Oct-2021

MISSOURI SPECIALTY MAC

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ABELCET 5 MG/ML 57665010141 $4.9800/ml

ABILIFY MAINTENA 300 MG 59148001871 $1746.5662/each

ABILIFY MAINTENA 300 MG 59148004580 $1746.5662/each

ABILIFY MAINTENA 400 MG 59148001971 $2328.7582/each

ABILIFY MAINTENA 400 MG 59148007280 $2328.7582/each

ABRAXANE 100 MG 68817013450 $1512.0200/each

ACTEMRA ACTPEN 162 MG/0.9 50242014301 $1195.5889/ml

ACTEMRA 162 MG/0.9 50242013801 $1195.5889/ml

ACTEMRA 200MG/10ML 50242013601 $115.2900/ml

ACTEMRA 400MG/20ML 50242013701 $115.2900/ml

ACTEMRA 80 MG/4 ML 50242013501 $115.2900/ml

ACTHAR 80 UNIT/ML 63004871001 $7940.9088/ml

ACTHREL 100 MCG 55566030201 $908.9098/each

ACTIMMUNE 100MCG/0.5 75987011110 $10016.2142/ml

ACTIMMUNE 100MCG/0.5 75987011111 $10016.2142/ml

ACTIVASE 100 MG 50242008527 $8659.5542/each

ACTIVASE 50 MG 50242004413 $4329.7771/each

ADAKVEO 100MG/10ML 00078088361 $238.3059/ml

ADCETRIS 50 MG 51144005001 $9210.0750/each

ADEMPAS 0.5 MG 50419025001 $128.5438/tablet

ADEMPAS 0.5 MG 50419025091 $128.5438/tablet

ADEMPAS 1 MG 50419025101 $128.5438/tablet

ADEMPAS 1 MG 50419025103 $0.0000 Delete

ADEMPAS 1 MG 50419025191 $128.5438/tablet

ADEMPAS 1.5 MG 50419025201 $128.5438/tablet

ADEMPAS 1.5 MG 50419025203 $0.0000 Delete

ADEMPAS 1.5 MG 50419025291 $128.5438/tablet

ADEMPAS 2 MG 50419025301 $128.5438/tablet

ADEMPAS 2 MG 50419025303 $0.0000 Delete

ADEMPAS 2 MG 50419025391 $128.5438/tablet

ADEMPAS 2.5 MG 50419025401 $128.5438/tablet

ADEMPAS 2.5 MG 50419025403 $0.0000 Delete

ADEMPAS 2.5 MG 50419025491 $128.5438/tablet

ADUHELM 170 MG/1.7 64406010101 $557.7600/ml

ADUHELM 300MG/3ML 64406010202 $557.7600/ml

ADVATE 1000 (+/-) 00944305302 $1.3572/each

ADVATE 1500 (+/-) 00944305402 $1.3572/each

ADVATE 2000 (+/-) 00944304510 $1.3572/each

ADVATE 250 (+/-) 00944305102 $1.3572/each

ADVATE 3000 (+/-) 00944304610 $1.3572/each

ADVATE 4000 (+/-) 00944304710 $1.3572/each

ADVATE 500 (+/-) 00944305202 $1.3572/each

ADYNOVATE 1000 (+/-) 00944462401 $1.9536/each

ADYNOVATE 1500 (+/-) 00944462701 $1.9536/each

ADYNOVATE 2000 (+/-) 00944462501 $1.9536/each

ADYNOVATE 250 (+/-) 00944462201 $1.9536/each

ADYNOVATE 3000 (+/-) 00944462801 $1.9536/each

ADYNOVATE 500 (+/-) 00944462301 $1.9536/each

ADYNOVATE 750 (+/-) 00944462601 $1.9536/each

AFINITOR DISPERZ 2 MG 00078062651 $531.4848/tablet

AFINITOR DISPERZ 2 MG 00078062661 $531.4855/tablet

AFINITOR DISPERZ 3 MG 00078062751 $536.8088/tablet

AFINITOR DISPERZ 3 MG 00078062761 $536.7942/tablet

AFINITOR DISPERZ 5 MG 00078062851 $558.7101/tablet

AFINITOR DISPERZ 5 MG 00078062861 $558.7062/tablet

AFINITOR 10 MG 00078056751 $558.7101/tablet

AFINITOR 10 MG 00078056761 $558.6763/tablet

AFSTYLA 1000 (+/-) 69911047602 $1.4365/each

AFSTYLA 1500 (+/-) 69911048002 $1.4365/each

AFSTYLA 2000 (+/-) 69911047702 $1.4365/each

AFSTYLA 250 (+/-) 69911047402 $1.4365/each

Page 1 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

AFSTYLA 2500 (+/-) 69911048102 $1.4365/each

AFSTYLA 3000 (+/-) 69911047802 $1.4365/each

AFSTYLA 500 (+/-) 69911047502 $1.4365/each

ALDURAZYME 2.9 MG/5ML 58468007001 $192.2474/ml

ALECENSA 150 MG 50242013001 $65.8085/capsule

ALFERON N 5MMUNIT/ML 54746000101 $597.6000/ml

ALIMTA 100 MG 00002764001 $769.6600/each

ALIMTA 500 MG 00002762301 $3848.2800/each

ALIQOPA 60 MG 50419038501 $4758.0000/each

ALKERAN 2 MG 52609000105 $11.2751/tablet

ALPHANATE 1000 (400) 68516460302 $1.0160/each

ALPHANATE 1000 (400) 68516461302 $1.0400/each

ALPHANATE 1500 (600) 68516461402 $1.0400/each

ALPHANATE 2000 (800) 68516460902 $1.0160/each

ALPHANATE 2000 (800) 68516461502 $1.0400/each

ALPHANATE 250 (100) 68516460101 $1.0160/each

ALPHANATE 250 (100) 68516461101 $1.0400/each

ALPHANATE 500 (200) 68516460201 $1.0160/each

ALPHANATE 500 (200) 68516461201 $1.0400/each

ALPHANINE SD 1000 (+/-) 68516360802 $1.1840/each

ALPHANINE SD 1500 (+/-) 68516360302 $1.1440/each

ALPHANINE SD 1500 (+/-) 68516360902 $1.1840/each

ALPHANINE SD 500 (+/-) 68516360102 $1.1440/each

ALPHANINE SD 500 (+/-) 68516360702 $1.1840/each

ALPROLIX 1000 UNIT 71104092201 $3.2064/each

ALPROLIX 2000 UNIT 71104093301 $3.2064/each

ALPROLIX 250 UNIT 71104096601 $3.2064/each

ALPROLIX 3000 UNIT 71104094401 $3.2064/each

ALPROLIX 4000 UNIT 71104097701 $3.2064/each

ALPROLIX 500 UNIT 71104091101 $3.2064/each

ALUNBRIG 180 MG 63020018030 $565.0308/tablet

ALUNBRIG 30 MG 63020011330 $188.4100/tablet

ALUNBRIG 90 MG 63020009007 $565.1589/tablet

ALUNBRIG 90 MG 63020009030 $565.0308/tablet

ALUNBRIG 90MG-180MG 63020019830 $565.0308/tablet

AMBISOME 50 MG 00469305130 $266.2208/each

AMIFOSTINE 500 MG 47335058140 $442.9208/each

AMIFOSTINE 500 MG 47335058142 $442.8947/each

AMONDYS-45 100 MG/2ML 60923022702 $800.0000/ml

ANDEXXA 200 MG 69853010201 $5500.0000/each

APOKYN 10 MG/ML 27505000401 $409.9104/ml Increase

APOKYN 10 MG/ML 27505000405 $409.9118/ml Increase

APTIVUS 250 MG 00597000302 $14.9849/capsule

ARALAST NP 1000 MG 00944281501 $0.5677/each

ARALAST NP 500 MG 00944281401 $0.5677/each

ARANESP 100 MCG/ML 55513000501 $766.2600/ml

ARANESP 100 MCG/ML 55513000504 $766.2600/ml

ARANESP 100MCG/0.5 55513002501 $1532.5200/ml

ARANESP 100MCG/0.5 55513002504 $1532.5200/ml

ARANESP 10MCG/0.4 55513009801 $191.5650/ml

ARANESP 10MCG/0.4 55513009804 $191.5650/ml

ARANESP 150MCG/0.3 55513002701 $3831.3000/ml

ARANESP 150MCG/0.3 55513002704 $3831.3000/ml

ARANESP 200 MCG/ML 55513000601 $1532.5200/ml

ARANESP 200MCG/0.4 55513002801 $3831.3000/ml

ARANESP 25 MCG/ML 55513000201 $191.5650/ml

ARANESP 25 MCG/ML 55513000204 $191.5650/ml

ARANESP 25MCG/0.42 55513005701 $456.1071/ml

ARANESP 25MCG/0.42 55513005704 $456.1071/ml

ARANESP 300 MCG/ML 55513011001 $2298.7800/ml

ARANESP 300MCG/0.6 55513011101 $3831.3000/ml

ARANESP 40 MCG/0.4 55513002101 $766.2600/ml

ARANESP 40 MCG/0.4 55513002104 $766.2600/ml

Page 2 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ARANESP 40 MCG/ML 55513000301 $306.5040/ml

ARANESP 40 MCG/ML 55513000304 $306.5040/ml

ARANESP 500 MCG/ML 55513003201 $3831.3000/ml

ARANESP 60 MCG/0.3 55513002301 $1532.5200/ml

ARANESP 60 MCG/0.3 55513002304 $1532.5200/ml

ARANESP 60 MCG/ML 55513000401 $459.7560/ml

ARANESP 60 MCG/ML 55513000404 $459.7560/ml

ARCALYST 220 MG 61755000101 $4980.0000/each

ARCALYST 220 MG 73604091404 $4980.0000/each

ARIKAYCE 590 MG/8.4 71558059028 $52.4326/ml

ARISTADA INITIO 675 MG/2.4 65757050003 $878.9828/ml

ARISTADA 1064MG/3.9 65757040403 $852.6375/ml

ARISTADA 441 MG/1.6 65757040103 $861.4003/ml

ARISTADA 662 MG/2.4 65757040203 $862.0544/ml

ARISTADA 882 MG/3.2 65757040303 $861.4003/ml

ARRANON 250MG/50ML 00078068306 $14.7073/ml

ARRANON 250MG/50ML 00078068361 $14.7074/ml

ARSENIC TRIOXIDE 12 MG/6 ML 70710161006 $85.3222/ml

ARZERRA 100 MG/5ML 00078066913 $120.6740/ml

ARZERRA 100 MG/5ML 00078066961 $120.6700/ml

ARZERRA 1000 MG/50 00078069061 $120.6740/ml

ASCENIV 10 % 69800025001 $72.7200/ml

ASPARLAS 3750/5 ML 72694051501 $4860.8000/ml

ASTAGRAF XL 0.5 MG 00469064773 $2.3623/capsule

ASTAGRAF XL 1 MG 00469067773 $4.7249/capsule

ASTAGRAF XL 5 MG 00469068773 $23.6237/capsule

ATGAM 50 MG/ML 00009722401 $450.7338/ml

ATGAM 50 MG/ML 00009722402 $450.7338/ml

ATRYN 1750 UNIT 42976012102 $2.7988/each

ATRYN 525 UNIT 42976012101 $2.7988/each

AUBAGIO 14 MG 58468021002 $265.9539/tablet

AUBAGIO 14 MG 58468021004 $265.9543/tablet

AUBAGIO 7 MG 58468021101 $265.9539/tablet

AUBAGIO 7 MG 58468021104 $265.9543/tablet

AUSTEDO 12 MG 68546017260 $101.9992/tablet

AUSTEDO 6 MG 68546017060 $67.9986/tablet

AUSTEDO 9 MG 68546017160 $76.4978/tablet

AVASTIN 25 MG/ML 50242006001 $150.0000/ml

AVASTIN 25 MG/ML 50242006010 $150.0000/ml

AVASTIN 25 MG/ML 50242006101 $150.0000/ml

AVASTIN 25 MG/ML 50242006110 $150.0000/ml

AVONEX PEN 30MCG/.5ML 59627033304 $7061.4292/each

AVONEX 30MCG/.5ML 59627022205 $7061.4292/each

AVSOLA 100 MG 55513067001 $480.0000/each

AVYCAZ 2.5 G 00456270001 $357.3748/each

AVYCAZ 2.5 G 00456270010 $357.3738/each

AYVAKIT 100 MG 72064011030 $1114.4576/tablet

AYVAKIT 200 MG 72064012030 $1114.4576/tablet

AYVAKIT 25 MG 72064012530 $1114.4576/tablet

AYVAKIT 300 MG 72064013030 $1114.4576/tablet

AYVAKIT 50 MG 72064015030 $1114.4576/tablet

AZATHIOPRINE SODIUM 100 MG 00143956601 $125.0000/each

AZEDRA DOSIMETRIC 30 MCI/2ML 71258001502 $9060.0000/each

AZEDRA THERAPEUTIC 337.5/22.5 71258001522 $101925.0000/each

BACLOFEN 10000/20ML 25021067820 $11.7672/ml Add

BACLOFEN 10000/20ML 67457056220 $9.2404/ml

BACLOFEN 20K MCG/20 25021068020 $23.5340/ml Add

BACLOFEN 20K MCG/20 67457056320 $18.4813/ml

BACLOFEN 40000/20ML 25021067920 $47.0680/ml Add

BACLOFEN 40000/20ML 67457056420 $36.9621/ml

BACLOFEN 50 MCG/ML 25021068171 $87.5683/ml Add

BAFIERTAM 95 MG 69387000101 $47.4780/capsule

BALVERSA 3 MG 59676003056 $294.5104/tablet

Page 3 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

BALVERSA 3 MG 59676003084 $294.5104/tablet

BALVERSA 4 MG 59676004028 $392.6805/tablet

BALVERSA 4 MG 59676004056 $392.6806/tablet

BALVERSA 5 MG 59676005028 $490.8509/tablet

BARACLUDE 0.05 MG/ML 00003161412 $4.5291/ml

BAVENCIO 200MG/10ML 44087353501 $170.2580/ml

BCG (TICE STRAIN) 50 MG 00052060202 $149.2165/each

BELEODAQ 500 MG 68152010809 $2000.9900/each

BELEODAQ 500 MG 72893000201 $2092.3900/each

BELRAPZO 25 MG/ML 42367052125 $646.7750/ml

BENDAMUSTINE HCL 25 MG/ML 42367052025 $636.3850/ml

BENDEKA 25 MG/ML 63459034804 $615.9762/ml

BENEFIX 1000 UNIT 58394063503 $1.2325/each

BENEFIX 2000 UNIT 58394063603 $1.2325/each

BENEFIX 250 UNIT 58394063303 $1.2325/each

BENEFIX 3000 UNIT 58394063703 $1.2325/each

BENEFIX 500 UNIT 58394063403 $1.2325/each

BENLYSTA 120 MG 49401010101 $563.8426/each

BENLYSTA 200 MG/ML 49401008835 $991.7969/ml

BENLYSTA 200 MG/ML 49401008847 $991.7969/ml

BENLYSTA 400 MG 49401010201 $1879.4080/each

BEOVU 6MG/0.05ML 00078082761 $36852.0000/ml

BERINERT 500(10 ML) 63833082502 $3237.0000/each

BESPONSA 0.9 MG 00008010001 $20029.6908/each

BETASERON 0.3 MG 50419052401 $572.9276/each

BETASERON 0.3 MG 50419052435 $572.9276/each

BETHKIS 300 MG/4ML 10122082028 $27.5045/ml

BETHKIS 300 MG/4ML 10122082056 $27.5045/ml

BIKTARVY 50-200-25 61958250101 $110.2969/tablet

BIKTARVY 50-200-25 61958250103 $110.2969/tablet

BIVALIRUDIN-0.9% NACL 250MG/50ML 00338957224 $9.9600/ml

BIVALIRUDIN-0.9% NACL 500MG/0.1L 00338957612 $9.9600/ml

BIVALIRUDIN 250 MG 00409830015 $479.6109/each

BIVALIRUDIN 250MG/50ML 70860040351 $3.4960/ml

BIVIGAM 10 % 69800650201 $13.2468/ml

BIVIGAM 10 % 69800650301 $13.2468/ml Add

BLENREP 100 MG 00173089601 $8401.1600/each

BLINCYTO 35 MCG 55513016001 $4242.1000/each

BORTEZOMIB 3.5 MG 43598086560 $1596.5681/each

BORTEZOMIB 3.5 MG 63323072110 $1596.5681/each

BOSENTAN 125 MG 00054052121 $16.4781/tablet

BOSENTAN 125 MG 00591251260 $18.7850/tablet

BOSENTAN 125 MG 47335003986 $16.4781/tablet

BOSENTAN 125 MG 49884005902 $16.4781/tablet

BOSENTAN 125 MG 65162087406 $16.4781/tablet

BOSENTAN 125 MG 68382044714 $42.6638/tablet

BOSENTAN 62.5 MG 00054052021 $16.4781/tablet

BOSENTAN 62.5 MG 00591251160 $18.7850/tablet

BOSENTAN 62.5 MG 10148062560 $77.0737/tablet

BOSENTAN 62.5 MG 47335003886 $16.4781/tablet

BOSENTAN 62.5 MG 49884005802 $16.4781/tablet

BOSENTAN 62.5 MG 65162087306 $16.4781/tablet

BOSENTAN 62.5 MG 68382044614 $42.6638/tablet

BOSULIF 100 MG 00069013501 $135.7669/tablet

BOSULIF 400 MG 00069019301 $543.0675/tablet

BOSULIF 500 MG 00069013601 $543.0675/tablet

BOTOX 100 UNIT 00023114501 $615.7800/each

BOTOX 200 UNIT 00023392102 $1231.5600/each

BRAFTOVI 50 MG 70255002001 $95.4417/capsule

BRAFTOVI 75 MG 70255002501 $70.1433/capsule

BRAFTOVI 75 MG 70255002503 $105.2150/capsule

BRINEURA 300MG/10ML 68135081102 $28370.9000/each

BRONCHITOL 40 MG 10122021204 $6.1931/capsule

Page 4 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

BRONCHITOL 40 MG 10122021214 $6.1930/capsule

BRONCHITOL 40 MG 10122021256 $6.1930/capsule

BRUKINSA 80 MG 72579001102 $111.9753/capsule

BUPHENYL 500 MG 75987006008 $27.1510/tablet

BYLVAY 1200 MCG 74528012001 $1314.7200/capsule Add

BYLVAY 200 MCG 74528002001 $219.1200/capsule Add

BYLVAY 400 MCG 74528004001 $438.2400/capsule Add

BYLVAY 600 MCG 74528006001 $657.3600/capsule Add

BYNFEZIA 2500MCG/ML 62756045236 $224.1000/ml

CABENUVA 400-600/2 49702025315 $965.2500/ml

CABENUVA 600-900/3 49702024015 $965.2500/ml

CABLIVI 11 MG 58468022501 $7270.8000/each

CABOMETYX 20 MG 42388002426 $719.2050/tablet

CABOMETYX 40 MG 42388002526 $719.2050/tablet

CABOMETYX 60 MG 42388002326 $719.2050/tablet

CALCITONIN-SALMON 200/ML 24201040002 $1252.4000/ml

CALQUENCE 100 MG 00310051260 $233.4624/capsule

CAMPTOSAR 300MG/15ML 00009752905 $7.5040/ml

CAPRELSA 100 MG 58468782003 $256.1181/tablet

CAPRELSA 300 MG 58468784003 $512.2362/tablet

CARBAGLU 200 MG 52276031205 $216.2915/tablet

CARBAGLU 200 MG 52276031260 $216.2915/tablet

CARBOPLATIN 150 MG 63323016721 $193.5000/each

CAYSTON 75 MG/ML 61958090101 $116.7138/ml

CELLCEPT 500 MG 00004029809 $105.1701/each

CEPROTIN 1000 UNIT 00944417510 $1.4940/each

CEPROTIN 1000 UNIT 00944417910 $1.4940/each

CEPROTIN 500 UNIT 00944417505 $1.4940/each

CEPROTIN 500 UNIT 00944417705 $1.4940/each

CERDELGA 84 MG 58468022001 $515.8120/capsule

CEREZYME 400 UNIT 58468466301 $1716.9596/each

CHENODAL 250 MG 68974087640 $471.1080/tablet

CHOLBAM 250 MG 45043000202 $826.6800/capsule

CHOLBAM 50 MG 45043000102 $274.7300/capsule

CIMDUO 300-300 MG 49502045093 $32.6778/tablet

CIMZIA 400 MG 50474070062 $4738.5110/each

CIMZIA 400MG/2ML 50474071079 $4738.5110/each

CIMZIA 400MG/2ML 50474071081 $4738.5110/each

CINQAIR 10 MG/ML 59310061031 $97.0000/ml

CINRYZE 500 (5 ML) 42227008105 $2830.1838/each

CINRYZE 500 (5 ML) 42227008301 $2830.1838/each

COAGADEX 250 (+/-) 64208775201 $8.8020/each

COAGADEX 250 (+/-) 64208775401 $8.8020/each

COAGADEX 500 (+/-) 64208775301 $8.8020/each

COAGADEX 500 (+/-) 64208775601 $8.8020/each

COMETRIQ 100 MG/DAY 42388001214 $320.1306/capsule

COMETRIQ 140 MG/DAY 42388001114 $160.0653/capsule

COMETRIQ 60 MG/DAY 42388001314 $213.4204/capsule

COMPLERA 200-25-300 61958110101 $100.3785/tablet

COPAXONE 20 MG/ML 68546031730 $230.9679/ml

COPAXONE 40 MG/ML 68546032512 $473.3640/ml

COPIKTRA 15 MG 71779011502 $266.1570/capsule

COPIKTRA 25 MG 71779012502 $266.1570/capsule

CORIFACT 1000-1600 63833051802 $9.7380/each

COSELA 300 MG 73462010101 $1417.0000/each

COSENTYX (2 SYRINGES) 150 MG/ML 00078063998 $2917.2304/ml

COSENTYX PEN (2 PENS) 150 MG/ML 00078063941 $2917.2304/ml

COSENTYX PEN 150 MG/ML 00078063968 $5834.4607/ml

COSENTYX SYRINGE 150 MG/ML 00078063997 $5834.4607/ml

COSENTYX SYRINGE 75MG/0.5ML 00078105697 $5834.4706/ml

COTELLIC 20 MG 50242071701 $110.7452/tablet

CRESEMBA 372 MG 00469042099 $323.5506/each

CRIXIVAN 400 MG 00006057362 $2.4742/capsule

Page 5 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

CRYSVITA 10 MG/ML 69794010201 $3661.0000/ml

CRYSVITA 20 MG/ML 69794020301 $7322.0000/ml

CRYSVITA 30 MG/ML 69794030401 $10983.0000/ml

CUTAQUIG 16.5 % 00069106102 $32.4248/ml

CUTAQUIG 16.5 % 00069147602 $32.4248/ml

CUTAQUIG 16.5 % 00069150902 $32.4252/ml

CUTAQUIG 16.5 % 00069196502 $32.4250/ml

CUTAQUIG 16.5 % 68982081001 $32.2638/ml

CUTAQUIG 16.5 % 68982081002 $31.9407/ml

CUTAQUIG 16.5 % 68982081003 $32.2638/ml

CUTAQUIG 16.5 % 68982081004 $31.9412/ml

CUTAQUIG 16.5 % 68982081005 $32.2638/ml

CUTAQUIG 16.5 % 68982081006 $32.2638/ml

CUVITRU 1 G/5 ML 00944285001 $36.8448/ml

CUVITRU 10 G/50 ML 00944285009 $36.8448/ml

CUVITRU 2 G/10 ML 00944285003 $36.8448/ml

CUVITRU 4 G/20 ML 00944285005 $36.8448/ml

CUVITRU 8 G/40 ML 00944285007 $36.8448/ml

CYCLOPHOSPHAMIDE 200 MG/ML 50742051902 $102.5500/ml

CYCLOPHOSPHAMIDE 200 MG/ML 50742052005 $102.5500/ml

CYCLOPHOSPHAMIDE 200 MG/ML 55150027001 $102.2000/ml Add

CYCLOPHOSPHAMIDE 200 MG/ML 55150027101 $102.2000/ml Add

CYCLOPHOSPHAMIDE 200 MG/ML 70860021803 $102.5500/ml

CYCLOPHOSPHAMIDE 200 MG/ML 70860021805 $102.5500/ml

CYCLOSPORINE 250 MG/5ML 00517086610 $5.8659/ml

CYRAMZA 100MG/10ML 00002766901 $125.6280/ml

CYRAMZA 500MG/50ML 00002767801 $125.6280/ml

CYSTADANE 1 G/1.7 ML 52276040001 $9.2294/gm

CYSTADROPS 0.37 % 55292041005 $384.3325/ml

CYSTAGON 150 MG 00378904501 $0.7980/capsule

CYSTAGON 150 MG 00378904505 $0.7581/capsule

CYSTAGON 50 MG 00378904001 $0.2738/capsule

CYSTAGON 50 MG 00378904005 $0.2601/capsule

CYSTARAN 0.44 % 54482002001 $110.4066/ml

CYTARABINE 20 MG/ML 61703030436 $0.5551/ml

CYTOGAM 50 MG/ML 44206053211 $26.6656/ml

CYTOGAM 50 MG/ML 70257053250 $26.6656/ml

CYTOGAM 50 MG/ML 70257053251 $26.6656/ml

DACARBAZINE 100 MG 63323012710 $8.5050/each

DALVANCE 500 MG 57970010001 $1621.6474/each

DANYELZA 40MG/10ML 73042020101 $2036.8000/ml

DARZALEX FASPRO 1800-30000 57894050301 $527.0533/ml

DARZALEX 100 MG/5ML 57894050205 $116.0041/ml

DARZALEX 400MG/20ML 57894050220 $116.0041/ml

DAUNORUBICIN HCL 20 MG 63323011908 $105.0000/each

DAURISMO 100 MG 00069153130 $619.5057/tablet

DAURISMO 25 MG 00069029860 $309.7528/tablet

DEFITELIO 80 MG/ML 68727080001 $382.5640/ml

DEFITELIO 80 MG/ML 68727080002 $382.5640/ml

DELSTRIGO 100-300 MG 00006500701 $75.2408/tablet

DESCOVY 200MG-25MG 61958200201 $62.7481/tablet

DESCOVY 200MG-25MG 61958200202 $62.7481/tablet

DILUENT FOR EPOPROSTENOL 00703925809 $0.2328/ml

DILUENT FOR TREPROSTINIL 00781602194 $0.3602/ml

DOCEFREZ 20 MG 47335028541 $268.8000/each

DOCEFREZ 80 MG 47335028641 $1075.3000/each

DOJOLVI 8.3KCAL/ML 69794005050 $9.7500/ml

DOPTELET 20 MG 71369002010 $347.5243/tablet

DOPTELET 20 MG 71369002015 $347.5243/tablet

DOPTELET 20 MG 71369002030 $347.5243/tablet

DOVATO 50MG-300MG 49702024613 $82.1385/tablet

DUOPA 4.63-20/ML 00074301207 $2.0103/ml

DUPIXENT PEN 200MG/1.14 00024591902 $1390.9457/ml

Page 6 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

DUPIXENT PEN 300 MG/2ML 00024591502 $792.8390/ml

DUPIXENT SYRINGE 200MG/1.14 00024591801 $1390.9457/ml

DUPIXENT SYRINGE 300 MG/2ML 00024591401 $792.8390/ml

DYSPORT 300 UNIT 15054053006 $520.6550/each

DYSPORT 500 UNIT 15054050001 $867.5900/each

EDURANT 25 MG 59676027801 $39.5762/tablet

EFAVIRENZ 200 MG 64980040709 $8.9432/capsule

EFAVIRENZ 50 MG 64980040603 $2.2372/capsule

EFAVIRENZ-LAMIVU-TENOFOV DISOP 400-300 MG 42385092931 $46.7431/tablet

EFAVIRENZ-LAMIVU-TENOFOV DISOP 600-300MG 42385092830 $46.7431/tablet

EGRIFTA SV 2 MG 62064024130 $200.8672/each

ELAPRASE 6 MG/3 ML 54092070001 $1055.7294/ml

ELELYSO 200 UNIT 00069010601 $814.9084/each

ELIGARD 22.5 MG 62935022305 $1355.0700/each

ELIGARD 30 MG 62935030330 $1808.7600/each

ELIGARD 45 MG 62935045345 $2710.1300/each

ELIGARD 7.5 MG 62935075375 $451.6900/each

ELITEK 1.5 MG 00024515010 $958.0300/each

ELITEK 7.5 MG 00024515175 $4790.1400/each

ELOCTATE 1000 UNIT 71104080401 $2.0930/each

ELOCTATE 1500 UNIT 71104080501 $2.0930/each

ELOCTATE 2000 UNIT 71104080601 $2.0930/each

ELOCTATE 250 UNIT 71104080101 $2.0930/each

ELOCTATE 3000 UNIT 71104080701 $2.0930/each

ELOCTATE 4000 UNIT 71104080801 $2.0930/each

ELOCTATE 500 UNIT 71104080201 $2.0930/each

ELOCTATE 5000 UNIT 71104080901 $2.0930/each

ELOCTATE 6000 UNIT 71104081001 $2.0930/each

ELOCTATE 750 UNIT 71104080301 $2.0930/each

ELZONRIS 1000MCG/ML 72187040101 $28065.4400/ml

EMCYT 140 MG 00013013202 $15.7910/capsule

EMFLAZA 18 MG 52856050203 $197.1250/tablet

EMFLAZA 22.75MG/ML 52856050521 $278.4916/ml

EMFLAZA 22.75MG/ML 52856050522 $332.9781/ml

EMFLAZA 30 MG 52856050303 $328.5585/tablet

EMFLAZA 36 MG 52856050403 $380.3435/tablet

EMFLAZA 6 MG 52856050101 $65.7066/tablet

EMPAVELI 1080 MG/20 73606001001 $219.3112/ml

EMPLICITI 300 MG 00003229111 $2000.6600/each

EMPLICITI 400 MG 00003452211 $2667.5300/each

EMTRICITABINE 200 MG 69097064202 $15.0638/capsule

EMTRIVA 10 MG/ML 61958060201 $0.7267/ml

EMTRIVA 200 MG 61958060101 $17.4369/capsule

ENBREL MINI 50MG/ML(1) 58406004401 $1462.1992/ml

ENBREL MINI 50MG/ML(1) 58406004404 $1462.1992/ml

ENBREL MINI 50MG/ML(1) 58406045601 $1492.0400/ml

ENBREL MINI 50MG/ML(1) 58406045604 $1492.0400/ml

ENBREL SURECLICK 50MG/ML(1) 58406003201 $1462.1992/ml

ENBREL SURECLICK 50MG/ML(1) 58406003204 $1462.1992/ml

ENBREL SURECLICK 50MG/ML(1) 58406044501 $1492.0400/ml

ENBREL SURECLICK 50MG/ML(1) 58406044504 $1492.0400/ml

ENBREL 25 MG 58406042534 $731.0996/each

ENBREL 25 MG 58406042541 $731.0996/each

ENBREL 25MG/0.5ML 58406001001 $1462.1992/ml

ENBREL 25MG/0.5ML 58406001004 $1462.1992/ml

ENBREL 25MG/0.5ML 58406005501 $1462.1992/ml

ENBREL 25MG/0.5ML 58406005504 $1462.1992/ml

ENBREL 25MG/0.5ML 58406045501 $0.0000 Delete

ENBREL 25MG/0.5ML 58406045504 $0.0000 Delete

ENBREL 50MG/ML(1) 58406002101 $1462.1992/ml

ENBREL 50MG/ML(1) 58406002104 $1462.1992/ml

ENBREL 50MG/ML(1) 58406043501 $1492.0400/ml

ENBREL 50MG/ML(1) 58406043504 $1492.0400/ml

Page 7 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ENDARI 5 G 42457042001 $20.0893/each

ENDARI 5 G 42457042060 $20.0860/each

ENHERTU 100 MG 65597040601 $2365.3700/each

ENSPRYNG 120 MG/ML 50242000701 $14615.3900/ml

ENTYVIO 300 MG 64764030020 $7247.5235/each

ENVARSUS XR 0.75 MG 68992307501 $4.2063/tablet

ENVARSUS XR 0.75 MG 68992307503 $4.2065/tablet

ENVARSUS XR 1 MG 68992301001 $5.6084/tablet

ENVARSUS XR 1 MG 68992301003 $5.6085/tablet

ENVARSUS XR 4 MG 68992304001 $22.4334/tablet

ENVARSUS XR 4 MG 68992304003 $22.4328/tablet

EPCLUSA 200MG-50MG 61958220301 $872.2000/tablet

EPCLUSA 400-100 MG 61958220101 $0.0000 Delete

EPIRUBICIN HCL 200 MG 61703034859 $2134.3860/each

EPIVIR HBV 25 MG/5 ML 00173066300 $0.7927/ml

EPOGEN 10000/ML 55513014401 $163.1472/ml

EPOGEN 10000/ML 55513014410 $163.1472/ml

EPOGEN 2000/ML 55513012601 $32.6294/ml

EPOGEN 2000/ML 55513012610 $32.6294/ml

EPOGEN 20000/2ML 55513028301 $163.1472/ml

EPOGEN 20000/2ML 55513028310 $163.1472/ml

EPOGEN 20000/ML 55513047801 $326.2944/ml

EPOGEN 20000/ML 55513047810 $326.2944/ml

EPOGEN 3000/ML 55513026701 $48.9442/ml

EPOGEN 3000/ML 55513026710 $48.9442/ml

EPOGEN 4000/ML 55513014801 $65.2589/ml

EPOGEN 4000/ML 55513014810 $65.2589/ml

EPOPROSTENOL SODIUM 0.5 MG 00703198501 $14.5800/each

EPOPROSTENOL SODIUM 0.5 MG 62756005940 $22.1610/each

EPOPROSTENOL SODIUM 1.5 MG 00703199501 $35.2080/each

EPOPROSTENOL SODIUM 1.5 MG 62756006040 $44.3220/each

ERBITUX 100MG/50ML 66733094823 $13.8543/ml

ERBITUX 200MG/0.1L 66733095823 $13.8542/ml

ERIVEDGE 150 MG 50242014001 $418.5245/capsule

ERLEADA 60 MG 59676060012 $106.5161/tablet

ERWINASE 10000 UNIT 81561041305 $4030.8400/each

ERWINAZE 10000 UNIT 57902024901 $4030.8400/each

ERWINAZE 10000 UNIT 57902024905 $4030.8400/each

ESBRIET 267 MG 50242012101 $37.4241/capsule

ESBRIET 267 MG 50242012206 $37.4241/tablet

ESBRIET 801 MG 50242012301 $112.2722/tablet

ESPEROCT 1000 (+/-) 00169810001 $2.0700/each

ESPEROCT 1500 (+/-) 00169815001 $2.0700/each

ESPEROCT 2000 (+/-) 00169820001 $2.0700/each

ESPEROCT 3000 (+/-) 00169830001 $2.0700/each

ESPEROCT 500 (+/-) 00169850001 $2.0700/each

ETHYOL 500 MG 76310001750 $1067.1210/each

ETOPOPHOS 100 MG 61269041020 $155.0000/each

ETRAVIRINE 100 MG 60219172107 $10.4592/tablet

ETRAVIRINE 200 MG 60219172206 $20.9185/tablet

EVENITY (2 SYRINGES) 210MG/2.34 55513088002 $822.6279/ml

EVENITY 105MG/1.17 55513088001 $822.6279/ml

EVKEEZA 1200MG/8ML 61755001001 $4668.7500/ml

EVKEEZA 345 MG/2.3 61755001301 $4668.7500/ml

EVOMELA 50 MG 68152010900 $2000.0000/each

EVOMELA 50 MG 72893000101 $2000.0000/each

EVOTAZ 300-150 MG 00003364111 $52.1778/tablet

EVRYSDI 0.75 MG/ML 50242017507 $139.6304/ml

EXONDYS-51 100 MG/2ML 60923036302 $800.0000/ml

EXONDYS-51 500MG/10ML 60923028410 $800.0000/ml

EXSERVAN 50 MG 70510220102 $52.1738/each

EXTAVIA 0.3 MG 00078056912 $436.5815/each

EXTAVIA 0.3 MG 00078056961 $436.5998/each

Page 8 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

EXTAVIA 0.3 MG 00078056999 $436.5998/each

EYLEA 2MG/0.05ML 61755000501 $36852.0000/ml

EYLEA 2MG/0.05ML 61755000502 $36852.0000/ml

FABRAZYME 35 MG 58468004001 $6630.3571/each

FABRAZYME 5 MG 58468004101 $947.0366/each

FARYDAK 10 MG 00078065006 $2337.6967/capsule

FARYDAK 15 MG 00078065106 $2337.6967/capsule

FARYDAK 20 MG 00078065206 $2337.6967/capsule

FASENRA PEN 30 MG/ML 00310183030 $5143.0797/ml

FASENRA 30 MG/ML 00310173030 $5143.0797/ml

FEIBA NF 1750-3250 64193042502 $2.0315/each

FEIBA NF 350-650 64193042602 $2.0315/each

FEIBA NF 700-1300 64193042402 $2.0315/each

FENSOLVI 45 MG 62935015350 $22487.6880/each

FERAHEME 510MG/17ML 59338077501 $69.9321/ml

FERAHEME 510MG/17ML 59338077510 $67.8950/ml

FERRIPROX (2 TIMES A DAY) 1000 MG 10122010401 $179.6716/tablet

FERRIPROX (3 TIMES A DAY) 1000 MG 10122010305 $143.7373/tablet Add

FERRIPROX 100 MG/ML 10122010150 $14.3737/ml

FERRIPROX 100 MG/ML 52609450207 $14.3737/ml

FERRIPROX 1000 MG 52609000705 $143.7373/tablet

FERUMOXYTOL 510MG/17ML 00781315401 $50.9214/ml

FIBRYGA 700-1300MG 68982034701 $1.0890/each

FIRDAPSE 10 MG 69616021103 $197.2800/tablet

FIRDAPSE 10 MG 69616021104 $197.2800/tablet

FIRDAPSE 10 MG 69616021106 $197.2800/tablet

FIRMAGON 120 MG 55566840301 $762.0900/each

FIRMAGON 80 MG 55566830301 $488.4500/each

FLEBOGAMMA DIF 10 % 61953000501 $9.4886/ml

FLEBOGAMMA DIF 10 % 61953000502 $9.4886/ml

FLEBOGAMMA DIF 10 % 61953000503 $9.4886/ml

FLEBOGAMMA DIF 5 % 61953000401 $4.7443/ml

FLEBOGAMMA DIF 5 % 61953000402 $4.7443/ml

FLEBOGAMMA DIF 5 % 61953000403 $4.7443/ml

FLEBOGAMMA DIF 5 % 61953000404 $4.7443/ml

FLEBOGAMMA DIF 5 % 61953000405 $4.7443/ml

FLOLAN 0.5 MG 00173051700 $18.6152/each

FLOLAN 1.5 MG 00173051900 $44.9594/each

FOLOTYN 20MG/ML(1) 48818000101 $6058.2600/ml

FOLOTYN 40 MG/2 ML 48818000102 $6058.2550/ml

FORTEO 20MCG/DOSE 00002840001 $1567.7538/ml

FOTIVDA 0.89 MG 45629008901 $1145.4000/capsule

FOTIVDA 1.34 MG 45629013401 $1145.4000/capsule

FRAGMIN 10000/ML 00069021702 $82.1551/ml

FRAGMIN 12500/0.5 00069022002 $205.4031/ml

FRAGMIN 15000/0.6 00069022302 $205.3918/ml

FRAGMIN 18000/0.72 00069022802 $205.3904/ml

FRAGMIN 2500/0.2ML 00069019502 $126.5966/ml

FRAGMIN 25000/ML 00069023201 $185.8326/ml

FRAGMIN 5000/0.2ML 00069019602 $205.3901/ml

FRAGMIN 7500/0.3ML 00069020602 $205.4117/ml

FULPHILA 6 MG/0.6ML 67457083306 $6888.7500/ml

FUZEON 90 MG 00004038140 $58.2653/each

GABLOFEN 10000/20ML 66794015501 $12.6427/ml

GABLOFEN 10000/20ML 66794015502 $11.7672/ml

GABLOFEN 20K MCG/20 66794015601 $25.2855/ml

GABLOFEN 20K MCG/20 66794015602 $23.5340/ml

GABLOFEN 40000/20ML 66794015701 $50.6257/ml

GABLOFEN 40000/20ML 66794015702 $47.0680/ml

GABLOFEN 50 MCG/ML 66794015101 $87.5683/ml

GALAFOLD 123 MG 71904010001 $1897.7179/capsule

GAMIFANT 10 MG/2 ML 66658050101 $3326.5404/ml

GAMIFANT 10 MG/2 ML 72171050101 $3326.5404/ml

Page 9 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

GAMIFANT 100MG/20ML 66658051001 $1681.7510/ml

GAMIFANT 50 MG/10ML 66658050501 $1681.7510/ml

GAMIFANT 50 MG/10ML 72171050501 $1681.7510/ml

GAMMAGARD LIQUID 10 % 00944270002 $11.9416/ml

GAMMAGARD LIQUID 10 % 00944270003 $11.9418/ml

GAMMAGARD LIQUID 10 % 00944270004 $11.9416/ml

GAMMAGARD LIQUID 10 % 00944270005 $11.9416/ml

GAMMAGARD LIQUID 10 % 00944270006 $11.9416/ml

GAMMAGARD LIQUID 10 % 00944270007 $11.9416/ml

GAMMAGARD S-D 10 G 00944265804 $1594.9600/each

GAMMAGARD S-D 5 G 00944265603 $797.4800/each

GAMMAKED 1 G/10 ML 76125090001 $12.7280/ml

GAMMAKED 10 G/100ML 76125090010 $12.7280/ml

GAMMAKED 20 G/200ML 76125090020 $12.7280/ml

GAMMAKED 5 G/50 ML 76125090050 $12.7280/ml

GAMMAPLEX 10 % 64208823501 $15.1216/ml Increase

GAMMAPLEX 10 % 64208823502 $15.1216/ml Increase

GAMMAPLEX 10 % 64208823503 $15.1216/ml Increase

GAMMAPLEX 10 % 64208823505 $15.1216/ml Increase

GAMMAPLEX 10 % 64208823506 $15.1216/ml Increase

GAMMAPLEX 10 % 64208823507 $15.1216/ml Increase

GAMMAPLEX 5 % 64208823402 $7.5608/ml Increase

GAMMAPLEX 5 % 64208823403 $7.5608/ml Increase

GAMMAPLEX 5 % 64208823404 $7.5608/ml Increase

GAMMAPLEX 5 % 64208823406 $7.5608/ml Increase

GAMMAPLEX 5 % 64208823407 $7.5608/ml Increase

GAMMAPLEX 5 % 64208823408 $7.5608/ml Increase

GAMUNEX-C 1 G/10 ML 13533080012 $10.4096/ml

GAMUNEX-C 10 G/100ML 13533080071 $10.4096/ml

GAMUNEX-C 2.5G/25ML 13533080015 $10.4096/ml

GAMUNEX-C 20 G/200ML 13533080024 $10.4096/ml

GAMUNEX-C 40 G/400ML 13533080040 $10.4096/ml

GAMUNEX-C 5 G/50 ML 13533080020 $10.4096/ml

GATTEX 5 MG 68875010201 $41496.8858/each

GATTEX 5 MG 68875010301 $1591.0502/each

GAVRETO 100 MG 50242021060 $159.7186/capsule

GAVRETO 100 MG 50242021090 $159.7186/capsule

GAVRETO 100 MG 72064021060 $159.7186/capsule

GAVRETO 100 MG 72064021090 $159.7186/capsule

GAZYVA 1000 MG/40 50242007001 $172.9309/ml

GEMCITABINE HCL 100 MG/ML 16729039130 $12.5400/ml

GEMCITABINE HCL 100 MG/ML 16729041903 $5.2668/ml

GEMCITABINE HCL 100 MG/ML 16729042333 $4.3890/ml

GEMCITABINE HCL 100 MG/ML 16729042605 $5.0160/ml

GEMCITABINE HCL 100 MG/ML 68001034234 $3.5102/ml

GEMCITABINE HCL 100 MG/ML 68001034836 $3.5055/ml

GEMCITABINE HCL 100 MG/ML 68001035937 $3.8983/ml

GENOTROPIN 0.2MG/0.25 00013264902 $28.8834/each

GENOTROPIN 0.4MG/0.25 00013265002 $57.7752/each

GENOTROPIN 0.6MG/0.25 00013265102 $86.6586/each

GENOTROPIN 0.8MG/0.25 00013265202 $115.5462/each

GENOTROPIN 1.2MG/0.25 00013265402 $173.3228/each

GENOTROPIN 1.4MG/0.25 00013265502 $202.2048/each

GENOTROPIN 1.6MG/0.25 00013265602 $231.0882/each

GENOTROPIN 1.8MG/0.25 00013265702 $259.9828/each

GENOTROPIN 12 MG/ML 00013264681 $1590.1578/each

GENOTROPIN 1MG/0.25ML 00013265302 $144.4366/each

GENOTROPIN 2MG/0.25ML 00013265802 $288.8648/each

GENOTROPIN 5 MG/ML 00013262681 $662.5584/each

GENVOYA 150-200-10 61958190101 $110.2969/tablet

GILENYA 0.5 MG 00078060715 $295.2954/capsule

GILOTRIF 20 MG 00597014130 $334.7363/tablet

GILOTRIF 30 MG 00597013730 $334.7363/tablet

Page 10 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

GILOTRIF 40 MG 00597013830 $334.7363/tablet

GIVLAARI 189 MG/ML 71336100101 $39000.0000/ml

GLASSIA 1 G/50 ML 00944288401 $0.5777/each

GLATIRAMER ACETATE 20 MG/ML 00378696093 $45.5000/ml

GLATIRAMER ACETATE 40 MG/ML 00378696112 $113.7500/ml

GLATOPA 20 MG/ML 00781323434 $48.7000/ml

GLATOPA 40 MG/ML 00781325089 $121.7500/ml

GLEOSTINE 10 MG 58181304005 $90.6061/capsule

GLEOSTINE 100 MG 58181304205 $1000.5019/capsule

GLEOSTINE 40 MG 58181304105 $362.4344/capsule

GLIADEL 7.7-192.3 24338005008 $4123.8100/each

GRANIX 300 MCG/ML 63459091859 $247.3644/ml

GRANIX 300MCG/0.5 63459091011 $494.7228/ml

GRANIX 300MCG/0.5 63459091015 $494.7287/ml

GRANIX 300MCG/0.5 63459091017 $593.2080/ml

GRANIX 300MCG/0.5 63459091036 $593.2080/ml

GRANIX 480MCG/0.8 63459091211 $494.8639/ml

GRANIX 480MCG/0.8 63459091215 $494.8577/ml

GRANIX 480MCG/0.8 63459091217 $590.4112/ml

GRANIX 480MCG/0.8 63459091236 $590.4112/ml

GRANIX 480MCG/1.6 63459092059 $247.4288/ml

HAEGARDA 2000 UNIT 63833082802 $1986.5120/each

HAEGARDA 3000 UNIT 63833082902 $2979.7631/each

HARVONI 33.75-150 61958180501 $1102.5000/each

HARVONI 45MG-200MG 61958180301 $1102.5000/tablet

HARVONI 45MG-200MG 61958180401 $1102.5000/each

HARVONI 90MG-400MG 61958180101 $1102.5000/tablet

HEALON ENDOCOAT 30 MG/ML 50474054706 $169.9059/ml

HEALON GV PRO 18 MG/ML 50474065165 $176.5732/ml

HEALON5 PRO 23 MG/ML 85446036991 $192.5600/ml

HEMLIBRA 105 MG/0.7 50242092201 $14480.5926/ml

HEMLIBRA 150 MG/ML 50242092301 $14480.5966/ml

HEMLIBRA 30 MG/ML 50242092001 $2896.1212/ml

HEMLIBRA 60MG/0.4ML 50242092101 $14480.5825/ml

HEMOFIL M 1501-2000 00944394602 $1.1680/each

HEMOFIL M 220-400 00944394002 $1.1680/each

HEMOFIL M 401-800 00944394202 $1.1680/each

HEMOFIL M 801-1500 00944394402 $1.1680/each

HEPAGAM B >312/ML(5) 70257005105 $166.2805/ml

HEPAGAM B >312/ML(5) 70257005151 $166.2805/ml

HEPAGAM B >312/ML(5) 70257005451 $166.2805/ml

HEPAGAM B >312/ML 70257005211 $189.9730/ml

HEPAGAM B >312/ML 70257005251 $189.9730/ml

HEPAGAM B >312/ML 70257005311 $189.9730/ml

HEPAGAM B >312/ML 70257005351 $189.9730/ml

HERCEPTIN HYLECTA 600-10000 50242007701 $935.0480/ml

HERCEPTIN 150 MG 50242013201 $7.9933/mg

HERCEPTIN 150 MG 50242013210 $7.9933/mg

HERZUMA 150 MG 63459030343 $1199.0000/each

HERZUMA 420 MG 63459030547 $3340.0000/each

HETLIOZ LQ 4 MG/ML 43068030402 $145.7065/ml

HETLIOZ LQ 4 MG/ML 43068030406 $145.7065/ml

HETLIOZ 20 MG 43068022001 $728.5328/capsule

HIZENTRA 1 G/5 ML 44206045101 $30.5760/ml

HIZENTRA 1 G/5 ML 44206045621 $30.5760/ml

HIZENTRA 10 G/50 ML 44206045510 $30.5760/ml

HIZENTRA 2 G/10 ML 44206045202 $30.5760/ml

HIZENTRA 2 G/10 ML 44206045722 $30.5760/ml

HIZENTRA 4 G/20 ML 44206045404 $30.5760/ml

HIZENTRA 4 G/20 ML 44206045824 $30.5760/ml

HUMATE-P 1000-2400 63833061702 $1.1398/each

HUMATE-P 250-600 63833061502 $1.1398/each

HUMATE-P 500-1200 63833061602 $1.1398/each

Page 11 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

HUMATROPE 12 MG 00002814801 $1654.3968/each

HUMATROPE 24 MG 00002814901 $3308.7936/each

HUMATROPE 5 MG 00002733511 $0.0000 Delete

HUMATROPE 6 MG 00002814701 $827.1984/each

HUMIRA PEN CROHN'S-UC-HS 40MG/0.8ML 00074433906 $2924.4213/each

HUMIRA PEN PSOR-UVEITS-ADOL HS 40MG/0.8ML 00074433907 $2924.4180/each

HUMIRA PEN 40MG/0.8ML 00074433902 $2924.4082/each

HUMIRA(CF) PEDIATRIC CROHN'S 80 MG-40MG 00074006702 $4386.6319/each

HUMIRA(CF) PEDIATRIC CROHN'S 80MG/0.8ML 00074254003 $5848.8425/each

HUMIRA(CF) PEN CROHN'S-UC-HS 80MG/0.8ML 00074012403 $5848.8425/each

HUMIRA(CF) PEN PEDIATRIC UC 80MG/0.8ML 00074012404 $5848.8360/each

HUMIRA(CF) PEN PSOR-UV-ADOL HS 80 MG-40MG 00074153903 $3899.2240/each

HUMIRA(CF) PEN 40MG/0.4ML 00074055402 $2924.4082/each

HUMIRA(CF) PEN 80MG/0.8ML 00074012402 $5848.8360/each

HUMIRA(CF) 10MG/0.1ML 00074081702 $2924.4082/each

HUMIRA(CF) 20MG/0.2ML 00074061602 $2924.4082/each

HUMIRA(CF) 40MG/0.4ML 00074024302 $2924.4082/each

HUMIRA 40MG/0.8ML 00074379902 $2924.4082/each

HYCAMTIN 0.25 MG 00078067201 $100.0910/capsule

HYCAMTIN 1 MG 00078067301 $400.3571/capsule

HYPERHEP B 110/0.5ML 13533063603 $173.3620/ml

HYPERHEP B 220 UNIT/1 13533063601 $163.4542/ml

HYPERHEP B 220 UNIT/1 13533063602 $163.4542/ml

HYPERHEP B 220/ML (5) 13533063605 $156.8451/ml

HYPERRAB 300 UNIT/1 13533031801 $650.3268/ml

HYPERRAB 300 UNIT/1 13533031803 $650.3268/ml

HYPERRAB 300 UNIT/1 13533031805 $650.3249/ml

HYPERRHO S-D 1500 UNIT 13533063102 $77.1053/each

HYPERRHO S-D 1500 UNIT 13533063111 $73.2544/each

HYPERRHO S-D 250 UNIT 13533066106 $28.0815/each

HYQVIA 10 G/100ML 00944251202 $16.2697/ml

HYQVIA 2.5G/25ML 00944251002 $16.2697/ml

HYQVIA 20 G/200ML 00944251302 $16.2697/ml

HYQVIA 30 G/300ML 00944251402 $16.2697/ml

HYQVIA 5 G/50 ML 00944251102 $16.2697/ml

IBANDRONATE SODIUM 3 MG/3 ML 62756021840 $84.2000/ml

IBRANCE 100 MG 00069018821 $619.9787/capsule

IBRANCE 100 MG 00069048603 $619.9787/tablet

IBRANCE 125 MG 00069018921 $619.9787/capsule

IBRANCE 125 MG 00069068803 $619.9787/tablet

IBRANCE 75 MG 00069018721 $619.9787/capsule

IBRANCE 75 MG 00069028403 $619.9787/tablet

ICLUSIG 10 MG 63020053630 $594.7116/tablet

ICLUSIG 15 MG 63020053530 $594.7116/tablet

ICLUSIG 30 MG 63020053330 $594.7116/tablet

ICLUSIG 45 MG 63020053430 $594.7116/tablet

IDELVION 1000 (+/-) 69911086602 $4.4736/each

IDELVION 2000 (+/-) 69911086702 $4.4736/each

IDELVION 250 (+/-) 69911086402 $4.4736/each

IDELVION 3500 (+/-) 69911086902 $4.4736/each

IDELVION 500 (+/-) 69911086502 $4.4736/each

IDHIFA 100 MG 59572071030 $937.7665/tablet

IDHIFA 50 MG 59572070530 $937.7665/tablet

IFOSFAMIDE-MESNA 1G-1G 00703410048 $0.0000 Delete

IFOSFAMIDE-MESNA 1G-1G 00703410058 $0.0000 Delete

IFOSFAMIDE-MESNA 3G-1G 00703410068 $0.0000 Delete

ILARIS 150 MG/ML 00078073461 $16636.8155/ml

ILUMYA 100 MG/ML 47335017795 $14376.9780/ml

ILUVIEN 0.19 MG 68611019002 $8764.8000/each

IMBRUVICA 140 MG 57962001428 $495.3531/tablet

IMBRUVICA 140 MG 57962014009 $165.1176/capsule

IMBRUVICA 140 MG 57962014012 $165.1176/capsule

IMBRUVICA 280 MG 57962028028 $495.3531/tablet

Page 12 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

IMBRUVICA 420 MG 57962042028 $495.3531/tablet

IMBRUVICA 560 MG 57962056028 $495.3531/tablet

IMBRUVICA 70 MG 57962007028 $495.3531/capsule

IMFINZI 120 MG/2.4 00310450012 $372.0000/ml

IMFINZI 500MG/10ML 00310461150 $371.9980/ml

IMLYGIC 10EXP6/ML 55513007801 $54.8600/ml

IMLYGIC 10EXP8/ML 55513007901 $5485.3900/ml

IMOGAM RABIES-HT 150 UNIT/1 49281019020 $397.9425/ml

INCRELEX 10 MG/ML 15054104005 $1261.2420/ml

INFED 100 MG/2ML 00023608201 $15.2737/ml

INFED 100 MG/2ML 00023608210 $15.2752/ml

INFLECTRA 100 MG 00069080901 $480.0000/each

INFUGEM 1200MG/120 62756007360 $3.8000/ml

INFUGEM 1300MG/130 62756000860 $3.8000/ml

INFUGEM 1400MG/140 62756010260 $3.8000/ml

INFUGEM 1500MG/150 62756021960 $3.8000/ml

INFUGEM 1600MG/160 62756032160 $3.8000/ml

INFUGEM 1700MG/170 62756043860 $3.8000/ml

INFUGEM 1800MG/180 62756053360 $3.8000/ml

INFUGEM 1900MG/190 62756061460 $3.8000/ml

INFUGEM 2000MG/200 62756074660 $3.8000/ml

INFUGEM 2200MG/220 62756097460 $3.8000/ml

INGREZZA INITIATION PACK 40 MG-80MG 70370204806 $250.5296/capsule

INGREZZA 40 MG 70370204001 $214.2728/capsule

INGREZZA 60 MG 70370106001 $233.8276/capsule

INGREZZA 80 MG 70370108001 $233.8276/capsule

INLYTA 1 MG 00069014501 $92.0105/tablet

INLYTA 5 MG 00069015111 $276.0314/tablet

INQOVI 35-100 MG 64842072709 $1493.0040/tablet

INREBIC 100 MG 59572072012 $182.1435/capsule

INTELENCE 100 MG 59676057001 $11.4684/tablet

INTELENCE 200 MG 59676057101 $22.9369/tablet

INTELENCE 25 MG 59676057201 $2.8671/tablet

INTRON A 10MM UNIT 00085435001 $306.0708/each

INTRON A 10MM/ML 00085113301 $307.8262/ml

INTRON A 18MM UNIT 00085435101 $550.9274/each

INTRON A 50MM UNIT 00085435201 $1530.3540/each

INTRON A 6MMUNIT/ML 00085116801 $186.6399/ml

INVEGA SUSTENNA 117MG/0.75 50458056201 $1910.9740/ml

INVEGA SUSTENNA 156 MG/ML 50458056301 $1911.0488/ml

INVEGA SUSTENNA 234MG/1.5 50458056401 $1911.0065/ml

INVEGA SUSTENNA 39MG/0.25 50458056001 $1910.8830/ml

INVEGA SUSTENNA 78MG/0.5ML 50458056101 $1910.9415/ml

INVEGA TRINZA 273MG/.875 50458060601 $3275.8997/ml

INVEGA TRINZA 410/1.315 50458060701 $3269.7274/ml

INVEGA TRINZA 546MG/1.75 50458060801 $3276.0836/ml

INVEGA TRINZA 819/2.625 50458060901 $3276.0111/ml

INVIRASE 500 MG 00004024451 $9.7641/tablet

IRESSA 250 MG 00310048230 $258.5908/tablet

IRINOTECAN HCL 300MG/15ML 55150035401 $2.6667/ml

IRINOTECAN HCL 300MG/15ML 59923071615 $2.8800/ml

IRINOTECAN HCL 300MG/15ML 72485021315 $1.3333/ml

IRINOTECAN HCL 500MG/25ML 61703034936 $2.3320/ml

ISENTRESS HD 600 MG 00006308001 $28.1970/tablet

ISENTRESS 100 MG 00006047761 $7.0492/tablet

ISENTRESS 100 MG 00006360361 $7.0492/each

ISENTRESS 25 MG 00006047361 $1.7623/tablet

ISENTRESS 400 MG 00006022761 $28.1970/tablet

ISTODAX 10 MG/2 ML 59572098401 $3198.6500/each

ISTURISA 1 MG 55292032020 $125.8950/tablet

ISTURISA 1 MG 55292032060 $125.8950/tablet

ISTURISA 10 MG 55292032220 $513.7125/tablet

ISTURISA 10 MG 55292032260 $513.7125/tablet

Page 13 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ISTURISA 5 MG 55292032120 $432.6000/tablet

ISTURISA 5 MG 55292032160 $432.6000/tablet

IXEMPRA 15 MG 70020191001 $1657.5000/each

IXEMPRA 45 MG 70020191101 $4972.5000/each

IXINITY 1000 UNIT 70504028305 $1.8240/each

IXINITY 1500 UNIT 70504028405 $1.8240/each

IXINITY 2000 UNIT 70504028805 $1.8240/each

IXINITY 250 UNIT 70504028705 $1.8240/each

IXINITY 3000 UNIT 70504028905 $1.8240/each

IXINITY 500 UNIT 70504028205 $1.8240/each

JAKAFI 10 MG 50881001060 $244.9164/tablet

JAKAFI 15 MG 50881001560 $244.9164/tablet

JAKAFI 20 MG 50881002060 $244.9164/tablet

JAKAFI 25 MG 50881002560 $244.9164/tablet

JAKAFI 5 MG 50881000560 $244.9164/tablet

JELMYTO 40 MG 72493010303 $21376.0000/each

JEMPERLI 500MG/10ML 00173089803 $1036.9380/ml

JEVTANA FDN10MG/ML 00024582411 $8083.6800/ml

JIVI 1000 (+/-) 00026394425 $2.0790/each

JIVI 2000 (+/-) 00026394625 $2.0790/each

JIVI 3000 (+/-) 00026394825 $2.0790/each

JIVI 500 (+/-) 00026394225 $2.0790/each

JULUCA 50 MG-25MG 49702024213 $96.9182/tablet

JUXTAPID 10 MG 76431011001 $1654.1468/capsule

JUXTAPID 20 MG 76431012001 $1654.1468/capsule

JUXTAPID 30 MG 76431013001 $1654.1468/capsule

JUXTAPID 40 MG 76431014001 $1590.5241/capsule

JUXTAPID 5 MG 76431010501 $1654.1468/capsule

JUXTAPID 60 MG 76431016001 $1590.5241/capsule

JYNARQUE 15 MG-15MG 59148007928 $285.9331/tablet

JYNARQUE 15 MG 59148008213 $285.9330/tablet

JYNARQUE 30 MG-15MG 59148008028 $285.9331/tablet

JYNARQUE 30 MG 59148008313 $285.9330/tablet

JYNARQUE 45 MG-15MG 59148008728 $285.9331/tablet

JYNARQUE 60 MG-30MG 59148008828 $285.9331/tablet

JYNARQUE 90 MG-30MG 59148008928 $285.9331/tablet

KADCYLA 100 MG 50242008801 $3296.4400/each

KADCYLA 160 MG 50242008701 $5274.3000/each

KALBITOR 10MG/ML(1) 47783010101 $5049.9391/ml

KALETRA 100MG-25MG 00074052260 $4.1605/tablet

KALETRA 100MG-25MG 00074157521 $4.1605/tablet

KALETRA 200MG-50MG 00074260521 $8.3211/tablet

KALETRA 200MG-50MG 00074679922 $8.3211/tablet

KALYDECO 150 MG 51167020001 $425.0097/tablet

KALYDECO 25 MG 51167060001 $425.0097/each

KALYDECO 50 MG 51167030001 $425.0097/each

KALYDECO 75 MG 51167040001 $425.0097/each

KANJINTI 150 MG 55513014101 $1199.0000/each

KANJINTI 420 MG 55513013201 $3340.0000/each

KANUMA 20 MG/10ML 25682000701 $1031.2100/ml

KCENTRA 1000 UNIT 63833038702 $2.6200/each

KCENTRA 500 UNIT 63833038602 $2.6200/each

KEDRAB 150 UNIT/1 76125015002 $361.6257/ml

KEDRAB 150 UNIT/1 76125015010 $330.1143/ml

KEPIVANCE 6.25 MG 66658011203 $2748.6053/each

KEPIVANCE 6.25 MG 66658011206 $2748.6069/each

KESIMPTA PEN 20MG/0.4ML 00078100768 $17525.4582/ml

KEVEYIS 50 MG 71090000101 $226.2368/tablet

KEVZARA 150MG/1.14 00024590801 $1597.4923/ml

KEVZARA 150MG/1.14 00024592001 $1597.4923/ml

KEVZARA 200MG/1.14 00024591001 $1597.4923/ml

KEVZARA 200MG/1.14 00024592201 $1597.4923/ml

KEYTRUDA 100 MG/4ML 00006302602 $1245.8358/ml

Page 14 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

KEYTRUDA 100 MG/4ML 00006302604 $1245.8358/ml

KHAPZORY 175 MG 68152011201 $704.1720/each

KHAPZORY 300 MG 68152011401 $1207.1520/each

KIMYRSA 1200 MG 70842022501 $4864.4640/each

KINERET 100MG/0.67 66658023407 $238.1259/ml

KISQALI FEMARA CO-PACK 200-2.5 MG 00078090961 $115.2138/tablet

KISQALI FEMARA CO-PACK 400-2.5 MG 00078091661 $161.2999/tablet

KISQALI FEMARA CO-PACK 600-2.5 MG 00078092361 $155.0960/tablet

KISQALI 200 MG/DAY 00078086001 $268.8323/tablet

KISQALI 400 MG/DAY 00078086714 $268.8332/tablet

KISQALI 400 MG/DAY 00078086742 $268.8332/tablet

KISQALI 600 MG/DAY 00078087421 $224.0274/tablet

KISQALI 600 MG/DAY 00078087463 $224.0276/tablet

KITABIS PAK 300 MG/5ML 24492085056 $16.0071/ml

KOATE 1000 (+/-) 76125067351 $1.1730/each

KOATE 1000 (+/-) 76125067650 $1.1730/each

KOATE 250 (+/-) 76125025221 $1.1730/each

KOATE 250 (+/-) 76125025620 $1.1730/each

KOATE 500 (+/-) 76125066830 $1.1730/each

KOATE 500 (+/-) 76125066931 $1.1730/each

KOGENATE FS 1000 (+/-) 00026378555 $1.3884/each

KOGENATE FS 2000 (+/-) 00026378665 $1.3884/each

KOGENATE FS 250 (+/-) 00026378225 $1.3884/each

KOGENATE FS 3000 (+/-) 00026378775 $1.3884/each

KOGENATE FS 500 (+/-) 00026378335 $1.3884/each

KORLYM 300 MG 76346007301 $547.8000/tablet

KORLYM 300 MG 76346007302 $547.8000/tablet

KOSELUGO 10 MG 00310061028 $75.3076/capsule

KOSELUGO 10 MG 00310061060 $75.3056/capsule

KOSELUGO 25 MG 00310062528 $188.2639/capsule

KOSELUGO 25 MG 00310062560 $188.2639/capsule

KOVALTRY 1000 (+/-) 00026382425 $1.4352/each

KOVALTRY 2000 (+/-) 00026382650 $1.4352/each

KOVALTRY 250 (+/-) 00026382125 $1.4352/each

KOVALTRY 3000 (+/-) 00026382850 $1.4352/each

KOVALTRY 500 (+/-) 00026382225 $1.4352/each

KRYSTEXXA 8 MG/ML 75987008010 $24748.1698/ml

KUVAN 500 MG 68135048211 $208.5300/each

KYLEENA 17.5MCG/24 50419042401 $995.2829/each

KYPROLIS 10 MG 76075010301 $429.8500/each

KYPROLIS 30 MG 76075010201 $1289.5600/each

KYPROLIS 60 MG 76075010101 $2579.1100/each

LAPATINIB 250 MG 68180080136 $47.9221/tablet

LEDIPASVIR-SOFOSBUVIR 90MG-400MG 72626260101 $420.0000/tablet

LEMTRADA 12MG/1.2ML 58468020001 $21222.9694/ml

LENVIMA 10 MG/DAY 62856071005 $676.0509/capsule

LENVIMA 10 MG/DAY 62856071030 $676.0516/capsule

LENVIMA 12 MG/DAY 62856071205 $225.3503/capsule

LENVIMA 12 MG/DAY 62856071230 $225.3505/capsule

LENVIMA 14 MG/DAY 62856071405 $338.0255/capsule

LENVIMA 14 MG/DAY 62856071430 $338.0258/capsule

LENVIMA 18 MG/DAY 62856071805 $225.3503/capsule

LENVIMA 18 MG/DAY 62856071830 $225.3505/capsule

LENVIMA 20 MG/DAY 62856072005 $338.0255/capsule

LENVIMA 20 MG/DAY 62856072030 $338.0258/capsule

LENVIMA 24 MG/DAY 62856072405 $225.3503/capsule

LENVIMA 24 MG/DAY 62856072430 $225.3505/capsule

LENVIMA 4 MG 62856070405 $676.0509/capsule

LENVIMA 4 MG 62856070430 $676.0516/capsule

LENVIMA 8 MG/DAY 62856070805 $338.0255/capsule

LENVIMA 8 MG/DAY 62856070830 $338.0258/capsule

LEUCOVORIN CALCIUM 10 MG/ML 63323063110 $1.9800/ml

LEUCOVORIN CALCIUM 10 MG/ML 63323063150 $1.9440/ml

Page 15 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

LEUKERAN 2 MG 76388063525 $26.4111/tablet

LEUKINE 250 MCG 00024584301 $259.7364/each

LEUKINE 250 MCG 71837584305 $286.3555/each

LEXIVA 50 MG/ML 49702020853 $0.7692/ml

LIBTAYO 350 MG/7ML 61755000801 $1345.8900/ml

LILETTA 20.1MCG/24 00023585801 $841.7196/each

LIORESAL INTRATHECAL 2000MCG/ML 70257056102 $42.5313/ml

LIORESAL INTRATHECAL 2000MCG/ML 70257056301 $42.5313/ml

LIORESAL INTRATHECAL 2000MCG/ML 70257056302 $42.5313/ml

LIORESAL INTRATHECAL 50 MCG/ML 70257056255 $29.6730/ml

LIORESAL INTRATHECAL 500 MCG/ML 70257056001 $10.6331/ml

LIORESAL INTRATHECAL 500 MCG/ML 70257056002 $10.6328/ml

LONSURF 15-6.14 MG 64842102501 $178.5056/tablet

LONSURF 15-6.14 MG 64842102502 $178.5054/tablet

LONSURF 15-6.14 MG 64842102503 $178.5056/tablet

LONSURF 20-8.19 MG 64842102001 $238.0081/tablet

LONSURF 20-8.19 MG 64842102002 $238.0076/tablet

LONSURF 20-8.19 MG 64842102003 $238.0071/tablet

LOPINAVIR-RITONAVIR 100MG-25MG 31722060360 $3.5943/tablet

LOPINAVIR-RITONAVIR 200MG-50MG 31722055612 $7.1887/tablet

LORBRENA 100 MG 00069023101 $587.6908/tablet

LORBRENA 25 MG 00069022701 $195.8973/tablet

LUCENTIS 0.3MG/0.05 50242008202 $23166.0000/ml

LUCENTIS 0.3MG/0.05 50242008203 $23166.0000/ml

LUCENTIS 0.5MG/0.05 50242008002 $38610.0000/ml

LUCENTIS 0.5MG/0.05 50242008003 $38610.0000/ml

LUMAKRAS 120 MG 55513048824 $74.2850/tablet

LUMAKRAS 120 MG 55513048840 $74.2850/tablet

LUMIZYME 50 MG 58468016001 $866.0245/each

LUMIZYME 50 MG 58468016002 $849.0464/each

LUMOXITI 1 MG 00310470001 $2114.5800/each

LUMOXITI 1 MG 73380470001 $2207.0000/each

LUPANETA PACK 11.25-5 MG 00074105305 $4431.8116/each

LUPANETA PACK 3.75MG-5MG 00074105205 $1477.2572/each

LUPKYNIS 7.9 MG 75626000101 $64.7800/capsule

LUPKYNIS 7.9 MG 75626000102 $64.7800/capsule

LUPRON DEPOT 11.25 MG 00074366303 $4405.1139/each

LUPRON DEPOT 22.5 MG 00074334603 $5249.3166/each

LUPRON DEPOT 3.75 MG 00074364103 $1468.3581/each

LUPRON DEPOT 30 MG 00074368303 $6999.1020/each

LUPRON DEPOT 45 MG 00074347303 $10498.8015/each

LUPRON DEPOT 7.5 MG 00074364203 $1749.7755/each

LUPRON DEPOT-PED 11.25 MG 00074228203 $3206.9367/each

LUPRON DEPOT-PED 11.25 MG 00074377903 $9620.8497/each

LUPRON DEPOT-PED 15 MG 00074244003 $3532.1220/each

LUPRON DEPOT-PED 30 MG 00074969403 $10596.3957/each

LUPRON DEPOT-PED 7.5 MG 00074210803 $1766.4372/each

LUTATHERA 10 MCI/ML 69488000301 $51760.0000/each

LUXTURNA 1.5X10EX11 71394041501 $846600.0000/ml

LYNPARZA 100 MG 00310066812 $119.9258/tablet

LYNPARZA 100 MG 00310066860 $119.9257/tablet

LYNPARZA 150 MG 00310067912 $119.9258/tablet

LYNPARZA 150 MG 00310067960 $119.9257/tablet

LYSODREN 500 MG 76336008060 $10.0934/tablet

MAKENA 275 MG/1.1 64011030103 $727.0800/ml

MARGENZA 250MG/10ML 74527002202 $207.7000/ml

MARGENZA 250MG/10ML 74527002203 $207.7000/ml

MARQIBO FNL 5MG/31 20536032201 $15662.3600/each

MARQIBO FNL 5MG/31 72893000803 $16135.7600/each

MATULANE 50 MG 54482005401 $103.6629/capsule

MAVENCLAD 10 MG 44087400000 $8486.4391/tablet

MAVENCLAD 10 MG 44087400004 $8486.4391/tablet

MAVENCLAD 10 MG 44087400005 $8486.4391/tablet

Page 16 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

MAVENCLAD 10 MG 44087400006 $8486.4391/tablet

MAVENCLAD 10 MG 44087400007 $8486.4391/tablet

MAVENCLAD 10 MG 44087400008 $8486.4391/tablet

MAVENCLAD 10 MG 44087400009 $8486.4391/tablet

MAVYRET 100MG-40MG 00074262528 $152.4286/tablet

MAVYRET 100MG-40MG 00074262580 $152.4286/tablet

MAVYRET 100MG-40MG 00074262584 $152.4286/tablet

MAYZENT 0.25 MG 00078097950 $66.0735/tablet

MAYZENT 0.25MG(12) 00078097912 $66.0731/tablet

MAYZENT 2 MG 00078098615 $264.2939/tablet

MEKINIST 0.5 MG 00078066615 $122.9160/tablet

MEKINIST 2 MG 00078066815 $418.3462/tablet

MEKTOVI 15 MG 70255001002 $68.8198/tablet

MELPHALAN 2 MG 47781020050 $8.2435/tablet

MEPSEVII 10 MG/5 ML 69794000101 $459.9540/ml

MESNEX 400 MG 67108356509 $78.2766/tablet

MIACALCIN 200/ML 67457067502 $1252.8400/ml

MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780600 $53.6507/each

MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780601 $53.6507/each

MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780605 $53.6507/each

MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780625 $53.6507/each

MIRCERA 100MCG/0.3 59353040309 $957.7536/ml

MIRCERA 150MCG/0.3 59353040409 $1436.5972/ml

MIRCERA 200MCG/0.3 59353040509 $1915.4740/ml

MIRCERA 30 MCG/0.3 59353040009 $287.3128/ml

MIRCERA 50 MCG/0.3 59353040109 $478.8768/ml

MIRCERA 75 MCG/0.3 59353040209 $718.3152/ml

MIRENA 20MCG/24HR 50419042301 $995.2829/each

MONJUVI 200 MG 73535020801 $1218.0000/each

MONOFERRIC 1000 MG/10 73594931001 $245.4413/ml

MONONINE 1000 (+/-) 00053623302 $1.1040/each

MOZOBIL 24MG/1.2ML 00024586201 $7350.0401/ml

MULPLETA 3 MG 59630055107 $1209.4286/tablet

MVASI 25 MG/ML 55513020601 $150.0000/ml

MVASI 25 MG/ML 55513020701 $150.0000/ml

MYALEPT FNL 5MG/ML 76431021001 $5275.8618/each

MYCAPSSA 20 MG 69880012028 $100.0646/capsule

MYCOPHENOLATE MOFETIL 500 MG 17478042240 $37.0000/each

MYCOPHENOLATE MOFETIL 500 MG 17478095740 $17.3250/each

MYCOPHENOLATE MOFETIL 500 MG 42023017204 $36.2500/each

MYCOPHENOLATE MOFETIL 500 MG 67457038681 $36.2500/each

MYCOPHENOLATE MOFETIL 500 MG 71288080321 $36.2500/each

MYLERAN 2 MG 76388071325 $23.3295/tablet

MYOBLOC 10000/2ML 10454071210 $575.1900/ml

MYOBLOC 2500/0.5ML 10454071010 $575.1900/ml

MYOBLOC 5000/ML 10454071110 $575.1900/ml

NABI-HB >1560/5ML 59730420301 $137.6469/ml

NABI-HB >1560/5ML 69800420301 $137.6469/ml

NABI-HB >312/ML 59730420201 $157.1594/ml

NABI-HB >312/ML 69800420201 $157.1594/ml

NAGLAZYME 5 MG/5 ML 68135002001 $402.3840/ml

NATPARA 100 MCG 68875020502 $5008.1608/each

NATPARA 25MCG/DOSE 68875020202 $5008.1608/each

NATPARA 50MCG/DOSE 68875020302 $5008.1608/each

NATPARA 75MCG/DOSE 68875020402 $5008.1608/each

NERLYNX 40 MG 70437024018 $101.6750/tablet

NERLYNX 40 MG 70437024033 $101.6594/tablet

NEULASTA ONPRO 6 MG/0.6ML 55513019201 $10589.6835/ml Increase

NEULASTA 6 MG/0.6ML 55513019001 $10589.6835/ml Increase

NEUPOGEN 300 MCG/ML 55513053001 $311.6817/ml

NEUPOGEN 300 MCG/ML 55513053010 $311.6847/ml

NEUPOGEN 300MCG/0.5 55513092401 $660.7260/ml

NEUPOGEN 300MCG/0.5 55513092410 $660.7359/ml

Page 17 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

NEUPOGEN 300MCG/0.5 55513092491 $660.7260/ml

NEUPOGEN 480MCG/0.8 55513020901 $657.6446/ml

NEUPOGEN 480MCG/0.8 55513020910 $657.6409/ml

NEUPOGEN 480MCG/0.8 55513020991 $657.6446/ml

NEUPOGEN 480MCG/1.6 55513054601 $310.1979/ml

NEUPOGEN 480MCG/1.6 55513054610 $310.1973/ml

NEVIRAPINE 50 MG/5 ML 65862005724 $0.3155/ml

NEXAVAR 200 MG 50419048858 $172.3080/tablet

NEXPLANON 68 MG 00052433001 $1026.5174/each Increase

NEXPLANON 68 MG 78206014501 $1026.5174/each Add

NEXVIAZYME 100 MG 58468042601 $1732.0490/each Add

NINLARO 2.3 MG 63020007801 $3618.4680/capsule

NINLARO 2.3 MG 63020007802 $3616.8080/capsule

NINLARO 2.3 MG 63020023001 $3618.4680/capsule

NINLARO 2.3 MG 63020023002 $3616.8080/capsule

NINLARO 3 MG 63020007901 $3618.4680/capsule

NINLARO 3 MG 63020007902 $3616.8080/capsule

NINLARO 3 MG 63020039001 $3618.4680/capsule

NINLARO 3 MG 63020039002 $3616.8080/capsule

NINLARO 4 MG 63020008001 $3618.4680/capsule

NINLARO 4 MG 63020008002 $3616.8080/capsule

NINLARO 4 MG 63020040001 $3618.4680/capsule

NINLARO 4 MG 63020040002 $3616.8080/capsule

NIPENT 10 MG 00409080101 $2217.3400/each

NITISINONE 10 MG 00254302202 $366.9237/capsule

NITISINONE 10 MG 63629223301 $759.7663/capsule

NITISINONE 2 MG 00254302002 $73.3851/capsule

NITISINONE 2 MG 63629223401 $151.9587/capsule

NITISINONE 5 MG 00254302102 $183.4616/capsule

NITISINONE 5 MG 63629223501 $379.8856/capsule

NITYR 10 MG 70709000060 $433.4087/tablet

NITYR 2 MG 70709000260 $86.6782/tablet

NITYR 5 MG 70709000560 $216.7132/tablet

NIVESTYM 300 MCG/ML 00069029310 $216.8100/ml

NIVESTYM 300MCG/0.5 00069029101 $433.6200/ml

NIVESTYM 300MCG/0.5 00069029110 $433.6200/ml

NIVESTYM 480MCG/0.8 00069029201 $433.6200/ml

NIVESTYM 480MCG/0.8 00069029210 $433.6200/ml

NIVESTYM 480MCG/1.6 00069029410 $216.8100/ml

NORDITROPIN FLEXPRO 10MG/1.5ML 00169770521 $913.8435/ml

NORDITROPIN FLEXPRO 15MG/1.5ML 00169770821 $1370.7587/ml

NORDITROPIN FLEXPRO 30 MG/3 ML 00169770321 $1370.7619/ml

NORDITROPIN FLEXPRO 5 MG/1.5ML 00169770421 $456.9217/ml

NORVIR 100 MG 00074333330 $8.3580/tablet

NORVIR 100 MG 00074339930 $8.3580/each

NORVIR 80 MG/ML 00074194063 $5.8508/ml

NOVOEIGHT 1000 (+/-) 00169781001 $1.6490/each

NOVOEIGHT 1500 (+/-) 00169781501 $1.6490/each

NOVOEIGHT 2000 (+/-) 00169782001 $1.6490/each

NOVOEIGHT 250 (+/-) 00169782501 $1.6490/each

NOVOEIGHT 3000 (+/-) 00169783001 $1.6490/each

NOVOEIGHT 500 (+/-) 00169785001 $1.6490/each

NOVOSEVEN RT 1 MG 00169720101 $2.1120/each

NOVOSEVEN RT 2 MG 00169720201 $2.1120/each

NOVOSEVEN RT 5 MG 00169720501 $2.1120/each

NOVOSEVEN RT 8 MG 00169720801 $2.1120/each

NPLATE 125 MCG 55513022301 $1028.2206/each

NPLATE 250 MCG 55513022101 $2056.4213/each

NPLATE 500 MCG 55513022201 $4112.8426/each

NUBEQA 300 MG 50419039501 $98.7434/tablet

NUCALA 100 MG/ML 00173089201 $3135.3201/ml

NUCALA 100 MG/ML 00173089242 $3135.3201/ml

NUCALA 100 MG 00173088101 $3135.3201/each

Page 18 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

NULIBRY 9.5 MG 73129000101 $1383.5586/each

NULOJIX 250 MG 00003037113 $921.6183/each

NUTROPIN AQ NUSPIN 10 MG/2 ML 50242007401 $618.6162/ml

NUTROPIN AQ NUSPIN 20 MG/2 ML 50242007601 $1237.2226/ml

NUTROPIN AQ NUSPIN 5 MG/2 ML 50242007501 $309.3056/ml

NUWIQ 1000 (+/-) 68982014301 $1.6104/each

NUWIQ 1000 (+/-) 68982014401 $1.6104/each

NUWIQ 2000 (+/-) 68982014501 $1.6104/each

NUWIQ 2000 (+/-) 68982014601 $1.6104/each

NUWIQ 250 (+/-) 68982013901 $1.6104/each

NUWIQ 250 (+/-) 68982014001 $1.6104/each

NUWIQ 2500 (+/-) 68982014701 $1.6104/each

NUWIQ 2500 (+/-) 68982014801 $1.6104/each

NUWIQ 3000 (+/-) 68982014901 $1.6104/each

NUWIQ 3000 (+/-) 68982015001 $1.6104/each

NUWIQ 4000 (+/-) 68982015101 $1.6104/each

NUWIQ 4000 (+/-) 68982015201 $1.6104/each

NUWIQ 500 (+/-) 68982014101 $1.6104/each

NUWIQ 500 (+/-) 68982014201 $1.6104/each

NYMALIZE 30 MG/5 ML 24338023012 $8.3855/ml

NYMALIZE 30MG/10ML 24338020512 $4.0707/ml

NYMALIZE 60 MG/10ML 24338026008 $8.3863/ml

NYMALIZE 60 MG/10ML 24338026012 $8.3858/ml

NYMALIZE 60 MG/20ML 24338020012 $4.0708/ml

NYMALIZE 60 MG/20ML 24338020016 $4.0736/ml

NYVEPRIA 6 MG/0.6ML 00069032401 $6476.2500/ml

OBIZUR 500 (+/-) 00944500101 $2.9500/each

OBIZUR 500 (+/-) 00944500105 $2.9500/each

OBIZUR 500 (+/-) 00944500110 $5.1600/each

OCALIVA 10 MG 69516001030 $252.1982/tablet

OCALIVA 5 MG 69516000530 $252.1982/tablet

OCREVUS 300MG/10ML 50242015001 $1675.7923/ml

OCTAGAM 10 % 68982085001 $13.8160/ml

OCTAGAM 10 % 68982085002 $13.8160/ml

OCTAGAM 10 % 68982085003 $13.8160/ml

OCTAGAM 10 % 68982085004 $13.8160/ml

OCTAGAM 10 % 68982085005 $13.8160/ml

OCTAGAM 5 % 68982084001 $6.9080/ml

OCTAGAM 5 % 68982084002 $6.9080/ml

OCTAGAM 5 % 68982084003 $6.9080/ml

OCTAGAM 5 % 68982084004 $6.9080/ml

OCTAGAM 5 % 68982084005 $5.9308/ml

OCTAPLAS 45 TO 70MG 68982095201 $0.8475/ml

OCTAPLAS 45 TO 70MG 68982095301 $0.8475/ml

OCTAPLAS 45 TO 70MG 68982095401 $0.8475/ml

OCTAPLAS 45 TO 70MG 68982095501 $0.8475/ml

OCTREOTIDE ACETATE 100 MCG/ML 67457024501 $4.6942/ml

OCTREOTIDE ACETATE 50 MCG/ML 67457023901 $2.7342/ml

OCTREOTIDE ACETATE 500 MCG/ML 67457024601 $23.4703/ml

ODEFSEY 200-25-25 61958210101 $100.3785/tablet

ODOMZO 200 MG 00078064515 $333.9920/capsule

ODOMZO 200 MG 47335030383 $413.7391/capsule

OFEV 100 MG 00597014360 $184.4858/capsule

OFEV 150 MG 00597014560 $184.4858/capsule

OGIVRI 150 MG 67457099115 $1199.0000/each

OGIVRI 420 MG 67457084744 $3340.0000/each

OLUMIANT 1 MG 00002473230 $78.0115/tablet

OLUMIANT 2 MG 00002418230 $78.0115/tablet

OMNITROPE 10MG/1.5ML 00781300407 $820.3018/ml

OMNITROPE 5 MG/1.5ML 00781300107 $408.4836/ml

OMNITROPE 5.8 MG 00781400436 $310.0043/each

ONCASPAR 750/ML 00944381001 $3683.0732/ml

ONCASPAR 750/ML 72694095401 $4027.4408/ml

Page 19 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ONGENTYS 50 MG 70370305002 $19.5880/capsule

ONIVYDE 43 MG/10ML 15054004301 $247.2000/ml

ONPATTRO 10 MG/5 ML 71336100001 $1892.4000/ml

ONTRUZANT 150 MG 00006503302 $1199.0000/each

ONTRUZANT 420 MG 00006503402 $3340.0000/each

ONUREG 200 MG 59572073007 $1505.2491/tablet

ONUREG 200 MG 59572073014 $1505.2484/tablet

ONUREG 300 MG 59572074007 $1505.2491/tablet

ONUREG 300 MG 59572074014 $1505.2484/tablet

OPDIVO 100MG/10ML 00003377412 $282.4720/ml

OPDIVO 240MG/24ML 00003373413 $282.4725/ml

OPDIVO 40 MG/4 ML 00003377211 $282.4725/ml

OPSUMIT 10 MG 66215050115 $350.9804/tablet

OPSUMIT 10 MG 66215050130 $350.9804/tablet

ORBACTIV 400 MG 70842014001 $991.6873/each

ORBACTIV 400 MG 70842014003 $1021.5640/each

ORENCIA CLICKJECT 125 MG/ML 00003218851 $1193.2205/ml

ORENCIA 125 MG/ML 00003218811 $1193.2205/ml

ORENCIA 250 MG 00003218713 $1208.8145/each

ORENCIA 50MG/0.4ML 00003281411 $2983.0514/ml

ORENCIA 87.5MG/0.7 00003281811 $1704.6008/ml

ORENITRAM ER 0.125 MG 66302030001 $5.8796/tablet

ORENITRAM ER 0.125 MG 66302030010 $5.8804/tablet

ORENITRAM ER 0.25 MG 66302030201 $11.7586/tablet

ORENITRAM ER 0.25 MG 66302030210 $11.7588/tablet

ORENITRAM ER 1 MG 66302031001 $47.0355/tablet

ORENITRAM ER 1 MG 66302031010 $47.0361/tablet

ORENITRAM ER 2.5 MG 66302032501 $117.5889/tablet

ORENITRAM ER 2.5 MG 66302032510 $117.5888/tablet

ORENITRAM ER 5 MG 66302035001 $235.1775/tablet

ORENITRAM ER 5 MG 66302035010 $235.1775/tablet

ORFADIN 10 MG 66658011060 $458.6546/capsule

ORFADIN 2 MG 66658010260 $91.7314/capsule

ORFADIN 20 MG 66658012060 $917.3091/capsule

ORFADIN 4 MG/ML 66658020490 $199.9674/ml

ORFADIN 5 MG 66658010560 $229.3271/capsule

ORGOVYX 120 MG 72974012001 $76.7916/tablet

ORKAMBI 100-125 MG 51167070002 $186.0317/tablet

ORKAMBI 100-125 MG 51167090001 $372.0634/each

ORKAMBI 150-188 MG 51167050002 $372.0634/each

ORKAMBI 200-125MG 51167080901 $186.0317/tablet

ORLADEYO 110 MG 72769010201 $1327.0989/capsule

ORLADEYO 150 MG 72769010101 $1327.0989/capsule

OTEZLA 10-20-30MG 55513036955 $70.6702/tablet Increase

OTEZLA 10-20-30MG 59572063255 $70.6702/tablet Increase

OTEZLA 30 MG 55513013760 $64.7810/tablet Increase

OTEZLA 30 MG 59572063106 $64.7810/tablet Increase

OTREXUP 10MG/0.4ML 54436001004 $395.9597/ml

OTREXUP 12.5MG/0.4 54436001204 $395.9597/ml

OTREXUP 15MG/0.4ML 54436001504 $395.9597/ml

OTREXUP 17.5MG/0.4 54436001704 $395.9597/ml

OTREXUP 20MG/0.4ML 54436002004 $395.9597/ml

OTREXUP 22.5MG/0.4 54436002204 $395.9597/ml

OTREXUP 25MG/0.4ML 54436002504 $395.9597/ml

OXBRYTA 500 MG 72786010101 $115.2815/tablet

OXERVATE 0.002 % 71981002007 $1725.1431/ml

OXLUMO 94.5MG/0.5 71336100201 $110000.0000/ml

OZURDEX 0.7 MG 00023334807 $1327.6680/each

PADCEV 20 MG 51144002001 $2277.0000/each

PADCEV 30 MG 51144003001 $3415.5000/each

PALYNZIQ 10MG/0.5ML 68135075620 $1073.6300/ml

PALYNZIQ 2.5 MG/0.5 68135005890 $1073.6300/ml

PALYNZIQ 20 MG/ML 68135067340 $536.8150/ml

Page 20 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

PALYNZIQ 20 MG/ML 68135067345 $536.8150/ml

PAMIDRONATE DISODIUM 60 MG/10ML 61703032518 $2.5362/ml

PANZYGA 10 % 00069101102 $17.1611/ml

PANZYGA 10 % 00069110902 $17.1611/ml

PANZYGA 10 % 00069122402 $17.1611/ml

PANZYGA 10 % 00069131202 $17.1611/ml

PANZYGA 10 % 00069141502 $17.1611/ml

PANZYGA 10 % 00069155802 $17.1611/ml

PANZYGA 10 % 68982082001 $16.5336/ml

PANZYGA 10 % 68982082002 $16.5336/ml

PANZYGA 10 % 68982082003 $16.5336/ml

PANZYGA 10 % 68982082004 $16.5336/ml

PANZYGA 10 % 68982082005 $16.5336/ml

PANZYGA 10 % 68982082006 $16.5336/ml

PANZYGA 10 % 68982082201 $17.4300/ml

PANZYGA 10 % 68982082202 $17.4300/ml

PANZYGA 10 % 68982082203 $17.4300/ml

PANZYGA 10 % 68982082204 $17.4300/ml

PANZYGA 10 % 68982082205 $17.4300/ml

PANZYGA 10 % 68982082206 $17.4300/ml

PARAGARD T 380-A 380 SQ MM 59365512801 $933.2520/each

PEGASYS 180MCG/0.5 00004035730 $2010.2923/ml

PEGASYS 180MCG/ML 00004035009 $1005.1462/ml

PEGINTRON 50 MCG/0.5 00085435301 $0.0000 Delete

PEMAZYRE 13.5 MG 50881002801 $1209.4286/tablet

PEMAZYRE 4.5 MG 50881002601 $1209.4286/tablet

PEMAZYRE 9 MG 50881002701 $1209.4286/tablet

PENTAM 300 300 MG 63323011310 $166.2224/each

PENTAMIDINE ISETHIONATE 300 MG 13925051510 $143.0550/each

PENTAMIDINE ISETHIONATE 300 MG 23155074841 $96.7230/each

PEPAXTO 20 MG 73657002001 $9500.0000/each

PERJETA 420MG/14ML 50242014501 $395.0107/ml

PERSERIS 120 MG 12496012001 $2450.8575/each

PERSERIS 90 MG 12496009001 $1838.1382/each

PH 12 DILUENT FOR FLOLAN 11.7-12.3 00173085702 $0.2804/ml

PHESGO 1200-600MG 50242024501 $847.1333/ml

PHESGO 600-600 MG 50242026001 $847.1000/ml

PHOTOFRIN 75 MG 76128015575 $21040.0000/each

PIFELTRO 100 MG 00006306901 $49.4422/tablet

PIQRAY 200 MG/DAY 00078070151 $622.3997/tablet

PIQRAY 200 MG/DAY 00078070184 $622.3997/tablet

PIQRAY 250 MG/DAY 00078071502 $311.1998/tablet

PIQRAY 250 MG/DAY 00078071561 $311.1998/tablet

PIQRAY 300 MG/DAY 00078070802 $311.1998/tablet

PIQRAY 300 MG/DAY 00078070851 $311.1998/tablet

PLEGRIDY PEN 125MCG/0.5 64406001101 $7090.2514/ml

PLEGRIDY PEN 63-94 MCG 64406001201 $7090.2514/ml

PLEGRIDY 125MCG/0.5 64406001501 $7090.2514/ml

PLEGRIDY 125MCG/0.5 64406001701 $7090.2514/ml

PLEGRIDY 63-94 MCG 64406001601 $7090.2514/ml

POLIVY 140 MG 50242010501 $15000.0000/each

POLIVY 30 MG 50242010301 $3214.2900/each

POMALYST 1 MG 59572050100 $903.9782/capsule

POMALYST 1 MG 59572050121 $903.9786/capsule

POMALYST 2 MG 59572050200 $903.9782/capsule

POMALYST 2 MG 59572050221 $903.9786/capsule

POMALYST 3 MG 59572050300 $903.9782/capsule

POMALYST 3 MG 59572050321 $903.9786/capsule

POMALYST 4 MG 59572050400 $903.9782/capsule

POMALYST 4 MG 59572050421 $903.9786/capsule

PONVORY 2 MG-10 MG 50458070714 $265.1388/tablet

PONVORY 20 MG 50458072030 $265.1388/tablet

PORTRAZZA 800MG/50ML 00002771601 $86.5950/ml

Page 21 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

POTELIGEO 20 MG/5 ML 42747076101 $804.5140/ml

PRALUENT PEN 150 MG/ML 61755002102 $230.8230/ml

PRALUENT PEN 150 MG/ML 72733590202 $224.1000/ml

PRALUENT PEN 75 MG/ML 61755002002 $230.8230/ml

PRALUENT PEN 75 MG/ML 72733590102 $224.1000/ml

PREVYMIS 240 MG 00006307502 $224.8271/tablet

PREVYMIS 240 MG 00006307504 $224.8271/tablet

PREVYMIS 240MG/12ML 00006500301 $25.7796/ml

PREVYMIS 480 MG 00006307602 $224.8271/tablet

PREVYMIS 480 MG 00006307604 $224.8271/tablet

PREVYMIS 480MG/24ML 00006500401 $12.8898/ml

PREZCOBIX 800-150 MG 59676057530 $68.5431/tablet

PREZISTA 100 MG/ML 59676056501 $4.9971/ml

PREZISTA 150 MG 59676056401 $7.4961/tablet

PREZISTA 600 MG 59676056201 $29.9843/tablet

PREZISTA 75 MG 59676056301 $3.7480/tablet

PREZISTA 800 MG 59676056630 $59.9687/tablet

PRIALT 100 MCG/ML 18860072010 $798.5729/ml

PRIALT 100 MCG/ML 18860072210 $798.5729/ml

PRIALT 100 MCG/ML 70720072010 $989.2372/ml

PRIALT 100 MCG/ML 70720072210 $938.8435/ml

PRIALT 25 MCG/ML 70720072310 $234.7109/ml

PRIVIGEN 10 % 44206043605 $12.1800/ml

PRIVIGEN 10 % 44206043710 $12.1800/ml

PRIVIGEN 10 % 44206043820 $12.1800/ml

PRIVIGEN 10 % 44206043940 $12.1800/ml

PROCRIT 10000/ML 59676031001 $262.9740/ml

PROCRIT 10000/ML 59676031002 $262.9642/ml

PROCRIT 2000/ML 59676030201 $52.6046/ml

PROCRIT 20000/2ML 59676031204 $262.9740/ml

PROCRIT 20000/ML 59676032004 $525.9480/ml

PROCRIT 3000/ML 59676030301 $78.8971/ml

PROCRIT 4000/ML 59676030401 $105.1896/ml

PROCRIT 40000/ML 59676034001 $1051.8960/ml

PROCYSBI 25 MG 75987010004 $105.7553/capsule

PROCYSBI 300 MG 75987014513 $423.0211/each

PROCYSBI 300 MG 75987014514 $423.0211/each

PROCYSBI 75 MG 75987010108 $105.7553/capsule

PROCYSBI 75 MG 75987014013 $105.7553/each

PROCYSBI 75 MG 75987014014 $105.7553/each

PROFILNINE 1000 (+/-) 68516320202 $1.2150/each

PROFILNINE 1000 (+/-) 68516320802 $1.2420/each

PROFILNINE 1500 (+/-) 68516320302 $1.2150/each

PROFILNINE 1500 (+/-) 68516320902 $1.2420/each

PROFILNINE 500 (+/-) 68516320101 $1.2150/each

PROFILNINE 500 (+/-) 68516320701 $1.2420/each

PROGRAF 0.2 MG 00469123050 $5.0648/each

PROGRAF 0.5 MG 00469060773 $3.0259/capsule

PROGRAF 1 MG 00469133050 $7.5592/each

PROGRAF 5 MG/ML 00469301601 $208.5821/ml

PROLASTIN C 1000 MG/20 13533070501 $0.5179/each

PROLASTIN C 1000 MG 13533070002 $0.5179/each

PROLEUKIN 22MM UNIT 76310002201 $4683.6000/each

PROLIA 60 MG/ML 55513071001 $1348.8230/ml

PROMACTA 12.5 MG 00078068415 $186.1302/tablet

PROMACTA 12.5 MG 00078097219 $186.1398/each

PROMACTA 12.5 MG 00078097223 $186.1302/each

PROMACTA 12.5 MG 00078097261 $186.1302/each

PROMACTA 25 MG 00078068515 $186.1302/tablet

PROMACTA 25 MG 00078069719 $186.1398/each

PROMACTA 25 MG 00078069723 $186.1401/each

PROMACTA 25 MG 00078069761 $186.1401/each

PROMACTA 50 MG 00078068615 $336.8366/tablet

Page 22 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

PROMACTA 50 MG 00078068655 $336.8362/tablet

PROMACTA 75 MG 00078068715 $505.2551/tablet

PROVENGE 50 MM/250 30237890006 $250.4101/ml

PULMOZYME 1 MG/ML 50242010040 $45.5081/ml

PURIXAN 20 MG/ML 60311045001 $12.3283/ml

PURIXAN 20 MG/ML 62484000202 $12.3283/ml

PURIXAN 20 MG/ML 62484002002 $12.9447/ml

QINLOCK 50 MG 73207010130 $371.5080/tablet

RADICAVA 30MG/100ML 70510217102 $5.8541/ml

RAPAMUNE 1 MG/ML 00008103004 $29.4804/ml

RAPAMUNE 1 MG/ML 00008103006 $29.4804/ml

RASUVO 10MG/0.2ML 59137051004 $600.8438/ml

RASUVO 12.5/0.25 59137051504 $480.6750/ml

RASUVO 15MG/0.3ML 59137052004 $400.5625/ml

RASUVO 17.5/0.35 59137052504 $343.3393/ml

RASUVO 20MG/0.4ML 59137053004 $300.4219/ml

RASUVO 22.5/0.45 59137053504 $267.0417/ml

RASUVO 25MG/0.5ML 59137054004 $240.3375/ml

RASUVO 30MG/0.6ML 59137055004 $200.2812/ml

RASUVO 7.5MG/0.15 59137050504 $801.1250/ml

RAVICTI 1.1GRAM/ML 75987005006 $210.0564/ml

REBIF REBIDOSE 22MCG/.5ML 44087332201 $1449.3775/ml

REBIF REBIDOSE 44MCG/.5ML 44087334401 $1449.3775/ml

REBIF REBIDOSE 8.8-22(6) 44087018801 $2070.5393/ml

REBIF 22MCG/.5ML 44087002203 $1449.3775/ml

REBIF 44MCG/.5ML 44087004403 $1449.3775/ml

REBIF 8.8-22(6) 44087882201 $2070.5393/ml

REBLOZYL 25 MG 59572071101 $3509.7381/each

REBLOZYL 75 MG 59572077501 $10529.2044/each

RECOMBINATE 1000 (+/-) 00944284310 $1.4790/each

RECOMBINATE 1500 (+/-) 00944284410 $1.4790/each

RECOMBINATE 2000 (+/-) 00944284510 $1.4790/each

RECOMBINATE 250 (+/-) 00944284110 $1.4790/each

RECOMBINATE 500 (+/-) 00944284210 $1.4790/each

REDITREX 10MG/0.4ML 66220081022 $182.8125/ml

REDITREX 12.5MG/0.5 66220081222 $146.2500/ml

REDITREX 15MG/0.6ML 66220081522 $121.8750/ml

REDITREX 17.5MG/0.7 66220081722 $104.4643/ml

REDITREX 20MG/0.8ML 66220082022 $91.4062/ml

REDITREX 22.5MG/0.9 66220082222 $81.2500/ml

REDITREX 25 MG/ML 66220082522 $73.1250/ml

REDITREX 7.5MG/.3ML 66220080722 $243.7500/ml

REMICADE 100 MG 57894003001 $480.0000/each

RENFLEXIS 100 MG 00006430502 $480.0000/each

REPATHA PUSHTRONEX 420 MG/3.5 72511077001 $146.9157/ml

REPATHA SURECLICK 140 MG/ML 72511076001 $237.3269/ml

REPATHA SURECLICK 140 MG/ML 72511076002 $237.3219/ml

REPATHA SYRINGE 140 MG/ML 72511075001 $237.3269/ml

RETACRIT 10000/ML 00069130810 $109.1970/ml

RETACRIT 10000/ML 59353001001 $109.1970/ml

RETACRIT 10000/ML 59353001010 $109.1970/ml

RETACRIT 2000/ML 00069130510 $21.8394/ml

RETACRIT 2000/ML 59353000201 $21.8394/ml

RETACRIT 2000/ML 59353000210 $21.8394/ml

RETACRIT 20000/2ML 00069131810 $109.1970/ml

RETACRIT 20000/2ML 59353022001 $109.1970/ml

RETACRIT 20000/2ML 59353022010 $109.1970/ml

RETACRIT 20000/ML 00069131110 $218.3940/ml

RETACRIT 20000/ML 59353012001 $218.3940/ml

RETACRIT 20000/ML 59353012010 $218.3940/ml

RETACRIT 3000/ML 00069130610 $32.7591/ml

RETACRIT 3000/ML 59353000301 $32.7591/ml

RETACRIT 3000/ML 59353000310 $32.7591/ml

Page 23 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

RETACRIT 4000/ML 00069130710 $43.6788/ml

RETACRIT 4000/ML 59353000401 $43.6788/ml

RETACRIT 4000/ML 59353000410 $43.6788/ml

RETACRIT 40000/ML 00069130904 $436.7880/ml

RETAVASE 10 UNIT 10122014301 $3218.4246/each

RETAVASE 20 UNIT 10122014102 $2599.2413/each

RETEVMO 40 MG 00002397760 $113.9866/capsule

RETEVMO 80 MG 00002298026 $170.9800/capsule

RETEVMO 80 MG 00002298060 $170.9800/capsule

RETROVIR 10 MG/ML 49702021326 $1.4230/ml

REVATIO 10 MG/12.5 00069033801 $18.0626/ml

REVCOVI 2.4 MG/1.5 57665000201 $7011.1372/ml

REVLIMID 10 MG 59572041000 $789.3710/capsule

REVLIMID 10 MG 59572041028 $789.3705/capsule

REVLIMID 15 MG 59572041500 $789.3710/capsule

REVLIMID 15 MG 59572041521 $789.3713/capsule

REVLIMID 2.5 MG 59572040200 $789.3710/capsule

REVLIMID 2.5 MG 59572040228 $789.3705/capsule

REVLIMID 20 MG 59572042000 $789.3710/capsule

REVLIMID 20 MG 59572042021 $789.3713/capsule

REVLIMID 25 MG 59572042500 $789.3710/capsule

REVLIMID 25 MG 59572042521 $789.3713/capsule

REVLIMID 5 MG 59572040500 $789.3710/capsule

REVLIMID 5 MG 59572040528 $789.3705/capsule

REYATAZ 50 MG 00003363810 $7.3456/each

REZUROCK 200 MG 79802020030 $514.6000/tablet Add

RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780500 $114.4600/each

RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780501 $114.4600/each

RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780505 $114.4600/each

RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780525 $114.4600/each

RHOPHYLAC 1500/2 ML 44206030001 $77.7843/ml

RHOPHYLAC 1500/2 ML 44206030010 $70.7130/ml

RIABNI 10 MG/ML 55513022401 $70.9632/ml

RIABNI 10 MG/ML 55513032601 $70.9632/ml

RIASTAP 900-1300MG 63833089151 $1.1610/each

RIBASPHERE RIBAPAK 600 MG(28) 66435010799 $20.0807/tablet

RIBASPHERE RIBAPAK 600-400 MG 66435010699 $16.7341/tablet

RIBASPHERE RIBAPAK 600-400(7) 66435010656 $16.7343/tablet

RIBASPHERE RIBAPAK 600-600(7) 66435010756 $20.0807/tablet

RIBASPHERE 600 MG 66435010456 $20.0807/tablet

RINVOQ 15 MG 00074230630 $173.2004/tablet

RISPERDAL CONSTA 12.5MG/2ML 50458030911 $259.8083/each

RISPERDAL CONSTA 25 MG/2 ML 50458030611 $519.5872/each

RISPERDAL CONSTA 37.5MG/2ML 50458030711 $779.4150/each

RISPERDAL CONSTA 50 MG/2 ML 50458030811 $1039.2428/each

RITONAVIR 100 MG 00054040713 $5.2000/tablet

RITONAVIR 100 MG 31722059730 $2.6000/tablet

RITONAVIR 100 MG 60687042025 $9.1406/tablet

RITONAVIR 100 MG 65862068730 $2.6000/tablet

RITUXAN HYCELA 1400/11.7 50242010801 $562.1008/ml

RITUXAN HYCELA 1600/13.4 50242010901 $560.9022/ml

RITUXAN 10 MG/ML 50242005110 $89.2544/ml

RITUXAN 10 MG/ML 50242005121 $89.2544/ml

RITUXAN 10 MG/ML 50242005306 $89.2544/ml

RIXUBIS 1000 UNIT 00944303002 $1.4025/each

RIXUBIS 2000 UNIT 00944303202 $1.4025/each

RIXUBIS 250 UNIT 00944302602 $1.4025/each

RIXUBIS 3000 UNIT 00944303402 $1.4025/each

RIXUBIS 500 UNIT 00944302802 $1.4025/each

ROMIDEPSIN 10 MG/2 ML 00703312508 $2878.7900/each

ROMIDEPSIN 27.5/5.5ML 00703400401 $1599.3000/ml

ROZLYTREK 100 MG 50242009130 $191.4976/capsule

ROZLYTREK 200 MG 50242009490 $191.4976/capsule

Page 24 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

RUBRACA 200 MG 69660020191 $144.1710/tablet

RUBRACA 250 MG 69660020291 $144.1710/tablet

RUBRACA 300 MG 69660020391 $144.1710/tablet

RUCONEST 2100 UNIT 68012035001 $6209.0640/each

RUCONEST 2100 UNIT 68012035002 $6209.0640/each

RUCONEST 2100 UNIT 71274035001 $6513.8400/each

RUCONEST 2100 UNIT 71274035002 $6513.8400/each

RUKOBIA 600 MG 49702025018 $124.3125/tablet

RUXIENCE 10 MG/ML 00069023801 $70.9632/ml

RUXIENCE 10 MG/ML 00069024901 $70.9632/ml

RUZURGI 10 MG 49938011001 $79.6800/tablet

RYBREVANT 350 MG/7ML 57894050101 $426.6328/ml

RYDAPT 25 MG 00078069802 $167.2704/capsule

RYDAPT 25 MG 00078069819 $167.2682/capsule

RYDAPT 25 MG 00078069851 $167.2679/capsule

RYDAPT 25 MG 00078069899 $167.2683/capsule

RYLAZE 10MG/0.5ML 68727090001 $8780.0000/ml

RYLAZE 10MG/0.5ML 68727090003 $8780.0000/ml

SABRIL 500 MG 67386011101 $174.4974/tablet

SABRIL 500 MG 67386021165 $174.4976/each

SAIZEN 5 MG 44087100502 $683.6480/each

SAIZEN 8.8 MG 44087108801 $1098.3014/each

SAIZEN-SAIZENPREP 8.8MG/1.51 44087001601 $1098.3014/each

SAMSCA 15 MG 59148002050 $518.1162/tablet

SAMSCA 30 MG 59148002150 $537.4844/tablet

SANDIMMUNE 100 MG/ML 00078011022 $14.6069/ml

SANDIMMUNE 250 MG/5ML 00078010901 $11.7252/ml

SANDIMMUNE 250 MG/5ML 00078010961 $11.7270/ml

SANDOSTATIN LAR DEPOT 10 MG 00078079061 $3203.0184/each

SANDOSTATIN LAR DEPOT 10 MG 00078081181 $3203.0184/each

SANDOSTATIN LAR DEPOT 20 MG 00078079761 $4196.5042/each

SANDOSTATIN LAR DEPOT 20 MG 00078081881 $4196.5042/each

SANDOSTATIN LAR DEPOT 30 MG 00078080461 $6283.9618/each

SANDOSTATIN LAR DEPOT 30 MG 00078082581 $6283.9618/each

SAPHNELO 300 MG/2ML 00310304000 $2291.0689/ml Add

SAPROPTERIN DIHYDROCHLORIDE 500 MG 49884087372 $159.5880/each

SARCLISA 100 MG/5ML 00024065401 $136.5820/ml

SARCLISA 500MG/25ML 00024065601 $136.5812/ml

SELZENTRY 150 MG 49702022318 $25.2882/tablet

SELZENTRY 20 MG/ML 49702023755 $3.3718/ml

SELZENTRY 25 MG 49702023308 $4.2148/tablet

SELZENTRY 300 MG 49702022418 $25.2882/tablet

SELZENTRY 75 MG 49702023508 $12.6441/tablet

SEROSTIM 4 MG 44087000407 $401.6294/each

SEROSTIM 5 MG 44087000507 $499.9960/each

SEROSTIM 6 MG 44087000607 $602.4442/each

SEVENFACT 1 MG 71127100001 $2061.0000/each

SEVENFACT 5 MG 71127500001 $10305.0000/each

SIGNIFOR LAR 10 MG 00078074881 $13851.5712/each

SIGNIFOR LAR 10 MG 00078075561 $13006.1664/each

SIGNIFOR LAR 10 MG 55292013901 $13851.5712/each

SIGNIFOR LAR 20 MG 00078064161 $13006.1664/each

SIGNIFOR LAR 20 MG 00078064181 $13851.5712/each

SIGNIFOR LAR 20 MG 55292014001 $13851.5712/each

SIGNIFOR LAR 30 MG 00078074181 $13851.5712/each

SIGNIFOR LAR 30 MG 00078076961 $13006.1664/each

SIGNIFOR LAR 30 MG 55292014101 $13851.5712/each

SIGNIFOR LAR 40 MG 00078064261 $13006.1664/each

SIGNIFOR LAR 40 MG 00078064281 $13851.5712/each

SIGNIFOR LAR 40 MG 55292014201 $13851.5712/each

SIGNIFOR LAR 60 MG 00078064361 $13851.5712/each

SIGNIFOR LAR 60 MG 00078064381 $13851.5712/each

SIGNIFOR LAR 60 MG 55292014301 $13851.5712/each

Page 25 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

SIGNIFOR 0.3 MG/ML 00078063306 $231.6165/ml

SIGNIFOR 0.3 MG/ML 00078063320 $243.1975/ml

SIGNIFOR 0.3 MG/ML 00078063361 $231.6198/ml

SIGNIFOR 0.3 MG/ML 55292013160 $243.1975/ml

SIGNIFOR 0.6 MG/ML 00078063406 $231.6165/ml

SIGNIFOR 0.6 MG/ML 00078063420 $243.1975/ml

SIGNIFOR 0.6 MG/ML 00078063461 $231.6198/ml

SIGNIFOR 0.6 MG/ML 55292013260 $243.1975/ml

SIGNIFOR 0.9 MG/ML 00078063506 $231.6165/ml

SIGNIFOR 0.9 MG/ML 00078063520 $243.1975/ml

SIGNIFOR 0.9 MG/ML 00078063561 $231.6198/ml

SIGNIFOR 0.9 MG/ML 55292013360 $243.1975/ml

SILDENAFIL CITRATE 10 MG/12.5 55150016613 $8.8800/ml

SILIQ 210 MG/1.5 00187000402 $1289.8928/ml

SIMPONI ARIA 50 MG/4 ML 57894035001 $491.8007/ml

SIMPONI 100 MG/ML 57894007101 $5959.7534/ml

SIMPONI 100 MG/ML 57894007102 $5959.7534/ml

SIMPONI 50MG/0.5ML 57894007001 $10364.7672/ml

SIMPONI 50MG/0.5ML 57894007002 $10364.7672/ml

SIMULECT 10 MG 00078039361 $2918.4644/each

SIMULECT 20 MG 00078033184 $3830.4888/each

SIROLIMUS 1 MG/ML 59762120506 $17.0875/ml

SIROLIMUS 1 MG/ML 60505619702 $17.0875/ml

SIROLIMUS 1 MG/ML 66689034702 $28.4083/ml

SIROLIMUS 1 MG/ML 69238159403 $17.0875/ml

SIRTURO 100 MG 59676070101 $158.9362/tablet

SIVEXTRO 200 MG 67919004001 $306.5090/each

SIVEXTRO 200 MG 67919004101 $384.7847/tablet

SIVEXTRO 200 MG 67919004102 $384.7847/tablet

SIVEXTRO 200 MG 72000031006 $400.1762/tablet

SIVEXTRO 200 MG 72000031030 $400.1762/tablet

SIVEXTRO 200 MG 72000032010 $318.7698/each

SKYLA 14MCG/24HR 50419042201 $828.7417/each

SKYRIZI (2 SYRINGES) KIT 150MG/1.66 00074204202 $16945.7149/each

SKYRIZI PEN 150 MG/ML 00074210001 $16945.7149/ml

SKYRIZI 150 MG/ML 00074105001 $16945.7149/ml

SODIUM PHENYLBUTYRATE 500 MG 49884017004 $17.8560/tablet

SOFOSBUVIR-VELPATASVIR 400-100 MG 72626270101 $0.0000 Delete

SOLIRIS 300MG/30ML 25682000101 $216.5636/ml

SOMATULINE DEPOT 120MG/0.5 15054112003 $17441.9520/ml

SOMATULINE DEPOT 120MG/0.5 15054112004 $18226.8000/ml

SOMATULINE DEPOT 60MG/0.2ML 15054106003 $27763.5000/ml

SOMATULINE DEPOT 60MG/0.2ML 15054106004 $29013.4800/ml

SOMATULINE DEPOT 90MG/0.3ML 15054109003 $24651.0000/ml

SOMATULINE DEPOT 90MG/0.3ML 15054109004 $25759.8800/ml

SOMAVERT 10 MG 00009716601 $228.5820/each

SOMAVERT 15 MG 00009716801 $342.9029/each

SOMAVERT 20 MG 00009718801 $457.1740/each

SOMAVERT 25 MG 00009719901 $571.4650/each

SOMAVERT 30 MG 00009720001 $685.7560/each

SOVALDI 150 MG 61958150401 $980.0000/each

SOVALDI 200 MG 61958150301 $980.0000/tablet

SOVALDI 200 MG 61958150501 $980.0000/each

SOVALDI 400 MG 61958150101 $980.0000/tablet

SPINRAZA 12MG/5ML 64406005801 $25500.0000/ml

SPRYCEL 100 MG 00003085222 $503.3406/tablet

SPRYCEL 140 MG 00003085722 $503.3406/tablet

SPRYCEL 20 MG 00003052711 $139.6362/tablet

SPRYCEL 50 MG 00003052811 $279.2718/tablet

SPRYCEL 70 MG 00003052411 $279.2718/tablet

SPRYCEL 80 MG 00003085522 $503.3406/tablet

STELARA 130MG/26ML 57894005427 $66.5699/ml

STELARA 45MG/0.5ML 57894006003 $23803.7669/ml

Page 26 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

STELARA 90 MG/ML 57894006103 $23803.7669/ml

STIVARGA 40 MG 50419017101 $222.2873/tablet

STIVARGA 40 MG 50419017103 $222.2873/tablet

STIVARGA 40 MG 50419017105 $222.2873/tablet

STIVARGA 40 MG 50419017106 $222.2873/tablet

STRENSIQ 18MG/.45ML 25682001012 $2888.6000/ml

STRENSIQ 28MG/0.7ML 25682001312 $2888.6000/ml

STRENSIQ 40 MG/ML 25682001612 $2888.6000/ml

STRENSIQ 80MG/0.8ML 25682001912 $7221.5000/ml

STRIBILD 150-200 MG 61958120101 $115.7016/tablet

SUCRAID 8500/ML 67871011104 $34.9755/ml Increase

SUNITINIB MALATE 12.5 MG 63304009127 $180.0665/capsule Add

SUNITINIB MALATE 25 MG 63304009227 $360.1334/capsule Add

SUNITINIB MALATE 37.5 MG 63304009327 $540.2002/capsule Add

SUNITINIB MALATE 50 MG 63304009427 $626.9412/capsule Add

SUPPRELIN LA 50 MG 67979000201 $42896.5447/each

SUSTIVA 200 MG 00056047492 $10.6234/capsule

SUSTIVA 50 MG 00056047030 $2.6575/capsule

SUSTOL 10MG/0.4ML 47426010106 $1656.6468/ml

SUTENT 12.5 MG 00069055038 $200.0737/capsule

SUTENT 25 MG 00069077038 $400.1481/capsule

SUTENT 37.5 MG 00069083038 $600.2221/capsule

SUTENT 50 MG 00069098038 $696.6011/capsule

SYLVANT 100 MG 73090042001 $1235.8900/each Increase

SYLVANT 400 MG 73090042101 $4943.5500/each Increase

SYMDEKO 100-150 MG 51167066101 $398.4000/tablet

SYMDEKO 50 MG-75MG 51167011301 $398.4000/tablet

SYMFI LO 400-300 MG 49502042593 $53.1193/tablet

SYMFI 600-300MG 49502047593 $53.1193/tablet

SYMTUZA 800-150 MG 59676080030 $132.1060/tablet

SYNAGIS 100 MG/ML 60574411301 $3031.6049/ml

SYNAGIS 50MG/0.5ML 60574411401 $3210.9682/ml

SYNAREL 2 MG/ML 00025016608 $354.9134/ml

SYNERCID 500 MG 61570026010 $464.1450/each

SYNRIBO 3.5 MG 63459017714 $1112.0000/each

TABLOID 40 MG 76388088025 $25.1761/tablet

TABRECTA 150 MG 00078070956 $168.4063/tablet

TABRECTA 200 MG 00078071656 $168.4063/tablet

TACROLIMUS 0.5 MG 00378204501 $0.2342/capsule

TACROLIMUS 0.5 MG 00781210201 $0.2311/capsule

TACROLIMUS 0.5 MG 00904662361 $0.6484/capsule

TACROLIMUS 0.5 MG 16714009801 $0.4134/capsule

TACROLIMUS 0.5 MG 16729004101 $0.1844/capsule

TACROLIMUS 0.5 MG 42291075201 $0.7944/capsule

TACROLIMUS 0.5 MG 51079081720 $0.5500/capsule

TACROLIMUS 0.5 MG 55111052501 $0.1844/capsule

TACROLIMUS 0.5 MG 60429037701 $0.1466/capsule

TACROLIMUS 0.5 MG 63629872501 $0.1744/capsule Add

TACROLIMUS 0.5 MG 64380072006 $0.2778/capsule

TACROLIMUS 0.5 MG 67877027801 $0.1675/capsule

TACROLIMUS 0.5 MG 68084044901 $0.9907/capsule

TACROLIMUS 0.5 MG 68462068501 $0.1675/capsule

TACROLIMUS 0.5 MG 69452015320 $0.2129/capsule

TACROLIMUS 0.5 MG 70377001411 $0.2000/capsule

TACROLIMUS 0.5 MG 70748021901 $0.1844/capsule

TAFINLAR 50 MG 00078068266 $74.7459/capsule

TAFINLAR 75 MG 00078068166 $96.3288/capsule

TAGRISSO 40 MG 00310134930 $504.9212/tablet

TAGRISSO 80 MG 00310135030 $504.9212/tablet

TAKHZYRO 300 MG/2ML 47783064401 $11660.2019/ml

TALTZ AUTOINJECTOR (2 PACK) 80 MG/ML 00002144527 $5878.8096/ml

TALTZ AUTOINJECTOR (3 PACK) 80 MG/ML 00002144509 $5878.8096/ml

TALTZ AUTOINJECTOR 80 MG/ML 00002144501 $5878.8096/ml

Page 27 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

TALTZ AUTOINJECTOR 80 MG/ML 00002144511 $5878.8096/ml

TALTZ SYRINGE 80 MG/ML 00002772401 $5878.8096/ml

TALTZ SYRINGE 80 MG/ML 00002772411 $5878.8096/ml

TALZENNA 0.25 MG 00069029630 $170.2669/capsule

TALZENNA 1 MG 00069119530 $510.8003/capsule

TARGRETIN 1 % 00187552560 $478.2086/gm

TASIGNA 150 MG 00078059251 $140.0276/capsule

TASIGNA 150 MG 00078059287 $140.0282/capsule

TASIGNA 200 MG 00078052651 $140.0276/capsule

TASIGNA 200 MG 00078052687 $140.0282/capsule

TASIGNA 50 MG 00078095166 $140.0277/capsule

TAVALISSE 100 MG 71332000101 $205.8400/tablet

TAVALISSE 150 MG 71332000201 $205.8400/tablet

TAZVERIK 200 MG 72607010000 $68.8277/tablet

TECENTRIQ 1200 MG/20 50242091701 $473.4925/ml

TECENTRIQ 840MG/14ML 50242091801 $473.4921/ml

TEGSEDI 284 MG/1.5 72126000701 $5999.0633/ml

TEMIXYS 300-300 MG 72606000201 $27.6250/tablet

TEMODAR 100 MG 00085138101 $999.0976/each

TENIPOSIDE 50 MG/5 ML 44567050701 $449.2710/ml

TEPADINA 100 MG 70121163101 $4700.0000/each

TEPEZZA 500 MG 75987013015 $14840.4000/each

TEPMETKO 225 MG 44087500003 $346.9168/tablet

TEPMETKO 225 MG 44087500006 $346.9168/tablet

TERIPARATIDE 20MCG/DOSE 47781065289 $1043.6915/ml

THALOMID 100 MG 59572021015 $276.2982/capsule

THALOMID 150 MG 59572021513 $295.4307/capsule

THALOMID 200 MG 59572022016 $314.5759/capsule

THALOMID 50 MG 59572020514 $170.2182/capsule

THALOMID 50 MG 59572020517 $187.2380/capsule

THIOTEPA 100 MG 72205004601 $4250.0000/each

THROMBATE III 500 (+/-) 13533060250 $3.8645/each

THROMBATE III 500 (+/-) 13533060320 $3.8645/each

THYMOGLOBULIN 25 MG 58468008001 $892.1187/each

THYROGEN 0.9 MG 58468003002 $1767.9299/each

TIBSOVO 250 MG 71334010001 $471.1080/tablet

TIGLUTIK 50 MG/10ML 70726030301 $5.5475/ml

TIVICAY PD 5 MG 49702025537 $6.2294/tablet

TIVICAY 10 MG 49702022613 $12.4589/tablet

TIVICAY 25 MG 49702022713 $31.1464/tablet

TIVICAY 50 MG 49702022813 $62.2928/tablet

TNKASE 50 MG 50242012047 $6472.7152/each

TOBI PODHALER 28 MG 00078063011 $44.8000/capsule

TOBI PODHALER 28 MG 00078063019 $44.8000/capsule

TOBI PODHALER 28 MG 00078063035 $44.7998/capsule

TOBI PODHALER 28 MG 00078063056 $44.7998/capsule

TOBI PODHALER 28 MG 49502034624 $44.7998/capsule

TOBI PODHALER 28 MG 49502040124 $44.7998/capsule

TOBRAMYCIN 300 MG/4ML 00093375028 $23.7636/ml

TOBRAMYCIN 300 MG/4ML 00093375063 $23.7636/ml

TOBRAMYCIN 300 MG/4ML 66993019594 $22.0036/ml

TOBRAMYCIN 300 MG/5ML 70644089999 $11.5843/ml

TOLVAPTAN 15 MG 60505470400 $450.0207/tablet

TOLVAPTAN 30 MG 60505470500 $466.8441/tablet

TOLVAPTAN 30 MG 67877063602 $478.6029/tablet

TOLVAPTAN 30 MG 67877063633 $478.6029/tablet

TOPOTECAN HCL 1 MG/ML(1) 16729024330 $126.0000/ml

TRACLEER 125 MG 66215010203 $193.0846/tablet

TRACLEER 125 MG 66215010206 $193.0846/tablet

TRACLEER 32 MG 66215010314 $193.0846/tablet

TRACLEER 32 MG 66215010356 $193.0846/tablet

TRACLEER 62.5 MG 66215010103 $193.0846/tablet

TRACLEER 62.5 MG 66215010106 $193.0846/tablet

Page 28 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

TRAZIMERA 150 MG 00069030801 $1199.0000/each

TRAZIMERA 420 MG 00069030501 $3340.0000/each

TREANDA 100 MG 63459039120 $2959.9128/each

TREANDA 25 MG 63459039008 $739.9782/each

TRELSTAR 11.25 MG 00023590411 $2293.3368/each

TRELSTAR 11.25 MG 00023590412 $2293.3368/each

TRELSTAR 11.25 MG 74676590400 $2293.3368/each

TRELSTAR 11.25 MG 74676590401 $2293.3368/each

TRELSTAR 22.5 MG 00023590622 $4586.6736/each

TRELSTAR 22.5 MG 00023590623 $4586.6736/each

TRELSTAR 22.5 MG 74676590600 $4586.6736/each

TRELSTAR 22.5 MG 74676590601 $4586.6736/each

TRELSTAR 3.75 MG 00023590203 $764.4456/each

TRELSTAR 3.75 MG 00023590204 $764.4456/each

TRELSTAR 3.75 MG 74676590200 $764.4456/each

TRELSTAR 3.75 MG 74676590201 $764.4456/each

TREMFYA 100 MG/ML 57894064001 $11747.3561/ml

TREMFYA 100 MG/ML 57894064011 $11747.3561/ml

TRETTEN 2500 UNIT 00169701301 $14.7240/each

TREXALL 10 MG 51285036801 $32.0745/tablet

TREXALL 15 MG 51285036901 $48.1134/tablet

TREXALL 5 MG 51285036601 $16.0389/tablet

TREXALL 7.5 MG 51285036701 $24.0567/tablet

TRIKAFTA 100-50-75 51167033101 $283.3398/tablet

TRIKAFTA 50-25-37.5 51167010602 $283.3398/tablet

TRIPTODUR 22.5 MG 24338015020 $17590.3660/each

TRISENOX 12 MG/6 ML 63459060106 $162.4583/ml

TRIUMEQ 600-50-300 49702023113 $103.4111/tablet

TRODELVY 180 MG 55135013201 $2135.0700/each

TROGARZO 200MG/1.33 62064012202 $958.2707/ml

TRUSELTIQ 100 MG/DAY 72730011101 $1019.7143/capsule

TRUSELTIQ 125 MG/DAY 72730010101 $509.8571/capsule

TRUSELTIQ 50 MG/DAY 72730050601 $509.8571/capsule

TRUSELTIQ 75 MG/DAY 72730020201 $339.9048/capsule

TRUXIMA 10 MG/ML 63459010310 $70.9632/ml

TRUXIMA 10 MG/ML 63459010450 $70.9632/ml

TUKYSA 150 MG 51144000212 $164.2985/tablet

TUKYSA 150 MG 51144000260 $164.2985/tablet

TUKYSA 50 MG 51144000160 $81.7052/tablet

TURALIO 200 MG 65597040220 $168.4485/capsule

TYBOST 150 MG 61958140101 $8.2332/tablet

TYKERB 250 MG 00078067119 $55.4660/tablet

TYMLOS 80MCG/DOSE 70539000102 $1346.4762/ml

TYSABRI 300MG/15ML 64406000801 $489.6377/ml

TYVASO INSTITUTIONAL START KIT 1.74MG/2.9 66302020604 $401.8482/ml

TYVASO REFILL KIT 1.74MG/2.9 66302020602 $222.1524/ml

TYVASO STARTER KIT 1.74MG/2.9 66302020601 $247.8234/ml

TYVASO 1.74MG/2.9 66302020603 $222.1518/ml

UDENYCA 6 MG/0.6ML 70114010101 $6888.7500/ml

UKONIQ 200 MG 73150020012 $131.9700/tablet

ULTOMIRIS 1100 MG/11 25682002801 $2126.1277/ml

ULTOMIRIS 300MG/30ML 25682002201 $212.6128/ml

ULTOMIRIS 300MG/3ML 25682002501 $2126.1280/ml

UNITUXIN 3.5 MG/ML 66302001401 $2611.3920/ml

UPLIZNA 100MG/10ML 72677055101 $4366.6667/ml

UPTRAVI 1000 MCG 66215061006 $319.3325/tablet

UPTRAVI 1200 MCG 66215061206 $319.3325/tablet

UPTRAVI 1400 MCG 66215061406 $319.3325/tablet

UPTRAVI 1600 MCG 66215061606 $319.3325/tablet

UPTRAVI 1800 MCG 66215071801 $318.7200/each Add

UPTRAVI 200 MCG 66215060206 $205.3369/tablet

UPTRAVI 200 MCG 66215060214 $205.3369/tablet

UPTRAVI 200-800MCG 66215062820 $143.7347/tablet

Page 29 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

UPTRAVI 400 MCG 66215060406 $319.3325/tablet

UPTRAVI 600 MCG 66215060606 $319.3325/tablet

UPTRAVI 800 MCG 66215060806 $319.3325/tablet

UVADEX 20 MCG/ML 64067021601 $53.3167/ml

VALCHLOR 0.016 % 69639012001 $80.9199/gm

VALRUBICIN 40 MG/ML 24201010104 $253.0791/ml

VALSTAR 40 MG/ML 67979000101 $350.3625/ml

VANTAS 50 MG 67979050001 $4873.8600/each

VARIZIG 125/1.2 ML 70257012611 $1529.8032/ml

VARIZIG 125/1.2 ML 70257012651 $1529.8032/ml

VARUBI 90 MG 69656010102 $314.3525/tablet

VARUBI 90 MG 70720010102 $330.0694/tablet

VECAMYL 2.5 MG 69413055840 $62.9472/tablet

VECTIBIX 100 MG/5ML 55513095401 $271.7380/ml

VECTIBIX 400MG/20ML 55513095601 $271.7375/ml

VELCADE 3.5 MG 63020004901 $1603.0000/each

VELETRI 0.5 MG 66215040301 $23.3263/each

VELETRI 1.5 MG 66215040201 $46.6526/each

VEMLIDY 25 MG 61958230101 $40.1431/tablet

VENCLEXTA STARTING PACK 10-50-100 00074057928 $66.0682/tablet

VENCLEXTA 10 MG 00074056111 $10.7120/tablet

VENCLEXTA 10 MG 00074056114 $10.7134/tablet

VENCLEXTA 100 MG 00074057611 $107.1298/tablet

VENCLEXTA 100 MG 00074057622 $107.1376/tablet

VENCLEXTA 100 MG 00074057634 $107.1376/tablet

VENCLEXTA 50 MG 00074056607 $53.5691/tablet

VENCLEXTA 50 MG 00074056611 $53.5649/tablet

VENTAVIS 10 MCG/ML 66215030200 $134.1612/ml

VENTAVIS 10 MCG/ML 66215030230 $134.1612/ml

VENTAVIS 20 MCG/ML 66215030300 $134.1612/ml

VENTAVIS 20 MCG/ML 66215030330 $134.1612/ml

VERZENIO 100 MG 00002481554 $232.2473/tablet

VERZENIO 150 MG 00002533754 $232.2473/tablet

VERZENIO 200 MG 00002621654 $232.2473/tablet

VERZENIO 50 MG 00002448354 $232.2473/tablet

VIEKIRA PAK 12.5-75-50 00074309328 $243.0137/tablet

VIGABATRIN 500 MG 00591385101 $113.7243/tablet

VIGABATRIN 500 MG 00591395550 $31.6491/each

VIGABATRIN 500 MG 16729052111 $5.7000/each

VIGABATRIN 500 MG 31722000950 $5.7000/each

VIGABATRIN 500 MG 43598065101 $104.0677/tablet

VIGABATRIN 500 MG 43598069750 $69.4059/each

VIGABATRIN 500 MG 49884035803 $91.9433/each

VIGABATRIN 500 MG 67877067463 $9.6026/each

VIGABATRIN 500 MG 69097096453 $5.7000/each

VIGABATRIN 500 MG 69238142505 $91.9433/each

VIGADRONE 500 MG 00245055650 $93.4336/each

VIGADRONE 500 MG 00245055689 $93.4348/each

VILTEPSO 250 MG/5ML 73292001101 $282.0000/ml

VIMIZIM 5 MG/5 ML 68135010001 $244.2180/ml

VINBLASTINE SULFATE 1 MG/ML 63323027810 $4.2444/ml

VIRACEPT 250 MG 63010001030 $3.9455/tablet

VIRACEPT 625 MG 63010002770 $9.8637/tablet

VIRAMUNE 50 MG/5 ML 00597004724 $0.7972/ml

VIREAD 150 MG 61958040401 $37.7556/tablet

VIREAD 200 MG 61958040501 $37.7556/tablet

VIREAD 250 MG 61958040601 $37.7556/tablet

VIREAD 40MG/SCOOP 61958040301 $11.1065/gm

VISTOGARD 10 G 69468015104 $3996.9480/each

VISTOGARD 10 G 69468015120 $3996.9480/each

VISUDYNE 15 MG 00187560015 $1702.8712/each

VITRAKVI 100 MG 50419039101 $544.4800/capsule

VITRAKVI 100 MG 71777039101 $544.4800/capsule

Page 30 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

VITRAKVI 20 MG/ML 50419039201 $145.1947/ml

VITRAKVI 20 MG/ML 71777039201 $0.0000 Delete

VITRAKVI 25 MG 50419039001 $181.4933/capsule

VITRAKVI 25 MG 71777039001 $181.4933/capsule

VIVITROL 380 MG 65757030001 $1409.6288/each

VIZIMPRO 15 MG 00069019730 $453.8772/tablet

VIZIMPRO 30 MG 00069119830 $453.8772/tablet

VIZIMPRO 45 MG 00069229930 $453.8772/tablet

VONVENDI 1300(+/-) 00944755302 $1.7820/each

VONVENDI 650 (+/-) 00944755102 $1.7820/each

VORAXAZE 1000 UNIT 50633021011 $33108.0360/each

VOSEVI 400-100 MG 61958240101 $863.3000/tablet

VOTRIENT 200 MG 00078067066 $120.8208/tablet

VPRIV 400 UNIT 54092070104 $1432.4931/each

VUMERITY 231 MG 64406002003 $61.6820/capsule

VYNDAMAX 61 MG 00069873030 $622.5000/capsule

VYNDAQEL 20 MG 00069197540 $155.6250/capsule

VYONDYS-53 100 MG/2ML 60923046502 $800.0000/ml

VYXEOS 44MG-100MG 68727074501 $8892.7000/each

VYXEOS 44MG-100MG 68727074502 $8892.0700/each

VYXEOS 44MG-100MG 68727074505 $8892.0700/each

WILATE 1K-1K UNIT 68982018202 $1.2920/each

WILATE 500-500 68982018201 $1.2920/each

WINRHO SDF 1500/1.3ML 70257033011 $383.9782/ml

WINRHO SDF 1500/1.3ML 70257033051 $383.9782/ml

WINRHO SDF 15000/13ML 70257030013 $386.3719/ml

WINRHO SDF 15000/13ML 70257030051 $386.3719/ml

WINRHO SDF 2500/2.2ML 70257035002 $380.5178/ml

WINRHO SDF 2500/2.2ML 70257035051 $380.5178/ml

WINRHO SDF 5000/4.4ML 70257031004 $380.5178/ml

WINRHO SDF 5000/4.4ML 70257031051 $380.5178/ml

XALKORI 200 MG 00069814120 $308.5377/capsule

XALKORI 250 MG 00069814020 $308.5377/capsule

XELJANZ XR 11 MG 00069050130 $161.7201/tablet

XELJANZ XR 22 MG 00069050230 $161.7201/tablet

XELJANZ 1 MG/ML 00069102902 $16.1720/ml

XELJANZ 10 MG 00069100201 $80.8600/tablet

XELJANZ 5 MG 00069100101 $80.8600/tablet

XEMBIFY 1 G/5 ML 13533081005 $32.9840/ml

XEMBIFY 10 G/50 ML 13533081050 $32.9840/ml

XEMBIFY 2 G/10 ML 13533081010 $32.9840/ml

XEMBIFY 4 G/20 ML 13533081020 $32.9840/ml

XEOMIN 100 UNIT 00259161001 $486.8200/each

XEOMIN 200 UNIT 00259162001 $973.6400/each

XEOMIN 50 UNIT 00259160501 $255.5300/each

XGEVA 120 MG/1.7 55513073001 $1459.4564/ml

XIAFLEX 0.9 MG 66887000301 $5286.2289/each

XOFIGO 1100KBQ/ML 50419020801 $25813.5600/each

XOLAIR 150 MG/ML 50242021501 $1139.0932/ml

XOLAIR 150 MG 50242004062 $1139.0932/each

XOLAIR 75MG/0.5ML 50242021401 $1139.0932/ml

XOSPATA 40 MG 00469142590 $269.2935/tablet

XPOVIO 100MG/WEEK 72237010105 $1149.2844/tablet

XPOVIO 100MG/WEEK 72237010305 $2873.2110/tablet

XPOVIO 120MG/WEEK 72237010103 $957.7370/tablet

XPOVIO 160MG/WEEK 72237010104 $718.3027/tablet

XPOVIO 40 MG/WEEK 72237010107 $2873.2110/tablet

XPOVIO 40 MG/WEEK 72237010207 $5746.4220/tablet

XPOVIO 60 MG/WEEK 72237010101 $1915.4740/tablet

XPOVIO 60 MG/WEEK 72237010401 $5746.4220/tablet

XPOVIO 80 MG/WEEK 72237010102 $1436.6055/tablet

XPOVIO 80 MG/WEEK 72237010106 $1436.6055/tablet

XPOVIO 80 MG/WEEK 72237010202 $2873.2110/tablet

Page 31 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

XPOVIO 80 MG/WEEK 72237010206 $2873.2110/tablet

XTANDI 40 MG 00469012599 $101.8883/capsule

XTANDI 40 MG 00469062599 $101.8883/tablet

XTANDI 80 MG 00469072560 $203.7766/tablet

XURIDEN 2 G 69468015230 $757.5000/each

XYNTHA SOLOFUSE 1000 (+/-) 58394002403 $1.2720/each

XYNTHA SOLOFUSE 2000 (+/-) 58394002503 $1.2720/each

XYNTHA SOLOFUSE 250 (+/-) 58394002203 $1.2720/each

XYNTHA SOLOFUSE 3000 (+/-) 58394001603 $1.2720/each

XYNTHA SOLOFUSE 500 (+/-) 58394002303 $1.2720/each

XYNTHA 1000 (+/-) 58394001401 $1.2720/each

XYNTHA 2000 (+/-) 58394001501 $1.2720/each

XYNTHA 250 (+/-) 58394001201 $1.2720/each

XYNTHA 500 (+/-) 58394001301 $1.2720/each

XYREM 500 MG/ML 68727010001 $30.6794/ml

XYWAV 0.5G/ML 68727015001 $28.3896/ml

YERVOY 200MG/40ML 00003232822 $771.2664/ml

YERVOY 50 MG/10ML 00003232711 $771.2684/ml

YONDELIS 1 MG 59676061001 $3097.2800/each

YONSA 125 MG 47335040181 $78.7277/tablet

YUTIQ 0.18 MG 71879013601 $8774.7600/each

ZALTRAP 100 MG/4ML 00024584001 $400.0000/ml

ZALTRAP 200 MG/8ML 00024584101 $400.0000/ml

ZANOSAR 1 G 00703463601 $349.2300/each

ZARXIO 300MCG/0.5 61314031801 $543.2328/ml

ZARXIO 300MCG/0.5 61314031810 $543.2387/ml

ZARXIO 480MCG/0.8 61314032601 $543.2378/ml

ZARXIO 480MCG/0.8 61314032610 $543.2378/ml

ZEJULA 100 MG 69656010330 $253.0438/capsule

ZEJULA 100 MG 69656010390 $185.1066/capsule

ZELAPAR 1.25 MG 00187045302 $80.4648/tablet

ZELBORAF 240 MG 50242009002 $45.0308/tablet

ZEMAIRA 1000 MG 00053720102 $0.5279/each

ZEPATIER 50MG-100MG 00006307402 $254.8000/tablet

ZEPOSIA 0.23-0.46 59572081007 $242.2805/capsule

ZEPOSIA 0.23-0.92 59572089091 $242.2797/capsule

ZEPOSIA 0.92 MG 59572082030 $242.2795/capsule

ZEPZELCA 4 MG 68727071201 $6898.3200/each

ZEVALIN 3.2MG/2ML 72893000704 $56409.2700/each

ZIEXTENZO 6 MG/0.6ML 61314086601 $6477.1245/ml

ZINPLAVA 1000 MG/40 00006302500 $94.6200/ml

ZIRABEV 25 MG/ML 00069031501 $150.0000/ml

ZIRABEV 25 MG/ML 00069034201 $150.0000/ml

ZOKINVY 50 MG 73079005030 $714.1320/capsule

ZOKINVY 75 MG 73079007530 $1071.1980/capsule

ZOLADEX 10.8 MG 70720095130 $2086.0423/each

ZOLADEX 3.6 MG 70720095036 $744.0220/each

ZOLEDRONIC ACID 4 MG/100ML 00409422901 $0.4824/ml

ZOLEDRONIC ACID 4 MG/100ML 25021082667 $0.4800/ml

ZOLEDRONIC ACID 4 MG/100ML 25021082682 $1.4400/ml

ZOLEDRONIC ACID 4 MG/100ML 70860021051 $0.3800/ml

ZOLEDRONIC ACID 4 MG 47335096241 $300.0000/each

ZOLINZA 100 MG 00006056840 $124.5797/capsule

ZOMACTON 10 MG 55566190101 $568.4000/each

ZOMACTON 10 MG 55566190201 $568.4000/each

ZOMACTON 5 MG 55566180101 $284.2000/each

ZORBTIVE 8.8 MG 44087338807 $1388.4071/each

ZORTRESS 1 MG 00078042220 $36.1283/tablet

ZORTRESS 1 MG 00078042261 $36.1257/tablet

ZULRESSO 100MG/20ML 72152054720 $372.5000/ml

ZUPLENZ 4 MG 89141044430 $35.2206/each

ZUPLENZ 8 MG 89141044830 $35.2206/each

ZYDELIG 100 MG 61958170101 $195.3931/tablet

ZYDELIG 150 MG 61958170201 $195.3931/tablet

ZYKADIA 150 MG 00078069484 $126.3228/tabletPage 32 of 33

NAME OF DRUG Strength NDC Price Effective October 1, 2021

Add

Delete

Increase

Decrease

ZYNLONTA 10 MG 79952011001 $23500.0000/each

ZYPREXA RELPREVV 210 MG 00002763511 $574.9380/each

ZYPREXA RELPREVV 300 MG 00002763611 $821.3400/each

ZYPREXA RELPREVV 405 MG 00002763711 $1108.8090/each

ZYVOX 200MG/0.1L 00009513704 $0.5706/ml

Page 33 of 33