TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018

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1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25 MG TABLET ORAL 09/06/2016 0.05038 0.05226 ( 3.6) hydralazine HCl 50 MG TABLET ORAL 07/11/2017 0.05946 0.06163 ( 3.5) captopril 25 MG TABLET ORAL 07/07/2015 1.10108 1.12225 ( 1.9) isosorbide dinitrate 20 MG TABLET ORAL 04/25/2018 0.62614 0.62617 ( 0.0) disulfiram 250 MG TABLET ORAL 09/08/2015 1.34000 1.30561 2.6 potassium chloride 20 MEQ PACKET ORAL 04/25/2018 7.22884 8.03280 ( 10.0) potassium chloride 8 MEQ TABLET ER ORAL 07/07/2015 0.16324 0.17082 ( 4.4) magnesium citrate SOLUTION ORAL 04/25/2018 0.00460 0.00573 ( 19.7) estradiol 0.1MG/24HR PATCH TDSW TRANSDERM 01/10/2018 9.39981 9.41700 ( 0.2) norethindrone 0.35 MG TABLET ORAL 04/18/2017 0.44148 0.44268 ( 0.3) bupivacaine HCl 2.5 MG/ML VIAL INJECTION 04/25/2018 0.07006 0.05494 27.5 bupivacaine HCl 5 MG/ML VIAL INJECTION 04/25/2018 0.05883 0.05226 12.6 hydroxyzine HCl 50 MG TABLET ORAL 07/07/2015 0.07705 0.08538 ( 9.8) clorazepate dipotassium 3.75 MG TABLET ORAL 05/16/2017 1.15200 1.17960 ( 2.3) lorazepam 0.5 MG TABLET ORAL 04/25/2018 0.02318 0.02539 ( 8.7) diazepam 5 MG/ML ORAL CONC ORAL 04/25/2018 1.23548 1.18903 3.9 diazepam 2 MG TABLET ORAL 04/25/2018 0.02385 0.02334 2.2 alprazolam 0.25 MG TABLET ORAL 04/26/2016 0.01340 0.01453 ( 7.8) fluphenazine HCl 10 MG TABLET ORAL 04/20/2018 0.75968 0.37078 104.9

2 Tennessee CoverRx List Run : 04/26/18 Dosage Form fluphenazine HCl 5 MG TABLET ORAL 01/10/2018 0.62377 0.29400 112.2 perphenazine 2 MG TABLET ORAL 04/25/2018 0.60809 0.59523 2.2 perphenazine 8 MG TABLET ORAL 04/25/2018 1.00969 0.93519 8.0 promethazine HCl 12.5 MG SUPP.RECT RECTAL 09/22/2015 8.22800 8.13400 1.2 promethazine HCl 25 MG SUPP.RECT RECTAL 09/06/2016 7.86400 7.21600 9.0 methylphenidate HCl 10 MG TABLET ORAL 03/20/2018 0.26733 0.29185 ( 8.4) methylphenidate HCl 20 MG TABLET ORAL 10/03/2017 0.42384 0.34974 21.2 acetaminophen with codeine 300MG-30MG TABLET ORAL 05/26/2015 0.14563 0.14123 3.1 acetaminophen with codeine 300MG-60MG TABLET ORAL 04/25/2018 0.23517 0.26130 ( 10.0) oxycodone HCl/acetaminophen 5 MG-325MG TABLET ORAL 10/03/2017 0.07491 0.07035 6.5 butalbital/aspirin/caffeine 50-325-40 CAPSULE ORAL 07/05/2016 1.40365 1.33839 4.9 acetaminophen 650 MG SUPP.RECT RECTAL 04/24/2018 0.32659 0.20703 57.8 naltrexone HCl 50 MG TABLET ORAL 04/25/2018 0.88440 0.89646 ( 1.3) valproic acid 250 MG CAPSULE ORAL 03/14/2017 0.26103 0.23584 10.7 ethosuximide 250 MG CAPSULE ORAL 04/25/2018 1.14396 1.13230 1.0 carbamazepine 100 MG TAB CHEW ORAL 04/19/2016 0.33109 0.34650 ( 4.4) clonazepam 0.5 MG TABLET ORAL 04/25/2018 0.01865 0.01840 1.4 amantadine HCl 100 MG CAPSULE ORAL 05/26/2015 1.02255 1.03863 ( 1.5) benztropine mesylate 0.5 MG TABLET ORAL 07/21/2015 0.11323 0.12047 ( 6.0) benztropine mesylate 2 MG TABLET ORAL 07/07/2015 0.15135 0.15611 ( 3.0) orphenadrine citrate 100 MG TABLET ER ORAL 01/06/2015 0.49245 0.49272 ( 0.1)

3 Tennessee CoverRx List Run : 04/26/18 Dosage Form dronabinol 10 MG CAPSULE ORAL 04/25/2018 9.00000 8.57260 5.0 dronabinol 2.5 MG CAPSULE ORAL 04/25/2018 3.54486 3.19000 11.1 meclizine HCl 25 MG TABLET ORAL 05/26/2015 0.22929 0.22445 2.2 oxybutynin chloride 5 MG TABLET ORAL 05/12/2015 0.28448 0.30722 ( 7.4) dextroamphetamine sulfate 10 MG TABLET ORAL 04/25/2018 1.23280 1.17263 5.1 labetalol HCl 200 MG TABLET ORAL 04/25/2018 0.35979 0.35992 ( 0.0) phentolamine mesylate 5 MG VIAL INJECTION 04/25/2018 371.17300 394.62500 ( 5.9) nadolol 20 MG TABLET ORAL 04/19/2016 2.16919 1.93094 12.3 nadolol 80 MG TABLET ORAL 04/25/2018 4.08870 3.27769 24.7 salicylic acid 10 CREAM (G) TOPICAL 04/25/2018 0.22333 0.21984 1.6 tretinoin 0.1 CREAM (G) TOPICAL 01/06/2015 4.65344 4.60592 1.0 urea 20 CREAM (G) TOPICAL 05/05/2015 0.06560 0.06455 1.6 danazol 200 MG CAPSULE ORAL 11/22/2016 5.14760 5.26119 ( 2.2) liothyronine sodium 25 MCG TABLET ORAL 03/06/2018 0.36716 0.37587 ( 2.3) dexamethasone 0.5 MG/5ML ELIXIR ORAL 08/18/2015 0.24946 0.20089 24.2 nystatin 100000/G POWDER TOPICAL 01/16/2018 0.45381 0.45560 ( 0.4) econazole nitrate 1 CREAM (G) TOPICAL 04/09/2018 0.28706 0.29286 ( 2.0) fluocinonide 0.05 CREAM (G) TOPICAL 09/29/2015 0.68563 0.69993 ( 2.0) fluocinonide 0.05 OINT. (G) TOPICAL 04/24/2018 0.66754 1.20530 ( 44.6) desonide 0.05 OINT. (G) TOPICAL 04/25/2018 1.42219 1.46931 ( 3.2) silver sulfadiazine 1 CREAM (G) TOPICAL 06/20/2017 0.14579 0.14583 ( 0.0)

4 Tennessee CoverRx List Run : 04/26/18 Dosage Form clindamycin phosphate 1 GEL (GRAM) TOPICAL 05/05/2015 3.07978 2.66392 15.6 clindamycin phosphate 1 SOLUTION TOPICAL 07/21/2015 0.51099 0.53287 ( 4.1) erythromycin base 5 MG/GRAM OINT. (G) OPHTHALMIC 04/03/2018 1.21940 1.41370 ( 13.7) amiloride/hydrochlorothiazide 5 MG-50 MG TABLET ORAL 04/25/2018 0.46297 0.43561 6.3 furosemide 10 MG/ML SOLUTION ORAL 04/25/2018 0.11658 0.11837 ( 1.5) amiloride HCl 5 MG TABLET ORAL 04/10/2018 0.30324 0.28113 7.9 probenecid 500 MG TABLET ORAL 04/25/2018 0.73365 0.69696 5.3 indomethacin 75 MG CAPSULE ER ORAL 09/06/2016 0.37504 0.37319 0.5 rifampin 300 MG CAPSULE ORAL 01/10/2016 0.69055 1.08774 ( 36.5) clindamycin HCl 150 MG CAPSULE ORAL 04/19/2016 0.11792 0.14874 ( 20.7) clindamycin HCl 300 MG CAPSULE ORAL 05/12/2015 0.33433 0.35510 ( 5.8) sulfasalazine 500 MG TABLET ORAL 07/21/2015 0.22262 0.21775 2.2 ciprofloxacin HCl 250 MG TABLET ORAL 08/15/2017 0.08080 0.07986 1.2 ciprofloxacin HCl 750 MG TABLET ORAL 04/25/2018 0.29775 0.31972 ( 6.9) nystatin 100000/ML ORAL SUSP ORAL 01/10/2018 0.07845 0.07990 ( 1.8) diphenhydramine HCl 25 MG CAPSULE ORAL 05/16/2017 0.03028 0.02613 15.9 norgestimate-ethinyl estradiol 0.25-0.035 TABLET ORAL 04/25/2018 0.22636 0.29576 ( 23.5) verapamil HCl 180 MG TABLET ER ORAL 07/11/2017 0.11993 0.12006 ( 0.1) clobetasol propionate 0.05 SOLUTION TOPICAL 03/21/2017 1.18134 1.33464 ( 11.5) alprazolam 2 MG TABLET ORAL 03/20/2018 0.06151 0.06472 ( 5.0)

5 Tennessee CoverRx List Run : 04/26/18 Dosage Form halobetasol propionate 0.05 CREAM (G) TOPICAL 07/21/2015 1.23066 1.24325 ( 1.0) fentanyl 50MCG/HR PATCH TD72 TRANSDERM 03/21/2017 4.06032 3.76464 7.9 etodolac 300 MG CAPSULE ORAL 04/25/2018 1.15696 1.11073 4.2 pravastatin sodium 10 MG TABLET ORAL 07/25/2017 0.12879 0.12036 7.0 ondansetron HCl 8 MG TABLET ORAL 09/06/2016 0.13311 0.13579 ( 2.0) diltiazem HCl 180 MG CAP ER DEG ORAL 04/24/2018 0.58196 0.47396 22.8 amlodipine besylate 2.5 MG TABLET ORAL 10/18/2016 0.01662 0.01642 1.2 norgestimate-ethinyl estradiol 7DAYSX3 28 TABLET ORAL 05/24/2016 0.23434 0.32415 ( 27.7) amiodarone HCl 100 MG TABLET ORAL 01/10/2017 2.72888 2.85120 ( 4.3) bisoprolol fumarate 5 MG TABLET ORAL 04/25/2018 0.43728 0.36403 20.1 clobetasol propionate 0.05 LOTION TOPICAL 04/25/2018 1.58165 1.63882 ( 3.5) tinidazole 500 MG TABLET ORAL 04/25/2018 1.97650 1.03917 90.2 desmopressin acetate 0.1 MG TABLET ORAL 04/24/2017 1.19126 1.05860 12.5 nifedipine 30 MG TAB ER 24 ORAL 04/25/2018 0.31932 0.31088 2.7 nifedipine 60 MG TAB ER 24 ORAL 04/25/2018 0.28408 0.28796 ( 1.3) pravastatin sodium 40 MG TABLET ORAL 03/15/2016 0.14759 0.18492 ( 20.2) megestrol acetate 400MG/10ML ORAL SUSP ORAL 04/25/2018 0.08925 0.09095 ( 1.9) calcipotriene 0.005 CREAM (G) TOPICAL 03/21/2017 2.43590 2.30614 5.6 timolol maleate 0.5 SOL-GEL OPHTHALMIC 04/25/2018 29.68400 27.75290 7.0 torsemide 20 MG TABLET ORAL 04/25/2018 0.10894 0.09501 14.7

6 Tennessee CoverRx List Run : 04/26/18 Dosage Form cetirizine HCl 1 MG/ML SOLUTION ORAL 04/25/2018 0.02535 0.02624 ( 3.4) benazepril/hydrochlorothiazide 20 MG-25MG TABLET ORAL 04/24/2018 0.60193 0.75295 ( 20.1) clobetasol propionate 0.05 GEL (GRAM) TOPICAL 06/19/2017 2.93260 2.80522 4.5 potassium chloride 20 MEQ TAB ER PRT ORAL 04/25/2018 0.30699 0.30807 ( 0.4) sotalol HCl 120 MG TABLET ORAL 04/25/2018 0.12355 0.15450 ( 20.0) fosinopril sodium 40 MG TABLET ORAL 04/25/2018 0.24462 0.23212 5.4 riluzole 50 MG TABLET ORAL 04/25/2018 1.44162 1.48919 ( 3.2) cromolyn sodium 20 MG/ML ORAL CONC ORAL 08/18/2015 0.86536 0.89107 ( 2.9) amoxicillin/potassium clav 400-57MG/5 SUSP RECON ORAL 07/03/2017 0.06981 0.06986 ( 0.1) medroxyprogesterone acetate 150 MG/ML SYRINGE INTRAMUSC 04/11/2018 54.32500 58.49675 ( 7.1) pantoprazole sodium 40 MG TABLET DR ORAL 04/10/2018 0.08814 0.07102 24.1 ammonium lactate 12 CREAM (G) TOPICAL 04/25/2018 0.10859 0.11026 ( 1.5) olanzapine 2.5 MG TABLET ORAL 07/25/2017 0.07893 0.09380 ( 15.9) buprenorphine HCl 2 MG TAB SUBL SUBLINGUAL 04/25/2018 0.83616 0.79551 5.1 levofloxacin 250 MG TABLET ORAL 04/25/2018 0.14123 0.15249 ( 7.4) hydrocodone/acetaminophen 10MG-325MG TABLET ORAL 05/03/2017 0.13293 0.13379 ( 0.6) alendronate sodium 5 MG TABLET ORAL 04/25/2018 0.19309 0.19609 ( 1.5) memantine HCl 10 MG TABLET ORAL 01/12/2016 0.19553 0.18537 5.5 niacin 1000 MG TAB ER 24H ORAL 04/25/2018 1.37722 1.40179 ( 1.8) tiagabine HCl 4 MG TABLET ORAL 05/17/2016 7.43800 6.82921 8.9

7 Tennessee CoverRx List Run : 04/26/18 Dosage Form raloxifene HCl 60 MG TABLET ORAL 10/03/2017 0.81380 1.08312 ( 24.9) cilostazol 100 MG TABLET ORAL 04/25/2018 0.13623 0.13378 1.8 repaglinide 2 MG TABLET ORAL 04/25/2018 0.31731 0.30806 3.0 pramipexole di-hcl 0.5 MG TABLET ORAL 04/24/2018 0.05196 0.06566 ( 20.9) diclofenac sodium 3 GEL (GRAM) TOPICAL 05/30/2017 1.18915 1.49276 ( 20.3) telmisartan 80 MG TABLET ORAL 01/16/2018 0.27515 0.27783 ( 1.0) abacavir sulfate 20 MG/ML SOLUTION ORAL 04/25/2018 0.81963 0.70054 17.0 ondansetron 4 MG TAB RAPDIS ORAL 04/16/2018 0.32140 0.14963 114.8 temozolomide 5 MG CAPSULE ORAL 04/25/2018 2.38520 2.80632 ( 15.0) temozolomide 20 MG CAPSULE ORAL 04/25/2018 8.55171 9.63536 ( 11.2) temozolomide 100 MG CAPSULE ORAL 01/19/2016 36.72368 42.94018 ( 14.5) propranolol HCl 1 MG/ML VIAL INTRAVEN 04/24/2018 5.03100 2.83800 77.3 progesterone, micronized 100 MG CAPSULE ORAL 04/25/2018 0.65593 0.65660 ( 0.1) progesterone, micronized 200 MG CAPSULE ORAL 04/25/2018 1.39079 1.64820 ( 15.6) zolmitriptan 2.5 MG TAB RAPDIS ORAL 04/25/2018 7.99400 6.63575 20.5 tiagabine HCl 2 MG TABLET ORAL 08/25/2015 7.35245 7.23773 1.6 atorvastatin calcium 80 MG TABLET ORAL 04/24/2018 0.17286 0.11911 45.1 nortriptyline HCl 50 MG CAPSULE ORAL 01/24/2017 0.19041 0.19524 ( 2.5) doxepin HCl 10 MG CAPSULE ORAL 03/07/2017 0.34036 0.53351 ( 36.2) doxepin HCl 100 MG CAPSULE ORAL 04/07/2015 1.73999 1.78369 ( 2.4)

8 Tennessee CoverRx List Run : 04/26/18 Dosage Form doxepin HCl 25 MG CAPSULE ORAL 04/25/2018 0.44682 0.70219 ( 36.4) doxepin HCl 50 MG CAPSULE ORAL 04/07/2015 0.63873 1.00574 ( 36.5) doxepin HCl 75 MG CAPSULE ORAL 04/25/2018 0.74310 1.69182 ( 56.1) bupropion HCl 100 MG TAB ER 12H ORAL 02/07/2017 0.17393 0.09201 89.0 oxycodone HCl 15 MG TABLET ORAL 02/20/2018 0.12355 0.12730 ( 2.9) oxycodone HCl 30 MG TABLET ORAL 04/21/2017 0.20475 0.21440 ( 4.5) clobetasol propionate 0.05 FOAM TOPICAL 06/28/2016 3.14286 3.19000 ( 1.5) galantamine HBr 8 MG TABLET ORAL 10/17/2017 0.54337 0.54382 ( 0.1) dextroamphetamine/amphetamine 7.5 MG TABLET ORAL 06/27/2017 0.57285 0.60153 ( 4.8) tolterodine tartrate 4 MG CAP ER 24H ORAL 04/25/2018 3.07515 3.37389 ( 8.9) tolterodine tartrate 2 MG CAP ER 24H ORAL 04/25/2018 3.15731 3.45708 ( 8.7) tacrolimus 0.1 OINT. (G) TOPICAL 04/25/2018 5.64787 5.67255 ( 0.4) metoprolol succinate 25 MG TAB ER 24H ORAL 04/10/2018 0.30445 0.43001 ( 29.2) desloratadine 5 MG TABLET ORAL 04/25/2018 0.57218 0.57596 ( 0.7) calcipotriene/betamethasone 0.005-.064 OINT. (G) TOPICAL 04/25/2018 7.46739 7.45120 0.2 hydrocodone bit/homatrop me-br 5-1.5 MG/5 SYRUP ORAL 12/02/2014 0.08637 0.09120 ( 5.3) zolmitriptan 5 MG TAB RAPDIS ORAL 04/25/2018 9.50400 9.48000 0.3 albuterol sulfate 1.25MG/3ML VIAL-NEB INHALATION 04/25/2018 0.25710 0.26353 ( 2.4) oxycodone HCl/acetaminophen 7.5-325 MG TABLET ORAL 06/06/2017 0.17473 0.18211 ( 4.1) oxycodone HCl/acetaminophen 10MG-325MG TABLET ORAL 05/23/2017 0.22512 0.22137 1.7

9 Tennessee CoverRx List Run : 04/26/18 Dosage Form eplerenone 50 MG TABLET ORAL 04/25/2018 2.21547 2.29319 ( 3.4) aripiprazole 20 MG TABLET ORAL 12/26/2017 0.67893 0.79194 ( 14.3) aripiprazole 30 MG TABLET ORAL 04/24/2018 1.41237 1.85545 ( 23.9) risperidone 2 MG TAB RAPDIS ORAL 08/04/2015 1.20552 1.15623 4.3 diltiazem HCl 360 MG TAB ER 24H ORAL 11/03/2015 3.49008 3.35236 4.1 bupropion HCl 150 MG TAB ER 24H ORAL 06/07/2016 0.51664 0.62956 ( 17.9) methylphenidate HCl 20 MG CPBP 30-70 ORAL 05/17/2016 3.43200 3.36336 2.0 methylphenidate HCl 40 MG CPBP 50-50 ORAL 08/02/2016 5.26770 5.42747 ( 2.9) ezetimibe/simvastatin 10 MG-40MG TABLET ORAL 04/25/2018 3.30660 3.35412 ( 1.4) duloxetine HCl 60 MG CAPSULE DR ORAL 08/09/2016 0.35242 0.36537 ( 3.5) fenofibrate,micronized 130 MG CAPSULE ORAL 08/04/2015 2.12375 2.10469 0.9 aripiprazole 1 MG/ML SOLUTION ORAL 01/30/2018 4.75182 6.09600 ( 22.1) entecavir 0.5 MG TABLET ORAL 04/25/2018 4.35556 4.34192 0.3 fluocinolone/shower cap 0.01 OIL TOPICAL 04/25/2018 0.69848 0.46799 49.3 rasagiline mesylate 1 MG TABLET ORAL 04/25/2018 10.35000 10.12383 2.2 hydrocodone/acetaminophen 5 MG-300MG TABLET ORAL 04/25/2018 0.99415 0.99080 0.3 dapsone 5 GEL (GRAM) TOPICAL 04/25/2018 5.55688 5.14308 8.0 fenofibrate nanocrystallized 145MG TABLET ORAL 02/28/2017 0.30478 0.28319 7.6 amlodipine besylate/valsartan 10MG-160MG TABLET ORAL 04/25/2018 0.42329 0.42344 ( 0.0) amlodipine bes/olmesartan med 5 MG-40 MG TABLET ORAL 05/09/2017 0.85313 1.03508 ( 17.6)

10 Tennessee CoverRx List Run : 04/26/18 Dosage Form desvenlafaxine succinate 50 MG TAB ER 24H ORAL 04/25/2018 1.08585 1.05190 3.2 lamotrigine 200 MG TAB ER 24 ORAL 01/30/2018 3.09716 2.73416 13.3 guanfacine HCl 1 MG TAB ER 24H ORAL 01/16/2018 0.50920 0.51885 ( 1.9) guanfacine HCl 2 MG TAB ER 24H ORAL 01/10/2018 0.52260 0.51845 0.8 mecobal/levomefolat Ca/B6 phos 2-3-35 MG TABLET ORAL 04/25/2018 0.99100 1.03359 ( 4.1) gatifloxacin 0.5 DROPS OPHTHALMIC 04/25/2018 30.84840 31.61920 ( 2.4) clonidine HCl 0.1 MG TAB ER 12H ORAL 04/25/2018 3.42430 3.63000 ( 5.7) Addition iron/fa/c/e/b12/bio/copper/dss 150-1-500 TABLET ORAL 04/25/2018 0.59901 0 0