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Dec-2017
MISSOURI SPECIALTY MAC
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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8-MOP 10 MG 00163065130 $3.4138/capsule
8-MOP 10 MG 00187065130 $3.4138/capsule
ABACAVIR 20 MG/ML 31722056224 $0.5281/ml
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 150-300MG 68180028607 $23.4113/tablet
ABELCET 5 MG/ML 57665010141 $9.6960/ml
ABELCET 5 MG/ML 61799010131 $10.2010/ml
ABELCET 5 MG/ML 61799010141 $9.3425/ml
ABILIFY MAINTENA 300 MG 59148001870 $1492.8055/each
ABILIFY MAINTENA 300 MG 59148001871 $1492.7497/each
ABILIFY MAINTENA 300 MG 59148004580 $1492.7497/each
ABILIFY MAINTENA 400 MG 59148001970 $1990.4185/each
ABILIFY MAINTENA 400 MG 59148001971 $1990.3363/each
ABILIFY MAINTENA 400 MG 59148007280 $1990.3363/each
ABRAXANE 100 MG 68817013450 $1269.8023/each
ACTEMRA 162 MG/0.9 50242013801 $1023.2198/ml
ACTEMRA 200MG/10ML 50242013601 $100.4223/ml
ACTEMRA 400MG/20ML 50242013701 $100.4218/ml
ACTEMRA 80 MG/4 ML 50242013501 $100.4218/ml
ACTH 40 UNIT/ML 00259010105 $2.4583/ml
ACTH 40 UNIT/ML 00314710105 $2.8926/ml
ACTH 40 UNIT/ML 00364662053 $1.3312/ml
ACTH 40 UNIT/ML 00456100105 $2.3573/ml
ACTH 40 UNIT/ML 00677026120 $1.2625/ml
ACTH 40 UNIT/ML 00839615625 $0.7777/ml
ACTH 40 UNIT/ML 51937010105 $1.4564/ml
ACTH 40 UNIT/ML 53638074205 $1.3635/ml
ACTH 80 UNIT/ML 00259010180 $3.2825/ml
ACTH 80 UNIT/ML 00314710205 $4.5086/ml
ACTH 80 UNIT/ML 00364662153 $2.1594/ml
ACTH 80 UNIT/ML 00456100205 $3.9249/ml
ACTH 80 UNIT/ML 00677026220 $2.0200/ml
ACTH 80 UNIT/ML 00839615725 $1.4342/ml
ACTH 80 UNIT/ML 51937010205 $2.8260/ml
ACTHAR H.P. 40 UNIT/ML 00053133001 $3.7269/ml
ACTHAR H.P. 40 UNIT/ML 00053133002 $13.1421/ml
ACTHAR H.P. 40 UNIT/ML 00075133001 $3.7269/ml
ACTHAR H.P. 40 UNIT/ML 00075133002 $13.1421/ml
ACTHAR H.P. 80 UNIT/ML 00053135001 $8.0760/ml
ACTHAR H.P. 80 UNIT/ML 00053135002 $22.5887/ml
ACTHAR H.P. 80 UNIT/ML 00075135002 $22.5887/ml
ACTHREL 100 MCG 55566030201 $843.0470/each
ACTIMMUNE 100MCG/0.5 42238011101 $8014.1076/ml
ACTIMMUNE 100MCG/0.5 42238011112 $8014.1076/ml
ACTIVASE 100 MG 50242008527 $8629.4804/each
ACTIVASE 50 MG 50242004413 $4314.7402/each
ADAGEN 250 UNIT/1 57665000101 $3420.5333/ml
ADCETRIS 50 MG 51144005001 $6900.3200/each
ADCIRCA 20 MG 66302046760 $61.3878/tablet
ADEFOVIR DIPIVOXIL 10 MG 42794000308 $30.1317/tablet
Page 1 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ADEMPAS 0.5 MG 50419025001 $103.2512/tablet
ADEMPAS 0.5 MG 50419025003 $103.2511/tablet
ADEMPAS 0.5 MG 50419025091 $103.2512/tablet
ADEMPAS 1 MG 50419025101 $103.2512/tablet
ADEMPAS 1 MG 50419025103 $103.2511/tablet
ADEMPAS 1 MG 50419025191 $103.2512/tablet
ADEMPAS 1.5 MG 50419025201 $103.2512/tablet
ADEMPAS 1.5 MG 50419025203 $103.2511/tablet
ADEMPAS 1.5 MG 50419025291 $103.2512/tablet
ADEMPAS 2 MG 50419025301 $103.2512/tablet
ADEMPAS 2 MG 50419025303 $103.2511/tablet
ADEMPAS 2 MG 50419025391 $103.2512/tablet
ADEMPAS 2.5 MG 50419025401 $103.2512/tablet
ADEMPAS 2.5 MG 50419025403 $103.2511/tablet
ADEMPAS 2.5 MG 50419025491 $103.2512/tablet
ADRENACLICK 0.3MG/0.3 52054080402 $232.7806/each Increase
ADRENACLICK 0.3MG/0.3 59630080401 $87.1125/each
ADRENACLICK 0.3MG/0.3 59630080402 $87.1024/each
ADRIAMYCIN RDF 20 MG 00013109694 $74.3360/each
ADRIAMYCIN 10 MG 00013100691 $28.6032/each
ADRIAMYCIN 20 MG 00013107694 $57.2064/each
ADRIAMYCIN 50 MG 00013101679 $143.0059/each
AFINITOR DISPERZ 2 MG 00078062651 $454.0790/tablet
AFINITOR DISPERZ 2 MG 00078062661 $454.0758/tablet
AFINITOR DISPERZ 3 MG 00078062751 $458.6276/tablet
AFINITOR DISPERZ 3 MG 00078062761 $458.6208/tablet
AFINITOR DISPERZ 5 MG 00078062851 $477.3393/tablet
AFINITOR DISPERZ 5 MG 00078062861 $477.3361/tablet
AFINITOR 10 MG 00078056751 $477.3393/tablet
AFINITOR 10 MG 00078056761 $477.3058/tablet
AFINITOR 2.5 MG 00078059451 $456.3548/tablet
AFINITOR 2.5 MG 00078059461 $456.3584/tablet
AFINITOR 5 MG 00078056651 $477.3393/tablet
AFINITOR 5 MG 00078056661 $477.3664/tablet
AFINITOR 7.5 MG 00078062051 $477.3393/tablet
AFINITOR 7.5 MG 00078062061 $477.3462/tablet
ALDURAZYME 2.9 MG/5ML 58468007001 $169.2760/ml
ALECENSA 150 MG 50242013001 $56.0281/capsule
ALFERON N 5MMUNIT/ML 54746000101 $606.0000/ml
ALIMTA 100 MG 00002764001 $659.9845/each
ALIMTA 500 MG 00002762301 $3299.9225/each
ALIQOPA 60 MG 50419038501 $4242.0000/each
ALKERAN 2 MG 00081004535 $4.3790/tablet
ALKERAN 2 MG 52609000105 $11.4336/tablet
ALKERAN 2 MG 54868433900 $6.5400/tablet
ALKERAN 2 MG 54868433901 $5.6914/tablet
ALKERAN 2 MG 54868433902 $5.7502/tablet
ALKERAN 2 MG 54868433903 $6.0702/tablet
ALKERAN 2 MG 54868433904 $5.7272/tablet
ALKERAN 2 MG 59572030250 $4.6634/tablet
ALKERAN 50 MG 00081013093 $1170.3375/each
Page 2 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ALKERAN 50 MG 52609300100 $1659.5310/each
ALUNBRIG 30 MG 76189011318 $79.9583/tablet
ALUNBRIG 30 MG 76189011321 $79.9583/tablet
AMBISOME 50 MG 00469305130 $210.0901/each
AMEVIVE 7.5 MG 59627002001 $565.6000/each
AMEVIVE 7.5 MG 59627002002 $565.6000/each
AMIFOSTINE 500 MG 47335058140 $456.4796/each
AMIFOSTINE 500 MG 47335058142 $456.4527/each
AMIFOSTINE 500 MG 62756058140 $456.4796/each
AMIFOSTINE 500 MG 62756058142 $456.4527/each
AMMONUL 10 %-10 % 00187001050 $922.3459/ml
AMPYRA 10 MG 10144042760 $37.7917/tablet
ANCOBON 250 MG 00004007701 $4.7019/capsule
ANCOBON 250 MG 00187355410 $77.6121/capsule
ANCOBON 250 MG 68258912401 $5.6188/capsule
ANCOBON 500 MG 00187355510 $150.1807/capsule
ANCOBON 500 MG 68258903801 $11.0872/capsule
ANZEMET 100 MG 00088120329 $64.1693/tablet
ANZEMET 100 MG 30698012105 $96.4611/tablet
ANZEMET 100 MG 54868413800 $74.5191/tablet
ANZEMET 100 MG 54868413801 $83.3704/tablet
ANZEMET 12.5/0.625 00088120869 $7.8881/ml
ANZEMET 50 MG 00088120229 $48.4133/tablet
ANZEMET 50 MG 30698012005 $72.7745/tablet
APOKYN 10 MG/ML 15054021101 $334.9833/ml
APOKYN 10 MG/ML 15054021105 $334.9833/ml
APOKYN 10 MG/ML 27505000401 $339.3600/ml
APOKYN 10 MG/ML 27505000405 $339.3600/ml
APTIVUS 100 MG/ML 00597000201 $5.2763/ml
APTIVUS 250 MG 00597000302 $12.5319/capsule
APTIVUS 250 MG 54569571900 $8.8348/capsule
ARALAST NP 1000 MG 00944281501 $0.5252/each
ARALAST NP 500 MG 00944281401 $0.5252/each
ARALAST 1000 MG 49669580002 $0.4141/each
ARALAST 500 MG 00944280101 $0.4242/each
ARALAST 500 MG 49669580001 $0.4141/each
ARANESP 100 MCG/ML 55513000501 $781.7400/ml
ARANESP 100 MCG/ML 55513000504 $781.7400/ml
ARANESP 100MCG/0.5 55513002501 $1563.4800/ml
ARANESP 100MCG/0.5 55513002504 $1563.4800/ml
ARANESP 10MCG/0.4 55513009801 $195.4350/ml
ARANESP 10MCG/0.4 55513009804 $195.4350/ml
ARANESP 150MCG/0.3 55513002701 $3908.7000/ml
ARANESP 150MCG/0.3 55513002704 $3908.7000/ml
ARANESP 200 MCG/ML 55513000601 $1563.4800/ml
ARANESP 200MCG/0.4 54868542800 $2801.8930/ml
ARANESP 200MCG/0.4 55513002801 $3908.7000/ml
ARANESP 25 MCG/ML 55513000201 $195.4350/ml
ARANESP 25 MCG/ML 55513000204 $195.4350/ml
ARANESP 25MCG/0.42 55513005701 $465.3214/ml
ARANESP 25MCG/0.42 55513005704 $465.3214/ml
Page 3 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ARANESP 300 MCG/ML 55513011001 $2345.2200/ml
ARANESP 300MCG/0.6 54868542900 $2800.5042/ml
ARANESP 300MCG/0.6 55513011101 $3908.7000/ml
ARANESP 40 MCG/0.4 55513002101 $781.7400/ml
ARANESP 40 MCG/0.4 55513002104 $781.7400/ml
ARANESP 40 MCG/ML 55513000301 $312.6960/ml
ARANESP 40 MCG/ML 55513000304 $312.6960/ml
ARANESP 500 MCG/ML 54868586700 $2799.3932/ml
ARANESP 500 MCG/ML 55513003201 $3908.7000/ml
ARANESP 60 MCG/0.3 55513002301 $1563.4800/ml
ARANESP 60 MCG/0.3 55513002304 $1563.4800/ml
ARANESP 60MCG/ML 55513000401 $469.0440/ml
ARANESP 60MCG/ML 55513000404 $469.0440/ml
ARCALYST 220 MG 61755000101 $5050.0000/each
AREDIA 90 MG 00083260901 $706.6566/each
ARISTADA 1064MG/3.9 65757040401 $712.4926/ml Add
ARISTADA 1064MG/3.9 65757040403 $712.4644/ml
ARISTADA 441 MG/1.6 65757040101 $719.8166/ml
ARISTADA 441 MG/1.6 65757040103 $719.7891/ml
ARISTADA 662 MG/2.4 65757040201 $720.3619/ml
ARISTADA 662 MG/2.4 65757040203 $720.3320/ml
ARISTADA 882 MG/3.2 65757040301 $719.8166/ml
ARISTADA 882 MG/3.2 65757040303 $719.7891/ml
ARRANON 250MG/50ML 00007440101 $14.8545/ml
ARRANON 250MG/50ML 00007440106 $14.8544/ml
ARRANON 250MG/50ML 00078068306 $14.8544/ml
ARRANON 250MG/50ML 00078068361 $14.8545/ml
ARZERRA 100 MG/5ML 00078066913 $111.5377/ml
ARZERRA 100 MG/5ML 00078066961 $111.5363/ml
ARZERRA 1000 MG/50 00078069061 $111.5381/ml
ASTAGRAF XL 0.5 MG 00469064773 $2.1819/capsule
ASTAGRAF XL 1 MG 00469067773 $4.3639/capsule
ASTAGRAF XL 5 MG 00469068773 $21.8197/capsule
ATGAM 50 MG/ML 00009722401 $368.0137/ml
ATGAM 50 MG/ML 00009722402 $368.0137/ml
ATRIPLA 600-200MG 15584010101 $85.7907/tablet
ATRIPLA 600-200MG 35356006430 $75.8837/tablet
ATRIPLA 600-200MG 54569580500 $111.5323/tablet
ATRIPLA 600-200MG 54868564300 $84.4587/tablet
ATRYN 1750 UNIT 42976012102 $2.8381/each
ATRYN 525 UNIT 42976012101 $2.8381/each
AUBAGIO 14 MG 58468021002 $222.5943/tablet
AUBAGIO 7 MG 58468021101 $222.5943/tablet
AUSTEDO 12 MG 68546017260 $83.0220/tablet
AUSTEDO 6 MG 68546017060 $55.3480/tablet
AUSTEDO 9 MG 68546017160 $62.2665/tablet
AUVI-Q 0.3MG/0.3 60842002301 $2272.5000/each
AVASTIN 25 MG/ML 50242006001 $191.5314/ml
AVASTIN 25 MG/ML 50242006002 $138.8750/ml
AVASTIN 25 MG/ML 50242006101 $191.5314/ml
AVONEX PEN 30MCG/.5ML 59627033304 $6349.8700/each
Page 4 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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AVONEX 30 MCG 59627011103 $1587.4675/each
AVONEX 30MCG/.5ML 59627022205 $6349.8700/each
AVYCAZ 2.5 G 00456270001 $302.2425/each
AVYCAZ 2.5 G 00456270010 $302.2425/each
AZACITIDINE 100 MG 00591289749 $314.3928/each
AZACITIDINE 100 MG 00781325394 $314.3928/each
AZACITIDINE 100 MG 00781925394 $314.3928/each
AZACITIDINE 100 MG 13925052301 $314.3928/each
AZACITIDINE 100 MG 43598030562 $404.0000/each
AZACITIDINE 100 MG 43598046562 $176.7500/each
AZACITIDINE 100 MG 51991079798 $314.3928/each
AZACITIDINE 100 MG 63323077139 $314.3928/each
AZACITIDINE 100 MG 64679009601 $314.3928/each
AZACITIDINE 100 MG 67457025430 $314.3928/each
AZACITIDINE 100 MG 68001031356 $314.3928/each
AZATHIOPRINE SODIUM 100 MG 00143956601 $252.5000/each
AZATHIOPRINE SODIUM 100 MG 51309022720 $52.3584/each
BANZEL 200 MG 62856058252 $10.0495/tablet
BANZEL 40 MG/ML 62856058446 $2.9114/ml
BANZEL 400 MG 62856058352 $20.0990/tablet
BARACLUDE 0.05 MG/ML 00003161412 $4.6206/ml
BAVENCIO 200MG/10ML 44087353501 $154.1826/ml
BAYHEP B 00026063202 $119.9880/ml
BAYHEP B 00026063203 $127.2600/ml
BCG (TICE STRAIN) 50 MG 00052060202 $154.0149/each
BELEODAQ 500 MG 68152010809 $1744.3407/each
BENDEKA 25 MG/ML 63459034804 $612.3883/ml
BENLYSTA 120 MG 49401010101 $509.2925/each
BENLYSTA 200 MG/ML 49401008801 $891.3603/ml
BENLYSTA 200 MG/ML 49401008835 $891.3250/ml
BENLYSTA 200 MG/ML 49401008842 $891.3603/ml
BENLYSTA 200 MG/ML 49401008847 $891.3250/ml
BENLYSTA 400 MG 49401010201 $1697.5777/each
BERINERT 500(10 ML) 63833082502 $2843.1500/each
BESPONSA 0.9 MG 00008010001 $18887.0000/each
BETASERON 0.3 MG 50419052309 $448.6420/each
BETASERON 0.3 MG 50419052325 $193.1659/each
BETASERON 0.3 MG 50419052401 $479.5884/each
BETASERON 0.3 MG 50419052435 $479.5913/each
BETHKIS 300 MG/4ML 10122082004 $25.5893/ml
BETHKIS 300 MG/4ML 10122082028 $25.5882/ml
BETHKIS 300 MG/4ML 10122082056 $25.5882/ml
BEXXAR 0.61MCI/ML 67800011110 $117.0338/ml
BEXXAR 5.6MCI/ML 67800012110 $1014.2925/ml
BICNU 100 MG 00015301260 $173.1241/each
BICNU 100 MG 00015301297 $173.1241/each
BICNU 100 MG 23155026141 $3781.0360/each
BIOZYME-C 250 UNIT/G 00053226202 $1.2221/gm
BIVALIRUDIN 250 MG 00409830015 $535.5525/each
BIVALIRUDIN 250 MG 00409830025 $535.5737/each
BIVIGAM 10 % 59730650201 $13.4380/ml Increase
Page 5 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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BIVIGAM 10 % 59730650301 $13.4379/ml Increase
BLINCYTO 35 MCG 55513016001 $3635.4445/each
BOSULIF 100 MG 00069013501 $113.9522/tablet
BOSULIF 500 MG 00069013601 $455.8090/tablet
BOTOX COSMETIC 100 UNIT 00023923201 $607.0100/each
BOTOX 100 UNIT 00023114501 $607.0100/each
BOTOX 100 UNIT 54868412300 $550.2109/each
BOTOX 200 UNIT 00023392102 $1214.0200/each
BRINEURA 300MG/10ML 68135081102 $27270.0000/each
BUPHENYL 0.94 G/G 75987007009 $50.0960/gm
BUPHENYL 500 MG 62592049604 $2.8055/tablet
BUPHENYL 500 MG 75987006008 $25.0480/tablet
BUPHENYL 500 MG 76325049603 $20.7353/tablet
BUSULFAN 60 MG/10ML 00517092001 $201.8990/ml
BUSULFAN 60 MG/10ML 00517092008 $201.8990/ml
BUSULFAN 60 MG/10ML 25021024110 $191.9000/ml
BUSULFEX 60 MG/10ML 59148004790 $232.5684/ml
BUSULFEX 60 MG/10ML 59148004791 $232.5597/ml
BUSULFEX 60 MG/10ML 59148007090 $232.5684/ml
BUSULFEX 60 MG/10ML 59148007091 $232.5597/ml
BUSULFEX 60 MG/10ML 59148007191 $146.9229/ml
BUSULFEX 60 MG/10ML 67286005308 $55.8884/ml
BUSULFEX 60 MG/10ML 67286005408 $73.3543/ml
CABOMETYX 20 MG 42388002426 $535.8841/tablet
CABOMETYX 40 MG 42388002526 $535.8841/tablet
CABOMETYX 60 MG 42388002326 $535.8841/tablet
CALCITONIN-SALMON 200/ML 00070449201 $6.7064/ml
CALCITONIN-SALMON 200/ML 00186160813 $7.5902/ml
CALCITRIOL 1 MCG/ML 00143972805 $4.5450/ml
CALCITRIOL 1 MCG/ML 00517013225 $5.0500/ml
CALCITRIOL 1 MCG/ML 00703731104 $4.3228/ml
CALCITRIOL 1 MCG/ML 17478083101 $6.8932/ml
CALCITRIOL 1 MCG/ML 17478093101 $7.5760/ml
CALCITRIOL 1 MCG/ML 61703023429 $6.3125/ml
CALCITRIOL 1 MCG/ML 63323073101 $6.0499/ml
CALCITRIOL 1 MCG/ML 66591031512 $10.5747/ml
CALCIUM FOLINATE 10 MG/ML 00703279701 $0.6380/ml
CAMPTOSAR 300MG/15ML 00009752905 $7.5413/ml
CAPRELSA 100 MG 00310782030 $216.6652/tablet
CAPRELSA 100 MG 58468782003 $216.6652/tablet
CAPRELSA 300 MG 00310784030 $433.3301/tablet
CAPRELSA 300 MG 58468784003 $433.3301/tablet
CARBAGLU 200 MG 52276031205 $188.6155/tablet
CARBAGLU 200 MG 52276031260 $188.6156/tablet
CARBOPLATIN 150 MG 10019091601 $264.5190/each
CARBOPLATIN 150 MG 10019091615 $264.5190/each
CARBOPLATIN 150 MG 55390015101 $30.3000/each
CARBOPLATIN 150 MG 63323016720 $217.1500/each
CARBOPLATIN 150 MG 63323016721 $217.1500/each
CARIMUNE NF NANOFILTERED 12 G 44206041812 $1163.5200/each
CARIMUNE NF NANOFILTERED 6 G 44206041706 $581.7600/each
Page 6 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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CARTICEL 12MM/0.4ML 58468102501 $33861.2600/each
CARTICEL 12MM/0.4ML 63861102501 $30725.4168/each
CARTICEL 12MM/0.4ML 69866102501 $38560.7900/each
CATHFLO ACTIVASE 2 MG 50242004163 $148.6417/each
CATHFLO ACTIVASE 2 MG 50242004164 $148.6417/each
CAYSTON 75 MG/ML 61958090101 $102.7273/ml
CELLCEPT 500 MG 00004029809 $109.0573/each
CEPROTIN 1000 UNIT 00944417510 $1.5150/each
CEPROTIN 1000 UNIT 00944417910 $1.5150/each
CEPROTIN 500 UNIT 00944417505 $1.5150/each
CEPROTIN 500 UNIT 00944417705 $1.5150/each
CERDELGA 84 MG 58468022001 $429.2500/capsule
CEREDASE 80 UNIT/ML 58468106001 $339.4040/ml
CEREZYME 200 UNIT 58468198301 $848.5100/each
CEREZYME 400 UNIT 58468466301 $1601.8600/each
CERUBIDINE 20 MG 00082415501 $125.2733/each
CESAMET 1 MG 00037122150 $36.3931/capsule
CESAMET 1 MG 00187024701 $16.9680/capsule
CHENODAL 250 MG 68974087640 $477.7300/tablet
CHOLBAM 250 MG 45043000202 $838.3000/capsule
CHOLBAM 50 MG 45043000102 $278.5917/capsule
CIMZIA 400 MG 50474070062 $3896.3780/each
CIMZIA 400MG/2ML 50474071079 $3896.3780/each
CIMZIA 400MG/2ML 50474071081 $3896.3780/each
CINQAIR 10 MG/ML 59310061031 $86.8600/ml
CINRYZE 500 (5 ML) 42227008105 $2786.3779/each
CISPLATIN 1 MG/ML 00703574711 $0.4070/ml
CISPLATIN 1 MG/ML 00703574811 $0.4070/ml
CISPLATIN 1 MG/ML 10019091001 $2.1210/ml
CISPLATIN 1 MG/ML 16729028811 $0.3646/ml
CISPLATIN 1 MG/ML 16729028838 $0.3030/ml
CISPLATIN 1 MG/ML 44567050901 $0.3787/ml
CISPLATIN 1 MG/ML 44567051001 $0.3030/ml
CISPLATIN 1 MG/ML 44567051101 $0.5050/ml
CISPLATIN 1 MG/ML 47781060925 $0.3030/ml
CISPLATIN 1 MG/ML 47781061023 $0.2525/ml
CISPLATIN 1 MG/ML 55390009901 $0.3737/ml
CISPLATIN 1 MG/ML 55390011250 $0.3737/ml
CISPLATIN 1 MG/ML 55390011299 $0.3737/ml
CISPLATIN 1 MG/ML 55390018701 $0.3737/ml
CISPLATIN 1 MG/ML 55390041450 $0.3737/ml
CISPLATIN 1 MG/ML 55390041499 $0.3737/ml
CISPLATIN 1 MG/ML 63323010351 $0.3646/ml
CISPLATIN 1 MG/ML 63323010364 $0.3646/ml
CISPLATIN 1 MG/ML 63323010365 $0.3646/ml
CISPLATIN 1 MG/ML 63323010391 $0.3646/ml
CISPLATIN 1 MG/ML 67457042410 $0.3434/ml
CISPLATIN 1 MG/ML 67457042551 $0.3434/ml
CISPLATIN 1 MG/ML 68001028324 $0.3535/ml
CISPLATIN 1 MG/ML 68001028327 $0.3535/ml
CISPLATIN 1 MG/ML 68001028332 $0.3535/ml
Page 7 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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CISPLATIN 1 MG/ML 68001028333 $0.3535/ml
CISPLATIN 1 MG/ML 70860020650 $0.3636/ml
CISPLATIN 1 MG/ML 70860020651 $0.3636/ml
CLOFARABINE 20 MG/20ML 00955174601 $146.4500/ml
CLOFARABINE 20 MG/20ML 43598030920 $133.3846/ml Add
CLOFARABINE 20 MG/20ML 63323057270 $148.2044/ml
CLOFARABINE 20 MG/20ML 67457054620 $127.9069/ml Add
CLOFARABINE 20 MG/20ML 70121123601 $95.9500/ml Add
CLOLAR 20 MG/20ML 00024586001 $148.2049/ml
CLOLAR 20 MG/20ML 00024591701 $148.2049/ml
CLOLAR 20 MG/20ML 58468010002 $130.9263/ml
COMETRIQ 100 MG/DAY 42388001214 $266.7273/capsule
COMETRIQ 140 MG/DAY 42388001114 $133.3636/capsule
COMETRIQ 60 MG/DAY 42388001314 $177.8182/capsule
COMPLERA 200-25-300 54569627000 $109.7596/tablet
COMPLERA 200-25-300 61958110101 $90.2526/tablet
COPAXONE 20 MG/ML 68546031730 $239.5047/ml
COPAXONE 40 MG/ML 68546032506 $490.8794/ml
COPAXONE 40 MG/ML 68546032512 $490.8600/ml
CORTIGEL-80 80 UNIT/ML 00281538415 $2.8482/ml
CORTROSYN 0.25 MG 00052073110 $107.6458/each
CORTROSYN 0.25 MG 00052073112 $71.7706/each
CORTROSYN 0.25 MG 00548590000 $107.6458/each
COSENTYX (2 SYRINGES) 150 MG/ML 00078063998 $2234.5088/ml
COSENTYX PEN (2 PENS) 150 MG/ML 00078063941 $2234.5088/ml
COSENTYX PEN 150 MG/ML 00078063968 $4469.0177/ml
COSENTYX SYRINGE 150 MG/ML 00078063997 $4469.0177/ml
COSMEGEN 0.5 MG 00006329822 $479.7500/each
COSMEGEN 0.5 MG 55292081155 $1365.0857/each
COSYNTROPIN 0.25 MG/ML 00781305271 $100.9282/ml
COSYNTROPIN 0.25 MG/ML 00781305295 $100.9257/ml
COSYNTROPIN 0.25 MG 00781344071 $81.0052/each
COSYNTROPIN 0.25 MG 00781344095 $81.0020/each
COSYNTROPIN 0.25 MG 67457022700 $89.0603/each
COSYNTROPIN 0.25 MG 67457022702 $89.0507/each
COSYNTROPIN 0.25 MG 67457025700 $81.0052/each
COSYNTROPIN 0.25 MG 67457025702 $81.0020/each
COTELLIC 20 MG 50242071701 $104.9550/tablet
CRESEMBA 372 MG 00469042099 $275.6997/each
CRIXIVAN 200 MG 00006057142 $1.1251/capsule
CRIXIVAN 200 MG 00006057143 $1.2815/capsule
CRIXIVAN 400 MG 00006057301 $2.5672/capsule
CRIXIVAN 400 MG 00006057318 $2.5634/capsule
CRIXIVAN 400 MG 00006057342 $2.5632/capsule
CRIXIVAN 400 MG 00006057362 $2.5630/capsule
CRIXIVAN 400 MG 16590006418 $2.8618/capsule
CRIXIVAN 400 MG 16590006430 $2.8618/capsule
CRIXIVAN 400 MG 16590006460 $2.8618/capsule
CRIXIVAN 400 MG 16590006490 $2.9960/capsule
CRIXIVAN 400 MG 21695036618 $6.2819/capsule
CRIXIVAN 400 MG 35356013918 $6.1540/capsule
Page 8 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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CRIXIVAN 400 MG 35356013960 $6.8378/capsule
CRIXIVAN 400 MG 52959050712 $3.0932/capsule
CRIXIVAN 400 MG 52959050718 $3.0769/capsule
CRIXIVAN 400 MG 52959050724 $2.8846/capsule
CRIXIVAN 400 MG 52959050730 $2.8786/capsule
CRIXIVAN 400 MG 54569862000 $2.5631/capsule
CRIXIVAN 400 MG 54868411300 $2.9723/capsule
CUBICIN RF 500 MG 67919001201 $449.9449/each
CUBICIN RF 500 MG 67919001202 $449.9449/each
CUBICIN 500 MG 67919001101 $449.9449/each
CUPRID 250 MG 00006067968 $0.5625/capsule
CUVITRU 1 G/5 ML 00944285001 $33.9360/ml
CUVITRU 1 G/5 ML 00944285002 $33.9373/ml
CUVITRU 2 G/10 ML 00944285003 $33.9360/ml
CUVITRU 2 G/10 ML 00944285004 $33.9373/ml
CUVITRU 4 G/20 ML 00944285005 $33.9360/ml
CUVITRU 4 G/20 ML 00944285006 $33.9373/ml
CUVITRU 8 G/40 ML 00944285007 $33.9360/ml
CUVITRU 8 G/40 ML 00944285008 $33.9373/ml
CUVPOSA 1 MG/5 ML 00259050116 $1.0666/ml
CYCLOPHOSPHAMIDE 1 G 00781324494 $665.8425/each
CYCLOPHOSPHAMIDE 1 G 10019093601 $577.0534/each
CYCLOPHOSPHAMIDE 1 G 10019093650 $577.0534/each
CYCLOPHOSPHAMIDE 1 G 10019093901 $574.9122/each
CYCLOPHOSPHAMIDE 1 G 10019093950 $574.9122/each
CYCLOPHOSPHAMIDE 1 G 10019094401 $574.9122/each
CYCLOPHOSPHAMIDE 1 G 10019094450 $574.9122/each
CYCLOPHOSPHAMIDE 1 G 10019095601 $739.8250/each
CYCLOPHOSPHAMIDE 1 G 10019095616 $739.8250/each
CYCLOPHOSPHAMIDE 2 G 00781325594 $1331.6850/each
CYCLOPHOSPHAMIDE 2 G 10019093701 $1154.1068/each
CYCLOPHOSPHAMIDE 2 G 10019093710 $1154.1068/each
CYCLOPHOSPHAMIDE 2 G 10019094201 $1149.8244/each
CYCLOPHOSPHAMIDE 2 G 10019094210 $1149.8244/each
CYCLOPHOSPHAMIDE 2 G 10019094501 $1149.8244/each
CYCLOPHOSPHAMIDE 2 G 10019094510 $1149.8244/each
CYCLOPHOSPHAMIDE 2 G 10019095701 $1479.6500/each
CYCLOPHOSPHAMIDE 2 G 10019095711 $1479.6500/each
CYCLOPHOSPHAMIDE 25 MG 00054038225 $7.5643/capsule
CYCLOPHOSPHAMIDE 25 MG 54868521800 $3.3062/tablet
CYCLOPHOSPHAMIDE 25 MG 54868521801 $4.8128/tablet
CYCLOPHOSPHAMIDE 25 MG 54868521802 $3.5716/tablet
CYCLOPHOSPHAMIDE 50 MG 00054038325 $13.8824/capsule
CYCLOPHOSPHAMIDE 50 MG 54868500500 $6.0571/tablet
CYCLOPHOSPHAMIDE 50 MG 54868500501 $6.0951/tablet
CYCLOPHOSPHAMIDE 500 MG 00781323394 $332.9263/each
CYCLOPHOSPHAMIDE 500 MG 10019093501 $289.0620/each
CYCLOPHOSPHAMIDE 500 MG 10019093525 $289.0620/each
CYCLOPHOSPHAMIDE 500 MG 10019093801 $287.9914/each
CYCLOPHOSPHAMIDE 500 MG 10019093825 $287.9914/each
CYCLOPHOSPHAMIDE 500 MG 10019094301 $287.9914/each
Page 9 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
CYCLOPHOSPHAMIDE 500 MG 10019094325 $287.9914/each
CYCLOPHOSPHAMIDE 500 MG 10019095501 $369.9125/each
CYCLOPHOSPHAMIDE 500 MG 10019095550 $369.9125/each
CYCLOSPORINE 250 MG/5ML 00574086610 $7.8994/ml
CYCLOSPORINE 250 MG/5ML 55390012210 $4.4442/ml
CYRAMZA 100MG/10ML 00002766901 $110.4233/ml
CYRAMZA 500MG/50ML 00002767801 $110.4233/ml
CYSTADANE 1 G/1.7 ML 52276040001 $8.0017/gm
CYSTADANE 1 G/1.7 ML 66621400001 $8.0017/gm
CYSTAGON 150 MG 00378904501 $0.8242/capsule
CYSTAGON 150 MG 00378904505 $0.7830/capsule
CYSTAGON 50 MG 00378904001 $0.2828/capsule
CYSTAGON 50 MG 00378904005 $0.2687/capsule
CYSTARAN 0.44 % 54482002001 $100.7980/ml
CYTARABINE 1 G 00703519401 $41.2282/each
CYTARABINE 100 MG/5ML 61703030538 $1.2625/ml
CYTARABINE 100 MG/5ML 67457045552 $0.9595/ml
CYTARABINE 100 MG 00469241020 $5.1510/each
CYTARABINE 100 MG 00703518203 $5.3530/each
CYTARABINE 100 MG 51309021910 $5.1510/each
CYTARABINE 100 MG 51309022205 $6.1610/each
CYTARABINE 2 G 00703519501 $82.4463/each
CYTARABINE 2 G 55390013401 $40.4000/each
CYTARABINE 2 G 55390080901 $32.3200/each
CYTARABINE 20 MG/ML 61703030346 $0.5474/ml
CYTARABINE 20 MG/ML 61703030350 $0.7878/ml
CYTARABINE 20 MG/ML 61703030425 $0.7878/ml
CYTARABINE 20 MG/ML 61703030436 $0.6197/ml
CYTARABINE 20 MG/ML 61703030509 $0.9999/ml
CYTARABINE 20 MG/ML 67457045450 $0.4040/ml
CYTARABINE 500 MG 00469242030 $20.5030/each
CYTARABINE 500 MG 00703519302 $21.6948/each
CYTARABINE 500 MG 51309022015 $20.5030/each
CYTARABINE 500 MG 51309022330 $21.5130/each
CYTOGAM 50 MG/ML 44206053211 $25.9570/ml
CYTOGAM 50 MG/ML 44206310101 $23.5128/ml
CYTOSAR-U POWDER W/DILUENT 100 MG 00009306301 $5.4338/each
CYTOSAR-U POWDER W/DILUENT 500 MG 00009307001 $21.5938/each
CYTOXAN LYOPHILIZED 1 G 00015054812 $41.5514/each
CYTOXAN LYOPHILIZED 1 G 00015054841 $41.5514/each
CYTOXAN LYOPHILIZED 2 G 00015054912 $83.1331/each
CYTOXAN LYOPHILIZED 2 G 00015054941 $83.1331/each
CYTOXAN LYOPHILIZED 500 MG 00015054712 $20.7757/each
CYTOXAN LYOPHILIZED 500 MG 00087054741 $20.7757/each
CYTOXAN 1 G 00087050541 $23.3310/each
CYTOXAN 2 G 00087050641 $42.4200/each
CYTOXAN 25 MG 00087050401 $1.9005/tablet
CYTOXAN 50 MG 00015050348 $1.0042/tablet
CYTOXAN 50 MG 00087050301 $3.4878/tablet
CYTOXAN 50 MG 00087050302 $3.3220/tablet
CYTOXAN 50 MG 00087050303 $2.6507/tablet
Page 10 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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CYTOXAN 500 MG 00087050201 $12.8371/each
CYTOXAN 500 MG 00087050241 $12.8371/each
DACARBAZINE 100 MG 00469227030 $6.9690/each
DACARBAZINE 100 MG 51309020410 $6.7670/each
DACARBAZINE 100 MG 51309020420 $6.7670/each
DACARBAZINE 100 MG 63323012710 $9.5445/each
DACOGEN 50 MG 59148004670 $1814.5155/each
DACOGEN 50 MG 62856060001 $1728.1100/each
DACTINOMYCIN 0.5 MG 55390033701 $593.8800/each
DAKLINZA 30 MG 00003021301 $757.5000/tablet
DAKLINZA 60 MG 00003021501 $757.5000/tablet
DAKLINZA 90 MG 00003001101 $757.5000/tablet
DALVANCE 500 MG 57970010001 $1550.0470/each
DAPTOMYCIN 500 MG 00409010601 $449.8944/each
DAPTOMYCIN 500 MG 00703012501 $449.9045/each
DAPTOMYCIN 500 MG 63323087115 $424.2000/each
DARZALEX 100 MG/5ML 57894050205 $98.1760/ml
DARZALEX 400MG/20ML 57894050220 $98.1760/ml
DAUNORUBICIN HCL 20 MG 00074503203 $137.1984/each
DAUNORUBICIN HCL 20 MG 00703503203 $137.1984/each
DAUNORUBICIN HCL 20 MG 63323011908 $106.0500/each
DAUNOXOME 2 MG/ML 56146030100 $8.6860/ml
DAUNOXOME 2 MG/ML 61958030101 $10.9888/ml
DECITABINE 50 MG 00781313980 $1706.9000/each
DECITABINE 50 MG 16729022405 $1161.5000/each
DECITABINE 50 MG 43598034837 $1161.5000/each
DECITABINE 50 MG 43598042737 $1161.5000/each
DECITABINE 50 MG 47335036141 $1553.5315/each
DECITABINE 50 MG 55111055610 $1641.7045/each
DEFITELIO 80 MG/ML 68727080001 $343.2990/ml
DEFITELIO 80 MG/ML 68727080002 $343.2990/ml
DEPOCYT 50 MG/5 ML 53905033101 $404.0000/ml
DEPOCYT 50 MG/5 ML 57665033101 $598.7280/ml
DESCOVY 200MG-25MG 61958200201 $52.7765/tablet
DEXRAZOXANE 250 MG 55390001402 $207.2939/each
DEXRAZOXANE 250 MG 67457020425 $277.0119/each
DEXRAZOXANE 250 MG 67457020725 $277.0026/each
DEXRAZOXANE 500 MG 47781057807 $402.9900/each
DEXRAZOXANE 500 MG 51991094298 $598.3139/each
DEXRAZOXANE 500 MG 67457020850 $553.9951/each
DEXRAZOXANE 500 MG 67457020950 $554.0154/each
DIBENZYLINE 10 MG 59212000101 $242.3798/capsule
DIBENZYLINE 10 MG 65197000101 $242.3798/capsule
DILUENT FOR EPOPROSTENOL 00703925809 $0.2376/ml
DILUENT FOR FLOLAN 00173051801 $0.2843/ml
DILUENT FOR REMODULIN 66302015050 $0.1919/ml
DILUENT 00081046201 $0.1596/ml
DOCEFREZ 20 MG 47335028541 $271.4880/each
DOCEFREZ 80 MG 47335028641 $1086.0530/each
DOCETAXEL 160 MG/8ML 00955102208 $187.1656/ml
DOCETAXEL 160 MG/8ML 16729023165 $277.7500/ml
Page 11 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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DOCETAXEL 160 MG/8ML 16729026765 $99.9900/ml
DOCETAXEL 160 MG/8ML 42367012129 $217.1500/ml
DOCETAXEL 160 MG/8ML 45963079056 $202.0000/ml
DOCETAXEL 160MG/16ML 00409020120 $34.7188/ml
DOCETAXEL 160MG/16ML 66758005003 $60.4485/ml
DOCETAXEL 160MG/16ML 66758095004 $60.4485/ml
DOCETAXEL 20 MG/2 ML 00409020102 $34.7188/ml
DOCETAXEL 20 MG/2 ML 66758005001 $60.4485/ml
DOCETAXEL 20 MG/2 ML 66758095002 $60.4485/ml
DOCETAXEL 200MG/10ML 39822220001 $70.7000/ml
DOCETAXEL 20MG/ML(1) 00409036601 $69.4375/ml
DOCETAXEL 20MG/ML(1) 00703572001 $202.0000/ml
DOCETAXEL 20MG/ML(1) 00955102001 $374.3363/ml
DOCETAXEL 20MG/ML(1) 16714046501 $246.1673/ml
DOCETAXEL 20MG/ML(1) 16729023163 $277.7500/ml
DOCETAXEL 20MG/ML(1) 16729026763 $99.9900/ml
DOCETAXEL 20MG/ML(1) 39822212001 $72.7200/ml
DOCETAXEL 20MG/ML(1) 42367012121 $217.1500/ml
DOCETAXEL 20MG/ML(1) 43598025811 $75.7500/ml
DOCETAXEL 20MG/ML(1) 43598061111 $50.5000/ml
DOCETAXEL 20MG/ML(1) 45963073454 $202.0000/ml
DOCETAXEL 80 MG/4 ML 00409036701 $69.4375/ml
DOCETAXEL 80 MG/4 ML 00703573001 $202.0000/ml
DOCETAXEL 80 MG/4 ML 00955102104 $374.3312/ml
DOCETAXEL 80 MG/4 ML 16714050001 $202.5959/ml
DOCETAXEL 80 MG/4 ML 16729023164 $277.7500/ml
DOCETAXEL 80 MG/4 ML 16729026764 $99.9900/ml
DOCETAXEL 80 MG/4 ML 39822218001 $70.7000/ml
DOCETAXEL 80 MG/4 ML 42367012125 $217.1500/ml
DOCETAXEL 80 MG/4 ML 43598025940 $75.7500/ml
DOCETAXEL 80 MG/4 ML 43598061040 $50.5000/ml
DOCETAXEL 80 MG/4 ML 45963076552 $79.5375/ml
DOCETAXEL 80 MG/8 ML 00409020110 $34.7188/ml
DOCETAXEL 80 MG/8 ML 66758005002 $60.4485/ml
DOCETAXEL 80 MG/8 ML 66758095003 $60.4485/ml
DOCETAXEL FNL 20MG/2 16729012049 $614.6935/ml
DOCETAXEL FNL 20MG/2 60505603506 $590.0824/ml
DOCETAXEL FNL 80MG/8 16729022850 $614.6935/ml
DOCETAXEL FNL 80MG/8 60505603706 $590.0824/ml
DOXIL 2 MG/ML 59676096001 $108.8679/ml
DOXIL 2 MG/ML 59676096002 $108.8679/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 16714074201 $97.8690/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 16714085601 $97.8710/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 43598028335 $97.8690/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 43598054125 $97.8710/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 47335004940 $97.8690/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 47335005040 $97.8710/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 59676096601 $97.8690/ml
DOXORUBICIN HCL LIPOSOME 2 MG/ML 59676096602 $97.8710/ml
DOXORUBICIN HCL 10 MG 00702023110 $31.5928/each
DOXORUBICIN HCL 10 MG 67457047810 $53.1361/each
Page 12 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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DOXORUBICIN HCL 20 MG 00702023206 $63.1856/each
DOXORUBICIN HCL 20 MG 55390024210 $16.7660/each
DOXORUBICIN HCL 50 MG 00702023301 $157.9640/each
DOXORUBICIN HCL 50 MG 67457043650 $265.6603/each
DTIC-DOME IV 100 MG 00026815110 $11.6327/each
DUOPA 4.63-20/ML 00074301207 $2.0386/ml
DUPIXENT 300 MG/2ML 00024591401 $718.6554/ml
DYSPORT 300 UNIT 15054053006 $496.1625/each
DYSPORT 500 UNIT 15054050001 $826.6850/each
EDURANT 25 MG 59676027801 $32.5472/tablet
EGRIFTA 2 MG 62064002130 $83.9141/each
ELAPRASE 6 MG/3 ML 54092070001 $1055.7294/ml
ELELYSO 200 UNIT 00069010601 $787.2445/each
ELIGARD 22.5 MG 00024059722 $575.7000/each
ELIGARD 22.5 MG 62935022305 $1368.6207/each
ELIGARD 30 MG 62935030330 $1826.8476/each
ELIGARD 45 MG 62935045345 $2737.2313/each
ELIGARD 7.5 MG 00024059707 $209.0700/each
ELIGARD 7.5 MG 62935075375 $456.2069/each
ELITEK 1.5 MG 00024515010 $811.7303/each
ELITEK 7.5 MG 00024515175 $4058.7355/each
ELSPAR 10000 UNIT 00006461200 $53.2573/each
EMCYT RX PAK 140 MG 00004013202 $4.5425/capsule
EMCYT 140 MG 00013013202 $14.7966/capsule
EMFLAZA 18 MG 42998050203 $132.1417/tablet
EMFLAZA 22.75MG/ML 42998050521 $223.2100/ml
EMFLAZA 30 MG 42998050303 $220.2473/tablet
EMFLAZA 36 MG 42998050403 $245.4300/tablet
EMFLAZA 6 MG 42998050101 $44.0461/tablet
EMPLICITI 300 MG 00003229111 $1847.9768/each
EMPLICITI 400 MG 00003452211 $2463.9657/each
EMTRIVA 10 MG/ML 61958060201 $0.7527/ml
EMTRIVA 200 MG 35356020530 $22.9669/capsule
EMTRIVA 200 MG 54569552100 $20.9409/capsule
EMTRIVA 200 MG 54868485300 $13.7688/capsule
EMTRIVA 200 MG 61958060101 $18.0628/capsule
ENBREL 25 MG 54868478200 $210.7364/each
ENBREL 25 MG 58406042534 $560.8025/each
ENBREL 25 MG 58406042541 $560.8025/each
ENBREL 25MG/0.5ML 58406045501 $1099.6127/ml
ENBREL 25MG/0.5ML 58406045504 $1099.6127/ml
ENBREL 50 MG/ML 54868544400 $429.6535/ml
ENBREL 50 MG/ML 58406043501 $1144.4949/ml
ENBREL 50 MG/ML 58406043504 $1144.4949/ml
ENBREL 50 MG/ML 58406044501 $1144.4949/ml
ENBREL 50 MG/ML 58406044504 $1144.4949/ml
ENBREL 50 MG/ML 58406045601 $1144.4949/ml Add
ENBREL 50 MG/ML 58406045604 $1144.4949/ml Add
ENOXAPARIN SODIUM 100 MG/ML 00548560500 $15.1500/ml
ENOXAPARIN SODIUM 100 MG/ML 00548563500 $15.1500/ml
ENOXAPARIN SODIUM 100 MG/ML 00703858021 $44.4400/ml
Page 13 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ENOXAPARIN SODIUM 100 MG/ML 00703858023 $20.0788/ml
ENOXAPARIN SODIUM 100 MG/ML 00781350005 $68.4125/ml
ENOXAPARIN SODIUM 100 MG/ML 00781350069 $44.4400/ml
ENOXAPARIN SODIUM 100 MG/ML 00955101010 $75.1703/ml
ENOXAPARIN SODIUM 100 MG/ML 62037086320 $55.5500/ml
ENOXAPARIN SODIUM 100 MG/ML 63323056884 $20.0788/ml
ENOXAPARIN SODIUM 100 MG/ML 63323056895 $10.1404/ml
ENOXAPARIN SODIUM 120MG/.8ML 00548560600 $22.7250/ml
ENOXAPARIN SODIUM 120MG/.8ML 00548563600 $22.7250/ml
ENOXAPARIN SODIUM 120MG/.8ML 00703861021 $66.6600/ml
ENOXAPARIN SODIUM 120MG/.8ML 00703861023 $30.1106/ml
ENOXAPARIN SODIUM 120MG/.8ML 00781361204 $102.6548/ml
ENOXAPARIN SODIUM 120MG/.8ML 00781361268 $66.6600/ml
ENOXAPARIN SODIUM 120MG/.8ML 00955101210 $112.7918/ml
ENOXAPARIN SODIUM 120MG/.8ML 62037086420 $83.3250/ml
ENOXAPARIN SODIUM 120MG/.8ML 63323056990 $30.1106/ml
ENOXAPARIN SODIUM 120MG/.8ML 63323056999 $15.2131/ml
ENOXAPARIN SODIUM 150 MG/ML 00548560700 $22.7250/ml
ENOXAPARIN SODIUM 150 MG/ML 00548563700 $22.7250/ml
ENOXAPARIN SODIUM 150 MG/ML 00703851021 $66.6600/ml
ENOXAPARIN SODIUM 150 MG/ML 00703851023 $30.1081/ml
ENOXAPARIN SODIUM 150 MG/ML 00781365505 $102.6605/ml
ENOXAPARIN SODIUM 150 MG/ML 00781365569 $66.6600/ml
ENOXAPARIN SODIUM 150 MG/ML 00955101510 $112.7928/ml
ENOXAPARIN SODIUM 150 MG/ML 62037086620 $83.3250/ml
ENOXAPARIN SODIUM 150 MG/ML 63323056984 $30.1081/ml
ENOXAPARIN SODIUM 150 MG/ML 63323056995 $15.2106/ml
ENOXAPARIN SODIUM 300MG/3ML 00781312293 $0.0000 Delete
ENOXAPARIN SODIUM 300MG/3ML 00955101601 $75.0868/ml
ENOXAPARIN SODIUM 300MG/3ML 63323056586 $23.7081/ml
ENOXAPARIN SODIUM 300MG/3ML 63323056593 $11.9719/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00548560100 $15.1500/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00548563100 $15.1500/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00703853021 $44.4400/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00703853023 $20.0990/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00781313301 $68.3292/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00781313363 $44.4400/ml
ENOXAPARIN SODIUM 30MG/0.3ML 00955100310 $75.0868/ml
ENOXAPARIN SODIUM 30MG/0.3ML 55154544005 $44.4400/ml
ENOXAPARIN SODIUM 30MG/0.3ML 55154939905 $20.0990/ml
ENOXAPARIN SODIUM 30MG/0.3ML 62037083920 $55.5500/ml
ENOXAPARIN SODIUM 30MG/0.3ML 63323056883 $20.0990/ml
ENOXAPARIN SODIUM 30MG/0.3ML 63323056894 $10.1337/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00548560200 $15.1500/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00548563200 $15.1500/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00703854021 $44.4400/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00703854023 $20.0485/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00781322402 $68.3292/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00781322464 $44.4400/ml
ENOXAPARIN SODIUM 40MG/0.4ML 00955100410 $75.0809/ml
ENOXAPARIN SODIUM 40MG/0.4ML 62037084920 $55.5500/ml
Page 14 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ENOXAPARIN SODIUM 40MG/0.4ML 63323056887 $20.0485/ml
ENOXAPARIN SODIUM 40MG/0.4ML 63323056896 $10.1253/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00548560300 $15.1500/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00548563300 $15.1500/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00703856021 $44.4400/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00703856023 $20.0822/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00781335603 $68.4162/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00781335666 $44.4400/ml
ENOXAPARIN SODIUM 60MG/0.6ML 00955100610 $75.1709/ml
ENOXAPARIN SODIUM 60MG/0.6ML 62037086120 $55.5500/ml
ENOXAPARIN SODIUM 60MG/0.6ML 63323056888 $20.0822/ml
ENOXAPARIN SODIUM 60MG/0.6ML 63323056898 $10.1337/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00548560400 $15.1500/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00548563400 $15.1500/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00703868021 $44.4400/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00703868023 $20.0738/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00781342804 $68.4144/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00781342868 $52.0150/ml
ENOXAPARIN SODIUM 80MG/0.8ML 00955100810 $75.1718/ml
ENOXAPARIN SODIUM 80MG/0.8ML 62037086220 $55.5500/ml
ENOXAPARIN SODIUM 80MG/0.8ML 63323056890 $20.0738/ml
ENOXAPARIN SODIUM 80MG/0.8ML 63323056899 $10.1379/ml
ENTYVIO 300 MG 64764030020 $5693.9255/each
ENVARSUS XR 0.75 MG 68992307501 $3.6284/tablet
ENVARSUS XR 0.75 MG 68992307503 $3.6286/tablet
ENVARSUS XR 1 MG 68992301001 $4.8379/tablet
ENVARSUS XR 1 MG 68992301003 $4.8379/tablet
ENVARSUS XR 4 MG 68992304001 $19.3516/tablet
ENVARSUS XR 4 MG 68992304003 $19.3516/tablet
EPCLUSA 400-100 MG 61958220101 $898.9000/tablet
EPINEPHRINE 0.15MG/0.3 49502010101 $157.8188/each
EPINEPHRINE 0.15MG/0.3 49502010102 $151.5000/each
EPINEPHRINE 0.3MG/0.3 00115169449 $199.5810/each
EPINEPHRINE 0.3MG/0.3 49502010201 $157.8188/each
EPINEPHRINE 0.3MG/0.3 49502010202 $151.5000/each
EPINEPHRINE 0.3MG/0.3 54505010201 $199.5760/each
EPINEPHRINE 0.3MG/0.3 54505010202 $199.5810/each
EPINEPHRINE 0.3MG/0.3 54569642500 $207.9041/each
EPIPEN 2-PAK 0.3MG/0.3 49502050002 $307.3480/each
EPIPEN 2-PAK 0.3MG/0.3 54569625700 $173.6511/each
EPIPEN 2-PAK 0.3MG/0.3 54868280401 $114.9720/each
EPIPEN JR 2-PAK 0.15MG/0.3 49502050102 $307.3480/each
EPIPEN JR 2-PAK 0.15MG/0.3 54569625800 $307.3594/each
EPIPEN JR 2-PAK 0.15MG/0.3 54868481900 $112.7541/each
EPIRUBICIN HCL 200 MG 61703034859 $2395.2554/each
EPIVIR HBV 25 MG/5 ML 00173066300 $0.8211/ml
EPIVIR 10 MG/ML 35356006624 $0.4945/ml
EPIVIR 10 MG/ML 49702020548 $0.4666/ml
EPIVIR 10 MG/ML 54569433300 $0.4666/ml
EPOGEN 10000/ML 55513014401 $167.4580/ml
EPOGEN 10000/ML 55513014410 $167.4580/ml
Page 15 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
EPOGEN 2000/ML 55513012601 $33.4916/ml
EPOGEN 2000/ML 55513012610 $33.4916/ml
EPOGEN 20000/2ML 55513028301 $167.4580/ml
EPOGEN 20000/2ML 55513028310 $167.4580/ml
EPOGEN 20000/ML 55513047801 $334.9160/ml
EPOGEN 20000/ML 55513047810 $334.9160/ml
EPOGEN 3000/ML 55513026701 $50.2374/ml
EPOGEN 3000/ML 55513026710 $50.2374/ml
EPOGEN 4000/ML 55513014801 $66.9832/ml
EPOGEN 4000/ML 55513014810 $66.9832/ml
EPOPROSTENOL SODIUM 0.5 MG 00703198501 $16.3620/each
EPOPROSTENOL SODIUM 1.5 MG 00703199501 $39.5112/each
ERBITUX 100MG/50ML 66733094823 $11.9063/ml
ERBITUX 200MG/0.1L 66733095823 $11.9063/ml
ERIVEDGE 150 MG 50242014001 $388.3930/capsule
ERWINAZE 10000 UNIT 57902024901 $3952.5744/each Increase
ERWINAZE 10000 UNIT 57902024905 $3952.5744/each Increase
ESBRIET 267 MG 50242012101 $31.8621/capsule
ESBRIET 267 MG 50242012203 $31.8634/tablet
ESBRIET 267 MG 50242012205 $31.8621/tablet
ESBRIET 267 MG 64116012101 $31.8621/capsule
ESBRIET 801 MG 50242012301 $95.5864/tablet
ETHYOL 500 MG 58178001701 $509.9692/each
ETHYOL 500 MG 58178001703 $509.9664/each
ETHYOL 500 MG 66220001703 $1005.4550/each
ETOPOPHOS 100 MG 00015340420 $142.3494/each
ETOPOSIDE 50 MG 00378326694 $76.0823/capsule Add
ETOPOSIDE 50 MG 54868535500 $40.4146/capsule Add
ETOPOSIDE 50 MG 54868535502 $47.2783/capsule Add
EUFLEXXA 20 MG/2 ML 55566410001 $171.6630/ml
EULEXIN 125 MG 00085052503 $2.2006/capsule
EULEXIN 125 MG 00085052504 $1.2139/capsule
EULEXIN 125 MG 00085052505 $2.0761/capsule
EULEXIN 125 MG 00085052506 $2.0757/capsule
EVOMELA 50 MG 68152010900 $2020.0000/each
EVOTAZ 300-150 MG 00003364111 $54.0508/tablet
EVOTAZ 300-150 MG 54569659500 $70.2688/tablet
EXJADE 125 MG 00078046815 $35.9338/tablet
EXJADE 250 MG 00078046915 $71.8662/tablet
EXJADE 500 MG 00078047015 $143.7297/tablet
EXONDYS 51 100 MG/2ML 60923036302 $808.0000/ml
EXONDYS 51 500MG/10ML 60923028410 $808.0000/ml
EXTAVIA 0.3 MG 00078056912 $400.4502/each
EXTAVIA 0.3 MG 00078056961 $400.4650/each
EXTAVIA 0.3 MG 00078056999 $400.4650/each
EYLEA 2MG/0.05ML 61755000502 $37370.0000/ml
FABRAZYME 35 MG 58468004001 $5719.6300/each
FABRAZYME 5 MG 58468004101 $817.0900/each
FARESTON 60 MG 11399000501 $4.1713/tablet
FARESTON 60 MG 42747032730 $42.0648/tablet
FARESTON 60 MG 54092017001 $4.1713/tablet
Page 16 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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FARYDAK 10 MG 00078065006 $1234.4456/capsule
FARYDAK 15 MG 00078065106 $1234.4456/capsule
FARYDAK 20 MG 00078065206 $1234.4456/capsule
FASLODEX 250 MG/5ML 00310072010 $191.0395/ml
FERAHEME 510MG/17ML 59338077501 $47.8526/ml
FERAHEME 510MG/17ML 59338077510 $47.8526/ml
FERRIPROX 100 MG/ML 52609450207 $11.1667/ml
FERRIPROX 500 MG 52609000601 $54.6432/tablet
FIRAZYR 30 MG/3 ML 54092070202 $3470.1715/ml
FIRAZYR 30 MG/3 ML 54092070203 $3470.1715/ml
FIRMAGON 120 MG 55566840301 $769.7109/each
FIRMAGON 80 MG 55566830301 $493.3345/each
FLEBOGAMMA DIF 10 % 61953000501 $8.9981/ml
FLEBOGAMMA DIF 10 % 61953000502 $8.9981/ml
FLEBOGAMMA DIF 10 % 61953000503 $8.9981/ml
FLEBOGAMMA DIF 10 % 61953000504 $8.9984/ml
FLEBOGAMMA DIF 10 % 61953000505 $8.9984/ml
FLEBOGAMMA DIF 10 % 61953000506 $8.9984/ml
FLEBOGAMMA DIF 5 % 61953000400 $4.4992/ml
FLEBOGAMMA DIF 5 % 61953000401 $4.4996/ml
FLEBOGAMMA DIF 5 % 61953000402 $4.4991/ml
FLEBOGAMMA DIF 5 % 61953000403 $4.4990/ml
FLEBOGAMMA DIF 5 % 61953000404 $4.4990/ml
FLEBOGAMMA DIF 5 % 61953000405 $4.4990/ml
FLEBOGAMMA DIF 5 % 61953000406 $4.4997/ml
FLEBOGAMMA DIF 5 % 61953000407 $4.4994/ml
FLEBOGAMMA DIF 5 % 61953000408 $4.4992/ml
FLEBOGAMMA DIF 5 % 61953000409 $4.4992/ml
FLEBOGAMMA 5 % 61953000301 $4.0723/ml
FLEBOGAMMA 5 % 61953000302 $4.0723/ml
FLEBOGAMMA 5 % 61953000303 $4.0723/ml
FLEBOGAMMA 5 % 61953000304 $4.0723/ml
FLOLAN 0.5 MG 00081046001 $17.9780/each
FLOLAN 0.5 MG 00173051700 $18.8769/each
FLOLAN 1.5 MG 00081046401 $26.5630/each
FLOLAN 1.5 MG 00173051900 $45.5914/each
FLOXURIDINE 500 MG 51309023110 $70.7000/each
FLOXURIDINE 500 MG 51309023210 $74.6996/each
FLOXURIDINE 500 MG 55390013501 $121.2048/each
FLOXURIDINE 500 MG 63323014507 $120.1900/each
FLUCYTOSINE 250 MG 00054042725 $66.3118/capsule Add
FLUCYTOSINE 250 MG 42494033901 $69.0775/capsule
FLUCYTOSINE 250 MG 64980017901 $66.3118/capsule
FLUCYTOSINE 250 MG 64980017903 $66.3119/capsule
FLUCYTOSINE 500 MG 00054042825 $128.3144/capsule Add
FLUCYTOSINE 500 MG 42494034001 $133.6662/capsule
FLUCYTOSINE 500 MG 64980018001 $128.3104/capsule
FLUCYTOSINE 500 MG 64980018003 $128.3104/capsule
FLUOROURACIL 1 G/20 ML 16729027605 $1.2074/ml
FLUOROURACIL 1 G/20 ML 16729027667 $1.1590/ml
FLUOROURACIL 1 G/20 ML 63323011720 $0.3030/ml
Page 17 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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FLUOROURACIL 1 G/20 ML 63323011728 $0.2803/ml
FLUOROURACIL 1 G/20 ML 68001026629 $1.1590/ml
FLUOROURACIL 1 G/20 ML 68001026631 $1.1590/ml
FLUTAMIDE 125 MG 00172496058 $3.5363/capsule
FLUTAMIDE 125 MG 00172496070 $3.5226/capsule
FLUTAMIDE 125 MG 00185112588 $1.5849/capsule
FLUTAMIDE 125 MG 00555087004 $1.5183/capsule
FLUTAMIDE 125 MG 00591246618 $1.5653/capsule
FLUTAMIDE 125 MG 49884075313 $1.5849/capsule
FLUTAMIDE 125 MG 54868462800 $2.4620/capsule
FLUTAMIDE 125 MG 60429027218 $0.5824/capsule
FLUTAMIDE 125 MG 69097091591 $1.5653/capsule
FOLOTYN 20MG/ML(1) 48818000101 $5003.3885/ml
FOLOTYN 40 MG/2 ML 48818000102 $5003.3885/ml
FORTEO 20MCG/DOSE 00002840001 $1261.6162/ml
FOSAMPRENAVIR CALCIUM 700 MG 00378352091 $16.8315/tablet
FRAGMIN 10000/ML 00069021701 $82.9074/ml
FRAGMIN 10000/ML 00069021702 $82.8958/ml
FRAGMIN 10000/ML 62856010201 $53.2196/ml
FRAGMIN 12500/0.5 00069022001 $207.2602/ml
FRAGMIN 12500/0.5 00069022002 $207.2540/ml
FRAGMIN 15000/0.6 00069022301 $207.2406/ml
FRAGMIN 15000/0.6 00069022302 $207.2419/ml
FRAGMIN 18000/0.72 00069022801 $207.2569/ml
FRAGMIN 18000/0.72 00069022802 $207.2408/ml
FRAGMIN 2500/0.2ML 00069019501 $127.7701/ml
FRAGMIN 2500/0.2ML 00069019502 $127.7398/ml
FRAGMIN 25000/ML 00069023201 $187.5065/ml
FRAGMIN 5000/0.2ML 00069019601 $207.2686/ml
FRAGMIN 5000/0.2ML 00069019602 $207.2419/ml
FRAGMIN 7500/0.3ML 00069020601 $207.2546/ml
FRAGMIN 7500/0.3ML 00069020602 $207.2621/ml
FUDR 500 MG 00004193508 $114.7865/each
FUDR 500 MG 61703033109 $101.8888/each
FUSILEV 50 MG 68152010100 $151.5000/each
FUZEON 90 MG 00004038140 $60.3569/each
GABLOFEN 10000/20ML 45945015501 $11.6655/ml
GABLOFEN 10000/20ML 45945015502 $10.8575/ml
GABLOFEN 20K MCG/20 45945015601 $23.3310/ml
GABLOFEN 20K MCG/20 45945015602 $21.7150/ml
GABLOFEN 40000/20ML 45945015701 $46.7125/ml
GABLOFEN 40000/20ML 45945015702 $43.4300/ml
GABLOFEN 50 MCG/ML 45945015101 $80.8000/ml
GABLOFEN 50 MCG/ML 66794015101 $80.8000/ml
GAMASTAN S-D 15 %-18 % 13533063503 $13.5239/ml
GAMIMUNE N 10 % 00026064812 $8.1810/ml
GAMIMUNE N 5 % 00161064035 $2.4038/ml
GAMMAGARD LIQUID 10 % 00944270002 $13.1936/ml
GAMMAGARD LIQUID 10 % 00944270003 $13.1938/ml
GAMMAGARD LIQUID 10 % 00944270004 $13.1936/ml
GAMMAGARD LIQUID 10 % 00944270005 $13.1936/ml
Page 18 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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GAMMAGARD LIQUID 10 % 00944270006 $13.1936/ml
GAMMAGARD LIQUID 10 % 00944270007 $13.1936/ml
GAMMAGARD S-D 10 G 00944265804 $1703.8700/each
GAMMAGARD S-D 5 G 00944265603 $851.9350/each
GAMMAKED 1 G/10 ML 76125090001 $12.4856/ml
GAMMAKED 10 G/100ML 76125090010 $12.4850/ml
GAMMAKED 2.5G/25ML 76125090025 $12.4848/ml
GAMMAKED 20 G/200ML 76125090020 $12.4850/ml
GAMMAKED 5 G/50 ML 76125090050 $12.4848/ml
GAMMAPLEX 10 % 64208823501 $15.1860/ml
GAMMAPLEX 10 % 64208823502 $15.1860/ml
GAMMAPLEX 10 % 64208823503 $15.1860/ml
GAMMAPLEX 10 % 64208823505 $15.1854/ml
GAMMAPLEX 10 % 64208823506 $15.1854/ml
GAMMAPLEX 10 % 64208823507 $15.1854/ml
GAMMAPLEX 5 % 64208823402 $7.3543/ml
GAMMAPLEX 5 % 64208823403 $7.3543/ml
GAMMAPLEX 5 % 64208823404 $7.3543/ml
GAMMAPLEX 5 % 64208823406 $7.3543/ml
GAMMAPLEX 5 % 64208823407 $7.3543/ml
GAMMAPLEX 5 % 64208823408 $7.3543/ml
GAMMAR-P I.V. 1 G 00053748601 $101.0000/each
GAMMAR-P I.V. 10 G 00053748610 $1010.0000/each
GAMMAR-P I.V. 2.5 G 00053748602 $252.5000/each
GAMMAR-P I.V. 5 G 00053748605 $505.0000/each
GAMMAR-P I.V. 5 G 00053748606 $262.6000/each
GAMULIN RH 300 MCG 00053759001 $49.2274/each
GAMUNEX-C 1 G/10 ML 13533080012 $10.8343/ml
GAMUNEX-C 1 G/10 ML 13533080013 $10.8344/ml
GAMUNEX-C 10 G/100ML 13533080071 $10.8344/ml
GAMUNEX-C 10 G/100ML 13533080072 $10.8348/ml
GAMUNEX-C 2.5G/25ML 13533080015 $10.8349/ml
GAMUNEX-C 2.5G/25ML 13533080016 $10.8354/ml
GAMUNEX-C 20 G/200ML 13533080024 $10.8344/ml
GAMUNEX-C 20 G/200ML 13533080025 $10.8348/ml
GAMUNEX-C 40 G/400ML 13533080040 $10.8344/ml
GAMUNEX-C 40 G/400ML 13533080041 $10.8348/ml
GAMUNEX-C 5 G/50 ML 13533080020 $10.8343/ml
GAMUNEX-C 5 G/50 ML 13533080021 $10.8347/ml
GATTEX 5 MG 68875010201 $36298.7233/each
GATTEX 5 MG 68875010301 $1391.7396/each
GAZYVA 1000 MG/40 50242007001 $150.6733/ml
GEL-ONE 30 MG/3 ML 85836015153 $328.2500/ml
GEL-ONE 30 MG/3 ML 87541030091 $335.9933/ml
GELSYN-3 16.8MG/2ML 89130311101 $174.2250/ml
GEMCITABINE HCL 1 G/26.3ML 00409018101 $1.7139/ml
GEMCITABINE HCL 1 G/26.3ML 00409018125 $1.7139/ml
GEMCITABINE HCL 1 G/26.3ML 45963062458 $1.7139/ml
GEMCITABINE HCL 2 G/52.6ML 00409018201 $1.7137/ml
GEMCITABINE HCL 2 G/52.6ML 00409018225 $1.7185/ml
GEMCITABINE HCL 2 G/52.6ML 45963063660 $1.7139/ml
Page 19 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
GEMCITABINE HCL 200MG/5.26 00409018301 $1.7147/ml
GEMCITABINE HCL 200MG/5.26 00409018325 $1.7147/ml
GEMCITABINE HCL 200MG/5.26 45963062357 $1.7147/ml
GENOTROPIN 0.2MG/0.25 00013264902 $24.7436/each
GENOTROPIN 0.2MG/0.25 54868560100 $12.0664/each
GENOTROPIN 0.4MG/0.25 00013265002 $49.4943/each
GENOTROPIN 0.6MG/0.25 00013265102 $74.2379/each
GENOTROPIN 0.8MG/0.25 00013265202 $98.9829/each
GENOTROPIN 0.8MG/0.25 54868576000 $63.7997/each
GENOTROPIN 1.2MG/0.25 00013265402 $148.4787/each
GENOTROPIN 1.4MG/0.25 00013265502 $173.2208/each
GENOTROPIN 1.6MG/0.25 00013265602 $197.9629/each
GENOTROPIN 1.8MG/0.25 00013265702 $222.7165/each
GENOTROPIN 12 MG/ML 00013264681 $1362.2274/each
GENOTROPIN 1MG/0.25ML 00013265302 $123.7337/each
GENOTROPIN 2MG/0.25ML 00013265802 $247.4587/each
GENOTROPIN 4 UNIT 00013260694 $66.8095/each
GENOTROPIN 5 MG/ML 00013261681 $222.6949/each
GENOTROPIN 5 MG/ML 00013261694 $222.6949/each
GENOTROPIN 5 MG/ML 00013262681 $567.5796/each
GENVISC 850 10 MG/ML 50653000601 $101.0000/ml
GENVOYA 150-200-10 54569663300 $120.6047/tablet
GENVOYA 150-200-10 61958190101 $92.7692/tablet
GEODON FNL 20MG/1 00049120301 $45.8508/each
GEODON FNL 20MG/1 00049120310 $45.8490/each
GEODON FNL 20MG/1 00049392020 $45.8558/each
GEODON FNL 20MG/1 00049392083 $45.8490/each
GEREF 0.5 MG 44087400501 $13.4431/each
GEREF 1 MG 44087401001 $23.7552/each
GILENYA 0.5 MG 00078060715 $249.5484/capsule
GILOTRIF 20 MG 00597014130 $274.5439/tablet
GILOTRIF 30 MG 00597013730 $274.5439/tablet
GILOTRIF 40 MG 00597013830 $274.5439/tablet
GLASSIA 1 G/50 ML 00944288401 $0.5252/each
GLATIRAMER ACETATE 20 MG/ML 00378696032 $182.1554/ml
GLATIRAMER ACETATE 20 MG/ML 00378696093 $174.8620/ml
GLATIRAMER ACETATE 40 MG/ML 00378696112 $423.6319/ml
GLATIRAMER ACETATE 40 MG/ML 00378696132 $441.3005/ml
GLATOPA 20 MG/ML 00781323434 $174.8620/ml
GLEOSTINE 10 MG 58181304005 $70.2455/capsule Increase
GLEOSTINE 100 MG 58181304205 $775.6638/capsule Increase
GLEOSTINE 40 MG 58181304105 $280.9901/capsule Increase
GLEOSTINE 5 MG 58181304305 $42.4200/capsule Increase
GLIADEL 7.7-192.3 00075999508 $1260.4800/each
GLIADEL 7.7-192.3 24338005008 $3848.8865/each
GLIADEL 7.7-192.3 61379010001 $2447.4825/each
GRANIX 300MCG/0.5 63459091011 $504.7172/ml
GRANIX 300MCG/0.5 63459091015 $504.7233/ml
GRANIX 300MCG/0.5 63459091017 $605.1920/ml
GRANIX 300MCG/0.5 63459091036 $605.1920/ml
GRANIX 480MCG/0.8 63459091211 $504.8611/ml
Page 20 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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GRANIX 480MCG/0.8 63459091212 $504.8748/ml
GRANIX 480MCG/0.8 63459091215 $504.8548/ml
GRANIX 480MCG/0.8 63459091217 $602.3388/ml
GRANIX 480MCG/0.8 63459091236 $602.3388/ml
GRASTEK 2800 UNIT 00006422930 $9.8088/tablet Increase
GRASTEK 2800 UNIT 52709150101 $9.8092/tablet Add
GRASTEK 2800 UNIT 52709150103 $9.8088/tablet Add
H.P. ACTHAR 80 UNIT/ML 63004773101 $5794.5720/ml
H.P. ACTHAR 80 UNIT/ML 63004871001 $7349.1640/ml
HAEGARDA 2000 UNIT 63833082802 $1898.8000/each
HAEGARDA 3000 UNIT 63833082902 $2848.2000/each
HARVONI 90MG-400MG 61958180101 $1136.2500/tablet
H-BIG 00074839904 $31.8150/ml
H-BIG 59730039901 $135.3400/ml
H-BIG 59730039905 $105.3632/ml
H-BIG 59730039911 $270.6800/ml
H-BIG 59730839901 $135.3400/ml
H-BIG 59730839902 $270.6800/ml
HEALON GV 14MG/ML 00016031955 $211.1818/ml
HEALON GV 14MG/ML 00016031985 $166.3529/ml
HEALON5 23 MG/ML 00016031660 $126.2500/ml
HEPAGAM B >312/ML(5) 53270005101 $141.2687/ml
HEPAGAM B >312/ML(5) 53270005401 $141.2687/ml
HEPAGAM B >312/ML(5) 60492005101 $129.2800/ml
HEPAGAM B >312/ML(5) 60492005102 $129.2800/ml
HEPAGAM B >312/ML(5) 70504005102 $145.5067/ml Increase
HEPAGAM B >312/ML(5) 70504005402 $141.2687/ml
HEPAGAM B >312/ML 53270005201 $161.3980/ml
HEPAGAM B >312/ML 53270005301 $161.3980/ml
HEPAGAM B >312/ML 60492005201 $147.7024/ml
HEPAGAM B >312/ML 60492005202 $147.7024/ml
HEPAGAM B >312/ML 70504005202 $166.2359/ml Increase
HEPAGAM B >312/ML 70504005302 $161.3980/ml
HEPSERA 10 MG 61958050101 $44.5639/tablet
HERCEPTIN 150 MG 50242013201 $9.8910/mg
HERCEPTIN 440 MG 50242005656 $9.8914/mg
HERCEPTIN 440 MG 50242013468 $9.8910/mg
HETLIOZ 20 MG 43068022001 $449.0420/capsule
HEXALEN 50 MG 62856000110 $16.0590/capsule
HIZENTRA 1 G/5 ML 44206045101 $33.9360/ml
HIZENTRA 10 G/50 ML 44206045510 $33.9360/ml
HIZENTRA 2 G/10 ML 44206045202 $33.9360/ml
HIZENTRA 4 G/20 ML 44206045404 $33.9360/ml
HUMATROPE 12 MG 00002814801 $1377.0744/each
HUMATROPE 24 MG 00002814901 $2754.1488/each
HUMATROPE 5 MG 00002733501 $378.4975/each
HUMATROPE 5 MG 00002733511 $573.7810/each
HUMATROPE 5 MG 00002733916 $176.7500/each
HUMATROPE 5 MG 00002734901 $573.7810/each
HUMATROPE 6 MG 00002814701 $688.5372/each
HUMIRA PEDIATRIC CROHN'S 40MG/0.8ML 00074379903 $2242.8262/each
Page 21 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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HUMIRA PEDIATRIC CROHN'S 40MG/0.8ML 00074379906 $2242.8262/each
HUMIRA PEN CROHN-UC-HS STARTER 40MG/0.8ML 00074433906 $2242.8262/each
HUMIRA PEN PSORIASIS-UVEITIS 40MG/0.8ML 00074433907 $2242.8211/each
HUMIRA PEN 40MG/0.8ML 00074433902 $2242.8211/each
HUMIRA 10MG/0.2ML 00074634702 $2242.8211/each
HUMIRA 20MG/0.4ML 00074937402 $2242.8211/each
HUMIRA 40MG/0.8ML 00074379902 $2242.8211/each
HUMIRA 40MG/0.8ML 54868482200 $632.6217/each
HYALGAN 10 MG/ML 08024072416 $50.0708/ml
HYALGAN 10 MG/ML 08024072420 $65.6500/ml
HYALGAN 10 MG/ML 21695037402 $127.8121/ml
HYALGAN 10 MG/ML 89122072420 $95.9500/ml
HYCAMTIN 0.25 MG 00007420511 $101.4979/capsule
HYCAMTIN 0.25 MG 00078067201 $101.4979/capsule
HYCAMTIN 1 MG 00007420711 $405.9846/capsule
HYCAMTIN 1 MG 00078067301 $405.9846/capsule
HYMOVIS 24 MG/3 ML 89122049663 $146.7867/ml
HYPERHEP B S-D 110/0.5ML 13533063603 $178.6690/ml
HYPERHEP B S-D 220 UNIT/1 13533063601 $168.4579/ml
HYPERHEP B S-D 220 UNIT/1 13533063602 $168.4579/ml
HYPERHEP B S-D 220 UNIT/1 13533063610 $153.1557/ml
HYPERHEP B S-D 220/ML (5) 13533063605 $161.6465/ml
HYPERHEP B S-D 220/ML (5) 13533063650 $161.6535/ml
HYPERHEP 00026061601 $119.9880/ml
HYPERHEP 00192061601 $119.9880/ml
HYPERHEP 220/ML (5) 00026061605 $115.1400/ml
HYPERHEP 220/ML (5) 00192061605 $115.1400/ml
HYPERRAB S-D 150 UNIT/1 13533061802 $358.6106/ml
HYPERRAB S-D 150 UNIT/1 13533061810 $327.3592/ml
HYPERRAB S-D 150 UNIT/1 13533061811 $327.3725/ml
HYPERRAB S-D 150 UNIT/1 13533061820 $358.6231/ml
HYPERRAB S-D 300 UNIT/2 13533061803 $85.8211/ml
HYPERRHO S-D 1500 UNIT 13533063102 $80.2849/each
HYPERRHO S-D 1500 UNIT 13533063110 $76.2752/each
HYPERRHO S-D 1500 UNIT 13533063120 $80.2898/each
HYPERRHO S-D 250 UNIT 13533066106 $29.2395/each
HYPERRHO S-D 250 UNIT 13533066160 $30.9363/each
HYQVIA 10 G/100ML 00944251202 $17.7952/ml
HYQVIA 2.5G/25ML 00944251002 $17.7952/ml
HYQVIA 20 G/200ML 00944251302 $17.7952/ml
HYQVIA 30 G/300ML 00944251402 $17.7952/ml
HYQVIA 5 G/50 ML 00944251102 $17.7952/ml
IBANDRONATE SODIUM 3 MG/3 ML 62756021840 $141.7367/ml
IBRANCE 100 MG 00069018821 $527.2705/capsule
IBRANCE 125 MG 00069018921 $527.2705/capsule
IBRANCE 75 MG 00069018721 $527.2705/capsule
ICLUSIG 15 MG 76189053530 $557.5537/tablet
ICLUSIG 45 MG 76189053430 $557.5537/tablet
IDHIFA 100 MG 59572071030 $837.3573/tablet
IDHIFA 50 MG 59572070530 $837.3573/tablet
IFEX/MESNEX 1G-1G 00015355410 $2280.9032/each
Page 22 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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IFEX/MESNEX 1G-1G 00015355610 $943.9460/each
IFEX/MESNEX 3G-1G 00015356410 $1368.4692/each
IFOSFAMIDE 1 G/20 ML 00703342711 $1.8554/ml
IFOSFAMIDE 1 G/20 ML 63323017420 $2.9315/ml
IFOSFAMIDE 1 G/20 ML 67457042920 $2.9290/ml
IFOSFAMIDE 3 G/60 ML 00703342911 $1.8103/ml
IFOSFAMIDE 3 G/60 ML 63323017460 $2.9315/ml
IFOSFAMIDE 3 G/60 ML 67457044360 $2.9290/ml
IFOSFAMIDE-MESNA 1G-1G 00703410048 $636.3000/each
IFOSFAMIDE-MESNA 1G-1G 00703410058 $1010.0000/each
IFOSFAMIDE-MESNA 3G-1G 00703410068 $945.3600/each
ILARIS 150 MG/ML 00078073461 $16215.5601/ml
ILARIS 180 MG/1.2 00078058261 $16215.5601/each
ILUVIEN 0.19 MG 68611019002 $8888.0000/each
IMBRUVICA 140 MG 57962014009 $124.5994/capsule
IMBRUVICA 140 MG 57962014012 $124.5993/capsule
IMFINZI 120 MG/2.4 00310450012 $351.3622/ml
IMFINZI 500MG/10ML 00310461150 $351.3598/ml
IMLYGIC 10EXP6/ML 55513007801 $47.0559/ml
IMLYGIC 10EXP8/ML 55513007901 $4705.4890/ml
IMMUGLOBIN 15 %-18 % 00281777016 $0.7929/ml
IMOGAM RABIES-HT 150 UNIT/1 49281019010 $334.7634/ml
IMOGAM RABIES-HT 150 UNIT/1 49281019020 $364.8827/ml
IMOGAM RABIES-HT 150 UNIT/1 49281019058 $364.8980/ml
IMPAVIDO 50 MG 69051030001 $577.1657/capsule
IMURAN 100 MG 00081059871 $53.0149/each
IMURAN 100 MG 60976059871 $53.0149/each
IMURAN 100 MG 65483055101 $53.0149/each
INCRELEX 10 MG/ML 15054104005 $933.0304/ml
INFED 100 MG/2ML 00364301247 $12.1478/ml
INFED 100 MG/2ML 52544093102 $12.7553/ml
INFED 100 MG/2ML 52544093107 $12.7560/ml
INFED 100 MG/2ML 54868431900 $13.9040/ml
INFERGEN 15MCG/.5ML 00187200601 $208.5684/ml
INFERGEN 15MCG/.5ML 00187200605 $208.5684/ml
INFERGEN 15MCG/.5ML 64116003124 $118.8534/ml
INFERGEN 15MCG/.5ML 66435020115 $292.5581/ml
INFERGEN 15MCG/.5ML 66435020196 $292.5581/ml
INFERGEN 9MCG/0.3ML 00187200702 $347.6139/ml
INFERGEN 9MCG/0.3ML 00187200706 $347.6139/ml
INFERGEN 9MCG/0.3ML 64116003924 $143.7791/ml
INFERGEN 9MCG/0.3ML 66435020195 $487.5943/ml
INFERGEN 9MCG/0.3ML 66435020199 $487.5775/ml
INFERGEN 9MCG/0.3ML 66435020209 $487.5968/ml
INFERGEN 9MCG/0.3ML 66435020295 $487.5968/ml
INFLECTRA 100 MG 00069080901 $955.7428/each
INGREZZA 40 MG 70370104001 $177.5917/capsule
INGREZZA 80 MG 70370108001 $209.5750/capsule Add
INLYTA 1 MG 00069014501 $76.7613/tablet
INLYTA 5 MG 00069015111 $230.2839/tablet
INNOHEP 20000/ML 00056034208 $73.3008/ml
Page 23 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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INNOHEP 20000/ML 00056034253 $73.3018/ml
INNOHEP 20000/ML 50222034208 $88.3750/ml
INNOHEP 20000/ML 50222034253 $88.3750/ml
INNOHEP 20000/ML 54653034208 $73.3008/ml
INNOHEP 20000/ML 54653034253 $73.3018/ml
INTELENCE 100 MG 54569610200 $8.5032/tablet
INTELENCE 100 MG 54868586400 $7.4042/tablet
INTELENCE 100 MG 59676057001 $9.8990/tablet
INTELENCE 200 MG 54569623000 $22.1082/tablet
INTELENCE 200 MG 59676057101 $19.7990/tablet
INTELENCE 25 MG 59676057201 $2.4745/tablet
INTRON A 10MM UNIT 00085057106 $95.1454/each
INTRON A 10MM UNIT 00085435001 $282.3960/each
INTRON A 10MM/ML 00085113301 $283.9836/ml
INTRON A 18MM UNIT 00085068901 $159.1053/each
INTRON A 18MM UNIT 00085435101 $508.3128/each
INTRON A 25MM UNIT 00085028502 $305.5133/each
INTRON A 50MM UNIT 00085435201 $1411.9800/each
INTRON A 50MM UNIT 54868334100 $799.3541/each
INTRON A 6MMUNIT/ML 00085095301 $57.0852/ml
INTRON A 6MMUNIT/ML 00085116801 $172.1837/ml
INVEGA SUSTENNA 117MG/0.75 50458056201 $1605.7519/ml
INVEGA SUSTENNA 156 MG/ML 50458056301 $1605.8293/ml
INVEGA SUSTENNA 234MG/1.5 50458056401 $1605.7855/ml
INVEGA SUSTENNA 39MG/0.25 50458056001 $1605.6576/ml
INVEGA SUSTENNA 78MG/0.5ML 50458056101 $1605.7384/ml
INVEGA TRINZA 273MG/.875 50458060601 $2752.6944/ml
INVEGA TRINZA 410/1.315 50458060701 $2747.4842/ml
INVEGA TRINZA 546MG/1.75 50458060801 $2752.8502/ml
INVEGA TRINZA 819/2.625 50458060901 $2752.7752/ml
INVERSINE 2.5 MG 17205062601 $4.3935/tablet
INVIRASE 200 MG 00004024515 $4.3990/capsule
INVIRASE 200 MG 54868369900 $2.3566/capsule
INVIRASE 200 MG 54868369901 $2.4655/capsule
INVIRASE 200 MG 54868369902 $2.6449/capsule
INVIRASE 500 MG 00004024451 $10.1146/tablet
INVIRASE 500 MG 54569566400 $10.2264/tablet
IPRIVASK 15 MG 00187001110 $227.2500/each
IPRIVASK 15 MG 51292011112 $151.5060/each
IPRIVASK 15 MG 83055011112 $151.5000/each
IRESSA 250 MG 00310048230 $255.7926/tablet
IRINOTECAN HCL 500MG/25ML 61703034936 $5.8588/ml
ISENTRESS HD 600 MG 00006308001 $23.3916/tablet
ISENTRESS 100 MG 00006047761 $5.8479/tablet
ISENTRESS 100 MG 00006360301 $5.8498/each
ISENTRESS 100 MG 00006360360 $5.8479/each
ISENTRESS 25 MG 00006047361 $1.4620/tablet
ISENTRESS 400 MG 00006022761 $23.3916/tablet
ISENTRESS 400 MG 54569603400 $30.4103/tablet
ISENTRESS 400 MG 54569603401 $23.3929/tablet
ISENTRESS 400 MG 54868011700 $24.1627/tablet
Page 24 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ISENTRESS 400 MG 66336021406 $21.5461/tablet
ISTODAX 10 MG/2 ML 46026098301 $2780.1267/each
ISTODAX 10 MG/2 ML 59572098301 $2956.4821/each
ISTODAX 10 MG/2 ML 59572098401 $3230.6365/each
IVEEGAM EN 5 G 64193025050 $412.0800/each
IXEMPRA 15 MG 70020191001 $1157.7832/each
IXEMPRA 45 MG 00015191113 $3473.3395/each
IXEMPRA 45 MG 70020191101 $3473.3395/each
JADENU SPRINKLE 180 MG 00078071315 $71.8662/each
JADENU SPRINKLE 180 MG 00078071319 $71.8615/each
JADENU SPRINKLE 360 MG 00078072015 $143.7297/each
JADENU SPRINKLE 360 MG 00078072019 $143.7331/each
JADENU SPRINKLE 90 MG 00078072715 $35.9338/each
JADENU SPRINKLE 90 MG 00078072719 $35.9358/each
JADENU 180 MG 00078065515 $71.8662/tablet
JADENU 360 MG 00078065615 $143.7297/tablet
JADENU 90 MG 00078065415 $35.9338/tablet
JAKAFI 10 MG 50881001060 $194.3745/tablet
JAKAFI 15 MG 50881001560 $194.3745/tablet
JAKAFI 20 MG 50881002060 $194.3745/tablet
JAKAFI 25 MG 50881002560 $194.3745/tablet
JAKAFI 5 MG 50881000560 $194.3745/tablet
JETREA 0.125/0.1 24856000201 $14224.1667/ml
JETREA 0.5 MG/0.2 24856000100 $19947.5000/ml
JEVTANA FDN10MG/ML 00024582411 $6856.2032/ml
JUXTAPID 10 MG 76431011001 $1213.6593/capsule
JUXTAPID 20 MG 76431012001 $1213.6593/capsule
JUXTAPID 30 MG 76431013001 $1213.6593/capsule
JUXTAPID 40 MG 76431014001 $1213.6593/capsule
JUXTAPID 5 MG 76431010501 $1213.6593/capsule
JUXTAPID 60 MG 76431016001 $1213.6593/capsule
KADCYLA 100 MG 50242008801 $2929.2525/each
KADCYLA 160 MG 50242008701 $4686.8040/each
KALBITOR 10MG/ML(1) 47783010101 $4641.3069/ml
KALETRA 100MG-25MG 00074052260 $4.0698/tablet
KALETRA 100MG-25MG 35356011160 $4.5298/tablet
KALETRA 100MG-25MG 52959096812 $5.0292/tablet
KALETRA 200MG-50MG 00074679922 $8.1396/tablet
KALETRA 200MG-50MG 21695036212 $14.4737/tablet
KALETRA 200MG-50MG 35356011201 $13.6187/tablet
KALETRA 200MG-50MG 35356011230 $13.6221/tablet
KALETRA 200MG-50MG 54569575200 $9.4364/tablet
KALETRA 200MG-50MG 54569575201 $6.4727/tablet
KALETRA 200MG-50MG 54569575202 $6.4727/tablet
KALETRA 200MG-50MG 54868556600 $9.4287/tablet
KALETRA 200MG-50MG 55045348201 $6.4558/tablet
KALETRA 200MG-50MG 55289094712 $11.6120/tablet
KALETRA 200MG-50MG 68071074812 $6.4636/tablet
KALETRA 400-100/5 00074395646 $3.0523/ml
KALETRA 400-100/5 54569552500 $3.1553/ml
KALYDECO 150 MG 51167020001 $430.9838/tablet
Page 25 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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KALYDECO 50 MG 51167030001 $430.9838/each
KALYDECO 75 MG 51167040001 $430.9838/each
KANUMA 20 MG/10ML 25682000701 $1010.0000/ml
KCENTRA 1000 UNIT 63833038702 $2.3331/each
KCENTRA 500 UNIT 63833038602 $2.3331/each
KEPIVANCE 6.25 MG 55513052001 $1388.8050/each
KEPIVANCE 6.25 MG 55513052006 $1388.7500/each
KEPIVANCE 6.25 MG 66658011201 $2320.6511/each
KEPIVANCE 6.25 MG 66658011203 $2320.5491/each
KEPIVANCE 6.25 MG 66658011206 $2320.5508/each
KEVEYIS 50 MG 51672417701 $137.8705/tablet
KEVEYIS 50 MG 71090000101 $151.5136/tablet
KEVZARA 150MG/1.14 00024590801 $1328.9474/ml
KEVZARA 200MG/1.14 00024591001 $1328.9474/ml
KEYTRUDA 100 MG/4ML 00006302601 $1156.7273/ml
KEYTRUDA 100 MG/4ML 00006302602 $1156.6823/ml
KEYTRUDA 50 MG 00006302901 $2212.3579/each
KEYTRUDA 50 MG 00006302902 $2212.2737/each
KINERET 100MG/0.67 66658023401 $196.0606/ml
KINERET 100MG/0.67 66658023407 $198.9980/ml
KINERET 100MG/0.67 66658023428 $196.0574/ml
KISQALI FEMARA CO-PACK 200-2.5 MG 00078090961 $90.2816/tablet
KISQALI FEMARA CO-PACK 400-2.5 MG 00078091661 $126.3943/tablet
KISQALI FEMARA CO-PACK 600-2.5 MG 00078092361 $121.5330/tablet
KISQALI 200 MG/DAY 00078086001 $210.6571/tablet
KISQALI 400 MG/DAY 00078086714 $210.6571/tablet
KISQALI 400 MG/DAY 00078086742 $210.6571/tablet
KISQALI 600 MG/DAY 00078087421 $175.5476/tablet
KISQALI 600 MG/DAY 00078087463 $175.5476/tablet
KITABIS PAK 300 MG/5ML 24492085056 $16.2321/ml
KORLYM 300 MG 76346007301 $436.3200/tablet
KORLYM 300 MG 76346007302 $436.3200/tablet
KRYSTEXXA 8 MG/ML 54396080101 $14140.0000/ml
KRYSTEXXA 8 MG/ML 60809080101 $18769.0522/ml
KRYSTEXXA 8 MG/ML 75987008010 $18769.0522/ml
KUVAN 100 MG 68135030002 $35.5183/tablet
KUVAN 100 MG 68135030111 $35.5197/each
KUVAN 100 MG 68135030122 $35.5183/each
KUVAN 500 MG 68135048210 $177.5987/each
KUVAN 500 MG 68135048211 $177.5917/each
KYLEENA 17.5MCG/24 50419042401 $866.9133/each
KYMRIAH 00078084619 $479750.0000/each
KYNAMRO 200 MG/ML 70688050201 $7687.1403/ml
KYNAMRO 200 MG/ML 70688050202 $7687.1403/ml
KYPROLIS 30 MG 76075010201 $1085.1238/each Increase
KYPROLIS 60 MG 76075010101 $2170.2375/each Increase
LAMIVUDINE 10 MG/ML 10135060571 $0.4772/ml
LAMIVUDINE 10 MG/ML 54838056670 $0.3499/ml
LAMIVUDINE 10 MG/ML 57237027424 $0.3367/ml
LAMIVUDINE 10 MG/ML 65862005524 $0.3499/ml
LARTRUVO 190MG/19ML 00002719001 $47.6720/ml
Page 26 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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LARTRUVO 500MG/50ML 00002892601 $47.6720/ml
LEMTRADA 12MG/1.2ML 58468020001 $17901.0717/ml
LENVIMA 10 MG/DAY 62856071005 $489.0077/capsule
LENVIMA 10 MG/DAY 62856071030 $489.0083/capsule
LENVIMA 14 MG/DAY 62856071405 $244.5038/capsule
LENVIMA 14 MG/DAY 62856071430 $244.5042/capsule
LENVIMA 18 MG/DAY 62856071805 $173.3833/capsule
LENVIMA 18 MG/DAY 62856071830 $173.3833/capsule
LENVIMA 20 MG/DAY 62856072005 $260.0750/capsule
LENVIMA 20 MG/DAY 62856072030 $260.0750/capsule
LENVIMA 24 MG/DAY 62856072405 $173.3833/capsule
LENVIMA 24 MG/DAY 62856072430 $173.3833/capsule
LENVIMA 8 MG/DAY 62856070805 $244.5038/capsule
LENVIMA 8 MG/DAY 62856070830 $244.5042/capsule
LETAIRIS 10 MG 61958080201 $311.5719/tablet
LETAIRIS 10 MG 61958080203 $291.4597/tablet
LETAIRIS 10 MG 61958080205 $311.5709/tablet
LETAIRIS 5 MG 61958080101 $311.5719/tablet
LETAIRIS 5 MG 61958080103 $291.4597/tablet
LETAIRIS 5 MG 61958080105 $311.5709/tablet
LEUCOVORIN CALCIUM 10 MG/ML 00074454102 $0.7070/ml
LEUCOVORIN CALCIUM 10 MG/ML 00074454104 $0.6868/ml
LEUCOVORIN CALCIUM 10 MG/ML 00517860525 $0.6565/ml
LEUCOVORIN CALCIUM 10 MG 00005452564 $5.6534/tablet
LEUCOVORIN CALCIUM 10 MG 00005452583 $5.6653/tablet
LEUCOVORIN CALCIUM 10 MG 00005452590 $5.6598/tablet
LEUCOVORIN CALCIUM 10 MG 00054449705 $6.2931/tablet
LEUCOVORIN CALCIUM 10 MG 00054449710 $5.5946/tablet
LEUCOVORIN CALCIUM 100 MG 00074514001 $5.0500/each
LEUCOVORIN CALCIUM 100 MG 00143955401 $16.1600/each
LEUCOVORIN CALCIUM 100 MG 00703514001 $20.2000/each
LEUCOVORIN CALCIUM 100 MG 25021081430 $20.2000/each
LEUCOVORIN CALCIUM 100 MG 25021081467 $8.8880/each
LEUCOVORIN CALCIUM 100 MG 51309024220 $32.2695/each
LEUCOVORIN CALCIUM 100 MG 58406062235 $31.8453/each
LEUCOVORIN CALCIUM 100 MG 68001028528 $20.2008/each
LEUCOVORIN CALCIUM 100 MG 68001028536 $20.2000/each
LEUCOVORIN CALCIUM 15 MG 00054449810 $5.3480/tablet
LEUCOVORIN CALCIUM 15 MG 51309074302 $13.2781/tablet
LEUCOVORIN CALCIUM 15 MG 51309074312 $12.7561/tablet
LEUCOVORIN CALCIUM 15 MG 51309074324 $13.2676/tablet
LEUCOVORIN CALCIUM 15 MG 54868591500 $13.4882/tablet
LEUCOVORIN CALCIUM 15 MG 58406062668 $6.7712/tablet
LEUCOVORIN CALCIUM 200 MG 00143955301 $24.2400/each
LEUCOVORIN CALCIUM 200 MG 25021081530 $40.4000/each
LEUCOVORIN CALCIUM 200 MG 25021081567 $15.5540/each
LEUCOVORIN CALCIUM 200 MG 61703041050 $6.4640/each
LEUCOVORIN CALCIUM 200 MG 63323071050 $21.2706/each
LEUCOVORIN CALCIUM 200 MG 63323071059 $21.2706/each
LEUCOVORIN CALCIUM 200 MG 68001028529 $40.4016/each
LEUCOVORIN CALCIUM 200 MG 68001028537 $40.4000/each
Page 27 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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LEUCOVORIN CALCIUM 350 MG 00074514501 $6.9690/each
LEUCOVORIN CALCIUM 350 MG 00143955201 $26.2600/each
LEUCOVORIN CALCIUM 350 MG 00703514501 $19.1395/each
LEUCOVORIN CALCIUM 350 MG 00703514591 $19.1395/each
LEUCOVORIN CALCIUM 350 MG 25021081630 $70.7000/each
LEUCOVORIN CALCIUM 350 MG 25021081667 $17.7760/each
LEUCOVORIN CALCIUM 350 MG 58406062333 $111.4535/each
LEUCOVORIN CALCIUM 350 MG 66479024725 $15.1500/each
LEUCOVORIN CALCIUM 350 MG 68001028638 $70.7000/each
LEUCOVORIN CALCIUM 350 MG 68001028639 $70.7028/each
LEUCOVORIN CALCIUM 50 MG 00143955501 $10.1000/each
LEUCOVORIN CALCIUM 50 MG 00469137030 $71.7100/each
LEUCOVORIN CALCIUM 50 MG 00703513001 $16.6145/each
LEUCOVORIN CALCIUM 50 MG 25021081310 $10.1000/each
LEUCOVORIN CALCIUM 50 MG 25021081366 $5.3328/each
LEUCOVORIN CALCIUM 50 MG 51309024110 $16.4125/each
LEUCOVORIN CALCIUM 50 MG 58406062137 $17.3922/each
LEUCOVORIN CALCIUM 50 MG 68001028522 $10.1004/each
LEUCOVORIN CALCIUM 50 MG 68001028540 $10.1000/each
LEUCOVORIN CALCIUM 500 MG 63323071100 $79.4971/each
LEUKERAN 2 MG 00081063535 $2.0707/tablet
LEUKERAN 2 MG 54868112600 $3.8925/tablet
LEUKERAN 2 MG 54868112601 $4.1485/tablet
LEUKERAN 2 MG 54868112602 $4.2952/tablet
LEUKERAN 2 MG 54868112603 $4.1630/tablet
LEUKERAN 2 MG 54868112604 $4.5149/tablet
LEUKERAN 2 MG 54868112605 $3.8650/tablet
LEUKERAN 2 MG 76388063525 $24.5709/tablet
LEUKINE 250 MCG 00024584301 $249.9916/each
LEUKINE 250 MCG 00024584305 $249.9811/each
LEUKINE 250 MCG 00702000201 $123.5856/each
LEUKINE 250 MCG 58406000201 $153.7422/each
LEUKINE 250 MCG 58406000233 $153.7422/each
LEUKINE 500 MCG/ML 50419005014 $301.6769/ml
LEUKINE 500 MCG/ML 50419005030 $325.9573/ml
LEUKINE 500 MCG/ML 50419059501 $319.9175/ml
LEUKINE 500 MCG/ML 50419059505 $301.6769/ml
LEUKINE 500 MCG/ML 54868318800 $355.2378/ml
LEUKINE 500 MCG/ML 58406005014 $273.9524/ml
LEUKINE 500 MCG/ML 58406005030 $273.9524/ml
LEUKINE 500 MCG/ML 58468018101 $371.7536/ml
LEUKINE 500 MCG/ML 58468018102 $371.7536/ml
LEUPROLIDE ACETATE 1 MG/0.2ML 00703401411 $111.1938/ml
LEUPROLIDE ACETATE 1 MG/0.2ML 00703401419 $111.1938/ml
LEUPROLIDE ACETATE 1 MG/0.2ML 00703402419 $111.1938/ml
LEVOLEUCOVORIN CALCIUM 10 MG/ML 00781320194 $46.0560/ml
LEVOLEUCOVORIN CALCIUM 10 MG/ML 67457060020 $41.4042/ml
LEVOLEUCOVORIN CALCIUM 10 MG/ML 67457060130 $41.4043/ml
LEVOLEUCOVORIN CALCIUM 175 MG 00591413054 $326.2300/each
LEVOLEUCOVORIN CALCIUM 50 MG 00143955801 $184.2240/each
LEVOLEUCOVORIN CALCIUM 50 MG 45963076257 $128.8760/each
Page 28 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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LEVOLEUCOVORIN CALCIUM 50 MG 70121109901 $184.2240/each
LEXIVA 50 MG/ML 49702020853 $0.7968/ml
LEXIVA 700 MG 35356006706 $35.9238/tablet
LEXIVA 700 MG 35356006760 $31.9846/tablet
LEXIVA 700 MG 49702020718 $19.5026/tablet
LEXIVA 700 MG 54569555000 $21.9650/tablet
LILETTA 19.5MCG/24 00023585801 $691.2238/each
LILETTA 19.5MCG/24 52544003554 $691.2238/each
LINEZOLID 100 MG/5ML 00054031950 $4.5234/ml
LINEZOLID 100 MG/5ML 59762130801 $4.4171/ml
LINEZOLID 600MG/300 00409488201 $0.2104/ml
LINEZOLID 600MG/300 00703906031 $0.4151/ml
LINEZOLID 600MG/300 00703906033 $0.2104/ml
LINEZOLID 600MG/300 00781343346 $0.2192/ml
LINEZOLID 600MG/300 00781343395 $0.2104/ml
LINEZOLID 600MG/300 55150024251 $0.2070/ml
LINEZOLID 600MG/300 57664068331 $0.2104/ml
LINEZOLID 600MG/300 57664068357 $0.2104/ml
LINEZOLID 600MG/300 63323071313 $0.2626/ml
LIORESAL INTRATHECAL 2000MCG/ML 58281056102 $43.4300/ml
LIORESAL INTRATHECAL 2000MCG/ML 58281056301 $43.4300/ml
LIORESAL INTRATHECAL 2000MCG/ML 58281056302 $43.4300/ml
LIORESAL INTRATHECAL 2000MCG/ML 70257056301 $43.4300/ml
LIORESAL INTRATHECAL 2000MCG/ML 70257056302 $43.4300/ml
LIORESAL INTRATHECAL 50 MCG/ML 58281056201 $73.7300/ml
LIORESAL INTRATHECAL 50 MCG/ML 70257056255 $30.3000/ml
LIORESAL INTRATHECAL 500 MCG/ML 58281056001 $10.8575/ml
LIORESAL INTRATHECAL 500 MCG/ML 58281056002 $10.8575/ml
LIPODOX 50 2 MG/ML 47335008350 $96.8913/ml
LIPODOX 2 MG/ML 47335008250 $96.8893/ml
LONSURF 15-6.14 MG 64842102501 $150.2128/tablet
LONSURF 15-6.14 MG 64842102502 $150.2128/tablet
LONSURF 15-6.14 MG 64842102503 $150.2128/tablet
LONSURF 20-8.19 MG 64842102001 $200.2840/tablet
LONSURF 20-8.19 MG 64842102002 $200.2840/tablet
LONSURF 20-8.19 MG 64842102003 $200.2837/tablet
LOPINAVIR-RITONAVIR 400-100/5 00527194748 $2.4419/ml
LOVENOX 100 MG/ML 00075062300 $83.6149/ml
LOVENOX 100 MG/ML 00075802001 $83.6178/ml
LOVENOX 100 MG/ML 00075802010 $83.6149/ml
LOVENOX 100 MG/ML 54868583500 $87.2464/ml
LOVENOX 120MG/.8ML 00075291201 $125.4635/ml
LOVENOX 120MG/.8ML 00075802201 $125.4680/ml
LOVENOX 120MG/.8ML 00075802210 $125.4635/ml
LOVENOX 120MG/.8ML 54868583700 $130.8707/ml
LOVENOX 150 MG/ML 00075291501 $125.4652/ml
LOVENOX 150 MG/ML 00075802501 $125.4705/ml
LOVENOX 150 MG/ML 00075802510 $125.4652/ml
LOVENOX 300MG/3ML 00075062603 $83.5203/ml
LOVENOX 300MG/3ML 00075803001 $83.5203/ml
LOVENOX 30MG/0.3ML 00075062430 $83.5203/ml
Page 29 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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LOVENOX 30MG/0.3ML 00075801301 $83.5247/ml
LOVENOX 30MG/0.3ML 00075801310 $83.5203/ml
LOVENOX 30MG/0.3ML 35356048110 $127.9496/ml
LOVENOX 30MG/0.3ML 55154402405 $83.5203/ml
LOVENOX 40MG/0.4ML 00075062040 $83.5169/ml
LOVENOX 40MG/0.4ML 00075801401 $83.5198/ml
LOVENOX 40MG/0.4ML 00075801410 $83.5169/ml
LOVENOX 40MG/0.4ML 54868544000 $94.7544/ml
LOVENOX 40MG/0.4ML 54868544001 $86.0112/ml
LOVENOX 60MG/0.6ML 00075062160 $83.6162/ml
LOVENOX 60MG/0.6ML 00075801601 $83.6201/ml
LOVENOX 60MG/0.6ML 00075801610 $83.6162/ml
LOVENOX 60MG/0.6ML 35356001910 $107.0390/ml
LOVENOX 60MG/0.6ML 54868558700 $89.1781/ml
LOVENOX 60MG/0.6ML 54868558701 $79.2615/ml
LOVENOX 80MG/0.8ML 00075062280 $83.6166/ml
LOVENOX 80MG/0.8ML 00075801801 $83.6197/ml
LOVENOX 80MG/0.8ML 00075801810 $83.6166/ml
LOVENOX 80MG/0.8ML 35356002010 $106.9685/ml
LOVENOX 80MG/0.8ML 54868511200 $87.2896/ml
LOVENOX 80MG/0.8ML 54868511201 $94.1126/ml
LUCENTIS 0.3MG/0.05 50242008201 $23634.0000/ml
LUCENTIS 0.3MG/0.05 50242008202 $23634.0000/ml
LUCENTIS 0.5MG/0.05 50242008001 $39390.0000/ml
LUCENTIS 0.5MG/0.05 50242008002 $39390.0000/ml
LUCENTIS 0.5MG/0.05 50242008003 $39390.0000/ml
LUMIZYME 50 MG 58468016001 $761.5400/each
LUMIZYME 50 MG 58468016002 $761.5400/each
LUPANETA PACK 11.25-5 MG 00074105305 $3391.3477/each
LUPANETA PACK 3.75MG-5MG 00074105205 $1130.4324/each
LUPRON DEPOT 11.25 MG 00074366303 $3391.3477/each
LUPRON DEPOT 22.5 MG 00074334603 $4041.2726/each
LUPRON DEPOT-3 MONTH 11.25 MG 00300362001 $1176.0339/each
LUPRON DEPOT 3.75 MG 00074364103 $1130.4324/each
LUPRON DEPOT 30 MG 00074368303 $5388.3803/each
LUPRON DEPOT 30 MG 54868556800 $2703.9612/each
LUPRON DEPOT 45 MG 00074347303 $8082.6765/each
LUPRON DEPOT 7.5 MG 00074364203 $1347.0976/each
LUPRON DEPOT-PED 11.25 MG 00074228203 $2468.9248/each
LUPRON DEPOT-PED 11.25 MG 00074377903 $7406.7845/each
LUPRON DEPOT-PED 11.25 MG 00300227001 $1206.1420/each
LUPRON DEPOT-PED 15 MG 00074244003 $2719.2634/each
LUPRON DEPOT-PED 15 MG 00300243701 $873.6500/each
LUPRON DEPOT-PED 30 MG 00074969403 $8157.8104/each
LUPRON DEPOT-PED 7.5 MG 00074210803 $1359.9145/each
LUPRON DEPOT-PED 7.5 MG 00300210601 $436.8250/each
LUPRON 1 MG/0.2ML 00300362624 $154.4867/ml
LYNPARZA 100 MG 00310066812 $113.4735/tablet
LYNPARZA 100 MG 00310066860 $113.4735/tablet
LYNPARZA 150 MG 00310067912 $113.4735/tablet
LYNPARZA 150 MG 00310067960 $113.4735/tablet
Page 30 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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LYNPARZA 50 MG 00310065758 $28.3684/capsule
LYSODREN 500 MG 00015308060 $4.8475/tablet
MACUGEN 0.3 MG/90 68782000101 $11166.1111/ml
MACUGEN 0.3 MG/90 68782000102 $8136.1111/ml
MAKENA 250 MG/ML 64011024301 $771.9935/ml
MAKENA 250 MG/ML 64011024702 $771.9935/ml
MARQIBO FNL 5MG/31 20536032201 $13373.6625/each
MATULANE 50 MG 00004005301 $46.8640/capsule
MATULANE 50 MG 54482005301 $82.4221/capsule
MATULANE 50 MG 54868136600 $51.4897/capsule
MAVYRET 100MG-40MG 00074262528 $158.7143/tablet
MEKINIST 0.5 MG 00078066615 $98.8063/tablet
MEKINIST 2 MG 00078066815 $352.7671/tablet
MELPHALAN HCL 50 MG 25021022160 $2020.0000/each
MELPHALAN HCL 50 MG 42023014901 $1160.4900/each
MELPHALAN HCL 50 MG 45963068602 $1659.5310/each
MELPHALAN HCL 50 MG 67457019501 $1659.5310/each
MELPHALAN HCL 50 MG 67457021501 $1659.5310/each
MELPHALAN HCL 50 MG 67457057901 $1659.5310/each
MELPHALAN 2 MG 47781020050 $9.2510/tablet
MESNA 100 MG/ML 00703480501 $3.0300/ml
MESNA 100 MG/ML 00703480503 $3.0300/ml
MESNA 100 MG/ML 10019095301 $3.3330/ml
MESNA 100 MG/ML 10019095302 $3.3330/ml
MESNA 100 MG/ML 10019095362 $3.3331/ml
MESNA 100 MG/ML 25021020110 $2.0200/ml
MESNA 100 MG/ML 25021020111 $2.0200/ml
MESNA 100 MG/ML 25021020166 $1.2120/ml
MESNA 100 MG/ML 25021020167 $1.2120/ml
MESNA 100 MG/ML 25021020168 $1.2726/ml
MESNA 100 MG/ML 25021020169 $1.2726/ml
MESNA 100 MG/ML 55390004501 $4.7472/ml
MESNA 100 MG/ML 63323073310 $6.6963/ml
MESNA 100 MG/ML 63323073311 $6.6963/ml
MESNA 100 MG/ML 63323073312 $10.7010/ml
MESNEX 100 MG/ML 00015356310 $17.7164/ml
MESNEX 100 MG/ML 00015356311 $17.7164/ml
MESNEX 100 MG/ML 00338130501 $3.3330/ml
MESNEX 100 MG/ML 00338130503 $3.3330/ml
MESNEX 400 MG 00015356512 $74.9420/tablet
MESNEX 400 MG 67108356509 $79.3769/tablet
METHOTREXATE 1 G 63323012250 $64.2360/each
METHOTREXATE 1 G 63323012259 $64.2360/each
METHOTREXATE 1 G 66479013929 $43.4300/each
METHOXSALEN 10 MG 45963032550 $67.4262/capsule
METHOXSALEN 10 MG 64380075216 $67.4262/capsule
METHOXSALEN 10 MG 68682006510 $67.4260/capsule
MIACALCIN 200/ML 54766014923 $1153.1624/ml
MIACALCIN 200/ML 67457067502 $1254.6422/ml
MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780600 $55.8631/each
MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780601 $55.8631/each
Page 31 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780605 $55.8631/each
MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT 00562780625 $55.8631/each
MICRHOGAM 250 UNIT 00562780801 $47.6655/each
MICRHOGAM 250 UNIT 00562780806 $47.6621/each
MICRHOGAM 250 UNIT 00562780826 $47.6614/each
MIRCERA 100MCG/0.3 00004040309 $606.0240/ml
MIRCERA 100MCG/0.3 59353040309 $925.8333/ml Increase
MIRCERA 150MCG/0.3 59353040409 $1388.7500/ml Increase
MIRCERA 200MCG/0.3 00004040509 $1212.0480/ml
MIRCERA 200MCG/0.3 59353040509 $1851.6667/ml Increase
MIRCERA 30 MCG/0.3 59353040009 $277.7500/ml Increase
MIRCERA 50 MCG/0.3 00004040109 $303.0120/ml
MIRCERA 50 MCG/0.3 59353040109 $462.9167/ml Increase
MIRCERA 75 MCG/0.3 00004040209 $454.5180/ml
MIRCERA 75 MCG/0.3 59353040209 $694.3750/ml Increase
MIRENA 20MCG/24HR 50419042101 $866.9133/each
MIRENA 20MCG/24HR 50419042301 $866.9133/each
MODERIBA 200-400 MG 00074322456 $13.1744/tablet
MODERIBA 400-400 MG 00074323956 $13.8677/tablet
MODERIBA 600-400 MG 00074327156 $17.3348/tablet
MODERIBA 600-600 MG 00074328256 $20.8015/tablet
MONOVISC 88 MG/4 ML 59676082001 $326.9875/ml
MOZOBIL 24MG/1.2ML 00024586201 $6114.4138/ml
MUSTARGEN 10 MG 00006775331 $140.4380/each
MUSTARGEN 10 MG 55292091151 $284.3680/each
MYCOPHENOLATE MOFETIL 500 MG 17478042240 $74.7400/each
MYCOPHENOLATE MOFETIL 500 MG 42023017204 $99.9900/each
MYLERAN 2 MG 00081071325 $2.3925/tablet
MYLERAN 2 MG 76388071325 $23.6574/tablet
MYLOTARG 4.5 MG 00008451001 $8282.0000/each
MYOBLOC 10000/2ML 10454071210 $586.8100/ml
MYOBLOC 2500/0.5ML 10454071010 $586.8100/ml
MYOBLOC 5000/ML 10454071110 $586.8100/ml
MYOBLOC 5000/ML 59075071110 $415.1100/ml
MYOZYME 50 MG 58468015001 $984.7500/each
NABI-HB >1560/5ML 49999042505 $146.7925/ml
NABI-HB >1560/5ML 54569473900 $135.4194/ml
NABI-HB >1560/5ML 59730420301 $129.9971/ml
NABI-HB >1560/5ML 59730440301 $139.2144/ml
NABI-HB >312/ML 59730420201 $148.4195/ml
NABI-HB >312/ML 59730440201 $156.0450/ml
NAGLAZYME 5 MG/5 ML 68135002001 $369.8620/ml
NATPARA 100 MCG 68875020502 $4583.1730/each
NATPARA 25MCG/DOSE 68875020202 $4583.1730/each
NATPARA 50MCG/DOSE 68875020302 $4583.1730/each
NATPARA 75MCG/DOSE 68875020402 $4583.1730/each
NEOSAR FOR INJECTION 1 G 00013563673 $30.4818/each
NEULASTA 6MG/0.6ML 54868522900 $5967.2883/ml
NEULASTA 6MG/0.6ML 55513019001 $9999.0000/ml
NEULASTA 6MG/0.6ML 55513019201 $9999.0000/ml
NEUMEGA 5 MG 54868556900 $297.0359/each
Page 32 of 54
NAME OF DRUG Strength NDC
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December 1, 2017
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NEUMEGA 5 MG 58394000401 $247.2480/each
NEUMEGA 5 MG 58394000402 $247.2480/each
NEUMEGA 5 MG 58394010408 $445.1920/each
NEUPOGEN 300 MCG/ML 54868252200 $235.1626/ml
NEUPOGEN 300 MCG/ML 55513053001 $317.9783/ml Increase
NEUPOGEN 300 MCG/ML 55513053010 $317.9813/ml Increase
NEUPOGEN 300MCG/0.5 54868502000 $523.0694/ml
NEUPOGEN 300MCG/0.5 55513092401 $674.0740/ml Increase
NEUPOGEN 300MCG/0.5 55513092410 $674.0841/ml Increase
NEUPOGEN 300MCG/0.5 55513092491 $674.0740/ml Increase
NEUPOGEN 480MCG/0.8 54868305000 $509.8072/ml
NEUPOGEN 480MCG/0.8 55513020901 $670.9304/ml Increase
NEUPOGEN 480MCG/0.8 55513020910 $670.9266/ml Increase
NEUPOGEN 480MCG/0.8 55513020991 $670.9304/ml Increase
NEUPOGEN 480MCG/1.6 55513054601 $316.4646/ml Increase
NEUPOGEN 480MCG/1.6 55513054610 $316.4639/ml Increase
NEVIRAPINE ER 100 MG 00378695077 $6.4466/tablet
NEVIRAPINE ER 100 MG 65862093290 $6.4466/tablet
NEVIRAPINE 50 MG/5 ML 00054045058 $0.6369/ml
NEXAVAR 200 MG 00026848858 $61.2767/tablet
NEXAVAR 200 MG 50419048858 $138.7019/tablet
NEXPLANON 68 MG 00052433001 $856.3790/each
NILANDRON 150 MG 54868573400 $12.8797/tablet
NILANDRON 150 MG 59212011114 $243.9806/tablet
NILUTAMIDE 150 MG 62559017331 $155.7390/tablet
NINLARO 2.3 MG 63020007801 $3187.5600/capsule
NINLARO 2.3 MG 63020007802 $3187.5600/capsule
NINLARO 3 MG 63020007901 $3187.5600/capsule
NINLARO 3 MG 63020007902 $3187.5600/capsule
NINLARO 4 MG 63020008001 $3187.5600/capsule
NINLARO 4 MG 63020008002 $3187.5600/capsule
NIPENT 10 MG 00409080101 $2228.3731/each
NIPENT 10 MG 00409080109 $2194.9522/each
NIPENT 10 MG 62701080001 $2146.0480/each
NITYR 10 MG 70709000060 $412.7702/tablet
NITYR 2 MG 70709000260 $82.5507/tablet
NITYR 5 MG 70709000560 $206.3935/tablet
NORDITROPIN FLEXPRO 10MG/1.5ML 00169770521 $748.1407/ml
NORDITROPIN FLEXPRO 15MG/1.5ML 00169770821 $1122.2110/ml
NORDITROPIN FLEXPRO 30 MG/3 ML 00169770321 $1122.2110/ml
NORDITROPIN FLEXPRO 5 MG/1.5ML 00169770421 $374.0703/ml
NORDITROPIN 4 MG 00169777411 $162.7615/each
NORDITROPIN 5 MG/1.5ML 32849011156 $187.9071/ml
NORDITROPIN 8 MG 00169777812 $325.5331/each
NORTHERA 100 MG 67386082019 $24.1044/capsule
NORTHERA 200 MG 67386082119 $48.2088/capsule
NORTHERA 300 MG 67386082219 $72.3133/capsule
NORVIR 100 MG 00074333330 $8.6581/tablet
NORVIR 100 MG 00074949202 $1.4989/capsule
NORVIR 100 MG 00074949254 $1.4989/capsule
NORVIR 100 MG 35356013830 $16.3012/capsule
Page 33 of 54
NAME OF DRUG Strength NDC
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December 1, 2017
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NORVIR 100 MG 54569565600 $11.2558/capsule
NORVIR 100 MG 54569617000 $11.2558/tablet
NORVIR 100 MG 54569617001 $8.6583/tablet
NORVIR 100 MG 54868378203 $12.9229/capsule
NORVIR 80 MG/ML 00074194063 $6.0608/ml
NPLATE 250 MCG 55513022101 $1737.3616/each
NPLATE 500 MCG 55513022201 $3474.7232/each
NUCALA 100 MG 00173088101 $2812.9712/each
NULOJIX 250 MG 00003037113 $955.6822/each
NUTROPIN AQ NUSPIN 10 MG/2 ML 50242007401 $582.5326/ml
NUTROPIN AQ NUSPIN 20 MG/2 ML 50242007601 $1165.0602/ml
NUTROPIN AQ NUSPIN 5 MG/2 ML 50242007501 $291.2638/ml
NUTROPIN AQ 10 MG/2 ML 50242002219 $225.3563/ml
NUTROPIN AQ 10 MG/2 ML 50242002308 $225.3563/ml
NUTROPIN AQ 10 MG/2 ML 50242011411 $225.3563/ml
NUTROPIN 10 MG 50242001819 $353.5000/each
NUTROPIN 10 MG 50242003450 $450.7125/each
NUTROPIN 5 MG 50242003249 $225.3613/each
NUTROPIN 5 MG 50242007201 $176.7500/each
NUTROPIN 5 MG 50242007202 $225.3563/each
NYMALIZE 30MG/10ML 24338020510 $4.5323/ml
NYMALIZE 30MG/10ML 24338020512 $4.5321/ml
NYMALIZE 60 MG/20ML 24338020012 $3.9408/ml
NYMALIZE 60 MG/20ML 24338020016 $3.9436/ml
NYMALIZE 60 MG/20ML 24338020020 $3.9413/ml
OCALIVA 10 MG 69516001030 $206.2925/tablet
OCALIVA 5 MG 69516000530 $206.2925/tablet
OCREVUS 300MG/10ML 50242015001 $1641.2500/ml
OCTAGAM 10 % 68982085001 $13.9804/ml
OCTAGAM 10 % 68982085002 $13.9804/ml
OCTAGAM 10 % 68982085003 $13.9804/ml
OCTAGAM 10 % 68982085004 $13.9804/ml
OCTAGAM 5 % 67467084301 $6.5196/ml
OCTAGAM 5 % 67467084302 $6.5196/ml
OCTAGAM 5 % 67467084303 $6.5196/ml
OCTAGAM 5 % 67467084304 $6.5196/ml
OCTAGAM 5 % 67467084305 $6.5196/ml
OCTAGAM 5 % 68209084301 $6.5196/ml
OCTAGAM 5 % 68209084302 $6.5196/ml
OCTAGAM 5 % 68209084303 $6.5196/ml
OCTAGAM 5 % 68209084304 $6.5196/ml
OCTAGAM 5 % 68982084001 $6.9902/ml
OCTAGAM 5 % 68982084002 $6.9902/ml
OCTAGAM 5 % 68982084003 $6.9902/ml
OCTAGAM 5 % 68982084004 $6.9902/ml
OCTAGAM 5 % 68982084005 $6.9902/ml
OCTREOTIDE ACETATE 100 MCG/ML 00781916771 $10.8676/ml
OCTREOTIDE ACETATE 100 MCG/ML 00781916795 $10.8676/ml
OCTREOTIDE ACETATE 100 MCG/ML 62756034944 $12.4988/ml
OCTREOTIDE ACETATE 100 MCG/ML 67457024500 $7.9793/ml
OCTREOTIDE ACETATE 100 MCG/ML 67457024501 $6.7731/ml
Page 34 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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OCTREOTIDE ACETATE 50 MCG/ML 00641617401 $4.5452/ml Add
OCTREOTIDE ACETATE 50 MCG/ML 00641617410 $4.5450/ml Add
OCTREOTIDE ACETATE 50 MCG/ML 00703330101 $4.5452/ml
OCTREOTIDE ACETATE 50 MCG/ML 00703330104 $4.5450/ml
OCTREOTIDE ACETATE 50 MCG/ML 00781916671 $9.4026/ml
OCTREOTIDE ACETATE 50 MCG/ML 00781916695 $4.9288/ml
OCTREOTIDE ACETATE 50 MCG/ML 25021045101 $4.5450/ml
OCTREOTIDE ACETATE 50 MCG/ML 62756034844 $5.7065/ml
OCTREOTIDE ACETATE 50 MCG/ML 63323036501 $5.1106/ml
OCTREOTIDE ACETATE 50 MCG/ML 63323036504 $2.3432/ml
OCTREOTIDE ACETATE 50 MCG/ML 67457023900 $4.0402/ml
OCTREOTIDE ACETATE 50 MCG/ML 67457023901 $3.9451/ml
OCTREOTIDE ACETATE 500 MCG/ML 00641617601 $35.3514/ml Add
OCTREOTIDE ACETATE 500 MCG/ML 00641617610 $35.3500/ml Add
OCTREOTIDE ACETATE 500 MCG/ML 00703332101 $35.3514/ml
OCTREOTIDE ACETATE 500 MCG/ML 00703332104 $35.3500/ml
OCTREOTIDE ACETATE 500 MCG/ML 00781916871 $50.4798/ml
OCTREOTIDE ACETATE 500 MCG/ML 00781916895 $50.4798/ml
OCTREOTIDE ACETATE 500 MCG/ML 25021045301 $35.3500/ml
OCTREOTIDE ACETATE 500 MCG/ML 62756035144 $58.0649/ml
OCTREOTIDE ACETATE 500 MCG/ML 63323037701 $50.1869/ml
OCTREOTIDE ACETATE 500 MCG/ML 63323037704 $15.0490/ml
OCTREOTIDE ACETATE 500 MCG/ML 67457024600 $40.0986/ml
OCTREOTIDE ACETATE 500 MCG/ML 67457024601 $33.8643/ml
OCULINUM 100 UNIT 00023050401 $510.0500/each
ODEFSEY 200-25-25 61958210101 $84.4272/tablet
ODOMZO 200 MG 00078064515 $338.6867/capsule
ODOMZO 200 MG 47335030383 $338.6867/capsule
OFEV 100 MG 00597014360 $145.4400/capsule
OFEV 150 MG 00597014560 $145.4400/capsule
OLYSIO 150 MG 59676022528 $797.9000/capsule
OMNITROPE 10MG/1.5ML 00781300407 $742.4779/ml
OMNITROPE 5 MG/1.5ML 00781300107 $371.2423/ml
OMNITROPE 5 MG/1.5ML 00781300144 $167.9428/ml
OMNITROPE 5.8 MG 00781400436 $308.9274/each
OMNITROPE 5.8 MG 00781401471 $308.9376/each
ONCASPAR 750/ML 00075064005 $404.0000/ml
ONCASPAR 750/ML 00944381001 $2937.9971/ml
ONIVYDE 43 MG/10ML 15054004301 $179.8810/ml Add
ONIVYDE 43 MG/10ML 69171039801 $179.8810/ml
OPDIVO 100MG/10ML 00003377412 $260.9163/ml
OPDIVO 40 MG/4 ML 00003377211 $260.9158/ml
OPSUMIT 10 MG 66215050115 $279.1640/tablet
OPSUMIT 10 MG 66215050130 $279.1640/tablet
ORALAIR 300 IR 59617001502 $13.4064/tablet
ORBACTIV 400 MG 65293000403 $976.3333/each
ORBACTIV 400 MG 65293001501 $976.3720/each
ORBACTIV 400 MG 65293001503 $976.3333/each
ORENCIA CLICKJECT 125 MG/ML 00003218851 $966.7139/ml
ORENCIA 125 MG/ML 00003218811 $966.7139/ml
ORENCIA 250 MG 00003218710 $996.9003/each
Page 35 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ORENCIA 50MG/0.4ML 00003281411 $2416.7848/ml
ORENCIA 87.5MG/0.7 00003281811 $1381.0199/ml
ORENITRAM ER 0.125 MG 66302030001 $4.9238/tablet
ORENITRAM ER 0.125 MG 66302030010 $4.9238/tablet
ORENITRAM ER 0.25 MG 66302030201 $9.8475/tablet
ORENITRAM ER 0.25 MG 66302030210 $9.8475/tablet
ORENITRAM ER 1 MG 66302031001 $39.3900/tablet
ORENITRAM ER 1 MG 66302031010 $39.3900/tablet
ORENITRAM ER 2.5 MG 66302032501 $98.4750/tablet
ORENITRAM ER 2.5 MG 66302032510 $98.4750/tablet
ORENITRAM ER 5 MG 66302035001 $196.9500/tablet
ORENITRAM ER 5 MG 66302035010 $196.9500/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
ORKAMBI 100-125 MG 51167070002 $188.6466/tablet
ORKAMBI 200-125MG 51167080901 $188.6466/tablet
ORTHOVISC 30 MG/2 ML 59676036001 $219.1700/ml
OTEZLA 10-20-30MG 59572063255 $56.9308/tablet
OTEZLA 30 MG 59572063006 $31.5625/tablet
OTEZLA 30 MG 59572063106 $52.1865/tablet
OTREXUP 10MG/0.4ML 54436001002 $390.6540/ml
OTREXUP 10MG/0.4ML 54436001004 $390.6491/ml
OTREXUP 12.5MG/0.4 54436001204 $390.6491/ml
OTREXUP 15MG/0.4ML 54436001502 $390.6540/ml
OTREXUP 15MG/0.4ML 54436001504 $390.6491/ml
OTREXUP 17.5MG/0.4 54436001704 $390.6491/ml
OTREXUP 20MG/0.4ML 54436002002 $390.6540/ml
OTREXUP 20MG/0.4ML 54436002004 $390.6491/ml
OTREXUP 22.5MG/0.4 54436002204 $390.6491/ml
OTREXUP 25MG/0.4ML 54436002502 $390.6540/ml
OTREXUP 25MG/0.4ML 54436002504 $390.6491/ml
OXALIPLATIN 100 MG 45963061159 $202.0000/each
OXALIPLATIN 100 MG 47335017840 $535.3000/each
OXALIPLATIN 100 MG 51991021998 $202.0000/each
OXALIPLATIN 100 MG 63323017650 $1248.9660/each
OXALIPLATIN 50 MG 45963061153 $101.0000/each
OXALIPLATIN 50 MG 47335017640 $267.6500/each
OXALIPLATIN 50 MG 51991021898 $101.0000/each
OXALIPLATIN 50 MG 63323017530 $599.9400/each
OXSORALEN 10 MG 00163060001 $0.6565/capsule
OXSORALEN 10 MG 00163060030 $3.4138/capsule
OXSORALEN-ULTRA 10 MG 00163065042 $19.7063/capsule
OXSORALEN-ULTRA 10 MG 00187065042 $85.7666/capsule
OZURDEX 0.7 MG 00023334807 $1346.3300/each
PAMIDRONATE DISODIUM 30 MG 00781314770 $94.2241/each
PAMIDRONATE DISODIUM 30 MG 55390012701 $40.4016/each
PAMIDRONATE DISODIUM 30 MG 59923060110 $18.9779/each
PAMIDRONATE DISODIUM 60 MG/10ML 61703032518 $2.8320/ml
Page 36 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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PAMIDRONATE DISODIUM 90 MG 55390012901 $121.2048/each
PAMIDRONATE DISODIUM 90 MG 59923060310 $56.9337/each
PARAGARD T 380-A 380 SQ MM 50907038006 $395.9200/each
PARAGARD T 380-A 380 SQ MM 50907038007 $362.6829/each
PARAGARD T 380-A 380 SQ MM 51285020401 $816.5850/each
PARAGARD T 380-A 380 SQ MM 54765038001 $395.9200/each
PARAGARD T 380-A 380 SQ MM 54765038005 $362.6829/each
PARAPLATIN 150 MG 00015321429 $292.0011/each
PEGASYS PROCLICK 135MCG/0.5 00004036030 $2003.3148/ml
PEGASYS PROCLICK 180MCG/0.5 00004036530 $2003.3148/ml
PEGASYS 180MCG/0.5 00004035730 $2003.3148/ml
PEGASYS 180MCG/ML 00004035009 $1001.6574/ml
PEGASYS 180MCG/ML 54868488700 $357.3942/ml
PEGINTRON REDIPEN 150MCG/0.5 54868503600 $445.8906/each
PEGINTRON REDIPEN 150MCG/0.5 54868503601 $435.3041/each
PEGINTRON 50 MCG/0.5 00085435301 $759.6917/each
PENTACARINAT 300 MG 00053100005 $78.7800/each
PENTAM 300 300 MG 00469011310 $79.7900/each
PENTAM 300 300 MG 00469113090 $100.4445/each
PENTAM 300 300 MG 00469113091 $79.7900/each
PENTAM 300 300 MG 63323011310 $168.5589/each
PENTAMIDINE ISETHIONATE 300 MG 00074454801 $38.1376/each
PENTAMIDINE ISETHIONATE 300 MG 00074454849 $38.1376/each
PENTAMIDINE ISETHIONATE 300 MG 00702454849 $38.1376/each
PENTOSTATIN 10 MG 55390024401 $1919.0000/each
PERJETA 420MG/14ML 50242014501 $340.8620/ml
PH 12 DILUENT FOR FLOLAN 00173085702 $0.2843/ml
PHENOXYBENZAMINE HCL 10 MG 00054034925 $109.0709/capsule
PHENOXYBENZAMINE HCL 10 MG 49884003801 $108.9497/capsule
PHENOXYBENZAMINE HCL 10 MG 66993006602 $108.9497/capsule
PHOTOFRIN 75 MG 00024155001 $2214.4856/each
PHOTOFRIN 75 MG 58914015575 $18789.9895/each
PHOTOFRIN 75 MG 76128015575 $20631.2700/each
PLATINOL-AQ 1 MG/ML 00015322026 $4.0396/ml
PLATINOL-AQ 1 MG/ML 00015322097 $4.0396/ml
PLATINOL-AQ 1 MG/ML 00015322126 $4.0393/ml
PLATINOL-AQ 1 MG/ML 00015322197 $4.0393/ml
PLEGRIDY PEN 125MCG/0.5 64406001101 $6349.8700/ml
PLEGRIDY PEN 63-94 MCG 64406001201 $6349.8700/ml
PLEGRIDY 125MCG/0.5 64406001501 $6349.8700/ml
PLEGRIDY 63-94 MCG 64406001601 $6349.8700/ml
POLYGAM S/D 2.5 G 52769047172 $214.1200/each
POLYGAM S-D 0.5 GRAM 00944047169 $60.6024/each
POLYGAM S-D 10 G 00944047180 $892.2020/each
POLYGAM S-D 2.5 G 00944047172 $223.0505/each
POLYGAM S-D 5 G 00944047175 $446.1010/each
POMALYST 1 MG 59572050100 $761.4970/capsule Increase
POMALYST 1 MG 59572050121 $761.4967/capsule Increase
POMALYST 2 MG 59572050200 $761.4970/capsule Increase
POMALYST 2 MG 59572050221 $761.4967/capsule Increase
POMALYST 3 MG 59572050300 $761.4970/capsule Increase
Page 37 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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POMALYST 3 MG 59572050321 $761.4967/capsule Increase
POMALYST 4 MG 59572050400 $761.4970/capsule Increase
POMALYST 4 MG 59572050421 $761.4967/capsule Increase
PORTRAZZA 800MG/50ML 00002771601 $84.0643/ml
PRALUENT PEN 150 MG/ML 00024590201 $565.6224/ml
PRALUENT PEN 150 MG/ML 00024590202 $565.6000/ml
PRALUENT PEN 75 MG/ML 00024590101 $565.6224/ml
PRALUENT PEN 75 MG/ML 00024590102 $565.6000/ml
PRALUENT SYRINGE 150 MG/ML 00024590401 $565.6224/ml
PRALUENT SYRINGE 75 MG/ML 00024590301 $565.6224/ml
PREZCOBIX 800-150 MG 54569659400 $73.2840/tablet
PREZCOBIX 800-150 MG 59676057530 $56.3701/tablet
PREZISTA 100 MG/ML 54569640300 $3.0604/ml
PREZISTA 100 MG/ML 59676056501 $4.1096/ml
PREZISTA 150 MG 59676056401 $6.1640/tablet
PREZISTA 600 MG 35356028460 $27.2641/tablet
PREZISTA 600 MG 54569608600 $32.0556/tablet
PREZISTA 600 MG 54868636900 $23.0537/tablet
PREZISTA 600 MG 59676056201 $24.6571/tablet
PREZISTA 75 MG 59676056301 $3.0825/tablet
PREZISTA 800 MG 54569636600 $64.1123/tablet
PREZISTA 800 MG 59676056630 $49.3153/tablet
PRIALT 100 MCG/ML 18860072010 $723.2105/ml
PRIALT 100 MCG/ML 18860072210 $723.2105/ml
PRIALT 25 MCG/ML 18860072310 $180.8026/ml
PRIVIGEN 10 % 44206043605 $13.7360/ml
PRIVIGEN 10 % 44206043710 $13.7360/ml
PRIVIGEN 10 % 44206043820 $13.7360/ml
PRIVIGEN 10 % 44206043892 $13.7365/ml
PRIVIGEN 10 % 44206043940 $13.7360/ml
PROCRIT 10000/ML 54868252300 $195.7878/ml
PROCRIT 10000/ML 54868252301 $184.2004/ml
PROCRIT 10000/ML 59676031000 $247.6618/ml
PROCRIT 10000/ML 59676031001 $247.6520/ml
PROCRIT 10000/ML 59676031002 $247.6520/ml
PROCRIT 2000/ML 59676030200 $49.5340/ml
PROCRIT 2000/ML 59676030201 $49.5304/ml
PROCRIT 20000/2ML 59676031200 $247.6618/ml
PROCRIT 20000/2ML 59676031204 $247.6520/ml
PROCRIT 20000/ML 54868567301 $368.2353/ml
PROCRIT 20000/ML 59676032000 $495.3236/ml
PROCRIT 20000/ML 59676032004 $495.3040/ml
PROCRIT 3000/ML 59676030300 $74.2969/ml
PROCRIT 3000/ML 59676030301 $74.2956/ml
PROCRIT 4000/ML 59676030400 $99.0681/ml
PROCRIT 4000/ML 59676030401 $99.0608/ml
PROCRIT 40000/ML 54868580200 $735.9804/ml
PROCRIT 40000/ML 59676034000 $990.6472/ml
PROCRIT 40000/ML 59676034001 $990.6080/ml
PROCYSBI 25 MG 49663000106 $84.6178/capsule
PROCYSBI 75 MG 49663000225 $84.6178/capsule
Page 38 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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PROGRAF 5 MG/ML 00469301601 $190.7425/ml
PROLASTIN C 1000 MG 13533070002 $0.4949/each
PROLASTIN C 1000 MG 13533070101 $0.4949/each
PROLASTIN C 1000 MG 13533070310 $0.4949/each
PROLASTIN 1000 MG 00192060135 $0.3434/each
PROLASTIN 500 MG 00192060130 $0.3434/each
PROLASTIN 500 MG 13533060130 $0.4141/each
PROLEUKIN 22MM UNIT 54868559600 $837.1380/each
PROLEUKIN 22MM UNIT 65483011607 $3428.6470/each
PROLIA 60 MG/ML 55513071001 $1139.4820/ml
PROMACTA 12.5 MG 00007464313 $123.6873/tablet
PROMACTA 12.5 MG 00078068415 $135.9322/tablet
PROMACTA 25 MG 00007464013 $115.7036/tablet
PROMACTA 25 MG 00078068515 $135.9322/tablet
PROMACTA 50 MG 00007464113 $215.2623/tablet
PROMACTA 50 MG 00078068615 $252.8811/tablet
PROMACTA 75 MG 00007464213 $322.8940/tablet
PROMACTA 75 MG 00078068715 $379.3220/tablet
PROVENGE 50 MM/250 30237890006 $189.8862/ml
PULMOZYME 1 MG/ML 50242010039 $44.2196/ml
PULMOZYME 1 MG/ML 50242010040 $44.2166/ml
PURIXAN 20 MG/ML 60311045001 $11.4694/ml
PURIXAN 20 MG/ML 62484002001 $11.4694/ml
QUDEXY XR 100 MG 00245107415 $14.9884/capsule
QUDEXY XR 100 MG 00245107430 $17.4605/capsule
QUDEXY XR 150 MG 00245107515 $18.4357/capsule
QUDEXY XR 150 MG 00245107530 $21.4770/capsule
QUDEXY XR 200 MG 00245107315 $20.5030/capsule
QUDEXY XR 200 MG 00245107330 $23.8848/capsule
QUDEXY XR 25 MG 00245107115 $5.8075/capsule
QUDEXY XR 25 MG 00245107130 $6.7653/capsule
QUDEXY XR 50 MG 00245107215 $7.5649/capsule
QUDEXY XR 50 MG 00245107230 $8.8126/capsule
QUTENZA 8 % 10144092801 $845.8851/each
QUTENZA 8 % 10144092901 $1691.7702/each
RADICAVA 30MG/100ML 70510217101 $5.4845/ml
RADICAVA 30MG/100ML 70510217102 $5.4843/ml
RAGWITEK 12 UNIT 00006542030 $9.8088/tablet Increase
RAGWITEK 12 UNIT 00006542054 $8.9991/tablet
RAGWITEK 12 UNIT 52709160101 $9.8092/tablet Add
RAGWITEK 12 UNIT 52709160103 $9.8088/tablet Add
RAPAMUNE 1 MG/ML 00008103001 $5.5348/ml
RAPAMUNE 1 MG/ML 00008103002 $5.5348/ml
RAPAMUNE 1 MG/ML 00008103004 $28.2872/ml
RAPAMUNE 1 MG/ML 00008103005 $5.5348/ml
RAPAMUNE 1 MG/ML 00008103006 $28.2872/ml
RAPAMUNE 1 MG/ML 00008103014 $5.5348/ml
RASUVO 10MG/0.2ML 59137051004 $593.3750/ml
RASUVO 12.5/0.25 59137051504 $474.7000/ml
RASUVO 15MG/0.3ML 59137052000 $395.5990/ml
RASUVO 15MG/0.3ML 59137052004 $395.5833/ml
Page 39 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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RASUVO 17.5/0.35 59137052500 $339.0849/ml
RASUVO 17.5/0.35 59137052504 $339.0714/ml
RASUVO 20MG/0.4ML 59137053000 $296.6992/ml
RASUVO 20MG/0.4ML 59137053004 $296.6875/ml
RASUVO 22.5/0.45 59137053504 $263.7222/ml
RASUVO 25MG/0.5ML 59137054004 $237.3500/ml
RASUVO 30MG/0.6ML 59137055004 $197.7917/ml
RASUVO 7.5MG/0.15 59137050504 $791.1667/ml
RAVICTI 1.1GRAM/ML 75987005006 $168.0741/ml
RAVICTI 1.1GRAM/ML 76325010025 $152.9342/ml
REBETOL 40 MG/ML 00085131801 $1.9594/ml
REBIF REBIDOSE 22MCG/.5ML 44087332201 $1157.1991/ml
REBIF REBIDOSE 44MCG/.5ML 44087334401 $1157.1991/ml
REBIF REBIDOSE 8.8-22(6) 44087018801 $1653.1415/ml
REBIF 22MCG/.5ML 44087002203 $1157.1991/ml
REBIF 44MCG/.5ML 44087004403 $1157.1991/ml
REBIF 8.8-22(6) 44087882201 $1653.1415/ml
RECLAST 5 MG/100ML 00078043561 $10.9467/ml
RECLAST 5 MG/100ML 35356035101 $17.9476/ml
REMICADE 100 MG 57894003001 $1179.4982/each
REMODULIN 1 MG/ML 66302010101 $59.5395/ml
REMODULIN 10 MG/ML 66302011001 $595.3950/ml
REMODULIN 2.5 MG/ML 66302010201 $148.8488/ml
REMODULIN 5 MG/ML 66302010501 $297.6975/ml
RENFLEXIS 100 MG 00006430501 $760.9557/each
RENFLEXIS 100 MG 00006430502 $760.9239/each
REPATHA PUSHTRONEX 420 MG/3.5 55513077001 $349.2436/ml
REPATHA SURECLICK 140 MG/ML 55513076001 $564.1658/ml
REPATHA SURECLICK 140 MG/ML 55513076002 $564.1658/ml
REPATHA SYRINGE 140 MG/ML 55513075001 $564.1658/ml
RESCRIPTOR 100 MG 00009376103 $0.7100/tablet
RESCRIPTOR 100 MG 49702020924 $1.2482/tablet
RESCRIPTOR 100 MG 63010002036 $0.8196/tablet
RESCRIPTOR 200 MG 00009757601 $1.4201/tablet
RESCRIPTOR 200 MG 49702022517 $2.4964/tablet
RESCRIPTOR 200 MG 54868452000 $1.6509/tablet
RETROVIR 10 MG/ML 00081010793 $1.0947/ml
RETROVIR 10 MG/ML 49702021301 $1.4742/ml
RETROVIR 10 MG/ML 49702021305 $1.4741/ml
RETROVIR 10 MG/ML 49702021326 $1.4741/ml
REVATIO 10 MG/12.5 00069033801 $16.9171/ml
REVATIO 10 MG/ML 00069033621 $67.8685/ml
REVLIMID 10 MG 59572041000 $668.9837/capsule Increase
REVLIMID 10 MG 59572041028 $668.9832/capsule Increase
REVLIMID 15 MG 59572041500 $668.9837/capsule Increase
REVLIMID 15 MG 59572041521 $668.9841/capsule Increase
REVLIMID 2.5 MG 59572040200 $668.9837/capsule Increase
REVLIMID 2.5 MG 59572040228 $668.9832/capsule Increase
REVLIMID 20 MG 59572042000 $668.9837/capsule Increase
REVLIMID 20 MG 59572042021 $668.9841/capsule Increase
REVLIMID 25 MG 59572042500 $668.9837/capsule Increase
Page 40 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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REVLIMID 25 MG 59572042521 $668.9841/capsule Increase
REVLIMID 5 MG 59572040500 $668.9837/capsule Increase
REVLIMID 5 MG 59572040528 $668.9832/capsule Increase
REYATAZ 150 MG 00003362412 $24.6315/capsule
REYATAZ 150 MG 35356006806 $48.4819/capsule
REYATAZ 150 MG 35356006860 $24.1320/capsule
REYATAZ 150 MG 54569553000 $18.4986/capsule
REYATAZ 150 MG 54868485700 $15.8952/capsule
REYATAZ 150 MG 68258914201 $16.7982/capsule
REYATAZ 200 MG 00003363112 $24.6315/capsule
REYATAZ 200 MG 35356020760 $24.1320/capsule
REYATAZ 200 MG 54569553200 $32.0223/capsule
REYATAZ 200 MG 54868485400 $24.7202/capsule
REYATAZ 300 MG 00003362212 $48.7971/capsule
REYATAZ 300 MG 35356011406 $55.7977/capsule
REYATAZ 300 MG 35356011430 $48.3708/capsule
REYATAZ 300 MG 54569586400 $63.4387/capsule
REYATAZ 300 MG 54868583800 $48.9732/capsule
REYATAZ 50 MG 00003363810 $7.6093/each
RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780500 $119.1800/each
RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780501 $119.1800/each
RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780505 $119.1800/each
RHOGAM ULTRA-FILTERED PLUS 1500 UNIT 00562780525 $119.1800/each
RHOGAM 1500 UNIT 00562780701 $111.5252/each
RHOGAM 1500 UNIT 00562780706 $111.5252/each
RHOGAM 1500 UNIT 00562780726 $111.5252/each
RHOPHYLAC 1500/2 ML 44206030001 $80.9919/ml
RHOPHYLAC 1500/2 ML 44206030010 $73.6290/ml
RIBASPHERE RIBAPAK 200-400 MG 66435010899 $25.6901/tablet
RIBASPHERE RIBAPAK 200-400(7) 66435010856 $25.6901/tablet
RIBASPHERE RIBAPAK 400-400 MG 66435010599 $27.0420/tablet
RIBASPHERE RIBAPAK 400-400(7) 66435010556 $27.0420/tablet
RIBASPHERE RIBAPAK 600-400 MG 66435010699 $33.8029/tablet
RIBASPHERE RIBAPAK 600-400(7) 66435010656 $33.8033/tablet
RIBASPHERE RIBAPAK 600-600 MG 66435010799 $40.5630/tablet
RIBASPHERE RIBAPAK 600-600(7) 66435010756 $40.5630/tablet
RIBASPHERE 400 MG 66435010356 $27.0420/tablet
RIBASPHERE 600 MG 66435010456 $40.5630/tablet
RIBATAB 400-400 MG 16241006976 $19.4935/tablet
RIBATAB 600-400 MG 16241033776 $24.4460/tablet
RIBATAB 600-600 MG 16241007076 $29.3354/tablet
RISPERDAL CONSTA 12.5MG/2ML 50458030911 $218.3216/each
RISPERDAL CONSTA 25 MG/2 ML 50458030611 $436.6028/each
RISPERDAL CONSTA 37.5MG/2ML 50458030711 $654.9345/each
RISPERDAL CONSTA 50 MG/2 ML 50458030811 $873.2561/each
RISPERIDONE 1 MG/ML 17856067301 $2.1042/ml
RISPERIDONE 2 MG/2 ML 17856067302 $1.1573/ml
RISPERIDONE 3 MG/3 ML 17856067303 $1.0521/ml
RITUXAN HYCELA 1400/11.7 50242010801 $524.8901/ml
RITUXAN HYCELA 1600/13.4 50242010901 $523.7709/ml
RITUXAN 10 MG/ML 50242005121 $87.7316/ml
Page 41 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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RITUXAN 10 MG/ML 50242005306 $87.7316/ml
ROFERON-A 36MM/ML 00004201209 $370.5185/ml
ROFERON-A 3MM/0.5 ML 00004201507 $37.4458/each
ROFERON-A 3MMUNIT/ML 00004200909 $30.9060/ml
ROFERON-A 6MM/0.5ML 00004201607 $74.8612/each
ROFERON-A 6MMUNIT/ML 00004200709 $61.7918/ml
ROFERON-A 6MMUNIT/ML 00004201109 $61.7480/ml
ROFERON-A 9MM/0.5ML 00004201707 $105.4053/each
ROFERON-A 9MM/0.9ML 00004201009 $96.6682/ml
ROFERON-A 9MM/0.9ML 00004690009 $86.7478/ml
RUBEX 50 MG 00015335222 $159.2972/each
RUBRACA 200 MG 69660020191 $115.6450/tablet
RUBRACA 250 MG 69660020291 $115.6450/tablet
RUBRACA 300 MG 69660020391 $115.6450/tablet
RUCONEST 2100 UNIT 68012035001 $5765.3931/each
RUCONEST 2100 UNIT 68012035002 $5765.3931/each
RYDAPT 25 MG 00078069802 $135.1784/capsule
RYDAPT 25 MG 00078069819 $135.1777/capsule
RYDAPT 25 MG 00078069851 $135.1777/capsule
RYDAPT 25 MG 00078069899 $135.1777/capsule
SABRIL 500 MG 67386011101 $122.1878/tablet
SABRIL 500 MG 67386021165 $122.1878/each
SAIZEN 5 MG 44087100502 $568.3270/each
SAIZEN 5 MG 54569493000 $276.9698/each
SAIZEN 8.8 MG 44087108801 $909.3333/each
SAIZEN 8.8MG/1.51 44087108001 $909.3333/each
SAIZEN 8.8MG/1.51 44087108002 $401.3033/each
SAIZEN-SAIZENPREP 8.8MG/1.51 44087001601 $909.3333/each
SAMSCA 15 MG 59148002050 $394.5615/tablet
SAMSCA 30 MG 59148002150 $409.3116/tablet
SANDIMMUNE 100 MG/ML 00078011022 $13.4158/ml
SANDIMMUNE 250 MG/5ML 00078010901 $10.7692/ml
SANDIMMUNE 250 MG/5ML 00078010961 $10.7706/ml
SANDOGLOBULIN 1 G 00078012094 $76.9115/each
SANDOGLOBULIN 12 G 00078024493 $586.8504/each
SANDOGLOBULIN 6 G 00078012496 $293.4252/each
SANDOSTATIN LAR DEPOT 10 MG 00078064661 $2859.0272/each
SANDOSTATIN LAR DEPOT 10 MG 00078064681 $2859.0272/each
SANDOSTATIN LAR DEPOT 10 MG 00078079061 $2999.1243/each
SANDOSTATIN LAR DEPOT 10 MG 00078081181 $2999.1243/each
SANDOSTATIN LAR DEPOT 20 MG 00078064761 $3570.8449/each
SANDOSTATIN LAR DEPOT 20 MG 00078064781 $3570.8449/each
SANDOSTATIN LAR DEPOT 20 MG 00078079761 $3929.3646/each
SANDOSTATIN LAR DEPOT 20 MG 00078081881 $3929.3646/each
SANDOSTATIN LAR DEPOT 30 MG 00078064861 $5347.0915/each
SANDOSTATIN LAR DEPOT 30 MG 00078064881 $5347.0915/each
SANDOSTATIN LAR DEPOT 30 MG 00078080461 $5883.9368/each
SANDOSTATIN LAR DEPOT 30 MG 00078082581 $5883.9368/each
SANDOSTATIN LAR 10 MG 00078034084 $1467.4795/each
SANDOSTATIN LAR 20 MG 00078034184 $1685.3769/each
SANDOSTATIN LAR 30 MG 00078034284 $2264.7836/each
Page 42 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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SANDOSTATIN 100 MCG/ML 00078018101 $27.1134/ml
SANDOSTATIN 100 MCG/ML 00078018161 $27.1185/ml
SANDOSTATIN 50 MCG/ML 00078018001 $13.9774/ml
SANDOSTATIN 50 MCG/ML 00078018061 $13.9784/ml
SANDOSTATIN 500 MCG/ML 00078018201 $130.7728/ml
SANDOSTATIN 500 MCG/ML 00078018261 $130.7849/ml
SANTYL 250 UNIT/G 00044527002 $2.2658/gm
SANTYL 250 UNIT/G 00044527003 $1.9042/gm
SANTYL 250 UNIT/G 16590020330 $1.7956/gm
SANTYL 250 UNIT/G 50484001030 $7.2383/gm
SANTYL 250 UNIT/G 50484001090 $6.8775/gm
SANTYL 250 UNIT/G 50484052715 $2.2658/gm
SANTYL 250 UNIT/G 50484052730 $1.9042/gm
SANTYL 250 UNIT/G 54569385400 $1.9836/gm
SANTYL 250 UNIT/G 55045213405 $1.8779/gm
SELZENTRY 150 MG 35356020860 $29.4474/tablet
SELZENTRY 150 MG 49702022318 $23.5621/tablet
SELZENTRY 150 MG 54569614300 $18.2034/tablet
SELZENTRY 20 MG/ML 49702023755 $3.1416/ml
SELZENTRY 25 MG 49702023308 $3.9270/tablet
SELZENTRY 300 MG 35356020960 $29.4474/tablet
SELZENTRY 300 MG 49702022418 $23.5621/tablet
SELZENTRY 300 MG 54569621400 $30.6320/tablet
SELZENTRY 300 MG 54868580900 $18.6810/tablet
SELZENTRY 75 MG 49702023508 $11.7811/tablet
SENSIPAR 30 MG 54868561600 $14.3905/tablet
SENSIPAR 30 MG 55513007330 $27.1589/tablet
SENSIPAR 60 MG 55513007430 $54.3178/tablet
SENSIPAR 90 MG 55513007530 $81.4767/tablet
SEROSTIM 4 MG 44087000401 $318.1205/each
SEROSTIM 4 MG 44087000407 $318.1096/each
SEROSTIM 5 MG 44087000501 $397.6527/each
SEROSTIM 5 MG 44087000507 $397.6370/each
SEROSTIM 6 MG 44087000601 $477.1850/each
SEROSTIM 6 MG 44087000607 $477.1658/each
SEROSTIM 6 MG 44087100605 $151.5000/each
SIGNIFOR LAR 20 MG 00078064161 $11312.0000/each
SIGNIFOR LAR 20 MG 00078064181 $11312.0000/each
SIGNIFOR LAR 40 MG 00078064261 $11312.0000/each
SIGNIFOR LAR 40 MG 00078064281 $11312.0000/each
SIGNIFOR LAR 60 MG 00078064361 $11312.0000/each
SIGNIFOR LAR 60 MG 00078064381 $11312.0000/each
SIGNIFOR 0.3 MG/ML 00078063306 $201.4479/ml
SIGNIFOR 0.3 MG/ML 00078063320 $201.4465/ml
SIGNIFOR 0.3 MG/ML 00078063361 $201.4445/ml
SIGNIFOR 0.6 MG/ML 00078063406 $201.4479/ml
SIGNIFOR 0.6 MG/ML 00078063420 $201.4465/ml
SIGNIFOR 0.6 MG/ML 00078063461 $201.4445/ml
SIGNIFOR 0.9 MG/ML 00078063506 $201.4479/ml
SIGNIFOR 0.9 MG/ML 00078063520 $201.4465/ml
SIGNIFOR 0.9 MG/ML 00078063561 $201.4445/ml
Page 43 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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SILDENAFIL CITRATE 10 MG/12.5 55150016613 $14.9480/ml
SILIQ 210 MG/1.5 00187000400 $1178.3800/ml
SILIQ 210 MG/1.5 00187000402 $1178.3333/ml
SIMPONI ARIA 50 MG/4 ML 57894035001 $417.2790/ml
SIMPONI 100 MG/ML 57894007101 $4820.6795/ml
SIMPONI 100 MG/ML 57894007102 $4820.6795/ml
SIMPONI 50MG/0.5ML 57894007001 $8383.7676/ml
SIMPONI 50MG/0.5ML 57894007002 $8383.7676/ml
SIMULECT 10 MG 00078039361 $2680.4996/each
SIMULECT 20 MG 00078033184 $3518.1633/each
SIRTURO 100 MG 59676070101 $161.1702/tablet
SIVEXTRO 200 MG 67919004001 $269.0337/each
SIVEXTRO 200 MG 67919004101 $337.7339/tablet
SIVEXTRO 200 MG 67919004102 $337.7339/tablet
SKYLA 14MCG/24HR 50419042201 $721.8470/each
SODIUM PHENYLACET-SOD BENZOATE 10 %-10 % 13811070550 $737.3000/ml
SODIUM PHENYLACET-SOD BENZOATE 10 %-10 % 67457084450 $707.8080/ml
SODIUM PHENYLACET-SOD BENZOATE 10 %-10 % 68382039601 $707.8080/ml
SODIUM PHENYLACET-SOD BENZOATE 10 %-10 % 68682000150 $707.8080/ml
SODIUM PHENYLBUTYRATE 0.94 G/G 42794008614 $18.1785/gm
SODIUM PHENYLBUTYRATE 0.94 G/G 76325020025 $18.1598/gm
SODIUM PHENYLBUTYRATE 500 MG 49884017004 $20.0384/tablet
SOLIRIS 300MG/30ML 25682000101 $219.6077/ml
SOMATULINE DEPOT 120MG/0.5 15054012001 $10922.1400/ml
SOMATULINE DEPOT 120MG/0.5 15054012002 $7267.9600/ml
SOMATULINE DEPOT 120MG/0.5 15054112003 $13968.3000/ml
SOMATULINE DEPOT 60MG/0.2ML 15054006001 $15836.8000/ml
SOMATULINE DEPOT 60MG/0.2ML 15054106003 $22230.1000/ml
SOMATULINE DEPOT 90MG/0.3ML 15054009001 $14065.9333/ml
SOMATULINE DEPOT 90MG/0.3ML 15054109003 $19738.7667/ml
SOMAVERT 10 MG 00009716601 $194.4755/each
SOMAVERT 15 MG 00009517802 $259.6609/each
SOMAVERT 15 MG 00009716801 $291.7284/each
SOMAVERT 20 MG 00009518002 $346.1977/each
SOMAVERT 20 MG 00009718801 $388.9510/each
SOMAVERT 25 MG 00009519901 $432.7547/each
SOMAVERT 25 MG 00009520104 $432.7685/each
SOMAVERT 25 MG 00009719901 $486.1938/each
SOMAVERT 30 MG 00009520001 $519.2915/each
SOMAVERT 30 MG 00009537604 $519.3121/each
SOMAVERT 30 MG 00009720001 $583.4265/each
SOVALDI 400 MG 61958150101 $1010.0000/tablet
SPINRAZA 12MG/5ML 64406005801 $25250.0000/ml
SPRYCEL 100 MG 00003085222 $406.6475/tablet
SPRYCEL 140 MG 00003085722 $406.6475/tablet
SPRYCEL 20 MG 00003052711 $112.8116/tablet
SPRYCEL 50 MG 00003052811 $225.6231/tablet
SPRYCEL 70 MG 00003052411 $225.6231/tablet
SPRYCEL 70 MG 54868575900 $92.2174/tablet
SPRYCEL 80 MG 00003085522 $406.6475/tablet
STELARA 130MG/26ML 57894005427 $62.1538/ml
Page 44 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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STELARA 45MG/0.5ML 57894006003 $19267.9720/ml
STELARA 90 MG/ML 57894006103 $19267.9720/ml
STIVARGA 40 MG 50419017101 $178.9323/tablet
STIVARGA 40 MG 50419017103 $178.9322/tablet
STRENSIQ 18MG/.45ML 25682001001 $2828.1120/ml
STRENSIQ 18MG/.45ML 25682001012 $2828.0000/ml
STRENSIQ 28MG/0.7ML 25682001301 $2828.1120/ml
STRENSIQ 28MG/0.7ML 25682001312 $2828.0000/ml
STRENSIQ 40 MG/ML 25682001601 $2828.1120/ml
STRENSIQ 40 MG/ML 25682001612 $2828.0000/ml
STRENSIQ 80MG/0.8ML 25682001901 $7070.2800/ml
STRENSIQ 80MG/0.8ML 25682001912 $7070.0000/ml
STRIBILD 150-200 MG 54569635200 $126.5145/tablet
STRIBILD 150-200 MG 61958120101 $104.0297/tablet
SUCRAID 8500/ML 67871011104 $31.5625/ml
SULFZIX 400-500/.4 69597090101 $117.1600/gm
SUPARTZ FX 10 MG/ML 89130444401 $93.0412/ml
SUPARTZ 10 MG/ML 08363776101 $93.0449/ml
SUPARTZ 10 MG/ML 08363776501 $49.2072/ml
SUPARTZ 10 MG/ML 89130555501 $93.0412/ml
SUPPRELIN LA 50 MG 67979000201 $29776.1837/each
SUSTIVA 200 MG 00056047492 $11.0047/capsule
SUSTIVA 200 MG 35356006990 $6.6588/capsule
SUSTIVA 200 MG 54569461100 $6.2005/capsule
SUSTIVA 200 MG 68258902101 $5.3825/capsule
SUSTIVA 50 MG 00056047030 $2.7529/capsule
SUSTIVA 600 MG 00056051030 $33.0142/tablet
SUSTIVA 600 MG 35356011506 $41.5028/tablet
SUSTIVA 600 MG 35356011530 $40.5784/tablet
SUSTIVA 600 MG 54569537400 $36.9100/tablet
SUSTIVA 600 MG 54868466800 $27.4551/tablet
SUSTIVA 600 MG 68258902001 $18.7738/tablet
SUSTOL 10MG/0.4ML 47426010106 $1281.1345/ml
SUTENT 12.5 MG 00069055030 $53.9720/capsule
SUTENT 12.5 MG 00069055038 $167.9262/capsule
SUTENT 25 MG 00069077030 $107.9438/capsule
SUTENT 25 MG 00069077038 $335.8531/capsule
SUTENT 37.5 MG 00069083038 $503.7801/capsule
SUTENT 50 MG 00069098030 $215.8875/capsule
SUTENT 50 MG 00069098038 $584.6731/capsule
SYLATRON 4-PACK 600 MCG 00085131202 $13284.5595/each
SYLATRON 200 MCG 00085434701 $1820.6664/each
SYLATRON 300 MCG 00085434801 $2730.9996/each
SYLATRON 600 MCG 00085434901 $5461.9992/each
SYLVANT 100 MG 57894042001 $892.5673/each
SYLVANT 400 MG 57894042101 $3570.2692/each
SYNAGIS 100 MG/ML 60574411301 $2857.5122/ml
SYNAGIS 50MG/0.5ML 60574411401 $3026.5660/ml
SYNAREL 2 MG/ML 00025016608 $327.2223/ml
SYNAREL 2 MG/ML 00033226040 $38.1578/ml
SYNERCID 500 MG 61570026001 $409.7564/each
Page 45 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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SYNERCID 500 MG 61570026010 $409.7408/each
SYNRIBO 3.5 MG 63459017714 $966.5700/each
SYNVISC 16MG/2ML 00008914901 $118.5067/ml
SYNVISC 16MG/2ML 00008914902 $99.1483/ml
SYNVISC 16MG/2ML 21695031301 $335.1860/ml
SYNVISC 16MG/2ML 21695031303 $335.1846/ml
SYNVISC 16MG/2ML 35356003401 $203.2706/ml
SYNVISC 16MG/2ML 54868421900 $151.1132/ml
SYNVISC 16MG/2ML 58468009001 $213.5847/ml
SYNVISC 16MG/2ML 66267092103 $112.2253/ml
SYNVISC-ONE 48 MG/6 ML 21695049301 $335.1846/ml
SYNVISC-ONE 48 MG/6 ML 58468009003 $213.5847/ml
SYPRINE 250 MG 00006066168 $4.3905/capsule
SYPRINE 250 MG 00187212010 $214.7947/capsule
TABLOID 40 MG 76388088025 $25.5300/tablet
TAFINLAR 50 MG 00078068266 $60.0847/capsule
TAFINLAR 50 MG 00173084608 $52.5786/capsule
TAFINLAR 75 MG 00078068166 $81.2285/capsule
TAFINLAR 75 MG 00173084708 $78.8626/capsule
TAGRISSO 40 MG 00310134930 $477.7552/tablet
TAGRISSO 80 MG 00310135030 $477.7552/tablet
TALTZ AUTOINJECTOR (2 PACK) 80 MG/ML 00002144527 $4825.1235/ml
TALTZ AUTOINJECTOR (3 PACK) 80 MG/ML 00002144509 $4825.1235/ml
TALTZ AUTOINJECTOR 80 MG/ML 00002144501 $4825.3146/ml
TALTZ AUTOINJECTOR 80 MG/ML 00002144511 $4825.1235/ml
TALTZ SYRINGE (2 PACK) 80 MG/ML 00002772427 $4825.1235/ml
TALTZ SYRINGE (3 PACK) 80 MG/ML 00002772409 $4825.1235/ml
TALTZ SYRINGE 80 MG/ML 00002772401 $4825.3146/ml
TALTZ SYRINGE 80 MG/ML 00002772411 $4825.1235/ml
TARABINE PFS 20 MG/ML 00013709173 $0.8207/ml
TARABINE PFS 20 MG/ML 00013710678 $1.0868/ml
TARCEVA 100 MG 50242006301 $232.9242/tablet
TARCEVA 100 MG 54868547400 $146.5596/tablet
TARCEVA 150 MG 50242006401 $263.4541/tablet
TARCEVA 150 MG 54868544700 $162.3451/tablet
TARCEVA 25 MG 50242006201 $84.8023/tablet
TARCEVA 25 MG 54868529000 $44.4143/tablet
TARGRETIN 1 % 00187552560 $490.8442/gm
TARGRETIN 1 % 64365050202 $13.3825/gm
TASIGNA 150 MG 00078059251 $104.4928/capsule
TASIGNA 150 MG 00078059287 $104.4933/capsule
TASIGNA 200 MG 00078052651 $104.4928/capsule
TASIGNA 200 MG 00078052687 $104.4933/capsule
TAXOTERE 20MG/ML(1) 00075800301 $581.3560/ml
TAXOTERE 80 MG/4 ML 00075800404 $581.3408/ml
TECENTRIQ 1200 MG/20 50242091701 $435.3100/ml
TECFIDERA 120 MG 64406000501 $114.8081/capsule
TECFIDERA 120-240 MG 64406000703 $114.8033/capsule
TECFIDERA 240 MG 64406000602 $114.8033/capsule
TECHNIVIE 12.5-75 MG 00074308228 $460.8305/tablet
TEMODAR 100 MG 00085138101 $921.8674/each
Page 46 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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TENIPOSIDE 50 MG/5 ML 44567050701 $504.1819/ml
TEPADINA 100 MG 53964000202 $6060.0000/each
TEPADINA 100 MG 70121163101 $4747.0000/each
TEPADINA 15 MG 53964000101 $909.0000/each
TEPADINA 15 MG 70121163001 $909.0000/each
THALOMID 100 MG 59572021015 $280.1819/capsule
THALOMID 100 MG 59572021095 $280.1815/capsule
THALOMID 150 MG 59572021513 $299.5833/capsule
THALOMID 150 MG 59572021593 $299.5833/capsule
THALOMID 200 MG 59572022016 $318.9977/capsule
THALOMID 200 MG 59572022096 $318.9976/capsule
THALOMID 50 MG 59572010511 $6.6371/capsule
THALOMID 50 MG 59572020514 $172.6108/capsule
THALOMID 50 MG 59572020517 $189.8699/capsule
THALOMID 50 MG 59572020594 $172.6100/capsule
THALOMID 50 MG 59572020597 $189.8659/capsule
THERACYS 81 MG 11793088001 $141.6020/each
THERACYS 81 MG 49281088001 $172.3717/each
THERACYS 81 MG 49281088003 $172.3666/each
THIOGUANINE 40 MG 00081088025 $5.2993/tablet
THIOTEPA 15 MG 00143956501 $1414.0000/each
THIOTEPA 15 MG 00703430102 $58.5800/each
THIOTEPA 15 MG 55390003010 $600.9500/each
THROMBATE III 1000 (+/-) 13533060330 $3.6866/each
THROMBATE III 500 (+/-) 13533060250 $3.9188/each
THROMBATE III 500 (+/-) 13533060320 $3.9188/each
THYMOGLOBULIN 25 MG 58468008001 $762.0854/each
THYROGEN 1.1 MG 58468003002 $1547.8250/each
TIVICAY 10 MG 49702022613 $10.3400/tablet
TIVICAY 25 MG 49702022713 $25.8506/tablet
TIVICAY 50 MG 49702022813 $51.7012/tablet
TIVICAY 50 MG 54569641900 $67.2145/tablet
TIVICAY 50 MG 54569641901 $47.8995/tablet
TOBI PODHALER 28 MG 00078063011 $43.1182/capsule
TOBI PODHALER 28 MG 00078063019 $43.1182/capsule
TOBI PODHALER 28 MG 00078063035 $43.1178/capsule
TOBI PODHALER 28 MG 00078063056 $43.1178/capsule
TOBRAMYCIN 300 MG/5ML 24492089999 $13.0001/ml
TOBRAMYCIN 300 MG/5ML 70644089999 $13.0001/ml
TOPIRAMATE ER 100 MG 00832107415 $10.1172/capsule
TOPIRAMATE ER 100 MG 00832107430 $12.7755/capsule
TOPIRAMATE ER 150 MG 00832107515 $12.4441/capsule
TOPIRAMATE ER 150 MG 00832107530 $15.7139/capsule
TOPIRAMATE ER 200 MG 00832107315 $13.8395/capsule
TOPIRAMATE ER 200 MG 00832107330 $17.4764/capsule
TOPIRAMATE ER 25 MG 00832107115 $3.9201/capsule
TOPIRAMATE ER 25 MG 00832107130 $4.9503/capsule
TOPIRAMATE ER 50 MG 00832107215 $5.1063/capsule
TOPIRAMATE ER 50 MG 00832107230 $6.4482/capsule
TOPOTECAN HCL 4 MG/4 ML 00409030201 $34.4662/ml
TOPOTECAN HCL 4 MG/4 ML 00409030225 $28.3356/ml
Page 47 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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TOPOTECAN HCL 4 MG/4 ML 00703471401 $26.9872/ml
TOPOTECAN HCL 4 MG/4 ML 00703471471 $26.9872/ml
TOPOTECAN HCL 4 MG/4 ML 25021023604 $37.8750/ml
TORISEL FDN 30MG/3 00008117901 $1735.2305/ml
TOTECT 500 MG 38423011001 $656.5000/each
TOTECT 500 MG 66220011001 $463.5900/each
TRACLEER 125 MG 66215010203 $168.1650/tablet
TRACLEER 125 MG 66215010206 $168.1650/tablet
TRACLEER 62.5 MG 66215010103 $168.1650/tablet
TRACLEER 62.5 MG 66215010106 $168.1650/tablet
TREANDA 100 MG 63459039120 $2935.4640/each
TREANDA 25 MG 63459039008 $733.8660/each
TRELSTAR DEPOT 3.75 MG 00009521901 $353.1667/each
TRELSTAR DEPOT 3.75 MG 00009766401 $489.8500/each
TRELSTAR LA 11.25 MG 00009521501 $1469.5500/each
TRELSTAR LA 11.25 MG 00009521601 $1059.5001/each
TRELSTAR 11.25 MG 00023590411 $2464.1172/each
TRELSTAR 11.25 MG 52544015402 $2464.1172/each
TRELSTAR 11.25/2ML 00023590412 $2464.1172/each
TRELSTAR 11.25/2ML 52544018876 $2464.1172/each
TRELSTAR 22.5 MG 00023590622 $4928.2344/each
TRELSTAR 22.5 MG 52544015602 $4928.2344/each
TRELSTAR 22.5MG/2ML 00023590623 $4928.2344/each
TRELSTAR 22.5MG/2ML 52544009276 $4928.2344/each
TRELSTAR 3.75 MG 00023590203 $821.3724/each
TRELSTAR 3.75 MG 52544015302 $821.3724/each
TRELSTAR 3.75MG/2ML 00023590204 $821.3724/each
TRELSTAR 3.75MG/2ML 52544018976 $821.3724/each
TRETINOIN 10 MG 00555080802 $27.1624/capsule
TRETINOIN 10 MG 10370026801 $27.1624/capsule
TRETINOIN 10 MG 42291084301 $23.1734/capsule
TRETINOIN 10 MG 68084007511 $25.5203/capsule
TRETINOIN 10 MG 68084007521 $27.8026/capsule
TRETINOIN 10 MG 68462079201 $27.1624/capsule
TREXALL 10 MG 00555092901 $12.7388/tablet
TREXALL 10 MG 51285036801 $26.8677/tablet
TREXALL 15 MG 00555094501 $19.1082/tablet
TREXALL 15 MG 51285036901 $40.3024/tablet
TREXALL 5 MG 00555092701 $6.3694/tablet
TREXALL 5 MG 51285036601 $13.4330/tablet
TREXALL 7.5 MG 00555092801 $9.5539/tablet
TREXALL 7.5 MG 51285036701 $20.1512/tablet
TRIPTODUR 22.5 MG 24338015020 $16160.0000/each
TRISENOX 10 MG/10ML 63459060010 $68.5487/ml
TRIUMEQ 600-50-300 49702023113 $87.4946/tablet
TRIUMEQ 600-50-300 54569656900 $113.7473/tablet
TRIZIVIR 150-300MG 35356011606 $46.4604/tablet
TRIZIVIR 150-300MG 35356011660 $43.6430/tablet
TRIZIVIR 150-300MG 49702021718 $27.0966/tablet
TRIZIVIR 150-300MG 54569519100 $27.0977/tablet
TRIZIVIR 150-300MG 68258915801 $22.8927/tablet
Page 48 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Increase
Decrease
TROKENDI XR 100 MG 17772010301 $21.3636/capsule
TROKENDI XR 100 MG 17772010315 $21.3635/capsule
TROKENDI XR 100 MG 17772010330 $21.3635/capsule Add
TROKENDI XR 200 MG 17772010401 $29.2238/capsule
TROKENDI XR 200 MG 17772010415 $29.2240/capsule
TROKENDI XR 200 MG 17772010430 $29.2240/capsule
TROKENDI XR 25 MG 17772010101 $8.2777/capsule
TROKENDI XR 25 MG 17772010115 $8.2780/capsule
TROKENDI XR 25 MG 17772010130 $8.2780/capsule Add
TROKENDI XR 50 MG 17772010201 $10.7826/capsule
TROKENDI XR 50 MG 17772010215 $10.7824/capsule
TROKENDI XR 50 MG 17772010230 $10.7824/capsule
TRUVADA 100-150 MG 61958070301 $52.7765/tablet
TRUVADA 133-200 MG 61958070401 $52.7765/tablet
TRUVADA 167-250 MG 61958070501 $52.7765/tablet
TRUVADA 200-300 MG 35356007003 $54.5534/tablet
TRUVADA 200-300 MG 35356007030 $54.1213/tablet
TRUVADA 200-300 MG 52959096903 $55.7458/tablet
TRUVADA 200-300 MG 54569558800 $68.6120/tablet
TRUVADA 200-300 MG 54569558802 $68.6137/tablet
TRUVADA 200-300 MG 54569558803 $52.7774/tablet
TRUVADA 200-300 MG 54868514100 $47.9603/tablet
TRUVADA 200-300 MG 55045348103 $28.9797/tablet
TRUVADA 200-300 MG 61958070101 $52.7765/tablet
TYBOST 150 MG 61958140101 $6.9252/tablet
TYKERB 250 MG 00078067119 $45.7649/tablet
TYMLOS 80MCG/DOSE 70539000101 $1052.1250/ml
TYMLOS 80MCG/DOSE 70539000102 $1052.0833/ml
TYSABRI 300MG/15ML 64406000801 $404.0000/ml
TYVASO INSTITUTIONAL START KIT 1.74MG/2.9 66302020604 $337.8276/ml
TYVASO REFILL KIT 1.74MG/2.9 66302020602 $186.7629/ml
TYVASO STARTER KIT 1.74MG/2.9 66302020601 $208.3436/ml
TYVASO 1.74MG/2.9 66302020603 $186.7629/ml
TYZEKA 600 MG 00078053815 $36.0587/tablet
UNITUXIN 3.5 MG/ML 66302001401 $1812.9500/ml
UPTRAVI 1000 MCG 66215061006 $254.2002/tablet
UPTRAVI 1200 MCG 66215061206 $254.2002/tablet
UPTRAVI 1400 MCG 66215061406 $254.2002/tablet
UPTRAVI 1600 MCG 66215061606 $254.2002/tablet
UPTRAVI 200 MCG 66215060206 $163.5190/tablet
UPTRAVI 200 MCG 66215060214 $163.4180/tablet
UPTRAVI 200-800MCG 66215062820 $114.3926/tablet
UPTRAVI 400 MCG 66215060406 $254.2002/tablet
UPTRAVI 600 MCG 66215060606 $254.2002/tablet
UPTRAVI 800 MCG 66215060806 $254.2002/tablet
UVADEX 20 MCG/ML 64067021601 $3.4931/ml
VALCHLOR 0.016 % 66215001660 $56.4758/gm
VALSTAR 40 MG/ML 53014021604 $74.6592/ml
VALSTAR 40 MG/ML 53014021624 $74.6592/ml
VALSTAR 40 MG/ML 67979000101 $242.3429/ml
VALSTAR 40 MG/ML 67979000102 $205.4236/ml
Page 49 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
VANTAS 50 MG 67979050001 $3704.9628/each
VARIZIG 125 UNIT 53270012501 $689.3250/each
VARIZIG 125/1.2 ML 53270012601 $1057.2175/ml
VARIZIG 125/1.2 ML 53270012602 $1057.2175/ml
VARIZIG 125/1.2 ML 70504012601 $1099.5028/ml Increase
VARIZIG 125/1.2 ML 70504012602 $1099.5028/ml Increase
VARUBI 90 MG 69656010102 $283.7090/tablet
VECAMYL 2.5 MG 69413055840 $63.8320/tablet
VECTIBIX 100 MG/5ML 55513095401 $233.1019/ml
VECTIBIX 400MG/20ML 55513095601 $233.1024/ml
VELCADE 3.5 MG 63020004901 $1619.0300/each
VELETRI 0.5 MG 66215040301 $22.7856/each
VELETRI 1.5 MG 66215040201 $45.5712/each
VELSAR 10 MG 00013737686 $28.5830/each
VEMLIDY 25 MG 61958230101 $33.5916/tablet
VENCLEXTA STARTING PACK 10-50-100 00074057928 $53.5875/tablet
VENCLEXTA 10 MG 00074056111 $8.6860/tablet
VENCLEXTA 10 MG 00074056114 $8.6896/tablet
VENCLEXTA 100 MG 00074057611 $86.8903/tablet
VENCLEXTA 100 MG 00074057622 $86.8985/tablet
VENCLEXTA 50 MG 00074056607 $43.4502/tablet
VENCLEXTA 50 MG 00074056611 $43.4502/tablet
VENOGLOBULIN-I 2.5 G 49669160200 $78.7800/each
VENOGLOBULIN-I 5 G 49669160300 $157.5600/each
VENOGLOBULIN-S 10 % 68516162201 $11.6150/ml
VENOGLOBULIN-S 10 % 68516162301 $11.6150/ml
VENOGLOBULIN-S 10 % 68516162401 $11.6150/ml
VENOGLOBULIN-S 5 % 49669161201 $5.8075/ml
VENOGLOBULIN-S 5 % 68516161201 $5.8075/ml
VENOGLOBULIN-S 5 % 68516161301 $5.8075/ml
VENOGLOBULIN-S 5 % 68516161401 $5.8075/ml
VENTAVIS 10 MCG/ML 66215030200 $124.9370/ml
VENTAVIS 10 MCG/ML 66215030230 $124.9370/ml
VENTAVIS 20 MCG/2ML 10148010100 $27.2700/ml
VENTAVIS 20 MCG/2ML 10148010130 $27.2700/ml
VENTAVIS 20 MCG/ML 66215030300 $124.9370/ml
VENTAVIS 20 MCG/ML 66215030330 $124.9370/ml
VERZENIO 100 MG 00002481554 $197.4550/tablet Add
VERZENIO 150 MG 00002533754 $197.4550/tablet Add
VERZENIO 200 MG 00002621654 $197.4550/tablet Add
VERZENIO 50 MG 00002448354 $197.4550/tablet Add
VIADUR 120MCG/24H 00026971101 $4592.4700/each
VIDAZA 100 MG 59572010201 $591.0924/each
VIDAZA 100 MG 67211010201 $471.2357/each
VIDEX FNL10MG/ML 00087663241 $0.5597/ml
VIDEX FNL10MG/ML 00087663341 $0.6109/ml
VIEKIRA PAK 12.5-75-50 00074309328 $250.4529/tablet
VIEKIRA XR 8.33-50 MG 00074006328 $333.9373/tablet
VIGABATRIN 500 MG 49884035803 $97.7502/each
VIGABATRIN 500 MG 49884035852 $109.9671/each
VIMIZIM 5 MG/5 ML 68135010001 $224.4220/ml
Page 50 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
VINBLASTINE SULFATE 1 MG/ML 51309020220 $3.0250/ml
VINBLASTINE SULFATE 1 MG/ML 51309020230 $2.4220/ml
VINBLASTINE SULFATE 1 MG/ML 63323027810 $4.3501/ml
VINBLASTINE SULFATE 10 MG 00469162030 $26.7650/each
VINBLASTINE SULFATE 10 MG 51309020320 $28.2295/each
VINBLASTINE SULFATE 10 MG 61703031018 $35.2288/each
VIRACEPT 250 MG 49999043103 $2.1507/tablet
VIRACEPT 250 MG 52959028930 $3.0834/tablet
VIRACEPT 250 MG 54569454303 $2.8440/tablet
VIRACEPT 250 MG 54868394700 $2.3814/tablet
VIRACEPT 250 MG 55289047727 $4.6181/tablet
VIRACEPT 250 MG 60760001018 $2.6158/tablet
VIRACEPT 250 MG 60760001063 $2.4154/tablet
VIRACEPT 250 MG 63010001030 $3.7865/tablet
VIRACEPT 250 MG 66267051418 $2.6827/tablet
VIRACEPT 250 MG 66267051463 $2.5303/tablet
VIRACEPT 625 MG 35356011701 $9.4580/tablet
VIRACEPT 625 MG 54569557300 $7.1101/tablet
VIRACEPT 625 MG 63010002770 $9.4662/tablet
VIRAMUNE XR 100 MG 00597012990 $8.3929/tablet
VIRAMUNE 50 MG/5 ML 00054390558 $0.2421/ml
VIRAMUNE 50 MG/5 ML 00597004724 $0.7349/ml
VIRAMUNE 50 MG/5 ML 35356007224 $0.4244/ml
VIREAD 150 MG 61958040401 $33.2798/tablet
VIREAD 200 MG 61958040501 $33.2798/tablet
VIREAD 250 MG 61958040601 $33.2798/tablet
VIREAD 300 MG 35356007306 $34.6388/tablet
VIREAD 300 MG 35356007330 $32.8869/tablet
VIREAD 300 MG 54569533400 $43.6708/tablet
VIREAD 300 MG 54868466900 $38.2668/tablet
VIREAD 300 MG 61958040101 $35.9095/tablet
VIREAD 300 MG 68258900301 $19.5771/tablet
VIREAD 40MG/SCOOP 61958040301 $9.7901/gm
VISTOGARD 10 G 69468015104 $4053.1300/each
VISTOGARD 10 G 69468015120 $4053.1300/each
VISUDYNE 15 MG 00187560015 $1652.8751/each
VITEKTA 150 MG 61958130201 $40.5498/tablet
VIVAGLOBIN 16 % 00053759603 $19.3920/ml
VIVAGLOBIN 16 % 00053759615 $19.3920/ml
VIVAGLOBIN 16 % 00053759625 $19.3920/ml
VIVITROL 380 MG 65757030001 $1322.0900/each
VORAXAZE 1000 UNIT 50633021011 $29001.1400/each
VOSEVI 400-100 MG 61958240101 $898.9000/tablet
VOTRIENT 200 MG 00078067066 $92.7421/tablet
VPRIV 400 UNIT 54092070104 $1390.7700/each
VUMON 50 MG/5 ML 00015307597 $52.0332/ml
VYXEOS 44MG-100MG 68727074501 $7827.5000/each
VYXEOS 44MG-100MG 68727074502 $7827.5000/each
VYXEOS 44MG-100MG 68727074505 $7827.5000/each
WINRHO SDF 1500 UNIT 00944295004 $262.1960/each
WINRHO SDF 1500 UNIT 60492002301 $262.1960/each
Page 51 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
WINRHO SDF 1500/1.3ML 53270330001 $317.1478/ml
WINRHO SDF 1500/1.3ML 70504330002 $333.0048/ml Increase
WINRHO SDF 15000/13ML 53270300001 $319.1235/ml
WINRHO SDF 15000/13ML 70504300002 $335.0799/ml Increase
WINRHO SDF 2500/2.2ML 53270350001 $314.2890/ml
WINRHO SDF 2500/2.2ML 70504350002 $330.0037/ml Increase
WINRHO SDF 5000 UNIT 00944295006 $873.8520/each
WINRHO SDF 5000 UNIT 60492002401 $873.8520/each
WINRHO SDF 5000/4.4ML 53270310001 $314.2890/ml
WINRHO SDF 5000/4.4ML 70504310002 $330.0037/ml Increase
WINRHO SDF 600 UNIT 00944295002 $114.7360/each
WINRHO SDF 600 UNIT 60492002101 $114.7360/each
WINRHO SDF 600/0.5ML 00944296701 $247.8338/ml
XALKORI 200 MG 00069814120 $257.4027/capsule
XALKORI 250 MG 00069814020 $257.4027/capsule
XELJANZ XR 11 MG 00069050130 $127.7909/tablet
XELJANZ 5 MG 00069100101 $63.8955/tablet
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 $1280.1631/ml
XIAFLEX 0.9 MG 66887000301 $3971.2796/each
XIZFLUS 400-500/.4 69597092101 $117.1600/gm
XOFIGO 1100KBQ/ML 50419020801 $23171.8442/each
XOLAIR 150 MG 50242004062 $1074.0239/each
XOLAIR 75 MG 50242004201 $229.6033/each
XTANDI 40 MG 00469012599 $86.6717/capsule
XURIDEN 2 G 69468015202 $757.5300/each
XURIDEN 2 G 69468015230 $757.5000/each
XYREM 500 MG/ML 68727010001 $22.6299/ml
YERVOY 200MG/40ML 00003232822 $713.8369/ml
YERVOY 50 MG/10ML 00003232711 $713.8377/ml
YESCARTA 71287011901 $376730.0000/each Add
YONDELIS 1 MG 59676061001 $2837.1708/each
ZALTRAP 100 MG/4ML 00024584001 $404.0000/ml
ZALTRAP 200 MG/8ML 00024584101 $404.0000/ml
ZANOSAR 1 G 00703463601 $352.7223/each
ZARXIO 300MCG/0.5 61314030401 $556.8332/ml
ZARXIO 300MCG/0.5 61314030410 $556.8332/ml
ZARXIO 480MCG/0.8 61314031201 $554.2122/ml
ZARXIO 480MCG/0.8 61314031210 $554.2122/ml
ZAVESCA 100 MG 66215020118 $300.9800/capsule
ZAVESCA 100 MG 66215020190 $300.9800/capsule
ZEJULA 100 MG 69656010390 $165.5278/capsule
ZELAPAR 1.25 MG 00187045302 $68.5095/tablet
ZELBORAF 240 MG 50242009001 $45.6638/tablet
ZELBORAF 240 MG 50242009002 $45.6638/tablet
ZEMAIRA 1000 MG 00053720102 $0.5252/each
ZEPATIER 50MG-100MG 00006307401 $656.5260/tablet
ZEPATIER 50MG-100MG 00006307402 $656.5000/tablet
ZERIT 1 MG/ML 00003196801 $0.4323/ml
Page 52 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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Decrease
ZEVALIN 3.2MG/2ML 68152010303 $47680.9162/each
ZIAGEN 20 MG/ML 49702022248 $0.6180/ml
ZIAGEN 20 MG/ML 54569539000 $0.6181/ml
ZINBRYTA 150 MG/ML 00074003301 $7308.8650/ml
ZINECARD 250 MG 00013871562 $217.6449/each
ZINECARD 250 MG 00013871762 $237.2288/each
ZINECARD 500 MG 00013872589 $435.2898/each
ZINECARD 500 MG 00013872789 $474.4677/each
ZINPLAVA 1000 MG/40 00006302500 $95.9500/ml
ZOLADEX 10.8 MG 00310095130 $1833.1500/each
ZOLADEX 10.8 MG 00310096130 $1139.2598/each
ZOLADEX 3.6 MG 00310095036 $611.0500/each
ZOLADEX 3.6 MG 54569394300 $611.0742/each
ZOLEDRONIC ACID 4 MG/100ML 00409422901 $0.6060/ml
ZOLEDRONIC ACID 4 MG/100ML 25021082666 $0.6060/ml
ZOLEDRONIC ACID 4 MG/100ML 25021082667 $0.6060/ml
ZOLEDRONIC ACID 4 MG/100ML 25021082682 $1.8180/ml
ZOLEDRONIC ACID 4 MG/5 ML 00143964201 $60.6000/ml
ZOLEDRONIC ACID 4 MG/5 ML 00409421501 $8.8880/ml
ZOLEDRONIC ACID 4 MG/5 ML 16729024231 $20.2000/ml
ZOLEDRONIC ACID 4 MG/5 ML 17478032705 $11.3625/ml
ZOLEDRONIC ACID 4 MG/5 ML 17478032745 $11.3625/ml
ZOLEDRONIC ACID 4 MG/5 ML 23155017031 $12.7260/ml
ZOLEDRONIC ACID 4 MG/5 ML 25021080166 $36.3600/ml
ZOLEDRONIC ACID 4 MG/5 ML 25021080167 $12.1200/ml
ZOLEDRONIC ACID 4 MG/5 ML 42023015101 $14.1400/ml
ZOLEDRONIC ACID 4 MG/5 ML 43598033011 $9.0900/ml
ZOLEDRONIC ACID 4 MG/5 ML 45963044055 $60.6000/ml
ZOLEDRONIC ACID 4 MG/5 ML 47335003540 $75.7500/ml
ZOLEDRONIC ACID 4 MG/5 ML 51991006598 $9.0900/ml Add
ZOLEDRONIC ACID 4 MG/5 ML 55111068507 $20.2000/ml
ZOLEDRONIC ACID 4 MG/5 ML 60505611000 $12.1200/ml
ZOLEDRONIC ACID 4 MG/5 ML 63323096198 $49.4900/ml
ZOLEDRONIC ACID 4 MG/5 ML 67457039054 $12.8997/ml
ZOLEDRONIC ACID 4 MG 47335096241 $378.7500/each
ZOLEDRONIC ACID 5 MG/100ML 00409422801 $2.2725/ml
ZOLEDRONIC ACID 5 MG/100ML 23155018631 $3.0300/ml
ZOLEDRONIC ACID 5 MG/100ML 25021083082 $3.5350/ml
ZOLEDRONIC ACID 5 MG/100ML 42023016301 $2.0099/ml
ZOLEDRONIC ACID 5 MG/100ML 43598033111 $2.3735/ml
ZOLEDRONIC ACID 5 MG/100ML 51991006498 $3.0300/ml Add
ZOLEDRONIC ACID 5 MG/100ML 55111068852 $3.0300/ml
ZOLEDRONIC ACID 5 MG/100ML 63323096600 $3.0300/ml
ZOLEDRONIC ACID 5 MG/100ML 67457061910 $3.0300/ml
ZOLINZA 100 MG 00006056840 $114.9481/capsule
ZOMACTON 10 MG 55566190101 $585.8000/each
ZOMACTON 5 MG 55566180101 $292.9000/each
ZOMETA 4 MG/100ML 00078059061 $9.3170/ml
ZOMETA 4 MG/5 ML 00078038725 $186.3410/ml
ZORBTIVE 8.8 MG 44087338807 $1172.4989/each
ZORTRESS 0.25 MG 00078041720 $8.2956/tablet
Page 53 of 54
NAME OF DRUG Strength NDC
Price Effective
December 1, 2017
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ZORTRESS 0.25 MG 00078041761 $8.3022/tablet
ZORTRESS 0.5 MG 00078041420 $16.5913/tablet
ZORTRESS 0.5 MG 00078041461 $16.6145/tablet
ZORTRESS 0.75 MG 00078041520 $24.8867/tablet
ZORTRESS 0.75 MG 00078041561 $24.9066/tablet
ZUPLENZ 4 MG 43288010410 $19.9475/each
ZUPLENZ 4 MG 57881044401 $32.8600/each
ZUPLENZ 4 MG 57881044410 $32.8563/each
ZUPLENZ 4 MG 89141044430 $29.5708/each
ZUPLENZ 8 MG 43288010810 $19.9475/each
ZUPLENZ 8 MG 57881044801 $32.8600/each
ZUPLENZ 8 MG 57881044810 $32.8563/each
ZUPLENZ 8 MG 89141044830 $29.5708/each
ZYDELIG 100 MG 61958170101 $171.9783/tablet
ZYDELIG 150 MG 61958170201 $171.9783/tablet
ZYKADIA 150 MG 00078064070 $106.4098/capsule
ZYPREXA RELPREVV 210 MG 00002763511 $595.5768/each
ZYPREXA RELPREVV 210 MG 00002765801 $595.6038/each
ZYPREXA RELPREVV 300 MG 00002763611 $850.8240/each
ZYPREXA RELPREVV 300 MG 00002765901 $850.8577/each
ZYPREXA RELPREVV 405 MG 00002763711 $1148.6124/each
ZYPREXA RELPREVV 405 MG 00002766001 $1148.6596/each
ZYTIGA 250 MG 57894015012 $79.0820/tablet
ZYTIGA 500 MG 57894019506 $158.1640/tablet
ZYVOX 100 MG/5ML 00009513601 $8.2137/ml
ZYVOX 200MG/0.1L 00009513701 $0.0000 Delete
ZYVOX 200MG/0.1L 00009513704 $0.6060/ml
ZYVOX 600MG/300 00009499201 $0.2693/ml
ZYVOX 600MG/300 00009499202 $0.2693/ml
ZYVOX 600MG/300 00009514004 $0.2693/ml
ZYVOX 600MG/300 00009780701 $0.2693/ml
ZYVOX 600MG/300 00009780702 $0.2693/ml
Page 54 of 54
