Bimatoprost implant, for intracameral administration, 1 ...

UPDATED: 6/9/2021

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

J0129 Abatacept 10 mg, injection (Orencia) $18.73 $18.73 3/1/2020J0586 AbobotulinumtoxinA, 5 units (Dysport) $7.57 $7.57 3/1/2020J0178 Aflibercept, 1 mg, injection (Eylea) $982.43 $982.43 3/1/2020J0202 Alemtuzumab, 1 mg (Lemtrada) $1,831.01 $1,831.01 3/1/2020J0221 Alglucosidase alfa, 10 mg, injection (Lumizyme) $148.61 $148.61 3/1/2020J7308 Aminolevulinic acid HCI for topical admin. 20% single unit dosage form (354 mg) (Levulan) (Kerastic $109.98 $109.98 3/1/2020J7196 Antithrombin (recombinant), 50 IU (ATryn) $105.51 $105.51 3/1/2020J3590 Asfotase alfa 1 mg (Strensiq) $75.60 $75.60 11/1/2015J9999 Avelumab injection, 1 mg (Bavencio) $8.12 $8.12 4/1/2017J0485 Belatacept, 1 mg, injection (Nulojix) $3.81 $3.81 3/1/2020J0490 Belimumab, 10 mg, injection (Benlysta) $38.49 $38.49 3/1/2020J0179 Brolucizumab-dbll injection 1 mg (Beovu) $333.46 $333.46 3/1/2020J0597 C1 Esterase Inhibitor (human), 10 units (Berinert) $27.59 $27.59 3/1/2020J0598 C1 esterase inhibitor (human), 10 units, injection (Cinryze) $43.64 $43.64 3/1/2020J0638 Canakinumab, 1 mg vial (Ilaris) $89.35 $89.35 3/1/2020J0716 Centruriodes Immune F(ab), 120 mg (Anascorp) $3,945.28 $3,945.28 3/1/2020J3590 Cerliponase alfa injection 1 kit (Brineura) $29,160.00 $29,160.00 6/1/2017J0717 Certolizumab pegol, 1 mg, injection (Cimzia) $5.45 $5.45 3/1/2020J0775 Collagenase clostridium histolyticum, 0.01 mg (Xiaflex) $37.59 $37.59 3/1/2020J0791 Crizanlizumab-tmca injection 5 mg (Adakveo) $122.44 $122.44 7/1/2020J0897 Denosumab, 1 mg (Xgeva) (Prolia) $14.46 $14.46 3/1/2020J1300 Eculizumab, 10 mg, injection (Soliris) $176.76 $176.76 3/1/2020J9358 fam-trastuzumab deruxtecan-nxki for injection 1 mg (Enhertu) $24.19 $24.19 7/1/2020J1458 Galsulfase injection for intravenous use 1 mg (Naglazyme) $399.53 $399.53 3/1/2020J1602 Golimumab Hydrochloride 1 mg (Simponi Aria) $25.82 $25.82 3/1/2020J7178 Human fibrinogen concentrate, 1 mg, injection (RiaSTAP) $0.98 $0.98 3/1/2020J3590 Human Topical Protein, 1 IU (Recothrom) $0.02 $0.02 1/1/2015J1744 Icatibant acetate, 1 mg (Firazyr) $152.40 $152.40 3/1/2020J3590 Idarucizumab injection 2.5 g/50 ml (Praxbind) $1,890.00 $1,890.00 10/1/2015J3590 Immune Globulin Subcutaneous, 20% solution 100 mg (Cuvitru) $18.14 $18.14 11/1/2016J0588 IncobotulinumtoxinA, 1 unit (Xeomin) $5.54 $5.54 3/1/2020J1823 inebilizumab-cdon injection 1 mg (Uplizna) $471.60 $471.60 1/1/2021J9227 isatuximab-irfc injection 10 mg (Sarclisa) $66.67 $66.67 10/11/2020J3590 Peanut (Arachis hypogaea) allergen powder-dnfp 1 daily dose (Palforzia) $32.04 $32.04 4/2/2020Q5108 Pegfilgrastim-jmdb injection 0.5 mg (Fulphila) $387.23 $387.23 3/1/2020S0145 Peginterferon Alfa-2a, 180 mcg/ml (Pegasys) $337.13 $337.13 3/1/2020J3590 Peginterferon Alfa-2b, 1 mcg (Sylatron) $3.10 $3.10 1/1/2015J2507 Pegloticase, 1 mg (Krystexxa) $302.72 $302.72 3/1/2020S0148 Pegylated interferon alfa-2b, 10 mcg (Peg-Intron) $105.30 $105.30 3/1/2020J9306 Pertuzumab, 1 mg, injection (Perjeta) $10.84 $10.84 3/1/2020J2724 Protein C concentrate, intravenous, human, 1 IU, injection (Ceprotin) $12.21 $12.21 3/1/2020J3590 Prothrombin complex concentrate (Human) 1 IU (Kcentra) $2.04 $2.04 1/1/2015J2778 Ranibizumab, 0.1 mg, injection (Lucentis) $406.05 $406.05 3/1/2020J2786 Reslizumab injection 1 mL(Cinqair) $94.69 $94.69 3/1/2020J2793 Rilonacept, 1 mg injection (Arcalyst) $24.59 $24.59 3/1/2020J3590 Secukinumab injection 150 mg (Cosentyx) $3,656.66 $3,656.66 4/1/2015J9999 tafasitamab-cxix for injection 1 mg (Monjuvi) $6.48 $6.48 8/10/2020 3/31/2021J9349 tafasitamab-cxix for injection 2 mg (Monjuvi) $12.66 $12.66 4/1/2021J3262 Tocilizumab, 1 mg (Actemra) $3.48 $3.48 3/1/2020J3357 Ustekinumab Injection for subcutaneous use, 1 mg (Stelara) $112.10 $112.10 3/1/2020J3358 Ustekinumab injection for intravenous use, 1 mg (Stelara IV) $13.49 $13.49 3/1/2020J3385 Velaglucerase Alfa, 100 units (VPRIV) $351.28 $351.28 3/1/2020J9400 Ziv-aflibercept, 1 ml or 25 mg, injection (Zaltrap) $9.96 $9.96 3/1/2020

J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg (17P) $19.80 $19.80 1/1/2015J0130 Abciximab, 10mg, injection (ReoPro) $423.96 $423.96 3/1/2020J1120 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.71 $16.71 3/1/2020J0133 Acyclovir, 5 mg, injection (Zovirax) $0.02 $0.02 3/1/2020J0153 Adenosine injection 1 mg (Adenoscan, Adenocard) $0.93 $0.93 3/1/2020J9354 Ado-trastuzumab Emtansine, 1 mg, injection (Kadcyla) $32.11 $32.11 3/1/2020J0180 Agalsidase Beta, 1 mg, injection (Fabrazyme) $129.86 $129.86 3/1/2020P9047 Albumin (human), 25%, 50 ml, infusion (Albuminar, Albutein, Bluminate), Plasbumin $40.22 $40.22 3/1/2020P9041 Albumin (human), 5%, 50 ml, infusion (Albiminar, Albutein, Buminate, Plasbumin) $20.10 $20.10 3/1/2020J9015 Aldesleukin, per single use vial (Proleukin, etc) $769.05 $769.05 3/1/2020J0215 Alefacept, 0.5 mg, injection (Amevive) $26.71 $26.71 3/1/2020J0205 Alglucerase, per 10 units, injection (Ceredase) $39.75 $39.75 3/1/2020J0220 Alglucosidase alfa, 10 mg, injection (Myozyme) $127.47 $127.47 3/1/2020J0257 Alpha 1 proteinase inhibitor (human), 10 mg (Glassia) $3.86 $3.86 3/1/2020J0256 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) (Aralast, Zemaira) $3.67 $3.67 3/1/2020J2997 Alteplase recombinant, 1 mg, injection (Activase) $32.24 $32.24 3/1/2020J3490 Amisulpride injection 1 mg (Barhemsys) $9.18 $9.18 8/4/2020J0207 Amifostine, 500mg, injection (Ethyol) $512.32 $512.32 3/1/2020J0278 Amikacin sulfate, 100 mg, injection (Amikin) $0.73 $0.73 3/1/2020J0280 Aminophylline, up to 250mg, injection $0.37 $0.37 3/1/2020J0300 Amobarbital, up to 125mg, injection (Amytal) $11.98 $11.98 3/1/2020J0285 Amphotericin B, 50 mg, injection (Amphocin) (Fungizone) $12.00 $12.00 3/1/2020J0288 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotec) $12.02 $12.02 3/1/2020J0287 Amphotericin B lipid complex, 10 mg, injection (Abelcet) $10.48 $10.48 3/1/2020J0289 Amphotericin B liposome, 10 mg, injection (Ambisome) $17.19 $17.19 3/1/2020J0290 Ampicillin sodium, 500mg, injection $2.25 $2.25 3/1/2020J0295 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $4.41 $4.41 3/1/2020J7188 Antihemophilic factor (recombinant) porcine sequence 1 IU (Orbizur) $5.85 $5.85 3/1/2020J7197 Antithrombin III (human), per IU (Throbate III) $1.91 $1.91 3/1/2020

DRUGS

BIOLOGICALS

Physician Drug Program Procedure Codes And RatesEffective January 1, 2021

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

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

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

J0400 Aripiprazole, intramuscular, 0.25 mg, injection (Abilify) $0.29 $0.29 3/1/2020J0401 Aripiprazole, extended release, 1 mg, injection $4.04 $4.04 3/1/2020J1943 Aripiprazole, lauroxil extended-release injectable suspension 1 mg (Aristada Initio) $3.00 $3.00 3/1/2020J9017 Arsenic trioxide, 1 mg (Trisenox) $34.55 $34.55 3/1/2020J9020 Asparaginase, 10,000 units (Elspar) $57.14 $57.14 3/1/2020J9019 Asparaginase Erwinia Chrysanthemi, 1,000 IUs, injection (Erwinaze) $334.98 $334.98 3/1/2020J0461 Atropine sulfate, 0.01 mg, injection $0.04 $0.04 3/1/2020J9025 Azacitidine 1 mg (Vidaza) $4.49 $4.49 3/1/2020J0456 Azithromycin, 500mg, injection (Zithromax) $18.02 $18.02 3/1/2020Q0144 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, Zithromax Z-Pak) $21.78 $21.78 3/1/2020J0475 Baclofen, 10mg, injection (Lioresal) $191.26 $191.26 3/1/2020J0476 Baclofen, 50 mcg for intrathecal trial, injection (Lioresal) $69.91 $69.91 3/1/2020Q0245 Bamlanivimab and etesevimab, 2100 MG $0.00 $0.00 2/9/2021J9037 belantamab mafodotin-blmf for injection (Blenrep) 0.5 mg $42.97 $42.97 4/1/2021J9032 Belinostat 10 mg (Beleodaq) $34.13 $34.13 3/1/2020J9033 Bendamustine HCl, 1 mg, injection (Treanda) $18.65 $18.65 3/1/2020J9036 Bendamustine HCl, 1 mg, injection (Belrapzo) $24.66 $24.66 3/1/2020J0702 Betamethasone acetate and betamethasone sodium phosphate, per 3mg, injection (Celestone)

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

J9035 Bevacizumab, 10 mg, injection (Avastin) $57.57 $57.57 3/1/2020Q5118 Bevacizumab-bzr injection 10 mg (Zirabev) $69.56 $69.56 3/1/2020J7351 Bimatoprost implant, for intracameral administration, 1 mcg (Durysta) $210.60 $210.60 10/1/2020J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.09 $29.09 3/1/2020J9039 Blinatumomab (Blincyto), 1 mcg $102.98 $102.98 3/1/2020J9041 Bortezomib, 0.1 mg, inj. (Velcade) $34.50 $34.50 3/1/2020J0585 Botulinum toxin type A, per unit (Botox) $5.96 $5.96 3/1/2020J0587 Botulinum toxin type B, per 100 units (Myobloc) $8.73 $8.73 3/1/2020J9042 Brentuximab vedotin, 1 mg (Adcetris) $99.19 $99.19 3/1/2020Q9991 Buprenorphine extended-release injection (< or = 100 mg) (Sublocade) $1,758.54 $1,758.54 3/1/2020Q9992 Buprenorphine extended-release injection (> 100 mg) (Sublocade) $1,758.54 $1,758.54 3/1/2020J0570 Buprenorphine implant, 74.2 mg (Probuphine) $1,344.55 $1,344.55 3/1/2020J0595 Butorphinol tartrate, 1 mg, injection (Stadol) $0.50 $0.50 3/1/2020J9043 Cabazitaxel, 1 mg (Jevtana) $135.47 $135.47 3/1/2020J3490 Cabotegravir extended-release injectable susension; rilpivirine extended-release injectable

suspension 1 mL (Cabenuva)$1,069.20 $1,069.20 2/21/2021

J9118 Calaspargase pegol-mknl injection 10 Units (Asparlas) $72.58 $72.58 3/1/2020J0636 Calcitriol, 0.1 mcg, injection (Calcijex) $0.43 $0.43 3/1/2020J0610 Calcium gluconate, per 10ml, injection $0.36 $0.36 3/1/2020J0620 Calcium glycerophosphate and calcium lactate, per 10ml, injection (Calphosan) $12.60 $12.60 1/1/2015J3590 caplacizumab-yhdp for injection 11 mg (Cablivi) $7,884.00 $7,884.00 2/25/2019J7336 Capsaicin 8% patch, per 1 square cm (Qutenza) $3.00 $3.00 3/1/2020J9045 Carboplatin, 50 mg (Paraplatin) $6.32 $6.32 3/1/2020J9047 Carfilzomib, 1 mg injection (Kyprolis) $31.11 $31.11 3/1/2020J9050 Carmustine, 100 mg (BiCNU) $157.16 $157.16 3/1/2020J0690 Cefazolin Sodium, 500 mg, Injection $0.66 $0.66 3/1/2020J0692 Cefepime HCL, 500 mg, injection (Maxipime) $6.76 $6.76 3/1/2020J0698 Cefotaxime Sodium, per 1 g (Claforan) $4.30 $4.30 3/1/2020J0694 Cefoxitin Sodium, 1g, injection (Mefoxin) $8.21 $8.21 3/1/2020J0712 Ceftaroline Fosamil Acetate, 10 mg (Teflaro) $0.74 $0.74 3/1/2020J0714 Ceftazidime; avibactam injection 0.625 g (Avycaz) $80.80 $80.80 3/1/2020J0713 Ceftazidime, per 500 mg, injection (Fortaz, Tazidime) $3.48 $3.48 3/1/2020J0715 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.25 $5.25 3/1/2020J0695 Ceftolozane/Tazobactam 75 mg, 1-0.5 gm vial (Zerbaxa) $4.70 $4.70 3/1/2020J0696 Ceftriaxone Sodium, per 250mg, injection (Rocephin) $1.48 $1.48 3/1/2020J0697 Cefuroxime sodium, per 750mg, injection (Zinacef) $3.45 $3.45 3/1/2020J9119 cemiplimab-rwlc injection, 1 mg (Libtayo) $27.45 $27.45 10/1/2019J1201 Cetrizine hydrochloride injection .5 mg (Quzyttir) $16.20 $16.20 7/1/2020J9119 cemiplimab-rwlc injection, 1 mg (Libtayo) $27.45 $27.45 3/1/2020J9055 Cetuximab, 10 mg, injection (Erbitux) $49.92 $49.92 3/1/2020J0720 Chloramphenicol sodium succinate, up to 1g, injection (Chloromycetin) $18.42 $18.42 3/1/2020J1990 Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $21.09 $21.09 3/1/2020J2400 Chloroprocaine HCl, per 30 ml, injection (Nesacaine) $12.75 $12.75 3/1/2020J1205 Chlorothiazide sodium, per 500 mg, injection (Diuril Sodium) $165.48 $165.48 3/1/2020J3230 Chlorpromazine HCl, up to 50 mg, injection (Thorazine) $3.23 $3.23 3/1/2020J0725 Chorionic Gonadotropin, per 1,000 USP units, injection (Novarel, Pregnyl, Profasil HP) $3.38 $3.38 3/1/2020J0740 Cidofovir, 375 mg, injection (Vistide) $764.08 $764.08 3/1/2020J0743 Cilastatin sodium imipenem, per 250mg, injection (Primaxin IM or IV) $14.31 $14.31 3/1/2020S0023 Cimetidine hydrochloride, 300 mg, injection (Tagamet) $0.61 $0.61 3/1/2020J0744 Ciprofloxacin for IV infusion, 200 mg, injection (Cipro) $5.35 $5.35 3/1/2020J9060 Cisplatin, powder or solution, per 10 mg $2.27 $2.27 3/1/2020J9065 Cladribine, per 1 mg, injection (Leustatin) $30.70 $30.70 3/1/2020J3490 Clevidipine injectable emulsion (Cleviprex) $2.89 $2.89 11/1/2016J0735 Clonidine hydrochloride, 1mg, 1 IU injection (Duracion) $56.12 $56.12 3/1/2020J7169 Coagulation factor Xa (recombinant) 10 mg (Andexxa) $297.00 $297.00 7/1/2020J0745 Codeine phosphate, per 30mg, injection $1.27 $1.27 3/1/2020J0770 Colistimethate Sodium,150 mg, injection (Coly-Mycin M) $19.93 $19.93 3/1/2020S4993 Contraceptive pills for birth control, 1 Pack $3.15 $3.15 3/1/2020J9999 Copanlisib injection, 1 mg (Aliqopa) $75.60 $75.60 9/18/2017J0800 Corticotropin, up to 40 units, injection (Acthar, ACTH) $2,360.58 $2,360.58 3/1/2020J0834 Cosyntropin, 0.25 injection (Cortrosyn) $91.38 $91.38 3/1/2020J3590 Crotalidae immune f(ab')2 (equine), lyophilized powder for solution 1 vial (Anavip) $1,317.60 $1,317.60 11/2/2018J0840 Crotalidae polyvalent immune fab (ovine) powder for solution for intravenous injection, up to 1 gram

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

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

J0895 Deferoxamine Mesylate, 500mg, injection (Desferal) $12.33 $12.33 3/1/2020J9155 Degarelix, 1 mg, injection (Firmagon) $2.88 $2.88 3/1/2020J3490 Delafloxacin for injection 300 mg (Baxdela) $0.48 $0.48 11/12/2017J9160 Denileukin Diftitox, 300 mcg (Ontak) $1,413.07 $1,413.07 3/1/2020J1000 Depo-estradiol cypionate, up to 5mg, injection (Depo-Estradiol) $6.19 $6.19 3/1/2020J2597 Desmopressin acetate, per 1 mcg, injection (DDAVP) $1.87 $1.87 3/1/2020J1094 Dexamethasone acetate, 1 mg, injection (Dalalone DP, Dexasone LA, Dexone LA, Cortastat LA) $0.23 $0.23 3/1/2020

J1095 Dexamethasone Intraocular suspension 9% 1 mcg (Dexycu) $1.30 $1.30 3/1/2020J7312 Dexamethasone, Intravitreal implant, 0.1 mg (Ozurdex) $196.37 $196.37 3/1/2020J1096 Dexamethasone ophthalmic insert 0.4 mg, 0.1 mg (Dextenza) $152.75 $152.75 3/1/2020J1100 Dexamethasone sodium phosphate, 1mg, injection (Cortastat, Dalalone) (Hexadrol) $0.08 $0.08 3/1/2020J1190 Dexrazoxane hydrochloride, per 250 mg, injection (Zinecard) (Totect) $181.33 $181.33 3/1/2020J7042 Dextrose 5% / normal saline (500 ml = 1 unit) $0.28 $0.28 3/1/2020J7060 Dextrose 5% / water (500 ml = 1 unit) $1.09 $1.09 3/1/2020J7121 Dextrose 5% in lactated ringers infusion, up to 1000 cc (Dextrose) $2.22 $2.22 3/1/2020J3360 Diazepam, up to 5 mg, injection (Valium, Zetran) $0.79 $0.79 3/1/2020J1730 Diazoxide, up to 300 mg, injection (Hyperstat IV) (Proglycern) $112.09 $112.09 3/1/2020J0500 Dicyclomine HCl, up to 20mg, injection (Bentyl, Dilomine) $11.94 $11.94 3/1/2020J3490 Defibrotide sodium injection, for intravenous use 1 ml (Defitelio) $356.40 $356.40 4/1/2016J1160 Digoxin, up to 0.5 mg injection (Lanoxin) $1.18 $1.18 3/1/2020J1110 Dihydroergotamine mesylate, per 1mg, injection (DHE 45) $24.55 $24.55 3/1/2020J1240 Dimenhydrinate, up to 50 mg, injection $3.13 $3.13 3/1/2020J0470 Dimercaprol, per 100mg, injection (BAL in oil) $26.72 $26.72 3/1/2020J9999 Dinutuximab Vial 1 ml (Unituxin) $1,603.80 $1,603.80 8/1/2015J1200 Diphenhydramine HCl, up to 50 mg, injection (Benadryl) $0.75 $0.75 3/1/2020J1245 Dipyridamole, per 10 mg, injection (Persantine IV) $0.73 $0.73 3/1/2020J1212 DMSO, dimethyl sulfoxide, 50%, 50 ml, injection $50.60 $50.60 3/1/2020J1250 Dobutamine HCl, per 250 mg, injection (Dobutrex) $5.16 $5.16 3/1/2020J9171 Docetaxel, 1 mg, injection (Taxotere) $17.65 $17.65 3/1/2020J1260 Dolasetron mesylate, 10 mg, injection (Anzemet) $4.20 $4.20 3/1/2020J1265 Dopamine HCI, 40 mg, injection $0.51 $0.51 3/1/2020J1267 Doripenem, 10 mg, injection (Doribax) $0.65 $0.65 3/1/2020J1270 Doxercalciferol, 1 mcg, injection (Hectorol) $2.81 $2.81 3/1/2020J9000 Doxorubicin HCl, 10 mg (Adriamycin) $4.76 $4.76 3/1/2020Q2049 Doxorubicin HCL Liposomal, Imported Lipodox. 10 mg (Doxil) $499.24 $499.24 3/1/2020Q2050 Doxorubicin Hydrochloride, Injection, Liposomal, Not otherwise specified, 10 mg $579.32 $579.32 3/1/2020J1790 Droperidol, up to 5 mg, injection (Inapsine) $1.32 $1.32 3/1/2020J1290 Ecallantide, 1 mg (Kalbitor) $275.82 $275.82 3/1/2020J3490 Edaravone injection (Radicava) 1 mg $19.55 $19.55 8/15/2017J0600 Edetate calcium disodium, up to 1000mg, injection (Calcium EDTA) $50.34 $50.34 3/1/2020J3590 Elapegademase-lvir injection 1 mg (Revcovi) $4,435.20 $4,435.20 11/28/2018J1322 Elosulfase alfa, injection 1mg (Vimizim) $239.80 $239.80 3/1/2020J9210 Emapalumab-lzsg injection (1 mg) (Gamifant) Manual Pricing Manual Pricing 12/28/2018J9177 Enfortumab vedotin-ejfv for injection .25 mg (Padcev) $27.96 $27.96 7/1/2020J1650 Enoxaparin sodium, 10 mg, injection (Lovenox) $5.91 $5.91 3/1/2020J0122 Ervacucline for injection 1 mg (Xerava) $1.00 $1.00 3/1/2020J0171 Adrenalin, epinephrine, 0.1 mg ampule, injection (Adrenalin) $0.04 $0.04 3/1/2020J9178 Epirubicin HCl, 2 mg, inj. (Ellence) $6.26 $6.26 3/1/2020Q4081 Epoetin Alfa, 100 units (for ESRD on dialysis), injection (Epogen, Procrit) $0.91 $0.91 3/1/2020Q5105 Epoetin Alfa, biosimilar injection (for ESRD on dialysis), 100 units (Retacrit) $1.23 $1.23 3/1/2020Q5106 Epoetin Alfa-epbx injection (for non-ESRD use), 1000 units (Retacrit) $12.27 $12.27 3/1/2020J0885 Epoetin alfa (for non-ESRD use), 1000 units, injection (Epogen, Procrit) $9.09 $9.09 3/1/2020J0887 Epoetin beta ESRD use, 1 microgram injection (Mircera) $2.02 $2.02 3/1/2020J0888 Epoetin beta non ESRD use, 1 microgram injection $2.02 $2.02 3/1/2020J1325 Epoprostenol, 0.5 mg, injection (Flolan) $14.39 $14.39 3/1/2020J9179 Eribulin Mesylate, 0.1 mg (Halaven) $90.23 $90.23 3/1/2020J1335 Ertapenem, 500 mg, injection (Invanz) $25.56 $25.56 3/1/2020J1364 Erythromycin lactobionate, per 500 mg, injection (Erthrocin) $6.77 $6.77 3/1/2020S0013 Esketamine nasal spray 1 mg (Spravato) $11.38 $11.38 1/1/2021J1380 Estradiol valerate, up to 10 mg, injection (Delestrogen) $8.63 $8.63 3/1/2020J1410 Estrogen conjugated, per 25 mg, injection (Premarin IV) $71.40 $71.40 3/1/2020J0606 Etelcalcetide injection 0.1 mg (Parsabiv) $3.71 $3.71 3/1/2020J1436 Etidronate disodium, per 300 mg, injection (Didronel) $71.56 $71.56 3/1/2020J9181 Etoposide, 10 mg (VePesid) $0.40 $0.40 3/1/2020J3590 Evinacumab-dgnb injection 1 mg (Evkeeza) $33.75 $33.75 2/19/2021J7191 Factor VIII (antihemophilic factor (porcine)), per IU (Hyate C) $1.86 $1.86 3/1/2020J3490 Famotidine injection 1 mg (Pepcid) $0.04 $0.04 1/1/2019J3010 Fentanyl Citrate, 0.1 mg, injection (Sublimaze) $0.28 $0.28 3/1/2020J1439 Ferric Carboxymaltos injection, 1 mg $1.17 $1.17 3/1/2020J1437 Ferric Derisomaltose Injection, 10mL Vial (Monoferric) $26.61 $26.61 10/2/2020Q0138 Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use), injection (Feraheme) $0.83 $0.83 3/1/2020

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

$0.83 $0.83 3/1/2020

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

J1631 Haloperidol decanoate, per 50 mg, injection (Haldol Decanoate-50) $2.41 $2.41 3/1/2020J1630 Haloperidol, up to 5 mg, injection (Haldol) $1.73 $1.73 3/1/2020J1640 Hemin, 1 mg, injection (Panhematin) $7.32 $7.32 3/1/2020J1642 Heparin sodium, per 10 units, injection (Heparin Lock Flush) $0.04 $0.04 3/1/2020J1644 Heparin sodium, per 1,000 units, injection (Heparin) $0.07 $0.07 3/1/2020J9225 Histrelin implant (Vantas), 50 mg $1,511.33 $1,511.33 3/1/2020J9226 Histrelin implant (Supprelin LA), 50 mg $14,687.27 $14,687.27 3/1/2020J3470 Hyaluronidase injection up to 150 units (Hydase, Amphadase, Vitrase) $17.31 $17.31 3/1/2020J3473 Hyaluronidase, recombinant, 1 USP unit (Hylenex) $0.41 $0.41 3/1/2020J0360 Hydralazine HCl, up to 20mg, injection (Apresoline) $6.08 $6.08 3/1/2020J1720 Hydrocortisone sodium succinate, up to 100 mg, injection (A-Hydrocort, Solu-Cortef) $2.23 $2.23 3/1/2020J1170 Hydromorphone, up to 4 mg, injection (Dilaudid) $1.28 $1.28 3/1/2020J1729 Hydroxyprogesterone caproate injection, 10 mg $17.47 $17.47 3/1/2020J1726 Hydroxyprogestorone caproate, 10 mg, injection (Makena) $34.67 $34.67 3/1/2020J3410 Hydroxyzine HCl, up to 25 mg, injection (Vistaril) $0.14 $0.14 3/1/2020J1980 Hyoscyamine sulfate, up to 0.25 mg, injection (Levsin) $9.31 $9.31 3/1/2020J3590 Ibalizumab-uiyk injection 1 mg (Trogarzo) $6.13 $6.13 4/1/2018J1740 Ibandronate sodium, 1 mg (Boniva) $139.27 $139.27 3/1/2020J1742 Ibutilide fumarate, 1 mg, injection (Corvert) $323.99 $323.99 3/1/2020J9211 Idarubicin HCl, 5 mg (Idamycin) $276.66 $276.66 3/1/2020J1743 Idursulfase, 1 mg, injection (Elaprase) $456.01 $456.01 3/1/2020J9208 Ifosfamide, per 1 g (Ifex) $38.00 $38.00 3/1/2020J1786 Imiglucerase, 10 units, injection (Cerezyme) $42.07 $42.07 3/1/2020J0742 Imipenem, cilastatin, and relebactam for injection 10 mg (Recarbrio) $2.31 $2.31 7/1/2020J1575 Immune Globulin Infusion 10% (Human) with recombinant human hyaluronidase 100 mg (Hyqvia) $11.37 $11.37 3/1/2020

J1599 Immune Globulin intravenous, human-ifas 500 mg (Panzyga) $94.12 $94.12 3/1/2020 4/21/2021J1599 Immune Globulin intravenous, human-ifas 500 mg (Panzyga) $89.64 $89.64 4/22/2021J1599 Immune Globulin intravenous, human-slra 10% liquid 500 mg (Asceniv) $490.86 $490.86 11/18/2019 3/31/2021J1554 Immune Globulin intravenous, human-slra 10% liquid 500 mg (Asceniv) $481.77 $481.77 4/1/2021J1558 Immune Globulin subcutaneous, human - klhw 20% solution 100 mg (Xembify) $16.84 $16.84 7/1/2020J1745 Infliximab, 10 mg, injection (Remicade) $55.16 $55.16 3/1/2020Q5104 Infliximab-abda, biosimilar, injection 10 mg (Renflexis) $57.38 $57.38 3/1/2020Q5121 infliximab-axxq, biosimilar 10 mg (Avsola) $51.50 $51.50 9/11/2020J0185 Injection, aprepitant, 1 mg (Cinvanti) $2.21 $2.21 3/1/2020J1944 Injection, aripiprazole lauroxil, 1 mg (Aristada) $2.92 $2.92 3/1/2020J9022 Injecton, atezolizumab, 10 mg (Tecentriq) $79.58 $79.58 3/1/2020J9023 Injection, avelumab, 10 mg (Bavencio) $83.34 $83.34 3/1/2020J9034 Injection, bendamustine hcl (Bendeka), 1 mg $24.87 $24.87 3/1/2020Q5107 Inection, bevacizumab, (Mvasi) 10 mg $76.82 $76.82 3/1/2020J0565 Injection, bezlotoxumab, 10 mg (Zinplava) $43.09 $43.09 3/1/2020J9044 Injection, bortezomib, 0.1 mg $37.45 $37.45 3/1/2020J0584 Injection, burosumab-twza 1 mg (Crysvita) $385.56 $385.56 3/1/2020Q0239 Injection, bamlanivimab-xxxx, 700 mg $0.00 $0.00 11/10/2020Q0243 Injection, casirivimab and imdevimab, 2400 mg $0.00 $0.00 11/21/2020J0693 Injection, cefiderocol, 5 mg (Fetroja) $0.99 $0.99 1/1/2021J0567 Injection, cerliponase alfa, 1 mg (Brineura) $102.06 $102.06 3/1/2020J9057 Injection, copanlisib, 1 mg (Aliqopa) $79.38 $79.38 3/1/2020J0841 Injection, crotalidae immune f(ab')2 (equine), 120 mg (Anavip) $1,383.48 $1,383.48 3/1/2020J9144 Injection, daratumumab, 10 mg and hyaluronidase-fihj (Darzalex Faspro) $43.85 $43.85 1/1/2021J9145 Injection, daratumumab, 10 mg (Darzalex) $49.27 $49.27 3/1/2020J1130 Injection, diclofenac sodium, 0.5 mg (Dyloject) $0.23 $0.23 3/1/2020J9173 Injection, durvalumab, 10 mg (Imfinizi) $78.90 $78.90 3/1/2020J1301 Injection, edaravone, 1 mg (Radicava) $20.53 $20.53 3/1/2020J9176 Injection, elotuzumab, 1 mg (Empliciti) $6.54 $6.54 3/1/2020J7175 Injection, factor X, (human), 1 IU (Coagadex) $8.78 $8.78 3/1/2020J1443 Injection, ferric pyrophosphate citrate solution, 0.1mg of iron (Triferic) $0.02 $0.02 3/1/2020J9198 Injection, gemcitabine hydrochloride 100 mg (Infugem) $41.04 $41.04 7/1/2020J1444 ferric pyrophosphate citrate solution, for hemodialysis use, 0.1 mg (Triferic) $0.03 $0.03 3/1/2020Q5101 Injection, Filgrastim (G-CSC), Biosimilar, 1 microgram (Zarxio) $1.07 $1.07 3/1/2020J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg (Akynzeo) $556.00 $556.00 3/1/2020J1627 Injection, granisetron, extended-release, 0.1 mg (Sustol) $4.83 $4.83 3/1/2020J7177 Injection, human fibrinogen concentrate (Fibryga), 1 mg $1.25 $1.25 3/1/2020J1746 Injection, ibalizumab-uiyk, 10 mg (Trogarzo) $64.35 $64.35 3/1/2020J1555 Injection, immune globuline, 100 mg (Cuvitru) $14.48 $14.48 3/1/2020Q5103 Injection, infliximab, biosimilar, 10 mg (Inflectra) $73.20 $73.20 3/1/2020J9229 Injection, inotuzumab ozogamicin, 0.1 mg (Besponsa) $2,356.20 $2,356.20 3/1/2020J0594 Injection, busulfan, 60 mg/10 ml (Busulfex) $34.84 $34.84 3/1/2020J9205 Injection, irinotecan liposome, 1 mg (Onivyde) $41.49 $41.49 3/1/2020J9153 injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine (Vyxeos) $199.83 $199.83 3/1/2020J9295 Injection, necitumumab, 1 mg (Portrazza) $5.52 $5.52 3/1/2020J9285 Injection, olaratumab 10 mg (Lartruvo) $52.45 $52.45 3/1/2020J9311 Injection, rifuximab,10 mg and hyaluronidase (Rituxan Hycela) $48.97 $48.97 3/1/2020J9312 Injection, rituximab, 10 mg (Rituxan) $100.17 $100.17 3/1/2020Q5115 Injection, rituximab-abbs, biosimilar, 10 mg (Truxima) $95.89 $95.89 3/1/2020J3590 Injection, rituximab-arrx, 10 mg (Riabni) $77.41 $77.41 1/5/2021J2797 Injection, rolapitant, 0.5 mg (Varubi) $1.00 $1.00 3/1/2020Q5111 Injection, pegfilgrastim-cbqv, biosimilar, 0.5 mg (Udenyca) $394.54 $394.54 3/1/2020Q5122 Injection, pegfilgrastim-apgf, 0.5 mg (Nyprevia) $353.25 $353.25 12/15/2020J2840 Injection, sebelipase alfa, 1 mg (Kanuma) $567.00 $567.00 3/1/2020J9325 Injection, talimogene laherparepvec, per 1 million plaque forming units (Imlygic) $48.44 $48.44 3/1/2020J9352 Injection, trabectedin, 0.1 mg (Yondelis) $297.56 $297.56 3/1/2020Q5114 Injection, trastuzumab-dkst 10 mg, (Ogivri) $99.82 $99.82 3/1/2020J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1

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

J3316 Injection, triptorelin, extended-release, 3.75 mg (Triptodur) $3,024.00 $3,024.00 3/1/2020J3397 Injection, vestronidase alfa-vjbk, 1 mg (Mepsevii) $239.84 $239.84 3/1/2020J7342 Installation, ciprofloxacin otic suspension, 6 mg (Otiprio) $32.12 $32.12 3/1/2020J1815 Insulin, per 5 units, injection $0.28 $0.28 3/1/2020J9212 Interferon Alfacon-1, recombinant, 1 mcg, injection (Infergen) $4.81 $4.81 3/1/2020J9215 Interferon alfa-N3, (human leukocyte derived), 250,000 IU (Alferon N) $19.39 $19.39 3/1/2020J9213 Interferon alfa-2A, recombinant, 3 million units (Roferon-A) $41.01 $41.01 3/1/2020J9214 Interferon alfa-2B, recombinant, 1 million units (Intron-A) $14.19 $14.19 3/1/2020Q3027 Interferon beta-1a, 1 mcg for intramuscular use, injection $34.86 $34.86 3/1/2020Q3028 Interferon beta-1a, 1 mcg for subcutaneous use, injection $19.82 $19.82 3/1/2020J1826 Interferon beta-1a, 30 mcg for intramuscular use, injection (Avonex) $781.30 $781.30 3/1/2020J1830 Interferon beta-1b, 0.25 mg, injection (Extavia) $177.43 $177.43 3/1/2020J9216 Interferon gamma-1B, 3 million units (Actimmune) $310.25 $310.25 3/1/2020

J9228 Ipilimumab, 1 mg, (Yervoy) $125.30 $125.30 3/1/2020J9206 Irinotecan, 20 mg (Camptosar) $126.51 $126.51 3/1/2020J1750 Iron dextran, 50 mg, injection (InFeD, Dexferrum) $11.81 $11.81 3/1/2020J1756 Iron sucrose, 1 mg, injection (Venofer) $0.35 $0.35 3/1/2020J1833 Isavuconazonium sulfate injection 1 mg (Cresemba) $0.72 $0.72 3/1/2020J9207 Ixabepilone, 1 mg, injection (Ixempra) $63.88 $63.88 3/1/2020J1850 Kanamycin sulfate, up to 75 mg, injection (Kantrex) $0.76 $0.76 3/1/2020J1840 Kanamycin sulfate, up to 500 mg, injection (Kantrex) $5.10 $5.10 3/1/2020J1885 Ketorolac tromethamine, per 15 mg, injection (Toradol) $0.34 $0.34 3/1/2020J3490 Givosiran injection, for subcutaneous use 1 mg (Givlaari) $222.86 $222.86 11/26/2019J3490 Lacosamide, per ml/10mg (Vimpat) $1.95 $1.95 1/1/2015J1930 Lanreotide, 1 mg, injection (Somatuline Depot) $26.91 $26.91 3/1/2020J1931 Laronidase, 0.1 mg, inj. (Aldurazyme) $24.41 $24.41 3/1/2020J0691 Lefamulin injection, 1 mg (Xenleta) $0.72 $0.72 7/1/2020J3490 Letermovir injection, for intravenous use 1 vial (Prevymis) $291.60 $291.60 12/11/2017J9223 lurbinectedin for injection, 0.1 mg (Zepzelca) $179.09 $179.09 1/1/2021J0640 Leucovorin Calcium, per 50 mg, injection (Wellcovorin) $0.78 $0.78 3/1/2020J9218 Leuprolide acetate, per 1 mg (Lupron) $7.48 $7.48 3/1/2020J9217 Leuprolide acetate (for depot suspension), 7.5 mg (Lupron Depot) (Eligard) $221.33 $221.33 3/1/2020J1950 Leuprolide acetate (for depot suspension), per 3.75 mg, injection (Lupron Depot) (Eligard) $442.60 $442.60 3/1/2020J9219 Leuprolide Acetate Implant 65mg (Viadur) $1,611.63 $1,611.63 3/1/2020J1953 Levetiracetam, 10 mg, injection (Keppra) $0.43 $0.43 3/1/2020J1955 Levocarnitine, per 1 g, injection (Carnitor) $5.89 $5.89 3/1/2020J1956 Levofloxacin, 250 mg, injection (Levaquin) $5.88 $5.88 3/1/2020J0641 Levoleucovorin calcium, 0.5 mg, injection (Fusilev) $1.05 $1.05 3/1/2020J0642 Levoleucovorin for injection, 0.5 mg (Khapzory) $2.14 $2.14 3/1/2020J1960 Levorphanol tartrate, up to 2 mg, injection (Levo-Dromoran) $3.18 $3.18 3/1/2020J3490 Lidocaine , for topical use 1 mg invoice required ***See Rate Table below 1/1/2015J2001 Lidocaine HCL for IV infusion, Injection 10 mg $0.02 $0.02 3/1/2020J2010 Lincomycin HCl, up to 300 mg, injection (Lincocin) $4.27 $4.27 3/1/2020J2020 Linezolid, 200 mg, injection (Zyvox) $28.15 $28.15 3/1/2020J2060 Lorazepam, 2 mg, injection (Ativan) $0.64 $0.64 3/1/2020J3490 Lumasiran injection, 1 mg (Oxlumo) $628.57 $628.57 12/22/2020J0896 Luspatercept-aamt for injection .25 mg (Reblozyl) $37.16 $37.16 7/1/2020J3475 Magnesium sulfate, per 500 mg, injection $0.05 $0.05 3/1/2020J2150 Mannitol, 25% in 50 ml, injection, (Osmitrol, Resectisol) $0.86 $0.86 3/1/2020J9999 Margetuximab-cmkb injection 1 mg (Margenza) $8.97 $8.97 3/11/2021J9230 Mechlorethamine HCl, 10 mg (Nitrogen Mustard) $144.75 $144.75 3/1/2020J1738 Meloxicam injection 1 mg (Anjeso) $3.38 $3.38 10/1/2020J9246 Melphalan for injection 1 mg (Evomela) $43.20 $43.20 7/1/2020J9245 Melphalan HCl, 50 mg, injection (Alkeran) $1,566.99 $1,566.99 3/1/2020J2175 Meperidine HCl, per 100 mg, injection (Demerol) $1.52 $1.52 3/1/2020J0670 Mepivacaine HCl, per 10ml, injection (Carbocaine) (Polocaine) $1.15 $1.15 3/1/2020J2186 Meropenem and vaborbactem for injection 10 mg/10 mg (20 mg) (Vabomere) $1.87 $1.87 3/1/2020J9209 Mesna, 200 mg (Mesnex) $7.89 $7.89 3/1/2020J0380 Metaraminol bitartrate, per 10mg, injection (Aramine) $1.15 $1.15 3/1/2020J7674 Methacholine chloride (Provocholine) $0.55 $0.55 3/1/2020J1230 Methadone HCl, up to 10 mg, injection (Dolophine) $2.96 $2.96 3/1/2020J2800 Methocarbamol up to 10 ml, injection (Robaxin) $10.24 $10.24 3/1/2020J9250 Methotrexate sodium, 5 mg $0.21 $0.21 3/1/2020J9260 Methotrexate sodium, 50 mg $2.26 $2.26 3/1/2020J7309 Methly aminolevulinate (MAL) for topical administration, 16.8%, 1 gram (Metvixia) $77.54 $77.54 3/1/2020J0210 Methyldopate HCl, up to 250mg, injection IV $15.22 $15.22 3/1/2020J3490 Methylene blue injection 1 mL (Provayblue) $20.14 $20.14 9/1/2016J2210 Methylergonovine maleate, up to 0.2 mg, injection (Methergine) $5.05 $5.05 3/1/2020J1020 Methylprednisolone acetate, 20mg, injection (Depo-Medrol) $2.41 $2.41 3/1/2020J1030 Methylprednisolone acetate, 40mg, injection (Depo-Medrol) $4.48 $4.48 3/1/2020J1040 Methylprednisolone acetate, 80mg, injection (Depo-Medrol) $9.43 $9.43 3/1/2020J2920 Methylprednisolone sodium succinate, up to 40 mg, injection (Solu-Medrol) $2.07 $2.07 3/1/2020J2930 Methylprednisolone sodium succinate, up to 125 mg, injection (Solu-Medrol) $3.03 $3.03 3/1/2020J2765 Metoclopramide HCl, up to 10 mg, injection (Reglan) $0.34 $0.34 3/1/2020J8499 metronidazole, oral 2g (Flagyl) $0.86 $0.86 3/1/2020J2250 Midazolam HCl, per 1 mg, injection (Versed) $0.15 $0.15 3/1/2020S0190 mifepristone tablets, for oral use 200 mcg (Mifeprex) $77.49 $77.49 3/1/2020J2260 Milrinone lactate, per 5 mg, injection (Primacor) $4.56 $4.56 3/1/2020S0191 misoprostol tablets, for oral use 200 mcg (Cytotec) $1.03 $1.03 3/1/2020J9280 Mitomycin, 5 mg (Mutamycin) $13.08 $13.08 3/1/2020J9281 mitomycin pyelocalyceal instillation, 1 mg (Jelmyto) $282.17 $282.17 1/1/2021J9293 Mitoxantrone HCl, per 5 mg, injection (Novantrone) $88.89 $88.89 3/1/2020J9204 Mogamuliumab-kpke injection 1 mg (Poteligeo) $210.91 $210.91 3/1/2020J7401 Mometasone furoate sinus implant 10 mcg (Sinuva) $10.71 $10.71 3/1/2020 3/31/2021J7402 Mometasone furoate sinus implant 10 mcg (Sinuva) $10.25 $10.25 4/1/2021J2274 Morphine preservative free, Injection 10 mg $10.22 $10.22 3/1/2020J2270 Morphine sulfate, up to 10 mg, injection $1.79 $1.79 3/1/2020J9313 Moxetumomab pasudotox-tdfk for injection 0.01 mg (Lumoxiti) $23.63 $23.63 3/1/2020J2300 Nalbuphine HCl, per 10 mg, injection (Nubain) $0.96 $0.96 3/1/2020J2310 Naloxone HCl, per 1 mg, injection (Narcan) $3.17 $3.17 3/1/2020J2315 Naltrexone, depot form, 1 mg, injection (Vivitrol) $1.88 $1.88 3/1/2020J2320 Nandrolone decanoate, up to 50 mg, injection (Deca-Durabolin) $4.77 $4.77 3/1/2020J2323 Natalizumab, 1 mg, injection (Tysabri) $7.54 $7.54 3/1/2020J9999 $549.94 $549.94 12/1/2020J9261 Nelarabine, 50 mg, injection (Arranon) $91.88 $91.88 3/1/2020J2710 Neostigmine methylsulfate, up to 0.5 mg, injection (Prostigmin) $0.10 $0.10 3/1/2020J9299 Nivolumab, 1 mg, injection (Opdivo) $26.64 $26.64 3/1/2020J7050 Normal saline solution, 250 cc infusion $0.26 $0.26 3/1/2020J7040 Normal saline solution, sterile (500 ml = 1 unit), infusion $0.52 $0.52 3/1/2020J7030 Normal saline solution, 1,000 cc, infusion $1.03 $1.03 3/1/2020J2326 Nusinersen injection for intrathecal use 0.1 mg (Spinraza) $1,181.25 $1,181.25 3/1/2020J9301 Obinutuzumab Inj 10 mg (Gazyva) $59.77 $59.77 3/1/2020J7316 Ocriplasmin, 0.125 mg, injection (Jetrea) $1,111.75 $1,111.75 3/1/2020J2353 Octreotide, depot form for IM injection, 1 mg (Sandostatin LAR Depot) $90.32 $90.32 3/1/2020J2354 Octreotide non-depot form for SC or IV injection, 25 mcg (Sandostatin) $2.21 $2.21 3/1/2020J9302 Ofatumumab, per 10 mg (Arzerra) $45.47 $45.47 3/1/2020S0166 Olanzapine, 2.5 mg (Zyprexa) $8.05 $8.05 3/1/2020J2358 Olanzapine long-acting, 1 mg (Zyprexa Relprevv) $2.75 $2.75 3/1/2020J9262 Omacetaxine mepesuccinate, 0.01 mg, injection (Synbrio) $2.58 $2.58 3/1/2020J0121 Omadacucline for injection, 1 mg (Nuzyra) $3.92 $3.92 3/1/2020J2405 Ondansetron HCl, per 1 mg, injection (Zofran) $0.22 $0.22 3/1/2020

J2355 Oprelvekin injection 5 mg (Neumega) $247.52 $247.52 3/1/2020J2407 Oritavancin diphosphate 10 mg (Orbactiv) $26.90 $26.90 3/1/2020J2360 Orphenadrine citrate, up to 60 mg, injection (Norflex) $9.04 $9.04 3/1/2020J2700 Oxacillin sodium, up to 250 mg, injection (Bactocile, Prostaphlin) $1.58 $1.58 3/1/2020J9263 Oxaliplatin, 0.5 mg, injection (Eloxatin) $9.51 $9.51 3/1/2020J2410 Oxymorphone HCl, up to 1 mg, injection (Numorphan) $2.51 $2.51 3/1/2020J2460 Oxytetracycline HCl, up to 50 mg, injection (Terramycin IM) $0.94 $0.94 3/1/2020J2590 Oxytocin, up to 10 units, injection (Pitocin) $2.05 $2.05 3/1/2020J9267 Paclitaxel, 1 mg injection (Taxol) $0.18 $0.18 3/1/2020J9264 Paclitaxel protein-bound particles, 1 mg, (Abraxane) $8.87 $8.87 3/1/2020J2425 Palifermin injection 50 mcg (Kepivance) $11.92 $11.92 3/1/2020J3490 Paliperidone palmitate extended-release injectable suspension 1 mg (Invega Trinza) $8.82 $8.82 3/1/2018J2426 Paliperidone palmitate extended-release injectable suspension 1 mg (Invega Sustenna) $6.52 $6.52 3/1/2020J2469 Palonosetron HCl, 25 mcg, injection (Aloxi) $17.25 $17.25 3/1/2020J2430 Pamidronate disodium, per 30 mg, injection (Aredia) $28.39 $28.39 3/1/2020J9303 Panitumumab, 10 mg, injection (Vectibix) $82.43 $82.43 3/1/2020J2440 Papaverine HCl, up to 60 mg, injection $0.57 $0.57 3/1/2020J2501 Paricalcitol, 1 mcg, injection (Zemplar) $3.93 $3.93 3/1/2020J2502 Pasireotide suspension 1 mg (Signifor LAR) $305.31 $305.31 3/1/2020J0222 Patisiran lipid complex injection 0.1 mg (Onpattro) $107.73 $107.73 3/1/2020J2503 Pegaptanib sodium, 0.3 mg, (Macugen) $1,033.23 $1,033.23 3/1/2020J9266 Pegaspargase, per single dose vial (Oncaspar) $2,098.12 $2,098.12 3/1/2020J2505 Pegfilgastrim, 6 mg, injection (Neulasta) $2,204.83 $2,204.83 3/1/2020Q5120 Pegfilgrastim-bmez injection 0.5 mg (Ziextenzo) $317.28 $317.28 7/1/2020J0890 Peginesatide, 0.1 mg (Omontys) $9.09 $9.09 3/1/2020J3590 Peginterferon beta-1a 0.5 ml (Plegridy) $2,576.88 $2,576.88 10/1/2014J9271 Pembrolizumab Powder 1 mg (Keytruda) $47.98 $47.98 3/1/2020J9305 Pemetrexed, 10 mg, injection (Alimta) $46.30 $46.30 3/1/2020J0561 Penicillin G benzathine, per 100,000 units, injection (Bicillin L-A) $4.07 $4.07 3/1/2020J0558 Injection, penicillin G benzathine and penicillin G procaine, per 100,000 units (Bicillin C-R) $3.22 $3.22 3/1/2020J2540 Penicillin G potassium, up to 600,000 units, injection (Pfizerpen) $0.94 $0.94 3/1/2020J2510 Penicillin G procaine, aqueous, up to 600,000 units, injection (Wycillin) $10.31 $10.31 3/1/2020J2545 Pentamidine isethionate, inhalation solution, per 300 mg, administered through a DME (Pentam

300, NebuPent)$54.43 $54.43

3/1/2020S0080 Pentamidine isethionate, 300 mg, injection (NebuPent) $42.56 $42.56 3/1/2020J3070 Pentazocine HCl, up to 30 mg, injection (Talwin) $6.12 $6.12 3/1/2020J2515 Pentobarbital sodium, per 50 mg, injection (Nembutal Sodium) $7.63 $7.63 3/1/2020J9268 Pentostatin, per 10 mg (Nipent) $1,832.85 $1,832.85 3/1/2020J2547 Peramivir (Rapivab) 1 mg 200 mg/20 ml vial $1.80 $1.80 3/1/2020J9316 Pertuzumab, trastuzumab, and hyaluronidase-zzxf injection, 10 mg (Phesgo) $76.24 $76.24 1/1/2021J2560 Phenobarbital sodium, up to 120 mg, injection $3.01 $3.01 3/1/2020J2760 Phentolamine mesylate, up to 5 mg, injection (Regitine) $21.12 $21.12 3/1/2020J1097 Phenylephrine and ketorolac injection1 mL (Omidria) $130.52 $130.52 3/1/2020J2370 Phenylephrine HCl, up to 1 ml, injection (Neosynephrine) $0.70 $0.70 3/1/2020J1165 Phenytoin sodium, per 50 mg, injection (Dilantin) $0.45 $0.45 3/1/2020J3430 Phytonadione (vitamin K), per 1 mg, injection (Mephyton) $3.63 $3.63 3/1/2020J2543 Piperacillin sodium/tazobactam sodium, injection, 1g/0.125g (1.125 g) (Zosyn) $5.16 $5.16 3/1/2020J0291 Plazomicin injection, for intravenous use 5 mg (Zemdri) $3.57 $3.57 3/1/2020J2562 Plerixafor, 1 mg, injection (Mozobil) $269.25 $269.25 3/1/2020J9309 Polatuzumab vedotin-piiq for injection 1 mg (Polivy) $119.05 $119.05 3/1/2020J9600 Porfimer sodium, 75 mg (Photofin) $2,508.93 $2,508.93 3/1/2020J3490 Posaconazole injection 1 mg (Noxafil) $1.91 $1.91 4/1/2014J3480 Potassium Chloride, per 2 mEq, injection $0.01 $0.01 3/1/2020J9307 Pralatrezate, 1 mg (Folotyn) $165.96 $165.96 3/1/2020J2730 Pralidoxime chloride, up to 1 g, injection (Protopam) $88.27 $88.27 3/1/2020J2650 Prednisolone acetate, up to 1 ml, injection (Predcor-50) $0.17 $0.17 3/1/2020J2690 Procainamide HCl, up to 1 g, injection (Pronestyl) $2.66 $2.66 3/1/2020J0780 Prochlorperazine, up to 10 mg, injection, (Compazine) $1.16 $1.16 3/1/2020J2675 Progesterone, per 50 mg, injection $1.51 $1.51 3/1/2020J2550 Promethazine HCl, up to 50 mg, injection (Phenergan) $1.37 $1.37 3/1/2020J1800 Propranolol HCl, up to 1 mg, injection (Inderal) $3.19 $3.19 3/1/2020J2720 Protamine sulfate, per 10 mg, injection $0.59 $0.59 3/1/202090377 Rabies immune globulin (human solution for intramuscular injection 150 IU (Kedrab $367.57 $367.57 1/1/202190399 Rabies immune globulin (human) solution 150 IU (Kedrab) $385.95 $385.95 3/1/2020 12/31/2020J2780 Ranitidine hydrochloride, 25 mg, injection (Zantac) $0.74 $0.74 3/1/2020J2783 Rasburicase, 0.5 mg, injection (Elitek) $155.52 $155.52 3/1/2020J1303 Ravulizumab-cwvz injection, 10 mg (Ultomiris) $237.59 $237.59 3/1/2020J0596 Recombinant human C1 esterase inhibitor 10 units (rhC1INH) (Ruconest) $29.49 $29.49 3/1/2020J2785 Regadenoson, 0.1 mg injection (Lexiscan) $47.51 $47.51 3/1/2020J3490 Remimazolam for injection 1 mg (Byfavo) $2.11 $2.11 1/28/2021J2993 Reteplase, 18.1 mg, injection (Retavase) $835.53 $835.53 3/1/2020J7120 Ringer's lactate infusion, up to 1,000 cc $0.91 $0.91 3/1/2020J2798 Risperidone for extended-release injectable suspension 0.5 mg (Perseris) $10.36 $10.36 3/1/2020J2794 Risperidone, long acting 0.5 mg, injection (Risperdal Consta) $4.94 $4.94 3/1/2020Q5119 Rituximab-pvvr injection 10 mg (Ruxience) $73.83 $73.83 7/1/2020J9308 Ramucirumab 5 mg (Cyramza) $56.72 $56.72 3/1/2020J3490 rolapitant injectable emulsion 1 vial (Varubi) $318.60 $318.60 11/15/2017J9315 Romidepsin, 1 mg (Istodax) $219.73 $219.73 3/1/2020J2796 Romiplostim, 10 mcg, injection (Nplate) $43.69 $43.69 3/1/2020J3111 Romosozumab-aqqg injection 1 mg (Evenity) $9.40 $9.40 3/1/2020J2795 Ropivacaine HCI injection 1 mg (Naropine) $0.07 $0.07 3/1/2020J9317 sacituzumab govitecan-hziy for injection 2.5 mg (Trodelvy) $29.51 $29.51 1/1/2021J2820 Sargramostim (GM-CSF), 50 mcg, injection (Leukine) $25.16 $25.16 3/1/2020J3490 Sildenafil, per vial (Revatio) $96.19 $96.19 1/1/2015Q2043 Sipuleucel-T, 3 units, injection 250 ml (Provenge) $32,876.62 $32,876.62 3/1/2020J2860 Slituxumab Injection 10 mg (Sylvant) $9.73 $9.73 3/1/2020J3490 Sodium bicarbonate7.5%, up to 50 ml $3.26 $3.26 1/1/2015J2916 Sodium ferric gluconate complex in sucrose, 12.5 mg, injection (Ferrlecit) $4.79 $4.79 3/1/2020J2995 Streptokinase, per 250,000 IU, injection (Streptase) $79.67 $79.67 3/1/2020J3000 Streptomycin, up to 1 g, injection $6.99 $6.99 3/1/2020J9320 Streptozocin, 1 g (Zanosar) $191.05 $191.05 3/1/2020J0330 Succinylcholine chloride, up to 20 mg, injection (Anectine) (Quelicin) $0.17 $0.17 3/1/2020J3490 sugammadex injection 1 mg (Bridion) $0.39 $0.39 1/1/2020J3030 Sumatriptan succinate, 6 mg, injection (Imitrex) (Alsuma) $66.76 $66.76 3/1/2020J9269 tagraxofusp-erzs injection 10 mcg (Elzonris) $277.03 $277.03 3/1/2020J3060 Taliglucerace alfa, 10 units, injection (Elelyso) $32.83 $32.83 3/1/2020J1447 TBO-filgrastim, 1 mcg, injection (Granix) $0.81 $0.81 3/1/2020J3090 Tedizolid phosphate injection 1 mg (Sivextro) $0.13 $0.13 3/1/2020

J3095 Telavancin , per 10 mg (Vibativ) $1.93 $1.93 3/1/2020J9328 Temozolomide, 1 mg, injection (Temodar) $5.10 $5.10 3/1/2020J9330 Temsirolimus, 1 mg, injection (Torisel) $48.01 $48.01 3/1/2020J3241 Teprotumumab-trbw for injection 10 mg (Tepezza) $315.88 $315.88 10/1/2020J3105 Terbutaline sulfate, up to 1 mg, injection (Brethine) $2.42 $2.42 3/1/2020J1071 Depo-Testosterone Cypionate, 1 mg injection (Delatrstryl) $0.04 $0.04 3/1/2020J3121 Testosterone enanthate, 1 mg injection $0.06 $0.06 3/1/2020S0189 Testosterone pellet, 75 mg (Testopel) $67.64 $67.64 3/1/2020J3145 Testosterone undecanoate 1 mg (Aveed) strength: 3 ml vial $1.24 $1.24 3/1/2020J9340 Thiotepa, 15 mg (Thioplex) $40.49 $40.49 3/1/2020J3240 Thyrotropin alpha, 0.9 mg provided in 1.1 mg vial, injection (Thyrogen) $840.76 $840.76 3/1/2020J3243 Tigecycline, 1 mg (Tygacil) $1.25 $1.25 3/1/2020J3260 Tobramycin sulfate, up to 80 mg, injection (Nebcin) $2.32 $2.32 3/1/2020J9351 Topotecan, 0.1 mg (Hycamtin) $27.40 $27.40 3/1/2020J3265 Torsemide, 10 mg/ml, injection (Demadex) $2.18 $2.18 3/1/2020J3285 Treprostinil njection 1 mg (Remodulin) $67.05 $67.05 3/1/2020J9355 Trastuzumab, 10 mg (Herceptin) $60.21 $60.21 3/1/2020J9999 trastuzumab and hyaluronidase-oysk injection 1 mg (Herceptin Hylecta) $8.42 $8.42 4/5/2019Q5117 trastuzumab-anns for injection, 10 mg (Kanjinti) $95.20 $95.20 3/1/2020Q5113 trasuzumab-pkrb for injection 10 mg (Herzuma) $100.98 $100.98 3/16/2020Q5112 trastuzumab-dttb for injection 10 mg (Ontruzant) $95.38 $95.38 4/15/2020Q5116 trastuzumab-qyyp for injection 10 mg (Trazimera) $91.56 $91.56 3/1/2020J3301 Triamcinolone acetonide, per 10 mg, injection (Kenalog-10, Kenalog-40) $1.38 $1.38 3/1/2020J3300 Triamcinolone acetonide, preservative free, 1 mg, injection (Trivaris) $3.26 $3.26 3/1/2020J3303 Triamcinolone hexacetonide, per 5mg injection (Aristospan) $1.34 $1.34 3/1/2020J9999 Trilaciclib for injection, 1 mg (Cosela) $5.10 $5.10 3/9/2021J3250 Trimethobenzamide HCl, up to 200 mg, injection (Tigan) $4.47 $4.47 3/1/2020J3305 Trimetrexate glucuronate, per 25 mg, injection (Neutrexin) $150.03 $150.03 3/1/2020J3315 Triptorelin pamoate (Trelstar Depot, Trelstar LA), 3.75 mg $149.49 $149.49 3/1/2020J3365 Urokinase, 250,000 IU, injection IV (Abbokinase) $458.71 $458.71 3/1/2020J3490 valproate sodium 1 mg (Depacon) $0.00 $0.00 1/1/2019J9357 Valrubicin, 200 mg, injection (Valstar) $966.32 $966.32 3/1/2020J3370 Vancomycin HCl, 500 mg, injection (Vancoled) (Vancocin) $3.15 $3.15 3/1/2020J3380 Vendolizumab Injection 1 mg (Entyvio) $17.88 $17.88 3/1/2020J3396 Verteporfin, 0.1 mg, inj. (Visudyne) $9.17 $9.17 3/1/2020J9360 Vinblastine sulfate, 1 mg (Velban) $1.07 $1.07 3/1/2020J9370 Vincristine sulfate, 1 mg (Vincasar PFS) $7.03 $7.03 3/1/2020J9371 Vincristine sulfate liposome, 1 mg (Marqibo) $2,110.15 $2,110.15 3/1/2020J9390 Vinorelbine tartrate, per 10 mg (Navelbine) $16.26 $16.26 3/1/2020J3420 Vitamin B-12 cyanocobalamin, up to 1,000 mcg, injection $0.25 $0.25 3/1/2020J2278 Ziconotide 1 mcg, (Prialt) $6.53 $6.53 3/1/2020J3489 Zoledronic acid, 1 mg, injection $111.96 $111.96 3/1/2020

90291 Cytomegalovirus Immune Globulin (CMV-IgIV), Human, 1 ml (CytoGam) $23.84 $23.84 3/1/2020J1460 Gamma globulin, intramuscular, 1 cc, injection (Gamastan S/D) $11.57 $11.57 3/1/2020J1560 Gamma globulin, intramuscular, over 10 cc, injection (Gamastan S/D) $115.78 $115.78 3/1/2020J1571 Injection, hepatitis B immune globulin, intramuscular, 0.5 ml, (Hepagam B) $48.45 $48.45 3/1/202090371 Hepatitis B Immune globulin (HBIg), human, 1 ml (BayHep B HepaGam B Nabi-HB ) $120.23 $120.23 3/1/2020J1573 Hepatitis B immune globulin, intravenous, 0.5 ml, injection (Hepagam B) $48.45 $48.45 3/1/2020J1559 Immune Globulin subcutaneous, 20% 100 mg (Hizentra) $7.30 $7.30 3/1/2020J1556 Immune Globulin intravenous, 10% 500 mg, injection (Bivigam) $41.04 $41.04 3/1/2020J1557 Immune Globulin (Gammaplex) intravenous, non-lyophilized (e.g., liquid) 500 mg $37.36 $37.36 3/1/2020J1566 Immune Globulin, intravenous, lyophilized, (e.g. powder) 500 mg, injection (Gammagard S-D) $28.13 $28.13 3/1/2020J1568 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Octagma) $35.15 $35.15 3/1/2020J1572 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Flebogamma) $32.59 $32.59 3/1/2020J1459 Immune globulin, intravenous, nonlyophilized (e.g., liquid), 500 mg, injection (Privigen) $34.23 $34.23 3/1/2020J1561 Immune Globulin, Intravenous, 500 mg, injection (Gamunex) $33.52 $33.52 3/1/2020J1569 Immune globulin, intravenous, nonlyophilized, (e.g., liquid), 500 mg, injection (Gammagard liquid) $31.86 $31.86 3/1/2020

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

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

$67.97 $67.97 3/1/2020

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

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

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

J1050 00009074630 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.55 $1.55 3/1/2020 1/27/2021J1050 00009074630 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $0.39 $0.39 1/28/2021J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.48 $1.48 1/1/2018 2/29/2020J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $1.55 $1.55 3/1/2020 1/27/2021J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG $0.39 $0.39 1/28/2021J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, $2.38 $2.38 1/1/2018 2/29/2020J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, $2.50 $2.50 3/1/2020 1/27/2021J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE, $0.56 $0.56 1/28/2021J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE $1.41 $1.41 1/1/2018 2/29/2020J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE $1.48 $1.48 3/1/2020 1/27/2021J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE ACETATE $0.41 $0.41 1/28/2021J1050 00548540000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 1/15/2018 2/29/2020J1050 00548540000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J1050 00548540025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 2/5/2018 2/29/2020J1050 00548540025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J1050 00548541000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 4/30/2019 2/29/2020J1050 00548541000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J1050 00548541025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 4/30/2019 2/29/2020J1050 00548541025 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J1050 00548570100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.39 $0.39 2/5/2018 2/29/2020J1050 00548570100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.41 $0.41 3/1/2020J1050 00548571100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.39 $0.39 4/22/2019 2/29/2020J1050 00548571100 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.41 $0.41 3/1/2020J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 9/25/2017 2/29/2020J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.61 $0.61 3/1/2020 2/22/2021

IMMUNE GLOBULINS

LARCs and Depo-Provera

J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 2/23/2021J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 9/25/2017 2/29/2020J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.60 $0.60 3/1/2020 2/22/2021J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 2/23/2021J1050 16714098101 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.455 $0.455 9/10/2020J1050 16714098102 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.419 $0.419 9/10/2020J1050 16714099901 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.59 $0.59 4/22/2020 5/5/2020J1050 16714099901 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.62 $0.62 5/6/2020J1050 59762453701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 7/1/2017 2/29/2020J1050 59762453701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.61 $0.61 3/1/2020J1050 59762453702 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 7/1/2017 2/29/2020J1050 59762453702 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.60 $0.60 3/1/2020J1050 59762453802 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.68 $0.68 7/1/2017 2/29/2020J1050 59762453802 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.71 $0.71 3/1/2020J1050 62756009040 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 11/20/2019 2/29/2020J1050 62756009040 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.61 $0.61 3/1/2020J1050 62756009045 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 11/20/2019 2/29/2020J1050 62756009045 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.60 $0.60 3/1/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 10/12/2018 1/2/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 1/3/2020 2/29/2020J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.58 $0.58 10/12/2018 1/2/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.32 $0.32 1/3/2020 2/29/2020J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE ACETAT $0.33 $0.33 3/1/2020J7296 50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEP $1,010.72 $1,010.72 1/14/2019 2/29/2020J7296 50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEP $1,061.26 $1,061.26 3/1/2020 12/31/2020J7296 50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEP $1,112.20 $1,112.20 1/1/2021J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $794.36 $794.36 1/1/2019 1/2/2020J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $834.08 $834.08 1/3/2020 2/29/2020J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $875.79 $875.79 3/1/2020 12/31/2020J7297 00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $940.60 $940.60 1/1/2021J7297 52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $794.36 $794.36 1/1/2019 1/2/2020J7297 52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $834.08 $834.08 1/3/2020 2/20/2020J7298 50419042101 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYS $963.51 $963.51 12/29/2017 2/29/2020J7298 50419042101 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYS $1,011.68 $1,011.68 3/1/2020J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYS $1,010.72 $1,010.72 1/14/2019 2/29/2020J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYS $1,061.26 $1,061.26 3/1/2020 12/31/2020J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYS $1,112.20 $1,112.20 1/1/2021J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $857.01 $857.01 8/15/2017 9/29/2019J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $937.57 $937.57 9/30/2019 2/29/2020J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45 3/1/2020J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $857.01 $857.01 9/1/2018 9/29/2019J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $937.57 $937.57 9/30/2019 2/29/2020J7300 59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45 3/1/2020J7301 50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYST $841.60 $841.60 1/14/2019 2/29/2020J7301 50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYST $883.68 $883.68 3/1/2020 12/31/2020J7301 50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYST $926.09 $926.09 1/1/2021J7307 00052027401 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INC $817.81 $817.81 7/1/2017 8/1/2019J7307 00052433001 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INC $1,040.45 $1,040.45 3/1/2020 9/30/2020J7307 00052433001 NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INC $1,092.48 $1,092.48 10/1/2020

A9552 Fluorodeoxyglucose F-18 FDG, diagnostic per study dose, up to 45mCi $650.35 $650.35 3/1/2020A9515 Choline C-11, diagnostic, per study dose up to 20 millicuries Invoice required invoice required 1/1/2017A9578 Gadobenate dimeglumine (MultiHance multipack), per ml, injection $5.65 $5.65 3/1/2020A9577 Gadobenate dimeglumine (MultiHance), per ml, injection $5.65 $5.65 3/1/2020A9585 Gadobutrol, 0.1 ml (Gadavist) $0.89 $0.89 3/1/2020A9579 Gadolinium-based magnetic resonance contrast agent, not otherwise specified, per ml $2.56 $2.56 3/1/2020A9576 Gadoteridol, (ProHance multipack), per ml, injection $5.65 $5.65 3/1/2020A9581 Gadoxetate Disodium, 1ml injection $13.52 $13.52 3/1/2020A9556 Gallium GA-67 citrate, diagnostic, per mCi $46.59 $46.59 3/1/2020A9571 Indium IN-111 oxyquinolone Labeled autologous platelets, diagnostic, per study dose $2,709.81 $2,709.81 3/1/2020A9570 Indium IN-111 oxyquinolone Labeled autologous white blood cells, diagnostic, per study dose $1,840.16 $1,840.16 3/1/2020A9547 Indium IN-111 oxyquinoline, diagnostic, per 0.5mCi $292.23 $292.23 3/1/2020A9548 Indium IN-111 pentetate, diagnostic, per 0.5mCi $272.80 $272.80 3/1/2020Q9968 Injection, nonradioactive, noncontrast, visualization adjunct (e.g., methylene blue, isosulfan blue) 1

mginvoice required invoice required 1/1/2015

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

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

RADIOPHARMACEUTICALSDiagnostic

A9569 Technetium TC-99M Exametazime Labeled Autologous white blood cells, diagnostic, per study dose

$1,840.16 $1,840.16 3/1/2020

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

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

90585 00052060301 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TU $161.78 $161.78 3/22/2018 2/29/202090585 00052060301 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TU $169.87 $169.87 3/1/202090585 00052060302 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TU $161.78 $161.78 3/22/2018 2/29/202090585 00052060302 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TU $169.87 $169.87 3/1/202090619 49281059005 MENQUADFI VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, Q $152.15 $152.15 9/3/202090619 49281059058 MENQUADFI VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, Q $152.15 $152.15 9/3/202090620 46028011402 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $164.80 $164.80 7/1/2017 2/20/202090620 46028011411 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $164.80 $164.80 7/1/2017 2/20/202090620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $183.86 $183.86 1/1/2020 2/29/202090620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $193.05 $193.05 3/1/202090620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $183.86 $183.86 1/1/2020 2/29/202090620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $193.05 $193.05 3/1/202090620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $183.86 $183.86 1/1/2020 2/29/202090620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $193.05 $193.05 3/1/2020 12/31/202090620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER $206.56 $206.56 1/1/202190621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $153.62 $153.62 1/1/2020 2/29/202090621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $161.30 $161.30 3/1/2020 12/31/202090621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $169.36 $169.36 1/1/202190621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $153.62 $153.62 1/1/2020 2/29/202090621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $161.30 $161.30 3/1/2020 12/31/202090621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $169.36 $169.36 1/1/202190621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $153.62 $153.62 1/1/2020 2/29/202090621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $161.30 $161.30 3/1/2020 12/31/202090621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VA $169.36 $169.36 1/1/202190632 00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $70.89 $70.89 8/1/2019 2/29/202090632 00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $74.44 $74.44 3/1/2020 11/11/202090632 00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $77.42 $77.42 11/12/202090632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $72.04 $72.04 8/1/2019 2/29/202090632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $75.64 $75.64 3/1/2020 11/11/202090632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $78.67 $78.67 11/12/202090632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $72.04 $72.04 8/1/2019 2/29/202090632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $75.64 $75.64 3/1/2020 11/11/202090632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $78.67 $78.67 11/12/202090632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $70.89 $70.89 8/1/2019 2/29/202090632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $74.44 $74.44 3/1/2020 11/11/202090632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUS $77.42 $77.42 11/12/202090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $73.00 $73.00 1/1/2020 2/29/202090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $76.65 $76.65 3/1/2020 12/31/202090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $78.95 $78.95 1/1/202190632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $73.00 $73.00 1/1/2020 2/29/202090632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $76.65 $76.65 3/1/2020 12/31/202090632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRA $78.95 $78.95 1/1/202190632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $73.00 $73.00 1/1/2020 2/29/202090632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $76.65 $76.65 3/1/2020 12/31/202090632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $78.95 $78.95 1/1/202190632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $73.00 $73.00 1/1/2020 2/29/202090632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $76.65 $76.65 3/1/2020 12/31/202090632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $78.95 $78.95 1/1/202190633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $33.52 $33.52 8/1/2019 2/29/202090633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $35.20 $35.20 3/1/2020 11/11/202090633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $36.61 $36.61 11/12/202090633 00006409509 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $31.28 $31.28 7/1/201790633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $33.52 $33.52 8/1/2019 2/29/202090633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $35.20 $35.20 3/1/2020 11/11/202090633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $36.61 $36.61 11/12/202090633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $33.52 $33.52 8/1/2019 2/29/202090633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $35.20 $35.20 3/1/2020 11/11/202090633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DO $36.61 $36.61 11/12/202090633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT D $34.10 $34.10 1/1/2020 2/29/202090633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT D $35.80 $35.80 3/1/202090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT D $34.10 $34.10 1/1/2020 2/29/202090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT D $35.80 $35.80 3/1/202090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $34.10 $34.10 1/1/2020 2/29/202090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $35.80 $35.80 3/1/2020 12/31/202090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $36.88 $36.88 1/1/202190633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $34.10 $34.10 1/1/2020 2/29/202090633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $35.80 $35.80 3/1/2020 12/31/202090633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCEN $36.88 $36.88 1/1/202190636 58160081501 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT D $99.50 $99.50 7/1/2017 2/29/202090636 58160081501 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT D $104.47 $104.47 3/1/202090636 58160081511 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT D $99.50 $99.50 7/1/2017 2/29/202090636 58160081511 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT D $104.47 $104.47 3/1/202090636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $110.85 $110.85 1/1/2020 2/29/202090636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $116.40 $116.40 3/1/2020 12/31/2020

THERAPEUTIC

VACCINES

90636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $119.89 $119.89 1/1/202190636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $110.85 $110.85 1/1/2020 2/29/202090636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $116.40 $116.40 3/1/2020 12/31/202090636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADU $119.89 $119.89 1/1/202190647 00006489700 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP $26.25 $26.25 8/10/2017 2/29/202090647 00006489700 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP $27.56 $27.56 3/1/202090647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP $26.25 $26.25 8/10/2017 2/29/202090647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP $27.56 $27.56 3/1/2020 11/11/202090647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-OMP $28.66 $28.66 11/12/202090648 49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $16.88 $16.88 1/1/2020 2/29/202090648 49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $17.73 $17.73 3/1/2020 12/31/202090648 49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $17.61 $17.61 1/1/202190648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJU $16.88 $16.88 1/1/2020 2/29/202090648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJU $17.73 $17.73 3/1/2020 12/31/202090648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJU $18.26 $18.26 1/1/202190648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $10.72 $10.72 1/1/2020 2/29/202090648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $11.25 $11.25 3/1/2020 12/31/202090648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $11.70 $11.70 1/1/202190648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $10.72 $10.72 1/1/2020 2/29/202090648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $11.25 $11.25 3/1/2020 12/31/202090648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJ $11.70 $11.70 1/1/202190648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $10.72 $10.72 1/1/2020 2/29/202090648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $11.25 $11.25 3/1/2020 12/31/202090648 58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PR $11.70 $11.70 1/1/202190649 00006404500 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $164.54 $164.54 7/1/2017 2/29/202090649 00006404500 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $172.77 $172.77 3/1/2020 5/28/202090649 00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $164.54 $164.54 7/1/2017 2/29/202090649 00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $172.77 $172.77 3/1/2020 5/28/202090649 00006404541 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $164.20 $164.20 7/1/2017 2/29/202090649 00006404541 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT $172.41 $172.41 3/1/2020 5/28/202090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $234.00 $234.00 8/1/2019 2/29/202090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $245.70 $245.70 3/1/2020 11/11/202090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $257.98 $257.98 11/12/202090651 00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $234.00 $234.00 8/1/2019 2/29/202090651 00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $245.70 $245.70 3/1/2020 11/11/202090651 00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 5 $257.98 $257.98 11/12/202090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $234.00 $234.00 8/1/2019 2/29/202090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $245.70 $245.70 3/1/2020 11/11/202090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $257.98 $257.98 11/12/202090651 00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $234.00 $234.00 8/1/2019 2/29/202090651 00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $245.70 $245.70 3/1/2020 11/11/202090651 00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, $257.98 $257.98 11/12/202090653 70461001903 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $53.14 $53.14 7/15/2019 2/29/202090653 70461001903 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $55.80 $55.80 3/1/2020 6/30/202090653 70461001904 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $53.14 $53.14 7/15/2019 2/29/202090653 70461001904 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $55.80 $55.80 3/1/2020 6/30/202090653 70461002003 FLUAD 2020-2021 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $55.80 $55.80 7/2/202090653 70461002004 FLUAD 2020-2021 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVAN $55.80 $55.80 7/2/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $49.96 $49.96 7/2/2019 2/29/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $52.46 $52.46 3/1/202090662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $52.46 $52.46 3/1/2020 6/30/202090662 49281012065 FLUZONE HIGH-DOSE QUAD 2020-21 - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRE $57.18 $57.18 7/6/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $49.96 $49.96 7/2/2019 2/29/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $52.45 $52.45 3/1/2020 2/29/202090662 49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESE $52.45 $52.45 3/1/2020 6/30/202090662 49281012088 FLUZONE HIGH-DOSE QUAD 2020-21 - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRE $57.18 $57.18 7/6/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $213.80 $213.80 1/1/2020 2/29/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $224.49 $224.49 3/1/2020 12/31/202090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $235.49 $235.49 1/1/202190670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $207.29 $207.29 1/1/2020 2/29/202090670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $217.66 $217.66 3/1/2020 12/31/202090670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $228.32 $228.32 1/1/202190670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $213.80 $213.80 1/1/2020 2/29/202090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $224.49 $224.49 3/1/2020 12/31/202090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FO $235.49 $235.49 1/1/202190672 66019030601 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $23.64 $23.64 8/5/2019 2/29/202090672 66019030610 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $23.64 $23.64 8/5/2019 2/29/202090672 66019030601 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $24.82 $24.82 3/1/2020 6/30/202090672 66019030610 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $24.82 $24.82 3/1/2020 6/30/202090672 66019030701 FLUMIST QUAD NASAL 2020-21 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $24.82 $24.82 7/1/202090672 66019030710 FLUMIST QUAD NASAL 2020-21 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (L $24.82 $24.82 7/1/202090674 70461031903 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $24.77 $24.77 7/15/2019 2/29/202090674 70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $24.77 $24.77 7/15/2019 2/29/202090674 70461031903 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $26.01 $26.01 3/1/2020 6/30/202090674 70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $26.01 $26.01 3/1/2020 6/30/202090674 70461032003 FLUCELVAX QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $27.05 $27.05 7/15/202090674 70461032004 FLUCELVAX QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), $27.05 $27.05 7/15/202090675 49281024658 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/2020 4/14/202090675 49281024658 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 4/15/2020 12/31/202090675 49281024658 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $416.81 $416.81 1/1/202190675 49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 1/1/2020 2/29/202090675 49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 3/1/2020 12/31/202090675 49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $416.81 $416.81 1/1/202190675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 1/1/2020 2/29/202090675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 3/1/2020 12/31/202090675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $416.81 $416.81 1/1/202190675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/202090675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.40 4/3/2020 4/14/202090675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $404.66 $404.66 4/15/2020 12/31/202090675 49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $416.81 $416.81 1/1/202190675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $357.52 $357.52 1/1/2020 2/29/202090675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $375.40 $375.40 3/1/2020 1/14/202190675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $390.41 $390.41 1/15/202190675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $357.52 $357.52 1/1/2020 2/29/202090675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $375.40 $375.40 3/1/2020 1/14/202190675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $390.41 $390.41 1/15/202190675 63851050101 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $262.40 $262.40 7/1/2017 1/23/202090675 63851050102 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR USE $337.12 $337.12 7/1/2017 4/30/2020

90675 63851051111 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $337.12 $337.12 7/1/2017 4/30/202090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $86.30 $86.30 8/1/2019 2/29/202090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $90.61 $90.61 3/1/2020 11/11/202090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $94.23 $94.23 11/12/202090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $86.29 $86.29 8/1/2019 2/29/202090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $90.61 $90.61 3/1/2020 11/11/202090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $94.23 $94.23 11/12/202090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $86.30 $86.30 8/1/2019 2/29/202090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $90.61 $90.61 3/1/2020 11/11/202090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIV $94.23 $94.23 11/12/202090681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $127.52 $127.52 1/1/2020 2/29/202090681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $133.90 $133.90 3/1/2020 12/31/202090681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $136.57 $136.57 1/1/202190681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $127.52 $127.52 1/1/2020 2/29/202090681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $133.90 $133.90 3/1/2020 12/31/202090681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 D $136.57 $136.57 1/1/202190682 49281071910 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $49.96 $49.96 7/2/2019 2/29/202090682 49281071910 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $52.46 $52.46 3/1/2020 6/30/202090682 49281071988 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $49.96 $49.96 7/2/2019 2/29/202090682 49281071988 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $52.45 $52.45 3/1/2020 6/30/202090682 49281072010 FLUBLOK QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $57.18 $57.18 7/6/202090682 49281072088 FLUBLOK QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4) $57.18 $57.18 7/6/202090685 33332021920 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.74 $17.74 7/15/2019 2/29/202090685 33332021921 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.74 $17.74 7/15/2019 2/29/202090685 49281051900 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $19.45 $19.45 7/2/2019 2/29/202090685 49281051925 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $19.45 $19.45 7/2/2019 2/29/202090685 33332021920 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $18.62 $18.62 3/1/2020 6/30/202090685 33332021921 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $18.62 $18.62 3/1/2020 6/30/202090685 49281051900 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $20.42 $20.42 3/1/2020 6/30/202090685 49281051925 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SP $20.42 $20.42 3/1/2020 6/30/202090685 33332022020 AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.37 $19.37 7/15/202090685 33332022021 AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.37 $19.37 7/15/202090686 33332031901 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.74 $17.74 7/15/2019 2/29/202090686 33332031902 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.74 $17.74 7/15/2019 2/29/202090686 58160089641 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $16.55 $16.55 7/16/2019 2/29/202090686 58160089652 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $16.55 $16.55 7/16/2019 2/29/202090686 19515090641 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $16.55 $16.55 7/16/2019 2/29/202090686 19515090652 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $16.55 $16.55 7/16/2019 2/29/202090686 49281041950 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $18.09 $18.09 7/2/2019 2/29/202090686 49281041988 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $18.09 $18.09 7/2/2019 2/29/202090686 49281041910 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.09 $18.09 7/2/2019 2/29/202090686 49281041958 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.09 $18.09 7/2/2019 2/29/202090686 33332031901 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $18.62 $18.62 3/1/2020 6/30/202090686 33332031902 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $18.62 $18.62 3/1/2020 6/30/202090686 58160089641 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $17.38 $17.38 3/1/2020 6/30/202090686 58160089652 FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $17.38 $17.38 3/1/2020 6/30/202090686 19515090641 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.38 $17.38 3/1/2020 6/30/202090686 19515090652 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.38 $17.38 3/1/2020 6/30/202090686 49281041950 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $19.00 $19.00 3/1/2020 6/30/202090686 49281041988 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $18.99 $18.99 3/1/2020 6/30/202090686 49281041910 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $19.00 $19.00 3/1/2020 6/30/202090686 49281041958 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.99 $18.99 3/1/2020 6/30/202090686 33332032001 AFLURIA QUAD 2020-21 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.37 $19.37 7/15/202090686 33332032002 AFLURIA QUAD 2020-21 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $19.37 $19.37 7/15/202090686 58160088541 FLUARIX QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $17.90 $17.90 7/20/202090686 58160088552 FLUARIX QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), S $17.90 $17.90 7/20/202090686 19515081641 FLULAVAL QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.90 $17.90 7/20/202090686 19515081652 FLULAVAL QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $17.90 $17.90 7/20/202090686 49281042050 FLUZONE QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $18.81 $18.81 7/6/202090686 49281042088 FLUZONE QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), $18.81 $18.81 7/6/202090686 49281042010 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.81 $18.81 7/6/202090686 49281042058 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $18.81 $18.81 7/6/202090687 49281063115 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.34 $8.34 7/2/2019 2/29/202090687 49281063178 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.34 $8.34 7/2/2019 2/29/202090687 49281063115 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.75 $8.75 3/1/2020 6/30/202090687 49281063178 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.75 $8.75 3/1/2020 6/30/202090687 33332042010 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.93 $8.93 7/15/202090687 33332042011 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.93 $8.93 7/15/202090687 49281063315 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.75 $8.75 7/6/202090687 49281063378 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $8.75 $8.75 7/6/202090688 19515089701 FLULAVAL QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $16.24 $16.24 3/1/2020 6/30/202090688 19515089711 FLULAVAL QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPL $16.24 $16.24 3/1/2020 6/30/202090688 33332041910 AFLURIA QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.16 $17.16 3/1/2020 6/30/202090688 33332041911 AFLURIA QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.16 $17.16 3/1/2020 6/30/202090688 33332042010 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.85 $17.85 7/15/202090688 33332042011 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.85 $17.85 7/15/202090688 49281063115 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.51 $17.51 3/1/2020 6/30/202090688 49281063178 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.51 $17.51 3/1/2020 6/30/202090688 49281063315 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.51 $17.51 7/6/202090688 49281063378 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT $17.51 $17.51 7/6/202090694 70461012003 FLUAD QUAD 2020-2021 SYRINGE $57.19 $57.19 7/15/202090694 70461012004 FLUAD QUAD 2020-2021 SYRINGE $57.19 $57.19 7/15/202090696 49281056210 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $53.18 $53.18 1/1/2020 2/29/202090696 49281056210 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $55.84 $55.84 3/1/2020 12/31/202090696 49281056210 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $57.52 $57.52 1/1/202190696 49281056258 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $53.18 $53.18 1/1/2020 2/29/202090696 49281056258 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $55.84 $55.84 3/1/2020 12/31/202090696 49281056258 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS V $57.51 $57.51 1/1/202190696 58160081201 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $52.13 $52.13 1/1/2020 2/29/202090696 58160081201 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $54.74 $54.74 3/1/2020 12/31/202090696 58160081201 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $56.93 $56.93 1/1/202190696 58160081211 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $52.13 $52.13 1/1/2020 2/29/202090696 58160081211 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $54.74 $54.74 3/1/2020 12/31/202090696 58160081211 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INA $56.93 $56.93 1/1/202190696 58160081243 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $52.13 $52.13 1/1/2020 2/29/202090696 58160081243 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $54.74 $54.74 3/1/2020 12/31/202090696 58160081243 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $56.93 $56.93 1/1/202190696 58160081252 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $52.13 $52.13 1/1/2020 2/29/2020

90696 58160081252 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $54.74 $54.74 3/1/2020 12/31/202090696 58160081252 KINRIX TIP-LOK SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VAC $56.93 $56.93 1/1/202190698 49281051005 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $98.97 $98.97 1/1/2020 2/29/202090698 49281051005 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $103.91 $103.91 3/1/2020 12/31/202090698 49281051005 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $108.07 $108.07 1/1/202190698 49281051105 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $98.97 $98.97 3/6/2020 3/19/202090698 49281051105 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $103.91 $103.91 3/20/2020 12/31/202090698 49281051105 PENTACEL VIAL KIT - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $108.07 $108.07 1/1/202190700 49281028610 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $30.33 $30.33 1/1/2020 2/29/202090700 49281028610 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $31.84 $31.84 3/1/2020 12/31/202090700 49281028610 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $33.12 $33.12 1/1/202190700 49281028658 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $30.33 $30.33 1/1/2020 2/29/202090700 49281028658 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $31.85 $31.85 3/1/2020 12/31/202090700 49281028658 DAPTACEL DTAP VACCINE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSS $33.13 $33.13 1/1/202190700 58160081001 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $23.83 $23.83 1/1/2020 2/29/202090700 58160081001 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $25.02 $25.02 3/1/2020 12/31/202090700 58160081001 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $26.02 $26.02 1/1/202190700 58160081011 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $23.83 $23.83 1/1/2020 2/29/202090700 58160081011 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $25.02 $25.02 3/1/2020 12/31/202090700 58160081011 INFANRIX DTAP VIAL - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VAC $26.02 $26.02 1/1/202190700 58160081043 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $23.83 $23.83 1/1/2020 2/29/202090700 58160081043 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $25.02 $25.02 3/1/2020 12/31/202090700 58160081043 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $26.02 $26.02 1/1/202190700 58160081052 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $23.83 $23.83 1/1/2020 2/29/202090700 58160081052 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $25.02 $25.02 3/1/2020 12/31/202090700 58160081052 INFANRIX DTAP SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS $26.02 $26.02 1/1/202190702 49281022510 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $57.42 $57.42 1/1/2020 2/29/202090702 49281022510 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $60.29 $60.29 3/1/2020 12/31/202090702 49281022510 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $63.31 $63.31 1/1/202190702 49281022558 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $57.42 $57.42 1/1/2020 2/29/202090702 49281022558 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $60.29 $60.29 3/1/2020 12/31/202090702 49281022558 DIPHTHERIA-TETANUS TOXOIDS-PED - DIPHTHERIA AND TETANUS TOXOIDS ADSORBED $63.31 $63.31 1/1/202190707 00006468100 M-M-R II VACCINE WITH DILUENT - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MM $78.72 $78.72 8/1/2019 2/29/202090707 00006468100 M-M-R II VACCINE WITH DILUENT - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MM $82.66 $82.66 3/1/2020 11/11/202090707 00006468100 M-M-R II VACCINE WITH DILUENT - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MM $86.79 $86.79 11/12/202090707 00006468101 M-M-R II VACCINE VIAL - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FO $78.72 $78.72 8/1/2019 2/29/202090707 00006468101 M-M-R II VACCINE VIAL - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FO $82.66 $82.66 3/1/2020 11/11/202090707 00006468101 M-M-R II VACCINE VIAL - MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FO $86.79 $86.79 11/12/202090710 00006417100 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $228.60 $228.60 8/1/2019 2/29/202090710 00006417100 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $240.02 $240.02 3/1/2020 11/11/202090710 00006417100 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $252.03 $252.03 11/12/202090710 00006417101 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $228.60 $228.60 8/1/2019 2/29/202090710 00006417101 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $240.02 $240.02 3/1/2020 11/11/202090710 00006417101 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $252.03 $252.03 11/12/202090710 00006499900 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $205.39 $205.39 8/10/2017 2/29/202090710 00006499900 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $215.66 $215.66 3/1/2020 9/17/202090710 00006499901 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $205.39 $205.39 8/10/2017 2/29/202090710 00006499901 PROQUAD VIAL - MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, F $215.66 $215.66 3/1/202090713 49281086010 IPOL VIAL - POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMU $35.45 $35.45 1/1/2020 2/29/202090713 49281086010 IPOL VIAL - POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMU $37.22 $37.22 3/1/202090713 49281086078 IPOL VIAL - POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMU $35.45 $35.45 1/1/2020 2/29/202090713 49281086078 IPOL VIAL - POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMU $37.22 $37.22 3/1/202090714 13533013100 TETANUS DIPHTHERIA TOXOIDS - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), $26.65 $26.65 1/1/2020 2/29/202090714 13533013100 TETANUS DIPHTHERIA TOXOIDS - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), $27.98 $27.98 3/1/202090714 13533013101 TETANUS DIPHTHERIA TOXOIDS - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), $26.65 $26.65 1/1/2020 2/29/202090714 13533013101 TETANUS DIPHTHERIA TOXOIDS - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), $27.98 $27.98 3/1/202090714 49281021510 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $34.30 $34.30 1/1/2020 2/29/202090714 49281021510 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $36.02 $36.02 3/1/2020 12/31/202090714 49281021510 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $37.46 $37.46 1/1/202190714 49281021515 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $34.30 $34.30 1/1/2020 2/29/202090714 49281021515 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $36.02 $36.02 3/1/2020 12/31/202090714 49281021515 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $37.46 $37.46 1/1/202190714 49281021558 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $34.30 $34.30 1/1/2020 2/29/202090714 49281021558 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $36.01 $36.01 3/1/2020 12/31/202090714 49281021558 TENIVAC VIAL - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FR $37.46 $37.46 1/1/202190714 49281021588 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $34.30 $34.30 1/1/2020 2/29/202090714 49281021588 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $36.01 $36.01 3/1/2020 12/31/202090714 49281021588 TENIVAC SYRINGE - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIV $37.46 $37.46 1/1/202190715 49281040010 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $44.89 $44.89 1/1/2020 2/29/202090715 49281040010 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $48.18 $48.18 3/1/2020 12/31/202090715 49281040010 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $49.62 $49.62 1/1/202190715 49281040015 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $45.41 $45.41 3/1/202090715 49281040020 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $45.89 $45.89 1/1/2020 2/29/202090715 49281040020 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $48.18 $48.18 3/1/2020 12/31/202090715 49281040020 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $49.63 $49.63 1/1/202190715 49281040058 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $44.89 $44.89 1/1/2020 2/29/202090715 49281040058 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $48.18 $48.18 3/1/2020 12/31/202090715 49281040058 ADACEL TDAP VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACC $49.63 $49.63 1/1/202190715 49281040088 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $45.41 $45.41 3/1/202090715 49281040089 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $45.89 $45.89 1/1/2020 2/29/202090715 49281040089 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $48.18 $48.18 3/1/2020 12/31/202090715 49281040089 ADACEL TDAP SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS V $49.63 $49.63 1/1/202190715 58160084201 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $41.31 $41.31 1/1/2020 2/29/202090715 58160084201 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $43.38 $43.38 3/1/2020 12/31/202090715 58160084201 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $44.68 $44.68 1/1/202190715 58160084205 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $41.31 $41.31 1/1/2020 2/29/202090715 58160084205 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $43.38 $43.38 3/1/2020 12/31/202090715 58160084205 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $44.68 $44.68 1/1/202190715 58160084211 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $41.31 $41.31 1/1/2020 2/29/202090715 58160084211 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $43.38 $43.38 3/1/2020 12/31/202090715 58160084211 BOOSTRIX TDAP VACCINE VIAL - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERT $44.68 $44.68 1/1/202190715 58160084234 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $41.31 $41.31 1/1/2020 2/29/202090715 58160084234 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $43.38 $43.38 3/1/2020 12/31/202090715 58160084234 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $44.68 $44.68 1/1/202190715 58160084243 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $41.31 $41.31 1/1/2020 2/29/202090715 58160084243 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $43.38 $43.38 3/1/2020 12/31/202090715 58160084243 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $44.68 $44.68 1/1/202190715 58160084252 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $41.31 $41.31 1/1/2020 2/29/202090715 58160084252 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $43.38 $43.38 3/1/2020 12/31/202090715 58160084252 BOOSTRIX TDAP VACCINE SYRINGE - TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR P $44.68 $44.68 1/1/202190716 00006482700 VARIVAX VACCINE WITH DILUENT - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUT $139.02 $139.02 8/1/201990716 00006482700 VARIVAX VACCINE WITH DILUENT - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUT $145.98 $145.98 3/1/2020 11/11/202090716 00006482700 VARIVAX VACCINE WITH DILUENT - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUT $153.27 $153.27 11/12/202090716 00006482701 VARIVAX VACCINE VIAL - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS U $139.02 $139.02 8/1/2019 2/29/202090716 00006482701 VARIVAX VACCINE VIAL - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS U $145.98 $145.98 3/1/2020 11/11/202090716 00006482701 VARIVAX VACCINE VIAL - VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS U $153.27 $153.27 11/12/202090723 58160081143 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $81.55 $81.55 1/1/2020 2/29/2020

90723 58160081143 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $85.62 $85.62 3/1/2020 12/31/202090723 58160081143 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $93.33 $93.33 1/1/202190723 58160081152 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $81.55 $81.55 1/1/2020 2/29/202090723 58160081152 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $85.62 $85.62 3/1/2020 12/31/202090723 58160081152 PEDIARIX 0.5 ML SYRINGE - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VA $93.33 $93.33 1/1/202190732 00006483701 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $110.43 $110.43 3/1/2020 11/11/202090732 00006483701 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $119.46 $119.46 11/12/202090732 00006483702 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $110.43 $110.43 3/1/202090732 00006483703 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $108.35 $108.35 8/1/2019 2/29/202090732 00006483703 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $113.77 $113.77 3/1/2020 11/11/202090732 00006483703 PNEUMOVAX 23 SYRINGE - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (P $119.46 $119.46 11/12/202090732 00006494300 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $108.35 $108.35 8/1/2019 2/29/202090732 00006494300 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $113.77 $113.77 3/1/2020 11/11/202090732 00006494300 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $119.46 $119.46 11/12/202090732 00006494301 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $108.35 $108.35 8/1/2019 2/29/202090732 00006494301 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $113.77 $113.77 3/1/2020 11/11/202090732 00006494301 PNEUMOVAX 23 VIAL - PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV2 $119.46 $119.46 11/12/202090734 46028020801 MENVEO A-C-Y-W-135-DIP VIAL KT - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROU $126.26 $126.26 7/1/2017 4/30/202090734 49281058905 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $131.46 $131.46 1/1/2020 2/29/202090734 49281058905 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $138.04 $138.04 3/1/2020 12/31/202090734 49281058905 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $144.94 $144.94 1/1/202190734 49281058958 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $131.46 $131.46 1/1/2020 2/29/202090734 49281058958 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $138.03 $138.03 3/1/2020 12/31/202090734 49281058958 MENACTRA VIAL - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W $144.94 $144.94 1/1/202190734 58160095509 MENVEO A-C-Y-W-135-DIP VIAL KT - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROU $137.92 $137.92 1/1/2020 2/29/202090734 58160095509 MENVEO A-C-Y-W-135-DIP VIAL KT - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROU $144.81 $144.81 3/1/2020 12/31/202090734 58160095509 MENVEO A-C-Y-W-135-DIP VIAL KT - MENINGOCOCCAL CONJUGATE VACCINE, SEROGROU $150.61 $150.61 1/1/202190736 00006496300 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $229.81 $229.81 7/1/2017 2/29/202090736 00006496300 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $241.30 $241.30 3/1/202090736 00006496301 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $219.05 $219.05 7/1/2017 2/29/202090736 00006496301 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $230.00 $230.00 3/1/202090736 00006496341 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $219.05 $219.05 7/1/2017 2/29/202090736 00006496341 ZOSTAVAX VIAL - ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJEC $230.00 $230.00 3/1/202090739 43528000201 HEPLISAV-B 20 MCG/0.5 ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DOSE $118.45 $118.45 2/5/2018 2/29/202090739 43528000201 HEPLISAV-B 20 MCG/0.5 ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DOSE $124.37 $124.37 3/1/202090739 43528000205 HEPLISAV-B 20 MCG/0.5 ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DOSE $118.45 $118.45 1/8/2018 2/29/202090739 43528000205 HEPLISAV-B 20 MCG/0.5 ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DOSE $124.37 $124.37 3/1/202090739 43528000301 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $124.37 $124.37 3/1/2020 6/30/202090739 43528000301 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $130.32 $130.32 7/1/2020 2/28/202190739 43528000301 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $136.81 $136.81 3/1/202190739 43528000305 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $124.37 $124.37 3/1/2020 6/30/202090739 43528000305 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $130.32 $130.32 7/1/2020 2/28/202190739 43528000305 HEPLISAV-B 20 MCG/0.5 ML SYRNG - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 2 DO $136.81 $136.81 3/1/202190740 00006499200 RECOMBIVAX HB 40 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOS $170.25 $170.25 7/1/2017 2/29/202090740 00006499200 RECOMBIVAX HB 40 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOS $178.76 $178.76 3/1/202090740 00006499201 RECOMBIVAX HB 40 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOS $170.25 $170.25 7/1/2017 2/29/202090740 00006499201 RECOMBIVAX HB 40 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOS $178.76 $178.76 3/1/202090744 00006409302 RECOMBIVAX HB 5 MCG/0.5 ML SYR - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESC $23.90 $23.90 7/1/2017 2/29/202090744 00006409302 RECOMBIVAX HB 5 MCG/0.5 ML SYR - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESC $25.09 $25.09 3/1/2020 11/11/202090744 00006409302 RECOMBIVAX HB 5 MCG/0.5 ML SYR - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESC $26.09 $26.09 11/12/202090744 00006498100 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $23.90 $23.90 8/10/2017 2/29/202090744 00006498100 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $25.09 $25.09 3/1/2020 11/11/202090744 00006498100 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.09 $26.09 11/12/202090744 00006498101 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $23.90 $23.90 8/10/2017 2/29/202090744 00006498101 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $25.09 $25.09 3/1/2020 11/11/202090744 00006498101 RECOMBIVAX HB 5 MCG/0.5 ML VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.09 $26.09 11/12/202090744 58160082001 ENGERIX-B 10 MCG/0.5 ML PED VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $22.97 $22.97 7/1/2017 2/29/202090744 58160082001 ENGERIX-B 10 MCG/0.5 ML PED VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $24.12 $24.12 3/1/2020 10/8/202090744 58160082011 ENGERIX-B 10 MCG/0.5 ML PED VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $22.97 $22.97 7/1/2017 2/29/202090744 58160082011 ENGERIX-B 10 MCG/0.5 ML PED VL - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $24.12 $24.12 3/1/2020 10/8/202090744 58160082043 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $24.84 $24.84 1/1/2020 2/29/202090744 58160082043 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.08 $26.08 3/1/2020 12/31/202090744 58160082043 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.61 $26.61 1/1/202190744 58160082052 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $24.84 $24.84 1/1/2020 2/29/202090744 58160082052 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.08 $26.08 3/1/2020 12/31/202090744 58160082052 ENGERIX-B PEDI 10 MCG/0.5 SYRN - HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCE $26.61 $26.61 1/1/202190746 00006409401 RECOMBIVAX HB 10 MCG/ML SYR - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $62.28 $62.28 7/1/2017 2/29/202090746 00006409401 RECOMBIVAX HB 10 MCG/ML SYR - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $65.40 $65.40 3/1/202090746 00006409402 RECOMBIVAX HB 10 MCG/ML SYR - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $62.28 $62.28 7/1/2017 2/29/202090746 00006409402 RECOMBIVAX HB 10 MCG/ML SYR - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $65.40 $65.40 3/1/202090746 00006409409 RECOMBIVAX HB 10 MCG/ML SYR - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $62.28 $62.28 7/1/2017 2/7/201990746 00006499500 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $63.39 $63.39 8/10/2017 2/29/202090746 00006499500 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $66.56 $66.56 3/1/202090746 00006499501 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $62.28 $62.28 8/10/2017 2/29/202090746 00006499501 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $65.40 $65.40 3/1/202090746 00006499541 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $62.28 $62.28 8/10/2017 2/29/202090746 00006499541 RECOMBIVAX HB 10 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOS $65.40 $65.40 3/1/202090746 58160082101 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCH $62.94 $62.94 1/1/2020 2/29/202090746 58160082101 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCH $66.09 $66.09 3/1/202090746 58160082111 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCH $62.94 $62.94 1/1/2020 2/29/202090746 58160082111 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCH $66.09 $66.09 3/1/202090746 58160082143 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SC $62.94 $62.94 1/1/2020 2/29/202090746 58160082143 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SC $66.09 $66.09 3/1/202090746 58160082152 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SC $62.94 $62.94 1/1/2020 2/29/202090746 58160082152 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SC $66.09 $66.09 3/1/202090747 58160082101 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPR $125.89 $125.89 1/1/2020 2/29/202090747 58160082101 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPR $132.18 $132.18 3/1/202090747 58160082111 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPR $125.89 $125.89 1/1/2020 2/29/202090747 58160082111 ENGERIX-B 20 MCG/ML VIAL - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPR $132.18 $132.18 3/1/202090747 58160082143 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPP $125.89 $125.89 1/1/2020 2/29/202090747 58160082143 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPP $132.18 $132.18 3/1/202090747 58160082152 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPP $125.89 $125.89 1/1/2020 2/29/202090747 58160082152 ENGERIX-B 20 MCG/ML SYRN - HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPP $132.18 $132.18 3/1/202090750 58160081912 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $155.95 $155.95 1/1/2020 2/29/202090750 58160081912 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $163.75 $163.75 3/1/2020 12/31/202090750 58160081912 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $175.21 $175.21 1/1/202190750 58160082311 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $155.95 $155.95 1/1/2020 2/29/202090750 58160082311 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $163.75 $163.75 3/1/2020 12/31/2020

90750 58160082311 SHINGRIX VIAL KIT - ZOSTER (SHINGLES) VACCINE (HZV), RECOMBINANT, SUBUNIT, ADJU $175.21 $175.21 1/1/202190756 70461041910 FLUCELVAX QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $23.44 $23.44 7/15/2019 2/29/202090756 70461041910 FLUCELVAX QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $24.61 $24.61 3/1/2020 6/30/202090756 70461041911 FLUCELVAX QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $23.44 $23.44 7/15/2019 2/29/202090756 70461041911 FLUCELVAX QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $24.61 $24.61 3/1/2020 6/30/202090756 70461042010 FLUCELVAX QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $25.60 $25.60 7/15/202090756 70461042011 FLUCELVAX QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4) $25.60 $25.60 7/15/202091300 59267100001 PFIZER COVID19 VACC (UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME CORON $0.00 $0.00 12/11/202091300 59267100002 PFIZER COVID19 VACC (UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME CORON $0.00 $0.00 12/11/202091300 59267100003 PFIZER COVID19 VACC (UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME CORON $0.00 $0.00 12/11/202091301 80777027310 MODERNA COVID19 VACC (UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME COR $0.00 $0.00 12/17/202091301 80777027399 MODERNA COVID19 VACC (UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME COR $0.00 $0.00 12/17/202091301 80777027315 MODERNA COVID-19 VACCINE (EUA) - SEVERE ACUTE RESPIRATORY SYNDROME CORON $0.00 $0.00 4/2/202191301 80777027398 MODERNA COVID-19 VACCINE (EUA) - SEVERE ACUTE RESPIRATORY SYNDROME CORON $0.00 $0.00 4/2/202191303 59676058005 JANSSEN COVID19 VACC(UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME CORO $0.00 $0.00 2/26/202191303 59676058015 JANSSEN COVID19 VACC(UNAPPROV) - SEVERE ACUTE RESPIRATORY SYNDROME CORO $0.00 $0.00 2/26/2021

J7170 50242092001 HEMLIBRA 30 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.83 $45.83 1/1/2020 5/31/2020J7170 50242092001 HEMLIBRA 30 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.63 $45.63 6/1/2020 12/31/2020J7170 50242092001 HEMLIBRA 30 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $46.96 $46.96 1/1/2021J7170 50242092101 HEMLIBRA 60 MG/0.4 ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.83 $45.83 1/1/2020 5/31/2020J7170 50242092101 HEMLIBRA 60 MG/0.4 ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.67 $45.67 6/1/2020 12/31/2020J7170 50242092101 HEMLIBRA 60 MG/0.4 ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $46.96 $46.96 1/1/2021J7170 50242092201 HEMLIBRA 105 MG/0.7 ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.83 $45.83 1/1/2020 12/31/2020J7170 50242092201 HEMLIBRA 105 MG/0.7 ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $46.96 $46.96 1/1/2021J7170 50242092301 HEMLIBRA 150 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.83 $45.83 1/1/2020 5/31/2020J7170 50242092301 HEMLIBRA 150 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $45.70 $45.70 6/1/2020 12/31/2020J7170 50242092301 HEMLIBRA 150 MG/ML VIAL - INJECTION, EMICIZUMAB-KXWH, 0.5 MG $46.96 $46.96 1/1/2021J7175 64208775201 COAGADEX 250 UNIT VIAL - INJECTION, FACTOR X, (HUMAN), 1 IU $7.15 $7.15 1/1/2020J7175 64208775301 COAGADEX 500 UNIT VIAL - INJECTION, FACTOR X, (HUMAN), 1 IU $7.15 $7.15 1/1/2020J7175 64208775401 COAGADEX 250 UNIT VIAL - INJECTION, FACTOR X, (HUMAN), 1 IU $7.15 $7.15 1/1/2020J7175 64208775601 COAGADEX 500 UNIT VIAL - INJECTION, FACTOR X, (HUMAN), 1 IU $7.15 $7.15 1/1/2020J7178 63833089151 RIASTAP VIAL - INJECTION, HUMAN FIBRINOGEN CONCENTRATE, NOT OTHERWISE SPEC $1.01 $1.01 12/1/2020J7178 63833089190 RIASTAP VIAL - INJECTION, HUMAN FIBRINOGEN CONCENTRATE, NOT OTHERWISE SPEC $1.01 $1.01 12/1/2020J7179 00944755001 VONVENDI 650 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VON $2.00 $2.00 6/1/2019 11/30/2020J7179 00944755001 VONVENDI 650 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VON $1.49 $1.49 12/1/2020J7179 00944755102 VONVENDI 650 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VON $2.00 $2.00 6/1/2019 11/30/2020J7179 00944755102 VONVENDI 650 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VON $1.49 $1.49 12/1/2020J7179 00944755201 VONVENDI 1,300 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VO $2.00 $2.00 6/1/2019 11/30/2020J7179 00944755201 VONVENDI 1,300 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VO $1.49 $1.49 12/1/2020J7179 00944755302 VONVENDI 1,300 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VO $2.00 $2.00 6/1/2019 11/30/2020J7179 00944755302 VONVENDI 1,300 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VO $1.49 $1.49 12/1/2020J7180 63833051802 CORIFACT KIT - INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 IU $7.71 $7.71 12/1/2018J7180 63833051802 CORIFACT KIT - INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 IU $7.96 $7.96 6/1/2019J7181 00169701301 TRETTEN 2,500 UNIT VIAL - INJECTION, FACTOR XIII A-SUBUNIT, (RECOMBINANT), PER IU $13.98 $13.98 1/8/2019J7181 00169711311 TRETTEN 2,500 UNIT VIAL - INJECTION, FACTOR XIII A-SUBUNIT, (RECOMBINANT), PER IU $13.98 $13.98 1/8/2019J7182 00169781001 NOVOEIGHT 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 12/1/2019 5/31/2020J7182 00169781001 NOVOEIGHT 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 6/1/2020 11/30/2020J7182 00169781001 NOVOEIGHT 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.16 $1.16 12/1/2020J7182 00169781501 NOVOEIGHT 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 12/1/2019 5/31/2020J7182 00169781501 NOVOEIGHT 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 6/1/2020 11/30/2020J7182 00169781501 NOVOEIGHT 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.16 $1.16 12/1/2020J7182 00169782001 NOVOEIGHT 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 12/1/2019 5/31/2020J7182 00169782001 NOVOEIGHT 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 6/1/2020 11/30/2020J7182 00169782001 NOVOEIGHT 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.16 $1.16 12/1/2020J7182 00169782501 NOVOEIGHT 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.11 $1.11 12/1/2019 5/31/2020J7182 00169782501 NOVOEIGHT 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.17 $1.17 6/1/2020 11/30/2020J7182 00169782501 NOVOEIGHT 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.16 $1.16 12/1/2020J7182 00169783001 NOVOEIGHT 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 12/1/2019 5/31/2020J7182 00169783001 NOVOEIGHT 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 6/1/2020 11/30/2020J7182 00169783001 NOVOEIGHT 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.16 $1.16 12/1/2020J7182 00169785001 NOVOEIGHT 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.11 $1.11 12/1/2019 5/31/2020J7182 00169785001 NOVOEIGHT 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.17 $1.17 6/1/2020 11/30/2020J7182 00169785001 NOVOEIGHT 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.16 $1.16 12/1/2020J7183 67467018101 WILATE 450-450 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 12/1/2019 5/31/2020J7183 67467018101 WILATE 450-450 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 6/1/2020 11/30/2020J7183 67467018101 WILATE 450-450 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.87 $0.87 12/1/2020J7183 67467018102 WILATE 900-900 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 12/1/2019 5/31/2020J7183 67467018102 WILATE 900-900 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 6/1/2020 11/30/2020J7183 67467018102 WILATE 900-900 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.87 $0.87 12/1/2020J7183 68982018201 WILATE 500-500 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 12/1/2019 5/31/2020J7183 68982018201 WILATE 500-500 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.82 $0.82 6/1/2020 11/30/2020J7183 68982018201 WILATE 500-500 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), W $0.87 $0.87 12/1/2020J7183 68982018202 WILATE 1,000-1,000 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN $0.82 $0.82 12/1/2019 5/31/2020J7183 68982018202 WILATE 1,000-1,000 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN $0.82 $0.82 6/1/2020 11/30/2020J7183 68982018202 WILATE 1,000-1,000 UNIT VIAL - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN $0.87 $0.87 12/1/2020J7185 58394001201 XYNTHA 250 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001201 XYNTHA 250 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 6/1/2020J7185 58394001301 XYNTHA 500 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001301 XYNTHA 500 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 6/1/2020J7185 58394001401 XYNTHA 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001401 XYNTHA 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 6/1/2020J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019J7185 58394001603 XYNTHA SOLOFUSE 3,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001603 XYNTHA SOLOFUSE 3,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 6/1/2020J7185 58394001201 XYNTHA 250 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001201 XYNTHA 250 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 6/1/2020J7185 58394001301 XYNTHA 500 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001301 XYNTHA 500 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 6/1/2020J7185 58394001401 XYNTHA 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001401 XYNTHA 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 6/1/2020J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.07 $1.07 4/1/2017 9/30/2017J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.04 $1.04 10/1/2017 5/31/2018J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.06 $1.06 6/1/2018 11/30/2018J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7185 58394001501 XYNTHA 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 6/1/2020J7185 58394001603 XYNTHA SOLOFUSE 3,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 12/1/2019 5/31/2020

CLOTTING FACTOR

J7185 58394001603 XYNTHA SOLOFUSE 3,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 6/1/2020J7185 58394002203 XYNTHA SOLOFUSE 250 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RE $1.09 $1.09 9/25/2020J7185 58394002303 XYNTHA SOLOFUSE 500 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RE $1.09 $1.09 9/25/2020J7185 58394002403 XYNTHA SOLOFUSE 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 12/1/2019 5/31/2020J7185 58394002403 XYNTHA SOLOFUSE 1,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 6/1/2020J7185 58394002503 XYNTHA SOLOFUSE 2,000 UNIT KIT - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 9/25/2020J7185 58394011501 XYNTHA 2,000 UNIT VIAL - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.09 $1.09 12/1/2019 5/31/2020J7185 58394011501 XYNTHA 2,000 UNIT VIAL - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.09 $1.09 6/1/2020J7185 58394011603 XYNTHA SOLOFUSE 3,000 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, $1.09 $1.09 12/1/2019 5/31/2020J7185 58394011603 XYNTHA SOLOFUSE 3,000 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, $1.09 $1.09 6/1/2020J7185 58394012203 XYNTHA SOLOFUSE 250 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 9/25/2020J7185 58394012303 XYNTHA SOLOFUSE 500 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, R $1.09 $1.09 9/25/2020J7185 58394012403 XYNTHA SOLOFUSE 1,000 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, $1.09 $1.09 12/1/2019 5/31/2020J7185 58394012403 XYNTHA SOLOFUSE 1,000 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, $1.09 $1.09 6/1/2020J7185 58394012503 XYNTHA SOLOFUSE 2,000 UNIT SYR - INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, $1.09 $1.09 9/25/2020J7186 68516460101 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460101 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516460201 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460201 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516460302 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460302 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516460402 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516460402 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460501 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460501 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516460601 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460601 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516460702 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460702 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516460802 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460802 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516460902 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516460902 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516461002 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461002 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516461101 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461101 ALPHANATE 250-100 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516461201 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461201 ALPHANATE 500-200 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRA $0.89 $0.89 6/1/2020J7186 68516461302 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461302 ALPHANATE 1,000-400 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516461402 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461402 ALPHANATE 1,500-600 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7186 68516461502 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.87 $0.87 12/1/2019 5/31/2020J7186 68516461502 ALPHANATE 2,000-800 UNIT VIAL - INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBR $0.89 $0.89 6/1/2020J7187 63833061502 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.97 $0.97 6/1/2020 11/30/2020J7187 63833061502 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.97 $0.97 12/1/2020J7187 63833061502 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.95 $0.95 12/1/2019 5/31/2020J7187 63833061502 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.97 $0.97 6/1/2020J7187 63833061602 HUMATE-P 1,200 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.95 $0.95 12/1/2019 5/31/2020J7187 63833061602 HUMATE-P 1,200 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 6/1/2020 11/30/2020J7187 63833061602 HUMATE-P 1,200 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 12/1/2020J7187 63833061702 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.95 $0.95 12/1/2019 5/31/2020J7187 63833061702 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 6/1/2020 11/30/2020J7187 63833061702 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 12/1/2020J7187 63833062501 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.95 $0.95 12/1/2019 5/31/2020J7187 63833062501 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.97 $0.97 6/1/2020 11/30/2020J7187 63833062501 HUMATE-P 600 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMA $0.97 $0.97 12/1/2020J7187 63833062601 HUMATE-P 1,200 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.95 $0.95 12/1/2019 5/31/2020J7187 63833062601 HUMATE-P 1,200 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 6/1/2020J7187 63833062701 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.95 $0.95 12/1/2019 5/31/2020J7187 63833062701 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 6/1/2020 11/30/2020J7187 63833062701 HUMATE-P 2,400 UNIT VWF:RCO - INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUM $0.97 $0.97 12/1/2020J7189 00169720101 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169720101 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169720101 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169720101 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169720201 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169720201 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169720201 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169720201 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169720501 NOVOSEVEN RT 5 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169720501 NOVOSEVEN RT 5 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169720501 NOVOSEVEN RT 5 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169720501 NOVOSEVEN RT 5 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169720801 NOVOSEVEN RT 8 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169720801 NOVOSEVEN RT 8 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169720801 NOVOSEVEN RT 8 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169720801 NOVOSEVEN RT 8 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169721111 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169721111 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169721111 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169721111 NOVOSEVEN RT 1 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169721211 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.81 $1.81 6/1/2019 5/31/2020J7189 00169721211 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.87 $1.87 6/1/2020 11/30/2020J7189 00169721211 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.89 $1.89 12/1/2020 1/14/2021J7189 00169721211 NOVOSEVEN RT 2 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 1/15/2021J7189 00169721511 NOVOSEVEN RT 5 MG VIAL - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.92 $1.92 2/3/2021J7190 00944293001 HEMOFIL M 250 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944293001 HEMOFIL M 250 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944293201 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944293201 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944293301 HEMOFIL M 1,700 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944293301 HEMOFIL M 1,700 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944394002 HEMOFIL M 250 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944394002 HEMOFIL M 250 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944394202 HEMOFIL M 500 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944394202 HEMOFIL M 500 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021

J7190 00944394402 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944394402 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944394501 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944394501 HEMOFIL M 1,000 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 00944394602 HEMOFIL M 1,700 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.96 $0.96 1/3/2020 1/4/2021J7190 00944394602 HEMOFIL M 1,700 UNIT NOMINAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.98 $0.98 1/5/2021J7190 76125025020 KOATE-DVI 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019 4/2/2020J7190 76125025221 KOATE 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7190 76125025620 KOATE 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7190 76125066730 KOATE-DVI 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019 4/2/2020J7190 76125066750 KOATE-DVI 1,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019 4/2/2020J7190 76125066830 KOATE 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7190 76125066931 KOATE 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7190 76125067351 KOATE 1,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7190 76125067650 KOATE 1,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER IU $0.77 $0.77 12/1/2019J7192 00026378225 KOGENATE FS 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.04 $1.04 12/1/2019 5/31/2020J7192 00026378225 KOGENATE FS 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.08 $1.08 6/1/2020 11/30/2020J7192 00026378225 KOGENATE FS 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.08 $1.08 12/1/2020 12/31/2020J7192 00026378225 KOGENATE FS 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.12 $1.12 1/1/2021J7192 00026378335 KOGENATE FS 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.04 $1.04 12/1/2019 5/31/2020J7192 00026378335 KOGENATE FS 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.08 $1.08 6/1/2020 11/30/2020J7192 00026378335 KOGENATE FS 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.08 $1.08 12/1/2020 12/31/2020J7192 00026378335 KOGENATE FS 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $1.12 $1.12 1/1/2021J7192 00026378555 KOGENATE FS 1,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.04 $1.04 12/1/2019 5/31/2020J7192 00026378555 KOGENATE FS 1,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.08 $1.08 6/1/2020 11/30/2020J7192 00026378555 KOGENATE FS 1,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.08 $1.08 12/1/2020 12/31/2020J7192 00026378555 KOGENATE FS 1,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.12 $1.12 1/1/2021J7192 00026378665 KOGENATE FS 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.04 $1.04 12/1/2019 5/31/2020J7192 00026378665 KOGENATE FS 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.08 $1.08 6/1/2020 11/30/2020J7192 00026378665 KOGENATE FS 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.08 $1.08 12/1/2020 12/31/2020J7192 00026378665 KOGENATE FS 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.12 $1.12 1/1/2021J7192 00026378775 KOGENATE FS 3,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.04 $1.04 12/1/2019 5/31/2020J7192 00026378775 KOGENATE FS 3,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.08 $1.08 6/1/2020 11/30/2020J7192 00026378775 KOGENATE FS 3,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.08 $1.08 12/1/2020 12/31/2020J7192 00026378775 KOGENATE FS 3,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.12 $1.12 1/1/2021J7192 00026382125 KOVALTRY 250 UNIT KIT - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER IU $1.07 $1.07 12/1/2018J7192 00026382225 KOVALTRY 500 UNIT KIT - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER IU $1.07 $1.07 12/1/2018J7192 00026382425 KOVALTRY 1,000 UNIT KIT - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00026382650 KOVALTRY 2,000 UNIT KIT - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00026382850 KOVALTRY 3,000 UNIT KIT - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018 12/31/2299J7192 00026482101 KOVALTRY 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00026482401 KOVALTRY 1,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00026482601 KOVALTRY 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00026482801 KOVALTRY 3,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.07 $1.07 12/1/2018J7192 00053813102 HELIXATE FS 250 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $0.95 $0.95 10/1/2017J7192 00053813202 HELIXATE FS 500 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $0.95 $0.95 10/1/2017J7192 00053813302 HELIXATE FS 1,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $0.95 $0.95 10/1/2017J7192 00053813402 HELIXATE FS 2,000 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), P $0.95 $0.95 10/1/2017J7192 00053813502 HELIXATE FS 3,000 UNITS VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $0.95 $0.95 10/1/2017J7192 00944284110 RECOMBINATE 220-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.22 $1.22 1/3/2020 11/30/2020J7192 00944284110 RECOMBINATE 220-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020J7192 00944284110 RECOMBINATE 220-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020 1/4/2021J7192 00944284110 RECOMBINATE 220-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.25 $1.25 1/5/2021J7192 00944284210 RECOMBINATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.22 $1.22 1/3/2020 11/30/2020J7192 00944284210 RECOMBINATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020 1/4/2021J7192 00944284210 RECOMBINATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.25 $1.25 1/5/2021J7192 00944284310 RECOMBINATE 801-1,240 UNIT VL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.22 $1.22 1/3/2020 11/30/2020J7192 00944284310 RECOMBINATE 801-1,240 UNIT VL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020 1/4/2021J7192 00944284310 RECOMBINATE 801-1,240 UNIT VL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.25 $1.25 1/5/2021J7192 00944284410 RECOMBINATE 1,241-1,800 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.22 $1.22 1/3/2020 11/30/2020J7192 00944284410 RECOMBINATE 1,241-1,800 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020 1/4/2021J7192 00944284410 RECOMBINATE 1,241-1,800 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.25 $1.25 1/5/2021J7192 00944284510 RECOMBINATE 1,801-2,400 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.22 $1.22 1/3/2020 11/30/2020J7192 00944284510 RECOMBINATE 1,801-2,400 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.23 $1.23 12/1/2020 1/4/2021J7192 00944284510 RECOMBINATE 1,801-2,400 UNIT V - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.25 $1.25 1/5/2021J7192 00944292102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944292102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944292102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944292102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944292202 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944292202 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944292302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 1/3/2020 11/30/2020J7192 00944292302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 12/1/2020 1/4/2021J7192 00944292302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.25 $1.25 1/5/2021J7192 00944292402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944292402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944292402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944294810 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944294810 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944294810 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944296510 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944296510 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944296510 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944304510 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944304510 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944304510 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944304512 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944304512 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944304512 ADVATE 1,801-2,400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944304610 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944304610 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944304610 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944304611 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944304611 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944304611 ADVATE 2,401-3,600 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944304710 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944304710 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944304710 ADVATE 3,601-4,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021

J7192 00944305102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305102 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305103 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305103 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305103 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305104 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305104 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305104 ADVATE 200-400 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305202 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305202 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305202 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305203 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305203 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305203 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305204 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305204 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305204 ADVATE 401-800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER $1.25 $1.25 1/5/2021J7192 00944305302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305302 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.25 $1.25 1/5/2021J7192 00944305303 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305303 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305303 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.25 $1.25 1/5/2021J7192 00944305304 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305304 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305304 ADVATE 801-1,200 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PE $1.25 $1.25 1/5/2021J7192 00944305402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305402 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944305403 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305403 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305403 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7192 00944305404 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 1/3/2020 11/30/2020J7192 00944305404 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.22 $1.22 12/1/2020 1/4/2021J7192 00944305404 ADVATE 1,201-1,800 UNIT VIAL - FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.25 $1.25 1/5/2021J7193 00053623302 MONONINE 1,000 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECO $1.09 $1.09 12/1/2018J7193 68516360102 ALPHANINE SD 500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RE $0.85 $0.85 4/1/2017J7193 68516360202 ALPHANINE SD 1,000 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 4/1/2017J7193 68516360302 ALPHANINE SD 1,500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 4/1/2017J7193 68516360402 ALPHANINE SD 500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RE $0.85 $0.85 4/1/2017J7193 68516360502 ALPHANINE SD 1,000 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 4/1/2017J7193 68516360602 ALPHANINE SD 1,500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 4/1/2017J7193 68516360702 ALPHANINE SD 500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RE $0.85 $0.85 2/1/2018J7193 68516360802 ALPHANINE SD 1,000 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 2/1/2018J7193 68516360902 ALPHANINE SD 1,500 UNIT VIAL - FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-R $0.85 $0.85 2/1/2018J7194 68516320101 PROFILNINE 500 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 4/1/2017J7194 68516320202 PROFILNINE 1,000 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 2/1/2018J7194 68516320502 PROFILNINE 1,000 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 4/1/2017J7194 68516320602 PROFILNINE 1,500 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 12/1/2018J7194 68516320701 PROFILNINE 500 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 12/1/2018J7194 68516320802 PROFILNINE 1,000 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 2/1/2018J7194 68516320902 PROFILNINE 1,500 UNIT VIAL - FACTOR IX, COMPLEX, PER IU $1.23 $1.23 2/1/2018J7195 58394013303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.35 $1.35 12/1/2019 5/31/2020J7195 58394013303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020 11/30/2020J7195 58394013303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.39 $1.39 12/1/2020J7195 58394013403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020 11/30/2020J7195 58394013403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.39 $1.39 12/1/2020J7195 58394013403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.35 $1.35 12/1/2019 5/31/2020J7195 58394013403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020J7195 58394013603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.35 $1.35 12/1/2019 5/31/2020J7195 58394013603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.41 $1.41 6/1/2020 11/30/2020J7195 58394013603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.39 $1.39 12/1/2020J7195 58394063303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.35 $1.35 12/1/2019 5/31/2020J7195 58394063303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020 11/30/2020J7195 58394063303 BENEFIX 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.39 $1.39 12/1/2020J7195 58394063403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020 11/30/2020J7195 58394063403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.39 $1.39 12/1/2020J7195 58394063403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.35 $1.35 12/1/2019 5/31/2020J7195 58394063403 BENEFIX 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.41 $1.41 6/1/2020J7195 58394063503 BENEFIX 1,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.35 $1.35 12/1/2019 5/31/2020J7195 58394063503 BENEFIX 1,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.41 $1.41 6/1/2020 11/30/2020J7195 58394063503 BENEFIX 1,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.39 $1.39 12/1/2020J7195 58394063603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.35 $1.35 12/1/2019 5/31/2020J7195 58394063603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.41 $1.41 6/1/2020 11/30/2020J7195 58394063603 BENEFIX 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.39 $1.39 12/1/2020J7195 58394063703 BENEFIX 3,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.35 $1.35 12/1/2019 5/31/2020J7195 58394063703 BENEFIX 3,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.41 $1.41 6/1/2020 11/30/2020J7195 58394063703 BENEFIX 3,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMB $1.39 $1.39 12/1/2020J7195 70504027001 IXINITY 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.44 $1.44 1/1/2020J7195 70504027101 IXINITY 1,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504027201 IXINITY 1,500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504027501 IXINITY 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.44 $1.44 1/1/2020J7195 70504027601 IXINITY 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504027701 IXINITY 3,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504028205 IXINITY 500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.44 $1.44 1/1/2020J7195 70504028305 IXINITY 1,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504028405 IXINITY 1,500 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504028506 IXINITY 1,000 UNIT RANGE-2 VLS - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, REC $1.44 $1.44 1/1/2020J7195 70504028606 IXINITY 1,500 UNIT RANGE-2 VLS - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, REC $1.44 $1.44 1/1/2020J7195 70504028705 IXINITY 250 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.44 $1.44 1/1/2020J7195 70504028805 IXINITY 2,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7195 70504028905 IXINITY 3,000 UNIT RANGE - INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.44 $1.44 1/1/2020J7198 64193032301 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193032301 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193032501 FEIBA NF 2,500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193032501 FEIBA NF 2,500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193032601 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021

J7198 64193032601 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193042302 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193042302 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193042402 FEIBA NF 1,000 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193042402 FEIBA NF 1,000 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193042502 FEIBA NF 2,500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193042502 FEIBA NF 2,500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7198 64193042602 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.81 $1.81 1/3/2020 1/4/2021J7198 64193042602 FEIBA NF 500 UNIT (NOMINAL) - ANTI-INHIBITOR, PER IU $1.87 $1.87 1/5/2021J7200 00944302602 RIXUBIS 250 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMB $1.21 $1.21 1/3/2020 1/4/2021J7200 00944302602 RIXUBIS 250 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMB $1.25 $1.25 1/5/2021J7200 00944302802 RIXUBIS 500 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMB $1.21 $1.21 1/3/2020 1/4/2021J7200 00944302802 RIXUBIS 500 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMB $1.25 $1.25 1/5/2021J7200 00944303002 RIXUBIS 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.21 $1.21 1/3/2020 1/4/2021J7200 00944303002 RIXUBIS 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.25 $1.25 1/5/2021J7200 00944303202 RIXUBIS 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.21 $1.21 1/3/2020 1/4/2021J7200 00944303202 RIXUBIS 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.25 $1.25 1/5/2021J7200 00944303402 RIXUBIS 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.21 $1.21 1/3/2020 1/4/2021J7200 00944303402 RIXUBIS 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOM $1.25 $1.25 1/5/2021J7201 64406091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 64406091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 64406091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 64406092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 64406092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 64406092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 64406093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 64406093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 64406093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 64406094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 64406094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 64406094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 64406096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 64406096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 64406096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 64406097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 64406097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 64406097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 71104091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 71104091101 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 71104092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104092201 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104093301 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104094401 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104095109 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095109 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095109 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104095201 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095201 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095201 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 71104095309 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095309 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095309 ALPROLIX 500 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 71104095409 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095409 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095409 ALPROLIX 1,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104095509 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095509 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095509 ALPROLIX 2,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104095609 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104095609 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104095609 ALPROLIX 3,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7201 71104096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 71104096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.96 $2.96 1/3/2020 11/30/2020J7201 71104096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $2.98 $2.98 12/1/2020 1/2/2021J7201 71104096601 ALPROLIX 250 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINA $3.07 $3.07 1/3/2021J7201 71104097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.96 $2.96 1/3/2020 11/30/2020J7201 71104097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $2.98 $2.98 12/1/2020 1/2/2021J7201 71104097701 ALPROLIX 4,000 UNIT NOMINAL - INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBIN $3.07 $3.07 1/3/2021J7202 69911086402 IDELVION 250 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.12 $4.12 2/7/2020 5/31/2020J7202 69911086402 IDELVION 250 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.04 $4.04 6/1/2020 11/30/2020J7202 69911086402 IDELVION 250 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.05 $4.05 12/1/2020 2/28/2021J7202 69911086402 IDELVION 250 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.20 $4.20 3/1/2021J7202 69911086502 IDELVION 500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.12 $4.12 2/7/2020 5/31/2020J7202 69911086502 IDELVION 500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.04 $4.04 6/1/2020 11/30/2020J7202 69911086502 IDELVION 500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.05 $4.05 12/1/2020 2/28/2021J7202 69911086502 IDELVION 500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (REC $4.20 $4.20 3/1/2021J7202 69911086602 IDELVION 1,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.12 $4.12 2/7/2020 5/31/2020J7202 69911086602 IDELVION 1,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.04 $4.04 6/1/2020 11/30/2020J7202 69911086602 IDELVION 1,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.05 $4.05 12/1/2020 2/28/2021J7202 69911086602 IDELVION 1,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.20 $4.20 3/1/2021J7202 69911086702 IDELVION 2,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.12 $4.12 2/7/2020 5/31/2020J7202 69911086702 IDELVION 2,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.04 $4.04 6/1/2020 11/30/2020J7202 69911086702 IDELVION 2,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.05 $4.05 12/1/2020 2/28/2021J7202 69911086702 IDELVION 2,000 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.20 $4.20 3/1/2021J7202 69911086902 IDELVION 3,500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.12 $4.12 2/7/2020 5/31/2020J7202 69911086902 IDELVION 3,500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.04 $4.04 6/1/2020 11/30/2020J7202 69911086902 IDELVION 3,500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.05 $4.05 12/1/2020 2/28/2021J7202 69911086902 IDELVION 3,500 UNIT RANGE VIAL - INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (R $4.20 $4.20 3/1/2021J7203 00169790101 REBINYN 1,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169790101 REBINYN 1,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.56 $3.56 6/1/2020J7203 00169790201 REBINYN 2,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169790201 REBINYN 2,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.56 $3.56 6/1/2020

J7203 00169790501 REBINYN 500 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169790501 REBINYN 500 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $3.56 $3.56 6/1/2020J7203 00169791111 REBINYN 1,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169791111 REBINYN 1,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.56 $3.56 6/1/2020J7203 00169792211 REBINYN 2,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169792211 REBINYN 2,000 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBIN $3.56 $3.56 6/1/2020J7203 00169795511 REBINYN 500 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $3.45 $3.45 1/8/2019 5/31/2020J7203 00169795511 REBINYN 500 UNIT VIAL - INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $3.56 $3.56 6/1/2020J7204 00169810001 ESPEROCT 1,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169810111 ESPEROCT 1,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169815001 ESPEROCT 1,500 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169815111 ESPEROCT 1,500 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169820001 ESPEROCT 2,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169820111 ESPEROCT 2,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169830001 ESPEROCT 3,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169830111 ESPEROCT 3,000 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOM $1.82 $1.82 12/1/2020J7204 00169850001 ESPEROCT 500 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOMBI $1.82 $1.82 12/1/2020J7204 00169850111 ESPEROCT 500 UNIT VIAL - INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOMBI $1.82 $1.82 12/1/2020J7205 64406080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 64406080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 64406080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 64406080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 64406081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 64406081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 64406081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 64406081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104048308 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048308 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048308 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048308 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104048408 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048408 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048408 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048408 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104048508 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048508 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048508 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048508 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104048608 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048608 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048608 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048608 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104048708 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048708 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048708 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048708 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104048808 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048808 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048808 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048808 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104048908 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104048908 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104048908 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104048908 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104049008 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104049008 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104049008 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104049008 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104049108 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104049108 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104049108 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104049108 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104049208 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104049208 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104049208 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104049208 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020

J7205 71104080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080101 ELOCTATE 250 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020J7205 71104080201 ELOCTATE 500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080301 ELOCTATE 750 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMBIN $1.99 $1.99 1/3/2021J7205 71104080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080401 ELOCTATE 1,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080501 ELOCTATE 1,500 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080601 ELOCTATE 2,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080701 ELOCTATE 3,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020 11/30/2020J7205 71104080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080801 ELOCTATE 4,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020J7205 71104080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104080901 ELOCTATE 5,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7205 71104081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $2.00 $2.00 1/3/2020 5/31/2020J7205 71104081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.94 $1.94 6/1/2020J7205 71104081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.92 $1.92 12/1/2020 1/2/2021J7205 71104081001 ELOCTATE 6,000 UNIT NOMINAL - INJECTION, FACTOR VIII, FC FUSION PROTEIN (RECOMB $1.99 $1.99 1/3/2021J7207 00944425202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944425202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944425202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944425402 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944425402 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944425402 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944425602 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944425602 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944425602 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944425802 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944425802 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944425802 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944462201 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462201 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462201 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944462202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462202 ADYNOVATE 200-400 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944462301 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462301 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462301 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944462302 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462302 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462302 ADYNOVATE 401-800 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, REC $1.77 $1.77 1/5/2021J7207 00944462401 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462401 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462401 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944462402 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462402 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462402 ADYNOVATE 801-1,250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944462501 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462501 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462501 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944462502 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462502 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462502 ADYNOVATE 1,251-2,500 UNIT VL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RE $1.77 $1.77 1/5/2021J7207 00944462601 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462601 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462601 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.77 $1.77 1/5/2021J7207 00944462602 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462602 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462602 ADYNOVATE 750 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.77 $1.77 1/5/2021J7207 00944462701 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462701 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462701 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.77 $1.77 1/5/2021J7207 00944462702 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462702 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462702 ADYNOVATE 1,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.77 $1.77 1/5/2021J7207 00944462801 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462801 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462801 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.77 $1.77 1/5/2021J7207 00944462802 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.68 $1.68 1/3/2020 11/30/2020J7207 00944462802 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.70 $1.70 12/1/2020 1/4/2021J7207 00944462802 ADYNOVATE 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.77 $1.77 1/5/2021J7208 00026394225 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.81 $1.81 7/1/2019 5/31/2020J7208 00026394225 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.81 $1.81 6/1/2020 12/31/2020J7208 00026394225 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.89 $1.89 1/1/2021J7208 00026394425 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026394425 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026394425 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021

J7208 00026394625 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026394625 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026394625 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021J7208 00026394825 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026394825 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026394825 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021J7208 00026494201 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.81 $1.81 7/1/2019 5/31/2020J7208 00026494201 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.81 $1.81 6/1/2020 12/31/2020J7208 00026494201 JIVI 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), $1.89 $1.89 1/1/2021J7208 00026494401 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026494401 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026494401 JIVI 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021J7208 00026494601 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026494601 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026494601 JIVI 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021J7208 00026494801 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 7/1/2019 5/31/2020J7208 00026494801 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.81 $1.81 6/1/2020 12/31/2020J7208 00026494801 JIVI 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT $1.89 $1.89 1/1/2021J7209 68982013901 NUWIQ 250 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.09 $1.09 12/1/2019 5/31/2020J7209 68982013901 NUWIQ 250 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 6/1/2020 11/30/2020J7209 68982013901 NUWIQ 250 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 12/1/2020J7209 68982014001 NUWIQ 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014001 NUWIQ 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014001 NUWIQ 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.17 $1.17 12/1/2020J7209 68982014101 NUWIQ 500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014101 NUWIQ 500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014101 NUWIQ 500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.17 $1.17 12/1/2020J7209 68982014201 NUWIQ 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014201 NUWIQ 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014201 NUWIQ 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINAN $1.17 $1.17 12/1/2020J7209 68982014301 NUWIQ 1,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014301 NUWIQ 1,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014301 NUWIQ 1,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.17 $1.17 12/1/2020J7209 68982014401 NUWIQ 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014401 NUWIQ 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.10534 $1.10534 6/1/2020 11/30/2020J7209 68982014401 NUWIQ 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.16767 $1.16767 12/1/2020J7209 68982014501 NUWIQ 2,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014501 NUWIQ 2,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.10534 $1.10534 6/1/2020 11/30/2020J7209 68982014501 NUWIQ 2,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.16767 $1.16767 12/1/2020J7209 68982014601 NUWIQ 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014601 NUWIQ 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.10534 $1.10534 6/1/2020 11/30/2020J7209 68982014601 NUWIQ 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.16767 $1.16767 12/1/2020J7209 68982014701 NUWIQ 2,500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014701 NUWIQ 2,500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014701 NUWIQ 2,500 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.17 $1.17 12/1/2020J7209 68982014801 NUWIQ 2,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014801 NUWIQ 2,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.10534 $1.10534 6/1/2020 11/30/2020J7209 68982014801 NUWIQ 2,500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.16767 $1.16767 12/1/2020J7209 68982014901 NUWIQ 3,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.09 $1.09 12/1/2019 5/31/2020J7209 68982014901 NUWIQ 3,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.11 $1.11 6/1/2020 11/30/2020J7209 68982014901 NUWIQ 3,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.17 $1.17 12/1/2020J7209 68982015001 NUWIQ 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7209 68982015001 NUWIQ 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.11 $1.11 6/1/2020 11/30/2020J7209 68982015001 NUWIQ 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.17 $1.17 12/1/2020J7209 68982015101 NUWIQ 4,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.09 $1.09 12/1/2019 5/31/2020J7209 68982015101 NUWIQ 4,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.11 $1.11 6/1/2020 11/30/2020J7209 68982015101 NUWIQ 4,000 UNIT VIAL PACK - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECO $1.17 $1.17 12/1/2020J7209 68982015201 NUWIQ 4,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.09 $1.09 12/1/2019 5/31/2020J7209 68982015201 NUWIQ 4,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.11 $1.11 6/1/2020 11/30/2020J7209 68982015201 NUWIQ 4,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.17 $1.17 12/1/2020J7210 69911047802 AFSTYLA 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 12/1/2019 5/31/2020J7210 69911047802 AFSTYLA 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 6/1/2020 11/30/2020J7210 69911047802 AFSTYLA 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.14 $1.14 12/1/2020J7210 69911047402 AFSTYLA 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.13 $1.13 12/1/2019 5/31/2020J7210 69911047402 AFSTYLA 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.13 $1.13 6/1/2020 11/30/2020J7210 69911047402 AFSTYLA 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.14 $1.14 12/1/2020J7210 69911047502 AFSTYLA 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.13 $1.13 12/1/2019 5/31/2020J7210 69911047502 AFSTYLA 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.13 $1.13 6/1/2020 11/30/2020J7210 69911047502 AFSTYLA 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINA $1.14 $1.14 12/1/2020J7210 69911047602 AFSTYLA 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 6/1/2020 11/30/2020J7210 69911047602 AFSTYLA 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.14 $1.14 12/1/2020J7210 69911047702 AFSTYLA 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 12/1/2019 5/31/2020J7210 69911047702 AFSTYLA 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 6/1/2020 11/30/2020J7210 69911047702 AFSTYLA 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.14 $1.14 12/1/2020J7210 69911047802 AFSTYLA 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBI $1.13 $1.13 12/1/2019J7210 69911048002 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 12/1/2019 5/31/2020J7210 69911048002 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 6/1/2020 11/30/2020J7210 69911048002 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.14 $1.14 12/1/2020J7210 69911048102 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 12/1/2019 5/31/2020J7210 69911048102 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 6/1/2020 11/30/2020J7210 69911048102 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.14 $1.14 12/1/2020J7210 69911049001 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 12/1/2019 5/31/2020J7210 69911049001 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 6/1/2020 11/30/2020J7210 69911049001 AFSTYLA 1,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.14 $1.14 12/1/2020J7210 69911049101 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 12/1/2019 5/31/2020J7210 69911049101 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.13 $1.13 6/1/2020 11/30/2020J7210 69911049101 AFSTYLA 2,500 UNIT RANGE VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, R $1.14 $1.14 12/1/2020J7211 00026382125 KOVALTRY 250 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.10 $1.10 6/1/2019 5/31/2020J7211 00026382125 KOVALTRY 250 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.10 $1.10 6/1/2020 12/31/2020J7211 00026382125 KOVALTRY 250 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.13 $1.13 1/1/2021J7211 00026382225 KOVALTRY 500 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.10 $1.10 6/1/2019 5/31/2020J7211 00026382225 KOVALTRY 500 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.10 $1.10 6/1/2020 12/31/2020J7211 00026382225 KOVALTRY 500 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBIN $1.13 $1.13 1/1/2021J7211 00026382425 KOVALTRY 1,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2019J7211 00026382425 KOVALTRY 1,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2020 12/31/2020J7211 00026382425 KOVALTRY 1,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.13 $1.13 1/1/2021J7211 00026382650 KOVALTRY 2,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2019 5/31/2020J7211 00026382650 KOVALTRY 2,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2020 12/31/2020

J7211 00026382650 KOVALTRY 2,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.13 $1.13 1/1/2021J7211 00026382850 KOVALTRY 3,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2019 5/31/2020J7211 00026382850 KOVALTRY 3,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2020 12/31/2020J7211 00026382850 KOVALTRY 3,000 UNIT KIT - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.13 $1.13 1/1/2021J7211 00026482101 KOVALTRY 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2019 5/31/2020J7211 00026482101 KOVALTRY 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2020 12/31/2020J7211 00026482101 KOVALTRY 250 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.13 $1.13 1/1/2021J7211 00026482201 KOVALTRY 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2019 5/31/2020J7211 00026482201 KOVALTRY 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.10 $1.10 6/1/2020 12/31/2020J7211 00026482201 KOVALTRY 500 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMB $1.13 $1.13 1/1/2021J7211 00026482401 KOVALTRY 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2019 5/31/2020J7211 00026482401 KOVALTRY 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2020 12/31/2020J7211 00026482401 KOVALTRY 1,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.13 $1.13 1/1/2021J7211 00026482601 KOVALTRY 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2019 5/31/2020J7211 00026482601 KOVALTRY 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2020 12/31/2020J7211 00026482601 KOVALTRY 2,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.13 $1.13 1/1/2021J7211 00026482801 KOVALTRY 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2019 5/31/2020J7211 00026482801 KOVALTRY 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.10 $1.10 6/1/2020 12/31/2020J7211 00026482801 KOVALTRY 3,000 UNIT VIAL - INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOM $1.13 $1.13 1/1/2021J7212 71127100001 SEVENFACT-FACTOR VIIA-(ANTIHEMOPHILIC FACTOR, RECOMBINANT) 1 MICROGRAM Invoice required Invoice required 1/1/2021J7212 71127110001 SEVENFACT-FACTOR VIIA-(ANTIHEMOPHILIC FACTOR, RECOMBINANT) 1 MICROGRAM Invoice required Invoice required 1/1/2021J7212 71127500001 SEVENFACT-FACTOR VIIA-(ANTIHEMOPHILIC FACTOR, RECOMBINANT) 1 MICROGRAM Invoice required Invoice required 1/1/2021J7212 71127510001 SEVENFACT-FACTOR VIIA-(ANTIHEMOPHILIC FACTOR, RECOMBINANT) 1 MICROGRAM Invoice required Invoice required 1/1/2021

*** J3490 Lidocaine , for topical use 1 mg Strength Invoice Required Invoice Required 1/1/2015LIDOCAINE-PRILOCAIME CREAM TOPICAL CREAM 2.5%-2.5% $0.89 $0.89LIDOCAINE HCl 2% JEL/PF APP 1 MG $0.02 $0.02SENSORCAINE 0.25% VIAL 2.5MG/ML $0.17 $0.17MARCAINE 0.5% VIAL 5 MG/ML $0.06 $0.06LIDOCAINE HCl 0.5% VIAL INJECTION 5 MG/ML $0.06 $0.06LIDOCAINE HCl 1% VIAL INJECTION 10 MG/ML $0.02 $0.02LIDOCAINE HCl 2% VIAL INJECTION 20 MG/ML $0.02 $0.02LICOCAINE HCl 2% GEL TOPICAL JELLY 2% $0.38 $0.38LIDOCAINE 2% VISCOUS SOLN ORAL SOLUTION 20 MG/ML $0.03 $0.03Lldocalne HCL 4% SOLN-TOPICAL SOLUTION 40 MG/ML $0.16 $0.16LIDOCAINE 2%-EPI 1:100,000 2%-1:100K $0.18 $0.18MARCAINE-EPI 0.25%-0.00005 VIAL 0.25-.0005 $0.27 $0.27SENSORCAINE-EPI 0.5%-0.0005 0.5-1:200K $0.43 $0.43SENSORCAINE-MPF 0.25% AMPUL 2.5 MG/ML $0.18 $0.18SENSORCAINE 0.5% AMPUL 5 MG/ML $0.18 $0.18BUPIVACAINE 0.75% AMPUL 7.5 MG/ML $0.16 $0.16BUPIVACAINE 0.25% VIAL 2.5 MG/ML $0.15 $0.15BUPIVACAINE 0.5% VIAL 5 MG/ML $0.17 $0.17BUPIVACAINE 0.75% VIAL 7.5 MG/ML $0.16 $0.16BUPIVACAIN-DEXTR 0.75% AMP 1 MG $0.08 $0.08BUPIVACAINE HCl/EPINEPHRINE/PF 7.5 MG/ML (0.75%)-1:200,000 VIAL $0.05 $0.05LIDOCAINE HCl 3% LOTION-TOPICAL LOTION 3% $0.59 $0.59LIDOCAINE HCL 4% AMPUL 40 MG/ML $0.68 $0.68LIDOCAINE HCL 1.5% AMPUL 15 MG/ML $0.35 $0.35LIDOCAINE HCL 1% AMPUL 10 MG/ML $0.20 $0.20LIDOCAINE HCI/PF 20 MG/ML (2%) AMPUL $0.02 $0.02LIDOCAINE HCL 2% VIAL 20 MG/ML $0.39 $0.39XYLOCAINE-MPF 1% VIAL 10 MG/ML $0.47 $0.47LIDOCAINE HCl 1% SYRINGE 10 MG/ML $0.41 $0.41XYLOCAINE-MPF 0.5% VIAL 5 MG/ML $0.22 $0.22XYLOCAINE IV 2% AMPUL 20 MG/ML $0.80 $0.80LIDOCAINE HCL 2% SYRINGE 100 MG/ML $0.39 $0.39LIDOCAINE HCL 1% SYRINGE 50 MG/5 ML $0.39 $0.39LIDOCAINE 0.4% IN D5W SOLN 4 MG/ML $0.02 $0.02LIDOCAINE 0.8% IN D5W SOLN 8 MG/ML $0.02 $0.02LIDOCAINE 5% IN D7.5W AMPUL 5% $2.65 $2.65LIDOCAINE 3% CREAM TOPICAL CREAM 3% $0.59 $0.59LIDOCAINE 5% OINTMENT (G) 1 MG $0.03 $0.03CHLOROPROCAINE HCI/PF 50 MG/5 ML (1%) AMPUL $0.32 $0.32LIDOCAINE HCl/EPINEPHRINE 15 MG/ML (1.5%)-1:200,000 AMPUL $0.06 $0.06LIDOCAINE HCl/EPINEPHRINE 15 MG/ML (1.5%)-1:200,000 VIAL $0.02 $0.02LIDOCAINE HCl/EPINEPHRINE 20 MG/ML (2%)-1:200,000 VIAL $0.01 $0.01LIDOCAINE-PRILOCAINE KIT $0.06 $0.06BUPIVACAINE-EPI 0.25%-0.0005 0.25-.0005 $0.10 $0.10MARCAINE 0.5%-EPI 0.0005 VIAL 0.5-1:200K $0.28 $0.28LIDOCAINE 1%-EPI 1:200,000 1%-1:200K $0.18 $0.18XYLOCAINE 1.5%-EPI 1:200,000 1.5-1:200K $0.50 $0.50XYLOCAINE 0.5%-EPI 1:200,000 0.5-1:200K $0.11 $0.11LIDOCAINE 1.5%-EPI 1:200,000 1.5-1:200K $0.24 $0.24LIDOCAINE 1%-EPI 1:100,000 1%-1:100K $0.10 $0.10LIDOCAINE 2%-EPI 1:100,000 2%-1:100K $0.12 $0.12XYLOCAINE 1%-EPI 1:200,000 1%-1:200K $0.35 $0.35XYLOCAINE 2%-EPI 1:200,000 2%-1:200K $0.67 $0.67BUPIVACAINE-EPI 0.5%-0.0005 0.5-1:200K $0.32 $0.32LIDOCAINE 4% CREAM TOPICAL CREAM 4% $0.92 $0.92LIDOCANE HCl 4% SOLUTION 1 MG $0.17 $0.17LIDOCAINE HCl 2% VIAL 20 MG/ML $0.35 $0.35XYLOCAINE-MPF 2% AMPUL 20 MG/ML $0.63 $0.63LIDOCAINE 2%-EPI 1:50,000 2%-1:50000 $0.18 $0.18

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