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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 12/01/2019 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% ANTICOAGULANT DRUGS ARIXTRA FONDAPARINUX SODIUM ‐0.4% ‐40.0% FONDAPARINUX SODIUM FONDAPARINUX SODIUM ‐40.0% 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% AVYCAZ CEFTAZIDIME/AVIBACTAM ‐0.4% CRESEMBA ISAVUCONAZONIUM SULFATE ‐0.4% CUBICIN DAPTOMYCIN ‐0.4% CUBICIN RF DAPTOMYCIN ‐0.4% DALVANCE DALBAVANCIN HCL ‐0.4% DAPTOMYCIN DAPTOMYCIN ‐0.4% IMPAVIDO MILTEFOSINE ‐0.4% LINEZOLID ORAL LINEZOLID ORAL ‐40.0% LINEZOLID IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% ‐40.0% LINEZOLID‐0.9% NACL LINEZOLID‐0.9% SODIUM CHLORIDE ‐0.4% ORBACTIV ORITAVANCIN DIPHOSPHATE ‐0.4% PENTAM 300 PENTAMIDINE ISETHIONATE ‐0.4% SIVEXTRO TEDIZOLID ‐0.4% SYNERCID QUINUPRISTIN/DALFOPRISTIN ‐0.4% VIBATIV TELAVANCIN HCL ‐0.4% ZYVOX ORAL LINEZOLID ORAL ‐0.4% ‐40.0% ZYVOX IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% ‐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 MYALEPT ‐0.4% SANDOSTATIN OCTREOTIDE ACETATE ‐30.0% SIGNIFOR PASIREOTIDE DIASPARTATE ‐0.4% SOMATULINE DEPOT LANREOTIDE ACETATE ‐0.4% SOMAVERT PEGVISOMANT ‐0.4% DEFICIENCY DRUGS ADAGEN PEGADEMASE BOVINE 1.0% ALDURAZYME LARONIDASE 1.0% AMMONUL /SOD PHENYLACET 1.0% CARBAGLU 1.0% CERDELGA 1.0% FABRAZYME AGALSIDASE BETA 1.0% GALAFOLD HCL 1.0% KUVAN SAPROPTERIN DIHYDROCHLORIDE ‐0.4% MEPSEVII VESTRONIDASE ALFA‐VJBK 1.0% NAGLAZYME GALSULFASE 1.0% NITYR 1.0% ORFADIN NITISINONE 1.0% PALYNZIQ ‐PQPZ 1.0% SODIUM PHENYLACET‐SOD BENZOATE SODIUM BENZOATE/SOD PHENYLACET 1.0% STRENSIQ 1.0% ZAVESCA 1.0% GROWTH HORMONE DRUGS GENOTROPIN SOMATROPIN ‐1.6% HUMATROPE SOMATROPIN ‐1.6% State and Specialty Pharmacy Drug Reimbursement

GROWTH HORMONE DRUGS CONT. 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 ‐7.0% 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% DRUGS BARACLUDE SOLUTION SOLUTION ‐0.4% BARACLUDE TABLETS ENTECAVIR TABLETS ‐0.4% ‐40.0% DAKLINZA DACLATASVIR DIHYDROCHLORIDE ‐1.6% ENTECAVIR TABLETS ENTECAVIR TABLETS ‐40.0% EPCLUSA SOFOSBUVIR/VELPATASVIR ‐1.6% EPIVIR HBV SOLUTION SOLUTION ‐0.4% EPIVIR HBV TABLET LAMIVUDINE TABLET ‐0.4% ‐60.0% HARVONI LEDIPASVIR/SOFOSBUVIR ‐1.6% HEPSERA DIPIVOXIL ‐0.4% INTRON A ALFA‐2B,RECOMB. ‐0.4% LAMIVUDINE TABLET LAMIVUDINE TABLET ‐60.0% LEDIPASVIR‐SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR ‐1.6% MAVYRET GLECAPREVIR/PIBRENTASVIR ‐3.0% MODERIBA ‐50.0% PEGASYS PEGINTERFERON ALFA‐2A ‐1.6% PEGASYS PROCLICK PEGINTERFERON ALFA‐2A ‐1.6% PEGINTRON PEGINTERFERON ALFA‐2B ‐1.6% REBETOL RIBAVIRIN ‐0.4% RIBASPHERE RIBAVIRIN ‐50.0% SOFOSBUVIR‐VELPATASVIR SOFOSBUVIR/VELPATASVIR ‐1.6% SOVALDI SOFOSBUVIR ‐1.6% VEMLIDY ‐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% HAEGARDA C1 ESTERASE INHIBITOR ‐0.4% ICATIBANT ICATIBANT ACETATE ‐0.4% RUCONEST C1 ESTERASE INHIBITOR, RECOMB ‐0.4% TAKHZYRO LANADELUMAB‐FLYO ‐0.4% IMMUNE DEFICIENCY DRUGS ACTIMMUNE ‐1B,RECOMB. ‐0.4% State and Specialty Pharmacy Drug Reimbursement

IMMUNE DEFICIENCY DRUGS CONT. BIVIGAM IMMUN GLOB G(IGG)/GLY/IGA OV50 ‐0.4% CARIMUNE NF NANOFILTERED IMMUN GLOBG(IGG)/SUCR/IGA OV50 ‐10.0% 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% KYNAMRO MIPOMERSEN SODIUM ‐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: IRON OVERLOAD DRUGS EXJADE DEFERASIROX ‐0.4% FERRIPROX DEFERIPRONE ‐0.4% JADENU DEFERASIROX ‐0.4% JADENU SPRINKLE DEFERASIROX ‐0.4% MISCELLANEOUS: INJECTABLE & OTHER ROUTE DRUGS GATTEX ‐0.4% RAVICTI ‐0.4% MULTIPLE SCLEROSIS DRUGS AMPYRA DALFAMPRIDINE ‐1.6% AUBAGIO TERIFLUNOMIDE ‐1.0% AVONEX INTERFERON BETA‐1A ‐1.6% AVONEX INTERFERON BETA‐1A/ALBUMIN ‐1.6% AVONEX PEN INTERFERON BETA‐1A ‐1.6% BETASERON INTERFERON BETA‐1B ‐1.6% COPAXONE GLATIRAMER ACETATE ‐2.6% DALFAMPRIDINE ER DALFAMPRIDINE ‐1.6% EXTAVIA INTERFERON BETA‐1B ‐1.6% GILENYA FINGOLIMOD HCL ‐1.6% GLATOPA GLATIRAMER ACETATE ‐2.6% 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% ONCOLOGY ‐ ADJUNCT THERAPY DRUGS ANZEMET DOLASETRON MESYLATE ‐0.4% CESAMET NABILONE ‐0.4% KEPIVANCE PALIFERMIN ‐0.4% MESNEX MESNA ‐0.4% VARUBI ROLAPITANT HCL ‐0.4% ZOMETA ZOLEDRONIC ACID ‐0.4% ZUPLENZ ONDANSETRON ‐0.4% ONCOLOGY ‐ ORAL DRUGS AFINITOR EVEROLIMUS ‐0.4% AFINITOR DISPERZ EVEROLIMUS ‐0.4% ALECENSA ALECTINIB HCL ‐0.4% ALKERAN MELPHALAN ‐0.4% ALUNBRIG BRIGATINIB ‐0.4% BALVERSA ERDAFITINIB ‐0.4% BOSULIF BOSUTINIB ‐0.4% BRAFTOVI ENCORAFENIB ‐0.4% CABOMETYX CABOZANTINIB S‐MALATE ‐0.4% CALQUENCE ACALABRUTINIB ‐0.4% CAPRELSA VANDETANIB ‐0.4% COMETRIQ CABOZANTINIB S‐MALATE ‐0.4% COPIKTRA DUVELISIB ‐0.4% COTELLIC COBIMETINIB FUMARATE ‐0.4% DAURISMO GLASDEGIB MALEATE ‐0.4% EMCYT ESTRAMUSTINE PHOSPHATE SODIUM ‐0.4% ERIVEDGE VISMODEGIB ‐0.4% ERLEADA APALUTAMIDE ‐0.4% FARESTON TOREMIFENE CITRATE ‐0.4% FARYDAK LACTATE ‐0.4% GILOTRIF AFATINIB DIMALEATE ‐0.4% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY ‐ ORAL DRUGS CONT. GLEEVEC IMATINIB MESYLATE ‐0.4% ‐40.0% HEXALEN ALTRETAMINE ‐0.4% 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% 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% LENVIMA LENVATINIB MESYLATE ‐0.4% LEUKERAN CHLORAMBUCIL ‐0.4% LONSURF /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% MYLERAN BUSULFAN ‐0.4% NERLYNX NERATINIB MALEATE ‐0.4% NEXAVAR SORAFENIB TOSYLATE ‐0.4% NILANDRON NILUTAMIDE ‐0.4% NINLARO IXAZOMIB CITRATE ‐0.4% NUBEQA DAROLUTAMIDE ‐0.4% ODOMZO SONIDEGIB PHOSPHATE ‐0.4% PIQRAY ALPELISIB ‐0.4% POMALYST POMALIDOMIDE ‐0.4% PURIXAN MERCAPTOPURINE ‐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% TAFINLAR DABRAFENIB MESYLATE ‐0.4% TAGRISSO OSIMERTINIB MESYLATE ‐0.4% TALZENNA TALAZOPARIB TOSYLATE ‐0.4% TARCEVA ERLOTINIB HCL ‐0.4% TARGRETIN BEXAROTENE ‐0.4% TASIGNA NILOTINIB HCL ‐0.4% TEMODAR TEMOZOLOMIDE ‐0.4% THALOMID THALIDOMIDE ‐0.4% TIBSOVO IVOSIDENIB ‐0.4% TREXALL METHOTREXATE SODIUM ‐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% XOSPATA GILTERITINIB FUMARATE ‐0.4% XPOVIO SELINEXOR ‐0.4% XTANDI ENZALUTAMIDE ‐0.4% YONSA ABIRATERONE ACET,SUBMICRONIZED ‐0.4% ZEJULA NIRAPARIB TOSYLATE ‐0.4% ZELBORAF VEMURAFENIB ‐0.4% ZOLINZA ‐0.4% ZYDELIG IDELALISIB ‐0.4% ZYKADIA CERITINIB ‐0.4% ZYTIGA ABIRATERONE ACETATE ‐0.4% ONCOLOGY DRUGS ABRAXANE PACLITAXEL PROTEIN‐BOUND 0.0% ADRUCIL FLUOROURACIL 0.0% ALIMTA PEMETREXED DISODIUM 0.0% ALKERAN MELPHALAN HCL ‐3.1% ARRANON NELARABINE 0.0% AVASTIN BEVACIZUMAB 0.0% BLEO 15K BLEOMYCIN SULFATE ‐2.0% BUSULFEX BUSULFAN ‐8.8% CAMPTOSAR IRINOTECAN HCL 0.0% CLOLAR CLOFARABINE ‐2.0% State and Specialty Pharmacy Drug Reimbursement

ONCOLOGY DRUGS CONT. COSMEGEN DACTINOMYCIN 0.2% 100 MG/5 ML VIAL CYTARABINE/PF 100 MG/5 ML VIAL ‐1.6% CYTARABINE 2 G/20 ML VIAL CYTARABINE/PF 2 G/20 ML VIAL ‐5.0% ERBITUX CETUXIMAB ‐0.9% ETOPOPHOS ETOPOSIDE PHOSPHATE 0.2% FASLODEX FULVESTRANT ‐6.4% FOLOTYN PRALATREXATE ‐0.4% IFEX IFOSFAMIDE 0.0% IFOSFAMIDE‐MESNA IFOSFAMIDE/MESNA ‐1.6% IXEMPRA IXABEPILONE 0.0% KYMRIAH TISAGENLECLEUCEL 0.0% LUPRON DEPOT LEUPROLIDE ACETATE ‐0.4% METHOTREXATE METHOTREXATE SODIUM ‐20.0% METHOTREXATE METHOTREXATE SODIUM/PF 1.0% METHOTREXATE SODIUM METHOTREXATE SODIUM/PF ‐20.0% MUTAMYCIN MITOMYCIN 0.0% NIPENT PENTOSTATIN 0.0% ONCASPAR PEGASPARGASE ‐1.0% SYLATRON PEGINTERFERON ALFA‐2B ‐1.6% SYNRIBO OMACETAXINE MEPESUCCINATE ‐5.0% TARGRETIN BEXAROTENE ‐0.4% TOPOSAR ETOPOSIDE ‐10.0% TORISEL TEMSIROLIMUS ‐0.9% TRELSTAR TRIPTORELIN PAMOATE ‐6.0% TRISENOX ARSENIC TRIOXIDE 0.0% VALCHLOR MECHLORETHAMINE HCL ‐0.4% VALSTAR VALRUBICIN 0.0% 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 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 ‐0.4% CEPROTIN PROTEIN C, HUMAN ‐0.4% CHENODAL CHENODIOL ‐0.4% CHOLBAM CHOLIC ACID ‐0.4% CLOVIQUE TRIENTINE HCL ‐0.4% CRYSVITA BUROSUMAB‐TWZA 0.0% CYSTADANE BETAINE ‐0.4% CYSTAGON CYSTEAMINE BITARTRATE ‐2.2% DIBENZYLINE PHENOXYBENZAMINE HCL 1.0% DUPIXENT DUPILUMAB ‐0.4% EMFLAZA DEFLAZACORT ‐0.4% ENDARI ‐0.4% EXONDYS 51 ETEPLIRSEN 1.0% 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% 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 1.0% ORALAIR GR POL‐ORC/SW VER/RYE/KENT/TIM ‐0.4% PREVYMIS LETERMOVIR ‐0.4% PRIALT ZICONOTIDE ACETATE ‐0.4% PROCYSBI CYSTEAMINE BITARTRATE ‐0.4% RADICAVA EDARAVONE ‐0.4% State and Specialty Pharmacy Drug Reimbursement

OTHER SPECIALTY CONDITION DRUGS CONT. RAGWITEK WEED POLLEN‐SHORT RAGWEED ‐0.4% RILUTEK RILUZOLE ‐0.4% RUZURGI AMIFAMPRIDINE 0.0% SABRIL VIGABATRIN ‐0.4% SAMSCA TOLVAPTAN ‐0.4% SAXENDA LIRAGLUTIDE ‐0.4% SOLIRIS ECULIZUMAB ‐0.4% SPINRAZA NUSINERSEN SODIUM/PF 0.0% SYNAREL NAFARELIN ACETATE ‐0.4% SYPRINE TRIENTINE HCL ‐0.4% TASMAR TOLCAPONE ‐0.4% TAVALISSE FOSTAMATINIB DISODIUM ‐0.4% TEGSEDI INOTERSEN SODIUM ‐0.4% TIGLUTIK RILUZOLE ‐0.4% VECAMYL MECAMYLAMINE HCL ‐0.4% VIGADRONE VIGABATRIN ‐0.4% VIVITROL NALTREXONE MICROSPHERES ‐0.4% VYNDAMAX TAFAMIDIS ‐0.4% VYNDAQEL TAFAMIDIS MEGLUMINE ‐0.4% XENAZINE TETRABENAZINE ‐0.4% XYREM ‐0.4% ZELAPAR SELEGILINE HCL ‐0.4% ZINPLAVA BEZLOTOXUMAB ‐0.4% ZOLGENSMA ONASEMNOGENE ABEPARVOVEC‐XIOI 0.0% PSORIASIS DRUGS OXSORALEN‐ULTRA METHOXSALEN ‐0.4% 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 ‐0.4% GLASSIA ALPHA‐1‐PROTEINASE INHIBITOR ‐0.4% KALYDECO IVACAFTOR ‐0.4% KITABIS PAK TOBRAMYCIN/NEBULIZER ‐0.4% NUCALA MEPOLIZUMAB ‐0.4% OFEV NINTEDANIB ESYLATE ‐0.4% ORKAMBI LUMACAFTOR/IVACAFTOR ‐0.4% PROLASTIN C ALPHA‐1‐PROTEINASE INHIBITOR ‐0.4% PULMOZYME DORNASE ALFA ‐0.4% SYMDEKO TEZACAFTOR/IVACAFTOR ‐0.4% TOBI TOBRAMYCIN IN 0.225% SOD CHLOR ‐0.4% TOBI PODHALER TOBRAMYCIN ‐0.4% TOBRAMYCIN TOBRAMYCIN IN 0.225% SOD CHLOR ‐0.4% TOBRAMYCIN TOBRAMYCIN/NEBULIZER ‐0.4% XOLAIR 150 MG VIAL OMALIZUMAB 150 MG VIAL ‐0.4% XOLAIR 75 MG/0.5 ML SYRINGE OMALIZUMAB 75 MG/0.5 ML SYRINGE 0.0% ZEMAIRA ALPHA‐1‐PROTEINASE INHIBITOR ‐0.4% PULMONARY HYPERTENSION DRUGS ADCIRCA TADALAFIL ‐0.4% ADEMPAS RIOCIGUAT ‐0.4% ALYQ TADALAFIL ‐0.4% DILUENT FOR EPOPROSTENOL DILUENT FOR EPOPROSTENOL(GLYC) ‐0.4% EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM (GLYCINE) ‐0.4% FLOLAN EPOPROSTENOL SODIUM (GLYCINE) ‐0.4% LETAIRIS AMBRISENTAN ‐0.4% 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% REVATIO SILDENAFIL CITRATE ‐0.4% TRACLEER ‐0.4% TREPROSTINIL TREPROSTINIL SODIUM ‐0.4% 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 ‐0.4% RASUVO METHOTREXATE/PF ‐0.4% * The Estimated Acquisition Cost (EAC) is equal to the wholesale acquisition cost plus the percentages in the brand and generic EAC columns.