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| Code / Rx# | Category | Tier | Formulation & FDA-Approved Legend Ingredients (NDC-11) | ICD-10 Triggers | Gross U&C |
|---|---|---|---|---|---|
|
RX0921 Rx# 000000921028 |
Pain Management | SUB_850 |
Pain Matrix Standard (Diclofenac 1.5% / Lidocaine 2.5% Cream)
• 51672-1356-01 | Diclofenac Sodium 3% Gel (Taro) (60GM • AWP $420.00)
• 51672-1355-05 | Lidocaine 5% Ointment (Taro) (60GM • AWP $360.00)
|
M1990, E1142, B0223, M5450 |
$795.00 AWP $780.00 + $15 |
|
PRX100001 Rx# 000000100001 |
Pain Management | ELEVATED |
Pain Matrix Elevated (Doxepin 2.5% / Lidocaine 1.25% / Prilocaine 1.25% Cream)
• 51672-4040-02 | Doxepin HCl 5% Cream (Taro) (60GM • AWP $1,850.00)
• 59115-0023-30 | Lidocaine 2.5% / Prilocaine 2.5% Cream (60GM • AWP $390.00)
|
G8929, M792, G5600, E1142 |
$2,255.00 AWP $2,240.00 + $15 |
|
DRX0923 Rx# 000000921030 |
Dermatology | SUB_850 |
Dermatology Matrix Standard (Calcipotriene 0.0025% / Betamethasone 0.025% Cream)
• 68462-0502-60 | Calcipotriene 0.005% Cream (Glenmark) (60GM • AWP $410.00)
• 51672-1299-03 | Betamethasone Dipropionate 0.05% Cream (60GM • AWP $340.00)
|
L400, L209, L309 |
$765.00 AWP $750.00 + $15 |
|
DRX100002 Rx# 000000100002 |
Dermatology | ELEVATED |
Dermatology Matrix Elevated (Tazarotene 0.033% / Dapsone 2.5% / Clobetasol 0.017% Cream)
• 51672-1359-06 | Tazarotene 0.1% Cream (Taro) (60GM • AWP $1,120.00)
• 51672-1416-06 | Dapsone 7.5% Gel (Taro) (60GM • AWP $980.00)
• 51672-1258-03 | Clobetasol Propionate 0.05% Cream (60GM • AWP $290.00)
|
L400, L700, L719 |
$2,405.00 AWP $2,390.00 + $15 |
|
FRX0925 Rx# 000000921032 |
Fungal & Seborrheic | SUB_850 |
Fungal Matrix Standard (Econazole 0.33% / Ketoconazole 0.67% / Hydrocortisone 0.83% Cream)
• 51672-1303-03 | Econazole Nitrate 1% Cream (Taro) (60GM • AWP $440.00)
• 51672-1298-03 | Ketoconazole 2% Cream (Taro) (60GM • AWP $195.00)
• 51672-1275-03 | Hydrocortisone 2.5% Cream (Taro) (60GM • AWP $145.00)
|
B353, B356, L219, B372 |
$795.00 AWP $780.00 + $15 |
|
FRX100003 Rx# 000000100003 |
Fungal & Seborrheic | ELEVATED |
Fungal Matrix Elevated (Oxiconazole 0.28% / Ciclopirox 0.33% / Urea 11.4% Cream)
• 51672-1365-06 | Oxiconazole Nitrate 1% Cream (Taro) (60GM • AWP $1,280.00)
• 51672-1312-08 | Ciclopirox Olamine 0.77% Cream (Taro) (90GM • AWP $480.00)
• 42808-0204-60 | Urea 40% Keratolytic Cream (60GM • AWP $320.00)
|
B351, B353, L608 |
$2,095.00 AWP $2,080.00 + $15 |
|
SRX0924 Rx# 000000921031 |
Wound & Scar | SUB_850 |
Scar & Keloid Matrix Standard (Flurandrenolide 0.025% / Triamcinolone 0.05% Cream)
• 24470-0912-60 | Flurandrenolide 0.05% Cream (60GM • AWP $520.00)
• 51672-1281-02 | Triamcinolone Acetonide 0.1% Cream (60GM • AWP $245.00)
|
L910, L905 |
$780.00 AWP $765.00 + $15 |
|
WRX100004 Rx# 000000100004 |
Wound & Scar | ELEVATED |
Wound & Antimicrobial Matrix Elevated (Mupirocin 0.67% / Metronidazole 0.33% / Lidocaine 1.67%)
• 68462-0564-30 | Mupirocin Calcium 2% Cream (Glenmark) (60GM • AWP $1,180.00)
• 51672-1343-03 | Metronidazole 1% Gel (Taro) (60GM • AWP $690.00)
• 51672-1355-05 | Lidocaine 5% Ointment (Taro) (60GM • AWP $360.00)
|
L089, L8990, L97909, T148 |
$2,245.00 AWP $2,230.00 + $15 |
|
NRX0922 Rx# 000000921029 |
Neuropathy & Field Therapy | SUB_850 |
Neuropathy Matrix Standard (Lidocaine 3.75% / Prilocaine 1.25% Cream)
• 51672-1355-05 | Lidocaine 5% Ointment (Taro) (60GM • AWP $360.00)
• 59115-0023-30 | Lidocaine 2.5% / Prilocaine 2.5% Cream (60GM • AWP $390.00)
|
E1142, G609, B0229 |
$765.00 AWP $750.00 + $15 |
|
AKX100005 Rx# 000000100005 |
Neuropathy & Field Therapy | ELEVATED |
Actinic Field Matrix Elevated (Fluorouracil 1.25% / Calcipotriene 0.0019% / Tacrolimus 0.038%)
• 51672-4062-01 | Fluorouracil 5% Cream (Taro) (40GM • AWP $1,150.00)
• 68462-0502-60 | Calcipotriene 0.005% Cream (Glenmark) (60GM • AWP $410.00)
• 51672-1353-06 | Tacrolimus 0.1% Ointment (Taro) (60GM • AWP $590.00)
|
L570, L400, C4499 |
$2,165.00 AWP $2,150.00 + $15 |
|
SPX2001 Rx# 000000200001 |
Specialty Derm | SPECIALTY_ALERT |
Opzelura (Ruxolitinib 1.5% Cream - 60g)
• 50881-0007-05 | Opzelura 1.5% Cream (Incyte) (60GM • AWP $2,150.00)
PA / Alert Criteria: Age >= 12; Mild-to-moderate Atopic Dermatitis (BSA <= 20%) or Nonsegmental Vitiligo (BSA <= 10%); Step-therapy failure of Topical Steroid or Tacrolimus 0.1%; Negative TB screen.
|
L209, L2089, L80 |
$2,165.00 AWP $2,150.00 + $15 |
|
SPX2002 Rx# 000000200002 |
Specialty Derm | SPECIALTY_ALERT |
Vtama (Tapinarof 1% Cream - 60g)
• 81672-5051-01 | Vtama 1% Cream (Organon/Dermavant) (60GM • AWP $1,680.00)
PA / Alert Criteria: Plaque Psoriasis or Atopic Dermatitis (Age >= 2); Step-therapy failure of 1 topical corticosteroid or Calcipotriene 0.005%.
|
L400, L409, L209 |
$1,695.00 AWP $1,680.00 + $15 |
|
SPX2003 Rx# 000000200003 |
Specialty Derm | SPECIALTY_ALERT |
Zoryve (Roflumilast 0.3% Cream - 60g)
• 80610-0306-60 | Zoryve 0.3% Cream (Arcutis) (60GM • AWP $1,050.00)
PA / Alert Criteria: Plaque Psoriasis or Seborrheic Dermatitis; Step-therapy failure of topical steroid or Ketoconazole 2%; No Child-Pugh B/C hepatic impairment.
|
L400, L219, L218 |
$1,065.00 AWP $1,050.00 + $15 |
|
SPX2004 Rx# 000000200004 |
Specialty Neuropathy | SPECIALTY_ALERT |
Qutenza (Capsaicin 8% Topical System - 2 Patch Kit)
• 70512-0802-02 | Qutenza 8% Patch (2-Patch System) (2EA • AWP $1,120.00)
PA / Alert Criteria: Diabetic Peripheral Neuropathy (DPN) of feet or Postherpetic Neuralgia (PHN); Inadequate response to Lidocaine 5% or Gabapentin/Pregabalin; Provider-administered.
|
E1142, B0229, B0223 |
$1,135.00 AWP $1,120.00 + $15 |
|
SPX2009 Rx# 000000200009 |
Nephrology Specialty | SPECIALTY_ALERT |
Tarpeyo (Budesonide 4mg Delayed-Release Caps - 120ct)
• 73650-0216-12 | Tarpeyo 4mg Delayed-Release Caps (120ct) (120EA • AWP $21,500.00)
PA / Alert Criteria: Biopsy-confirmed Primary IgA Nephropathy (IgAN); UPCR >= 1.5 g/g or proteinuria >= 1.0 g/day; eGFR >= 35; Stable on maximally tolerated ACEi/ARB >= 90 days.
|
N02B1, N028, N029 |
$21,515.00 AWP $21,500.00 + $15 |
|
SPX2010 Rx# 000000200010 |
Nephrology REMS Specialty | SPECIALTY_ALERT |
Filspari (Sparsentan 400mg Tablets - REMS - 30ct)
• 68974-0400-30 | Filspari 400mg Film-Coated Tablets (30ct) (30EA • AWP $14,600.00)
PA / Alert Criteria: Biopsy-confirmed IgAN with UPCR >= 1.5 g/g; Filspari REMS Certified; Baseline & monthly ALT/AST < 3x ULN; Negative pregnancy test; Discontinue ACEi/ARB prior to Day 1.
|
N02B9, N02B1, N028 |
$14,615.00 AWP $14,600.00 + $15 |