ProcCode NDC Description Facility Non-Facility Effective Date End/Obsolete Date

J0129 Abatacept 10 mg, injection (Orencia) $18.73 $18.73 3/1/2020J0586 AbobotulinumtoxinA, 5 units (Dysport) $7.57 $7.57 3/1/2020J0178 Aflibercept, 1 mg, injection (Eylea) $982.43 $982.43 3/1/2020J0202 Alemtuzumab, 1 mg (Lemtrada) $1,831.01 $1,831.01 3/1/2020J0221 Alglucosidase alfa, 10 mg, injection (Lumizyme) $148.61 $148.61 3/1/2020J7308 Aminolevulinic acid HCI for topical admin. 20% single unit dosage form (354 mg) (Levulan) (Kerastick) $109.98 $109.98 3/1/2020J7196 Antithrombin (recombinant), 50 IU (ATryn) $105.51 $105.51 3/1/2020J3590 Asfotase alfa 1 mg (Strensiq) $75.60 $75.60 11/1/2015J9999 Avelumab injection, 1 mg (Bavencio) $8.12 $8.12 4/1/2017J0485 Belatacept, 1 mg, injection (Nulojix) $3.81 $3.81 3/1/2020J0490 Belimumab, 10 mg, injection (Benlysta) $38.49 $38.49 3/1/2020J0179 Brolucizumab-dbll injection 1 mg (Beovu) $333.46 $333.46 3/1/2020J0597 C1 Esterase Inhibitor (human), 10 units (Berinert) $27.59 $27.59 3/1/2020J0598 C1 esterase inhibitor (human), 10 units, injection (Cinryze) $43.64 $43.64 3/1/2020J0638 Canakinumab, 1 mg vial (Ilaris) $89.35 $89.35 3/1/2020J0716 Centruriodes Immune F(ab), 120 mg (Anascorp) $3,945.28 $3,945.28 3/1/2020J3590 Cerliponase alfa injection 1 kit (Brineura) $29,160.00 $29,160.00 6/1/2017J0717 Certolizumab pegol, 1 mg, injection (Cimzia) $5.45 $5.45 3/1/2020J0775 Collagenase clostridium histolyticum, 0.01 mg (Xiaflex) $37.59 $37.59 3/1/2020J0791 Crizanlizumab-tmca injection 5 mg (Adakveo) $122.44 $122.44 7/1/2020J0897 Denosumab, 1 mg (Xgeva) (Prolia) $14.46 $14.46 3/1/2020J1300 Eculizumab, 10 mg, injection (Soliris) $176.76 $176.76 3/1/2020J9358 fam-trastuzumab deruxtecan-nxki for injection 1 mg (Enhertu) $24.19 $24.19 7/1/2020J1458 Galsulfase injection for intravenous use 1 mg (Naglazyme) $399.53 $399.53 3/1/2020J1602 Golimumab Hydrochloride 1 mg (Simponi Aria) $25.82 $25.82 3/1/2020J7178 Human fibrinogen concentrate, 1 mg, injection (RiaSTAP) $0.98 $0.98 3/1/2020J3590 Human Topical Protein, 1 IU (Recothrom) $0.02 $0.02 1/1/2015J1744 Icatibant acetate, 1 mg (Firazyr) $152.40 $152.40 3/1/2020J3590 Idarucizumab injection 2.5 g/50 ml (Praxbind) $1,890.00 $1,890.00 10/1/2015J3590 Immune Globulin Subcutaneous, 20% solution 100 mg (Cuvitru) $18.14 $18.14 11/1/2016J0588 IncobotulinumtoxinA, 1 unit (Xeomin) $5.54 $5.54 3/1/2020J3590 inebilizumab-cdon injection 1 mg (Uplizna) $471.60 $471.60 7/23/2020J9227 isatuximab-irfc injection 10 mg (Sarclisa) $66.67 $66.67 10/11/2020J3590 Peanut (Arachis hypogaea) allergen powder-dnfp 1 daily dose (Palforzia) $32.04 $32.04 4/2/2020Q5108 Pegfilgrastim-jmdb injection 0.5 mg (Fulphila) $387.23 $387.23 3/1/2020S0145 Peginterferon Alfa-2a, 180 mcg/ml (Pegasys) $337.13 $337.13 3/1/2020J3590 Peginterferon Alfa-2b, 1 mcg (Sylatron) $3.10 $3.10 1/1/2015J2507 Pegloticase, 1 mg (Krystexxa) $302.72 $302.72 3/1/2020S0148 Pegylated interferon alfa-2b, 10 mcg (Peg-Intron) $105.30 $105.30 3/1/2020J9306 Pertuzumab, 1 mg, injection (Perjeta) $10.84 $10.84 3/1/2020J2724 Protein C concentrate, intravenous, human, 1 IU, injection (Ceprotin) $12.21 $12.21 3/1/2020J3590 Prothrombin complex concentrate (Human) 1 IU (Kcentra) $2.04 $2.04 1/1/2015J2778 Ranibizumab, 0.1 mg, injection (Lucentis) $406.05 $406.05 3/1/2020J2786 Reslizumab injection 1 mL(Cinqair) $94.69 $94.69 3/1/2020J2793 Rilonacept, 1 mg injection (Arcalyst) $24.59 $24.59 3/1/2020J3590 Secukinumab injection 150 mg (Cosentyx) $3,656.66 $3,656.66 4/1/2015J9999 tafasuitamab-cxix for injection 1 mg (Monjuvi) $6.48 $6.48 8/10/2020J3262 Tocilizumab, 1 mg (Actemra) $3.48 $3.48 3/1/2020J3357 Ustekinumab Injection for subcutaneous use, 1 mg (Stelara) $112.10 $112.10 3/1/2020J3358 Ustekinumab injection for intravenous use, 1 mg (Stelara IV) $13.49 $13.49 3/1/2020J3385 Velaglucerase Alfa, 100 units (VPRIV) $351.28 $351.28 3/1/2020J9400 Ziv-aflibercept, 1 ml or 25 mg, injection (Zaltrap) $9.96 $9.96 3/1/2020

J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg (17P) $19.80 $19.80 1/1/2015J0130 Abciximab, 10mg, injection (ReoPro) $423.96 $423.96 3/1/2020J1120 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.71 $16.71 3/1/2020J0133 Acyclovir, 5 mg, injection (Zovirax) $0.02 $0.02 3/1/2020J0153 Adenosine injection 1 mg (Adenoscan, Adenocard) $0.93 $0.93 3/1/2020J9354 Ado-trastuzumab Emtansine, 1 mg, injection (Kadcyla) $32.11 $32.11 3/1/2020J0180 Agalsidase Beta, 1 mg, injection (Fabrazyme) $129.86 $129.86 3/1/2020P9047 Albumin (human), 25%, 50 ml, infusion (Albuminar, Albutein, Bluminate), Plasbumin $40.22 $40.22 3/1/2020P9041 Albumin (human), 5%, 50 ml, infusion (Albiminar, Albutein, Buminate, Plasbumin) $20.10 $20.10 3/1/2020J9015 Aldesleukin, per single use vial (Proleukin, etc) $769.05 $769.05 3/1/2020J0215 Alefacept, 0.5 mg, injection (Amevive) $26.71 $26.71 3/1/2020J0205 Alglucerase, per 10 units, injection (Ceredase) $39.75 $39.75 3/1/2020J0220 Alglucosidase alfa, 10 mg, injection (Myozyme) $127.47 $127.47 3/1/2020J0257 Alpha 1 proteinase inhibitor (human), 10 mg (Glassia) $3.86 $3.86 3/1/2020J0256 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) (Aralast, Zemaira) $3.67 $3.67 3/1/2020J2997 Alteplase recombinant, 1 mg, injection (Activase) $32.24 $32.24 3/1/2020J0207 Amifostine, 500mg, injection (Ethyol) $512.32 $512.32 3/1/2020J0278 Amikacin sulfate, 100 mg, injection (Amikin) $0.73 $0.73 3/1/2020J0280 Aminophylline, up to 250mg, injection $0.37 $0.37 3/1/2020J0300 Amobarbital, up to 125mg, injection (Amytal) $11.98 $11.98 3/1/2020J0285 Amphotericin B, 50 mg, injection (Amphocin) (Fungizone) $12.00 $12.00 3/1/2020J0288 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotec) $12.02 $12.02 3/1/2020J0287 Amphotericin B lipid complex, 10 mg, injection (Abelcet) $10.48 $10.48 3/1/2020J0289 Amphotericin B liposome, 10 mg, injection (Ambisome) $17.19 $17.19 3/1/2020J0290 Ampicillin sodium, 500mg, injection $2.25 $2.25 3/1/2020J0295 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $4.41 $4.41 3/1/2020J7188 Antihemophilic factor (recombinant) porcine sequence 1 IU (Orbizur) $5.85 $5.85 3/1/2020J7199 Antihempohilic factor VIII (recombinant) 1 IU (Nuwiq) $1.92 $1.92 3/1/2020J7197 Antithrombin III (human), per IU (Throbate III) $1.91 $1.91 3/1/2020J3490 Aprepitant injectable emulsion, for intravenous use 1 mg (Cinvanti) $2.45 $2.45 1/4/2018

DRUGS

BIOLOGICALS

Physician Drug Program Procedure Codes And RatesEffective March 1, 2020

The inclusion of a rate on this table does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Policies on the DMA Web Site.

Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes, and deletion to this schedule.

****Please note: LARCs, Vaccines, and Clotting Factor rates are priced off of the NDC.****

J0400 Aripiprazole, intramuscular, 0.25 mg, injection (Abilify) $0.29 $0.29 3/1/2020J0401 Aripiprazole, extended release, 1 mg, injection $4.04 $4.04 3/1/2020J1943 Aripiprazole, lauroxil extended-release injectable suspension 1 mg (Aristada Initio) $3.00 $3.00 3/1/2020J9017 Arsenic trioxide, 1 mg (Trisenox) $34.55 $34.55 3/1/2020J9020 Asparaginase, 10,000 units (Elspar) $57.14 $57.14 3/1/2020J9019 Asparaginase Erwinia Chrysanthemi, 1,000 IUs, injection (Erwinaze) $334.98 $334.98 3/1/2020J0461 Atropine sulfate, 0.01 mg, injection $0.04 $0.04 3/1/2020J9025 Azacitidine 1 mg (Vidaza) $4.49 $4.49 3/1/2020J0456 Azithromycin, 500mg, injection (Zithromax) $18.02 $18.02 3/1/2020Q0144 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, Zithromax Z-Pak) $21.78 $21.78 3/1/2020J0475 Baclofen, 10mg, injection (Lioresal) $191.26 $191.26 3/1/2020J0476 Baclofen, 50 mcg for intrathecal trial, injection (Lioresal) $69.91 $69.91 3/1/2020J9031 BCG live (intravesical), per installation (Tice BCG, Theracys) $113.99 $113.99 3/1/2020J9032 Belinostat 10 mg (Beleodaq) $34.13 $34.13 3/1/2020J9033 Bendamustine HCl, 1 mg, injection (Treanda) $18.65 $18.65 3/1/2020J0702 Betamethasone acetate and betamethasone sodium phosphate, per 3mg, injection (Celestone)

(Soluspan)$5.76 $5.76 3/1/2020

J9035 Bevacizumab, 10 mg, injection (Avastin) $57.57 $57.57 3/1/2020Q5118 Bevacizumab-bzr injection 10 mg (Zirabev) $69.56 $69.56 3/1/2020J7351 Bimatoprost implant, for intracameral administration, 1 mcg (Durysta) $210.60 $210.60 10/1/2020J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.09 $29.09 3/1/2020J9039 Blinatumomab (Blincyto), 1 mcg $102.98 $102.98 3/1/2020J9041 Bortezomib, 0.1 mg, inj. (Velcade) $34.50 $34.50 3/1/2020J0585 Botulinum toxin type A, per unit (Botox) $5.96 $5.96 3/1/2020J0587 Botulinum toxin type B, per 100 units (Myobloc) $8.73 $8.73 3/1/2020J9042 Brentuximab vedotin, 1 mg (Adcetris) $99.19 $99.19 3/1/2020Q9991 Buprenorphine extended-release injection (< or = 100 mg) (Sublocade) $1,758.54 $1,758.54 3/1/2020Q9992 Buprenorphine extended-release injection (> 100 mg) (Sublocade) $1,758.54 $1,758.54 3/1/2020J0570 Buprenorphine implant, 74.2 mg (Probuphine) $1,344.55 $1,344.55 3/1/2020J0595 Butorphinol tartrate, 1 mg, injection (Stadol) $0.50 $0.50 3/1/2020J9043 Cabazitaxel, 1 mg (Jevtana) $135.47 $135.47 3/1/2020J9118 Calaspargase pegol-mknl injection 10 Units (Asparlas) $72.58 $72.58 3/1/2020J0636 Calcitriol, 0.1 mcg, injection (Calcijex) $0.43 $0.43 3/1/2020J0610 Calcium gluconate, per 10ml, injection $0.36 $0.36 3/1/2020J0620 Calcium glycerophosphate and calcium lactate, per 10ml, injection (Calphosan) $12.60 $12.60 1/1/2015J3590 caplacizumab-yhdp for injection 11 mg (Cablivi) $7,884.00 $7,884.00 2/25/2019J7336 Capsaicin 8% patch, per 1 square cm (Qutenza) $3.00 $3.00 3/1/2020J9045 Carboplatin, 50 mg (Paraplatin) $6.32 $6.32 3/1/2020J9047 Carfilzomib, 1 mg injection (Kyprolis) $31.11 $31.11 3/1/2020J9050 Carmustine, 100 mg (BiCNU) $157.16 $157.16 3/1/2020J0690 Cefazolin Sodium, 500 mg, Injection $0.66 $0.66 3/1/2020J0692 Cefepime HCL, 500 mg, injection (Maxipime) $6.76 $6.76 3/1/2020J0698 Cefotaxime Sodium, per 1 g (Claforan) $4.30 $4.30 3/1/2020J0694 Cefoxitin Sodium, 1g, injection (Mefoxin) $8.21 $8.21 3/1/2020J0712 Ceftaroline Fosamil Acetate, 10 mg (Teflaro) $0.74 $0.74 3/1/2020J0714 Ceftazidime; avibactam injection 0.625 g (Avycaz) $80.80 $80.80 3/1/2020J0713 Ceftazidime, per 500 mg, injection (Fortaz, Tazidime) $3.48 $3.48 3/1/2020J0715 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.25 $5.25 3/1/2020J0695 Ceftolozane/Tazobactam 75 mg, 1-0.5 gm vial (Zerbaxa) $4.70 $4.70 3/1/2020J0696 Ceftriaxone Sodium, per 250mg, injection (Rocephin) $1.48 $1.48 3/1/2020J0697 Cefuroxime sodium, per 750mg, injection (Zinacef) $3.45 $3.45 3/1/2020J9119 cemiplimab-rwlc injection, 1 mg (Libtayo) $27.45 $27.45 10/1/2019J1201 Cetrizine hydrochloride injection .5 mg (Quzyttir) $16.20 $16.20 7/1/2020J9119 cemiplimab-rwlc injection, 1 mg (Libtayo) $27.45 $27.45 3/1/2020J9055 Cetuximab, 10 mg, injection (Erbitux) $49.92 $49.92 3/1/2020J0720 Chloramphenicol sodium succinate, up to 1g, injection (Chloromycetin) $18.42 $18.42 3/1/2020J1990 Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $21.09 $21.09 3/1/2020J2400 Chloroprocaine HCl, per 30 ml, injection (Nesacaine) $12.75 $12.75 3/1/2020J1205 Chlorothiazide sodium, per 500 mg, injection (Diuril Sodium) $165.48 $165.48 3/1/2020J3230 Chlorpromazine HCl, up to 50 mg, injection (Thorazine) $3.23 $3.23 3/1/2020J0725 Chorionic Gonadotropin, per 1,000 USP units, injection (Novarel, Pregnyl, Profasil HP) $3.38 $3.38 3/1/2020J0740 Cidofovir, 375 mg, injection (Vistide) $764.08 $764.08 3/1/2020J0743 Cilastatin sodium imipenem, per 250mg, injection (Primaxin IM or IV) $14.31 $14.31 3/1/2020S0023 Cimetidine hydrochloride, 300 mg, injection (Tagamet) $0.61 $0.61 3/1/2020J0744 Ciprofloxacin for IV infusion, 200 mg, injection (Cipro) $5.35 $5.35 3/1/2020J9060 Cisplatin, powder or solution, per 10 mg $2.27 $2.27 3/1/2020J9065 Cladribine, per 1 mg, injection (Leustatin) $30.70 $30.70 3/1/2020J3490 Clevidipine injectable emulsion (Cleviprex) $2.89 $2.89 11/1/2016J0735 Clonidine hydrochloride, 1mg, 1 IU injection (Duracion) $56.12 $56.12 3/1/2020J7199 Coagulation factor IX (recombinant) vials (Ixinity) $1.92 $1.92 3/1/2020J7169 Coagulation factor Xa (recombinant) 10 mg (Andexxa) $297.00 $297.00 7/1/2020J0745 Codeine phosphate, per 30mg, injection $1.27 $1.27 3/1/2020J0770 Colistimethate Sodium,150 mg, injection (Coly-Mycin M) $19.93 $19.93 3/1/2020S4993 Contraceptive pills for birth control, 1 tablet $3.15 $3.15 3/1/2020J9999 Copanlisib injection, 1 mg (Aliqopa) $75.60 $75.60 9/18/2017J0800 Corticotropin, up to 40 units, injection (Acthar, ACTH) $2,360.58 $2,360.58 3/1/2020J0834 Cosyntropin, 0.25 injection (Cortrosyn) $91.38 $91.38 3/1/2020J3590 Crotalidae immune f(ab')2 (equine), lyophilized powder for solution 1 vial (Anavip) $1,317.60 $1,317.60 11/2/2018J0840 Crotalidae polyvalent immune fab (ovine) powder for solution for intravenous injection, up to 1 gram (1

vial) (CroFab)$2,194.76 $2,194.76 3/1/2020

J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar) $1.87 $1.87 3/1/2020J9100 Cytarabine, 100 mg (Cytosar-U) $1.20 $1.20 3/1/2020J9098 Cytarabine Liposome, 10 MG (Depocyt) $415.84 $415.84 3/1/2020J7070 D-5-W, 1,000 cc, infusion $2.18 $2.18 3/1/2020J9130 Dacarbazine, 100 mg (DTIC- Dome) $4.61 $4.61 3/1/2020J7513 Daclizumab, parenteral, 25 mg (Zenapax) $316.36 $316.36 3/1/2020J9120 Dactinomycin, 0.5 mg (Cosmegen) $494.49 $494.49 3/1/2020J0875 Dalbavancin hydrochloride 5 mg (Dalvance) $15.31 $15.31 3/1/2020J1645 Dalteparin sodium, per 2500 IU, injection (Fragmin) $10.81 $10.81 3/1/2020J0878 Daptomycin, 1 mg (Cubicin) $0.35 $0.35 3/1/2020J0881 Darbepoetin alfa, 1 mcg, (for non-ESRD use), injection (Aranesp) $2.78 $2.78 3/1/2020J0882 Darbepoetin alfa for ESRD on dialysis, 1 mcg (Aranesp) $2.78 $2.78 3/1/2020J9151 Daunorubicin citrate, liposomal formulation, 10 mg (Daunoxome) $56.18 $56.18 3/1/2020J9150 Daunorubicin HCl, 10 mg (Cerubidine) $17.17 $17.17 3/1/2020J0894 Decitabine, 1 mg, injection (Dacogen) $27.17 $27.17 3/1/2020J0895 Deferoxamine Mesylate, 500mg, injection (Desferal) $12.33 $12.33 3/1/2020J9155 Degarelix, 1 mg, injection (Firmagon) $2.88 $2.88 3/1/2020J3490 Delafloxacin for injection 300 mg (Baxdela) $0.48 $0.48 11/12/2017

J9160 Denileukin Diftitox, 300 mcg (Ontak) $1,413.07 $1,413.07 3/1/2020J1000 Depo-estradiol cypionate, up to 5mg, injection (Depo-Estradiol) $6.19 $6.19 3/1/2020J2597 Desmopressin acetate, per 1 mcg, injection (DDAVP) $1.87 $1.87 3/1/2020J1094 Dexamethasone acetate, 1 mg, injection (Dalalone DP, Dexasone LA, Dexone LA, Cortastat LA) $0.23 $0.23 3/1/2020

J1095 Dexamethasone Intraocular suspension 9% 1 mcg (Dexycu) $1.30 $1.30 3/1/2020J7312 Dexamethasone, Intravitreal implant, 0.1 mg (Ozurdex) $196.37 $196.37 3/1/2020J1096 Dexamethasone ophthalmic insert 0.4 mg, 1 mg (Dextenza) $152.75 $152.75 3/1/2020J1100 Dexamethasone sodium phosphate, 1mg, injection (Cortastat, Dalalone) (Hexadrol) $0.08 $0.08 3/1/2020J1190 Dexrazoxane hydrochloride, per 250 mg, injection (Zinecard) (Totect) $181.33 $181.33 3/1/2020J7042 Dextrose 5% / normal saline (500 ml = 1 unit) $0.28 $0.28 3/1/2020J7060 Dextrose 5% / water (500 ml = 1 unit) $1.09 $1.09 3/1/2020J7121 Dextrose 5% in lactated ringers infusion, up to 1000 cc (Dextrose) $2.22 $2.22 3/1/2020J3360 Diazepam, up to 5 mg, injection (Valium, Zetran) $0.79 $0.79 3/1/2020J1730 Diazoxide, up to 300 mg, injection (Hyperstat IV) (Proglycern) $112.09 $112.09 3/1/2020J0500 Dicyclomine HCl, up to 20mg, injection (Bentyl, Dilomine) $11.94 $11.94 3/1/2020J3490 Defibrotide sodium injection, for intravenous use 1 ml (Defitelio) $356.40 $356.40 4/1/2016J1160 Digoxin, up to 0.5 mg injection (Lanoxin) $1.18 $1.18 3/1/2020J1110 Dihydroergotamine mesylate, per 1mg, injection (DHE 45) $24.55 $24.55 3/1/2020J1240 Dimenhydrinate, up to 50 mg, injection $3.13 $3.13 3/1/2020J0470 Dimercaprol, per 100mg, injection (BAL in oil) $26.72 $26.72 3/1/2020J9999 Dinutuximab Vial 1 ml (Unituxin) $1,603.80 $1,603.80 8/1/2015J1200 Diphenhydramine HCl, up to 50 mg, injection (Benadryl) $0.75 $0.75 3/1/2020J1245 Dipyridamole, per 10 mg, injection (Persantine IV) $0.73 $0.73 3/1/2020J1212 DMSO, dimethyl sulfoxide, 50%, 50 ml, injection $50.60 $50.60 3/1/2020J1250 Dobutamine HCl, per 250 mg, injection (Dobutrex) $5.16 $5.16 3/1/2020J9171 Docetaxel, 1 mg, injection (Taxotere) $17.65 $17.65 3/1/2020J1260 Dolasetron mesylate, 10 mg, injection (Anzemet) $4.20 $4.20 3/1/2020J1265 Dopamine HCI, 40 mg, injection $0.51 $0.51 3/1/2020J1267 Doripenem, 10 mg, injection (Doribax) $0.65 $0.65 3/1/2020J1270 Doxercalciferol, 1 mcg, injection (Hectorol) $2.81 $2.81 3/1/2020J9000 Doxorubicin HCl, 10 mg (Adriamycin) $4.76 $4.76 3/1/2020Q2049 Doxorubicin HCL Liposomal, Imported Lipodox. 10 mg (Doxil) $499.24 $499.24 3/1/2020Q2050 Doxorubicin Hydrochloride, Injection, Liposomal, Not otherwise specified, 10 mg $579.32 $579.32 3/1/2020J1790 Droperidol, up to 5 mg, injection (Inapsine) $1.32 $1.32 3/1/2020J1290 Ecallantide, 1 mg (Kalbitor) $275.82 $275.82 3/1/2020J3490 Edaravone injection (Radicava) 1 mg $19.55 $19.55 8/15/2017J0600 Edetate calcium disodium, up to 1000mg, injection (Calcium EDTA) $50.34 $50.34 3/1/2020J3590 Elapegademase-lvir injection 1 mg (Revcovi) $4,435.20 $4,435.20 11/28/2018J1322 Elosulfase alfa, injection 1mg (Vimizim) $239.80 $239.80 3/1/2020J9210 Emapalumab-lzsg injection (1 mg) (Gamifant) Manual Pricing Manual Pricing 12/28/2018J9177 Enfortumab vedotin-ejfv for injection .25 mg (Padcev) $27.96 $27.96 7/1/2020J1650 Enoxaparin sodium, 10 mg, injection (Lovenox) $5.91 $5.91 3/1/2020J0122 Ervacucline for injection 1 mg (Xerava) $1.00 $1.00 3/1/2020J0171 Adrenalin, epinephrine, 0.1 mg ampule, injection (Adrenalin) $0.04 $0.04 3/1/2020J9178 Epirubicin HCl, 2 mg, inj. (Ellence) $6.26 $6.26 3/1/2020Q4081 Epoetin Alfa, 100 units (for ESRD on dialysis), injection (Epogen, Procrit) $0.91 $0.91 3/1/2020Q5105 Epoetin Alfa, biosimilar injection (for ESRD on dialysis), 100 units (Retacrit) $1.23 $1.23 3/1/2020Q5106 Epoetin Alfa-epbx injection (for non-ESRD use), 1000 units (Retacrit) $12.27 $12.27 3/1/2020J0885 Epoetin alfa (for non-ESRD use), 1000 units, injection (Epogen, Procrit) $9.09 $9.09 3/1/2020J0887 Epoetin beta ESRD use, 1 microgram injection (Mircera) $2.02 $2.02 3/1/2020J0888 Epoetin beta non ESRD use, 1 microgram injection $2.02 $2.02 3/1/2020J1325 Epoprostenol, 0.5 mg, injection (Flolan) $14.39 $14.39 3/1/2020J3032 eptinezumab-jjmr injection 1 mg (Vyepti) $16.15 $16.15 10/1/2020J9179 Eribulin Mesylate, 0.1 mg (Halaven) $90.23 $90.23 3/1/2020J1335 Ertapenem, 500 mg, injection (Invanz) $25.56 $25.56 3/1/2020J1364 Erythromycin lactobionate, per 500 mg, injection (Erthrocin) $6.77 $6.77 3/1/2020J3490 Esketamine nasal spray 1 device (28 mg) (Spravato) $318.60 $318.60 3/8/2019J1380 Estradiol valerate, up to 10 mg, injection (Delestrogen) $8.63 $8.63 3/1/2020J1410 Estrogen conjugated, per 25 mg, injection (Premarin IV) $71.40 $71.40 3/1/2020J0606 Etelcalcetide injection 0.1 mg (Parsabiv) $3.71 $3.71 3/1/2020J1436 Etidronate disodium, per 300 mg, injection (Didronel) $71.56 $71.56 3/1/2020J9181 Etoposide, 10 mg (VePesid) $0.40 $0.40 3/1/2020J7191 Factor VIII (antihemophilic factor (porcine)), per IU (Hyate C) $1.86 $1.86 3/1/2020J3010 Fentanyl Citrate, 0.1 mg, injection (Sublimaze) $0.28 $0.28 3/1/2020J1439 Ferric Carboxymaltos injection, 1 mg $1.17 $1.17 3/1/2020Q0138 Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use), injection (Feraheme) $0.83 $0.83 3/1/2020

Q0139 Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis), injection (Feraheme)

$0.83 $0.83 3/1/2020

J1442 Filgrastim (G-CSF), 1 mcg, injection (Neupogen) $1.06 $1.06 3/1/2020Q5110 Filgrastim-aafi injection 1 mcg (Nivestym) $0.83 $0.83 3/1/2020J9200 Floxuridine, 500 mg (FUDR) $51.23 $51.23 3/1/2020J7311 Fluocinolone acetonide intravitreal 1 implant (Retisert) $21,907.52 $21,907.52 3/1/2020J7313 Fluocinolone acetonide intravitreal implant 0.01 mg (Iluvien) $515.49 $515.49 3/1/2020J7314 Fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq) $525.42 $525.42 3/1/2020J9185 Fludarabine phosphate, 50 mg, injection (Fludara) $201.18 $201.18 3/1/2020J9190 Fluorouracil, 500 mg (Adrucil) $1.87 $1.87 3/1/2020J2680 Fluphenazine decanoate, up to 25 mg, injection (Prolixin) $2.37 $2.37 3/1/2020J1652 Fondaparinux sodium, 0.5 mg, injection (Arixtra) $6.25 $6.25 3/1/2020J1453 Fosaprepitant, 1 mg, injection (Emend) $1.57 $1.57 3/1/2020J1455 Foscarnet sodium, per 1,000 mg, injection (Foscavir) $10.40 $10.40 3/1/2020J9395 Fulvestrant, 25 mg, injection (Faslodex) $81.54 $81.54 3/1/2020J1940 Furosemide, up 20 mg, injection (Lasix) $0.19 $0.19 3/1/2020J1570 Ganciclovir sodium, 500 mg, injection (Cytovene) $43.94 $43.94 3/1/2020J1580 Gentamicin, up to 80 mg, injection $1.04 $1.04 3/1/2020J9201 Gemcitabine HCl, 200 mg (Gemzar) $132.06 $132.06 3/1/2020J9199 Gemcitabine in sodium chloride injection 200 mg (Infugem) $86.18 $86.18 3/1/2020J9203 Gemtuzumab Ozogamicin, 0.1 mg, injection (Mylotarg) $202.81 $202.81 3/1/2020J0223 Givosiran injection, for subcutaneous use .5 mg (Givlaari) $107.18 $107.18 7/1/2020J1610 Glucagon hydrochloride, per 1 mg, injection (GlucaGen) $68.80 $68.80 3/1/2020J1600 Gold sodium thiomalate, up to 50 mg, injection (Myochrysine, Aurolate) $7.86 $7.86 3/1/2020J9202 Goserelin acetate implant, per 3.6 mg (Zoladex) $190.13 $190.13 3/1/2020J1626 Granisetron hydrochloride, 100 mcg, injection (Kytril) $4.97 $4.97 3/1/2020J1631 Haloperidol decanoate, per 50 mg, injection (Haldol Decanoate-50) $2.41 $2.41 3/1/2020J1630 Haloperidol, up to 5 mg, injection (Haldol) $1.73 $1.73 3/1/2020J1640 Hemin, 1 mg, injection (Panhematin) $7.32 $7.32 3/1/2020J1642 Heparin sodium, per 10 units, injection (Heparin Lock Flush) $0.04 $0.04 3/1/2020J1644 Heparin sodium, per 1,000 units, injection (Heparin) $0.07 $0.07 3/1/2020

J9225 Histrelin implant (Vantas), 50 mg $1,511.33 $1,511.33 3/1/2020J9226 Histrelin implant (Supprelin LA), 50 mg $14,687.27 $14,687.27 3/1/2020J3470 Hyaluronidase injection up to 150 units (Hydase, Amphadase, Vitrase) $17.31 $17.31 3/1/2020J3473 Hyaluronidase, recombinant, 1 USP unit (Hylenex) $0.41 $0.41 3/1/2020J0360 Hydralazine HCl, up to 20mg, injection (Apresoline) $6.08 $6.08 3/1/2020J1720 Hydrocortisone sodium succinate, up to 100 mg, injection (A-Hydrocort, Solu-Cortef) $2.23 $2.23 3/1/2020J1170 Hydromorphone, up to 4 mg, injection (Dilaudid) $1.28 $1.28 3/1/2020J1729 Hydroxyprogesterone caproate injection, 10 mg $17.47 $17.47 3/1/2020J1726 Hydroxyprogestorone caproate, 10 mg, injection (Makena) $34.67 $34.67 3/1/2020J3410 Hydroxyzine HCl, up to 25 mg, injection (Vistaril) $0.14 $0.14 3/1/2020J1980 Hyoscyamine sulfate, up to 0.25 mg, injection (Levsin) $9.31 $9.31 3/1/2020J3590 Ibalizumab-uiyk injection 1 mg (Trogarzo) $6.13 $6.13 4/1/2018J1740 Ibandronate sodium, 1 mg (Boniva) $139.27 $139.27 3/1/2020J1742 Ibutilide fumarate, 1 mg, injection (Corvert) $323.99 $323.99 3/1/2020J9211 Idarubicin HCl, 5 mg (Idamycin) $276.66 $276.66 3/1/2020J1743 Idursulfase, 1 mg, injection (Elaprase) $456.01 $456.01 3/1/2020J9208 Ifosfamide, per 1 g (Ifex) $38.00 $38.00 3/1/2020J1786 Imiglucerase, 10 units, injection (Cerezyme) $42.07 $42.07 3/1/2020J0742 Imipenem, cilastatin, and relebactam for injection 10 mg (Recarbrio) $2.31 $2.31 7/1/2020J1575 Immune Globulin Infusion 10% (Human) with recombinant human hyaluronidase 100 mg (Hyqvia) $11.37 $11.37 3/1/2020

J1599 Immune Globulin intravenous, human-ifas 500 mg (Panzyga) $94.12 $94.12 3/1/2020J1599 Immune Globulin intravenous, human-slra 10% liquid 500 mg (Asceniv) $490.86 $490.86 11/18/2019J1558 Immune Globulin subcutaneous, human - klhw 20% solution 100 mg (Xembify) $16.84 $16.84 7/1/2020J1745 Infliximab, 10 mg, injection (Remicade) $55.16 $55.16 3/1/2020Q5104 Infliximab-abda, biosimilar, injection 10 mg (Renflexis) $57.38 $57.38 3/1/2020J0185 Injection, aprepitant, 1 mg (Cinvanti) $2.21 $2.21 3/1/2020J1944 Injection, aripiprazole lauroxil, 1 mg (Aristada) $2.92 $2.92 3/1/2020J9022 Injecton, atezolizumab, 10 mg (Tecentriq) $79.58 $79.58 3/1/2020J9023 Injection, avelumab, 10 mg (Bavencio) $83.34 $83.34 3/1/2020J9034 Injection, bendamustine hcl (Bendeka), 1 mg $24.87 $24.87 3/1/2020Q5107 Inection, bevacizumab, (Mvasi) 10 mg $76.82 $76.82 3/1/2020J0565 Injection, bezlotoxumab, 10 mg (Zinplava) $43.09 $43.09 3/1/2020J9044 Injection, bortezomib, 0.1 mg $37.45 $37.45 3/1/2020J0584 Injection, burosumab-twza 1 mg (Crysvita) $385.56 $385.56 3/1/2020J0567 Injection, cerliponase alfa, 1 mg (Brineura) $102.06 $102.06 3/1/2020J9057 Injection, copanlisib, 1 mg (Aliqopa) $79.38 $79.38 3/1/2020J0841 Injection, crotalidae immune f(ab')2 (equine), 120 mg (Anavip) $1,383.48 $1,383.48 3/1/2020J9145 Injection, daratumumab, 10 mg (Darzalex) $49.27 $49.27 3/1/2020J9999 Injection, daratumumab and hyaluronidase-fihj 10 mg (Darzalex Faspro) $45.44 $45.44 5/6/2020J1130 Injection, diclofenac sodium, 0.5 mg (Dyloject) $0.23 $0.23 3/1/2020J9173 Injection, durvalumab, 10 mg (Imfinizi) $78.90 $78.90 3/1/2020J1301 Injection, edaravone, 1 mg (Radicava) $20.53 $20.53 3/1/2020J9176 Injection, elotuzumab, 1 mg (Empliciti) $6.54 $6.54 3/1/2020J7170 Injection, emicizumab-kxwh, 0.5 mg (Hemlibra) $48.70 $48.70 3/1/2020J7175 Injection, factor X, (human), 1 IU (Coagadex) $8.78 $8.78 3/1/2020J1443 Injection, ferric pyrophosphate citrate solution, 0.1mg of iron (Triferic) $0.02 $0.02 3/1/2020J9198 Injection, gemcitabine hydrochloride 100 mg (Infugem) $41.04 $41.04 7/1/2020J1444 ferric pyrophosphate citrate solution, for hemodialysis use, 0.1 mg (Triferic) $0.03 $0.03 3/1/2020Q5101 Injection, Filgrastim (G-CSC), Biosimilar, 1 microgram (Zarxio) $1.07 $1.07 3/1/2020J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg (Akynzeo) $556.00 $556.00 3/1/2020J1627 Injection, granisetron, extended-release, 0.1 mg (Sustol) $4.83 $4.83 3/1/2020J7177 Injection, human fibrinogen concentrate (Fibryga), 1 mg $1.25 $1.25 3/1/2020J1746 Injection, ibalizumab-uiyk, 10 mg (Trogarzo) $64.35 $64.35 3/1/2020J1555 Injection, immune globuline, 100 mg (Cuvitru) $14.48 $14.48 3/1/2020Q5103 Injection, infliximab, biosimilar, 10 mg (Inflectra) $73.20 $73.20 3/1/2020J9229 Injection, inotuzumab ozogamicin, 0.1 mg (Besponsa) $2,356.20 $2,356.20 3/1/2020J0594 Injection, busulfan, 60 mg/10 ml (Busulfex) $34.84 $34.84 3/1/2020J9205 Injection, irinotecan liposome, 1 mg (Onivyde) $41.49 $41.49 3/1/2020J9153 injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine (Vyxeos) $199.83 $199.83 3/1/2020J9295 Injection, necitumumab, 1 mg (Portrazza) $5.52 $5.52 3/1/2020J9285 Injection, olaratumab 10 mg (Lartruvo) $52.45 $52.45 3/1/2020J9311 Injection, rifuximab,10 mg and hyaluronidase (Rituxan Hycela) $48.97 $48.97 3/1/2020J9312 Injection, rituximab, 10 mg (Rituxan) $100.17 $100.17 3/1/2020Q5115 Injection, rituximab-abbs, biosimilar, 10 mg (Truxima) $95.89 $95.89 3/1/2020J2797 Injection, rolapitant, 0.5 mg (Varubi) $1.00 $1.00 3/1/2020Q5111 Injection, pegfilgrastim-cbqv, biosimilar, 0.5 mg (Udenyca) $394.54 $394.54 3/1/2020J2840 Injection, sebelipase alfa, 1 mg (Kanuma) $567.00 $567.00 3/1/2020J9325 Injection, talimogene laherparepvec, per 1 million plaque forming units (Imlygic) $48.44 $48.44 3/1/2020J9352 Injection, trabectedin, 0.1 mg (Yondelis) $297.56 $297.56 3/1/2020Q5114 Injection, trastuzumab-dkst 10 mg, (Ogivri) $99.82 $99.82 3/1/2020J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1

mg (Zilretta)$19.83 $19.83 3/1/2020

J3316 Injection, triptorelin, extended-release, 3.75 mg (Triptodur) $3,024.00 $3,024.00 3/1/2020J3397 Injection, vestronidase alfa-vjbk, 1 mg (Mepsevii) $239.84 $239.84 3/1/2020J7342 Installation, ciprofloxacin otic suspension, 6 mg (Otiprio) $32.12 $32.12 3/1/2020J1815 Insulin, per 5 units, injection $0.28 $0.28 3/1/2020J9212 Interferon Alfacon-1, recombinant, 1 mcg, injection (Infergen) $4.81 $4.81 3/1/2020J9215 Interferon alfa-N3, (human leukocyte derived), 250,000 IU (Alferon N) $19.39 $19.39 3/1/2020J9213 Interferon alfa-2A, recombinant, 3 million units (Roferon-A) $41.01 $41.01 3/1/2020J9214 Interferon alfa-2B, recombinant, 1 million units (Intron-A) $14.19 $14.19 3/1/2020Q3027 Interferon beta-1a, 1 mcg for intramuscular use, injection $34.86 $34.86 3/1/2020Q3028 Interferon beta-1a, 1 mcg for subcutaneous use, injection $19.82 $19.82 3/1/2020J1826 Interferon beta-1a, 30 mcg for intramuscular use, injection (Avonex) $781.30 $781.30 3/1/2020J1830 Interferon beta-1b, 0.25 mg, injection (Extavia) $177.43 $177.43 3/1/2020J9216 Interferon gamma-1B, 3 million units (Actimmune) $310.25 $310.25 3/1/2020J9228 Ipilimumab, 1 mg, (Yervoy) $125.30 $125.30 3/1/2020J9206 Irinotecan, 20 mg (Camptosar) $126.51 $126.51 3/1/2020J1750 Iron dextran, 50 mg, injection (InFeD, Dexferrum) $11.81 $11.81 3/1/2020J1756 Iron sucrose, 1 mg, injection (Venofer) $0.35 $0.35 3/1/2020J1833 Isavuconazonium sulfate injection 1 mg (Cresemba) $0.72 $0.72 3/1/2020J9207 Ixabepilone, 1 mg, injection (Ixempra) $63.88 $63.88 3/1/2020J1850 Kanamycin sulfate, up to 75 mg, injection (Kantrex) $0.76 $0.76 3/1/2020J1840 Kanamycin sulfate, up to 500 mg, injection (Kantrex) $5.10 $5.10 3/1/2020J1885 Ketorolac tromethamine, per 15 mg, injection (Toradol) $0.34 $0.34 3/1/2020J3490 Givosiran injection, for subcutaneous use 1 mg (Givlaari) $222.86 $222.86 11/26/2019J3490 Lacosamide, per ml/10mg (Vimpat) $1.95 $1.95 1/1/2015J1930 Lanreotide, 1 mg, injection (Somatuline Depot) $26.91 $26.91 3/1/2020

J1931 Laronidase, 0.1 mg, inj. (Aldurazyme) $24.41 $24.41 3/1/2020J0691 Lefamulin injection, 1 mg (Xenleta) $0.72 $0.72 7/1/2020J3490 Letermovir injection, for intravenous use 1 vial (Prevymis) $291.60 $291.60 12/11/2017J9999 lurbinectedin for injection, 1 mg (Zepzelca) $1,790.91 $1,790.91 6/19/2020J0640 Leucovorin Calcium, per 50 mg, injection (Wellcovorin) $0.78 $0.78 3/1/2020J9218 Leuprolide acetate, per 1 mg (Lupron) $7.48 $7.48 3/1/2020J9217 Leuprolide acetate (for depot suspension), 7.5 mg (Lupron Depot) (Eligard) $221.33 $221.33 3/1/2020J1950 Leuprolide acetate (for depot suspension), per 3.75 mg, injection (Lupron Depot) (Eligard) $442.60 $442.60 3/1/2020J9219 Leuprolide Acetate Implant 65mg (Viadur) $1,611.63 $1,611.63 3/1/2020J1953 Levetiracetam, 10 mg, injection (Keppra) $0.43 $0.43 3/1/2020J1955 Levocarnitine, per 1 g, injection (Carnitor) $5.89 $5.89 3/1/2020J1956 Levofloxacin, 250 mg, injection (Levaquin) $5.88 $5.88 3/1/2020J0641 Levoleucovorin calcium, 0.5 mg, injection (Fusilev) $1.05 $1.05 3/1/2020J0642 Levoleucovorin for injection, 0.5 mg (Khapzory) $2.14 $2.14 3/1/2020J1960 Levorphanol tartrate, up to 2 mg, injection (Levo-Dromoran) $3.18 $3.18 3/1/2020J3490 Lidocaine , for topical use 1 mg invoice required ***See Rate Table below 1/1/2015J2001 Lidocaine HCL for IV infusion, Injection 10 mg $0.02 $0.02 3/1/2020J2010 Lincomycin HCl, up to 300 mg, injection (Lincocin) $4.27 $4.27 3/1/2020J2020 Linezolid, 200 mg, injection (Zyvox) $28.15 $28.15 3/1/2020J2060 Lorazepam, 2 mg, injection (Ativan) $0.64 $0.64 3/1/2020J0896 Luspatercept-aamt for injection .25 mg (Reblozyl) $37.16 $37.16 7/1/2020J3475 Magnesium sulfate, per 500 mg, injection $0.05 $0.05 3/1/2020J2150 Mannitol, 25% in 50 ml, injection, (Osmitrol, Resectisol) $0.86 $0.86 3/1/2020J9230 Mechlorethamine HCl, 10 mg (Nitrogen Mustard) $144.75 $144.75 3/1/2020J1738 Meloxicam injection 1 mg (Anjeso) $3.38 $3.38 10/1/2020J9246 Melphalan for injection 1 mg (Evomela) $43.20 $43.20 7/1/2020J9245 Melphalan HCl, 50 mg, injection (Alkeran) $1,566.99 $1,566.99 3/1/2020J2175 Meperidine HCl, per 100 mg, injection (Demerol) $1.52 $1.52 3/1/2020J0670 Mepivacaine HCl, per 10ml, injection (Carbocaine) (Polocaine) $1.15 $1.15 3/1/2020J2186 Meropenem and vaborbactem for injection 10 mg/10 mg (20 mg) (Vabomere) $1.87 $1.87 3/1/2020J9209 Mesna, 200 mg (Mesnex) $7.89 $7.89 3/1/2020J0380 Metaraminol bitartrate, per 10mg, injection (Aramine) $1.15 $1.15 3/1/2020J7674 Methacholine chloride (Provocholine) $0.55 $0.55 3/1/2020J1230 Methadone HCl, up to 10 mg, injection (Dolophine) $2.96 $2.96 3/1/2020J2800 Methocarbamol up to 10 ml, injection (Robaxin) $10.24 $10.24 3/1/2020J9250 Methotrexate sodium, 5 mg $0.21 $0.21 3/1/2020J9260 Methotrexate sodium, 50 mg $2.26 $2.26 3/1/2020J7309 Methly aminolevulinate (MAL) for topical administration, 16.8%, 1 gram (Metvixia) $77.54 $77.54 3/1/2020J0210 Methyldopate HCl, up to 250mg, injection IV $15.22 $15.22 3/1/2020J3490 Methylene blue injection 1 mL (Provayblue) $20.14 $20.14 9/1/2016J2210 Methylergonovine maleate, up to 0.2 mg, injection (Methergine) $5.05 $5.05 3/1/2020J1020 Methylprednisolone acetate, 20mg, injection (Depo-Medrol) $2.41 $2.41 3/1/2020J1030 Methylprednisolone acetate, 40mg, injection (Depo-Medrol) $4.48 $4.48 3/1/2020J1040 Methylprednisolone acetate, 80mg, injection (Depo-Medrol) $9.43 $9.43 3/1/2020J2920 Methylprednisolone sodium succinate, up to 40 mg, injection (Solu-Medrol) $2.07 $2.07 3/1/2020J2930 Methylprednisolone sodium succinate, up to 125 mg, injection (Solu-Medrol) $3.03 $3.03 3/1/2020J2765 Metoclopramide HCl, up to 10 mg, injection (Reglan) $0.34 $0.34 3/1/2020J8499 metronidazole, oral 2g (Flagyl) $0.86 $0.86 3/1/2020J2250 Midazolam HCl, per 1 mg, injection (Versed) $0.15 $0.15 3/1/2020S0190 mifepristone tablets, for oral use 200 mcg (Mifeprex) $77.49 $77.49 3/1/2020J2260 Milrinone lactate, per 5 mg, injection (Primacor) $4.56 $4.56 3/1/2020S0191 misoprostol tablets, for oral use 200 mcg (Cytotec) $1.03 $1.03 3/1/2020J9280 Mitomycin, 5 mg (Mutamycin) $13.08 $13.08 3/1/2020J9999 mitomycin for pyelocalyceal solution, 1 mg (Jelmyto) $288.58 $288.58 6/17/2020J9293 Mitoxantrone HCl, per 5 mg, injection (Novantrone) $88.89 $88.89 3/1/2020J9204 Mogamuliumab-kpke injection 1 mg (Poteligeo) $210.91 $210.91 3/1/2020J7401 Mometasone furoate sinus implant 10 mcg (Sinuva) $10.71 $10.71 3/1/2020J2274 Morphine preservative free, Injection 10 mg $10.22 $10.22 3/1/2020J2270 Morphine sulfate, up to 10 mg, injection $1.79 $1.79 3/1/2020J9313 Moxetumomab pasudotox-tdfk for injection 0.01 mg (Lumoxiti) $23.63 $23.63 3/1/2020J2300 Nalbuphine HCl, per 10 mg, injection (Nubain) $0.96 $0.96 3/1/2020J2310 Naloxone HCl, per 1 mg, injection (Narcan) $3.17 $3.17 3/1/2020J2315 Naltrexone, depot form, 1 mg, injection (Vivitrol) $1.88 $1.88 3/1/2020J2320 Nandrolone decanoate, up to 50 mg, injection (Deca-Durabolin) $4.77 $4.77 3/1/2020J2323 Natalizumab, 1 mg, injection (Tysabri) $7.54 $7.54 3/1/2020J9261 Nelarabine, 50 mg, injection (Arranon) $91.88 $91.88 3/1/2020J2710 Neostigmine methylsulfate, up to 0.5 mg, injection (Prostigmin) $0.10 $0.10 3/1/2020J9299 Nivolumab, 1 mg, injection (Opdivo) $26.64 $26.64 3/1/2020J7050 Normal saline solution, 250 cc infusion $0.26 $0.26 3/1/2020J7040 Normal saline solution, sterile (500 ml = 1 unit), infusion $0.52 $0.52 3/1/2020J7030 Normal saline solution, 1,000 cc, infusion $1.03 $1.03 3/1/2020J2326 Nusinersen injection for intrathecal use 0.1 mg (Spinraza) $1,181.25 $1,181.25 3/1/2020J9301 Obinutuzumab Inj 10 mg (Gazyva) $59.77 $59.77 3/1/2020J7316 Ocriplasmin, 0.125 mg, injection (Jetrea) $1,111.75 $1,111.75 3/1/2020J2353 Octreotide, depot form for IM injection, 1 mg (Sandostatin LAR Depot) $90.32 $90.32 3/1/2020J2354 Octreotide non-depot form for SC or IV injection, 25 mcg (Sandostatin) $2.21 $2.21 3/1/2020J9302 Ofatumumab, per 10 mg (Arzerra) $45.47 $45.47 3/1/2020S0166 Olanzapine, 2.5 mg (Zyprexa) $8.05 $8.05 3/1/2020J2358 Olanzapine long-acting, 1 mg (Zyprexa Relprevv) $2.75 $2.75 3/1/2020J9262 Omacetaxine mepesuccinate, 0.01 mg, injection (Synbrio) $2.58 $2.58 3/1/2020J0121 Omadacucline for injection, 1 mg (Nuzyra) $3.92 $3.92 3/1/2020J2405 Ondansetron HCl, per 1 mg, injection (Zofran) $0.22 $0.22 3/1/2020J2407 Oritavancin diphosphate 10 mg (Orbactiv) $26.90 $26.90 3/1/2020J2360 Orphenadrine citrate, up to 60 mg, injection (Norflex) $9.04 $9.04 3/1/2020J2700 Oxacillin sodium, up to 250 mg, injection (Bactocile, Prostaphlin) $1.58 $1.58 3/1/2020J9263 Oxaliplatin, 0.5 mg, injection (Eloxatin) $9.51 $9.51 3/1/2020J2410 Oxymorphone HCl, up to 1 mg, injection (Numorphan) $2.51 $2.51 3/1/2020J2460 Oxytetracycline HCl, up to 50 mg, injection (Terramycin IM) $0.94 $0.94 3/1/2020J2590 Oxytocin, up to 10 units, injection (Pitocin) $2.05 $2.05 3/1/2020J9267 Paclitaxel, 1 mg injection (Taxol) $0.18 $0.18 3/1/2020J9264 Paclitaxel protein-bound particles, 1 mg, (Abraxane) $8.87 $8.87 3/1/2020J2425 Palifermin injection 50 mcg (Kepivance) $11.92 $11.92 3/1/2020J3490 Paliperidone palmitate extended-release injectable suspension 1 mg (Invega Trinza) $8.82 $8.82 3/1/2018J2426 Paliperidone palmitate extended-release injectable suspension 1 mg (Invega Sustenna) $6.52 $6.52 3/1/2020J2469 Palonosetron HCl, 25 mcg, injection (Aloxi) $17.25 $17.25 3/1/2020J2430 Pamidronate disodium, per 30 mg, injection (Aredia) $28.39 $28.39 3/1/2020J9303 Panitumumab, 10 mg, injection (Vectibix) $82.43 $82.43 3/1/2020J2440 Papaverine HCl, up to 60 mg, injection $0.57 $0.57 3/1/2020

J2501 Paricalcitol, 1 mcg, injection (Zemplar) $3.93 $3.93 3/1/2020J2502 Pasireotide suspension 1 mg (Signifor LAR) $305.31 $305.31 3/1/2020J0222 Patisiran lipid complex injection 0.1 mg (Onpattro) $107.73 $107.73 3/1/2020J2503 Pegaptanib sodium, 0.3 mg, (Macugen) $1,033.23 $1,033.23 3/1/2020J9266 Pegaspargase, per single dose vial (Oncaspar) $2,098.12 $2,098.12 3/1/2020J2505 Pegfilgastrim, 6 mg, injection (Neulasta) $2,204.83 $2,204.83 3/1/2020Q5120 Pegfilgrastim-bmez injection 0.5 mg (Ziextenzo) $317.28 $317.28 7/1/2020J0890 Peginesatide, 0.1 mg (Omontys) $9.09 $9.09 3/1/2020J9271 Pembrolizumab Powder 1 mg (Keytruda) $47.98 $47.98 3/1/2020J9305 Pemetrexed, 10 mg, injection (Alimta) $46.30 $46.30 3/1/2020J0561 Penicillin G benzathine, per 100,000 units, injection (Bicillin L-A) $4.07 $4.07 3/1/2020J0558 Injection, penicillin G benzathine and penicillin G procaine, per 100,000 units (Bicillin C-R) $3.22 $3.22 3/1/2020J2540 Penicillin G potassium, up to 600,000 units, injection (Pfizerpen) $0.94 $0.94 3/1/2020J2510 Penicillin G procaine, aqueous, up to 600,000 units, injection (Wycillin) $10.31 $10.31 3/1/2020J2545 Pentamidine isethionate, inhalation solution, per 300 mg, administered through a DME (Pentam 300,

NebuPent)$54.43 $54.43

3/1/2020S0080 Pentamidine isethionate, 300 mg, injection (NebuPent) $42.56 $42.56 3/1/2020J3070 Pentazocine HCl, up to 30 mg, injection (Talwin) $6.12 $6.12 3/1/2020J2515 Pentobarbital sodium, per 50 mg, injection (Nembutal Sodium) $7.63 $7.63 3/1/2020J9268 Pentostatin, per 10 mg (Nipent) $1,832.85 $1,832.85 3/1/2020J2547 Peramivir (Rapivab) 1 mg 200 mg/20 ml vial $1.80 $1.80 3/1/2020J9999 Pertuzumab, trastuzumab, and hyaluronidase-zzxf injection, 1 mL (Phesgo) $914.87 $914.87 7/1/2020J2560 Phenobarbital sodium, up to 120 mg, injection $3.01 $3.01 3/1/2020J2760 Phentolamine mesylate, up to 5 mg, injection (Regitine) $21.12 $21.12 3/1/2020J1097 Phenylephrine and ketorolac injection1 mL (Omidria) $130.52 $130.52 3/1/2020J2370 Phenylephrine HCl, up to 1 ml, injection (Neosynephrine) $0.70 $0.70 3/1/2020J1165 Phenytoin sodium, per 50 mg, injection (Dilantin) $0.45 $0.45 3/1/2020J3430 Phytonadione (vitamin K), per 1 mg, injection (Mephyton) $3.63 $3.63 3/1/2020J2543 Piperacillin sodium/tazobactam sodium, injection, 1g/0.125g (1.125 g) (Zosyn) $5.16 $5.16 3/1/2020J0291 Plazomicin injection, for intravenous use 5 mg (Zemdri) $3.57 $3.57 3/1/2020J2562 Plerixafor, 1 mg, injection (Mozobil) $269.25 $269.25 3/1/2020J9309 Polatuzumab vedotin-piiq for injection 1 mg (Polivy) $119.05 $119.05 3/1/2020J9600 Porfimer sodium, 75 mg (Photofin) $2,508.93 $2,508.93 3/1/2020J3480 Potassium Chloride, per 2 mEq, injection $0.01 $0.01 3/1/2020J9307 Pralatrezate, 1 mg (Folotyn) $165.96 $165.96 3/1/2020J2730 Pralidoxime chloride, up to 1 g, injection (Protopam) $88.27 $88.27 3/1/2020J2650 Prednisolone acetate, up to 1 ml, injection (Predcor-50) $0.17 $0.17 3/1/2020J2690 Procainamide HCl, up to 1 g, injection (Pronestyl) $2.66 $2.66 3/1/2020J0780 Prochlorperazine, up to 10 mg, injection, (Compazine) $1.16 $1.16 3/1/2020J2675 Progesterone, per 50 mg, injection $1.51 $1.51 3/1/2020J2550 Promethazine HCl, up to 50 mg, injection (Phenergan) $1.37 $1.37 3/1/2020J1800 Propranolol HCl, up to 1 mg, injection (Inderal) $3.19 $3.19 3/1/2020J2720 Protamine sulfate, per 10 mg, injection $0.59 $0.59 3/1/202090399 Rabies immune globulin (human) solution 150 IU (Kedrab) $385.95 $385.95 3/1/2020J2780 Ranitidine hydrochloride, 25 mg, injection (Zantac) $0.74 $0.74 3/1/2020J2783 Rasburicase, 0.5 mg, injection (Elitek) $155.52 $155.52 3/1/2020J1303 Ravulizumab-cwvz injection, 10 mg (Ultomiris) $237.59 $237.59 3/1/2020J0596 Recombinant human C1 esterase inhibitor 10 units (rhC1INH) (Ruconest) $29.49 $29.49 3/1/2020J2993 Reteplase, 18.1 mg, injection (Retavase) $835.53 $835.53 3/1/2020J7120 Ringer's lactate infusion, up to 1,000 cc $0.91 $0.91 3/1/2020J2798 Risperidone for extended-release injectable suspension 0.5 mg (Perseris) $10.36 $10.36 3/1/2020J2794 Risperidone, long acting 0.5 mg, injection (Risperdal Consta) $4.94 $4.94 3/1/2020Q5119 Rituximab-pvvr injection 10 mg (Ruxience) $73.83 $73.83 7/1/2020J9308 Ramucirumab 5 mg (Cyramza) $56.72 $56.72 3/1/2020J3490 rolapitant injectable emulsion 1 vial (Varubi) $318.60 $318.60 11/15/2017J9315 Romidepsin, 1 mg (Istodax) $219.73 $219.73 3/1/2020J2796 Romiplostim, 10 mcg, injection (Nplate) $43.69 $43.69 3/1/2020J3111 Romosozumab-aqqg injection 1 mg (Evenity) $9.40 $9.40 3/1/2020J2795 Ropivacaine HCI injection 1 mg (Naropine) $0.07 $0.07 3/1/2020J9999 sacituzumab govitecan-hziy for injection 1 mg (Trodelvy) $12.08 $12.08 4/23/2020J2820 Sargramostim (GM-CSF), 50 mcg, injection (Leukine) $25.16 $25.16 3/1/2020J3490 Sildenafil, per vial (Revatio) $96.19 $96.19 1/1/2015Q2043 Sipuleucel-T, 3 units, injection 250 ml (Provenge) $32,876.62 $32,876.62 3/1/2020J2860 Slituxumab Injection 10 mg (Sylvant) $9.73 $9.73 3/1/2020J3490 Sodium bicarbonate7.5%, up to 50 ml $3.26 $3.26 1/1/2015J2916 Sodium ferric gluconate complex in sucrose, 12.5 mg, injection (Ferrlecit) $4.79 $4.79 3/1/2020J2995 Streptokinase, per 250,000 IU, injection (Streptase) $79.67 $79.67 3/1/2020J3000 Streptomycin, up to 1 g, injection $6.99 $6.99 3/1/2020J9320 Streptozocin, 1 g (Zanosar) $191.05 $191.05 3/1/2020J0330 Succinylcholine chloride, up to 20 mg, injection (Anectine) (Quelicin) $0.17 $0.17 3/1/2020J3490 sugammadex injection 1 mg (Bridion) $0.39 $0.39 1/1/2020J3030 Sumatriptan succinate, 6 mg, injection (Imitrex) (Alsuma) $66.76 $66.76 3/1/2020J9269 tagraxofusp-erzs injection 10 mcg (Elzonris) $277.03 $277.03 3/1/2020J3060 Taliglucerace alfa, 10 units, injection (Elelyso) $32.83 $32.83 3/1/2020J1447 TBO-filgrastim, 1 mcg, injection (Granix) $0.81 $0.81 3/1/2020J3090 Tedizolid phosphate injection 1 mg (Sivextro) $0.13 $0.13 3/1/2020J3095 Telavancin , per 10 mg (Vibativ) $1.93 $1.93 3/1/2020J9328 Temozolomide, 1 mg, injection (Temodar) $5.10 $5.10 3/1/2020J9330 Temsirolimus, 1 mg, injection (Torisel) $48.01 $48.01 3/1/2020J3241 Teprotumumab-trbw for injection 10 mg (Tepezza) $315.88 $315.88 10/1/2020J3105 Terbutaline sulfate, up to 1 mg, injection (Brethine) $2.42 $2.42 3/1/2020J1071 Depo-Testosterone Cypionate, 1 mg injection (Delatrstryl) $0.04 $0.04 3/1/2020J3121 Testosterone enanthate, 1 mg injection $0.06 $0.06 3/1/2020S0189 Testosterone pellet, 75 mg (Testopel) $67.64 $67.64 3/1/2020J3145 Testosterone undecanoate 1 mg (Aveed) strength: 3 ml vial $1.24 $1.24 3/1/2020J9340 Thiotepa, 15 mg (Thioplex) $40.49 $40.49 3/1/2020J3240 Thyrotropin alpha, 0.9 mg provided in 1.1 mg vial, injection (Thyrogen) $840.76 $840.76 3/1/2020J3243 Tigecycline, 1 mg (Tygacil) $1.25 $1.25 3/1/2020J3260 Tobramycin sulfate, up to 80 mg, injection (Nebcin) $2.32 $2.32 3/1/2020J9351 Topotecan, 0.1 mg (Hycamtin) $27.40 $27.40 3/1/2020J3265 Torsemide, 10 mg/ml, injection (Demadex) $2.18 $2.18 3/1/2020J3285 Treprostinil njection 1 mg (Remodulin) $67.05 $67.05 3/1/2020J9355 Trastuzumab, 10 mg (Herceptin) $60.21 $60.21 3/1/2020J9999 trastuzumab and hyaluronidase-oysk injection 1 mg (Herceptin Hylecta) $8.42 $8.42 4/5/2019Q5117 trastuzumab-anns for injection, 10 mg (Kanjinti) $95.20 $95.20 3/1/2020Q5113 trasuzumab-pkrb for injection 10 mg (Herzuma) $100.98 $100.98 3/16/2020Q5112 trastuzumab-dttb for injection 10 mg (Ontruzant) $95.38 $95.38 4/15/2020Q5116 trastuzumab-qyyp for injection 10 mg (Trazimera) $91.56 $91.56 3/1/2020

J3301 Triamcinolone acetonide, per 10 mg, injection (Kenalog-10, Kenalog-40) $1.38 $1.38 3/1/2020J3300 Triamcinolone acetonide, preservative free, 1 mg, injection (Trivaris) $3.26 $3.26 3/1/2020J3303 Triamcinolone hexacetonide, per 5mg injection (Aristospan) $1.34 $1.34 3/1/2020J3250 Trimethobenzamide HCl, up to 200 mg, injection (Tigan) $4.47 $4.47 3/1/2020J3305 Trimetrexate glucuronate, per 25 mg, injection (Neutrexin) $150.03 $150.03 3/1/2020J3315 Triptorelin pamoate (Trelstar Depot, Trelstar LA), 3.75 mg $149.49 $149.49 3/1/2020J3365 Urokinase, 250,000 IU, injection IV (Abbokinase) $458.71 $458.71 3/1/2020J3490 valproate sodium 1 mg (Depacon) $0.00 $0.00 1/1/2019J9357 Valrubicin, 200 mg, injection (Valstar) $966.32 $966.32 3/1/2020J3370 Vancomycin HCl, 500 mg, injection (Vancoled) (Vancocin) $3.15 $3.15 3/1/2020J3380 Vendolizumab Injection 1 mg (Entyvio) $17.88 $17.88 3/1/2020J3396 Verteporfin, 0.1 mg, inj. (Visudyne) $9.17 $9.17 3/1/2020J9360 Vinblastine sulfate, 1 mg (Velban) $1.07 $1.07 3/1/2020J9370 Vincristine sulfate, 1 mg (Vincasar PFS) $7.03 $7.03 3/1/2020J9371 Vincristine sulfate liposome, 1 mg (Marqibo) $2,110.15 $2,110.15 3/1/2020J9390 Vinorelbine tartrate, per 10 mg (Navelbine) $16.26 $16.26 3/1/2020J3420 Vitamin B-12 cyanocobalamin, up to 1,000 mcg, injection $0.25 $0.25 3/1/2020J2278 Ziconotide 1 mcg, (Prialt) $6.53 $6.53 3/1/2020J3489 Zoledronic acid, 1 mg, injection $111.96 $111.96 3/1/2020

90291 Cytomegalovirus Immune Globulin (CMV-IgIV), Human, 1 ml (CytoGam) $23.84 $23.84 3/1/2020J1460 Gamma globulin, intramuscular, 1 cc, injection (Gamastan S/D) $11.57 $11.57 3/1/2020J1560 Gamma globulin, intramuscular, over 10 cc, injection (Gamastan S/D) $115.78 $115.78 3/1/2020J1571 Injection, hepatitis B immune globulin, intramuscular, 0.5 ml, (Hepagam B) $48.45 $48.45 3/1/202090371 Hepatitis B Immune globulin (HBIg), human, 1 ml (BayHep B HepaGam B Nabi-HB ) $120.23 $120.23 3/1/2020J1573 Hepatitis B immune globulin, intravenous, 0.5 ml, injection (Hepagam B) $48.45 $48.45 3/1/2020J1559 Immune Globulin subcutaneous, 20% 100 mg (Hizentra) $7.30 $7.30 3/1/2020J1556 Immune Globulin intravenous, 10% 500 mg, injection (Bivigam) $41.04 $41.04 3/1/2020J1557 Immune Globulin (Gammaplex) intravenous, non-lyophilized (e.g., liquid) 500 mg $37.36 $37.36 3/1/2020J1566 Immune Globulin, intravenous, lyophilized, (e.g. powder) 500 mg, injection (Gammagard S-D) $28.13 $28.13 3/1/2020

J1568 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Octagma) $35.15 $35.15 3/1/2020J1572 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Flebogamma) $32.59 $32.59 3/1/2020J1459 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Privigen) $34.23 $34.23 3/1/2020J1561 Immune Globulin, Intravenous, 500 mg, injection (Gamunex) $33.52 $33.52 3/1/2020J1569 Immune globulin, intravenous, nonlyophilized, (e.g., liquid), 500 mg, injection (Gammagard liquid) $31.86 $31.86 3/1/2020

J1562 Immune globulin, subcutaneous, 100 mg (Vivaglobin) $7.10 $7.10 3/1/2020J7504 Lymphocyte Immune Globulin, anit-thymocyte globulin equine, parenteral, 250 mg (Atgam) $384.62 $384.62 3/1/202090375

Rabies Immune Globulin (RIg), human, for intramuscular and/or subcutaneous use 150 IU (HyperRab-HyperRab-B)

$67.97 $67.97 3/1/2020

90376 Rabies Immune Globulin, Heat-treated (Rig-HT), human, 2 ml (Imogam Rabies-HT) $78.24 $78.24 3/1/2020J2790 Rho D immune globulin, human, full dose, 300 mcg $89.91 $89.91 3/1/2020J2788 Rho(D) Immune Globulin, 50 mcg $28.49 $28.49 3/1/2020J2792 Rho(D) Immune Globulin (RhIgIV), Intravenous, Human, Solvent Detergent, 100 IU, injection $15.65 $15.65 3/1/2020J2791 Rho( D) immune globulin (human), intramuscular or intravenous, 100 IU, injection $5.34 $5.34 3/1/202090389 Tetanus Immune Globulin (Tlg), Human, for Intramuscular use,

250 U/1 ml (BayTet)$140.25 $140.25 3/1/2020

90396 Varicella-Zoster Immune Globulin, human, 125 units $110.64 $110.64 3/1/2020

J1050 00009074630 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.55 $1.55 3/1/2020J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.48 $1.48 1/1/2018J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.55 $1.55 3/1/2020J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 $2.38 $2.38 1/1/2018J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 $2.50 $2.50 3/1/2020J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 $1.41 $1.41 1/1/2018J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 $1.48 $1.48 3/1/2020J1050 00548540000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 1/15/2018J1050 00548540000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J1050 00548540025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 2/5/2018J1050 00548540025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J1050 00548541000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 4/30/2019J1050 00548541000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J1050 00548541025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 4/30/2019J1050 00548541025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J1050 00548570100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.39 $0.39 2/5/2018J1050 00548570100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.41 $0.41 3/1/2020J1050 00548571100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.39 $0.39 4/22/2019J1050 00548571100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.41 $0.41 3/1/2020J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 9/25/2017J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.61 $0.61 3/1/2020J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 9/25/2017J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.60 $0.60 3/1/2020J1050 16714098101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.455 $0.455 9/10/2020J1050 16714098102 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.419 $0.419 9/10/2020J1050 16714099901 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.59 $0.59 4/22/2020 5/5/2020J1050 16714099901 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.62 $0.62 5/6/2020J1050 59762453701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 7/1/2017J1050 59762453701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.61 $0.61 3/1/2020J1050 59762453702 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 7/1/2017J1050 59762453702 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.60 $0.60 3/1/2020J1050 59762453802 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.68 $0.68 7/1/2017J1050 59762453802 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.71 $0.71 3/1/2020J1050 62756009040 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 11/20/2019J1050 62756009040 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.61 $0.61 3/1/2020J1050 62756009045 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 11/20/2019J1050 62756009045 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.60 $0.60 3/1/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 10/12/2018 1/2/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 1/3/2020 2/29/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.58 $0.58 10/12/2018 1/2/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.32 $0.32 1/3/2020 2/29/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.33 $0.33 3/1/2020J7296 50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPT $1,010.72 $1,010.72 1/14/2019J7296 50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPT $1,061.26 $1,061.26 3/1/2020J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $794.36 $794.36 1/1/2019 1/2/2020J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $834.08 $834.08 1/3/2020 2/29/2020

LARCs and Depo-Provera

IMMUNE GLOBULINS

J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $875.79 $875.79 3/1/2020J7297 52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $794.36 $794.36 1/1/2019 1/2/2020J7297 52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $834.08 $834.08 1/3/2020 2/20/2020J7297 52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE $834.08 $834.08 1/3/2020J7298 50419042101 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTE $963.51 $963.51 12/29/2017J7298 50419042101 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTE $1,011.68 $1,011.68 3/1/2020J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTE $1,010.72 $1,010.72 1/14/2019J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTE $1,061.26 $1,061.26 3/1/2020J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $857.01 $857.01 8/15/2017 9/29/2019J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $937.57 $937.57 9/30/2019J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45 3/1/2020J7300 51285020402 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $783.34 $783.34 7/1/2017 2/6/2020J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $857.01 $857.01 9/1/2018 9/29/2019J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $937.57 $937.57 9/30/2019J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45 3/1/2020J7301 50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM $841.60 $841.60 1/14/2019J7301 50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM $883.68 $883.68 3/1/2020J7307 00052027401 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCL $817.81 $817.81 7/1/2017 8/1/2019J7307 00052433001 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCL $943.72 $943.72 5/24/2018J7307 00052433001 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCL $1,040.45 $1,040.45 3/1/2020 9/30/2020J7307 00052433001 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCL $1,092.48 $1,092.48 10/1/2020

A9552 Fluorodeoxyglucose F-18 FDG, diagnostic per study dose, up to 45mCi $650.35 $650.35 3/1/2020A9515 Choline C-11, diagnostic, per study dose up to 20 millicuries Invoice required invoice required 1/1/2017A9578 Gadobenate dimeglumine (MultiHance multipack), per ml, injection $5.65 $5.65 3/1/2020A9577 Gadobenate dimeglumine (MultiHance), per ml, injection $5.65 $5.65 3/1/2020A9585 Gadobutrol, 0.1 ml (Gadavist) $0.89 $0.89 3/1/2020A9579 Gadolinium-based magnetic resonance contrast agent, not otherwise specified, per ml $2.56 $2.56 3/1/2020A9576 Gadoteridol, (ProHance multipack), per ml, injection $5.65 $5.65 3/1/2020A9581 Gadoxetate Disodium, 1ml injection $13.52 $13.52 3/1/2020A9556 Gallium GA-67 citrate, diagnostic, per mCi $46.59 $46.59 3/1/2020A9571 Indium IN-111 oxyquinolone Labeled autologous platelets, diagnostic, per study dose $2,709.81 $2,709.81 3/1/2020A9570 Indium IN-111 oxyquinolone Labeled autologous white blood cells, diagnostic, per study dose $1,840.16 $1,840.16 3/1/2020

A9547 Indium IN-111 oxyquinoline, diagnostic, per 0.5mCi $292.23 $292.23 3/1/2020A9548 Indium IN-111 pentetate, diagnostic, per 0.5mCi $272.80 $272.80 3/1/2020Q9968 Injection, nonradioactive, noncontrast, visualization adjunct (e.g., methylene blue, isosulfan blue) 1 mg invoice required invoice required 1/1/2015

A9582 Iodine I-123 Iobenguane, Diagnostic, per study dose, up to 15 millicuries $3,749.59 $3,749.59 3/1/2020A9516 Iodine I-123 sodium iodide capsule(s), diagnostic, per 100 µCi $72.95 $72.95 3/1/2020A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 mCi (DaTscan) $2,142.62 $2,142.62 3/1/2020A9554 Iodine I-125 sodium iothalamate, diagnostic per study dose, up to 10µCi $2,074.45 $2,074.45 3/1/2020A9590 Iodine i-131, iobenguane, 1 millicurie (Azeda) $342.47 $342.47 3/1/2020A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 μCi $49.60 $49.60 3/1/2020A9529 Iodine I-131 sodium iodide solution, diagnostic, per mCi $149.82 $149.82 3/1/2020A9531 Iodine I-131 Sodium Iodide, Diagnostic, Per Microcurie (Up To 100 Microcuries) $55.24 $55.24 3/1/2020A9528 Iodine I-131 sodium iodide capsules, diagnostic, per mCi $55.24 $55.24 3/1/2020Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $1.39 $1.39 3/1/2020Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.41 $0.41 3/1/2020Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.21 $0.21 3/1/2020Q9951 Low Osmolar Contrast Material, 400 or greater Mg/Ml Iodine Concentration, Per Ml invoice required invoice required 1/1/2015A9513 Lutetium lu 177, dotatate, therapeutic, 1 millicurie (Lutathera) $269.33 $269.33 3/1/2020

A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi invoice required invoice required 1/1/2015Q9957 Injection, perflutren lipid microspheres, per ml $62.74 $62.74 3/1/2020A4641 Radiopharmaceutical, diagnostic, not otherwise classified (dosimetric use) 1ml (Azedra) invoice required invoice required 10/29/2018A9699 Radiopharmaceutical, therapeutic, not otherwise classified, (therapeutic use) 1 ml (Azedra) invoice required invoice required 10/29/2018J2785 Regadenoson, 0.1 mg injection (Lexiscan) $47.51 $47.51 3/1/2020A9555 Rubidium RB-82, diagnostic per study, up to 60mCi $30,941.35 $30,941.35 3/1/2020A9604 Samarium Sm-153 lexidronamm, therapeutic, 1 mg (Quadramet) $1,607.34 $1,607.34 3/1/2020J2805 Injection, Sincalide, per mcg (Kinevac) $55.49 $55.49 3/1/2020A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries invoice required invoice required 1/1/2015Q9950 Sulfur Hexafluoride Lipid-type A Microspheres 1 mL (Lumason) $25.37 $25.37 3/1/2020A9700 Supply of injectable contrast material for use in echocardiography, per study invoice required invoice required 1/1/2015A9503 Technetium Tc-99 medronate, diagnostic, per study dose, up to 30 mCi $40.33 $40.33 3/1/2020A9500 Technetium Tc-99 sestamibi, diagnostic, per study dose, up to 40 mCi $121.95 $121.95 3/1/2020A9502 Technetium Tc-99 tetrofosmin, diagnostic, per study dose, up to 40 mCi $121.31 $121.31 3/1/2020A9557 Technetium TC-99m bicisate, diagnostic per study dose, up to 25mCi $921.97 $921.97 3/1/2020A9510 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 mCi $28.24 $28.24 3/1/2020A9569 Technetium TC-99M Exametazime Labeled Autologous white blood cells, diagnostic, per study dose $1,840.16 $1,840.16 3/1/2020

A9521 Technetium T-99m exametazime, diagnostic, per study dose, up to 25 mCi $723.40 $723.40 3/1/2020A9560 Technetium TC-99m labeled red blood cells, diagnostic per study dose, up to 30mCi $95.45 $95.45 3/1/2020A9540 Technetium TC99m macroaggregated albumin, diagnostic per study dose, up to 10mCi $40.33 $40.33 3/1/2020A9537 Technetium TC99m mebrofenin, diagnostic per study, up to 15mCi $68.17 $68.17 3/1/2020A9562 Technetium TC-99m meriatide, diagnostic per study dose, up to 15mCi $259.50 $259.50 3/1/2020A9561 Technetium TC-99m oxidronate, diagnostic per study dose, up to 30mCi $42.36 $42.36 3/1/2020A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 mCi $69.59 $69.59 3/1/2020A9512 Technetium Tc-99m pertechnetate, diagnostic, per mCi $12.54 $12.54 3/1/2020A9538 Technetium TC99m pyrophosphate, diagnostic, per study dose, up to 25mCi $52.44 $52.44 3/1/2020A9541 Technetium TC99m sulphur colloid, diagnostic per study dose, up to 20mCi $54.02 $54.02 3/1/2020A9505 Thallium TI-201 thallous chloride, diagnostic, per mCi $63.14 $63.14 3/1/2020A9558 Xenon Xe-133 gas, diagnostic, per 10 mCi $43.65 $43.65 3/1/2020A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries $22,763.78 $22,763.78 3/1/2020J3590 Romosozumab-aqqg injection 1 mg (Evenity) $8.95 $8.95 10/1/2019

A9564 Chromic phosphate P-32 suspension, therapeutic, per mCi $323.12 $323.12 3/1/2020A9530 Iodine I-131 Sodium Iodide Solution, Therapeutic, Per Millicurie invoice required invoice required 1/1/2015A9606 Radium ra-223 dichloride, therapeutic,per microcurle $127.77 $127.77 3/1/2020A9563 Sodium Phosphate P-32, therapeutic, per mCi $317.05 $317.05 3/1/2020A9600 Strontium Sr-89 chloride, therapeutic, per mCi $895.67 $895.67 3/1/2020

90585 00052060301 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUB $161.78 $161.78 3/22/2018 2/29/202090585 00052060301 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUB $169.87 $169.87 3/1/202090585 00052060302 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUB $161.78 $161.78 3/22/2018 2/29/202090585 00052060302 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUB $169.87 $169.87 3/1/2020

THERAPEUTIC

RADIOPHARMACEUTICALSDiagnostic

VACCINES

90619 49281059005 MENQUADFI VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUA $152.15 $152.15 9/3/202090619 49281059058 MENQUADFI VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUA $152.15 $152.15 9/3/202090620 46028011401 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $164.80 $164.80 7/1/2017 12/19/201990620 46028011402 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $164.80 $164.80 7/1/2017 2/20/202090620 46028011411 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $164.80 $164.80 7/1/2017 2/20/202090620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $175.10 $175.10 1/1/2019 12/31/201990620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $183.86 $183.86 1/1/2020 2/29/202090620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $193.05 $193.05 3/1/202090620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $175.10 $175.10 1/1/2019 12/31/201990620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $183.86 $183.86 1/1/2020 2/29/202090620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $193.05 $193.05 3/1/202090620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $175.10 $175.10 1/1/2019 12/31/201990620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $183.86 $183.86 1/1/2020 2/29/202090620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER M $193.05 $193.05 3/1/202090621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $143.70 $143.70 1/15/2019 12/31/201990621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $153.62 $153.62 1/1/2020 2/29/202090621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $161.30 $161.30 3/1/202090621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $143.70 $143.70 1/15/2019 12/31/201990621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $153.62 $153.62 1/1/2020 2/29/202090621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $161.30 $161.30 3/1/202090621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $143.70 $143.70 1/15/2019 12/31/201990621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $153.62 $153.62 1/1/2020 2/29/202090621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACC $161.30 $161.30 3/1/202090632 00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $70.89 $70.89 8/1/2019 2/29/202090632 00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $74.44 $74.44 3/1/202090632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $72.04 $72.04 8/1/2019 2/29/202090632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $75.64 $75.64 3/1/202090632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $70.63 $70.63 11/15/2018 7/31/201990632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $72.04 $72.04 8/1/2019 2/29/202090632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $75.64 $75.64 3/1/202090632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $68.14 $68.14 8/10/2017 11/15/201890632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $69.50 $69.50 11/15/2018 7/31/201990632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $70.89 $70.89 8/1/2019 2/29/202090632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSC $74.44 $74.44 3/1/202090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $70.87 $70.87 1/1/2019 12/31/201990632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $73.00 $73.00 1/1/2020 2/29/202090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $76.65 $76.65 3/1/202090632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $70.87 $70.87 1/1/2019 12/31/201990632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $73.00 $73.00 1/1/2020 2/29/202090632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAM $76.65 $76.65 3/1/202090632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $70.87 $70.87 1/1/2019 12/31/201990632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $73.00 $73.00 1/1/2020 2/29/202090632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $76.65 $76.65 3/1/202090632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $70.87 $70.87 1/1/2019 12/31/201990632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $73.00 $73.00 1/1/2020 2/29/202090632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INT $76.65 $76.65 3/1/202090633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $33.52 $33.52 8/1/2019 2/29/202090633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $35.20 $35.20 3/1/202090633 00006409509 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $31.28 $31.28 7/1/201790633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOS $33.52 $33.52 8/1/2019 2/29/202090633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOS $35.20 $35.20 3/1/202090633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOS $33.52 $33.52 8/1/2019 2/29/202090633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOS $35.20 $35.20 3/1/202090633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $33.10 $33.10 1/1/2019 12/31/201990633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $34.10 $34.10 1/1/2020 2/29/202090633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $35.80 $35.80 3/1/202090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $33.10 $33.10 1/1/2019 12/31/201990633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $34.10 $34.10 1/1/2020 2/29/202090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $35.80 $35.80 3/1/202090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $33.10 $33.10 1/1/2019 12/31/201990633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $34.10 $34.10 1/1/2020 2/29/202090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $35.80 $35.80 3/1/202090633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $33.10 $33.10 1/1/2019 12/31/201990633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $34.10 $34.10 1/1/2020 2/29/202090633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT $35.80 $35.80 3/1/202090636 58160081501 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOS $99.50 $99.50 7/1/2017 2/29/202090636 58160081501 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOS $104.47 $104.47 3/1/202090636 58160081511 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOS $99.50 $99.50 7/1/2017 2/29/202090636 58160081511 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOS $104.47 $104.47 3/1/202090636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $105.58 $105.58 1/1/2019 12/31/201990636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $110.85 $110.85 1/1/2020 2/29/202090636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $116.40 $116.40 3/1/202090636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $105.58 $105.58 1/1/2019 12/31/201990636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $110.85 $110.85 1/1/2020 2/29/202090636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT $116.40 $116.40 3/1/202090647 00006489700 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP C $26.25 $26.25 8/10/2017 2/29/202090647 00006489700 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP C $27.56 $27.56 3/1/202090647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP C $26.25 $26.25 8/10/2017 2/29/202090647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP C $27.56 $27.56 3/1/202090648 49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP- $16.88 $16.88 1/1/2020 2/29/202090648 49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP- $17.73 $17.73 3/1/202090648 49281054505 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP- $15.45 $15.45 7/1/2017 12/5/201990648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $16.88 $16.88 1/1/2020 2/29/202090648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $17.73 $17.73 3/1/202090648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $10.40 $10.40 1/1/2019 12/31/201990648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $10.72 $10.72 1/1/2020 2/29/202090648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $11.25 $11.25 3/1/202090648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $10.40 $10.40 1/1/2019 12/31/201990648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $10.72 $10.72 1/1/2020 2/29/202090648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUG $11.25 $11.25 3/1/202090648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $10.40 $10.40 1/1/2019 12/31/201990648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $10.72 $10.72 1/1/2020 2/29/202090648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $11.25 $11.25 3/1/202090649 00006404500 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $164.54 $164.54 7/1/2017 2/29/202090649 00006404500 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $172.77 $172.77 3/1/2020 5/28/202090649 00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $164.54 $164.54 7/1/2017 2/29/202090649 00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $172.77 $172.77 3/1/2020 5/28/202090649 00006404541 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $164.20 $164.20 7/1/2017 2/29/2020

90649 00006404541 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4 $172.41 $172.41 3/1/2020 5/28/202090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, $234.00 $234.00 8/1/2019 2/29/202090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, $245.70 $245.70 3/1/202090651 00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, $234.00 $234.00 8/1/2019 2/29/202090651 00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, $245.70 $245.70 3/1/202090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52 $234.00 $234.00 8/1/2019 2/29/202090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52 $245.70 $245.70 3/1/202090651 00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52 $234.00 $234.00 8/1/2019 2/29/202090651 00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52 $245.70 $245.70 3/1/202090653 70461001903 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $53.14 $53.14 7/15/2019 2/29/202090653 70461001903 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $55.80 $55.80 3/1/2020 6/30/202090653 70461001904 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $53.14 $53.14 7/15/2019 2/29/202090653 70461001904 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $55.80 $55.80 3/1/2020 6/30/202090653 70461002003 FLUAD 2020-2021 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $55.80 $55.80 7/2/202090653 70461002004 FLUAD 2020-2021 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTE $55.80 $55.80 7/2/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $49.96 $49.96 7/2/2019 2/29/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $52.46 $52.46 3/1/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $52.46 $52.46 3/1/2020 6/30/202090662 49281012065 FLUZONE HIGH-DOSE QUAD 2020-21 - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $57.18 $57.18 7/6/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $49.96 $49.96 7/2/2019 2/29/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $52.45 $52.45 3/1/2020 2/29/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESER $52.45 $52.45 3/1/2020 6/30/202090662 49281012088 FLUZONE HIGH-DOSE QUAD 2020-21 - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $57.18 $57.18 7/6/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $200.00 $200.00 1/15/2019 12/31/201990670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $213.80 $213.80 1/1/2020 2/29/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $213.80 $213.80 1/1/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $224.49 $224.49 3/1/202090670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $193.91 $193.91 1/15/2019 12/31/201990670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $207.29 $207.29 1/1/2020 2/29/202090670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $217.66 $217.66 3/1/202090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $200.00 $200.00 1/15/2019 12/31/201990670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $213.80 $213.80 1/1/2020 2/29/202090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR $224.49 $224.49 3/1/202090672 66019030601 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $23.64 $23.64 8/5/2019 2/29/202090672 66019030610 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $23.64 $23.64 8/5/2019 2/29/202090672 66019030601 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $24.82 $24.82 3/1/2020 6/30/202090672 66019030610 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $24.82 $24.82 3/1/2020 6/30/202090672 66019030701 FLUMIST QUAD NASAL 2020-21 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $24.82 $24.82 7/1/202090672 66019030710 FLUMIST QUAD NASAL 2020-21 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LA $24.82 $24.82 7/1/202090674 70461031903 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $24.77 $24.77 7/15/2019 2/29/202090674 70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $24.77 $24.77 7/15/2019 2/29/202090674 70461031903 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $26.01 $26.01 3/1/2020 6/30/202090674 70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $26.01 $26.01 3/1/2020 6/30/202090674 70461032003 FLUCELVAX QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $27.05 $27.05 7/15/202090674 70461032004 FLUCELVAX QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), D $27.05 $27.05 7/15/202090675 49281024658 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/202090675 49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 1/1/2020 2/29/202090675 49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 3/1/202090675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $367.04 $367.04 1/1/2019 12/31/201990675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 1/1/2020 2/29/202090675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 3/1/202090675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/202090675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/202090675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $347.11 $347.11 1/1/2018 12/31/201990675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $357.52 $357.52 1/1/2020 2/29/202090675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $375.40 $375.40 3/1/202090675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $347.11 $347.11 1/1/2018 12/31/201990675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $357.52 $357.52 1/1/2020 2/29/202090675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $375.40 $375.40 3/1/202090675 63851050101 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $262.40 $262.40 7/1/2017 1/23/202090675 63851050102 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $337.12 $337.12 7/1/2017 4/30/202090675 63851051111 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $337.12 $337.12 7/1/2017 4/30/202090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $86.30 $86.30 8/1/2019 2/29/202090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $90.61 $90.61 3/1/202090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $86.29 $86.29 8/1/2019 2/29/202090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $90.61 $90.61 3/1/202090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $86.30 $86.30 8/1/2019 2/29/202090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE $90.61 $90.61 3/1/202090681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $123.81 $123.81 1/1/2019 12/31/201990681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $127.52 $127.52 1/1/2020 2/29/202090681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $133.90 $133.90 3/1/202090681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $123.81 $123.81 1/1/2019 12/31/201990681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $127.52 $127.52 1/1/2020 2/29/202090681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DO $133.90 $133.90 3/1/202090682 49281071910 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $49.96 $49.96 7/2/2019 2/29/202090682 49281071988 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $49.96 $49.96 7/2/2019 2/29/202090682 49281071910 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $52.46 $52.46 3/1/2020 6/30/202090682 49281071988 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $52.45 $52.45 3/1/2020 6/30/202090682 49281072010 FLUBLOK QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $57.18 $57.18 7/6/202090682 49281072088 FLUBLOK QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), D $57.18 $57.18 7/6/202090685 33332021920 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.74 $17.74 7/15/2019 2/29/202090685 33332021921 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.74 $17.74 7/15/2019 2/29/202090685 49281051900 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.45 $19.45 7/2/2019 2/29/202090685 49281051925 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.45 $19.45 7/2/2019 2/29/202090685 33332021920 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.62 $18.62 3/1/2020 6/30/202090685 33332021921 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.62 $18.62 3/1/2020 6/30/202090685 49281051900 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $20.42 $20.42 3/1/2020 6/30/202090685 49281051925 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $20.42 $20.42 3/1/2020 6/30/202090685 33332022020 AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $19.37 $19.37 7/15/202090685 33332022021 AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $19.37 $19.37 7/15/202090686 33332031901 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.74 $17.74 7/15/2019 2/29/202090686 33332031902 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.74 $17.74 7/15/2019 2/29/202090686 58160089641 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $16.55 $16.55 7/16/2019 2/29/202090686 58160089652 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $16.55 $16.55 7/16/2019 2/29/202090686 19515090641 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $16.55 $16.55 7/16/2019 2/29/202090686 19515090652 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $16.55 $16.55 7/16/2019 2/29/202090686 49281041950 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $18.09 $18.09 7/2/2019 2/29/202090686 49281041988 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $18.09 $18.09 7/2/2019 2/29/2020

90686 49281041910 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT V $18.09 $18.09 7/2/2019 2/29/202090686 49281041