Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) · aclovate alclometasone...

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Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) Brand Reference Generic Name Strength Brand/ Generic Dosage Form AAC Rate ABILIFY ARIPIPRAZOLE 10 MG Brand TABLET 24.9766 $ ABILIFY ARIPIPRAZOLE 15 MG Brand TABLET 24.9496 $ ABILIFY ARIPIPRAZOLE 2 MG Brand TABLET 24.8781 $ ABILIFY ARIPIPRAZOLE 20 MG Brand TABLET 35.2793 $ ABILIFY ARIPIPRAZOLE 30 MG Brand TABLET 35.2164 $ ABILIFY ARIPIPRAZOLE 5 MG Brand TABLET 24.9991 $ ABREVA DOCOSANOL 10 % Brand CREAM (GRAM) 7.3675 $ ABSORICA ISOTRETINOIN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.6428 $ ABSORICA ISOTRETINOIN 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.5036 $ ABSORICA ISOTRETINOIN 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.7065 $ ABSORICA ISOTRETINOIN 30 MG Brand CAPSULE 24.6580 $ ABSORICA ISOTRETINOIN 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.7200 $ ACANYA CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2%-2.5% Brand GEL WITH PUMP (GRAM) 6.4075 $ ACCOLATE ZAFIRLUKAST 20 MG Generic TABLET 1.2456 $ ACCUNEB ALBUTEROL SULFATE 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.3908 $ ACCUNEB ALBUTEROL SULFATE 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.2755 $ ACCUPRIL QUINAPRIL HCL 10 MG Generic TABLET 0.1783 $ ACCUPRIL QUINAPRIL HCL 20 MG Generic TABLET 0.1663 $ ACCUPRIL QUINAPRIL HCL 40 MG Generic TABLET 0.1629 $ ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1596 $ ACETAMINOPHEN ACETAMINOPHEN 325 MG Generic TABLET 0.0200 $ ACETAMINOPHEN ACETAMINOPHEN 500 MG Generic TABLET 0.0183 $ ACETAMINOPHEN W/CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 120-12MG/5 Generic ELIXIR 0.0100 $ ACETAMINOPHEN W/CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 300MG-30MG Generic TABLET 0.1013 $ ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 120-12MG/5 Generic SOLUTION, ORAL 0.0100 $ ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 300MG-60MG Generic TABLET 0.2043 $ ACETAZOLAMIDE ACETAZOLAMIDE 500 MG Generic CAPSULE, EXTENDED RELEASE 1.8748 $ ACIPHEX RABEPRAZOLE SODIUM 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.9608 $ ACIPHEX RABEPRAZOLE SODIUM 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 10.2373 $ ACITRETIN ACITRETIN 25 MG Generic CAPSULE 23.7270 $ ACLOVATE ALCLOMETASONE DIPROPIONATE 0.0005 Generic CREAM (GRAM) 1.2497 $ ACLOVATE ALCLOMETASONE DIPROPIONATE 0.0005 Generic OINTMENT (GRAM) 1.0838 $ ACTIGALL URSODIOL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.1651 $ ACTIVELLA ESTRADIOL/NORETHINDRONE ACETATE 0.5-0.1MG Generic TABLET 3.1500 $ ACTIVELLA ESTRADIOL/NORETHINDRONE ACETATE 1 MG-0.5MG Generic TABLET 3.6950 $ ACTONEL RISEDRONATE SODIUM 150 MG Brand TABLET 207.6350 $ ACTONEL RISEDRONATE SODIUM 35 MG Brand TABLET 48.1646 $ ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG Generic TABLET 2.9220 $ ACTOS PIOGLITAZONE HCL 15 MG Generic TABLET 0.2090 $ ACTOS PIOGLITAZONE HCL 15 MG Brand TABLET 8.1126 $ ACTOS PIOGLITAZONE HCL 30 MG Generic TABLET 0.2816 $ ACTOS PIOGLITAZONE HCL 30 MG Brand TABLET 13.0084 $ ACTOS PIOGLITAZONE HCL 45 MG Generic TABLET 0.2935 $ ACULAR KETOROLAC TROMETHAMINE 0.005 Generic DROPS 1.7844 $ ACULAR LS KETOROLAC TROMETHAMINE 0.004 Generic DROPS 6.4320 $ ACZONE DAPSONE 0.05 Brand GEL (GRAM) 6.5230 $ ADALAT NIFEDIPINE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7818 $ ADALAT CC NIFEDIPINE 30 MG Generic TABLET, EXTENDED RELEASE 0.3980 $ ADALAT CC NIFEDIPINE 60 MG Generic TABLET, EXTENDED RELEASE 0.8656 $ ADALAT CC NIFEDIPINE 90 MG Generic TABLET, EXTENDED RELEASE 1.7292 $ ADAPALENE ADAPALENE 0.1% Generic GEL (GRAM) 2.7025 $ ADAPALENE ADAPALENE 0.001 Generic CREAM (GRAM) 3.9340 $ ADAPALENE ADAPALENE 0.001 Brand GEL (GRAM) 7.2325 $ ADAPALENE ADAPALENE 0.001 Brand CREAM (GRAM) 7.8645 $ 1 of 45

Transcript of Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) · aclovate alclometasone...

Page 1: Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) · aclovate alclometasone dipropionate 0.0005 generic cream (gram) $ 1.2497 aclovate alclometasone dipropionate 0.0005

Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ABILIFY ARIPIPRAZOLE 10 MG Brand TABLET 24.9766$ABILIFY ARIPIPRAZOLE 15 MG Brand TABLET 24.9496$ABILIFY ARIPIPRAZOLE 2 MG Brand TABLET 24.8781$ABILIFY ARIPIPRAZOLE 20 MG Brand TABLET 35.2793$ABILIFY ARIPIPRAZOLE 30 MG Brand TABLET 35.2164$ABILIFY ARIPIPRAZOLE 5 MG Brand TABLET 24.9991$ABREVA DOCOSANOL 10 % Brand CREAM (GRAM) 7.3675$ABSORICA ISOTRETINOIN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.6428$ABSORICA ISOTRETINOIN 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.5036$ABSORICA ISOTRETINOIN 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.7065$ABSORICA ISOTRETINOIN 30 MG Brand CAPSULE 24.6580$ABSORICA ISOTRETINOIN 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.7200$ACANYA CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2%-2.5% Brand GEL WITH PUMP (GRAM) 6.4075$ACCOLATE ZAFIRLUKAST 20 MG Generic TABLET 1.2456$ACCUNEB ALBUTEROL SULFATE 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.3908$ACCUNEB ALBUTEROL SULFATE 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.2755$ACCUPRIL QUINAPRIL HCL 10 MG Generic TABLET 0.1783$ACCUPRIL QUINAPRIL HCL 20 MG Generic TABLET 0.1663$ACCUPRIL QUINAPRIL HCL 40 MG Generic TABLET 0.1629$ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1596$ACETAMINOPHEN ACETAMINOPHEN 325 MG Generic TABLET 0.0200$ACETAMINOPHEN ACETAMINOPHEN 500 MG Generic TABLET 0.0183$ACETAMINOPHEN W/CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 120-12MG/5 Generic ELIXIR 0.0100$ACETAMINOPHEN W/CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 300MG-30MG Generic TABLET 0.1013$ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 120-12MG/5 Generic SOLUTION, ORAL 0.0100$ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE PHOSPHATE 300MG-60MG Generic TABLET 0.2043$ACETAZOLAMIDE ACETAZOLAMIDE 500 MG Generic CAPSULE, EXTENDED RELEASE 1.8748$ACIPHEX RABEPRAZOLE SODIUM 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.9608$ACIPHEX RABEPRAZOLE SODIUM 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 10.2373$ACITRETIN ACITRETIN 25 MG Generic CAPSULE 23.7270$ACLOVATE ALCLOMETASONE DIPROPIONATE 0.0005 Generic CREAM (GRAM) 1.2497$ACLOVATE ALCLOMETASONE DIPROPIONATE 0.0005 Generic OINTMENT (GRAM) 1.0838$ACTIGALL URSODIOL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.1651$ACTIVELLA ESTRADIOL/NORETHINDRONE ACETATE 0.5-0.1MG Generic TABLET 3.1500$ACTIVELLA ESTRADIOL/NORETHINDRONE ACETATE 1 MG-0.5MG Generic TABLET 3.6950$ACTONEL RISEDRONATE SODIUM 150 MG Brand TABLET 207.6350$ACTONEL RISEDRONATE SODIUM 35 MG Brand TABLET 48.1646$ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG Generic TABLET 2.9220$ACTOS PIOGLITAZONE HCL 15 MG Generic TABLET 0.2090$ACTOS PIOGLITAZONE HCL 15 MG Brand TABLET 8.1126$ACTOS PIOGLITAZONE HCL 30 MG Generic TABLET 0.2816$ACTOS PIOGLITAZONE HCL 30 MG Brand TABLET 13.0084$ACTOS PIOGLITAZONE HCL 45 MG Generic TABLET 0.2935$ACULAR KETOROLAC TROMETHAMINE 0.005 Generic DROPS 1.7844$ACULAR LS KETOROLAC TROMETHAMINE 0.004 Generic DROPS 6.4320$ACZONE DAPSONE 0.05 Brand GEL (GRAM) 6.5230$ADALAT NIFEDIPINE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7818$ADALAT CC NIFEDIPINE 30 MG Generic TABLET, EXTENDED RELEASE 0.3980$ADALAT CC NIFEDIPINE 60 MG Generic TABLET, EXTENDED RELEASE 0.8656$ADALAT CC NIFEDIPINE 90 MG Generic TABLET, EXTENDED RELEASE 1.7292$ADAPALENE ADAPALENE 0.1% Generic GEL (GRAM) 2.7025$ADAPALENE ADAPALENE 0.001 Generic CREAM (GRAM) 3.9340$ADAPALENE ADAPALENE 0.001 Brand GEL (GRAM) 7.2325$ADAPALENE ADAPALENE 0.001 Brand CREAM (GRAM) 7.8645$

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Page 2: Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) · aclovate alclometasone dipropionate 0.0005 generic cream (gram) $ 1.2497 aclovate alclometasone dipropionate 0.0005

Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ADCIRCA TADALAFIL 20 MG Brand TABLET 30.6160$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 10 MG Generic TABLET 0.9044$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 10 MG Brand TABLET 4.0973$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 15 MG Generic TABLET 1.0800$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 20 MG Generic TABLET 0.9926$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 30 MG Generic TABLET 0.9217$ADDERALL AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 5 MG Generic TABLET 0.9578$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 10 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8817$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 10 MG Generic CAPSULE, EXT RELEASE 24 HR 3.9380$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 15 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9800$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 15 MG Generic CAPSULE, EXT RELEASE 24 HR 4.2572$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 20 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8788$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 20 MG Generic CAPSULE, EXT RELEASE 24 HR 3.7500$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 25 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8934$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 25 MG Generic CAPSULE, EXT RELEASE 24 HR 3.7200$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 30 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8756$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 30 MG Generic CAPSULE, EXT RELEASE 24 HR 4.0150$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 5 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8714$ADDERALL XR AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE 5 MG Generic CAPSULE, EXT RELEASE 24 HR 4.1650$ADOXA DOXYCYCLINE MONOHYDRATE 100 MG Generic TABLET 0.8234$ADOXA DOXYCYCLINE MONOHYDRATE 50 MG Generic TABLET 0.2425$ADRENACLICK EPINEPHRINE 0.3MG/0.3 Brand PEN INJECTOR (EA) 167.4224$ADSORBOCARPINE PILOCARPINE HCL 0.01 Generic DROPS 3.4996$ADSORBOCARPINE PILOCARPINE HCL 2% Generic DROPS 2.5099$ADULT ROBITUSSIN PEAK COLD GUAIFENESIN/DEXTROMETHORPHAN HBR 100-10MG/5 Brand LIQUID (ML) 0.0298$ADVAIR DISKUS FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 100-50 MCG Brand DISK, WITH INHALATION DEVICE 3.6592$ADVAIR DISKUS FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 250-50 MCG Brand DISK, WITH INHALATION DEVICE 4.5651$ADVAIR DISKUS FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 500-50 MCG Brand DISK, WITH INHALATION DEVICE 6.0087$ADVAIR HFA FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 115-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 22.6906$ADVAIR HFA FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 230-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 29.8060$ADVAIR HFA FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 45-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 18.3671$ADVIL IBUPROFEN 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.1638$ADVIL IBUPROFEN 200 MG Generic TABLET 0.0300$ADVIL IBUPROFEN 200 MG Brand TABLET 0.0860$AGGRENOX ASPIRIN/DIPYRIDAMOLE 25MG-200MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 4.8767$AK-PENTOLATE CYCLOPENTOLATE HCL 0.01 Generic DROPS 3.6402$AK-TROL NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE 0.001 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 2.9736$ALA-CORT HYDROCORTISONE 0.01 Generic CREAM (GRAM) 0.1082$ALAWAY KETOTIFEN FUMARATE 0.00025 Generic DROPS 1.0743$ALBENZA ALBENDAZOLE 200 MG Brand TABLET 82.4740$ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML Generic VIAL, NEBULIZER (ML) 0.0441$ALBUTEROL SULFATE ALBUTEROL SULFATE 5 MG/ML Generic SOLUTION, NON-ORAL 0.5302$ALDACTAZIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 25 MG-25MG Generic TABLET 0.7925$ALDACTONE SPIRONOLACTONE 25 MG Generic TABLET 0.0810$ALDACTONE SPIRONOLACTONE 50 MG Generic TABLET 0.2391$ALDARA IMIQUIMOD 0.05 Generic CREAM IN PACKET 12.7640$ALDOMET METHYLDOPA 250 MG Generic TABLET 0.0874$ALDOMET METHYLDOPA 500 MG Generic TABLET 0.1853$ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG Generic TABLET 0.1875$ALESSE-21 LEVONORGESTREL-ETHINYL ESTRADIOL 0.1-0.02 Generic TABLET 0.3536$ALIGN BIFIDOBACTERIUM INFANTIS 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.7914$ALINIA NITAZOXANIDE 100 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 2.0655$ALINIA NITAZOXANIDE 500 MG Brand TABLET 24.0852$ALL DAY ALLERGY CETIRIZINE HCL 10 MG Generic TABLET 0.1029$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ALLEGRA FEXOFENADINE HCL 180 MG Generic TABLET 0.4900$ALLEGRA ALLERGY FEXOFENADINE HCL 60 MG Generic TABLET 1.0345$ALLER-CHLOR CHLORPHENIRAMINE MALEATE 4 MG Generic TABLET 0.0157$ALLERGEN ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4 %-1.4% Generic DROPS 0.7535$ALLERGY DIPHENHYDRAMINE HCL 25 MG Generic TABLET 0.0431$ALLERGY DIPHENHYDRAMINE HCL 25 MG Generic CAPSULE 0.0433$ALLERGY RELIEF-D CETIRIZINE HCL/PSEUDOEPHEDRINE HCL 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.5800$ALLOPURINOL ALLOPURINOL 100 MG Generic TABLET 0.0267$ALLOPURINOL ALLOPURINOL 300 MG Generic TABLET 0.0610$ALORA ESTRADIOL .025MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.0950$ALORA ESTRADIOL .075MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.3908$ALORA ESTRADIOL 0.05MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.2416$ALORA ESTRADIOL 0.1MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.3188$ALPHAGAN BRIMONIDINE TARTRATE 0.002 Generic DROPS 1.0010$ALPHAGAN P BRIMONIDINE TARTRATE 0.001 Brand DROPS 17.5033$ALPHAGAN P BRIMONIDINE TARTRATE 0.0015 Brand DROPS 17.9908$ALPHAGAN P BRIMONIDINE TARTRATE 0.0015 Generic DROPS 14.9020$ALPRAZOLAM ALPRAZOLAM 0.25 MG Generic TABLET 0.0260$ALPRAZOLAM ALPRAZOLAM 0.5 MG Generic TABLET 0.0200$ALPRAZOLAM ALPRAZOLAM 1 MG Generic TABLET 0.0257$ALPRAZOLAM ALPRAZOLAM 2 MG Generic TABLET 0.0600$ALPRAZOLAM ER ALPRAZOLAM 3 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8467$ALPRAZOLAM XR ALPRAZOLAM 0.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2834$ALPRAZOLAM XR ALPRAZOLAM 1 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3700$ALPRAZOLAM XR ALPRAZOLAM 2 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5425$ALREX LOTEPREDNOL ETABONATE 0.002 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 31.3900$ALSUMA SUMATRIPTAN SUCCINATE 6 MG/0.5ML Generic PEN INJECTOR (ML) 147.8614$ALTABAX RETAPAMULIN 1.0% Brand OINTMENT (GRAM) 7.4018$ALTACE RAMIPRIL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1141$ALTACE RAMIPRIL 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1050$ALTACE RAMIPRIL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$ALVESCO CICLESONIDE 160 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 30.0843$ALVESCO CICLESONIDE 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 28.3000$ALZ-NAC ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM 600-2-6 MG Generic TABLET 1.8172$AMARYL GLIMEPIRIDE 1 MG Generic TABLET 0.0200$AMARYL GLIMEPIRIDE 2 MG Generic TABLET 0.0500$AMARYL GLIMEPIRIDE 4 MG Generic TABLET 0.0570$AMBIEN ZOLPIDEM TARTRATE 10 MG Generic TABLET 0.0232$AMBIEN ZOLPIDEM TARTRATE 10 MG Brand TABLET 9.5760$AMBIEN ZOLPIDEM TARTRATE 5 MG Generic TABLET 0.0333$AMBIEN CR ZOLPIDEM TARTRATE 12.5 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 2.5540$AMBIEN CR ZOLPIDEM TARTRATE 12.5 MG Brand TABLET, EXTENDED RELEASE MULTIPHASE 10.3692$AMBIEN CR ZOLPIDEM TARTRATE 6.25 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 2.7175$AMILORIDE HCL AMILORIDE HCL 5 MG Generic TABLET 0.4292$AMITIZA LUBIPROSTONE 24MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.7814$AMITIZA LUBIPROSTONE 8 MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.8000$AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG Generic TABLET 0.3193$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG Generic TABLET 0.0300$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG Generic TABLET 0.0200$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Generic TABLET 0.0200$AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Brand TABLET 3.0650$AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 10MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3625$AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 10MG-40MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2260$AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3540$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1468$AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2214$AMLODIPINE-ATORVASTATIN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 10MG-10MG Generic TABLET 4.9723$AMLODIPINE-ATORVASTATIN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM 5 MG-40 MG Generic TABLET 5.7005$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 200-28.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1680$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 250-62.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6769$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 400-57MG/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1346$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 500-125 MG Generic TABLET 0.6485$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 600-42.9/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1539$AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAVULANATE 875-125 MG Generic TABLET 0.5490$AMOXICILLIN AMOXICILLIN 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0218$AMOXICILLIN AMOXICILLIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0517$AMOXICILLIN AMOXICILLIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0750$AMOXICILLIN AMOXICILLIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0265$AMOXICILLIN AMOXICILLIN 400 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0287$AMOXICILLIN AMOXICILLIN 875MG Generic TABLET 0.1373$AMOXICILLIN-CLAVULANATE ER AMOXICILLIN/POTASSIUM CLAVULANATE 1000-62.5 Generic TABLET, EXTENDED RELEASE 12 HR 2.8740$AMOXIL AMOXICILLIN 250 MG Generic TABLET, CHEWABLE 0.2375$AMOXIL AMOXICILLIN 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0782$AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE 7.5 MG Generic TABLET 1.0618$AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1380$ANAFRANIL CLOMIPRAMINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.8800$ANAFRANIL CLOMIPRAMINE HCL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.9030$ANAPROX NAPROXEN SODIUM 275 MG Generic TABLET 0.0660$ANAPROX DS NAPROXEN SODIUM 550 MG Generic TABLET 0.1188$ANASPAZ HYOSCYAMINE SULFATE 0.125 MG Generic TABLET,DISINTEGRATING 0.2267$ANDRODERM TESTOSTERONE 2 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 5.9500$ANDRODERM TESTOSTERONE 4 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 12.0217$ANDROGEL TESTOSTERONE 1.25G (1%) Brand GEL IN METERED-DOSE PUMP 2.5143$ANDROGEL TESTOSTERONE 1.25G-1.62 Brand GEL IN PACKET (GRAM) 8.8962$ANDROGEL TESTOSTERONE 2.5G-1.62% Brand GEL IN PACKET (GRAM) 5.0250$ANDROGEL TESTOSTERONE 20.25/1.25 Brand GEL IN METERED-DOSE PUMP 4.8571$ANDROGEL TESTOSTERONE 25MG(1%) Brand GEL IN PACKET (GRAM) 4.7411$ANDROGEL TESTOSTERONE 50 MG (1%) Brand GEL IN PACKET (GRAM) 2.5000$ANESTACON LIDOCAINE HCL 2% Generic JEL (ML) 0.2743$ANEXSIA HYDROCODONE BIT/ACETAMINOPHEN 5MG-325MG Generic TABLET 0.1228$ANEXSIA HYDROCODONE BIT/ACETAMINOPHEN 7.5-325MG Generic TABLET 0.1951$ANGELIQ DROSPIRENONE/ESTRADIOL 0.5 MG-1MG Brand TABLET 3.2975$ANORO ELLIPTA UMECLIDINIUM BROMIDE/VILANTEROL TRIFENATATE 62.5-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.5050$ANTABUSE DISULFIRAM 250 MG Generic TABLET 2.4386$ANTACID-ANTIGAS MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE 200-200-20 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0100$ANTARA FENOFIBRATE,MICRONIZED 130 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.3425$ANTARA FENOFIBRATE,MICRONIZED 130 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.9710$ANTI-DIARRHEAL LOPERAMIDE HCL 2 MG Generic TABLET 0.1029$ANTIVERT MECLIZINE HCL 12.5 MG Generic TABLET 0.0667$ANTIVERT MECLIZINE HCL 25 MG Generic TABLET 0.2658$ANTIVERT/25 MECLIZINE HCL 25 MG Generic TABLET, CHEWABLE 0.0286$ANUSOL-HC HYDROCORTISONE 0.025 Generic CREAM (GRAM) 0.2582$ANUSOL-HC HYDROCORTISONE 2.500% Brand CREAM (GRAM) 0.2480$APIDRA INSULIN GLULISINE 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 15.0711$APIDRA SOLOSTAR INSULIN GLULISINE 100/ML Brand INSULIN PEN (ML) 19.4875$APRESOLINE HYDRALAZINE HCL 10 MG Generic TABLET 0.1043$APRESOLINE HYDRALAZINE HCL 50 MG Generic TABLET 0.1150$APRISO MESALAMINE 0.375G Brand CAPSULE, EXT RELEASE 24 HR 2.7968$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ARALEN PHOSPHATE CHLOROQUINE PHOSPHATE 500 MG Generic TABLET 1.9496$ARCAPTA NEOHALER INDACATEROL MALEATE 75 MCG Brand CAPSULE, WITH INHALATION DEVICE 5.8635$ARICEPT DONEPEZIL HCL 10 MG Generic TABLET 0.0752$ARICEPT DONEPEZIL HCL 23 MG Generic TABLET 8.8275$ARICEPT DONEPEZIL HCL 23 MG Brand TABLET 10.9291$ARICEPT DONEPEZIL HCL 5 MG Generic TABLET 0.1200$ARIMIDEX ANASTROZOLE 1 MG Generic TABLET 0.2393$ARISTOCORT TRIAMCINOLONE ACETONIDE 0.00025 Generic CREAM (GRAM) 0.1317$ARISTOCORT TRIAMCINOLONE ACETONIDE 0.001 Generic CREAM (GRAM) 0.1444$ARISTOCORT TRIAMCINOLONE ACETONIDE 0.001 Generic OINTMENT (GRAM) 0.1397$ARISTOCORT TRIAMCINOLONE ACETONIDE 0.5% Generic CREAM (GRAM) 0.4893$ARISTOCORT HP TRIAMCINOLONE ACETONIDE 0.005 Generic OINTMENT (GRAM) 0.5100$ARIXTRA FONDAPARINUX SODIUM 2.5 MG/0.5 Generic DISPOSABLE SYRINGE (ML) 78.0798$ARMOUR THYROID THYROID,PORK 120 MG Brand TABLET 0.5396$ARMOUR THYROID THYROID,PORK 15 MG Brand TABLET 0.2257$ARMOUR THYROID THYROID,PORK 30 MG Brand TABLET 0.2667$ARMOUR THYROID THYROID,PORK 60 MG Brand TABLET 0.2875$ARMOUR THYROID THYROID,PORK 90 MG Brand TABLET 0.4580$AROMASIN EXEMESTANE 25 MG Generic TABLET 9.9750$ARTHROTEC 50 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.4500$ARTHROTEC 50 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.7983$ARTHROTEC 75 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.6015$ARTHROTEC 75 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.6830$ARTIFICIAL TEARS POLYVINYL ALCOHOL 0.014 Generic DROPS 0.1260$ARTIFICIAL TEARS MINERAL OIL/PETROLATUM,WHITE 15 %-83 % Generic OINTMENT (GRAM) 0.5864$ASACOL MESALAMINE 400 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 2.0957$ASACOL HD MESALAMINE 800 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.7475$ASMANEX MOMETASONE FUROATE 110MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 126.6120$ASMANEX MOMETASONE FUROATE 220MCG 120 Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 227.0250$ASMANEX MOMETASONE FUROATE 220MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 136.8425$ASMANEX MOMETASONE FUROATE 220MCG(60) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 161.2271$ASPIRIN ASPIRIN 325 MG Generic TABLET 0.0100$ASTELIN AZELASTINE HCL 137 MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 1.1010$ASTEPRO AZELASTINE HCL 205.5MCG Brand AEROSOL, SPRAY WITH PUMP (ML) 3.9525$ASTEPRO AZELASTINE HCL 205.5MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 3.7350$ATACAND CANDESARTAN CILEXETIL 16 MG Brand TABLET 2.8430$ATACAND CANDESARTAN CILEXETIL 16 MG Generic TABLET 2.3524$ATACAND CANDESARTAN CILEXETIL 32 MG Generic TABLET 2.6309$ATACAND CANDESARTAN CILEXETIL 32 MG Brand TABLET 3.8270$ATARAX HYDROXYZINE HCL 10 MG Generic TABLET 0.0957$ATARAX HYDROXYZINE HCL 10 MG/5 ML Generic SYRUP 0.0600$ATARAX HYDROXYZINE HCL 25 MG Generic TABLET 0.0900$ATARAX HYDROXYZINE HCL 50 MG Generic TABLET 0.2200$ATELVIA RISEDRONATE SODIUM 35 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 36.0157$ATIVAN LORAZEPAM 0.5 MG Generic TABLET 0.0200$ATIVAN LORAZEPAM 1 MG Generic TABLET 0.0220$ATIVAN LORAZEPAM 2 MG Generic TABLET 0.0440$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Generic TABLET 0.1248$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Brand TABLET 5.2149$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Generic TABLET 0.1610$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Brand TABLET 7.2694$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Generic TABLET 0.1655$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Brand TABLET 7.9236$ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Generic TABLET 0.1793$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Brand TABLET 6.1348$ATOVAQUONE-PROGUANIL HCL ATOVAQUONE/PROGUANIL HCL 250-100 MG Generic TABLET 5.3244$ATOVAQUONE-PROGUANIL HCL ATOVAQUONE/PROGUANIL HCL 62.5-25MG Generic TABLET 1.2181$ATRALIN TRETINOIN 0% Brand GEL (GRAM) 7.7626$ATRIPLA EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE 600-200MG Brand TABLET 65.6976$ATROPINE CARE ATROPINE SULFATE 0.01 Generic DROPS 2.6100$ATROVENT IPRATROPIUM BROMIDE 0.2 MG/ML Generic SOLUTION, NON-ORAL 0.0594$ATROVENT IPRATROPIUM BROMIDE 21 MCG Generic AEROSOL, SPRAY (ML) 0.7281$ATROVENT IPRATROPIUM BROMIDE 42MCG Generic AEROSOL, SPRAY (ML) 1.5067$ATROVENT HFA IPRATROPIUM BROMIDE 17MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.6580$AUGMENTIN AMOXICILLIN/POTASSIUM CLAVULANATE 400-57MG Generic TABLET, CHEWABLE 1.3645$AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG Generic TABLET 0.4275$AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG Brand TABLET 3.7563$AVAPRO IRBESARTAN 150 MG Brand TABLET 3.6973$AVAPRO IRBESARTAN 150 MG Generic TABLET 0.2229$AVAPRO IRBESARTAN 300 MG Brand TABLET 3.9251$AVAPRO IRBESARTAN 300 MG Generic TABLET 0.3471$AVAPRO IRBESARTAN 75 MG Brand TABLET 3.3241$AVELOX MOXIFLOXACIN HCL 400 MG Brand TABLET 24.5820$AVELOX MOXIFLOXACIN HCL 400 MG Generic TABLET 15.4250$AVENTYL HCL NORTRIPTYLINE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1009$AVENTYL HCL NORTRIPTYLINE HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1415$AVINZA MORPHINE SULFATE 120 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 18.0206$AVINZA MORPHINE SULFATE 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.2277$AVITA TRETINOIN 0.00025 Generic CREAM (GRAM) 3.4058$AVITA TRETINOIN 0.025% Generic GEL (GRAM) 1.2900$AVITA TRETINOIN 0.0% Brand CREAM (GRAM) 5.3402$AVLOSULFON DAPSONE 25 MG Generic TABLET 0.8492$AVODART DUTASTERIDE 0.5 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.3953$AVONEX INTERFERON BETA-1A 30MCG/.5ML Brand KIT 4,423.2500$AXERT ALMOTRIPTAN MALATE 12.5 MG Brand TABLET 32.1982$AXID NIZATIDINE 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2236$AXID NIZATIDINE Generic SOLUTION, ORAL 0.5248$AXIRON TESTOSTERONE 30MG/1.5ML Brand SOLUTION IN METERED-DOSE PUMP WITH APPL. 4.2320$AYGESTIN NORETHINDRONE ACETATE 5 MG Generic TABLET 1.5875$AYR SALINE SODIUM CHLORIDE/ALOE VERA 0 Brand GEL (GRAM) 0.1800$AYR SALINE SODIUM CHLORIDE 0.0065 Generic AEROSOL, SPRAY (ML) 0.0272$AYR SALINE SODIUM CHLORIDE 0.0065 Brand AEROSOL, SPRAY (ML) 0.0400$AZASITE AZITHROMYCIN 1% Brand DROPS 39.6820$AZELASTINE HCL AZELASTINE HCL 0% Generic DROPS 8.7800$AZELEX AZELAIC ACID 20% Brand CREAM (GRAM) 8.9984$AZILECT RASAGILINE MESYLATE 1 MG Brand TABLET 15.3689$AZITHROMYCIN AZITHROMYCIN 100 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 1.0910$AZITHROMYCIN AZITHROMYCIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7481$AZITHROMYCIN AZITHROMYCIN 250 MG Generic TABLET 0.4075$AZITHROMYCIN AZITHROMYCIN 500 MG Generic TABLET 2.5396$AZOPT BRINZOLAMIDE 0.01 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 14.9775$AZOR AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL 10 MG-40MG Brand TABLET 5.6950$AZOR AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL 5MG-40MG Brand TABLET 5.7071$AZULFIDINE SULFASALAZINE 500 MG Generic TABLET 0.1847$AZULFIDINE SULFASALAZINE 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2200$BACIGUENT BACITRACIN 500 UNIT/G Generic OINTMENT (GRAM) 0.0695$BACITRACIN BACITRACIN 500 UNIT/G Generic OINTMENT (GRAM) 17.1967$BACITRACIN ZINC BACITRACIN ZINC 500 UNIT/G Generic OINTMENT (GRAM) 0.1767$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0911$BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG Generic TABLET 0.0900$BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG Generic TABLET 0.0623$BACTROBAN MUPIROCIN CALCIUM 2 % Generic CREAM (GRAM) 2.7767$BACTROBAN MUPIROCIN 2% Generic OINTMENT (GRAM) 0.3292$BACTROBAN MUPIROCIN CALCIUM 2% Brand CREAM (GRAM) 4.2993$BACTROBAN NASAL MUPIROCIN CALCIUM 0.02 Brand OINTMENT (GRAM) 11.4342$BANZEL RUFINAMIDE 400 MG Brand TABLET 10.8158$BENADRYL DIPHENHYDRAMINE HCL 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.8047$BENAZEPRIL HCL BENAZEPRIL HCL 10 MG Generic TABLET 0.0622$BENAZEPRIL HCL BENAZEPRIL HCL 20 MG Generic TABLET 0.0488$BENAZEPRIL HCL BENAZEPRIL HCL 40 MG Generic TABLET 0.0655$BENAZEPRIL HCL BENAZEPRIL HCL 5 MG Generic TABLET 0.0617$BENAZEPRIL-HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 10-12.5MG Generic TABLET 1.5075$BENAZEPRIL-HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20-12.5 MG Generic TABLET 1.4757$BENAZEPRIL-HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20-25MG Generic TABLET 1.5780$BENEMID PROBENECID 500 MG Generic TABLET 0.4700$BENICAR OLMESARTAN MEDOXOMIL 20 MG Brand TABLET 3.6760$BENICAR OLMESARTAN MEDOXOMIL 40 MG Brand TABLET 5.1180$BENICAR OLMESARTAN MEDOXOMIL 5 MG Brand TABLET 2.9893$BENICAR HCT OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE 20-12.5 MG Brand TABLET 3.6478$BENICAR HCT OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE 40 MG-25MG Brand TABLET 5.1246$BENICAR HCT OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE 40-12.5 MG Brand TABLET 5.1043$BENTYL DICYCLOMINE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0575$BENTYL DICYCLOMINE HCL 20 MG Generic TABLET 0.0735$BENZAC 5 BENZOYL PEROXIDE 0.05 Generic GEL (GRAM) 0.1200$BENZAC AC BENZOYL PEROXIDE 0.05 Generic CLEANSER (GRAM) 0.0414$BENZACLIN CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1 %-5 % Brand GEL WITH PUMP (GRAM) 7.2571$BENZACLIN CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1 %-5 % Generic GEL (GRAM) 5.7706$BENZACLIN CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1 %-5 % Brand GEL (GRAM) 6.7553$BENZAMYCIN ERYTHROMYCIN BASE/BENZOYL PEROXIDE 3 %-5 % Generic GEL (GRAM) 1.1425$BENZEFOAM BENZOYL PEROXIDE 5.30% Generic FOAM (GRAM) 1.8748$BENZEFOAM ULTRA BENZOYL PEROXIDE 0.098 Generic FOAM (GRAM) 2.2792$BENZONATATE BENZONATATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0846$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 0.5 MG Generic TABLET 0.1274$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 1 MG Generic TABLET 0.1225$BENZTROPINE MESYLATE BENZTROPINE MESYLATE 2 MG Generic TABLET 0.1440$BEPREVE BEPOTASTINE BESILATE 0.015 Brand DROPS 28.4379$BESIVANCE BESIFLOXACIN HCL 0.006 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 23.5769$BETAGAN LEVOBUNOLOL HCL 0.005 Generic DROPS 2.0600$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0% Generic CREAM (GRAM) 1.5286$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0% Generic OINTMENT (GRAM) 1.5071$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL 0.050% Generic OINTMENT (GRAM) 2.7800$BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL 0.05 % Brand OINTMENT (GRAM) 3.0008$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.001 Generic LOTION (ML) 0.7516$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.10% Generic CREAM (GRAM) 0.6711$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.10% Generic OINTMENT (GRAM) 0.6770$BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.12 % Generic FOAM (GRAM) 3.4705$BETAPACE SOTALOL HCL 120 MG Generic TABLET 0.1663$BETAPACE SOTALOL HCL 80 MG Generic TABLET 0.1200$BETASERON INTERFERON BETA-1B 0.3 MG Brand KIT 336.3225$BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 10 MG Generic TABLET 0.1105$BETIMOL TIMOLOL 0.50% Brand DROPS 12.9330$BETOPTIC S BETAXOLOL HCL 0% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 17.5580$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

BEYAZ DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM 3-0.02(24) Brand TABLET 3.5575$BIAXIN CLARITHROMYCIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7950$BIAXIN CLARITHROMYCIN 500 MG Generic TABLET 2.1254$BIAXIN XL CLARITHROMYCIN 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.5400$BICITRA CITRIC ACID/SODIUM CITRATE 334-500MG Generic SOLUTION, ORAL 0.0146$BIOZYME-C COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/G Brand OINTMENT (GRAM) 5.8600$BISAC-EVAC BISACODYL 10 MG Generic SUPPOSITORY, RECTAL 0.0863$BIVIGAM IMMUNE GLOBULIN,GAMMA(IGG) 10% Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 10.4378$BLEPH-10 SULFACETAMIDE SODIUM 0.1 Generic DROPS 3.1617$BLEPHAMIDE S.O.P. SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE 10 %-0.2 % Brand OINTMENT (GRAM) 24.4393$BONIVA IBANDRONATE SODIUM 150 MG Generic TABLET 42.2791$BREO ELLIPTA FLUTICASONE FUROATE/VILANTEROL TRIFENATATE 100-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.2700$BREVICON NORETHINDRONE-ETHINYL ESTRADIOL 0.5-0.035 Generic TABLET 0.5802$BRILINTA TICAGRELOR 90 MG Brand TABLET 3.9375$BRINTELLIX VORTIOXETINE HYDROBROMIDE 20 MG Brand TABLET 7.0217$BROMDAY BROMFENAC SODIUM 0.0009 Brand DROPS 95.3745$BROMDAY BROMFENAC SODIUM 0.0009 Generic DROPS 51.6575$BROMFED DM DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE 10-30-2/5 Generic SYRUP 0.2060$BROVANA ARFORMOTEROL TARTRATE 15MCG/2ML Brand VIAL, NEBULIZER (ML) 4.3089$BUDESONIDE EC BUDESONIDE 3 MG Generic CAPSULE, DELAYED & EXTENDED RELEASE 10.5700$BUMETANIDE BUMETANIDE 0.5 MG Generic TABLET 0.3147$BUMETANIDE BUMETANIDE 2 MG Generic TABLET 0.7724$BUMEX BUMETANIDE 1 MG Generic TABLET 0.4003$BUPRENORPHINE-NALOXONE BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG Generic TABLET, SUBLINGUAL 3.9575$BUPRENORPHINE-NALOXONE BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG Generic TABLET, SUBLINGUAL 6.2471$BUPROPION HCL SR BUPROPION HCL 100 MG Generic TABLET, EXTENDED RELEASE 0.2702$BUPROPION HCL SR BUPROPION HCL 150 MG Generic TABLET, EXTENDED RELEASE 0.7968$BUPROPION HCL SR BUPROPION HCL 150 MG Generic TABLET, EXTENDED RELEASE 0.2610$BUPROPION HCL SR BUPROPION HCL 150 MG Brand TABLET, EXTENDED RELEASE 3.9212$BUPROPION HCL SR BUPROPION HCL 200 MG Generic TABLET, EXTENDED RELEASE 0.4567$BUSPAR BUSPIRONE HCL 10 MG Generic TABLET 0.0750$BUSPAR BUSPIRONE HCL 15 MG Generic TABLET 0.0950$BUSPAR BUSPIRONE HCL 30 MG Generic TABLET 0.6433$BUSPAR BUSPIRONE HCL 5 MG Generic TABLET 0.0485$BUSPIRONE HCL BUSPIRONE HCL 7.5 MG Generic TABLET 0.8500$BUTALB-CAFF-ACETAMINOPH-CODEIN BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE 50-325-30 Generic CAPSULE (HARD, SOFT, ETC.) 0.2839$BUTALBITAL COMPOUND W/CODEINE CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE 30-50-325 Generic CAPSULE (HARD, SOFT, ETC.) 2.1164$BUTALBITAL-ACETAMINOPHEN-CAFFE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40 Brand CAPSULE 2.3733$BUTALBITAL-ASPIRIN-CAFFEINE BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 Generic CAPSULE (HARD, SOFT, ETC.) 1.0117$BUTRANS BUPRENORPHINE 10 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 58.1814$BUTRANS BUPRENORPHINE 20 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 103.4360$BUTRANS BUPRENORPHINE 5 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 39.9371$BYDUREON EXENATIDE MICROSPHERES 2 MG Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 97.8000$BYETTA EXENATIDE 10MCG/0.04 Brand PEN INJECTOR (ML) 159.3467$BYETTA EXENATIDE 5MCG/0.02 Brand PEN INJECTOR (ML) 316.4936$BYSTOLIC NEBIVOLOL HCL 10 MG Brand TABLET 2.5306$BYSTOLIC NEBIVOLOL HCL 2.5 MG Brand TABLET 2.5233$BYSTOLIC NEBIVOLOL HCL 20 MG Brand TABLET 2.5750$BYSTOLIC NEBIVOLOL HCL 5 MG Brand TABLET 2.5307$CABERGOLINE CABERGOLINE 0.5 MG Generic TABLET 12.7562$CALAN VERAPAMIL HCL 120 MG Generic TABLET 0.0724$CALAN VERAPAMIL HCL 40 MG Generic TABLET 0.1508$CALAN SR VERAPAMIL HCL 120 MG Generic TABLET, EXTENDED RELEASE 0.2540$CALAN SR VERAPAMIL HCL 180 MG Generic TABLET, EXTENDED RELEASE 0.1900$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

CALAN SR VERAPAMIL HCL 240 MG Generic TABLET, EXTENDED RELEASE 0.1829$CALCIPOTRIENE CALCIPOTRIENE 0.01% Generic SOLUTION, NON-ORAL 2.8700$CALCIPOTRIENE CALCIPOTRIENE 0.0% Generic CREAM (GRAM) 4.9300$CALCIPOTRIENE CALCIPOTRIENE 0.0% Brand CREAM (GRAM) 7.0590$CALCITONIN-SALMON CALCITONIN,SALMON,SYNTHETIC 200/DOSE Generic AEROSOL, SPRAY WITH PUMP (ML) 14.3380$CALCITONIN-SALMON CALCITONIN,SALMON,SYNTHETIC 200/DOSE Brand AEROSOL, SPRAY WITH PUMP (ML) 13.0923$CALCITRIOL CALCITRIOL 0.25 MCG Generic CAPSULE (HARD, SOFT, ETC.) 0.6025$CALCITRIOL CALCITRIOL 0.5 MCG Generic CAPSULE (HARD, SOFT, ETC.) 0.9575$CALCITRIOL CALCITRIOL 3MCG/G Brand OINTMENT (GRAM) 6.2342$CALCIUM ACETATE CALCIUM ACETATE 667 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6033$CAL-GEST CALCIUM CARBONATE 200(500)MG Generic TABLET, CHEWABLE 0.0125$CAMBIA DICLOFENAC POTASSIUM 50 MG Brand POWDER IN PACKET (EA) 29.5240$CAMRESE LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 150-30(84) Generic TABLET, DOSE PACK, 3 MONTHS 1.9675$CAMRESE LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 150-30(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.9463$CAMRESE LO LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 100-20(84) Generic TABLET, DOSE PACK, 3 MONTHS 2.0080$CAMRESE LO LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 100-20(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.8920$CANASA MESALAMINE 1000 MG Brand SUPPOSITORY, RECTAL 20.6600$CAPOTEN CAPTOPRIL 100 MG Generic TABLET 1.1605$CAPOTEN CAPTOPRIL 25 MG Generic TABLET 0.4369$CAPSAICIN CAPSAICIN 0.025 % Generic CREAM (GRAM) 0.1160$CAPTOPRIL CAPTOPRIL 12.5 MG Generic TABLET 0.5243$CAPTOPRIL CAPTOPRIL 50 MG Generic TABLET 0.9275$CARAC FLUOROURACIL 1% Brand CREAM (GRAM) 23.2255$CARAFATE SUCRALFATE 1 G Generic TABLET 0.2173$CARAFATE SUCRALFATE 1 G/10 ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.2520$CARBAMAZEPINE CARBAMAZEPINE 100 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.2025$CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1400$CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.2064$CARBAMAZEPINE CARBAMAZEPINE 200 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.4650$CARBAMAZEPINE CARBAMAZEPINE 200 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7160$CARBAMAZEPINE CARBAMAZEPINE 300 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.3740$CARBAMAZEPINE CARBAMAZEPINE 300 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7550$CARBAMAZEPINE ER CARBAMAZEPINE 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.2849$CARBAMAZEPINE ER CARBAMAZEPINE 400 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.5135$CARBAMAZEPINE ER CARBAMAZEPINE 400 MG Brand TABLET, EXTENDED RELEASE 12 HR 2.9600$CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 10MG-100MG Generic TABLET 0.2067$CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG-100MG Generic TABLET 0.1457$CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG-100MG Generic TABLET,DISINTEGRATING 0.7880$CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG-250MG Generic TABLET 0.1986$CARBIDOPA-LEVODOPA-ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 Generic TABLET 2.7400$CARDIZEM DILTIAZEM HCL 120 MG Generic TABLET 0.2000$CARDIZEM DILTIAZEM HCL 30 MG Generic TABLET 0.0538$CARDIZEM DILTIAZEM HCL 60 MG Generic TABLET 0.1000$CARDIZEM DILTIAZEM HCL 90 MG Generic TABLET 0.1274$CARDIZEM CD DILTIAZEM HCL 120 MG Generic CAPSULE, EXT RELEASE 24 HR 0.4563$CARDIZEM CD DILTIAZEM HCL 180 MG Generic CAPSULE, EXT RELEASE 24 HR 0.4533$CARDIZEM CD DILTIAZEM HCL 240 MG Generic CAPSULE, EXT RELEASE 24 HR 0.5865$CARDIZEM CD DILTIAZEM HCL 300 MG Generic CAPSULE, EXT RELEASE 24 HR 0.7740$CARDURA DOXAZOSIN MESYLATE 1 MG Generic TABLET 0.5400$CARDURA DOXAZOSIN MESYLATE 2 MG Generic TABLET 0.5520$CARDURA DOXAZOSIN MESYLATE 4 MG Generic TABLET 0.6075$CARDURA DOXAZOSIN MESYLATE 8 MG Generic TABLET 0.7250$CARISOPRODOL CARISOPRODOL 250 MG Generic TABLET 2.6325$CARMOL 20 UREA 0.2 Generic CREAM (GRAM) 0.1060$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

CARNITOR LEVOCARNITINE (WITH SUGAR) 100 MG/ML Generic SOLUTION, ORAL 0.1689$CARNITOR LEVOCARNITINE 330 MG Generic TABLET 0.5408$CASODEX BICALUTAMIDE 50 MG Generic TABLET 0.3633$CATAFLAM DICLOFENAC POTASSIUM 50 MG Generic TABLET 0.1060$CATAPRES CLONIDINE HCL 0.1 MG Generic TABLET 0.0321$CATAPRES CLONIDINE HCL 0.2 MG Generic TABLET 0.0400$CATAPRES CLONIDINE HCL 0.3 MG Generic TABLET 0.0500$CATAPRES-TTS 1 CLONIDINE 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 18.6578$CATAPRES-TTS 2 CLONIDINE 0.2MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 29.8800$CATAPRES-TTS 3 CLONIDINE 0.3MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 45.2914$CEDAX CEFTIBUTEN DIHYDRATE 400 MG Brand CAPSULE (HARD, SOFT, ETC.) 30.7447$CEFDINIR CEFDINIR 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5011$CEFDINIR CEFDINIR 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5200$CEFPROZIL CEFPROZIL 500 MG Generic TABLET 1.9840$CEFTIN CEFUROXIME AXETIL 250 MG Generic TABLET 1.7843$CEFTIN CEFUROXIME AXETIL 250 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.3207$CEFTIN CEFUROXIME AXETIL 500 MG Generic TABLET 3.3927$CEFZIL CEFPROZIL 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3041$CEFZIL CEFPROZIL 250 MG Generic TABLET 2.0046$CEFZIL CEFPROZIL 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5700$CELEBREX CELECOXIB 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.0961$CELEBREX CELECOXIB 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.7718$CELEXA CITALOPRAM HYDROBROMIDE 10 MG Generic TABLET 0.0459$CELEXA CITALOPRAM HYDROBROMIDE 10 MG/5 ML Generic SOLUTION, ORAL 0.1260$CELEXA CITALOPRAM HYDROBROMIDE 20 MG Generic TABLET 0.0338$CELEXA CITALOPRAM HYDROBROMIDE 40 MG Generic TABLET 0.0400$CELLCEPT MYCOPHENOLATE MOFETIL 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4200$CELLCEPT MYCOPHENOLATE MOFETIL 500 MG Generic TABLET 0.4339$CENESTIN ESTROGENS,CONJ.,SYNTHETIC A 0.625 MG Brand TABLET 3.4871$CEPHALEXIN CEPHALEXIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1214$CEPHALEXIN CEPHALEXIN 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1310$CEPHULAC LACTULOSE 10 G/15 ML Generic SOLUTION, ORAL 0.0110$CESIA DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 Generic TABLET 0.4800$CETIRIZINE HCL CETIRIZINE HCL 5 MG Generic TABLET 0.1157$CEVIMELINE HCL CEVIMELINE HCL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.0740$CEVIMELINE HCL CEVIMELINE HCL 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 3.5200$CHANTIX VARENICLINE TARTRATE 0.5(11)-1 Brand TABLET, DOSE PACK 4.1845$CHANTIX VARENICLINE TARTRATE 1 MG Brand TABLET 3.9764$CHILDREN'S CETIRIZINE HCL CETIRIZINE HCL 10 MG Generic TABLET, CHEWABLE 2.4880$CHILDREN'S CLARITIN LORATADINE 5 MG Brand TABLET, CHEWABLE 0.8925$CHILDREN'S CLARITIN LORATADINE 5 MG/5 ML Generic SOLUTION, ORAL 0.0429$CHILDREN'S FERROUS SULFATE FERROUS SULFATE 15 MG/ML Generic DROPS 0.0610$CHILDREN'S MOTRIN IBUPROFEN 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0400$CHILDREN'S MOTRIN IBUPROFEN 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0602$CHILDREN'S MUCINEX GUAIFENESIN/DEXTROMETHORPHAN HBR 100-5 MG/5 Brand LIQUID (ML) 0.0454$CHILDRENS NASALCROM CROMOLYN SODIUM 5.2 MG Generic AEROSOL, SPRAY WITH PUMP (ML) 0.2699$CHILDREN'S PAIN & FEVER ACETAMINOPHEN 160 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0200$CHILDREN'S ZYRTEC CETIRIZINE HCL 1 MG/ML Generic SOLUTION, ORAL 0.0300$CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0736$CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$CHLORDIAZEPOXIDE-AMITRIPTYLINE AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 25 MG-10MG Generic TABLET 1.7648$CHLORDIAZEPOXIDE-CLIDINIUM CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 5 MG-2.5MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6067$CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 250 MG Generic TABLET 1.1276$CHLORPROMAZINE HCL CHLORPROMAZINE HCL 10 MG Generic TABLET 0.6000$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

CHLORPROMAZINE HCL CHLORPROMAZINE HCL 25 MG Generic TABLET 1.1117$CHLORPROMAZINE HCL CHLORPROMAZINE HCL 50 MG Generic TABLET 1.5150$CHLORTHALIDONE CHLORTHALIDONE 50 MG Generic TABLET 0.7363$CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G Generic POWDER (GRAM) 0.2360$CIALIS TADALAFIL 10 MG Brand TABLET 30.4375$CIALIS TADALAFIL 20 MG Brand TABLET 30.3289$CIALIS TADALAFIL 5 MG Brand TABLET 5.2197$CICLOPIROX CICLOPIROX 0.0077 Generic GEL (GRAM) 1.8450$CICLOPIROX CICLOPIROX 0.01 Generic SHAMPOO 0.7240$CILOSTAZOL CILOSTAZOL 100 MG Generic TABLET 0.1560$CILOSTAZOL CILOSTAZOL 50 MG Generic TABLET 0.1325$CILOXAN CIPROFLOXACIN HCL 0.003 Brand OINTMENT (GRAM) 33.7004$CILOXAN CIPROFLOXACIN HCL 0.003 Generic DROPS 0.8338$CIMETIDINE CIMETIDINE 400 MG Generic TABLET 0.3100$CIMETIDINE CIMETIDINE 800 MG Generic TABLET 0.6616$CIPRO CIPROFLOXACIN HCL 250 MG Generic TABLET 0.1200$CIPRO CIPROFLOXACIN HCL 500 MG Generic TABLET 0.1563$CIPRO CIPROFLOXACIN HCL 750 MG Generic TABLET 0.2341$CIPRO CIPROFLOXACIN Brand SUSPENSION, MICROCAPSULE RECONSTITUTED 1.2394$CIPRO HC CIPROFLOXACIN HCL/HYDROCORTISONE 0.2 %-1 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 16.3815$CIPRODEX CIPROFLOXACIN HCL/DEXAMETHASONE 0.3 %-0.1% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 19.4773$CITRANATAL 90 DHA PRENATAL VIT WITH CA NO.64/IRON CARB&GLUC/FOLIC ACID/DSS/DHA 90-1-300MG Generic COMBINATION PACKAGE (EA) 0.0973$CITRANATAL ASSURE PRENATAL VITAMINS NO.38/IRON CBN&GLUCON/FOLIC ACID/DSS/DHA 35-1-50MG Generic COMBINATION PACKAGE (EA) 0.5327$CITRUCEL METHYLCELLULOSE (WITH SUGAR) 0 Brand POWDER (GRAM) 0.0130$CLARINEX DESLORATADINE 5 MG Generic TABLET 0.7400$CLARITIN LORATADINE 10 MG Brand TABLET 0.9067$CLARITIN LORATADINE 10 MG Brand TABLET,DISINTEGRATING 0.5840$CLARITIN LORATADINE 10 MG Generic TABLET 0.1260$CLARITIN-D 12 HOUR LORATADINE/PSEUDOEPHEDRINE SULFATE 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.7386$CLARITIN-D 12 HOUR LORATADINE/PSEUDOEPHEDRINE SULFATE 5 MG-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.8030$CLARITIN-D 24 HOUR LORATADINE/PSEUDOEPHEDRINE SULFATE 10MG-240MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5825$CLARITIN-D 24 HOUR LORATADINE/PSEUDOEPHEDRINE SULFATE 10MG-240MG Brand TABLET, EXTENDED RELEASE 24 HR 1.0215$CLEOCIN CLINDAMYCIN PHOSPHATE 0.02 Generic CREAM WITH APPLICATOR 1.5081$CLEOCIN CLINDAMYCIN PHOSPHATE 100 MG Brand SUPPOSITORY, VAGINAL 29.9393$CLEOCIN HCL CLINDAMYCIN HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1168$CLEOCIN HCL CLINDAMYCIN HCL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2518$CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL 75 MG/5 ML Generic SOLUTION, RECONSTITUTED, ORAL 0.4020$CLEOCIN T CLINDAMYCIN PHOSPHATE 0.01 Generic GEL (GRAM) 1.6483$CLEOCIN T CLINDAMYCIN PHOSPHATE 1.00% Generic SOLUTION, NON-ORAL 0.9600$CLEOCIN T CLINDAMYCIN PHOSPHATE 1.00% Generic LOTION (ML) 1.3937$CLEOCIN T CLINDAMYCIN PHOSPHATE 0.01 Generic SWAB, MEDICATED 0.3800$CLIMARA ESTRADIOL .025MG/24H Brand PATCH, TRANSDERMAL WEEKLY 20.4445$CLIMARA ESTRADIOL .025MG/24H Generic PATCH, TRANSDERMAL WEEKLY 17.9289$CLIMARA ESTRADIOL .0375MG/24 Generic PATCH, TRANSDERMAL WEEKLY 15.8833$CLIMARA ESTRADIOL .0375MG/24 Brand PATCH, TRANSDERMAL WEEKLY 20.7176$CLIMARA ESTRADIOL .075MG/24H Generic PATCH, TRANSDERMAL WEEKLY 17.1825$CLIMARA ESTRADIOL .075MG/24H Brand PATCH, TRANSDERMAL WEEKLY 21.5151$CLIMARA ESTRADIOL 0.05MG/24H Generic PATCH, TRANSDERMAL WEEKLY 16.5300$CLIMARA ESTRADIOL 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 18.4378$CLIMARA ESTRADIOL 0.1MG/24HR Brand PATCH, TRANSDERMAL WEEKLY 21.6332$CLIMARA PRO ESTRADIOL/LEVONORGESTREL 45-15/24H Brand PATCH, TRANSDERMAL WEEKLY 27.3489$CLINDAGEL CLINDAMYCIN PHOSPHATE 0.01 Brand GEL (ML) 6.5900$CLINDAMYCIN PHOS-BENZOYL PEROX CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2(1)%-5% Generic GEL, EXTENDED RELEASE (GRAM) 3.0857$CLINDAMYCIN PHOS-BENZOYL PEROX CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2(1)%-5% Brand GEL, EXTENDED RELEASE (GRAM) 5.3399$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 150 MG/ML Generic VIAL (ML) 0.7122$CLINORIL SULINDAC 150 MG Generic TABLET 0.1167$CLINORIL SULINDAC 200 MG Generic TABLET 0.1678$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.0005 Generic FOAM (GRAM) 4.3425$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.1% Generic SHAMPOO 2.1950$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.1% Generic LOTION (ML) 4.0940$CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE/EMOLLIENT 0.0005 Brand FOAM (GRAM) 5.5601$CLOBEX CLOBETASOL PROPIONATE 0% Brand SPRAY, NON-AEROSOL (ML) 5.2580$CLODERM CLOCORTOLONE PIVALATE 0.001 Brand CREAM (GRAM) 5.9563$CLONAZEPAM CLONAZEPAM 0.5 MG Generic TABLET,DISINTEGRATING 0.7714$CLOTRIMAZOLE-BETAMETHASONE CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 1 %-0.05 % Generic LOTION (ML) 3.7523$CLOTRIMAZOLE-BETAMETHASONE CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 1 %-0.05 % Generic CREAM (GRAM) 0.9364$CLOZAPINE CLOZAPINE 200 MG Generic TABLET 3.0471$CLOZARIL CLOZAPINE 100 MG Generic TABLET 1.0100$CLOZARIL CLOZAPINE 25 MG Generic TABLET 0.4760$CODEINE SULFATE CODEINE SULFATE 30 MG Generic TABLET 0.3700$COLACE DOCUSATE SODIUM 100 MG Brand CAPSULE 0.2673$COLACE DOCUSATE SODIUM 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0169$COLACE GLYCERIN ADULT Brand SUPPOSITORY, RECTAL 0.0240$COLACE GLYCERIN ADULT Generic SUPPOSITORY, RECTAL 0.0633$COLAZAL BALSALAZIDE DISODIUM 750 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5875$COLCHICINE COLCHICINE 0.6 MG Brand TABLET 5.2482$COLESTID COLESTIPOL HCL 1 G Generic TABLET 0.5939$COL-PROBENECID COLCHICINE/PROBENECID 0.5-500MG Generic TABLET 0.7475$COLY-MYCIN S NEOMYCIN SULFATE/COLISTIN SULFATE/HYDROCORTISONE/THONZONIUM 3.3-3-10/1 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 6.6340$COLYTE PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL 240-22.72G Generic SOLUTION, RECONSTITUTED, ORAL 0.0027$COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL MALEATE 0.2%-0.5% Brand DROPS 19.2593$COMBIPATCH ESTRADIOL/NORETHINDRONE ACETATE .05-.14/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 9.6989$COMBIPATCH ESTRADIOL/NORETHINDRONE ACETATE .05-.25/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 9.0775$COMBIVENT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 18-103MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.1427$COMBIVENT RESPIMAT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 20-100 MCG Brand AEROSOL WITH ADAPTER (GRAM) 63.5867$COMPAZINE PROCHLORPERAZINE MALEATE 10 MG Generic TABLET 0.0627$COMPAZINE PROCHLORPERAZINE MALEATE 25 MG Generic SUPPOSITORY, RECTAL 7.5381$COMPAZINE PROCHLORPERAZINE MALEATE 5 MG Generic TABLET 0.0533$CONCEPT DHA PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 35-1-200MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8300$CONCEPT OB PRENATAL VITAMINS NO.15/IRON FUMARATE & POLYSAC COMP/FA 85 MG-1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7944$CONCERTA METHYLPHENIDATE HCL 18 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.3756$CONCERTA METHYLPHENIDATE HCL 27 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.5820$CONCERTA METHYLPHENIDATE HCL 27 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.5543$CONCERTA METHYLPHENIDATE HCL 36 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.1416$CONCERTA METHYLPHENIDATE HCL 36 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.7800$CONCERTA METHYLPHENIDATE HCL 54 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.5430$CONCERTA METHYLPHENIDATE HCL 54 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.5170$CONSTANT-T THEOPHYLLINE ANHYDROUS 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.2577$COPAXONE GLATIRAMER ACETATE 20 MG/ML Brand SYRINGE KIT (EA) 4,879.3417$CORDARONE AMIODARONE HCL 200 MG Generic TABLET 0.1557$CORDRAN FLURANDRENOLIDE 4MCG/SQ CM Brand TAPE, MEDICATED 300.8028$COREG CARVEDILOL 12.5 MG Generic TABLET 0.0393$COREG CARVEDILOL 25 MG Generic TABLET 0.0478$COREG CARVEDILOL 3.125 MG Generic TABLET 0.0397$COREG CARVEDILOL 6.25 MG Generic TABLET 0.0335$COREG CR CARVEDILOL PHOSPHATE 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.1429$COREG CR CARVEDILOL PHOSPHATE 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.1650$COREG CR CARVEDILOL PHOSPHATE 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.3427$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

COREG CR CARVEDILOL PHOSPHATE 80 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.1450$CORGARD NADOLOL 20 MG Generic TABLET 2.1425$CORGARD NADOLOL 40 MG Generic TABLET 2.7760$CORTEF HYDROCORTISONE 10 MG Generic TABLET 0.3253$CORTEF HYDROCORTISONE 5 MG Generic TABLET 0.2361$CORTENEMA HYDROCORTISONE 100MG/60ML Generic ENEMA (ML) 0.0802$CORTISPORIN NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE 3.5-10K-1 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 1.9720$CORTISPORIN NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE 3.5-10K-1 Generic SOLUTION, NON-ORAL 1.9940$CORTISPORIN NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE 3.5-10K-10 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 15.6664$COSOPT DORZOLAMIDE HCL/TIMOLOL MALEATE 2%-0.5% Generic DROPS 1.2364$COSOPT PF DORZOLAMIDE HCL/TIMOLOL MALEATE/PF 2 %-0.5 % Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 1.3725$COUMADIN WARFARIN SODIUM 1 MG Brand TABLET 1.4485$COUMADIN WARFARIN SODIUM 1 MG Generic TABLET 0.1629$COUMADIN WARFARIN SODIUM 10 MG Generic TABLET 0.1969$COUMADIN WARFARIN SODIUM 2 MG Generic TABLET 0.1685$COUMADIN WARFARIN SODIUM 2 MG Brand TABLET 1.5251$COUMADIN WARFARIN SODIUM 2.5 MG Generic TABLET 0.1374$COUMADIN WARFARIN SODIUM 2.5 MG Brand TABLET 1.5666$COUMADIN WARFARIN SODIUM 3 MG Generic TABLET 0.1876$COUMADIN WARFARIN SODIUM 3 MG Brand TABLET 1.5970$COUMADIN WARFARIN SODIUM 4 MG Generic TABLET 0.1862$COUMADIN WARFARIN SODIUM 5 MG Generic TABLET 0.1674$COUMADIN WARFARIN SODIUM 5 MG Brand TABLET 1.6858$COUMADIN WARFARIN SODIUM 6 MG Generic TABLET 0.2120$COUMADIN WARFARIN SODIUM 7.5 MG Generic TABLET 0.1773$COZAAR LOSARTAN POTASSIUM 100 MG Brand TABLET 3.7712$COZAAR LOSARTAN POTASSIUM 100 MG Generic TABLET 0.0967$COZAAR LOSARTAN POTASSIUM 25 MG Generic TABLET 0.0470$COZAAR LOSARTAN POTASSIUM 50 MG Generic TABLET 0.0759$CREON LIPASE/PROTEASE/AMYLASE 12K-38K-60 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.0440$CREON LIPASE/PROTEASE/AMYLASE 24-76-120K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.9783$CREON LIPASE/PROTEASE/AMYLASE 6K-19K-30K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 1.1064$CRESTOR ROSUVASTATIN CALCIUM 10 MG Brand TABLET 5.8248$CRESTOR ROSUVASTATIN CALCIUM 20 MG Brand TABLET 5.8280$CRESTOR ROSUVASTATIN CALCIUM 40 MG Brand TABLET 5.8374$CRESTOR ROSUVASTATIN CALCIUM 5 MG Brand TABLET 5.8231$CRINONE PROGESTERONE,MICRONIZED 0.08 Brand GEL WITH PREFILLED APPLICATOR (GRAM) 15.2563$CROMOLYN SODIUM CROMOLYN SODIUM 0.04 Generic DROPS 0.5625$CUTIVATE FLUTICASONE PROPIONATE 0.00005 Generic OINTMENT (GRAM) 0.4433$CUTIVATE FLUTICASONE PROPIONATE 0.0005 Generic CREAM (GRAM) 0.4800$CYANOCOBALAMIN INJECTION CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 3.1800$CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL 5 MG Generic TABLET 0.0575$CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 25 MG Generic TABLET 1.6256$CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.8920$CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 4.0861$CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6750$CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED 25 MG Brand CAPSULE 1.5427$CYMBALTA DULOXETINE HCL 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.2396$CYMBALTA DULOXETINE HCL 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.0433$CYMBALTA DULOXETINE HCL 30 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.9583$CYMBALTA DULOXETINE HCL 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.6566$CYMBALTA DULOXETINE HCL 60 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.9609$CYMBALTA DULOXETINE HCL 60 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.8638$CYTOMEL LIOTHYRONINE SODIUM 25 MCG Generic TABLET 0.7600$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

CYTOMEL LIOTHYRONINE SODIUM 25 MCG Brand TABLET 1.3634$CYTOMEL LIOTHYRONINE SODIUM 5 MCG Generic TABLET 0.4876$CYTOMEL LIOTHYRONINE SODIUM 5 MCG Brand TABLET 1.0101$CYTOMEL LIOTHYRONINE SODIUM 50 MCG Generic TABLET 1.1482$CYTOTEC MISOPROSTOL 200 MCG Generic TABLET 0.8047$CYTOXAN CYCLOPHOSPHAMIDE 50 MG Generic TABLET 2.5986$DALIRESP ROFLUMILAST 500 MCG Brand TABLET 6.9875$DALLERGY CHLORCYCLIZINE HCL/PHENYLEPHRINE HCL 12.5-5MG/5 Brand LIQUID (ML) 0.1124$DALMANE FLURAZEPAM HCL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2961$DANTRIUM DANTROLENE SODIUM 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8252$DANTROLENE SODIUM DANTROLENE SODIUM 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3417$DAPSONE DAPSONE 100 MG Generic TABLET 1.0483$DAYPRO OXAPROZIN 600 MG Generic TABLET 1.8400$DAYTRANA METHYLPHENIDATE 10MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.6120$DAYTRANA METHYLPHENIDATE 15MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.3657$DAYTRANA METHYLPHENIDATE 20 MG/9 HR Brand PATCH, TRANSDERMAL 24 HOURS 7.6120$DAYTRANA METHYLPHENIDATE 30MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.5471$DAZIDOX OXYCODONE HCL 10 MG Generic TABLET 0.2496$DAZIDOX OXYCODONE HCL 20 MG Generic TABLET 0.4333$DDAVP DESMOPRESSIN ACETATE 0.1 MG Generic TABLET 1.1650$DDAVP DESMOPRESSIN ACETATE 0.2 MG Generic TABLET 0.9546$DDAVP DESMOPRESSIN (NON-REFRIGERATED) 10/SPRAY Generic AEROSOL, SPRAY WITH PUMP (ML) 20.7150$DEBROX CARBAMIDE PEROXIDE 0.065 Generic DROPS 0.1350$DEBROX CARBAMIDE PEROXIDE 7% Brand DROPS 0.2978$DECADRON DEXAMETHASONE SOD PHOSPHATE 0% Generic DROPS 3.4700$DECADRON DEXAMETHASONE 0.5 MG Generic TABLET 0.0440$DECADRON DEXAMETHASONE 0.5 MG/5ML Generic ELIXIR 0.1856$DECADRON DEXAMETHASONE 4 MG Generic TABLET 0.1122$DECADRON PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 4 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.1253$DELATESTRYL TESTOSTERONE ENANTHATE 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 14.1580$DELTASONE PREDNISONE 10 MG Generic TABLET 0.1333$DELTASONE PREDNISONE 2.5 MG Generic TABLET 0.1180$DELTASONE PREDNISONE 20 MG Generic TABLET 0.1920$DELTASONE PREDNISONE 5 MG Generic TABLET 0.1350$DELZICOL MESALAMINE 400 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.2980$DEMADEX TORSEMIDE 20 MG Generic TABLET 0.1183$DEMEROL MEPERIDINE HCL 50 MG Generic TABLET 0.1629$DEMULEN 1/35-21 ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG Generic TABLET 0.6200$DENAVIR PENCICLOVIR 1.0% Brand CREAM (GRAM) 84.6802$DEPAKENE VALPROIC ACID 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1655$DEPAKOTE DIVALPROEX SODIUM 125 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0602$DEPAKOTE DIVALPROEX SODIUM 250 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0789$DEPAKOTE DIVALPROEX SODIUM 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.7627$DEPAKOTE DIVALPROEX SODIUM 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1230$DEPAKOTE ER DIVALPROEX SODIUM 250 MG Brand TABLET, EXTENDED RELEASE 24 HR 2.3061$DEPAKOTE ER DIVALPROEX SODIUM 250 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.6918$DEPAKOTE ER DIVALPROEX SODIUM 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 4.0117$DEPAKOTE ER DIVALPROEX SODIUM 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.5318$DEPAKOTE SPRINKLE DIVALPROEX SODIUM 125 MG Generic CAPSULE, SPRINKLE 0.6410$DEPO-ESTRADIOL ESTRADIOL CYPIONATE 5 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 10.4932$DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 150 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 56.2467$DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 58.8211$DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 100 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 7.2990$DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 9.4495$

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Page 15: Average Acquisition Cost (AAC) Price List (Effective 7/04/2014) · aclovate alclometasone dipropionate 0.0005 generic cream (gram) $ 1.2497 aclovate alclometasone dipropionate 0.0005

Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 10.9900$DERMA-SMOOTHE-FS FLUOCINOLONE ACETONIDE 0.0001 Generic OIL (ML) 1.4443$DERMA-SMOOTHE-FS FLUOCINOLONE ACETONIDE/SHOWER CAP 0.0% Generic OIL (ML) 1.4986$DERMA-SMOOTHE-FS FLUOCINOLONE ACETONIDE/SHOWER CAP 0.01 % Brand OIL (ML) 1.6268$DERMOTIC FLUOCINOLONE ACETONIDE OIL 0.0% Generic DROPS 8.4600$DERMOTIC FLUOCINOLONE ACETONIDE OIL 0.0001 Brand DROPS 1.3878$DESENEX TERBINAFINE HCL 0.01 Brand CREAM (GRAM) 0.4712$DESENEX TERBINAFINE HCL 0.01 Generic CREAM (GRAM) 0.3069$DESENEX MICONAZOLE NITRATE 2 % Brand POWDER (GRAM) 0.0626$DESIPRAMINE HCL DESIPRAMINE HCL 50 MG Generic TABLET 2.0125$DESOGEN DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 Generic TABLET 0.3546$DESONATE DESONIDE 0.05 % Brand GEL (GRAM) 5.9300$DESONIDE DESONIDE 0.0005 Generic OINTMENT (GRAM) 2.9478$DESONIDE DESONIDE 0.0005 Generic CREAM (GRAM) 4.0908$DESOWEN DESONIDE 0.0005 Generic LOTION (ML) 2.4875$DESOXIMETASONE DESOXIMETASONE 0.05% Generic CREAM (GRAM) 3.7000$DESOXIMETASONE DESOXIMETASONE 0.25 % Generic OINTMENT (GRAM) 4.4714$DESOXIMETASONE DESOXIMETASONE 0% Generic CREAM (GRAM) 1.4122$DESQUAM-X BENZOYL PEROXIDE 10.00% Generic CLEANSER (GRAM) 0.0435$DESYREL TRAZODONE HCL 100 MG Generic TABLET 0.0431$DESYREL TRAZODONE HCL 150 MG Generic TABLET 0.0882$DESYREL TRAZODONE HCL 50 MG Generic TABLET 0.0200$DETROL TOLTERODINE TARTRATE 2 MG Generic TABLET 2.1900$DETROL LA TOLTERODINE TARTRATE 2 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8055$DETROL LA TOLTERODINE TARTRATE 2 MG Generic CAPSULE, EXT RELEASE 24 HR 5.5500$DETROL LA TOLTERODINE TARTRATE 4 MG Brand CAPSULE, EXT RELEASE 24 HR 7.1480$DETROL LA TOLTERODINE TARTRATE 4 MG Generic CAPSULE, EXT RELEASE 24 HR 4.8514$DEXAMETHASONE DEXAMETHASONE 0.5 MG/5ML Generic SOLUTION, ORAL 0.0310$DEXAMETHASONE DEXAMETHASONE 1 MG Generic TABLET 0.2227$DEXAMETHASONE INTENSOL DEXAMETHASONE 1 MG/ML Brand DROPS 0.6505$DEXAMPEX DEXTROAMPHETAMINE SULFATE 10 MG Generic TABLET 1.7000$DEXEDRINE DEXTROAMPHETAMINE SULFATE 10 MG Generic CAPSULE, EXTENDED RELEASE 3.6780$DEXEDRINE DEXTROAMPHETAMINE SULFATE 15 MG Generic CAPSULE, EXTENDED RELEASE 4.2521$DEXEDRINE DEXTROAMPHETAMINE SULFATE 5 MG Generic TABLET 1.9825$DEXEDRINE DEXTROAMPHETAMINE SULFATE 5 MG Generic CAPSULE, EXTENDED RELEASE 4.2640$DEXILANT DEXLANSOPRAZOLE 30 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 5.9044$DEXILANT DEXLANSOPRAZOLE 60 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 5.9083$DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 15 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 5.4200$DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 5.6448$DIABETA GLYBURIDE 1.25 MG Generic TABLET 0.1050$DIABETA GLYBURIDE 2.5 MG Generic TABLET 0.1125$DIABETA GLYBURIDE 5 MG Generic TABLET 0.2270$DIAMOX ACETAZOLAMIDE 125 MG Generic TABLET 1.6525$DIAMOX ACETAZOLAMIDE 250 MG Generic TABLET 2.3600$DIASTAT ACUDIAL DIAZEPAM 5-7.5-10MG Generic KIT 287.3350$DIAZEPAM DIAZEPAM 5 MG/5 ML Generic SOLUTION, ORAL 0.0923$DICLOFENAC SODIUM DICLOFENAC SODIUM 0.10% Generic DROPS 1.7400$DICLOFENAC SODIUM DICLOFENAC SODIUM 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3775$DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4161$DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5200$DIFFERIN ADAPALENE 0.001 Brand LOTION (ML) 5.1509$DIFFERIN ADAPALENE 0.003 Brand GEL WITH PUMP (GRAM) 5.8608$DIFFERIN ADAPALENE 0.003 Brand GEL (GRAM) 5.8770$DIFLUCAN FLUCONAZOLE 100 MG Generic TABLET 1.5700$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

DIFLUCAN FLUCONAZOLE 150 MG Generic TABLET 2.2032$DIFLUCAN FLUCONAZOLE 200 MG Generic TABLET 2.4900$DIGOXIN DIGOXIN 250 MCG Generic TABLET 1.0927$DIGOXIN DIGOXIN 250 MCG Brand TABLET 0.5228$DIGOXIN DIGOXIN 50 MCG/ML Generic SOLUTION, ORAL 0.5640$DILACOR XR DILTIAZEM HCL 120 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5129$DILACOR XR DILTIAZEM HCL 180 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5700$DILACOR XR DILTIAZEM HCL 240 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5870$DILANTIN PHENYTOIN SODIUM EXTENDED 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1572$DILANTIN PHENYTOIN SODIUM EXTENDED 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.6206$DILANTIN PHENYTOIN SODIUM EXTENDED 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.5350$DILANTIN PHENYTOIN 50 MG Brand TABLET, CHEWABLE 0.5665$DILANTIN PHENYTOIN 50 MG Generic TABLET, CHEWABLE 0.3850$DILAUDID HYDROMORPHONE HCL 2 MG Generic TABLET 0.0914$DILAUDID HYDROMORPHONE HCL 4 MG Generic TABLET 0.1143$DILAUDID HYDROMORPHONE HCL 8 MG Generic TABLET 0.4740$DILTIAZEM 24HR CD DILTIAZEM HCL 360 MG Generic CAPSULE, EXT RELEASE 24 HR 7.4596$DILTIAZEM ER DILTIAZEM HCL 120 MG Generic CAPSULE, EXTENDED RELEASE 0.4814$DILTIAZEM ER DILTIAZEM HCL 180 MG Generic CAPSULE, EXTENDED RELEASE 0.5545$DILTIAZEM ER DILTIAZEM HCL 240 MG Generic CAPSULE, EXTENDED RELEASE 0.6975$DILTIAZEM ER DILTIAZEM HCL 300 MG Generic CAPSULE, EXTENDED RELEASE 1.3200$DILTIAZEM ER DILTIAZEM HCL 360 MG Generic CAPSULE, EXTENDED RELEASE 0.9000$DILTIAZEM ER DILTIAZEM HCL 60 MG Generic CAPSULE, EXTENDED RELEASE 12 HR 0.9948$DIOVAN VALSARTAN 160 MG Brand TABLET 4.4615$DIOVAN VALSARTAN 320 MG Brand TABLET 5.6577$DIOVAN VALSARTAN 40 MG Brand TABLET 3.4650$DIOVAN VALSARTAN 80 MG Brand TABLET 4.1280$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG Brand TABLET 4.2907$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG Generic TABLET 0.2800$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG Brand TABLET 4.9369$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG Generic TABLET 0.3057$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG Generic TABLET 0.2700$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG Brand TABLET 6.9278$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG Generic TABLET 0.3588$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG Brand TABLET 4.6092$DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG Generic TABLET 0.2300$DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0203$DIPHENOXYLATE-ATROPINE DIPHENOXYLATE HCL/ATROPINE SULFATE 2.5-.025MG Generic TABLET 0.1461$DIPROLENE BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL 0.0005 Generic LOTION (ML) 1.7900$DIPROLENE AF BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL 0.0005 Generic CREAM (GRAM) 0.4040$DIPROSONE BETAMETHASONE DIPROPIONATE 0.0005 Generic LOTION (ML) 0.5680$DISALCID SALSALATE 500 MG Generic TABLET 0.8634$DITROPAN OXYBUTYNIN CHLORIDE 5 MG Generic TABLET 0.4237$DITROPAN XL OXYBUTYNIN CHLORIDE 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9963$DITROPAN XL OXYBUTYNIN CHLORIDE 15 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.1060$DITROPAN XL OXYBUTYNIN CHLORIDE 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9563$DIULO METOLAZONE 2.5 MG Generic TABLET 0.4320$DIULO METOLAZONE 5 MG Generic TABLET 0.5500$DIVIGEL ESTRADIOL 0.5MG(0.1) Brand GEL IN PACKET (EA) 2.7830$DIVIGEL ESTRADIOL 1MG(0.1%) Brand GEL IN PACKET (GRAM) 2.7845$DOLOBID DIFLUNISAL 500 MG Generic TABLET 1.3221$DOLOPHINE HCL METHADONE HCL 10 MG Generic TABLET 0.0834$DOLOPHINE HCL METHADONE HCL 5 MG Generic TABLET 0.0536$DONATUSSIN PHENYLEPHRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN 5-12.5-120 Brand LIQUID (ML) 0.1200$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

DONNATAL PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE HB 16.2MG/5ML Generic ELIXIR 0.7448$DORYX DOXYCYCLINE HYCLATE 100 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 10.0368$DORYX DOXYCYCLINE HYCLATE 150 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 13.2750$DORYX DOXYCYCLINE HYCLATE 150 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 19.2392$DORYX DOXYCYCLINE HYCLATE 200 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 26.8137$DORZOLAMIDE HCL DORZOLAMIDE HCL 0.02 Generic DROPS 1.8264$DOXEPIN HCL DOXEPIN HCL 75 MG Generic CAPSULE 0.6960$DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4803$DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 50 MG Generic CAPSULE 0.3198$DRISDOL ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT Generic CAPSULE (HARD, SOFT, ETC.) 0.3650$DRISDOL ERGOCALCIFEROL (VITAMIN D2) 8000/ML Generic DROPS 1.0279$DRONABINOL DRONABINOL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 10.6683$DRONABINOL DRONABINOL 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.9062$DRONABINOL DRONABINOL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.9133$DRYSOL ALUMINUM CHLORIDE 0.2 Brand SOLUTION, NON-ORAL 0.1250$DUET DHA BALANCED PRENATAL VITAMIN NO.105/IRON EDTA &POLYSACCHA/FA/OM3/DHA/EPA 27-1-380MG Brand COMBINATION PACKAGE, TABLET & DR CAP 1.6368$DUET DHA EC STUARTNATAL PRENATAL VITAMINS COMB NO.19/IRON BG HCL&SUC-PROT/FA/OMEGA-3 29-1-400MG Generic COMBINATION PACKAGE, TABLET & DR CAP 0.5471$DUET DHA WITH FERRAZONE PRENATAL VITAMINS COMB NO.48/IRON NA FEREDETATE/FA/OMEGA-3 30-1-440MG Generic COMBINATION PACKAGE, TABLET & DR CAP 1.7011$DUEXIS IBUPROFEN/FAMOTIDINE 800-26.6MG Brand TABLET 8.7129$DULERA MOMETASONE FUROATE/FORMOTEROL FUMARATE 100-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.7527$DULERA MOMETASONE FUROATE/FORMOTEROL FUMARATE 200-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.7293$DUONEB IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 0.5-3MG/3 Generic AMPUL FOR NEBULIZATION (ML) 0.0808$DURAGESIC FENTANYL 100 MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 107.9625$DURAGESIC FENTANYL 100 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 16.1394$DURAGESIC FENTANYL 12 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 15.1177$DURAGESIC FENTANYL 25MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 29.1644$DURAGESIC FENTANYL 25MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 4.8107$DURAGESIC FENTANYL 50MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 53.7700$DURAGESIC FENTANYL 50MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 8.6896$DURAGESIC FENTANYL 75MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 79.4748$DURAGESIC FENTANYL 75MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 13.8485$DUREZOL DIFLUPREDNATE 0.0005 Brand DROPS 23.2591$DURICEF CEFADROXIL HYDRATE 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2722$DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5-25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1000$DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5-25 MG Brand CAPSULE 1.2150$DYMISTA AZELASTINE HCL/FLUTICASONE PROPIONATE 137-50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 6.0810$DYNACIN MINOCYCLINE HCL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3179$E.E.S. 200 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.4425$EC-NAPROSYN NAPROXEN 375 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2975$EC-NAPROSYN NAPROXEN 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1475$ECONOPRED PLUS PREDNISOLONE ACETATE 1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 9.1639$ECONOPRED PLUS PREDNISOLONE ACETATE 0.01 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 16.9323$EFFEXOR VENLAFAXINE HCL 37.5 MG Generic TABLET 0.3029$EFFEXOR VENLAFAXINE HCL 75 MG Generic TABLET 0.2980$EFFEXOR XR VENLAFAXINE HCL 150 MG Generic CAPSULE, EXT RELEASE 24 HR 0.2316$EFFEXOR XR VENLAFAXINE HCL 150 MG Brand CAPSULE, EXT RELEASE 24 HR 7.3502$EFFEXOR XR VENLAFAXINE HCL 37.5 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1698$EFFEXOR XR VENLAFAXINE HCL 37.5 MG Brand CAPSULE, EXT RELEASE 24 HR 6.6532$EFFEXOR XR VENLAFAXINE HCL 75 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1867$EFFEXOR XR VENLAFAXINE HCL 75 MG Brand CAPSULE, EXT RELEASE 24 HR 7.0855$EFFIENT PRASUGREL HCL 10 MG Brand TABLET 8.6904$EFUDEX FLUOROURACIL 5.00% Generic CREAM (GRAM) 4.0407$ELAVIL AMITRIPTYLINE HCL 10 MG Generic TABLET 0.0288$ELAVIL AMITRIPTYLINE HCL 100 MG Generic TABLET 0.1262$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ELAVIL AMITRIPTYLINE HCL 25 MG Generic TABLET 0.0343$ELAVIL AMITRIPTYLINE HCL 50 MG Generic TABLET 0.1133$ELDEPRYL SELEGILINE HCL 5 MG Generic TABLET 1.8097$ELESTAT EPINASTINE HCL 0.05% Generic DROPS 10.2275$ELESTRIN ESTRADIOL 0.87G Brand GEL IN METERED-DOSE PUMP 2.7658$ELIDEL PIMECROLIMUS 1% Brand CREAM (GRAM) 6.3275$ELIMITE PERMETHRIN 5% Generic CREAM (GRAM) 1.2282$ELIQUIS APIXABAN 2.5 MG Brand TABLET 4.6780$ELIQUIS APIXABAN 5 MG Brand TABLET 4.7023$ELMIRON PENTOSAN POLYSULFATE SODIUM 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.9391$ELOCON MOMETASONE FUROATE 0.10% Generic CREAM (GRAM) 0.3436$ELOCON MOMETASONE FUROATE 0.10% Generic OINTMENT (GRAM) 0.2786$ELOCON MOMETASONE FUROATE 0.001 Generic SOLUTION, NON-ORAL 0.2107$EMEND APREPITANT 125MG-80MG Brand CAPSULE, DOSE PACK 133.0567$EMEND APREPITANT 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 57.4810$EMLA LIDOCAINE/PRILOCAINE 2.5%-2.5% Generic CREAM (GRAM) 0.7500$ENABLEX DARIFENACIN HYDROBROMIDE 15 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1886$ENABLEX DARIFENACIN HYDROBROMIDE 7.5 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1600$ENALAPRIL-HYDROCHLOROTHIAZIDE ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 5MG-12.5MG Generic TABLET 0.0760$ENBREL ETANERCEPT 25 MG Brand VIAL (EA) 324.5964$ENBREL ETANERCEPT 50 MG/ML Brand DISPOSABLE SYRINGE (ML) 668.2088$ENBREL ETANERCEPT 50 MG/ML Brand PEN INJECTOR (ML) 669.4178$ENJUVIA ESTROGENS,CONJ.,SYNTHETIC B 1.25 MG Brand TABLET 2.3269$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 100 MG/ML Generic DISPOSABLE SYRINGE (ML) 33.7900$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 120MG/.8ML Generic DISPOSABLE SYRINGE (ML) 48.6796$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 69.2180$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 30MG/0.3ML Generic DISPOSABLE SYRINGE (ML) 39.8485$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 40MG/0.4ML Generic DISPOSABLE SYRINGE (ML) 35.0977$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 60MG/0.6ML Generic DISPOSABLE SYRINGE (ML) 35.8321$ENOXAPARIN SODIUM ENOXAPARIN SODIUM 80MG/0.8ML Generic DISPOSABLE SYRINGE (ML) 38.4508$ENTACAPONE ENTACAPONE 200 MG Generic TABLET 2.6800$EPI E-Z PEN JR. EPINEPHRINE 0.15MG/0.3 Brand PEN INJECTOR (EA) 167.2600$EPIDUO ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% Brand GEL (GRAM) 5.8583$EPIDUO ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% Brand GEL WITH PUMP (GRAM) 5.9000$EPINEPHRINE EPINEPHRINE 0.3MG/0.3 Generic AUTO-INJECTOR (EA) 138.6964$EPLERENONE EPLERENONE 25 MG Generic TABLET 2.1211$EPLERENONE EPLERENONE 50 MG Generic TABLET 1.9961$EPOGEN EPOETIN ALFA 20000/ML Brand VIAL (ML) 344.0274$EPZICOM ABACAVIR SULFATE/LAMIVUDINE 600-300MG Brand TABLET 33.3578$EQUILET CALCIUM CARBONATE 200(500)MG Brand TABLET, CHEWABLE 0.0300$ERYGEL ERYTHROMYCIN BASE/ETHYL ALCOHOL 0.02 Generic GEL (GRAM) 0.7058$ERY-TAB ERYTHROMYCIN BASE 333 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 3.2063$ERY-TAB ERYTHROMYCIN BASE 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 3.4335$ERYTHROCIN STEARATE ERYTHROMYCIN STEARATE 250 MG Brand TABLET 4.0033$ERYTHROMYCIN ERYTHROMYCIN BASE/ETHYL ALCOHOL 2 % Generic SWAB, MEDICATED 0.8776$ERYTHROMYCIN ERYTHROMYCIN BASE/ETHYL ALCOHOL 0.02 Generic SOLUTION, NON-ORAL 0.5925$ERYTHROMYCIN ERYTHROMYCIN BASE 250 MG Generic TABLET 4.4630$ERYTHROMYCIN ERYTHROMYCIN BASE 250 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.6100$ERYTHROMYCIN ERYTHROMYCIN BASE 500 MG Generic TABLET 6.7261$ERYTHROMYCIN ERYTHROMYCIN BASE 5MG/G Generic OINTMENT (GRAM) 3.0637$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Generic TABLET 0.1365$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Brand TABLET 5.2065$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Generic TABLET 0.1600$ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Brand TABLET 5.6550$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG Generic TABLET 0.2200$ESGIC BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 Generic TABLET 0.2399$ESIDRIX HYDROCHLOROTHIAZIDE 25 MG Generic TABLET 0.0153$ESIDRIX HYDROCHLOROTHIAZIDE 50 MG Generic TABLET 0.0580$ESKALITH LITHIUM CARBONATE 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0313$ESKALITH LITHIUM CARBONATE 300 MG Generic TABLET 0.1688$ESKALITH CR LITHIUM CARBONATE 450 MG Generic TABLET, EXTENDED RELEASE 0.2870$ESTAZOLAM ESTAZOLAM 2 MG Generic TABLET 0.4035$ESTRACE ESTRADIOL 0.0% Brand CREAM WITH APPLICATOR 3.4375$ESTRACE ESTRADIOL 0.5 MG Generic TABLET 0.0719$ESTRACE ESTRADIOL 1 MG Generic TABLET 0.0742$ESTRACE ESTRADIOL 2 MG Generic TABLET 0.1045$ESTRING ESTRADIOL 7.5MCG/24H Brand RING, VAGINAL 235.4490$ESTROPIPATE ESTROPIPATE 1.5 MG Generic TABLET 0.5568$ESTROSTEP FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 5-7-9-7 Generic TABLET 1.0060$ESZOPICLONE ESZOPICLONE 1 MG Generic TABLET 0.7925$ESZOPICLONE ESZOPICLONE 2 MG Generic TABLET 0.7975$ESZOPICLONE ESZOPICLONE 3 MG Generic TABLET 0.8027$ETHOSUXIMIDE ETHOSUXIMIDE 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5882$EVAMIST ESTRADIOL 1.53/SPRAY Brand SPRAY, NON-AEROSOL (ML) 10.9596$EVISTA RALOXIFENE HCL 60 MG Brand TABLET 5.8740$EVISTA RALOXIFENE HCL 60 MG Generic TABLET 5.2128$EVOCLIN CLINDAMYCIN PHOSPHATE 1.0% Generic FOAM (GRAM) 3.8520$EXALGO HYDROMORPHONE HCL 16 MG Brand TABLET, EXTENDED RELEASE 24 HR 24.4799$EXALGO HYDROMORPHONE HCL 32 MG Brand TABLET, EXTENDED RELEASE 24 HR 50.0205$EXALGO HYDROMORPHONE HCL 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2659$EXELON RIVASTIGMINE 13.3MG/24H Brand PATCH, TRANSDERMAL 24 HOURS 10.9380$EXELON RIVASTIGMINE 4.6MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 10.9411$EXELON RIVASTIGMINE 9.5MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 10.9644$EXFORGE AMLODIPINE BESYLATE/VALSARTAN 10MG-320MG Brand TABLET 6.6175$EXFORGE HCT AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE 10-320-25 Brand TABLET 7.0075$FAMCICLOVIR FAMCICLOVIR 250 MG Generic TABLET 0.7665$FAMCICLOVIR FAMCICLOVIR 500 MG Generic TABLET 1.3300$FAMOTIDINE FAMOTIDINE 40 MG Generic TABLET 0.0629$FANAPT ILOPERIDONE 12 MG Brand TABLET 12.5627$FANAPT ILOPERIDONE 6 MG Brand TABLET 12.5974$FELDENE PIROXICAM 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9800$FELDENE PIROXICAM 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7000$FELODIPINE ER FELODIPINE 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4183$FELODIPINE ER FELODIPINE 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6048$FELODIPINE ER FELODIPINE 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5964$FEMARA LETROZOLE 2.5 MG Generic TABLET 0.2000$FEMCARE CLOTRIMAZOLE 0.01 Generic CREAM WITH APPLICATOR 0.0800$FEMCON FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.4-35(21) Generic TABLET, CHEWABLE 2.1039$FEMCON FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.4-35(21) Brand TABLET, CHEWABLE 2.7252$FEMECAL OB PLUS DHA PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX & ASPGL/FA/DHA 22-6-1-200 Generic COMBINATION PACKAGE (EA) 0.6250$FEMHRT NORETHINDRONE ACETATE/ETHINYL ESTRADIOL 1MG-5MCG Brand TABLET 1.7842$FEMRING ESTRADIOL ACETATE 0.05MG/24H Brand RING, VAGINAL 219.4614$FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 145MG Generic TABLET 2.1395$FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 145MG Brand TABLET 6.0037$FENOFIBRATE FENOFIBRATE,MICRONIZED 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.2317$FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 48 MG Generic TABLET 0.8975$FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 48 MG Brand TABLET 2.1361$FERRO-BOB FERROUS SULFATE 325(65) MG Generic TABLET 0.0100$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

FERROUS GLUCONATE FERROUS GLUCONATE 324(38)MG Generic TABLET 0.0464$FERROUS SULFATE FERROUS SULFATE 220(44)/5 Generic SOLUTION, ORAL 0.0061$FERROUS SULFATE FERROUS SULFATE 325(65) MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1408$FETZIMA LEVOMILNACIPRAN HYDROCHLORIDE 40 MG Brand CAPSULE, EXTENDED RELEASE 24HR 6.7775$FIBER PSYLLIUM HUSK 0.52G Generic CAPSULE 0.0400$FIBER CALCIUM POLYCARBOPHIL 625 MG Generic TABLET 0.0583$FIBER LAXATIVE CALCIUM POLYCARBOPHIL 625 MG Brand TABLET 0.1123$FINACEA AZELAIC ACID 15.0% Brand GEL (GRAM) 4.1888$FINASTERIDE FINASTERIDE 5 MG Generic TABLET 0.1734$FIRST-LANSOPRAZOLE LANSOPRAZOLE 3 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3833$FIRST-MOUTHWASH BLM MAG HYDROXIDE/AL HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAINE 25-200/30 Generic MOUTHWASH 0.1000$FLAGYL METRONIDAZOLE 250 MG Generic TABLET 0.2800$FLAGYL METRONIDAZOLE 500 MG Generic TABLET 0.5125$FLECAINIDE ACETATE FLECAINIDE ACETATE 100 MG Generic TABLET 0.3214$FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG Generic TABLET 0.6000$FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG Generic TABLET 0.1809$FLECTOR DICLOFENAC EPOLAMINE 1.30% Brand PATCH, TRANSDERMAL 12 HOURS 7.1338$FLEXERIL CYCLOBENZAPRINE HCL 10 MG Generic TABLET 0.0243$FLOMAX TAMSULOSIN HCL 0.4 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1504$FLONASE FLUTICASONE PROPIONATE 50 MCG Generic SPRAY, SUSPENSION 0.4891$FLONASE FLUTICASONE PROPIONATE 50 MCG Brand SPRAY, SUSPENSION 4.9734$FLORINEF ACETATE FLUDROCORTISONE ACETATE 0.1 MG Generic TABLET 0.4633$FLOVENT FLUTICASONE PROPIONATE 110MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.6250$FLOVENT FLUTICASONE PROPIONATE 220 MCG Brand AEROSOL WITH ADAPTER (GRAM) 22.6641$FLOVENT FLUTICASONE PROPIONATE 44MCG Brand AEROSOL WITH ADAPTER (GRAM) 12.3864$FLOVENT DISKUS FLUTICASONE PROPIONATE 100 MCG Brand DISK, WITH INHALATION DEVICE 2.1771$FLOVENT DISKUS FLUTICASONE PROPIONATE 250 MCG Brand DISK, WITH INHALATION DEVICE 2.9650$FLOVENT DISKUS FLUTICASONE PROPIONATE 50 MCG Brand DISK, WITH INHALATION DEVICE 2.0933$FLOXIN OFLOXACIN 0.003 Generic DROPS 2.5100$FLUCONAZOLE FLUCONAZOLE 10 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5064$FLUCONAZOLE FLUCONAZOLE 40 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6887$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0001 Generic SOLUTION, NON-ORAL 2.4467$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.00025 Generic OINTMENT (GRAM) 1.3614$FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0% Generic CREAM (GRAM) 1.5814$FLUOCINONIDE FLUOCINONIDE 0.0005 Generic CREAM (GRAM) 2.0058$FLUOCINONIDE FLUOCINONIDE 0.1 % Generic CREAM (GRAM) 11.4050$FLUOR-A-DAY SODIUM FLUORIDE/XYLITOL 0.25(0.55) Brand TABLET, CHEWABLE 0.7873$FLUOR-A-DAY SODIUM FLUORIDE/XYLITOL 0.5(1.1)MG Brand TABLET, CHEWABLE 0.6943$FLUOR-A-DAY SODIUM FLUORIDE 2.5 MG/ML Brand DROPS 1.5507$FLUORIDE SODIUM FLUORIDE 1MG(2.2MG) Generic TABLET, CHEWABLE 0.0300$FLUOROMETHOLONE FLUOROMETHOLONE 0.001 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 9.1167$FLUOXETINE HCL FLUOXETINE HCL 60 MG Generic TABLET 3.6850$FLUPHENAZINE HCL FLUPHENAZINE HCL 1 MG Generic TABLET 0.0983$FLURBIPROFEN FLURBIPROFEN 100 MG Generic TABLET 0.2077$FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM 0.0003 Generic DROPS 0.8361$FLUVASTATIN SODIUM FLUVASTATIN SODIUM 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.0979$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic TABLET 0.2917$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic CAPSULE, EXT RELEASE 24 HR 7.9275$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25 MG Generic TABLET 0.1812$FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50 MG Generic TABLET 0.2420$FLUZONE 2012-2013 INFLUENZA VIRUS VACCINE TVS 2012-2013 (36 MOS AND OLDER)/PF 45MCG/.5ML Brand DISPOSABLE SYRINGE (ML) 22.3000$FLUZONE 2012-2013 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (6 MOS AND OLDER) 45MCG/.5ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 20.0600$FLUZONE HIGH-DOSE 2012-13 INFLUENZA VIRUS VACCINE TRIVALENT-SPLIT 2012-2013 (65YR+)/PF 180MCG/0.5 Brand DISPOSABLE SYRINGE (ML) 52.7000$FLUZONE INTRADERMAL 2012-2013 INFLUENZA VIRUS VACCINE TVS 2012-2013 (18 YRS-64 YRS)/PF 27MCG/.1ML Brand DISPOSABLE SYRINGE (ML) 154.0000$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

FML FORTE FLUOROMETHOLONE 0.0025 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 17.1400$FML S.O.P. FLUOROMETHOLONE 0.10% Brand OINTMENT (GRAM) 25.4286$FOCALIN DEXMETHYLPHENIDATE HCL 10 MG Generic TABLET 1.0150$FOCALIN DEXMETHYLPHENIDATE HCL 5 MG Generic TABLET 0.6975$FOCALIN XR DEXMETHYLPHENIDATE HCL 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.0800$FOCALIN XR DEXMETHYLPHENIDATE HCL 15 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.3501$FOCALIN XR DEXMETHYLPHENIDATE HCL 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.1350$FOCALIN XR DEXMETHYLPHENIDATE HCL 25 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.3180$FOCALIN XR DEXMETHYLPHENIDATE HCL 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.3937$FOCALIN XR DEXMETHYLPHENIDATE HCL 5 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.9915$FOLBALIN PLUS CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE 2-2.5-25MG Generic TABLET 0.4186$FOLBEE CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE 1-2.5-25MG Generic TABLET 0.5020$FOLGARD RX CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE 1-2.2-25MG Generic TABLET 0.3310$FOLIC ACID FOLIC ACID 1 MG Generic TABLET 0.0314$FORADIL FORMOTEROL FUMARATE 12 MCG Brand CAPSULE, WITH INHALATION DEVICE 3.2425$FORTAMET METFORMIN HCL 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 7.0783$FORTEO TERIPARATIDE 20MCG/DOSE Brand PEN INJECTOR (ML) 568.7113$FORTESTA TESTOSTERONE 10 MG (2%) Brand GEL IN METERED-DOSE PUMP 5.7250$FOSAMAX ALENDRONATE SODIUM 35 MG Generic TABLET 0.5700$FOSAMAX ALENDRONATE SODIUM 70 MG Generic TABLET 0.4896$FOSAMAX PLUS D ALENDRONATE SODIUM/CHOLECALCIFEROL (VITAMIN D3) 70 MG-2800 Brand TABLET 29.5417$FRAGMIN DALTEPARIN SODIUM,PORCINE 12500/0.5 Brand DISPOSABLE SYRINGE (ML) 170.2572$FRAGMIN DALTEPARIN SODIUM,PORCINE 5000/0.2ML Brand DISPOSABLE SYRINGE (ML) 176.2251$FRESHKOTE EYE LUBRICANT COMBINATION NO.1 2-0.9-1.8% Brand DROPS 1.8225$FROVA FROVATRIPTAN SUCCINATE 2.5 MG Brand TABLET 42.5903$FURADANTIN NITROFURANTOIN 25 MG/5 ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 1.6999$FUROSEMIDE FUROSEMIDE 20 MG Generic TABLET 0.0100$FUROSEMIDE FUROSEMIDE 40 MG Generic TABLET 0.0100$FUROSEMIDE FUROSEMIDE 80 MG Brand TABLET 0.8999$FUROSEMIDE FUROSEMIDE 80 MG Generic TABLET 0.0250$GABAPENTIN GABAPENTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0350$GABAPENTIN GABAPENTIN 250 MG/5ML Generic SOLUTION, ORAL 0.1975$GABAPENTIN GABAPENTIN 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 2.4828$GABAPENTIN GABAPENTIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0494$GABAPENTIN GABAPENTIN 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$GABAPENTIN GABAPENTIN 600 MG Generic TABLET 0.1578$GABAPENTIN GABAPENTIN 800 MG Generic TABLET 0.3173$GALANTAMINE HBR GALANTAMINE HBR 16 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.1726$GALANTAMINE HBR GALANTAMINE HBR 8 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.3823$GARAMYCIN GENTAMICIN SULFATE 0.001 Generic CREAM (GRAM) 1.2194$GARAMYCIN GENTAMICIN SULFATE 0.1% Generic OINTMENT (GRAM) 1.5431$GARAMYCIN GENTAMICIN SULFATE 0.3% Generic OINTMENT (GRAM) 3.6151$GARAMYCIN GENTAMICIN SULFATE 0.3% Generic DROPS 0.8814$GATIFLOXACIN GATIFLOXACIN 0.5 % Generic DROPS 41.1290$GATIFLOXACIN GATIFLOXACIN 0.5 % Brand DROPS 42.9590$GELNIQUE OXYBUTYNIN CHLORIDE 0.1 Brand GEL IN PACKET (GRAM) 6.5000$GENAPHED PSEUDOEPHEDRINE HCL 30 MG Generic TABLET 0.0405$GENERESS FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.8-25(24) Brand TABLET, CHEWABLE 3.0920$GENTEAL MILD TO MODERATE HYPROMELLOSE 0.3 % Brand DROPS 0.4463$GENTEAL SEVERE HYPROMELLOSE 0.3 % Brand GEL (GRAM) 0.8758$GEODON ZIPRASIDONE HCL 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.3153$GEODON ZIPRASIDONE HCL 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.8464$GEODON ZIPRASIDONE HCL 60 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.0995$GEODON ZIPRASIDONE HCL 80 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.0152$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

GESTICARE DHA PRENATAL VIT WITH CALCIUM #60/IRON/FOLIC ACID/DHA 27-1-250MG Brand COMBINATION PACKAGE, TAB MP 24HR & CAP 1.2495$GIANVI ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) Generic TABLET 1.9138$GIANVI ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) Brand TABLET 2.1094$GLIPIZIDE ER GLIPIZIDE 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2977$GLIPIZIDE ER GLIPIZIDE 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1771$GLIPIZIDE XL GLIPIZIDE 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3032$GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL 2.5-500 MG Generic TABLET 0.3950$GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL 5 MG-500MG Generic TABLET 0.4740$GLUCAGEN GLUCAGON,HUMAN RECOMBINANT 1 MG Brand KIT 173.7079$GLUCAGEN GLUCAGON,HUMAN RECOMBINANT 1 MG Brand VIAL (EA) 161.2012$GLUCOPHAGE METFORMIN HCL 1000 MG Generic TABLET 0.0357$GLUCOPHAGE METFORMIN HCL 500 MG Generic TABLET 0.0200$GLUCOPHAGE METFORMIN HCL 850 MG Generic TABLET 0.0425$GLUCOPHAGE XR METFORMIN HCL 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.0495$GLUCOPHAGE XR METFORMIN HCL 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.0929$GLUCOTROL GLIPIZIDE 10 MG Generic TABLET 0.0473$GLUCOTROL GLIPIZIDE 5 MG Generic TABLET 0.0293$GLUCOVANCE GLYBURIDE/METFORMIN HCL 2.5-500 MG Generic TABLET 0.0825$GLUCOVANCE GLYBURIDE/METFORMIN HCL 5 MG-500MG Generic TABLET 0.0825$GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 3 MG Generic TABLET 0.0377$GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 6 MG Generic TABLET 0.0876$GLYCOPYRROLATE GLYCOPYRROLATE 1 MG Generic TABLET 0.2850$GOLYTELY PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL 227.1-21.5 Brand POWDER IN PACKET (EA) 12.1756$GOLYTELY PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL 236-22.74G Generic SOLUTION, RECONSTITUTED, ORAL 0.0031$GRALISE GABAPENTIN 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.3759$GRALISE GABAPENTIN 600 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.6860$GRANISETRON HCL GRANISETRON HCL 1 MG Generic TABLET 5.8850$GUAIFENESIN-CODEINE GUAIFENESIN/CODEINE PHOSPHATE 100-10MG/5 Generic LIQUID (ML) 0.0191$HABITROL NICOTINE 21 MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 3.0402$HABITROL NICOTINE Generic PATCH, TRANSDERMAL 24 HOURS 1.7624$HALCION TRIAZOLAM 0.125 MG Generic TABLET 0.6923$HALCION TRIAZOLAM 0.25 MG Generic TABLET 0.9940$HALDOL HALOPERIDOL 0.5 MG Generic TABLET 0.2100$HALDOL HALOPERIDOL 1 MG Generic TABLET 0.3100$HALDOL HALOPERIDOL 10 MG Generic TABLET 0.9133$HALDOL HALOPERIDOL 5 MG Generic TABLET 0.6207$HALDOL DECANOATE 100 HALOPERIDOL DECANOATE 100 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 43.3034$HALFLYTELY-BISACODYL BISACODYL/SODIUM CHLOR/SODIUM BICARB/POTASSIUM CHL/PEG 3350 5 MG-210 G Brand KIT 63.4725$HALOG HALCINONIDE 0.1 % Brand CREAM (GRAM) 3.4850$HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 23.5911$HEALTHYLAX POLYETHYLENE GLYCOL 3350 17G Generic POWDER IN PACKET (EA) 1.4302$HEMORRHOIDAL OINTMENT PHENYLEPHRINE HCL/SHARK LIVER OIL/MINERAL OIL/PETROLAT,WHT 0 Generic OINTMENT (GRAM) 0.1673$HEPARIN SODIUM HEPARIN SODIUM,PORCINE 10000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 4.4134$HEPARIN SODIUM HEPARIN SODIUM,PORCINE 5000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.3020$HIPREX METHENAMINE HIPPURATE 1 G Generic TABLET 1.6438$HUMALOG INSULIN LISPRO 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 17.7924$HUMALOG INSULIN LISPRO 100/ML Brand INSULIN PEN (ML) 22.9011$HUMALOG INSULIN LISPRO 100/ML Brand CARTRIDGE (ML) 22.0125$HUMALOG MIX 75-25 INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML Brand INSULIN PEN (ML) 23.0229$HUMALOG MIX 75-25 INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 18.3009$HUMIBID DM GUAIFENESIN/DEXTROMETHORPHAN HBR 600MG-30MG Brand TABLET, EXTENDED RELEASE 12 HR 0.4369$HUMIBID L.A. GUAIFENESIN 600 MG Generic TABLET, EXTENDED RELEASE 0.3960$HUMIRA ADALIMUMAB 40MG/0.8ML Brand KIT 1,201.3825$HUMIRA ADALIMUMAB 40MG/0.8ML Brand PEN INJECTOR KIT (EA) 1,203.6846$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

HUMULIN 70-30 NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.5596$HUMULIN 70-30 NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML Brand INSULIN PEN (ML) 18.5080$HUMULIN N NPH, HUMAN INSULIN ISOPHANE 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.9755$HUMULIN N NPH, HUMAN INSULIN ISOPHANE 100/ML (3) Brand INSULIN PEN (ML) 19.3940$HUMULIN R INSULIN REGULAR, HUMAN 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.9477$HUMULIN R INSULIN REGULAR, HUMAN 500/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 48.6017$HYCODAN HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE 5-1.5 MG/5 Generic SYRUP 0.1000$HYDRALAZINE HCL HYDRALAZINE HCL 100 MG Generic TABLET 0.1275$HYDRALAZINE HCL HYDRALAZINE HCL 25 MG Generic TABLET 0.1306$HYDREA HYDROXYUREA 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3667$HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0688$HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic TABLET 0.1280$HYDROCODONE/ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 10MG-325MG Brand TABLET 2.2196$HYDROCODONE/ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 10MG-325MG Generic TABLET 0.1102$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 10-660MG Generic TABLET 0.1768$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 10MG-300MG Generic TABLET 1.3150$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 10MG-650MG Generic TABLET 0.0817$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 5MG-300MG Brand TABLET 1.3513$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 5MG-300MG Generic TABLET 0.9300$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 7.5-300MG Generic TABLET 1.0200$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 Generic SOLUTION, ORAL 0.1090$HYDROCODONE-ACETAMINOPHEN HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/15 Generic SOLUTION, ORAL 0.0442$HYDROCODONE-CHLORPHENIRAMINE HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX 10-8MG/5ML Generic SUSPENSION, EXTENDED RELEASE 12 HR 0.5492$HYDROCODONE-CHLORPHENIRAMINE HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX 10-8MG/5ML Brand SUSPENSION, EXTENDED RELEASE 12 HR 1.1273$HYDROCORTISONE HYDROCORTISONE 0.01 Generic OINTMENT (GRAM) 0.1356$HYDROCORTISONE HYDROCORTISONE 1 % Brand CREAM (GRAM) 0.2014$HYDROCORTISONE HYDROCORTISONE 0.025 Generic CREAM (GRAM) 0.1107$HYDROCORTISONE HYDROCORTISONE 0.025 Generic OINTMENT (GRAM) 0.1100$HYDROCORTISONE HYDROCORTISONE 20 MG Generic TABLET 0.5950$HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE 0.001 Generic CREAM (GRAM) 3.1289$HYDROCORTISONE-ACETIC ACID ACETIC ACID/HYDROCORTISONE 2 %-1 % Generic DROPS 8.8025$HYDROCORTISONE-PRAMOXINE HYDROCORTISONE ACETATE/PRAMOXINE HCL 1 %-1 % Generic CREAM WITH APPLICATOR 1.6918$HYDROMORPHONE HCL HYDROMORPHONE HCL 1 MG/ML Generic LIQUID (ML) 0.3024$HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200 MG Generic TABLET 0.0964$HYGROTON CHLORTHALIDONE 25 MG Generic TABLET 0.4945$HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.375 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.8364$HYTONE HYDROCORTISONE 3% Generic LOTION (ML) 0.1630$HYTRIN TERAZOSIN HCL 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0725$HYTRIN TERAZOSIN HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0730$HYTRIN TERAZOSIN HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0700$HYTRIN TERAZOSIN HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0588$HYZAAR LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 100-12.5MG Generic TABLET 0.1458$HYZAAR LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 100MG-25MG Generic TABLET 0.1358$HYZAAR LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 50-12.5 MG Generic TABLET 0.0983$IBUPROFEN IBUPROFEN 400 MG Generic TABLET 0.0550$IBUPROFEN IBUPROFEN 600 MG Generic TABLET 0.0560$IBUPROFEN IBUPROFEN 800 MG Generic TABLET 0.0720$ILEVRO NEPAFENAC 0.003 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 89.3285$IMDUR ISOSORBIDE MONONITRATE 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2647$IMDUR ISOSORBIDE MONONITRATE 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3029$IMIPRAMINE HCL IMIPRAMINE HCL 10 MG Generic TABLET 0.1014$IMIPRAMINE HCL IMIPRAMINE HCL 25 MG Generic TABLET 0.1429$IMIPRAMINE HCL IMIPRAMINE HCL 50 MG Generic TABLET 0.2238$IMITREX SUMATRIPTAN SUCCINATE 100 MG Generic TABLET 1.0576$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

IMITREX SUMATRIPTAN 20 MG Generic SPRAY, NON-AEROSOL (EA) 39.1700$IMITREX SUMATRIPTAN 20 MG Brand SPRAY, NON-AEROSOL (EA) 42.6725$IMITREX SUMATRIPTAN SUCCINATE 25 MG Generic TABLET 1.0592$IMITREX SUMATRIPTAN 5 MG Generic SPRAY, NON-AEROSOL (EA) 33.5962$IMITREX SUMATRIPTAN SUCCINATE 50 MG Generic TABLET 1.0118$IMITREX SUMATRIPTAN SUCCINATE 6 MG/0.5ML Brand CARTRIDGE (ML) 208.7900$IMITREX SUMATRIPTAN SUCCINATE 6 MG/0.5ML Generic CARTRIDGE (ML) 136.6900$IMURAN AZATHIOPRINE 50 MG Generic TABLET 0.3129$INDAPAMIDE INDAPAMIDE 1.25 MG Generic TABLET 0.1434$INDERAL PROPRANOLOL HCL 10 MG Generic TABLET 0.0282$INDERAL PROPRANOLOL HCL 20 MG Generic TABLET 0.0269$INDERAL PROPRANOLOL HCL 40 MG Generic TABLET 0.0316$INDERAL LA PROPRANOLOL HCL 120 MG Generic CAPSULE, EXTENDED RELEASE 24HR 2.3871$INDERAL LA PROPRANOLOL HCL 160 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.7550$INDERAL LA PROPRANOLOL HCL 60 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.6475$INDERAL LA PROPRANOLOL HCL 80 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.8783$INDOCIN INDOMETHACIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1417$INDOCIN SR INDOMETHACIN 75 MG Generic CAPSULE, EXTENDED RELEASE 1.4467$INDOMETHACIN INDOMETHACIN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1617$INTUNIV GUANFACINE HCL 1 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.3620$INTUNIV GUANFACINE HCL 2 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.0650$INTUNIV GUANFACINE HCL 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.3820$INTUNIV GUANFACINE HCL 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.2125$INVEGA PALIPERIDONE 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 21.3118$INVEGA PALIPERIDONE 6 MG Brand TABLET, EXTENDED RELEASE 24 HR 23.4022$INVEGA PALIPERIDONE 9 MG Brand TABLET, EXTENDED RELEASE 24 HR 34.2650$INVOKANA CANAGLIFLOZIN 100 MG Brand TABLET 9.2363$INVOKANA CANAGLIFLOZIN 300 MG Brand TABLET 9.2567$IRBESARTAN IRBESARTAN 75 MG Generic TABLET 0.2070$IRBESARTAN-HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG Generic TABLET 0.2738$ISENTRESS RALTEGRAVIR POTASSIUM 400 MG Brand TABLET 18.1262$ISONIAZID ISONIAZID 100 MG Generic TABLET 0.0754$ISONIAZID ISONIAZID 300 MG Generic TABLET 0.9475$ISTALOL TIMOLOL MALEATE 0.005 Brand DROPS, ONCE DAILY 44.0109$ITRACONAZOLE ITRACONAZOLE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.9450$JALYN DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 4.4050$JANUMET SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50-1000 MG Brand TABLET 4.5633$JANUMET SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50MG-500MG Brand TABLET 4.5300$JANUMET XR SITAGLIPTIN PHOSPHATE/METFORMIN HCL 100-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 9.1550$JANUMET XR SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50-1000 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 4.5436$JANUVIA SITAGLIPTIN PHOSPHATE 100 MG Brand TABLET 9.1313$JANUVIA SITAGLIPTIN PHOSPHATE 25 MG Brand TABLET 9.3850$JANUVIA SITAGLIPTIN PHOSPHATE 50 MG Brand TABLET 9.0733$JOLESSA LEVONORGESTREL-ETHINYL ESTRADIOL 0.15-0.03 Generic TABLET, DOSE PACK, 3 MONTHS 0.7025$JOLESSA LEVONORGESTREL-ETHINYL ESTRADIOL 0.15-0.03 Brand TABLET, DOSE PACK, 3 MONTHS 0.8840$JOLIVETTE NORETHINDRONE 0.35 MG Generic TABLET 0.5667$JOLIVETTE NORETHINDRONE 0.35 MG Brand TABLET 0.4467$JUST D CHOLECALCIFEROL (VITAMIN D3) 400/ML Generic DROPS 0.0850$K EFFERVESCENT POTASSIUM BICARBONATE/CITRIC ACID 25 MEQ Generic TABLET, EFFERVESCENT 0.1929$KAON-CL 10 POTASSIUM CHLORIDE 10 MEQ Brand TABLET, EXTENDED RELEASE 0.3760$KAON-CL 10 POTASSIUM CHLORIDE 10 MEQ Generic TABLET, EXTENDED RELEASE 0.3048$KAPVAY CLONIDINE HCL 0.1 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.1125$KARIGEL SODIUM FLUORIDE 0.011 Generic GEL (GRAM) 0.0605$KARIGEL SODIUM FLUORIDE 0.011 Brand GEL (GRAM) 0.0768$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

KAY CIEL POTASSIUM CHLORIDE 20 MEQ Generic PACKET (EA) 2.7667$K-DUR POTASSIUM CHLORIDE 20 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.2908$KEFLEX CEPHALEXIN 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0980$KEFLEX CEPHALEXIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1689$KENALOG TRIAMCINOLONE ACETONIDE 0.00025 Generic OINTMENT (GRAM) 0.1471$KENALOG TRIAMCINOLONE ACETONIDE 0% Generic LOTION (ML) 0.4850$KENALOG TRIAMCINOLONE ACETONIDE 0% Generic LOTION (ML) 0.5900$KENALOG TRIAMCINOLONE ACETONIDE 0.147MG/G Brand AEROSOL (GRAM) 3.4366$KENALOG IN ORABASE TRIAMCINOLONE ACETONIDE 0.001 Generic PASTE (GRAM) 11.2242$KENALOG-40 TRIAMCINOLONE ACETONIDE 40 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 6.2729$KEPPRA LEVETIRACETAM 100 MG/ML Brand SOLUTION, ORAL 1.1743$KEPPRA LEVETIRACETAM 100 MG/ML Generic SOLUTION, ORAL 0.0638$KEPPRA LEVETIRACETAM 1000 MG Generic TABLET 0.4306$KEPPRA LEVETIRACETAM 1000 MG Brand TABLET 12.4583$KEPPRA LEVETIRACETAM 250 MG Generic TABLET 0.0988$KEPPRA LEVETIRACETAM 500 MG Brand TABLET 6.0820$KEPPRA LEVETIRACETAM 500 MG Generic TABLET 0.1427$KEPPRA LEVETIRACETAM 750 MG Generic TABLET 0.2550$KEPPRA XR LEVETIRACETAM 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4650$KEPPRA XR LEVETIRACETAM 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.3500$KEPPRA XR LEVETIRACETAM 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6729$KEPPRA XR LEVETIRACETAM 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.1400$KETEK TELITHROMYCIN 400 MG Brand TABLET 16.0656$KETOCONAZOLE KETOCONAZOLE 2.00% Generic SHAMPOO 0.0818$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 10 MG Generic TABLET 0.6200$KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 60 MG/2 ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.5318$KLARON SULFACETAMIDE SODIUM 10% Generic SUSPENSION, TOPICAL (ML) 0.5834$KLONOPIN CLONAZEPAM 0.125 MG Generic TABLET,DISINTEGRATING 0.7120$KLONOPIN CLONAZEPAM 0.25 MG Generic TABLET,DISINTEGRATING 0.7901$KLONOPIN CLONAZEPAM 0.5 MG Generic TABLET 0.0158$KLONOPIN CLONAZEPAM 1 MG Generic TABLET 0.0244$KLONOPIN CLONAZEPAM 1 MG Generic TABLET,DISINTEGRATING 0.6400$KLONOPIN CLONAZEPAM 2 MG Generic TABLET 0.0373$KLONOPIN CLONAZEPAM 2 MG Generic TABLET,DISINTEGRATING 0.6188$KLOR-CON POTASSIUM CHLORIDE 25 MEQ Generic PACKET (EA) 1.5851$KLOR-CON 8 POTASSIUM CHLORIDE 8 MEQ Generic TABLET, EXTENDED RELEASE 0.4350$KOMBIGLYZE XR SAXAGLIPTIN HCL/METFORMIN HCL 2.5-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 4.6483$KOMBIGLYZE XR SAXAGLIPTIN HCL/METFORMIN HCL 5MG-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 8.9449$KONSYL PSYLLIUM SEED Generic POWDER (GRAM) 0.0300$K-PHOS NEUTRAL PHOSPHORUS #1 250 MG Generic TABLET 0.3300$KWELL LINDANE 0.01 Generic SHAMPOO 1.6740$LAC-HYDRIN AMMONIUM LACTATE 0.12 Generic LOTION (GRAM) 0.0800$LAC-HYDRIN AMMONIUM LACTATE 0.12 Generic CREAM (GRAM) 0.0717$LACRI-LUBE S.O.P. MINERAL OIL/PETROLATUM,WHITE 42.5-56.8% Brand OINTMENT (GRAM) 2.3150$LACTULOSE LACTULOSE 10 G/15 ML Generic SOLUTION, ORAL 0.0100$LAMICTAL LAMOTRIGINE 100 MG Generic TABLET 0.0796$LAMICTAL LAMOTRIGINE 100 MG Brand TABLET 7.3680$LAMICTAL LAMOTRIGINE 150 MG Generic TABLET 0.0956$LAMICTAL LAMOTRIGINE 150 MG Brand TABLET 8.3150$LAMICTAL LAMOTRIGINE 200 MG Generic TABLET 0.1038$LAMICTAL LAMOTRIGINE 200 MG Brand TABLET 8.9700$LAMICTAL LAMOTRIGINE 25 MG Generic TABLET 0.0670$LAMICTAL LAMOTRIGINE 25 MG Brand TABLET 6.6240$LAMICTAL LAMOTRIGINE 25 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.2327$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

LAMICTAL LAMOTRIGINE 5 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.2237$LAMICTAL XR LAMOTRIGINE 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.9182$LAMICTAL XR LAMOTRIGINE 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 9.7100$LAMICTAL XR LAMOTRIGINE 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 13.8497$LAMISIL TERBINAFINE HCL 250 MG Generic TABLET 0.1908$LAMIVUDINE-ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE 150-300MG Generic TABLET 8.9152$LANOXIN DIGOXIN 125 MCG Generic TABLET 1.0663$LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 8.1036$LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.5975$LANSOPRAZOLE LANSOPRAZOLE 15 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.1500$LANSOPRAZOLE LANSOPRAZOLE 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.3300$LANSOPRAZOLE LANSOPRAZOLE 30 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 8.9175$LANTUS INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 21.4424$LANTUS SOLOSTAR INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG 100/ML (3) Brand INSULIN PEN (ML) 21.3837$LARIAM MEFLOQUINE HCL 250 MG Generic TABLET 4.7122$LASIX FUROSEMIDE 10 MG/ML Generic SOLUTION, ORAL 0.0983$LASTACAFT ALCAFTADINE 0.0025 Brand DROPS 41.5138$LATANOPROST LATANOPROST 0.00005 Brand DROPS 46.2380$LATANOPROST LATANOPROST 0.01% Generic DROPS 3.4956$LATUDA LURASIDONE HCL 120 MG Brand TABLET 33.5340$LATUDA LURASIDONE HCL 20 MG Brand TABLET 22.4960$LATUDA LURASIDONE HCL 40 MG Brand TABLET 22.4582$LATUDA LURASIDONE HCL 80 MG Brand TABLET 22.5089$LEFLUNOMIDE LEFLUNOMIDE 10 MG Generic TABLET 0.4429$LEFLUNOMIDE LEFLUNOMIDE 20 MG Generic TABLET 0.2816$LESCOL XL FLUVASTATIN SODIUM 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1685$LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 5 MG Generic TABLET 0.8971$LEUKERAN CHLORAMBUCIL 2 MG Brand TABLET 8.9145$LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.9214$LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.8583$LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Brand VIAL, NEBULIZER (ML) 2.0293$LEVAQUIN LEVOFLOXACIN 250 MG Generic TABLET 0.2350$LEVAQUIN LEVOFLOXACIN 250MG/10ML Generic SOLUTION, ORAL 0.9325$LEVAQUIN LEVOFLOXACIN 500 MG Generic TABLET 0.3000$LEVAQUIN LEVOFLOXACIN 750 MG Generic TABLET 0.5814$LEVEMIR INSULIN DETEMIR 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 21.5021$LEVEMIR FLEXPEN INSULIN DETEMIR 100/ML (3) Brand INSULIN PEN (ML) 21.4252$LEVITRA VARDENAFIL HCL 20 MG Brand TABLET 26.6760$LEVLEN 28 LEVONORGESTREL-ETHINYL ESTRADIOL 0.15-0.03 Generic TABLET 0.4954$LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG Generic TABLET 0.3685$LEVOTHROID LEVOTHYROXINE SODIUM 100 MCG Generic TABLET 0.4194$LEVOTHROID LEVOTHYROXINE SODIUM 100 MCG Brand TABLET 0.8237$LEVOTHROID LEVOTHYROXINE SODIUM 112 MCG Generic TABLET 0.4994$LEVOTHROID LEVOTHYROXINE SODIUM 112 MCG Brand TABLET 0.8365$LEVOTHROID LEVOTHYROXINE SODIUM 125 MCG Generic TABLET 0.4551$LEVOTHROID LEVOTHYROXINE SODIUM 125 MCG Brand TABLET 0.8439$LEVOTHROID LEVOTHYROXINE SODIUM 137 MCG Generic TABLET 0.5393$LEVOTHROID LEVOTHYROXINE SODIUM 137 MCG Brand TABLET 0.8617$LEVOTHROID LEVOTHYROXINE SODIUM 150 MCG Generic TABLET 0.4790$LEVOTHROID LEVOTHYROXINE SODIUM 150 MCG Brand TABLET 0.8740$LEVOTHROID LEVOTHYROXINE SODIUM 175MCG Generic TABLET 0.5877$LEVOTHROID LEVOTHYROXINE SODIUM 175MCG Brand TABLET 0.9600$LEVOTHROID LEVOTHYROXINE SODIUM 200 MCG Generic TABLET 0.6004$LEVOTHROID LEVOTHYROXINE SODIUM 200 MCG Brand TABLET 0.9671$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

LEVOTHROID LEVOTHYROXINE SODIUM 25 MCG Generic TABLET 0.3081$LEVOTHROID LEVOTHYROXINE SODIUM 25 MCG Brand TABLET 0.7244$LEVOTHROID LEVOTHYROXINE SODIUM 300 MCG Brand TABLET 1.2041$LEVOTHROID LEVOTHYROXINE SODIUM 50 MCG Generic TABLET 0.3645$LEVOTHROID LEVOTHYROXINE SODIUM 50 MCG Brand TABLET 0.7835$LEVOTHROID LEVOTHYROXINE SODIUM 75 MCG Generic TABLET 0.4501$LEVOTHROID LEVOTHYROXINE SODIUM 75 MCG Brand TABLET 0.7997$LEVOTHROID LEVOTHYROXINE SODIUM 88 MCG Generic TABLET 0.4126$LEVOTHROID LEVOTHYROXINE SODIUM 88 MCG Brand TABLET 0.8153$LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG Generic TABLET 0.7659$LEVSIN HYOSCYAMINE SULFATE 0.125 MG Generic TABLET 0.5754$LEVSIN HYOSCYAMINE SULFATE 0.125MG/ML Generic DROPS 1.1125$LEVSIN-SL HYOSCYAMINE SULFATE 0.125 MG Generic TABLET, SUBLINGUAL 0.1753$LEXIVA FOSAMPRENAVIR CALCIUM 700 MG Brand TABLET 14.3656$LIALDA MESALAMINE 1.2 G Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 6.4713$LIBRIUM CHLORDIAZEPOXIDE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0900$LIDAMANTLE LIDOCAINE HCL 0.03 Generic CREAM (GRAM) 1.4175$LIDAMANTLE HC HYDROCORTISONE ACETATE/LIDOCAINE HCL 0.5 %-3 % Generic CREAM (GRAM) 1.2200$LIDEX FLUOCINONIDE 0.0005 Generic OINTMENT (GRAM) 1.8191$LIDEX FLUOCINONIDE 0.0005 Generic SOLUTION, NON-ORAL 1.4490$LIDEX FLUOCINONIDE 0.0005 Generic GEL (GRAM) 1.7037$LIDEX-E FLUOCINONIDE/EMOLLIENT 0.05% Generic CREAM (GRAM) 1.8050$LIDOCAINE LIDOCAINE 5.00% Generic OINTMENT (GRAM) 1.5959$LIDOCAINE LIDOCAINE 5%(700MG) Generic ADHESIVE PATCH, MEDICATED 7.2865$LIDOCAINE LIDOCAINE 5%(700MG) Brand ADHESIVE PATCH, MEDICATED 8.3641$LIDOCAINE HCL LIDOCAINE HCL 40 MG/ML Generic SOLUTION, NON-ORAL 0.0839$LINDANE LINDANE 1 % Generic LOTION (ML) 1.6400$LINZESS LINACLOTIDE 145 MCG Brand CAPSULE (HARD, SOFT, ETC.) 7.4350$LINZESS LINACLOTIDE 290 MCG Brand CAPSULE (HARD, SOFT, ETC.) 7.4238$LIORESAL BACLOFEN 10 MG Generic TABLET 0.1278$LIORESAL BACLOFEN 20 MG Generic TABLET 0.3616$LIPOFEN FENOFIBRATE 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.2191$LITHIUM CARBONATE LITHIUM CARBONATE 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0589$LITHIUM CARBONATE LITHIUM CARBONATE 600 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2380$LITHOBID LITHIUM CARBONATE 300 MG Generic TABLET, EXTENDED RELEASE 0.1871$LIVALO PITAVASTATIN CALCIUM 2 MG Brand TABLET 5.2268$L-METHYLFOLATE CALCIUM LEVOMEFOLATE CALCIUM 15 MG Generic TABLET 1.6780$L-METHYLFOLATE FORTE LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGAL OIL 15-90.314 Generic CAPSULE (HARD, SOFT, ETC.) 3.2641$LO LOESTRIN FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 1MG-10(24) Brand TABLET 3.0800$LO/OVRAL-21 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG Generic TABLET 0.5200$LODINE ETODOLAC 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1193$LODINE ETODOLAC 400 MG Generic TABLET 1.0156$LODINE ETODOLAC 500 MG Generic TABLET 1.0044$LODINE XL ETODOLAC 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8153$LOESTRIN NORETHINDRONE A-E ESTRADIOL 1.5-0.03MG Generic TABLET 0.6938$LOESTRIN NORETHINDRONE A-E ESTRADIOL 1MG-20MCG Generic TABLET 0.6073$LOESTRIN 24 FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 1MG-20(24) Brand TABLET 2.5320$LOESTRIN FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 1.5-0.03MG Generic TABLET 0.3420$LOESTRIN FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 1MG-20MCG Generic TABLET 0.3880$LOFIBRA FENOFIBRATE 160 MG Generic TABLET 0.9370$LOFIBRA FENOFIBRATE 54 MG Generic TABLET 0.5471$LONITEN MINOXIDIL 10 MG Generic TABLET 0.2414$LONITEN MINOXIDIL 2.5 MG Generic TABLET 0.1340$LOPERAMIDE LOPERAMIDE HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1364$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

LOPID GEMFIBROZIL 600 MG Generic TABLET 0.1380$LOPRESSOR METOPROLOL TARTRATE 100 MG Generic TABLET 0.0346$LOPRESSOR METOPROLOL TARTRATE 50 MG Generic TABLET 0.0200$LOPROX CICLOPIROX OLAMINE 0.77 % Generic CREAM (GRAM) 0.4720$LORAZEPAM LORAZEPAM 2 MG/ML Generic CONCENTRATE, ORAL 0.5083$LORTAB HYDROCODONE BITARTRATE/ACETAMINOPHEN 10-300/15 Brand SOLUTION, ORAL 0.3800$LORTAB HYDROCODONE BIT/ACETAMINOPHEN 10MG-500MG Generic TABLET 0.2597$LORTAB HYDROCODONE BIT/ACETAMINOPHEN 7.5-500MG Generic TABLET 0.1382$LOSEC OMEPRAZOLE 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.1056$LOTEMAX LOTEPREDNOL ETABONATE 0.5 % Brand OINTMENT (GRAM) 53.0265$LOTEMAX LOTEPREDNOL ETABONATE 0.005 Brand GEL (GRAM) 26.3500$LOTEMAX LOTEPREDNOL ETABONATE 0.005 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 32.8755$LOTRIMIN CLOTRIMAZOLE 0.01 Generic CREAM (GRAM) 0.7960$LOTRIMIN CLOTRIMAZOLE 0.01 Generic SOLUTION, NON-ORAL 0.4888$LOVAZA OMEGA-3 ACID ETHYL ESTERS 1 G Brand CAPSULE (HARD, SOFT, ETC.) 1.8369$LOXAPINE LOXAPINE SUCCINATE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3728$LOZOL INDAPAMIDE 2.5 MG Generic TABLET 0.2725$LUMIGAN BIMATOPROST 0.0001 Brand DROPS 43.5002$LUMIGAN BIMATOPROST 0% Brand DROPS 38.3011$LUNESTA ESZOPICLONE 1 MG Brand TABLET 10.5660$LUNESTA ESZOPICLONE 2 MG Brand TABLET 10.4050$LUNESTA ESZOPICLONE 3 MG Brand TABLET 10.4467$LURIDE SODIUM FLUORIDE 0.25(0.55) Generic TABLET, CHEWABLE 0.0312$LUVOX CR FLUVOXAMINE MALEATE 100 MG Brand CAPSULE, EXT RELEASE 24 HR 10.8447$LYBREL LEVONORGESTREL-ETHINYL ESTRADIOL 90-20MCG Brand TABLET 1.6592$LYRICA PREGABALIN 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2501$LYRICA PREGABALIN 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2516$LYRICA PREGABALIN 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2496$LYRICA PREGABALIN 225 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2463$LYRICA PREGABALIN 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2116$LYRICA PREGABALIN 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2510$LYRICA PREGABALIN 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2415$LYRICA PREGABALIN 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2497$LYSTEDA TRANEXAMIC ACID 650 MG Brand TABLET 4.7362$MACROBID NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.8311$MACRODANTIN NITROFURANTOIN MACROCRYSTAL 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3350$MACRODANTIN NITROFURANTOIN MACROCRYSTAL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7563$MAGNESIUM OXIDE MAGNESIUM OXIDE 400 MG Generic TABLET 0.0300$MATZIM LA DILTIAZEM HCL 180 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.2682$MAXAIR AUTOHALER PIRBUTEROL ACETATE 200 MCG Brand AEROSOL, BREATH ACTIVATED 34.4094$MAXALT RIZATRIPTAN BENZOATE 10 MG Generic TABLET 1.1520$MAXALT RIZATRIPTAN BENZOATE 10 MG Brand TABLET 32.5879$MAXALT RIZATRIPTAN BENZOATE 5 MG Generic TABLET 1.3492$MAXALT RIZATRIPTAN BENZOATE 5 MG Brand TABLET 32.4330$MAXALT MLT RIZATRIPTAN BENZOATE 10 MG Generic TABLET,DISINTEGRATING 1.5789$MAXALT MLT RIZATRIPTAN BENZOATE 10 MG Brand TABLET,DISINTEGRATING 31.2372$MAXIFLOR DIFLORASONE DIACETATE 0.0005 Generic CREAM (GRAM) 4.5480$MAXITROL NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE 3.5-10K-.1 Generic OINTMENT (GRAM) 4.5226$MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 MG-50MG Generic TABLET 0.2100$MAXZIDE-25 MG TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5-25 MG Generic TABLET 0.1730$MEDROL METHYLPREDNISOLONE 16 MG Generic TABLET 2.5000$MEDROL METHYLPREDNISOLONE 4 MG Generic TABLET, DOSE PACK 0.7878$MEDROL METHYLPREDNISOLONE 4 MG Generic TABLET 1.0900$MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 10 MG Generic TABLET 0.1667$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 2.5 MG Generic TABLET 0.1167$MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 5 MG Generic TABLET 0.1300$MEFENAMIC ACID MEFENAMIC ACID 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.8586$MEGACE MEGESTROL ACETATE 20 MG Generic TABLET 0.1250$MEGACE MEGESTROL ACETATE 40 MG Generic TABLET 0.1650$MEGACE MEGESTROL ACETATE 400MG/10ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0700$MELOXICAM MELOXICAM 7.5 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.7043$MENEST ESTROGENS,ESTERIFIED 0.625 MG Brand TABLET 1.3524$MEPHYTON PHYTONADIONE 5 MG Brand TABLET 17.2286$MEPRON ATOVAQUONE 750 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 5.8432$MERCAPTOPURINE MERCAPTOPURINE 50 MG Generic TABLET 0.9717$MESALAMINE MESALAMINE WITH CLEANSING WIPES 4G/60ML Generic KIT 127.1895$MESTINON PYRIDOSTIGMINE BROMIDE 60 MG Generic TABLET 0.3120$METAXALONE METAXALONE 800 MG Generic TABLET 3.1300$METHOCARBAMOL METHOCARBAMOL 500 MG Generic TABLET 0.0774$METHOTREXATE METHOTREXATE SODIUM 2.5 MG Generic TABLET 2.3160$METHOTREXATE METHOTREXATE SODIUM/PF 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.3800$METHOTREXATE METHOTREXATE SODIUM 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.8243$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG Generic TABLET 0.7311$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG Generic TABLET 1.0015$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG Generic TABLET, EXTENDED RELEASE 1.6600$METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG Generic TABLET 0.5433$METHYLPHENIDATE HCL CD METHYLPHENIDATE HCL 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 3.9964$METHYLPHENIDATE HCL CD METHYLPHENIDATE HCL 40 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 5.2181$METHYLPREDNISOLONE METHYLPREDNISOLONE 32 MG Generic TABLET 3.5700$METHYLPREDNISOLONE METHYLPREDNISOLONE 8 MG Generic TABLET 1.5193$METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE 80 MG/ML Generic VIAL (ML) 7.4589$METICORTEN PREDNISONE 1 MG Generic TABLET 0.1733$METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 10 MG Generic TABLET 0.0500$METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5 MG Generic TABLET 0.0500$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7005$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.1229$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3496$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1513$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3443$METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1475$METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG Generic TABLET 0.0242$METROCREAM METRONIDAZOLE 0.0075 Generic CREAM (GRAM) 2.4310$METROGEL METRONIDAZOLE 0.0075 Generic GEL (GRAM) 2.6840$METROGEL METRONIDAZOLE 1% Generic GEL (GRAM) 3.6757$METROGEL METRONIDAZOLE 0.01 Generic GEL WITH PUMP (GRAM) 3.9368$METROGEL METRONIDAZOLE 0.01 Brand GEL (GRAM) 4.3088$METROGEL METRONIDAZOLE 0.01 Brand GEL WITH PUMP (GRAM) 4.9018$METROGEL-VAGINAL METRONIDAZOLE 0.0075 Generic GEL WITH APPLICATOR (GRAM) 0.3346$METROGEL-VAGINAL METRONIDAZOLE 0.0075 Brand GEL WITH APPLICATOR (GRAM) 0.3179$METROLOTION METRONIDAZOLE 0.0075 Generic LOTION (ML) 3.0162$MEVACOR LOVASTATIN 10 MG Generic TABLET 0.0640$MEVACOR LOVASTATIN 20 MG Generic TABLET 0.0833$MEVACOR LOVASTATIN 40 MG Generic TABLET 0.0914$MICARDIS TELMISARTAN 40 MG Brand TABLET 4.5445$MICARDIS TELMISARTAN 40 MG Generic TABLET 3.4344$MICARDIS TELMISARTAN 80 MG Brand TABLET 4.4976$MICARDIS TELMISARTAN 80 MG Generic TABLET 3.2800$MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZIDE 80 MG-25MG Brand TABLET 4.4296$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZIDE 80 MG-25MG Generic TABLET 3.4950$MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG Brand TABLET 4.6375$MICRO-K POTASSIUM CHLORIDE 10 MEQ Generic CAPSULE, EXTENDED RELEASE 0.6106$MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML Generic VIAL (ML) 0.5900$MIGRANAL DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY Brand AEROSOL, SPRAY WITH PUMP (ML) 221.2921$MILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0043$MILLIPRED DP PREDNISOLONE 5 MG (48) Brand TABLET, DOSE PACK 6.4732$MINASTRIN 24 FE NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 1MG-20(24) Brand TABLET, CHEWABLE 3.0300$MINIPRESS PRAZOSIN HCL 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1883$MINIPRESS PRAZOSIN HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2829$MINIPRESS PRAZOSIN HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6151$MINIVELLE ESTRADIOL .0375MG/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.4129$MINOCIN MINOCYCLINE HCL 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2556$MINOCIN MINOCYCLINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1650$MINOCYCLINE HCL MINOCYCLINE HCL 100 MG Generic TABLET 1.6211$MIRALAX POLYETHYLENE GLYCOL 3350 17G/DOSE Generic POWDER (GRAM) 0.0304$MIRALAX POLYETHYLENE GLYCOL 3350 17G/DOSE Brand POWDER (GRAM) 0.0400$MIRAPEX PRAMIPEXOLE DI-HCL 0.25 MG Generic TABLET 0.0900$MIRAPEX PRAMIPEXOLE DI-HCL 0.5 MG Generic TABLET 0.0867$MIRAPEX PRAMIPEXOLE DI-HCL 1 MG Generic TABLET 0.1050$MIRAPEX ER PRAMIPEXOLE DI-HCL 0.75 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2736$MIRCETTE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL 21-5 Generic TABLET 0.8400$MIRTAZAPINE MIRTAZAPINE 15 MG Generic TABLET,DISINTEGRATING 0.9140$MIRTAZAPINE MIRTAZAPINE 30 MG Generic TABLET,DISINTEGRATING 0.8300$MIRTAZAPINE MIRTAZAPINE 45 MG Generic TABLET,DISINTEGRATING 1.3646$MIRTAZAPINE MIRTAZAPINE 7.5 MG Generic TABLET 1.1814$MIRVASO BRIMONIDINE TARTRATE 0.33 % Brand GEL (GRAM) 7.8920$MOBIC MELOXICAM 15 MG Generic TABLET 0.0277$MOBIC MELOXICAM 7.5 MG Generic TABLET 0.0248$MOBISYL TROLAMINE SALICYLATE 0.1 Brand CREAM (GRAM) 0.0495$MODAFINIL MODAFINIL 100 MG Generic TABLET 13.7850$MODAFINIL MODAFINIL 200 MG Brand TABLET 35.7977$MODAFINIL MODAFINIL 200 MG Generic TABLET 13.9136$MODURETIC AMILORIDE HCL/HYDROCHLOROTHIAZIDE 5MG-50MG Generic TABLET 0.2425$MOEXIPRIL HCL MOEXIPRIL HCL 15 MG Generic TABLET 0.4365$MOEXIPRIL HCL MOEXIPRIL HCL 7.5 MG Generic TABLET 0.5625$MOEXIPRIL-HYDROCHLOROTHIAZIDE MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 15-25MG Generic TABLET 0.6425$MONISTAT-DERM MICONAZOLE NITRATE 2% Generic CREAM (GRAM) 0.0700$MONODOX DOXYCYCLINE MONOHYDRATE 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 13.7148$MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 Generic TABLET 0.3800$MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 Brand TABLET 1.1950$MONOPRIL FOSINOPRIL SODIUM 20 MG Generic TABLET 0.1600$MONOPRIL FOSINOPRIL SODIUM 40 MG Generic TABLET 0.1899$MORPHINE SULFATE MORPHINE SULFATE 10 MG/5 ML Generic SOLUTION, ORAL 0.0660$MORPHINE SULFATE MORPHINE SULFATE 100 MG Generic TABLET, EXTENDED RELEASE 2.9283$MORPHINE SULFATE MORPHINE SULFATE 100 MG/5ML Generic SOLUTION, ORAL 0.4426$MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET 0.1082$MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET, EXTENDED RELEASE 0.4923$MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET 0.1643$MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET, EXTENDED RELEASE 0.9464$MORPHINE SULFATE MORPHINE SULFATE 60 MG Generic TABLET, EXTENDED RELEASE 1.1172$MORPHINE SULFATE ER MORPHINE SULFATE 20 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 3.9240$MORPHINE SULFATE ER MORPHINE SULFATE 200 MG Generic TABLET, EXTENDED RELEASE 3.9390$MORPHINE SULFATE ER MORPHINE SULFATE 30 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 4.1116$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

MORPHINE SULFATE ER MORPHINE SULFATE 60 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 8.6827$MORPHINE SULFATE ER MORPHINE SULFATE 80 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 11.2140$MOVIPREP PEG 3350/SODIUM SULFATE/SOD CHLORIDE/KCL/ASCORBATE SOD/VIT C 7.5-2.691G Brand POWDER IN PACKET (EA) 75.5841$MOXEZA MOXIFLOXACIN HCL 0.005 Brand DROPS, VISCOUS (ML) 31.5220$MUCINEX GUAIFENESIN 1200 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6500$MUCINEX D GUAIFENESIN/PSEUDOEPHEDRINE HCL 1200-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.7900$MUCINEX D GUAIFENESIN/PSEUDOEPHEDRINE HCL 600MG-60MG Brand TABLET, EXTENDED RELEASE 12 HR 0.5014$MUCINEX DM GUAIFENESIN/DEXTROMETHORPHAN HBR 1200-60MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6628$MULTAQ DRONEDARONE HCL 400 MG Brand TABLET 6.0500$MULTIVITAMINS WITH FLUORIDE MULTIVITAMINS WITH FLUORIDE 0.25 MG/ML Generic DROPS 0.1866$MYCELEX CLOTRIMAZOLE 10 MG Generic TROCHE 0.4717$MYCIFRADIN NEOMYCIN SULFATE 500 MG Generic TABLET 0.7547$MYCOLOG II NYSTATIN/TRIAMCINOLONE ACETONIDE 100000-0.1 Generic OINTMENT (GRAM) 4.6418$MYCOLOG II NYSTATIN/TRIAMCINOLONE ACETONIDE 100000-0.1 Generic CREAM (GRAM) 3.4739$MYCOSTATIN NYSTATIN 100000/G Generic POWDER (GRAM) 0.9892$MYCOSTATIN NYSTATIN 100000/G Generic OINTMENT (GRAM) 0.5371$MYCOSTATIN NYSTATIN 100000/G Generic CREAM (GRAM) 0.6591$MYCOSTATIN NYSTATIN 100000/ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0917$MYCOSTATIN NYSTATIN 500K UNIT Generic TABLET 0.5000$MYDRIACYL TROPICAMIDE 0.01 Generic DROPS 3.3100$MYFORTIC MYCOPHENOLATE SODIUM 360 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 7.8500$MYRBETRIQ MIRABEGRON 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.9160$MYRBETRIQ MIRABEGRON 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.9242$MYSOLINE PRIMIDONE 250 MG Generic TABLET 0.1204$MYSOLINE PRIMIDONE 50 MG Generic TABLET 0.1067$NAFTIN NAFTIFINE HCL 0.01 Brand CREAM (GRAM) 8.0769$NAMENDA MEMANTINE HCL 10 MG Brand TABLET 4.6281$NAMENDA MEMANTINE HCL 5 MG Brand TABLET 4.6362$NAMENDA MEMANTINE HCL 5 MG-10 MG Brand TABLET, DOSE PACK 4.4287$NAMENDA XR MEMANTINE HCL 28 MG Brand CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 8.7605$NAPROSYN NAPROXEN 125 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0685$NAPROSYN NAPROXEN 250 MG Generic TABLET 0.0370$NAPROSYN NAPROXEN 375 MG Generic TABLET 0.0522$NAPROSYN NAPROXEN 500 MG Generic TABLET 0.0588$NARATRIPTAN HCL NARATRIPTAN HCL 2.5 MG Generic TABLET 4.9443$NASACORT AQ TRIAMCINOLONE ACETONIDE 55MCG Generic AEROSOL, SPRAY (GRAM) 3.9138$NASALIDE FLUNISOLIDE 25 MCG Generic AEROSOL, SPRAY (ML) 1.9275$NASONEX MOMETASONE FUROATE 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 8.9935$NATAZIA ESTRADIOL VALERATE/DIENOGEST 3-2-1(28) Brand TABLET 3.3825$NATURAL FIBER PSYLLIUM SEED (WITH DEXTROSE) Generic POWDER (GRAM) 0.0100$NAVANE THIOTHIXENE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3600$NECON NORETHINDRONE-ETHINYL ESTRADIOL 7 DAYS X 3 Generic TABLET 0.6490$NECON NORETHINDRONE-ETHINYL ESTRADIOL 7 DAYS X 3 Brand TABLET 0.4225$NEOCIDIN NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D 1.75MG-10K Generic DROPS 4.3307$NEOMYCIN-BACITRACIN-POLYMYXIN NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B 3.5MG-400 Generic OINTMENT (GRAM) 8.4146$NEPHROCAPS FOLIC ACID/VITAMIN B COMP W-C 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2775$NESTABS DHA PRENATAL VITAMINS COMB NO.87/IRON BISGLY/FOLIC ACID/DHA 32-1-230MG Generic COMBINATION PACKAGE (EA) 1.0660$NEUPOGEN FILGRASTIM 300MCG/0.5 Brand DISPOSABLE SYRINGE (ML) 616.3362$NEVANAC NEPAFENAC 0% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 50.4220$NEXIUM ESOMEPRAZOLE MAGNESIUM 10 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.8409$NEXIUM ESOMEPRAZOLE MAGNESIUM 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.3149$NEXIUM ESOMEPRAZOLE MAGNESIUM 20 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.5940$NEXIUM ESOMEPRAZOLE MAGNESIUM 40 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.8493$NEXIUM ESOMEPRAZOLE MAGNESIUM 40 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.6276$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

NIACIN NIACIN 500 MG Generic TABLET 0.0237$NIACIN NIACIN 500 MG Generic TABLET, EXTENDED RELEASE 0.0589$NIACIN ER NIACIN 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.8800$NIACIN ER NIACIN 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.9715$NIACIN ER NIACIN 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.4375$NIASPAN NIACIN 1000 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.6494$NIASPAN NIACIN 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.6750$NIASPAN NIACIN 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.3597$NICORELIEF NICOTINE POLACRILEX 2 MG Brand GUM 0.4096$NICORETTE NICOTINE POLACRILEX 4 MG Generic GUM 0.2646$NICORETTE NICOTINE POLACRILEX 4 MG Brand GUM 0.4201$NICOTINE PATCH NICOTINE 14MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 1.7525$NICOTROL NICOTINE 10 MG Brand CARTRIDGE (EA) 1.3644$NICOTROL NS NICOTINE 10 MG/ML Brand SPRAY, NON-AEROSOL (ML) 5.9955$NIFEDIPINE ER NIFEDIPINE 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4113$NIFEDIPINE ER NIFEDIPINE 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5677$NIFEDIPINE ER NIFEDIPINE 90 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7717$NIRAVAM ALPRAZOLAM 0.25 MG Generic TABLET,DISINTEGRATING 0.8651$NIRAVAM ALPRAZOLAM 0.5 MG Generic TABLET,DISINTEGRATING 1.3542$NITRO-BID NITROGLYCERIN 0.02 Brand OINTMENT (GRAM) 0.9182$NITRO-DUR NITROGLYCERIN 0.2MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.6371$NITRO-DUR NITROGLYCERIN 0.4MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.6155$NITROGLYCERIN NITROGLYCERIN 0.4 MG Brand TABLET, SUBLINGUAL 0.4494$NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Brand SPRAY, NON-AEROSOL (GRAM) 31.1988$NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Generic SPRAY, NON-AEROSOL (GRAM) 29.5353$NIZORAL KETOCONAZOLE 0.02 Generic CREAM (GRAM) 0.6629$NIZORAL KETOCONAZOLE 200 MG Generic TABLET 1.7420$NOLVADEX TAMOXIFEN CITRATE 20 MG Generic TABLET 0.6027$NORFLEX ORPHENADRINE CITRATE 100 MG Generic TABLET, EXTENDED RELEASE 0.4620$NORINYL 1+35 NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-35MCG Generic TABLET 0.2700$NORMODYNE LABETALOL HCL 100 MG Generic TABLET 0.2691$NORMODYNE LABETALOL HCL 200 MG Generic TABLET 0.3760$NORMODYNE LABETALOL HCL 300 MG Generic TABLET 0.6933$NORPRAMIN DESIPRAMINE HCL 25 MG Generic TABLET 0.9506$NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1689$NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2100$NORVIR RITONAVIR 100 MG Brand TABLET 8.2854$NOVOLOG INSULIN ASPART 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 17.8728$NOVOLOG INSULIN ASPART 100/ML Brand CARTRIDGE (ML) 22.8979$NOVOLOG FLEXPEN INSULIN ASPART 100/ML Brand INSULIN PEN (ML) 22.8408$NOVOLOG MIX 70-30 INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 18.4176$NOVOLOG MIX 70-30 FLEXPEN INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML Brand INSULIN PEN (ML) 22.9985$NUCYNTA TAPENTADOL HCL 100 MG Brand TABLET 3.9583$NUCYNTA TAPENTADOL HCL 50 MG Brand TABLET 2.5555$NUCYNTA TAPENTADOL HCL 75 MG Brand TABLET 2.9869$NUCYNTA ER TAPENTADOL HCL 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 5.0900$NUCYNTA ER TAPENTADOL HCL 50 MG Brand TABLET, EXTENDED RELEASE 12 HR 2.7484$NUEDEXTA DEXTROMETHORPHAN HBR/QUINIDINE SULFATE 20 MG-10MG Brand CAPSULE (HARD, SOFT, ETC.) 10.3533$NULYTELY SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG 420G Generic SOLUTION, RECONSTITUTED, ORAL 0.0044$NUVARING ETONOGESTREL/ETHINYL ESTRADIOL 0.12-0.015 Brand RING, VAGINAL 88.4971$NUVIGIL ARMODAFINIL 150 MG Brand TABLET 16.2080$NUVIGIL ARMODAFINIL 250 MG Brand TABLET 16.2933$NUVIGIL ARMODAFINIL 50 MG Brand TABLET 5.3448$OCELLA ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG Generic TABLET 1.0000$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

OCELLA ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG Brand TABLET 1.9082$OCUFLOX OFLOXACIN 0.003 Generic DROPS 0.7455$OCUPRESS CARTEOLOL HCL 0.01 Generic DROPS 1.1745$OGEN ESTROPIPATE 0.75 MG Generic TABLET 0.2900$OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.5 MG-50 Brand TABLET 0.9774$OLANZAPINE OLANZAPINE 10 MG Generic TABLET 0.2653$OLANZAPINE OLANZAPINE 10 MG Brand TABLET 18.3557$OLANZAPINE OLANZAPINE 15 MG Generic TABLET 0.4061$OLANZAPINE OLANZAPINE 2.5 MG Generic TABLET 0.1683$OLANZAPINE OLANZAPINE 20 MG Generic TABLET 0.5254$OLANZAPINE OLANZAPINE 5 MG Brand TABLET 11.7435$OLANZAPINE OLANZAPINE 5 MG Generic TABLET 0.2032$OLANZAPINE OLANZAPINE 7.5 MG Generic TABLET 0.1800$OLANZAPINE ODT OLANZAPINE 10 MG Generic TABLET,DISINTEGRATING 5.2100$OLANZAPINE ODT OLANZAPINE 15 MG Generic TABLET,DISINTEGRATING 3.8615$OLANZAPINE ODT OLANZAPINE 20 MG Generic TABLET,DISINTEGRATING 8.1470$OLANZAPINE ODT OLANZAPINE 5 MG Generic TABLET,DISINTEGRATING 2.9021$OLANZAPINE-FLUOXETINE HCL OLANZAPINE/FLUOXETINE HCL 6MG-50MG Generic CAPSULE 10.5275$OMEPRAZOLE OMEPRAZOLE 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.5083$OMEPRAZOLE OMEPRAZOLE 40 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.1746$OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G Generic CAPSULE (HARD, SOFT, ETC.) 10.8354$OMNARIS CICLESONIDE 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 11.1980$OMNICEF CEFDINIR 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6190$ONDANSETRON HCL ONDANSETRON HCL 4 MG Generic TABLET 0.4516$ONDANSETRON HCL ONDANSETRON HCL 4 MG/5 ML Generic SOLUTION, ORAL 0.9472$ONDANSETRON HCL ONDANSETRON HCL 8 MG Generic TABLET 0.5637$ONDANSETRON ODT ONDANSETRON 4 MG Generic TABLET,DISINTEGRATING 0.6067$ONDANSETRON ODT ONDANSETRON 8 MG Generic TABLET,DISINTEGRATING 0.5005$ONFI CLOBAZAM 10 MG Brand TABLET 7.8344$ONGLYZA SAXAGLIPTIN HCL 5 MG Brand TABLET 8.9382$OPANA OXYMORPHONE HCL 10 MG Generic TABLET 3.3073$OPANA OXYMORPHONE HCL 5 MG Generic TABLET 1.7767$OPANA ER OXYMORPHONE HCL 10 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 4.0040$OPANA ER OXYMORPHONE HCL 10 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.7703$OPANA ER OXYMORPHONE HCL 15 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 5.5638$OPANA ER OXYMORPHONE HCL 15 MG Generic TABLET, EXTENDED RELEASE 12 HR 3.7463$OPANA ER OXYMORPHONE HCL 20 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 7.0663$OPANA ER OXYMORPHONE HCL 20 MG Brand TABLET, EXTENDED RELEASE 12 HR 6.7251$OPANA ER OXYMORPHONE HCL 20 MG Generic TABLET, EXTENDED RELEASE 12 HR 4.6680$OPANA ER OXYMORPHONE HCL 30 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 10.1622$OPANA ER OXYMORPHONE HCL 30 MG Brand TABLET, EXTENDED RELEASE 12 HR 9.6353$OPANA ER OXYMORPHONE HCL 30 MG Generic TABLET, EXTENDED RELEASE 12 HR 6.4760$OPANA ER OXYMORPHONE HCL 40 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 13.2710$OPANA ER OXYMORPHONE HCL 5 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 2.0835$OPANA ER OXYMORPHONE HCL 5 MG Brand TABLET, EXTENDED RELEASE 12 HR 1.9535$OPANA ER OXYMORPHONE HCL 7.5 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.9500$ORACEA DOXYCYCLINE MONOHYDRATE 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 14.0033$ORAPRED PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML Generic SOLUTION, ORAL 0.0750$ORENCIA ABATACEPT 125 MG/ML Brand DISPOSABLE SYRINGE (ML) 607.9282$ORTHO EVRA NORELGESTROMIN/ETHINYL ESTRADIOL 150-20/24H Brand PATCH, TRANSDERMAL WEEKLY 35.4100$ORTHO EVRA NORELGESTROMIN/ETHINYL ESTRADIOL 150-35/24H Generic PATCH, TRANSDERMAL WEEKLY 32.0050$ORTHO TRI-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 Generic TABLET 0.4244$ORTHO TRI-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 Brand TABLET 0.7214$ORTHO TRI-CYCLEN LO NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 LO Brand TABLET 3.9583$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ORUDIS KETOPROFEN 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2448$OSPHENA OSPEMIFENE 60 MG Brand TABLET 5.0750$OVCON-35 NORETHINDRONE-ETHINYL ESTRADIOL 0.4-0.035 Generic TABLET 0.8980$OXCARBAZEPINE OXCARBAZEPINE 150 MG Generic TABLET 0.1867$OXCARBAZEPINE OXCARBAZEPINE 300 MG Generic TABLET 0.2348$OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5771$OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.9712$OXCARBAZEPINE OXCARBAZEPINE 600 MG Generic TABLET 0.4681$OXISTAT OXICONAZOLE NITRATE 0.01 Brand LOTION (ML) 6.8653$OXISTAT OXICONAZOLE NITRATE 0.01 Brand CREAM (GRAM) 5.9004$OXYCODONE CONCENTRATE OXYCODONE HCL 20 MG/ML Generic CONCENTRATE, ORAL 5.3379$OXYCODONE HCL OXYCODONE HCL 10 MG Brand TABLET, EXTENDED RELEASE 12 HR 2.2115$OXYCODONE HCL OXYCODONE HCL 20 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.2268$OXYCODONE HCL OXYCODONE HCL 40 MG Brand TABLET, EXTENDED RELEASE 12 HR 7.5013$OXYCODONE HCL OXYCODONE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2433$OXYCODONE HCL OXYCODONE HCL 5 MG/5 ML Generic SOLUTION, ORAL 0.2270$OXYCODONE HCL OXYCODONE HCL 80 MG Brand TABLET, EXTENDED RELEASE 12 HR 14.0658$OXYCODONE W/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN 5MG-325MG Generic TABLET 0.1696$OXYCODONE-ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN 5 MG-500MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0902$OXYCONTIN OXYCODONE HCL 15 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.3000$OXYCONTIN OXYCODONE HCL 30 MG Brand TABLET, EXTENDED RELEASE 12 HR 5.9891$OXYCONTIN OXYCODONE HCL 60 MG Brand TABLET, EXTENDED RELEASE 12 HR 10.8979$OXYMORPHONE HCL OXYMORPHONE HCL 40 MG Generic TABLET, EXTENDED RELEASE 12 HR 8.8419$OXYMORPHONE HCL ER OXYMORPHONE HCL 10 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.6368$OXYTROL OXYBUTYNIN 3.9MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 38.4592$PANCREAZE LIPASE/PROTEASE/AMYLASE 10.5K-25K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.0239$PANCREAZE LIPASE/PROTEASE/AMYLASE 16.8-40-70 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.2334$PANCRELIPASE 5,000 LIPASE/PROTEASE/AMYLASE 5K-17K-27K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.7824$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1398$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0943$PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 6.7180$PARAFON FORTE DSC CHLORZOXAZONE 500 MG Generic TABLET 0.1960$PARICALCITOL PARICALCITOL 1 MCG Generic CAPSULE 8.7200$PARLODEL BROMOCRIPTINE MESYLATE 2.5 MG Generic TABLET 0.9844$PARNATE TRANYLCYPROMINE SULFATE 10 MG Generic TABLET 1.6942$PAROXETINE HCL PAROXETINE HCL 12.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.6100$PAROXETINE HCL PAROXETINE HCL 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.4417$PAROXETINE HCL PAROXETINE HCL 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.5300$PATADAY OLOPATADINE HCL 0.002 Brand DROPS 51.0744$PATANASE OLOPATADINE HCL 0.006 Brand AEROSOL, SPRAY WITH PUMP (GRAM) 6.2877$PATANOL OLOPATADINE HCL 0.001 Brand DROPS 27.9828$PAXIL PAROXETINE HCL 10 MG Generic TABLET 0.1226$PAXIL PAROXETINE HCL 20 MG Brand TABLET 4.5610$PAXIL PAROXETINE HCL 20 MG Generic TABLET 0.1111$PAXIL PAROXETINE HCL 30 MG Generic TABLET 0.1290$PAXIL PAROXETINE HCL 40 MG Generic TABLET 0.1442$PEDIAFLOR SODIUM FLUORIDE 0.5 MG/ML Generic DROPS 0.1520$PEDIAPRED PREDNISOLONE SOD PHOSPHATE 5 MG/5 ML Generic SOLUTION, ORAL 0.5264$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG Generic TABLET 0.1425$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG/5ML Generic SOLUTION, RECONSTITUTED, ORAL 0.0286$PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 500 MG Generic TABLET 0.1778$PENLAC CICLOPIROX 0.08 Generic SOLUTION, NON-ORAL 4.4860$PENNSAID DICLOFENAC SODIUM 0.015 Brand DROPS 1.4911$PENTASA MESALAMINE 250 MG Brand CAPSULE, EXTENDED RELEASE 1.8168$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

PENTASA MESALAMINE 500 MG Brand CAPSULE, EXTENDED RELEASE 3.5400$PEPCID FAMOTIDINE 20 MG Generic TABLET 0.0358$PEPTO-BISMOL BISMUTH SUBSALICYLATE 262MG/15ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0134$PERCOCET OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG Generic TABLET 0.8548$PERCOCET OXYCODONE HCL/ACETAMINOPHEN 10MG-650MG Generic TABLET 0.3510$PERCOCET OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG Generic TABLET 0.4084$PERCOCET OXYCODONE HCL/ACETAMINOPHEN 7.5-500MG Generic TABLET 0.4036$PERFOROMIST FORMOTEROL FUMARATE 20 MCG/2ML Brand VIAL, NEBULIZER (ML) 4.4994$PERIACTIN CYPROHEPTADINE HCL 2 MG/5 ML Generic SYRUP 0.0924$PERIACTIN CYPROHEPTADINE HCL 4 MG Generic TABLET 0.6233$PERIDEX CHLORHEXIDINE GLUCONATE 0.0012 Generic MOUTHWASH 0.0100$PERIOSTAT DOXYCYCLINE HYCLATE 20 MG Generic TABLET 0.4960$PERMITIL FLUPHENAZINE HCL 10 MG Generic TABLET 0.2498$PERMITIL FLUPHENAZINE HCL 5 MG Generic TABLET 0.1924$PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 100 MG Generic TABLET 0.4566$PHENERGAN PROMETHAZINE HCL 12.5 MG Generic SUPPOSITORY, RECTAL 9.5772$PHENERGAN PROMETHAZINE HCL 12.5 MG Generic TABLET 0.1300$PHENERGAN PROMETHAZINE HCL 25 MG Generic SUPPOSITORY, RECTAL 8.5882$PHENERGAN PROMETHAZINE HCL 25 MG Generic TABLET 0.0817$PHENERGAN W/CODEINE CODEINE/PROMETHAZINE HCL 10-6.25/5 Generic SYRUP 0.0227$PHENOBARBITAL PHENOBARBITAL 16.2 MG Generic TABLET 0.1755$PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML Generic ELIXIR 0.1300$PHENOBARBITAL PHENOBARBITAL 32.4MG Generic TABLET 0.2046$PHENOBARBITAL PHENOBARBITAL 64.8MG Generic TABLET 0.2760$PHENOBARBITAL PHENOBARBITAL 97.2MG Generic TABLET 0.4033$PICATO INGENOL MEBUTATE 0.015 % Brand GEL (EA) 216.9275$PIOGLITAZONE-METFORMIN PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG Generic TABLET 2.5950$PLAN B LEVONORGESTREL 0.75 MG Generic TABLET 12.7139$PLAN B ONE-STEP LEVONORGESTREL 1.5 MG Generic TABLET 32.5929$PLAN B ONE-STEP LEVONORGESTREL 1.5 MG Brand TABLET 31.1400$PLAVIX CLOPIDOGREL BISULFATE 75 MG Generic TABLET 0.1143$PLAVIX CLOPIDOGREL BISULFATE 75 MG Brand TABLET 6.1780$POLYMYXIN B SUL-TRIMETHOPRIM POLYMYXIN B SULFATE/TRIMETHOPRIM 10K/ML-0.1 Generic DROPS 0.8630$POLYSPORIN BACITRACIN/POLYMYXIN B SULFATE 500-10K/G Generic OINTMENT (GRAM) 3.8075$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.3717$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML Generic LIQUID (ML) 0.0136$POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ Generic CAPSULE, EXTENDED RELEASE 0.6100$POTASSIUM CITRATE POTASSIUM CITRATE 10 MEQ Generic TABLET, EXTENDED RELEASE 1.3175$PRADAXA DABIGATRAN ETEXILATE MESYLATE 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.6737$PRADAXA DABIGATRAN ETEXILATE MESYLATE 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.6750$PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 0.125 MG Generic TABLET 0.1153$PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 1.5 MG Generic TABLET 0.0780$PRAVACHOL PRAVASTATIN SODIUM 10 MG Generic TABLET 0.4211$PRAVACHOL PRAVASTATIN SODIUM 20 MG Generic TABLET 0.4200$PRAVACHOL PRAVASTATIN SODIUM 40 MG Generic TABLET 0.5637$PRAVACHOL PRAVASTATIN SODIUM 80 MG Generic TABLET 0.7063$PREDNICARBATE PREDNICARBATE 0.1 % Generic OINTMENT (GRAM) 1.1325$PREDNISONE PREDNISONE 5 MG/5 ML Generic SOLUTION, ORAL 0.1791$PREFERA-OB ONE PRENATAL VITAMIN COMBINATION NO.19/IRON/FOLIC ACID/DHA 22-6-1-200 Brand CAPSULE (HARD, SOFT, ETC.) 2.7867$PREFERA-OB PLUS DHA PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA 28-6-1-203 Brand COMBINATION PACKAGE (EA) 1.0266$PRELONE PREDNISOLONE 15 MG/5 ML Generic SOLUTION, ORAL 0.0540$PREMARIN ESTROGENS, CONJUGATED 0.3 MG Brand TABLET 3.1880$PREMARIN ESTROGENS, CONJUGATED 0.45MG Brand TABLET 3.1884$PREMARIN ESTROGENS, CONJUGATED 0.625 MG Brand TABLET 3.1808$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

PREMARIN ESTROGENS, CONJUGATED 0.625 MG/G Brand CREAM WITH APPLICATOR 7.0863$PREMARIN ESTROGENS, CONJUGATED 0.9 MG Brand TABLET 3.2012$PREMARIN ESTROGENS, CONJUGATED 1.25 MG Brand TABLET 3.2001$PREMPHASE ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.625 (14) Brand TABLET 3.7795$PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.3-1.5MG Brand TABLET 3.8960$PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.45-1.5MG Brand TABLET 3.9234$PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.625-2.5 Brand TABLET 3.9266$PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.625-5 MG Brand TABLET 3.9206$PRENATAL PLUS PRENATAL VITAMINS COMB NO.72/FERROUS FUMARATE/FOLIC ACID 27 MG-1 MG Generic TABLET 0.4600$PRENATE DHA PRENATAL VITAMINS COMB NO.47/FERROUS FUMARATE/FA CMB #1/DHA 27-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9429$PRENATE DHA PRENATAL VITAMINS NO.38/IRON FUMARATE/FOLATE COMB NO.6/DHA 28-1-300MG Brand CAPSULE 3.4716$PRENATE ESSENTIAL PRENATAL VIT WITH CA NO.68/IRON FUMARATE/FOLIC ACID #1/DHA 28-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7850$PRENEXA PRENATAL VIT WITH CALCIUM NO.66/IRON FUM/FOLIC ACID/DSS/DHA 27-1.25-55 Generic CAPSULE (HARD, SOFT, ETC.) 2.8280$PREPARATION H PHENYLEPHRINE HCL/MINERAL OIL/PETROLATUM,WHITE 0.25 %-14% Brand OINTMENT WITH APPLICATOR 0.1696$PREPARATION H PHENYLEPHRINE/PRAMOXINE/GLYCERIN/WHITE PETROLATUM 0.25%-1% Brand CREAM (GRAM) 0.1892$PREPOPIK SODIUM PICOSULFATE/MAGNESIUM OXIDE/CITRIC ACID 10-12/16.1 Brand POWDER IN PACKET (EA) 40.4375$PREVIDENT SODIUM FLUORIDE 1.10% Brand PASTE (ML) 0.0089$PREVIDENT 5000 SODIUM FLUORIDE 0.011 Brand GEL (ML) 0.0092$PREVIDENT 5000 ENAMEL PROTECT SODIUM FLUORIDE/POTASSIUM NITRATE 1.1%-5% Brand PASTE (ML) 0.0088$PREVIDENT 5000 PLUS SODIUM FLUORIDE 0.011 Generic CREAM (GRAM) 0.0800$PREVIDENT 5000 PLUS SODIUM FLUORIDE 0.011 Brand CREAM (GRAM) 0.0563$PREVPAC LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN 30-500-500 Brand COMBINATION PACKAGE (EA) 5.2233$PRILOSEC OMEPRAZOLE 10 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.2683$PRILOSEC OTC OMEPRAZOLE MAGNESIUM 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 0.6363$PRIMACARE ONE PNV WITH CA NO.37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS 27-1-330MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8275$PRIMSOL TRIMETHOPRIM 50 MG/5 ML Brand SOLUTION, ORAL 0.6291$PRINIVIL LISINOPRIL 10 MG Generic TABLET 0.0206$PRINIVIL LISINOPRIL 20 MG Generic TABLET 0.0289$PRINIVIL LISINOPRIL 40 MG Generic TABLET 0.0497$PRINIVIL LISINOPRIL 5 MG Generic TABLET 0.0183$PRINIVIL LISINOPRIL Generic TABLET 0.0200$PRINZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG Generic TABLET 0.0367$PRINZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG Generic TABLET 0.0435$PRINZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG Generic TABLET 0.0506$PRISTIQ ER DESVENLAFAXINE SUCCINATE 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7766$PRISTIQ ER DESVENLAFAXINE SUCCINATE 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.8093$PROAMATINE MIDODRINE HCL 10 MG Generic TABLET 1.2378$PROAMATINE MIDODRINE HCL 2.5 MG Generic TABLET 0.3543$PROAMATINE MIDODRINE HCL 5 MG Generic TABLET 0.6120$PROCRIT EPOETIN ALFA 40000/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 780.3831$PROCTOFOAM-HC HYDROCORTISONE ACETATE/PRAMOXINE HCL 1 %-1 % Brand FOAM (GRAM) 7.1667$PROCTOSOL-HC HYDROCORTISONE 2.5 % Brand CREAM WITH APPLICATOR 0.4750$PROCTOSOL-HC HYDROCORTISONE 2.5 % Generic CREAM WITH APPLICATOR 0.3244$PROGESTERONE PROGESTERONE,MICRONIZED 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2633$PROGESTERONE PROGESTERONE,MICRONIZED 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 2.0599$PROGESTERONE PROGESTERONE,MICRONIZED 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.4450$PROGRAF TACROLIMUS 0.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9650$PROGRAF TACROLIMUS 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3933$PROLENSA BROMFENAC SODIUM 0.07% Brand DROPS 75.6675$PROLOPRIM TRIMETHOPRIM 100 MG Generic TABLET 0.3025$PROMETHAZINE HCL PROMETHAZINE HCL 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.8420$PROMETHAZINE HCL PROMETHAZINE HCL 50 MG Generic TABLET 0.2000$PROMISEB EMOLLIENT COMBINATION NO.43 0.00% Brand CREAM (GRAM) 3.1615$PROPAFENONE HCL PROPAFENONE HCL 225 MG Generic TABLET 0.3172$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

PROPRANOLOL HCL PROPRANOLOL HCL 60 MG Generic TABLET 0.6886$PROPRANOLOL HCL PROPRANOLOL HCL 80 MG Generic TABLET 0.0583$PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG Generic TABLET 0.6348$PROTOPIC TACROLIMUS 0.0% Brand OINTMENT (GRAM) 6.5225$PROTOPIC TACROLIMUS 0.001 Brand OINTMENT (GRAM) 6.7663$PROVENTIL ALBUTEROL SULFATE 2 MG/5 ML Generic SYRUP 0.0100$PROVENTIL ALBUTEROL SULFATE 4 MG Generic TABLET 1.0216$PROZAC FLUOXETINE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$PROZAC FLUOXETINE HCL 10 MG Generic TABLET 0.0916$PROZAC FLUOXETINE HCL 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0308$PROZAC FLUOXETINE HCL 20 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.0572$PROZAC FLUOXETINE HCL 20 MG/5 ML Generic SOLUTION, ORAL 0.0244$PROZAC FLUOXETINE HCL 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2863$PROZAC FLUOXETINE HCL 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 14.1087$PULMICORT BUDESONIDE 0.25MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 3.4600$PULMICORT BUDESONIDE 0.5 MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 3.9556$PULMICORT BUDESONIDE 1 MG/2 ML Brand AMPUL FOR NEBULIZATION (ML) 9.8272$PULMICORT FLEXHALER BUDESONIDE 180 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 163.4100$PULMICORT FLEXHALER BUDESONIDE 90 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 122.1639$PYRIDIUM PHENAZOPYRIDINE HCL 200 MG Generic TABLET 1.2056$PYRIDOXINE HCL PYRIDOXINE HCL 25 MG Generic TABLET 0.0279$QNASL BECLOMETHASONE DIPROPIONATE 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 13.7683$QUALAQUIN QUININE SULFATE 324 MG Generic CAPSULE 5.6516$QUESTRAN CHOLESTYRAMINE (WITH SUGAR) 4 G Generic POWDER IN PACKET (EA) 1.9450$QUESTRAN CHOLESTYRAMINE (WITH SUGAR) 4 G Generic POWDER (GRAM) 0.2200$QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME 4 G Generic POWDER IN PACKET (EA) 1.3340$QUILLIVANT XR METHYLPHENIDATE HCL 5 MG/ML Brand SUSPENSION,EXTENDED RELEASE,RECONST.24HR 1.0900$QUINAPRIL HCL QUINAPRIL HCL 5 MG Generic TABLET 0.1479$QVAR BECLOMETHASONE DIPROPIONATE 40 MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.4512$QVAR BECLOMETHASONE DIPROPIONATE 80 MCG Brand AEROSOL WITH ADAPTER (GRAM) 19.3836$RANEXA RANOLAZINE 500 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.1840$RANITIDINE HCL RANITIDINE HCL 15 MG/ML Generic SYRUP 0.0246$RANITIDINE HCL RANITIDINE HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7589$RAPAFLO SILODOSIN 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.8842$RAPAFLO SILODOSIN 8 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.8536$RAPAMUNE SIROLIMUS 1 MG Brand TABLET 16.2454$REFRESH TEARS CARBOXYMETHYLCELLULOSE SODIUM 0.005 Brand DROPS 0.4920$REGLAN METOCLOPRAMIDE HCL 5 MG/5 ML Generic SOLUTION, ORAL 0.0100$RELAFEN NABUMETONE 500 MG Generic TABLET 0.2160$RELAFEN NABUMETONE 750 MG Generic TABLET 0.2643$RELPAX ELETRIPTAN HBR 20 MG Brand TABLET 34.0333$RELPAX ELETRIPTAN HBR 40 MG Brand TABLET 32.9546$REMERON MIRTAZAPINE 15 MG Generic TABLET 0.1695$REMERON MIRTAZAPINE 30 MG Generic TABLET 0.2154$REMERON MIRTAZAPINE 45 MG Generic TABLET 0.4028$RENVELA SEVELAMER CARBONATE 800 MG Brand TABLET 3.7204$REQUIP ROPINIROLE HCL 0.25 MG Generic TABLET 0.1492$REQUIP ROPINIROLE HCL 0.5 MG Generic TABLET 0.1737$REQUIP ROPINIROLE HCL 1 MG Generic TABLET 0.1352$RESTASIS CYCLOSPORINE 0.0005 Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 5.1309$RESTORIL TEMAZEPAM 15 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0668$RESTORIL TEMAZEPAM 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0852$RETIN-A TRETINOIN 0.0001 Generic GEL (GRAM) 2.6873$RETIN-A TRETINOIN 0.0005 Generic CREAM (GRAM) 4.1300$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

RETIN-A TRETINOIN 0.001 Generic CREAM (GRAM) 4.4325$RETIN-A MICRO TRETINOIN MICROSPHERES 0.0004 Brand GEL (GRAM) 15.5176$RETIN-A MICRO TRETINOIN MICROSPHERES 0% Brand GEL (GRAM) 13.0649$RETIN-A MICRO PUMP TRETINOIN MICROSPHERES 0% Brand GEL WITH PUMP (GRAM) 13.9028$RETIN-A MICRO PUMP TRETINOIN MICROSPHERES 0.10% Brand GEL WITH PUMP (GRAM) 13.9028$REVATIO SILDENAFIL CITRATE 20 MG Brand TABLET 25.4688$REVATIO SILDENAFIL CITRATE 20 MG Generic TABLET 0.7333$REVIA NALTREXONE HCL 50 MG Generic TABLET 1.0771$RHINOCORT AQUA BUDESONIDE 32MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 16.4080$RIFADIN RIFAMPIN 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.3880$RIFADIN RIFAMPIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7677$RISPERDAL RISPERIDONE 0.25 MG Generic TABLET 0.0571$RISPERDAL RISPERIDONE 0.5 MG Generic TABLET 0.0722$RISPERDAL RISPERIDONE 1 MG Generic TABLET 0.1480$RISPERDAL RISPERIDONE 1 MG/ML Generic SOLUTION, ORAL 0.3879$RISPERDAL RISPERIDONE 2 MG Generic TABLET 0.1056$RISPERDAL RISPERIDONE 3 MG Generic TABLET 0.1060$RISPERDAL RISPERIDONE 4 MG Generic TABLET 0.1240$RISPERDAL M-TAB RISPERIDONE 1 MG Generic TABLET,DISINTEGRATING 1.7843$RISPERIDONE RISPERIDONE 0.5 MG Generic TABLET,DISINTEGRATING 1.3060$RISPERIDONE ODT RISPERIDONE 2 MG Generic TABLET,DISINTEGRATING 2.8077$RITALIN LA METHYLPHENIDATE HCL 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 5.9594$RITALIN LA METHYLPHENIDATE HCL 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 3.8316$RITALIN LA METHYLPHENIDATE HCL 40 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 3.8702$RIZATRIPTAN RIZATRIPTAN BENZOATE 5 MG Generic TABLET,DISINTEGRATING 1.4380$ROBAXIN-750 METHOCARBAMOL 750 MG Generic TABLET 0.0831$ROXICET OXYCODONE HCL/ACETAMINOPHEN 5-325/5ML Brand SOLUTION, ORAL 0.0921$ROXICODONE OXYCODONE HCL 15 MG Generic TABLET 0.2526$ROXICODONE OXYCODONE HCL 30 MG Generic TABLET 0.4392$ROXICODONE OXYCODONE HCL 5 MG Generic TABLET 0.1421$ROZEREM RAMELTEON 8 MG Brand TABLET 7.3760$RYTHMOL PROPAFENONE HCL 150 MG Generic TABLET 0.1780$SAFYRAL DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM 3-0.03(21) Brand TABLET 3.6859$SALAGEN PILOCARPINE HCL 5 MG Generic TABLET 0.9733$SALEX SALICYLIC ACID 6% Generic SHAMPOO 0.0921$SANCTURA XR TROSPIUM CHLORIDE 60 MG Generic CAPSULE, EXT RELEASE 24 HR 5.3360$SANCTURA XR TROSPIUM CHLORIDE 60 MG Brand CAPSULE, EXT RELEASE 24 HR 5.9811$SAPHRIS ASENAPINE MALEATE 10 MG Brand TABLET, SUBLINGUAL 11.9818$SAPHRIS ASENAPINE MALEATE 5 MG Brand TABLET, SUBLINGUAL 12.2410$SARAFEM FLUOXETINE HCL 20 MG Generic TABLET 0.4900$SARNA MENTHOL/CAMPHOR 0.5 %-0.5% Brand LOTION (ML) 0.0300$SAVELLA MILNACIPRAN HCL 100 MG Brand TABLET 3.0088$SAVELLA MILNACIPRAN HCL 12.5-25-50 Brand TABLET, DOSE PACK 3.0448$SAVELLA MILNACIPRAN HCL 25 MG Brand TABLET 2.8960$SAVELLA MILNACIPRAN HCL 50 MG Brand TABLET 3.0022$SECTRAL ACEBUTOLOL HCL 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2216$SELEGILINE HCL SELEGILINE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5400$SELSEB SELENIUM SULFIDE 2.3% Generic SHAMPOO 0.6025$SELSUN RX SELENIUM SULFIDE 2.50% Generic SUSPENSION, TOPICAL (ML) 0.0760$SENNA PLUS SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG Generic TABLET 0.0240$SENSIPAR CINACALCET HCL 30 MG Brand TABLET 16.5759$SENSIPAR CINACALCET HCL 60 MG Brand TABLET 33.3660$SERAX OXAZEPAM 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7875$SEREVENT DISKUS SALMETEROL XINAFOATE 50 MCG Brand DISK, WITH INHALATION DEVICE 3.2560$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

SEROQUEL QUETIAPINE FUMARATE 100 MG Generic TABLET 0.1817$SEROQUEL QUETIAPINE FUMARATE 100 MG Brand TABLET 6.6150$SEROQUEL QUETIAPINE FUMARATE 200 MG Generic TABLET 0.3060$SEROQUEL QUETIAPINE FUMARATE 25 MG Generic TABLET 0.1117$SEROQUEL QUETIAPINE FUMARATE 300 MG Generic TABLET 0.4325$SEROQUEL QUETIAPINE FUMARATE 400 MG Generic TABLET 0.4700$SEROQUEL QUETIAPINE FUMARATE 50 MG Generic TABLET 0.1628$SEROQUEL XR QUETIAPINE FUMARATE 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.1100$SEROQUEL XR QUETIAPINE FUMARATE 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 13.3540$SEROQUEL XR QUETIAPINE FUMARATE 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 17.5207$SEROQUEL XR QUETIAPINE FUMARATE 400 MG Brand TABLET, EXTENDED RELEASE 24 HR 20.6300$SEROQUEL XR QUETIAPINE FUMARATE 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7475$SERTRALINE HCL SERTRALINE HCL 100 MG Generic TABLET 0.0808$SERTRALINE HCL SERTRALINE HCL 100 MG Brand TABLET 5.5131$SERTRALINE HCL SERTRALINE HCL 20 MG/ML Generic CONCENTRATE, ORAL 0.7681$SERTRALINE HCL SERTRALINE HCL 25 MG Generic TABLET 0.0633$SERTRALINE HCL SERTRALINE HCL 50 MG Generic TABLET 0.0555$SERTRALINE HCL SERTRALINE HCL 50 MG Brand TABLET 5.8035$SERZONE NEFAZODONE HCL 100 MG Generic TABLET 0.4596$SERZONE NEFAZODONE HCL 200 MG Generic TABLET 0.5000$SERZONE NEFAZODONE HCL 250 MG Generic TABLET 0.5278$SILENOR DOXEPIN HCL 3 MG Brand TABLET 7.9972$SILENOR DOXEPIN HCL 6 MG Brand TABLET 8.9161$SILVADENE SILVER SULFADIAZINE 0.01 Generic CREAM (GRAM) 0.1725$SILVADENE SILVER SULFADIAZINE 0.01 Brand CREAM (GRAM) 0.2157$SIMBRINZA BRINZOLAMIDE/BRIMONIDINE TARTRATE 1 %-0.2 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 11.2113$SIMETHICONE SIMETHICONE 125 MG Brand TABLET, CHEWABLE 0.2025$SIMPONI GOLIMUMAB 50MG/0.5ML Brand PEN INJECTOR (ML) 5,377.8169$SIMVASTATIN SIMVASTATIN 10 MG Generic TABLET 0.0300$SIMVASTATIN SIMVASTATIN 20 MG Generic TABLET 0.0241$SIMVASTATIN SIMVASTATIN 40 MG Generic TABLET 0.0400$SIMVASTATIN SIMVASTATIN 5 MG Generic TABLET 0.0500$SIMVASTATIN SIMVASTATIN 80 MG Generic TABLET 0.0769$SINEMET CR CARBIDOPA/LEVODOPA 25MG-100MG Generic TABLET, EXTENDED RELEASE 0.2525$SINEMET CR CARBIDOPA/LEVODOPA 50MG-200MG Generic TABLET, EXTENDED RELEASE 0.4880$SINEQUAN DOXEPIN HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1850$SINEQUAN DOXEPIN HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2813$SINEQUAN DOXEPIN HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5400$SINGULAIR MONTELUKAST SODIUM 10 MG Generic TABLET 0.2413$SINGULAIR MONTELUKAST SODIUM 10 MG Brand TABLET 5.6295$SINGULAIR MONTELUKAST SODIUM 4 MG Generic TABLET, CHEWABLE 0.3550$SINGULAIR MONTELUKAST SODIUM 4 MG Generic GRANULES IN PACKET (EA) 4.3300$SINGULAIR MONTELUKAST SODIUM 4 MG Brand GRANULES IN PACKET (EA) 5.5491$SINGULAIR MONTELUKAST SODIUM 5 MG Generic TABLET, CHEWABLE 0.3207$SINGULAIR MONTELUKAST SODIUM 5 MG Brand TABLET, CHEWABLE 5.3936$SLO-NIACIN NIACIN 250 MG Generic TABLET, EXTENDED RELEASE 0.0697$SODIUM BICARBONATE SODIUM BICARBONATE 1 MEQ/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0651$SODIUM BICARBONATE SODIUM BICARBONATE 650 MG Generic TABLET 0.0141$SODIUM CHLORIDE SODIUM CHLORIDE FOR INHALATION 0.90% Generic VIAL, NEBULIZER (ML) 0.0567$SODIUM CHLORIDE SODIUM CHLORIDE IRRIGATING SOLUTION 0.90% Generic SOLUTION, IRRIGATION 0.0124$SODIUM CHLORIDE SODIUM CHLORIDE 0.90% Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0800$SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % Generic INTRAVENOUS SOLUTION 0.0013$SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE 15G/60ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1308$SODIUM SULFACETAMIDE-SULFUR SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) Generic CLEANSER (GRAM) 0.0780$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

SOLARAZE DICLOFENAC SODIUM 0.03 Brand GEL (GRAM) 10.9644$SOLODYN MINOCYCLINE HCL 55 MG Brand TABLET, EXTENDED RELEASE 24 HR 31.4015$SOLODYN MINOCYCLINE HCL 65 MG Brand TABLET, EXTENDED RELEASE 24 HR 30.2309$SOLODYN MINOCYCLINE HCL 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 31.5559$SOMA CARISOPRODOL 350 MG Generic TABLET 0.0709$SONATA ZALEPLON 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2700$SPECTAZOLE ECONAZOLE NITRATE 1.00% Generic CREAM (GRAM) 0.4750$SPIRIVA TIOTROPIUM BROMIDE 18 MCG Brand CAPSULE, WITH INHALATION DEVICE 9.0265$SPIRONOLACTONE SPIRONOLACTONE 100 MG Generic TABLET 0.5782$SPRIX KETOROLAC TROMETHAMINE 15.75 MG Brand SPRAY, NON-AEROSOL (EA) 33.0000$STADOL NS BUTORPHANOL TARTRATE 10 MG/ML Generic AEROSOL, SPRAY (ML) 13.2575$STARLIX NATEGLINIDE 120 MG Generic TABLET 0.8980$STRATTERA ATOMOXETINE HCL 10 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.8183$STRATTERA ATOMOXETINE HCL 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.8488$STRATTERA ATOMOXETINE HCL 18 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.7594$STRATTERA ATOMOXETINE HCL 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.7921$STRATTERA ATOMOXETINE HCL 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.4523$STRATTERA ATOMOXETINE HCL 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.4843$STRATTERA ATOMOXETINE HCL 80 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.1387$STROMECTOL IVERMECTIN 3 MG Brand TABLET 4.4639$SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG Brand FILM, MEDICATED (EA) 3.8136$SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG Brand TABLET, SUBLINGUAL 5.3475$SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 4MG-1MG Brand FILM, MEDICATED (EA) 6.8097$SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG Brand TABLET, SUBLINGUAL 9.6600$SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG Brand FILM, MEDICATED (EA) 6.7924$SUBSYS FENTANYL 600 MCG Brand SPRAY, NON-AEROSOL (EA) 71.1931$SUBUTEX BUPRENORPHINE HCL 2 MG Generic TABLET, SUBLINGUAL 1.6100$SUBUTEX BUPRENORPHINE HCL 8 MG Generic TABLET, SUBLINGUAL 2.1867$SUDAFED 12-HOUR PSEUDOEPHEDRINE HCL 120 MG Generic TABLET, EXTENDED RELEASE 0.3900$SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 4 MG/0.5ML Generic PEN INJECTOR (ML) 173.6400$SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 6 MG/0.5ML Generic VIAL (ML) 71.5074$SUMAVEL DOSEPRO SUMATRIPTAN SUCCINATE 6 MG/0.5ML Brand NEEDLE-FREE INJECTOR (ML) 275.4558$SUPRAX CEFIXIME 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 5.9755$SUPREP SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE 17.5-3.13G Brand SOLUTION, RECONSTITUTED, ORAL 0.2100$SUREPRIN 81 ASPIRIN 81 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0100$SUSTIVA EFAVIRENZ 600 MG Brand TABLET 24.7408$SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE 160-4.5MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 24.1249$SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE 80-4.5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 21.0352$SYMBYAX OLANZAPINE/FLUOXETINE HCL 12MG-25MG Generic CAPSULE (HARD, SOFT, ETC.) 16.6740$SYMLINPEN 120 PRAMLINTIDE ACETATE 2700/2.7ML Brand PEN INJECTOR (ML) 105.9245$SYMMETREL AMANTADINE HCL 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4711$SYMMETREL AMANTADINE HCL 100 MG Generic TABLET 1.6444$SYNALAR FLUOCINOLONE ACETONIDE 0.0001 Generic CREAM (GRAM) 1.9650$TACLONEX CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE 0.005-.064 Brand SUSPENSION, TOPICAL (GRAM) 9.9460$TACLONEX CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE 0.005-.064 Brand OINTMENT (GRAM) 9.9292$TAMIFLU OSELTAMIVIR PHOSPHATE 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.7729$TAMIFLU OSELTAMIVIR PHOSPHATE 45 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.7304$TAMIFLU OSELTAMIVIR PHOSPHATE 6 MG/ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.7842$TAMIFLU OSELTAMIVIR PHOSPHATE 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 10.6020$TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG Generic TABLET 0.2675$TAPAZOLE METHIMAZOLE 10 MG Generic TABLET 0.2250$TAPAZOLE METHIMAZOLE 5 MG Generic TABLET 0.1258$TAZORAC TAZAROTENE 0.0005 Brand CREAM (GRAM) 8.2200$TAZORAC TAZAROTENE 0.0005 Brand GEL (GRAM) 8.2116$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

TAZORAC TAZAROTENE 0.001 Brand GEL (GRAM) 8.9279$TAZORAC TAZAROTENE 0.001 Brand CREAM (GRAM) 8.1373$TEGRETOL CARBAMAZEPINE 100 MG Generic TABLET, CHEWABLE 0.1883$TEGRETOL CARBAMAZEPINE 200 MG Brand TABLET 1.4500$TEGRETOL CARBAMAZEPINE 200 MG Generic TABLET 0.5626$TEGRETOL XR CARBAMAZEPINE 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 0.7440$TEKTURNA ALISKIREN HEMIFUMARATE 150 MG Brand TABLET 3.6486$TEKTURNA ALISKIREN HEMIFUMARATE 300 MG Brand TABLET 4.5886$TEMAZEPAM TEMAZEPAM 7.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 4.9200$TEMOVATE CLOBETASOL PROPIONATE 0.050% Generic OINTMENT (GRAM) 2.3757$TEMOVATE CLOBETASOL PROPIONATE 0.0005 Generic CREAM (GRAM) 2.4866$TEMOVATE CLOBETASOL PROPIONATE 0.0005 Generic SOLUTION, NON-ORAL 0.4719$TEMOVATE CLOBETASOL PROPIONATE 0.0005 Generic GEL (GRAM) 3.4401$TEMOVATE EMOLLIENT CLOBETASOL PROPIONATE/EMOLLIENT 0.0005 Generic CREAM (GRAM) 0.6369$TEMOZOLOMIDE TEMOZOLOMIDE 100 MG Generic CAPSULE 153.5576$TENEX GUANFACINE HCL 1 MG Generic TABLET 0.0770$TENEX GUANFACINE HCL 2 MG Generic TABLET 0.1050$TENORETIC 100 ATENOLOL/CHLORTHALIDONE 100MG-25MG Generic TABLET 0.1757$TENORETIC 50 ATENOLOL/CHLORTHALIDONE 50 MG-25MG Generic TABLET 0.1027$TENORMIN ATENOLOL 100 MG Generic TABLET 0.0300$TENORMIN ATENOLOL 25 MG Generic TABLET 0.0100$TENORMIN ATENOLOL 50 MG Generic TABLET 0.0183$TERAZOL 3 TERCONAZOLE 0.8% Generic CREAM WITH APPLICATOR 1.6156$TERAZOL 3 TERCONAZOLE 80 MG Generic SUPPOSITORY, VAGINAL 25.6475$TERAZOL 7 TERCONAZOLE 0.004 Generic CREAM WITH APPLICATOR 0.6950$TESSALON BENZONATATE 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1267$TESTIM TESTOSTERONE 50 MG (1%) Brand GEL (GRAM) 2.4733$THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.1986$THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.3310$THIORIDAZINE HCL THIORIDAZINE HCL 50 MG Generic TABLET 0.4650$THORAZINE CHLORPROMAZINE HCL 100 MG Generic TABLET 1.9750$TIKOSYN DOFETILIDE 250 MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.7165$TIMOLOL MALEATE TIMOLOL MALEATE 0.0025 Generic GEL-FORMING SOLUTION 22.0801$TIMOLOL MALEATE TIMOLOL MALEATE 0.005 Generic GEL-FORMING SOLUTION 15.2715$TIMOPTIC TIMOLOL MALEATE 0.0025 Generic DROPS 0.5286$TIMOPTIC TIMOLOL MALEATE 0.005 Generic DROPS 0.6708$TINDAMAX TINIDAZOLE 500 MG Generic TABLET 5.8950$TINDAMAX TINIDAZOLE 500 MG Brand TABLET 6.1750$TIROSINT LEVOTHYROXINE SODIUM 100 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.0019$TIROSINT LEVOTHYROXINE SODIUM 112 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8897$TIROSINT LEVOTHYROXINE SODIUM 125 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8932$TIROSINT LEVOTHYROXINE SODIUM 50 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.9620$TIROSINT LEVOTHYROXINE SODIUM 75 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8983$TIROSINT LEVOTHYROXINE SODIUM 88 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.9200$TIZANIDINE HCL TIZANIDINE HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7160$TIZANIDINE HCL TIZANIDINE HCL 4 MG Generic CAPSULE 2.4539$TIZANIDINE HCL TIZANIDINE HCL 6 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.9849$TOBRADEX TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% Brand OINTMENT (GRAM) 47.4617$TOBRADEX TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 17.8384$TOBRADEX ST TOBRAMYCIN/DEXAMETHASONE 0.3%-0.05% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 24.5916$TOBREX TOBRAMYCIN 0.003 Generic DROPS 1.1088$TOBREX TOBRAMYCIN 0.003 Brand OINTMENT (GRAM) 28.0625$TOPAMAX TOPIRAMATE 100 MG Brand TABLET 10.1580$TOPAMAX TOPIRAMATE 100 MG Generic TABLET 0.1000$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

TOPAMAX TOPIRAMATE 15 MG Generic CAPSULE, SPRINKLE 0.4067$TOPAMAX TOPIRAMATE 200 MG Generic TABLET 0.1456$TOPAMAX TOPIRAMATE 25 MG Brand TABLET 3.6513$TOPAMAX TOPIRAMATE 25 MG Generic TABLET 0.0362$TOPAMAX TOPIRAMATE 25 MG Generic CAPSULE, SPRINKLE 0.8104$TOPAMAX TOPIRAMATE 50 MG Generic TABLET 0.0678$TOPAMAX TOPIRAMATE 50 MG Brand TABLET 7.6779$TOVIAZ FESOTERODINE FUMARATE 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1214$TOVIAZ FESOTERODINE FUMARATE 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1418$TRADJENTA LINAGLIPTIN 5 MG Brand TABLET 9.0640$TRAMADOL HCL TRAMADOL HCL 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.2688$TRAMADOL HCL TRAMADOL HCL 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.8050$TRAMADOL HCL TRAMADOL HCL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.9480$TRAMADOL HCL-ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG Generic TABLET 0.2300$TRANDOLAPRIL TRANDOLAPRIL 4 MG Generic TABLET 0.3790$TRANEXAMIC ACID TRANEXAMIC ACID 650 MG Generic TABLET 3.7400$TRANSDERM-SCOP SCOPOLAMINE 1.5MG/72HR Brand PATCH, TRANSDERMAL 72 HOURS 15.7229$TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 15 MG Generic TABLET 0.3580$TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 3.75 MG Generic TABLET 0.1200$TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 7.5 MG Generic TABLET 0.2875$TRAVATAN Z TRAVOPROST 0% Brand DROPS 41.0548$TRENTAL PENTOXIFYLLINE 400 MG Generic TABLET, EXTENDED RELEASE 0.1846$TRETINOIN MICROSPHERE TRETINOIN MICROSPHERES 0.1 % Generic GEL (GRAM) 11.1850$TREXIMET SUMATRIPTAN SUCCINATE/NAPROXEN SODIUM 85MG-500MG Brand TABLET 26.0825$TRICOR FENOFIBRATE,MICRONIZED 134MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4620$TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2 MG Generic TABLET 0.4883$TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 5 MG Generic TABLET 0.4963$TRI-LEVLEN 28 LEVONORGESTREL-ETHINYL ESTRADIOL 6-5-10 Generic TABLET 0.5083$TRILIPIX FENOFIBRIC ACID (CHOLINE) 135 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.9023$TRILIPIX FENOFIBRIC ACID (CHOLINE) 135 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.8520$TROSPIUM CHLORIDE TROSPIUM CHLORIDE 20 MG Generic TABLET 1.8820$TRUVADA EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE 200-300 MG Brand TABLET 41.3000$TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 227.1620$TUMS CALCIUM CARBONATE 300MG(750) Brand TABLET, CHEWABLE 0.0600$ULORIC FEBUXOSTAT 40 MG Brand TABLET 6.8411$ULORIC FEBUXOSTAT 80 MG Brand TABLET 6.8406$ULTRAM TRAMADOL HCL 50 MG Brand TABLET 2.1580$ULTRAM TRAMADOL HCL 50 MG Generic TABLET 0.0200$ULTRAVATE HALOBETASOL PROPIONATE 0% Generic CREAM (GRAM) 3.1588$ULTRAVATE HALOBETASOL PROPIONATE 0% Generic OINTMENT (GRAM) 3.0225$UREA UREA 40 % Generic CREAM (GRAM) 0.0700$UREACIN 40 UREA 40% Brand CREAM (GRAM) 0.1100$URELLE METHENAMINE/METHYLENE BLUE/SALICYLATE/SODIUM PHOS/HYOSCY 81-0.12MG Brand TABLET 4.2979$UROXATRAL ALFUZOSIN HCL 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2125$URSODIOL URSODIOL 500 MG Generic TABLET 3.2975$VAGIFEM ESTRADIOL 10 MCG Brand TABLET 11.9222$VALIUM DIAZEPAM 10 MG Generic TABLET 0.0270$VALIUM DIAZEPAM 2 MG Generic TABLET 0.0200$VALIUM DIAZEPAM 5 MG Generic TABLET 0.0220$VALTREX VALACYCLOVIR HCL 1000 MG Generic TABLET 1.1635$VALTREX VALACYCLOVIR HCL 1000 MG Brand TABLET 11.2857$VALTREX VALACYCLOVIR HCL 500 MG Generic TABLET 0.7293$VALTREX VALACYCLOVIR HCL 500 MG Brand TABLET 6.6657$VANCOCIN HCL VANCOMYCIN HCL 125 MG Generic CAPSULE (HARD, SOFT, ETC.) 17.9468$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

VANCOCIN HCL VANCOMYCIN HCL 500 MG Generic VIAL (SDV,MDV OR ADDITIVE) (EA) 3.2775$VANCOMYCIN HCL VANCOMYCIN HCL 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 27.0356$VANOS FLUOCINONIDE 0% Brand CREAM (GRAM) 14.7546$VASCEPA ICOSAPENT ETHYL 1 G Brand CAPSULE (HARD, SOFT, ETC.) 1.5612$VASERETIC ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 10MG-25MG Generic TABLET 0.1175$VASOTEC ENALAPRIL MALEATE 10 MG Generic TABLET 0.1300$VASOTEC ENALAPRIL MALEATE 2.5 MG Generic TABLET 0.0800$VASOTEC ENALAPRIL MALEATE 20 MG Generic TABLET 0.1867$VASOTEC ENALAPRIL MALEATE 5 MG Generic TABLET 0.1275$VELTIN CLINDAMYCIN PHOSPHATE/TRETINOIN 1.2-0.025% Brand GEL (GRAM) 8.6438$VENLAFAXINE HCL VENLAFAXINE HCL 100 MG Generic TABLET 0.4125$VENLAFAXINE HCL VENLAFAXINE HCL 25 MG Generic TABLET 0.3950$VENLAFAXINE HCL VENLAFAXINE HCL 50 MG Generic TABLET 0.4178$VENLAFAXINE HCL ER VENLAFAXINE HCL 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7000$VENLAFAXINE HCL ER VENLAFAXINE HCL 225 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.6036$VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7977$VENLAFAXINE HCL ER VENLAFAXINE HCL 75 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7931$VERAMYST FLUTICASONE FUROATE 27.5 MCG Brand SPRAY, SUSPENSION 11.5842$VERAPAMIL ER VERAPAMIL HCL 120 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.3275$VERAPAMIL ER VERAPAMIL HCL 180 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.5300$VERAPAMIL ER VERAPAMIL HCL 240 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.6640$VERAPAMIL ER PM VERAPAMIL HCL 100 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.0100$VERAPAMIL ER PM VERAPAMIL HCL 300 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.9534$VERAPAMIL HCL VERAPAMIL HCL 360 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 1.4346$VERAPAMIL HCL VERAPAMIL HCL 80 MG Generic TABLET 0.0500$VESICARE SOLIFENACIN SUCCINATE 10 MG Brand TABLET 7.1192$VESICARE SOLIFENACIN SUCCINATE 5 MG Brand TABLET 7.1048$VFEND VORICONAZOLE 200 MG Generic TABLET 24.4065$VIAGRA SILDENAFIL CITRATE 100 MG Brand TABLET 30.4371$VIAGRA SILDENAFIL CITRATE 50 MG Brand TABLET 27.5325$VIBRAMYCIN DOXYCYCLINE HYCLATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.6150$VIBRAMYCIN DOXYCYCLINE HYCLATE 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9775$VIBRA-TABS DOXYCYCLINE HYCLATE 100 MG Generic TABLET 2.5658$VICKS VAPORUB EUCALYPTUS/MENTHOL/CAMPHOR/TURPENTINE OIL/PETROLATUM,WHITE Brand OINTMENT (GRAM) 0.0655$VICODIN HYDROCODONE BIT/ACETAMINOPHEN 5 MG-500MG Generic TABLET 0.0457$VICODIN ES HYDROCODONE BIT/ACETAMINOPHEN 7.5-750MG Generic TABLET 0.1187$VICOPROFEN HYDROCODONE/IBUPROFEN 7.5-200 MG Generic TABLET 0.3088$VICTOZA 2-PAK LIRAGLUTIDE Brand PEN INJECTOR (ML) 57.3737$VIGAMOX MOXIFLOXACIN HCL 1% Brand DROPS 33.9790$VIIBRYD VILAZODONE HYDROCHLORIDE 20 MG Brand TABLET 5.2989$VIIBRYD VILAZODONE HYDROCHLORIDE 40 MG Brand TABLET 5.2785$VIMOVO NAPROXEN/ESOMEPRAZOLE MAGNESIUM 500MG-20MG Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 12.7875$VIMPAT LACOSAMIDE 100 MG Brand TABLET 9.2670$VIMPAT LACOSAMIDE 150 MG Brand TABLET 9.9644$VIMPAT LACOSAMIDE 200 MG Brand TABLET 9.8011$VIMPAT LACOSAMIDE 50 MG Brand TABLET 5.7477$VIREAD TENOFOVIR DISOPROXIL FUMARATE 300 MG Brand TABLET 28.1214$VISTARIL HYDROXYZINE PAMOATE 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0700$VISTARIL HYDROXYZINE PAMOATE 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0825$VITAMIN B-6 PYRIDOXINE HCL 50 MG Generic TABLET 0.0179$VITAMIN D CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT Generic CAPSULE 0.0438$VOLTAREN DICLOFENAC SODIUM 1% Brand GEL (GRAM) 0.4057$VOLTAREN DICLOFENAC SODIUM 50 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2773$VOLTAREN DICLOFENAC SODIUM 75 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2574$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

VYTORIN EZETIMIBE/SIMVASTATIN 10 MG-10MG Brand TABLET 5.3300$VYTORIN EZETIMIBE/SIMVASTATIN 10MG-20MG Brand TABLET 5.8550$VYTORIN EZETIMIBE/SIMVASTATIN 10MG-40MG Brand TABLET 5.8521$VYTORIN EZETIMIBE/SIMVASTATIN 10MG-80MG Brand TABLET 5.8980$VYVANSE LISDEXAMFETAMINE DIMESYLATE 20 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.2660$VYVANSE LISDEXAMFETAMINE DIMESYLATE 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4233$VYVANSE LISDEXAMFETAMINE DIMESYLATE 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4300$VYVANSE LISDEXAMFETAMINE DIMESYLATE 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4233$VYVANSE LISDEXAMFETAMINE DIMESYLATE 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.0750$VYVANSE LISDEXAMFETAMINE DIMESYLATE 70 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4200$WATER WATER FOR IRRIGATION,STERILE 0% Generic SOLUTION, IRRIGATION 0.0016$WELCHOL COLESEVELAM HCL 3.75 G Brand POWDER IN PACKET (EA) 11.9175$WELCHOL COLESEVELAM HCL 625 MG Brand TABLET 1.9990$WELLBUTRIN BUPROPION HCL 100 MG Generic TABLET 0.4937$WELLBUTRIN BUPROPION HCL 75 MG Generic TABLET 0.4208$WELLBUTRIN XL BUPROPION HCL 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5663$WELLBUTRIN XL BUPROPION HCL 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2180$WELLBUTRIN XL BUPROPION HCL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5894$WESTCORT HYDROCORTISONE VALERATE 0% Generic OINTMENT (GRAM) 4.5238$WESTCORT HYDROCORTISONE VALERATE 0% Generic CREAM (GRAM) 3.1396$XARELTO RIVAROXABAN 10 MG Brand TABLET 9.2371$XARELTO RIVAROXABAN 15 MG Brand TABLET 9.1847$XARELTO RIVAROXABAN 20 MG Brand TABLET 9.1725$XIFAXAN RIFAXIMIN 200 MG Brand TABLET 13.9849$XIFAXAN RIFAXIMIN 550 MG Brand TABLET 22.5956$XOPENEX HFA LEVALBUTEROL TARTRATE 45MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 3.3211$ZALEPLON ZALEPLON 5 MG Generic CAPSULE 0.2314$ZANAFLEX TIZANIDINE HCL 2 MG Generic TABLET 0.2421$ZANAFLEX TIZANIDINE HCL 4 MG Generic TABLET 0.2057$ZANTAC RANITIDINE HCL 150 MG Generic TABLET 0.0680$ZANTAC RANITIDINE HCL 300 MG Generic TABLET 0.1456$ZARONTIN ETHOSUXIMIDE 250 MG/5ML Generic SOLUTION, ORAL 0.2652$ZEBETA BISOPROLOL FUMARATE 10 MG Generic TABLET 0.2409$ZEBETA BISOPROLOL FUMARATE 5 MG Generic TABLET 0.3457$ZEMPLAR PARICALCITOL 1 MCG Brand CAPSULE (HARD, SOFT, ETC.) 10.8093$ZENCIA SULFACETAMIDE SODIUM/SULFUR 9 %-4 % Brand CLEANSER (ML) 0.1539$ZESTRIL LISINOPRIL 30 MG Generic TABLET 0.0800$ZETIA EZETIMIBE 10 MG Brand TABLET 5.9496$ZETONNA CICLESONIDE 37 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 22.5083$ZIAC BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE 10-6.25MG Generic TABLET 0.1383$ZIAC BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE 2.5-6.25MG Generic TABLET 0.0900$ZIAC BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE 5-6.25MG Generic TABLET 0.0860$ZINC OXIDE ZINC OXIDE 20% Generic OINTMENT (GRAM) 0.0550$ZIOPTAN TAFLUPROST/PF 0% Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 3.3200$ZIRGAN GANCICLOVIR 0% Brand GEL (GRAM) 49.4001$ZOLMITRIPTAN ZOLMITRIPTAN 2.5 MG Generic TABLET 7.8900$ZOMIG ZOLMITRIPTAN 2.5 MG Brand TABLET 57.3998$ZOMIG ZOLMITRIPTAN 5 MG Generic TABLET 9.6111$ZOMIG ZOLMITRIPTAN 5 MG Brand TABLET 66.8417$ZOMIG ZOLMITRIPTAN 5 MG Brand SPRAY, NON-AEROSOL (EA) 44.0280$ZOMIG ZMT ZOLMITRIPTAN 5 MG Generic TABLET,DISINTEGRATING 8.9415$ZOMIG ZMT ZOLMITRIPTAN 5 MG Brand TABLET,DISINTEGRATING 59.8298$ZONEGRAN ZONISAMIDE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1475$ZONEGRAN ZONISAMIDE 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.7250$

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Average Acquisition Cost (AAC) Price List(Effective 7/04/2014)

Brand Reference Generic Name Strength Brand/Generic

Dosage Form AAC Rate

ZONEGRAN ZONISAMIDE 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1250$ZOSTAVAX ZOSTER VACCINE LIVE/PF 19400 UNIT Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 178.6389$ZOVIRAX ACYCLOVIR 5% Generic OINTMENT (GRAM) 20.2489$ZOVIRAX ACYCLOVIR 5% Brand OINTMENT (GRAM) 29.2746$ZOVIRAX ACYCLOVIR 5% Brand CREAM (GRAM) 118.3720$ZOVIRAX ACYCLOVIR 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1064$ZOVIRAX ACYCLOVIR 200 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.4975$ZOVIRAX ACYCLOVIR 400 MG Generic TABLET 0.1175$ZOVIRAX ACYCLOVIR 800 MG Generic TABLET 0.2250$ZYFLO CR ZILEUTON 600 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 17.3599$ZYLET TOBRAMYCIN/LOTEPREDNOL ETABONATE 0.3%-0.5% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 34.2251$

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