118 / 208
Top 20 NDC by Plan Paid
50458014130
49702023113
00051846233
61958070101
61958120101
00186504031
00088221905
00169750111
50881002060
00169643810
63402030830
50881001560
00169406013
00078060715
00074379902
58468021002
76346007301
00003085222
58406044504
00074433902
$0
$30,000
$60,000
$90,000
$120,000
TOP CONDITION
# OF CLAIMANTS
MEMBER PAID
% PLAN PAID
OF TOTAL
PLAN PAID
PLAN PAID
NDC DESCRIPTION (DRUG
NAME)
Oth skin inflam, wo
comp, wo comorb
5
$5,370.00
7.48 %
$126,481.89
Humira
Adult rheumatoid
arthritis, wo comp, wo
comorb
3
$4,299.24
5.62 %
$94,953.92
ENBREL
Leukemia, wo surg, w
a/m
1
$1,500.00
5.01 %
$84,671.48
SPRYCEL
Hyper-funct adrenal
gland, wo surg
1
$600.00
4.30 %
$72,640.12
Korlym
Multiple sclerosis, wo
surg
1
$2,040.00
4.18 %
$70,725.25
Aubagio
Adult rheumatoid
arthritis, wo comp, wo
comorb
1
$1,740.00
2.64 %
$44,590.35
Humira
Multiple sclerosis, wo
surg
1
$660.00
2.62 %
$44,284.79
Gilenya
Diabetes, wo comp, wo
comorb, wo surg
10
$2,380.00
1.89 %
$31,912.74
Victoza
Oth hematologic dis, wo
surg
1
$300.00
1.81 %
$30,568.77
JAKAFI
Page 17 of 41
Incurred: 2/1/2016 to 1/31/2017
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