DRUG ITEM_DESCRIPTION BILL_ITEM_ID GROUP_ID CDM PYXIS_ID RXMNEMONIC THERAPY_CLASS NDC DISPENSE_QTY DISPENSE_QTY_UOM DISPENSE_FACTOR DISPENSE_FACTOR_UOM DISPENSE_CATEGORY PRICE_SCHEDULE COST_BASE COST COST_BEG_EFFECTIVE PRICE_SCHED_BASE CDM_COST HCPCS_COST PATIENT_PRICE FORMULARY_STATUS HCPCS HCPCS_DESC QCF REVCODE CPT4 CPT4_MOD acetaminophen acetaminophen 500mg tablet 8316226 696519 60006505028 60006505028 apap500 miscellaneous analgesics 00904-6730-61 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0332 1/8/2024 7:47 0.0332 0.0332 0 0.03 Formulary 0 637 aspirin aspirin 81mg chewable tablet 8316396 688938 60006506406 60006506406 asp81 salicylates 00904-4040-73 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.01639 11/11/2021 9:52 0.01639 0.01639 0 0.02 Formulary 0 637 cloNIDine cloNIDine 0.1mg tablet 8316715 696175 60006509517 60006509517 clo0.1 "antiadrenergic agents, centrally acting" 00228-2127-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0273 11/11/2021 9:52 0.0273 0.0273 0 10 Formulary 0 637 diphenhydrAMINE diphenhydrAMINE 25mg capsule 8317836 695820 60006511877 60006511877 dip25 "miscellaneous anxiolytics, sedatives and hypnotics" 00904-5306-24 1 cap(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0325 11/15/2021 8:21 0.0325 0.0325 0 0.03 Formulary 0 637 EPINEPHrine EPINEPHrine 1mg/mL 1mL amp 8320568 34247594 60006512859 60006512859 epi1t vasopressors 54288-0103-10 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 8.249 11/11/2021 9:52 8.249 8.249 0.82 58.5 Formulary J0171 Adrenalin epinephrine inject 10 636 hydrocortisone hydrocortisone sod succ PF 100mg/2mL vial 8326069 40517886 60006515233 60006515233 hyd glucocorticoids 00009-0825-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 12.26 1/8/2024 7:47 12.26 12.26 12.26 82.6 Formulary J1720 Hydrocortisone sodium succ I 1 636 loperamide loperamide 2mg cap 8317594 694058 60006517395 60006517395 lop2 antidiarrheals 00378-2100-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2225 11/11/2021 9:52 0.2225 0.2225 0 10 Formulary 0 637 methylPREDNISolone methylPREDNISolone sod succ PF 125mg/2mL 8320405 33687429 60006519037 60006519037 met125PF glucocorticoids 00009-0047-22 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 7.1028 11/11/2021 9:52 7.1028 7.1028 7.1 51.7 Formulary J2930 Methylprednisolone injection up to 125 mg 1 636 penicillin G benzathine pen G benzathine 1.2 MillionUnits (G/K) 8316722 691640 60006521306 60006521306 bicLA natural penicillins 60793-0701-10 1 syringe(s) 2 mL INJ - COA PMC - INJ PMC COST 10.5085 10/10/2023 16:25 21.017 21.017 1.75 120 Formulary J0561 Penicillin G benzathine inj 12 636 JZ prochlorperazine prochlorperazine 5mg/mL 2mL vial 8316106 686731 60006523401 60006523401 proc5soln antihistamines 23155-0294-42 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 1.9195 11/11/2021 9:52 3.839 3.839 3.84 43.6 Formulary J0780 Prochlorperazine injection 1 636 promethazine promethazine 25mg/mL vial 8317003 694664 60006523500 60006523500 pro25inj antihistamines 00641-0928-25 1 vial(s) 1 mL IVPB - COA PMC - INJ PMC COST 1.53 3/30/2023 14:52 1.53 1.53 1.53 25.9 Formulary J2550 Promethazine hcl injection 1 259 promethazine promethazine 50mg/mL amp 8317009 694723 60006523518 60006523518 prom50soln antihistamines 00641-0929-21 1 amp 1 mL INJ - COA PMC - INJ PMC COST 3.17 3/30/2023 14:54 3.17 3.17 3.17 37.6 Formulary J2550 Promethazine hcl injection 1 636 promethazine promethazine 25mg tab 8317001 694642 60006523583 60006523583 pro25tab antihistamines 00904-7304-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.15 11/20/2023 12:34 0.15 0.15 0 10 Formulary 0 637 triamcinolone triamcinolone acetonide 40mg/mL 1mL 8317655 692215 60006526800 60006526800 tri40 adrenal cortical steroids 70121-1657-01 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 3.29 11/11/2021 9:52 3.29 3.29 0.82 38.7 Formulary J3301 Triamcinolone acet inj NOS 4 636 tuberculin purified protein derivative tuberculin unit(s) per 0.1mL 1mL PPD MDV 8341429 278410074 60006527469 60006527469 tub5 in vivo diagnostic biologicals 42023-0104-01 1 EA 1 mL MDV INJ - COA PMC - INJ PMC COST 75.7 11/11/2021 9:52 75.7 75.7 0 300 Formulary 0 302 86580 cefTRIAXone cefTRIAXone 1000mg IM inj 8322560 36141732 60006528871 60006528871 cef1000inj third generation cephalosporins 60505-6148-04 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 1.083 11/11/2021 9:52 1.083 1.083 0.27 21 Formulary J0696 Ceftriaxone sodium injection 4 636 ibuprofen ibuprofen 200mg tab 8317367 687486 60006529192 60006529192 ibu200 nonsteroidal anti-inflammatory agents 00904-7912-51 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0176 11/11/2021 9:52 0.0176 0.0176 0 0.02 Formulary 0 637 enalapril enalapril 10mg tablet 8316999 691766 60006529622 60006529622 ena10 angiotensin converting enzyme (ace) inhibitors 23155-0772-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0626 1/8/2024 7:47 0.0626 0.0626 0 10 Formulary 0 637 lidocaine lidocaine 1% 2mL PF inj 8317537 692973 60006530232 60006530232 lidopf1 antiarrhythmic agents 63323-0492-16 1 amp 2 mL INJ - COA PMC - INJ PMC COST 0.4266 11/11/2021 9:52 0.8532 0.8532 0 20.1 Formulary 0 259 ketorolac ketorolac 30mg/mL vial 8317466 691109 60006532915 60006532915 ket30 nonsteroidal anti-inflammatory agents 63323-0162-16 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 0.752 11/11/2021 9:52 0.752 0.752 0.38 18.8 Formulary J1885 Ketorolac tromethamine inj 2 636 medroxyPROGESTERone medroxyPROGESTERone 150mg/mL 1mL vial 8317862 696444 60006539985 60006539985 med150 67457-0887-99 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 17.16 11/11/2021 9:52 17.16 17.16 0.11 112 Formulary J1050 Medroxyprogesterone acetate 150 636 aspirin aspirin enteric coated 81mg tablet 8316400 689132 60006540298 60006540298 asa81ec salicylates 70000-0178-02 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.02 12/3/2021 10:24 0.02 0.02 0 0.02 Formulary 0 637 measles/mumps/rubella virus vaccine measles-mumps-rubella vaccine 8317632 694792 60006540561 60006540561 mmr vaccine combinations 00006-4681-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 76.24 11/15/2021 9:42 76.24 76.24 0 300 Formulary 0 636 90707 varicella virus vaccine varicella virus vaccine live vial 8317730 693074 60006543219 60006543219 var viral vaccines 00006-4827-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 128 11/15/2021 9:43 128 128 0 393 Formulary 0 636 90716 hepatitis B pediatric vaccine hepatitis B vaccine ped 5mcg/0.5mL 8316124 691533 60006551634 60006551634 hep5 viral vaccines 00006-4093-02 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 37.64 11/15/2021 9:43 18.82 18.82 0 122 Formulary 0 636 90744 hepatitis A adult vaccine hepatitis A vaccine adult 1440 Unit(s)/mL 8331249 59041076 60006557334 60006557334 hep1440susp viral vaccines 58160-0826-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 85 2/24/2023 15:03 85 85 0 300 Formulary 0 636 90632 diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) peds 0.5mL 8320708 35160297 60006561344 60006561344 DTaPpeds 58160-0810-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 105.28 12/1/2021 8:27 52.64 52.64 0 219.6 Formulary 0 636 90700 "diphtheria/hepB/pertussis,acel/polio/tet" "diphth/hepB/pertussis,acel/polio/tetanus vaccine 0.5mL syringe" 8320621 34922578 60006561377 60006561377 pediarix0.5syr 58160-0811-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 172.6 11/15/2021 9:46 86.3 86.3 0 300 Formulary 0 636 90723 "typhoid vaccine, inactivated" "typhoid vaccine, inactivated 0.5mL syringe" 8322912 38249772 60006561401 60006561401 typ bacterial vaccines 49281-0790-51 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 119.63 2/8/2023 10:25 59.815 59.815 0 248.3 Formulary 0 636 90691 hepatitis A pediatric vaccine hepatitis A pediatric PF vaccine 720 units/0.5 mL syringe 8320633 34936123 60006561484 60006561484 hep720 viral vaccines 58160-0825-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 50 9/13/2022 0:00 25 25 0 134 Formulary 0 636 90633 yellow fever vaccine "yellow fever vaccine, live 0.5mL vial" 8327122 42606327 60006561559 60006561559 yelfev viral vaccines 49281-0915-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 167.73 12/12/2022 21:39 167.73 167.73 0 450 Formulary 0 636 90717 hepatitis A pediatric vaccine hepatitis A peds vaccine 25 Unit(s)/0.5mL (VFC) 8320228 32430472 60006561567 60006561567 hep25vfc viral vaccines 00006-4095-02V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 0:00 0.01 0.01 0 0.01 Formulary 0 636 90633 SL diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) peds (VFC) 0.5mL syringe 8320241 32432649 60006561658 60006561658 dipvfc vaccine combinations 58160-0810-11V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 10/11/2023 8:38 0.01 0.01 0 0.01 Formulary 0 636 90700 SL measles/mumps/rubella virus vaccine measles/mumps/rubella virus vacc 0.5mL (VFC) 8320232 32430971 60006561674 60006561674 meavfc vaccine combinations 00006-4681-00V 1 EA 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 11/22/2021 7:28 0.01 0.01 0 0.01 Formulary 0 636 90707 SL "diphtheria/hepB/pertussis,acel/polio/tet" "diphth/hepB/pertuss,acel/polio/tetanus vacc 0.5mL (VFC)" 8320233 32431074 60006561757 60006561757 dipvfc vaccine combinations 58160-0811-52V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 0:00 0.01 0.01 0 0.01 Formulary 0 636 90723 SL hepatitis B pediatric vaccine hepatitis B peds vacc 10mcg/0.5mL (VFC) 8320240 32432159 60006561773 60006561773 hep10vfc viral vaccines 58160-0820-11V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 16:53 0.01 0.01 0 0.01 Formulary 0 636 90744 SL niCARdipine niCARdipine 2.5mg/mL 10mL vial 8318580 7707667 60006562151 60006562151 niC2.5i calcium channel blocking agents 00143-9689-10 1 vial(s) 10 mL LVP As Directed Rate PMC - INJ PMC COST 0.917 4/6/2023 15:33 9.17 9.17 0.04 64.1 Formulary J2404 "Injection, nicardipine, 0.1 mg" 250 636 meningococcal conjugate vaccine meningococcal conjugate (Menactra) vaccine 8333409 68654586 60006564082 60006564082 men bacterial vaccines 49281-0589-05 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 165 9/13/2022 0:00 82.5 82.5 0 300 Formulary 0 636 90734 tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss acel (Tdap) 8333418 68656024 60006564470 60006564470 Tdapbc vaccine combinations 58160-0842-52 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 69.562 1/8/2024 7:47 34.781 34.781 0 183 Formulary 0 636 90715 measles/mumps/rubella/varicella virus va measles/mumps/rubella/varicella virus vaccine vial (G/K) 8320634 34936556 60006565014 60006565014 proquad vaccine combinations 00006-4171-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 255 9/13/2022 0:00 255 255 0 519 Formulary 0 636 90710 JZ tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss acel (Tdap) (VFC) 8320099 32074437 60006565584 60006565584 Tdapvfcbc toxoids 58160-0842-52V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:25 0.01 0.01 0 0.01 Formulary 0 636 90715 SL meningococcal conjugate vaccine meningococcal conj (Menactra) vacc 0.5mL (VFC) 8333414 68655509 60006565642 60006565642 menvfc bacterial vaccines 49281-0589-05V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:10 0.01 0.01 0 0.01 Formulary 0 636 90734 SL tetanus-diphth toxoids (Td) adult/adol tetanus-diphtheria (Tenivac) 5-2LFU/ 0.5mL 7 years and over 8318083 1343630 60006565741 60006565741 td 49281-0215-15 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 69.28 11/15/2021 9:47 34.64 34.64 0 182.2 Formulary 0 636 90714 measles/mumps/rubella/varicella virus va measles/mumps/rubella/varicella vacc 0.5mL (VFC) (G/K) 8320235 32431273 60006566137 60006566137 meavfc vaccine combinations 00006-4171-00V 1 EA 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 16:29 0.01 0.01 0 0.01 Formulary 0 636 90710 JZ rotavirus vaccine rotavirus vaccine pentavalent 2mL oral soln (VFC) 8320237 32431439 60006566145 60006566145 rotpentavalentvfc viral vaccines 00006-4047-41V 1 EA 2 mL MED - COA PMC - DIRECT COST PMC COST 0.005 2/18/2022 16:42 0.01 0.01 0 0.01 Formulary 0 636 90680 SL hepatitis A-hepatitis B vaccine hep A-hepB vacc 720 units-20 mcg/mL 8327173 43462837 60006568349 60006568349 hepABvac vaccine combinations 58160-0815-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 115 9/22/2022 0:00 115 115 0 354 Formulary 0 636 90636 "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio peds (Kinrix) 0.5mL 8320622 34922755 60006570550 60006570550 kinrix0.5mL vaccine combinations 58160-0812-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 52.64 11/15/2021 10:13 26.32 26.32 0 140.6 Formulary 0 636 90696 hepatitis B adult vaccine hepatitis B vaccine adult 20mcg/mL 8318673 8591599 60006570626 60006570626 hepb20 viral vaccines 58160-0821-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 73 11/15/2021 10:14 73 73 0 301 Formulary 0 636 90746 diphth/haemophilus/pertussis/tetanus/pol diphth/haemophilus/pertussis/tetanus/polio (VFC) peds 0.5mL syringe 8320650 35012363 60006570642 DONOTLOAD pentacelVFC vaccine combinations 49281-0510-05V 1 vial(s) 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 16:04 0.01 0.01 0 0.01 Formulary 0 636 90698 SL pneumococcal 13-valent vaccine pneumococcal 13-valent vacc 0.5mL (VFC) 8320234 32431184 60006574891 60006574891 pnevfc bacterial vaccines 00005-1971-02V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:27 0.01 0.01 0 0.01 Formulary 0 636 90670 SL haemophilus b conjugate (PRP-OMP) vaccin haemophilus b conjugate (PRP-OMP) vaccine 8318091 1352985 60006574925 60006574925 haeHIB bacterial vaccines 00006-4897-00 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 25.18 11/15/2021 10:19 12.59 12.59 0 84.6 Formulary 0 636 90647 pneumococcal 13-valent vaccine pneumococcal 13-valent conjugate vacc 0.5mL 8320626 34923067 60006575476 60006575476 pne13 bacterial vaccines 00005-1971-02 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 526 11/15/2021 10:20 263 263 0 535 Formulary 0 636 90670 eriBULin eriBULin mesylate 1mg/2mL SDV (G/K) 8333433 68658407 60006581698 60006581698 erib1 mitotic inhibitors 62856-0389-01 1 vial(s) 2 mL CHEMO IVPB - COA PMC - INJ PMC COST 6834 1/8/2024 7:47 13668 13668 1366.8 27345 Formulary J9179 Eribulin mesylate injection 10 636 JZ meningococcal conjugate vaccine meningococcal conj (Menveo) vaccine 0.5mL 8320627 34923233 60006585673 60006585673 men0.5 bacterial vaccines 58160-0955-09 1 EA 1 EA INJ - COA PMC - INJ PMC COST 139.26 11/15/2021 10:21 139.26 139.26 0 426.8 Formulary 0 636 90734 hepatitis A pediatric vaccine hepatitis A peds vaccine 25 units/0.5 mL syringe 8320638 34987743 60006588263 60006588263 hep25 viral vaccines 00006-4095-02 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 45 11/30/2021 9:04 22.5 22.5 0 121.5 Formulary 0 636 90633 haemophilus b conjugate (PRP-OMP) vaccin haemophilus b conj (PRP-OMP) vacc (VFC) 0.5mL 8320230 32430731 60006589675 60006589675 haevfc bacterial vaccines 00006-4897-00V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:34 0.01 0.01 0 0.01 Formulary 0 636 90647 SL tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss (Adacel) (Tdap) (VFC) 8326503 40796154 60006590046 DONOTLOAD TdapAdacel vaccine combinations 49281-0400-20V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/2/2022 12:15 0 0 0 0 Formulary 0 636 90715 SL rotavirus vaccine rotavirus vaccine pentavalent 2mL oral susp 8320623 34922842 60006590715 60006590715 rotpentavalent viral vaccines 00006-4047-20 1 syringe(s) 2 mL MED - COA PMC - INJ PMC COST 80.62 2/21/2023 9:34 161.24 161.24 0 450 Formulary 0 636 90680 "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio 0.5mL (VFC) 8320643 34996169 60006590749 60006590749 kinVFC vaccine combinations 58160-0812-11V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 16:10 0.01 0.01 0 0.01 Formulary 0 636 90696 SL diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP)(VFC) ped 0.5 mL susp 8327267 45219365 60006590928 DONOTLOAD dip15vfc vaccine combinations 49281-0286-10V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:19 0.01 0.01 0 0.01 Formulary 0 636 90700 SL human papillomavirus vaccine human papillomavirus vaccine 9-valent susp 0.5mL 8334923 150527614 60006590943 60006590943 hum9 viral vaccines 00006-4121-02 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 275 9/13/2022 0:00 137.5 137.5 0 421.5 Formulary 0 636 90651 human papillomavirus vaccine human papillomavirus vaccine 9-valent (VFC) susp 0.5mL 8334941 151279080 60006590945 60006590945 hum9VFC viral vaccines 00006-4121-02V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:30 0.01 0.01 0 0.01 Formulary 0 636 90651 SL meningococcal group B vaccine meningococcal group B (Bexsero) vaccine recombinant 0.5mL 8335186 157561325 60006590978 60006590978 menBex0.5 bacterial vaccines 58160-0976-20 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 275 9/13/2022 0:00 137.5 137.5 0 421.5 Formulary 0 636 90620 meningococcal group B vaccine meningococcal group B (Bexsero) vaccine recombinant 0.5mL (VFC) 8335771 177709721 60006591058 60006591058 menBexVFC bacterial vaccines 58160-0976-20V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 14:35 0.01 0.01 0 0.01 Formulary 0 636 90620 SL diphenhydrAMINE diphenhydrAMINE 12.5mg/5mL oral liquid 120mL MDC 8330372 53165410 60006591298 60006591298 dip300 antihistamines 50580-0534-04 1 bottle 120 mL Special Delivery MDC COA PMC - DIRECT COST PMC COST 0.03712 11/11/2021 9:52 4.4544 4.4544 0 4.45 Formulary 0 637 tetanus-diphth toxoids (Td) adult/adol tetanus-diphth toxoids (Td) adult/adol 2-2LFU/0.5 mL syringe 8338254 221134921 60006591332 60006591332 td22 vaccine combinations 13533-0131-01 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 43.364 1/8/2024 7:47 21.682 21.682 0 120 Formulary 0 636 90714 "Zoster Vaccine Recombinant, Adjuvanted" zoster vaccine recomb vial 8339142 248831268 60006591611 60006591611 zosarecom viral vaccines 58160-0823-11 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 215 9/13/2022 0:00 215 215 0 450 Formulary 0 636 90750 hepatitis A pediatric vaccine hepatitis A pediatric PF vaccine 720 units/0.5 mL syringe (VFC) 8320654 35039101 60006591815 60006591815 hep720VFC viral vaccines 58160-0825-52V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:55 0.01 0.01 0 0.01 Formulary 0 636 90633 SL tetanus/diphth/pertuss (Tdap) adult/adol "tetanus/diphtheria/pertussis, acel/ adult (Adacel)" 8344180 311440051 60006592210 60006592210 adacel vaccine combinations 49281-0400-20 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 72.72 10/21/2022 15:09 36.36 36.36 0 190.8 Formulary 0 636 90715 diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) ped 0.5 mL susp 8344253 312134428 60006592239 60006592239 dip150.5 vaccine combinations 49281-0286-10 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 22.14 8/10/2023 14:48 11.07 11.07 0 75.5 Formulary 0 636 90700 ibuprofen ibuprofen 100 mg/5 mL susp 118 mL MDC 8344666 316528767 60006592463 60006592463 ibup100susp nonsteroidal anti-inflammatory agents 50580-0601-21 1 EA 118 mL Special Delivery MDC COA PMC - MED PMC COST 0.02208 11/11/2021 9:52 2.60544 2.60544 0 29.6 Formulary 0 637 rotavirus vaccine rotavirus vaccine monovalent 1mL (Rotarix VFC) 8344909 317935019 60006592642 DONOTLOAD rot1VFCmono viral vaccines 58160-0854-52V 1 EA 1 mL MED - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 0:00 0.01 0.01 0 0.01 Formulary 0 636 90681 SL magnesium hydroxide magnesium hydroxide 80mg/mL susp 480mL MDC 8345240 322306552 60006592783 60006592783 maghy480mdc antacids 00536-2470-85 1 bottle 480 mL Special Delivery MDC COA PMC - DIRECT COST PMC COST 0.005 12/1/2021 11:34 2.4 2.4 0 2.4 Formulary 0 637 acetaminophen acetaminophen 160 mg/5 mL oral liq 118mL MDC 8345604 326112138 60006593010 60006593010 acetaminliq118mLMDC miscellaneous analgesics 00904-7014-20 1 bottle 118 mL Special Delivery MDC COA PMC - MED PMC COST 0.0222 12/28/2023 8:06 2.6196 2.6196 0 29.7 Formulary 0 637 dexamethasone dexamethasone 10mg/mL 1mL inj 8345649 326878999 60006593055 60006593055 dexainj10 glucocorticoids 00641-0367-21 1 mL 1 mL INJ - COA PMC - INJ PMC COST 1.58 11/15/2021 10:33 1.58 1.58 0.16 26.4 Formulary J1100 Dexamethasone sodium phos 10 636 rotavirus vaccine rotavirus vaccine monovalent 1mL (Rotarix) 8345651 326892561 60006593057 60006593057 rotmonovalent viral vaccines 58160-0854-52 1 EA 1 mL MED - COA PMC - INJ PMC COST 126.28 11/15/2021 10:33 126.28 126.28 0 387.9 Formulary 0 636 90681 silver sulfADIAZINE topical silver sulfADIAZINE 1% cream 20gm 8345652 326892971 60006593058 60006593058 sil20gm topical antibiotics 67877-0124-20 1 tube 20 gm Bulk PMC - MED PMC COST 0.2215 11/11/2021 9:52 4.43 4.43 0 39 Formulary 0 637 meningococcal conjugate vaccine meningococcal conj vacc (MenQuadfi) ACYW (VFC) 0.5mL 8345746 327061403 60006593083 60006593083 menquadfivfc bacterial vaccines 49281-0590-05V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 13:54 0.01 0.01 0 0.01 Formulary 0 636 90619 SL meningococcal conjugate vaccine meningococcal conjugate vacc (MenQuadfi) ACYW 0.5mL 8345747 327061497 60006593087 60006593087 medquadfi bacterial vaccines 49281-0590-05 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 228.24 8/19/2022 16:47 114.12 114.12 0 351.4 Formulary 0 636 90619 pneumococcal 20-valent conjugate vaccine pneumococcal 20-valent conjugate vaccine 0.5mL 8345955 328423599 60006593290 60006593290 prevnar20 bacterial vaccines 00005-2000-10 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 463.74 11/22/2023 0:00 231.87 231.87 0 472.8 Formulary 0 636 90677 "diphtheria/haem/hepB/pert,acel/polio/tet" "VFC - diphtheria/haem/hepB/pert,acel/polio/tetan 0.5mL syringe" 8408164 331917041 60006593445 DONOTLOAD vaxelis0.5VFC vaccine combinations 63361-0243-15V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 4/14/2023 10:04 0 0 0 0 Formulary 0 636 90697 SL gadobutrol RAD gadobutrol 1mmol/mL 15mL soln 8920701 349763937 60006594041 60006594041 RAD gadobutrol (Gadavist) 1mmol/mL 15mL soln magnetic resonance imaging contrast media 50419-0325-13 1 vial(s) 15 mL INJ - COA PMC - DIRECT COST PMC COST 2.90866 4/10/2023 11:43 43.6299 43.6299 0.29 43.63 Formulary A9585 Gadobutrol injection 150 636 "influenza vaccine, inact" "influenza vacc (Fluzone HD) high-dose PF, 65 years & over 0.7mL" 8948593 354747696 60006594197 60006594197 FluzoneHD2023 viral vaccines 49281-0123-65 1 syringe(s) 0.7 mL INJ - COA PMC - DIRECT COST PMC COST 107.1428 9/27/2023 10:10 74.99996 74.99996 0 75 Formulary 0 636 90662 "influenza vaccine, inact" "influenza vacc (FluZone) quad PF, 6 months and over 0.5mL" 8954798 355012102 60006594200 60006594200 Fluzone2023 viral vaccines 49281-0423-50 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 70 9/27/2023 10:08 35 35 0 35 Formulary 0 636 90686 "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio peds (Quadracel) 0.5mL 8954895 355091819 60006594202 60006594202 Quadracel vaccine combinations 49281-0564-15 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 130 8/10/2023 9:33 65 65 0 269 Formulary 0 636 90696 "influenza vaccine, inact" influenza vacc (Flublok) 18 years and older 8951726 355093850 60006594204 60006594204 Flublok2023 viral vaccines 49281-0723-10 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 156 8/30/2023 0:00 78 78 0 78 Formulary 0 636 90682 "influenza virus vaccine, live" "VFC - influenza vacc (FluMist nasal) quad, live 0.2mL" 8954981 355133516 60006594207 60006594207 FluMistVFC2023 viral vaccines 66019-0310-10 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0 9/27/2023 10:11 0 0 0 0 Formulary 0 636 90672 "influenza vaccine, inact" "VFC - influenza vacc (FluZone) quad PF, 6 months and over" 8957013 355644536 60006594223 60006594223 Fluzone2023VFC viral vaccines 49281-0423-50 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 9/27/2023 10:09 0 0 0 0 Formulary 0 636 90686 "influenza virus vaccine, live" "influenza vacc (FluMist nasal) quad, live 0.2mL" 8958268 355727483 60006594227 60006594227 FluMist2023 viral vaccines 66019-0310-10 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 45 8/30/2023 0:00 45 45 0 45 Formulary 0 636 90672 SARS-CoV-2 (COVID-19) mRNA-LNP(12+yr) va SARS-CoV-2 (COVID-19) (Moderna) mRNA-LNP 0.5 mL vaccine 8964921 356912949 60006594261 60006594261 Spikevax50 viral vaccines 80777-0102-93 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 56.4 11/2/2023 0:00 28.2 28.2 0 150 Formulary 0 636 91322 SARS-CoV-2 (COVID-19) mRNA-LNP(6mo-12yr) SARS-CoV-2 (COVID-19) (PED Moderna 6mo-11yr) 0.25mL vaccine 8963530 357026838 60006594262 60006594262 SARPEDMOD0.25 viral vaccines 80777-0287-92 1 EA 0.25 mL INJ - COA PMC - INJ PMC COST 600 11/29/2023 11:04 150 150 0 459 Formulary 0 636 91321 SARS-CoV-2 (COVID-19) mRNA-LNP(6mo-12yr) VFC- SARS-CoV-2 (COVID-19) (PED Moderna 6mo-11yr) 0.25mL vaccine 8966635 357028111 60006594263 60006594263 SARPEDMOD0.25VFC viral vaccines 80777-0287-92 1 EA 0.25 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/11/2023 0:00 0 0 0 0 Formulary 0 636 91321 SARS-CoV-2 (COVID-19) mRNA-LNP(12+yr) va VFC - SARS-CoV-2 (COVID-19) (Moderna) mRNA-LNP 0.5 mL vaccine 8966643 357028456 60006594264 60006594264 Spikevax50VFC viral vaccines 80777-0102-93 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/11/2023 0:00 0 0 0 0 Formulary 0 636 91322 pneumococcal 23-valent vaccine pneumococcal 23-valent vaccine 0.5 mL 8318214 2778674 60006800163 60006800163 pneumo23 bacterial vaccines 00006-4943-00 1 vial(s) 0.5 mL MED - COA PMC - INJ PMC COST 124 11/15/2021 10:34 62 62 0 257 Formulary 0 636 90732