85 / 99
Top 25 NDC by Plan Paid
TOP CONDITION
# OF CLAIMANTS
MEMBER PAID
% PLAN PAID
OF TOTAL
PLAN PAID
PLAN PAID
NDC DESCRIPTION (DRUG
NAME)
Cataract, wo comp, wo
surg
4
$595.00
2.26 %
$7,065.65
RESTASIS
Diabetes, wo comp, wo
comorb, wo surg
1
$525.00
2.22 %
$6,964.80
Trulicity
Mood disorder, bipolar,
wo comp, wo comorb
1
$270.00
1.91 %
$5,989.00
Latuda
unavailable
1
$0.00
1.79 %
$5,606.48
Diclofenac sodium
unavailable
1
$0.00
1.76 %
$5,514.06
LIVIXIL PAK
Environmental trauma
2
$0.00
1.74 %
$5,463.18
EPIPEN
Pulmonology disease S&S
2
$385.00
1.40 %
$4,395.42
Xarelto
Diabetes, wo comp, wo
comorb, wo surg
1
$350.00
1.32 %
$4,144.32
FARXIGA
Diabetes, wo comp, wo
comorb, wo surg
6
$1,015.00
1.27 %
$3,972.06
ONETOUCH ULTRA TEST
STRIPS
Diabetes, wo comp, w
comorb, wo surg
1
$175.00
1.13 %
$3,537.28
FARXIGA
Embolism & thrombosis
veins, wo comp, wo surg
1
$221.12
1.12 %
$3,519.34
ELIQUIS
Diabetes, wo comp, w
comorb, wo surg
2
$365.00
1.08 %
$3,378.20
Tresiba
Diabetes, wo comp, w
comorb, wo surg
1
$350.00
1.07 %
$3,348.12
JANUMET
Inflam bowel disease, w
comp, wo comorb, wo
surg
1
$245.00
1.02 %
$3,183.80
Lialda
Urinary incontinence, w
comorb, w surg
1
$35.00
0.99 %
$3,088.66
Myrbetriq
Asthma, wo comp, w
comorb
1
$323.20
0.96 %
$3,015.05
Combivent Respimat
Diabetes, wo comp, wo
comorb, wo surg
1
$335.00
0.96 %
$2,994.79
KOMBIGLYZE
Asthma, wo comp, w
comorb
32
$780.00
0.90 %
$2,818.55
PROAIR
1,891
$57,916.81
40.09 %
$125,576.95
Remaining NDC Codes
Page 18 of 28
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