Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Acetaminophen 80 Mg Po Chew $ 0.54 Acetaminophen 325 Mg Po Tabs $ 0.11 Acetaminophen 325 Mg Po Tabs $ 0.46 Acetaminophen 325 Mg Po Tabs $ 0.39 Acetaminophen 325 Mg Po Tabs $ 0.55 Acetaminophen 325 Mg Po Tabs $ 0.21 Acetaminophen 120 Mg Pr Supp $ 4.17 Acetaminophen 120 Mg Pr Supp $ 4.17 Acetaminophen 325 Mg Pr Supp $ 4.68 Acetaminophen 325 Mg Pr Supp $ 5.73 Acetaminophen 325 Mg Pr Supp $ 5.74 Acetaminophen 650 Mg Pr Supp $ 5.06 Acetaminophen 650 Mg Pr Supp $ 5.06 Acetaminophen 650 Mg Pr Supp $ 5.08 Acetaminophen 650 Mg Pr Supp $ 4.25 Acetazolamide 125 Mg Po Tabs $ 15.59 Acetazolamide 125 Mg Po Tabs $ 15.59 Acetazolamide 250 Mg Po Tabs $ 20.61 Acetazolamide Sodium 500 Mg Ij Solr $ 377.16 Albuterol Sulfate 2 Mg Po Tabs $ 42.01 Allopurinol 100 Mg Po Tabs $ 2.70 Allopurinol 100 Mg Po Tabs $ 3.45 Allopurinol 100 Mg Po Tabs $ 3.45 Allopurinol 100 Mg Po Tabs $ 3.45 Allopurinol 300 Mg Po Tabs $ 5.42 Allopurinol 300 Mg Po Tabs $ 6.61 Allopurinol 300 Mg Po Tabs $ 6.61 Alprazolam 0.25 Mg Po Tabs $ 4.54 Alprazolam 0.25 Mg Po Tabs $ 0.49 Alprazolam 0.25 Mg Po Tabs $ 4.66 Alprazolam 0.25 Mg Po Tabs $ 4.97 Alprazolam 0.5 Mg Po Tabs $ 0.49 Alprazolam 0.5 Mg Po Tabs $ 5.28 Alprazolam 0.5 Mg Po Tabs $ 5.31 Alprazolam 0.5 Mg Po Tabs $ 6.67 Alprazolam 1 Mg Po Tabs $ 6.42 Alprazolam 1 Mg Po Tabs $ 8.27 Amantadine Hcl 100 Mg Po Caps $ 14.44 Amantadine Hcl 100 Mg Po Caps $ 13.86 Urea 15 G Po Pack $ 30.03 Urea 15 G Po Pack $ 30.03 Cyclophosphamide 25 Mg Po Caps $ 66.94 Amitriptyline Hcl 10 Mg Po Tabs $ 2.16 Amitriptyline Hcl 10 Mg Po Tabs $ 2.27 Amitriptyline Hcl 10 Mg Po Tabs $ 2.27 Amitriptyline Hcl 100 Mg Po Tabs $ 18.16 Amitriptyline Hcl 100 Mg Po Tabs $ 18.16 Amitriptyline Hcl 25 Mg Po Tabs $ 2.58 Amitriptyline Hcl 25 Mg Po Tabs $ 4.55 Amitriptyline Hcl 50 Mg Po Tabs $ 9.08 Amitriptyline Hcl 50 Mg Po Tabs $ 5.11 Amitriptyline Hcl 50 Mg Po Tabs $ 9.08 Amoxicillin 250 Mg Po Caps $ 1.78 Amoxicillin 500 Mg Po Caps $ 3.13 Amoxicillin 500 Mg Po Caps $ 3.10 Amoxicillin 500 Mg Po Caps $ 3.10 Amphotericin B 50 Mg Iv Solr $ 326.04 Ampicillin Sodium 2 G Ij Solr $ 119.78 Ampicillin Sodium 2 G Ij Solr $ 113.79 Ampicillin Sodium 2 G Ij Solr $ 119.78 Ampicillin Sodium 2 G Ij Solr $ 64.35

Page 1 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Ampicillin Sodium 2 G Ij Solr $ 119.76 Ampicillin Sodium 2 G Ij Solr $ 113.83 Ampicillin Sodium 500 Mg Ij Solr $ 31.50 Terbutaline Sulfate 5 Mg Po Tabs $ 47.52 Aspirin 81 Mg Po Chew $ 0.43 Aspirin 81 Mg Po Chew $ 0.04 Aspirin 81 Mg Po Chew $ 0.07 Aspirin 81 Mg Po Chew $ 0.29 Aspirin 81 Mg Po Chew $ 0.14 Aspirin 81 Mg Po Chew $ 0.47 Aspirin 81 Mg Po Chew $ 0.16 Aspirin 81 Mg Po Chew $ 0.29 Aspirin 325 Mg Po Tabs $ 0.07 Aspirin 325 Mg Po Tabs $ 0.07 Aspirin 600 Mg Pr Supp $ 10.78 Atenolol 25 Mg Po Tabs $ 5.85 Atenolol 25 Mg Po Tabs $ 5.72 Atenolol 25 Mg Po Tabs $ 5.56 Atenolol 25 Mg Po Tabs $ 5.85 Atenolol 25 Mg Po Tabs $ 5.85 Atenolol 50 Mg Po Tabs $ 6.06 Atenolol 50 Mg Po Tabs $ 6.05 Atenolol 50 Mg Po Tabs $ 5.96 Atenolol 50 Mg Po Tabs $ 5.66 Emtricitabine 200 Mg Po Caps $ 153.45 Venlafaxine Hcl 18.75 Mg (1/4 X 75 Mg) Po Tabs $ 3.90 B & B A-3 Athletic Supporter Misc $ 38.04 B & B A-3 Athletic Supporter Misc $ 36.82 B & B A-3 Athletic Supporter Misc $ 38.04 B & B A-3 Athletic Supporter Misc $ 36.82 B & B A-3 Athletic Supporter Misc $ 36.82 B & B S-10 Swimmer Supporter Misc $ 33.46 Bacitracin 50000 Units Im Solr $ 95.15 Bacitracin 50000 Units Im Solr $ 95.15 Bacitracin 50000 Units Im Solr $ 95.17 Bacitracin 50000 Units Im Solr $ 95.15 Bacitracin 50000 Units Im Solr $ 85.80 Bacitracin 50000 Units Im Solr $ 77.22 Isavuconazonium Sulfate 372 Mg Iv Solr $ 1,718.25 Bacitracin-Neomycin-Polymyxin 400-5-5000 Ex Oint $ 1.99 Bacitracin-Polymyxin B 500-10000 Unit/Gm Ex Oint $ 2.80 Baclofen 10 Mg Po Tabs $ 17.67 Benzonatate 100 Mg Po Caps $ 16.70 Benzonatate 100 Mg Po Caps $ 17.90 Benzonatate 100 Mg Po Caps $ 17.90 Benztropine Mesylate 0.5 Mg Po Tabs $ 2.77 Benztropine Mesylate 0.5 Mg Po Tabs $ 2.77 Benztropine Mesylate 0.5 Mg Po Tabs $ 2.77 Benztropine Mesylate 1 Mg Po Tabs $ 2.92 Benztropine Mesylate 2 Mg Po Tabs $ 3.71 Bisoprolol Fumarate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 4.36 Bisoprolol Fumarate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 4.36 Bethanechol Chloride 25 Mg Po Tabs $ 19.09 Bethanechol Chloride 5 Mg Po Tabs $ 6.12 Bethanechol Chloride 5 Mg Po Tabs $ 6.44 Repaglinide 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 2.42 Repaglinide 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 2.42 Bisacodyl 10 Mg Pr Supp $ 1.29 Bisacodyl 10 Mg Pr Supp $ 1.13 Bisacodyl 10 Mg Pr Supp $ 6.80 Bisacodyl 10 Mg Pr Supp $ 1.42

Page 2 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Bisacodyl 10 Mg Pr Supp $ 8.17 Bisacodyl 10 Mg Pr Supp $ 1.17 Bisacodyl 10 Mg Pr Supp $ 3.03 K Phos Mono-Sod Phos Di & Mono 155-852-130 Mg Po Tabs $ 3.63 K Phos Mono-Sod Phos Di & Mono 155-852-130 Mg Po Tabs $ 3.64 Carbamazepine 100 Mg Po Chew $ 4.71 Carbamazepine 100 Mg Po Chew $ 4.71 Carbamazepine 200 Mg Po Tabs $ 11.43 Cangrelor Tetrasodium 50 Mg Iv Solr $ 4,080.55 Cangrelor Tetrasodium 50 Mg Iv Solr $ 4,080.55 Cangrelor Tetrasodium 50 Mg Iv Solr $ 4,080.55 Cefazolin Sodium 1 G Ij Solr $ 7.89 Cefazolin Sodium 1 G Ij Solr $ 11.73 Cefazolin Sodium 1 G Ij Solr $ 18.66 Cefazolin Sodium 1 G Ij Solr $ 14.16 Cefazolin Sodium 1 G Ij Solr $ 18.68 Cefazolin Sodium 10 G Ij Solr $ 51.48 Cefazolin Sodium 10 G Ij Solr $ 94.81 Cefazolin Sodium 10 G Ij Solr $ 94.81 Cefazolin Sodium 500 Mg Ij Solr $ 69.61 Cefazolin Sodium 500 Mg Ij Solr $ 7.21 Cefazolin Sodium 500 Mg Ij Solr $ 13.73 Chlordiazepoxide Hcl 10 Mg Po Caps $ 2.85 Chlordiazepoxide Hcl 5 Mg Po Caps $ 2.52 Chlordiazepoxide Hcl 5 Mg Po Caps $ 5.79 Chlorpheniramine Maleate 4 Mg Po Tabs $ 0.45 Chlorpromazine Hcl 10 Mg Po Tabs $ 30.04 Chlorpromazine Hcl 100 Mg Po Tabs $ 106.44 Chlorpromazine Hcl 25 Mg Po Tabs $ 54.63 Chlorthalidone 25 Mg Po Tabs $ 8.63 Chorionic Gonadotropin 10000 Units Im Solr $ 870.80 Clindamycin Hcl 150 Mg Po Caps $ 8.52 Carbidopa-Levodopa 12.5-125 Mg ( 1/2 X 25-250 Mg) Po Tabs $ 3.40 Carbidopa-Levodopa 12.5-125 Mg ( 1/2 X 25-250 Mg) Po Tabs $ 3.07 Naltrexone Hcl 50 Mg Po Tabs $ 30.57 Naltrexone Hcl 50 Mg Po Tabs $ 24.61 Clomipramine Hcl 50 Mg Po Caps $ 51.04 Clonidine Hcl 0.1 Mg Po Tabs $ 2.15 Clonidine Hcl 0.1 Mg Po Tabs $ 1.85 Clonidine Hcl 0.2 Mg Po Tabs $ 3.22 Clonidine Hcl 0.2 Mg Po Tabs $ 2.69 Clorazepate Dipotassium 3.75 Mg Po Tabs $ 28.84 Clorazepate Dipotassium 7.5 Mg Po Tabs $ 35.88 Clorazepate Dipotassium 7.5 Mg Po Tabs $ 20.33 Remifentanil Hcl 5 Mg Iv Solr $ 1,490.52 Colchicine 0.6 Mg Po Tabs $ 48.16 Colchicine 0.6 Mg Po Tabs $ 48.16 Rasagiline Mesylate 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 52.77 Hydroxocobalamin 5 G Iv Solr $ 4,474.53 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 7.41 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 7.81 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 8.22 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 7.97 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 7.81 Cyclobenzaprine Hcl 10 Mg Po Tabs $ 8.28 Cyclophosphamide 500 Mg Ij Solr $ 1,870.62 Cyproheptadine Hcl 4 Mg Po Tabs $ 7.63 Cyproheptadine Hcl 4 Mg Po Tabs $ 7.63 Dacarbazine 100 Mg Iv Solr $ 83.58 Dacarbazine 200 Mg Iv Solr $ 106.13 Ertapenem Sodium 1 G Iv Solr $ 1,158.99

Page 3 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Minocycline Hcl 50 Mg Po Caps $ 12.15 Minocycline Hcl 50 Mg Po Caps $ 12.15 Amphetamine-Dextroamphet Er 20 Mg Po Cp24 $ 50.41 Amphetamine-Dextroamphet Er 20 Mg Po Cp24 $ 43.84 Dexamethasone 0.5 Mg Po Tabs $ 0.99 Dexamethasone 0.5 Mg Po Tabs $ 1.48 Colistimethate Sodium (Cba) 150 Mg Ij Solr $ 240.17 Dexamethasone 2 Mg Po Tabs $ 4.25 Dexamethasone 4 Mg Po Tabs $ 8.50 Diazepam 2 Mg Po Tabs $ 1.72 Diazepam 2 Mg Po Tabs $ 1.73 Diazepam 5 Mg Po Tabs $ 1.57 Diazepam 5 Mg Po Tabs $ 2.29 Diazepam 5 Mg Po Tabs $ 2.29 Diazepam 5 Mg Po Tabs $ 1.43 Dicloxacillin Sodium 250 Mg Po Caps $ 9.85 Metronidazole 500 Mg Po Tabs $ 5.21 Metronidazole 500 Mg Po Tabs $ 5.21 Metronidazole 500 Mg Po Tabs $ 5.21 Dicyclomine Hcl 10 Mg Po Caps $ 1.89 Dicyclomine Hcl 10 Mg Po Caps $ 3.21 Dicyclomine Hcl 10 Mg Po Caps $ 4.71 Dicyclomine Hcl 10 Mg Po Caps $ 3.89 Dicyclomine Hcl 10 Mg Po Caps $ 4.72 Dicyclomine Hcl 20 Mg Po Tabs $ 5.55 Dicyclomine Hcl 20 Mg Po Tabs $ 4.15 Losartan Potassium 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 6.00 Losartan Potassium 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 6.43 Digoxin 125 Mcg Po Tabs $ 16.45 Digoxin 125 Mcg Po Tabs $ 10.17 Digoxin 125 Mcg Po Tabs $ 16.45 Digoxin 250 Mcg Po Tabs $ 16.45 Digoxin 250 Mcg Po Tabs $ 10.17 Digoxin 250 Mcg Po Tabs $ 16.45 Diltiazem Hcl 60 Mg Po Tabs $ 2.02 Diltiazem Hcl 90 Mg Po Tabs $ 15.32 Diltiazem Hcl 90 Mg Po Tabs $ 15.32 Dimenhydrinate 50 Mg Po Tabs $ 0.38 Diphenoxylate-Atropine 2.5-0.025 Mg Po Tabs $ 6.26 Diphenoxylate-Atropine 2.5-0.025 Mg Po Tabs $ 5.01 Dipyridamole 25 Mg Po Tabs $ 7.59 Divalproex Sodium 125 Mg Po Tbec $ 6.34 Divalproex Sodium 250 Mg Po Tbec $ 12.46 Divalproex Sodium 250 Mg Po Tbec $ 12.46 Divalproex Sodium 250 Mg Po Tbec $ 12.46 Divalproex Sodium 250 Mg Po Tbec $ 12.60 Divalproex Sodium 250 Mg Po Tbec $ 7.68 Mesalamine 400 Mg Po Cpdr $ 33.28 Docusate Sodium 100 Mg Po Caps $ 0.31 Docusate Sodium 100 Mg Po Caps $ 0.42 Docusate Sodium 100 Mg Po Caps $ 1.01 Docusate Sodium 100 Mg Po Caps $ 1.24 Doxepin Hcl 10 Mg Po Caps $ 4.58 Doxepin Hcl 25 Mg Po Caps $ 6.01 Doxepin Hcl 25 Mg Po Caps $ 5.88 Doxepin Hcl 50 Mg Po Caps $ 8.35 Doxepin Hcl 50 Mg Po Caps $ 8.37 Doxorubicin Hcl 50 Mg Iv Solr $ 309.54 Doxorubicin Hcl 50 Mg Iv Solr $ 1,328.31 Doxycycline Hyclate 100 Mg Iv Solr $ 180.18 Doxycycline Hyclate 100 Mg Iv Solr $ 225.91

Page 4 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Bupropion Hcl 25 Mg (1/4 X 100 Mg) Po Tabs $ 2.15 Racepinephrine Hcl 2.25 % In Nebu $ 12.87 Erythromycin Stearate 250 Mg Po Tabs $ 93.85 Methylphenidate Hcl 20 Mg Po Tabs $ 10.71 Methylphenidate Hcl 20 Mg Po Tabs $ 10.82 Methylphenidate Hcl 20 Mg Po Tabs $ 11.55 Metformin Hcl 1000 Mg Po Tabs $ 9.81 Metformin Hcl 1000 Mg Po Tabs $ 10.37 Metformin Hcl 1000 Mg Po Tabs $ 10.37 Metformin Hcl 1000 Mg Po Tabs $ 10.32 Metformin Hcl 1000 Mg Po Tabs $ 0.77 Ferrous Sulfate 325 (65 Fe) Mg Po Tabs $ 0.79 Ferrous Sulfate 325 (65 Fe) Mg Po Tabs $ 0.79 Ferrous Sulfate 325 (65 Fe) Mg Po Tabs $ 0.18 Bisacodyl 5 Mg Po Tbec $ 0.51 Bisacodyl 5 Mg Po Tbec $ 0.20 Methotrexate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 22.31 Methyldopa 125 Mg (1/2 X 250 Mg) Po Tabs $ 1.49 Fluphenazine Hcl 2.5 Mg Po Tabs $ 5.42 Fluphenazine Hcl 2.5 Mg Po Tabs $ 7.01 Fluphenazine Hcl 2.5 Mg Po Tabs $ 4.93 Fluphenazine Hcl 5 Mg Po Tabs $ 65.78 Fluphenazine Hcl 5 Mg Po Tabs $ 76.29 Fluphenazine Hcl 5 Mg Po Tabs $ 5.72 Fluphenazine Hcl 5 Mg Po Tabs $ 5.72 Folic Acid 1 Mg Po Tabs $ 2.37 Methylprednisolone 2 Mg (1/2 X 4 Mg) Po Tabs $ 5.11 Methylprednisolone 2 Mg (1/2 X 4 Mg) Po Tabs $ 5.90 Furosemide 20 Mg Po Tabs $ 3.07 Furosemide 40 Mg Po Tabs $ 1.00 Furosemide 40 Mg Po Tabs $ 9.42 Furosemide 40 Mg Po Tabs $ 3.50 Furosemide 40 Mg Po Tabs $ 3.42 Furosemide 80 Mg Po Tabs $ 9.37 Furosemide 80 Mg Po Tabs $ 3.40 Gemfibrozil 600 Mg Po Tabs $ 17.38 Gemfibrozil 600 Mg Po Tabs $ 17.38 Glyburide 5 Mg Po Tabs $ 6.46 Glyburide 5 Mg Po Tabs $ 5.56 Haloperidol 0.5 Mg Po Tabs $ 2.48 Haloperidol 0.5 Mg Po Tabs $ 2.33 Haloperidol 0.5 Mg Po Tabs $ 2.33 Haloperidol 0.5 Mg Po Tabs $ 2.33 Trifluoperazine Hcl 5 Mg Po Tabs $ 18.21 Haloperidol 10 Mg Po Tabs $ 12.82 Haloperidol 10 Mg Po Tabs $ 10.26 Haloperidol 10 Mg Po Tabs $ 13.46 Haloperidol 5 Mg Po Tabs $ 7.32 Haloperidol 5 Mg Po Tabs $ 7.32 Haloperidol 5 Mg Po Tabs $ 7.32 Haloperidol 5 Mg Po Tabs $ 7.32 Hydralazine Hcl 10 Mg Po Tabs $ 2.95 Hydralazine Hcl 10 Mg Po Tabs $ 2.97 Hydralazine Hcl 10 Mg Po Tabs $ 2.93 Hydralazine Hcl 10 Mg Po Tabs $ 2.95 Hydralazine Hcl 25 Mg Po Tabs $ 3.63 Hydralazine Hcl 25 Mg Po Tabs $ 3.63 Hydralazine Hcl 25 Mg Po Tabs $ 3.63 Hydralazine Hcl 25 Mg Po Tabs $ 3.63 Hydralazine Hcl 50 Mg Po Tabs $ 4.03 Hydralazine Hcl 50 Mg Po Tabs $ 4.03

Page 5 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Hydralazine Hcl 50 Mg Po Tabs $ 4.02 Hydralazine Hcl 50 Mg Po Tabs $ 4.03 Hydrochlorothiazide 25 Mg Po Tabs $ 0.61 Hydrochlorothiazide 25 Mg Po Tabs $ 0.61 Hydrochlorothiazide 25 Mg Po Tabs $ 0.61 Hydrochlorothiazide 50 Mg Po Tabs $ 1.18 Hydrochlorothiazide 50 Mg Po Tabs $ 1.18 Hydrochlorothiazide 50 Mg Po Tabs $ 1.18 Hydrocortisone 10 Mg Po Tabs $ 4.10 Hydrocortisone 10 Mg Po Tabs $ 4.10 Hydrocortisone 10 Mg Po Tabs $ 4.10 Hydrocortisone Acetate 25 Mg Pr Supp $ 103.14 Rivaroxaban 20 Mg Po Tabs $ 128.13 Rivaroxaban 20 Mg Po Tabs $ 128.13 Selenium 50 Mcg Po Tabs $ 0.34 Selegiline Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 10.59 Hydromorphone Hcl 2 Mg Po Tabs $ 5.11 Hydromorphone Hcl 2 Mg Po Tabs $ 1.31 Hydromorphone Hcl 4 Mg Po Tabs $ 5.13 Hydromorphone Hcl 4 Mg Po Tabs $ 1.50 Hydroxyzine Hcl 10 Mg Po Tabs $ 4.46 Hydroxyzine Hcl 10 Mg Po Tabs $ 4.65 Hydroxyzine Hcl 10 Mg Po Tabs $ 4.46 Rivastigmine 13.3 Mg/24Hr Td Pt24 $ 124.58 Rivastigmine 13.3 Mg/24Hr Td Pt24 $ 115.85 Ibuprofen 200 Mg Po Tabs $ 0.21 Ibuprofen 200 Mg Po Tabs $ 0.39 Ibuprofen 200 Mg Po Tabs $ 0.27 Ibuprofen 200 Mg Po Tabs $ 0.15 Ibuprofen 400 Mg Po Tabs $ 1.54 Ibuprofen 400 Mg Po Tabs $ 0.54 Ibuprofen 400 Mg Po Tabs $ 1.86 Ibuprofen 400 Mg Po Tabs $ 2.81 Ibuprofen 400 Mg Po Tabs $ 2.62 Ibuprofen 400 Mg Po Tabs $ 2.85 Ibuprofen 600 Mg Po Tabs $ 2.18 Ibuprofen 600 Mg Po Tabs $ 3.92 Ibuprofen 600 Mg Po Tabs $ 3.78 Ibuprofen 600 Mg Po Tabs $ 3.68 Ibuprofen 600 Mg Po Tabs $ 3.68 Ibuprofen 600 Mg Po Tabs $ 2.07 Ibuprofen 600 Mg Po Tabs $ 1.72 Ibuprofen 600 Mg Po Tabs $ 3.68 Ibuprofen 800 Mg Po Tabs $ 2.86 Ibuprofen 800 Mg Po Tabs $ 0.85 Ibuprofen 800 Mg Po Tabs $ 3.06 Ibuprofen 800 Mg Po Tabs $ 3.06 Ibuprofen 800 Mg Po Tabs $ 5.76 Imipramine Hcl 10 Mg Po Tabs $ 3.07 Imipramine Hcl 25 Mg Po Tabs $ 6.24 Imipramine Hcl 25 Mg Po Tabs $ 5.13 Imipramine Hcl 50 Mg Po Tabs $ 8.72 Indapamide 2.5 Mg Po Tabs $ 11.08 Indomethacin 25 Mg Po Caps $ 2.87 Indomethacin 25 Mg Po Caps $ 2.87 Indomethacin 25 Mg Po Caps $ 2.72 Isoniazid 300 Mg Po Tabs $ 3.63 Isosorbide Dinitrate 20 Mg Po Tabs $ 8.52 Isosorbide Dinitrate 5 Mg Po Tabs $ 9.99 Isosorbide Dinitrate 5 Mg Po Tabs $ 7.04 Isosorbide Dinitrate 5 Mg Po Tabs $ 7.04

Page 6 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Aripiprazole Er 300 Mg Im Srer $ 9,294.56 Methylprednisolone 500 Mg Piggyback In Acudose $ 148.01 Leucovorin Calcium 5 Mg Po Tabs $ 16.87 Leucovorin Calcium 5 Mg Po Tabs $ 14.65 Levothyroxine Sodium 200 Mcg Iv Solr $ 1,150.39 Levothyroxine Sodium 25 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 50 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 50 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 75 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 100 Mcg Or Tabs $ 4.37 Levothyroxine Sodium 100 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 100 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 125 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 150 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 200 Mcg Or Tabs $ 10.62 Lisinopril 20 Mg Po Tabs $ 7.61 Lisinopril 20 Mg Po Tabs $ 7.61 Lisinopril 20 Mg Po Tabs $ 7.57 Lisinopril 20 Mg Po Tabs $ 7.53 Lisinopril 20 Mg Po Tabs $ 7.53 Lithium Carbonate 150 Mg Po Caps $ 1.34 Lithium Carbonate 300 Mg Po Caps $ 1.25 Loperamide Hcl 2 Mg Po Caps $ 9.76 Loperamide Hcl 2 Mg Po Caps $ 9.52 Lorazepam 0.5 Mg Po Tabs $ 0.65 Lorazepam 0.5 Mg Po Tabs $ 2.68 Lorazepam 0.5 Mg Po Tabs $ 2.68 Lorazepam 0.5 Mg Po Tabs $ 0.64 Lorazepam 0.5 Mg Po Tabs $ 4.60 Lorazepam 0.5 Mg Po Tabs $ 0.47 Lorazepam 0.5 Mg Po Tabs $ 4.60 Lorazepam 1 Mg Po Tabs $ 0.79 Lorazepam 1 Mg Po Tabs $ 0.74 Lorazepam 1 Mg Po Tabs $ 6.48 Lorazepam 1 Mg Po Tabs $ 0.51 Lorazepam 1 Mg Po Tabs $ 3.04 Lorazepam 1 Mg Po Tabs $ 5.99 Maprotiline Hcl 25 Mg Po Tabs $ 8.24 Medroxyprogesterone Acetate 10 Mg Po Tabs $ 3.51 Medroxyprogesterone Acetate 2.5 Mg Po Tabs $ 2.24 Megestrol Acetate 20 Mg Po Tabs $ 4.95 Megestrol Acetate 40 Mg Po Tabs $ 7.48 Aprepitant 40 Mg Po Caps $ 786.04 Aprepitant 40 Mg Po Caps $ 1,012.80 Aprepitant 40 Mg Po Caps $ 786.04 Aprepitant 40 Mg Po Caps $ 786.04 Meprobamate 200 Mg Po Tabs $ 10.01 Meprobamate 400 Mg Po Tabs $ 13.09 Methadone Hcl 10 Mg Po Tabs $ 2.18 Methadone Hcl 10 Mg Po Tabs $ 1.07 Methadone Hcl 10 Mg Po Tabs $ 3.16 Methadone Hcl 10 Mg Po Tabs $ 3.72 Methadone Hcl 10 Mg Po Tabs $ 3.75 Methadone Hcl 10 Mg Po Tabs $ 3.13 Methadone Hcl 10 Mg Po Tabs $ 3.13 Methadone Hcl 5 Mg Po Tabs $ 3.29 Methadone Hcl 5 Mg Po Tabs $ 2.78 Methadone Hcl 5 Mg Po Tabs $ 1.90 Methazolamide 50 Mg Po Tabs $ 54.78 Methazolamide 50 Mg Po Tabs $ 73.04 Prednisone 20 Mg Po Tabs $ 2.04

Page 7 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Prednisone 20 Mg Po Tabs $ 1.83 Prednisone 20 Mg Po Tabs $ 1.69 Prednisone 20 Mg Po Tabs $ 1.70 Prednisone 20 Mg Po Tabs $ 1.85 Methotrexate 2.5 Mg Po Tabs $ 25.48 Methotrexate Sodium 1 G Ij Solr $ 562.48 Methotrexate Sodium 1 G Ij Solr $ 437.78 Methyldopa 250 Mg Po Tabs $ 2.63 Methyldopa 250 Mg Po Tabs $ 2.66 Methyldopa 500 Mg Po Tabs $ 9.30 Methylphenidate Hcl 10 Mg Po Tabs $ 7.45 Methylphenidate Hcl 10 Mg Po Tabs $ 7.35 Methylphenidate Hcl 10 Mg Po Tabs $ 7.54 Methylphenidate Hcl 5 Mg Po Tabs $ 12.43 Methylphenidate Hcl 5 Mg Po Tabs $ 5.28 Methylphenidate Hcl 5 Mg Po Tabs $ 5.23 Methylprednisolone 4 Mg Po Tabs $ 10.22 Methylprednisolone 4 Mg Po Tabs $ 10.22 Metoclopramide Hcl 10 Mg Po Tabs $ 6.84 Metoclopramide Hcl 10 Mg Po Tabs $ 1.99 Metoclopramide Hcl 5 Mg Po Tabs $ 0.97 Metoclopramide Hcl 5 Mg Po Tabs $ 2.29 Metoclopramide Hcl 5 Mg Po Tabs $ 2.38 Metoclopramide Hcl 5 Mg Po Tabs $ 6.44 Metoprolol Tartrate 100 Mg Po Tabs $ 5.73 Metoprolol Tartrate 100 Mg Po Tabs $ 5.73 Metoprolol Tartrate 100 Mg Po Tabs $ 5.73 Metoprolol Tartrate 50 Mg Po Tabs $ 3.97 Metoprolol Tartrate 50 Mg Po Tabs $ 3.97 Metoprolol Tartrate 50 Mg Po Tabs $ 4.13 Metoprolol Tartrate 50 Mg Po Tabs $ 3.97 Metronidazole 250 Mg Po Tabs $ 3.10 Metronidazole 250 Mg Po Tabs $ 3.11 Lamivudine 75 Mg (1/2 X 150 Mg) Po Tabs $ 25.60 Lamivudine 75 Mg (1/2 X 150 Mg) Po Tabs $ 51.20 Minocycline Hcl 100 Mg Po Caps $ 24.29 Minocycline Hcl 100 Mg Po Caps $ 24.29 Minoxidil 10 Mg Po Tabs $ 9.23 Minoxidil 2.5 Mg Po Tabs $ 4.20 Morphine Sulfate 15 Mg Po Tabs $ 6.50 Morphine Sulfate 15 Mg Po Tabs $ 3.71 Loxapine Succinate 25 Mg Po Caps $ 13.76 Multi-Vitamins Po Tabs $ 0.20 Nadolol 20 Mg Po Tabs $ 26.22 Nadolol 20 Mg Po Tabs $ 24.25 Nadolol 40 Mg Po Tabs $ 51.67 Nadolol 40 Mg Po Tabs $ 28.37 Nafcillin Sodium 1 G Ij Solr $ 127.74 Nafcillin Sodium 10 G Iv Solr $ 1,214.50 Naproxen 250 Mg Po Tabs $ 6.26 Naproxen 250 Mg Po Tabs $ 5.53 Naproxen 375 Mg Po Tabs $ 7.06 Naproxen 375 Mg Po Tabs $ 7.58 Naproxen Sodium 275 Mg Po Tabs $ 21.59 Naproxen Sodium 275 Mg Po Tabs $ 21.57 Naproxen Sodium 275 Mg Po Tabs $ 16.37 Neomycin Sulfate 500 Mg Po Tabs $ 11.64 Neomycin Sulfate 500 Mg Po Tabs $ 9.75 Neomycin Sulfate 500 Mg Po Tabs $ 11.66 Nabumetone 250 Mg (1/2 X 500 Mg) Po Tabs $ 2.95 Nabumetone 250 Mg (1/2 X 500 Mg) Po Tabs $ 4.64

Page 8 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Fluticasone-Salmeterol 100-50 Mcg/Dose In Aepb $ 92.99 Nephrocaps 1 Mg Po Caps $ 4.80 Nephrocaps 1 Mg Po Caps $ 4.81 Levothyroxine Sodium 6.25 Mcg (1/4 X 25 Mcg) Or Tabs $ 0.79 Apixaban 5 Mg Po Tabs $ 63.51 Nifedipine 10 Mg Po Caps $ 14.04 Nifedipine 10 Mg Po Caps $ 9.20 Nifedipine 10 Mg Po Caps $ 7.64 Nitrofurantoin Macrocrystal 50 Mg Po Caps $ 19.76 Nitrofurantoin Macrocrystal 50 Mg Po Caps $ 16.24 Morphine Sulfate Er 100 Mg Po Tbcr $ 54.60 Morphine Sulfate Er 100 Mg Po Tbcr $ 65.78 Morphine Sulfate Er 100 Mg Po Tbcr $ 15.16 Morphine Sulfate Er 100 Mg Po Tbcr $ 65.78 Nitroglycerin 0.4 Mg Sl Subl $ 10.70 Nitroglycerin 0.4 Mg Sl Subl $ 10.70 Nitroglycerin 0.4 Mg Sl Subl $ 7.26 Tisseel Duplospray Applicator 40Cm Kit 0601130Mr $ 4,296.11 Nortriptyline Hcl 10 Mg Po Caps $ 3.15 Nortriptyline Hcl 10 Mg Po Caps $ 0.92 Nortriptyline Hcl 10 Mg Po Caps $ 5.33 Nortriptyline Hcl 25 Mg Po Caps $ 6.31 Nortriptyline Hcl 25 Mg Po Caps $ 10.49 Folic Acid 100 Mcg (1/4 X 400 Mcg) Po Tabs $ 0.07 O-2 Suspensory Misc $ 60.92 O-2 Suspensory Misc $ 60.92 O-2 Suspensory Misc $ 60.92 O-2 Suspensory Misc $ 60.92 Oxazepam 10 Mg Po Caps $ 6.23 Oxazepam 10 Mg Po Caps $ 13.41 Oxazepam 15 Mg Po Caps $ 10.40 Oxazepam 15 Mg Po Caps $ 15.55 Oxybutynin Chloride 5 Mg Po Tabs $ 3.19 Oxybutynin Chloride 5 Mg Po Tabs $ 4.43 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 10.55 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 9.79 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 9.90 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 9.30 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 9.94 Oxycodone-Acetaminophen 5-325 Mg Po Tabs $ 9.79 Aripiprazole 1 Mg (1/2 X 2 Mg) Po Tabs $ 114.67 Aripiprazole 1 Mg (1/2 X 2 Mg) Po Tabs $ 114.79 Penicillin G Potassium 20000000 Units Ij Solr $ 434.43 Penicillin G Potassium 5000000 Units Ij Solr $ 108.61 Penicillin G Potassium 5000000 Units Ij Solr $ 108.61 Penicillin G Potassium 5000000 Units Ij Solr $ 108.61 Penicillin G Potassium 5000000 Units Ij Solr $ 108.61 Penicillin V Potassium 250 Mg Po Tabs $ 4.91 Penicillin V Potassium 250 Mg Po Tabs $ 3.27 Penicillin V Potassium 250 Mg Po Tabs $ 6.08 Penicillin V Potassium 500 Mg Po Tabs $ 8.34 Hydrocortisone Na Succinate Pf 100 Mg Ij Solr $ 115.26 Hydrocortisone Na Succinate Pf 100 Mg Ij Solr $ 115.22 Perphenazine 2 Mg Po Tabs $ 14.05 Perphenazine 2 Mg Po Tabs $ 12.85 Perphenazine 2 Mg Po Tabs $ 12.48 Perphenazine 4 Mg Po Tabs $ 15.02 Perphenazine 4 Mg Po Tabs $ 19.21 Phenazopyridine Hcl 100 Mg Po Tabs $ 19.31 Phenazopyridine Hcl 100 Mg Po Tabs $ 17.16 Phenobarbital 32.4 Mg Po Tabs $ 4.83

Page 9 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Phenobarbital 32.4 Mg Po Tabs $ 3.25 Phenytoin Sodium Extended 100 Mg Po Caps $ 4.59 Phenytoin Sodium Extended 100 Mg Po Caps $ 2.42 Phenytoin Sodium Extended 100 Mg Po Caps $ 2.42 Phenytoin Sodium Extended 100 Mg Po Caps $ 4.58 Phenytoin Sodium Extended 100 Mg Po Caps $ 4.58 Polymyxin B Sulfate 500000 Units Ij Solr $ 94.38 Polymyxin B Sulfate 500000 Units Ij Solr $ 94.38 Tisseel Vh 4 Ml Ex Kit $ 1,395.42 Potassium Bicarbonate 25 Meq Po Tbef $ 2.37 Potassium Bicarbonate 25 Meq Po Tbef $ 2.42 Potassium Bicarbonate 25 Meq Po Tbef $ 2.71 Potassium Bicarbonate 25 Meq Po Tbef $ 2.17 Potassium Bicarbonate 25 Meq Po Tbef $ 1.72 Potassium Bicarbonate 25 Meq Po Tbef $ 11.23 Fibrin Sealant Patch 2X4 (Evarrest) $ 5,448.00 Pralidoxime Chloride 1 G Iv Solr $ 743.89 Prazosin Hcl 1 Mg Po Caps $ 6.81 Prazosin Hcl 1 Mg Po Caps $ 12.96 Prazosin Hcl 1 Mg Po Caps $ 18.82 Prazosin Hcl 2 Mg Po Caps $ 9.10 Prazosin Hcl 2 Mg Po Caps $ 6.37 Prazosin Hcl 5 Mg Po Caps $ 16.41 Prazosin Hcl 5 Mg Po Caps $ 15.61 Prednisone 1 Mg Po Tabs $ 4.53 Prednisone 1 Mg Po Tabs $ 1.99 Prednisone 10 Mg Po Tabs $ 1.56 Prednisone 10 Mg Po Tabs $ 1.72 Prednisone 2.5 Mg Po Tabs $ 1.18 Prednisone 5 Mg Po Tabs $ 1.48 Prednisone 5 Mg Po Tabs $ 1.62 Prednisone 5 Mg Po Tabs $ 1.46 Prednisone 5 Mg Po Tabs $ 1.44 Prednisone 50 Mg Po Tabs $ 2.91 Primidone 250 Mg Po Tabs $ 7.12 Primidone 250 Mg Po Tabs $ 7.12 Probenecid 500 Mg Po Tabs $ 8.19 Probenecid 500 Mg Po Tabs $ 7.03 Gemtuzumab Ozogamicin 4.5 Mg Iv Solr $ 46,013.81 Prochlorperazine Maleate 10 Mg Po Tabs $ 6.51 Prochlorperazine Maleate 10 Mg Po Tabs $ 6.40 Prochlorperazine Maleate 10 Mg Po Tabs $ 6.38 Prochlorperazine Maleate 5 Mg Po Tabs $ 4.24 Prochlorperazine Maleate 5 Mg Po Tabs $ 4.25 Promethazine Hcl 25 Mg Po Tabs $ 3.76 Promethazine Hcl 25 Mg Po Tabs $ 3.62 Daptomycin 500 Mg Iv Solr (Piggyback Component) $ 2,427.04 Propranolol Hcl 10 Mg Po Tabs $ 2.92 Propranolol Hcl 10 Mg Po Tabs $ 2.92 Propranolol Hcl 10 Mg Po Tabs $ 2.92 Propranolol Hcl 20 Mg Po Tabs $ 3.65 Propranolol Hcl 20 Mg Po Tabs $ 3.65 Propranolol Hcl 40 Mg Po Tabs $ 5.12 Propranolol Hcl 40 Mg Po Tabs $ 5.12 Propylthiouracil 50 Mg Po Tabs $ 6.44 Pseudoephedrine Hcl 30 Mg Po Tabs $ 0.23 Pseudoephedrine Hcl 30 Mg Po Tabs $ 0.73 Pyrazinamide 500 Mg Po Tabs $ 44.01 Pyridoxine Hcl 25 Mg Po Tabs $ 0.24 Voriconazole 50 Mg Po Tabs $ 83.84 Voriconazole 50 Mg Po Tabs $ 69.47

Page 10 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Quinidine Sulfate 200 Mg Po Tabs $ 1.44 Quinidine Sulfate 300 Mg Po Tabs $ 2.77 Reserpine 0.1 Mg Po Tabs $ 8.54 Reserpine 0.25 Mg Po Tabs $ 11.78 Simethicone 80 Mg Po Chew $ 0.64 Simethicone 80 Mg Po Chew $ 0.27 Simethicone 80 Mg Po Chew $ 0.32 Simethicone 80 Mg Po Chew $ 0.27 Empagliflozin 25 Mg Po Tabs $ 140.96 Sodium Bicarbonate 650 Mg Po Tabs $ 0.49 Sodium Bicarbonate 650 Mg Po Tabs $ 0.39 Sodium Bicarbonate 650 Mg Po Tabs $ 0.09 Sodium Chloride 1 G Po Tabs $ 0.57 Spironolactone 25 Mg Po Tabs $ 3.29 Spironolactone 25 Mg Po Tabs $ 1.34 Infliximab-Dyyb 100 Mg Iv Solr $ 5,155.35 Sulfadiazine 500 Mg Po Tabs $ 36.09 Sulfasalazine 500 Mg Po Tabs $ 1.74 Sulfasalazine 500 Mg Po Tabs $ 1.82 Sulfasalazine 500 Mg Po Tbec $ 16.92 Sulfasalazine 500 Mg Po Tbec $ 3.13 Tamoxifen Citrate 10 Mg Po Tabs $ 13.54 Tamoxifen Citrate 10 Mg Po Tabs $ 4.10 Temazepam 15 Mg Po Caps $ 5.26 Temazepam 15 Mg Po Caps $ 5.08 Temazepam 15 Mg Po Caps $ 1.10 Lithium Carbonate 225 Mg (1/2 X 450 Mg) Po Tbcr $ 1.92 Lithium Carbonate 225 Mg (1/2 X 450 Mg) Po Tbcr $ 1.92 Tetanus Immune Globulin 250 Unit/Ml Im Inj $ 2,886.90 Acetaminophen 80 Mg Pr Supp $ 5.73 Thiamine Hcl 100 Mg Po Tabs $ 0.36 Thiamine Hcl 100 Mg Po Tabs $ 0.27 Thiamine Hcl 100 Mg Po Tabs $ 0.24 Thiamine Hcl 100 Mg Po Tabs $ 0.27 Thiamine Hcl 100 Mg Po Tabs $ 0.27 Thiamine Hcl 100 Mg Po Tabs $ 0.22 Thiamine Hcl 100 Mg Po Tabs $ 0.26 Thioguanine 40 Mg Po Tabs $ 216.88 Thioridazine Hcl 25 Mg Po Tabs $ 5.99 Thioridazine Hcl 50 Mg Po Tabs $ 6.81 Thioridazine Hcl 50 Mg Po Tabs $ 7.49 Thiotepa 15 Mg Ij Solr $ 3,241.56 Thiothixene 1 Mg Po Caps $ 8.49 Thiothixene 1 Mg Po Caps $ 8.49 Thiothixene 10 Mg Po Caps $ 36.52 Thiothixene 5 Mg Po Caps $ 17.03 Thyroid 30 Mg Po Tabs $ 6.47 Thyroid 60 Mg Po Tabs $ 7.19 Thyroid 60 Mg Po Tabs $ 6.40 Oxidized Cellulose Ex Pads $ 895.90 Tolmetin Sodium 200 Mg Po Tabs $ 5.36 Trazodone Hcl 100 Mg Po Tabs $ 9.95 Trazodone Hcl 50 Mg Po Tabs $ 5.99 Trazodone Hcl 50 Mg Po Tabs $ 7.68 Triamterene-Hctz 37.5-25 Mg Po Tabs $ 2.81 Triamterene-Hctz 37.5-25 Mg Po Tabs $ 2.81 Triamterene-Hctz 75-50 Mg Po Tabs $ 7.96 Triamterene-Hctz 75-50 Mg Po Tabs $ 6.56 Trifluoperazine Hcl 1 Mg Po Tabs $ 6.26 Trifluoperazine Hcl 1 Mg Po Tabs $ 6.26 Trifluoperazine Hcl 1 Mg Po Tabs $ 6.26

Page 11 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Clorazepate Dipotassium 15 Mg Po Tabs $ 33.43 Trihexyphenidyl Hcl 2 Mg Po Tabs $ 1.93 Trihexyphenidyl Hcl 2 Mg Po Tabs $ 1.31 Theophylline Er 100 Mg Po Cp24 $ 18.84 Trimethoprim 100 Mg Po Tabs $ 4.89 Trimethoprim 100 Mg Po Tabs $ 4.89 Meropenem-Sodium Chloride 500 Mg/50Ml Iv Solr $ 143.18 Valproic Acid 250 Mg Po Caps $ 7.19 Valproic Acid 250 Mg Po Caps $ 7.37 Vancomycin Hcl 500 Mg Iv Solr $ 68.98 Vancomycin Hcl 500 Mg Iv Solr $ 68.98 Vancomycin Hcl 500 Mg Iv Solr $ 60.06 Vancomycin Hcl 500 Mg Iv Solr $ 25.74 Vancomycin Hcl 500 Mg Iv Solr $ 25.74 Verapamil Hcl 120 Mg Po Tabs $ 5.36 Verapamil Hcl 80 Mg Po Tabs $ 4.08 Bortezomib 3.5 Mg Ij Solr $ 8,733.14 Vitamin B-12 100 Mcg Po Tabs $ 0.12 Vitamin B-12 100 Mcg Po Tabs $ 2.18 Vitamin B-12 100 Mcg Po Tabs $ 2.18 Vitamin B-12 100 Mcg Po Tabs $ 0.12 Vitamin B-12 500 Mcg Po Tabs $ 0.39 Vitamin B-12 500 Mcg Po Tabs $ 0.26 Vitamin B-12 500 Mcg Po Tabs $ 0.39 Vitamin B-12 500 Mcg Po Tabs $ 0.32 Vitamin B-12 500 Mcg Po Tabs $ 0.32 Vitamin B-12 500 Mcg Po Tabs $ 0.19 Vitamin B-2 100 Mg Po Tabs $ 0.63 Vitamin B-6 100 Mg Po Tabs $ 0.27 Vitamin B-6 100 Mg Po Tabs $ 0.34 Vitamin B-6 100 Mg Po Tabs $ 0.22 Vitamin C 250 Mg Po Tabs $ 0.22 Vitamin C 500 Mg Po Tabs $ 0.34 Vitamin C 500 Mg Po Tabs $ 0.17 Vitamin E 100 Units Po Caps $ 0.22 Vitamin E 400 Units Po Caps $ 0.89 Vitamin E 400 Units Po Caps $ 0.46 Vitamin E 400 Units Po Caps $ 0.38 Warfarin Sodium 10 Mg Po Tabs $ 27.46 Warfarin Sodium 10 Mg Po Tabs $ 27.44 Warfarin Sodium 2 Mg Po Tabs $ 4.54 Warfarin Sodium 2 Mg Po Tabs $ 18.45 Warfarin Sodium 2 Mg Po Tabs $ 18.45 Warfarin Sodium 2.5 Mg Po Tabs $ 4.68 Warfarin Sodium 2.5 Mg Po Tabs $ 19.02 Warfarin Sodium 2.5 Mg Po Tabs $ 19.05 Warfarin Sodium 5 Mg Po Tabs $ 4.82 Warfarin Sodium 5 Mg Po Tabs $ 19.81 Warfarin Sodium 5 Mg Po Tabs $ 4.93 Warfarin Sodium 5 Mg Po Tabs $ 19.85 Warfarin Sodium 7.5 Mg Po Tabs $ 26.46 Warfarin Sodium 7.5 Mg Po Tabs $ 26.46 Yellow Fever Vaccine Subq Inj $ 207.36 Linaclotide 72 Mcg Po Caps $ 121.21 Acebutolol Hcl 200 Mg Po Caps $ 8.40 Acebutolol Hcl 200 Mg Po Caps $ 8.40 Butalbital-Apap-Caffeine 50-325-40 Mg Po Tabs $ 12.07 Acetazolamide Er 500 Mg Po Cp12 $ 30.67 Acetazolamide Er 500 Mg Po Cp12 $ 30.70 Acyclovir 200 Mg Po Caps $ 10.93 Acyclovir 200 Mg Po Caps $ 6.99

Page 12 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Acyclovir 200 Mg Po Caps $ 6.95 Acyclovir 200 Mg Po Caps $ 1.46 Umeclidinium Bromide 62.5 Mcg/Inh In Aepb $ 86.71 Acyclovir 800 Mg Po Tabs $ 30.14 Acyclovir 800 Mg Po Tabs $ 26.22 Alvimopan 12 Mg Po Caps $ 1,416.47 Alteplase 100 Mg Iv Solr $ 47,944.35 Levothyroxine Sodium 37.5 Mcg (1/2 X 75 Mcg) Or Tabs $ 1.97 Levothyroxine Sodium 37.5 Mcg (1/2 X 75 Mcg) Or Tabs $ 5.14 Alum Sulfate-Ca Acetate Ex Pack $ 8.10 Alum Sulfate-Ca Acetate Ex Pack $ 8.10 Morphine Sulfate Er 15 Mg Po Tbcr $ 9.82 Morphine Sulfate Er 15 Mg Po Tbcr $ 13.16 Morphine Sulfate Er 15 Mg Po Tbcr $ 2.76 Cyclosporine 100 Mg Po Caps $ 99.89 Cyclosporine 100 Mg Po Caps $ 125.60 Amiodarone Hcl 200 Mg Po Tabs $ 23.12 Amiodarone Hcl 200 Mg Po Tabs $ 4.33 Amiodarone Hcl 200 Mg Po Tabs $ 24.18 Amiodarone Hcl 200 Mg Po Tabs $ 24.18 Amlodipine Besylate 10 Mg Po Tabs $ 16.97 Amlodipine Besylate 2.5 Mg Po Tabs $ 12.38 Amlodipine Besylate 2.5 Mg Po Tabs $ 12.38 Amlodipine Besylate 5 Mg Po Tabs $ 12.36 Amlodipine Besylate 5 Mg Po Tabs $ 13.60 Amlodipine Besylate 5 Mg Po Tabs $ 12.79 Aripiprazole 2 Mg Po Tabs $ 229.59 Aripiprazole 2 Mg Po Tabs $ 229.59 Aripiprazole 2 Mg Po Tabs $ 255.10 Aripiprazole 2 Mg Po Tabs $ 229.34 Amphetamine-Dextroamphetamine 10 Mg Po Tabs $ 60.37 Amphetamine-Dextroamphetamine 10 Mg Po Tabs $ 12.26 Amphetamine-Dextroamphetamine 10 Mg Po Tabs $ 12.26 Amphetamine-Dextroamphetamine 10 Mg Po Tabs $ 14.71 Amphetamine-Dextroamphetamine 10 Mg Po Tabs $ 12.26 Ampicillin-Sulbactam Sodium 1.5 (1-0.5) G Ij Solr $ 55.31 Ampicillin-Sulbactam Sodium 1.5 (1-0.5) G Ij Solr $ 65.19 Ampicillin-Sulbactam Sodium 1.5 (1-0.5) G Ij Solr $ 65.19 Ampicillin-Sulbactam Sodium 1.5 (1-0.5) G Ij Solr $ 30.03 Methylprednisolone 1 Mg (1/4 X 4 Mg) Po Tabs $ 2.55 Methylprednisolone 1 Mg (1/4 X 4 Mg) Po Tabs $ 2.95 Cefazolin 3 Gm Ivpb Ads $ 56.80 Azathioprine 50 Mg Po Tabs $ 15.09 Aztreonam 1 G Ij Solr $ 234.32 Aztreonam 1 G Ij Solr $ 248.82 Aztreonam 1 G Ij Solr $ 282.71 Midostaurin 25 Mg Po Caps $ 1,302.45 Taliglucerase Alfa 200 Units Iv Solr $ 4,246.44 Benazepril Hcl 10 Mg Po Tabs $ 6.74 Bleomycin Sulfate 15 Units Ij Solr $ 305.12 Bromocriptine Mesylate 2.5 Mg Po Tabs $ 26.85 Bumetanide 0.5 Mg Po Tabs $ 7.13 Bumetanide 0.5 Mg Po Tabs $ 17.18 Bumetanide 0.5 Mg Po Tabs $ 7.74 Bupropion Hcl 100 Mg Po Tabs $ 14.01 Bupropion Hcl 100 Mg Po Tabs $ 14.04 Bupropion Hcl 75 Mg Po Tabs $ 5.68 Bupropion Hcl 75 Mg Po Tabs $ 5.15 Bupropion Hcl 75 Mg Po Tabs $ 5.67 Buspirone Hcl 10 Mg Po Tabs $ 9.62 Buspirone Hcl 10 Mg Po Tabs $ 9.62

Page 13 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Buspirone Hcl 10 Mg Po Tabs $ 9.62 Buspirone Hcl 10 Mg Po Tabs $ 9.33 Buspirone Hcl 10 Mg Po Tabs $ 9.62 Buspirone Hcl 10 Mg Po Tabs $ 9.62 Acamprosate Calcium 333 Mg Po Tbec $ 11.91 Acamprosate Calcium 333 Mg Po Tbec $ 12.56 Busulfan 2 Mg Po Tabs $ 200.97 Calcitriol 0.25 Mcg Po Caps $ 8.65 Calcitriol 0.25 Mcg Po Caps $ 8.65 Captopril 12.5 Mg Po Tabs $ 11.14 Captopril 25 Mg Po Tabs $ 13.30 Captopril 50 Mg Po Tabs $ 20.73 Glycopyrrolate 1 Mg Po Tabs $ 9.39 Ticagrelor 90 Mg Po Tabs $ 53.50 Cefoxitin Sodium 1 G Iv Solr $ 51.48 Cefoxitin Sodium 1 G Iv Solr $ 27.54 Cefoxitin Sodium 2 G Iv Solr $ 160.88 Cefoxitin Sodium 2 G Iv Solr $ 55.00 Cefoxitin Sodium 2 G Iv Solr $ 109.40 Cefoxitin Sodium 2 G Iv Solr $ 85.80 Chlorthalidone 6.25 Mg (1/4 X 25 Mg) Po Tabs $ 2.16 Primaquine Phosphate 26.3 Mg Po Tabs $ 14.45 Ceftazidime 1 G Ij Solr $ 44.62 Ceftazidime 1 G Ij Solr $ 36.04 Ceftazidime 1 G Ij Solr $ 36.04 Ceftazidime 2 G Ij Solr $ 80.74 Guanfacine Hcl 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 3.12 Guanfacine Hcl 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 3.12 Ceftriaxone Sodium 1 G Ij Solr $ 317.94 Ceftriaxone Sodium 1 G Ij Solr $ 12.87 Ceftriaxone Sodium 1 G Ij Solr $ 317.94 Ceftriaxone Sodium 1 G Ij Solr $ 328.54 Ceftriaxone Sodium 1 G Ij Solr $ 328.54 Buprenorphine Hcl 8 Mg Sl Subl $ 60.49 Buprenorphine Hcl 8 Mg Sl Subl $ 59.50 Buprenorphine Hcl 8 Mg Sl Subl $ 55.34 Ondansetron 8 Mg Po Tbdp $ 84.29 Ondansetron 8 Mg Po Tbdp $ 84.29 Ondansetron 8 Mg Po Tbdp $ 84.29 Azithromycin 500 Mg Po Tabs $ 111.30 Azithromycin 500 Mg Po Tabs $ 111.30 C1 Esterase Inhibitor (Human) 500 Units Iv Kit $ 16,098.84 Chlorothiazide Sodium 500 Mg Iv Solr $ 417.78 Chlorothiazide Sodium 500 Mg Iv Solr $ 891.96 Chlorothiazide Sodium 500 Mg Iv Solr $ 514.80 Chlorothiazide Sodium 500 Mg Iv Solr $ 891.96 Imipenem-Cilastatin 250 Mg Iv Solr $ 148.84 Imipenem-Cilastatin 500 Mg Iv Solr $ 280.15 Metolazone 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 11.89 Metolazone 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 8.12 Ibrutinib 140 Mg Po Caps $ 1,233.14 Clarithromycin 250 Mg Po Tabs $ 43.01 Clarithromycin 500 Mg Po Tabs $ 43.01 Clomipramine Hcl 25 Mg Po Caps $ 80.38 Clonazepam 0.5 Mg Po Tabs $ 5.13 Clonazepam 0.5 Mg Po Tabs $ 5.76 Clonazepam 0.5 Mg Po Tabs $ 5.11 Clonazepam 0.5 Mg Po Tabs $ 21.89 Clonazepam 0.5 Mg Po Tabs $ 5.08 Clonazepam 0.5 Mg Po Tabs $ 5.36 Clonazepam 0.5 Mg Po Tabs $ 5.36

Page 14 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Clonazepam 1 Mg Po Tabs $ 5.65 Clonazepam 1 Mg Po Tabs $ 5.82 Clonazepam 1 Mg Po Tabs $ 6.11 Clonazepam 1 Mg Po Tabs $ 7.51 Clonazepam 1 Mg Po Tabs $ 6.47 Clonazepam 1 Mg Po Tabs $ 6.11 Clonazepam 1 Mg Po Tabs $ 24.97 Clotrimazole 10 Mg Mt Troc $ 22.99 Clotrimazole 10 Mg Mt Troc $ 24.56 Clotrimazole 10 Mg Mt Troc $ 11.50 Clozapine 100 Mg Po Tabs $ 24.45 Clozapine 100 Mg Po Tabs $ 24.53 Clozapine 100 Mg Po Tabs $ 24.51 Clozapine 100 Mg Po Tabs $ 24.51 Clozapine 100 Mg Po Tabs $ 24.51 Clozapine 100 Mg Po Tabs $ 24.72 Clozapine 100 Mg Po Tabs $ 14.75 Clozapine 100 Mg Po Tabs $ 24.72 Clozapine 25 Mg Po Tabs $ 9.43 Clozapine 25 Mg Po Tabs $ 9.44 Clozapine 25 Mg Po Tabs $ 9.46 Quinidine Sulfate 100 Mg (1/2 X 200 Mg) Po Tabs $ 0.72 Pancrelipase (Lip-Prot-Amyl) 16800 Units Po Cpep $ 41.37 Ethambutol Hcl 100 Mg Po Tabs $ 4.23 Cyclosporine 25 Mg Po Caps $ 25.03 Dantrolene Sodium 25 Mg Po Caps $ 7.64 Deferoxamine Mesylate 500 Mg Ij Solr $ 80.75 Demeclocycline Hcl 150 Mg Po Tabs $ 67.22 Rivastigmine 9.5 Mg/24Hr Td Pt24 $ 120.81 Rivastigmine 9.5 Mg/24Hr Td Pt24 $ 115.85 Rivastigmine 9.5 Mg/24Hr Td Pt24 $ 115.85 Doxazosin Mesylate 1 Mg Po Tabs $ 9.65 Doxazosin Mesylate 2 Mg Po Tabs $ 26.88 Doxazosin Mesylate 2 Mg Po Tabs $ 9.65 Doxazosin Mesylate 4 Mg Po Tabs $ 10.12 Doxazosin Mesylate 4 Mg Po Tabs $ 10.12 Dronabinol 2.5 Mg Po Caps $ 42.13 Dronabinol 2.5 Mg Po Caps $ 42.13 Dronabinol 2.5 Mg Po Caps $ 42.13 Leucovorin Calcium 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 7.24 Enalapril Maleate 10 Mg Po Tabs $ 13.90 Enalapril Maleate 2.5 Mg Po Tabs $ 10.42 Enalapril Maleate 2.5 Mg Po Tabs $ 10.42 Enalapril Maleate 5 Mg Po Tabs $ 13.23 Enalapril Maleate 5 Mg Po Tabs $ 4.76 Minoxidil 0.625 Mg (1/4 X 2.5 Mg) Po Tabs $ 1.05 Minoxidil 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 2.10 Minoxidil 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 6.06 Estradiol 1 Mg Po Tabs $ 4.86 Estrogens Conjugated 25 Mg Ij Solr $ 1,616.97 Estrogens Conjugated 0.3 Mg Po Tabs $ 48.25 Estrogens Conjugated 0.625 Mg Po Tabs $ 48.25 Ethacrynate Sodium 50 Mg Iv Solr $ 20,696.95 Ethacrynate Sodium 50 Mg Iv Solr $ 20,702.40 Ethambutol Hcl 400 Mg Po Tabs $ 6.69 Glyburide 0.625 Mg (1/2 X 1.25 Mg) Po Tabs $ 0.99 Lovastatin 20 Mg Po Tabs $ 16.97 Bumetanide 1 Mg Po Tabs $ 7.80 Bumetanide 1 Mg Po Tabs $ 19.09 Bumetanide 1 Mg Po Tabs $ 19.28 Simvastatin 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 0.88

Page 15 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Famotidine 20 Mg Po Tabs $ 12.44 Famotidine 20 Mg Po Tabs $ 12.43 Famotidine 20 Mg Po Tabs $ 17.32 Famotidine 20 Mg Po Tabs $ 17.32 Famotidine 20 Mg Po Tabs $ 91.93 Chlorpromazine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 4.29 Chlorpromazine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 30.04 Flecainide Acetate 50 Mg Po Tabs $ 14.44 Valacyclovir Hcl 250 Mg (1/2 X 500 Mg) Po Tabs $ 25.83 Valacyclovir Hcl 250 Mg (1/2 X 500 Mg) Po Tabs $ 25.81 Fluconazole 100 Mg Po Tabs $ 62.59 Propafenone Hcl 75 Mg (1/2 X 150 Mg) Po Tabs $ 1.57 Propafenone Hcl 75 Mg (1/2 X 150 Mg) Po Tabs $ 3.35 Raltegravir Potassium 400 Mg Po Tabs $ 225.14 Fludarabine Phosphate 50 Mg Iv Solr $ 835.76 Fludrocortisone Acetate 0.1 Mg Po Tabs $ 5.35 Ropinirole Hcl 0.125 Mg (1/2 X 0.25 Mg) Po Tabs $ 14.48 Ropinirole Hcl 0.125 Mg (1/2 X 0.25 Mg) Po Tabs $ 8.96 Fluoxetine Hcl 10 Mg Po Caps $ 17.30 Fluoxetine Hcl 20 Mg Po Caps $ 19.05 Fluoxetine Hcl 20 Mg Po Caps $ 19.08 Fluoxetine Hcl 20 Mg Po Caps $ 19.08 Fluoxetine Hcl 20 Mg Po Caps $ 19.08 Fluvoxamine Maleate 50 Mg Po Tabs $ 18.38 Fosinopril Sodium 10 Mg Po Tabs $ 8.51 Fosinopril Sodium 10 Mg Po Tabs $ 14.46 Fosinopril Sodium 10 Mg Po Tabs $ 8.51 Darunavir Ethanolate 600 Mg Po Tabs $ 241.63 Ganciclovir Sodium 500 Mg Iv Solr $ 617.76 Glipizide 5 Mg Po Tabs $ 2.40 Glipizide 5 Mg Po Tabs $ 2.49 Glipizide 5 Mg Po Tabs $ 2.70 Glipizide 5 Mg Po Tabs $ 2.60 Glyburide 2.5 Mg Po Tabs $ 3.28 Culturelle Po Caps $ 4.58 Culturelle Po Caps $ 7.29 Culturelle Po Caps $ 4.58 Culturelle Po Caps $ 4.13 Goserelin Acetate 3.6 Mg Subq Impl $ 3,460.84 Fludrocortisone Acetate 0.025 Mg (1/4 X 0.1 Mg) Po Tabs $ 1.34 Sodium Bicarbonate 162.5 Mg (1/2 X 325 Mg) Po Tabs $ 0.18 Hemin 350 Mg Iv Solr $ 41,796.83 Hydrocortisone 5 Mg Po Tabs $ 2.42 Hydrocortisone 5 Mg Po Tabs $ 2.42 Hydrocortisone 5 Mg Po Tabs $ 2.42 Incobotulinumtoxina 100 Units Im Solr $ 2,625.94 Hydroxychloroquine Sulfate 200 Mg Po Tabs $ 31.17 Hydroxychloroquine Sulfate 200 Mg Po Tabs $ 29.23 Hydroxyurea 500 Mg Po Caps $ 9.13 Ramipril 10 Mg Po Caps $ 16.94 Ramipril 10 Mg Po Caps $ 15.85 Ramipril 10 Mg Po Caps $ 15.85 Ifosfamide 3 G Iv Solr $ 925.38 Indocyanine Green 25 Mg Iv Solr $ 707.55 Indocyanine Green 25 Mg Iv Solr $ 707.55 Indomethacin Sodium 1 Mg Iv Solr $ 2,881.68 Indomethacin Sodium 1 Mg Iv Solr $ 2,506.08 Interferon Alfa-2B 50000000 Units Ij Solr $ 6,538.19 Isradipine 2.5 Mg Po Caps $ 9.76 Isradipine 5 Mg Po Caps $ 14.27 Itraconazole 100 Mg Po Caps $ 172.64

Page 16 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Labetalol Hcl 100 Mg Po Tabs $ 4.81 Labetalol Hcl 200 Mg Po Tabs $ 24.94 Leuprolide Acetate 7.5 Mg Im Kit $ 8,442.22 Famciclovir 250 Mg Po Tabs $ 45.20 Famciclovir 250 Mg Po Tabs $ 45.20 Levothyroxine Sodium 88 Mcg Or Tabs $ 10.62 Levothyroxine Sodium 112 Mcg Or Tabs $ 10.62 Lisinopril 10 Mg Po Tabs $ 1.07 Lisinopril 10 Mg Po Tabs $ 7.07 Lisinopril 10 Mg Po Tabs $ 114.05 Lisinopril 10 Mg Po Tabs $ 7.11 Lisinopril 5 Mg Po Tabs $ 0.56 Lisinopril 5 Mg Po Tabs $ 6.88 Lithium Carbonate Er 300 Mg Po Tbcr $ 3.32 Lithium Carbonate Er 450 Mg Po Tbcr $ 3.84 Lithium Carbonate Er 450 Mg Po Tbcr $ 3.58 Loratadine 10 Mg Po Tabs $ 6.61 Loratadine 10 Mg Po Tabs $ 1.31 Loratadine 10 Mg Po Tabs $ 0.50 Olanzapine 2.5Mg (1/2 X 5Mg) Tbdp $ 51.03 Melphalan Hcl 50 Mg Iv Solr $ 1,634.40 Melphalan 2 Mg Po Tabs $ 97.13 Mercaptopurine 50 Mg Po Tabs $ 29.24 Mercaptopurine 50 Mg Po Tabs $ 58.52 Mesalamine Er 250 Mg Po Cpcr $ 26.05 Ethacrynic Acid 25 Mg Po Tabs $ 209.72 Metformin Hcl 500 Mg Po Tabs $ 5.03 Metformin Hcl 500 Mg Po Tabs $ 0.27 Metformin Hcl 500 Mg Po Tabs $ 0.34 Methimazole 10 Mg Po Tabs $ 5.49 Methimazole 10 Mg Po Tabs $ 5.49 Methimazole 5 Mg Po Tabs $ 3.17 Methohexital Sodium 0.5 G Ij Solr $ 608.39 Methylergonovine Maleate 0.2 Mg Po Tabs $ 533.80 Methylergonovine Maleate 0.2 Mg Po Tabs $ 480.42 Methylergonovine Maleate 0.2 Mg Po Tabs $ 507.11 Methylprednisolone Sodium Succ 2000 Mg Ij Solr $ 713.07 Methylprednisolone Sodium Succ 500 Mg Ij Solr $ 198.34 Metolazone 2.5 Mg Po Tabs $ 18.43 Metolazone 2.5 Mg Po Tabs $ 14.82 Metolazone 5 Mg Po Tabs $ 26.67 Metoprolol Xl Tbcr 100 Mg Or $ 11.33 Metoprolol Xl Tbcr 100 Mg Or $ 11.33 Metoprolol Xl Tbcr 100 Mg Or $ 13.33 Metoprolol Xl Tbcr 50 Mg Or $ 7.97 Metoprolol Xl Tbcr 50 Mg Or $ 7.54 Metoprolol Xl Tbcr 50 Mg Or $ 7.54 Metoprolol Xl Tbcr 50 Mg Or $ 8.86 Metoprolol Xl Tbcr 50 Mg Or $ 7.97 Mexiletine Hcl 150 Mg Po Caps $ 18.13 Topiramate 25 Mg Tab For Qsymia Discontinuation $ 18.27 Midodrine Hcl 5 Mg Po Tabs $ 17.37 Midodrine Hcl 5 Mg Po Tabs $ 17.29 Midodrine Hcl 5 Mg Po Tabs $ 29.72 Misoprostol 100 Mcg Po Tabs $ 7.01 Misoprostol 100 Mcg Po Tabs $ 5.89 Misoprostol 200 Mcg Po Tabs $ 13.73 Misoprostol 200 Mcg Po Tabs $ 10.22 Misoprostol 200 Mcg Po Tabs $ 8.58 Mitomycin 20 Mg Iv Solr $ 3,213.50 Mitomycin 5 Mg Iv Solr $ 1,236.97

Page 17 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Fluticasone Furoate 200 Mcg/Act In Aepb $ 66.45 Fluticasone Furoate 200 Mcg/Act In Aepb $ 66.46 Glycerin (Laxative) 1 G Pr Supp $ 6.03 Nabumetone 500 Mg Po Tabs $ 5.89 Nabumetone 500 Mg Po Tabs $ 9.84 Nabumetone 500 Mg Po Tabs $ 9.55 Atazanavir Sulfate 150 Mg Po Caps $ 209.24 Nicotine Polacrilex 2 Mg Mt Gum $ 2.82 Nicotine Polacrilex 2 Mg Mt Gum $ 2.02 Nicotine Polacrilex 2 Mg Mt Gum $ 2.02 Dabigatran Etexilate Mesylate 75 Mg Po Caps $ 57.28 Dabigatran Etexilate Mesylate 75 Mg Po Caps $ 61.86 Nimodipine 30 Mg Po Caps $ 133.74 Nimodipine 30 Mg Po Caps $ 133.71 Diphenoxylate-Atropine 1.25-0.0125 (1/2 X 2.5-0.025) Mg Po Tabs $ 2.50 Mirtazapine 3.75 Mg (1/2 X 7.5 Mg) Po Tabs $ 9.42 Mirtazapine 3.75 Mg (1/2 X 7.5 Mg) Po Tabs $ 18.83 Paroxetine Hcl 20 Mg Po Tabs $ 55.15 Paroxetine Hcl 20 Mg Po Tabs $ 19.54 Paroxetine Hcl 20 Mg Po Tabs $ 19.54 Paroxetine Hcl 20 Mg Po Tabs $ 18.90 Paroxetine Hcl 20 Mg Po Tabs $ 21.00 Paroxetine Hcl 30 Mg Po Tabs $ 19.51 Paroxetine Hcl 30 Mg Po Tabs $ 20.12 Paroxetine Hcl 30 Mg Po Tabs $ 20.13 Paroxetine Hcl 30 Mg Po Tabs $ 20.13 Paroxetine Hcl 30 Mg Po Tabs $ 19.51 Phenoxybenzamine Hcl 10 Mg Po Caps $ 925.53 Phentolamine Mesylate 5 Mg Ij Solr $ 2,428.86 Phentolamine Mesylate 5 Mg Ij Solr $ 2,428.81 Phenytoin 50 Mg Po Chew $ 5.61 Phenytoin 50 Mg Po Chew $ 8.41 Phenytoin Sodium Extended 30 Mg Po Caps $ 9.60 Pimozide 2 Mg Po Tabs $ 20.16 Bupropion Hcl 37.5 Mg (1/2 X 75 Mg) Po Tabs $ 4.26 Bupropion Hcl 37.5 Mg (1/2 X 75 Mg) Po Tabs $ 5.68 Potassium & Sodium Phosphates 280-160-250 Mg Po Pack $ 4.67 Potassium & Sodium Phosphates 280-160-250 Mg Po Pack $ 4.67 Pravastatin Sodium 40 Mg Po Tabs $ 34.28 Pravastatin Sodium 40 Mg Po Tabs $ 34.28 Primidone 50 Mg Po Tabs $ 3.54 Primidone 50 Mg Po Tabs $ 3.54 Procarbazine Hcl 50 Mg Po Caps $ 840.15 Prochlorperazine 25 Mg Pr Supp $ 87.64 Promethazine Hcl 12.5 Mg Pr Supp $ 126.59 Promethazine Hcl 12.5 Mg Pr Supp $ 126.59 Promethazine Hcl 25 Mg Pr Supp $ 31.80 Promethazine Hcl 25 Mg Pr Supp $ 80.38 Propafenone Hcl 150 Mg Po Tabs $ 11.70 Propafenone Hcl 150 Mg Po Tabs $ 6.71 Propafenone Hcl 150 Mg Po Tabs $ 6.71 Propafenone Hcl 150 Mg Po Tabs $ 11.70 Propafenone Hcl 150 Mg Po Tabs $ 11.70 Interlink Secondary Infusion Set $ 6.29 Epoprostenol Sodium 1.5 Mg Iv Solr $ 401.90 Epoprostenol Sodium 1.5 Mg Iv Solr $ 387.32 Lacosamide 100 Mg Po Tabs $ 135.97 Hydrocortisone 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.00 Hydrocortisone 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.42 Pyridostigmine Bromide 60 Mg Po Tabs $ 10.60 Pyridostigmine Bromide 60 Mg Po Tabs $ 10.58

Page 18 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Pyridostigmine Bromide 60 Mg Po Tabs $ 9.12 Pyridostigmine Bromide Er 180 Mg Po Tbcr $ 177.38 Quinapril Hcl 10 Mg Po Tabs $ 8.74 Quinapril Hcl 10 Mg Po Tabs $ 41.56 Quinapril Hcl 10 Mg Po Tabs $ 8.74 Fosinopril Sodium 5 Mg (1/2 X 10 Mg) Po Tabs $ 4.26 Fosinopril Sodium 5 Mg (1/2 X 10 Mg) Po Tabs $ 7.24 Aminocaproic Acid 500 Mg Po Tabs $ 174.68 Ramipril 2.5 Mg Po Caps $ 1.26 Ramipril 2.5 Mg Po Caps $ 12.91 Ramipril 2.5 Mg Po Caps $ 12.91 Ramipril 5 Mg Po Caps $ 13.55 Ramipril 5 Mg Po Caps $ 1.42 Ramipril 5 Mg Po Caps $ 1.42 Ramipril 5 Mg Po Caps $ 13.55 Riluzole 50 Mg Po Tabs $ 296.87 Riluzole 50 Mg Po Tabs $ 264.12 Rifampin 600 Mg Iv Solr $ 972.79 Rifampin 150 Mg Po Caps $ 23.18 Rifampin 150 Mg Po Caps $ 11.18 Rifampin 150 Mg Po Caps $ 11.28 Rifampin 300 Mg Po Caps $ 46.96 Rifampin 300 Mg Po Caps $ 21.73 Rifampin 300 Mg Po Caps $ 9.75 Rifampin 300 Mg Po Caps $ 9.49 Selegiline Hcl 5 Mg Po Tabs $ 21.18 Selegiline Hcl 5 Mg Po Tabs $ 15.03 Sennosides 8.6 Mg Po Tabs $ 0.35 Sennosides 8.6 Mg Po Tabs $ 0.24 Sennosides 8.6 Mg Po Tabs $ 0.34 Sennosides 8.6 Mg Po Tabs $ 1.50 Sennosides 8.6 Mg Po Tabs $ 0.17 Sennosides 8.6 Mg Po Tabs $ 0.72 Sennosides 8.6 Mg Po Tabs $ 0.18 Sennosides 8.6 Mg Po Tabs $ 0.18 Sennosides 8.6 Mg Po Tabs $ 0.14 Sertraline Hcl 100 Mg Po Tabs $ 20.38 Sertraline Hcl 100 Mg Po Tabs $ 20.33 Sertraline Hcl 100 Mg Po Tabs $ 20.36 Sertraline Hcl 100 Mg Po Tabs $ 20.38 Sertraline Hcl 100 Mg Po Tabs $ 20.36 Sertraline Hcl 50 Mg Po Tabs $ 20.38 Simvastatin 10 Mg Po Tabs $ 20.16 Simvastatin 10 Mg Po Tabs $ 20.11 Simvastatin 20 Mg Po Tabs $ 35.19 Simvastatin 20 Mg Po Tabs $ 35.05 Simvastatin 20 Mg Po Tabs $ 69.15 Simvastatin 40 Mg Po Tabs $ 35.19 Simvastatin 40 Mg Po Tabs $ 35.19 Simvastatin 40 Mg Po Tabs $ 35.05 Simvastatin 5 Mg Po Tabs $ 1.76 Simvastatin 5 Mg Po Tabs $ 20.14 Simvastatin 5 Mg Po Tabs $ 14.99 Sincalide 5 Mcg Ij Solr $ 868.04 Sincalide 5 Mcg Ij Solr $ 786.50 Fluticasone Furoate-Vilanterol 100-25 Mcg/Inh In Aepb $ 41.46 Sotalol Hcl 80 Mg Po Tabs $ 18.32 Sotalol Hcl 80 Mg Po Tabs $ 16.78 Spironolactone 100 Mg Po Tabs $ 10.19 Spironolactone 100 Mg Po Tabs $ 10.56 Streptozocin 1 G Iv Solr $ 543.98

Page 19 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Succimer 100 Mg Po Caps $ 70.72 Sucralfate 1 G Po Tabs $ 5.73 Sucralfate 1 G Po Tabs $ 2.72 Temazepam 7.5 Mg Po Caps $ 41.33 Temazepam 7.5 Mg Po Caps $ 33.82 Alteplase 1Mg/Ml For Neurosurgery Intraventricular $ 1,313.24 Tobramycin Sulfate 1.2 G Ij Solr $ 953.40 Tobramycin Sulfate 1.2 G Ij Solr $ 1,430.00 Estradiol 0.5 Mg Po Tabs $ 3.94 Tranylcypromine Sulfate 10 Mg Po Tabs $ 48.13 Ursodiol 300 Mg Po Caps $ 68.53 Ursodiol 300 Mg Po Caps $ 52.56 Vancomycin Hcl 10 G Iv Solr $ 1,157.70 Vancomycin Hcl 10 G Iv Solr $ 1,157.70 Vancomycin Hcl 10 G Iv Solr $ 354.00 Vecuronium Bromide 10 Mg Iv Solr $ 62.03 Vecuronium Bromide 10 Mg Iv Solr $ 72.93 Vecuronium Bromide 10 Mg Iv Solr $ 54.05 Vecuronium Bromide 10 Mg Iv Solr $ 42.90 Vecuronium Bromide 10 Mg Iv Solr $ 42.90 Vecuronium Bromide 10 Mg Iv Solr $ 54.05 Vecuronium Bromide 10 Mg Iv Solr $ 44.62 Vecuronium Bromide 20 Mg Iv Solr $ 85.80 Warfarin Sodium 1 Mg Po Tabs $ 4.35 Warfarin Sodium 1 Mg Po Tabs $ 17.69 Warfarin Sodium 1 Mg Po Tabs $ 4.17 Fluorescein Sodium 0.6 Mg Op Strp $ 1.07 Zolpidem Tartrate 5 Mg Po Tabs $ 33.03 Zolpidem Tartrate 5 Mg Po Tabs $ 33.03 Ph Test Vi Test $ 284.43 Haemophilus B Polysac Conj Vac Im Solr $ 23.01 Haemophilus B Polysac Conj Vac Im Solr $ 23.01 Beneprotein Po Pack $ 4.83 Meclizine Hcl 12.5 Mg Po Tabs $ 0.66 Meclizine Hcl 12.5 Mg Po Tabs $ 2.33 Meclizine Hcl 12.5 Mg Po Tabs $ 0.26 Meclizine Hcl 25 Mg Po Tabs $ 2.87 T.E.D. Knee Length 2X-Large $ 69.57 Quinidine Gluconate Er 324 Mg Po Tbcr $ 64.80 Venlafaxine Hcl 50 Mg Po Tabs $ 14.74 Onabotulinumtoxina 100 Units Ij Solr $ 3,274.25 Carbidopa-Levodopa Er 25-100 Mg Po Tbcr $ 5.97 Carbidopa-Levodopa Er 25-100 Mg Po Tbcr $ 6.66 Carbidopa-Levodopa Er 25-100 Mg Po Tbcr $ 5.97 Carbidopa-Levodopa Er 25-100 Mg Po Tbcr $ 6.66 Potassium Chloride Er 10 Meq Po Tb Cr $ 4.65 Potassium Chloride Er 10 Meq Po Tb Cr $ 4.65 Rasagiline Mesylate 1 Mg Po Tabs $ 105.50 Pilocarpine Hcl 5 Mg Po Tabs $ 12.97 Pilocarpine Hcl 5 Mg Po Tabs $ 21.46 Pilocarpine Hcl 5 Mg Po Tabs $ 21.45 Tacrolimus 1 Mg Po Caps $ 31.89 Tacrolimus 1 Mg Po Caps $ 31.89 Tacrolimus 1 Mg Po Caps $ 31.89 Tacrolimus 5 Mg Po Caps $ 159.43 Verapamil Hcl Er 240 Mg Po Tbcr $ 11.70 Verapamil Hcl Er 240 Mg Po Tbcr $ 13.28 Verapamil Hcl Er 240 Mg Po Tbcr $ 18.58 Verapamil Hcl Er 240 Mg Po Tbcr $ 11.70 Verapamil Hcl Er 240 Mg Po Tbcr $ 75.93 Lisinopril 2.5 Mg Po Tabs $ 4.69

Page 20 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Lisinopril 2.5 Mg Po Tabs $ 4.63 Valacyclovir Hcl 1 G Po Tabs $ 90.39 Valacyclovir Hcl 500 Mg Po Tabs $ 51.65 Valacyclovir Hcl 500 Mg Po Tabs $ 51.65 Valacyclovir Hcl 500 Mg Po Tabs $ 51.65 Verapamil Hcl Er 120 Mg Po Tbcr $ 7.67 Verapamil Hcl Er 120 Mg Po Tbcr $ 52.37 Sargramostim 250 Mcg Ij Solr $ 1,500.78 Fluvoxamine Maleate 25 Mg Po Tabs $ 16.45 Leucovorin Calcium 1.25 Mg (1/4 X 5 Mg) Po Tabs $ 3.63 Chlorpromazine Hcl 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 5.21 Midodrine Hcl 10 Mg Po Tabs $ 12.09 Midodrine Hcl 10 Mg Po Tabs $ 35.59 Midodrine Hcl 10 Mg Po Tabs $ 69.50 Aspirin Ec 325 Mg Po Tbec $ 0.11 Aspirin Ec 325 Mg Po Tbec $ 0.16 Aspirin Ec 325 Mg Po Tbec $ 0.28 Prasugrel Hcl 5 Mg Po Tabs $ 131.27 Prasugrel Hcl 5 Mg Po Tabs $ 131.27 Vivonex Pediatric Po Pack $ 42.97 Lamotrigine 25 Mg Po Tabs $ 29.67 Lamotrigine 25 Mg Po Tabs $ 32.51 Lamotrigine 100 Mg Po Tabs $ 36.77 Lamotrigine 100 Mg Po Tabs $ 37.14 Lamotrigine 100 Mg Po Tabs $ 1.64 Lamotrigine 200 Mg Po Tabs $ 40.42 Lamotrigine 200 Mg Po Tabs $ 44.31 Lamotrigine 200 Mg Po Tabs $ 43.87 Donepezil Hcl 10 Mg Po Tabs $ 61.88 Aspirin Ec 81 Mg Po Tbec $ 0.34 Aspirin Ec 81 Mg Po Tbec $ 0.36 Aspirin Ec 81 Mg Po Tbec $ 0.10 Aspirin Ec 81 Mg Po Tbec $ 0.15 Aspirin Ec 81 Mg Po Tbec $ 0.43 Aspirin Ec 81 Mg Po Tbec $ 0.05 Aspirin Ec 81 Mg Po Tbec $ 0.11 Aspirin Ec 81 Mg Po Tbec $ 0.31 Aspirin Ec 81 Mg Po Tbec $ 0.05 Aspirin Ec 81 Mg Po Tbec $ 0.05 Alteplase Inj Bolus For Cardiac Arrest With Pe $ 23,972.20 Lamotrigine 150 Mg Po Tabs $ 137.19 Lamotrigine 150 Mg Po Tabs $ 40.70 Lamotrigine 150 Mg Po Tabs $ 40.30 Clonidine 0.3 Mg/24Hr Td Ptwk $ 553.12 Clonidine 0.3 Mg/24Hr Td Ptwk $ 553.75 Clonidine 0.3 Mg/24Hr Td Ptwk $ 553.75 Terazosin Hcl 1 Mg Po Caps $ 11.47 Terazosin Hcl 1 Mg Po Caps $ 11.48 Terazosin Hcl 5 Mg Po Caps $ 11.48 Verapamil Hcl Er 180 Mg Po Tbcr $ 10.30 Verapamil Hcl Er 180 Mg Po Tbcr $ 10.30 Tramadol Hcl 50 Mg Po Tabs $ 0.61 Tramadol Hcl 50 Mg Po Tabs $ 5.99 Tramadol Hcl 50 Mg Po Tabs $ 6.23 Tramadol Hcl 50 Mg Po Tabs $ 5.99 Tramadol Hcl 50 Mg Po Tabs $ 5.69 Tramadol Hcl 50 Mg Po Tabs $ 5.69 Metformin Hcl 850 Mg Po Tabs $ 8.58 Metformin Hcl 850 Mg Po Tabs $ 8.56 Metformin Hcl 850 Mg Po Tabs $ 0.51 Granisetron Hcl 1 Mg Po Tabs $ 421.92

Page 21 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Varicella Virus Vaccine Live 1350 Pfu/0.5Ml Subq Inj $ 190.38 Glyburide Micronized 1.5 Mg Po Tabs $ 0.94 Glyburide Micronized 3 Mg Po Tabs $ 25.94 Glyburide Micronized 3 Mg Po Tabs $ 4.33 Losartan Potassium 25 Mg Po Tabs $ 4.98 Losartan Potassium 25 Mg Po Tabs $ 12.03 Losartan Potassium 25 Mg Po Tabs $ 12.87 Losartan Potassium 50 Mg Po Tabs $ 16.16 Losartan Potassium 50 Mg Po Tabs $ 5.79 Losartan Potassium 50 Mg Po Tabs $ 16.18 Losartan Potassium 50 Mg Po Tabs $ 16.18 Losartan Potassium 50 Mg Po Tabs $ 16.09 Losartan Potassium 50 Mg Po Tabs $ 16.09 Losartan Potassium 50 Mg Po Tabs $ 31.83 Losartan Potassium 50 Mg Po Tabs $ 16.07 Losartan Potassium 50 Mg Po Tabs $ 31.83 Sorbsan Wound Dressing Ex Pads $ 127.43 Losartan Potassium-Hctz 50-12.5 Mg Po Tabs $ 16.35 Losartan Potassium-Hctz 50-12.5 Mg Po Tabs $ 35.18 Losartan Potassium-Hctz 50-12.5 Mg Po Tabs $ 17.89 Thioguanine 20 Mg (1/2 X 40 Mg) Po Tabs $ 53.88 Mycophenolate Mofetil 250 Mg Po Caps $ 28.36 Mycophenolate Mofetil 250 Mg Po Caps $ 28.05 Mycophenolate Mofetil 250 Mg Po Caps $ 6.71 Mycophenolate Mofetil 250 Mg Po Caps $ 28.56 Ondansetron Hcl 2 Mg (1/2 X 4 Mg) Po Tabs $ 84.51 Ondansetron Hcl 2 Mg (1/2 X 4 Mg) Po Tabs $ 88.59 Tramadol Hcl Er 200 Mg Po Tb24 $ 43.03 Sumatriptan Succinate 25 Mg Po Tabs $ 61.41 Sumatriptan Succinate 50 Mg Po Tabs $ 179.75 Sumatriptan Succinate 50 Mg Po Tabs $ 179.75 Sumatriptan Succinate 50 Mg Po Tabs $ 179.76 Diclofenac Sodium 25 Mg Po Tbec $ 10.17 Diclofenac Sodium 25 Mg Po Tbec $ 10.17 Diclofenac Sodium 75 Mg Po Tbec $ 12.68 Diclofenac Sodium 75 Mg Po Tbec $ 10.33 Desmopressin Acetate 0.2 Mg Po Tabs $ 10.10 Ranolazine Er 500 Mg Po Tb12 $ 53.53 Ranolazine Er 500 Mg Po Tb12 $ 50.86 Pioglitazone Hcl 15 Mg Po Tabs $ 50.09 Pioglitazone Hcl 15 Mg Po Tabs $ 50.09 Lamivudine 150 Mg Po Tabs $ 51.20 Guanfacine Hcl 1 Mg Po Tabs $ 6.23 Clonidine 0.1 Mg/24Hr Td Ptwk $ 236.83 Clonidine 0.1 Mg/24Hr Td Ptwk $ 237.08 Clonidine 0.1 Mg/24Hr Td Ptwk $ 237.08 Clonidine 0.1 Mg/24Hr Td Ptwk $ 236.83 Measles, Mumps & Rubella Vac Ij Solr $ 671.84 Tretinoin 10 Mg Po Caps $ 267.07 Tretinoin 10 Mg Po Caps $ 213.66 Saquinavir Mesylate 200 Mg Po Caps $ 37.37 Chlorthalidone 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 1.97 Chlorthalidone 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 16.41 Desmopressin Acetate 0.1 Mg Po Tabs $ 21.59 Desmopressin Acetate 0.1 Mg Po Tabs $ 21.45 Desmopressin Acetate 0.1 Mg Po Tabs $ 21.45 Desmopressin Acetate 0.1 Mg Po Tabs $ 9.00 Aclidinium Bromide 400 Mcg/Act In Aepb $ 479.11 Xeroform Petrolatum Dressing Ex Pads 5X9 $ 7.50 Sevelamer Carbonate 0.8 G Po Pack $ 145.29 Goserelin Acetate 10.8 Mg Subq Impl $ 9,888.12

Page 22 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Glimepiride 1 Mg Po Tabs $ 2.87 Glimepiride 2 Mg Po Tabs $ 4.65 Glimepiride 4 Mg Po Tabs $ 8.78 Valganciclovir Hcl 450 Mg Po Tabs $ 460.44 Quikclot Control Zfold 3In X 2Yards Hemostat Dressing $ 1,134.85 Mepolizumab 100 Mg Subq Solr $ 16,097.39 Cosyntropin 0.25 Mg Ij Solr $ 914.46 Paroxetine Hcl 10 Mg Po Tabs $ 20.12 Paroxetine Hcl 10 Mg Po Tabs $ 18.73 Indinavir Sulfate 400 Mg Po Caps $ 21.77 Ramelteon 8 Mg Po Tabs $ 105.70 Mycophenolate Sodium 360 Mg Po Tbec $ 92.86 Hyoscyamine Sulfate Er 0.375 Mg Po Tb12 $ 7.06 Gemcitabine Hcl 200 Mg Iv Solr $ 106.13 Gemcitabine Hcl 200 Mg Iv Solr $ 353.76 Gemcitabine Hcl 200 Mg Iv Solr $ 84.46 Gemcitabine Hcl 1 G Iv Solr $ 530.64 Gemcitabine Hcl 1 G Iv Solr $ 433.36 Topotecan Hcl 4 Mg Iv Solr $ 1,280.28 Topotecan Hcl 4 Mg Iv Solr $ 1,061.28 Meropenem 500 Mg Iv Solr $ 85.80 Meropenem 1 G Iv Solr $ 102.96 Meropenem 1 G Iv Solr $ 94.38 Meropenem 1 G Iv Solr $ 371.80 B Complex Po Caps $ 0.29 Mirtazapine 15 Mg Po Tabs $ 19.41 Mirtazapine 15 Mg Po Tabs $ 19.41 Mirtazapine 15 Mg Po Tabs $ 19.31 Mirtazapine 15 Mg Po Tabs $ 19.41 Mirtazapine 15 Mg Po Tabs $ 20.44 Olanzapine 5 Mg Po Tabs $ 94.49 Olanzapine 5 Mg Po Tabs $ 94.49 Olanzapine 5 Mg Po Tabs $ 94.49 Olanzapine 5 Mg Po Tabs $ 94.49 Olanzapine 10 Mg Po Tabs $ 142.39 Olanzapine 10 Mg Po Tabs $ 142.39 Olanzapine 10 Mg Po Tabs $ 142.41 Olanzapine 10 Mg Po Tabs $ 132.45 Olanzapine 10 Mg Po Tabs $ 142.39 Olanzapine 7.5 Mg Po Tabs $ 114.99 Zafirlukast 20 Mg Po Tabs $ 21.39 Zafirlukast 20 Mg Po Tabs $ 14.64 Omeprazole 40 Mg Po Cpdr $ 52.87 Omeprazole 40 Mg Po Cpdr $ 52.88 Omeprazole 40 Mg Po Cpdr $ 52.88 Omeprazole 40 Mg Po Cpdr $ 52.87 Fenofibrate 54 Mg Po Tabs $ 5.66 Fenofibrate 54 Mg Po Tabs $ 5.66 Fenofibrate 160 Mg Po Tabs $ 16.99 Fenofibrate 160 Mg Po Tabs $ 16.99 Fenofibrate 160 Mg Po Tabs $ 20.59 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 117.84 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 111.54 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 111.54 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 117.84 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 117.84 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 67.93 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 67.93 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 150.67 Piperacillin Sod-Tazobactam So 4.5 (4-0.5) G Iv Solr $ 150.67 Piperacillin Sod-Tazobactam So 3.375 (3-0.375) G Iv Solr $ 88.38

Page 23 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Piperacillin Sod-Tazobactam So 3.375 (3-0.375) G Iv Solr $ 155.55 Piperacillin Sod-Tazobactam So 3.375 (3-0.375) G Iv Solr $ 73.35 Piperacillin Sod-Tazobactam So 3.375 (3-0.375) G Iv Solr $ 155.55 Piperacillin Sod-Tazobactam So 3.375 (3-0.375) G Iv Solr $ 73.35 Gabapentin 400 Mg Po Caps $ 11.46 Gabapentin 300 Mg Po Caps $ 1.33 Gabapentin 300 Mg Po Caps $ 9.57 Gabapentin 300 Mg Po Caps $ 1.40 Gabapentin 100 Mg Po Caps $ 3.83 Risperidone 2 Mg Po Tabs $ 50.47 Risperidone 1 Mg Po Tabs $ 32.48 Risperidone 1 Mg Po Tabs $ 32.55 Bupropion Hcl Er (Sr) 100 Mg Po Tb12 $ 12.08 Bupropion Hcl Er (Sr) 100 Mg Po Tb12 $ 12.08 Bupropion Hcl Er (Sr) 100 Mg Po Tb12 $ 12.08 Bupropion Hcl Er (Sr) 150 Mg Po Tb12 $ 13.85 Bupropion Hcl Er (Sr) 150 Mg Po Tb12 $ 13.85 Sodium Zirconium Cyclosilicate 5 G Po Pack $ 187.32 Remifentanil Hcl 2 Mg Iv Solr $ 1,103.53 Remifentanil Hcl 2 Mg Iv Solr $ 1,051.74 Remifentanil Hcl 2 Mg Iv Solr $ 1,103.56 Pembrolizumab 50 Mg Iv Solr $ 11,933.12 Levofloxacin 250 Mg Po Tabs $ 120.20 Levofloxacin 250 Mg Po Tabs $ 105.29 Levofloxacin 500 Mg Po Tabs $ 120.27 Topiramate 25 Mg Po Tabs $ 18.06 Topiramate 25 Mg Po Tabs $ 15.02 Topiramate 25 Mg Po Tabs $ 15.02 Topiramate 25 Mg Po Tabs $ 15.85 Topiramate 100 Mg Po Tabs $ 43.19 Topiramate 100 Mg Po Tabs $ 49.69 Topiramate 100 Mg Po Tabs $ 44.33 Warfarin Sodium 3 Mg Po Tabs $ 4.70 Warfarin Sodium 3 Mg Po Tabs $ 19.16 Warfarin Sodium 6 Mg Po Tabs $ 25.60 Gelatin Adsorbable Op Film $ 1,219.16 Oxycodone-Acetaminophen 2.5-162.5 Mg (1/2 X 5-325) Po Tabs $ 5.28 Hydroxyzine Hcl 25 Mg Po Tabs $ 6.54 Hydroxyzine Hcl 25 Mg Po Tabs $ 6.58 Hydroxyzine Hcl 25 Mg Po Tabs $ 2.32 Carbidopa-Levodopa 10-100 Mg Po Tabs $ 8.92 Carbidopa-Levodopa 10-100 Mg Po Tabs $ 5.07 Carbidopa-Levodopa 25-100 Mg Po Tabs $ 9.06 Carbidopa-Levodopa 25-100 Mg Po Tabs $ 6.23 Carbidopa-Levodopa 25-100 Mg Po Tabs $ 4.27 Carbidopa-Levodopa 25-100 Mg Po Tabs $ 10.04 Carbidopa-Levodopa 25-250 Mg Po Tabs $ 7.94 Methylprednisolone Sodium Succ 125 Mg Ij Solr $ 83.12 Methylprednisolone Sodium Succ 40 Mg Ij Solr $ 51.62 Methylprednisolone Sodium Succ 40 Mg Ij Solr $ 51.62 Risperidone Microspheres Er 37.5 Mg Im Srer $ 3,961.56 Tizanidine Hcl 4 Mg Po Tabs $ 10.47 Tizanidine Hcl 4 Mg Po Tabs $ 10.47 Tizanidine Hcl 4 Mg Po Tabs $ 10.47 Atorvastatin Calcium 10 Mg Po Tabs $ 28.94 Atorvastatin Calcium 10 Mg Po Tabs $ 28.91 Atorvastatin Calcium 20 Mg Po Tabs $ 41.28 Atorvastatin Calcium 20 Mg Po Tabs $ 41.23 Atorvastatin Calcium 20 Mg Po Tabs $ 39.31 Atorvastatin Calcium 20 Mg Po Tabs $ 38.83 Sertraline Hcl 25 Mg Po Tabs $ 20.36

Page 24 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Sertraline Hcl 25 Mg Po Tabs $ 20.38 Nelfinavir Mesylate 250 Mg Po Tabs $ 34.72 Therapeutic-M Po Tabs $ 0.77 Therapeutic-M Po Tabs $ 0.34 Interlink Primary Infusion Set $ 14.09 Peginterferon Alfa-2B 200 Mcg Subq Kit $ 10,788.36 Pantoprazole Sodium 40 Mg Po Tbec $ 37.66 Pantoprazole Sodium 40 Mg Po Tbec $ 37.66 Pantoprazole Sodium 40 Mg Po Tbec $ 29.25 Pantoprazole Sodium 40 Mg Po Tbec $ 3.10 Azithromycin 250 Mg Po Tabs $ 55.66 Azithromycin 250 Mg Po Tabs $ 55.59 Azithromycin 250 Mg Po Tabs $ 55.66 Azithromycin 250 Mg Po Tabs $ 55.66 Olanzapine 2.5 Mg Po Tabs $ 80.06 Olanzapine 2.5 Mg Po Tabs $ 80.06 Olanzapine 2.5 Mg Po Tabs $ 80.07 Olanzapine 2.5 Mg Po Tabs $ 80.06 Olanzapine 2.5 Mg Po Tabs $ 74.49 Pramipexole Dihydrochloride 0.125 Mg Po Tabs $ 23.90 Pramipexole Dihydrochloride 0.125 Mg Po Tabs $ 23.17 Pramipexole Dihydrochloride 1 Mg Po Tabs $ 23.90 Pramipexole Dihydrochloride 1 Mg Po Tabs $ 23.17 Pramipexole Dihydrochloride 0.25 Mg Po Tabs $ 23.90 Pentoxifylline Er 400 Mg Po Tbcr $ 8.16 Pentoxifylline Er 400 Mg Po Tbcr $ 10.71 Warfarin Sodium 4 Mg Po Tabs $ 4.71 Warfarin Sodium 4 Mg Po Tabs $ 19.16 Warfarin Sodium 4 Mg Po Tabs $ 19.17 Mycophenolate Mofetil 500 Mg Po Tabs $ 56.11 Mycophenolate Mofetil 500 Mg Po Tabs $ 56.86 Mycophenolate Mofetil 500 Mg Po Tabs $ 56.67 Apraclonidine Hcl 1 % Op Soln $ 237.90 Torsemide 5 Mg Po Tabs $ 4.53 Finasteride 5 Mg Po Tabs $ 22.26 Finasteride 5 Mg Po Tabs $ 22.35 Finasteride 5 Mg Po Tabs $ 22.36 Mitotane 500 Mg Po Tabs $ 41.18 Bicalutamide 50 Mg Po Tabs $ 132.70 Bicalutamide 50 Mg Po Tabs $ 131.23 Bicalutamide 50 Mg Po Tabs $ 117.72 Anastrozole 1 Mg Po Tabs $ 95.12 Anastrozole 1 Mg Po Tabs $ 14.81 Anastrozole 1 Mg Po Tabs $ 14.82 Atorvastatin Calcium 40 Mg Po Tabs $ 41.28 Atorvastatin Calcium 40 Mg Po Tabs $ 39.32 Atorvastatin Calcium 40 Mg Po Tabs $ 39.32 Atorvastatin Calcium 40 Mg Po Tabs $ 41.23 Atorvastatin Calcium 40 Mg Po Tabs $ 41.28 Atorvastatin Calcium 40 Mg Po Tabs $ 39.27 Anagrelide Hcl 0.5 Mg Po Caps $ 79.82 Anagrelide Hcl 0.5 Mg Po Caps $ 79.82 Imiquimod 5 % Ex Crea $ 53.63 Trihexyphenidyl Hcl .5 Mg (1/4 X 2 Mg) Po Tabs $ 0.33 Azithromycin 500 Mg Iv Solr $ 30.03 Azithromycin 500 Mg Iv Solr $ 51.48 Azithromycin 500 Mg Iv Solr $ 63.75 Azithromycin 500 Mg Iv Solr $ 78.65 Azithromycin 500 Mg Iv Solr $ 42.90 B-Complex/Vitamin C Po Tabs $ 0.51 B-Complex/Vitamin C Po Tabs $ 0.37

Page 25 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

B-Complex/Vitamin C Po Tabs $ 0.38 Amphetamine-Dextroamphetamine 5 Mg Po Tabs $ 14.71 Amphetamine-Dextroamphetamine 5 Mg Po Tabs $ 12.26 Prednisone 0.25 Mg (1/4 X 1 Mg) Po Tabs $ 0.45 Tramadol Hcl Er 100 Mg Po Tb24 $ 26.02 Ropinirole Hcl 0.25 Mg Po Tabs $ 17.88 Ropinirole Hcl 1 Mg Po Tabs $ 17.88 Ropinirole Hcl 2 Mg Po Tabs $ 17.88 Ropinirole Hcl 0.5 Mg Po Tabs $ 17.88 Quetiapine Fumarate 25 Mg Po Tabs $ 28.57 Quetiapine Fumarate 25 Mg Po Tabs $ 28.57 Quetiapine Fumarate 25 Mg Po Tabs $ 28.57 Quetiapine Fumarate 100 Mg Po Tabs $ 49.03 Quetiapine Fumarate 100 Mg Po Tabs $ 49.03 Quetiapine Fumarate 100 Mg Po Tabs $ 49.03 Quetiapine Fumarate 100 Mg Po Tabs $ 49.03 Quetiapine Fumarate 100 Mg Po Tabs $ 49.03 Quetiapine Fumarate 200 Mg Po Tabs $ 92.50 Quetiapine Fumarate 200 Mg Po Tabs $ 92.50 Quetiapine Fumarate 200 Mg Po Tabs $ 92.56 Tiagabine Hcl 4 Mg Po Tabs $ 56.74 Tiagabine Hcl 4 Mg Po Tabs $ 80.22 Tiagabine Hcl 12 Mg Po Tabs $ 68.30 Pravastatin Sodium 10 Mg Po Tabs $ 22.99 Pravastatin Sodium 10 Mg Po Tabs $ 22.99 Rabies Vaccine, Pcec Im Susr $ 473.15 Raloxifene Hcl 60 Mg Po Tabs $ 50.97 Glyburide Micronized 6 Mg Po Tabs $ 7.69 Carvedilol 6.25 Mg Po Tabs $ 15.28 Carvedilol 6.25 Mg Po Tabs $ 15.28 Carvedilol 25 Mg Po Tabs $ 15.28 Carvedilol 25 Mg Po Tabs $ 15.02 Carvedilol 12.5 Mg Po Tabs $ 15.02 Carvedilol 12.5 Mg Po Tabs $ 15.28 Carvedilol 3.125 Mg Po Tabs $ 14.89 Carvedilol 3.125 Mg Po Tabs $ 15.28 Icaps Lutein & Zeaxanthin Po Tbec $ 1.39 Amphotericin B Liposome 50 Mg Iv Susr $ 1,346.43 Clopidogrel Bisulfate 75 Mg Po Tabs $ 49.77 Clopidogrel Bisulfate 75 Mg Po Tabs $ 49.76 Clopidogrel Bisulfate 75 Mg Po Tabs $ 49.76 Lactase 3000 Units Po Tabs $ 0.92 Montelukast Sodium 10 Mg Po Tabs $ 40.45 Montelukast Sodium 10 Mg Po Tabs $ 40.45 Montelukast Sodium 10 Mg Po Tabs $ 34.16 Montelukast Sodium 10 Mg Po Tabs $ 34.16 Montelukast Sodium 10 Mg Po Tabs $ 40.44 Montelukast Sodium 10 Mg Po Tabs $ 35.95 Repaglinide 0.5 Mg Po Tabs $ 4.83 Repaglinide 1 Mg Po Tabs $ 4.83 Oxycodone Hcl 5 Mg Po Tabs $ 3.87 Oxycodone Hcl 5 Mg Po Tabs $ 2.63 Oxycodone Hcl 5 Mg Po Tabs $ 3.96 Oxycodone Hcl 5 Mg Po Tabs $ 3.87 Oxycodone Hcl 5 Mg Po Tabs $ 3.87 Pramipexole Dihydrochloride 0.5 Mg Po Tabs $ 23.90 Pramipexole Dihydrochloride 0.5 Mg Po Tabs $ 23.17 Candesartan Cilexetil 16 Mg Po Tabs $ 21.85 Candesartan Cilexetil 16 Mg Po Tabs $ 22.69 Tolterodine Tartrate 1 Mg Po Tabs $ 23.91 Tolterodine Tartrate 1 Mg Po Tabs $ 23.66

Page 26 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Ezetimibe 10 Mg Po Tabs $ 98.67 Ezetimibe 10 Mg Po Tabs $ 18.70 Ezetimibe 10 Mg Po Tabs $ 80.68 Ezetimibe 10 Mg Po Tabs $ 73.85 Ezetimibe 10 Mg Po Tabs $ 73.51 Micafungin Sodium 100 Mg Iv Solr $ 1,018.78 Progesterone Micronized 100 Mg Po Caps $ 15.02 Losartan Potassium-Hctz 25-6.25 Mg (1/2 X 50-12.5 Mg) Po Tabs $ 8.95 Losartan Potassium-Hctz 25-6.25 Mg (1/2 X 50-12.5 Mg) Po Tabs $ 8.95 Verapamil Hcl Cr 60 Mg (1/2 X 120 Mg) Po Tbcr $ 3.35 Verapamil Hcl Cr 60 Mg (1/2 X 120 Mg) Po Tbcr $ 16.57 Cefdinir 300 Mg Po Caps $ 36.52 Cefdinir 300 Mg Po Caps $ 36.57 T.E.D. Thigh Length/M-Regular Misc $ 96.20 T.E.D. Thigh Length/L-Regular Misc $ 57.02 T.E.D. Thigh Length/S-Regular Misc $ 96.20 T.E.D. Knee Length/S-Regular Misc $ 22.89 T.E.D. Knee Length/M-Regular Misc $ 20.71 T.E.D. Knee Length 3X-Large $ 72.14 T.E.D. Knee Length/Xl-Regular Misc $ 67.34 T.E.D. Knee Length/L-Long Misc $ 22.89 Nitroglycerin 0.1 Mg/Hr Td Pt24 $ 13.29 Canagliflozin 100 Mg Po Tabs $ 141.37 Citalopram Hydrobromide 20 Mg Po Tabs $ 18.33 Citalopram Hydrobromide 20 Mg Po Tabs $ 18.27 Citalopram Hydrobromide 20 Mg Po Tabs $ 18.12 Silver Nitrate-Pot Nitrate 75-25 % Ex Misc $ 5.19 Leuprolide Acetate 3.75 Mg Im Kit $ 7,084.40 Infliximab 100 Mg Iv Solr $ 6,362.27 Leflunomide 10 Mg Po Tabs $ 117.43 Leflunomide 20 Mg Po Tabs $ 42.90 Leflunomide 20 Mg Po Tabs $ 117.43 Mycophenolate Mofetil Hcl 500 Mg Iv Solr $ 926.45 Trastuzumab 440 Mg Iv Solr $ 24,904.81 Cephalexin 250 Mg Po Caps $ 4.96 Cephalexin 500 Mg Po Caps $ 9.84 Megestrol Acetate 10 Mg (1/2 X 20 Mg) Po Tabs $ 2.35 Megestrol Acetate 10 Mg (1/2 X 20 Mg) Po Tabs $ 2.35 Antivenin Latrodectus Mactans Ij Kit $ 237.74 Isosorbide Mononitrate Er 60 Mg Po Tb24 $ 10.19 Ibuprofen 100 Mg (1/2 X 200 Mg) Po Tabs $ 0.24 Leuprolide Acetate 1 Mg/0.2Ml Ij Kit $ 4,045.14 Leuprolide Acetate 1 Mg/0.2Ml Ij Kit $ 1,029.60 Leuprolide Acetate 1 Mg/0.2Ml Ij Kit $ 4,045.14 Leuprolide Acetate 1 Mg/0.2Ml Ij Kit $ 4,045.14 Onabotulinumtoxina 200 Units Ij Solr $ 6,548.50 Thyrotropin Alfa 1.1 Mg Im Solr $ 8,100.88 Thyrotropin Alfa 1.1 Mg Im Solr $ 8,100.88 Thyrotropin Alfa 1.1 Mg Im Solr $ 8,855.72 Octreotide Acetate 20 Mg Im Kit $ 16,989.23 Octreotide Acetate 30 Mg Im Kit $ 28,842.53 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 23.48 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 21.09 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 23.51 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 23.51 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 23.51 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 21.97 Oxybutynin Chloride Er 5 Mg Po Tb24 $ 23.51 Celecoxib 100 Mg Po Caps $ 33.05 Celecoxib 200 Mg Po Caps $ 54.15 Celecoxib 200 Mg Po Caps $ 54.20

Page 27 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Celecoxib 200 Mg Po Caps $ 54.20 Celecoxib 200 Mg Po Caps $ 54.20 Isosorbide Mononitrate Er 30 Mg Po Tb24 $ 7.99 Isosorbide Mononitrate Er 30 Mg Po Tb24 $ 23.97 Streptomycin Sulfate 1 G Im Solr $ 670.31 Belladonna Alkaloids-Opium 16.2-60 Mg Pr Supp $ 239.19 Phenol 89 % Ex Swab $ 39.02 Cilostazol 100 Mg Po Tabs $ 13.05 Cilostazol 100 Mg Po Tabs $ 13.05 Tacrolimus 0.5 Mg Po Caps $ 15.94 Ritonavir 100 Mg Po Tabs $ 66.19 Ritonavir 100 Mg Po Tabs $ 73.55 Hyoscyamine Sulfate 0.125 Mg Sl Subl $ 7.84 Sacubitril-Valsartan 97-103 Mg Po Tabs $ 72.80 Sacubitril-Valsartan 49-51 Mg Po Tabs $ 72.80 Sacubitril-Valsartan 24-26 Mg Po Tabs $ 72.80 Methylprednisolone Sodium Succ 1000 Mg Ij Solr For Ards $ 359.43 Risperidone 0.25 Mg Po Tabs $ 9.35 Risperidone 0.25 Mg Po Tabs $ 27.89 Risperidone 0.5 Mg Po Tabs $ 10.26 Risperidone 0.5 Mg Po Tabs $ 30.61 Pioglitazone Hcl 30 Mg Po Tabs $ 76.55 Pioglitazone Hcl 30 Mg Po Tabs $ 76.55 Pioglitazone Hcl 45 Mg Po Tabs $ 14.73 Pioglitazone Hcl 45 Mg Po Tabs $ 83.06 Pioglitazone Hcl 45 Mg Po Tabs $ 83.03 Pioglitazone Hcl 45 Mg Po Tabs $ 83.03 Sennosides-Docusate Sodium 8.6-50 Mg Po Tabs $ 0.92 Sennosides-Docusate Sodium 8.6-50 Mg Po Tabs $ 0.64 Sennosides-Docusate Sodium 8.6-50 Mg Po Tabs $ 1.29 Sennosides-Docusate Sodium 8.6-50 Mg Po Tabs $ 0.25 Sennosides-Docusate Sodium 8.6-50 Mg Po Tabs $ 0.29 Dimenhydrinate 25 Mg (1/2 X 50 Mg) Po Tab $ 0.13 Ciprofloxacin Hcl 250 Mg Po Tabs $ 32.85 Alteplase Iv Soln For Ischemic Stroke $ 47,944.35 Ciprofloxacin Hcl 750 Mg Po Tabs $ 54.77 Clorazepate Dipotassium 1.875 Mg (1/2 X 3.75 Mg) Po Tabs $ 4.82 Carbidopa-Levodopa Er 50-200 Mg Po Tbcr $ 12.91 Imiglucerase 400 Units Iv Solr $ 8,945.62 Oseltamivir Phosphate 75 Mg Po Caps $ 110.52 Oseltamivir Phosphate 75 Mg Po Caps $ 110.52 Entacapone 200 Mg Po Tabs $ 32.45 Entacapone 200 Mg Po Tabs $ 28.28 Entacapone 200 Mg Po Tabs $ 32.45 Oxcarbazepine 300 Mg Po Tabs $ 18.77 Oxcarbazepine 300 Mg Po Tabs $ 19.70 Oxcarbazepine 300 Mg Po Tabs $ 19.66 Oxcarbazepine 150 Mg Po Tabs $ 10.40 Oxcarbazepine 150 Mg Po Tabs $ 10.27 Dofetilide 125 Mcg Po Caps $ 89.17 Dofetilide 125 Mcg Po Caps $ 69.67 Dofetilide 250 Mcg Po Caps $ 89.17 Dofetilide 250 Mcg Po Caps $ 61.23 Dofetilide 250 Mcg Po Caps $ 89.17 Dofetilide 250 Mcg Po Caps $ 61.16 Dofetilide 500 Mcg Po Caps $ 89.17 Dofetilide 500 Mcg Po Caps $ 61.16 Ivabradine Hcl 5 Mg Po Tabs $ 63.26 Levetiracetam 250 Mg Po Tabs $ 20.56 Levetiracetam 250 Mg Po Tabs $ 55.23 Levetiracetam 250 Mg Po Tabs $ 20.56

Page 28 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Levetiracetam 500 Mg Po Tabs $ 22.62 Levetiracetam 500 Mg Po Tabs $ 25.13 Levetiracetam 500 Mg Po Tabs $ 5.14 Levetiracetam 500 Mg Po Tabs $ 25.15 Levetiracetam 500 Mg Po Tabs $ 5.14 Levetiracetam 500 Mg Po Tabs $ 25.13 Niacin Er (Antihyperlipidemic) 500 Mg Po Tbcr $ 30.29 Niacin Er (Antihyperlipidemic) 500 Mg Po Tbcr $ 30.26 Levothyroxine Sodium 44 Mcg (1/2 X 88 Mcg) Or Tabs $ 2.00 Levothyroxine Sodium 44 Mcg (1/2 X 88 Mcg) Or Tabs $ 2.00 Rifaximin 550 Mg Po Tabs $ 338.70 Zonisamide 100 Mg Po Caps $ 12.30 Zonisamide 100 Mg Po Caps $ 15.69 Zonisamide 100 Mg Po Caps $ 6.46 Pentamidine Isethionate 300 Mg In Solr $ 909.23 Linezolid 600 Mg Po Tabs $ 1,313.26 Linezolid 600 Mg Po Tabs $ 1,308.45 Rivastigmine Tartrate 1.5 Mg Po Caps $ 30.34 Rivastigmine Tartrate 3 Mg Po Caps $ 30.34 Vancomycin Hcl 1 G Iv Solr $ 136.42 Vancomycin Hcl 1 G Iv Solr $ 51.40 Vancomycin Hcl 1 G Iv Solr $ 51.40 Levonorgestrel 20 Mcg/24Hr Iu Iud $ 5,194.71 Nafcillin Sodium 2 G Ij Solr $ 247.88 Nafcillin Sodium 2 G Ij Solr $ 70.44 Pentamidine Isethionate 300 Mg Ij Solr $ 909.22 Dinoprostone 10 Mg Va Inst $ 2,236.90 Nitroglycerin 0.2 Mg/Hr Td Pt24 $ 13.60 Nitroglycerin 0.2 Mg/Hr Td Pt24 $ 18.56 Nitroglycerin 0.3 Mg/Hr Td Pt24 $ 47.69 Nitroglycerin 0.3 Mg/Hr Td Pt24 $ 179.62 Nitroglycerin 0.4 Mg/Hr Td Pt24 $ 20.80 Nitroglycerin 0.6 Mg/Hr Td Pt24 $ 17.13 Nitroglycerin 0.8 Mg/Hr Td Pt24 $ 51.74 Felodipine Er 2.5 Mg Po Tb24 $ 10.80 Felodipine Er 5 Mg Po Tb24 $ 10.80 Felodipine Er 5 Mg Po Tb24 $ 11.30 Penicillin V Potassium 125 Mg (1/2 X 250 Mg) Po Tabs $ 8.51 Fosfomycin Tromethamine 3 G Po Pack $ 745.75 Tolvaptan 30 Mg Po Tabs $ 2,547.75 Topiramate 15 Mg Po Cpsp $ 17.30 Aspirin-Dipyridamole Er 25-200 Mg Po Cp12 $ 49.51 Aspirin-Dipyridamole Er 25-200 Mg Po Cp12 $ 59.74 Aspirin-Dipyridamole Er 25-200 Mg Po Cp12 $ 60.18 Aspirin-Dipyridamole Er 25-200 Mg Po Cp12 $ 80.64 Fluorescein Sodium 1 Mg Op Strp $ 1.31 Fluorescein Sodium 1 Mg Op Strp $ 1.34 Fluorescein Sodium 1 Mg Op Strp $ 1.61 Voriconazole 100 Mg (1/2 X 200 Mg ) Po Tabs $ 167.69 Voriconazole 100 Mg (1/2 X 200 Mg ) Po Tabs $ 167.69 Omeprazole 20 Mg Po Cpdr $ 22.77 Omeprazole 20 Mg Po Cpdr $ 29.69 Omeprazole 20 Mg Po Cpdr $ 30.75 Omeprazole 20 Mg Po Cpdr $ 31.81 Omeprazole 20 Mg Po Cpdr $ 29.68 Scopolamine 1 Mg/3Days Td Pt72 $ 153.01 Scopolamine 1 Mg/3Days Td Pt72 $ 182.72 Scopolamine 1 Mg/3Days Td Pt72 $ 182.72 Scopolamine 1 Mg/3Days Td Pt72 $ 182.72 Diltiazem Hcl 15 Mg (1/2 X 30 Mg) Po Tabs $ 1.61 Diltiazem Hcl 15 Mg (1/2 X 30 Mg) Po Tabs $ 7.14

Page 29 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Vedolizumab 300 Mg Iv Solr $ 35,242.57 Leucovorin Calcium 50 Mg Ij Solr $ 85.80 Occult Blood Vi Strp $ 4.23 Mirtazapine 15 Mg Po Tbdp $ 16.84 Venlafaxine Hcl Er 37.5 Mg Po Cp24 $ 29.77 Venlafaxine Hcl Er 37.5 Mg Po Cp24 $ 29.77 Venlafaxine Hcl Er 37.5 Mg Po Cp24 $ 29.77 Venlafaxine Hcl Er 37.5 Mg Po Cp24 $ 29.77 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 30.01 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 33.36 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 33.36 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 33.36 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 33.36 Venlafaxine Hcl Er 75 Mg Po Cp24 $ 126.80 Venlafaxine Hcl Er 150 Mg Po Cp24 $ 5.02 Venlafaxine Hcl Er 150 Mg Po Cp24 $ 36.34 Nicotine 7 Mg/24Hr Td Pt24 $ 18.01 Nicotine 7 Mg/24Hr Td Pt24 $ 15.26 Nicotine 7 Mg/24Hr Td Pt24 $ 18.01 Nicotine 7 Mg/24Hr Td Pt24 $ 20.42 Nicotine 7 Mg/24Hr Td Pt24 $ 9.66 Nicotine 14 Mg/24Hr Td Pt24 $ 18.01 Nicotine 14 Mg/24Hr Td Pt24 $ 15.26 Nicotine 14 Mg/24Hr Td Pt24 $ 15.26 Nicotine 14 Mg/24Hr Td Pt24 $ 9.66 Nicotine 14 Mg/24Hr Td Pt24 $ 15.32 Nicotine 21 Mg/24Hr Td Pt24 $ 15.26 Nicotine 21 Mg/24Hr Td Pt24 $ 18.01 Nicotine 21 Mg/24Hr Td Pt24 $ 15.32 Nicotine 21 Mg/24Hr Td Pt24 $ 15.26 Nicotine 21 Mg/24Hr Td Pt24 $ 15.32 Fentanyl 25 Mcg/Hr Td Pt72 $ 152.08 Fentanyl 25 Mcg/Hr Td Pt72 $ 152.05 Fentanyl 25 Mcg/Hr Td Pt72 $ 152.05 Fentanyl 25 Mcg/Hr Td Pt72 $ 152.05 Fentanyl 25 Mcg/Hr Td Pt72 $ 152.05 Fentanyl 50 Mcg/Hr Td Pt72 $ 278.01 Fentanyl 50 Mcg/Hr Td Pt72 $ 278.01 Fentanyl 50 Mcg/Hr Td Pt72 $ 277.99 Fentanyl 50 Mcg/Hr Td Pt72 $ 278.01 Fentanyl 50 Mcg/Hr Td Pt72 $ 188.47 Fentanyl 50 Mcg/Hr Td Pt72 $ 278.01 Fentanyl 50 Mcg/Hr Td Pt72 $ 277.99 Fentanyl 75 Mcg/Hr Td Pt72 $ 424.04 Fentanyl 75 Mcg/Hr Td Pt72 $ 424.07 Fentanyl 75 Mcg/Hr Td Pt72 $ 424.07 Fentanyl 75 Mcg/Hr Td Pt72 $ 287.50 Fentanyl 75 Mcg/Hr Td Pt72 $ 424.04 Fentanyl 100 Mcg/Hr Td Pt72 $ 562.78 Fentanyl 100 Mcg/Hr Td Pt72 $ 562.79 Isoniazid 150 Mg (1/2 X 300 Mg) Po Tabs $ 0.91 Oxycodone Hcl Er 10 Mg Po T12A $ 35.46 Ertapenem Sodium 1 G Ij Solr $ 1,103.90 Ertapenem Sodium 1 G Ij Solr $ 1,004.46 Divalproex Sodium 125 Mg Po Csdr $ 10.15 Divalproex Sodium 125 Mg Po Csdr $ 8.01 Divalproex Sodium 125 Mg Po Csdr $ 10.15 Theophylline Er 450 Mg Po Tb12 $ 43.22 Salmeterol Xinafoate 50 Mcg/Dose In Aepb $ 44.51 Diazepam 10 Mg Po Tabs $ 3.04 Sodium Zirconium Cyclosilicate 10 G Po Pack $ 187.33

Page 30 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Sodium Zirconium Cyclosilicate 10 G Po Pack $ 187.32 Estradiol 0.1 Mg/24Hr Td Ptwk $ 158.02 Atorvastatin Calcium 80 Mg Po Tabs $ 40.52 Atorvastatin Calcium 80 Mg Po Tabs $ 41.28 Atorvastatin Calcium 80 Mg Po Tabs $ 41.23 Atorvastatin Calcium 80 Mg Po Tabs $ 39.27 Olanzapine 5 Mg Po Tbdp $ 100.93 Olanzapine 5 Mg Po Tbdp $ 102.06 Olanzapine 5 Mg Po Tbdp $ 102.06 Olanzapine 10 Mg Po Tbdp $ 148.30 Olanzapine 10 Mg Po Tbdp $ 147.77 Olanzapine 10 Mg Po Tbdp $ 147.77 Olanzapine 10 Mg Po Tbdp $ 148.30 Colesevelam Hcl 625 Mg Po Tabs $ 31.32 Colesevelam Hcl 625 Mg Po Tabs $ 26.76 Dactinomycin 0.5 Mg Iv Solr $ 3,386.66 Lurasidone Hcl 40 Mg Po Tabs $ 349.89 Levofloxacin 750 Mg Po Tabs $ 482.56 Levofloxacin 750 Mg Po Tabs $ 175.99 Romidepsin 10 Mg Iv Solr $ 15,947.43 Omni-Stat Nose Bleed Pads $ 100.10 Ceftazidime 500 Mg Ij Solr $ 56.63 Valsartan 40 Mg Po Tabs $ 56.37 Valsartan 40 Mg Po Tabs $ 28.60 Valsartan 40 Mg Po Tabs $ 27.80 Valsartan 40 Mg Po Tabs $ 11.60 Valsartan 40 Mg Po Tabs $ 27.52 Primidone 25 Mg (1/2 X 50 Mg) $ 2.83 Quetiapine Fumarate 300 Mg Po Tabs $ 72.56 Crotalidae Polyval Immune Fab Iv Solr $ 17,422.70 Tolterodine Tartrate Er 2 Mg Po Cp24 $ 57.46 Tolterodine Tartrate Er 2 Mg Po Cp24 $ 57.46 Tolterodine Tartrate Er 4 Mg Po Cp24 $ 57.46 Tolterodine Tartrate Er 4 Mg Po Cp24 $ 57.46 Caspofungin Acetate 50 Mg Iv Solr $ 1,839.84 Caspofungin Acetate 50 Mg Iv Solr $ 1,835.98 Caspofungin Acetate 70 Mg Iv Solr $ 1,906.80 Dabigatran Etexilate Mesylate 150 Mg Po Caps $ 57.28 Dabigatran Etexilate Mesylate 150 Mg Po Caps $ 61.86 Peginterferon Alfa-2B 150 Mcg/0.5Ml Subq Kit $ 4,743.57 Ziprasidone Hcl 20 Mg Po Caps $ 64.09 Ziprasidone Hcl 20 Mg Po Caps $ 63.38 Ziprasidone Hcl 40 Mg Po Caps $ 64.09 Ziprasidone Hcl 40 Mg Po Caps $ 64.09 Ziprasidone Hcl 40 Mg Po Caps $ 64.09 Ziprasidone Hcl 40 Mg Po Caps $ 63.38 Ziprasidone Hcl 60 Mg Po Caps $ 76.91 Ziprasidone Hcl 80 Mg Po Caps $ 76.91 Ziprasidone Hcl 80 Mg Po Caps $ 76.91 Tolvaptan 15 Mg Po Tabs $ 2,455.94 Pantoprazole Sodium 40 Mg Iv Solr $ 42.90 Pantoprazole Sodium 40 Mg Iv Solr $ 42.90 Pantoprazole Sodium 40 Mg Iv Solr $ 42.90 Pantoprazole Sodium 40 Mg Iv Solr $ 42.90 Pantoprazole Sodium 40 Mg Iv Solr $ 60.78 Diltiazem Hcl Er Coated Beads 120 Mg Po Cp24 $ 8.57 Diltiazem Hcl Er Coated Beads 120 Mg Po Cp24 $ 6.64 Diltiazem Hcl Er Coated Beads 120 Mg Po Cp24 $ 8.57 Diltiazem Hcl Er Coated Beads 180 Mg Po Cp24 $ 10.34 Diltiazem Hcl Er Coated Beads 180 Mg Po Cp24 $ 8.02 Diltiazem Hcl Er Coated Beads 240 Mg Po Cp24 $ 4.34

Page 31 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Diltiazem Hcl Er Coated Beads 240 Mg Po Cp24 $ 14.66 Diltiazem Hcl Er Coated Beads 300 Mg Po Cp24 $ 19.16 Diltiazem Hcl Er Coated Beads 300 Mg Po Cp24 $ 19.16 Diltiazem Hcl Er Coated Beads 300 Mg Po Cp24 $ 14.75 Diltiazem Hcl Er Coated Beads 300 Mg Po Cp24 $ 19.16 Metoprolol Succinate Er 25 Mg Po Tb24 $ 7.54 Metoprolol Succinate Er 25 Mg Po Tb24 $ 11.28 Metoprolol Succinate Er 25 Mg Po Tb24 $ 7.54 Metoprolol Succinate Er 25 Mg Po Tb24 $ 8.86 Metoprolol Succinate Er 25 Mg Po Tb24 $ 9.15 Carbamazepine Er 100 Mg Po Cp12 $ 14.04 Carbamazepine Er 100 Mg Po Cp12 $ 15.21 Fidaxomicin 200 Mg Po Tabs $ 1,053.04 Tamsulosin Hcl 0.4 Mg Po Caps $ 30.09 Tamsulosin Hcl 0.4 Mg Po Caps $ 30.16 Tamsulosin Hcl 0.4 Mg Po Caps $ 30.13 Tamsulosin Hcl 0.4 Mg Po Caps $ 30.09 Tamsulosin Hcl 0.4 Mg Po Caps $ 30.13 Galantamine Hydrobromide 4 Mg Po Tabs $ 21.82 Tucks 50 % Ex Pads $ 0.67 Tucks 50 % Ex Pads $ 0.76 Tucks 50 % Ex Pads $ 0.54 Co-Enzyme Q-10 50 Mg Po Caps $ 2.43 Co-Enzyme Q-10 50 Mg Po Caps $ 3.10 Alteplase 2 Mg Ij Solr $ 1,313.24 Valsartan 80 Mg Po Tabs $ 34.66 Valsartan 80 Mg Po Tabs $ 33.23 Valsartan 80 Mg Po Tabs $ 67.39 Valsartan 80 Mg Po Tabs $ 34.66 Valsartan 160 Mg Po Tabs $ 37.27 Valsartan 160 Mg Po Tabs $ 35.38 Valsartan 160 Mg Po Tabs $ 35.74 Glucose 4 G Po Chew $ 0.77 Glucose 4 G Po Chew $ 0.92 Glucose 4 G Po Chew $ 0.86 Glucose 4 G Po Chew $ 0.86 Digoxin Immune Fab 40 Mg Iv Solr $ 20,816.81 Metaxalone 200 Mg (1/4 X 800 Mg) Po Tabs $ 10.70 Glyburide 1.25 Mg Po Tabs $ 1.97 Tetracycline Hcl 500 Mg Po Caps $ 112.61 Melatonin 1 Mg Po Tabs $ 0.38 Melatonin 1 Mg Po Tabs $ 0.14 Melatonin 1 Mg Po Tabs $ 0.13 Melatonin 1 Mg Po Tabs $ 0.62 Ampicillin-Sulbactam Sodium 3 (2-1) G Ij Solr $ 104.39 Ampicillin-Sulbactam Sodium 3 (2-1) G Ij Solr $ 123.09 Ampicillin-Sulbactam Sodium 3 (2-1) G Ij Solr $ 123.09 Olmesartan Medoxomil 20 Mg Po Tabs $ 49.41 Olmesartan Medoxomil 20 Mg Po Tabs $ 44.89 Olmesartan Medoxomil 20 Mg Po Tabs $ 44.89 Olmesartan Medoxomil 20 Mg Po Tabs $ 49.14 Olmesartan Medoxomil 20 Mg Po Tabs $ 62.89 Olmesartan Medoxomil 20 Mg Po Tabs $ 44.89 Olmesartan Medoxomil 20 Mg Po Tabs $ 49.15 Fluconazole 50 Mg Po Tabs $ 40.05 K Phos Mono-Sod Phos Di & Mono 77.5-426-65 Mg (1/2 X 155-852-130 Mg) Po Tabs $ 0.82 Bromocriptine Mesylate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 13.44 Bromocriptine Mesylate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 44.82 Canagliflozin 300 Mg Po Tabs $ 141.37 Quikclot Gauze 4Inx4In Hemostat Dressing $ 142.93 Amoxicillin-Pot Clavulanate 250-125 Mg Po Tabs $ 42.31

Page 32 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Voriconazole 200 Mg Po Tabs $ 335.38 Voriconazole 200 Mg Iv Solr $ 1,280.07 Amoxicillin-Pot Clavulanate 500-125 Mg Po Tabs $ 27.06 Amoxicillin-Pot Clavulanate 500-125 Mg Po Tabs $ 27.06 Amoxicillin-Pot Clavulanate 875-125 Mg Po Tabs $ 35.04 Amoxicillin-Pot Clavulanate 875-125 Mg Po Tabs $ 35.40 Amoxicillin-Pot Clavulanate 875-125 Mg Po Tabs $ 36.12 Ziprasidone Mesylate 20 Mg Im Solr $ 426.26 Ziprasidone Mesylate 20 Mg Im Solr $ 426.28 Ziprasidone Mesylate 20 Mg Im Solr $ 426.28 Escitalopram Oxalate 10 Mg Po Tabs $ 30.94 Escitalopram Oxalate 10 Mg Po Tabs $ 30.94 Escitalopram Oxalate 10 Mg Po Tabs $ 30.94 Escitalopram Oxalate 10 Mg Po Tabs $ 33.71 Escitalopram Oxalate 10 Mg Po Tabs $ 33.71 Escitalopram Oxalate 20 Mg Po Tabs $ 32.28 Escitalopram Oxalate 20 Mg Po Tabs $ 35.18 Escitalopram Oxalate 20 Mg Po Tabs $ 35.18 Rasburicase 1.5 Mg Iv Solr $ 4,724.11 Metaxalone 800 Mg Po Tabs $ 42.83 Metaxalone 800 Mg Po Tabs $ 34.97 Bortezomib Iv 1 Mg/Ml Inj $ 8,733.14 Aripiprazole 10 Mg Po Tabs $ 229.59 Aripiprazole 10 Mg Po Tabs $ 229.59 Aripiprazole 10 Mg Po Tabs $ 255.10 Aripiprazole 15 Mg Po Tabs $ 229.59 Aripiprazole 15 Mg Po Tabs $ 219.80 Aripiprazole 15 Mg Po Tabs $ 229.34 Divalproex Sodium Er 250 Mg Po Tb24 $ 17.55 Divalproex Sodium Er 250 Mg Po Tb24 $ 17.55 Divalproex Sodium Er 250 Mg Po Tb24 $ 17.55 Divalproex Sodium Er 250 Mg Po Tb24 $ 17.55 Divalproex Sodium Er 250 Mg Po Tb24 $ 17.55 Carbidopa-Levodopa 6.25-62.5 Mg (1/4 X 25-250 Mg) Po Tab $ 1.53 Dtap-Ipv-Hib Vaccine Im Susr $ 819.51 Adalimumab 40 Mg/0.8Ml Subq Pskt $ 14,094.23 Melatonin 3 Mg Po Tabs $ 2.81 Melatonin 3 Mg Po Tabs $ 2.81 Melatonin 3 Mg Po Tabs $ 2.03 Melatonin 3 Mg Po Tabs $ 1.85 Melatonin 3 Mg Po Tabs $ 0.14 Melatonin 3 Mg Po Tabs $ 0.89 Melatonin 3 Mg Po Tabs $ 1.54 Melatonin 3 Mg Po Tabs $ 0.49 Glucagon Hcl Rdna (Diagnostic) 1 Mg Ij Solr $ 934.88 Glucagon Hcl Rdna (Diagnostic) 1 Mg Ij Solr $ 934.88 Estradiol 0.05 Mg/24Hr Td Ptwk $ 165.94 Estradiol 0.05 Mg/24Hr Td Ptwk $ 282.73 Estradiol 0.05 Mg/24Hr Td Ptwk $ 165.94 Cyclosporine 0.05 % Op Emul $ 79.75 Secretin Acetate (Human) 16 Mcg Iv Solr $ 2,860.20 Risperidone 0.5 Mg Po Tbdp $ 35.15 Risperidone 0.5 Mg Po Tbdp $ 35.15 Risperidone 0.5 Mg Po Tbdp $ 35.15 Risperidone 1 Mg Po Tbdp $ 41.08 Risperidone 1 Mg Po Tbdp $ 39.35 Risperidone 1 Mg Po Tbdp $ 39.35 Risperidone 1 Mg Po Tbdp $ 41.07 Risperidone 1 Mg Po Tbdp $ 41.07 Ondansetron Hcl 4 Mg Po Tabs $ 5.31 Ondansetron Hcl 4 Mg Po Tabs $ 5.31

Page 33 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Ondansetron Hcl 4 Mg Po Tabs $ 5.31 Ondansetron Hcl 4 Mg Po Tabs $ 199.54 Alteplase 2 Mg Inj Solution $ 1,313.24 Pemetrexed Disodium 100 Mg Iv Solr $ 3,855.01 Ondansetron 4 Mg Po Tbdp $ 52.47 Ondansetron 4 Mg Po Tbdp $ 59.76 Ondansetron 4 Mg Po Tbdp $ 52.47 Ondansetron 4 Mg Po Tbdp $ 50.61 Ondansetron 4 Mg Po Tbdp $ 50.58 Ondansetron 4 Mg Po Tbdp $ 50.61 Estrogens Conjugated 0.45 Mg Po Tabs $ 48.25 Lansoprazole 30 Mg Po Tbdp $ 42.21 Lansoprazole 30 Mg Po Tbdp $ 118.72 Escitalopram Oxalate 2.5 Mg (1/2 X 5 Mg) Po Tab $ 14.79 Fluticasone-Salmeterol 500-50 Mcg/Dose In Aepb $ 96.23 Theophylline Er 300 Mg Po Tb12 $ 4.88 Theophylline Er 300 Mg Po Tb12 $ 30.72 Daptomycin 500 Mg Iv Solr $ 2,427.04 Daptomycin 500 Mg Iv Solr $ 2,427.04 Risperidone Microspheres Er 25 Mg Im Srer $ 2,640.92 Ivabradine Hcl 7.5 Mg Po Tabs $ 63.26 Memantine Hcl 10 Mg Po Tabs $ 43.64 Memantine Hcl 10 Mg Po Tabs $ 43.58 Zonisamide 25 Mg Po Caps $ 3.93 Memantine Hcl 5 Mg Po Tabs $ 6.82 Memantine Hcl 5 Mg Po Tabs $ 43.64 Metoprolol Tartrate 25 Mg Po Tabs $ 1.74 Metoprolol Tartrate 25 Mg Po Tabs $ 1.74 Metoprolol Tartrate 25 Mg Po Tabs $ 1.74 Pemetrexed Disodium 500 Mg Iv Solr $ 19,275.02 Prosource Po Pack $ 4.29 Glipizide Er 2.5 Mg Po Tb24 $ 9.72 Glipizide Er 5 Mg Po Tb24 $ 2.91 Glipizide Er 10 Mg Po Tb24 $ 5.76 Aspirin 300 Mg Pr Supp $ 10.42 Cinacalcet Hcl 30 Mg Po Tabs $ 219.18 Cinacalcet Hcl 30 Mg Po Tabs $ 230.72 Buprenorphine Hcl 1 Mg (1/2 Of 2 Mg) Sl Subl $ 14.80 Olanzapine 10 Mg Im Solr $ 294.44 Olanzapine 10 Mg Im Solr $ 296.73 Olanzapine 10 Mg Im Solr $ 383.53 Olanzapine 10 Mg Im Solr $ 296.73 Tiotropium Bromide Monohydrate 18 Mcg In Caps $ 145.96 Thyroid 15 Mg Po Tabs $ 5.51 Alteplase For Pe Without Cardiac Arrest $ 47,944.35 Duloxetine Hcl 20 Mg Po Cpep $ 12.87 Duloxetine Hcl 20 Mg Po Cpep $ 50.04 Duloxetine Hcl 30 Mg Po Cpep $ 13.73 Duloxetine Hcl 30 Mg Po Cpep $ 56.14 Duloxetine Hcl 30 Mg Po Cpep $ 13.73 Duloxetine Hcl 60 Mg Po Cpep $ 56.14 Duloxetine Hcl 60 Mg Po Cpep $ 56.14 Duloxetine Hcl 60 Mg Po Cpep $ 13.73 Insulin Pen Needle 29G X 12.7Mm Misc $ 4.07 Mesalamine Er 500 Mg Po Cpcr $ 52.10 Tisseel Tip Spray Kit 0600065Pr $ 2,390.95 Pemetrexed Disodium 500 Mg Iv Solr G-Cmc $ 19,275.02 Vancomycin Hcl 5 G Iv Solr $ 682.11 Vancomycin Hcl 5 G Iv Solr $ 763.05 Vancomycin Hcl 5 G Iv Solr $ 209.07 Vancomycin Hcl 5 G Iv Solr $ 763.05

Page 34 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Mesalamine 1000 Mg Pr Supp $ 332.27 Mesalamine 1000 Mg Pr Supp $ 252.42 Mesalamine 1000 Mg Pr Supp $ 332.27 Mesalamine 1000 Mg Pr Supp $ 332.27 Paclitaxel Protein-Bound Part 100 Mg Iv Susr $ 7,507.39 Linaclotide 145 Mcg Po Caps $ 121.21 Linaclotide 145 Mcg Po Caps $ 97.18 Fentanyl 12 (12.5) Mcg/Hr Td Pt72 $ 145.16 Fentanyl 12 (12.5) Mcg/Hr Td Pt72 $ 145.16 Fentanyl 12 (12.5) Mcg/Hr Td Pt72 $ 145.16 Fentanyl 12 (12.5) Mcg/Hr Td Pt72 $ 145.15 Fentanyl 12 (12.5) Mcg/Hr Td Pt72 $ 145.16 Morphine Sulfate 7.5 (1/2 X 15 Mg) Po Tabs $ 1.18 Tigecycline 50 Mg Iv Solr $ 1,342.79 Tigecycline 50 Mg Iv Solr $ 1,006.36 Tigecycline 50 Mg Iv Solr $ 1,006.35 Tigecycline 50 Mg Iv Solr $ 1,342.77 Sildenafil Citrate 20 Mg Po Tabs $ 143.02 Sildenafil Citrate 20 Mg Po Tabs $ 143.02 Methadone Hcl 40 Mg Po Tbso $ 2.37 Pregabalin 25 Mg Po Caps $ 66.95 Pregabalin 25 Mg Po Caps $ 60.25 Pregabalin 50 Mg Po Caps $ 66.95 Pregabalin 50 Mg Po Caps $ 73.64 Pregabalin 50 Mg Po Caps $ 60.25 Pregabalin 75 Mg Po Caps $ 73.64 Pregabalin 75 Mg Po Caps $ 66.95 Pregabalin 75 Mg Po Caps $ 60.25 Pregabalin 75 Mg Po Caps $ 60.25 Pregabalin 100 Mg Po Caps $ 73.64 Pregabalin 100 Mg Po Caps $ 66.95 Pregabalin 100 Mg Po Caps $ 60.25 Lopinavir-Ritonavir 200-50 Mg Po Tabs $ 73.22 Imatinib Mesylate 100 Mg Po Tabs $ 803.42 Isavuconazonium Sulfate 186 Mg Po Caps $ 794.21 Quetiapine Fumarate 50 Mg Po Tabs $ 46.95 Quetiapine Fumarate 50 Mg Po Tabs $ 46.95 Quetiapine Fumarate 50 Mg Po Tabs $ 46.98 Hydroxychloroquine Sulfate 100 Mg (1/2 X 200 Mg) Po Tab $ 4.41 Hydroxychloroquine Sulfate 100 Mg (1/2 X 200 Mg) Po Tab $ 15.59 Risperidone Microspheres Er 50 Mg Im Srer $ 5,282.15 Selegiline 6 Mg/24Hr Td Pt24 $ 299.56 Sulfamethoxazole-Trimethoprim 800-160 Mg Po Tabs $ 2.10 Sulfamethoxazole-Trimethoprim 800-160 Mg Po Tabs $ 2.10 Acetylcholine Chloride 20 Mg Io Solr $ 848.56 Tamoxifen Citrate 2.5 Mg (1/4 X 10 Mg) Po Tabs $ 1.03 Sirolimus 1 Mg Po Tabs $ 250.86 Indapamide 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 3.05 Indapamide 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 5.54 Peginterferon Alfa-2B 600 Mcg Subq Kit $ 32,365.03 Praziquantel 600 Mg Po Tabs $ 641.19 Empagliflozin 10 Mg Po Tabs $ 140.96 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.97 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.97 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.97 Hydroxyzine Hcl 50 Mg Po Tabs $ 8.02 Hydroxyzine Hcl 50 Mg Po Tabs $ 2.92 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.97 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.97 Hydroxyzine Hcl 50 Mg Po Tabs $ 7.98 Mexiletine Hcl 250 Mg Po Caps $ 25.01

Page 35 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Ivacaftor 150 Mg Po Tabs $ 2,324.75 Hydroxyzine Hcl 2.5 Mg (1/4 X 10 Mg) Po Tabs $ 1.14 Clonidine 0.2 Mg/24Hr Td Ptwk $ 399.17 Clonidine 0.2 Mg/24Hr Td Ptwk $ 398.72 Clonidine 0.2 Mg/24Hr Td Ptwk $ 399.17 Clonidine 0.2 Mg/24Hr Td Ptwk $ 398.72 Bivalirudin Trifluoroacetate 250 Mg Iv Solr $ 5,163.20 Bivalirudin Trifluoroacetate 250 Mg Iv Solr $ 1,089.60 Bivalirudin Trifluoroacetate 250 Mg Iv Solr $ 1,089.60 Vitamin D (Ergocalciferol) 1.25 Mg (50000 Ut) Po Caps $ 14.10 Ibuprofen 300 Mg (1/2 X 600 Mg) Po Tabs $ 1.09 Cyclophosphamide 1 G Ij Solr $ 3,101.09 Bacitracin 500 Unit/Gm Ex Oint $ 1.65 Bacitracin 500 Unit/Gm Ex Oint $ 1.65 Roflumilast 250 Mcg (1/2 X 500 Mcg) Po Tabs $ 40.18 Roflumilast 250 Mcg (1/2 X 500 Mcg) Po Tabs $ 46.00 Trihexyphenidyl Hcl 1 Mg (1/2 X 2 Mg) Po Tabs $ 0.66 Trihexyphenidyl Hcl 1 Mg (1/2 X 2 Mg) Po Tabs $ 0.66 Ondansetron Hcl 8 Mg Po Tabs $ 295.01 Ondansetron Hcl 8 Mg Po Tabs $ 6.74 Ondansetron Hcl 8 Mg Po Tabs $ 6.74 Ondansetron Hcl 8 Mg Po Tabs $ 6.76 Emtricitabine-Tenofovir Df 200-300 Mg Po Tabs $ 473.54 Emtricitabine-Tenofovir Df 200-300 Mg Po Tabs $ 502.76 Amiodarone 150 Mg In D5W 100 Ml Ivpb $ 23.52 Oxcarbazepine 75 Mg (1/2 X 150 Mg) Po Tabs $ 5.46 Oxcarbazepine 75 Mg (1/2 X 150 Mg) Po Tabs $ 5.46 Perphenazine 1 Mg (1/2 X 2 Mg) Po Tabs $ 7.03 Perphenazine 1 Mg (1/2 X 2 Mg) Po Tabs $ 7.03 Naloxone Hcl 4 Mg/0.1Ml Na Liqd $ 536.25 Flecainide Acetate 25 Mg (1/2 X 50 Mg) Po Tabs $ 7.22 Verapamil Hcl Cr 90 Mg (1/2 X 180 Mg) Po Tbcr $ 5.15 Verapamil Hcl Cr 90 Mg (1/2 X 180 Mg) Po Tbcr $ 5.15 Oxidized Cellulose Ex Pads 2 X 4 $ 716.72 Oxidized Cellulose Ex Pads 1 X 2 $ 389.42 Phenobarbital 16.2 Mg Po Tabs $ 4.93 Phenobarbital 16.2 Mg Po Tabs $ 3.82 Sinus Rinse Kit Na Pack $ 4.72 Talc 4 G Pl Powd $ 1,201.20 Hydroxyzine Hcl 5 Mg ( 1/2 X 10 Mg) Po Tabs $ 2.27 Hydroxyzine Hcl 5 Mg ( 1/2 X 10 Mg) Po Tabs $ 2.04 Eplerenone 50 Mg Po Tabs $ 29.79 Quikclot Combat Gauze 3Inx4Yd Roll $ 306.45 Dronedarone Hcl 400 Mg Po Tabs $ 94.15 Sevelamer Carbonate 800 Mg Po Tabs $ 43.58 Sevelamer Carbonate 800 Mg Po Tabs $ 43.58 Sevelamer Carbonate 800 Mg Po Tabs $ 43.58 Sevelamer Carbonate 800 Mg Po Tabs $ 27.04 Nadolol 10 Mg ( 1/2 X 20 Mg) Po Tabs $ 12.13 Nadolol 10 Mg ( 1/2 X 20 Mg) Po Tabs $ 12.12 Pilocarpine Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 5.45 Pilocarpine Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 7.21 Pilocarpine Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 5.78 Metoprolol Succinate 6.25 Mg (1/4 X 25 Mg) Po Tb24 $ 2.00 Metoprolol Succinate 6.25 Mg (1/4 X 25 Mg) Po Tb24 $ 2.10 Enfamil Expecta 28-0.8 & 200 Mg Po Misc $ 1.39 Bortezomib Subcutaneous 2.5 Mg/Ml Inj $ 8,733.14 Pioglitazone Hcl 7.5 Mg (1/2 X 15 Mg) Po Tabs $ 25.03 Pioglitazone Hcl 7.5 Mg (1/2 X 15 Mg) Po Tabs $ 49.09 Ulipristal Acetate 30 Mg Po Tabs $ 306.74 Witch Hazel-Glycerin Ex Pads $ 0.38

Page 36 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Witch Hazel-Glycerin Ex Pads $ 0.44 Irbesartan 300 Mg Po Tabs $ 26.40 Irbesartan 300 Mg Po Tabs $ 26.40 Cefepime Hcl 1 G Ij Solr $ 51.48 Umeclidinium-Vilanterol 62.5-25 Mcg/Inh In Aepb $ 60.34 Lamotrigine 75 Mg (1/2 X 150 Mg) Po Tabs $ 21.38 Prenatal Formula 27-1 Mg Po Tabs $ 2.57 Prenatal Formula 27-1 Mg Po Tabs $ 5.10 Trastuzumab 150 Mg Iv Solr $ 8,490.25 Zafirlukast 10 Mg (1/2 X 20 Mg) Po Tabs $ 7.73 Zafirlukast 10 Mg (1/2 X 20 Mg) Po Tabs $ 16.27 Febuxostat 40 Mg Po Tabs $ 94.39 Tisseel Duplocath Drip Applicator 921020 $ 399.26 Medroxyprogesterone Acetate 5 Mg (1/2 X 10 Mg) Po Tab $ 1.76 Clobazam 5 Mg (1/2 X 10Mg) Oral Tab $ 31.71 Rasburicase 7.5 Mg Iv Solr $ 23,620.53 Oxycodone Hcl Er 20 Mg Po T12A $ 66.05 Mafenide Acetate 5 % Ex Pack $ 1,058.13 Risperidone 0.25 Mg Po Tbdp $ 32.03 Cyclobenzaprine Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 5.87 Cyclobenzaprine Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 11.73 Trabectedin 1 Mg Iv Solr $ 16,218.74 Progesterone 200 Mg Va Supp $ 48.24 Amphetamine-Dextroamphet Er 5 Mg Po Cp24 $ 43.84 Amphetamine-Dextroamphet Er 5 Mg Po Cp24 $ 50.41 Zinc Sulfate 220 (50 Zn) Mg Po Caps $ 0.84 Deferoxamine Mesylate (213 Mg/Ml) Im Dilution $ 80.75 Naltrexone Hcl 25Mg (1/2 50Mg) Po Tabs $ 18.02 Rivastigmine 4.6 Mg/24Hr Td Pt24 $ 115.85 Rivastigmine 4.6 Mg/24Hr Td Pt24 $ 115.85 Methylphenidate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 6.19 Methylphenidate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 1.20 Quinapril Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 4.37 Modafinil 100 Mg Po Tabs $ 188.60 Modafinil 100 Mg Po Tabs $ 157.78 Modafinil 100 Mg Po Tabs $ 188.78 Glipizide 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 1.34 Glipizide 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 1.20 Atenolol 12.5 Mg ( 1/2 X 25 Mg) Po Tabs $ 2.86 Atenolol 12.5 Mg ( 1/2 X 25 Mg) Po Tabs $ 5.85 Metoprolol Tartrate 12.5 Mg ( 1/2 X 25 Mg) Po Tabs $ 1.00 Metoprolol Tartrate 12.5 Mg ( 1/2 X 25 Mg) Po Tabs $ 0.97 Metoprolol Tartrate 12.5 Mg ( 1/2 X 25 Mg) Po Tabs $ 0.87 Rivaroxaban 10 Mg Po Tabs $ 128.13 Levorphanol Tartrate 2 Mg Po Tabs $ 15.31 Nifedipine Er 30 Mg Po Tb24 $ 9.97 Nifedipine Er 30 Mg Po Tb24 $ 11.35 Nifedipine Er 30 Mg Po Tb24 $ 9.97 Cilostazol 50 Mg Po Tabs $ 13.05 Cilostazol 50 Mg Po Tabs $ 13.05 Leucovorin Calcium 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 48.91 Nutrisource Fiber Po Pack $ 3.47 Nutrisource Fiber Po Pack $ 3.40 Rufinamide 200 Mg Po Tabs $ 103.10 Theophylline Er 225 Mg (1/2 X 450 Mg) Po Tab Tb12 $ 3.39 Rosuvastatin Calcium 40 Mg Po Tabs $ 63.95 Rosuvastatin Calcium 40 Mg Po Tabs $ 63.95 Rosuvastatin Calcium 40 Mg Po Tabs $ 10.32 Rosuvastatin Calcium 40 Mg Po Tabs $ 63.96 Ondansetron 2 Mg Odt (1/2 Of 4 Mg Odt) $ 52.47 Torsemide 2.5 Mg (1/2 Of 5 Mg) Po Tabs $ 2.27

Page 37 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Letrozole 2.5 Mg Po Tabs $ 129.52 Tisseel Tip Spray Set 0600065 $ 376.55 Aztreonam 2 G Ij Solr $ 468.64 Aztreonam 2 G Ij Solr $ 497.64 Aztreonam 2 G Ij Solr $ 574.43 Thrombin 5000 Units Ex Solr $ 615.76 Lurasidone Hcl 20 Mg (1/2 X 40 Mg) Po Tabs $ 144.86 Imatinib Mesylate 400 Mg Po Tabs $ 1,838.23 Bisoprolol-Hydrochlorothiazide 10-6.25 Mg Po Tabs $ 24.10 Methohexital Sodium 2.5 G Ij Solr $ 1,575.61 Roflumilast 500 Mcg Po Tabs $ 103.27 Roflumilast 500 Mcg Po Tabs $ 103.30 Doxylamine Succinate (Sleep) 25 Mg Po Tabs $ 1.37 Doxylamine Succinate (Sleep) 25 Mg Po Tabs $ 1.34 Doxylamine Succinate (Sleep) 25 Mg Po Tabs $ 1.79 Doxylamine Succinate (Sleep) 25 Mg Po Tabs $ 1.79 Probenecid 250 Mg (1/2 X 500 Mg) Po Tabs $ 3.52 Probenecid 250 Mg (1/2 X 500 Mg) Po Tabs $ 3.52 Rivaroxaban 15 Mg Po Tabs $ 128.12 Rivaroxaban 15 Mg Po Tabs $ 128.13 Rivaroxaban 15 Mg Po Tabs $ 128.13 Esomeprazole Sodium 40 Mg Iv Solr $ 299.44 Esomeprazole Sodium 40 Mg Iv Solr $ 383.09 Esomeprazole Sodium 40 Mg Iv Solr $ 344.78 Esomeprazole Sodium 40 Mg Iv Solr $ 299.44 Esomeprazole Sodium 40 Mg Iv Solr $ 429.00 Fluticasone Furoate-Vilanterol 200-25 Mcg/Inh In Aepb $ 41.46 Tetracycline Hcl 250 Mg Po Caps $ 56.31 Promethazine Hcl 6.25 Mg (1/2 X 12.5 Mg) Po Tabs $ 1.75 Paliperidone Er 3 Mg Po Tb24 $ 218.28 Paliperidone Er 3 Mg Po Tb24 $ 218.52 Paliperidone Er 3 Mg Po Tb24 $ 337.07 Paliperidone Er 3 Mg Po Tb24 $ 218.76 Primidone 125 Mg (1/2 X 250 Mg) Po Tabs $ 3.56 Primidone 125 Mg (1/2 X 250 Mg) Po Tabs $ 3.40 Famciclovir 500 Mg Po Tabs $ 90.75 Famciclovir 500 Mg Po Tabs $ 99.75 Insulin Pen Needle 30G X 8 Mm Misc $ 3.59 Insulin Pen Needle 30G X 8 Mm Misc $ 2.88 Insulin Pen Needle 30G X 8 Mm Misc $ 2.88 Theophylline Er 150 Mg (1/2 X 300 Mg) Po Tab Tb12 $ 1.48 Theophylline Er 150 Mg (1/2 X 300 Mg) Po Tab Tb12 $ 2.46 Omni-Stat Gauze 4X4 Each $ 214.50 Leucovorin Calcium 100 Mg Ij Solr $ 171.60 Floseal Applicator Tips $ 606.82 Methacholine Chloride 100 Mg In Solr $ 643.50 Oxygen $ 146.79 Cefuroxime Axetil 250 Mg Po Tabs $ 141.26 Cilostazol 25 Mg (1/2 X 50 Mg) Po Tabs $ 85.72 Cilostazol 25 Mg (1/2 X 50 Mg) Po Tabs $ 13.05 Dronedarone Hcl 200 Mg (1/2 X 400 Mg) Po Tabs $ 61.16 Dronedarone Hcl 200 Mg (1/2 X 400 Mg) Po Tabs $ 81.18 Indomethacin 50 Mg Pr Supp $ 926.16 Methsuximide 300 Mg Po Caps $ 36.58 Captopril 6.25 Mg (1/2 X 12.5 Mg) Po Tabs $ 5.57 Captopril 6.25 Mg (1/2 X 12.5 Mg) Po Tabs $ 7.96 Misoprostol 25 Mcg (1/4 X 100 Mcg) Po Tabs $ 1.75 Misoprostol 50 Mcg (1/2 X 100 Mcg) Po Tabs $ 3.50 T.E.D. Thigh Belted/Xl-Long Misc $ 57.03 Lidocaine 4 % Ex Ptch $ 13.23 Lidocaine 4 % Ex Ptch $ 10.12

Page 38 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Lidocaine 4 % Ex Ptch $ 29.98 Divalproex Sodium Er 500 Mg Po Tb24 $ 29.14 Divalproex Sodium Er 500 Mg Po Tb24 $ 26.44 Divalproex Sodium Er 500 Mg Po Tb24 $ 29.14 Divalproex Sodium Er 500 Mg Po Tb24 $ 17.67 Propranolol Hcl Er 60 Mg Po Cp24 $ 14.71 Propranolol Hcl Er 60 Mg Po Cp24 $ 15.59 Propranolol Hcl Er 60 Mg Po Cp24 $ 14.71 Propranolol Hcl Er 80 Mg Po Cp24 $ 17.05 Propranolol Hcl Er 80 Mg Po Cp24 $ 17.22 Cyclophosphamide 2 G Ij Solr $ 7,981.32 Cyclophosphamide 2 G Ij Solr $ 7,482.51 Leucovorin Calcium 25 Mg Po Tabs $ 97.87 Amiodarone Hcl 100 Mg Po Tabs $ 53.12 Amiodarone Hcl 100 Mg Po Tabs $ 53.12 Doxycycline Hyclate 100 Mg Po Tabs $ 39.55 Doxycycline Hyclate 100 Mg Po Tabs $ 43.95 Doxycycline Hyclate 100 Mg Po Tabs $ 43.95 Methylphenidate Hcl Er 18 Mg Po Tbcr $ 99.41 Methylphenidate Hcl Er 18 Mg Po Tbcr $ 66.79 Calcium Carbonate Antacid 750 Mg Po Chew $ 1.45 Calcium Carbonate Antacid 750 Mg Po Chew $ 0.29 Calcium Carbonate Antacid 750 Mg Po Chew $ 0.30 Calcium Carbonate Antacid 750 Mg Po Chew $ 0.19 Diphenhydramine Hcl 25 Mg Po Caps $ 0.29 Diphenhydramine Hcl 25 Mg Po Caps $ 0.33 Diphenhydramine Hcl 25 Mg Po Caps $ 0.18 Meningococcal A C Y&W-135 Olig Im Solr $ 183.40 Cyclobenzaprine Hcl 5 Mg Po Tabs $ 11.73 Cyclobenzaprine Hcl 5 Mg Po Tabs $ 11.73 Cyclobenzaprine Hcl 5 Mg Po Tabs $ 11.73 Cyclobenzaprine Hcl 5 Mg Po Tabs $ 11.73 Cyclobenzaprine Hcl 5 Mg Po Tabs $ 11.73 Fluticasone-Salmeterol 250-50 Mcg/Dose In Aepb $ 92.99 Naloxegol Oxalate 25 Mg Po Tabs $ 101.64 Ceftriaxone Sodium 2 G Ij Solr $ 653.58 Ceftriaxone Sodium 2 G Ij Solr $ 24.45 Ceftriaxone Sodium 2 G Ij Solr $ 652.87 Warfarin Sodium 0.5 Mg (1/2 X 1Mg) Po Tabs $ 2.17 Warfarin Sodium 0.5 Mg (1/2 X 1Mg) Po Tabs $ 7.33 Omni-Stat Granules 3 Gram Pouch $ 250.25 Diazepam 0.5 Mg (1/4 X 2 Mg) Po Tabs $ 0.23 Glycerin (Laxative) 2 G Pr Supp $ 3.09 Rifaximin 200 Mg Po Tabs $ 177.68 Menthol 9.1 Mg Mt Lozg $ 0.59 Metoprolol Succinate 12.5 Mg ( 1/2 X 25 Mg) Po Tb24 $ 3.99 Metoprolol Succinate 12.5 Mg ( 1/2 X 25 Mg) Po Tb24 $ 5.13 Candesartan Cilexetil 8 Mg Po Tabs $ 21.85 Xeroform Petrolatum Dressing Ex Pads 1X8 $ 18.28 Xeroform Petrolatum Dressing Ex Pads 1X8 $ 5.11 Xeroform Petrolatum Dressing Ex Pads 1X8 $ 5.11 Ifosfamide 1 G Iv Solr $ 513.40 Furosemide 10 Mg (1/2 X 20 Mg) Po Tabs $ 0.58 Furosemide 10 Mg (1/2 X 20 Mg) Po Tabs $ 0.54 Methadone Hcl 2.5 Mg ( 1/2 X 5 Mg) Po Tabs $ 1.38 Escitalopram Oxalate 5 Mg Po Tabs $ 29.67 Escitalopram Oxalate 5 Mg Po Tabs $ 32.25 Escitalopram Oxalate 5 Mg Po Tabs $ 32.25 Finasteride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 11.91 Finasteride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 11.18 Pain-Ease Spray For Iv Therapy $ 7.79

Page 39 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Amiodarone Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 26.56 Quinapril Hcl 5 Mg Po Tabs $ 8.74 Metoprolol Tartrate 6.25 Mg (1/4 X 25 Mg) Po Tabs $ 0.50 Carbidopa-Levodopa 12.5-50 Mg (1/2 X 25-100 Mg) Po Tabs $ 4.53 Sumatriptan Succinate 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 100.99 Fenofibrate 80 Mg (1/2 X 160 Mg) Po Tabs $ 25.49 Methazolamide 25 Mg Po Tabs $ 27.39 Micafungin Sodium 50 Mg Iv Solr $ 802.23 Alprazolam 0.125 Mg (1/2 X 0.25 Mg) Po Tabs $ 2.27 Efavirenz 600 Mg Po Tabs $ 280.46 Asparaginase Erwinia Chrysanth 10000 Units Ij Solr $ 21,320.42 Cholestyramine Light 4 G Po Pack $ 23.96 Cholestyramine Light 4 G Po Pack $ 23.95 Cholestyramine Light 4 G Po Pack $ 23.96 Cholestyramine Light 4 G Po Pack $ 23.96 Etoposide Phosphate 100 Mg Iv Solr $ 1,246.49 Lamivudine-Zidovudine 150-300 Mg Po Tabs $ 128.90 Lamivudine-Zidovudine 150-300 Mg Po Tabs $ 111.02 Quinine Sulfate 324 Mg Po Caps $ 52.38 Quinine Sulfate 324 Mg Po Caps $ 50.56 Morphine Sulfate Er 30 Mg Po Tbcr $ 24.17 Morphine Sulfate Er 30 Mg Po Tbcr $ 22.68 Morphine Sulfate Er 30 Mg Po Tbcr $ 5.25 Rufinamide 100 Mg (1/2 X 200 Mg) Po Tabs $ 24.20 Gelatin Absorbable 12-7 Mm Ex Misc $ 48.18 Verapamil Hcl 40 Mg Po Tabs $ 1.98 Verapamil Hcl 40 Mg Po Tabs $ 1.98 Glucarpidase 1000 Units Iv Solr $ 172,472.78 Hydrochlorothiazide 12.5 Mg Po Tabs $ 3.04 Hydrochlorothiazide 12.5 Mg Po Tabs $ 5.89 Donepezil Hcl 5 Mg Po Tabs $ 61.88 Ixabepilone 45 Mg Iv Solr $ 18,735.40 Ixabepilone 15 Mg Iv Solr $ 6,245.13 Fluticasone-Umeclidin-Vilant 100-62.5-25 Mcg/Inh In Aepb $ 49.50 Methylprednisolone Sodium Succ 1000 Mg Ij Solr $ 359.43 Eplerenone 25 Mg Po Tabs $ 31.02 Aspirin 162.5 Mg (1/2 X 325 Mg) Po Tabs $ 0.10 Amlodipine Besylate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 6.19 Amlodipine Besylate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 6.19 Amitriptyline Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 0.64 Amitriptyline Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 1.14 Candesartan Cilexetil 32 Mg Po Tabs $ 30.72 Aspirin 40.5 Mg (1/2 X 81 Mg) Po Chew $ 0.28 Atorvastatin Calcium 5 Mg (1/2 X 10 Mg) Po Tabs $ 2.25 Atorvastatin Calcium 5 Mg (1/2 X 10 Mg) Po Tabs $ 14.47 Atorvastatin Calcium 5 Mg (1/2 X 10 Mg) Po Tabs $ 14.47 Azathioprine 25 Mg (1/2 X 50 Mg) Po Tabs $ 4.68 Azathioprine 25 Mg (1/2 X 50 Mg) Po Tabs $ 5.16 Primidone 12.5 Mg (1/4 X 50 Mg) Po Tabs $ 1.42 Baclofen 5 Mg (1/2 X 10 Mg) Po Tabs $ 1.57 Baclofen 5 Mg (1/2 X 10 Mg) Po Tabs $ 8.84 Folic Acid 400 Mcg Po Tabs $ 0.10 Folic Acid 400 Mcg Po Tabs $ 0.11 Bisoprolol-Hydrochlorothiazide 2.5-6.25 Mg Po Tabs $ 25.56 Bisoprolol-Hydrochlorothiazide 5-6.25 Mg Po Tabs $ 25.56 Benztropine Mesylate 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 1.39 Benztropine Mesylate 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 4.29 Bethanechol Chloride 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 9.55 Bethanechol Chloride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.55 Bethanechol Chloride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.06 Irbesartan 75 Mg Po Tabs $ 9.18

Page 40 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Irbesartan 75 Mg Po Tabs $ 51.24 Carvedilol 1.5625 (1/2 X 3.125 Mg) Po Tabs $ 7.52 Carvedilol 1.5625 (1/2 X 3.125 Mg) Po Tabs $ 7.64 Ciprofloxacin Hcl 125 Mg (1/2 X 250 Mg) Po Tabs $ 16.42 Clonazepam 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 2.68 Clopidogrel Bisulfate 37.5 Mg (1/2 X 75 Mg) Po Tabs $ 1.47 Clopidogrel Bisulfate 37.5 Mg (1/2 X 75 Mg) Po Tabs $ 1.47 Colchicine 0.3 Mg (1/2 X 0.6 Mg) Po Tabs $ 21.01 Colchicine 0.3 Mg (1/2 X 0.6 Mg) Po Tabs $ 58.16 Clonidine Hcl 0.025 Mg (1/4 X 0.1 Mg) Po Tabs $ 0.42 Clonidine Hcl 0.025 Mg (1/4 X 0.1 Mg) Po Tabs $ 0.43 Clonidine Hcl 0.05 Mg (1/2 X 0.1 Mg) Po Tabs $ 1.85 Montelukast Sodium 5 Mg Po Chew $ 35.95 Montelukast Sodium 5 Mg Po Chew $ 40.45 Montelukast Sodium 5 Mg Po Chew $ 35.96 Dexamethasone 1 Mg Po Tabs $ 2.12 Diazepam 1 Mg (1/2 X 2 Mg) Po Tabs $ 0.45 Diazepam 1 Mg (1/2 X 2 Mg) Po Tabs $ 0.86 Diazepam 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 0.79 Digoxin 0.0625 Mg (1/2 X 0.125 Mg) Po Tabs $ 5.08 Digoxin 0.0625 Mg (1/2 X 0.125 Mg) Po Tabs $ 8.22 Diltiazem Hcl 45 Mg (1/2 X 90 Mg) Po Tabs $ 3.07 Diltiazem Hcl 45 Mg (1/2 X 90 Mg) Po Tabs $ 15.32 Diltiazem Hcl 30 Mg Po Tabs $ 7.14 Diltiazem Hcl 30 Mg Po Tabs $ 7.14 Diltiazem Hcl 30 Mg Po Tabs $ 7.14 Enalapril Maleate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 3.35 Enalapril Maleate 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 5.21 Famotidine 10 Mg Po Tabs $ 2.15 Famotidine 10 Mg Po Tabs $ 2.25 Famotidine 10 Mg Po Tabs $ 2.35 Famotidine 10 Mg Po Tabs $ 1.91 Doxazosin Mesylate 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 4.83 Doxazosin Mesylate 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 3.93 Entacapone 100 Mg (1/2 X 200 Mg) Po Tabs $ 16.23 Entacapone 100 Mg (1/2 X 200 Mg) Po Tabs $ 28.28 Furosemide 5 Mg (1/4 X 20 Mg) Po Tabs $ 0.29 Gemfibrozil 300 Mg (1/2 X 600 Mg) Po Tabs $ 15.85 Gemfibrozil 300 Mg (1/2 X 600 Mg) Po Tabs $ 16.55 Glimepiride 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 1.45 Glimepiride 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 1.44 Darunavir Ethanolate 800 Mg Po Tabs $ 483.25 Haloperidol 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 1.17 Haloperidol 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 1.06 Haloperidol 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.66 Haloperidol 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.66 Hydralazine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 1.47 Hydrochlorothiazide 12.5 Mg Po Caps $ 3.04 Hydrochlorothiazide 12.5 Mg Po Caps $ 3.04 Isosorbide Dinitrate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.53 Isosorbide Dinitrate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.53 Labetalol Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 8.16 Labetalol Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 2.04 Lamotrigine 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 14.87 Lamotrigine 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 14.87 Levetiracetam 125 Mg (1/2 X 250 Mg) Po Tabs $ 0.99 Metronidazole 125 Mg (1/2 X 250 Mg) Po Tabs $ 1.99 Olanzapine 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 44.47 Oxybutynin Chloride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.22 Oxybutynin Chloride 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.22 Phenazopyridine Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 1.82

Page 41 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Propylthiouracil 25 Mg (1/2 X 50 Mg) Po Tabs $ 2.67 Propylthiouracil 25 Mg (1/2 X 50 Mg) Po Tabs $ 2.67 Benazepril Hcl 5 Mg Po Tabs $ 7.51 Sucralfate 500 Mg (1/2 X 1 Gm) Po Tabs $ 1.36 Sucralfate 500 Mg (1/2 X 1 Gm) Po Tabs $ 2.54 Sulfasalazine 250 Mg (1/2 X 500 Mg) Po Tabs $ 0.92 Sulfasalazine 125 Mg (1/4 X 500 Mg) Po Tabs $ 0.46 Tamoxifen Citrate 5 Mg (1/2 X 10 Mg) Po Tabs $ 2.05 Tamoxifen Citrate 5 Mg (1/2 X 10 Mg) Po Tabs $ 2.05 Trihexyphenidyl Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 3.93 Trihexyphenidyl Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 1.30 Prednisone 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 0.91 Prednisone 0.5 Mg (1/2 X 1 Mg) Po Tabs $ 1.81 Prednisone 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 6.47 Pyridostigmine Bromide 15 Mg (1/4 X 60 Mg) Po Tabs $ 16.30 Pyridostigmine Bromide 30 Mg (1/2 X 60 Mg) Po Tabs $ 32.59 Pyridostigmine Bromide 30 Mg (1/2 X 60 Mg) Po Tabs $ 4.38 Risperidone 0.125 Mg (1/2 X 0.25 Mg) Po Tabs $ 13.94 Risperidone 0.125 Mg (1/2 X 0.25 Mg) Po Tabs $ 7.79 Sertraline Hcl 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 1.44 Sertraline Hcl 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 10.18 Buspirone Hcl 5 Mg Po Tabs $ 5.51 Buspirone Hcl 5 Mg Po Tabs $ 5.51 Buspirone Hcl 5 Mg Po Tabs $ 5.35 Buspirone Hcl 5 Mg Po Tabs $ 5.51 Trazodone Hcl 12.5 Mg (1/4 X 50 Mg) Po Tabs $ 3.11 Sotalol Hcl 40 Mg (1/2 X 80 Mg) Po Tabs $ 17.80 Sotalol Hcl 40 Mg (1/2 X 80 Mg) Po Tabs $ 8.40 Spironolactone 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 1.53 Spironolactone 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 1.75 Spironolactone 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 1.65 Topiramate 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 9.14 Topiramate 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 9.03 Valsartan 20 Mg (1/2 X 40 Mg) Po Tabs $ 14.07 Valsartan 20 Mg (1/2 X 40 Mg) Po Tabs $ 17.77 Carbidopa-Levodopa 2.5-25 Mg (1/4 X 10-100 Mg) Po Tabs $ 2.17 Verapamil Hcl 20 Mg (1/2 X 40 Mg) Po Tabs $ 0.99 Verapamil Hcl 20 Mg (1/2 X 40 Mg) Po Tabs $ 1.98 Verapamil Hcl 20 Mg (1/2 X 40 Mg) Po Tabs $ 1.98 Isosorbide Mononitrate Cr 15 Mg (1/2 X 30 Mg) Po Tb24 $ 11.98 Metformin Hcl 250 Mg (1/2 X 500 Mg) Po Tabs $ 2.51 Metformin Hcl 250 Mg (1/2 X 500 Mg) Po Tabs $ 2.52 Metformin Hcl 425 Mg (1/2 X 850 Mg) Po Tabs $ 4.29 Paroxetine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 10.06 Paroxetine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 5.21 Paroxetine Hcl 5 Mg (1/2 X 10 Mg) Po Tabs $ 9.37 Quetiapine Fumarate 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 13.51 Quetiapine Fumarate 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 14.29 Simethicone 40 Mg (1/2 X 80 Mg) Po Chew $ 0.24 Simethicone 40 Mg (1/2 X 80 Mg) Po Chew $ 0.32 Zolpidem Tartrate 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 16.54 Lorazepam 0.125 Mg (1/4 X 0.5 Mg) Po Tabs $ 0.33 Lorazepam 0.25 Mg (1/2 X 0.5 Mg) Po Tabs $ 0.33 Trazodone Hcl 25 Mg (1/2 X 50 Mg) Po Tabs $ 3.83 Warfarin Sodium 3.75 Mg (1/2 X 7.5 Mg) Po Tabs $ 3.42 Warfarin Sodium 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 2.34 Warfarin Sodium 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 2.36 Levothyroxine Sodium 12.5 Mcg (1/2 X 25 Mcg) Or Tabs $ 1.41 Levothyroxine Sodium 12.5 Mcg (1/2 X 25 Mcg) Or Tabs $ 1.57 Incobotulinumtoxina 50 Units Im Solr $ 1,378.34 Venlafaxine Hcl 12.5 Mg (1/2 X 25 Mg) Po Tabs $ 6.95

Page 42 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Venlafaxine Hcl 25 Mg Po Tabs $ 13.89 Erythromycin Lactobionate 500 Mg Iv Solr $ 638.38 Interferon Alfa-2B 18000000 Units Ij Solr $ 2,353.49 Buspirone Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 2.80 Lubiprostone 24 Mcg Po Caps $ 53.07 Thrombin (Recombinant) 5000 Units Ex Solr $ 737.88 Cinacalcet Hcl 15 Mg (1/2 X 30 Mg) Po Tabs $ 84.77 Polyethylene Glycol 3350 Po Pack $ 7.56 Polyethylene Glycol 3350 Po Pack $ 11.73 Polyethylene Glycol 3350 Po Pack $ 21.50 Polyethylene Glycol 3350 Po Pack $ 8.19 Polyethylene Glycol 3350 Po Pack $ 13.46 Polyethylene Glycol 3350 Po Pack $ 13.44 Polyethylene Glycol 3350 Po Pack $ 11.94 Linagliptin 5 Mg Po Tabs $ 124.75 Linagliptin 5 Mg Po Tabs $ 124.75 Leucovorin Calcium 350 Mg Ij Solr $ 162.59 Aripiprazole 5 Mg Po Tabs $ 229.59 Aripiprazole 5 Mg Po Tabs $ 229.19 Aripiprazole 5 Mg Po Tabs $ 229.58 Aripiprazole 5 Mg Po Tabs $ 229.34 Aripiprazole 5 Mg Po Tabs $ 255.10 Bupropion Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 4.30 Bupropion Hcl 50 Mg (1/2 X 100 Mg) Po Tabs $ 3.79 Methimazole 2.5 Mg ( 1/2 X 5 Mg) Po Tab $ 1.59 Methimazole 2.5 Mg ( 1/2 X 5 Mg) Po Tab $ 1.59 Allopurinol 50 Mg (1/2 X 100 Mg) Po Tabs $ 0.80 Allopurinol 50 Mg (1/2 X 100 Mg) Po Tabs $ 2.70 Allopurinol 150 Mg (1/2 X 300 Mg) Po Tabs $ 6.61 Peginterferon Alfa-2B 300 Mcg Subq Kit $ 16,182.51 Amphetamine-Dextroamphet Er 10 Mg Po Cp24 $ 43.84 Citalopram Hydrobromide 10 Mg Po Tabs $ 17.39 Methylphenidate Hcl Er 27 Mg Po Tbcr $ 71.32 Methylphenidate Hcl Er 27 Mg Po Tbcr $ 68.46 Methylphenidate Hcl Er 27 Mg Po Tbcr $ 101.91 Methylphenidate Hcl Er 27 Mg Po Tbcr $ 58.14 Lisinopril 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 2.35 Lisinopril 1.25 Mg (1/2 X 2.5 Mg) Po Tabs $ 2.35 Benzocaine 20 % Mt Soln $ 58.04 Ceftazidime-Avibactam 2.5 (2-0.5) G Iv Solr $ 1,954.79 Ceftazidime-Avibactam 2.5 (2-0.5) G Iv Solr $ 1,954.79 Duoderm Cgf Dressing Ex Misc $ 79.18 Tiagabine Hcl 2 Mg (1/2 X 4 Mg) Po Tabs $ 23.94 Acetazolamide 62.5 Mg (1/2 X 125 Mg) Po Tabs $ 7.79 Oxycodone Hcl 30 Mg Po Tabs $ 25.66 Oxycodone Hcl 30 Mg Po Tabs $ 25.66 Oxycodone Hcl 30 Mg Po Tabs $ 25.66 Cefoxitin Sodium-Dextrose 2-2.2 Gm-%(50Ml) Iv Solr $ 199.74 Flucytosine 500 Mg Po Caps $ 1,135.46 Flucytosine 500 Mg Po Caps $ 506.46 Niacin 50 Mg Po Tabs $ 0.14 Niacin 50 Mg Po Tabs $ 0.33 Apixaban 2.5 Mg Po Tabs $ 63.51 Mirtazapine 7.5 Mg Po Tabs $ 18.83 Mirtazapine 7.5 Mg Po Tabs $ 18.83 Sodium Chloride 500 Mg (1/2 X 1 Gm) Po Tabs $ 0.27 Irbesartan 150 Mg Po Tabs $ 21.96 Irbesartan 150 Mg Po Tabs $ 22.39 Irbesartan 150 Mg Po Tabs $ 24.01 Irbesartan 150 Mg Po Tabs $ 21.96 Irbesartan 150 Mg Po Tabs $ 53.93

Page 43 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Carbidopa-Levodopa 5-50 Mg (1/2 X 10-100 Mg) Po Tabs $ 4.34 Lubiprostone 8 Mcg Po Caps $ 53.07 Propylthiouracil 12.5 Mg (1/4 X 50 Mg) Po Tabs $ 1.34 Calcium Acetate (Phos Binder) 667 Mg Po Caps $ 5.65 Hurricaine Spr Extension Tubes Misc $ 0.77 Loratadine 5 Mg (1/2 X 10 Mg) Po Tabs $ 1.08 Loratadine 5 Mg (1/2 X 10 Mg) Po Tabs $ 2.95 Buprenorphine Hcl 2 Mg Sl Subl $ 32.18 Buprenorphine Hcl 2 Mg Sl Subl $ 29.60 Buspirone Hcl 7.5 Mg (1/2 X 15 Mg) Po Tabs $ 7.22 Hydrocodone-Homatropine 5-1.5 Mg Po Tabs $ 7.04 Hydrocodone-Homatropine 5-1.5 Mg Po Tabs $ 7.60 Mercaptopurine 12.5 Mg (1/4 X 50 Mg) Po Tabs $ 7.29 Mercaptopurine 25 Mg (1/2 X 50 Mg) Po Tabs $ 14.66 Mycophenolate Sodium 180 Mg Po Tbec $ 46.43 Midodrine Hcl 2.5 Mg Po Tabs $ 10.23 Midodrine Hcl 2.5 Mg Po Tabs $ 12.10 Gelatin Absorbable 100 Ex Misc $ 235.25 Buprenorphine Hcl-Naloxone Hcl 2-0.5 Mg Sl Subl $ 41.62 Buprenorphine Hcl-Naloxone Hcl 2-0.5 Mg Sl Subl $ 41.66 Romiplostim 250 Mcg Subq Solr $ 10,125.56 Oxycodone Hcl Er 40 Mg Po T12A $ 113.07 Fluticasone Furoate 100 Mcg/Act In Aepb $ 49.64 Ampicillin Sodium 1 G Ij Solr $ 61.74 Ampicillin Sodium 1 G Ij Solr $ 58.67 Ampicillin Sodium 1 G Ij Solr $ 61.74 Ampicillin Sodium 1 G Ij Solr $ 61.74 Ampicillin Sodium 1 G Ij Solr $ 42.90 Olmesartan Medoxomil 5 Mg Po Tabs $ 36.72 Buprenorphine Hcl-Naloxone Hcl 8-2 Mg Sl Subl $ 74.51 Buprenorphine Hcl-Naloxone Hcl 8-2 Mg Sl Subl $ 74.51 Doxycycline Hyclate 50 Mg (1/2 X 100 Mg) Po Tabs $ 19.78 Calmol-4 76-10 % Pr Supp $ 4.29 Levoleucovorin Calcium 50 Mg Iv Solr $ 429.00 Promethazine Hcl 12.5 Mg Po Tabs $ 3.50 Ticagrelor 60 Mg Po Tabs $ 53.50 Mesalamine 1.2 G Po Tbec $ 72.28 Calcium Carbonate-Vitamin D 500-200 Mg-Unit Po Tabs $ 0.44 Levothyroxine Sodium 100 Mcg Iv Solr $ 905.91 Levothyroxine Sodium 100 Mcg Iv Solr $ 787.72 Levothyroxine Sodium 100 Mcg Iv Solr $ 905.91 Vitamin D3 25 Mcg (1000 Ut) Po Tabs $ 0.21 Vitamin D3 25 Mcg (1000 Ut) Po Tabs $ 0.28 Vitamin D3 25 Mcg (1000 Ut) Po Tabs $ 0.21 Medroxyprogesterone 1.25 Mg (1/2 X 2.5 Mg) Po Tab $ 1.12 Rosuvastatin Calcium 5 Mg Po Tabs $ 63.96 Rosuvastatin Calcium 5 Mg Po Tabs $ 63.96 Rosuvastatin Calcium 5 Mg Po Tabs $ 10.32 Liothyronine Sodium 5 Mcg Po Tabs $ 6.08 Liothyronine Sodium 5 Mcg Po Tabs $ 13.51 Buspirone Hcl 30 Mg Po Tabs $ 25.98 Methohexital 10 Mg/Ml Inj Dil $ 608.39 Torsemide 10 Mg Po Tabs $ 5.03 Torsemide 10 Mg Po Tabs $ 5.03 Torsemide 20 Mg Po Tabs $ 5.87 Torsemide 20 Mg Po Tabs $ 5.87 Baclofen 2.5 Mg (1/4 X 10 Mg) Po Tabs $ 4.42 Bisoprolol Fumarate 5 Mg Po Tabs $ 10.03 Quinupristin-Dalfopristin 500 Mg Iv Solr $ 2,210.16 Pyrazinamide 250 Mg (1/2 X 500 Mg) Po Tabs $ 10.23 Pyrazinamide 250 Mg (1/2 X 500 Mg) Po Tabs $ 10.22

Page 44 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Ceftaroline Fosamil 600 Mg Iv Solr $ 1,046.68 Fludrocortisone Acetate 0.05 Mg (1/2 X 0.1 Mg) Po Tabs $ 2.68 Fludrocortisone Acetate 0.05 Mg (1/2 X 0.1 Mg) Po Tabs $ 2.88 Rosuvastatin Calcium 10 Mg Po Tabs $ 51.08 Rosuvastatin Calcium 10 Mg Po Tabs $ 10.32 Rosuvastatin Calcium 10 Mg Po Tabs $ 74.62 Rosuvastatin Calcium 10 Mg Po Tabs $ 63.88 Rosuvastatin Calcium 10 Mg Po Tabs $ 63.96 T.E.D. Knee Length/L-Regular Misc $ 58.31 Levorphanol Tartrate 1 Mg (1/2 X 2 Mg) Po Tabs $ 4.93 Metaxalone 400 Mg (1/2 X 800 Mg) Po Tabs $ 21.42 Dutasteride 0.5 Mg Po Caps $ 43.26 Dutasteride 0.5 Mg Po Caps $ 43.24 Dutasteride 0.5 Mg Po Caps $ 43.26 Dutasteride 0.5 Mg Po Caps $ 43.21 Dutasteride 0.5 Mg Po Caps $ 43.24 Dutasteride 0.5 Mg Po Caps $ 43.24 Omega-3-Acid Ethyl Esters 1 G Po Caps $ 14.79 Spironolactone 6.25 Mg (1/4 X 25 Mg) Po Tabs $ 0.77 Buspirone Hcl 15 Mg Po Tabs $ 14.44 Buspirone Hcl 15 Mg Po Tabs $ 14.24 Buspirone Hcl 15 Mg Po Tabs $ 14.44 Buspirone Hcl 15 Mg Po Tabs $ 14.44 Pyridostigmine Bromide 90 Mg (1/2 X 180 Mg) Po Tbcr $ 88.69 Carisoprodol 350 Mg Po Tabs $ 4.26 Carisoprodol 350 Mg Po Tabs $ 4.26 Carisoprodol 350 Mg Po Tabs $ 4.26 Venlafaxine Hcl 37.5 Mg Po Tabs $ 14.30 Venlafaxine Hcl 37.5 Mg Po Tabs $ 14.30 Venlafaxine Hcl 37.5 Mg Po Tabs $ 14.30 Chlordiazepoxide Hcl 25 Mg Po Caps $ 4.79 Chlordiazepoxide Hcl 25 Mg Po Caps $ 3.06 Chlordiazepoxide Hcl 25 Mg Po Caps $ 2.19 Metronidazole 62.5 Mg (1/4 X 250 Mg) Po Tabs $ 0.99 Hydromorphone 1 Mg (1/2 X 2 Mg) Po Tabs $ 4.93 Pancrelipase (Lip-Prot-Amyl) 6000 Units Po Cpep $ 13.35 Lacosamide 50 Mg Po Tabs $ 86.97 Sodium Bicarbonate 325 Mg Po Tabs $ 0.36 Oseltamivir Phosphate 30 Mg Po Caps $ 101.39 Oseltamivir Phosphate 30 Mg Po Caps $ 101.39 Oseltamivir Phosphate 30 Mg Po Caps $ 101.39 Oseltamivir Phosphate 30 Mg Po Caps $ 101.39 Levothyroxine Sodium 56 Mcg (1/2 X 112 Mcg) Or Tabs $ 2.42 Levothyroxine Sodium 56 Mcg (1/2 X 112 Mcg) Or Tabs $ 2.32 Rufinamide 50 Mg (1/4 X 200 Mg) Po Tabs $ 12.11 Alteplase Inj Bolus For Ischemic Stroke $ 47,944.35 Hydromorphone 0.5 Mg (1/4 X 2 Mg) Po Tabs $ 0.86 Aripiprazole Er 400 Mg Im Prsy $ 12,392.75 Insulin Pen Needle 32G X 6 Mm Misc $ 4.38 Prasugrel Hcl 10 Mg Po Tabs $ 131.27 Prasugrel Hcl 10 Mg Po Tabs $ 131.27 Prasugrel Hcl 10 Mg Po Tabs $ 131.27 Cyclosporine Modified 25 Mg Po Caps $ 9.83 Cyclosporine Modified 25 Mg Po Caps $ 18.32 Cyclosporine Modified 25 Mg Po Caps $ 18.45 Cyclosporine Modified 100 Mg Po Caps $ 39.30 Cyclosporine Modified 100 Mg Po Caps $ 73.22 Levothyroxine Sodium 100 Mcg/ 5 Ml Dilution Inj $ 905.91 Phenytoin 25 Mg (1/2 X 50 Mg) Po Chew $ 2.42 Phenytoin 25 Mg (1/2 X 50 Mg) Po Chew $ 5.61 Dapsone 100 Mg Po Tabs $ 21.61

Page 45 of 46 Geisinger Holy Spirit Hospital Medications Published: February 1, 2020

MEDICATION CHARGE

Sildenafil Citrate 10 Mg ( 1/2 X 20 Mg) Po Tab $ 100.24 Sildenafil Citrate 10 Mg ( 1/2 X 20 Mg) Po Tab $ 78.82 Sildenafil Citrate 10 Mg ( 1/2 X 20 Mg) Po Tab $ 71.52 Vitamin C 125 Mg (1/2 X 250 Mg) Po Tabs $ 0.10 Vitamin C 125 Mg (1/2 X 250 Mg) Po Tabs $ 0.12 Amphetamine-Dextroamphetamine 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 7.36 Ciprofloxacin Hcl 500 Mg Po Tabs $ 38.38 Ciprofloxacin Hcl 500 Mg Po Tabs $ 35.26 Albendazole 200 Mg Po Tabs $ 1,142.81 Albendazole 200 Mg Po Tabs $ 1,039.32 Tisseel Tip Spray Dupl 40Cm 0601130 $ 676.59 Sulfamethoxazole-Trimethoprim 400-80 Mg Po Tabs $ 4.75 Bleed Arrest Nose Bleed Sponge $ 214.50 Quikclot Control 12In X 12In Hemostat Dressing $ 1,301.44 Naloxegol Oxalate 12.5 Mg Po Tabs $ 101.64 Pantoprazole Sodium 40 Mg Po Pack $ 129.26 Pancrelipase (Lip-Prot-Amyl) 10440 Units Po Tabs $ 25.22 Metformin Er 500 Mg Po Tb24 $ 5.33 Metformin Er 500 Mg Po Tb24 $ 5.33 Aminocaproic Acid 250 Mg (1/2 X 500 Mg) Po Tabs $ 11.93 Clobazam 10 Mg Po Tabs $ 130.88 Donepezil Hcl 2.5 Mg (1/2 X 5 Mg) Po Tabs $ 29.81 Alteplase Iv Soln For Ischemic Stroke Holy Spirit $ 47,944.35 Trihexyphenidyl Hcl 5 Mg Po Tabs $ 2.60 Quikclot Control 8Inx8In Hemostat Dressing $ 1,260.97 Cefepime Hcl 2 G Ij Solr $ 85.80 Cefepime Hcl 2 G Ij Solr $ 85.80 Cefepime Hcl 2 G Ij Solr $ 288.57 Cefepime Hcl 2 G Ij Solr $ 288.57 Cefepime Hcl 2 G Ij Solr $ 84.08 Cefepime Hcl 2 G Ij Solr $ 288.55 Magnesium Chloride 64 Mg Po Tbec $ 0.76 Magnesium Chloride 64 Mg Po Tbec $ 1.03 Atovaquone-Proguanil Hcl 250-100 Mg Po Tabs $ 52.97 Aspirin 300 Mg (1/2 X 600 Mg) Pr Supp $ 5.39 Tizanidine Hcl 2 Mg Po Tabs $ 8.74 Perampanel 2 Mg Po Tabs $ 138.71 Perampanel 4 Mg Po Tabs $ 274.56 Perampanel 8 Mg Po Tabs $ 274.56 Folic Acid 200 Mcg (1/2 X 400 Mcg) Po Tabs $ 0.13 Vitamin D3 10 Mcg (400 Unit) Po Tabs $ 0.18 Desmopressin Acetate 0.05 Mg (1/2 X 0.1 Mg) Po Tabs $ 10.80 Aerochamber Mv Misc $ 25.41 Lavender Essential Oil Ud $ 38.61 Sweet Orange Essential Oil Ud $ 38.61 Norgestrel-Ethinyl Estradiol 0.3-30 Mg-Mcg Po Tabs $ 7.79

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