIUM,LIPID COMPLEX -0.4% ORALAIR GR POL-ORC/SW VER/RYE/KENT/TIM -0.4% OXBRYTA VOXELOTOR -0.4% PHENOXYBENZAMINE HCL PHENOXYBENZAMINE HCL -1.0% PREVYMIS LETERMOVIR -0.4% PRIALT ZICONOTIDE ACETATE -0.4% PROCYSBI CYSTEAMINE BITARTRATE -0.4% RADICAVA EDARAVONE -0.4% RAGWITEK WEED POLLEN-SHORT RAGWEED -0.4% RILUTEK RILUZOLE -0.4% -10.0% RILUZOLE RILUZOLE -10.0% RUZURGI AMIFAMPRIDINE 0.0% SABRIL VIGABATRIN -0.4% -1.0% SAMSCA TOLVAPTAN -0.4% SAXENDA LIRAGLUTIDE -0.4% SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE -10.0% SOLIRIS ECULIZUMAB -0.4% SYNAREL NAFARELIN ACETATE -0.4% SYPRINE TRIENTINE HCL -0.4% -10.0% TASMAR TOLCAPONE -0.4% -1.0% TAVALISSE FOSTAMATINIB DISODIUM -0.4% TEGSEDI INOTERSEN SODIUM -0.4% TETRABENAZINE TETRABENAZINE -10.0% TIGLUTIK RILUZOLE -0.4% TOLCAPONE TOLCAPONE -1.0% TRIENTINE HCL TRIENTINE HCL -10.0% VECAMYL MECAMYLAMINE HCL -0.4% VIGABATRIN VIGABATRIN -1.0% VIGADRONE VIGABATRIN -0.4% -1.0% VILTEPSO VILTOLARSEN 0.0% VIVITROL NALTREXONE MICROSPHERES -0.4% VYNDAMAX TAFAMIDIS -0.4% VYNDAQEL TAFAMIDIS MEGLUMINE -0.4% VYONDYS-53 GOLODIRSEN 0.0% XENAZINE TETRABENAZINE -0.4% -10.0% XYREM SODIUM OXYBATE -0.4% ZELAPAR SELEGILINE HCL -0.4% ZINPLAVA BEZLOTOXUMAB -0.4% PSORIASIS DRUGS METHOXSALEN METHOXSALEN -1.0% OXSORALEN-ULTRA METHOXSALEN -0.4% -1.0% PULMONARY DRUGS ARALAST NP ALPHA-1-PROTEINASE INHIBITOR -0.4% ARIKAYCE AMIKACIN LIPOSOMAL/NEB.ACCESSR -0.4% BETHKIS TOBRAMYCIN -0.4% CAYSTON AZTREONAM LYSINE -0.4% ESBRIET PIRFENIDONE -0.4% FASENRA PEN BENRALIZUMAB -1.0% GLASSIA ALPHA-1-PROTEINASE INHIBITOR -0.4% KALYDECO IVACAFTOR -0.4% KITABIS PAK TOBRAMYCIN/NEBULIZER -0.4% -10.0% NUCALA MEPOLIZUMAB -1.0% OFEV NINTEDANIB ESYLATE -0.4% ORKAMBI LUMACAFTOR/IVACAFTOR -0.4% PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR -0.4% PULMOZYME DORNASE ALFA -0.4% State and Specialty Pharmacy Drug Reimbursement

PULMONARY DRUGS CONT. SYMDEKO TEZACAFTOR/IVACAFTOR -0.4% TOBI TOBRAMYCIN IN 0.225% SOD CHLOR -0.4% -15.0% TOBI PODHALER TOBRAMYCIN -0.4% TOBRAMYCIN IN 0.225% SOD CHLOR TOBRAMYCIN IN 0.225% SOD CHLOR -15.0% TOBRAMYCIN/NEBULIZER TOBRAMYCIN/NEBULIZER -10.0% TRIKAFTA ELEXACAFTOR/TEZACAFTOR/IVACAFT -0.4% XOLAIR 150 MG VIAL OMALIZUMAB 150 MG VIAL -1.3% XOLAIR 75 MG/0.5 ML SYRINGE OMALIZUMAB 75 MG/0.5 ML SYRINGE -1.3% ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR -0.4% PULMONARY HYPERTENSION DRUGS ADCIRCA TADALAFIL -0.4% -10.0% ADEMPAS RIOCIGUAT -0.4% ALYQ TADALAFIL -0.4% -10.0% AMBRISENTAN AMBRISENTAN -10.0% BOSENTAN BOSENTAN -10.0% DILUENT FOR EPOPROSTENOL(GLYC) DILUENT FOR EPOPROSTENOL(GLYC) -1.0% DILUENT FOR FLOLAN DILUENT FOR EPOPROSTENOL(GLYC) -0.4% -1.0% EPOPROSTENOL SODIUM (GLYCINE) EPOPROSTENOL SODIUM (GLYCINE) -10.0% FLOLAN EPOPROSTENOL SODIUM (GLYCINE) -0.4% -10.0% LETAIRIS AMBRISENTAN -0.4% -10.0% OPSUMIT MACITENTAN -0.4% ORENITRAM ER TREPROSTINIL DIOLAMINE -0.4% PH 12 DILUENT FOR FLOLAN DILUENT FOR EPOPROSTENOL(GLYC) -0.4% REMODULIN TREPROSTINIL SODIUM -0.4% -1.0% REVATIO SILDENAFIL CITRATE -0.4% -10.0% SILDENAFIL CITRATE SILDENAFIL CITRATE -10.0% TADALAFIL TADALAFIL -10.0% TRACLEER BOSENTAN -0.4% TRACLEER BOSENTAN -0.4% -10.0% TREPROSTINIL SODIUM TREPROSTINIL SODIUM -1.0% TYVASO TREPROSTINIL -0.4% TYVASO INSTITUTIONAL START KIT TREPROSTINIL/NEBULIZER/ACCESOR -0.4% TYVASO REFILL KIT TREPROSTINIL/NEB ACCESSORIES -0.4% TYVASO STARTER KIT TREPROSTINIL/NEBULIZER/ACCESOR -0.4% UPTRAVI SELEXIPAG -0.4% VELETRI EPOPROSTENOL SODIUM (ARGININE) -0.4% VENTAVIS ILOPROST TROMETHAMINE -0.4% RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY CONDITIONS DRUGS OTREXUP METHOTREXATE/PF -0.4% RASUVO METHOTREXATE/PF -0.4% SPINAL MUSCULAR ATROPHY DRUGS EVRYSDI RISDIPLAM 0.0% SPINRAZA NUSINERSEN SODIUM/PF 0.0% ZOLGENSMA ONASEMNOGENE ABEPARVOVEC-XIOI 0.0% * The Estimated Acquisition Cost (EAC) is equal to the wholesale acquisition cost plus the percentages in the brand and generic EAC columns.