Price Hikes: January 1-6, 2021 WAC % Brand Name Generic Name Brand/Generic Manufacturer Change Effective Date 1 ABRAXANE paclitaxel protein-bound Brand named CELGENE 4.5 01/01/2021 2 ACETYLCYSTEINE acetylcysteine Generically named HOSPIRA/ 4.99 01/01/2021 3 ACTEMRA tocilizumab Brand named INC. 3 01/01/2021 4 ACTHIB Haemophilus b conjugate vaccine(tetanus toxoid conjugate)/PFBrand named -PASTEUR 2.99 01/01/2021 5 ACTIQ fentanyl citrate Brand named TEVA USA 9.4 01/01/2021 6 ACULAR ketorolac tromethamine Brand named INC. 5 01/01/2021 7 ACULAR LS ketorolac tromethamine Brand named ALLERGAN INC. 5 01/01/2021 8 ACUVAIL ketorolac tromethamine/PF Brand named ALLERGAN INC. 5 01/01/2021 9 ACZONE dapsone Brand named ALMIRALL LLC 3 01/02/2021 10 ADACEL TDAP diphtheriapertussis(acellular)tetanus vaccine/PF Brand named SANOFI-PASTEUR 3.01 01/01/2021 11 ADDERALL sulf-saccharate/amphetamine sulf-aspartateBrand named TEVA USA 9.4 01/01/2021 12 ADEMPAS riociguat Brand named BAYERPHARM DIV 6 01/01/2021 13 ADIPEX-P phentermine HCl Brand named TEVA SELECT BRA 9.4 01/01/2021 14 ADLYXIN lixisenatide Brand named SANOFI-AVENTIS 5.1 01/03/2021 15 ADVAIR HFA propionate/ xinafoate Brand named GLAXOSMITHKLINE 3 01/01/2021 16 ADVATE antihemophilic factor (FVIII) recombinant,full length Brand named BAXALTA US INC. 2.96 01/05/2021 17 ADYNOVATE antihemophilic factor (FVIII) recombinant, full length, peg Brand named BAXALTA US INC. 2.78 01/05/2021 18 AEMCOLO RIFAMYCIN SODIUM Brand named ARIES/REDHILL B 3 01/01/2021 19 AIRDUO RESPICLICK fluticasone propionate/salmeterol xinafoate Brand named TEVA SPECIALTY 9.4 01/01/2021 20 AJOVY SYRINGE fremanezumab-vfrm Brand named TEVA USA 5 01/01/2021 21 ALDURAZYME laronidase Brand named GENZYME 5 01/15/2021 22 ALECENSA alectinib HCl Brand named GENENTECH INC. 3 01/01/2021 23 ALIQOPA copanlisib di-HCl Brand named BAYERPHARM DIV 1.99 01/01/2021 24 ALOCRIL nedocromil sodium Brand named ALLERGAN INC. 5 01/01/2021 25 ALPHAGAN P tartrate Brand named ALLERGAN INC. 5 01/01/2021 26 ALPROLIX factor IX recombinant, Fc fusion protein Brand named BIOVERATIV THER 3.09 01/03/2021 27 ALREX loteprednol etabonate Brand named VALEANT/BAUSCH 5 01/01/2021 28 ALTABAX retapamulin Brand named ALMIRALL LLC 3 01/02/2021 29 ALUNBRIG brigatinib Brand named MILLENNIUM PHAR 4 01/04/2021 30 AMBIEN zolpidem tartrate Brand named SANOFI-AVENTIS 5.01 01/03/2021 31 AMBIEN CR zolpidem tartrate Brand named SANOFI-AVENTIS 5.01 01/03/2021 32 AMBISOME amphotericin B liposome Brand named ASTELLAS PHARMA 3 01/05/2021 33 AMELUZ aminolevulinic acid HCl Brand named BIOFRONTERA INC 5.35 01/01/2021 34 AMINOPHYLLINE aminophylline Generically named HOSPIRA/PFIZER 5.09 01/01/2021 35 AMPYRA dalfampridine Brand named ACORDA THERAPEU 9.5 01/01/2021 36 AMRIX HCl Brand named TEVA USA 9.4 01/01/2021

1 Price Hikes: January 1-6, 2021 WAC % Brand Name Generic Name Brand/Generic Manufacturer Change Effective Date 37 ANALPRAM HC hydrocortisone acetate/pramoxine HCl Brand named SEBELA PHARMACE 5 01/01/2021 38 ANASCORP centruroides (scorpion) polyvalent antivenom Brand named RARE DISEASE 2.5 01/01/2021 39 ANNOVERA segesterone acetate/ethinyl estradiol Brand named THERAPEUTICSMD 4.5 01/01/2021 40 ANORO ELLIPTA umeclidinium bromide/ trifenatate Brand named GLAXOSMITHKLINE 3 01/01/2021 41 ANTIVENIN MICRURUS antiveninMicrurusFULVIUS fulvius Generically named WYETH/PFIZER 5 01/01/2021 42 ANUSOL-HC hydrocortisone Brand named SALIX PHARMACEU 7.9 01/01/2021 43 APLENZIN HBr Brand named VALEANT/BAUSCH 7.9 01/01/2021 44 APTIOM eslicarbazepine acetate Brand named SUNOVION PHARMA 4.7 01/01/2021 45 APTIVUS tipranavir Brand named BOEHRINGER ING. 4 01/01/2021 46 ARALAST NP alpha-1-proteinase inhibitor Brand named BAXALTA US INC. 1.79 01/05/2021 47 ARAVA leflunomide Brand named SANOFI-AVENTIS 5.01 01/03/2021 48 ARIKAYCE amikacin sulfate liposomal with nebulizer accessories Brand named INSMED INCORPOR 6.5 01/01/2021 49 ARMOUR THYROID thyroidpork Brand named FOREST/ALLERGAN 5 01/01/2021 50 ARNUITY ELLIPTA Brand named GLAXOSMITHKLINE 3 01/01/2021 51 ARTISS thrombin(hum plas)/fibrinogen/aprotininsyn/ Brand named BAXTER HEALTHCA 6.09 01/01/2021 52 ASPARLAS calaspargase pegol-mknl Brand named SERVIER PHARMAC 1.27 01/01/2021 53 ASTAGRAF XL tacrolimus Brand named ASTELLAS PHARMA 3 01/05/2021 54 ATGAM lymphocyte immune globulinantithymocyte (equine) Brand named PHARMACI/PFIZER 5 01/01/2021 55 ATIVAN lorazepam Brand named VALEANT/BAUSCH 7.9 01/01/2021 56 ATROPINE SULFATE atropine sulfate Generically named HOSPIRA/PFIZER 2.96 01/01/2021 57 ATROVENT HFA ipratropium bromide Brand named BOEHRINGER ING. 4 01/01/2021 58 AUBAGIO teriflunomide Brand named SANOFI-AVENTIS 5.1 01/03/2021 59 AUSTEDO deutetrabenazine Brand named TEVA USA 5.9 01/01/2021 60 AVALIDE irbesartan/hydrochlorothiazide Brand named SANOFI-AVENTIS 5.01 01/03/2021 61 AVAPRO irbesartan Brand named SANOFI-AVENTIS 5.01 01/03/2021 62 AVONEX interferon beta-1a Brand named -IDEC 2 01/01/2021 63 AVONEX PEN interferon beta-1a Brand named BIOGEN-IDEC 2 01/01/2021 64 AXUMIN fluciclovine F 18 Brand named BLUE EARTH DIAG 19.85 01/01/2021 65 AYGESTIN norethindrone acetate Brand named TEVA WOMEN'S HE 9.39 01/01/2021 66 AZASAN azathioprine Brand named SALIX PHARMACEU 7.9 01/01/2021 67 AZELEX azelaic acid Brand named ALMIRALL LLC 3 01/02/2021 68 AZILECT rasagiline mesylate Brand named TEVA NEUROSCIEN 9.4 01/01/2021 69 AZOR amlodipine besylate/olmesartan medoxomil Brand named DAIICHI SANKYO 4.58 01/01/2021 70 BELBUCA buprenorphine HCl Brand named BIODELIVERY SCI 5 01/01/2021 71 BENEFIX factor IX human recombinant Brand named WYETH/PFIZER 2.84 01/01/2021

2 Price Hikes: January 1-6, 2021 WAC % Brand Name Generic Name Brand/Generic Manufacturer Change Effective Date 72 BENICAR olmesartan medoxomil Brand named DAIICHI SANKYO 4.55 01/01/2021 73 BENICAR HCT olmesartan medoxomil/hydrochlorothiazide Brand named DAIICHI SANKYO 4.58 01/01/2021 74 BENLYSTA belimumab Brand named GLAXOSMITHKLINE 5 01/01/2021 75 BEPREVE bepotastine besilate Brand named VALEANT/BAUSCH 5 01/01/2021 76 BERINERT C1 esterase inhibitor Brand named CSL BEHRING LLC 4.84 01/01/2021 77 BESIVANCE besifloxacin HCl Brand named VALEANT/BAUSCH 6 01/01/2021 78 BESPONSA inotuzumab ozogamicin Brand named WYETH/PFIZER 1.5 01/01/2021 79 BETAPACE HCl Brand named COVIS PHARMA 5 01/04/2021 80 BETAPACE AF sotalol HCl Brand named COVIS PHARMA 5 01/04/2021 81 BETASERON interferon beta-1b Brand named BAYERPHARM DIV 3 01/01/2021 82 BEVESPI AEROSPHEREglycopyrrolate/ fumarate Brand named ASTRAZENECA 3 01/01/2021 83 BEXSERO meningococcal group B vaccine 4-component Brand named GLAXOSMITHKLINE 7 01/01/2021 84 BEYAZ drospirenone/ethinyl estradiol/levomefolate calcium Brand named BAYERPHARM DIV 4.98 01/01/2021 85 BIDIL isosorbide dinitrate/hydralazine HCl Brand named ARBOR PHARMACEU 3 01/01/2021 86 BIJUVA estradiol/progesterone Brand named THERAPEUTICSMD 4.5 01/01/2021 87 BIKTARVY bictegravir sodium/emtricitabine/tenofovir alafenamide fumar Brand named GILEAD SCIENCES 4.8 01/01/2021 88 BLEPH-10 sulfacetamide sodium Brand named ALLERGAN INC. 5 01/01/2021 89 BLEPHAMIDE sulfacetamide sodium/prednisolone acetate Brand named ALLERGAN INC. 5 01/01/2021 90 BLEPHAMIDE S.O.P. sulfacetamide sodium/prednisolone acetate Brand named ALLERGAN INC. 5 01/01/2021 91 BONJESTA doxylamine succinate/pyri