Oct-2021
MISSOURI SPECIALTY MAC
NAME OF DRUG Strength NDC Price Effective October 1, 2021
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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NAME OF DRUG Strength NDC Price Effective October 1, 2021
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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
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NAME OF DRUG Strength NDC Price Effective October 1, 2021
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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
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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
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