Percent Brand Name Generic Name Strength How Supplied NDC from AWP/SWP Adcetris. Amprya dalfampridine 10 mg 60 count bottle

Transcription

1 Department of General Services Procurement Division Contract # Pharmaceutical Acquisitions Section Exhibit G-1 April 30, 2015 Walgreens Specialty Pharmacy LLC, Products Pricing Crescent Healthcare, Inc., Option Care Enterprises, Inc., River City Pharmacy, Inc. and Walgreens Home Care Inc. Percent Brand Name Generic Name Strength How Supplied NDC from AWP/SWP Adcetris Alphanate Alphanate AlphaNine AlphaNine AlphaNine brentuximab vedotin antihemophilic factor/von Willebrand factor complex [human] antihemophilic factor/von Willebrand factor complex [human] Coagulation Factor IX (Human) Coagulation Factor IX (Human) Coagulation Factor IX (Human) 50 mg single-use vial % 250 IU FVIII range vial % 500 IU FVIII range vial % 500 unit vial w/ 10mL diluent 1000 unit vial w/ 10mL diluent 1500 unit vial w/ 10mL diluent single-dose vial % single-dose vial % single-dose vial % Amprya dalfampridine 10 mg 60 count bottle % Apokyn apomorphine HCL injection 10 mg/ml 3 ml cartridge % Aralast NP alpha-1 proteinase inhibitor 0.5 g single-dose vial % Aralast NP alpha-1 proteinase inhibitor 1 g single-dose vial % 200 mcg/1 ml single-dose vial % 300 mcg/1 ml single-dose vial % 25 mcg/1 ml single-dose vial % 40 mcg/1 ml single-dose vial % 60 mcg/1 ml single-dose vial % 100 mcg/1 ml single-dose vial % 150 mcg/0.75 ml single-dose vial % 200 mcg/0.4 ml 300 mcg/0.6 ml 500 mcg/1 ml 25 mcg/0.42ml 40 mcg/0.4 ml 60 mcg/0.3 ml 100 mcg/0.5 ml 150 mcg/0.3ml % % % % % % % % Arzerra ofatumumab 1,000 mg/50 ml single-use vial % 1 of 14

2 ATryn antithrombin [recombinant] 1750 IU vial % Aubagio teriflunomide 7 mg tablet % Avandaryl rosiglitazone maleate and glimepiride 4 mg/1 mg tablet % Avandaryl rosiglitazone maleate and glimepiride 4 mg/2 mg tablet % Avandaryl rosiglitazone maleate and glimepiride 4 mg/4 mg tablet % Avandaryl rosiglitazone maleate and glimepiride 8 mg/2 mg tablet % Avandaryl rosiglitazone maleate and glimepiride 8 mg/4 mg tablet % Avandia rosiglitazone maleate 2 mg tablet % Avandia rosiglitazone maleate 4 mg tablet % Avandia rosiglitazone maleate 8 mg tablet % Avonex Avonex Avonex Baraclue Baraclue Baraclue Baraclue Betaseron interferon beta-1a interferon beta-1a interferon beta-1a 33 mcg (6.6 million intnl units) 30 mcg 30 mcg entecavir 0.5 mg tablet entecavir 0.5 mg tablet entecavir 1 mg tablet single-use vial single-use prefilled syringe Single-Use Prefilled Autoinjector entecavir 0.05 mg/ml oral solution interferon beta-1b 0.3 mg single-use vial % % % % % % % % Cayston aztreonam 75 mg single-use vial % Copaxone glatiramer acetate injection 20 mg w/40 mg of mannitol single-use prefilled syringe % Cystagon cysteamine 50 mg capsules Cystagon cysteamine 150 mg capsules LD - No Access LD - No Access Dacogen decitabine 50 mg single-dose vial % Dificid Enbrel Enbrel Enbrel Enbrel enoxaperi sodium enoxaperi sodium enoxaperi sodium Fidaxomicin etanercept etanercept etanercept 200 mg (bottle of 20) tablet single-use prefilled 50 mg syringe single-use prefilled 25 mg syringe single-use prefilled 50 mg SureClick autoinjector etanercept 25 mg multiple-use vial single-use prefilled 30 mg/0.3 ml syringe single-use prefilled 40 mg/0.4 ml syringe graduated single-use 60 mg/0.6 ml prefilled syringe 2 of % % % % % % % %

3 enoxaperi sodium enoxaperi sodium enoxaperi sodium enoxaperi sodium EPIVIR-HBV EPIVIR-HBV Epogen Epogen Epogen Epogen Epogen Epogen 80 mg/0.8 ml 100 mg/1 ml 120 mg/0.8 ml 150 mg/1 ml lamivudine 100 mg tablet graduated single-use prefilled syringe graduated single-use prefilled syringe graduated single-use prefilled syringe graduated single-use prefilled syringe lamivudine 240 ml oral solution single-dose preservative-free vial 2,000 units/1ml (citrate-buffered) single-dose preservative-free vial 3,000 units/1 ml (citrate-buffered) single-dose preservative-free vial 4,000 units/1 ml (citrate-buffered) single-dose preservative-free vial 10, 000 units/1 ml (citrate-buffered) multiple-dose preserved 10,000 units/1 ml vial multiple-dose preserved 20,000 units/1 ml vial % % % % % % % % % % % % Egrifta tesamorelin 2 mg single-use vial % Erivedge vismodegib 150 mg capsule % Exjade deferasirox 125 mg tablet % Exjade deferasirox 250 mg tablet % Exjade deferasirox 500 mg tablet % Eylea afilbercept injection 2 mg / 0.05 ml single-use vial % Flolan - generic Flolan - generic Forteo epoprostenol 0.5 mg single-dose vial epoprostenol 1.5 mg single-dose vial prefilled delivery device teriparatide injection 2.4 ml (pen) dalteparin sodium injection 2,500 IU / 0.2 ml syringe dalteparin sodium injection 5,000 IU / 0.2 ml syringe dalteparin sodium injection 7,500 IU / 0.3 ml syringe single-dose graduated dalteparin sodium injection 10,000 IU / 1 ml syringe dalteparin sodium injection 12,500 IU / 0.5 ml syringe dalteparin sodium injection 15,000 IU / 0.6 ml syringe dalteparin sodium injection 18,000 IU / 0.72 ml syringe dalteparin sodium injection 95,000 IU / 3.8 ml multiple dose vial 3 of % % % % % % % % % % %

4 Fuzeon Gablofen Gablofen Gablofen Gablofen Gablofen Gablofen enfuvirtide 90 mg single-use vial baclofen injection 50 mcg/1 ml single-use syringe baclofen injection 10,000 mcg/20 ml single-use syringe baclofen injection 10,000 mcg/20 ml single-use vial baclofen injection 20,000 mcg/20 ml single-use syringe baclofen injection 20,000 mcg/20 ml single-use vial baclofen injection 40,000 mcg/20 ml single-use syringe Gablofen baclofen injection 40,000 mcg/20 ml single-use vial Gammagard Liquid Immune Globulin Infusion (human) 10 ml single-use bottle Gammagard Liquid Immune Globulin Infusion (human) 25 ml single-use bottle Gammagard Liquid Immune Globulin Infusion (human) 50 ml single-use bottle Gammagard Liquid Immune Globulin Infusion (human) 100 ml single-use bottle Gammagard Liquid Immune Globulin Infusion (human) 200 ml single-use bottle Gammagard Liquid Immune Globulin Infusion (human) 300 ml single-use bottle Gammagard S/D Gammagard S/D Immune Globulin Intravenous (human) 2.5 g single-use bottle Immune Globulin Intravenous (human) 5 g single-use bottle % % % % % % % % % % % % % % % % Gammagard S/D Immune Globulin Intravenous (human) 10 g single-use bottle % Gammagard S/D LESS IGA Immune Globulin Intravenous (human) 5 g single-use bottle % Gammagard S/D LESS IGA Immune Globulin Intravenous (human) 10 g single-use bottle % Gamunex -C immune globuln injection [human] caprylate chromatography purified 10% 10 ml vial % Gamunex -C immune globuln injection [human] caprylate chromatography purified 10% 25 ml vial % Gamunex -C immune globuln injection [human] caprylate chromatography purified 10% 50 ml vial % Gamunex -C immune globuln injection [human] caprylate chromatography purified 10% 100 ml vial % Gamunex -C immune globuln injection [human] caprylate chromatography purified 10% 200 ml vial % Glassia alpha-1 proteinase inhibitor [human] 1 gm single-dose vial % Gleevec Gleevec H.P. Acthar Gel Hepsera imatinib mesylate imatinib mesylate repository corticostropin adefovir dipivoxil 100 mg tablet % 400 mg tablet % 8 USP/ml 5 ml multi-dose vial % 10 mg Tablet % Hizentra immune globuln subcutaneus [human] 20% 5 ml single-use vial % Hizentra immune globuln subcutaneus [human] 20% 10 ml single-use vial % 4 of 14

5 Hizentra immune globuln subcutaneus [human] 20% 20 ml single-use vial % Hizentra immune globuln subcutaneus [human] 20% 50 ml single-use vial % Humira Humira adalimumab adalimumab 20 mg prefilled glass syringe % 40 mg prefilled glass syringe % Hycamtin (oral) topotecan 0.25 mg capsule % Hycamtin (oral) topotecan 1.0 mg capsule % Iclusig ponatinib 15 mg tablet % Iclusig ponatinib 15 mg tablet % Nexplanon etonogestrel implant 68 mg single implant preloaded in needle % Increlex mecasemin 40 mg multi-dose vial % Inlyta Axitinib 1 mg tablet % Inlyta Axitinib 5 mg tablet % Inton A Inton A Inton A Interferon alfa-2b, recombinant Interferon alfa-2b, recombinant Interferon alfa-2b, recombinant 10 million IU per vial vial % 18 million IU per vial vial % 50 million IU per vial vial % Jakafi ruxolitinib 5 mg tablet % Jakafi ruxolitinib 10 mg tablet % Jakafi ruxolitinib 15 mg tablet % Jakafi ruxolitinib 20 mg tablet % Jakafi ruxolitinib 25 mg tablet % Jetrea ocriplasmin 2.5 mg/ml vial % Kadcyla ado-trastuzumab emtansine 100 mg vial % Kalbitor ecallantide 10 mg/ml vial % KOGENATE FS KOGENATE FS KOGENATE FS KOGENATE FS KOGENATE FS recombinant factor VIII (rfviii) recombinant factor VIII (rfviii) recombinant factor VIII (rfviii) recombinant factor VIII (rfviii) recombinant factor VIII (rfviii) 250 IU vial % 500 IU vial % 1000 IU vial % 2000 IU vial % 3000 IU vial % Krystexxa pegloticase 8 mg/ml vial % Kynamro mipmersen sodium 200 mg/ml pre-filled syringe % Letairis ambrisentan 5 mg tablet % Letairis ambrisentan 10 mg tablet % 5 of 14

6 LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1 mg/0.2 ml vial % Ilaris canakinumab 180 mg vial % Lioresal Lioresal Lioresal Lioresal Lioresal lioresal lioresal lioresal lioresal lioresal 10 mg/20 ml ampules % 10 mg/5 ml ampules % 40 mg/20ml ampules % 10 mg/20 ml ampules % 40 mg/20ml ampules % 30 mg/0.3 ml pre-filled syringe % 40 mg/0.4 ml pre-filled syringe % 60 mg/0.6 ml pre-filled syringe % 80 mg/0.8 ml pre-filled syringe % 100 mg/1 ml pre-filled syringe % 300 mg/ 3 ml vial % 120 mg / 0.8 ml pre-filled syringe % 150 mg / 1 ml pre-filled syringe % Lucentis ranibizumab 0.5 mg vial % Lucentis ranibizumab 0.3 mg vial % Lupron Depot LEUPROLIDE ACETATE 3.75 mg pre-filled syringe % Lupron Depot LEUPROLIDE ACETATE mg pre-filled syringe % Macugen pegaptanib sodium 0.3 mg pre-filled syringe % Makena hydroxyprogesterone caproate 1250 mg multi-dose vial % Matulane procarbazine 50 mg capsule % Mononine MuGard lyophilized concentrate of Factor IX GLY/CARB HOMOPOLY A/POT HYDROX 1000 IU vial % Not avaiable oral solution % Naglazyme galsufase 5 mg / 5 ml vial % Neulasta Neupogen Neupogen Neupogen Neupogen pegfilgrastim filgrastim filgrastim filgrastim filgrastim 6 mg / 0.6 ml pre-filled syringe % 300 mcg/ml vial % 480 mcg /1.6 ml vial % 300 mcg/ 0.5 ml pre-filled syringe % 480 mcg /0.8 ml pre-filled syringe % Nexavar sorafenib 400 mg tablet % ONDANSETRON IV ondansetron 2 mg vial % 6 of 14

7 ONDANSETRON IV ONDANSETRON IV ONDANSETRON IV ONDANSETRON IV ONDANSETRON IV Pegasys Pegasys Pegasys Pegasys ondansetron ondansetron ondansetron ondansetron ondansetron peginterferon alfa-2a peginterferon alfa-2a peginterferon alfa-2a peginterferon alfa-2a 2 mg vial % 2 mg vial % 4 mg vial % 5 mg vial % 6 mg vial % 180 mcg per 1 ml single use vial % 180 mcg per 0.5 ml pre-filled syringe % 180 mcg per 0.5 ml autoinjector % 135 mcg per 0.5 ml autoinjector % Perjeta pertuzumab 420 mg/14 ml vial % Pomalyst pomalidone 1 mg capsule % Pomalyst pomalidone 2 mg capsule % Pomalyst pomalidone 3 mg capsule % Pomalyst pomalidone 4 mg capsule % Procrit Procrit Procrit Procrit Procrit Procrit Procrit Promacta Promacta Promacta Promacta Reclast Remicade Revatio Revatio eltrombopag eltrombopag eltrombopag eltrombopag zoledronic acid infliximab sildenafil sildenafil 2000 Units/ml vial % 3000 Units/ml vial % 4000 Units/ml vial % 10,000 Units/ml vial % 40,000 Units/ml vial % 20,000 Units / 2 ml multi-dose vial % 20,000 Units/ml multi-dose vial % 12.5 mg tablet % 25 mg tablet % 50 mg tablet % 75 mg tablet % 5 mg/100 ml injection % 100 mg vial % 20 mg tablet % 10 mg (12.5 ml) vial % Revlimid lenalidomide 2.5 mg/ml capsule % Revlimid lenalidomide 5 mg capsule % Revlimid lenalidomide 10 mg capsule % 7 of 14

8 Revlimid lenalidomide 15 mg capsule % Revlimid lenalidomide 20 mg capsule % Revlimid lenalidomide 25 mg capsule % RhoGAM PLUS Rho(D) Immune Globulin (Human) 300 μg (1500 IU) prefilled syringe % RhoGAM PLUS Rho(D) Immune Globulin (Human) 50 μg (250 IU) prefilled syringe % RiaSTAP fibrinogen concentrate [human] 1 gm vial % Ribasphere ribavirin 200 mg tablet % Ribasphere ribavirin 400 mg tablet % Ribasphere ribavirin 600 mg tablet % Simponi golimumab 50 mg/0.5 ml prefilled syringe % Simponi golimumab 100 mg/1 ml prefilled syringe % Solesta Dextranomer in stabilized sodium hyaluronate 50 mg/ml, 15 mg/ml glass syringe % Soliris eculizumab 10 mg/ml single-use vial % Somavert pegvisomant 10 mg single-dose vial % Somavert pegvisomant 15 mg single-dose vial % Somavert pegvisomant 20 mg single-dose vial % Sprycel dasatinib 20 mg tablet % Sprycel dasatinib 50 mg tablet % Sprycel dasatinib 70 mg tablet % Sprycel dasatinib 80 mg tablet % Sprycel dasatinib 100 mg tablet % Sprycel dasatinib 140 mg tablet % Stelara ustekinumab 45 mg pre-filled syringe % Stelara ustekinumab 90 mg pre-filled syringe % Stivarga regorafenib 40 mg tablet % Sutent sunitinib malate 12.5 mg capsule % Sutent sunitinib malate 25 mg capsule % Sutent sunitinib malate 50 mg capsule % Synagis palivizumab 50 mg vial % Synagis palivizumab 100 mg vial % Tarceva erlotinib 25 mg tablet % Tarceva erlotinib 100 mg tablet % 8 of 14

9 Tarceva erlotinib 150 mg tablet % Tasigna Nilotinib 150 mg capsule % Tasigna Nilotinib 200 mg capsule % Tecfidera dimethyl fumarate 120 mg capsule % Tecfidera dimethyl fumarate 240 mg capsule % Temodar temozolomide 5 mg capsule % Temodar temozolomide 20 mg capsule % Temodar temozolomide 100 mg capsule % Temodar temozolomide 140 mg capsule % Temodar temozolomide 180 mg capsule % Temodar temozolomide 250 mg capsule % Temodar temozolomide 180 mg vial % Testopel testosterone 78mg subcutaneous implant % Thalomid thalidomide 50 mg capsule % Thalomid thalidomide 100 mg capsule % Thalomid thalidomide 150 mg capsule % Thalomid thalidomide 200 mg capsule % Tobi tobramycin inhalation solution 300 mg / 5 ml ampule % Topi Podhaler tobramycin inhalation powder 28 mg capsule % Tracleer bosentan 62.5 mg tablet : 16.00% Tracleer bosentan 125 mg tablet % Tykerb lapatinib 250 mg tablet % Tysabri natalizumab 300 mg / 15 ml vial % Visudyne verteporfin 15 mg vial % Votrient pazopanib 200 mg tablet % VPRIV velaglucerase alfa 400 units vial % Xalkori crizotinib 250 mg capsule % Xeloda capecitabine 500 mg tablet % Xiaflex coliagenase clostridum histolyticum 0.9 mg vial % Xolair omalizumab 150 mg / 5 ml vial % Xtandi enzalutamide 40 mg capsule % Yervoy ipilimumab 50 mg/10 ml vial % 9 of 14

10 Yervoy ipilimumab 200 mg/40 ml vial % Zelboraf vemurafenib 240 mg tablet % Zoladex goserelin 3.6 mg implant % Zoladex goserelin 10.8 mg implant % Zytiga abiraterone acetate 1000 mg tablet % Travasol amino acid formulas 10% solution % Liposyn soybean oil 20% solution % Non-Specified Product Limited distribution pharmaceuticals 12.50% Non-limited distribution Branded pharmaceuticals 15.50% Non-limited distribution Generic pharmaceuticals 27.00% Infusion 12.00% 10 of 14

11 Department of General Services Procurement Division Contract # Pharmaceutical Acquisitions Section Exhibit G-2 April 30, 2015 Walgreens Specialty Pharmacy LLC, Services Pricing Crescent Healthcare, Inc., Option Care Enterprises, Inc., River City Pharmacy, Inc. and Walgreens Home Care Inc. PER DIEM INJECTABLE AND INFUSION SERVICES HCPCS Description of per diem* Injectable and Infusion Services Rate S9325 Home infusion therapy, pain management infusion $85.00 S9326 Home infusion therapy, continuous (twenty-four hours or more) pain management infusion $85.00 S9327 Home infusion therapy, intermittent (less than twenty-four hours) pain $85.00 S9329 Home infusion therapy, chemotherapy infusions $90.00 S9330 Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion $90.00 S9331 Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy infusion $95.00 S9335 Home therapy, hemodialysis $0.00 S9336 Home infusion therapy, continuous anticoagulant infusion therapy (e. g. Heparin) $85.00 S9338 Home infusion therapy, immunotherapy $90.00 S9340 Home therapy; enteral nutrition $10.00 S9341 Home therapy; enteral nutrition via gravity $15.00 S9342 Home therapy; enteral nutrition via pump $20.00 S9343 Home therapy; enteral nutrition via bolus $12.00 S9345 Home infusion therapy, anti-hemophilic agent infusion therapy (e. g. Factor viii) $85.00 S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e. g. prolastin) $85.00 S9347 Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or $90.00 subcutaneous infusion therapy (e. g. Epoprostenol) S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e. g. $90.00 dobutamine) S9351 Home infusion therapy, continuous or intermittent anti-emetic infusion therapy $85.00 S9353 Home infusion therapy, continuous insulin infusion therapy $70.00 S9355 Home infusion therapy, chelation therapy $85.00 S9357 Home infusion therapy, enzyme replacement intravenous therapy; (e. g. Imiglucerase) $90.00 S9359 Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e. g. Infliximab) $90.00 S9361 Home infusion therapy, diuretic intravenous therapy $80.00 S9363 Home infusion therapy, anti-spasmodic therapy $85.00 S9364 Home infusion therapy, total parenteral nutrition (tpn) $ of 14

12 Department of General Services Procurement Division Contract # Pharmaceutical Acquisitions Section Exhibit G-2 April 30, 2015 Walgreens Specialty Pharmacy LLC, Services Pricing Crescent Healthcare, Inc., Option Care Enterprises, Inc., River City Pharmacy, Inc. and Walgreens Home Care Inc. S9365 S9366 S9367 S9368 S9370 S9372 S9373 S9374 S9375 S9376 S9377 S9379 S9490 S9494 S9497 S9500 S9501 S9502 S9503 S9504 S9537 Home infusion therapy, total parenteral nutrition (tpn); one liter per day Home infusion therapy, total parenteral nutrition (tpn); more than one liter but no more than two liters per day Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no more than three liters per day Home infusion therapy, total parenteral nutrition (tpn); more than three liters per day Home therapy, intermittent anti-emetic injection therapy Home therapy; intermittent anticoagulant injection therapy (e. G. Heparin) Home infusion therapy, hydration therapy Home infusion therapy, hydration therapy; one liter per day Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day Home infusion therapy, hydration therapy; more than three liters per day Home infusion therapy, infusion therapy, not otherwise classified Home infusion therapy, corticosteroid infusion Home infusion therapy, antibiotic, antiviral, or antifungal therapy Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours Home therapy; hematopoietic hormone injection therapy (e. g. Erythropoietin, g-csf, gm.-csf) 12 of 14 $ $ $ $ $65.00 $65.00 $75.00 $75.00 $75.00 $80.00 $80.00 $85.00 $85.00 $ $ $90.00 $95.00 $ $ $ $45.00

13 Department of General Services Procurement Division Contract # Pharmaceutical Acquisitions Section Exhibit G-2 April 30, 2015 Walgreens Specialty Pharmacy LLC, Services Pricing Crescent Healthcare, Inc., Option Care Enterprises, Inc., River City Pharmacy, Inc. and Walgreens Home Care Inc. S9542 S9558 S9559 S9560 S9562 S9590 Home injectable therapy, not otherwise classified Home injectable therapy; growth hormone Home injectable therapy, interferon Home injectable therapy; hormonal therapy (e. g. ; leuprolide, goserelin) Home injectable therapy, palivizumab Home therapy, irrigation therapy (e. g. Sterile irrigation of an organ or anatomical cavity) $65.00 $45.00 $45.00 $65.00 $50.00 $55.00 S9810 CPT Code Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour Infusion administration up to 2 hours $ $ CPT Code $ Infusion for each additional hour after two hours * "per diem" means infusion services that are bundled together and payment includes professional pharmacy services, patient monitoring, education, and counseling activities, all necessary supplies and equipment, and administrative and other support services. Diluent, Solution, Heparin, Saline, Sterile Water, Etc. are included. Drug products and nursing visits are coded separately from the per diem. 13 of 14

14 Department of General Services Procurement Division Contract # Pharmaceutical Acquisitions Section Exhibit G-2 April 30, 2015 Walgreens Specialty Pharmacy LLC, Services Pricing Crescent Healthcare, Inc., Option Care Enterprises, Inc., River City Pharmacy, Inc. and Walgreens Home Care Inc. COMPOUNDING SERVICES CODE Description of Compounding Services Rate S9430 Pharmacy compounding and dispensing services $25.00 B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix $ B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength over 100 grams of protein - premix Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per day Parenteral nutrition supply kit; premix, per day Parenteral nutrition supply kit; home mix, per day Parenteral nutrition administration kit, per day Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - amirosyn rf, nephramine, renamine - premix Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - freamine hbc, hepatamine - premix PROFESSIONAL SERVICES $ $ $ $8.77 $9.09 $11.21 $28.39 $13.50 $5.27 CODE Description of Professional Services Rate S9123 Nursing care, in the home; by registered nurse, per hour (use for general nursing care only $ of 14