Average Acquisition Cost (AAC) Price List (Effective 3/1/2016) › pacific › sites › default ›...

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Average Acquisition Cost (AAC) Price List (Effective 3/1/2016) Generic Name Brand Reference Strength Brand/ Generic Dosage Form AAC Rate 0.9 % SODIUM CHLORIDE SODIUM CHLORIDE 0.9 % Generic INTRAVENOUS SOLUTION 0.0219 $ ABACAVIR SULFATE/LAMIVUDINE EPZICOM 600-300MG Brand TABLET 41.5081 $ ABATACEPT ORENCIA 125 MG/ML Brand DISPOSABLE SYRINGE (ML) 831.5169 $ ACAMPROSATE CALCIUM ACAMPROSATE CALCIUM 333 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.8100 $ ACARBOSE ACARBOSE 25 MG Generic TABLET 0.3660 $ ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1950 $ ACEBUTOLOL HCL SECTRAL 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2400 $ ACETAMINOPHEN ACETAMINOPHEN 325 MG Generic TABLET 0.0129 $ ACETAMINOPHEN ACETAMINOPHEN 500 MG Generic TABLET 0.0300 $ ACETAMINOPHEN CHILDREN'S PAIN & FEVER 160 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0417 $ ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 120-12MG/5 Generic SOLUTION, ORAL 0.0150 $ ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 300MG-15MG Generic TABLET 0.1429 $ ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN W/CODEINE 300MG-30MG Generic TABLET 0.2667 $ ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 300MG-60MG Generic TABLET 0.3200 $ ACETAZOLAMIDE ACETAZOLAMIDE 500 MG Generic CAPSULE, EXTENDED RELEASE 2.4200 $ ACETAZOLAMIDE DIAMOX 125 MG Generic TABLET 1.6900 $ ACETAZOLAMIDE DIAMOX 250 MG Generic TABLET 2.2900 $ ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID 2 %-1 % Generic DROPS 9.3060 $ ACETYLCYSTEINE ACETYLCYSTEINE 200 MG/ML Generic VIAL (ML) 0.3200 $ ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ALZ-NAC 600-2-6 MG Generic TABLET 1.8172 $ ACITRETIN ACITRETIN 25 MG Generic CAPSULE 22.7950 $ ACLIDINIUM BROMIDE TUDORZA PRESSAIR 400 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 285.1241 $ ACYCLOVIR ZOVIRAX 800 MG Generic TABLET 0.2700 $ ACYCLOVIR ZOVIRAX 400 MG Generic TABLET 0.1011 $ ACYCLOVIR ZOVIRAX 5.0% Brand OINTMENT (GRAM) 33.6657 $ ACYCLOVIR ZOVIRAX 5.0% Generic OINTMENT (GRAM) 18.6225 $ ACYCLOVIR ZOVIRAX 200 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5816 $ ACYCLOVIR ZOVIRAX 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1200 $ ACYCLOVIR ZOVIRAX 5.0% Brand CREAM (GRAM) 128.8487 $ ADALIMUMAB HUMIRA 40MG/0.8ML Brand KIT 1,828.7141 $ ADALIMUMAB HUMIRA 40MG/0.8ML Brand PEN INJECTOR KIT (EA) 1,851.0847 $ ADAPALENE DIFFERIN 0.1% Brand LOTION (ML) 7.4797 $ ADAPALENE ADAPALENE 0.1% Brand GEL (GRAM) 9.3700 $ ADAPALENE ADAPALENE 0.1% Generic GEL (GRAM) 2.5325 $ ADAPALENE ADAPALENE 0.1% Brand CREAM (GRAM) 7.8645 $ ADAPALENE ADAPALENE 0.1% Generic CREAM (GRAM) 4.3800 $ ADAPALENE DIFFERIN 0.3% Brand GEL WITH PUMP (GRAM) 8.7933 $ ADAPALENE DIFFERIN 0.3% Brand GEL (GRAM) 8.8155 $ ADAPALENE ADAPALENE 0.3 % Generic GEL (GRAM) 3.2075 $ ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL (GRAM) 8.4961 $ ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL WITH PUMP (GRAM) 8.4640 $ ALBUTEROL SULFATE ACCUNEB 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.3300 $ ALBUTEROL SULFATE ACCUNEB 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.3100 $ ALBUTEROL SULFATE PROVENTIL 4 MG Generic TABLET 0.8684 $ ALBUTEROL SULFATE PROVENTIL 2 MG/5 ML Generic SYRUP 0.0100 $ ALBUTEROL SULFATE PROAIR RESPICLICK 90 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 47.6571 $ ALBUTEROL SULFATE ALBUTEROL SULFATE 5 MG/ML Generic SOLUTION, NON-ORAL 0.5400 $ ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML Generic VIAL, NEBULIZER (ML) 0.0462 $ ALCAFTADINE LASTACAFT 0.3% Brand DROPS 55.3773 $ ALCLOMETASONE DIPROPIONATE ACLOVATE 0.1% Generic CREAM (GRAM) 2.1033 $ ALCLOMETASONE DIPROPIONATE ACLOVATE 0.1% Generic OINTMENT (GRAM) 1.0575 $ ALENDRONATE SODIUM FOSAMAX 35 MG Generic TABLET 0.2838 $ ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG Generic TABLET 0.1767 $ ALENDRONATE SODIUM FOSAMAX 70 MG Generic TABLET 0.6321 $ 1 of 49

Transcript of Average Acquisition Cost (AAC) Price List (Effective 3/1/2016) › pacific › sites › default ›...

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

0.9 % SODIUM CHLORIDE SODIUM CHLORIDE 0.9 % Generic INTRAVENOUS SOLUTION 0.0219$ABACAVIR SULFATE/LAMIVUDINE EPZICOM 600-300MG Brand TABLET 41.5081$ABATACEPT ORENCIA 125 MG/ML Brand DISPOSABLE SYRINGE (ML) 831.5169$ACAMPROSATE CALCIUM ACAMPROSATE CALCIUM 333 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.8100$ACARBOSE ACARBOSE 25 MG Generic TABLET 0.3660$ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1950$ACEBUTOLOL HCL SECTRAL 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2400$ACETAMINOPHEN ACETAMINOPHEN 325 MG Generic TABLET 0.0129$ACETAMINOPHEN ACETAMINOPHEN 500 MG Generic TABLET 0.0300$ACETAMINOPHEN CHILDREN'S PAIN & FEVER 160 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0417$ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 120-12MG/5 Generic SOLUTION, ORAL 0.0150$ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 300MG-15MG Generic TABLET 0.1429$ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN W/CODEINE 300MG-30MG Generic TABLET 0.2667$ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 300MG-60MG Generic TABLET 0.3200$ACETAZOLAMIDE ACETAZOLAMIDE 500 MG Generic CAPSULE, EXTENDED RELEASE 2.4200$ACETAZOLAMIDE DIAMOX 125 MG Generic TABLET 1.6900$ACETAZOLAMIDE DIAMOX 250 MG Generic TABLET 2.2900$ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID 2 %-1 % Generic DROPS 9.3060$ACETYLCYSTEINE ACETYLCYSTEINE 200 MG/ML Generic VIAL (ML) 0.3200$ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ALZ-NAC 600-2-6 MG Generic TABLET 1.8172$ACITRETIN ACITRETIN 25 MG Generic CAPSULE 22.7950$ACLIDINIUM BROMIDE TUDORZA PRESSAIR 400 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 285.1241$ACYCLOVIR ZOVIRAX 800 MG Generic TABLET 0.2700$ACYCLOVIR ZOVIRAX 400 MG Generic TABLET 0.1011$ACYCLOVIR ZOVIRAX 5.0% Brand OINTMENT (GRAM) 33.6657$ACYCLOVIR ZOVIRAX 5.0% Generic OINTMENT (GRAM) 18.6225$ACYCLOVIR ZOVIRAX 200 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5816$ACYCLOVIR ZOVIRAX 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1200$ACYCLOVIR ZOVIRAX 5.0% Brand CREAM (GRAM) 128.8487$ADALIMUMAB HUMIRA 40MG/0.8ML Brand KIT 1,828.7141$ADALIMUMAB HUMIRA 40MG/0.8ML Brand PEN INJECTOR KIT (EA) 1,851.0847$ADAPALENE DIFFERIN 0.1% Brand LOTION (ML) 7.4797$ADAPALENE ADAPALENE 0.1% Brand GEL (GRAM) 9.3700$ADAPALENE ADAPALENE 0.1% Generic GEL (GRAM) 2.5325$ADAPALENE ADAPALENE 0.1% Brand CREAM (GRAM) 7.8645$ADAPALENE ADAPALENE 0.1% Generic CREAM (GRAM) 4.3800$ADAPALENE DIFFERIN 0.3% Brand GEL WITH PUMP (GRAM) 8.7933$ADAPALENE DIFFERIN 0.3% Brand GEL (GRAM) 8.8155$ADAPALENE ADAPALENE 0.3 % Generic GEL (GRAM) 3.2075$ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL (GRAM) 8.4961$ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL WITH PUMP (GRAM) 8.4640$ALBUTEROL SULFATE ACCUNEB 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.3300$ALBUTEROL SULFATE ACCUNEB 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.3100$ALBUTEROL SULFATE PROVENTIL 4 MG Generic TABLET 0.8684$ALBUTEROL SULFATE PROVENTIL 2 MG/5 ML Generic SYRUP 0.0100$ALBUTEROL SULFATE PROAIR RESPICLICK 90 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 47.6571$ALBUTEROL SULFATE ALBUTEROL SULFATE 5 MG/ML Generic SOLUTION, NON-ORAL 0.5400$ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML Generic VIAL, NEBULIZER (ML) 0.0462$ALCAFTADINE LASTACAFT 0.3% Brand DROPS 55.3773$ALCLOMETASONE DIPROPIONATE ACLOVATE 0.1% Generic CREAM (GRAM) 2.1033$ALCLOMETASONE DIPROPIONATE ACLOVATE 0.1% Generic OINTMENT (GRAM) 1.0575$ALENDRONATE SODIUM FOSAMAX 35 MG Generic TABLET 0.2838$ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG Generic TABLET 0.1767$ALENDRONATE SODIUM FOSAMAX 70 MG Generic TABLET 0.6321$

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Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

ALENDRONATE SODIUM/CHOLECALCIFEROL (VITAMIN D3) FOSAMAX PLUS D 70 MG-2800 Brand TABLET 29.5417$ALFUZOSIN HCL UROXATRAL 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2467$ALISKIREN HEMIFUMARATE TEKTURNA 300 MG Brand TABLET 5.9263$ALISKIREN HEMIFUMARATE TEKTURNA 150 MG Brand TABLET 4.0098$ALLOPURINOL ALLOPURINOL 100 MG Generic TABLET 0.2400$ALLOPURINOL ALLOPURINOL 300 MG Generic TABLET 0.3033$ALMOTRIPTAN MALATE AXERT 12.5 MG Brand TABLET 37.1196$ALPRAZOLAM ALPRAZOLAM 0.25 MG Generic TABLET 0.0200$ALPRAZOLAM ALPRAZOLAM 0.5 MG Generic TABLET 0.0200$ALPRAZOLAM ALPRAZOLAM 1 MG Generic TABLET 0.0269$ALPRAZOLAM ALPRAZOLAM 2 MG Generic TABLET 0.0600$ALPRAZOLAM ALPRAZOLAM XR 0.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3600$ALPRAZOLAM ALPRAZOLAM XR 1 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4700$ALPRAZOLAM ALPRAZOLAM XR 2 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5000$ALPRAZOLAM ALPRAZOLAM ER 3 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8467$ALPRAZOLAM NIRAVAM 0.25 MG Generic TABLET,DISINTEGRATING 1.0800$ALPRAZOLAM NIRAVAM 0.5 MG Generic TABLET,DISINTEGRATING 1.3542$ALUMINUM CHLORIDE DRYSOL 20.0% Brand SOLUTION, NON-ORAL 0.1392$AMANTADINE HCL SYMMETREL 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4400$AMANTADINE HCL SYMMETREL 100 MG Generic TABLET 1.6600$AMILORIDE HCL AMILORIDE HCL 5 MG Generic TABLET 0.4763$AMILORIDE HCL/HYDROCHLOROTHIAZIDE MODURETIC 5MG-50MG Generic TABLET 0.4100$AMIODARONE HCL CORDARONE 200 MG Generic TABLET 0.1975$AMITRIPTYLINE HCL ELAVIL 10 MG Generic TABLET 0.1354$AMITRIPTYLINE HCL ELAVIL 100 MG Generic TABLET 1.0600$AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG Generic TABLET 1.6575$AMITRIPTYLINE HCL ELAVIL 25 MG Generic TABLET 0.2700$AMITRIPTYLINE HCL ELAVIL 50 MG Generic TABLET 0.5300$AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75 MG Generic TABLET 0.7700$AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE-AMITRIPTYLINE 25 MG-10MG Generic TABLET 1.7648$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG Generic TABLET 0.0203$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG Generic TABLET 0.0281$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Brand TABLET 3.6512$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Generic TABLET 0.0205$AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM AMLODIPINE-ATORVASTATIN 5 MG-40 MG Generic TABLET 5.7005$AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM AMLODIPINE-ATORVASTATIN 10MG-10MG Generic TABLET 4.9723$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4566$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5 MG-40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2391$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 10MG-40MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1677$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1800$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5 MG-10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3315$AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG Generic CAPSULE 0.5061$AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL AZOR 5MG-40MG Brand TABLET 8.0325$AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL AZOR 10 MG-40MG Brand TABLET 7.7733$AMLODIPINE BESYLATE/VALSARTAN AMLODIPINE-VALSARTAN 5MG-160MG Generic TABLET 0.5025$AMLODIPINE BESYLATE/VALSARTAN EXFORGE 10MG-320MG Brand TABLET 6.6300$AMLODIPINE BESYLATE/VALSARTAN AMLODIPINE-VALSARTAN 10MG-320MG Generic TABLET 0.8750$AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE EXFORGE HCT 10-320-25 Brand TABLET 8.4383$AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE AMLODIPINE-VALSARTAN-HCTZ 10-320-25 Generic TABLET 5.3675$AMMONIUM LACTATE LAC-HYDRIN 12.0% Generic LOTION (GRAM) 0.0600$AMMONIUM LACTATE LAC-HYDRIN 12.0% Generic CREAM (GRAM) 0.0656$AMOXICILLIN AMOXICILLIN 875MG Generic TABLET 0.1271$AMOXICILLIN AMOXIL 250 MG Generic TABLET, CHEWABLE 0.3000$AMOXICILLIN AMOXICILLIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0880$

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Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

AMOXICILLIN AMOXIL 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0703$AMOXICILLIN AMOXICILLIN 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0201$AMOXICILLIN AMOXICILLIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0304$AMOXICILLIN AMOXICILLIN 400 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0444$AMOXICILLIN AMOXICILLIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0401$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 600-42.9/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1431$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 500-125 MG Generic TABLET 0.5100$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 875-125 MG Generic TABLET 0.7377$AMOXICILLIN/POTASSIUM CLAVULANATE AUGMENTIN 400-57MG Generic TABLET, CHEWABLE 2.0595$AMOXICILLIN/POTASSIUM CLAVULANATE AUGMENTIN 125-31.25/ Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 5.3300$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 250-62.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6278$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1363$AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0839$AMOXICILLIN/POTASSIUM CLAVULANATE AMOXICILLIN-CLAVULANATE ER 1000-62.5 Generic TABLET, EXTENDED RELEASE 12 HR 3.6400$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 10 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9150$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 10 MG Generic CAPSULE, EXT RELEASE 24 HR 4.0857$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 20 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8475$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 20 MG Generic CAPSULE, EXT RELEASE 24 HR 3.6050$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 30 MG Brand CAPSULE, EXT RELEASE 24 HR 6.7917$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 30 MG Generic CAPSULE, EXT RELEASE 24 HR 3.6825$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 5 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8775$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 5 MG Generic CAPSULE, EXT RELEASE 24 HR 3.9800$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 15 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9725$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 15 MG Generic CAPSULE, EXT RELEASE 24 HR 4.0460$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 25 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9540$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 25 MG Generic CAPSULE, EXT RELEASE 24 HR 3.5700$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 15 MG Generic TABLET 0.9334$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 5 MG Generic TABLET 0.6169$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 10 MG Generic TABLET 0.6087$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 30 MG Generic TABLET 0.6218$AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 20 MG Generic TABLET 0.5669$AMPICILLIN SODIUM/SULBACTAM SODIUM UNASYN 3 G Brand VIAL (EA) 5.2701$AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1400$ANASTROZOLE ARIMIDEX 1 MG Generic TABLET 0.1644$ANTIPYRINE/BENZOCAINE/GLYCERIN ALLERGEN 5.4 %-1.4% Generic DROPS 0.4271$APIXABAN ELIQUIS 2.5 MG Brand TABLET 5.3080$APIXABAN ELIQUIS 5 MG Brand TABLET 5.3029$APREPITANT EMEND 125MG-80MG Brand CAPSULE, DOSE PACK 187.8191$APREPITANT EMEND 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 81.1402$ARFORMOTEROL TARTRATE BROVANA 15MCG/2ML Brand VIAL, NEBULIZER (ML) 5.9271$ARIPIPRAZOLE ABILIFY 10 MG Brand TABLET 28.3721$ARIPIPRAZOLE ABILIFY 10 MG Generic TABLET 8.1643$ARIPIPRAZOLE ABILIFY 15 MG Brand TABLET 28.3900$ARIPIPRAZOLE ABILIFY 15 MG Generic TABLET 6.0283$ARIPIPRAZOLE ABILIFY 20 MG Brand TABLET 40.1460$ARIPIPRAZOLE ABILIFY 20 MG Generic TABLET 17.9800$ARIPIPRAZOLE ABILIFY 30 MG Brand TABLET 40.1633$ARIPIPRAZOLE ABILIFY 30 MG Generic TABLET 17.9800$ARIPIPRAZOLE ABILIFY 5 MG Brand TABLET 28.3582$ARIPIPRAZOLE ABILIFY 5 MG Generic TABLET 7.0872$ARIPIPRAZOLE ABILIFY 2 MG Brand TABLET 28.3727$ARIPIPRAZOLE ABILIFY 2 MG Generic TABLET 7.7275$ARIPIPRAZOLE ABILIFY MAINTENA 400 MG Brand SUSPENSION,EXTENDED RELEASE VIAL 1,630.5719$ARMODAFINIL NUVIGIL 200 MG Brand TABLET 19.4631$

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Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

ARMODAFINIL NUVIGIL 150 MG Brand TABLET 19.5864$ARMODAFINIL NUVIGIL 50 MG Brand TABLET 6.5197$ARMODAFINIL NUVIGIL 250 MG Brand TABLET 19.3312$ASCORBIC ACID VITAMIN C 500 MG Generic TABLET 0.0267$ASENAPINE MALEATE SAPHRIS 5 MG Brand TABLET, SUBLINGUAL 14.6660$ASENAPINE MALEATE SAPHRIS 10 MG Brand TABLET, SUBLINGUAL 14.6438$ASPIRIN SUREPRIN 81 81 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0175$ASPIRIN ASPIRIN 325 MG Generic TABLET 0.0100$ASPIRIN ASPIRIN 81 MG Generic TABLET, CHEWABLE 0.0363$ASPIRIN ASPIRIN EC 325 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0197$ASPIRIN/DIPYRIDAMOLE AGGRENOX 25MG-200MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 6.8600$ASPIRIN/DIPYRIDAMOLE AGGRENOX 25MG-200MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 4.5700$ATAZANAVIR SULFATE REYATAZ 300 MG Brand CAPSULE 48.2175$ATENOLOL TENORMIN 100 MG Generic TABLET 0.0300$ATENOLOL TENORMIN 50 MG Generic TABLET 0.0200$ATENOLOL TENORMIN 25 MG Generic TABLET 0.0113$ATENOLOL/CHLORTHALIDONE TENORETIC 50 50 MG-25MG Generic TABLET 0.4020$ATENOLOL/CHLORTHALIDONE TENORETIC 100 100MG-25MG Generic TABLET 0.6175$ATOMOXETINE HCL STRATTERA 10 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.7892$ATOMOXETINE HCL STRATTERA 18 MG Brand CAPSULE (HARD, SOFT, ETC.) 10.7456$ATOMOXETINE HCL STRATTERA 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 10.6617$ATOMOXETINE HCL STRATTERA 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.6500$ATOMOXETINE HCL STRATTERA 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.7800$ATOMOXETINE HCL STRATTERA 80 MG Brand CAPSULE (HARD, SOFT, ETC.) 12.5550$ATOMOXETINE HCL STRATTERA 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 12.4433$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Brand TABLET 6.5318$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Generic TABLET 0.1076$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Brand TABLET 9.1052$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Generic TABLET 0.1241$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Brand TABLET 9.9247$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Generic TABLET 0.1290$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Brand TABLET 6.6869$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Generic TABLET 0.1513$ATOVAQUONE MEPRON 750 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 5.8432$ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 250-100 MG Generic TABLET 5.6500$ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 62.5-25MG Generic TABLET 1.2181$ATROPINE SULFATE ATROPINE CARE 1.0% Generic DROPS 4.4233$AZATHIOPRINE IMURAN 50 MG Generic TABLET 0.4320$AZELAIC ACID FINACEA 15.0% Brand GEL (GRAM) 5.2812$AZELAIC ACID AZELEX 20.0% Brand CREAM (GRAM) 11.1626$AZELASTINE HCL ASTEPRO 205.5MCG Brand AEROSOL, SPRAY WITH PUMP (ML) 4.7425$AZELASTINE HCL ASTEPRO 205.5MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 3.5182$AZELASTINE HCL ASTELIN 137 MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 0.8200$AZELASTINE HCL AZELASTINE HCL 0.1% Generic DROPS 8.7500$AZELASTINE HCL/FLUTICASONE PROPIONATE DYMISTA 137-50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 7.0600$AZITHROMYCIN AZITHROMYCIN 100 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 1.2000$AZITHROMYCIN AZITHROMYCIN 250 MG Generic TABLET 0.6834$AZITHROMYCIN AZITHROMYCIN 500 MG Generic TABLET 1.8717$AZITHROMYCIN AZITHROMYCIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7448$AZITHROMYCIN AZASITE 1.0% Brand DROPS 59.2293$BACITRACIN BACIGUENT 500 UNIT/G Generic OINTMENT (GRAM) 0.0620$BACITRACIN BACITRACIN 500 UNIT/G Generic OINTMENT (GRAM) 29.1680$BACITRACIN ZINC BACITRACIN ZINC 500 UNIT/G Generic OINTMENT (GRAM) 0.1767$BACITRACIN/POLYMYXIN B SULFATE POLYSPORIN 500-10K/G Generic OINTMENT (GRAM) 4.2025$

4 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

BACLOFEN LIORESAL 10 MG Generic TABLET 0.2056$BACLOFEN LIORESAL 20 MG Generic TABLET 0.3262$BALSALAZIDE DISODIUM COLAZAL 750 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5400$BECLOMETHASONE DIPROPIONATE QNASL 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 19.4341$BECLOMETHASONE DIPROPIONATE QVAR 40 MCG Brand AEROSOL WITH ADAPTER (GRAM) 16.2100$BECLOMETHASONE DIPROPIONATE QVAR 80 MCG Brand AEROSOL WITH ADAPTER (GRAM) 21.7093$BENAZEPRIL HCL BENAZEPRIL HCL 5 MG Generic TABLET 0.0622$BENAZEPRIL HCL BENAZEPRIL HCL 10 MG Generic TABLET 0.0778$BENAZEPRIL HCL BENAZEPRIL HCL 20 MG Generic TABLET 0.0810$BENAZEPRIL HCL BENAZEPRIL HCL 40 MG Generic TABLET 0.1050$BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG Generic TABLET 1.1503$BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG Generic TABLET 1.2535$BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-25MG Generic TABLET 1.3415$BENZOCAINE/MENTHOL CEPACOL SORE THROAT 15MG-3.6MG Brand LOZENGE 0.1520$BENZONATATE BENZONATATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3679$BENZONATATE TESSALON 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4826$BENZOYL PEROXIDE BENZAC 5 5.0% Generic GEL (GRAM) 0.1500$BENZOYL PEROXIDE DESQUAM-X 10.0% Generic CLEANSER (GRAM) 0.0500$BENZOYL PEROXIDE BENZEFOAM 5.3% Generic FOAM (GRAM) 2.0278$BENZOYL PEROXIDE BENZEFOAM ULTRA 9.8% Generic FOAM (GRAM) 2.4322$BENZOYL PEROXIDE BENZAC AC 5.0% Generic CLEANSER (GRAM) 0.0467$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 0.5 MG Generic TABLET 0.2001$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 1 MG Generic TABLET 0.2047$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 2 MG Generic TABLET 0.2376$BENZYL ALCOHOL ULESFIA 5 % Brand LOTION (GRAM) 0.7103$BEPOTASTINE BESILATE BEPREVE 1.5% Brand DROPS 31.4867$BESIFLOXACIN HCL BESIVANCE 0.6% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 25.7358$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.1% Generic CREAM (GRAM) 1.7467$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.1% Generic OINTMENT (GRAM) 1.5900$BETAMETHASONE DIPROPIONATE DIPROSONE 0.1% Generic LOTION (ML) 0.5800$BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL DIPROLENE 0.1% Generic LOTION (ML) 2.0476$BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL DIPROLENE AF 0.1% Generic CREAM (GRAM) 0.8250$BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE 0.05 % Brand OINTMENT (GRAM) 3.0008$BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE 0.1% Generic OINTMENT (GRAM) 2.1400$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% Generic CREAM (GRAM) 0.6800$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% Generic OINTMENT (GRAM) 0.7400$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% Generic LOTION (ML) 0.7300$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.12 % Generic FOAM (GRAM) 4.2700$BETAXOLOL HCL BETOPTIC S 0.3% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 25.6275$BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 10 MG Generic TABLET 0.1232$BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 25 MG Generic TABLET 0.5033$BICALUTAMIDE CASODEX 50 MG Generic TABLET 0.4400$BIFIDOBACTERIUM INFANTIS ALIGN 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.7914$BIMATOPROST LUMIGAN 0.0% Brand DROPS 57.1763$BISACODYL BISAC-EVAC 10 MG Generic SUPPOSITORY, RECTAL 0.0889$BISACODYL BISACODYL 5 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0579$BISACODYL/SODIUM CHLOR/SODIUM BICARB/POTASSIUM CHL/PEG 3350 HALFLYTELY-BISACODYL 5 MG-210 G Brand KIT 63.4725$BISMUTH SUBSALICYLATE PEPTO-BISMOL 262MG/15ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0155$BISOPROLOL FUMARATE ZEBETA 10 MG Generic TABLET 0.4700$BISOPROLOL FUMARATE ZEBETA 5 MG Generic TABLET 0.4720$BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 2.5-6.25MG Generic TABLET 0.1017$BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 5-6.25MG Generic TABLET 0.0767$BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 10-6.25MG Generic TABLET 0.1050$BRIMONIDINE TARTRATE ALPHAGAN P 0.2% Brand DROPS 23.3823$

5 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

BRIMONIDINE TARTRATE ALPHAGAN P 0.2% Generic DROPS 18.8200$BRIMONIDINE TARTRATE ALPHAGAN P 0.1% Brand DROPS 23.2178$BRIMONIDINE TARTRATE MIRVASO 0.33 % Brand GEL (GRAM) 11.4916$BRIMONIDINE TARTRATE ALPHAGAN 0.2% Generic DROPS 0.9200$BRIMONIDINE TARTRATE/TIMOLOL MALEATE COMBIGAN 0.2%-0.5% Brand DROPS 25.5980$BRINZOLAMIDE AZOPT 1.0% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 23.8875$BRINZOLAMIDE/BRIMONIDINE TARTRATE SIMBRINZA 1 %-0.2 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 15.7446$BROMFENAC SODIUM BROMDAY 0.1% Generic DROPS 41.4475$BROMFENAC SODIUM PROLENSA 0.1% Brand DROPS 67.5598$BROMOCRIPTINE MESYLATE PARLODEL 2.5 MG Generic TABLET 2.9600$BUDESONIDE PULMICORT 0.25MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 2.9700$BUDESONIDE PULMICORT 0.5 MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 3.5100$BUDESONIDE BUDESONIDE EC 3 MG Generic CAPSULE, DELAYED & EXTENDED RELEASE 7.9200$BUDESONIDE UCERIS 9 MG Brand TABLET, DELAYED & EXTENDED RELEASE 51.4991$BUDESONIDE PULMICORT 1 MG/2 ML Brand AMPUL FOR NEBULIZATION (ML) 9.8880$BUDESONIDE BUDESONIDE 1 MG/2 ML Generic AMPUL FOR NEBULIZATION (ML) 10.0500$BUDESONIDE RHINOCORT AQUA 32MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 16.4233$BUDESONIDE BUDESONIDE 32MCG Generic AEROSOL, SPRAY WITH PUMP (GRAM) 13.5800$BUDESONIDE PULMICORT FLEXHALER 90 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 143.7637$BUDESONIDE PULMICORT FLEXHALER 180 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 191.7421$BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 80-4.5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 23.8288$BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 160-4.5MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 27.1165$BUMETANIDE BUMETANIDE 0.5 MG Generic TABLET 0.6620$BUMETANIDE BUMEX 1 MG Generic TABLET 0.5800$BUMETANIDE BUMETANIDE 2 MG Generic TABLET 1.0800$BUPRENORPHINE BUTRANS 5 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 48.9450$BUPRENORPHINE BUTRANS 10 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 73.4455$BUPRENORPHINE BUTRANS 20 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 131.5256$BUPRENORPHINE BUTRANS 15 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 105.9000$BUPRENORPHINE BUTRANS 7.5 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 62.4800$BUPRENORPHINE HCL SUBUTEX 2 MG Generic TABLET, SUBLINGUAL 1.3800$BUPRENORPHINE HCL SUBUTEX 8 MG Generic TABLET, SUBLINGUAL 2.3800$BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE-NALOXONE 2 MG-0.5MG Generic TABLET, SUBLINGUAL 3.9575$BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 8 MG-2 MG Brand TABLET, SUBLINGUAL 9.6600$BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE-NALOXONE 8 MG-2 MG Generic TABLET, SUBLINGUAL 5.7400$BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 2 MG-0.5MG Brand FILM, MEDICATED (EA) 3.9885$BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 8 MG-2 MG Brand FILM, MEDICATED (EA) 6.8482$BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 4MG-1MG Brand FILM, MEDICATED (EA) 7.1503$BUPRENORPHINE HCL/NALOXONE HCL ZUBSOLV 5.7-1.4 MG Brand TABLET, SUBLINGUAL 7.1506$BUPROPION HCL WELLBUTRIN 75 MG Generic TABLET 0.3925$BUPROPION HCL WELLBUTRIN 100 MG Generic TABLET 0.3969$BUPROPION HCL BUPROPION HCL SR 150 MG Brand TABLET, EXTENDED RELEASE 6.0467$BUPROPION HCL BUPROPION HCL SR 150 MG Generic TABLET, EXTENDED RELEASE 0.2071$BUPROPION HCL BUPROPION HCL SR 100 MG Generic TABLET, EXTENDED RELEASE 0.2728$BUPROPION HCL BUPROPION HCL SR 200 MG Generic TABLET, EXTENDED RELEASE 0.4732$BUPROPION HCL WELLBUTRIN XL 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 33.8723$BUPROPION HCL WELLBUTRIN XL 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6700$BUPROPION HCL WELLBUTRIN XL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7014$BUPROPION HCL BUPROPION HCL SR 150 MG Generic TABLET, EXTENDED RELEASE 0.7968$BUSPIRONE HCL BUSPIRONE HCL 7.5 MG Generic TABLET 0.8725$BUSPIRONE HCL BUSPAR 5 MG Generic TABLET 0.0500$BUSPIRONE HCL BUSPAR 10 MG Generic TABLET 0.0800$BUSPIRONE HCL BUSPAR 15 MG Generic TABLET 0.0900$BUSPIRONE HCL BUSPAR 30 MG Generic TABLET 0.7300$

6 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

BUTALBITAL/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 50-300-40 Brand CAPSULE 3.9986$BUTALBITAL/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 50-300-40 Generic CAPSULE 2.6050$BUTALBITAL/ACETAMINOPHEN/CAFFEINE ESGIC 50-325-40 Generic TABLET 1.0800$BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE BUTALB-ACETAMINOPH-CAFF-CODEIN 50-300-30 Generic CAPSULE 4.4325$BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE BUTALB-CAFF-ACETAMINOPH-CODEIN 50-325-30 Generic CAPSULE (HARD, SOFT, ETC.) 1.0900$BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 Generic CAPSULE (HARD, SOFT, ETC.) 1.0650$BUTORPHANOL TARTRATE STADOL NS 10 MG/ML Generic AEROSOL, SPRAY (ML) 14.7700$CABERGOLINE CABERGOLINE 0.5 MG Generic TABLET 9.4499$CALCIPOTRIENE CALCIPOTRIENE 0.005 % Generic OINTMENT (GRAM) 4.3640$CALCIPOTRIENE CALCIPOTRIENE 0.0% Brand CREAM (GRAM) 7.0590$CALCIPOTRIENE CALCIPOTRIENE 0.0% Generic CREAM (GRAM) 4.1100$CALCIPOTRIENE CALCIPOTRIENE 0.0% Generic SOLUTION, NON-ORAL 2.8700$CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TACLONEX 0.005-.064 Brand OINTMENT (GRAM) 9.9292$CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TACLONEX 0.005-.064 Brand SUSPENSION, TOPICAL (GRAM) 11.7898$CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 200/DOSE Brand AEROSOL, SPRAY WITH PUMP (ML) 14.2550$CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 200/DOSE Generic AEROSOL, SPRAY WITH PUMP (ML) 13.3300$CALCITRIOL CALCITRIOL 3MCG/G Brand OINTMENT (GRAM) 7.9202$CALCITRIOL CALCITRIOL 0.25 MCG Generic CAPSULE (HARD, SOFT, ETC.) 0.6536$CALCITRIOL CALCITRIOL 0.5 MCG Generic CAPSULE (HARD, SOFT, ETC.) 1.0100$CALCIUM ACETATE CALCIUM ACETATE 667 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4000$CALCIUM CARBONATE EQUILET 200(500)MG Brand TABLET, CHEWABLE 0.0288$CALCIUM CARBONATE CAL-GEST 200(500)MG Generic TABLET, CHEWABLE 0.0154$CALCIUM CARBONATE TUMS 300MG(750) Brand TABLET, CHEWABLE 0.0517$CALCIUM POLYCARBOPHIL FIBER LAXATIVE 625 MG Brand TABLET 0.1123$CALCIUM POLYCARBOPHIL FIBER 625 MG Generic TABLET 0.0600$CANAGLIFLOZIN INVOKANA 100 MG Brand TABLET 11.5210$CANAGLIFLOZIN INVOKANA 300 MG Brand TABLET 11.5120$CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL 8 MG Generic TABLET 2.4380$CANDESARTAN CILEXETIL ATACAND 16 MG Brand TABLET 2.8430$CANDESARTAN CILEXETIL ATACAND 16 MG Generic TABLET 2.4527$CANDESARTAN CILEXETIL ATACAND 32 MG Brand TABLET 3.8270$CANDESARTAN CILEXETIL ATACAND 32 MG Generic TABLET 2.6309$CAPSAICIN CAPSAICIN 0.025 % Generic CREAM (GRAM) 0.1400$CAPTOPRIL CAPOTEN 100 MG Generic TABLET 1.8240$CAPTOPRIL CAPOTEN 25 MG Generic TABLET 1.0280$CAPTOPRIL CAPTOPRIL 50 MG Generic TABLET 1.6500$CAPTOPRIL CAPTOPRIL 12.5 MG Generic TABLET 1.0150$CARBAMAZEPINE TEGRETOL 200 MG Brand TABLET 1.8243$CARBAMAZEPINE TEGRETOL 200 MG Generic TABLET 0.7100$CARBAMAZEPINE TEGRETOL 100 MG Generic TABLET, CHEWABLE 0.4550$CARBAMAZEPINE CARBAMAZEPINE 200 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7120$CARBAMAZEPINE CARBAMAZEPINE 200 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.3100$CARBAMAZEPINE CARBAMAZEPINE 300 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7075$CARBAMAZEPINE CARBAMAZEPINE 300 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.3000$CARBAMAZEPINE CARBAMAZEPINE 100 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.1350$CARBAMAZEPINE TEGRETOL XR 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 0.9781$CARBAMAZEPINE CARBAMAZEPINE ER 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.6300$CARBAMAZEPINE CARBAMAZEPINE ER 400 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.9179$CARBAMAZEPINE CARBAMAZEPINE ER 400 MG Generic TABLET, EXTENDED RELEASE 12 HR 3.2159$CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.2606$CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1478$CARBAMIDE PEROXIDE DEBROX 6.5% Brand DROPS 0.2978$CARBAMIDE PEROXIDE DEBROX 6.5% Generic DROPS 0.1160$CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-100MG Generic TABLET,DISINTEGRATING 0.8440$

7 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

CARBIDOPA/LEVODOPA SINEMET CR 50MG-200MG Generic TABLET, EXTENDED RELEASE 0.4600$CARBIDOPA/LEVODOPA SINEMET CR 25MG-100MG Generic TABLET, EXTENDED RELEASE 0.5142$CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 10MG-100MG Generic TABLET 0.1680$CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-100MG Generic TABLET 0.1267$CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-250MG Generic TABLET 0.1880$CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 25-100-200 Generic TABLET 2.5400$CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 50-200-200 Generic TABLET 2.9713$CARBOXYMETHYLCELLULOSE SODIUM REFRESH TEARS 0.5% Brand DROPS 0.5134$CARBOXYMETHYLCELLULOSE SODIUM/HYPROMELLOSE GENTEAL 0.25%-0.3% Brand DROPS, LIQUID GEL 0.4333$CARISOPRODOL SOMA 350 MG Generic TABLET 0.0829$CARISOPRODOL CARISOPRODOL 250 MG Generic TABLET 2.6450$CARTEOLOL HCL OCUPRESS 1.0% Generic DROPS 1.1975$CARVEDILOL COREG 25 MG Generic TABLET 0.0544$CARVEDILOL COREG 12.5 MG Generic TABLET 0.0551$CARVEDILOL COREG 3.125 MG Generic TABLET 0.0411$CARVEDILOL COREG 6.25 MG Generic TABLET 0.0410$CARVEDILOL PHOSPHATE COREG CR 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 8.0801$CARVEDILOL PHOSPHATE COREG CR 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 8.1053$CARVEDILOL PHOSPHATE COREG CR 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 8.3939$CARVEDILOL PHOSPHATE COREG CR 80 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 8.0706$CEFADROXIL HYDRATE DURICEF 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2600$CEFDINIR OMNICEF 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5388$CEFDINIR CEFDINIR 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9600$CEFDINIR CEFDINIR 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.4100$CEFIXIME SUPRAX 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 8.2479$CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL 200 MG Generic TABLET 6.5575$CEFPROZIL CEFZIL 250 MG Generic TABLET 2.1250$CEFPROZIL CEFPROZIL 500 MG Generic TABLET 1.7733$CEFPROZIL CEFZIL 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3100$CEFPROZIL CEFZIL 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5140$CEFTIBUTEN DIHYDRATE CEDAX 400 MG Brand CAPSULE (HARD, SOFT, ETC.) 30.7447$CEFUROXIME AXETIL CEFTIN 250 MG Generic TABLET 1.4042$CEFUROXIME AXETIL CEFTIN 500 MG Generic TABLET 2.5949$CEFUROXIME AXETIL CEFTIN 250 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 2.0558$CELECOXIB CELECOXIB 400 MG Generic CAPSULE 1.2559$CELECOXIB CELEBREX 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.3932$CELECOXIB CELEBREX 100 MG Generic CAPSULE 0.9700$CELECOXIB CELEBREX 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.8768$CELECOXIB CELEBREX 200 MG Generic CAPSULE 1.3000$CEPHALEXIN CEPHALEXIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1200$CEPHALEXIN CEPHALEXIN 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1001$CEPHALEXIN KEFLEX 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1775$CEPHALEXIN KEFLEX 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1673$CERTOLIZUMAB PEGOL CIMZIA 400MG/2ML Brand SYRINGE KIT (EA) 3,218.5425$CETIRIZINE HCL CHILDREN'S CETIRIZINE HCL 10 MG Generic TABLET, CHEWABLE 3.8450$CETIRIZINE HCL CHILDREN'S ZYRTEC 1 MG/ML Generic SOLUTION, ORAL 0.0285$CETIRIZINE HCL ALL DAY ALLERGY 10 MG Generic TABLET 0.0680$CETIRIZINE HCL CETIRIZINE HCL 5 MG Generic TABLET 0.1100$CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ALLERGY RELIEF-D 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.6588$CEVIMELINE HCL CEVIMELINE HCL 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.1916$CEVIMELINE HCL CEVIMELINE HCL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.9800$CHLORAMBUCIL LEUKERAN 2 MG Brand TABLET 19.4808$CHLORCYCLIZINE HCL/PHENYLEPHRINE HCL DALLERGY 12.5-5MG/5 Brand LIQUID (ML) 0.1124$CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$

8 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0815$CHLORDIAZEPOXIDE HCL LIBRIUM 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0875$CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE CHLORDIAZEPOXIDE-CLIDINIUM 5 MG-2.5MG Generic CAPSULE (HARD, SOFT, ETC.) 2.1590$CHLORHEXIDINE GLUCONATE PERIDEX 0.1% Generic MOUTHWASH 0.0100$CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 250 MG Generic TABLET 1.1700$CHLOROQUINE PHOSPHATE ARALEN PHOSPHATE 500 MG Generic TABLET 5.1827$CHLORPHENIRAMINE MALEATE ALLER-CHLOR 4 MG Generic TABLET 0.0100$CHLORPROMAZINE HCL THORAZINE 100 MG Generic TABLET 6.6780$CHLORTHALIDONE HYGROTON 25 MG Generic TABLET 0.9482$CHLORTHALIDONE CHLORTHALIDONE 50 MG Generic TABLET 0.9425$CHLORZOXAZONE PARAFON FORTE DSC 500 MG Generic TABLET 0.2000$CHOLECALCIFEROL (VITAMIN D3) JUST D 400/ML Generic DROPS 0.0850$CHOLECALCIFEROL (VITAMIN D3) VITAMIN D 2000 UNIT Generic CAPSULE 0.0438$CHOLESTYRAMINE (WITH SUGAR) QUESTRAN 4 G Generic POWDER IN PACKET (EA) 1.8908$CHOLESTYRAMINE (WITH SUGAR) QUESTRAN 4 G Generic POWDER (GRAM) 0.2225$CHOLESTYRAMINE/ASPARTAME QUESTRAN LIGHT 4 G Generic POWDER IN PACKET (EA) 2.0100$CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT 4 G Generic POWDER (GRAM) 0.2400$CICLESONIDE ALVESCO 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 32.0749$CICLESONIDE ALVESCO 160 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 32.3430$CICLESONIDE ZETONNA 37 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 32.8353$CICLESONIDE OMNARIS 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 16.3358$CICLOPIROX PENLAC 8.0% Generic SOLUTION, NON-ORAL 4.3325$CICLOPIROX CICLOPIROX 0.8% Generic GEL (GRAM) 1.4625$CICLOPIROX CICLOPIROX 1.0% Generic SHAMPOO 0.6480$CICLOPIROX OLAMINE LOPROX 0.77 % Generic CREAM (GRAM) 0.4975$CILOSTAZOL CILOSTAZOL 100 MG Generic TABLET 0.1683$CILOSTAZOL CILOSTAZOL 50 MG Generic TABLET 0.1525$CIMETIDINE CIMETIDINE 400 MG Generic TABLET 0.4258$CIMETIDINE CIMETIDINE 800 MG Generic TABLET 0.9122$CINACALCET HCL SENSIPAR 30 MG Brand TABLET 22.0146$CINACALCET HCL SENSIPAR 60 MG Brand TABLET 42.7813$CIPROFLOXACIN CIPRO Brand SUSPENSION, MICROCAPSULE RECONSTITUTED 1.2394$CIPROFLOXACIN HCL CILOXAN 0.3% Brand OINTMENT (GRAM) 48.9110$CIPROFLOXACIN HCL CIPROFLOXACIN HCL 0.2 % Generic DROPPERETTE, SINGLE-USE DROP DISPENSER 6.1800$CIPROFLOXACIN HCL CILOXAN 0.3% Generic DROPS 1.2200$CIPROFLOXACIN HCL CIPRO 250 MG Generic TABLET 0.1900$CIPROFLOXACIN HCL CIPRO 500 MG Generic TABLET 0.2100$CIPROFLOXACIN HCL CIPRO 750 MG Generic TABLET 0.3200$CIPROFLOXACIN HCL/DEXAMETHASONE CIPRODEX 0.3 %-0.1% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 22.2750$CIPROFLOXACIN HCL/HYDROCORTISONE CIPRO HC 0.2 %-1 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 22.7275$CITALOPRAM HYDROBROMIDE CELEXA 20 MG Generic TABLET 0.0350$CITALOPRAM HYDROBROMIDE CELEXA 40 MG Generic TABLET 0.0500$CITALOPRAM HYDROBROMIDE CELEXA 10 MG/5 ML Generic SOLUTION, ORAL 0.2364$CITALOPRAM HYDROBROMIDE CELEXA 10 MG Generic TABLET 0.0560$CITRIC ACID/SODIUM CITRATE BICITRA 334-500MG Generic SOLUTION, ORAL 0.0522$CLARITHROMYCIN BIAXIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7986$CLARITHROMYCIN BIAXIN XL 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.6325$CLARITHROMYCIN BIAXIN 500 MG Generic TABLET 1.0100$CLINDAMYCIN HCL CLEOCIN HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1400$CLINDAMYCIN HCL CLEOCIN HCL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3000$CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 75 MG/5 ML Generic SOLUTION, RECONSTITUTED, ORAL 0.3586$CLINDAMYCIN PHOSPHATE CLINDAGEL 1.0% Brand GEL (ML) 6.5900$CLINDAMYCIN PHOSPHATE EVOCLIN 1.0% Generic FOAM (GRAM) 3.6950$CLINDAMYCIN PHOSPHATE CLEOCIN 2.0% Generic CREAM WITH APPLICATOR 2.1500$

9 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

CLINDAMYCIN PHOSPHATE CLEOCIN T 1.0% Generic SOLUTION, NON-ORAL 1.0000$CLINDAMYCIN PHOSPHATE CLEOCIN T 1.0% Generic LOTION (ML) 1.3143$CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 150 MG/ML Generic VIAL (ML) 0.7122$CLINDAMYCIN PHOSPHATE CLEOCIN T 1.0% Generic GEL (GRAM) 1.7882$CLINDAMYCIN PHOSPHATE CLEOCIN T 1.0% Generic SWAB, MEDICATED 0.3800$CLINDAMYCIN PHOSPHATE CLEOCIN 100 MG Brand SUPPOSITORY, VAGINAL 38.0095$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE BENZACLIN 1 %-5 % Brand GEL (GRAM) 9.0300$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE BENZACLIN 1 %-5 % Generic GEL (GRAM) 6.4700$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE ACANYA 1.2%-2.5% Brand GEL WITH PUMP (GRAM) 8.3886$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE CLINDAMYCIN PHOS-BENZOYL PEROX 1.2(1)%-5% Brand GEL, EXTENDED RELEASE (GRAM) 5.3399$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE CLINDAMYCIN PHOS-BENZOYL PEROX 1.2(1)%-5% Generic GEL, EXTENDED RELEASE (GRAM) 3.0800$CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE BENZACLIN 1 %-5 % Brand GEL WITH PUMP (GRAM) 9.3900$CLINDAMYCIN PHOSPHATE/TRETINOIN VELTIN 1.2-0.025% Brand GEL (GRAM) 10.9671$CLOBAZAM ONFI 10 MG Brand TABLET 12.1700$CLOBETASOL PROPIONATE TEMOVATE 0.1% Generic SOLUTION, NON-ORAL 2.2560$CLOBETASOL PROPIONATE TEMOVATE 0.1% Generic GEL (GRAM) 7.5092$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.1% Generic SHAMPOO 2.2763$CLOBETASOL PROPIONATE CLOBEX 0.1% Brand SPRAY, NON-AEROSOL (ML) 6.3269$CLOBETASOL PROPIONATE TEMOVATE 0.1% Generic OINTMENT (GRAM) 3.3829$CLOBETASOL PROPIONATE TEMOVATE 0.1% Generic CREAM (GRAM) 3.9430$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.1% Generic LOTION (ML) 3.1540$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.1% Generic FOAM (GRAM) 5.6300$CLOBETASOL PROPIONATE/EMOLLIENT TEMOVATE EMOLLIENT 0.1% Generic CREAM (GRAM) 2.6420$CLOBETASOL PROPIONATE/EMOLLIENT CLOBETASOL PROPIONATE 0.1% Brand FOAM (GRAM) 5.5601$CLOCORTOLONE PIVALATE CLODERM 0.1% Brand CREAM (GRAM) 6.4923$CLOCORTOLONE PIVALATE CLOCORTOLONE PIVALATE 0.1 % Generic CREAM (GRAM) 5.8775$CLOMIPRAMINE HCL ANAFRANIL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.5850$CLOMIPRAMINE HCL ANAFRANIL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.6567$CLONAZEPAM KLONOPIN 0.5 MG Generic TABLET 0.0188$CLONAZEPAM KLONOPIN 1 MG Generic TABLET 0.0297$CLONAZEPAM KLONOPIN 2 MG Generic TABLET 0.0396$CLONAZEPAM KLONOPIN 0.125 MG Generic TABLET,DISINTEGRATING 0.8729$CLONAZEPAM KLONOPIN 0.25 MG Generic TABLET,DISINTEGRATING 0.8200$CLONAZEPAM CLONAZEPAM 0.5 MG Generic TABLET,DISINTEGRATING 0.7750$CLONAZEPAM KLONOPIN 1 MG Generic TABLET,DISINTEGRATING 0.8617$CLONAZEPAM KLONOPIN 2 MG Generic TABLET,DISINTEGRATING 1.2833$CLONIDINE CATAPRES-TTS 1 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 19.2600$CLONIDINE CATAPRES-TTS 2 0.2MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 27.1829$CLONIDINE CATAPRES-TTS 3 0.3MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 45.2940$CLONIDINE HCL CATAPRES 0.1 MG Generic TABLET 0.0357$CLONIDINE HCL CATAPRES 0.2 MG Generic TABLET 0.0500$CLONIDINE HCL CATAPRES 0.3 MG Generic TABLET 0.0600$CLONIDINE HCL CLONIDINE HCL ER 0.1 MG Generic TABLET, EXTENDED RELEASE 12 HR 3.3375$CLOPIDOGREL BISULFATE PLAVIX 75 MG Brand TABLET 6.1750$CLOPIDOGREL BISULFATE PLAVIX 75 MG Generic TABLET 0.0842$CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 15 MG Generic TABLET 0.7849$CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 3.75 MG Generic TABLET 0.3468$CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 7.5 MG Generic TABLET 0.3630$CLOTRIMAZOLE MYCELEX 10 MG Generic TROCHE 0.7600$CLOTRIMAZOLE FEMCARE 1.0% Generic CREAM WITH APPLICATOR 0.0800$CLOTRIMAZOLE LOTRIMIN 1.0% Generic CREAM (GRAM) 0.5657$CLOTRIMAZOLE LOTRIMIN 1.0% Generic SOLUTION, NON-ORAL 1.8654$CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % Generic CREAM (GRAM) 0.7146$CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % Generic LOTION (ML) 3.5383$

10 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

CLOZAPINE CLOZARIL 25 MG Generic TABLET 0.4580$CLOZAPINE CLOZARIL 100 MG Generic TABLET 0.9200$CLOZAPINE CLOZAPINE 200 MG Generic TABLET 3.4875$CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL COMPOUND W/CODEINE 30-50-325 Generic CAPSULE (HARD, SOFT, ETC.) 1.9467$CODEINE SULFATE CODEINE SULFATE 30 MG Generic TABLET 0.4200$CODEINE/PROMETHAZINE HCL PHENERGAN W/CODEINE 10-6.25/5 Generic SYRUP 0.0206$COLCHICINE COLCHICINE 0.6 MG Brand TABLET 6.3203$COLCHICINE COLCHICINE 0.6 MG Generic TABLET 5.0531$COLCHICINE/PROBENECID COL-PROBENECID 0.5-500MG Generic TABLET 0.7300$COLESEVELAM HCL WELCHOL 625 MG Brand TABLET 2.7681$COLESEVELAM HCL WELCHOL 3.75 G Brand POWDER IN PACKET (EA) 16.4350$COLESTIPOL HCL COLESTID 1 G Generic TABLET 0.8900$COLLAGENASE CLOSTRIDIUM HISTOLYTICUM BIOZYME-C 250 UNIT/G Brand OINTMENT (GRAM) 6.4420$CROMOLYN SODIUM CROMOLYN SODIUM 20 MG/ML Generic SOLUTION, ORAL 0.8467$CROMOLYN SODIUM CHILDRENS NASALCROM 5.2 MG Generic AEROSOL, SPRAY WITH PUMP (ML) 0.2500$CROMOLYN SODIUM CROMOLYN SODIUM 4.0% Generic DROPS 0.5900$CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 1000MCG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 5.6900$CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLBALIN PLUS 2-2.5-25MG Generic TABLET 0.4600$CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLGARD RX 1-2.2-25MG Generic TABLET 0.2480$CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLBEE 1-2.5-25MG Generic TABLET 0.5625$CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL 5 MG Generic TABLET 0.0514$CYCLOBENZAPRINE HCL FLEXERIL 10 MG Generic TABLET 0.0174$CYCLOPENTOLATE HCL AK-PENTOLATE 1.0% Generic DROPS 2.9950$CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 25 MG Generic TABLET 1.6256$CYCLOPHOSPHAMIDE CYTOXAN 50 MG Generic TABLET 2.5986$CYCLOSPORINE RESTASIS 0.1% Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 6.7874$CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 25 MG Brand CAPSULE 1.7756$CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8583$CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.8224$CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.9159$CYPROHEPTADINE HCL PERIACTIN 2 MG/5 ML Generic SYRUP 0.0940$CYPROHEPTADINE HCL PERIACTIN 4 MG Generic TABLET 0.5540$CYSTEINE HCL L-CYSTEINE 50 MG/ML Generic VIAL (ML) 0.7578$DABIGATRAN ETEXILATE MESYLATE PRADAXA 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.3017$DABIGATRAN ETEXILATE MESYLATE PRADAXA 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.3083$DALTEPARIN SODIUM,PORCINE FRAGMIN 5000/0.2ML Brand DISPOSABLE SYRINGE (ML) 185.0356$DALTEPARIN SODIUM,PORCINE FRAGMIN 12500/0.5 Brand DISPOSABLE SYRINGE (ML) 184.8490$DANTROLENE SODIUM DANTRIUM 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8067$DANTROLENE SODIUM DANTROLENE SODIUM 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3333$DAPAGLIFLOZIN PROPANEDIOL FARXIGA 10 MG Brand TABLET 11.5333$DAPAGLIFLOZIN PROPANEDIOL FARXIGA 5 MG Brand TABLET 11.5263$DAPSONE ACZONE 5.0% Brand GEL (GRAM) 7.5631$DAPSONE DAPSONE 100 MG Generic TABLET 2.6880$DAPSONE AVLOSULFON 25 MG Generic TABLET 2.2044$DARIFENACIN HYDROBROMIDE ENABLEX 7.5 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.5563$DARIFENACIN HYDROBROMIDE ENABLEX 15 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.8275$DESIPRAMINE HCL DESIPRAMINE HCL 10 MG Generic TABLET 0.8575$DESIPRAMINE HCL NORPRAMIN 25 MG Generic TABLET 1.0375$DESIPRAMINE HCL DESIPRAMINE HCL 50 MG Generic TABLET 2.1760$DESLORATADINE CLARINEX 5 MG Generic TABLET 0.1601$DESMOPRESSIN (NON-REFRIGERATED) DDAVP 10/SPRAY Generic AEROSOL, SPRAY WITH PUMP (ML) 16.9600$DESMOPRESSIN ACETATE DDAVP 0.1 MG Generic TABLET 1.1100$DESMOPRESSIN ACETATE DDAVP 0.2 MG Generic TABLET 1.1364$DESOGESTREL-ETHINYL ESTRADIOL CESIA 7 DAYS X 3 Generic TABLET 0.4960$

11 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 0.15-0.03 Generic TABLET 0.4830$DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL MIRCETTE 21-5 Generic TABLET 0.7901$DESONIDE DESONIDE 0.1% Generic CREAM (GRAM) 3.2800$DESONIDE DESONIDE 0.1% Generic OINTMENT (GRAM) 3.1300$DESONIDE DESOWEN 0.1% Generic LOTION (ML) 2.7325$DESONIDE DESONATE 0.05 % Brand GEL (GRAM) 7.0384$DESOXIMETASONE DESOXIMETASONE 0.25 % Generic OINTMENT (GRAM) 4.4480$DESOXIMETASONE DESOXIMETASONE 0.1% Generic CREAM (GRAM) 5.0552$DESOXIMETASONE DESOXIMETASONE 0.3% Generic CREAM (GRAM) 1.5025$DESVENLAFAXINE SUCCINATE PRISTIQ ER 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.8100$DESVENLAFAXINE SUCCINATE PRISTIQ ER 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.7940$DEXAMETHASONE DECADRON 0.5 MG/5ML Generic ELIXIR 0.2079$DEXAMETHASONE DEXAMETHASONE 0.5 MG/5ML Generic SOLUTION, ORAL 0.0300$DEXAMETHASONE DEXAMETHASONE INTENSOL 1 MG/ML Brand DROPS 0.8047$DEXAMETHASONE DECADRON 0.5 MG Generic TABLET 0.0440$DEXAMETHASONE DEXAMETHASONE 1 MG Generic TABLET 0.2500$DEXAMETHASONE DEXAMETHASONE 0.75 MG Generic TABLET 0.0875$DEXAMETHASONE DECADRON 4 MG Generic TABLET 0.1025$DEXAMETHASONE SOD PHOSPHATE DECADRON PHOSPHATE 4 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.4649$DEXAMETHASONE SOD PHOSPHATE DECADRON 0.1% Generic DROPS 8.6834$DEXLANSOPRAZOLE DEXILANT 30 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 7.0414$DEXLANSOPRAZOLE DEXILANT 60 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 7.0695$DEXMETHYLPHENIDATE HCL FOCALIN 5 MG Generic TABLET 0.6800$DEXMETHYLPHENIDATE HCL FOCALIN 10 MG Generic TABLET 0.9650$DEXMETHYLPHENIDATE HCL FOCALIN XR 5 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.1866$DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 5 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 5.7800$DEXMETHYLPHENIDATE HCL FOCALIN XR 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.2904$DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 10 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 6.6775$DEXMETHYLPHENIDATE HCL FOCALIN XR 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.5827$DEXMETHYLPHENIDATE HCL FOCALIN XR 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.2545$DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 5.3900$DEXMETHYLPHENIDATE HCL FOCALIN XR 25 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.6382$DEXMETHYLPHENIDATE HCL FOCALIN XR 15 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 9.5685$DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 15 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 5.5475$DEXTROAMPHETAMINE SULFATE DEXEDRINE 10 MG Generic CAPSULE, EXTENDED RELEASE 3.7600$DEXTROAMPHETAMINE SULFATE DEXEDRINE 15 MG Generic CAPSULE, EXTENDED RELEASE 4.4800$DEXTROAMPHETAMINE SULFATE DEXEDRINE 5 MG Generic CAPSULE, EXTENDED RELEASE 4.2640$DEXTROAMPHETAMINE SULFATE DEXAMPEX 10 MG Generic TABLET 1.4345$DEXTROAMPHETAMINE SULFATE DEXEDRINE 5 MG Generic TABLET 1.2275$DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE AMPHETAMINE SALT COMBO 7.5 MG Generic TABLET 0.8297$DEXTROMETHORPHAN HBR/PROMETHAZINE HCL PROMETHAZINE-DM 15-6.25/5 Generic SYRUP 0.0247$DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE BROMFED DM 10-30-2/5 Generic SYRUP 0.2233$DEXTROMETHORPHAN HBR/QUINIDINE SULFATE NUEDEXTA 20 MG-10MG Brand CAPSULE (HARD, SOFT, ETC.) 10.7250$DIAZEPAM VALIUM 10 MG Generic TABLET 0.0243$DIAZEPAM VALIUM 2 MG Generic TABLET 0.0240$DIAZEPAM VALIUM 5 MG Generic TABLET 0.0243$DIAZEPAM DIASTAT ACUDIAL 5-7.5-10MG Generic KIT 258.5560$DIAZEPAM DIAZEPAM 5 MG/5 ML Generic SOLUTION, ORAL 0.1061$DICLOFENAC EPOLAMINE FLECTOR 1.3% Brand PATCH, TRANSDERMAL 12 HOURS 9.1243$DICLOFENAC POTASSIUM CATAFLAM 50 MG Generic TABLET 0.7100$DICLOFENAC POTASSIUM CAMBIA 50 MG Brand POWDER IN PACKET (EA) 44.7163$DICLOFENAC SODIUM DICLOFENAC SODIUM 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3643$DICLOFENAC SODIUM PENNSAID 1.5% Brand DROPS 1.5450$DICLOFENAC SODIUM DICLOFENAC SODIUM 1.5 % Generic DROPS 1.3360$

12 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

DICLOFENAC SODIUM DICLOFENAC SODIUM 0.1% Generic DROPS 1.9592$DICLOFENAC SODIUM VOLTAREN 50 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2458$DICLOFENAC SODIUM VOLTAREN 75 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2038$DICLOFENAC SODIUM PENNSAID 20MG/G(2%) Brand SOLUTION IN METERED-DOSE PUMP (GRAM) 13.8360$DICLOFENAC SODIUM VOLTAREN 1.0% Brand GEL (GRAM) 0.4548$DICLOFENAC SODIUM SOLARAZE 3.0% Brand GEL (GRAM) 10.9644$DICLOFENAC SODIUM DICLOFENAC SODIUM 3 % Generic GEL (GRAM) 8.1000$DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 75 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.6830$DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 75 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.2800$DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 50 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.7983$DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 50 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.4275$DICLOFENAC SUBMICRONIZED ZORVOLEX 35 MG Brand CAPSULE 3.0854$DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2333$DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5200$DICYCLOMINE HCL BENTYL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0600$DICYCLOMINE HCL BENTYL 20 MG Generic TABLET 0.1000$DIFLORASONE DIACETATE MAXIFLOR 0.1% Generic CREAM (GRAM) 11.2177$DIFLUNISAL DOLOBID 500 MG Generic TABLET 1.3525$DIFLUPREDNATE DUREZOL 0.1% Brand DROPS 29.0578$DIGOXIN DIGOXIN 50 MCG/ML Generic SOLUTION, ORAL 0.6882$DIGOXIN DIGOXIN 125 MCG Brand TABLET 2.2775$DIGOXIN LANOXIN 125 MCG Generic TABLET 0.7300$DIGOXIN DIGOXIN 250 MCG Brand TABLET 6.9600$DIGOXIN DIGOXIN 250 MCG Generic TABLET 0.9000$DIHYDROERGOTAMINE MESYLATE MIGRANAL 0.5MG/SPRY Brand AEROSOL, SPRAY WITH PUMP (ML) 367.1716$DILTIAZEM HCL DILTIAZEM ER 60 MG Generic CAPSULE, EXTENDED RELEASE 12 HR 2.2860$DILTIAZEM HCL CARDIZEM CD 180 MG Generic CAPSULE, EXT RELEASE 24 HR 0.4333$DILTIAZEM HCL CARDIZEM CD 240 MG Generic CAPSULE, EXT RELEASE 24 HR 0.5871$DILTIAZEM HCL CARDIZEM CD 300 MG Generic CAPSULE, EXT RELEASE 24 HR 0.6975$DILTIAZEM HCL CARDIZEM CD 120 MG Generic CAPSULE, EXT RELEASE 24 HR 0.4046$DILTIAZEM HCL DILTIAZEM ER 360 MG Generic CAPSULE, EXTENDED RELEASE 0.9380$DILTIAZEM HCL DILTIAZEM ER 180 MG Generic CAPSULE, EXTENDED RELEASE 0.4583$DILTIAZEM HCL DILTIAZEM ER 120 MG Generic CAPSULE, EXTENDED RELEASE 0.4750$DILTIAZEM HCL DILTIAZEM ER 240 MG Generic CAPSULE, EXTENDED RELEASE 0.6867$DILTIAZEM HCL DILTIAZEM ER 300 MG Generic CAPSULE, EXTENDED RELEASE 1.3200$DILTIAZEM HCL CARDIZEM 30 MG Generic TABLET 0.1040$DILTIAZEM HCL CARDIZEM 60 MG Generic TABLET 0.2250$DILTIAZEM HCL CARDIZEM 90 MG Generic TABLET 0.2565$DILTIAZEM HCL CARDIZEM 120 MG Generic TABLET 0.2125$DILTIAZEM HCL DILTIAZEM 24HR CD 360 MG Generic CAPSULE, EXT RELEASE 24 HR 8.0650$DILTIAZEM HCL DILACOR XR 180 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5700$DILTIAZEM HCL DILACOR XR 240 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5943$DILTIAZEM HCL DILACOR XR 120 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.4650$DILTIAZEM HCL MATZIM LA 180 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.0640$DILTIAZEM HCL DILTIAZEM ER 360 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.3600$DIPHENHYDRAMINE HCL ALLERGY 25 MG Generic CAPSULE 0.0314$DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0265$DIPHENHYDRAMINE HCL BENADRYL 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.6700$DIPHENHYDRAMINE HCL ALLERGY 25 MG Generic TABLET 0.0413$DIPHENHYDRAMINE HCL BENADRYL ALLERGY 12.5MG/5ML Generic LIQUID (ML) 0.0090$DIPHENOXYLATE HCL/ATROPINE SULFATE DIPHENOXYLATE-ATROPINE 2.5-.025MG Generic TABLET 0.3640$DIPYRIDAMOLE DIPYRIDAMOLE 50 MG Generic TABLET 0.1875$DISULFIRAM ANTABUSE 250 MG Generic TABLET 2.0913$DISULFIRAM DISULFIRAM 500 MG Generic TABLET 4.3320$

13 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

DIVALPROEX SODIUM DEPAKOTE 250 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1283$DIVALPROEX SODIUM DEPAKOTE 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 5.7093$DIVALPROEX SODIUM DEPAKOTE 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1986$DIVALPROEX SODIUM DEPAKOTE 125 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0914$DIVALPROEX SODIUM DEPAKOTE SPRINKLE 125 MG Brand CAPSULE, SPRINKLE 1.4644$DIVALPROEX SODIUM DEPAKOTE SPRINKLE 125 MG Generic CAPSULE, SPRINKLE 0.7300$DIVALPROEX SODIUM DEPAKOTE ER 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 4.7998$DIVALPROEX SODIUM DEPAKOTE ER 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.3011$DIVALPROEX SODIUM DEPAKOTE ER 250 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.4442$DOCOSANOL ABREVA 10 % Brand CREAM (GRAM) 7.4067$DOCUSATE SODIUM COLACE 100 MG Brand CAPSULE 0.2880$DOCUSATE SODIUM COLACE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0297$DOCUSATE SODIUM DOCUSATE SODIUM 250 MG Generic CAPSULE 0.0400$DOCUSATE SODIUM DIOCTO 50 MG/5 ML Generic LIQUID (ML) 0.0400$DOFETILIDE TIKOSYN 250 MCG Brand CAPSULE (HARD, SOFT, ETC.) 7.7064$DOFETILIDE TIKOSYN 500 MCG Brand CAPSULE 7.9615$DONEPEZIL HCL ARICEPT 10 MG Generic TABLET 0.1877$DONEPEZIL HCL ARICEPT 5 MG Generic TABLET 0.1814$DONEPEZIL HCL ARICEPT 23 MG Brand TABLET 10.9291$DONEPEZIL HCL ARICEPT 23 MG Generic TABLET 7.1400$DORZOLAMIDE HCL DORZOLAMIDE HCL 2.0% Generic DROPS 1.3700$DORZOLAMIDE HCL/TIMOLOL MALEATE COSOPT 2%-0.5% Generic DROPS 1.4173$DORZOLAMIDE HCL/TIMOLOL MALEATE/PF COSOPT PF 2 %-0.5 % Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 2.1879$DOXAZOSIN MESYLATE CARDURA 1 MG Generic TABLET 0.3000$DOXAZOSIN MESYLATE CARDURA 2 MG Generic TABLET 0.3500$DOXAZOSIN MESYLATE CARDURA 4 MG Generic TABLET 0.3631$DOXAZOSIN MESYLATE CARDURA 8 MG Generic TABLET 0.5350$DOXEPIN HCL SINEQUAN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3850$DOXEPIN HCL DOXEPIN HCL 100 MG Generic CAPSULE 0.8400$DOXEPIN HCL SINEQUAN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4025$DOXEPIN HCL SINEQUAN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6050$DOXEPIN HCL DOXEPIN HCL 75 MG Generic CAPSULE 0.9280$DOXEPIN HCL SILENOR 3 MG Brand TABLET 11.7569$DOXEPIN HCL SILENOR 6 MG Brand TABLET 11.7388$DOXYCYCLINE HYCLATE PERIOSTAT 20 MG Generic TABLET 0.3583$DOXYCYCLINE HYCLATE DORYX 100 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 8.9500$DOXYCYCLINE HYCLATE DORYX 200 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 30.8185$DOXYCYCLINE HYCLATE VIBRAMYCIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2100$DOXYCYCLINE HYCLATE VIBRAMYCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.0375$DOXYCYCLINE HYCLATE VIBRA-TABS 100 MG Generic TABLET 1.1400$DOXYCYCLINE HYCLATE DORYX 150 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 19.2392$DOXYCYCLINE HYCLATE DORYX 150 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 13.2750$DOXYCYCLINE MONOHYDRATE ADOXA 50 MG Generic TABLET 0.3100$DOXYCYCLINE MONOHYDRATE ORACEA 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 19.3140$DOXYCYCLINE MONOHYDRATE ADOXA 100 MG Generic TABLET 0.8800$DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4900$DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 50 MG Generic CAPSULE 0.2880$DOXYCYCLINE MONOHYDRATE MONODOX 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 13.7148$DOXYLAMINE SUCCINATE/PYRIDOXINE HCL DICLEGIS 10 MG-10MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 5.6209$DRONABINOL DRONABINOL 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.9275$DRONABINOL DRONABINOL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.8875$DRONEDARONE HCL MULTAQ 400 MG Brand TABLET 8.2100$DROSPIRENONE/ESTRADIOL ANGELIQ 0.5 MG-1MG Brand TABLET 4.1405$DROSPIRENONE/ESTRADIOL ANGELIQ 0.25-0.5MG Brand TABLET 4.1790$

14 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM BEYAZ 3-0.02(24) Brand TABLET 4.6839$DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM SAFYRAL 3-0.03(21) Brand TABLET 4.7719$DULAGLUTIDE TRULICITY 1.5 MG/0.5 Brand PEN INJECTOR (ML) 273.7163$DULOXETINE HCL CYMBALTA 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.2050$DULOXETINE HCL CYMBALTA 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.5856$DULOXETINE HCL CYMBALTA 30 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.0150$DULOXETINE HCL CYMBALTA 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.2217$DULOXETINE HCL CYMBALTA 60 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.9400$DULOXETINE HCL CYMBALTA 60 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.3352$DUTASTERIDE AVODART 0.5 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.3460$DUTASTERIDE AVODART 0.5 MG Generic CAPSULE 0.6060$DUTASTERIDE/TAMSULOSIN HCL JALYN 0.5-0.4 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.2600$ECONAZOLE NITRATE SPECTAZOLE 1.0% Generic CREAM (GRAM) 4.1000$EFAVIRENZ SUSTIVA 600 MG Brand TABLET 29.7643$EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ATRIPLA 600-200MG Brand TABLET 76.3715$EFINACONAZOLE JUBLIA 10 % Brand SOLUTION WITH APPLICATOR (ML) 129.0886$ELETRIPTAN HBR RELPAX 20 MG Brand TABLET 40.2254$ELETRIPTAN HBR RELPAX 40 MG Brand TABLET 40.6397$EMOLLIENT COMBINATION NO.43 PROMISEB 0.0% Brand CREAM (GRAM) 3.1615$EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TRUVADA 200-300 MG Brand TABLET 46.7366$ENALAPRIL MALEATE VASOTEC 5 MG Generic TABLET 0.4767$ENALAPRIL MALEATE VASOTEC 10 MG Generic TABLET 0.4600$ENALAPRIL MALEATE VASOTEC 20 MG Generic TABLET 0.4600$ENALAPRIL MALEATE VASOTEC 2.5 MG Generic TABLET 0.2620$ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE VASERETIC 10MG-25MG Generic TABLET 0.2100$ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE 5MG-12.5MG Generic TABLET 0.1800$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 30MG/0.3ML Generic DISPOSABLE SYRINGE (ML) 28.1622$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 69.3836$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 120MG/.8ML Generic DISPOSABLE SYRINGE (ML) 52.0205$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 60MG/0.6ML Generic DISPOSABLE SYRINGE (ML) 40.8356$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 80MG/0.8ML Generic DISPOSABLE SYRINGE (ML) 22.6879$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 100 MG/ML Generic DISPOSABLE SYRINGE (ML) 19.4483$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 40MG/0.4ML Generic DISPOSABLE SYRINGE (ML) 24.8800$ENTACAPONE ENTACAPONE 200 MG Generic TABLET 2.1760$EPINASTINE HCL ELESTAT 0.1% Generic DROPS 9.4033$EPINEPHRINE EPINEPHRINE 0.1 MG/ML Generic SYRINGE (ML) 0.4600$EPINEPHRINE EPI E-Z PEN JR. 0.15MG/0.3 Brand PEN INJECTOR (EA) 252.3611$EPINEPHRINE ADRENACLICK 0.3MG/0.3 Brand PEN INJECTOR (EA) 252.6600$EPINEPHRINE EPINEPHRINE 0.3MG/0.3 Generic AUTO-INJECTOR (EA) 173.5347$EPINEPHRINE AUVI-Q 0.15/0.15 Brand AUTO-INJECTOR (EA) 245.2865$EPLERENONE EPLERENONE 25 MG Generic TABLET 2.5350$EPLERENONE EPLERENONE 50 MG Generic TABLET 2.1850$EPOETIN ALFA EPOGEN 20000/ML Brand VIAL (ML) 426.3557$EPOETIN ALFA PROCRIT 40000/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 860.4769$ERGOCALCIFEROL (VITAMIN D2) DRISDOL 8000/ML Generic DROPS 1.0279$ERGOCALCIFEROL (VITAMIN D2) DRISDOL 50000 UNIT Generic CAPSULE (HARD, SOFT, ETC.) 0.2967$ERYTHROMYCIN BASE ERYTHROMYCIN 5MG/G Generic OINTMENT (GRAM) 2.9900$ERYTHROMYCIN BASE ERYTHROMYCIN 250 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.5874$ERYTHROMYCIN BASE ERYTHROMYCIN 250 MG Generic TABLET 7.1450$ERYTHROMYCIN BASE ERYTHROMYCIN 500 MG Generic TABLET 14.5774$ERYTHROMYCIN BASE ERY-TAB 333 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 6.5309$ERYTHROMYCIN BASE ERY-TAB 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 7.7175$ERYTHROMYCIN BASE/BENZOYL PEROXIDE BENZAMYCIN 3 %-5 % Generic GEL (GRAM) 6.8712$ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYGEL 2.0% Generic GEL (GRAM) 4.1675$

15 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYTHROMYCIN 2 % Generic SWAB, MEDICATED 0.8776$ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYTHROMYCIN 2.0% Generic SOLUTION, NON-ORAL 0.6420$ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 3.6440$ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 250 MG Brand TABLET 8.7714$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Brand TABLET 7.4155$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Generic TABLET 0.1200$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Brand TABLET 8.0546$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Generic TABLET 0.1689$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG Generic TABLET 0.0925$ESOMEPRAZOLE MAGNESIUM NEXIUM 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.9888$ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.9111$ESOMEPRAZOLE MAGNESIUM NEXIUM 40 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.9643$ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM 40 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.5900$ESOMEPRAZOLE MAGNESIUM NEXIUM 20 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 8.0495$ESOMEPRAZOLE MAGNESIUM NEXIUM 40 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.9620$ESOMEPRAZOLE MAGNESIUM NEXIUM 10 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 8.3112$ESTAZOLAM ESTAZOLAM 2 MG Generic TABLET 0.5120$ESTRADIOL ESTRACE 1 MG Generic TABLET 0.1300$ESTRADIOL ESTRACE 2 MG Generic TABLET 0.1400$ESTRADIOL ESTRACE 0.5 MG Generic TABLET 0.1200$ESTRADIOL ESTRING 7.5MCG/24H Brand RING, VAGINAL 293.3590$ESTRADIOL DIVIGEL 1MG(0.1%) Brand GEL IN PACKET (GRAM) 3.0836$ESTRADIOL CLIMARA .0375MG/24 Brand PATCH, TRANSDERMAL WEEKLY 20.7176$ESTRADIOL CLIMARA .0375MG/24 Generic PATCH, TRANSDERMAL WEEKLY 16.2000$ESTRADIOL DIVIGEL 0.5MG(0.1) Brand GEL IN PACKET (EA) 3.4316$ESTRADIOL VAGIFEM 10 MCG Brand TABLET 18.6586$ESTRADIOL ALORA 0.05MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 13.2320$ESTRADIOL ESTRADIOL 0.05MG/24H Generic PATCH, TRANSDERMAL SEMIWEEKLY 9.4621$ESTRADIOL ALORA 0.1MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 14.3074$ESTRADIOL ESTRADIOL 0.1MG/24HR Generic PATCH, TRANSDERMAL SEMIWEEKLY 9.2204$ESTRADIOL ALORA .025MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 11.1011$ESTRADIOL ESTRADIOL .025MG/24H Generic PATCH, TRANSDERMAL SEMIWEEKLY 9.2543$ESTRADIOL ALORA .075MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 14.4133$ESTRADIOL ESTRADIOL .075MG/24H Generic PATCH, TRANSDERMAL SEMIWEEKLY 9.6785$ESTRADIOL CLIMARA 0.1MG/24HR Brand PATCH, TRANSDERMAL WEEKLY 25.6692$ESTRADIOL CLIMARA 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 18.8214$ESTRADIOL CLIMARA 0.05MG/24H Generic PATCH, TRANSDERMAL WEEKLY 17.7457$ESTRADIOL MINIVELLE .0375MG/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 15.0465$ESTRADIOL ESTRADIOL .0375MG/24 Generic PATCH, TRANSDERMAL SEMIWEEKLY 8.7593$ESTRADIOL CLIMARA .025MG/24H Brand PATCH, TRANSDERMAL WEEKLY 20.4445$ESTRADIOL CLIMARA .025MG/24H Generic PATCH, TRANSDERMAL WEEKLY 15.8100$ESTRADIOL CLIMARA .075MG/24H Brand PATCH, TRANSDERMAL WEEKLY 28.0954$ESTRADIOL CLIMARA .075MG/24H Generic PATCH, TRANSDERMAL WEEKLY 16.7340$ESTRADIOL ESTRACE 0.0% Brand CREAM WITH APPLICATOR 5.9207$ESTRADIOL ELESTRIN 0.87G Brand GEL IN METERED-DOSE PUMP 3.3067$ESTRADIOL EVAMIST 1.53/SPRAY Brand SPRAY, NON-AEROSOL (ML) 12.8998$ESTRADIOL ACETATE FEMRING 0.05MG/24H Brand RING, VAGINAL 341.3034$ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 15.1879$ESTRADIOL VALERATE/DIENOGEST NATAZIA 3-2-1(28) Brand TABLET 4.4897$ESTRADIOL/LEVONORGESTREL CLIMARA PRO 45-15/24H Brand PATCH, TRANSDERMAL WEEKLY 33.0822$ESTRADIOL/NORETHINDRONE ACETATE COMBIPATCH .05-.14/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 17.4699$ESTRADIOL/NORETHINDRONE ACETATE COMBIPATCH .05-.25/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 17.6196$ESTRADIOL/NORETHINDRONE ACETATE ACTIVELLA 1 MG-0.5MG Generic TABLET 3.7100$ESTRADIOL/NORETHINDRONE ACETATE ACTIVELLA 0.5-0.1MG Generic TABLET 3.2860$

16 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

ESTROGENS, CONJUGATED PREMARIN 0.625 MG Brand TABLET 4.1375$ESTROGENS, CONJUGATED PREMARIN 0.3 MG Brand TABLET 4.1390$ESTROGENS, CONJUGATED PREMARIN 0.9 MG Brand TABLET 4.1830$ESTROGENS, CONJUGATED PREMARIN 1.25 MG Brand TABLET 4.1505$ESTROGENS, CONJUGATED PREMARIN 0.45MG Brand TABLET 4.1560$ESTROGENS, CONJUGATED PREMARIN 0.625 MG/G Brand CREAM WITH APPLICATOR 9.1714$ESTROGENS, CONJUGATED/BAZEDOXIFENE ACETATE DUAVEE 0.45-20 MG Brand TABLET 4.5240$ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.45-1.5MG Brand TABLET 5.0792$ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.3-1.5MG Brand TABLET 5.0860$ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.625-5 MG Brand TABLET 5.1022$ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.625-2.5 Brand TABLET 5.0820$ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPHASE 0.625 (14) Brand TABLET 4.9540$ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 0.625 MG Brand TABLET 3.4871$ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA 1.25 MG Brand TABLET 2.4200$ESTROGENS,ESTERIFIED MENEST 0.625 MG Brand TABLET 1.8510$ESTROPIPATE OGEN 0.75 MG Generic TABLET 0.3650$ESTROPIPATE ESTROPIPATE 1.5 MG Generic TABLET 0.4738$ESZOPICLONE LUNESTA 3 MG Brand TABLET 13.7904$ESZOPICLONE ESZOPICLONE 3 MG Generic TABLET 0.7100$ESZOPICLONE LUNESTA 2 MG Brand TABLET 11.9547$ESZOPICLONE ESZOPICLONE 2 MG Generic TABLET 0.5550$ESZOPICLONE LUNESTA 1 MG Brand TABLET 12.1397$ESZOPICLONE ESZOPICLONE 1 MG Generic TABLET 0.7625$ETANERCEPT ENBREL 50 MG/ML Brand DISPOSABLE SYRINGE (ML) 927.5946$ETANERCEPT ENBREL 25 MG Brand VIAL (EA) 448.1276$ETANERCEPT ENBREL 50 MG/ML Brand PEN INJECTOR (ML) 927.4000$ETHINYL ESTRADIOL/DROSPIRENONE OCELLA 0.03-3MG Brand TABLET 2.4200$ETHINYL ESTRADIOL/DROSPIRENONE OCELLA 0.03-3MG Generic TABLET 1.7240$ETHINYL ESTRADIOL/DROSPIRENONE GIANVI 0.02-3(24) Brand TABLET 2.2817$ETHINYL ESTRADIOL/DROSPIRENONE GIANVI 0.02-3(24) Generic TABLET 1.9271$ETHOSUXIMIDE ETHOSUXIMIDE 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.0200$ETHOSUXIMIDE ZARONTIN 250 MG/5ML Generic SOLUTION, ORAL 0.2652$ETHYNODIOL D-ETHINYL ESTRADIOL DEMULEN 1/35-21 1 MG-35MCG Generic TABLET 0.5950$ETODOLAC LODINE 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3100$ETODOLAC LODINE 400 MG Generic TABLET 0.7500$ETODOLAC ETODOLAC ER 400 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.1400$ETODOLAC LODINE 500 MG Generic TABLET 0.9800$ETODOLAC LODINE XL 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.3350$ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 0.12-0.015 Brand RING, VAGINAL 113.8225$EUCALYPTUS/MENTHOL/CAMPHOR/TURPENTINE OIL/PETROLATUM,WHITE VICKS VAPORUB Generic OINTMENT (GRAM) 0.0655$EVEROLIMUS ZORTRESS 0.5 MG Brand TABLET 14.4283$EVEROLIMUS ZORTRESS 0.75 MG Brand TABLET 21.8194$EXEMESTANE AROMASIN 25 MG Generic TABLET 7.2175$EXENATIDE BYETTA 5MCG/0.02 Brand PEN INJECTOR (ML) 459.5863$EXENATIDE BYETTA 10MCG/0.04 Brand PEN INJECTOR (ML) 231.8752$EXENATIDE MICROSPHERES BYDUREON 2 MG Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 131.1238$EXENATIDE MICROSPHERES BYDUREON PEN 2MG/0.65ML Brand PEN INJECTOR (EA) 131.8427$EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 2-0.9-1.8% Brand DROPS 1.7980$EZETIMIBE ZETIA 10 MG Brand TABLET 8.2485$EZETIMIBE/SIMVASTATIN VYTORIN 10 MG-10MG Brand TABLET 7.7857$EZETIMIBE/SIMVASTATIN VYTORIN 10MG-20MG Brand TABLET 7.8200$EZETIMIBE/SIMVASTATIN VYTORIN 10MG-80MG Brand TABLET 8.2273$EZETIMIBE/SIMVASTATIN VYTORIN 10MG-40MG Brand TABLET 8.1581$FAMCICLOVIR FAMCICLOVIR 500 MG Generic TABLET 1.4550$

17 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

FAMCICLOVIR FAMCICLOVIR 250 MG Generic TABLET 0.6988$FAMOTIDINE FAMOTIDINE 40MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 1.0900$FAMOTIDINE PEPCID 20 MG Generic TABLET 0.0400$FAMOTIDINE FAMOTIDINE 40 MG Generic TABLET 0.0700$FEBUXOSTAT ULORIC 40 MG Brand TABLET 8.6400$FEBUXOSTAT ULORIC 80 MG Brand TABLET 8.4804$FELBAMATE FELBAMATE 600 MG Generic TABLET 4.1467$FELODIPINE FELODIPINE ER 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7171$FELODIPINE FELODIPINE ER 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5183$FELODIPINE FELODIPINE ER 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5665$FENOFIBRATE LOFIBRA 160 MG Generic TABLET 0.6400$FENOFIBRATE LOFIBRA 54 MG Generic TABLET 0.5400$FENOFIBRATE LIPOFEN 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.5103$FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 48 MG Brand TABLET 2.2408$FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 48 MG Generic TABLET 0.8308$FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 145MG Brand TABLET 6.0037$FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 145MG Generic TABLET 0.9400$FENOFIBRATE,MICRONIZED ANTARA 130 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.9710$FENOFIBRATE,MICRONIZED ANTARA 130 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.0817$FENOFIBRATE,MICRONIZED TRICOR 134MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3700$FENOFIBRATE,MICRONIZED FENOFIBRATE 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.2000$FENOFIBRATE,MICRONIZED FENOFIBRATE 67 MG Generic CAPSULE 0.7725$FENOFIBRIC ACID (CHOLINE) TRILIPIX 135 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.2121$FENOFIBRIC ACID (CHOLINE) TRILIPIX 135 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.4860$FENTANYL DURAGESIC 25MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 29.9092$FENTANYL DURAGESIC 25MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 4.4058$FENTANYL DURAGESIC 50MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 64.9433$FENTANYL DURAGESIC 50MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 6.8363$FENTANYL DURAGESIC 75MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 98.0708$FENTANYL DURAGESIC 75MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 9.8077$FENTANYL DURAGESIC 100 MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 117.8350$FENTANYL DURAGESIC 100 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 12.1377$FENTANYL DURAGESIC 12 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 15.5263$FENTANYL SUBSYS 600 MCG Brand SPRAY, NON-AEROSOL (EA) 104.6509$FENTANYL CITRATE FENTANYL CITRATE 800 MCG Generic LOZENGE ON A HANDLE 16.0075$FENTANYL CITRATE FENTANYL CITRATE 1600 MCG Generic LOZENGE ON A HANDLE 24.4700$FERROUS GLUCONATE FERROUS GLUCONATE 324(38)MG Generic TABLET 0.0464$FERROUS SULFATE FERRO-BOB 325(65) MG Generic TABLET 0.0150$FERROUS SULFATE FERROUS SULFATE 325(65) MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.3520$FERROUS SULFATE CHILDREN'S FERROUS SULFATE 15 MG/ML Generic DROPS 0.0610$FERROUS SULFATE FERROUS SULFATE 220(44)/5 Generic SOLUTION, ORAL 0.0061$FESOTERODINE FUMARATE TOVIAZ 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.8740$FESOTERODINE FUMARATE TOVIAZ 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.8885$FEXOFENADINE HCL ALLEGRA ALLERGY 60 MG Generic TABLET 1.0345$FEXOFENADINE HCL ALLEGRA 180 MG Generic TABLET 0.3700$FILGRASTIM NEUPOGEN 300MCG/0.5 Brand DISPOSABLE SYRINGE (ML) 644.4554$FINASTERIDE FINASTERIDE 5 MG Generic TABLET 0.1496$FLECAINIDE ACETATE FLECAINIDE ACETATE 100 MG Generic TABLET 0.5657$FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG Generic TABLET 0.2814$FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG Generic TABLET 0.5089$FLUCONAZOLE DIFLUCAN 100 MG Generic TABLET 1.7000$FLUCONAZOLE DIFLUCAN 200 MG Generic TABLET 2.3425$FLUCONAZOLE DIFLUCAN 150 MG Generic TABLET 2.1662$FLUCONAZOLE FLUCONAZOLE 40 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6075$

18 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

FLUCONAZOLE FLUCONAZOLE 10 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.4029$FLUDROCORTISONE ACETATE FLORINEF ACETATE 0.1 MG Generic TABLET 0.4200$FLUNISOLIDE NASALIDE 25 MCG Generic AEROSOL, SPRAY (ML) 2.1600$FLUOCINOLONE ACETONIDE SYNALAR 0.0% Generic CREAM (GRAM) 2.2550$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0% Generic CREAM (GRAM) 1.5725$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0% Generic OINTMENT (GRAM) 1.5650$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0% Generic SOLUTION, NON-ORAL 2.2360$FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS 0.0% Generic OIL (ML) 1.4200$FLUOCINOLONE ACETONIDE OIL DERMOTIC 0.0% Brand DROPS 1.3878$FLUOCINOLONE ACETONIDE OIL DERMOTIC 0.0% Generic DROPS 8.4250$FLUOCINOLONE ACETONIDE/SHOWER CAP DERMA-SMOOTHE-FS 0.01 % Brand OIL (ML) 1.6268$FLUOCINOLONE ACETONIDE/SHOWER CAP DERMA-SMOOTHE-FS 0.0% Generic OIL (ML) 1.4540$FLUOCINONIDE VANOS 0.1% Brand CREAM (GRAM) 14.7546$FLUOCINONIDE FLUOCINONIDE 0.1 % Generic CREAM (GRAM) 11.4050$FLUOCINONIDE LIDEX 0.1% Generic GEL (GRAM) 1.7425$FLUOCINONIDE FLUOCINONIDE 0.1% Generic CREAM (GRAM) 1.3240$FLUOCINONIDE LIDEX 0.1% Generic OINTMENT (GRAM) 2.4425$FLUOCINONIDE LIDEX 0.1% Generic SOLUTION, NON-ORAL 1.2300$FLUOCINONIDE/EMOLLIENT LIDEX-E 0.1% Generic CREAM (GRAM) 1.6633$FLUOROMETHOLONE FML S.O.P. 0.1% Brand OINTMENT (GRAM) 34.6999$FLUOROMETHOLONE FLUOROMETHOLONE 0.1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 12.3500$FLUOROMETHOLONE FML FORTE 0.3% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 23.3928$FLUOROURACIL CARAC 0.5% Brand CREAM (GRAM) 45.2414$FLUOROURACIL EFUDEX 5.0% Generic CREAM (GRAM) 3.2500$FLUOXETINE HCL PROZAC 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0400$FLUOXETINE HCL PROZAC 20 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.6051$FLUOXETINE HCL PROZAC 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$FLUOXETINE HCL PROZAC 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 19.5214$FLUOXETINE HCL PROZAC 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2096$FLUOXETINE HCL PROZAC 10 MG Generic TABLET 1.0340$FLUOXETINE HCL PROZAC 20 MG/5 ML Generic SOLUTION, ORAL 0.0578$FLUOXETINE HCL SARAFEM 20 MG Generic TABLET 1.4380$FLUOXETINE HCL FLUOXETINE HCL 60 MG Generic TABLET 6.8729$FLUPHENAZINE DECANOATE FLUPHENAZINE DECANOATE 25 MG/ML Generic VIAL (ML) 26.8800$FLUPHENAZINE HCL FLUPHENAZINE HCL 1 MG Generic TABLET 0.1200$FLUPHENAZINE HCL PERMITIL 10 MG Generic TABLET 0.2500$FLUPHENAZINE HCL PERMITIL 5 MG Generic TABLET 0.1718$FLURANDRENOLIDE CORDRAN 4MCG/SQ CM Brand TAPE, MEDICATED 321.6925$FLURAZEPAM HCL DALMANE 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3570$FLURBIPROFEN FLURBIPROFEN 100 MG Generic TABLET 0.3635$FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM 0.0% Generic DROPS 0.8361$FLUTAMIDE FLUTAMIDE 125 MG Generic CAPSULE 0.5875$FLUTICASONE FUROATE VERAMYST 27.5 MCG Brand SPRAY, SUSPENSION 18.0410$FLUTICASONE FUROATE/VILANTEROL TRIFENATATE BREO ELLIPTA 100-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.7300$FLUTICASONE PROPIONATE CUTIVATE 0.1% Generic CREAM (GRAM) 0.4450$FLUTICASONE PROPIONATE CUTIVATE 0.0% Generic OINTMENT (GRAM) 0.4333$FLUTICASONE PROPIONATE FLOVENT DISKUS 100 MCG Brand DISK, WITH INHALATION DEVICE 2.3871$FLUTICASONE PROPIONATE FLOVENT DISKUS 250 MCG Brand DISK, WITH INHALATION DEVICE 3.3678$FLUTICASONE PROPIONATE FLOVENT DISKUS 50 MCG Brand DISK, WITH INHALATION DEVICE 2.4363$FLUTICASONE PROPIONATE FLOVENT 110MCG Brand AEROSOL WITH ADAPTER (GRAM) 16.7296$FLUTICASONE PROPIONATE FLOVENT 44MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.2882$FLUTICASONE PROPIONATE FLOVENT 220 MCG Brand AEROSOL WITH ADAPTER (GRAM) 26.1567$FLUTICASONE PROPIONATE FLONASE 50 MCG Brand SPRAY, SUSPENSION 4.9734$FLUTICASONE PROPIONATE FLONASE 50 MCG Generic SPRAY, SUSPENSION 0.2800$

19 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 100-50 MCG Brand DISK, WITH INHALATION DEVICE 4.2833$FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 250-50 MCG Brand DISK, WITH INHALATION DEVICE 5.3162$FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 500-50 MCG Brand DISK, WITH INHALATION DEVICE 6.9993$FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 45-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 21.4233$FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 115-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 26.5467$FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 230-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 33.7450$FLUVASTATIN SODIUM FLUVASTATIN SODIUM 20 MG Generic CAPSULE 3.6400$FLUVASTATIN SODIUM FLUVASTATIN SODIUM 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.0979$FLUVASTATIN SODIUM LESCOL XL 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1685$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25 MG Generic TABLET 0.2150$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50 MG Generic TABLET 0.2440$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic TABLET 0.3100$FLUVOXAMINE MALEATE LUVOX CR 100 MG Brand CAPSULE, EXT RELEASE 24 HR 10.8447$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic CAPSULE, EXT RELEASE 24 HR 7.3027$FOLIC ACID FOLIC ACID 1 MG Generic TABLET 0.0406$FOLIC ACID/VITAMIN B COMP W-C NEPHROCAPS 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2721$FONDAPARINUX SODIUM ARIXTRA 2.5 MG/0.5 Generic DISPOSABLE SYRINGE (ML) 78.0798$FONDAPARINUX SODIUM FONDAPARINUX SODIUM 7.5MG/0.6 Generic SYRINGE (ML) 122.4421$FORMOTEROL FUMARATE FORADIL 12 MCG Brand CAPSULE, WITH INHALATION DEVICE 3.8843$FORMOTEROL FUMARATE PERFOROMIST 20 MCG/2ML Brand VIAL, NEBULIZER (ML) 6.4390$FOSAMPRENAVIR CALCIUM LEXIVA 700 MG Brand TABLET 16.4225$FOSFOMYCIN TROMETHAMINE MONUROL 3 G Brand PACKET (EA) 62.1135$FOSINOPRIL SODIUM MONOPRIL 40 MG Generic TABLET 0.1700$FOSINOPRIL SODIUM FOSINOPRIL SODIUM 10 MG Generic TABLET 0.1250$FOSINOPRIL SODIUM MONOPRIL 20 MG Generic TABLET 0.1300$FUROSEMIDE LASIX 10 MG/ML Generic SOLUTION, ORAL 0.0950$FUROSEMIDE FUROSEMIDE 20 MG Generic TABLET 0.0111$FUROSEMIDE FUROSEMIDE 40 MG Generic TABLET 0.0110$FUROSEMIDE FUROSEMIDE 80 MG Brand TABLET 1.1803$FUROSEMIDE FUROSEMIDE 80 MG Generic TABLET 0.0252$GABAPENTIN GABAPENTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0321$GABAPENTIN GABAPENTIN 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 3.1704$GABAPENTIN GABAPENTIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0427$GABAPENTIN GABAPENTIN 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0879$GABAPENTIN GABAPENTIN 250 MG/5ML Generic SOLUTION, ORAL 0.1617$GABAPENTIN GRALISE 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 4.7106$GABAPENTIN GRALISE 600 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.6958$GABAPENTIN GABAPENTIN 800 MG Generic TABLET 0.2245$GABAPENTIN GABAPENTIN 600 MG Generic TABLET 0.2349$GALANTAMINE HBR GALANTAMINE HBR 8 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.2900$GALANTAMINE HBR GALANTAMINE HBR 16 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.1675$GALANTAMINE HBR GALANTAMINE HBR 4 MG Generic TABLET 1.4200$GANCICLOVIR ZIRGAN 0.2% Brand GEL (GRAM) 52.3925$GATIFLOXACIN GATIFLOXACIN 0.5 % Brand DROPS 42.9590$GATIFLOXACIN GATIFLOXACIN 0.5 % Generic DROPS 40.4500$GEMFIBROZIL LOPID 600 MG Generic TABLET 0.0900$GENTAMICIN SULFATE GARAMYCIN 0.1% Generic CREAM (GRAM) 2.5503$GENTAMICIN SULFATE GARAMYCIN 0.1% Generic OINTMENT (GRAM) 2.3148$GENTAMICIN SULFATE GARAMYCIN 0.3% Generic OINTMENT (GRAM) 3.7275$GENTAMICIN SULFATE GARAMYCIN 0.3% Generic DROPS 7.8900$GLATIRAMER ACETATE COPAXONE 20 MG/ML Brand SYRINGE (ML) 212.3010$GLIMEPIRIDE AMARYL 1 MG Generic TABLET 0.1100$GLIMEPIRIDE AMARYL 2 MG Generic TABLET 0.1557$GLIMEPIRIDE AMARYL 4 MG Generic TABLET 0.2311$

20 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

GLIPIZIDE GLUCOTROL 5 MG Generic TABLET 0.0300$GLIPIZIDE GLUCOTROL 10 MG Generic TABLET 0.0500$GLIPIZIDE GLIPIZIDE ER 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3100$GLIPIZIDE GLIPIZIDE ER 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1600$GLIPIZIDE GLIPIZIDE XL 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2164$GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 2.5-500 MG Generic TABLET 0.5400$GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 5 MG-500MG Generic TABLET 0.4483$GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 1 MG Brand VIAL (EA) 237.9500$GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 1 MG Brand KIT 223.6457$GLYBURIDE DIABETA 1.25 MG Generic TABLET 0.1100$GLYBURIDE DIABETA 2.5 MG Generic TABLET 0.1425$GLYBURIDE DIABETA 5 MG Generic TABLET 0.2000$GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED 3 MG Generic TABLET 0.0377$GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED 6 MG Generic TABLET 0.0876$GLYBURIDE/METFORMIN HCL GLUCOVANCE 5 MG-500MG Generic TABLET 0.0367$GLYBURIDE/METFORMIN HCL GLUCOVANCE 2.5-500 MG Generic TABLET 0.0296$GLYCERIN COLACE ADULT Brand SUPPOSITORY, RECTAL 0.0240$GLYCERIN COLACE ADULT Generic SUPPOSITORY, RECTAL 0.0633$GLYCOPYRROLATE GLYCOPYRROLATE 1 MG Generic TABLET 0.4300$GLYCOPYRROLATE GLYCOPYRROLATE 2 MG Generic TABLET 0.7700$GLYCOPYRROLATE CUVPOSA 1 MG/5 ML Brand SOLUTION, ORAL 0.9500$GOLIMUMAB SIMPONI 50MG/0.5ML Brand PEN INJECTOR (ML) 6,943.5096$GRANISETRON SANCUSO 3.1MG/24HR Brand PATCH, TRANSDERMAL WEEKLY 447.2637$GRANISETRON HCL GRANISETRON HCL 1 MG Generic TABLET 4.4749$GUAIFENESIN HUMIBID L.A. 600 MG Generic TABLET, EXTENDED RELEASE 0.2910$GUAIFENESIN Q-TUSSIN 100 MG/5ML Generic LIQUID (ML) 0.0115$GUAIFENESIN CHEST CONGESTION RELIEF 400 MG Generic TABLET 0.0650$GUAIFENESIN MUCINEX 600 MG Brand TABLET,EXTENDED RELEASE BIPHASIC 12 HR 0.3936$GUAIFENESIN MUCINEX 1200 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6126$GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE 100-10MG/5 Generic LIQUID (ML) 0.0378$GUAIFENESIN/DEXTROMETHORPHAN HBR ADULT ROBITUSSIN PEAK COLD 100-10MG/5 Brand LIQUID (ML) 0.0298$GUAIFENESIN/DEXTROMETHORPHAN HBR TUSSIN DM 100-10MG/5 Generic SYRUP 0.0143$GUAIFENESIN/DEXTROMETHORPHAN HBR CHILDREN'S MUCINEX 100-5 MG/5 Brand LIQUID (ML) 0.0454$GUAIFENESIN/DEXTROMETHORPHAN HBR HUMIBID DM 600MG-30MG Brand TABLET, EXTENDED RELEASE 12 HR 0.4388$GUAIFENESIN/DEXTROMETHORPHAN HBR MUCINEX DM 1200-60MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6628$GUAIFENESIN/PSEUDOEPHEDRINE HCL MUCINEX D 600MG-60MG Brand TABLET, EXTENDED RELEASE 12 HR 0.5008$GUAIFENESIN/PSEUDOEPHEDRINE HCL MUCINEX D 1200-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.7900$GUANFACINE HCL INTUNIV 1 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3600$GUANFACINE HCL GUANFACINE HCL ER 1 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6860$GUANFACINE HCL INTUNIV 2 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3300$GUANFACINE HCL INTUNIV 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.2700$GUANFACINE HCL INTUNIV 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3650$GUANFACINE HCL GUANFACINE HCL ER 4 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9289$GUANFACINE HCL TENEX 1 MG Generic TABLET 0.0798$GUANFACINE HCL TENEX 2 MG Generic TABLET 0.1100$HALCINONIDE HALOG 0.1 % Brand CREAM (GRAM) 4.6062$HALOBETASOL PROPIONATE ULTRAVATE 0.1% Generic OINTMENT (GRAM) 2.2175$HALOBETASOL PROPIONATE ULTRAVATE 0.1% Generic CREAM (GRAM) 2.6575$HALOPERIDOL HALDOL 0.5 MG Generic TABLET 0.2175$HALOPERIDOL HALDOL 1 MG Generic TABLET 0.3700$HALOPERIDOL HALDOL 10 MG Generic TABLET 0.7600$HALOPERIDOL HALOPERIDOL 2 MG Generic TABLET 0.4300$HALOPERIDOL HALDOL 5 MG Generic TABLET 0.7500$HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 27.0086$

21 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

HALOPERIDOL DECANOATE HALDOL DECANOATE 100 100 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 56.7600$HALOPERIDOL LACTATE HALOPERIDOL LACTATE 2 MG/ML Generic CONCENTRATE, ORAL 0.0700$HEPARIN SODIUM,PORCINE HEPARIN SODIUM 5000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.4946$HEPARIN SODIUM,PORCINE HEPARIN SODIUM 10000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 3.5000$HYDRALAZINE HCL APRESOLINE 10 MG Generic TABLET 0.1100$HYDRALAZINE HCL HYDRALAZINE HCL 100 MG Generic TABLET 0.1173$HYDRALAZINE HCL HYDRALAZINE HCL 25 MG Generic TABLET 0.1200$HYDRALAZINE HCL APRESOLINE 50 MG Generic TABLET 0.1300$HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic TABLET 0.1175$HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0684$HYDROCHLOROTHIAZIDE ESIDRIX 25 MG Generic TABLET 0.0101$HYDROCHLOROTHIAZIDE ESIDRIX 50 MG Generic TABLET 0.0445$HYDROCODONE BIT/ACETAMINOPHEN ANEXSIA 5MG-325MG Generic TABLET 0.1259$HYDROCODONE BIT/ACETAMINOPHEN ANEXSIA 7.5-325MG Generic TABLET 0.2021$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-500/15 Generic SOLUTION, ORAL 0.0442$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-325/15 Generic SOLUTION, ORAL 0.0862$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10MG-300MG Generic TABLET 1.5220$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 5MG-300MG Brand TABLET 1.3083$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 5MG-300MG Generic TABLET 1.3100$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-300MG Generic TABLET 1.0580$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN 10MG-325MG Brand TABLET 2.8800$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN 10MG-325MG Generic TABLET 0.1777$HYDROCODONE BIT/ACETAMINOPHEN VICODIN 5 MG-500MG Generic TABLET 0.0457$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10MG-650MG Generic TABLET 0.0817$HYDROCODONE BIT/ACETAMINOPHEN LORTAB 10MG-500MG Generic TABLET 0.2597$HYDROCODONE BIT/ACETAMINOPHEN VICODIN ES 7.5-750MG Generic TABLET 0.1187$HYDROCODONE BIT/ACETAMINOPHEN LORTAB 7.5-500MG Generic TABLET 0.1382$HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10-660MG Generic TABLET 0.1768$HYDROCODONE BITARTRATE/ACETAMINOPHEN LORTAB 10-300/15 Brand SOLUTION, ORAL 0.3740$HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE HYCODAN 5-1.5 MG/5 Generic SYRUP 0.1129$HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX HYDROCODONE-CHLORPHENIRAMINE 10-8MG/5ML Brand SUSPENSION, EXTENDED RELEASE 12 HR 1.2389$HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX HYDROCODONE-CHLORPHENIRAMINE 10-8MG/5ML Generic SUSPENSION, EXTENDED RELEASE 12 HR 0.4633$HYDROCODONE/IBUPROFEN VICOPROFEN 7.5-200 MG Generic TABLET 0.4072$HYDROCORTISONE CORTEF 10 MG Generic TABLET 0.3778$HYDROCORTISONE HYDROCORTISONE 20 MG Generic TABLET 0.6512$HYDROCORTISONE CORTEF 5 MG Generic TABLET 0.2750$HYDROCORTISONE PROCTOSOL-HC 2.5 % Generic CREAM WITH APPLICATOR 2.1500$HYDROCORTISONE ANUSOL-HC 2.5% Brand CREAM (GRAM) 0.2725$HYDROCORTISONE ANUSOL-HC 2.5% Generic CREAM (GRAM) 0.2582$HYDROCORTISONE HYDROCORTISONE 1 % Brand CREAM (GRAM) 0.2014$HYDROCORTISONE ALA-CORT 1.0% Generic CREAM (GRAM) 0.1316$HYDROCORTISONE HYDROCORTISONE 2.5% Generic CREAM (GRAM) 0.1000$HYDROCORTISONE HYDROCORTISONE 1.0% Generic OINTMENT (GRAM) 0.1210$HYDROCORTISONE HYDROCORTISONE 2.5% Generic OINTMENT (GRAM) 0.1240$HYDROCORTISONE HYTONE 2.5% Generic LOTION (ML) 0.2285$HYDROCORTISONE CORTENEMA 100MG/60ML Generic ENEMA (ML) 0.1022$HYDROCORTISONE ACETATE/LIDOCAINE HCL LIDAMANTLE HC 0.5 %-3 % Generic CREAM (GRAM) 0.8600$HYDROCORTISONE ACETATE/PRAMOXINE HCL PROCTOFOAM-HC 1 %-1 % Brand FOAM (GRAM) 11.6558$HYDROCORTISONE ACETATE/PRAMOXINE HCL HYDROCORTISONE-PRAMOXINE 1 %-1 % Generic CREAM WITH APPLICATOR 1.6918$HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE 0.1% Generic CREAM (GRAM) 3.0020$HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE 0.1 % Generic SOLUTION, NON-ORAL 0.7850$HYDROCORTISONE VALERATE WESTCORT 0.2% Generic OINTMENT (GRAM) 3.2256$HYDROCORTISONE VALERATE WESTCORT 0.2% Generic CREAM (GRAM) 3.8320$HYDROMORPHONE HCL DILAUDID 2 MG Generic TABLET 0.1000$

22 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

HYDROMORPHONE HCL DILAUDID 4 MG Generic TABLET 0.1200$HYDROMORPHONE HCL DILAUDID 8 MG Generic TABLET 0.3578$HYDROMORPHONE HCL HYDROMORPHONE HCL 1 MG/ML Generic LIQUID (ML) 0.4197$HYDROMORPHONE HCL EXALGO 32 MG Brand TABLET, EXTENDED RELEASE 24 HR 50.0205$HYDROMORPHONE HCL EXALGO 16 MG Brand TABLET, EXTENDED RELEASE 24 HR 24.4799$HYDROMORPHONE HCL EXALGO 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2659$HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200 MG Generic TABLET 1.8100$HYDROXYPROPYL CELLULOSE LACRISERT 5 MG Brand INSERT 6.3750$HYDROXYUREA HYDREA 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3900$HYDROXYZINE HCL ATARAX 10 MG/5 ML Generic SYRUP 0.0520$HYDROXYZINE HCL ATARAX 10 MG Generic TABLET 0.1000$HYDROXYZINE HCL ATARAX 25 MG Generic TABLET 0.1527$HYDROXYZINE HCL ATARAX 50 MG Generic TABLET 0.1900$HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE 100 MG Generic CAPSULE 0.4000$HYDROXYZINE PAMOATE VISTARIL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0700$HYDROXYZINE PAMOATE VISTARIL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0850$HYOSCYAMINE SULFATE ANASPAZ 0.125 MG Generic TABLET,DISINTEGRATING 0.3080$HYOSCYAMINE SULFATE LEVSIN 0.125MG/ML Generic DROPS 1.2300$HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.375 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.8364$HYOSCYAMINE SULFATE LEVSIN 0.125 MG Generic TABLET 0.4986$HYOSCYAMINE SULFATE LEVSIN-SL 0.125 MG Generic TABLET, SUBLINGUAL 0.2700$HYPROMELLOSE GENTEAL SEVERE 0.3 % Brand GEL (GRAM) 0.6200$HYPROMELLOSE GENTEAL MILD TO MODERATE 0.3 % Brand DROPS 0.4463$IBANDRONATE SODIUM BONIVA 150 MG Generic TABLET 24.9700$IBUPROFEN ADVIL 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.1638$IBUPROFEN IBUPROFEN 400 MG Generic TABLET 0.0676$IBUPROFEN IBUPROFEN 600 MG Generic TABLET 0.0602$IBUPROFEN ADVIL 200 MG Brand TABLET 0.1124$IBUPROFEN ADVIL 200 MG Generic TABLET 0.0410$IBUPROFEN IBUPROFEN 800 MG Generic TABLET 0.0703$IBUPROFEN CHILDREN'S MOTRIN 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0350$IBUPROFEN CHILDREN'S MOTRIN 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0300$IBUPROFEN/FAMOTIDINE DUEXIS 800-26.6MG Brand TABLET 17.4259$ICOSAPENT ETHYL VASCEPA 1 G Brand CAPSULE (HARD, SOFT, ETC.) 1.8769$ILOPERIDONE FANAPT 6 MG Brand TABLET 18.7380$ILOPERIDONE FANAPT 12 MG Brand TABLET 29.9253$IMIPRAMINE HCL IMIPRAMINE HCL 10 MG Generic TABLET 0.1083$IMIPRAMINE HCL IMIPRAMINE HCL 25 MG Generic TABLET 0.1400$IMIPRAMINE HCL IMIPRAMINE HCL 50 MG Generic TABLET 0.2190$IMIQUIMOD ALDARA 5.0% Generic CREAM IN PACKET 4.9675$INDACATEROL MALEATE ARCAPTA NEOHALER 75 MCG Brand CAPSULE, WITH INHALATION DEVICE 6.9567$INDAPAMIDE LOZOL 2.5 MG Generic TABLET 0.2725$INDAPAMIDE INDAPAMIDE 1.25 MG Generic TABLET 0.2900$INDOMETHACIN INDOMETHACIN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1567$INDOMETHACIN INDOCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1178$INDOMETHACIN INDOCIN SR 75 MG Generic CAPSULE, EXTENDED RELEASE 1.3023$INGENOL MEBUTATE PICATO 0.015 % Brand GEL (EA) 261.7275$INSULIN ASPART NOVOLOG 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 22.5597$INSULIN ASPART NOVOLOG FLEXPEN 100/ML Brand INSULIN PEN (ML) 29.0279$INSULIN ASPART NOVOLOG 100/ML Brand CARTRIDGE (ML) 28.2679$INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 70-30/ML Brand INSULIN PEN (ML) 29.0333$INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART NOVOLOG MIX 70-30 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 23.4829$INSULIN DETEMIR LEVEMIR FLEXPEN 100/ML (3) Brand INSULIN PEN (ML) 25.6320$INSULIN DETEMIR LEVEMIR 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 25.6356$

23 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG LANTUS 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 23.6813$INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG LANTUS SOLOSTAR 100/ML (3) Brand INSULIN PEN (ML) 23.6742$INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG TOUJEO SOLOSTAR 300/ML Brand INSULIN PEN (ML) 71.2556$INSULIN GLULISINE APIDRA 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 22.5128$INSULIN GLULISINE APIDRA SOLOSTAR 100/ML Brand INSULIN PEN (ML) 29.3861$INSULIN LISPRO HUMALOG 100/ML Brand CARTRIDGE (ML) 28.6058$INSULIN LISPRO HUMALOG 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 22.5546$INSULIN LISPRO HUMALOG 100/ML Brand INSULIN PEN (ML) 29.1200$INSULIN LISPRO PROTAMINE & INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 23.3256$INSULIN LISPRO PROTAMINE & INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML Brand INSULIN PEN (ML) 29.4089$INSULIN REGULAR, HUMAN HUMULIN R 500/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 62.0828$INSULIN REGULAR, HUMAN HUMULIN R 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 12.8326$INTERFERON BETA-1A AVONEX 30MCG/.5ML Brand KIT 5,395.4891$INTERFERON BETA-1B BETASERON 0.3 MG Brand KIT 420.4494$IPRATROPIUM BROMIDE ATROVENT HFA 17MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 21.1325$IPRATROPIUM BROMIDE ATROVENT 0.2 MG/ML Generic SOLUTION, NON-ORAL 0.0657$IPRATROPIUM BROMIDE ATROVENT 42MCG Generic AEROSOL, SPRAY (ML) 1.4756$IPRATROPIUM BROMIDE ATROVENT 21 MCG Generic AEROSOL, SPRAY (ML) 0.6779$IPRATROPIUM BROMIDE/ALBUTEROL SULFATE DUONEB 0.5-3MG/3 Generic AMPUL FOR NEBULIZATION (ML) 0.0628$IPRATROPIUM BROMIDE/ALBUTEROL SULFATE COMBIVENT RESPIMAT 20-100 MCG Brand AEROSOL WITH ADAPTER (GRAM) 70.5027$IRBESARTAN AVAPRO 150 MG Brand TABLET 4.9721$IRBESARTAN AVAPRO 150 MG Generic TABLET 0.2390$IRBESARTAN AVAPRO 300 MG Brand TABLET 5.2244$IRBESARTAN AVAPRO 300 MG Generic TABLET 0.4719$IRBESARTAN AVAPRO 75 MG Brand TABLET 3.6565$IRBESARTAN IRBESARTAN 75 MG Generic TABLET 0.2682$IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 150-12.5MG Generic TABLET 0.3100$IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 300-12.5MG Brand TABLET 3.7563$IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 300-12.5MG Generic TABLET 0.4560$IRON BISGL & PS CMPLX/FOLIC ACID/VIT B&C#12/SUCCINIC ACID IROSPAN 65-1MG(24) Generic TABLET 3.0194$IRON/FOLATE NO.8/PS-DHA/PS-EPA/FAD/NADH/BETAINE/MULTIVIT #47 ENLYTE 1.5-8.73MG Generic CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE 4.1079$ISONIAZID ISONIAZID 100 MG Generic TABLET 0.1131$ISONIAZID ISONIAZID 300 MG Generic TABLET 0.1451$ISOSORBIDE MONONITRATE IMDUR 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2535$ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER 120 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5275$ISOSORBIDE MONONITRATE IMDUR 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2148$ISOTRETINOIN ABSORICA 30 MG Brand CAPSULE 29.8264$ISOTRETINOIN ABSORICA 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 11.9757$ISOTRETINOIN ABSORICA 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.7971$ISOTRETINOIN ABSORICA 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.5036$ISOTRETINOIN ABSORICA 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.3263$ITRACONAZOLE ITRACONAZOLE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.0700$IVERMECTIN STROMECTOL 3 MG Brand TABLET 4.4650$KETOCONAZOLE KETOCONAZOLE 2.0% Generic SHAMPOO 0.0800$KETOCONAZOLE NIZORAL 2.0% Generic CREAM (GRAM) 1.1280$KETOCONAZOLE NIZORAL 200 MG Generic TABLET 2.0500$KETOPROFEN ORUDIS 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3966$KETOROLAC TROMETHAMINE ACULAR LS 0.4% Generic DROPS 9.7900$KETOROLAC TROMETHAMINE SPRIX 15.75 MG Brand SPRAY, NON-AEROSOL (EA) 188.4000$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 10 MG Generic TABLET 0.7975$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 60 MG/2 ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.2291$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 15 MG/ML Generic VIAL (ML) 1.9652$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 30MG/ML(1) Generic VIAL (ML) 2.1253$KETOROLAC TROMETHAMINE ACULAR 0.5% Generic DROPS 2.0453$

24 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

KETOTIFEN FUMARATE ALAWAY 0.025 % Brand DROPS 1.4900$KETOTIFEN FUMARATE ALAWAY 0.0% Generic DROPS 1.0743$LABETALOL HCL NORMODYNE 300 MG Generic TABLET 0.5600$LABETALOL HCL NORMODYNE 200 MG Generic TABLET 0.3800$LABETALOL HCL NORMODYNE 100 MG Generic TABLET 0.2936$LACOSAMIDE VIMPAT 50 MG Brand TABLET 7.0534$LACOSAMIDE VIMPAT 100 MG Brand TABLET 10.9197$LACOSAMIDE VIMPAT 150 MG Brand TABLET 11.8434$LACOSAMIDE VIMPAT 200 MG Brand TABLET 11.5610$LACOSAMIDE VIMPAT 10 MG/ML Brand SOLUTION, ORAL 1.2819$LACTULOSE CEPHULAC 10 G/15 ML Generic SOLUTION, ORAL 0.0100$LACTULOSE LACTULOSE 10 G/15 ML Generic SOLUTION, ORAL 0.0192$LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 150-300MG Generic TABLET 2.6178$LAMOTRIGINE LAMOTRIGINE ER 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.8100$LAMOTRIGINE LAMOTRIGINE ER 50 MG Generic TABLET, EXTENDED RELEASE 24 HR 8.2200$LAMOTRIGINE LAMICTAL XR 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 20.2964$LAMOTRIGINE LAMICTAL XR 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 7.4600$LAMOTRIGINE LAMICTAL XR 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 20.0489$LAMOTRIGINE LAMICTAL XR 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 7.4100$LAMOTRIGINE LAMICTAL 100 MG Brand TABLET 10.2891$LAMOTRIGINE LAMICTAL 100 MG Generic TABLET 0.0941$LAMOTRIGINE LAMICTAL 25 MG Brand TABLET 9.5022$LAMOTRIGINE LAMICTAL 25 MG Generic TABLET 0.0900$LAMOTRIGINE LAMICTAL 25 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.2500$LAMOTRIGINE LAMICTAL 5 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.1950$LAMOTRIGINE LAMICTAL 150 MG Brand TABLET 11.9311$LAMOTRIGINE LAMICTAL 150 MG Generic TABLET 0.1000$LAMOTRIGINE LAMICTAL 200 MG Brand TABLET 12.6304$LAMOTRIGINE LAMICTAL 200 MG Generic TABLET 0.1000$LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.6965$LANSOPRAZOLE LANSOPRAZOLE 15 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.8100$LANSOPRAZOLE LANSOPRAZOLE 30 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 11.7609$LANSOPRAZOLE LANSOPRAZOLE 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.5429$LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 11.8337$LANSOPRAZOLE LANSOPRAZOLE 30 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 11.6934$LANSOPRAZOLE FIRST-LANSOPRAZOLE 3 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3833$LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN PREVPAC 30-500-500 Brand COMBINATION PACKAGE (EA) 5.2233$LATANOPROST LATANOPROST 0.0% Brand DROPS 54.4452$LATANOPROST LATANOPROST 0.0% Generic DROPS 2.7186$LEFLUNOMIDE LEFLUNOMIDE 10 MG Generic TABLET 0.6556$LEFLUNOMIDE LEFLUNOMIDE 20 MG Generic TABLET 3.5420$LETROZOLE FEMARA 2.5 MG Generic TABLET 0.2300$LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 5 MG Generic TABLET 0.9100$LEVALBUTEROL HCL LEVALBUTEROL HCL 0.31MG/3ML Generic VIAL, NEBULIZER (ML) 1.0475$LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.6356$LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Brand VIAL, NEBULIZER (ML) 2.8238$LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.8200$LEVALBUTEROL TARTRATE XOPENEX HFA 45MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 4.3360$LEVETIRACETAM KEPPRA XR 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.0769$LEVETIRACETAM KEPPRA XR 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4050$LEVETIRACETAM KEPPRA 100 MG/ML Brand SOLUTION, ORAL 1.3485$LEVETIRACETAM KEPPRA 100 MG/ML Generic SOLUTION, ORAL 0.0600$LEVETIRACETAM KEPPRA XR 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3932$LEVETIRACETAM KEPPRA XR 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7482$

25 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

LEVETIRACETAM KEPPRA 750 MG Generic TABLET 0.2500$LEVETIRACETAM KEPPRA 250 MG Generic TABLET 0.1047$LEVETIRACETAM KEPPRA 500 MG Brand TABLET 6.8491$LEVETIRACETAM KEPPRA 500 MG Generic TABLET 0.1448$LEVETIRACETAM KEPPRA 1000 MG Brand TABLET 14.3763$LEVETIRACETAM KEPPRA 1000 MG Generic TABLET 0.4309$LEVOBUNOLOL HCL BETAGAN 0.5% Generic DROPS 3.3660$LEVOCARNITINE CARNITOR 330 MG Generic TABLET 0.6125$LEVOCARNITINE (WITH SUGAR) CARNITOR 100 MG/ML Generic SOLUTION, ORAL 0.1855$LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG Generic TABLET 0.1875$LEVOFLOXACIN LEVAQUIN 250MG/10ML Generic SOLUTION, ORAL 1.0300$LEVOFLOXACIN LEVAQUIN 250 MG Generic TABLET 0.2200$LEVOFLOXACIN LEVAQUIN 500 MG Generic TABLET 0.2600$LEVOFLOXACIN LEVAQUIN 750 MG Generic TABLET 0.5700$LEVOMEFOLATE CALCIUM L-METHYLFOLATE 7.5 MG Generic TABLET 1.9900$LEVOMEFOLATE CALCIUM L-METHYLFOLATE CALCIUM 15 MG Generic TABLET 1.6250$LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGAL OIL L-METHYLFOLATE FORTE 15-90.314 Generic CAPSULE (HARD, SOFT, ETC.) 3.1925$LEVOMILNACIPRAN HYDROCHLORIDE FETZIMA 20 MG Brand CAPSULE, EXTENDED RELEASE 24HR 9.5649$LEVOMILNACIPRAN HYDROCHLORIDE FETZIMA 40 MG Brand CAPSULE, EXTENDED RELEASE 24HR 10.0002$LEVONORGESTREL PLAN B ONE-STEP 1.5 MG Brand TABLET 30.7350$LEVONORGESTREL PLAN B ONE-STEP 1.5 MG Generic TABLET 31.5185$LEVONORGESTREL PLAN B 0.75 MG Generic TABLET 12.7139$LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE LO 100-20(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.7360$LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE LO 100-20(84) Generic TABLET, DOSE PACK, 3 MONTHS 2.0080$LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE 150-30(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.9710$LEVONORGESTREL-ETHINYL ESTRADIOL LEVLEN 28 0.15-0.03 Generic TABLET 0.4400$LEVONORGESTREL-ETHINYL ESTRADIOL TRI-LEVLEN 28 6-5-10 Generic TABLET 0.7051$LEVONORGESTREL-ETHINYL ESTRADIOL ALESSE-21 0.1-0.02 Generic TABLET 0.5490$LEVONORGESTREL-ETHINYL ESTRADIOL JOLESSA 0.15-0.03 Brand TABLET, DOSE PACK, 3 MONTHS 0.9541$LEVONORGESTREL-ETHINYL ESTRADIOL JOLESSA 0.15-0.03 Generic TABLET, DOSE PACK, 3 MONTHS 0.9720$LEVONORGESTREL-ETHINYL ESTRADIOL AMETHYST 90-20MCG Generic TABLET 1.6000$LEVOTHYROXINE SODIUM LEVOTHROID 112 MCG Brand TABLET 1.0500$LEVOTHYROXINE SODIUM LEVOTHROID 112 MCG Generic TABLET 0.4927$LEVOTHYROXINE SODIUM LEVOTHROID 25 MCG Brand TABLET 1.0154$LEVOTHYROXINE SODIUM LEVOTHROID 25 MCG Generic TABLET 0.3400$LEVOTHYROXINE SODIUM LEVOTHROID 50 MCG Brand TABLET 1.0200$LEVOTHYROXINE SODIUM LEVOTHROID 50 MCG Generic TABLET 0.3639$LEVOTHYROXINE SODIUM LEVOTHROID 100 MCG Brand TABLET 1.0500$LEVOTHYROXINE SODIUM LEVOTHROID 100 MCG Generic TABLET 0.4509$LEVOTHYROXINE SODIUM LEVOTHROID 75 MCG Brand TABLET 1.0300$LEVOTHYROXINE SODIUM LEVOTHROID 75 MCG Generic TABLET 0.4362$LEVOTHYROXINE SODIUM LEVOTHROID 200 MCG Brand TABLET 1.1014$LEVOTHYROXINE SODIUM LEVOTHROID 200 MCG Generic TABLET 0.6700$LEVOTHYROXINE SODIUM LEVOTHROID 125 MCG Brand TABLET 1.0544$LEVOTHYROXINE SODIUM LEVOTHROID 125 MCG Generic TABLET 0.5060$LEVOTHYROXINE SODIUM LEVOTHROID 150 MCG Brand TABLET 1.0500$LEVOTHYROXINE SODIUM LEVOTHROID 150 MCG Generic TABLET 0.5500$LEVOTHYROXINE SODIUM LEVOTHROID 175MCG Brand TABLET 1.0900$LEVOTHYROXINE SODIUM LEVOTHROID 175MCG Generic TABLET 0.6471$LEVOTHYROXINE SODIUM LEVOTHROID 300 MCG Brand TABLET 1.1550$LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG Generic TABLET 0.8375$LEVOTHYROXINE SODIUM TIROSINT 150 MCG Brand CAPSULE 3.2532$LEVOTHYROXINE SODIUM TIROSINT 125 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.4290$LEVOTHYROXINE SODIUM TIROSINT 112 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.4922$

26 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

LEVOTHYROXINE SODIUM TIROSINT 100 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.5236$LEVOTHYROXINE SODIUM TIROSINT 88 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.5270$LEVOTHYROXINE SODIUM TIROSINT 75 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.4840$LEVOTHYROXINE SODIUM TIROSINT 50 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.5017$LEVOTHYROXINE SODIUM LEVOTHROID 88 MCG Brand TABLET 1.0440$LEVOTHYROXINE SODIUM LEVOTHROID 88 MCG Generic TABLET 0.4509$LEVOTHYROXINE SODIUM LEVOTHROID 137 MCG Brand TABLET 1.0450$LEVOTHYROXINE SODIUM LEVOTHROID 137 MCG Generic TABLET 0.5441$LIDOCAINE LIDOCAINE 5.0% Generic OINTMENT (GRAM) 4.9246$LIDOCAINE LIDOCAINE 5%(700MG) Brand ADHESIVE PATCH, MEDICATED 11.4181$LIDOCAINE LIDOCAINE 5%(700MG) Generic ADHESIVE PATCH, MEDICATED 4.1100$LIDOCAINE HCL ANESTACON 2.0% Generic JEL (ML) 0.2400$LIDOCAINE HCL LIDOCAINE HCL VISCOUS 2 % Generic SOLUTION, ORAL 0.0325$LIDOCAINE HCL LIDOCAINE HCL 40 MG/ML Generic SOLUTION, NON-ORAL 0.0810$LIDOCAINE HCL LIDAMANTLE 3.0% Generic CREAM (GRAM) 1.2040$LIDOCAINE HCL/PF LIDOCAINE HCL 10 MG/ML Generic VIAL (ML) 0.2800$LIDOCAINE/PRILOCAINE EMLA 2.5%-2.5% Generic CREAM (GRAM) 1.0300$LINACLOTIDE LINZESS 145 MCG Brand CAPSULE (HARD, SOFT, ETC.) 9.6656$LINACLOTIDE LINZESS 290 MCG Brand CAPSULE (HARD, SOFT, ETC.) 9.6500$LINAGLIPTIN TRADJENTA 5 MG Brand TABLET 11.3603$LINDANE LINDANE 1 % Generic LOTION (ML) 1.6300$LINDANE KWELL 1.0% Generic SHAMPOO 1.7533$LINEZOLID ZYVOX 600 MG Brand TABLET 161.2397$LIOTHYRONINE SODIUM CYTOMEL 25 MCG Brand TABLET 1.7403$LIOTHYRONINE SODIUM CYTOMEL 25 MCG Generic TABLET 0.7667$LIOTHYRONINE SODIUM CYTOMEL 5 MCG Brand TABLET 1.2858$LIOTHYRONINE SODIUM CYTOMEL 5 MCG Generic TABLET 0.4507$LIOTHYRONINE SODIUM CYTOMEL 50 MCG Generic TABLET 1.0000$LIPASE/PROTEASE/AMYLASE CREON 6K-19K-30K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 1.2777$LIPASE/PROTEASE/AMYLASE CREON 12K-38K-60 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.5500$LIPASE/PROTEASE/AMYLASE CREON 24-76-120K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.9530$LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 5K-17K-27K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.8751$LIPASE/PROTEASE/AMYLASE ZENPEP 20-68-109K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.7850$LIPASE/PROTEASE/AMYLASE PANCREAZE 16.8-40-70 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.9053$LIPASE/PROTEASE/AMYLASE PANCREAZE 10.5K-25K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.4445$LIPASE/PROTEASE/AMYLASE CREON 36-114-180 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.4864$LIRAGLUTIDE VICTOZA 2-PAK Brand PEN INJECTOR (ML) 73.4026$LISDEXAMFETAMINE DIMESYLATE VYVANSE 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9265$LISDEXAMFETAMINE DIMESYLATE VYVANSE 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.5950$LISDEXAMFETAMINE DIMESYLATE VYVANSE 70 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9802$LISDEXAMFETAMINE DIMESYLATE VYVANSE 20 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9543$LISDEXAMFETAMINE DIMESYLATE VYVANSE 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9761$LISDEXAMFETAMINE DIMESYLATE VYVANSE 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9792$LISINOPRIL PRINIVIL 5 MG Generic TABLET 0.0265$LISINOPRIL PRINIVIL 10 MG Generic TABLET 0.0274$LISINOPRIL PRINIVIL 20 MG Generic TABLET 0.0389$LISINOPRIL PRINIVIL 40 MG Generic TABLET 0.0482$LISINOPRIL PRINIVIL Generic TABLET 0.0193$LISINOPRIL ZESTRIL 30 MG Generic TABLET 0.0818$LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 20-12.5 MG Generic TABLET 0.0400$LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 20-25MG Generic TABLET 0.0500$LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 10-12.5MG Generic TABLET 0.0363$LITHIUM CARBONATE ESKALITH 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$LITHIUM CARBONATE LITHIUM CARBONATE 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0700$

27 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

LITHIUM CARBONATE LITHIUM CARBONATE 600 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1075$LITHIUM CARBONATE ESKALITH 300 MG Generic TABLET 0.1725$LITHIUM CARBONATE ESKALITH CR 450 MG Generic TABLET, EXTENDED RELEASE 0.2600$LITHIUM CARBONATE LITHOBID 300 MG Generic TABLET, EXTENDED RELEASE 0.2300$LOPERAMIDE HCL LOPERAMIDE 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2450$LOPERAMIDE HCL ANTI-DIARRHEAL 2 MG Generic TABLET 0.0988$LORATADINE CLARITIN 10 MG Brand TABLET,DISINTEGRATING 0.4500$LORATADINE CHILDREN'S CLARITIN 5 MG/5 ML Generic SOLUTION, ORAL 0.0400$LORATADINE CLARITIN 10 MG Brand TABLET 0.6800$LORATADINE CLARITIN 10 MG Generic TABLET 0.0422$LORATADINE CHILDREN'S CLARITIN 5 MG Brand TABLET, CHEWABLE 0.7383$LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 12 HOUR 5 MG-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.4913$LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 12 HOUR 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.6771$LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 24 HOUR 10MG-240MG Brand TABLET, EXTENDED RELEASE 24 HR 0.9915$LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 24 HOUR 10MG-240MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5035$LORAZEPAM ATIVAN 0.5 MG Generic TABLET 0.0216$LORAZEPAM ATIVAN 1 MG Generic TABLET 0.0304$LORAZEPAM ATIVAN 2 MG Generic TABLET 0.0516$LORAZEPAM LORAZEPAM 2 MG/ML Generic CONCENTRATE, ORAL 0.8400$LOSARTAN POTASSIUM COZAAR 25 MG Generic TABLET 0.0497$LOSARTAN POTASSIUM COZAAR 50 MG Generic TABLET 0.0661$LOSARTAN POTASSIUM COZAAR 100 MG Brand TABLET 3.7712$LOSARTAN POTASSIUM COZAAR 100 MG Generic TABLET 0.0856$LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 50-12.5 MG Generic TABLET 0.0893$LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 100MG-25MG Generic TABLET 0.1202$LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 100-12.5MG Generic TABLET 0.1341$LOTEPREDNOL ETABONATE LOTEMAX 0.5 % Brand OINTMENT (GRAM) 58.3283$LOTEPREDNOL ETABONATE LOTEMAX 0.5% Brand GEL (GRAM) 28.9889$LOTEPREDNOL ETABONATE LOTEMAX 0.5% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 36.3360$LOTEPREDNOL ETABONATE ALREX 0.2% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 34.8425$LOVASTATIN MEVACOR 20 MG Generic TABLET 0.0767$LOVASTATIN MEVACOR 40 MG Generic TABLET 0.1000$LOVASTATIN MEVACOR 10 MG Generic TABLET 0.0646$LOXAPINE SUCCINATE LOXAPINE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3900$LUBIPROSTONE AMITIZA 24MCG Brand CAPSULE (HARD, SOFT, ETC.) 5.1633$LUBIPROSTONE AMITIZA 8 MCG Brand CAPSULE (HARD, SOFT, ETC.) 5.2417$LURASIDONE HCL LATUDA 40 MG Brand TABLET 29.2572$LURASIDONE HCL LATUDA 80 MG Brand TABLET 29.3300$LURASIDONE HCL LATUDA 20 MG Brand TABLET 29.2726$LURASIDONE HCL LATUDA 120 MG Brand TABLET 44.0581$LURASIDONE HCL LATUDA 60 MG Brand TABLET 29.3000$MAG HYDROXIDE/AL HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAINE FIRST-MOUTHWASH BLM 25-200/30 Generic MOUTHWASH 0.1000$MAGNESIUM CITRATE CITRATE OF MAGNESIA Generic SOLUTION, ORAL 0.0044$MAGNESIUM HYDROXIDE MILK OF MAGNESIA 400 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0011$MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ANTACID-ANTIGAS 200-200-20 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0100$MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ALMACONE-2 400-400-40 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0100$MAGNESIUM OXIDE MAGNESIUM OXIDE 400 MG Generic TABLET 0.0340$MECLIZINE HCL ANTIVERT 12.5 MG Generic TABLET 0.0850$MECLIZINE HCL ANTIVERT 25 MG Generic TABLET 0.2300$MECLIZINE HCL ANTIVERT/25 25 MG Generic TABLET, CHEWABLE 0.0300$MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 66.2853$MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 88.1800$MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 10 MG Generic TABLET 0.1886$MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 2.5 MG Generic TABLET 0.1375$

28 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 5 MG Generic TABLET 0.1300$MEFENAMIC ACID MEFENAMIC ACID 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.8586$MEFLOQUINE HCL LARIAM 250 MG Generic TABLET 6.3975$MEGESTROL ACETATE MEGACE 20 MG Generic TABLET 0.1480$MEGESTROL ACETATE MEGACE 40 MG Generic TABLET 0.2150$MEGESTROL ACETATE MEGACE 400MG/10ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0660$MELOXICAM MELOXICAM 7.5 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.7818$MELOXICAM MOBIC 7.5 MG Generic TABLET 0.0300$MELOXICAM MOBIC 15 MG Generic TABLET 0.0263$MEMANTINE HCL NAMENDA 10 MG Brand TABLET 5.4339$MEMANTINE HCL MEMANTINE HCL 10 MG Generic TABLET 0.3925$MEMANTINE HCL NAMENDA 5 MG Brand TABLET 5.9072$MEMANTINE HCL MEMANTINE HCL 5 MG Generic TABLET 0.3843$MEMANTINE HCL NAMENDA 5 MG-10 MG Brand TABLET, DOSE PACK 5.5335$MEMANTINE HCL NAMENDA XR 21 MG Brand CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 11.1631$MEMANTINE HCL NAMENDA XR 28 MG Brand CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 11.2536$MENTHOL/CAMPHOR SARNA 0.5 %-0.5% Brand LOTION (ML) 0.0300$MEPERIDINE HCL DEMEROL 50 MG Generic TABLET 0.5367$MERCAPTOPURINE MERCAPTOPURINE 50 MG Generic TABLET 1.9700$MESALAMINE APRISO 0.375G Brand CAPSULE, EXT RELEASE 24 HR 3.3058$MESALAMINE ASACOL HD 800 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 7.0393$MESALAMINE PENTASA 500 MG Brand CAPSULE, EXTENDED RELEASE 4.4846$MESALAMINE PENTASA 250 MG Brand CAPSULE, EXTENDED RELEASE 2.3312$MESALAMINE DELZICOL 400 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.8541$MESALAMINE MESALAMINE 4 G/60 ML Generic ENEMA (ML) 0.2208$MESALAMINE CANASA 1000 MG Brand SUPPOSITORY, RECTAL 28.4798$MESALAMINE LIALDA 1.2 G Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 7.5200$MESALAMINE WITH CLEANSING WIPES MESALAMINE 4G/60ML Generic KIT 97.8200$METAXALONE METAXALONE 800 MG Generic TABLET 3.5720$METFORMIN HCL GLUCOPHAGE 500 MG Generic TABLET 0.0201$METFORMIN HCL GLUCOPHAGE 850 MG Generic TABLET 0.0401$METFORMIN HCL GLUCOPHAGE 1000 MG Generic TABLET 0.0352$METFORMIN HCL GLUCOPHAGE XR 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1125$METFORMIN HCL FORTAMET 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 11.5650$METFORMIN HCL GLUCOPHAGE XR 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.0520$METHADONE HCL DOLOPHINE HCL 10 MG Generic TABLET 0.2032$METHADONE HCL DOLOPHINE HCL 5 MG Generic TABLET 0.2300$METHENAMINE HIPPURATE HIPREX 1 G Generic TABLET 1.4775$METHENAMINE/METHYLENE BLUE/SALICYLATE/SODIUM PHOS/HYOSCY URELLE 81-0.12MG Brand TABLET 5.3723$METHIMAZOLE TAPAZOLE 10 MG Generic TABLET 0.1700$METHIMAZOLE TAPAZOLE 5 MG Generic TABLET 0.1600$METHOCARBAMOL METHOCARBAMOL 500 MG Generic TABLET 0.1004$METHOCARBAMOL ROBAXIN-750 750 MG Generic TABLET 0.1293$METHOTREXATE SODIUM METHOTREXATE 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 3.1025$METHOTREXATE SODIUM METHOTREXATE 2.5 MG Generic TABLET 1.5804$METHOTREXATE SODIUM/PF METHOTREXATE 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.9400$METHYLCELLULOSE (WITH SUGAR) CITRUCEL 0.0% Brand POWDER (GRAM) 0.0150$METHYLDOPA ALDOMET 250 MG Generic TABLET 0.1323$METHYLDOPA ALDOMET 500 MG Generic TABLET 0.2842$METHYLERGONOVINE MALEATE METHYLERGONOVINE MALEATE 0.2 MG Generic TABLET 20.8040$METHYLNALTREXONE BROMIDE RELISTOR 12MG/0.6ML Brand SYRINGE (ML) 160.7827$METHYLPHENIDATE DAYTRANA 10MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 10.1043$METHYLPHENIDATE DAYTRANA 15MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 9.7442$METHYLPHENIDATE DAYTRANA 20 MG/9 HR Brand PATCH, TRANSDERMAL 24 HOURS 10.1043$

29 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

METHYLPHENIDATE DAYTRANA 30MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 10.0182$METHYLPHENIDATE HCL CONCERTA 54 MG Brand TABLET, EXTENDED RELEASE 24 HR 10.2868$METHYLPHENIDATE HCL CONCERTA 54 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.6892$METHYLPHENIDATE HCL CONCERTA 18 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.9467$METHYLPHENIDATE HCL CONCERTA 36 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.5855$METHYLPHENIDATE HCL CONCERTA 36 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.9900$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG Generic TABLET 0.7100$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG Generic TABLET 0.5150$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG Generic TABLET 1.0100$METHYLPHENIDATE HCL METADATE ER 20 MG Brand TABLET, EXTENDED RELEASE 1.8678$METHYLPHENIDATE HCL METADATE ER 20 MG Generic TABLET, EXTENDED RELEASE 3.8850$METHYLPHENIDATE HCL CONCERTA 27 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.1241$METHYLPHENIDATE HCL CONCERTA 27 MG Generic TABLET, EXTENDED RELEASE 24 HR 6.8069$METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD 20 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 3.6475$METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 3.9964$METHYLPHENIDATE HCL RITALIN LA 20 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 4.5250$METHYLPHENIDATE HCL RITALIN LA 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 4.5500$METHYLPHENIDATE HCL RITALIN LA 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.6394$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG/5 ML Generic SOLUTION, ORAL 1.0300$METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD 40 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 5.2100$METHYLPHENIDATE HCL QUILLIVANT XR 5 MG/ML Brand SUSPENSION,EXTENDED RELEASE,RECONST.24HR 1.3409$METHYLPHENIDATE HCL METADATE ER 10 MG Generic TABLET, EXTENDED RELEASE 5.7587$METHYLPREDNISOLONE MEDROL 16 MG Generic TABLET 2.5828$METHYLPREDNISOLONE METHYLPREDNISOLONE 32 MG Generic TABLET 3.6329$METHYLPREDNISOLONE MEDROL 4 MG Generic TABLET 0.9191$METHYLPREDNISOLONE METHYLPREDNISOLONE 8 MG Generic TABLET 1.6312$METHYLPREDNISOLONE MEDROL 4 MG Generic TABLET, DOSE PACK 0.5700$METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE 80 MG/ML Generic VIAL (ML) 7.4589$METOCLOPRAMIDE HCL REGLAN 5 MG/5 ML Generic SOLUTION, ORAL 0.0125$METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 10 MG Generic TABLET 0.0450$METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5 MG Generic TABLET 0.0453$METOLAZONE DIULO 2.5 MG Generic TABLET 1.3100$METOLAZONE DIULO 5 MG Generic TABLET 1.5400$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1550$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3500$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1500$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3040$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5400$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9900$METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG Generic TABLET 0.0300$METOPROLOL TARTRATE LOPRESSOR 100 MG Generic TABLET 0.0325$METOPROLOL TARTRATE LOPRESSOR 50 MG Generic TABLET 0.0222$METRONIDAZOLE METROGEL 1.0% Brand GEL (GRAM) 4.3088$METRONIDAZOLE METROGEL 1.0% Generic GEL (GRAM) 3.6175$METRONIDAZOLE METROGEL 1.0% Brand GEL WITH PUMP (GRAM) 4.9018$METRONIDAZOLE METROGEL 1.0% Generic GEL WITH PUMP (GRAM) 3.9240$METRONIDAZOLE FLAGYL 250 MG Generic TABLET 0.2760$METRONIDAZOLE FLAGYL 500 MG Generic TABLET 0.4800$METRONIDAZOLE METROLOTION 0.8% Generic LOTION (ML) 3.2150$METRONIDAZOLE METROGEL 0.8% Generic GEL (GRAM) 2.0325$METRONIDAZOLE METROCREAM 0.8% Generic CREAM (GRAM) 2.2925$METRONIDAZOLE METROGEL-VAGINAL 0.8% Brand GEL WITH APPLICATOR (GRAM) 0.3528$METRONIDAZOLE METROGEL-VAGINAL 0.8% Generic GEL WITH APPLICATOR (GRAM) 1.4000$MEXILETINE HCL MEXILETINE HCL 150 MG Generic CAPSULE 0.6025$

30 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

MICONAZOLE NITRATE MICONAZOLE 7 2 % Generic CREAM WITH APPLICATOR 0.0950$MICONAZOLE NITRATE MONISTAT-DERM 2.0% Generic CREAM (GRAM) 0.1267$MICONAZOLE NITRATE DESENEX 2 % Brand POWDER (GRAM) 0.0626$MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML Generic VIAL (ML) 0.5900$MIDODRINE HCL PROAMATINE 10 MG Generic TABLET 1.0133$MIDODRINE HCL PROAMATINE 5 MG Generic TABLET 0.3800$MIDODRINE HCL PROAMATINE 2.5 MG Generic TABLET 0.4633$MILNACIPRAN HCL SAVELLA 25 MG Brand TABLET 4.2369$MILNACIPRAN HCL SAVELLA 50 MG Brand TABLET 4.2505$MILNACIPRAN HCL SAVELLA 100 MG Brand TABLET 4.3420$MILNACIPRAN HCL SAVELLA 12.5-25-50 Brand TABLET, DOSE PACK 4.3647$MILRINONE LACTATE MILRINONE LACTATE 1 MG/ML Generic VIAL (ML) 0.3500$MINERAL OIL/PETROLATUM,WHITE ARTIFICIAL TEARS 15 %-83 % Generic OINTMENT (GRAM) 0.5663$MINERAL OIL/PETROLATUM,WHITE LACRI-LUBE S.O.P. 42.5-56.8% Brand OINTMENT (GRAM) 2.4492$MINOCYCLINE HCL SOLODYN 65 MG Brand TABLET, EXTENDED RELEASE 24 HR 33.2237$MINOCYCLINE HCL SOLODYN 55 MG Brand TABLET, EXTENDED RELEASE 24 HR 34.5102$MINOCYCLINE HCL SOLODYN 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 34.6799$MINOCYCLINE HCL MINOCIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3900$MINOCYCLINE HCL MINOCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2300$MINOCYCLINE HCL MINOCYCLINE HCL 100 MG Generic TABLET 3.8285$MINOCYCLINE HCL DYNACIN 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2800$MINOXIDIL LONITEN 10 MG Generic TABLET 0.2025$MINOXIDIL LONITEN 2.5 MG Generic TABLET 0.1160$MIRABEGRON MYRBETRIQ 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.4285$MIRABEGRON MYRBETRIQ 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.4655$MIRTAZAPINE MIRTAZAPINE 15 MG Generic TABLET,DISINTEGRATING 0.8975$MIRTAZAPINE MIRTAZAPINE 30 MG Generic TABLET,DISINTEGRATING 0.9800$MIRTAZAPINE MIRTAZAPINE 45 MG Generic TABLET,DISINTEGRATING 1.1100$MIRTAZAPINE REMERON 15 MG Generic TABLET 0.1056$MIRTAZAPINE REMERON 30 MG Generic TABLET 0.1600$MIRTAZAPINE REMERON 45 MG Generic TABLET 0.3700$MIRTAZAPINE MIRTAZAPINE 7.5 MG Generic TABLET 2.0520$MISOPROSTOL CYTOTEC 200 MCG Generic TABLET 0.8064$MODAFINIL MODAFINIL 100 MG Generic TABLET 11.7283$MODAFINIL MODAFINIL 200 MG Brand TABLET 40.5620$MODAFINIL MODAFINIL 200 MG Generic TABLET 9.8470$MOEXIPRIL HCL MOEXIPRIL HCL 7.5 MG Generic TABLET 0.6475$MOEXIPRIL HCL MOEXIPRIL HCL 15 MG Generic TABLET 0.8650$MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG Generic TABLET 0.6000$MOMETASONE FUROATE ELOCON 0.1% Generic SOLUTION, NON-ORAL 0.2850$MOMETASONE FUROATE ASMANEX 220MCG 120 Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 269.8575$MOMETASONE FUROATE ASMANEX 220MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 160.0816$MOMETASONE FUROATE ASMANEX 220MCG(60) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 188.2640$MOMETASONE FUROATE ELOCON 0.1% Generic CREAM (GRAM) 0.2500$MOMETASONE FUROATE ELOCON 0.1% Generic OINTMENT (GRAM) 0.1900$MOMETASONE FUROATE NASONEX 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 13.0210$MOMETASONE FUROATE ASMANEX 110MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 148.8879$MOMETASONE FUROATE/FORMOTEROL FUMARATE DULERA 100-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 19.7753$MOMETASONE FUROATE/FORMOTEROL FUMARATE DULERA 200-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 19.7337$MONTELUKAST SODIUM SINGULAIR 4 MG Brand GRANULES IN PACKET (EA) 5.5491$MONTELUKAST SODIUM SINGULAIR 4 MG Generic GRANULES IN PACKET (EA) 4.3050$MONTELUKAST SODIUM SINGULAIR 4 MG Generic TABLET, CHEWABLE 0.3568$MONTELUKAST SODIUM SINGULAIR 5 MG Brand TABLET, CHEWABLE 6.2202$MONTELUKAST SODIUM SINGULAIR 5 MG Generic TABLET, CHEWABLE 0.3172$

31 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

MONTELUKAST SODIUM SINGULAIR 10 MG Brand TABLET 6.4923$MONTELUKAST SODIUM SINGULAIR 10 MG Generic TABLET 0.1830$MORPHINE SULFATE MORPHINE SULFATE 10 MG/5 ML Generic SOLUTION, ORAL 0.0500$MORPHINE SULFATE MORPHINE SULFATE 100 MG/5ML Generic SOLUTION, ORAL 0.4706$MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET 0.2171$MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET 0.3080$MORPHINE SULFATE MORPHINE SULFATE ER 200 MG Generic TABLET, EXTENDED RELEASE 4.2900$MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET, EXTENDED RELEASE 0.7800$MORPHINE SULFATE MORPHINE SULFATE 60 MG Generic TABLET, EXTENDED RELEASE 1.5900$MORPHINE SULFATE MORPHINE SULFATE 100 MG Generic TABLET, EXTENDED RELEASE 2.6271$MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET, EXTENDED RELEASE 0.3641$MORPHINE SULFATE AVINZA 120 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 18.0206$MORPHINE SULFATE AVINZA 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.2277$MORPHINE SULFATE MORPHINE SULFATE ER 20 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 3.9000$MORPHINE SULFATE MORPHINE SULFATE ER 80 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 11.2140$MORPHINE SULFATE MORPHINE SULFATE ER 30 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 4.3250$MORPHINE SULFATE MORPHINE SULFATE ER 60 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 8.6827$MOXIFLOXACIN HCL VIGAMOX 0.5% Brand DROPS 47.4064$MOXIFLOXACIN HCL MOXEZA 0.5% Brand DROPS, VISCOUS (ML) 43.6444$MOXIFLOXACIN HCL AVELOX 400 MG Brand TABLET 24.5820$MOXIFLOXACIN HCL AVELOX 400 MG Generic TABLET 9.8375$MULTIVITAMINS WITH FLUORIDE MULTIVITAMINS WITH FLUORIDE 0.25 MG/ML Generic DROPS 0.1866$MUPIROCIN BACTROBAN 2.0% Generic OINTMENT (GRAM) 0.3100$MUPIROCIN CALCIUM BACTROBAN 2.0% Brand CREAM (GRAM) 4.7447$MUPIROCIN CALCIUM BACTROBAN 2 % Generic CREAM (GRAM) 5.1703$MUPIROCIN CALCIUM BACTROBAN NASAL 2.0% Brand OINTMENT (GRAM) 15.2584$MYCOPHENOLATE MOFETIL CELLCEPT 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2095$MYCOPHENOLATE MOFETIL CELLCEPT 500 MG Generic TABLET 0.4085$MYCOPHENOLATE SODIUM MYFORTIC 360 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 8.8691$MYCOPHENOLATE SODIUM MYCOPHENOLIC ACID 360 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 5.7400$NABUMETONE RELAFEN 500 MG Generic TABLET 0.2133$NABUMETONE RELAFEN 750 MG Generic TABLET 0.2600$NADOLOL CORGARD 40 MG Generic TABLET 2.0119$NADOLOL NADOLOL 80 MG Generic TABLET 3.7425$NADOLOL CORGARD 20 MG Generic TABLET 2.3116$NAFTIFINE HCL NAFTIN 1.0% Brand CREAM (GRAM) 2.8269$NALOXEGOL OXALATE MOVANTIK 25 MG Brand TABLET 8.7901$NALTREXONE HCL REVIA 50 MG Generic TABLET 1.0400$NAPROXEN NAPROSYN 250 MG Generic TABLET 0.0350$NAPROXEN NAPROSYN 375 MG Generic TABLET 0.0400$NAPROXEN NAPROSYN 500 MG Generic TABLET 0.0722$NAPROXEN NAPROSYN 125 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0745$NAPROXEN EC-NAPROSYN 375 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.3967$NAPROXEN EC-NAPROSYN 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2200$NAPROXEN SODIUM ANAPROX 275 MG Generic TABLET 0.5364$NAPROXEN SODIUM ANAPROX DS 550 MG Generic TABLET 2.0750$NAPROXEN SODIUM ALEVE 220 MG Generic TABLET 0.0575$NAPROXEN/ESOMEPRAZOLE MAGNESIUM VIMOVO 500MG-20MG Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 26.0568$NARATRIPTAN HCL NARATRIPTAN HCL 2.5 MG Generic TABLET 5.1200$NATEGLINIDE STARLIX 120 MG Generic TABLET 0.9083$NEBIVOLOL HCL BYSTOLIC 5 MG Brand TABLET 3.2023$NEBIVOLOL HCL BYSTOLIC 20 MG Brand TABLET 3.2811$NEBIVOLOL HCL BYSTOLIC 2.5 MG Brand TABLET 3.1940$NEBIVOLOL HCL BYSTOLIC 10 MG Brand TABLET 3.1963$

32 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

NEFAZODONE HCL SERZONE 100 MG Generic TABLET 0.8733$NEFAZODONE HCL SERZONE 200 MG Generic TABLET 1.0900$NEFAZODONE HCL SERZONE 250 MG Generic TABLET 1.0029$NEOMYCIN SULFATE MYCIFRADIN 500 MG Generic TABLET 0.7547$NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B/HYDROCORTISONE NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 Generic OINTMENT (GRAM) 13.6825$NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 Generic OINTMENT (GRAM) 8.5050$NEOMYCIN SULFATE/COLISTIN SULFATE/HYDROCORTISONE/THONZONIUM COLY-MYCIN S 3.3-3-10/1 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 15.9192$NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D NEOCIDIN 1.75MG-10K Generic DROPS 4.9475$NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-1 Generic SOLUTION, NON-ORAL 8.6800$NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-1 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 8.6700$NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-10 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 14.8500$NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE MAXITROL 3.5-10K-.1 Generic OINTMENT (GRAM) 3.7600$NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE AK-TROL 0.1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 2.7200$NEPAFENAC NEVANAC 0.1% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 71.8100$NEPAFENAC ILEVRO 0.3% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 98.7325$NIACIN NIASPAN 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.9500$NIACIN NIACIN ER 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7667$NIACIN NIASPAN 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.6850$NIACIN NIACIN ER 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.4600$NIACIN NIASPAN 1000 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.5550$NIACIN NIACIN ER 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.8700$NIACIN NIACIN 500 MG Generic TABLET 0.0237$NIACIN SLO-NIACIN 250 MG Generic TABLET, EXTENDED RELEASE 0.0697$NIACIN NIACIN 500 MG Generic TABLET, EXTENDED RELEASE 0.0589$NICOTINE NICODERM CQ 7MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 1.7646$NICOTINE NICODERM CQ 14MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 3.0260$NICOTINE NICOTINE PATCH 14MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 1.9771$NICOTINE HABITROL 21 MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 3.1708$NICOTINE HABITROL Generic PATCH, TRANSDERMAL 24 HOURS 1.8463$NICOTINE NICOTROL NS 10 MG/ML Brand SPRAY, NON-AEROSOL (ML) 7.3085$NICOTINE NICOTROL 10 MG Brand CARTRIDGE (EA) 1.6619$NICOTINE POLACRILEX NICORELIEF 2 MG Brand GUM 0.4000$NICOTINE POLACRILEX NICORELIEF 2 MG Generic GUM 0.2827$NICOTINE POLACRILEX NICORETTE 4 MG Brand GUM 0.3996$NICOTINE POLACRILEX NICORETTE 4 MG Generic GUM 0.2720$NIFEDIPINE NIFEDIPINE ER 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2589$NIFEDIPINE NIFEDIPINE ER 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3225$NIFEDIPINE NIFEDIPINE ER 90 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6400$NIFEDIPINE ADALAT CC 30 MG Generic TABLET, EXTENDED RELEASE 0.4199$NIFEDIPINE ADALAT CC 60 MG Generic TABLET, EXTENDED RELEASE 0.5844$NIFEDIPINE ADALAT CC 90 MG Generic TABLET, EXTENDED RELEASE 0.8824$NIFEDIPINE ADALAT 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6800$NITAZOXANIDE ALINIA 500 MG Brand TABLET 40.9814$NITAZOXANIDE ALINIA 100 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 3.5979$NITROFURANTOIN FURADANTIN 25 MG/5 ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 1.7775$NITROFURANTOIN MACROCRYSTAL MACRODANTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.0718$NITROFURANTOIN MACROCRYSTAL MACRODANTIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8275$NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS MACROBID 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2000$NITROGLYCERIN NITRO-BID 2.0% Brand OINTMENT (GRAM) 0.9900$NITROGLYCERIN NITRO-DUR 0.4MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.6374$NITROGLYCERIN NITRO-DUR 0.2MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.6400$NITROGLYCERIN NITROGLYCERIN 0.4 MG Brand TABLET, SUBLINGUAL 0.9060$NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Brand SPRAY, NON-AEROSOL (GRAM) 31.1988$NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Generic SPRAY, NON-AEROSOL (GRAM) 25.7775$

33 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

NIZATIDINE AXID Generic SOLUTION, ORAL 0.4750$NIZATIDINE AXID 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2100$NORELGESTROMIN/ETHINYL ESTRADIOL ORTHO EVRA 150-20/24H Brand PATCH, TRANSDERMAL WEEKLY 39.5400$NORETHINDRONE JOLIVETTE 0.35 MG Brand TABLET 0.4412$NORETHINDRONE JOLIVETTE 0.35 MG Generic TABLET 0.5950$NORETHINDRONE ACETATE AYGESTIN 5 MG Generic TABLET 1.6943$NORETHINDRONE ACETATE-ETHINYL ESTRADIOL GILDESS 1.5-0.03MG Brand TABLET 0.4300$NORETHINDRONE ACETATE-ETHINYL ESTRADIOL JINTELI 1MG-5MCG Generic TABLET 2.1000$NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE LOMEDIA 24 FE 1MG-20(24) Generic TABLET 2.0260$NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE GILDESS FE 1.5-30(21) Brand TABLET 0.3000$NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE GILDESS FE 1MG-20(21) Brand TABLET 0.3000$NORETHINDRONE A-E ESTRADIOL LOESTRIN 1.5-0.03MG Generic TABLET 0.8133$NORETHINDRONE A-E ESTRADIOL LOESTRIN 1MG-20MCG Generic TABLET 0.7525$NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LO LOESTRIN FE 1MG-10(24) Brand TABLET 3.6927$NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE MINASTRIN 24 FE 1MG-20(24) Brand TABLET, CHEWABLE 4.1900$NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LOESTRIN FE 1.5-0.03MG Generic TABLET 0.5387$NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LOESTRIN FE 1MG-20MCG Generic TABLET 0.4708$NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE ESTROSTEP FE 5-7-9-7 Generic TABLET 1.0060$NORETHINDRONE-ETHINYL ESTRADIOL OVCON-35 0.4-0.035 Generic TABLET 0.7125$NORETHINDRONE-ETHINYL ESTRADIOL BREVICON 0.5-0.035 Generic TABLET 0.6925$NORETHINDRONE-ETHINYL ESTRADIOL NORINYL 1+35 1 MG-35MCG Generic TABLET 0.3800$NORETHINDRONE-ETHINYL ESTRADIOL NECON 7 DAYS X 3 Brand TABLET 0.3109$NORETHINDRONE-ETHINYL ESTRADIOL NECON 7 DAYS X 3 Generic TABLET 0.6752$NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE GENERESS FE 0.8-25(24) Brand TABLET, CHEWABLE 3.8902$NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE GENERESS FE 0.8-25(24) Generic TABLET, CHEWABLE 3.5300$NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE FEMCON FE 0.4-35(21) Brand TABLET, CHEWABLE 2.7252$NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE FEMCON FE 0.4-35(21) Generic TABLET, CHEWABLE 2.4100$NORETHINDRONE-MESTRANOL NECON 1 MG-50MCG Generic TABLET 0.5600$NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 0.25-0.035 Brand TABLET 0.9397$NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 0.25-0.035 Generic TABLET 0.3391$NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 7DAYSX3 28 Brand TABLET 0.6516$NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 7DAYSX3 28 Generic TABLET 0.3701$NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO 7DAYSX3 LO Brand TABLET 4.9625$NORGESTREL-ETHINYL ESTRADIOL LO/OVRAL-21 0.3-0.03MG Generic TABLET 0.5800$NORGESTREL-ETHINYL ESTRADIOL OGESTREL 0.5 MG-50 Brand TABLET 0.9200$NORTRIPTYLINE HCL AVENTYL HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1071$NORTRIPTYLINE HCL AVENTYL HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1829$NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2350$NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2200$NPH, HUMAN INSULIN ISOPHANE HUMULIN N 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 12.8304$NPH, HUMAN INSULIN ISOPHANE HUMULIN N 100/ML (3) Brand INSULIN PEN (ML) 27.5391$NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN HUMULIN 70-30 70-30/ML Brand INSULIN PEN (ML) 26.8884$NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN HUMULIN 70-30 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 12.6837$NYSTATIN MYCOSTATIN 100000/G Generic CREAM (GRAM) 0.7463$NYSTATIN MYCOSTATIN 100000/G Generic OINTMENT (GRAM) 0.6200$NYSTATIN MYCOSTATIN 100000/G Generic POWDER (GRAM) 0.6771$NYSTATIN MYCOSTATIN 100000/ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1034$NYSTATIN MYCOSTATIN 500K UNIT Generic TABLET 0.4975$NYSTATIN/TRIAMCINOLONE ACETONIDE MYCOLOG II 100000-0.1 Generic CREAM (GRAM) 3.0625$NYSTATIN/TRIAMCINOLONE ACETONIDE MYCOLOG II 100000-0.1 Generic OINTMENT (GRAM) 4.3175$OFLOXACIN FLOXIN 0.3% Generic DROPS 22.5757$OFLOXACIN OCUFLOX 0.3% Generic DROPS 3.2900$OLANZAPINE OLANZAPINE 7.5 MG Generic TABLET 0.2200$OLANZAPINE OLANZAPINE 10 MG Brand TABLET 18.3557$

34 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

OLANZAPINE OLANZAPINE 10 MG Generic TABLET 0.2650$OLANZAPINE OLANZAPINE 5 MG Brand TABLET 11.7200$OLANZAPINE OLANZAPINE 5 MG Generic TABLET 0.1800$OLANZAPINE OLANZAPINE 2.5 MG Generic TABLET 0.1650$OLANZAPINE OLANZAPINE 15 MG Generic TABLET 0.4014$OLANZAPINE OLANZAPINE 20 MG Generic TABLET 0.5300$OLANZAPINE OLANZAPINE ODT 15 MG Generic TABLET,DISINTEGRATING 2.9407$OLANZAPINE OLANZAPINE ODT 20 MG Generic TABLET,DISINTEGRATING 5.1856$OLANZAPINE OLANZAPINE ODT 5 MG Generic TABLET,DISINTEGRATING 1.8131$OLANZAPINE OLANZAPINE ODT 10 MG Generic TABLET,DISINTEGRATING 4.4308$OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 6MG-50MG Generic CAPSULE 10.5275$OLANZAPINE/FLUOXETINE HCL SYMBYAX 12MG-25MG Generic CAPSULE (HARD, SOFT, ETC.) 16.6740$OLMESARTAN MEDOXOMIL BENICAR 5 MG Brand TABLET 4.1500$OLMESARTAN MEDOXOMIL BENICAR 20 MG Brand TABLET 4.7628$OLMESARTAN MEDOXOMIL BENICAR 40 MG Brand TABLET 7.0425$OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE TRIBENZOR 20-5-12.5 Brand TABLET 5.7970$OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 20-12.5 MG Brand TABLET 4.9546$OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 40-12.5 MG Brand TABLET 6.8600$OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 40 MG-25MG Brand TABLET 7.0390$OLOPATADINE HCL PATANOL 0.1% Brand DROPS 45.3675$OLOPATADINE HCL OLOPATADINE HCL 0.1 % Generic DROPS 8.2100$OLOPATADINE HCL PATADAY 0.2% Brand DROPS 60.3467$OLOPATADINE HCL PATANASE 0.6% Brand AEROSOL, SPRAY WITH PUMP (GRAM) 7.9989$OLOPATADINE HCL OLOPATADINE HCL 0.6 % Generic AEROSOL, SPRAY WITH PUMP (GRAM) 5.9600$OMEGA-3 ACID ETHYL ESTERS LOVAZA 1 G Brand CAPSULE (HARD, SOFT, ETC.) 2.3237$OMEGA-3 ACID ETHYL ESTERS LOVAZA 1 G Generic CAPSULE 1.0600$OMEPRAZOLE LOSEC 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.0613$OMEPRAZOLE OMEPRAZOLE 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.4846$OMEPRAZOLE PRILOSEC 10 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.2932$OMEPRAZOLE OMEPRAZOLE 40 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.2726$OMEPRAZOLE MAGNESIUM PRILOSEC OTC 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 0.6476$OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE 40MG-1.1G Generic CAPSULE (HARD, SOFT, ETC.) 13.1131$ONDANSETRON ONDANSETRON ODT 4 MG Generic TABLET,DISINTEGRATING 0.5206$ONDANSETRON ONDANSETRON ODT 8 MG Generic TABLET,DISINTEGRATING 0.5591$ONDANSETRON HCL ONDANSETRON HCL 4 MG/5 ML Generic SOLUTION, ORAL 0.7300$ONDANSETRON HCL ONDANSETRON HCL 4 MG Generic TABLET 0.1570$ONDANSETRON HCL ONDANSETRON HCL 8 MG Generic TABLET 0.1877$ORPHENADRINE CITRATE NORFLEX 100 MG Generic TABLET, EXTENDED RELEASE 0.5000$OSELTAMIVIR PHOSPHATE TAMIFLU 6 MG/ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 2.0950$OSELTAMIVIR PHOSPHATE TAMIFLU 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 12.5500$OSELTAMIVIR PHOSPHATE TAMIFLU 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.6975$OSELTAMIVIR PHOSPHATE TAMIFLU 45 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.7096$OSPEMIFENE OSPHENA 60 MG Brand TABLET 5.0750$OXAPROZIN DAYPRO 600 MG Generic TABLET 2.3858$OXAZEPAM SERAX 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6525$OXCARBAZEPINE OXCARBAZEPINE 300 MG Generic TABLET 0.4017$OXCARBAZEPINE OXCARBAZEPINE 600 MG Generic TABLET 0.5714$OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 1.2683$OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5900$OXCARBAZEPINE OXCARBAZEPINE 150 MG Generic TABLET 0.1700$OXICONAZOLE NITRATE OXISTAT 1.0% Brand LOTION (ML) 11.2658$OXICONAZOLE NITRATE OXISTAT 1.0% Brand CREAM (GRAM) 10.1975$OXYBUTYNIN OXYTROL 3.9MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 60.0101$OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG/5 ML Generic SYRUP 0.0356$

35 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

OXYBUTYNIN CHLORIDE DITROPAN 5 MG Generic TABLET 0.4014$OXYBUTYNIN CHLORIDE DITROPAN XL 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8300$OXYBUTYNIN CHLORIDE DITROPAN XL 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8100$OXYBUTYNIN CHLORIDE GELNIQUE 10.0% Brand GEL IN PACKET (GRAM) 8.5801$OXYBUTYNIN CHLORIDE DITROPAN XL 15 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9800$OXYCODONE HCL OXYCODONE HCL 5 MG/5 ML Generic SOLUTION, ORAL 0.2175$OXYCODONE HCL OXYCODONE CONCENTRATE 20 MG/ML Generic CONCENTRATE, ORAL 7.7467$OXYCODONE HCL OXYCODONE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5057$OXYCODONE HCL ROXICODONE 5 MG Generic TABLET 0.0824$OXYCODONE HCL DAZIDOX 10 MG Generic TABLET 0.1777$OXYCODONE HCL ROXICODONE 15 MG Generic TABLET 0.1877$OXYCODONE HCL ROXICODONE 30 MG Generic TABLET 0.3265$OXYCODONE HCL DAZIDOX 20 MG Generic TABLET 0.2548$OXYCODONE HCL OXYCODONE HCL ER 10 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 2.9200$OXYCODONE HCL OXYCODONE HCL ER 10 MG Generic TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 2.5100$OXYCODONE HCL OXYCONTIN 15 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 4.2956$OXYCODONE HCL OXYCODONE HCL ER 20 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 5.2486$OXYCODONE HCL OXYCODONE HCL ER 20 MG Generic TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 4.7500$OXYCODONE HCL OXYCONTIN 30 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 7.4389$OXYCODONE HCL OXYCODONE HCL ER 40 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 8.9722$OXYCODONE HCL OXYCODONE HCL ER 40 MG Generic TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 6.8200$OXYCODONE HCL OXYCONTIN 60 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 12.8217$OXYCODONE HCL OXYCODONE HCL ER 80 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 16.4375$OXYCODONE HCL OXYCODONE HCL ER 80 MG Generic TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 14.1100$OXYCODONE HCL OXYCONTIN 60 MG Brand TABLET, EXTENDED RELEASE 12 HR 11.7546$OXYCODONE HCL/ACETAMINOPHEN PERCOCET 7.5-325MG Generic TABLET 0.3182$OXYCODONE HCL/ACETAMINOPHEN ENDOCET 10MG-325MG Brand TABLET 14.6250$OXYCODONE HCL/ACETAMINOPHEN PERCOCET 10MG-325MG Generic TABLET 0.3375$OXYCODONE HCL/ACETAMINOPHEN XARTEMIS XR 7.5-325MG Brand TABLET, ORAL ONLY, IR AND ER, BIPHASIC 2.1850$OXYCODONE HCL/ACETAMINOPHEN PERCOCET 7.5-500MG Generic TABLET 0.4036$OXYCODONE HCL/ACETAMINOPHEN PERCOCET 10MG-650MG Generic TABLET 0.3510$OXYCODONE HCL/ACETAMINOPHEN ROXICET 5-325/5ML Brand SOLUTION, ORAL 0.0922$OXYCODONE HCL/ACETAMINOPHEN OXYCODONE W/ACETAMINOPHEN 5MG-325MG Generic TABLET 0.0767$OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 2.5-325MG Generic TABLET 1.8080$OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 5 MG-500MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0902$OXYMORPHONE HCL OPANA 5 MG Generic TABLET 2.3681$OXYMORPHONE HCL OPANA 10 MG Generic TABLET 3.0857$OXYMORPHONE HCL OPANA ER 5 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.4906$OXYMORPHONE HCL OXYMORPHONE HCL ER 10 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.7631$OXYMORPHONE HCL OXYMORPHONE HCL 40 MG Generic TABLET, EXTENDED RELEASE 12 HR 11.1806$OXYMORPHONE HCL OPANA ER 15 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 6.3693$OXYMORPHONE HCL OPANA ER 5 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 2.3567$OXYMORPHONE HCL OPANA ER 10 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 4.5814$OXYMORPHONE HCL OPANA ER 20 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 8.0729$OXYMORPHONE HCL OPANA ER 30 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 11.6337$OXYMORPHONE HCL OPANA ER 40 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 15.2640$OXYMORPHONE HCL OPANA ER 7.5 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.9500$OXYMORPHONE HCL OPANA ER 15 MG Generic TABLET, EXTENDED RELEASE 12 HR 4.9134$OXYMORPHONE HCL OPANA ER 30 MG Generic TABLET, EXTENDED RELEASE 12 HR 7.8250$PALIPERIDONE INVEGA 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 29.6840$PALIPERIDONE INVEGA 6 MG Brand TABLET, EXTENDED RELEASE 24 HR 29.6840$PALIPERIDONE INVEGA 9 MG Brand TABLET, EXTENDED RELEASE 24 HR 44.9382$PALIPERIDONE PALMITATE INVEGA SUSTENNA 117MG/0.75 Brand SYRINGE (ML) 1,339.6645$PALIPERIDONE PALMITATE INVEGA SUSTENNA 156 MG/ML Brand SYRINGE (ML) 1,339.5574$

36 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

PALIPERIDONE PALMITATE INVEGA SUSTENNA 234MG/1.5 Brand SYRINGE (ML) 1,339.7011$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 8.7706$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0800$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0988$PANTOPRAZOLE SODIUM PROTONIX 40 MG Brand GRANULES DELAYED RELEASE FOR SUSP PACKET 9.5214$PARICALCITOL ZEMPLAR 1 MCG Brand CAPSULE (HARD, SOFT, ETC.) 10.8093$PARICALCITOL PARICALCITOL 1 MCG Generic CAPSULE 6.5750$PAROXETINE HCL PAXIL 10 MG Generic TABLET 0.1135$PAROXETINE HCL PAXIL 20 MG Brand TABLET 5.0285$PAROXETINE HCL PAXIL 20 MG Generic TABLET 0.1049$PAROXETINE HCL PAXIL 30 MG Generic TABLET 0.1329$PAROXETINE HCL PAXIL 40 MG Generic TABLET 0.1547$PAROXETINE HCL PAROXETINE HCL 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.3300$PAROXETINE HCL PAROXETINE HCL 12.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.9700$PAROXETINE HCL PAROXETINE HCL 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.3240$PAROXETINE MESYLATE BRISDELLE 7.5 MG Brand CAPSULE 5.6847$PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL GAVILYTE-G 236-22.74G Brand SOLUTION, RECONSTITUTED, ORAL 0.0033$PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL GOLYTELY 236-22.74G Generic SOLUTION, RECONSTITUTED, ORAL 0.0034$PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL COLYTE 240-22.72G Generic SOLUTION, RECONSTITUTED, ORAL 0.0027$PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL GOLYTELY 227.1-21.5 Brand POWDER IN PACKET (EA) 12.1756$PEG 3350/SODIUM SULFATE/SOD CHLORIDE/KCL/ASCORBATE SOD/VIT C MOVIPREP 7.5-2.691G Brand POWDER IN PACKET (EA) 83.0965$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG/5ML Generic SOLUTION, RECONSTITUTED, ORAL 0.0500$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG Generic TABLET 0.2300$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 500 MG Generic TABLET 0.4200$PENTOSAN POLYSULFATE SODIUM ELMIRON 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.7871$PENTOXIFYLLINE TRENTAL 400 MG Generic TABLET, EXTENDED RELEASE 0.1817$PERAMPANEL FYCOMPA 4 MG Brand TABLET 21.7866$PERMETHRIN ELIMITE 5.0% Generic CREAM (GRAM) 0.8700$PERPHENAZINE PERPHENAZINE 4 MG Generic TABLET 1.2280$PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 100 MG Generic TABLET 0.4566$PHENELZINE SULFATE PHENELZINE SULFATE 15 MG Generic TABLET 0.5820$PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML Generic ELIXIR 0.1400$PHENOBARBITAL PHENOBARBITAL 16.2 MG Generic TABLET 0.4460$PHENOBARBITAL PHENOBARBITAL 32.4MG Generic TABLET 0.5600$PHENOBARBITAL PHENOBARBITAL 64.8MG Generic TABLET 0.7000$PHENOBARBITAL PHENOBARBITAL 97.2MG Generic TABLET 1.0036$PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE HB DONNATAL 16.2MG/5ML Generic ELIXIR 0.7448$PHENYLEPHRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN DONATUSSIN 5-12.5-120 Brand LIQUID (ML) 0.1200$PHENYLEPHRINE HCL/MINERAL OIL/PETROLATUM,WHITE PREPARATION H 0.25 %-14% Brand OINTMENT WITH APPLICATOR 0.1550$PHENYLEPHRINE HCL/SHARK LIVER OIL/MINERAL OIL/PETROLAT,WHT HEMORRHOIDAL OINTMENT 0.0% Generic OINTMENT (GRAM) 0.1673$PHENYLEPHRINE/PRAMOXINE/GLYCERIN/WHITE PETROLATUM PREPARATION H 0.25%-1% Brand CREAM (GRAM) 0.1950$PHENYTOIN PHENYTOIN 125 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1000$PHENYTOIN DILANTIN 50 MG Brand TABLET, CHEWABLE 0.7566$PHENYTOIN DILANTIN 50 MG Generic TABLET, CHEWABLE 0.4140$PHENYTOIN SODIUM EXTENDED DILANTIN 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.8200$PHENYTOIN SODIUM EXTENDED DILANTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3371$PHENYTOIN SODIUM EXTENDED DILANTIN 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.7146$PHOSPHORUS #1 K-PHOS NEUTRAL 250 MG Generic TABLET 0.3300$PILOCARPINE HCL SALAGEN 5 MG Generic TABLET 1.1220$PILOCARPINE HCL ADSORBOCARPINE 1.0% Generic DROPS 4.2233$PILOCARPINE HCL ADSORBOCARPINE 2.0% Generic DROPS 2.6600$PIMECROLIMUS ELIDEL 1.0% Brand CREAM (GRAM) 7.7677$PINDOLOL PINDOLOL 10 MG Generic TABLET 1.1725$PIOGLITAZONE HCL ACTOS 15 MG Brand TABLET 8.1126$

37 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

PIOGLITAZONE HCL ACTOS 15 MG Generic TABLET 0.1580$PIOGLITAZONE HCL ACTOS 30 MG Brand TABLET 17.2669$PIOGLITAZONE HCL ACTOS 30 MG Generic TABLET 0.2627$PIOGLITAZONE HCL ACTOS 45 MG Generic TABLET 0.2514$PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE-METFORMIN 15MG-500MG Generic TABLET 1.6250$PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET 15MG-850MG Generic TABLET 1.8180$PIPERACILLIN SODIUM/TAZOBACTAM SODIUM PIPERACILLIN-TAZOBACTAM 3.375 G Generic VIAL (EA) 3.7500$PIROXICAM FELDENE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8960$PIROXICAM FELDENE 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.6457$PITAVASTATIN CALCIUM LIVALO 2 MG Brand TABLET 6.7011$PNV WITH CA NO.37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS PRIMACARE ONE 27-1-330MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8900$POLYETHYLENE GLYCOL 3350 HEALTHYLAX 17G Generic POWDER IN PACKET (EA) 1.6840$POLYETHYLENE GLYCOL 3350 MIRALAX 17G/DOSE Brand POWDER (GRAM) 0.0322$POLYETHYLENE GLYCOL 3350 MIRALAX 17G/DOSE Generic POWDER (GRAM) 0.0221$POLYMYXIN B SULFATE/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM 10K/ML-0.1 Generic DROPS 0.8600$POLYVINYL ALCOHOL ARTIFICIAL TEARS 1.4% Generic DROPS 0.1300$POTASSIUM BICARBONATE/CITRIC ACID K EFFERVESCENT 25 MEQ Generic TABLET, EFFERVESCENT 0.3956$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ Generic CAPSULE, EXTENDED RELEASE 0.5700$POTASSIUM CHLORIDE MICRO-K 10 MEQ Generic CAPSULE, EXTENDED RELEASE 0.4144$POTASSIUM CHLORIDE KAY CIEL 20 MEQ Generic PACKET (EA) 1.1300$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML Generic LIQUID (ML) 0.2800$POTASSIUM CHLORIDE KAON-CL 10 10 MEQ Brand TABLET, EXTENDED RELEASE 0.3875$POTASSIUM CHLORIDE KAON-CL 10 10 MEQ Generic TABLET, EXTENDED RELEASE 0.2833$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.2650$POTASSIUM CHLORIDE K-DUR 20 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.2250$POTASSIUM CHLORIDE KLOR-CON 8 8 MEQ Generic TABLET, EXTENDED RELEASE 0.4300$POTASSIUM CITRATE POTASSIUM CITRATE 10 MEQ Generic TABLET, EXTENDED RELEASE 1.1900$POTASSIUM CITRATE POTASSIUM CITRATE ER 15 MEQ Generic TABLET, EXTENDED RELEASE 1.9850$PRAMIPEXOLE DI-HCL MIRAPEX 1 MG Generic TABLET 0.0900$PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG Generic TABLET 0.0975$PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG Generic TABLET 0.0680$PRAMIPEXOLE DI-HCL MIRAPEX 0.25 MG Generic TABLET 0.0688$PRAMIPEXOLE DI-HCL MIRAPEX 0.5 MG Generic TABLET 0.0700$PRAMIPEXOLE DI-HCL MIRAPEX ER 0.75 MG Brand TABLET, EXTENDED RELEASE 24 HR 13.4886$PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 0.75 MG Generic TABLET 0.1100$PRAMLINTIDE ACETATE SYMLINPEN 120 2700/2.7ML Brand PEN INJECTOR (ML) 151.5722$PRAMOXINE HCL SARNA SENSITIVE 1 % Brand LOTION (ML) 0.0300$PRASUGREL HCL EFFIENT 10 MG Brand TABLET 11.3180$PRAVASTATIN SODIUM PRAVACHOL 80 MG Generic TABLET 0.5300$PRAVASTATIN SODIUM PRAVACHOL 10 MG Generic TABLET 0.4700$PRAVASTATIN SODIUM PRAVACHOL 20 MG Generic TABLET 0.3300$PRAVASTATIN SODIUM PRAVACHOL 40 MG Generic TABLET 0.4744$PRAZOSIN HCL MINIPRESS 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4200$PRAZOSIN HCL MINIPRESS 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6543$PRAZOSIN HCL MINIPRESS 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8605$PREDNICARBATE PREDNICARBATE 0.1 % Generic OINTMENT (GRAM) 1.1325$PREDNISOLONE PRELONE 15 MG/5 ML Generic SOLUTION, ORAL 0.0550$PREDNISOLONE MILLIPRED DP 5 MG (48) Brand TABLET, DOSE PACK 7.1204$PREDNISOLONE ACETATE ECONOPRED PLUS 1.0% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 22.5199$PREDNISOLONE ACETATE ECONOPRED PLUS 1.0% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 7.2416$PREDNISOLONE SOD PHOSPHATE PEDIAPRED 5 MG/5 ML Generic SOLUTION, ORAL 0.6600$PREDNISOLONE SOD PHOSPHATE ORAPRED 15 MG/5 ML Generic SOLUTION, ORAL 0.0900$PREDNISONE PREDNISONE 5 MG/5 ML Generic SOLUTION, ORAL 0.2300$PREDNISONE METICORTEN 1 MG Generic TABLET 0.2743$

38 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

PREDNISONE DELTASONE 10 MG Generic TABLET 0.1369$PREDNISONE DELTASONE 2.5 MG Generic TABLET 0.1971$PREDNISONE DELTASONE 20 MG Generic TABLET 0.1982$PREDNISONE DELTASONE 5 MG Generic TABLET 0.1597$PREGABALIN LYRICA 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4953$PREGABALIN LYRICA 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4800$PREGABALIN LYRICA 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4745$PREGABALIN LYRICA 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4737$PREGABALIN LYRICA 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4800$PREGABALIN LYRICA 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4780$PREGABALIN LYRICA 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.4843$PREGABALIN LYRICA 225 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.5248$PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 CONCEPT DHA 35-1-200MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8700$PRENATAL VIT WITH CA NO.64/IRON CARB&GLUC/FOLIC ACID/DSS/DHA CITRANATAL 90 DHA 90-1-300MG Generic COMBINATION PACKAGE (EA) 0.8200$PRENATAL VIT WITH CA NO.68/IRON FUMARATE/FOLIC ACID #1/DHA PRENATE ESSENTIAL 28-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7850$PRENATAL VIT WITH CALCIUM #60/IRON/FOLIC ACID/DHA GESTICARE DHA 27-1-250MG Brand COMBINATION PACKAGE, TAB MP 24HR & CAP 1.2495$PRENATAL VIT WITH CALCIUM NO.66/IRON FUM/FOLIC ACID/DSS/DHA PRENEXA 27-1.25-55 Generic CAPSULE (HARD, SOFT, ETC.) 2.8280$PRENATAL VITAMIN COMBINATION NO.19/IRON/FOLIC ACID/DHA PREFERA-OB ONE 22-6-1-200 Brand CAPSULE (HARD, SOFT, ETC.) 3.5948$PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA PREFERA-OB PLUS DHA 28-6-1-203 Brand COMBINATION PACKAGE (EA) 1.2319$PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX & ASPGL/FA/DHA FEMECAL OB PLUS DHA 22-6-1-200 Generic COMBINATION PACKAGE (EA) 0.6250$PRENATAL VITAMIN NO.105/IRON EDTA &POLYSACCHA/FA/OM3/DHA/EPA DUET DHA BALANCED 27-1-380MG Generic COMBINATION PACKAGE, TABLET & DR CAP 1.6368$PRENATAL VITAMINS COMB NO.19/IRON BG HCL&SUC-PROT/FA/OMEGA-3 DUET DHA EC STUARTNATAL 29-1-400MG Generic COMBINATION PACKAGE, TABLET & DR CAP 0.5471$PRENATAL VITAMINS COMB NO.47/FERROUS FUMARATE/FA CMB #1/DHA PRENATE DHA 27-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1040$PRENATAL VITAMINS COMB NO.48/IRON NA FEREDETATE/FA/OMEGA-3 DUET DHA WITH FERRAZONE 30-1-440MG Generic COMBINATION PACKAGE, TABLET & DR CAP 1.7011$PRENATAL VITAMINS COMB NO.72/FERROUS FUMARATE/FOLIC ACID PRENATAL PLUS 27 MG-1 MG Generic TABLET 0.2200$PRENATAL VITAMINS COMB NO.87/IRON BISGLY/FOLIC ACID/DHA NESTABS DHA 32-1-230MG Generic COMBINATION PACKAGE (EA) 1.4951$PRENATAL VITAMINS NO.15/IRON FUMARATE & POLYSAC COMP/FA CONCEPT OB 85 MG-1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8800$PRENATAL VITAMINS NO.38/IRON CBN&GLUCON/FOLIC ACID/DSS/DHA CITRANATAL ASSURE 35-1-50MG Generic COMBINATION PACKAGE (EA) 0.5700$PRENATAL VITAMINS NO.38/IRON FUMARATE/FOLATE COMB NO.6/DHA PRENATE DHA 28-1-300MG Brand CAPSULE 3.4716$PRIMIDONE MYSOLINE 250 MG Generic TABLET 0.1787$PRIMIDONE MYSOLINE 50 MG Generic TABLET 0.1553$PROBENECID BENEMID 500 MG Generic TABLET 0.5000$PROCHLORPERAZINE MALEATE COMPAZINE 25 MG Generic SUPPOSITORY, RECTAL 7.6400$PROCHLORPERAZINE MALEATE COMPAZINE 10 MG Generic TABLET 0.1400$PROCHLORPERAZINE MALEATE COMPAZINE 5 MG Generic TABLET 0.0500$PROGESTERONE,MICRONIZED PROGESTERONE 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 2.1700$PROGESTERONE,MICRONIZED PROGESTERONE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1633$PROGESTERONE,MICRONIZED PROGESTERONE 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.1417$PROGESTERONE,MICRONIZED CRINONE 8.0% Brand GEL WITH PREFILLED APPLICATOR (GRAM) 15.2563$PROMETHAZINE HCL PROMETHAZINE HCL 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.8480$PROMETHAZINE HCL PHENERGAN 25 MG Generic SUPPOSITORY, RECTAL 8.6900$PROMETHAZINE HCL PHENERGAN 12.5 MG Generic SUPPOSITORY, RECTAL 9.8150$PROMETHAZINE HCL PROMETHAZINE HCL 6.25MG/5ML Generic SYRUP 0.0364$PROMETHAZINE HCL PHENERGAN 12.5 MG Generic TABLET 0.0916$PROMETHAZINE HCL PHENERGAN 25 MG Generic TABLET 0.0839$PROMETHAZINE HCL PROMETHAZINE HCL 50 MG Generic TABLET 0.2209$PROPAFENONE HCL RYTHMOL 150 MG Generic TABLET 0.2065$PROPAFENONE HCL PROPAFENONE HCL 225 MG Generic TABLET 0.4111$PROPAFENONE HCL PROPAFENONE HCL ER 225 MG Generic CAPSULE, EXTENDED RELEASE 12 HR 5.7660$PROPAFENONE HCL PROPAFENONE HCL ER 425 MG Generic CAPSULE, EXTENDED RELEASE 12 HR 6.7325$PROPRANOLOL HCL INDERAL LA 80 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.8827$PROPRANOLOL HCL INDERAL LA 120 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.9167$PROPRANOLOL HCL INDERAL LA 160 MG Generic CAPSULE, EXTENDED RELEASE 24HR 3.0500$PROPRANOLOL HCL INDERAL LA 60 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.7700$

39 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

PROPRANOLOL HCL INDERAL 10 MG Generic TABLET 0.1804$PROPRANOLOL HCL INDERAL 20 MG Generic TABLET 0.2217$PROPRANOLOL HCL INDERAL 40 MG Generic TABLET 0.3240$PROPRANOLOL HCL PROPRANOLOL HCL 60 MG Generic TABLET 0.8822$PROPRANOLOL HCL PROPRANOLOL HCL 80 MG Generic TABLET 0.5500$PROPYLENE GLYCOL/POLYETHYLENE GLYCOL 400 SYSTANE 0.3 %-0.4% Brand DROPS 0.6588$PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG Generic TABLET 0.7425$PSEUDOEPHEDRINE HCL GENAPHED 30 MG Generic TABLET 0.0434$PSEUDOEPHEDRINE HCL SUDAFED 12-HOUR 120 MG Generic TABLET, EXTENDED RELEASE 0.3890$PSEUDOEPHEDRINE HCL/CODEINE PHOSPHATE/GUAIFENESIN CHERATUSSIN DAC 30-10-100 Generic SYRUP 0.1950$PSYLLIUM HUSK FIBER 0.52G Generic CAPSULE 0.0420$PSYLLIUM SEED KONSYL Generic POWDER (GRAM) 0.0300$PSYLLIUM SEED (WITH DEXTROSE) NATURAL FIBER Generic POWDER (GRAM) 0.0100$PYRIDOSTIGMINE BROMIDE MESTINON 60 MG Generic TABLET 0.5900$PYRIDOXINE HCL VITAMIN B-6 50 MG Generic TABLET 0.0120$PYRIDOXINE HCL PYRIDOXINE HCL 25 MG Generic TABLET 0.0279$QUETIAPINE FUMARATE SEROQUEL XR 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 14.0909$QUETIAPINE FUMARATE SEROQUEL 50 MG Generic TABLET 0.1524$QUETIAPINE FUMARATE SEROQUEL 400 MG Generic TABLET 0.4257$QUETIAPINE FUMARATE SEROQUEL 25 MG Generic TABLET 0.0909$QUETIAPINE FUMARATE SEROQUEL 100 MG Brand TABLET 6.6150$QUETIAPINE FUMARATE SEROQUEL 100 MG Generic TABLET 0.1727$QUETIAPINE FUMARATE SEROQUEL 200 MG Generic TABLET 0.2662$QUETIAPINE FUMARATE SEROQUEL 300 MG Generic TABLET 0.3987$QUETIAPINE FUMARATE SEROQUEL XR 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 15.4778$QUETIAPINE FUMARATE SEROQUEL XR 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 20.2600$QUETIAPINE FUMARATE SEROQUEL XR 400 MG Brand TABLET, EXTENDED RELEASE 24 HR 23.8625$QUETIAPINE FUMARATE SEROQUEL XR 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.8020$QUINAPRIL HCL ACCUPRIL 10 MG Generic TABLET 0.1600$QUINAPRIL HCL ACCUPRIL 20 MG Generic TABLET 0.1580$QUINAPRIL HCL QUINAPRIL HCL 5 MG Generic TABLET 0.1425$QUINAPRIL HCL ACCUPRIL 40 MG Generic TABLET 0.1600$QUININE SULFATE QUALAQUIN 324 MG Generic CAPSULE 4.0175$RABEPRAZOLE SODIUM ACIPHEX 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 14.9476$RABEPRAZOLE SODIUM ACIPHEX 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.7100$RALOXIFENE HCL EVISTA 60 MG Brand TABLET 6.3200$RALOXIFENE HCL EVISTA 60 MG Generic TABLET 2.6800$RALTEGRAVIR POTASSIUM ISENTRESS 400 MG Brand TABLET 20.8135$RAMELTEON ROZEREM 8 MG Brand TABLET 9.6856$RAMIPRIL ALTACE 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0960$RAMIPRIL ALTACE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$RAMIPRIL ALTACE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$RANITIDINE HCL ZANTAC 150 MG Generic TABLET 0.0758$RANITIDINE HCL ZANTAC 300 MG Generic TABLET 0.1477$RANITIDINE HCL RANITIDINE HCL 15 MG/ML Generic SYRUP 0.0400$RANITIDINE HCL RANITIDINE HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7425$RANITIDINE HCL RANITIDINE HCL 300 MG Generic CAPSULE 1.1900$RANOLAZINE RANEXA 500 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.8337$RANOLAZINE RANEXA 1000 MG Brand TABLET, EXTENDED RELEASE 12 HR 7.9475$RASAGILINE MESYLATE AZILECT 1 MG Brand TABLET 18.3917$REPAGLINIDE REPAGLINIDE 2 MG Generic TABLET 0.8133$RETAPAMULIN ALTABAX 1.0% Brand OINTMENT (GRAM) 10.9212$RIFAMPIN RIFADIN 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.3880$RIFAMPIN RIFADIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8875$

40 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

RIFAXIMIN XIFAXAN 550 MG Brand TABLET 27.5775$RIFAXIMIN XIFAXAN 200 MG Brand TABLET 15.4453$RISEDRONATE SODIUM ACTONEL 35 MG Brand TABLET 59.5445$RISEDRONATE SODIUM RISEDRONATE SODIUM 35 MG Generic TABLET 39.0500$RISEDRONATE SODIUM ATELVIA 35 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 44.8883$RISEDRONATE SODIUM ACTONEL 150 MG Brand TABLET 238.7836$RISEDRONATE SODIUM RISEDRONATE SODIUM 150 MG Generic TABLET 142.5050$RISPERIDONE RISPERDAL 1 MG/ML Generic SOLUTION, ORAL 0.4400$RISPERIDONE RISPERDAL 1 MG Generic TABLET 0.1073$RISPERIDONE RISPERDAL 2 MG Generic TABLET 0.1146$RISPERIDONE RISPERDAL 3 MG Generic TABLET 0.1194$RISPERIDONE RISPERDAL 4 MG Generic TABLET 0.1506$RISPERIDONE RISPERDAL M-TAB 1 MG Generic TABLET,DISINTEGRATING 1.9740$RISPERIDONE RISPERIDONE ODT 2 MG Generic TABLET,DISINTEGRATING 2.8077$RISPERIDONE RISPERIDONE 0.5 MG Generic TABLET,DISINTEGRATING 1.1500$RISPERIDONE RISPERDAL 0.25 MG Generic TABLET 0.0733$RISPERIDONE RISPERDAL 0.5 MG Generic TABLET 0.1022$RISPERIDONE MICROSPHERES RISPERDAL CONSTA 25 MG/2 ML Brand SYRINGE (EA) 365.6561$RISPERIDONE MICROSPHERES RISPERDAL CONSTA 37.5MG/2ML Brand SYRINGE (EA) 548.0296$RISPERIDONE MICROSPHERES RISPERDAL CONSTA 50 MG/2 ML Brand SYRINGE (EA) 731.3718$RITONAVIR NORVIR 100 MG Brand TABLET 8.2229$RIVAROXABAN XARELTO 10 MG Brand TABLET 10.6050$RIVAROXABAN XARELTO 15 MG Brand TABLET 10.5692$RIVAROXABAN XARELTO 20 MG Brand TABLET 10.5889$RIVASTIGMINE EXELON 13.3MG/24H Brand PATCH, TRANSDERMAL 24 HOURS 14.4128$RIVASTIGMINE EXELON 4.6MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 15.3550$RIVASTIGMINE EXELON 4.6MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 9.6300$RIVASTIGMINE EXELON 9.5MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 14.3160$RIVASTIGMINE EXELON 9.5MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 13.5200$RIVASTIGMINE TARTRATE RIVASTIGMINE 1.5 MG Generic CAPSULE 1.8480$RIVASTIGMINE TARTRATE RIVASTIGMINE 3 MG Generic CAPSULE 1.6000$RIZATRIPTAN BENZOATE MAXALT 5 MG Brand TABLET 32.4330$RIZATRIPTAN BENZOATE MAXALT 5 MG Generic TABLET 1.2400$RIZATRIPTAN BENZOATE MAXALT 10 MG Brand TABLET 32.5879$RIZATRIPTAN BENZOATE MAXALT 10 MG Generic TABLET 1.4980$RIZATRIPTAN BENZOATE RIZATRIPTAN 5 MG Generic TABLET,DISINTEGRATING 0.5495$RIZATRIPTAN BENZOATE MAXALT MLT 10 MG Brand TABLET,DISINTEGRATING 31.3150$RIZATRIPTAN BENZOATE MAXALT MLT 10 MG Generic TABLET,DISINTEGRATING 1.1500$ROFLUMILAST DALIRESP 500 MCG Brand TABLET 8.9340$ROPINIROLE HCL REQUIP 0.25 MG Generic TABLET 0.2082$ROPINIROLE HCL REQUIP 1 MG Generic TABLET 0.1994$ROPINIROLE HCL REQUIP 2 MG Generic TABLET 0.1550$ROPINIROLE HCL REQUIP 0.5 MG Generic TABLET 0.2567$ROPINIROLE HCL ROPINIROLE HCL 4 MG Generic TABLET 0.1582$ROPINIROLE HCL ROPINIROLE HCL 3 MG Generic TABLET 0.1337$ROPINIROLE HCL ROPINIROLE HCL 2 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6733$ROSUVASTATIN CALCIUM CRESTOR 10 MG Brand TABLET 7.9015$ROSUVASTATIN CALCIUM CRESTOR 20 MG Brand TABLET 7.8894$ROSUVASTATIN CALCIUM CRESTOR 40 MG Brand TABLET 7.8981$ROSUVASTATIN CALCIUM CRESTOR 5 MG Brand TABLET 7.8964$RUFINAMIDE BANZEL 40 MG/ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 2.2973$RUFINAMIDE BANZEL 400 MG Brand TABLET 15.6168$SALICYLIC ACID SALEX 6.0% Generic SHAMPOO 0.5545$SALMETEROL XINAFOATE SEREVENT DISKUS 50 MCG Brand DISK, WITH INHALATION DEVICE 5.2700$

41 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

SALSALATE DISALCID 500 MG Generic TABLET 1.1240$SAXAGLIPTIN HCL ONGLYZA 5 MG Brand TABLET 11.6014$SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 5MG-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 11.6379$SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2.5-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 5.5420$SCOPOLAMINE TRANSDERM-SCOP 1.5MG/72HR Brand PATCH, TRANSDERMAL 72 HOURS 17.0280$SELEGILINE HCL ELDEPRYL 5 MG Generic TABLET 1.5567$SELEGILINE HCL SELEGILINE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1700$SELENIUM SULFIDE SELSEB 2.3% Generic SHAMPOO 0.6025$SELENIUM SULFIDE SELSUN RX 2.5% Generic SUSPENSION, TOPICAL (ML) 0.0700$SENNOSIDES SENNA 8.6 MG Generic TABLET 0.0264$SENNOSIDES/DOCUSATE SODIUM SENNA PLUS 8.6MG-50MG Generic TABLET 0.0289$SERTRALINE HCL SERTRALINE HCL 25 MG Generic TABLET 0.1300$SERTRALINE HCL SERTRALINE HCL 50 MG Brand TABLET 7.4072$SERTRALINE HCL SERTRALINE HCL 50 MG Generic TABLET 0.0792$SERTRALINE HCL SERTRALINE HCL 100 MG Generic TABLET 0.0675$SERTRALINE HCL SERTRALINE HCL 20 MG/ML Generic CONCENTRATE, ORAL 0.7925$SEVELAMER CARBONATE RENVELA 800 MG Brand TABLET 4.9010$SILDENAFIL CITRATE REVATIO 20 MG Brand TABLET 27.7609$SILDENAFIL CITRATE REVATIO 20 MG Generic TABLET 0.5800$SILDENAFIL CITRATE VIAGRA 50 MG Brand TABLET 32.3871$SILDENAFIL CITRATE VIAGRA 100 MG Brand TABLET 33.2163$SILODOSIN RAPAFLO 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.7324$SILODOSIN RAPAFLO 8 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.5990$SILVER SULFADIAZINE SILVADENE 1.0% Brand CREAM (GRAM) 0.2100$SILVER SULFADIAZINE SILVADENE 1.0% Generic CREAM (GRAM) 0.2183$SIMETHICONE GAS RELIEF 80 MG Generic TABLET, CHEWABLE 0.0360$SIMETHICONE SIMETHICONE 125 MG Brand TABLET, CHEWABLE 0.2040$SIMVASTATIN SIMVASTATIN 5 MG Generic TABLET 0.0433$SIMVASTATIN SIMVASTATIN 10 MG Generic TABLET 0.0300$SIMVASTATIN SIMVASTATIN 20 MG Generic TABLET 0.0300$SIMVASTATIN SIMVASTATIN 40 MG Generic TABLET 0.0400$SIMVASTATIN SIMVASTATIN 80 MG Generic TABLET 0.0871$SIROLIMUS RAPAMUNE 1 MG Brand TABLET 19.9833$SITAGLIPTIN PHOSPHATE JANUVIA 25 MG Brand TABLET 11.7622$SITAGLIPTIN PHOSPHATE JANUVIA 50 MG Brand TABLET 11.5783$SITAGLIPTIN PHOSPHATE JANUVIA 100 MG Brand TABLET 11.5780$SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET XR 50-1000 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 5.7540$SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET XR 100-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 11.5617$SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET 50MG-500MG Brand TABLET 5.8028$SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET 50-1000 MG Brand TABLET 5.7800$SODIUM BICARBONATE SODIUM BICARBONATE 1 MEQ/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0696$SODIUM BICARBONATE SODIUM BICARBONATE 650 MG Generic TABLET 0.0100$SODIUM CHLORIDE SODIUM CHLORIDE 0.9% Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0851$SODIUM CHLORIDE AYR SALINE 0.7% Brand AEROSOL, SPRAY (ML) 0.0400$SODIUM CHLORIDE AYR SALINE 0.7% Generic AEROSOL, SPRAY (ML) 0.0371$SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE 0.9% Generic VIAL, NEBULIZER (ML) 0.0325$SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE 7 % Generic VIAL, NEBULIZER (ML) 0.0600$SODIUM CHLORIDE IRRIGATING SOLUTION SODIUM CHLORIDE 0.9% Generic SOLUTION, IRRIGATION 0.0134$SODIUM CHLORIDE/ALOE VERA AYR SALINE 0.0% Brand GEL (GRAM) 0.1700$SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG NULYTELY 420G Generic SOLUTION, RECONSTITUTED, ORAL 0.0040$SODIUM FLUORIDE PREVIDENT 5000 PLUS 1.1% Brand CREAM (GRAM) 0.0563$SODIUM FLUORIDE PREVIDENT 5000 PLUS 1.1% Generic CREAM (GRAM) 0.0800$SODIUM FLUORIDE KARIGEL 1.1% Brand GEL (GRAM) 0.0768$SODIUM FLUORIDE KARIGEL 1.1% Generic GEL (GRAM) 0.0620$

42 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

SODIUM FLUORIDE PREVIDENT 5000 1.1% Brand GEL (ML) 0.0092$SODIUM FLUORIDE PEDIAFLOR 0.5 MG/ML Generic DROPS 0.1500$SODIUM FLUORIDE FLUOR-A-DAY 2.5 MG/ML Brand DROPS 3.2620$SODIUM FLUORIDE LURIDE 0.25(0.55) Generic TABLET, CHEWABLE 0.0300$SODIUM FLUORIDE FLUORIDE 1MG(2.2MG) Generic TABLET, CHEWABLE 0.0280$SODIUM FLUORIDE PREVIDENT 1.1% Brand PASTE (ML) 0.0089$SODIUM FLUORIDE/POTASSIUM NITRATE PREVIDENT 5000 ENAMEL PROTECT 1.1%-5% Brand PASTE (ML) 0.0088$SODIUM FLUORIDE/XYLITOL FLUOR-A-DAY 0.5(1.1)MG Brand TABLET, CHEWABLE 0.6943$SODIUM FLUORIDE/XYLITOL FLUOR-A-DAY 0.25(0.55) Brand TABLET, CHEWABLE 0.9447$SODIUM PICOSULFATE/MAGNESIUM OXIDE/CITRIC ACID PREPOPIK 10-12/16.1 Brand POWDER IN PACKET (EA) 53.2600$SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE 15G/60ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1310$SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE SUPREP 17.5-3.13G Brand SOLUTION, RECONSTITUTED, ORAL 0.2147$SOLIFENACIN SUCCINATE VESICARE 5 MG Brand TABLET 9.1754$SOLIFENACIN SUCCINATE VESICARE 10 MG Brand TABLET 9.1777$SOTALOL HCL BETAPACE 80 MG Generic TABLET 0.0964$SOTALOL HCL BETAPACE 120 MG Generic TABLET 0.1225$SPIRONOLACTONE SPIRONOLACTONE 100 MG Generic TABLET 0.5700$SPIRONOLACTONE ALDACTONE 25 MG Generic TABLET 0.1074$SPIRONOLACTONE ALDACTONE 50 MG Generic TABLET 0.2735$SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ALDACTAZIDE 25 MG-25MG Generic TABLET 1.1313$SUCRALFATE CARAFATE 1 G/10 ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.3300$SUCRALFATE CARAFATE 1 G Generic TABLET 0.1950$SULFACETAMIDE SODIUM BLEPH-10 10.0% Generic DROPS 2.7300$SULFACETAMIDE SODIUM KLARON 10.0% Generic SUSPENSION, TOPICAL (ML) 0.8517$SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE BLEPHAMIDE S.O.P. 10 %-0.2 % Brand OINTMENT (GRAM) 28.9015$SULFACETAMIDE SODIUM/SULFUR ZENCIA 9 %-4 % Brand CLEANSER (ML) 0.2416$SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 10-5%(W/W) Generic CLEANSER (GRAM) 0.0780$SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM 200-40MG/5 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.2800$SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM 400MG-80MG Generic TABLET 0.1125$SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM DS 800-160 MG Generic TABLET 0.0733$SULFASALAZINE AZULFIDINE 500 MG Generic TABLET 0.1880$SULFASALAZINE AZULFIDINE 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2692$SULINDAC CLINORIL 150 MG Generic TABLET 0.1680$SULINDAC CLINORIL 200 MG Generic TABLET 0.1900$SUMATRIPTAN IMITREX 5 MG Generic SPRAY, NON-AEROSOL (EA) 47.9847$SUMATRIPTAN IMITREX 20 MG Brand SPRAY, NON-AEROSOL (EA) 67.0431$SUMATRIPTAN IMITREX 20 MG Generic SPRAY, NON-AEROSOL (EA) 51.4603$SUMATRIPTAN SUCCINATE IMITREX 50 MG Generic TABLET 0.7869$SUMATRIPTAN SUCCINATE IMITREX 100 MG Generic TABLET 0.8600$SUMATRIPTAN SUCCINATE IMITREX 25 MG Generic TABLET 0.9914$SUMATRIPTAN SUCCINATE IMITREX 6 MG/0.5ML Brand CARTRIDGE (ML) 309.5982$SUMATRIPTAN SUCCINATE IMITREX 6 MG/0.5ML Generic CARTRIDGE (ML) 116.6700$SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 4 MG/0.5ML Generic PEN INJECTOR (ML) 173.6400$SUMATRIPTAN SUCCINATE SUMAVEL DOSEPRO 6 MG/0.5ML Brand NEEDLE-FREE INJECTOR (ML) 291.3988$SUMATRIPTAN SUCCINATE ALSUMA 6 MG/0.5ML Generic PEN INJECTOR (ML) 150.4980$SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 6 MG/0.5ML Generic VIAL (ML) 67.2846$SUMATRIPTAN SUCCINATE/NAPROXEN SODIUM TREXIMET 85MG-500MG Brand TABLET 74.7492$SUVOREXANT BELSOMRA 10 MG Brand TABLET 9.1585$TACROLIMUS PROTOPIC 0.0% Brand OINTMENT (GRAM) 7.1096$TACROLIMUS PROTOPIC 0.1% Brand OINTMENT (GRAM) 7.1825$TACROLIMUS PROTOPIC 0.1 % Generic OINTMENT (GRAM) 6.3089$TACROLIMUS PROGRAF 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6100$TACROLIMUS PROGRAF 0.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5100$TADALAFIL CIALIS 10 MG Brand TABLET 30.4375$

43 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

TADALAFIL CIALIS 20 MG Brand TABLET 35.8069$TADALAFIL CIALIS 5 MG Brand TABLET 7.4667$TADALAFIL ADCIRCA 20 MG Brand TABLET 44.2886$TAFLUPROST/PF ZIOPTAN 0.0% Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 5.1162$TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG Generic TABLET 0.3100$TAMOXIFEN CITRATE NOLVADEX 20 MG Generic TABLET 0.5588$TAMSULOSIN HCL FLOMAX 0.4 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1998$TAPENTADOL HCL NUCYNTA 50 MG Brand TABLET 4.1727$TAPENTADOL HCL NUCYNTA 75 MG Brand TABLET 4.9626$TAPENTADOL HCL NUCYNTA 100 MG Brand TABLET 6.5163$TAPENTADOL HCL NUCYNTA ER 50 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.5440$TAPENTADOL HCL NUCYNTA ER 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 8.4290$TAPENTADOL HCL NUCYNTA ER 200 MG Brand TABLET, EXTENDED RELEASE 12 HR 13.7585$TAPENTADOL HCL NUCYNTA ER 250 MG Brand TABLET, EXTENDED RELEASE 12 HR 17.2936$TAZAROTENE TAZORAC 0.1% Brand GEL (GRAM) 9.9460$TAZAROTENE TAZORAC 0.1% Brand GEL (GRAM) 10.8137$TAZAROTENE TAZORAC 0.1% Brand CREAM (GRAM) 10.4030$TELITHROMYCIN KETEK 400 MG Brand TABLET 16.0656$TELMISARTAN MICARDIS 40 MG Brand TABLET 4.5445$TELMISARTAN MICARDIS 40 MG Generic TABLET 0.3850$TELMISARTAN MICARDIS 80 MG Brand TABLET 4.9427$TELMISARTAN MICARDIS 80 MG Generic TABLET 0.7000$TELMISARTAN TELMISARTAN 20 MG Generic TABLET 2.1200$TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80-12.5MG Brand TABLET 4.6375$TELMISARTAN/HYDROCHLOROTHIAZIDE TELMISARTAN-HYDROCHLOROTHIAZID 80-12.5MG Generic TABLET 6.0602$TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80 MG-25MG Brand TABLET 4.4296$TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80 MG-25MG Generic TABLET 4.8910$TEMAZEPAM RESTORIL 15 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0766$TEMAZEPAM RESTORIL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0878$TEMAZEPAM TEMAZEPAM 7.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.4610$TEMAZEPAM TEMAZEPAM 22.5 MG Generic CAPSULE 6.4836$TEMOZOLOMIDE TEMOZOLOMIDE 100 MG Generic CAPSULE 165.9100$TENOFOVIR DISOPROXIL FUMARATE VIREAD 300 MG Brand TABLET 32.1365$TERAZOSIN HCL HYTRIN 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0883$TERAZOSIN HCL HYTRIN 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$TERAZOSIN HCL HYTRIN 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$TERAZOSIN HCL HYTRIN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$TERBINAFINE HCL LAMISIL 250 MG Generic TABLET 0.1780$TERBINAFINE HCL DESENEX 1.0% Brand CREAM (GRAM) 0.3550$TERBINAFINE HCL DESENEX 1.0% Generic CREAM (GRAM) 0.3520$TERCONAZOLE TERAZOL 3 80 MG Generic SUPPOSITORY, VAGINAL 25.6475$TERCONAZOLE TERAZOL 7 0.4% Generic CREAM WITH APPLICATOR 0.7457$TERCONAZOLE TERAZOL 3 0.8% Generic CREAM WITH APPLICATOR 1.5875$TERIPARATIDE FORTEO 20MCG/DOSE Brand PEN INJECTOR (ML) 929.1562$TESTOSTERONE ANDROGEL 1.25G (1%) Brand GEL IN METERED-DOSE PUMP 2.8733$TESTOSTERONE ANDRODERM 4 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 15.2200$TESTOSTERONE AXIRON 30MG/1.5ML Brand SOLUTION IN METERED-DOSE PUMP WITH APPL. 5.5483$TESTOSTERONE ANDROGEL 20.25/1.25 Brand GEL IN METERED-DOSE PUMP 6.1700$TESTOSTERONE ANDRODERM 2 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 7.4952$TESTOSTERONE ANDROGEL 2.5G-1.62% Brand GEL IN PACKET (GRAM) 6.3109$TESTOSTERONE ANDROGEL 25MG(1%) Brand GEL IN PACKET (GRAM) 5.9542$TESTOSTERONE ANDROGEL 50 MG (1%) Brand GEL IN PACKET (GRAM) 3.1600$TESTOSTERONE ANDROGEL 50 MG (1%) Generic GEL IN PACKET (GRAM) 2.1220$TESTOSTERONE TESTIM 50 MG (1%) Brand GEL (GRAM) 3.1515$

44 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

TESTOSTERONE FORTESTA 10 MG (2%) Brand GEL IN METERED-DOSE PUMP 6.1800$TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 100 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 6.3700$TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 20.0914$TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 6.3600$TESTOSTERONE ENANTHATE DELATESTRYL 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 14.1580$TETRACAINE HCL TETRACAINE HCL 0.5 % Generic DROPS 0.5750$TETRACYCLINE HCL TETRACYCLINE HCL 500 MG Generic CAPSULE 9.7625$THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.4000$THEOPHYLLINE ANHYDROUS CONSTANT-T 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.4440$THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.3850$THIORIDAZINE HCL THIORIDAZINE HCL 50 MG Generic TABLET 0.4533$THIOTHIXENE NAVANE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5327$THYROID,PORK ARMOUR THYROID 15 MG Brand TABLET 0.4457$THYROID,PORK ARMOUR THYROID 15 MG Generic TABLET 0.1950$THYROID,PORK ARMOUR THYROID 30 MG Brand TABLET 0.5200$THYROID,PORK ARMOUR THYROID 30 MG Generic TABLET 0.2600$THYROID,PORK ARMOUR THYROID 60 MG Brand TABLET 0.5800$THYROID,PORK ARMOUR THYROID 60 MG Generic TABLET 0.2175$THYROID,PORK ARMOUR THYROID 90 MG Brand TABLET 0.9080$THYROID,PORK ARMOUR THYROID 90 MG Generic TABLET 0.4075$THYROID,PORK ARMOUR THYROID 120 MG Brand TABLET 1.0638$THYROID,PORK ARMOUR THYROID 120 MG Generic TABLET 0.4725$TICAGRELOR BRILINTA 90 MG Brand TABLET 4.8946$TIMOLOL BETIMOL 0.5% Brand DROPS 12.9330$TIMOLOL MALEATE ISTALOL 0.5% Brand DROPS, ONCE DAILY 52.7704$TIMOLOL MALEATE TIMOPTIC 0.3% Generic DROPS 0.5075$TIMOLOL MALEATE TIMOPTIC 0.5% Generic DROPS 0.8585$TIMOLOL MALEATE TIMOLOL MALEATE 0.3% Generic GEL-FORMING SOLUTION 22.0801$TIMOLOL MALEATE TIMOLOL MALEATE 0.5% Generic GEL-FORMING SOLUTION 19.0700$TINIDAZOLE TINDAMAX 500 MG Brand TABLET 6.1750$TINIDAZOLE TINDAMAX 500 MG Generic TABLET 5.5100$TIOTROPIUM BROMIDE SPIRIVA 18 MCG Brand CAPSULE, WITH INHALATION DEVICE 10.0406$TIOTROPIUM BROMIDE SPIRIVA RESPIMAT 1.25 MCG Brand MIST INHALER (GRAM) 71.4300$TIOTROPIUM BROMIDE SPIRIVA RESPIMAT 2.5 MCG Brand MIST INHALER (GRAM) 75.4267$TIZANIDINE HCL ZANAFLEX 2 MG Generic TABLET 0.1700$TIZANIDINE HCL ZANAFLEX 4 MG Generic TABLET 0.2052$TIZANIDINE HCL TIZANIDINE HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7160$TIZANIDINE HCL TIZANIDINE HCL 4 MG Generic CAPSULE 2.1850$TIZANIDINE HCL TIZANIDINE HCL 6 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.4100$TOBRAMYCIN TOBREX 0.3% Brand OINTMENT (GRAM) 49.6763$TOBRAMYCIN TOBREX 0.3% Generic DROPS 1.7300$TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 0.3%-0.05% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 31.6999$TOBRAMYCIN/DEXAMETHASONE TOBRADEX 0.3 %-0.1% Brand OINTMENT (GRAM) 53.2720$TOBRAMYCIN/DEXAMETHASONE TOBRADEX 0.3 %-0.1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 14.7200$TOBRAMYCIN/LOTEPREDNOL ETABONATE ZYLET 0.3%-0.5% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 36.9520$TOFACITINIB CITRATE XELJANZ 5 MG Brand TABLET 50.7902$TOLMETIN SODIUM TOLMETIN SODIUM 400 MG Generic CAPSULE 1.6100$TOLTERODINE TARTRATE DETROL LA 4 MG Brand CAPSULE, EXT RELEASE 24 HR 7.8725$TOLTERODINE TARTRATE DETROL LA 4 MG Generic CAPSULE, EXT RELEASE 24 HR 4.7827$TOLTERODINE TARTRATE DETROL LA 2 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8055$TOLTERODINE TARTRATE DETROL LA 2 MG Generic CAPSULE, EXT RELEASE 24 HR 4.5922$TOLTERODINE TARTRATE DETROL 2 MG Generic TABLET 1.7200$TOPIRAMATE TROKENDI XR 100 MG Brand CAPSULE, EXT RELEASE 24 HR 17.6142$TOPIRAMATE TROKENDI XR 200 MG Brand CAPSULE, EXT RELEASE 24 HR 24.1032$

45 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

TOPIRAMATE TOPAMAX 50 MG Brand TABLET 9.2616$TOPIRAMATE TOPAMAX 50 MG Generic TABLET 0.0600$TOPIRAMATE TOPAMAX 100 MG Brand TABLET 12.4654$TOPIRAMATE TOPAMAX 100 MG Generic TABLET 0.0800$TOPIRAMATE TOPAMAX 200 MG Generic TABLET 0.1400$TOPIRAMATE TOPAMAX 25 MG Brand TABLET 4.6658$TOPIRAMATE TOPAMAX 25 MG Generic TABLET 0.0400$TOPIRAMATE TOPAMAX 15 MG Generic CAPSULE, SPRINKLE 0.4100$TOPIRAMATE TOPAMAX 25 MG Brand CAPSULE, SPRINKLE 4.9809$TOPIRAMATE TOPAMAX 25 MG Generic CAPSULE, SPRINKLE 0.4760$TORSEMIDE TORSEMIDE 5 MG Generic TABLET 0.1850$TORSEMIDE DEMADEX 20 MG Generic TABLET 0.1400$TRAMADOL HCL ULTRAM 50 MG Brand TABLET 2.3900$TRAMADOL HCL ULTRAM 50 MG Generic TABLET 0.0200$TRAMADOL HCL TRAMADOL HCL 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.1840$TRAMADOL HCL TRAMADOL HCL 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.6000$TRAMADOL HCL TRAMADOL HCL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.3800$TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG Generic TABLET 0.2383$TRANDOLAPRIL TRANDOLAPRIL 4 MG Generic TABLET 0.3790$TRANEXAMIC ACID LYSTEDA 650 MG Brand TABLET 4.7362$TRANEXAMIC ACID TRANEXAMIC ACID 650 MG Generic TABLET 3.6725$TRANYLCYPROMINE SULFATE PARNATE 10 MG Generic TABLET 1.6942$TRAVOPROST TRAVATAN Z 0.0% Brand DROPS 56.3400$TRAVOPROST (BENZALKONIUM) TRAVOPROST 0.004 % Generic DROPS 31.0600$TRAZODONE HCL DESYREL 50 MG Generic TABLET 0.0648$TRAZODONE HCL DESYREL 100 MG Generic TABLET 0.1197$TRAZODONE HCL DESYREL 150 MG Generic TABLET 0.2336$TRETINOIN RETIN-A 0.0% Generic GEL (GRAM) 4.4438$TRETINOIN AVITA 0.0% Generic GEL (GRAM) 3.9444$TRETINOIN ATRALIN 0.1% Brand GEL (GRAM) 11.5850$TRETINOIN RETIN-A 0.1% Generic CREAM (GRAM) 4.7683$TRETINOIN RETIN-A 0.1% Generic CREAM (GRAM) 5.0296$TRETINOIN AVITA 0.0% Brand CREAM (GRAM) 5.7879$TRETINOIN AVITA 0.0% Generic CREAM (GRAM) 4.1200$TRETINOIN MICROSPHERES RETIN-A MICRO 0.0% Brand GEL (GRAM) 15.5176$TRETINOIN MICROSPHERES RETIN-A MICRO 0.1% Brand GEL (GRAM) 13.0649$TRETINOIN MICROSPHERES TRETINOIN MICROSPHERE 0.1 % Generic GEL (GRAM) 11.9160$TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 0.0% Brand GEL WITH PUMP (GRAM) 13.9028$TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 0.1% Brand GEL WITH PUMP (GRAM) 13.9028$TRIAMCINOLONE ACETONIDE NASACORT AQ 55MCG Generic AEROSOL, SPRAY (GRAM) 3.8260$TRIAMCINOLONE ACETONIDE KENALOG-40 40 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 6.9546$TRIAMCINOLONE ACETONIDE ARISTOCORT 0.0% Generic CREAM (GRAM) 0.1380$TRIAMCINOLONE ACETONIDE ARISTOCORT 0.1% Generic CREAM (GRAM) 0.1529$TRIAMCINOLONE ACETONIDE ARISTOCORT 0.5% Generic CREAM (GRAM) 0.4700$TRIAMCINOLONE ACETONIDE KENALOG 0.0% Generic OINTMENT (GRAM) 0.2231$TRIAMCINOLONE ACETONIDE ARISTOCORT 0.1% Generic OINTMENT (GRAM) 0.1595$TRIAMCINOLONE ACETONIDE ARISTOCORT HP 0.5% Generic OINTMENT (GRAM) 0.5100$TRIAMCINOLONE ACETONIDE KENALOG 0.0% Generic LOTION (ML) 0.4763$TRIAMCINOLONE ACETONIDE KENALOG 0.1% Generic LOTION (ML) 0.5080$TRIAMCINOLONE ACETONIDE KENALOG IN ORABASE 0.1% Generic PASTE (GRAM) 8.9600$TRIAMCINOLONE ACETONIDE KENALOG 0.147MG/G Brand AEROSOL (GRAM) 6.8732$TRIAMTERENE/HYDROCHLOROTHIAZIDE DYAZIDE 37.5-25 MG Brand CAPSULE 1.3200$TRIAMTERENE/HYDROCHLOROTHIAZIDE DYAZIDE 37.5-25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2100$TRIAMTERENE/HYDROCHLOROTHIAZIDE MAXZIDE 75 MG-50MG Generic TABLET 0.1800$

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Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

TRIAMTERENE/HYDROCHLOROTHIAZIDE MAXZIDE-25 MG 37.5-25 MG Generic TABLET 0.1900$TRIAZOLAM HALCION 0.25 MG Generic TABLET 1.1423$TRIAZOLAM HALCION 0.125 MG Generic TABLET 1.0200$TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2 MG Generic TABLET 0.0600$TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 5 MG Generic TABLET 0.1200$TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL 300 MG Generic CAPSULE 1.2550$TRIMETHOPRIM PROLOPRIM 100 MG Generic TABLET 0.3000$TRIMETHOPRIM PRIMSOL 50 MG/5 ML Brand SOLUTION, ORAL 1.1005$TROLAMINE SALICYLATE MOBISYL 10.0% Brand CREAM (GRAM) 0.0500$TROPICAMIDE MYDRIACYL 1.0% Generic DROPS 3.3155$TROSPIUM CHLORIDE TROSPIUM CHLORIDE 20 MG Generic TABLET 1.1975$TROSPIUM CHLORIDE SANCTURA XR 60 MG Brand CAPSULE, EXT RELEASE 24 HR 5.9811$TROSPIUM CHLORIDE SANCTURA XR 60 MG Generic CAPSULE, EXT RELEASE 24 HR 4.4117$UMECLIDINIUM BROMIDE/VILANTEROL TRIFENATATE ANORO ELLIPTA 62.5-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.7700$UREA CARMOL 20 20.0% Generic CREAM (GRAM) 0.1060$UREA UREACIN 40 40.0% Brand CREAM (GRAM) 0.1814$UREA UREA 40 % Generic CREAM (GRAM) 0.0700$URSODIOL ACTIGALL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.4600$URSODIOL URSODIOL 500 MG Generic TABLET 2.9900$VALACYCLOVIR HCL VALTREX 500 MG Brand TABLET 8.8154$VALACYCLOVIR HCL VALTREX 500 MG Generic TABLET 0.4525$VALACYCLOVIR HCL VALTREX 1000 MG Brand TABLET 12.0757$VALACYCLOVIR HCL VALTREX 1000 MG Generic TABLET 0.7200$VALGANCICLOVIR HCL VALGANCICLOVIR HCL 450 MG Generic TABLET 48.2475$VALPROIC ACID DEPAKENE 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1700$VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) VALPROIC ACID 250 MG/5ML Generic SOLUTION, ORAL 0.1225$VALSARTAN DIOVAN 320 MG Brand TABLET 7.4291$VALSARTAN DIOVAN 320 MG Generic TABLET 0.5500$VALSARTAN DIOVAN 160 MG Brand TABLET 5.8489$VALSARTAN DIOVAN 160 MG Generic TABLET 0.3820$VALSARTAN DIOVAN 80 MG Brand TABLET 5.4279$VALSARTAN DIOVAN 80 MG Generic TABLET 0.3000$VALSARTAN DIOVAN 40 MG Brand TABLET 4.2839$VALSARTAN DIOVAN 40 MG Generic TABLET 0.3906$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 80-12.5MG Brand TABLET 6.3679$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 80-12.5MG Generic TABLET 0.2900$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-12.5MG Brand TABLET 5.9281$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-12.5MG Generic TABLET 0.3200$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-25MG Brand TABLET 6.8206$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-25MG Generic TABLET 0.2640$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320MG-25MG Brand TABLET 8.9689$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320MG-25MG Generic TABLET 0.3413$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320-12.5MG Brand TABLET 8.4444$VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320-12.5MG Generic TABLET 0.3717$VANCOMYCIN HCL VANCOCIN HCL 500 MG Generic VIAL (SDV,MDV OR ADDITIVE) (EA) 3.9635$VANCOMYCIN HCL VANCOMYCIN HCL 1 G Generic VIAL (EA) 5.5325$VANCOMYCIN HCL VANCOMYCIN HCL 10 G Generic VIAL (EA) 35.0000$VANCOMYCIN HCL VANCOCIN HCL 125 MG Generic CAPSULE (HARD, SOFT, ETC.) 10.5400$VANCOMYCIN HCL VANCOMYCIN HCL 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 17.1100$VARDENAFIL HCL LEVITRA 20 MG Brand TABLET 31.6100$VARENICLINE TARTRATE CHANTIX 0.5 MG Brand TABLET 4.8544$VARENICLINE TARTRATE CHANTIX 1 MG Brand TABLET 5.0100$VARENICLINE TARTRATE CHANTIX 0.5(11)-1 Brand TABLET, DOSE PACK 5.2960$VENLAFAXINE HCL VENLAFAXINE HCL ER 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.1712$

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Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

VENLAFAXINE HCL VENLAFAXINE HCL ER 75 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.3680$VENLAFAXINE HCL VENLAFAXINE HCL ER 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.2531$VENLAFAXINE HCL VENLAFAXINE HCL ER 225 MG Generic TABLET, EXTENDED RELEASE 24 HR 8.4700$VENLAFAXINE HCL VENLAFAXINE HCL 25 MG Generic TABLET 0.3360$VENLAFAXINE HCL EFFEXOR 37.5 MG Generic TABLET 0.2238$VENLAFAXINE HCL VENLAFAXINE HCL 50 MG Generic TABLET 0.2406$VENLAFAXINE HCL EFFEXOR 75 MG Generic TABLET 0.4453$VENLAFAXINE HCL VENLAFAXINE HCL 100 MG Generic TABLET 0.2571$VENLAFAXINE HCL EFFEXOR XR 37.5 MG Brand CAPSULE, EXT RELEASE 24 HR 8.4031$VENLAFAXINE HCL EFFEXOR XR 37.5 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1442$VENLAFAXINE HCL EFFEXOR XR 75 MG Brand CAPSULE, EXT RELEASE 24 HR 8.9312$VENLAFAXINE HCL EFFEXOR XR 75 MG Generic CAPSULE, EXT RELEASE 24 HR 0.2263$VENLAFAXINE HCL EFFEXOR XR 150 MG Brand CAPSULE, EXT RELEASE 24 HR 9.1814$VENLAFAXINE HCL EFFEXOR XR 150 MG Generic CAPSULE, EXT RELEASE 24 HR 0.2359$VERAPAMIL HCL CALAN 120 MG Generic TABLET 0.0700$VERAPAMIL HCL VERAPAMIL HCL 80 MG Generic TABLET 0.0500$VERAPAMIL HCL VERAPAMIL ER 180 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.8080$VERAPAMIL HCL VERAPAMIL ER 240 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.9930$VERAPAMIL HCL VERAPAMIL ER 120 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.9120$VERAPAMIL HCL VERAPAMIL HCL 360 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 1.5600$VERAPAMIL HCL CALAN SR 240 MG Generic TABLET, EXTENDED RELEASE 0.1800$VERAPAMIL HCL CALAN SR 180 MG Generic TABLET, EXTENDED RELEASE 0.1950$VERAPAMIL HCL CALAN SR 120 MG Generic TABLET, EXTENDED RELEASE 0.2350$VERAPAMIL HCL CALAN 40 MG Generic TABLET 0.1500$VERAPAMIL HCL VERAPAMIL ER PM 100 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.0000$VERAPAMIL HCL VERAPAMIL ER PM 300 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 2.1775$VILAZODONE HYDROCHLORIDE VIIBRYD 10 MG Brand TABLET 6.4867$VILAZODONE HYDROCHLORIDE VIIBRYD 20 MG Brand TABLET 6.6406$VILAZODONE HYDROCHLORIDE VIIBRYD 40 MG Brand TABLET 6.6070$VORICONAZOLE VFEND 200 MG Generic TABLET 16.7887$VORTIOXETINE HYDROBROMIDE BRINTELLIX 10 MG Brand TABLET 9.0283$VORTIOXETINE HYDROBROMIDE BRINTELLIX 20 MG Brand TABLET 9.1920$WARFARIN SODIUM COUMADIN 10 MG Generic TABLET 0.3000$WARFARIN SODIUM COUMADIN 2 MG Brand TABLET 1.8387$WARFARIN SODIUM COUMADIN 2 MG Generic TABLET 0.1957$WARFARIN SODIUM COUMADIN 1 MG Brand TABLET 1.7464$WARFARIN SODIUM COUMADIN 1 MG Generic TABLET 0.2700$WARFARIN SODIUM COUMADIN 5 MG Brand TABLET 2.0291$WARFARIN SODIUM COUMADIN 5 MG Generic TABLET 0.2100$WARFARIN SODIUM COUMADIN 2.5 MG Brand TABLET 1.8886$WARFARIN SODIUM COUMADIN 2.5 MG Generic TABLET 0.2500$WARFARIN SODIUM COUMADIN 7.5 MG Generic TABLET 0.2300$WARFARIN SODIUM COUMADIN 3 MG Brand TABLET 1.9253$WARFARIN SODIUM COUMADIN 3 MG Generic TABLET 0.2613$WARFARIN SODIUM COUMADIN 4 MG Generic TABLET 0.2500$WARFARIN SODIUM COUMADIN 6 MG Generic TABLET 0.2940$WATER FOR IRRIGATION,STERILE WATER 0.0% Generic SOLUTION, IRRIGATION 0.0022$ZAFIRLUKAST ACCOLATE 20 MG Generic TABLET 1.4300$ZALEPLON ZALEPLON 5 MG Generic CAPSULE 0.2700$ZALEPLON SONATA 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3400$ZILEUTON ZYFLO CR 600 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 24.9721$ZINC OXIDE ZINC OXIDE 20.0% Generic OINTMENT (GRAM) 0.0614$ZIPRASIDONE HCL GEODON 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9450$ZIPRASIDONE HCL GEODON 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9700$

48 of 49

Average Acquisition Cost (AAC) Price List(Effective 3/1/2016)

Generic Name Brand Reference Strength Brand/Generic

Dosage Form AAC Rate

ZIPRASIDONE HCL GEODON 60 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2740$ZIPRASIDONE HCL GEODON 80 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2600$ZOLMITRIPTAN ZOMIG ZMT 5 MG Brand TABLET,DISINTEGRATING 59.8298$ZOLMITRIPTAN ZOMIG ZMT 5 MG Generic TABLET,DISINTEGRATING 10.8300$ZOLMITRIPTAN ZOMIG 5 MG Brand SPRAY, NON-AEROSOL (EA) 52.1044$ZOLMITRIPTAN ZOMIG 2.5 MG Brand TABLET 57.3998$ZOLMITRIPTAN ZOLMITRIPTAN 2.5 MG Generic TABLET 8.0717$ZOLMITRIPTAN ZOMIG 5 MG Brand TABLET 75.2184$ZOLMITRIPTAN ZOMIG 5 MG Generic TABLET 9.3600$ZOLPIDEM TARTRATE AMBIEN 5 MG Generic TABLET 0.0367$ZOLPIDEM TARTRATE AMBIEN 10 MG Brand TABLET 13.9646$ZOLPIDEM TARTRATE AMBIEN 10 MG Generic TABLET 0.0300$ZOLPIDEM TARTRATE AMBIEN CR 6.25 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 2.7367$ZOLPIDEM TARTRATE AMBIEN CR 12.5 MG Brand TABLET, EXTENDED RELEASE MULTIPHASE 13.8014$ZOLPIDEM TARTRATE AMBIEN CR 12.5 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 0.9200$ZONISAMIDE ZONEGRAN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1375$ZONISAMIDE ZONISAMIDE 50 MG Generic CAPSULE 0.1617$ZONISAMIDE ZONEGRAN 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.2568$ZONISAMIDE ZONEGRAN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1520$ZOSTER VACCINE LIVE/PF ZOSTAVAX 19400 UNIT Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 178.6389$

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