Medication Listing Medication Name Strength Units Dosage Form Generic Name NDC Price Manufacturer 8-MOP 10 MG CAPSULE(S) METHOXSALEN 00187-0651-42 1,843.80 Valeant Pharmaceuticals International ABELCET 5 MG/ML (20MG AMPHOTERICIN B LIPID 57665-0101-41 $240.00 Sigma-Tau Pharmaceuticals, Inc. COMPLEX ABILIFY 1 MG/ML (150ML ARIPIPRAZOLE 59148-0013-15 $758.60 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 10 MG TABLET(S) ARIPIPRAZOLE 59148-0008-35 2,297.75 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 15 MG TABLET(S) ARIPIPRAZOLE 59148-0009-35 2,297.75 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 2 MG TABLET(S) ARIPIPRAZOLE 59148-0006-13 $689.36 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 20 MG TABLET(S) ARIPIPRAZOLE 59148-0010-35 3,249.50 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 30 MG TABLET(S) ARIPIPRAZOLE 59148-0011-35 3,249.50 Bristol-Myers Squibb Patient Assistance Foundation ABILIFY 5 MG TABLET(S) ARIPIPRAZOLE 59148-0007-35 2,297.75 Bristol-Myers Squibb Patient Assistance Foundation ABRAXANE 100 MG MG PACLITAXEL 68817-0134-50 1,119.60 Abraxis Oncology PROTEIN-BOUND ACCOLATE 10 MG TABLET(S) ZAFIRLUKAST 00310-0401-60 $130.04 AstraZeneca Foundation ACCOLATE 20 MG TABLET(S) ZAFIRLUKAST 00310-0402-60 $130.04 AstraZeneca Foundation ACCUPRIL 10 MG TABLET(S) QUINAPRIL 00071-0530-23 $211.51 Pfizer, Inc. HYDROCHLORIDE ACCUPRIL 20 MG TABLET(S) QUINAPRIL 00071-0532-23 $235.01 Pfizer, Inc. HYDROCHLORIDE ACCUPRIL 40 MG TABLET(S) QUINAPRIL 00071-0535-23 $211.51 Pfizer, Inc. HYDROCHLORIDE ACCUPRIL 5 MG TABLET(S) QUINAPRIL 00071-0527-23 $211.51 Pfizer, Inc. HYDROCHLORIDE ACCURETIC 10/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZID 00071-0222-23 $209.48 Pfizer, Inc. E/QUINAPRIL HYDROCHLORIDE Printed Date: 8/10/2012 Page 1 of 94 Medication Name Strength Units Dosage Form Generic Name NDC Price Manufacturer ACCURETIC 20/12.5 MG-MG TABLET(S) HYDROCHLOROTHIAZID 00071-0220-23 $209.48 Pfizer, Inc. E/QUINAPRIL HYDROCHLOR ACCURETIC 20/25 MG-MG TABLET(S) HYDROCHLOROTHIAZID 00071-0223-23 $209.48 Pfizer, Inc. E/QUINAPRIL HYDROCHLORIDE ACIPHEX 20 MG TABLET(S) RABEPRAZOLE SODIUM 62856-0243-90 $863.39 Johnson & Johnson Health Care Systems, Inc. ACIPHEX 20 MG TABLET(S) RABEPRAZOLE SODIUM 62856-0243-30 $287.80 Johnson & Johnson Health Care Systems, Inc. ACTIMMUNE 2,000,000 iu/0.5 ml 12 SOL INTERFERON 64116-0011-12 5,372.35 Intermune Pharmaceuticals GAMMA-1B ACTIVASE 100 MG UNIT(S) ALTEPLASE, 50242-0085-27 5,863.49 Genentech, Inc. RECOMBINANT ACTIVASE 50 MG UNIT(S) ALTEPLASE, 50242-0044-13 2,931.74 Genentech, Inc. RECOMBINANT ACTIVELLA 0.5/0.1 MG-MG TABLET(S) ESTRADIOL/NORETHIN 00169-5175-10 $114.42 Novo Nordisk Pharmaceuticals, DRONE ACETATE Inc ACTOPLUS MET 15/500 MG/MG TABLET(S) METFORMIN 64764-0155-18 $969.74 Takeda Pharmaceuticals HYDROCHLORIDE/PIOG America, Inc. LITAZONE HYDROCHLORIDE ACTOPLUS MET 15/850 MG/MG TABLET(S) METFORMIN 64764-0158-18 $969.74 Takeda Pharmaceuticals HYDROCHLORIDE/PIOG America, Inc. LITAZONE HYDROCHLORIDE ACTOPLUS MET XR 1000/15 MG TABLET(S) METFORMIN 64764-0510-30 $175.00 Takeda Pharmaceuticals HYDROCHLORIDE/PIOG America, Inc. LITAZONE HYDROCHLORIDE ACTOPLUS MET XR 1000/30 MG TABLET(S) METFORMIN 64764-0310-30 $346.88 Takeda Pharmaceuticals HYDROCHLORIDE/PIOG America, Inc. LITAZONE HYDROCHLORIDE ACTOS 15 MG TABLET(S) PIOGLITAZONE 64764-0151-05 $638.14 Takeda Pharmaceuticals HYDROCHLORIDE America, Inc. ACTOS 30 MG TABLET(S) PIOGLITAZONE 64764-0301-15 $975.26 Takeda Pharmaceuticals HYDROCHLORIDE America, Inc. ACTOS 45 MG TABLET(S) PIOGLITAZONE 64764-0451-25 1,057.94 Takeda Pharmaceuticals HYDROCHLORIDE America, Inc. Printed Date: 8/10/2012 Page 2 of 94 Medication Name Strength Units Dosage Form Generic Name NDC Price Manufacturer ACUVAIL 0.45 % (0.4 ML )DROP(S) KETOROLAC 00023-3507-30 $174.59 Allergan TROMETHAMINE ACZONE 5 % (30 GM )GEL/JELLY DAPSONE 00023-3670-30 $175.27 Allergan ADACEL 2.5/0.5/2 MCG/ML LFINJECTION(S U ) TDAP VACCINE 49281-0400-10 $474.65 Sanofi-Aventis Pharmaceuticals ADAGEN 250 U/ML INJECTION(S) PEGADEMASE BOVINE 57665-0001-01 4,410.00 Accredo Therapeutics ADALAT CC 30 MG TABLET(S) NIFEDIPINE 00085-1701-02 $161.34 Bayer HealthCare Pharmaceuticals ADALAT CC 60 MG TABLET(S) NIFEDIPINE 00085-1716-02 $287.44 Bayer HealthCare Pharmaceuticals ADALAT CC 90 MG TABLET(S) NIFEDIPINE 00085-1722-01 $336.84 Bayer HealthCare Pharmaceuticals ADCETRIS 50 MG MG brentuximab vedotin 51144-0050-01 5,400.00 Seattle Genetics ADCIRCA 20 MG TABLET(S) TADALAFIL 66302-0467-60 1,600.56 United Therapeutics Corporation ADENOSCAN 3 MG/ML (20 INJECTION(S) ADENOSINE 00469-0871-20 $261.29 Astellas Pharma US, Inc. ADVAIR DISKUS 100/50 0.01;0.05 MG/ACTUATION;MGPUFF(S) FLUTICASONE 00173-0695-00 $225.55 GlaxoSmithKline PROPIONATE ADVAIR DISKUS 250/50 0.25;0.05 MG/ACTUATION;MGPUFF(S) FLUTICASONE 00173-0696-00 $280.24 GlaxoSmithKline PROPIONATE ADVAIR DISKUS 500/50 0.5;0.05 MG/ACTUATION;MGPUFF(S) FLUTICASONE 00173-0697-00 $368.59 GlaxoSmithKline PROPIONATE ADVAIR HFA 115/21 MCT (12 GMPUFF(S) FLUTICASONE 00173-0716-00 $226.64 GlaxoSmithKline PROPIONATE/SALMETE ROL XINAFOATE ADVAIR HFA 115/30.45 MCG/ACTUATIONPUFF(S) FLUTICASONE/SALMET 00173-0716-20 $261.90 GlaxoSmithKline EROL ADVAIR HFA 230/21 MCG/ACTUATIONPUFF(S) FLUTICASONE/SALMET 00173-0717-00 $313.01 GlaxoSmithKline EROL ADVAIR HFA 230/30.45 MCG PUFF(S) FLUTICASONE/SALMET 00173-0717-20 $344.48 GlaxoSmithKline EROL ADVAIR HFA 45/21 MCG/ACTUATIONPUFF(S) FLUTICASONE/SALMET 00173-0715-00 $174.66 GlaxoSmithKline EROL ADVICOR 1000/20 MG-MG TABLET(S) LOVASTATIN/NIACIN 00074-3007-90 $446.46 Abbott Laboratories ADVICOR 1000/40 MG-MG TABLET(S) LOVASTATIN/NIACIN 00074-3010-90 $516.86 Abbott Laboratories ADVICOR 500/20 MG TABLET(S) LOVASTATIN/NIACIN 00074-3005-90 $388.26 Abbott Laboratories ADVICOR 750/20 MG-MG TABLET(S) LOVASTATIN/NIACIN 00074-3072-90 $416.45 Abbott Laboratories AEROCHAMBER -- DEVICE SPACER, INHALATION 00456-3154-67 $39.62 Forest Pharmaceuticals, Inc. AEROCHAMBER w/MASK LARGE - DEVICE SPACER, INHALATION 00456-0746-13 $53.42 Forest Pharmaceuticals, Inc. Printed Date: 8/10/2012 Page 3 of 94 Medication Name Strength Units Dosage Form Generic Name NDC Price Manufacturer AEROCHAMBER w/MASK MEDIUM - DEVICE SPACER, INHALATION 00456-0745-13 $53.42 Forest Pharmaceuticals, Inc. AEROCHAMBER w/MASK SMALL - DEVICE SPACER, INHALATION 00456-0744-13 $53.42 Forest Pharmaceuticals, Inc. AFINITOR 10 MG TABLET(S) EVEROLIMUS 00078-0567-51 8,396.40 Novartis Pharmaceuticals Corporation AFINITOR 5 MG TABLET(S) EVEROLIMUS 00078-0566-61 7,961.36 Novartis Pharmaceuticals Corporation AGGRASTAT 0.05 mg/100ml SOL TIROFIBAN 25208-0002-01 $287.55 Merck & Co., Inc. HYDROCHLORIDE AGGRASTAT 0.05 mg/250ml SOL TIROFIBAN 25208-0002-02 $602.10 Merck & Co., Inc. HYDROCHLORIDE AGGRASTAT 0.25 mg/50ml SOL TIROFIBAN 00006-3713-50 $557.50 Merck & Co., Inc. HYDROCHLORIDE AGGRENOX 25-200 MG CAPSULE(S) ASPIRIN/DIPYRIDAMOLE 00597-0001-60 $267.35 Boehringer Ingelheim Pharmaceuticals, Inc. ALBENZA 200 mg TABLET(S) ALBENDAZOLE 52054-0550-28 $966.00 GlaxoSmithKline ALCAINE 0.5 % (15 ML) DROP(S) PROPARACAINE 00998-0016-15 $32.88 Alcon Laboratories, Inc. HYDROCHLORIDE ALDACTAZIDE 25-25 MG-MG TABLET(S) HYDROCHLOROTHIAZID 00025-1011-31 $111.72 Pfizer, Inc. E/SPIRONOLACTONE ALDACTAZIDE 50-50 MG-MG TABLET(S) HYDROCHLOROTHIAZID 00025-1021-31 $206.05 Pfizer, Inc. E/SPIRONOLACTONE ALDACTONE 100 MG TABLET(S) SPIRONOLACTONE 00025-1031-31 $320.47 Pfizer, Inc. ALDACTONE 25 MG TABLET(S) SPIRONOLACTONE 00025-1001-31 $108.84 Pfizer, Inc. ALDACTONE 50 MG TABLET(S) SPIRONOLACTONE 00025-1041-31 $191.16 Pfizer, Inc. ALIMTA 500 MG MG PEMETREXED 00002-7623-01 3,204.36 Eli Lilly and Company ALINIA 500 MG TABLET(S) NITAZOXANIDE 67546-0111-11 1,365.60 Romark Laboratories ALODOX 20 MG TABLET(S) DOXYCYCLINE 54799-0534-66 $94.80 OcuSOFT, Inc. HYCLATE ALOMIDE 0.1 % (10 ML) DROP(S) LODOXAMIDE 00065-0345-10 $100.56 Alcon Laboratories, Inc. TROMETHAMINE ALOXI 0.05 MG/ML (5 MG PALONOSETRON 62856-0797-01 $445.20 Eisai, Inc. HYDROCHLORIDE ALPHAGAN P 0.1 % 15ml DROP(S) BRIMONIDINE 00023-9321-15 $215.98 Allergan TARTRATE ALREX 0.2 % (10ML) DROP(S) LOTEPREDNOL 24208-0353-10 $263.51 Bausch & Lomb Incorporated ETABONATE ALTABAX OINTMENT 1 % (15 GM )APPLICATION RETAPAMULIN 00007-5180-22 $93.96 GlaxoSmithKline Printed Date: 8/10/2012 Page 4 of 94 Medication Name Strength Units Dosage Form Generic Name NDC Price Manufacturer AMBISOME 50 MG INJECTION(S) AMPHOTERICIN B 00469-3051-30 $188.40 Astellas Pharma US, Inc. LIPOSOME AMERGE 1 mg TABLET(S) NARATRIPTAN 00173-0561-00 $280.86 GlaxoSmithKline HYDROCHLORIDE AMERGE 2.5 mg TABLET(S) NARATRIPTAN 00173-0562-00 $280.86 GlaxoSmithKline HYDROCHLORIDE AMITIZA 24 MCG CAPSULE(S) LUBIPROSTONE 64764-0240-60 $296.30 Takeda Pharmaceuticals America, Inc. AMITIZA 8 MCG CAPSULE(S) LUBIPROSTONE 64764-0080-60 $296.30 Takeda Pharmaceuticals America, Inc. AMTURNIDE 150-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE 00078-0610-15 $89.28 Novartis Pharmaceuticals BESYLATE/HYDROCHLO Corporation ROTHIAZIDE AMTURNIDE 300-10-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE 00078-0613-15 $112.68 Novartis Pharmaceuticals BESYLATE/HYDROCHLO Corporation ROTHIAZIDE AMTURNIDE 300-10-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE 00078-0614-15 $112.68 Novartis Pharmaceuticals BESYLATE/HYDROCHLO Corporation ROTHIAZIDE AMTURNIDE 300-5-12.5 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE 00078-0611-15 $112.68 Novartis Pharmaceuticals BESYLATE/HYDROCHLO Corporation ROTHIAZIDE AMTURNIDE 300-5-25 MG-MG-MG TABLET(S) ALISKIREN/AMLODIPINE 00078-0612-15 $112.68 Novartis Pharmaceuticals BESYLATE/HYDROCHLO Corporation ROTHIAZIDE ANADROL-50 50 MG TABLET(S) OXYMETHOLONE 68220-0055-10 2,993.50 Meda Pharmaceuticals ANAFRANIL 25 MG CAPSULE(S) CLOMIPRAMINE 00406-9906-03 $420.48 Mallinckrodt Pharmaceuticals HYDROCHLORIDE ANAFRANIL 50 MG CAPSULE(S) CLOMIPRAMINE 00406-9907-03 $420.48 Mallinckrodt Pharmaceuticals HYDROCHLORIDE ANAFRANIL 75 MG CAPSULE(S) CLOMIPRAMINE 00406-9908-03 $420.48 Mallinckrodt Pharmaceuticals HYDROCHLORIDE ANALPRAM-HC CREAM 1-1 %-% (30 GMAPPLICATION HYDROCORTISONE 00496-0778-04 $74.16 Ferndale Laboratories, Inc.