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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 04/01/2021 EAC* EAC* Label Generic Name - Label - Generic / 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 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 0.9% SODIUM CHLOR LINEZOLID IN 0.9% SODIUM CHLOR -0.4% LINEZOLID IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% -40.0% LINEZOLID ORAL LINEZOLID ORAL -40.0% ORBACTIV ORITAVANCIN DIPHOSPHATE -0.4% PENTAM 300 PENTAMIDINE ISETHIONATE -0.4% -1.0% PENTAMIDINE ISETHIONATE PENTAMIDINE ISETHIONATE -1.0% SIVEXTRO TEDIZOLID -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 -1.0% MULPLETA LUSUTROMBOPAG -0.4% NPLATE ROMIPLOSTIM -0.4% PROMACTA ELTROMBOPAG OLAMINE -1.0% ENDOCRINE DISORDER DRUGS BYNFEZIA ACETATE -0.4% MYALEPT -0.4% MYCAPSSA OCTREOTIDE ACETATE -0.4% OCTREOTIDE ACETATE OCTREOTIDE ACETATE -1.0% OCTREOTIDE ACETATE OCTREOTIDE ACETATE -30.0% SANDOSTATIN OCTREOTIDE ACETATE -30.0% -1.0% SIGNIFOR DIASPARTATE -0.4% SOMATULINE DEPOT ACETATE -0.4% SOMAVERT -0.4% DEFICIENCY DRUGS ADAGEN PEGADEMASE BOVINE 1.0% ALDURAZYME LARONIDASE 1.0% AMMONUL /SOD PHENYLACET 1.0% -10.0% CARBAGLU 1.0% CERDELGA 1.0% FABRAZYME AGALSIDASE BETA 1.0% GALAFOLD HCL 1.0% KUVAN SAPROPTERIN DIHYDROCHLORIDE -0.7% -0.1% KUVAN SAPROPTERIN DIHYDROCHLORIDE -0.7% -1.0% MEPSEVII VESTRONIDASE ALFA-VJBK 1.0% MIGLUSTAT -10.0% NAGLAZYME GALSULFASE 1.0% NITYR 1.0% ORFADIN NITISINONE 1.0% PALYNZIQ -PQPZ 1.0% SAPROPTERIN DIHYDROCHLORIDE SAPROPTERIN DIHYDROCHLORIDE -0.1% State and Specialty Pharmacy Drug Reimbursement

ENZYME DEFICIENCY DRUGS CONT. SAPROPTERIN DIHYDROCHLORIDE SAPROPTERIN DIHYDROCHLORIDE -1.0% SODIUM BENZOATE/SOD PHENYLACET SODIUM BENZOATE/SOD PHENYLACET -10.0% STRENSIQ 1.0% ZAVESCA MIGLUSTAT 1.0% -10.0% DRUGS EGRIFTA SV TESAMORELIN ACETATE -1.6% GENOTROPIN SOMATROPIN -2.0% HUMATROPE SOMATROPIN -2.0% INCRELEX -1.6% NORDITROPIN FLEXPRO SOMATROPIN -2.0% NUTROPIN AQ NUSPIN SOMATROPIN -2.0% OMNITROPE SOMATROPIN -2.0% SAIZEN SOMATROPIN -2.0% SAIZEN-SAIZENPREP SOMATROPIN -2.0% SEROSTIM SOMATROPIN -2.0% ZOMACTON SOMATROPIN -2.0% ZORBTIVE SOMATROPIN -2.0% HEMOPHILIA DRUGS ADVATE ANTIHEMOPHIL.FVIII,FULL LENGTH -22.0% 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 -22.0% HEMLIBRA EMICIZUMAB-KXWH -6.0% HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN -20.0% HUMATE-P ANTIHEMOPHILIC FACTOR/VWF -18.0% IDELVION FACTOR IX RECOM,ALBUMIN FUSION -4.0% 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 -22.0% KOVALTRY ANTIHEMOPHIL.FVIII,FULL LENGTH -22.0% 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 -1.0% BARACLUDE ENTECAVIR TABLET -1.0% -40.0% ENTECAVIR TABLET ENTECAVIR TABLET -40.0% EPCLUSA SOFOSBUVIR/VELPATASVIR -2.0% EPIVIR HBV SOLUTION LAMIVUDINE SOLUTION -2.5% EPIVIR HBV TABLET LAMIVUDINE TABLET -2.5% -60.0% HARVONI LEDIPASVIR/SOFOSBUVIR -2.0% HEPSERA ADEFOVIR DIPIVOXIL -1.0% -10.0% INTRON A INTERFERON ALFA-2B,RECOMB. -0.4% LAMIVUDINE TABLET LAMIVUDINE TABLET -60.0% LEDIPASVIR-SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR -2.0% 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 -2.0% SOVALDI SOFOSBUVIR -2.0% VEMLIDY TENOFOVIR ALAFENAMIDE -2.0% VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV -3.0% ZEPATIER ELBASVIR/GRAZOPREVIR -2.0% HEREDITARY ANGIOEDEMA DRUGS BERINERT C1 ESTERASE INHIBITOR -0.4% CINRYZE C1 ESTERASE INHIBITOR -0.4% FIRAZYR ACETATE -0.4% -5.0% HAEGARDA C1 ESTERASE INHIBITOR -0.4% ICATIBANT ACETATE ICATIBANT ACETATE -5.0% ORLADEYO BEROTRALSTAT HYDROCHLORIDE -0.4% RUCONEST C1 ESTERASE INHIBITOR, RECOMB -0.4% State and Specialty Pharmacy Drug Reimbursement

HEREDITARY ANGIOEDEMA DRUGS CONT. 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% 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 -5.0% EXJADE DEFERASIROX -0.4% -5.0% FERRIPROX DEFERIPRONE -0.4% FERRIPROX (2 TIMES A DAY) DEFERIPRONE -0.4% JADENU DEFERASIROX -0.4% -5.0% JADENU SPRINKLE DEFERASIROX -0.4% MISCELLANEOUS: INJECTABLE & OTHER ROUTE DRUGS GATTEX -0.4% RAVICTI -0.4% DRUGS AMPYRA DALFAMPRIDINE -1.6% -30.0% AUBAGIO TERIFLUNOMIDE -1.0% AVONEX INTERFERON BETA-1A -2.0% AVONEX INTERFERON BETA-1A/ALBUMIN -2.0% AVONEX PEN INTERFERON BETA-1A -2.0% BAFIERTAM MONOMETHYL FUMARATE -1.6% BETASERON INTERFERON BETA-1B -2.0% COPAXONE GLATIRAMER ACETATE -2.6% -30.0% DALFAMPRIDINE DALFAMPRIDINE -30.0% DIMETHYL FUMARATE DIMETHYL FUMARATE -5.0% EXTAVIA INTERFERON BETA-1B -2.0% GILENYA FINGOLIMOD HCL -2.6% GLATIRAMER ACETATE GLATIRAMER ACETATE -30.0% GLATOPA GLATIRAMER ACETATE -2.6% -30.0% KESIMPTA PEN -1.6% MAVENCLAD -1.6% MAYZENT SIPONIMOD -1.6% PLEGRIDY PEGINTERFERON BETA-1A -1.6% PLEGRIDY PEN PEGINTERFERON BETA-1A -1.6% REBIF INTERFERON BETA-1A/ALBUMIN -2.0% REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN -2.0% TECFIDERA DIMETHYL FUMARATE -1.6% -5.0% VUMERITY DIROXIMEL FUMARATE -1.6% ZEPOSIA OZANIMOD HYDROCHLORIDE -1.6% ONCOLOGY - ADJUNCT THERAPY DRUGS LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM -1.0% MESNEX MESNA -0.4% VARUBI ROLAPITANT HCL -0.4% ZOLEDRONIC ACID ZOLEDRONIC ACID -20.0% ZUPLENZ ONDANSETRON -0.4% ONCOLOGY - ORAL DRUGS ABIRATERONE ACETATE ABIRATERONE ACETATE -50.0% AFINITOR -0.4% AFINITOR EVEROLIMUS -0.4% -1.0% AFINITOR DISPERZ EVEROLIMUS -0.4% ALECENSA HCL -0.4% ALKERAN -0.4% -10.0% ALUNBRIG -0.4% AYVAKIT -0.4% BALVERSA -0.4% BEXAROTENE -10.0% BOSULIF -1.0% BRAFTOVI -0.4% BRUKINSA -0.4% CABOMETYX S-MALATE -0.4% CALQUENCE -0.4% CAPECITABINE -25.0% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY - ORAL DRUGS CONT. CAPRELSA -0.4% COMETRIQ CABOZANTINIB S-MALATE -0.4% COPIKTRA -0.4% COTELLIC FUMARATE -0.4% CYCLOPHOSPHAMIDE -10.0% DAURISMO MALEATE -0.4% EMCYT SODIUM -2.0% ERIVEDGE -0.4% ERLEADA APALUTAMIDE -0.4% HCL ERLOTINIB HCL -10.0% ETOPOSIDE -10.0% EVEROLIMUS EVEROLIMUS -1.0% FARESTON TOREMIFENE CITRATE -0.4% -1.0% FARYDAK LACTATE -0.4% FLUTAMIDE FLUTAMIDE -10.0% GAVRETO -0.4% GILOTRIF DIMALEATE -0.4% GLEEVEC MESYLATE -2.0% -40.0% HYCAMTIN HCL -0.4% IBRANCE -0.4% ICLUSIG HCL -0.4% IDHIFA MESYLATE -0.4% IMATINIB MESYLATE IMATINIB MESYLATE -40.0% IMBRUVICA -0.4% INLYTA -0.4% INQOVI /CEDAZURIDINE -0.4% INREBIC DIHYDROCHLORIDE -0.4% IRESSA -0.4% JAKAFI PHOSPHATE -0.4% KISQALI SUCCINATE -0.4% KISQALI FEMARA CO-PACK RIBOCICLIB SUCCINATE/ -0.4% KOSELUGO /VITAMIN E TPGS -0.4% LAPATINIB DITOSYLATE -0.4% LENVIMA MESYLATE -0.4% LEUKERAN -0.4% LONSURF TRIFLURIDINE/TIPIRACIL HCL -0.4% LORBRENA -0.4% LYNPARZA -0.4% LYSODREN -0.4% MATULANE HCL -0.4% MEKINIST DIMETHYL SULFOXIDE -0.4% MEKTOVI -0.4% MELPHALAN MELPHALAN -10.0% MERCAPTOPURINE -40.0% MYLERAN -0.4% NERLYNX MALEATE -0.4% NEXAVAR TOSYLATE -0.4% NILANDRON NILUTAMIDE -0.4% -10.0% NILUTAMIDE NILUTAMIDE -10.0% NINLARO CITRATE -0.4% NUBEQA DAROLUTAMIDE -0.4% ODOMZO PHOSPHATE -0.4% ONUREG -0.4% ORGOVYX RELUGOLIX -0.4% PEMAZYRE -0.4% PIQRAY -0.4% POMALYST POMALIDOMIDE -0.4% PURIXAN MERCAPTOPURINE -0.4% QINLOCK -0.4% RETEVMO -0.4% REVLIMID -1.0% ROZLYTREK -0.4% RUBRACA CAMSYLATE -0.4% RYDAPT -1.0% SPRYCEL -0.4% STIVARGA -0.4% SUTENT MALATE -1.0% TABLOID THIOGUANINE -0.4% TABRECTA HYDROCHLORIDE -0.4% TAFINLAR MESYLATE -0.4% TAGRISSO MESYLATE -0.4% TALZENNA TOSYLATE -0.4% TARCEVA ERLOTINIB HCL -2.0% -10.0% TARGRETIN BEXAROTENE -0.4% -10.0% TASIGNA HCL -0.4% TAZVERIK TAZEMETOSTAT HYDROBROMIDE -0.4% TEMODAR -1.0% -40.0% TEMOZOLOMIDE TEMOZOLOMIDE -40.0% TEPMETKO HCL -0.4% THALOMID THALIDOMIDE -0.4% TIBSOVO -0.4% TOREMIFENE CITRATE TOREMIFENE CITRATE -1.0% TRETINOIN -10.0% TREXALL SODIUM -0.4% TUKYSA -0.4% TURALIO HYDROCHLORIDE -0.4% TYKERB LAPATINIB DITOSYLATE -0.4% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY - ORAL DRUGS CONT. UKONIQ TOSYLATE -0.4% VENCLEXTA -0.4% VENCLEXTA STARTING PACK VENETOCLAX -0.4% VERZENIO -0.4% VITRAKVI SULFATE -0.4% VIZIMPRO -0.4% VOTRIENT HCL -0.4% XALKORI -0.4% XELODA CAPECITABINE -1.0% -25.0% XOSPATA FUMARATE -0.4% XPOVIO SELINEXOR -0.4% XTANDI ENZALUTAMIDE -0.4% YONSA ABIRATERONE ACET,SUBMICRONIZED -0.4% ZEJULA TOSYLATE -0.4% ZELBORAF -0.4% ZOLINZA -0.4% ZYDELIG -0.4% ZYKADIA -0.4% ZYTIGA ABIRATERONE ACETATE -1.0% ZYTIGA ABIRATERONE ACETATE -1.0% -50.0% ONCOLOGY DRUGS ABRAXANE PROTEIN-BOUND 0.0% ADRUCIL 0.0% -10.0% ALIMTA DISODIUM 0.0% ALKERAN MELPHALAN HCL -3.1% -10.0% ARRANON 0.0% AVASTIN 0.0% SULFATE BLEOMYCIN SULFATE -10.0% BUSULFAN BUSULFAN -10.0% BUSULFEX BUSULFAN -8.8% -10.0% CAMPTOSAR HCL 0.0% -10.0% CARBOPLATIN -10.0% CISPLATIN -10.0% CLOFARABINE -10.0% CLOLAR CLOFARABINE -2.0% -10.0% COSMEGEN -2.0% -10.0% CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE -10.0% 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 -10.0% DACTINOMYCIN DACTINOMYCIN -10.0% HCL EPIRUBICIN HCL -10.0% ERBITUX -0.9% ETOPOPHOS ETOPOSIDE PHOSPHATE 0.0% ETOPOSIDE ETOPOSIDE -10.0% FLOXURIDINE -10.0% FLUOROURACIL FLUOROURACIL -10.0% FOLOTYN -0.4% IFEX 0.0% -10.0% IFOSFAMIDE IFOSFAMIDE -10.0% IFOSFAMIDE/MESNA IFOSFAMIDE/MESNA -10.0% IRINOTECAN HCL IRINOTECAN HCL -10.0% IXEMPRA 0.0% KYMRIAH TISAGENLECLEUCEL 0.0% LEUPROLIDE ACETATE LEUPROLIDE ACETATE -10.0% LUPRON DEPOT LEUPROLIDE ACETATE -1.0% MELPHALAN HCL MELPHALAN HCL -10.0% METHOTREXATE SODIUM METHOTREXATE SODIUM/PF -20.0% MITOMYCIN MITOMYCIN -10.0% MUTAMYCIN MITOMYCIN 0.0% -10.0% NIPENT 0.0% ONCASPAR -1.0% OXALIPLATIN -1.0% PACLITAXEL PACLITAXEL -10.0% SYNRIBO OMACETAXINE MEPESUCCINATE -5.0% TARGRETIN BEXAROTENE -1.6% TECARTUS BREXUCABTAGENE AUTOLEUCEL 0.0% TEMSIROLIMUS -1.0% 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 -1.0% VALSTAR VALRUBICIN 0.0% -1.0% VANTAS HISTRELIN ACETATE -0.4% VECTIBIX -0.9% VELCADE 0.0% XGEVA DENOSUMAB -0.4% YESCARTA AXICABTAGENE CILOLEUCEL 0.0% ZANOSAR STREPTOZOCIN 0.0% ZOLADEX GOSERELIN ACETATE -10.0% OPHTHALMIC CONDITIONS DRUGS CYSTADROPS HCL -0.4% CYSTARAN CYSTEAMINE HCL -0.4% LUXTURNA VORETIGENE NEPARVOVEC-RZYL -0.4% State and Specialty Pharmacy Drug Reimbursement

OPHTHALMIC CONDITIONS DRUGS CONT. 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 -0.4% BENLYSTA BELIMUMAB -0.4% BUPHENYL -0.4% -10.0% 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 -0.4% ENSPRYNG SATRALIZUMAB-MWGE 0.0% EXONDYS-51 ETEPLIRSEN 0.0% FIRDAPSE PHOSPHATE 0.0% GAMIFANT EMAPALUMAB-LZSG -0.4% GRASTEK GRASS POLLEN-TIMOTHY, STANDARD -0.4% HETLIOZ TASIMELTEON -0.4% IMCIVREE SETMELANOTIDE ACETATE 0.0% INGREZZA 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 -1.0% LUPRON DEPOT (LUPANETA) LEUPROLIDE ACETATE -1.0% LUPRON DEPOT-PED LEUPROLIDE ACETATE -1.0% NATPARA 1.0% NORTHERA DROXIDOPA -0.4% NYMALIZE -0.4% OCALIVA OBETICHOLIC ACID -0.4% ONGENTYS OPICAPONE -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 ACETATE -0.4% PROCYSBI CYSTEAMINE BITARTRATE -0.4% RADICAVA EDARAVONE -0.4% RAGWITEK WEED POLLEN-SHORT RAGWEED -0.4% RILUTEK -0.4% -10.0% RILUZOLE RILUZOLE -10.0% RUZURGI AMIFAMPRIDINE 0.0% SABRIL VIGABATRIN -0.4% -1.0% SAMSCA TOLVAPTAN -0.4% SAMSCA TOLVAPTAN -0.4% -15.0% SAXENDA -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 SODIUM -0.4% TETRABENAZINE -10.0% TIGLUTIK RILUZOLE -0.4% TOLCAPONE TOLCAPONE -1.0% TOLVAPTAN TOLVAPTAN -15.0% 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 -0.4% VYNDAQEL TAFAMIDIS MEGLUMINE -0.4% VYONDYS-53 GOLODIRSEN 0.0% XENAZINE TETRABENAZINE -0.4% -10.0% XYREM -0.4% XYWAV SODIUM,CALCIUM,MAG,POT OXYBATE 0.0% ZELAPAR SELEGILINE HCL -0.4% ZINPLAVA BEZLOTOXUMAB -0.4% ZOKINVY LONAFARNIB -0.4% State and Specialty Pharmacy Drug Reimbursement

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% -15.0% CAYSTON AZTREONAM LYSINE -0.4% ESBRIET PIRFENIDONE -0.4% FASENRA PEN BENRALIZUMAB -1.0% GLASSIA ALPHA-1-PROTEINASE INHIBITOR -0.4% KALYDECO -0.4% KITABIS PAK TOBRAMYCIN/NEBULIZER -0.4% -15.0% NUCALA MEPOLIZUMAB -1.0% OFEV ESYLATE -0.4% ORKAMBI LUMACAFTOR/IVACAFTOR -0.4% PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR -0.4% PULMOZYME DORNASE ALFA -1.0% SYMDEKO TEZACAFTOR/IVACAFTOR -0.4% TOBI TOBRAMYCIN IN 0.225% SOD CHLOR -1.0% -15.0% TOBI PODHALER TOBRAMYCIN -1.0% TOBRAMYCIN TOBRAMYCIN -15.0% TOBRAMYCIN IN 0.225% SOD CHLOR TOBRAMYCIN IN 0.225% SOD CHLOR -15.0% TOBRAMYCIN/NEBULIZER TOBRAMYCIN/NEBULIZER -15.0% TRIKAFTA ELEXACAFTOR/TEZACAFTOR/IVACAFT -0.4% XOLAIR 150 MG VIAL OMALIZUMAB 150 MG VIAL -2.0% XOLAIR 75 MG/0.5 ML SYRINGE OMALIZUMAB 75 MG/0.5 ML SYRINGE -2.0% ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR -0.4% PULMONARY HYPERTENSION DRUGS ADCIRCA -0.4% -20.0% ADEMPAS RIOCIGUAT -0.4% ALYQ TADALAFIL -0.4% -20.0% AMBRISENTAN -15.0% BOSENTAN -15.0% DILUENT FOR EPOPROSTENOL(GLYC) DILUENT FOR EPOPROSTENOL(GLYC) -1.0% EPOPROSTENOL SODIUM (GLYCINE) EPOPROSTENOL SODIUM (GLYCINE) -10.0% FLOLAN EPOPROSTENOL SODIUM (GLYCINE) -0.4% -10.0% LETAIRIS AMBRISENTAN -0.4% -15.0% OPSUMIT -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% -50.0% SILDENAFIL CITRATE SILDENAFIL CITRATE -50.0% TADALAFIL TADALAFIL -20.0% TRACLEER BOSENTAN -0.4% TRACLEER BOSENTAN -0.4% -15.0% 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 -0.4% VENTAVIS ILOPROST TROMETHAMINE -0.4% RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY CONDITIONS DRUGS OTREXUP METHOTREXATE/PF -2.5% RASUVO METHOTREXATE/PF -2.5% REDITREX METHOTREXATE/PF -2.5% DRUGS EVRYSDI RISDIPLAM 0.0% SPINRAZA NUSINERSEN SODIUM/PF 0.0% ZOLGENSMA ONASEMNOGENE ABEPARVOVEC-XIOI 0.0%