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Top Drug Utilization Ranked by Net Paid

Top Drugs
NDC NumberGeneric/Brand CategoryPrescription TierSubmission Method CategoryDrug NameFDB Standard Therapeutic ClassMetricsNumber of ClaimantsNumber of PrescriptionsPlan Net PaidHRA Net PaidTotal Net Paid% of Total Prescriptions% of Plan Net Paid% of HRA Net Paid% of Total Net PaidPlan Net Paid per PrescriptionHRA Net Paid per PrescriptionTotal Net Paid per PrescriptionAverage Days SupplyIngredient Cost Paid per Day Of Therapy
00002143380Brand DrugTier 3RetailTRULICITYDIABETIC THERAPY956$36,385$0$36,3850.1%0.5%0.0%0.5%$649.74$0.00$649.7428.20$23.84
Subtotal--56$36,385$0$36,3850.1%0.5%0.0%0.5%$649.74$0.00$649.7428.20$23.84
Subtotal --56$36,385$0$36,3850.1%0.5%0.0%0.5%$649.74$0.00$649.7428.20$23.84
Home DeliveryTRULICITYDIABETIC THERAPY14$7,567$0$7,5670.0%0.1%0.0%0.1%$1,891.77$0.00$1,891.7784.00$22.52
Subtotal--4$7,567$0$7,5670.0%0.1%0.0%0.1%$1,891.77$0.00$1,891.7784.00$22.52
Subtotal --4$7,567$0$7,5670.0%0.1%0.0%0.1%$1,891.77$0.00$1,891.7784.00$22.52
00002143480Brand DrugTier 3RetailTRULICITYDIABETIC THERAPY955$30,751$0$30,7510.1%0.4%0.0%0.4%$559.11$0.00$559.1128.55$23.39
Subtotal--55$30,751$0$30,7510.1%0.4%0.0%0.4%$559.11$0.00$559.1128.55$23.39
Subtotal --55$30,751$0$30,7510.1%0.4%0.0%0.4%$559.11$0.00$559.1128.55$23.39
00002322830Brand DrugTier 3RetailSTRATTERAPSYCHOSTIMULANTS-ANTIDEPRESSANTS716$2,456$0$2,4560.0%0.0%0.0%0.0%$153.50$0.00$153.5030.00$15.52
Subtotal--16$2,456$0$2,4560.0%0.0%0.0%0.0%$153.50$0.00$153.5030.00$15.52
Subtotal --16$2,456$0$2,4560.0%0.0%0.0%0.0%$153.50$0.00$153.5030.00$15.52
00002322930Brand DrugTier 3RetailSTRATTERAPSYCHOSTIMULANTS-ANTIDEPRESSANTS25$3,551$0$3,5510.0%0.1%0.0%0.1%$710.11$0.00$710.1130.00$26.30
Subtotal--5$3,551$0$3,5510.0%0.1%0.0%0.1%$710.11$0.00$710.1130.00$26.30
Subtotal --5$3,551$0$3,5510.0%0.1%0.0%0.1%$710.11$0.00$710.1130.00$26.30
00002323830Brand DrugTier 3RetailSTRATTERAPSYCHOSTIMULANTS-ANTIDEPRESSANTS23$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0020.33$13.21
Subtotal--3$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0020.33$13.21
Subtotal --3$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0020.33$13.21
00002323930Brand DrugTier 3RetailSTRATTERAPSYCHOSTIMULANTS-ANTIDEPRESSANTS35$1,801$0$1,8010.0%0.0%0.0%0.0%$360.17$0.00$360.1730.00$14.64
Subtotal--5$1,801$0$1,8010.0%0.0%0.0%0.0%$360.17$0.00$360.1730.00$14.64
Subtotal --5$1,801$0$1,8010.0%0.0%0.0%0.0%$360.17$0.00$360.1730.00$14.64
00002325030Brand DrugTier 3RetailSTRATTERAPSYCHOSTIMULANTS-ANTIDEPRESSANTS25$1,969$0$1,9690.0%0.0%0.0%0.0%$393.83$0.00$393.8330.00$15.76
Subtotal--5$1,969$0$1,9690.0%0.0%0.0%0.0%$393.83$0.00$393.8330.00$15.76
Subtotal --5$1,969$0$1,9690.0%0.0%0.0%0.0%$393.83$0.00$393.8330.00$15.76
00002446230Brand DrugTier 3RetailCIALISMISCELLANEOUS1228$1,400$0$1,4000.0%0.0%0.0%0.0%$50.00$0.00$50.0022.75$4.68
Subtotal--28$1,400$0$1,4000.0%0.0%0.0%0.0%$50.00$0.00$50.0022.75$4.68
Subtotal --28$1,400$0$1,4000.0%0.0%0.0%0.0%$50.00$0.00$50.0022.75$4.68
00002446234Brand DrugTier 3Home DeliveryCIALISMISCELLANEOUS36$3,042$0$3,0420.0%0.0%0.0%0.0%$507.08$0.00$507.0890.00$9.56
Subtotal--6$3,042$0$3,0420.0%0.0%0.0%0.0%$507.08$0.00$507.0890.00$9.56
Subtotal --6$3,042$0$3,0420.0%0.0%0.0%0.0%$507.08$0.00$507.0890.00$9.56
RetailCIALISMISCELLANEOUS46$920$0$9200.0%0.0%0.0%0.0%$153.34$0.00$153.3436.00$6.49
Subtotal--6$920$0$9200.0%0.0%0.0%0.0%$153.34$0.00$153.3436.00$6.49
Subtotal --6$920$0$9200.0%0.0%0.0%0.0%$153.34$0.00$153.3436.00$6.49
00002446330Brand DrugTier 3RetailCIALISMISCELLANEOUS46$1,355$0$1,3550.0%0.0%0.0%0.0%$225.88$0.00$225.8813.33$22.85
Subtotal--6$1,355$0$1,3550.0%0.0%0.0%0.0%$225.88$0.00$225.8813.33$22.85
Subtotal --6$1,355$0$1,3550.0%0.0%0.0%0.0%$225.88$0.00$225.8813.33$22.85
Home DeliveryCIALISMISCELLANEOUS22$1,333$0$1,3330.0%0.0%0.0%0.0%$666.48$0.00$666.4890.00$9.63
Subtotal--2$1,333$0$1,3330.0%0.0%0.0%0.0%$666.48$0.00$666.4890.00$9.63
Subtotal --2$1,333$0$1,3330.0%0.0%0.0%0.0%$666.48$0.00$666.4890.00$9.63
00002446430Brand DrugTier 3RetailCIALISMISCELLANEOUS2498$19,617$0$19,6170.1%0.3%0.0%0.3%$200.17$0.00$200.1721.65$13.51
Subtotal--98$19,617$0$19,6170.1%0.3%0.0%0.3%$200.17$0.00$200.1721.65$13.51
Subtotal --98$19,617$0$19,6170.1%0.3%0.0%0.3%$200.17$0.00$200.1721.65$13.51
Home DeliveryCIALISMISCELLANEOUS11$866$0$8660.0%0.0%0.0%0.0%$866.48$0.00$866.4890.00$9.63
Subtotal--1$866$0$8660.0%0.0%0.0%0.0%$866.48$0.00$866.4890.00$9.63
Subtotal --1$866$0$8660.0%0.0%0.0%0.0%$866.48$0.00$866.4890.00$9.63
00002446534Brand DrugTier 3RetailCIALISMISCELLANEOUS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$9.67
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$9.67
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$9.67
00002512330Brand DrugTier 1RetailEFFIENTANTICOAGULANTS14$1,840$0$1,8400.0%0.0%0.0%0.0%$459.98$0.00$459.9830.00$15.62
Subtotal--4$1,840$0$1,8400.0%0.0%0.0%0.0%$459.98$0.00$459.9830.00$15.62
Subtotal --4$1,840$0$1,8400.0%0.0%0.0%0.0%$459.98$0.00$459.9830.00$15.62
Home DeliveryEFFIENTANTICOAGULANTS11$1,284$0$1,2840.0%0.0%0.0%0.0%$1,283.70$0.00$1,283.7090.00$14.54
Subtotal--1$1,284$0$1,2840.0%0.0%0.0%0.0%$1,283.70$0.00$1,283.7090.00$14.54
Subtotal --1$1,284$0$1,2840.0%0.0%0.0%0.0%$1,283.70$0.00$1,283.7090.00$14.54
Tier 3RetailEFFIENTANTICOAGULANTS29$3,298$0$3,2980.0%0.0%0.0%0.0%$366.49$0.00$366.4930.00$14.84
Subtotal--9$3,298$0$3,2980.0%0.0%0.0%0.0%$366.49$0.00$366.4930.00$14.84
Subtotal --9$3,298$0$3,2980.0%0.0%0.0%0.0%$366.49$0.00$366.4930.00$14.84
Home DeliveryEFFIENTANTICOAGULANTS13$3,208$0$3,2080.0%0.0%0.0%0.0%$1,069.35$0.00$1,069.3590.00$14.10
Subtotal--3$3,208$0$3,2080.0%0.0%0.0%0.0%$1,069.35$0.00$1,069.3590.00$14.10
Subtotal --3$3,208$0$3,2080.0%0.0%0.0%0.0%$1,069.35$0.00$1,069.3590.00$14.10
00002751001Brand DrugTier 1RetailHUMALOGDIABETIC THERAPY860$39,690$0$39,6900.1%0.6%0.0%0.6%$661.50$0.00$661.5027.23$25.80
Subtotal--60$39,690$0$39,6900.1%0.6%0.0%0.6%$661.50$0.00$661.5027.23$25.80
Subtotal --60$39,690$0$39,6900.1%0.6%0.0%0.6%$661.50$0.00$661.5027.23$25.80
00002751659Brand DrugTier 2RetailHUMALOGDIABETIC THERAPY112$5,543$0$5,5430.0%0.1%0.0%0.1%$461.88$0.00$461.8830.00$16.69
Subtotal--12$5,543$0$5,5430.0%0.1%0.0%0.1%$461.88$0.00$461.8830.00$16.69
Subtotal --12$5,543$0$5,5430.0%0.1%0.0%0.1%$461.88$0.00$461.8830.00$16.69
00002771227Brand DrugTier 2RetailHUMALOG KWIKPEN U-200DIABETIC THERAPY115$19,047$0$19,0470.0%0.3%0.0%0.3%$1,269.82$0.00$1,269.8224.00$52.86
Subtotal--15$19,047$0$19,0470.0%0.3%0.0%0.3%$1,269.82$0.00$1,269.8224.00$52.86
Subtotal --15$19,047$0$19,0470.0%0.3%0.0%0.3%$1,269.82$0.00$1,269.8224.00$52.86
00002771559Brand DrugTier 1RetailBASAGLAR KWIKPEN U-100DIABETIC THERAPY48229$103,609$0$103,6090.3%1.5%0.0%1.5%$452.44$0.00$452.4429.28$15.41
Subtotal--229$103,609$0$103,6090.3%1.5%0.0%1.5%$452.44$0.00$452.4429.28$15.41
Subtotal --229$103,609$0$103,6090.3%1.5%0.0%1.5%$452.44$0.00$452.4429.28$15.41
Home DeliveryBASAGLAR KWIKPEN U-100DIABETIC THERAPY1122$25,395$0$25,3950.0%0.4%0.0%0.4%$1,154.30$0.00$1,154.3090.00$12.83
Subtotal--22$25,395$0$25,3950.0%0.4%0.0%0.4%$1,154.30$0.00$1,154.3090.00$12.83
Subtotal --22$25,395$0$25,3950.0%0.4%0.0%0.4%$1,154.30$0.00$1,154.3090.00$12.83
Tier 3RetailBASAGLAR KWIKPEN U-100DIABETIC THERAPY2023$9,369$0$9,3690.0%0.1%0.0%0.1%$407.34$0.00$407.3427.91$15.55
Subtotal--23$9,369$0$9,3690.0%0.1%0.0%0.1%$407.34$0.00$407.3427.91$15.55
Subtotal --23$9,369$0$9,3690.0%0.1%0.0%0.1%$407.34$0.00$407.3427.91$15.55
Home DeliveryBASAGLAR KWIKPEN U-100DIABETIC THERAPY33$4,818$0$4,8180.0%0.1%0.0%0.1%$1,606.05$0.00$1,606.0590.00$17.84
Subtotal--3$4,818$0$4,8180.0%0.1%0.0%0.1%$1,606.05$0.00$1,606.0590.00$17.84
Subtotal --3$4,818$0$4,8180.0%0.1%0.0%0.1%$1,606.05$0.00$1,606.0590.00$17.84
00002803101Brand DrugTier 2RetailGLUCAGON EMERGENCY KITDIABETIC THERAPY611$3,136$0$3,1360.0%0.0%0.0%0.0%$285.09$0.00$285.098.91$31.87
Subtotal--11$3,136$0$3,1360.0%0.0%0.0%0.0%$285.09$0.00$285.098.91$31.87
Subtotal --11$3,136$0$3,1360.0%0.0%0.0%0.0%$285.09$0.00$285.098.91$31.87
00002821501Brand DrugTier 1RetailHUMULIN RDIABETIC THERAPY16$903$0$9030.0%0.0%0.0%0.0%$150.44$0.00$150.4430.00$4.98
Subtotal--6$903$0$9030.0%0.0%0.0%0.0%$150.44$0.00$150.4430.00$4.98
Subtotal --6$903$0$9030.0%0.0%0.0%0.0%$150.44$0.00$150.4430.00$4.98
00002831501Brand DrugTier 1RetailHUMULIN NDIABETIC THERAPY21$415$0$4150.0%0.0%0.0%0.0%$415.28$0.00$415.2830.00$13.82
Subtotal--1$415$0$4150.0%0.0%0.0%0.0%$415.28$0.00$415.2830.00$13.82
Subtotal --1$415$0$4150.0%0.0%0.0%0.0%$415.28$0.00$415.2830.00$13.82
00002840001Brand DrugTier 2RetailFORTEOMISCELLANEOUS12$6,392$0$6,3920.0%0.1%0.0%0.1%$3,195.89$0.00$3,195.8930.00$107.16
Subtotal--2$6,392$0$6,3920.0%0.1%0.0%0.1%$3,195.89$0.00$3,195.8930.00$107.16
Subtotal --2$6,392$0$6,3920.0%0.1%0.0%0.1%$3,195.89$0.00$3,195.8930.00$107.16
00002879959Brand DrugTier 2RetailHUMALOGDIABETIC THERAPY1998$67,729$0$67,7290.1%1.0%0.0%1.0%$691.11$0.00$691.1128.21$24.45
Subtotal--98$67,729$0$67,7290.1%1.0%0.0%1.0%$691.11$0.00$691.1128.21$24.45
Subtotal --98$67,729$0$67,7290.1%1.0%0.0%1.0%$691.11$0.00$691.1128.21$24.45
Home DeliveryHUMALOGDIABETIC THERAPY718$29,874$0$29,8740.0%0.4%0.0%0.4%$1,659.69$0.00$1,659.6990.00$19.00
Subtotal--18$29,874$0$29,8740.0%0.4%0.0%0.4%$1,659.69$0.00$1,659.6990.00$19.00
Subtotal --18$29,874$0$29,8740.0%0.4%0.0%0.4%$1,659.69$0.00$1,659.6990.00$19.00
00002880559Brand DrugTier 2RetailHUMULIN N KWIKPENDIABETIC THERAPY11$448$0$4480.0%0.0%0.0%0.0%$447.77$0.00$447.7730.00$14.88
Subtotal--1$448$0$4480.0%0.0%0.0%0.0%$447.77$0.00$447.7730.00$14.88
Subtotal --1$448$0$4480.0%0.0%0.0%0.0%$447.77$0.00$447.7730.00$14.88
00002882427Brand DrugTier 2RetailHUMULIN R U-500 KWIKPENDIABETIC THERAPY212$16,712$0$16,7120.0%0.2%0.0%0.2%$1,392.71$0.00$1,392.7122.42$62.07
Subtotal--12$16,712$0$16,7120.0%0.2%0.0%0.2%$1,392.71$0.00$1,392.7122.42$62.07
Subtotal --12$16,712$0$16,7120.0%0.2%0.0%0.2%$1,392.71$0.00$1,392.7122.42$62.07
00003085222Brand DrugTier 3RetailSPRYCELANTINEOPLASTICS112$140,816$0$140,8160.0%2.1%0.0%2.1%$11,734.66$0.00$11,734.6630.00$399.47
Subtotal--12$140,816$0$140,8160.0%2.1%0.0%2.1%$11,734.66$0.00$11,734.6630.00$399.47
Subtotal --12$140,816$0$140,8160.0%2.1%0.0%2.1%$11,734.66$0.00$11,734.6630.00$399.47
00003089321Brand DrugTier 3RetailELIQUISANTICOAGULANTS112$3,560$0$3,5600.0%0.1%0.0%0.1%$296.71$0.00$296.7130.00$12.99
Subtotal--12$3,560$0$3,5600.0%0.1%0.0%0.1%$296.71$0.00$296.7130.00$12.99
Subtotal --12$3,560$0$3,5600.0%0.1%0.0%0.1%$296.71$0.00$296.7130.00$12.99
00003089421Brand DrugTier 3RetailELIQUISANTICOAGULANTS1482$24,106$0$24,1060.1%0.4%0.0%0.4%$293.98$0.00$293.9831.46$13.09
Subtotal--82$24,106$0$24,1060.1%0.4%0.0%0.4%$293.98$0.00$293.9831.46$13.09
Subtotal --82$24,106$0$24,1060.1%0.4%0.0%0.4%$293.98$0.00$293.9831.46$13.09
Home DeliveryELIQUISANTICOAGULANTS34$3,829$0$3,8290.0%0.1%0.0%0.1%$957.26$0.00$957.2690.00$12.30
Subtotal--4$3,829$0$3,8290.0%0.1%0.0%0.1%$957.26$0.00$957.2690.00$12.30
Subtotal --4$3,829$0$3,8290.0%0.1%0.0%0.1%$957.26$0.00$957.2690.00$12.30
00003218851Brand DrugTier 3RetailORENCIA CLICKJECTANTIARTHRITICS18$28,909$0$28,9090.0%0.4%0.0%0.4%$3,613.61$0.00$3,613.6128.00$131.87
Subtotal--8$28,909$0$28,9090.0%0.4%0.0%0.4%$3,613.61$0.00$3,613.6128.00$131.87
Subtotal --8$28,909$0$28,9090.0%0.4%0.0%0.4%$3,613.61$0.00$3,613.6128.00$131.87
00004082205Brand DrugTier 3RetailTAMIFLUANTIVIRALS2118$1,684$0$1,6840.0%0.0%0.0%0.0%$93.54$0.00$93.546.78$34.41
Subtotal--18$1,684$0$1,6840.0%0.0%0.0%0.0%$93.54$0.00$93.546.78$34.41
Subtotal --18$1,684$0$1,6840.0%0.0%0.0%0.0%$93.54$0.00$93.546.78$34.41
00004110020Brand DrugTier 1RetailXELODAANTINEOPLASTICS25$2,715$0$2,7150.0%0.0%0.0%0.0%$543.07$0.00$543.0721.00$26.19
Subtotal--5$2,715$0$2,7150.0%0.0%0.0%0.0%$543.07$0.00$543.0721.00$26.19
Subtotal --5$2,715$0$2,7150.0%0.0%0.0%0.0%$543.07$0.00$543.0721.00$26.19
00004110150Brand DrugTier 1RetailXELODAANTINEOPLASTICS26$14,854$0$14,8540.0%0.2%0.0%0.2%$2,475.61$0.00$2,475.6118.50$158.91
Subtotal--6$14,854$0$14,8540.0%0.2%0.0%0.2%$2,475.61$0.00$2,475.6118.50$158.91
Subtotal --6$14,854$0$14,8540.0%0.2%0.0%0.2%$2,475.61$0.00$2,475.6118.50$158.91
00006003330Brand DrugTier 3RetailBELSOMRASEDATIVE NON-BARBITURATE48$2,370$0$2,3700.0%0.0%0.0%0.0%$296.24$0.00$296.2428.75$13.05
Subtotal--8$2,370$0$2,3700.0%0.0%0.0%0.0%$296.24$0.00$296.2428.75$13.05
Subtotal --8$2,370$0$2,3700.0%0.0%0.0%0.0%$296.24$0.00$296.2428.75$13.05
00006007861Brand DrugTier 3RetailJANUMET XRDIABETIC THERAPY213$1,897$0$1,8970.0%0.0%0.0%0.0%$145.90$0.00$145.9030.00$7.02
Subtotal--13$1,897$0$1,8970.0%0.0%0.0%0.0%$145.90$0.00$145.9030.00$7.02
Subtotal --13$1,897$0$1,8970.0%0.0%0.0%0.0%$145.90$0.00$145.9030.00$7.02
00006008061Brand DrugTier 3RetailJANUMET XRDIABETIC THERAPY220$7,175$0$7,1750.0%0.1%0.0%0.1%$358.75$0.00$358.7530.00$13.20
Subtotal--20$7,175$0$7,1750.0%0.1%0.0%0.1%$358.75$0.00$358.7530.00$13.20
Subtotal --20$7,175$0$7,1750.0%0.1%0.0%0.1%$358.75$0.00$358.7530.00$13.20
00006008131Brand DrugTier 3RetailJANUMET XRDIABETIC THERAPY639$14,675$0$14,6750.1%0.2%0.0%0.2%$376.28$0.00$376.2830.00$13.16
Subtotal--39$14,675$0$14,6750.1%0.2%0.0%0.2%$376.28$0.00$376.2830.00$13.16
Subtotal --39$14,675$0$14,6750.1%0.2%0.0%0.2%$376.28$0.00$376.2830.00$13.16
00006008154Brand DrugTier 3RetailJANUMET XRDIABETIC THERAPY110$4,026$0$4,0260.0%0.1%0.0%0.1%$402.56$0.00$402.5630.00$13.39
Subtotal--10$4,026$0$4,0260.0%0.1%0.0%0.1%$402.56$0.00$402.5630.00$13.39
Subtotal --10$4,026$0$4,0260.0%0.1%0.0%0.1%$402.56$0.00$402.5630.00$13.39
00006011231Brand DrugTier 3RetailJANUVIADIABETIC THERAPY323$9,223$0$9,2230.0%0.1%0.0%0.1%$400.99$0.00$400.9930.00$13.33
Subtotal--23$9,223$0$9,2230.0%0.1%0.0%0.1%$400.99$0.00$400.9930.00$13.33
Subtotal --23$9,223$0$9,2230.0%0.1%0.0%0.1%$400.99$0.00$400.9930.00$13.33
00006011254Brand DrugTier 3RetailJANUVIADIABETIC THERAPY320$7,984$0$7,9840.0%0.1%0.0%0.1%$399.21$0.00$399.2130.00$13.27
Subtotal--20$7,984$0$7,9840.0%0.1%0.0%0.1%$399.21$0.00$399.2130.00$13.27
Subtotal --20$7,984$0$7,9840.0%0.1%0.0%0.1%$399.21$0.00$399.2130.00$13.27
Home DeliveryJANUVIADIABETIC THERAPY27$7,796$0$7,7960.0%0.1%0.0%0.1%$1,113.68$0.00$1,113.6890.00$12.37
Subtotal--7$7,796$0$7,7960.0%0.1%0.0%0.1%$1,113.68$0.00$1,113.6890.00$12.37
Subtotal --7$7,796$0$7,7960.0%0.1%0.0%0.1%$1,113.68$0.00$1,113.6890.00$12.37
00006022131Brand DrugTier 3RetailJANUVIADIABETIC THERAPY10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00006022761Brand DrugTier 2RetailISENTRESSANTIVIRALS10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00006027731Brand DrugTier 3RetailJANUVIADIABETIC THERAPY20137$53,612$0$53,6120.2%0.8%0.0%0.8%$391.33$0.00$391.3330.00$13.21
Subtotal--137$53,612$0$53,6120.2%0.8%0.0%0.8%$391.33$0.00$391.3330.00$13.21
Subtotal --137$53,612$0$53,6120.2%0.8%0.0%0.8%$391.33$0.00$391.3330.00$13.21
00006027754Brand DrugTier 3RetailJANUVIADIABETIC THERAPY215$5,746$0$5,7460.0%0.1%0.0%0.1%$383.08$0.00$383.0828.67$13.33
Subtotal--15$5,746$0$5,7460.0%0.1%0.0%0.1%$383.08$0.00$383.0828.67$13.33
Subtotal --15$5,746$0$5,7460.0%0.1%0.0%0.1%$383.08$0.00$383.0828.67$13.33
Home DeliveryJANUVIADIABETIC THERAPY22$2,173$0$2,1730.0%0.0%0.0%0.0%$1,086.31$0.00$1,086.3190.00$12.07
Subtotal--2$2,173$0$2,1730.0%0.0%0.0%0.0%$1,086.31$0.00$1,086.3190.00$12.07
Subtotal --2$2,173$0$2,1730.0%0.0%0.0%0.0%$1,086.31$0.00$1,086.3190.00$12.07
00006027782Brand DrugTier 3RetailJANUVIADIABETIC THERAPY11$407$0$4070.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
Subtotal--1$407$0$4070.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
Subtotal --1$407$0$4070.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
00006033530Brand DrugTier 3RetailBELSOMRASEDATIVE NON-BARBITURATE14$1,361$0$1,3610.0%0.0%0.0%0.0%$340.34$0.00$340.3445.00$9.99
Subtotal--4$1,361$0$1,3610.0%0.0%0.0%0.0%$340.34$0.00$340.3445.00$9.99
Subtotal --4$1,361$0$1,3610.0%0.0%0.0%0.0%$340.34$0.00$340.3445.00$9.99
00006057561Brand DrugTier 3RetailJANUMETDIABETIC THERAPY426$10,397$0$10,3970.0%0.2%0.0%0.2%$399.90$0.00$399.9030.00$13.29
Subtotal--26$10,397$0$10,3970.0%0.2%0.0%0.2%$399.90$0.00$399.9030.00$13.29
Subtotal --26$10,397$0$10,3970.0%0.2%0.0%0.2%$399.90$0.00$399.9030.00$13.29
Home DeliveryJANUMETDIABETIC THERAPY13$3,355$0$3,3550.0%0.0%0.0%0.0%$1,118.24$0.00$1,118.2490.00$12.42
Subtotal--3$3,355$0$3,3550.0%0.0%0.0%0.0%$1,118.24$0.00$1,118.2490.00$12.42
Subtotal --3$3,355$0$3,3550.0%0.0%0.0%0.0%$1,118.24$0.00$1,118.2490.00$12.42
00006057761Brand DrugTier 3RetailJANUMETDIABETIC THERAPY952$18,186$0$18,1860.1%0.3%0.0%0.3%$349.73$0.00$349.7329.69$12.23
Subtotal--52$18,186$0$18,1860.1%0.3%0.0%0.3%$349.73$0.00$349.7329.69$12.23
Subtotal --52$18,186$0$18,1860.1%0.3%0.0%0.3%$349.73$0.00$349.7329.69$12.23
00006057762Brand DrugTier 3RetailJANUMETDIABETIC THERAPY14$1,630$0$1,6300.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
Subtotal--4$1,630$0$1,6300.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
Subtotal --4$1,630$0$1,6300.0%0.0%0.0%0.0%$407.48$0.00$407.4830.00$13.54
00006391968Brand DrugTier 3RetailSINEMET CRANTIPARKINSON12$84$0$840.0%0.0%0.0%0.0%$42.12$0.00$42.1230.00$1.70
Subtotal--2$84$0$840.0%0.0%0.0%0.0%$42.12$0.00$42.1230.00$1.70
Subtotal --2$84$0$840.0%0.0%0.0%0.0%$42.12$0.00$42.1230.00$1.70
00006496300Brand DrugTier 3RetailZOSTAVAXBIOLOGICALS11$229$0$2290.0%0.0%0.0%0.0%$229.11$0.00$229.111.00$228.11
Subtotal--1$229$0$2290.0%0.0%0.0%0.0%$229.11$0.00$229.111.00$228.11
Subtotal --1$229$0$2290.0%0.0%0.0%0.0%$229.11$0.00$229.111.00$228.11
00006496341Brand DrugTier 3RetailZOSTAVAXBIOLOGICALS1414$2,610$0$2,6100.0%0.0%0.0%0.0%$186.44$0.00$186.441.00$215.99
Subtotal--14$2,610$0$2,6100.0%0.0%0.0%0.0%$186.44$0.00$186.441.00$215.99
Subtotal --14$2,610$0$2,6100.0%0.0%0.0%0.0%$186.44$0.00$186.441.00$215.99
00008112312Brand DrugTier 3RetailDUAVEEESTROGENS210$84$0$840.0%0.0%0.0%0.0%$8.43$0.00$8.4330.00$5.43
Subtotal--10$84$0$840.0%0.0%0.0%0.0%$8.43$0.00$8.4330.00$5.43
Subtotal --10$84$0$840.0%0.0%0.0%0.0%$8.43$0.00$8.4330.00$5.43
00008121130Brand DrugTier 3RetailPRISTIQ ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS35$1,070$0$1,0700.0%0.0%0.0%0.0%$213.93$0.00$213.9330.00$10.98
Subtotal--5$1,070$0$1,0700.0%0.0%0.0%0.0%$213.93$0.00$213.9330.00$10.98
Subtotal --5$1,070$0$1,0700.0%0.0%0.0%0.0%$213.93$0.00$213.9330.00$10.98
00008122230Brand DrugTier 3Home DeliveryPRISTIQ ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS11$759$0$7590.0%0.0%0.0%0.0%$758.68$0.00$758.6890.00$10.10
Subtotal--1$759$0$7590.0%0.0%0.0%0.0%$758.68$0.00$758.6890.00$10.10
Subtotal --1$759$0$7590.0%0.0%0.0%0.0%$758.68$0.00$758.6890.00$10.10
RetailPRISTIQ ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS25$533$0$5330.0%0.0%0.0%0.0%$106.68$0.00$106.6830.00$10.73
Subtotal--5$533$0$5330.0%0.0%0.0%0.0%$106.68$0.00$106.6830.00$10.73
Subtotal --5$533$0$5330.0%0.0%0.0%0.0%$106.68$0.00$106.6830.00$10.73
00009034702Brand DrugTier 3RetailDEPO-TESTOSTERONEANDROGENS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$2.42
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$2.42
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$2.42
00009041701Brand DrugTier 3RetailDEPO-TESTOSTERONEANDROGENS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.19
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.19
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.19
00009518201Brand DrugTier 3RetailCAVERJECTMISCELLANEOUS11$477$0$4770.0%0.0%0.0%0.0%$477.36$0.00$477.3630.00$18.55
Subtotal--1$477$0$4770.0%0.0%0.0%0.0%$477.36$0.00$477.3630.00$18.55
Subtotal --1$477$0$4770.0%0.0%0.0%0.0%$477.36$0.00$477.3630.00$18.55
00009519101Brand DrugTier 3RetailDETROL LAANTISPASMODIC AND ANTICHOLINERGIC AGENTS112$3,367$0$3,3670.0%0.0%0.0%0.0%$280.59$0.00$280.5930.00$11.98
Subtotal--12$3,367$0$3,3670.0%0.0%0.0%0.0%$280.59$0.00$280.5930.00$11.98
Subtotal --12$3,367$0$3,3670.0%0.0%0.0%0.0%$280.59$0.00$280.5930.00$11.98
00009540001Brand DrugTier 3RetailNICOTROLCNS STIMULANTS38$2,996$0$2,9960.0%0.0%0.0%0.0%$374.54$0.00$374.5430.00$12.45
Subtotal--8$2,996$0$2,9960.0%0.0%0.0%0.0%$374.54$0.00$374.5430.00$12.45
Subtotal --8$2,996$0$2,9960.0%0.0%0.0%0.0%$374.54$0.00$374.5430.00$12.45
00009766701Brand DrugTier 2RetailCLEOCINOTHER ANTIBIOTICS45$485$0$4850.0%0.0%0.0%0.0%$97.02$0.00$97.023.00$52.48
Subtotal--5$485$0$4850.0%0.0%0.0%0.0%$97.02$0.00$97.023.00$52.48
Subtotal --5$485$0$4850.0%0.0%0.0%0.0%$97.02$0.00$97.023.00$52.48
00013215036Brand DrugTier 2RetailESTRINGESTROGENS14$1,030$0$1,0300.0%0.0%0.0%0.0%$257.44$0.00$257.4490.00$4.19
Subtotal--4$1,030$0$1,0300.0%0.0%0.0%0.0%$257.44$0.00$257.4490.00$4.19
Subtotal --4$1,030$0$1,0300.0%0.0%0.0%0.0%$257.44$0.00$257.4490.00$4.19
00023031604Brand DrugTier 2RetailFML S.O.P.OPHTHALMIC PREPARATIONS10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00023320503Brand DrugTier 2RetailLUMIGANOPHTHALMIC PREPARATIONS519$2,954$0$2,9540.0%0.0%0.0%0.0%$155.45$0.00$155.4524.74$7.85
Subtotal--19$2,954$0$2,9540.0%0.0%0.0%0.0%$155.45$0.00$155.4524.74$7.85
Subtotal --19$2,954$0$2,9540.0%0.0%0.0%0.0%$155.45$0.00$155.4524.74$7.85
Home DeliveryLUMIGANOPHTHALMIC PREPARATIONS22$594$0$5940.0%0.0%0.0%0.0%$296.78$0.00$296.7860.00$6.60
Subtotal--2$594$0$5940.0%0.0%0.0%0.0%$296.78$0.00$296.7860.00$6.60
Subtotal --2$594$0$5940.0%0.0%0.0%0.0%$296.78$0.00$296.7860.00$6.60
00023320505Brand DrugTier 2RetailLUMIGANOPHTHALMIC PREPARATIONS25$1,170$0$1,1700.0%0.0%0.0%0.0%$233.96$0.00$233.9618.00$18.40
Subtotal--5$1,170$0$1,1700.0%0.0%0.0%0.0%$233.96$0.00$233.9618.00$18.40
Subtotal --5$1,170$0$1,1700.0%0.0%0.0%0.0%$233.96$0.00$233.9618.00$18.40
00023320508Brand DrugTier 2RetailLUMIGANOPHTHALMIC PREPARATIONS11$464$0$4640.0%0.0%0.0%0.0%$464.29$0.00$464.2930.00$16.77
Subtotal--1$464$0$4640.0%0.0%0.0%0.0%$464.29$0.00$464.2930.00$16.77
Subtotal --1$464$0$4640.0%0.0%0.0%0.0%$464.29$0.00$464.2930.00$16.77
00023520660Brand DrugTier 3RetailACZONEALL OTHER DERMATOLOGICALS59$3,686$0$3,6860.0%0.1%0.0%0.1%$409.56$0.00$409.5630.00$18.31
Subtotal--9$3,686$0$3,6860.0%0.1%0.0%0.1%$409.56$0.00$409.5630.00$18.31
Subtotal --9$3,686$0$3,6860.0%0.1%0.0%0.1%$409.56$0.00$409.5630.00$18.31
00023530105Brand DrugTier 3RetailRESTASIS MULTIDOSEOPHTHALMIC PREPARATIONS13$774$0$7740.0%0.0%0.0%0.0%$257.88$0.00$257.8830.00$15.54
Subtotal--3$774$0$7740.0%0.0%0.0%0.0%$257.88$0.00$257.8830.00$15.54
Subtotal --3$774$0$7740.0%0.0%0.0%0.0%$257.88$0.00$257.8830.00$15.54
00023587080Brand DrugTier 3RetailCORDRANGLUCOCORTICOIDS10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00023915530Brand DrugTier 3RetailTAZORACALL OTHER DERMATOLOGICALS34$1,057$0$1,0570.0%0.0%0.0%0.0%$264.16$0.00$264.1630.00$11.44
Subtotal--4$1,057$0$1,0570.0%0.0%0.0%0.0%$264.16$0.00$264.1630.00$11.44
Subtotal --4$1,057$0$1,0570.0%0.0%0.0%0.0%$264.16$0.00$264.1630.00$11.44
00023915630Brand DrugTier 1RetailTAZORACALL OTHER DERMATOLOGICALS12$651$0$6510.0%0.0%0.0%0.0%$325.27$0.00$325.2715.00$24.60
Subtotal--2$651$0$6510.0%0.0%0.0%0.0%$325.27$0.00$325.2715.00$24.60
Subtotal --2$651$0$6510.0%0.0%0.0%0.0%$325.27$0.00$325.2715.00$24.60
Tier 3RetailTAZORACALL OTHER DERMATOLOGICALS11$290$0$2900.0%0.0%0.0%0.0%$290.27$0.00$290.2730.00$12.30
Subtotal--1$290$0$2900.0%0.0%0.0%0.0%$290.27$0.00$290.2730.00$12.30
Subtotal --1$290$0$2900.0%0.0%0.0%0.0%$290.27$0.00$290.2730.00$12.30
00023916330Brand DrugTier 3RetailRESTASISOPHTHALMIC PREPARATIONS414$3,805$0$3,8050.0%0.1%0.0%0.1%$271.79$0.00$271.7927.86$15.60
Subtotal--14$3,805$0$3,8050.0%0.1%0.0%0.1%$271.79$0.00$271.7927.86$15.60
Subtotal --14$3,805$0$3,8050.0%0.1%0.0%0.1%$271.79$0.00$271.7927.86$15.60
Home DeliveryRESTASISOPHTHALMIC PREPARATIONS13$3,379$0$3,3790.0%0.0%0.0%0.0%$1,126.19$0.00$1,126.1990.00$14.74
Subtotal--3$3,379$0$3,3790.0%0.0%0.0%0.0%$1,126.19$0.00$1,126.1990.00$14.74
Subtotal --3$3,379$0$3,3790.0%0.0%0.0%0.0%$1,126.19$0.00$1,126.1990.00$14.74
00023916360Brand DrugTier 3RetailRESTASISOPHTHALMIC PREPARATIONS36$1,972$0$1,9720.0%0.0%0.0%0.0%$328.64$0.00$328.6430.00$15.73
Subtotal--6$1,972$0$1,9720.0%0.0%0.0%0.0%$328.64$0.00$328.6430.00$15.73
Subtotal --6$1,972$0$1,9720.0%0.0%0.0%0.0%$328.64$0.00$328.6430.00$15.73
00023921105Brand DrugTier 2RetailCOMBIGANOPHTHALMIC PREPARATIONS523$2,424$0$2,4240.0%0.0%0.0%0.0%$105.38$0.00$105.3825.39$5.87
Subtotal--23$2,424$0$2,4240.0%0.0%0.0%0.0%$105.38$0.00$105.3825.39$5.87
Subtotal --23$2,424$0$2,4240.0%0.0%0.0%0.0%$105.38$0.00$105.3825.39$5.87
Home DeliveryCOMBIGANOPHTHALMIC PREPARATIONS11$319$0$3190.0%0.0%0.0%0.0%$319.29$0.00$319.2990.00$4.66
Subtotal--1$319$0$3190.0%0.0%0.0%0.0%$319.29$0.00$319.2990.00$4.66
Subtotal --1$319$0$3190.0%0.0%0.0%0.0%$319.29$0.00$319.2990.00$4.66
00023932105Brand DrugTier 2RetailALPHAGAN POPHTHALMIC PREPARATIONS14$405$0$4050.0%0.0%0.0%0.0%$101.31$0.00$101.3121.50$6.10
Subtotal--4$405$0$4050.0%0.0%0.0%0.0%$101.31$0.00$101.3121.50$6.10
Subtotal --4$405$0$4050.0%0.0%0.0%0.0%$101.31$0.00$101.3121.50$6.10
00024414260Brand DrugTier 3RetailMULTAQOTHER CARDIOVASCULAR PREPS315$7,515$0$7,5150.0%0.1%0.0%0.1%$501.01$0.00$501.0130.00$19.71
Subtotal--15$7,515$0$7,5150.0%0.1%0.0%0.1%$501.01$0.00$501.0130.00$19.71
Subtotal --15$7,515$0$7,5150.0%0.1%0.0%0.1%$501.01$0.00$501.0130.00$19.71
00024576105Brand DrugTier 2RetailSOLIQUA 100-33DIABETIC THERAPY24$2,600$0$2,6000.0%0.0%0.0%0.0%$649.97$0.00$649.9730.25$21.45
Subtotal--4$2,600$0$2,6000.0%0.0%0.0%0.0%$649.97$0.00$649.9730.25$21.45
Subtotal --4$2,600$0$2,6000.0%0.0%0.0%0.0%$649.97$0.00$649.9730.25$21.45
00024590102Brand DrugTier 2RetailPRALUENT PENLIPOTROPICS19$9,801$0$9,8010.0%0.1%0.0%0.1%$1,088.96$0.00$1,088.9628.00$40.32
Subtotal--9$9,801$0$9,8010.0%0.1%0.0%0.1%$1,088.96$0.00$1,088.9628.00$40.32
Subtotal --9$9,801$0$9,8010.0%0.1%0.0%0.1%$1,088.96$0.00$1,088.9628.00$40.32
00024590202Brand DrugTier 2RetailPRALUENT PENLIPOTROPICS15$5,477$0$5,4770.0%0.1%0.0%0.1%$1,095.37$0.00$1,095.3728.00$40.53
Subtotal--5$5,477$0$5,4770.0%0.1%0.0%0.1%$1,095.37$0.00$1,095.3728.00$40.53
Subtotal --5$5,477$0$5,4770.0%0.1%0.0%0.1%$1,095.37$0.00$1,095.3728.00$40.53
00032122401Brand DrugTier 2RetailCREONENZYMES13$3,219$0$3,2190.0%0.0%0.0%0.0%$1,072.95$0.00$1,072.9530.00$37.07
Subtotal--3$3,219$0$3,2190.0%0.0%0.0%0.0%$1,072.95$0.00$1,072.9530.00$37.07
Subtotal --3$3,219$0$3,2190.0%0.0%0.0%0.0%$1,072.95$0.00$1,072.9530.00$37.07
00032301613Brand DrugTier 2RetailCREONENZYMES22$1,262$0$1,2620.0%0.0%0.0%0.0%$631.04$0.00$631.0430.00$37.43
Subtotal--2$1,262$0$1,2620.0%0.0%0.0%0.0%$631.04$0.00$631.0430.00$37.43
Subtotal --2$1,262$0$1,2620.0%0.0%0.0%0.0%$631.04$0.00$631.0430.00$37.43
00037480235Brand DrugTier 3RetailELESTRINESTROGENS13$230$0$2300.0%0.0%0.0%0.0%$76.53$0.00$76.5330.00$6.46
Subtotal--3$230$0$2300.0%0.0%0.0%0.0%$76.53$0.00$76.5330.00$6.46
Subtotal --3$230$0$2300.0%0.0%0.0%0.0%$76.53$0.00$76.5330.00$6.46
00037682210Brand DrugTier 2RetailPROCTOFOAM-HCHEMORRHOIDAL PREPARATIONS44$277$0$2770.0%0.0%0.0%0.0%$69.33$0.00$69.336.00$21.64
Subtotal--4$277$0$2770.0%0.0%0.0%0.0%$69.33$0.00$69.336.00$21.64
Subtotal --4$277$0$2770.0%0.0%0.0%0.0%$69.33$0.00$69.336.00$21.64
00046087221Brand DrugTier 3RetailPREMARINESTROGENS815$3,875$0$3,8750.0%0.1%0.0%0.1%$258.35$0.00$258.3529.07$11.95
Subtotal--15$3,875$0$3,8750.0%0.1%0.0%0.1%$258.35$0.00$258.3529.07$11.95
Subtotal --15$3,875$0$3,8750.0%0.1%0.0%0.1%$258.35$0.00$258.3529.07$11.95
Home DeliveryPREMARINESTROGENS14$257$0$2570.0%0.0%0.0%0.0%$64.14$0.00$64.1490.00$3.65
Subtotal--4$257$0$2570.0%0.0%0.0%0.0%$64.14$0.00$64.1490.00$3.65
Subtotal --4$257$0$2570.0%0.0%0.0%0.0%$64.14$0.00$64.1490.00$3.65
00046110081Brand DrugTier 3RetailPREMARINESTROGENS14$319$0$3190.0%0.0%0.0%0.0%$79.85$0.00$79.8530.00$5.30
Subtotal--4$319$0$3190.0%0.0%0.0%0.0%$79.85$0.00$79.8530.00$5.30
Subtotal --4$319$0$3190.0%0.0%0.0%0.0%$79.85$0.00$79.8530.00$5.30
00046110091Brand DrugTier 3Home DeliveryPREMARINESTROGENS13$734$0$7340.0%0.0%0.0%0.0%$244.70$0.00$244.7090.00$4.94
Subtotal--3$734$0$7340.0%0.0%0.0%0.0%$244.70$0.00$244.7090.00$4.94
Subtotal --3$734$0$7340.0%0.0%0.0%0.0%$244.70$0.00$244.7090.00$4.94
00046110281Brand DrugTier 3RetailPREMARINESTROGENS112$962$0$9620.0%0.0%0.0%0.0%$80.15$0.00$80.1530.00$5.30
Subtotal--12$962$0$9620.0%0.0%0.0%0.0%$80.15$0.00$80.1530.00$5.30
Subtotal --12$962$0$9620.0%0.0%0.0%0.0%$80.15$0.00$80.1530.00$5.30
00046110381Brand DrugTier 3RetailPREMARINESTROGENS111$886$0$8860.0%0.0%0.0%0.0%$80.53$0.00$80.5330.00$5.31
Subtotal--11$886$0$8860.0%0.0%0.0%0.0%$80.53$0.00$80.5330.00$5.31
Subtotal --11$886$0$8860.0%0.0%0.0%0.0%$80.53$0.00$80.5330.00$5.31
00046110511Brand DrugTier 3Home DeliveryPREMPROESTROGENS15$1,546$0$1,5460.0%0.0%0.0%0.0%$309.18$0.00$309.1884.00$6.06
Subtotal--5$1,546$0$1,5460.0%0.0%0.0%0.0%$309.18$0.00$309.1884.00$6.06
Subtotal --5$1,546$0$1,5460.0%0.0%0.0%0.0%$309.18$0.00$309.1884.00$6.06
00046110711Brand DrugTier 3RetailPREMPROESTROGENS10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00049234045Brand DrugTier 2RetailRELPAXNON-NARCOTIC ANALGESICS35$170$0$1700.0%0.0%0.0%0.0%$34.01$0.00$34.012.40$87.00
Subtotal--5$170$0$1700.0%0.0%0.0%0.0%$34.01$0.00$34.012.40$87.00
Subtotal --5$170$0$1700.0%0.0%0.0%0.0%$34.01$0.00$34.012.40$87.00
00051846231Brand DrugTier 3RetailANDROGELANDROGENS222$37,379$0$37,3790.0%0.5%0.0%0.5%$1,699.06$0.00$1,699.0630.00$58.79
Subtotal--22$37,379$0$37,3790.0%0.5%0.0%0.5%$1,699.06$0.00$1,699.0630.00$58.79
Subtotal --22$37,379$0$37,3790.0%0.5%0.0%0.5%$1,699.06$0.00$1,699.0630.00$58.79
00051846233Brand DrugTier 3RetailANDROGELANDROGENS645$36,386$0$36,3860.1%0.5%0.0%0.5%$808.58$0.00$808.5829.33$29.84
Subtotal--45$36,386$0$36,3860.1%0.5%0.0%0.5%$808.58$0.00$808.5829.33$29.84
Subtotal --45$36,386$0$36,3860.1%0.5%0.0%0.5%$808.58$0.00$808.5829.33$29.84
00052027301Brand DrugTier 2RetailNUVARINGSYSTEMIC CONTRACEPTIVES49$2,101$0$2,1010.0%0.0%0.0%0.0%$233.43$0.00$233.4346.67$4.98
Subtotal--9$2,101$0$2,1010.0%0.0%0.0%0.0%$233.43$0.00$233.4346.67$4.98
Subtotal --9$2,101$0$2,1010.0%0.0%0.0%0.0%$233.43$0.00$233.4346.67$4.98
00052027303Brand DrugTier 2RetailNUVARINGSYSTEMIC CONTRACEPTIVES1759$14,101$0$14,1010.1%0.2%0.0%0.2%$239.01$0.00$239.0148.97$4.86
Subtotal--59$14,101$0$14,1010.1%0.2%0.0%0.2%$239.01$0.00$239.0148.97$4.86
Subtotal --59$14,101$0$14,1010.1%0.2%0.0%0.2%$239.01$0.00$239.0148.97$4.86
Home DeliveryNUVARINGSYSTEMIC CONTRACEPTIVES13$1,176$0$1,1760.0%0.0%0.0%0.0%$392.01$0.00$392.0184.00$4.67
Subtotal--3$1,176$0$1,1760.0%0.0%0.0%0.0%$392.01$0.00$392.0184.00$4.67
Subtotal --3$1,176$0$1,1760.0%0.0%0.0%0.0%$392.01$0.00$392.0184.00$4.67
00052030151Brand DrugTier 3RetailGANIRELIX ACETATEOTHER HORMONES11$1,229$0$1,2290.0%0.0%0.0%0.0%$1,229.34$0.00$1,229.346.00$218.22
Subtotal--1$1,229$0$1,2290.0%0.0%0.0%0.0%$1,229.34$0.00$1,229.346.00$218.22
Subtotal --1$1,229$0$1,2290.0%0.0%0.0%0.0%$1,229.34$0.00$1,229.346.00$218.22
00052031301Brand DrugTier 3RetailFOLLISTIM AQOTHER HORMONES11$574$0$5740.0%0.0%0.0%0.0%$573.63$0.00$573.633.00$217.88
Subtotal--1$574$0$5740.0%0.0%0.0%0.0%$573.63$0.00$573.633.00$217.88
Subtotal --1$574$0$5740.0%0.0%0.0%0.0%$573.63$0.00$573.633.00$217.88
00052031601Brand DrugTier 3RetailFOLLISTIM AQOTHER HORMONES11$1,227$0$1,2270.0%0.0%0.0%0.0%$1,227.25$0.00$1,227.256.00$217.88
Subtotal--1$1,227$0$1,2270.0%0.0%0.0%0.0%$1,227.25$0.00$1,227.256.00$217.88
Subtotal --1$1,227$0$1,2270.0%0.0%0.0%0.0%$1,227.25$0.00$1,227.256.00$217.88
00053687100Brand DrugTier 3RetailSTIMATEOTHER HORMONES11$626$0$6260.0%0.0%0.0%0.0%$625.88$0.00$625.883.00$234.88
Subtotal--1$626$0$6260.0%0.0%0.0%0.0%$625.88$0.00$625.883.00$234.88
Subtotal --1$626$0$6260.0%0.0%0.0%0.0%$625.88$0.00$625.883.00$234.88
00054000285Generic DrugTier 1RetailFLUCONAZOLEANTIFUNGALS12$29$0$290.0%0.0%0.0%0.0%$14.33$0.00$14.337.00$3.37
Subtotal--2$29$0$290.0%0.0%0.0%0.0%$14.33$0.00$14.337.00$3.37
Subtotal --2$29$0$290.0%0.0%0.0%0.0%$14.33$0.00$14.337.00$3.37
00054000385Generic DrugTier 1RetailFLUCONAZOLEANTIFUNGALS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.00$5.25
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.00$5.25
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.00$5.25
00054001025Generic DrugTier 1RetailFLECAINIDE ACETATEOTHER CARDIOVASCULAR PREPS112$42$0$420.0%0.0%0.0%0.0%$3.51$0.00$3.5130.00$0.37
Subtotal--12$42$0$420.0%0.0%0.0%0.0%$3.51$0.00$3.5130.00$0.37
Subtotal --12$42$0$420.0%0.0%0.0%0.0%$3.51$0.00$3.5130.00$0.37
00054001725Generic DrugTier 1RetailPREDNISONEGLUCOCORTICOIDS76104$25$0$250.1%0.0%0.0%0.0%$0.24$0.00$0.2413.95$0.36
Subtotal--104$25$0$250.1%0.0%0.0%0.0%$0.24$0.00$0.2413.95$0.36
Subtotal --104$25$0$250.1%0.0%0.0%0.0%$0.24$0.00$0.2413.95$0.36
00054001729Generic DrugTier 1RetailPREDNISONEGLUCOCORTICOIDS67$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.29$0.41
Subtotal--7$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.29$0.41
Subtotal --7$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0010.29$0.41
00054001825Generic DrugTier 1RetailPREDNISONEGLUCOCORTICOIDS95112$16$0$160.1%0.0%0.0%0.0%$0.14$0.00$0.147.90$0.37
Subtotal--112$16$0$160.1%0.0%0.0%0.0%$0.14$0.00$0.147.90$0.37
Subtotal --112$16$0$160.1%0.0%0.0%0.0%$0.14$0.00$0.147.90$0.37
00054001829Generic DrugTier 1RetailPREDNISONEGLUCOCORTICOIDS78$12$0$120.0%0.0%0.0%0.0%$1.47$0.00$1.478.13$0.59
Subtotal--8$12$0$120.0%0.0%0.0%0.0%$1.47$0.00$1.478.13$0.59
Subtotal --8$12$0$120.0%0.0%0.0%0.0%$1.47$0.00$1.478.13$0.59
00054001925Generic DrugTier 1RetailPREDNISONEGLUCOCORTICOIDS6469$0$0$00.1%0.0%0.0%0.0%$0.00$0.00$0.005.03$0.30
Subtotal--69$0$0$00.1%0.0%0.0%0.0%$0.00$0.00$0.005.03$0.30
Subtotal --69$0$0$00.1%0.0%0.0%0.0%$0.00$0.00$0.005.03$0.30
00054002025Generic DrugTier 1RetailLITHIUM CARBONATE ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS28$148$0$1480.0%0.0%0.0%0.0%$18.51$0.00$18.5130.00$0.92
Subtotal--8$148$0$1480.0%0.0%0.0%0.0%$18.51$0.00$18.5130.00$0.92
Subtotal --8$148$0$1480.0%0.0%0.0%0.0%$18.51$0.00$18.5130.00$0.92
00054002125Generic DrugTier 1RetailLITHIUM CARBONATE ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS112$123$0$1230.0%0.0%0.0%0.0%$10.29$0.00$10.2930.00$0.64
Subtotal--12$123$0$1230.0%0.0%0.0%0.0%$10.29$0.00$10.2930.00$0.64
Subtotal --12$123$0$1230.0%0.0%0.0%0.0%$10.29$0.00$10.2930.00$0.64
00054002821Generic DrugTier 1RetailCILOSTAZOLANTICOAGULANTS12$4$0$40.0%0.0%0.0%0.0%$2.10$0.00$2.1030.00$0.37
Subtotal--2$4$0$40.0%0.0%0.0%0.0%$2.10$0.00$2.1030.00$0.37
Subtotal --2$4$0$40.0%0.0%0.0%0.0%$2.10$0.00$2.1030.00$0.37
00054004544Generic DrugTier 1RetailIPRATROPIUM BROMIDETOPICAL NASAL AND OTIC PREPARATIONS11$22$0$220.0%0.0%0.0%0.0%$22.28$0.00$22.2830.00$1.04
Subtotal--1$22$0$220.0%0.0%0.0%0.0%$22.28$0.00$22.2830.00$1.04
Subtotal --1$22$0$220.0%0.0%0.0%0.0%$22.28$0.00$22.2830.00$1.04
00054004641Generic DrugTier 1Home DeliveryIPRATROPIUM BROMIDETOPICAL NASAL AND OTIC PREPARATIONS13$286$0$2860.0%0.0%0.0%0.0%$95.21$0.00$95.2174.00$1.62
Subtotal--3$286$0$2860.0%0.0%0.0%0.0%$95.21$0.00$95.2174.00$1.62
Subtotal --3$286$0$2860.0%0.0%0.0%0.0%$95.21$0.00$95.2174.00$1.62
RetailIPRATROPIUM BROMIDETOPICAL NASAL AND OTIC PREPARATIONS410$108$0$1080.0%0.0%0.0%0.0%$10.79$0.00$10.7926.60$0.74
Subtotal--10$108$0$1080.0%0.0%0.0%0.0%$10.79$0.00$10.7926.60$0.74
Subtotal --10$108$0$1080.0%0.0%0.0%0.0%$10.79$0.00$10.7926.60$0.74
00054006447Generic DrugTier 1RetailONDANSETRON HCLANTINAUSEANTS22$771$0$7710.0%0.0%0.0%0.0%$385.68$0.00$385.6816.00$24.22
Subtotal--2$771$0$7710.0%0.0%0.0%0.0%$385.68$0.00$385.6816.00$24.22
Subtotal --2$771$0$7710.0%0.0%0.0%0.0%$385.68$0.00$385.6816.00$24.22
00054008525Generic DrugTier 1RetailZALEPLONSEDATIVE NON-BARBITURATE48$9$0$90.0%0.0%0.0%0.0%$1.08$0.00$1.0830.00$0.25
Subtotal--8$9$0$90.0%0.0%0.0%0.0%$1.08$0.00$1.0830.00$0.25
Subtotal --8$9$0$90.0%0.0%0.0%0.0%$1.08$0.00$1.0830.00$0.25
00054010122Generic DrugTier 1RetailAMLODIPINE BESYLATEOTHER CARDIOVASCULAR PREPS37$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.11
Subtotal--7$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.11
Subtotal --7$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.11
00054010231Generic DrugTier 1RetailAMLODIPINE BESYLATEOTHER CARDIOVASCULAR PREPS16$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$0.11
Subtotal--6$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$0.11
Subtotal --6$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0031.00$0.11
00054010925Generic DrugTier 1Home DeliveryRAMIPRILOTHER ANTIHYPERTENSIVES11$107$0$1070.0%0.0%0.0%0.0%$106.70$0.00$106.7090.00$1.46
Subtotal--1$107$0$1070.0%0.0%0.0%0.0%$106.70$0.00$106.7090.00$1.46
Subtotal --1$107$0$1070.0%0.0%0.0%0.0%$106.70$0.00$106.7090.00$1.46
00054016625Generic DrugTier 1RetailMYCOPHENOLATE MOFETILMISCELLANEOUS11$22$0$220.0%0.0%0.0%0.0%$21.58$0.00$21.5830.00$1.02
Subtotal--1$22$0$220.0%0.0%0.0%0.0%$21.58$0.00$21.5830.00$1.02
Subtotal --1$22$0$220.0%0.0%0.0%0.0%$21.58$0.00$21.5830.00$1.02
00054016629Generic DrugTier 1RetailMYCOPHENOLATE MOFETILMISCELLANEOUS11$14$0$140.0%0.0%0.0%0.0%$14.35$0.00$14.3530.00$0.81
Subtotal--1$14$0$140.0%0.0%0.0%0.0%$14.35$0.00$14.3530.00$0.81
Subtotal --1$14$0$140.0%0.0%0.0%0.0%$14.35$0.00$14.3530.00$0.81
00054022025Generic DrugTier 1RetailQUETIAPINE FUMARATEATARACTICS-TRANQUILIZERS11$4$0$40.0%0.0%0.0%0.0%$3.64$0.00$3.6430.00$0.42
Subtotal--1$4$0$40.0%0.0%0.0%0.0%$3.64$0.00$3.6430.00$0.42
Subtotal --1$4$0$40.0%0.0%0.0%0.0%$3.64$0.00$3.6430.00$0.42
00054022925Generic DrugTier 1RetailQUETIAPINE FUMARATEATARACTICS-TRANQUILIZERS13$25$0$250.0%0.0%0.0%0.0%$8.19$0.00$8.1930.00$0.57
Subtotal--3$25$0$250.0%0.0%0.0%0.0%$8.19$0.00$8.1930.00$0.57
Subtotal --3$25$0$250.0%0.0%0.0%0.0%$8.19$0.00$8.1930.00$0.57
00054023025Generic DrugTier 1RetailQUETIAPINE FUMARATEATARACTICS-TRANQUILIZERS16$49$0$490.0%0.0%0.0%0.0%$8.21$0.00$8.2130.00$0.57
Subtotal--6$49$0$490.0%0.0%0.0%0.0%$8.21$0.00$8.2130.00$0.57
Subtotal --6$49$0$490.0%0.0%0.0%0.0%$8.21$0.00$8.2130.00$0.57
00054023525Generic DrugTier 1RetailMORPHINE SULFATENARCOTIC ANALGESICS11$8$0$80.0%0.0%0.0%0.0%$8.20$0.00$8.2030.00$0.57
Subtotal--1$8$0$80.0%0.0%0.0%0.0%$8.20$0.00$8.2030.00$0.57
Subtotal --1$8$0$80.0%0.0%0.0%0.0%$8.20$0.00$8.2030.00$0.57
00054023763Generic DrugTier 1RetailMORPHINE SULFATENARCOTIC ANALGESICS14$19$0$190.0%0.0%0.0%0.0%$4.63$0.00$4.637.00$0.59
Subtotal--4$19$0$190.0%0.0%0.0%0.0%$4.63$0.00$4.637.00$0.59
Subtotal --4$19$0$190.0%0.0%0.0%0.0%$4.63$0.00$4.637.00$0.59
00054025922Generic DrugTier 1Home DeliveryMONTELUKAST SODIUMBRONCHIAL DILATORS1112$1,428$0$1,4280.0%0.0%0.0%0.0%$118.97$0.00$118.9787.50$1.70
Subtotal--12$1,428$0$1,4280.0%0.0%0.0%0.0%$118.97$0.00$118.9787.50$1.70
Subtotal --12$1,428$0$1,4280.0%0.0%0.0%0.0%$118.97$0.00$118.9787.50$1.70
RetailMONTELUKAST SODIUMBRONCHIAL DILATORS2024$212$0$2120.0%0.0%0.0%0.0%$8.85$0.00$8.8532.50$0.48
Subtotal--24$212$0$2120.0%0.0%0.0%0.0%$8.85$0.00$8.8532.50$0.48
Subtotal --24$212$0$2120.0%0.0%0.0%0.0%$8.85$0.00$8.8532.50$0.48
00054026425Generic DrugTier 1RetailHYDROMORPHONE HCLNARCOTIC ANALGESICS15$157$0$1570.0%0.0%0.0%0.0%$31.48$0.00$31.4818.60$1.64
Subtotal--5$157$0$1570.0%0.0%0.0%0.0%$31.48$0.00$31.4818.60$1.64
Subtotal --5$157$0$1570.0%0.0%0.0%0.0%$31.48$0.00$31.4818.60$1.64
00054029225Generic DrugTier 1RetailESZOPICLONESEDATIVE NON-BARBITURATE33$43$0$430.0%0.0%0.0%0.0%$14.45$0.00$14.4530.00$0.78
Subtotal--3$43$0$430.0%0.0%0.0%0.0%$14.45$0.00$14.4530.00$0.78
Subtotal --3$43$0$430.0%0.0%0.0%0.0%$14.45$0.00$14.4530.00$0.78
00054029613Generic DrugTier 1RetailALOSETRON HCLMISCELLANEOUS13$6,280$0$6,2800.0%0.1%0.0%0.1%$2,093.49$0.00$2,093.4930.00$70.08
Subtotal--3$6,280$0$6,2800.0%0.1%0.0%0.1%$2,093.49$0.00$2,093.4930.00$70.08
Subtotal --3$6,280$0$6,2800.0%0.1%0.0%0.1%$2,093.49$0.00$2,093.4930.00$70.08
00054034807Generic DrugTier 1RetailTINIDAZOLEANTIPARASITICS56$145$0$1450.0%0.0%0.0%0.0%$24.19$0.00$24.191.83$19.54
Subtotal--6$145$0$1450.0%0.0%0.0%0.0%$24.19$0.00$24.191.83$19.54
Subtotal --6$145$0$1450.0%0.0%0.0%0.0%$24.19$0.00$24.191.83$19.54
00054039063Generic DrugTier 1RetailOXYCODONE HCLNARCOTIC ANALGESICS66$8$0$80.0%0.0%0.0%0.0%$1.27$0.00$1.274.67$4.66
Subtotal--6$8$0$80.0%0.0%0.0%0.0%$1.27$0.00$1.274.67$4.66
Subtotal --6$8$0$80.0%0.0%0.0%0.0%$1.27$0.00$1.274.67$4.66
00054040013Generic DrugTier 1RetailDESVENLAFAXINE SUCCINATE ERPSYCHOSTIMULANTS-ANTIDEPRESSANTS14$267$0$2670.0%0.0%0.0%0.0%$66.83$0.00$66.8330.00$2.20
Subtotal--4$267$0$2670.0%0.0%0.0%0.0%$66.83$0.00$66.8330.00$2.20
Subtotal --4$267$0$2670.0%0.0%0.0%0.0%$66.83$0.00$66.8330.00$2.20
00054051744Generic DrugTier 1RetailMORPHINE SULFATENARCOTIC ANALGESICS10$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal--0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
Subtotal --0$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.000.00$0.00
00054054618Generic DrugTier 1RetailTELMISARTAN-HYDROCHLOROTHIAZIDOTHER ANTIHYPERTENSIVES544$4,727$0$4,7270.1%0.1%0.0%0.1%$107.42$0.00$107.4230.00$3.92
Subtotal--44$4,727$0$4,7270.1%0.1%0.0%0.1%$107.42$0.00$107.4230.00$3.92
Subtotal --44$4,727$0$4,7270.1%0.1%0.0%0.1%$107.42$0.00$107.4230.00$3.92
00054252725Generic DrugTier 1RetailLITHIUM CARBONATEPSYCHOSTIMULANTS-ANTIDEPRESSANTS39$3$0$30.0%0.0%0.0%0.0%$0.32$0.00$0.3230.00$0.20
Subtotal--9$3$0$30.0%0.0%0.0%0.0%$0.32$0.00$0.3230.00$0.20
Subtotal --9$3$0$30.0%0.0%0.0%0.0%$0.32$0.00$0.3230.00$0.20
00054317644Generic DrugTier 1RetailDEXAMETHASONE INTENSOLGLUCOCORTICOIDS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$0.75
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$0.75
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.005.00$0.75
00054317763Generic DrugTier 1RetailDEXAMETHASONEGLUCOCORTICOIDS11$3$0$30.0%0.0%0.0%0.0%$2.63$0.00$2.6310.00$1.15
Subtotal--1$3$0$30.0%0.0%0.0%0.0%$2.63$0.00$2.6310.00$1.15
Subtotal --1$3$0$30.0%0.0%0.0%0.0%$2.63$0.00$2.6310.00$1.15
00054327099Generic DrugTier 1RetailFLUTICASONE PROPIONATETOPICAL NASAL AND OTIC PREPARATIONS299566$1,854$0$1,8540.7%0.0%0.0%0.0%$3.28$0.00$3.2830.14$0.42
Subtotal--566$1,854$0$1,8540.7%0.0%0.0%0.0%$3.28$0.00$3.2830.14$0.42
Subtotal --566$1,854$0$1,8540.7%0.0%0.0%0.0%$3.28$0.00$3.2830.14$0.42
Home DeliveryFLUTICASONE PROPIONATETOPICAL NASAL AND OTIC PREPARATIONS1220$944$0$9440.0%0.0%0.0%0.0%$47.19$0.00$47.1990.00$0.80
Subtotal--20$944$0$9440.0%0.0%0.0%0.0%$47.19$0.00$47.1990.00$0.80
Subtotal --20$944$0$9440.0%0.0%0.0%0.0%$47.19$0.00$47.1990.00$0.80
00054329450Generic DrugTier 1RetailFUROSEMIDEDIURETICS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.13
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.13
Subtotal --1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.13
00054350049Generic DrugTier 1RetailLIDOCAINE HCL VISCOUSANESTHETIC LOCAL TOPICAL77$9$0$90.0%0.0%0.0%0.0%$1.22$0.00$1.2210.57$0.76
Subtotal--7$9$0$90.0%0.0%0.0%0.0%$1.22$0.00$1.2210.57$0.76
Subtotal --7$9$0$90.0%0.0%0.0%0.0%$1.22$0.00$1.2210.57$0.76
00054354258Generic DrugTier 1RetailMEGESTROL ACETATEMISCELLANEOUS23$290$0$2900.0%0.0%0.0%0.0%$96.65$0.00$96.6528.00$3.65
Subtotal--3$290$0$2900.0%0.0%0.0%0.0%$96.65$0.00$96.6528.00$3.65
Subtotal --3$290$0$2900.0%0.0%0.0%0.0%$96.65$0.00$96.6528.00$3.65
00054414622Generic DrugTier 1RetailCLOTRIMAZOLEANTIFUNGALS11$12$0$120.0%0.0%0.0%0.0%$11.95$0.00$11.957.00$2.99
Subtotal--1$12$0$120.0%0.0%0.0%0.0%$11.95$0.00$11.957.00$2.99
Subtotal --1$12$0$120.0%0.0%0.0%0.0%$11.95$0.00$11.957.00$2.99
00054417925Generic DrugTier 1RetailDEXAMETHASONEGLUCOCORTICOIDS16$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.05
Subtotal--6$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.05
Subtotal --6$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.0030.00$0.05
00054418125Generic DrugTier 1RetailDEXAMETHASONEGLUCOCORTICOIDS22$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.001.00$0.27
Subtotal--2$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.001.00$0.27
Subtotal --2$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.001.00$0.27
00054418225Generic DrugTier 1RetailDEXAMETHASONEGLUCOCORTICOIDS11$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.003.00$0.56
Subtotal--1$0$0$00.0%0.0%0.0%0.0%$0.00$0.00$0.003.00$0.56
 
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All Drugs
NDC NumberGeneric/Brand CategoryPrescription TierSubmission Method CategoryMetricsNumber of ClaimantsNumber of PrescriptionsPlan Net PaidHRA Net PaidTotal Net Paid% of Total Prescriptions% of Plan Net Paid% of HRA Net Paid% of Total Net PaidPlan Net Paid per PrescriptionHRA Net Paid per PrescriptionTotal Net Paid per PrescriptionAverage Days SupplyIngredient Cost Paid per Day Of Therapy
00074433902Brand DrugTier 2Retail1086$389,825$0$389,8250.1%5.7%0.0%5.7%$4,532.85$0.00$4,532.8528.00$167.98
68546032512Brand DrugTier 2Retail534$195,938$0$195,9380.0%2.9%0.0%2.9%$5,762.89$0.00$5,762.8928.00$209.98
00169406013Brand DrugTier 3Retail42245$189,164$0$189,1640.3%2.8%0.0%2.8%$772.10$0.00$772.1029.82$26.34
50242007601Brand DrugTier 2Retail322$171,356$0$171,3560.0%2.5%0.0%2.5%$7,788.91$0.00$7,788.9125.55$314.26
61958180101Brand DrugTier 2Retail25$153,690$0$153,6900.0%2.2%0.0%2.2%$30,737.96$0.00$30,737.9628.00$1,099.17
00003085222Brand DrugTier 3Retail112$140,816$0$140,8160.0%2.1%0.0%2.1%$11,734.66$0.00$11,734.6630.00$399.47
00074379902Brand DrugTier 2Retail332$139,707$0$139,7070.0%2.0%0.0%2.0%$4,365.84$0.00$4,365.8427.00$163.18
00597014560Brand DrugTier 3Retail212$104,874$0$104,8740.0%1.5%0.0%1.5%$8,739.47$0.00$8,739.4730.00$293.76
00002771559Brand DrugTier 1Retail48229$103,609$0$103,6090.3%1.5%0.0%1.5%$452.44$0.00$452.4429.28$15.41
00169633910Brand DrugTier 3Retail25144$100,593$0$100,5930.2%1.5%0.0%1.5%$698.56$0.00$698.5628.67$24.45
44087334401Brand DrugTier 3Retail112$80,781$0$80,7810.0%1.2%0.0%1.2%$6,731.76$0.00$6,731.7628.00$242.85
64406000602Brand DrugTier 2Retail111$75,180$0$75,1800.0%1.1%0.0%1.1%$6,834.56$0.00$6,834.5630.00$229.15
50474071079Brand DrugTier 2Retail220$75,180$0$75,1800.0%1.1%0.0%1.1%$3,758.99$0.00$3,758.9928.00$135.68
58406044504Brand DrugTier 3Retail217$72,758$0$72,7580.0%1.1%0.0%1.1%$4,279.90$0.00$4,279.9028.00$161.17
61958220101Brand DrugTier 2Retail13$69,791$0$69,7910.0%1.0%0.0%1.0%$23,263.79$0.00$23,263.7928.00$835.71
00169643810Brand DrugTier 2Retail28166$68,637$0$68,6370.2%1.0%0.0%1.0%$413.47$0.00$413.4726.38$15.86
59572041000Brand DrugTier 2Retail14$68,526$0$68,5260.0%1.0%0.0%1.0%$17,131.49$0.00$17,131.4928.00$613.27
00002879959Brand DrugTier 2Retail1998$67,729$0$67,7290.1%1.0%0.0%1.0%$691.11$0.00$691.1128.21$24.45
50458014130Brand DrugTier 2Retail22160$67,652$0$67,6520.2%1.0%0.0%1.0%$422.82$0.00$422.8229.89$14.35
50419048858Brand DrugTier 2Retail14$64,410$0$64,4100.0%0.9%0.0%0.9%$16,102.61$0.00$16,102.6130.00$538.05
49702023113Brand DrugTier 2Retail226$62,222$0$62,2220.0%0.9%0.0%0.9%$2,393.16$0.00$2,393.1630.00$83.90
00469012599Brand DrugTier 3Retail26$60,191$0$60,1910.0%0.9%0.0%0.9%$10,031.85$0.00$10,031.8530.00$336.15
00006027731Brand DrugTier 3Retail20137$53,612$0$53,6120.2%0.8%0.0%0.8%$391.33$0.00$391.3330.00$13.21
68546032512Brand DrugTier 1Retail59$52,773$0$52,7730.0%0.8%0.0%0.8%$5,863.69$0.00$5,863.6928.00$209.98
59572041028Brand DrugTier 2Retail13$52,068$0$52,0680.0%0.8%0.0%0.8%$17,355.87$0.00$17,355.8728.00$621.28
59572063106Brand DrugTier 3Retail316$48,203$0$48,2030.0%0.7%0.0%0.7%$3,012.66$0.00$3,012.6630.00$101.91
00078060715Brand DrugTier 3Retail17$46,944$0$46,9440.0%0.7%0.0%0.7%$6,706.24$0.00$6,706.2430.00$238.23
57894015012Brand DrugTier 2Retail15$46,501$0$46,5010.0%0.7%0.0%0.7%$9,300.25$0.00$9,300.2530.00$310.54
50458057930Brand DrugTier 2Retail21133$44,952$0$44,9520.2%0.7%0.0%0.7%$337.99$0.00$337.9929.72$13.01
57894007002Brand DrugTier 2Retail111$43,741$0$43,7410.0%0.6%0.0%0.6%$3,976.44$0.00$3,976.4429.82$140.30
58406045504Brand DrugTier 3Retail110$42,065$0$42,0650.0%0.6%0.0%0.6%$4,206.52$0.00$4,206.5228.00$161.91
00169633910Brand DrugTier 3Home Delivery516$41,576$0$41,5760.0%0.6%0.0%0.6%$2,598.47$0.00$2,598.4789.81$28.93
00088221905Brand DrugTier 3Retail5298$40,210$0$40,2100.1%0.6%0.0%0.6%$410.31$0.00$410.3128.15$15.33
00002751001Brand DrugTier 1Retail860$39,690$0$39,6900.1%0.6%0.0%0.6%$661.50$0.00$661.5027.23$25.80
00169406012Brand DrugTier 2Retail1673$38,765$0$38,7650.1%0.6%0.0%0.6%$531.03$0.00$531.0327.97$18.95
00310621030Brand DrugTier 3Retail12100$38,465$0$38,4650.1%0.6%0.0%0.6%$384.65$0.00$384.6530.00$14.46
00051846231Brand DrugTier 3Retail222$37,379$0$37,3790.0%0.5%0.0%0.5%$1,699.06$0.00$1,699.0630.00$58.79
00051846233Brand DrugTier 3Retail645$36,386$0$36,3860.1%0.5%0.0%0.5%$808.58$0.00$808.5829.33$29.84
00002143380Brand DrugTier 3Retail956$36,385$0$36,3850.1%0.5%0.0%0.5%$649.74$0.00$649.7428.20$23.84
00186037020Brand DrugTier 3Retail37148$35,468$0$35,4680.2%0.5%0.0%0.5%$239.65$0.00$239.6529.98$10.28
69516001030Brand DrugTier 3Retail16$35,286$0$35,2860.0%0.5%0.0%0.5%$5,881.06$0.00$5,881.0630.00$198.70
57894007001Brand DrugTier 2Retail18$33,149$0$33,1490.0%0.5%0.0%0.5%$4,143.59$0.00$4,143.5930.00$139.45
50242012205Brand DrugTier 2Retail14$32,180$0$32,1800.0%0.5%0.0%0.5%$8,044.91$0.00$8,044.9130.00$269.50
31722083260Generic DrugTier 1Retail17$31,874$0$31,8740.0%0.5%0.0%0.5%$4,553.48$0.00$4,553.4830.00$152.08
00169406013Brand DrugTier 3Home Delivery414$31,190$0$31,1900.0%0.5%0.0%0.5%$2,227.83$0.00$2,227.8390.00$24.75
00002143480Brand DrugTier 3Retail955$30,751$0$30,7510.1%0.4%0.0%0.4%$559.11$0.00$559.1128.55$23.39
00002879959Brand DrugTier 2Home Delivery718$29,874$0$29,8740.0%0.4%0.0%0.4%$1,659.69$0.00$1,659.6990.00$19.00
00003218851Brand DrugTier 3Retail18$28,909$0$28,9090.0%0.4%0.0%0.4%$3,613.61$0.00$3,613.6128.00$131.87
59417010710Brand DrugTier 2Retail17126$28,221$0$28,2210.2%0.4%0.0%0.4%$223.98$0.00$223.9830.00$9.90
00173069600Brand DrugTier 3Retail2299$28,164$0$28,1640.1%0.4%0.0%0.4%$284.49$0.00$284.4930.00$12.23
 
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