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NDC HCPCS HCPCS Description NDC Description Rebateable Rebate Start Date Rebate End Date Medicare Only60574-4111-01 90378 RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN (RSV-IGIM), FORSYNAGIS (SINGLE USE VIAL,PF) 100 MG Y 03/01/2008 99/99/999960574-4112-01 90378 RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN (RSV-IGIM), FORSYNAGIS (SINGLE USE VIAL,PF) 50 MG Y 03/01/2008 99/99/9999

00074-1584-01 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (150 ML CONTAINER,PF) 0.9% Y 03/01/2008 99/99/999900074-1966-04 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (25X10ML,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900074-1966-07 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (VIAL, FLIPTOP PLASTIC) 0.9% Y 03/01/2008 99/99/999900074-1966-12 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (25X10ML,LS-PLASTIC) 0.9% Y 03/01/2008 99/99/999900074-1966-14 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (FLIPTOP,LS-PLASTIC) 0.9% Y 03/01/2008 99/99/999900074-2102-05 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL,PF) 0.9% Y 03/01/2008 99/99/999900074-3977-03 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION BACTERIOSTATIC (VIAL,FLIPTOP,LATEX-FREE) Y 03/01/2008 99/99/999900074-4027-02 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (AMP,PF,LATEX-FREE) Y 03/01/2008 99/99/999900074-4029-03 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (AMP,PF,LATEX-FREE) Y 03/01/2008 99/99/999900074-4044-02 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (AMP,PF,LATEX-FREE) Y 03/01/2008 99/99/999900074-4887-10 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (VIAL, FLIPTOP,PF) Y 03/01/2008 99/99/999900074-4887-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (VIAL, FLIPTOP,PF) Y 03/01/2008 99/99/999900074-4887-50 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (VIAL, FLIPTOP,PF) Y 03/01/2008 99/99/999900074-4887-99 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (VIAL, FLIPTOP,PF) Y 03/01/2008 99/99/999900074-4888-10 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL, FLIPTOP, ADDITIVE) 0.9% Y 03/01/2008 99/99/999900074-4888-12 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL,FLIPTOP,LIFESHIELD) 0.9% Y 03/01/2008 99/99/999900074-4888-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL, FLIPTOP, ADDITIVE) 0.9% Y 03/01/2008 99/99/999900074-4888-50 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL, FLIPTOP, ADDITIVE) 0.9% Y 03/01/2008 99/99/999900074-7101-66 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (ADD-VANT,LIFECARE,PF) 0.9% Y 03/01/2008 99/99/999900074-7984-13 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LIFECARE SINGLE-P/F) 0.9% Y 03/01/2008 99/99/999900074-7984-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LIFECARE,QUAD PACK,LF) 0.9% Y 03/01/2008 99/99/999900074-7984-36 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LIFECARE,QUAD PACK,LF) 0.9% Y 03/01/2008 99/99/999900264-1800-31 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (100 ML PAB) 0.9% Y 03/01/2008 99/99/999900264-1800-36 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (100 ML PAB) 0.9% Y 03/01/2008 99/99/999900338-0049-10 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (QUAD PACK, MINI-BAG) 0.9% Y 03/01/2008 99/99/999900338-0049-11 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (QUAD PACK, MINI-BAG) 0.9% Y 03/01/2008 99/99/999900338-0049-31 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (MULTI PACK, MINI-BAG) 0.9% Y 03/01/2008 99/99/999900338-0049-41 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (SINGLE PACK, MINI-BAG) 0.9% Y 03/01/2008 99/99/999900338-0553-11 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (MINI-BAG PLUS) 0.9% Y 03/01/2008 99/99/999900338-8301-79 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE FLUSH (SRN,BLUNT CANNULA) 0.9% Y 03/01/2008 99/99/999900338-8302-69 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE FLUSH (SRN,BLUNT CANNULA) 0.9% Y 03/01/2008 99/99/999900338-8303-70 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE FLUSH (SRN,BLUNT CANNULA) 0.9% Y 03/01/2008 99/99/999900338-8303-72 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE FLUSH (SRN,BLUNT CANNULA) 0.9% Y 03/01/2008 99/99/999900409-1918-32 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LUER LOCK,50X2ML,PF) 0.9% Y 03/01/2008 99/99/999900409-1918-33 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LUER LOCK,PF,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900409-1918-35 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LUER LOCK,PF,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900409-1966-04 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (25X10ML,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900409-1966-05 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (25X20ML,LATEX-FREE) 0.9% Y 03/01/2008 99/99/9999

NDC HCPCS HCPCS Description NDC Description Rebateable Rebate Start Date Rebate End Date Medicare Only00409-1966-07 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (VIAL,FLIPTOP PLASTIC) 0.9% Y 03/01/2008 99/99/999900409-1966-12 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (25X10ML, LS-PLASTIC) 0.9% Y 03/01/2008 99/99/999900409-1966-14 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (FLIPTOP,LS-PLASTIC) 0.9% Y 03/01/2008 99/99/999900409-2102-02 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (25X2ML,PF) 0.9% Y 03/01/2008 99/99/999900409-2102-05 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (25X5ML,PF) 0.9% Y 03/01/2008 99/99/999900409-3977-03 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION BACTERIOSTATIC (VIAL,FLIPTOP,LATEX-FREE) Y 03/01/2008 99/99/999900409-4029-03 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (AMP,PF,LATEX-FREE) Y 03/01/2008 99/99/999900409-4044-02 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (25X10ML,PF,LATEX-FREE) Y 03/01/2008 99/99/999900409-4887-10 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (FTV,25X10ML,PF) Y 03/01/2008 99/99/999900409-4887-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (25X20ML,STERILE,PF) Y 03/01/2008 99/99/999900409-4887-50 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (FTV,25X50ML,PF) Y 03/01/2008 99/99/999900409-4887-99 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION (FTV,25X100ML,PF) Y 03/01/2008 99/99/999900409-4888-10 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL,FLIPTOP,ADDITIVE) 0.9% Y 03/01/2008 99/99/999900409-4888-12 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (25X10ML,PF,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900409-4888-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL, FLIPTOP, ADDITIVE) 0.9% Y 03/01/2008 99/99/999900409-4888-50 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL,FLIPTOP,ADDITIVE) 0.9% Y 03/01/2008 99/99/999900409-7101-66 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (ADD-VANT,LIFECARE) 0.9% Y 03/01/2008 99/99/999900409-7984-13 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (48X50ML,PF,LATEX-FREE) 0.9% Y 03/01/2008 99/99/999900409-7984-20 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LIFECARE,QUAD PACK,LF) 0.9% Y 03/01/2008 99/99/999900409-7984-36 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (LFCARE,QUAD,LF,80X50ML) 0.9% Y 03/01/2008 99/99/999900487-9301-02 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (ROBOT READY,30X3ML) 0.9% Y 03/01/2008 99/99/999900487-9301-03 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (VIAL) 0.9% Y 03/01/2008 99/99/999900487-9301-33 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE 0.9% Y 03/01/2008 99/99/999900517-0648-25 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE BACTERIOSTATIC (M.D.V.) 0.9% Y 03/01/2008 99/99/999900517-0662-25 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML WATER FOR INJECTION BACTERIOSTATIC (M.D.V.) Y 03/01/2008 99/99/999900517-2802-25 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML SODIUM CHLORIDE (S.D.V.,PF) 0.9% Y 03/01/2008 99/99/999900517-2810-25 A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH

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