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PRESCRIPTION DRUG PROGRAM FORMULARY EFFECTIVE JULY 1, 2008

www.MyIBXTPA.com a b Dear Participant: In an effort to continue our commitment to provide you with comprehensive coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected FDA-approved prescription medications reviewed by the Pharmacy and Therapeutics Committee. These prescription medications have been selected for their reported medical effectiveness, safety, and value, while providing you with the highest level of coverage under your prescription program.

The following information serves as a guide when reviewing the list of formulary drugs on the following pages. • Bolded drug = Formulary generic available at lowest copay • Non-bolded drug = Formulary brand available at middle copay • Drug in parenthesis ( ) = Non-formulary brand drug available at the highest copay. It is displayed next to the equivalent formulary generic Drug that is available at the lowest copay. For example: amoxicillin is the formulary generic drug available at the lowest copay. (Amoxil) is the non-formulary brand available at the highest copay. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary. • Covered brand drugs not listed are non-formulary and are available at the highest copay.

The above information is highlighted in a key box indicated on every other page of the formulary list.

Our pharmacy benefits manager, FutureScripts®, continuously monitors effectiveness and safety of drugs and drug prescribing patterns.

1 Please note: Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call 1-888-678-7013 for any questions about your prescription drug benefit. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Prescription Drug Program Formulary information can also be obtained at www.MyIBXTPA.com.

Dear Physician: This is a listing of formulary medications to be considered for your patient, a Prescription Drug Program Formulary participant. Please refer to this Prescription Drug Program Formulary in order to choose a medication. Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for your independent professional judgment. Rather, it is offered as a tool to help our members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.

2 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR clarithromycin (Biaxin) clarithromycin SR 24 hr DRUG NAME (Biaxin XL) clindamycin (Cleocin) acyclovir (Zovirax) troches Agenerase (Mycelex) amantadine (Symmetrel) Combivir amoxicillin (Amoxil) Crixivan amoxicillin/clavulanate Dapsone (Augmentin) Daraprim ampicillin (Principen) demeclocycline Augmentin XR (Declomycin) Atripla dicloxacillin azithromycin 250mg, didanosine delayed-rel 500mg, 600mg 200mg, 250mg, (Zithromax) 400mg (Videx EC) cefaclor (Ceclor) hyclate cefaclor ER (Vibramycin, Periostat) cefadroxil for susp doxycycline 250mg/5ml (Duricef) monohydrate (Monodox) cefadroxil 500mg/5ml Emtriva suspension (Duricef) Epivir cefdinir (Omnicef) Epzicom cefuroxime axetil (Ceftin) erythromycin, cephalexin (Keflex) delayed release chloroquine phosphate (Eryc, Ery-Tab) (Aralen) erythromycin Cipro oral suspension ethylsuccinate (EES, ciprofloxacin tabs (Cipro) EryPed) Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

3 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR methenamine hippurate INFECTION (Cont.) (Hiprex, Urex) DRUG NAME (Flagyl) caps erythromycin stearate (Minocin, Dynacin) (Erythrocin) minocycline tabs erythromycin suspension Mintezol w/sulfa (Pediazole) Mycobutin ethambutol (Myambutol) nitrofurantoin famciclovir (Famvir) macrocrystals Fansidar (Macrodantin) Flagyl ER Norvir fluconazole (Diflucan) (Mycostatin) Fortovase ofloxacin (Floxin) Fuzeon penicillin VK (Veetids) ganciclovir (Cytovene) phenazopyridine Gris-PEG (Pyridium) griseofulvin microsize Prezista suspension (Grifulvin V) Primaquine Grifulvin V tabs pyrazinamide Hepsera Rescriptor HIVID Reyataz hydroxychloroquine ribavirin (Rebetol) (Plaquenil) rifampin (Rifadin) Isentress Rifater isoniazid rimantadine itraconazole (Sporonax) (Flumadine) Kaletra Selzentry tabs sulfamethoxazole/tmp (Nizoral tabs) (Septra DS) Levaquin sulfisoxazole tabs Lexiva Sustiva mebendazole (Vermox) Tamiflu mefloquine (Lariam) terbinafine tablets Mepron (Lamisil Tablets) methenamine-hysoc- (Sumycin) meth blue-sod Tobi phosphenyl sal tab Trizivir 120mg hyoscyamine Truvada (Urimar) Valcyte Valtrex Vfend 4 1. ANTIBIOTICS & DRUG NAME OTHER DRUGS USED FOR cyclosporine modified INFECTION (Cont.) (Neoral) DRUG NAME 200mg (Danocrine) Videx Emcyt Videx EC 125mg etoposide (VePesid) Viracept Fareston Viramune Femara Viread flutamide (Eulexin) Xifaxan Gleevec Zerit Hexalen Ziagen hydroxyurea (Hydrea) zidovudine 300mg, leucovorin calcium 10mg/ml syrup Leukeran (Retrovir) Lysodren 2. CANCER & ORGAN Matulane TRANSPLANT DRUGS (Megace) mercaptopurine DRUG NAME (Purinethol) Alkeran methotrexate Aromasin Myleran azathioprine (Imuran) (Deltasone) Casodex Prograf CeeNU Rapamune Cellcept tamoxifen (Nolvadex) cyclophosphamide Targretin (Cytoxan) Temodar cyclosporine thioguanine (Sandimmune) Xeloda Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

5 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH carbidopa/levodopa CR DRUG NAME (Sinemet CR) Celontin Abilify chlorpromazine acetaminophen with choline magnesium codeine (Tylenol with trisalicylate Codeine #2, #3, #4) citalopram (Celexa) acetazolamide clomipramine HCl Adderall XR (Anafranil) alprazolam (Xanax) clonazepam (Klonopin) amantadine (Symmetrel) clonazepam wafer tablet amitriptyline (Klonopin wafer tablet) amoxapine clozapine (Clozaril) apap/butalbital codeine tabs (Phrenilin, Phrenilin Forte) Comtan apap-salicylamide- Concerta phenyltolox-caffeine Depakote cap 325-250-20-50mg Depakote ER (Durulac cap) desipramine (Norpramin) Aricept dexmethylphenidate Aricept ODT (Focalin) with codeine dextroamphetamine/ Avinza amphetamine mixture benztropine (Adderall) bromocriptine mesylate diazepam (Valium) (Parlodel) diclofenac potassium buproprion XL (Cataflam) (Wellbutrin XL) diclofenac bupropion (Wellbutrin) (Voltaren XR) bupropion ER diflunisal (Dolobid) (Wellbutrin SR) doxepin (Sinequan) buspirone (BuSpar) Duragesic 12mcg butalbital/apap/ ergotamine/caffeine caffeine (Fioricet) supp (Cafergot) butalbital/aspirin/ ergotamine/caffeine caffeine (Fiorinal) tabs (Cafergot) butalbital/aspirin/ ethosuximide (Zarontin) caffeine/codeine etodolac (Lodine XL) (Fiorinal with Codeine) fenoprofen calcium carbamazepine (Tegretol) (Nalfon) carbidopa/levodopa fentanyl citrate OTFC (Sinemet) (Actiq) 6 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH (Cont.) Imitrex NS DRUG NAME indomethacin (Indocin SR) isometheptene/ fentanyl transdermal dichloralphenazone/ (Duragesic) apap (Midrin) fluoxetine (Prozac) ketoprofen (Oruvail, Orudis) fluphenazine ketorolac (Toradol oral) flurbiprofen (Ansaid) Lamictal fluvoxamine lamotrigine Disp tabs gabapentin (Neurontin) 5mg, 25mg (Lamictal haloperidol Chew Tabs 5mg, 25mg) hydrocodone/ Lexapro acetaminophen lithium carbonate (Vicodin, Norco, Maxidone) (Eskalith) hydrocodone/ lithium carbonate SR acetaminophen elixir (Eskalith CR, Lithobid) (Lortab) lorazepam (Ativan) hydrocodone/ loxapine (Loxitane) acetaminophen ES maprotiline (Vicodin ES) Maxalt, Maxalt-MLT hydrocodone/ibuprofen meclofenamate (Vicoprofen) meperidine HCl syrup hydromorphone HCl (Demerol) supps (Dilaudid) meperidine HCl tabs hydromorphone HCl (Demerol) tabs (Dilaudid) methadone (Dolophine) ibuprofen (Motrin) methamphetamine ibuprofen/oxycodone HCl (Desoxyn) (Combunox) methylphenidate, SR imipramine (Tofranil) (Ritalin SR) Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

7 3. PAIN, NERVOUS DRUG NAME SYSTEM, & PSYCH (Cont.) Parnate DRUG NAME paroxetine tabs (Paxil) perphenazine migergot (Cafergot) phenobarbital Mirapex phenytoin mirtazapine (Remeron) piroxicam (Feldene) mirtazapine primidone (Mysoline) rapid dissolve tabs propoxyphene HCl/apap (Remeron SolTab) propoxyphene morphine sulfate soln napsylate/apap (MSIR) (Darvocet-N) morphine sulfate Prostigmin supp (RMS) pyridostigmine (Mestinon) morphine sulfate tabs Restoril 7.5mg (MSIR) morphine sulfate, Risperdal extended release salsalate (MS Contin) selegiline HCl (Eldepryl) nabumetone (Relafen) Seroquel Namenda sertraline (Zoloft) naproxen (Naprosyn) Sonata naproxen sodium Strattera (Anaprox DS) sulindac (Clinoril) naproxen sodium SA Tegretol XR (Naprelan) temazepam 15mg, 30mg Nardil (Restoril 15mg, 30mg) nefazodone thioridazine Neurontin soln thiothixene (Navane) nortriptyline (Pamelor) tolmetin oxaprozin (Daypro) tramadol (Ultram) oxazepam (Serax) tranycypromine sulfate oxcarbazepine (Trileptal) (Parnate) oxycodone (OxyIR) trazodone (Desyrel) oxycodone/apap caps trifluoperazine (Tylox) trihexyphenidyl oxycodone/apap tabs valproic (Depakene) (Roxicet, Percocet) venlafaxine (Effexor) oxycodone/aspirin zolpidem tartrate (Percodan) (Ambien) oxycodone CR 12 hour Zomig tabs (OxyContin) Zomig, Zomig ZMT paroxetine HCL susp Zyprexa (Paxil susp) 8 4. HEART, BLOOD PRESSURE, DRUG NAME & CHOLESTEROL chlorthalidone DRUG NAME chlorthalidone/atenolol (Tenoretic) acebutolol (Sectral) cholestyramine amiloride (Midamor) (Questran Light) amiloride/HCTZ cilostazol (Pletal) (Moduretic) clonidine (Catapres tablets) aminocaproic acid colestipol hcl (Colestid) (Amicar) Coumadin amiodarone HCl digoxin (Cordarone) Dilatrate-SR amlodipine (Norvasc) diltiazem (Cardizem) amlodipine/benazepril diltiazem extended (Lotrel) release (Cardizem CD, anagrelide (Agrylin) Dilacor XR) atenolol (Tenormin) diltiazem ER 24 hour Azor (Tiazac) benazepril (Lotensin) diltiazem SR (Cardizem SR) benazepril/HCTZ Diovan (Lotensin HCT) Diovan HCT Benicar dipyridamole (Persantine) Benicar HCT disopyramide (Norpace) betaxolol (Kerlone) disopyramide CR bisoprolol/HCTZ (Ziac) 150mg (Norpace CR) bumetanide (Bumex) doxazosin mesylate captopril (Capoten) (Cardura) captopril/HCTZ Edecrin (Capozide) enalapril (Vasotec) carvedilol (Coreg) chlorothiazide Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

9 4. HEART, BLOOD PRESSURE, DRUG NAME & CHOLESTEROL (Cont.) nadolol (Corgard) nadolol-bendroflume DRUG NAME thiazide (Corzide) fenofibrate 67mg, Niaspan 134mg, 200mg (Lofibra) nifedipine ER flecainide (Tambocor) (Adalat CC, Procardia XL) fosinopril (Monopril) Nimotop furosemide (Lasix) Nitro-Bid gemfibrozil (Lopid) nitroglycerin patches guanabenz (Nitro-Dur) guanfacine HCl (Tenex) nitroglycerin SL (Nitrostat hydralazine SL) hydrochlorothiazide nitroglycerin, oral (HCTZ) extended release hydrochlorothiazide pentoxifylline (Trental) 12.5mg (Microzide) pindolol indapamide (Lozol) pravastatin 10mg, 20mg, Inderal LA 40mg (Pravachol) isosorbide dinitrate prazosin (Minipress) (Isordil tabs) procainamide (Pronestyl) isosorbide dinitrate Procanbid extended release propafenone (Rythmol) isosorbide mononitrate propranolol (Inderal) (Ismo) propranolol/HCTZ isosorbide mononitrate (Inderide) ER (Imdur) quinapril/HCTZ isradipine (DynaCirc) (Accuretic) labetalol HCl (Trandate) quinidine gluconate Lanoxin extended release lisinopril (Prinivil) quinidine sulfate lisinopril/HCTZ (Prinzide) ramipril (Altace) lovastatin (Mevacor) simvastatin (Zocor) Mephyton sotalol HCl (Betapace AF) methyldopa metolazone (Zaroxolyn) (Aldactone) metoprolol (Lopressor) spironolactone/HCTZ metoprolol succinate (Aldactazide) (Toprol XL) Sular mexiletine HCl (Mexitil) terazosin (Hytrin) minoxidil (Loniten) ticlopidine HCl (Ticlid) moexipril/HCTZ (Uniretic)

10 4. HEART, BLOOD PRESSURE, DRUG NAME & CHOLESTEROL (Cont.) Bactroban cream benzoyl peroxide/ DRUG NAME erythromycin timolol (Blocadren) (Benzamycin Gel, except torsemide (Demadex) Benzamycin pak) trandolapril (Mavik) benzoyl peroxide/urea triamterene/HCTZ cream (Zoderm) (Dyazide, Maxzide 25) / Tricor clotrimazole (Lotrisone) verapamil (Calan) betamethasone verapamil extended- dipropionate 0.05% release (Verelan) cream, lotion, oint verapamil extended- betamethasone release PM (Verelan PM) dipropionate verapamil SR (Calan SR, augmented 0.05% gel, Isoptin SR) oint (Diprolene) warfarin betamethasone Zetia dipropionate augmented 0.05% 5. SKIN MEDICATIONS cream (Diprolene AF) DRUG NAME 0.1% cream, lotion, oint (Beta-Val) dipropionate cream ciclopirox cream, susp (Aclovate) (Loprox) 0.1% cream, ciclopirox solution, lotion, oint (Cyclocort) (Penlac) anthralin 1% cream clindamycin (Cleocin T) (Psoriatec)

Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

11 5. SKIN MEDICATIONS DRUG NAME (Cont.) 2.5% cream, lotion, oint DRUG NAME (Hytone) 0.05% cream, lotion, oint, gel 0.1% cream/soln (Temovate) (Locoid) 0.05% cream, gel (Topicort) 0.2% cream, oint desoximetasone 0.25% (Westcort) cream, oint (Topicort) isotretinoin (Accutane) diacetate ketoconazole cream 0.05% cream, oint (Nizoral cream) (Psorcon) ketoconazole shampoo 2% Dovonex (Nizoral shampoo) econazole (Spectazole) lidocaine (Xylocaine) Efudex cream lindane lotion erythromycin gel (Erygel, Loprox gel Emgel) cream erythromycin solution (Elocon) erythromycin swabs metronidazole cream (Erycette) (MetroCream) acetonide metronidazole lotion 0.01% cream, soln (Metrolotion) (Synalar) oint (Bactroban) 0.025% cream (Synalar) Noritate fluocinolone acetonide nystatin (Mycostatin) 0.025% oint (Synalar) nystatin/ 0.05% gel, (Mycolog II) oint, cream (Lidex) Oxsoralen lotion 1% fluocinonide 0.05% gel, Oxsoralen Ultra oint, cream (Lidex E) permethrin (Elimite) Fluoroplex podofilox soln (Condylox) fluorouracil solution ointment (Efudex) (Dermatop) propionate prilocaine/lidocaine 0.05% cream, 0.005% (Emla cream) oint (Cutivate) Regranex gentamicin topical selenium sulfide cream, oint (Selsun Rx) silver sulfadiazine (Silvadene) 12 5. SKIN MEDICATIONS DRUG NAME (Cont.) benzocaine/antipyrine DRUG NAME (Benzotic) gluconate sodium sulfacetamide (Peridex) lotion (Klaron) Cipro HC Otic sodium sulfacetamide/ (Nasarel) sulfur (Sulfacet-R, Plexion) sulfacetamide sodium nasal suspension 10% lotion (Sebizon) (Flonase) sulfacetamide sodium/ ipratropium (Atrovent urea lotion (Carmol scalp Nasal Spray) lotion) Nasacort AQ tretinoin (Retin-A, Avita) Nasonex triamcinolone 0.025% /polymyxin/ cream, lotion (Kenalog) hydrocortisone triamcinolone acetonide (Cortisporin Otic) 0.1% lotion, cream, ofloxacin otic (Floxin oint (Kenalog) Otic) triamcinolone 0.5% triamcinolone (Kenalog cream, oint (Kenalog) in Orabase) urea cream (Keralac cream) 7. DIABETES, THYROID, Zovirax oint & OTHER MISCELLANEOUS 6. EAR, NOSE, THROAT HORMONES MEDICATIONS DRUG NAME DRUG NAME acetic acid/HC (Acetasol HC) Accu-Check Monitor Bactroban Nasal Oint Accu-Check Test Strips Actoplus Met Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

13 7. DIABETES, THYROID, DRUG NAME STEROIDS, & OTHER hydrocortisone 20mg MISCELLANEOUS tabs (Cortef) HORMONES (Cont.) Iletin insulins Insulin syringes DRUG NAME Lancets Actos Lantus vial, cartridge Androgel levothyroxine Avandamet (Levoxyl, Synthroid) Avandaryl metformin (Glucophage) Avandia metformin ER Byetta (Glucophage XR) calcitriol capsules metformin/glyburide (Rocaltrol capsules) (Glucovance) Cortef 5mg, 10mg methimazole (Tapazole) Cytadren Cytomel (Medrol) danazol (Danocrine) Novolin desmopressin acetate Novolog aerosol spray/nasal Novolog mix soln/tabs (DDAVP) OneTouch Monitor OneTouch Test Strips (Decadron) oxandrolone (Oxandrin) acetate Prandin (Florinef) sodium glimepiride 1mg, phosphate (Pediapred, 2mg, 4mg (Amaryl) Orapred) glipizide (Glucotrol) prednisolone syrup glipizide ER (Glucotrol XL) (Prelone) Glucagon Emergency Kit prednisone tabs glyburide (Diabeta, (Deltasone) Micronase) propylthiouracil glyburide micronized Sensipar (Glynase) Starlix Humalog Symlin Humulin insulins tolbutamide Zavesca

14 8. STOMACH, ULCER, & DRUG NAME BOWEL MEDS Nexium For Delayed-Release DRUG NAME Oral Suspension nizatidine (Axid) Asacol omeprazole (Prilosec) balsalazide (Colazal) ondansetron HCL (Zofran) Canasa supp pancrelipase EC/SA Carafate susp (Pancrease, Pancrease MT) chlordiazepoxide/ pantoprazole (Protonix) clidinium PEG 3350 & electrolytes cimetidine (Tagamet) (Nulytely) dicyclomine (Bentyl) Pentasa diphenoxylate HCl/ phenobarb/hyoscyamine/ atropine (Lomotil) atrop/scop (Donnatal) Emend Prevacid famotidine 40mg (Pepcid) Prevacid Granules For Oral Gastrocrom Suspension granisetron (Kytril) Prevacid Orally hydrocortisone (Anusol-HC Disintegrating Tablets rectal cream, supp) prochlorperazine hydrocortisone retention (Compazine tabs, supp) enema (Colocort) Proctofoam-HC hyoscyamine (Levsin, promethazine (Phenergan Levsinex, Levbid) tab, supp) Kristalose ranitidine 300mg (Zantac) lactulose soln sucralfate tabs (Carafate) mesalamine rectal susp sulfasalazine (Azulfidine) (Rowasa) trimethobenzamide metoclopramide (Reglan) (Tigan oral, supp) misoprostol (Cytotec) ursodiol (Actigall) Nexium Zantac syrup Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

15 9. BIOTECHNOLOGY DRUG NAME DRUG NAME flurbiprofen (Ansaid) Humira Avonex hydrocortisone 20mg Copaxone tabs (Cortef) Lovenox hydroxychloroquine Peg-Intron (Plaquenil) Procrit ibuprofen (Motrin) 10. BONES, JOINTS, & indomethacin (Indocin) MUSCLES indomethacin SR (Indocin SR) DRUG NAME ketoprofen (Orudis) Actonel ketoprofen SR (Oruvail) alendronate (Fosamax) ketorolac (Toradol oral) alendronate/Vitamin D leflunomide 10mg, (Fosamax Plus D) 20mg (Arava) allopurinol (Zyloprim) meclofenamate azathioprine (Imuran) meloxicam (Mobic) baclofen methocarbamol calcitonin-salmon (Robaxin) (rDNA origin) nasal methotrexate spray (Miacalcin) methylprednisolone carisoprodol (Soma) (Medrol) chlorzoxazone (Parafon nabumetone (Relafen) Forte) naproxen (Naprosyn) choline magnesium naproxen sodium trisalicylate (Anaprox DS) colchicine naproxen sodium SA Cortef 5mg, 10mg (Naprelan) cyclobenzaprine hcl oxaprozin (Daypro) (Flexeril) piroxicam (Feldene) dexamethasone (Decadron) prednisolone sodium diazepam (Valium) phosphate (Pediapred, diclofenac potassium Orapred) (Cataflam) prednisolone syrup diclofenac sodium (Prelone) (Voltaren XR) prednisone tabs diflunisal (Dolobid) (Deltasone) Enbrel probenecid etodolac (Lodine XL) salsalate Evista Skelaxin fenoprofen calcium sulfasalazine (Azulfidine) (Nalfon) 16 10. BONES, JOINTS, & DRUG NAME MUSCLES (Cont.) Estraderm (Estrace) DRUG NAME estradiol transdermal sulfinpyrazone (Climara) sulindac (Clinoril) Estratest HS tizanidine (Zanaflex) Estring tolmetin estropipate (Ogen) 11. FEMALE, HORMONE Femhrt REPLACEMENT, fluconazole 150mg BIRTH CONTROL (Diflucan) Follistim The Injectable Fertility Follistim AQ Agents in this section are /ethinyl only covered under certain estradiol (Seasonale, benefi ts programs. Please Triphasil) check your booklet/member Lunelle handbook to determine coverage. acetate (Provera) DRUG NAME medroxyprogesterone acetate 150mg/mL Bravelle (Depo-Provera) Cenestin Menopur clindamycin cream Methergine (Cleocin) metronidazole vaginal Depo-Provera 150mg gel 0.75% (Metrogel) Depo Sub Q Provera 104mg norethindrone /ethinyl norethindrone acetate estradiol (Aygestin) esterified estrogens/ methyltestosterone Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

17 11. FEMALE, HORMONE DRUG NAME REPLACEMENT, bacitracin/polymyxin B BIRTH CONTROL (Cont.) ophth oint (Polysporin) DRUG NAME betaxolol Betimol norethindrone/ethinyl Betoptic S estradiol Blephamide norethindrone/ethinyl brimonidine estradiol, Fe carbachol 3% (Isopto norethindrone acetate/ Carbachol 3%) ethinyl estradiol/ carteolol ferrous fumarate ciprofloxacin (Ciloxan) (Estrostep Fe) Cosopt norethindrone/mestranol cromolyn ophth (Crolom) /ethinyl cyclopentolate HCl estradiol (Cyclogyl) /ethinyl dexamethasone ophth estradiol Diamox sequels Novarel dipivefrin HCl (Propine) Nuvaring erythromycin nystatin (FML, Ortho Evra Liquifilm) Premarin gentamicin ophth (Gentak) Premarin Vaginal Cream HMS Premphase homatropine 5% (Isopto Prempro Homatropine) Prometrium Isopto Homatropine Repronex levobunolol (Betagan) terconazole cream Lotemax (Terazol 3) Lumigan Vivelle, Vivelle Dot methazolamide 12. EYE MEDICATIONS neomycin/polymyxin B/ dexamethasone DRUG NAME (Maxitrol) acetazolamide ofloxacin (Ocuflox) Acular Optivar Alphagan P Patanol Alrex Phospholine Iodide atropine sulfate (Isopto pilocarpine (Pilocar, Atropine) Isopto Carpine) Azopt Pilopine HS gel bacitracin ophth polymyxin B/neo/ bacitracin (Neosporin oint) 18 12. EYE MEDICATIONS 13. ALLERGY, COUGH & (Cont.) COLD, LUNG MEDS DRUG NAME DRUG NAME polymyxin B/neo/ acetylcysteine (Mucomyst) gramicidin (Neosporin Advair Diskus soln) albuterol inhaler (Proventil, Ventolin) (Econopred Plus, Pred- albuterol syrup, soln, Forte) tabs (Proventil, Ventolin) prednisolone sodium Alupent aerosol phosphate (Inflamase aminophylline tabs Forte) Astelin prednisolone/sodium Atrovent HFA aerosol sulfacetamide (Vasocidin Azmacort oint) benzonatate (Tessalon sulfacetamide (Bleph 10) Perles) timolol ophth (Timoptic) brompheniramine/ timolol XE (Timoptic XE) phenlephrine Tobradex (Brovex D) tobramycin (Tobrex) chlorpheniramine/ trifluridine (Viroptic) trimethoprim sulfate/ (Rynatan) polymyxin B (Polytrim) chlorpheniramine/ tropicamide (Mydriacyl) phenylephrine/ Trusopt methscopolamine Vexol chewable tabs, syrup Vigamox (Extendryl) Voltaren Xalatan

Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

19 13. ALLERGY, COUGH & DRUG NAME COLD, LUNG MEDS (Cont.) hydroxyzine HCl DRUG NAME hydroxyzine pamoate (Vistaril) chlorpheniramine/ Intal oral inhaler phenylephrine/ ipratropium-albuterol methscopolamine (Duoneb) extended release ipratropium inhalation (Hista-Vent DA) soln (Atrovent soln) Combivent MDI Maxair Cortef 5mg, 10mg metaproterenol tabs, cromolyn inhalation syrup soln (Intal soln) metaproterenol cyproheptadine inhalation soln dexamethasone (Decadron) methylprednisolone Elixophyllin (Medrol) EpiPen Nasacort AQ EpiPen Jr. Auto-Injector/E*Z Nasonex Extendryl SR phenylephrine- fexofenadine (Allegra) carbinoxamine w/ Flovent HFA hydrocodone liqd flunisolide (Nasarel) 8-4-5mg/5ml (Max HC) Foradil phenylephrine/cpm/ guaifenesin/codeine hydrocodone (Guiatuss AC) (Histussin-HC) guaifenesin/hydrocodone phenylephrine HCL/ guaifenesin/ COD/prometh phenylephrine/ (Phenergan VC w/codeine) hydrocodone (Duratuss phenylephrine/ HD elixir) hydrocodone/BPM guaifenesin/ (Flutuss HC liquid) / phenylephrine/ codeine (Guiatuss DAC, hydrocodone/CP Novahistine) (Maxituss HC) hydrocodone/ prednisolone sodium homatropine syrup phosphate (Pediapred, (Hycodan) Orapred) hydrocortisone 20mg prednisolone syrup tabs (Cortef) (Prelone) prednisone tabs (Deltasone)

20 13. ALLERGY, COUGH & DRUG NAME COLD, LUNG MEDS (Cont.) theophylline extended DRUG NAME release caps 12H theophylline extended promethazine release tabs (Theochron, (Phenergan) Uniphyl) promethazine/codeine Tilade promethazine/ Tracleer dextromethorphan Vospire ER promethazine/ phenylephrine/ 14. URINARY & codeine PROSTATE MEDS Proventil HFA DRUG NAME pseudoephedrine/ brompheniramine/ bethanechol (Urecholine) hydrocodone liquid doxazosin mesylate (Brovex HC) (Cardura) pseudoephedrine/cpm/ finasteride (Proscar) codeine (Novahistine DH) flavoxate (Urispas) pseudoephedrine/ methenamine/ guaifenesin extended methylene blue/ release (Zephrex LA) benzoic acid/ Pulmicort Respules, salicylic acid/atropine Turbuhaler (Prosed EC tab) Pulmozyme methenamine/ Serevent Diskus phenylsalicylate/ Singulair atropine/hyoscyamine/ Spiriva benzoic acid/ terbutaline sulfate tabs methylene blue (Urised) (Brethine) Muse Theo-24 oxybutynin (Ditropan) Key Type of Covered Drug* You pay • Bolded drug is a formulary generic. Lowest copay • Non-bolded drug is a formulary brand. Middle copay • Drug in parenthesis ( ) is a non-formulary brand Highest copay drug. It is displayed to help you identify the equivalent formulary generic drug that is available at the lowest copay. • Covered brand drugs not listed are non-formulary. Highest copay * Unless specifically excluded from your contract

21 14. URINARY & DRUG NAME PROSTATE MEDS (Cont.) prenatal vitamins DRUG NAME with folic acid (Stuartnatal Plus with or oxybutynin ER without iron) (Ditropan XL) sodium drops phenazopyridine (Luride drops) (Pyridium) vitamin D (Drisdol) potassium cirate (Urocit-K) 16. DIAGNOSTICS & terazosin (Hytrin) MISCELLANEOUS AGENTS Viagra DRUG NAME 15. VITAMINS & Antabuse ELECTROLYTES benzoyl peroxide DRUG NAME urea cream Chemet ergocalciferol (Calciferol) etidronate 200mg, fluoride 400mg (Didronel) folic acid midodrine (ProAmatine) iron, carbonyl 15mg PhosLo (Icar) pilocarpine 5mg Micro-K 8mEq (Salagen) multivitamin with pilocarpine fluoride drops, tabs hydrochloride 7.5mg (Tri-Vi-Flor, Poly-Vi-Flor (Salagen) with and without iron) sodium fluoride potassium bicarbonate/ solution rinse effervescent 25mEq (K-Lyte) 20mEq (K-Dur) potassium chloride 10mEq (Klor-Con 10, Kaon-CL 10, Klotrix, K-Tab, K-Dur, Micro-K) potassium chloride 8mEq (Klor-Con 8) potassium chloride liquid potassium powder 20mEq (K-Lor)

22 A amcinonide, 11 Abilify, 6 Amicar, 9 Accu-Check, Monitor, 14 amiloride, 9 Accu-Check Test Strips, 14 amiloride/HCTZ, 9 Accuretic, 10 aminocaproic acid, 9 Accutane, 12 aminophylline, 19 acebutolol, 9 amiodarone HCl, 9 acetaminophen with codeine, 6 amitriptyline, 6 Acetasol HC, 13 amlodipine, 9 acetazolamide, 6, 18 amlodipine/benazepril, 9 acetic acid/HC, 13 amoxapine, 6 acetylcysteine, 19 amoxicillin, 3 Aclovate, 9 amoxicillin/clavulanate, 3 Actigall, 15 Amoxil, 3 Actiq, 6 ampicillin, 3 Actonel, 16 Anafranil, 6 Actoplus Met, 14 anagrelide, 9 Actos, 14 Anaprox, DS, 8, 16 Acular, 18 Androgel, 14 acyclovir, 3 Ansaid, 7, 16 Adalat CC, 10 Antabuse, 22 Adderall, 6 anthralin cream, 11 Adderall XR, 6 Anusol-HC Rectal, 15 Advair Diskus, 19 apap/butalbital, 6 Agenerase, 3 apap-salicylamide-phenyltolox- Agrylin, 9 caffeine, 6 albuterol, 19 Aralen, 3 alclometasone, 11 Arava, 16 Aldactazide, 10 Aricept, 6 Aldactone, 10 Aromasin, 5 alendronate, 16 Asacol, 15 alendronate/Vitamin D, 16 aspirin with codeine, 6 Alkeran, 5 Astelin, 19 Allegra, 20 atenolol, 9 allopurinol, 16 Ativan, 7 Alphagan P, 18 Atripla, 3 alprazolam, 6 atropine sulfate, 18 Alrex, 18 Atrovent HFA, 19 Altace, 10 Atrovent Nasal Spray, 13 Alupent, 19 Atrovent soln, 20 amantadine, 3, 6 Augmentin, 3 Amaryl, 14 Augmentin XR, 3 Ambien, 8 23 Avandamet, 14 betaxolol, 9, 18 Avandaryl, 14 bethanechol, 21 Avandia, 14 Betimol, 18 Avinza, 6 Betoptic S, 18 Avita, 13 Biaxin, 3 Avonex, 16 Biaxin XL, 3 Axid, 15 bisoprolol/HCTZ, 9 Aygestin, 17 Bleph 10, 19 azathioprine, 5, 16 Blephamide, 18 azithromycin, 3 Blocadren, 11 Azmacort, 19 Bravelle, 17 Azopt, 18 Brethine, 21 Azor, 9 brimonidine, 18 Azulfidine, 15, 16 bromocriptine mesylate, 6 brompheniramine/ B phenlephrine, 19 bacitracin ophth, 18 Brovex D, 19 bacitracin/polymyxin B ophth, 18 Brovex HC, 21 baclofen, 16 bumetanide, 9 Bactroban, 11, 12, 13 Bumex, 9 balsalazide, 15 bupropion, ER, XL, 6 benazepril, 9 BuSpar, 6 benazepril/HCTZ, 9 buspirone, 6 Benicar, 9 butalbital/apap/caffeine, 6 Benicar HCT, 9 butalbital/aspirin/caffeine, 6 Bentyl, 15 butalbital/aspirin/caffeine/ Benzamycin Gel, 11 codeine, 6 benzocaine/antipyrine, 13 Byetta, 14 benzonatate, 19 Benzotic, 13 C benzoyl peroxide urea cream, 22 Cafergot, 6, 8 benzoyl peroxide/erythromycin Calan. SR, 11 gel, 11 Calciferol, 22 benzoyl peroxide/urea cream, 11 calcitonin-salmon nasal spray, 16 benztropine, 6 calcitriol, 14 Betagan, 18 Canasa, 15 betamethasone dipropionate, 11 Capoten, 9 betamethasone dipropionate Capozide, 9 augmented, 11 captopril, 9 betamethasone valerate, 11 captopril/HCTZ, 9 betamethasone/clotrimazole, 11 Carafate, 15 Betapace, AF, 10 carbachol, 18 Beta-Val, 11 carbamazepine, 6 24 carbidopa/levodopa, CR, 6 Cipro HC Otic, 13 Cardizem, CD, SR, 9 ciprofloxacin, 3, 18 Cardura, 9, 21 citalopram, 6 carisoprodol, 16 clarithromycin, SR 24 HR, 3 Carmol scalp lotion, 13 Cleocin, 3, 17 carteolol, 18 Cleocin T, 11 carvedilol, 9 Climara, 17 Casodex, 5 clindamycin, 3, 11, 17 Cataflam, 6, 16 Clinoril, 8, 17 Catapres, 9 clobetasol, 12 Ceclor, 3 clomipramine HCl, 6 CeeNU, 5 clonazepam, 6 cefaclor, ER, 3 clonidine, 9 cefadroxil, 3 clotrimazole troches, 3 cefdinir, 3 clozapine, 6 Ceftin, 3 Clozaril, 6 cefuroxime axetil, 3 codeine, 6 Celexa, 6 Colazal, 15 Cellcept, 5 Colazal, 15 Celontin, 6 colchicine, 16 Cenestin, 17 Colestid, 9 cephalexin, 3 colestipol hcl, 9 Chemet, 22 Colocort, 15 chlordiazepoxide/clidinium, 15 Colyte, 15 chlorhexidine gluconate, 13 Combivent MDI, 20 chloroquine phosphate, 3 Combivir, 3 chlorothiazide, 9 Combunox, 7 chlorpheniramine/ Compazine, 15 phenylephrine, 19 Comtan, 6 chlorpheniramine/phenylephrine/ Concerta, 6 methscopolamine, ER, 19,20 Condylox, 12 chlorpromazine, 6 Copaxone, 16 chlorthalidone, 9 Cordarone, 9 chlorthalidone/atenolol, 9 Coreg, 9 chlorzoxazone, 16 Corgard, 10 cholestyramine, 9 Cortef, 14, 16, 20 choline magnesium Cortisporin Otic, 13 trisalicylate, 6, 16 Corzide, 10 ciclopirox, 11 Cosopt, 18 cilostazol, 9 Coumadin, 9 Ciloxan, 18 Crixivan, 3 cimetidine, 15 Crolom, 18 Cipro, 3 cromolyn inhalation soln, 20 25 cromolyn ophth, 18 dextroamphetamine/ Cutivate, 12 amphetamine, 6 cyclobenzaprine hcl, 16 Diabeta, 14 Cyclocort, 11 Diamox sequels, 18 Cyclogyl, 18 diazepam, 6, 16 cyclopentolate HCl, 18 diclofenac potassium, 6, 16 cyclophosphamide, 5 diclofenac sodium, 6, 16 cyclosporine, 5 dicloxacillin, 3 cyclosporine modified, 5 dicyclomine, 15 cyproheptadine, 20 didanosine delayed-rel, 3 Cytadren, 14 Didronel, 22 Cytomel, 14 , 12 Cytotec, 15 Diflucan, 4, 17 Cytovene, 4 diflunisal, 6, 16 Cytoxan, 5 digoxin, 9 Dilacor XR, 9 D Dilatrate-SR, 9 danazol, 5, 14 Dilaudid, 7 Danocrine, 5, 14 diltiazem, ER, SR, 9 Dapsone, 3 Diovan, 9 Daraprim, 3 Diovan HCT, 9 Darvocet-N, 8 diphenoxylate HCL/atropine, 15 Daypro, 8, 16 dipivefrin HCl, 18 DDAVP, 14 Diprolene, AF, 11 Decadron, 14, 16, 20 dipyridamole, 9 Declomycin, 3 disopyramide, CR, 9 Deltasone, 5, 14, 16, 20 Ditropan, 21 Demadex, 11 Ditropan XL, 22 demeclocycline, 3 Dolobid, 6, 16 Demerol, 7 Dolophine, 7 Depakene, 8 Donnatal, 15 Depakote, ER, 6 Dovonex, 12 Depo Sub Q Provera, 17 doxazosin mesylate, 9, 21 Depo-Provera, 17 doxepin, 6 Dermatop, 12 doxycycline hyclate, 3 desipramine, 6 doxycycline monohydrate, 3 desmopressin acetate, 14 Drisdol, 22 desogestrel/ethinyl estradiol, 17 Duoneb, 20 desoximetasone, 12 Duragesic, 6, 7 Desoxyn, 7 Duratuss HD elixir, 20 Desyrel, 8 Duricef, 3 dexamethasone, 14, 16, 18, 20 Durulac, 6 dexmethylphenidate, 6 Dyazide, 11 26 Dynacin, 4 Estrace, 17 DynaCirc, 10 Estraderm, 17 estradiol, 17 E estradiol transdermal, 17 econazole, 12 Estratest, HS, 17 Econopred Plus, 19 Estring, 17 Edecrin, 9 estropipate, 17 EES, 4 Estrostep, 18 Effexor, 8 ethambutol, 4 Efudex, 12 ethosuximide, 6 Eldepryl, 8 etidronate, 22 Elimite, 12 etodolac, 6, 16 Elixophyllin, 20 etoposide, 5 Elocon, 12 Eulexin, 5 Emcyt, 5 Evista, 16 Emend, 15 Extendryl, SR, 19, 20 Emgel, 12 Emla, 12 F Emtriva, 3 famciclovir, 4 enalapril, 9 famotidine, 15 enalapril/HCTZ, 10 Famvir, 4 Enbrel, 16 Fansidar, 4 EpiPen, 20 Fareston, 5 EpiPen Jr. Auto-Injector/E*Z, 20 Feldene, 8, 16 Epivir, 3 felodipine ER, 10 Epzicom, 3 Femara, 5 ergocalciferol, 22 Femhrt, 17 ergotamine/caffeine, 6 fenofibrate, 10 Eryc, 3 fenoprofen calcium, 6, 16 Erycette, 12 fentanyl citrate, 6 Erygel, 12 fentanyl transdermal, 7 EryPed, 4 fexofenadine, 20 Ery-Tab, 3 finasteride, 21 Erythrocin, 4 Fioricet, 6 erythromycin, 12, 18 Fiorinal, 6 erythromycin ethylsuccinate, 3 Fiorinal with Codeine, 6 erythromycin stearate, 4 Flagyl, 4 erythromycin suspension w/ Flagyl ER, 4 sulfa, 4 flavoxate, 21 erythromycin, delayed release, 3 flecainide, 10 Eskalith, CR, 7 Flexeril, 16 esterified estrogens/ Flonase, 13 methyltestosterone, 17 Florinef, 14 27 Flovent HFA, 20 Glucophage, XR, 14 Floxin, 4 Glucotrol, XL, 14 Floxin Otic, 13 Glucovance, 14 fluconazole, 4, 17 glyburide, micronized, 14 fludrocortisone acetate, 14 Glynase, 14 Flumadine, 4 GoLytely, 15 flunisolide, 13, 20 granisetron, 15 fluocinolone acetonide, 12 Grifulvin V, 4 fluocinonide, 12 griseofulvin micro susp, 4 fluoride, 22 Gris-PEG, 4 fluorometholone, 18 guaifenesin/codeine, 20 Fluoroplex, 12 guaifenesin/hydrocodone, 20 fluorouracil solution, 12 guaifenesin/phenylephrine/ fluoxetine, 7 hydrocodone, 20 fluphenazine, 7 guaifenesin/pseudoephedrine/ flurbiprofen, 7, 16 codeine, 20 flutamide, 5 guanabenz, 10 fluticasone propionate, 12, 13 guanfacine HCl, 10 Flutuss HC liquid, 20 Guiatuss AC, 20 fluvoxamine, 7 Guiatuss DAC, 20 FML, 18 Focalin, 6 H folic acid, 22 haloperidol, 7 Follistim, AQ, 17 HCTZ, 10 Foradil, 20 Hepsera, 4 Fortovase, 4 Hexalen, 5 Fosamax, 16 Hiprex, 4 Fosamax Plus D, 16 Hista-Vent DA, 20 fosinopril, 10 Histussin-HC, 20 furosemide, 10 HIVID, 4 Fuzeon, 4 HMS, 18 homatropine, 18 G Humalog, 14 gabapentin, 7 Humira, 16 ganciclovir, 4 Humulin insulins, 14 Gastrocrom, 15 Hycodan, 20 gemfibrozil, 10 hydralazine, 10 Gentak, 18 Hydrea, 5 gentamicin, 12, 18 hydrochlorothiazide, 10 Gleevec, 5 hydrocodone, 21 glimepiride, 14 hydrocodone/acetaminophen, glipizide, ER, 14 ES, 7 Glucagon Emergency Kit, 14 hydrocodone/homatropine, 20 28 hydrocodone/ibuprofen, 7 Isopto Carbachol, 18 hydrocortisone, 12 Isopto Carpine, 18 hydrocortisone butyrate, 12 Isopto Homatropine, 18 hydrocortisone rectal, 15 Isordil, 10 hydrocortisone tabs, 14, 16, 20 isosorbide dinitrate, ER, 10 hydrocortisone valerate, 12 isosorbide mononitrate, ER, 10 hydromorphone HCl, 7 isotretinoin, 12 hydroxychloroquine, 4, 16 isradipine, 10 hydroxyurea, 5 itraconazole, 4 hydroxyzine HCl, 20 hydroxyzine pamoate, 20 K hyoscyamine, 15 Kaletra, 4 Hytone, 12 Kaon-CL 10, 22 Hytrin, 10, 22 K-Dur, 22 Keflex, 3 I Kenalog, 13 ibuprofen, 7, 16 Kenalog in Orabase, 14 ibuprofen/oxycodone HCl, 7 Keralac cream, 13 Icar, 22 Kerlone, 9 Iletin insulins, 14 ketoconazole, 4, 12 Imdur, 10 ketoprofen, 7, 16 imipramine, 7 ketorolac, 7, 16 Imitrex, 7 Klaron, 13 Imuran, 5, 16 Klonopin, 6 indapamide, 10 K-Lor, 22 Inderal, 10 Klor-Con, 22 Inderal LA, 10 Klotrix, 22 Inderide, 10 K-Lyte, 22 Indocin, SR, 7, 16 Kristalose, 15 indomethacin, SR, 7, 16 Kronofed A Jr., 21 Inflamase Forte, 19 K-Tab, 22 Insulin Syringes, 14 Kytril, 15 Intal, 20 ipratropium, 13, 20 L ipratropium-albuterol, 20 labetalol HCl, 10 iron, carbonyl, 22 lactulose, 15 Isentress, 4 Lamictal, 7 Ismo, 10 Lamisil, 4 isometheptene/ lamotrigine, 7 dichloralphenazone/apap, 7 Lancets, 14 isoniazid, 4 Lanoxin, 10 Isoptin SR, 11 Lantus, 14 Isopto Atropine, 18 Lariam, 4 29 Lasix, 10 Lozol, 10 leflunomide, 16 Lumigan, 18 leucovorin calcium, 5 Lunelle, 17 Leukeran, 5 Luride, 22 Levaquin, 4 Lysodren, 5 Levbid, 15 levobunolol, 18 M levonorgestrel/ethinyl Macrodantin, 4 estradiol, 17 maprotiline, 7 levothyroxine, 14 Matulane, 5 Levoxyl, 14 Mavik, 11 Levsin, 15 Max HC, 20 Levsinex, 15 Maxair, 20 Lexapro, 7 Maxalt, 7 Lexiva, 4 Maxidone, 7 Lidex, 12 Maxitrol, 18 Lidex E, 12 Maxituss HC, 20 lidocaine, 12 Maxzide, 11 lindane, 12 mebendazole, 4 Liquifilm, 18 meclofenamate, 7, 16 lisinopril, 10 Medrol, 14, 16, 20 lisinopril/HCTZ, 10 medroxyprogesterone acetate, 17 lithium carbonate, SR, 7 mefloquine, 4 Lithobid, 7 Megace, 5 Locoid, 12 megestrol, 5 Lodine XL, 6, 16 meloxicam, 16 Lofibra, 10 Menopur, 17 Lomotil, 15 meperidine, 7 Loniten, 10 Mephyton, 10 Lopid, 10 Mepron, 4 Lopressor, 10 mercaptopurine, 5 Loprox, 11, 12 mesalamine rectal, 15 lorazepam, 7 Mestinon, 8 Lortab, 7 metaproterenol, 20 Lotemax, 18 metformim/glyburide, 14 Lotensin, 9 metformin, ER, 14 Lotensin HCT, 9 methadone, 7 Lotrel, 9 methamphetamine, 7 Lotrisone, 11 methazolamide, 18 lovastatin, 10 methenamine hippurate, 4 Lovenox, 16 methenamine/methylene blue/ loxapine, 7 benzoic acid/salicylic acid/ Loxitane, 7 atropine, 21 30 methenamine/phenylsalicylate/ mometasone, 12 atropine/hyoscyamine/benzoic Monodox, 3 acid/methylene blue, 21 Monopril, 10 methenamine-hyosc-meth morphine sulfate, ER, 8 blue-sod phosphenyl Motrin, 7, 16 hyoscyamine, 4 MS Contin, 8 Methergine, 17 MSIR, 8 methimazole, 14 Mucomyst, 19 methocarbamol, 16 multivitamin with fluoride, 22 methotrexate, 5, 16 mupirocin, 12 methyldopa, 10 Muse, 21 methylphenidate, SR, 7 Myambutol, 4 methylprednisolone, 14, 16, 20 Mycelex, 3 metoclopramide, 15 Mycobutin, 4 metolazone, 10 Mycolog II, 12 metoprolol, 10 Mycostatin, 4, 12 metoprolol succinate, 10 Mydriacyl, 19 MetroCream, 12 Myleran, 5 Metrogel, 17 Mysoline, 8 Metrolotion, 12 metronidazole, 4, 12, 17 N Mevacor, 10 nabumetone, 8, 16 mexiletine HCl, 10 nadolol, 10 Mexitil, 10 nadolol-bendroflumethiazide, 10 Miacalcin, 16 Nalfon, 6, 16 Micro-K, 22 Namenda, 8 Micronase, 14 Naprelan, 8, 16 Microzide, 10 Naprosyn, 8, 16 Midamor, 9 naproxen, 8, 16 midodrine, 22 naproxen sodium, SA, 8, 16 Midrin, 7 Nardil, 8 migergot, 8 Nasacort AQ, 13, 20 Minipress, 10 Nasarel, 13, 20 Minocin, 4 Nasonex, 13, 20 minocycline, 4 Navane, 8 minoxidil, 10 nefazodone, 8 Mintezol, 4 neomycin/polymyxin B/ Mirapex, 8 dexamethasone, 18 mirtazapine, 8 neomycin/polymyxin/ misoprostol, 15 hydrocortisone, 13 Mobic, 16 Neoral, 5 Moduretic, 9 Neosporin, 18, 19 moexipril/HCTZ, 10 Neurontin, 7, 8 31 Nexium, 15 ofloxacin otic, 13 Niaspan, 10 Ogen, 17 nifedipine ER, 10 omeprazole, 15 Nimotop, 10 Omnicef, 3 Nitro-Bid, 10 ondansetron HCL, 15 Nitro-Dur, 10 OneTouch Monitor, 14 nitrofurantoin macrocrystals, 4 OneTouch Test Strips, 14 nitroglycerin, 10 Optivar, 18 Nitrostat SL, 10 Orapred, 14, 16, 20 nizatidine, 15 Ortho Evra, 18 Nizoral, 4, 12 Orudis, 7, 16 Nolvadex, 5 Oruvail, 7, 16 Norco, 7 Oxandrin, 14 norethindrone, 17 oxandrolone, 14 norethindrone acetate, 17 oxaprozin, 8, 16 norethindrone/ethinyl oxazepam, 8 estradiol, 18 oxcarbazepine, 8 norethindrone acetate/ethinyl Oxsoralen, 12 estradiol/ferrous fumarate, 18 Oxsoralen Ultra, 12 norethindrone/mestranol, 18 oxybutynin, 21 norgestimate/ethinyl estradiol, 18 oxybutynin chloride, 22 norgestrel/ethinyl estradiol, 18 oxycodone, CR, 8 Noritate, 12 oxycodone/apap, 8 Norpace, 9 oxycodone/aspirin, 8 Norpace CR, 9 OxyContin, 8 Norpramin, 6 OxyIR, 8 nortriptyline, 8 Norvasc, 9 P Norvir, 4 Pamelor, 8 Novahistine, 20 Pancrease, MT, 15 Novahistine DH, 21 Pancrelipase EC/SA, 15 Novarel, 18 pantoprazole, 15 Novolin, 14 Parafon Forte, 16 Novolog, 14 Parlodel, 6 Novolog mix, 14 Parnate, 8 Nulytely, 15 paroxetine, 8 Nuvaring, 18 Patanol, 18 nystatin, 4, 12, 18 Paxil, 8 nystatin/triamcinolone, 12 Pediapred, 14, 16, 20 Pediazole, 4 O PEG 3350 & electrolytes, 15 Ocuflox, 18 Peg-Intron, 16 ofloxacin, 4, 13, 18 penicillin VK, 4 32 Penlac, 11 polymyxin B/neo/bacitracin, 18 Pentasa, 15 polymyxin B/neo/gramicidin, 19 pentoxifylline, 10 Polysporin, 18 Pepcid, 15 Polytrim, 19 Percocet, 8 Poly-Vi-Flor, 22 Percodan, 8 potassium bicarbonate/potassium Peridex, 13 citrate, 22 Periostat, 3 potassium chloride, 22 permethrin, 12 potassium cirate, 22 perphenazine, 8 potassium powder, 22 Persantine, 9 Prandin, 14 phenazopyridine, 4, 22 Pravachol, 10 Phenergan, 15, 21 pravastatin, 10 Phenergan VC w/codeine, 20 prazosin, 10 phenobarb/hyoscyamine/atrop/ Pred-Forte, 19 scop, 15 prednicarbate, 12 phenobarbital, 8 prednisolone, 14, 16 phenylephrine HCL/COD/ prednisolone acetate, 19 prometh, 20 prednisolone sodium phosphate, phenylephrine/cpm/hydrocodone, 14, 16, 19, 20 20 prednisolone syrup, 20 phenylephrine/hydrocodone/ prednisolone/sodium BPM, 20 sulfacetamide, 19 phenylephrine/hydrocodone/ prednisone, 5, 14, 16, 20 CP, 20 Prelone, 14, 16, 20 phenylephrine-carbinoxamine w/ Premarin, 18 hydrocodone, 20 Premarin Vaginal Cream, 18 phenytoin, 8 Premphase, 18 PhosLo, 22 Prempro, 18 Phospholine Iodide, 18 prenatal vitamins with folic Phrenilin Forte, 6 acid, 22 Pilocar, 18 Prevacid, 15 pilocarpine, 18, 22 Prezista, 4 pilocarpine hydrochloride, 22 prilocaine/lidocaine, 12 Pilopine HS gel, 18 Prilosec, 15 pindolol, 10 Primaquine, 4 piroxicam, 8, 16 primidone, 8 Plaquenil, 4, 16 Principen, 3 Plendil, 10 Prinivil, 10 Pletal, 9 Prinzide, 10 Plexion, 13 ProAmatine, 22 podofilox, 12 probenecid, 16 procainamide, 10 33 Procanbid, 10 Pyridium, 4, 22 Procardia XL, 10 pyridostigmine, 8 prochlorperazine, 15 Procrit, 16 Q Proctofoam-HC, 15 Questran, 9 Prograf, 5 quinapril/HCTZ, 10 promethazine, 15, 21 quinidine gluconate extended promethazine/codeine, 21 release, 10 promethazine/ quinidine sulfate, 10 dextromethorphan, 21 promethazine/phenylephrine/ R codeine, 21 ramipril, 10 Prometrium, 18 ranitidine, 15 Pronestyl, 10 Rapamune, 5 propafenone, 10 Rebetol, 4 Propine, 18 Reglan, 15 propoxyphene HCl/apap, 8 Regranex, 12 propoxyphene napsylate/apap, 8 Relafen, 8, 16 propranolol, 10 Remeron, 8 propranolol/HCTZ, 10 Repronex, 18 propylthiouracil, 14 Rescriptor, 4 Proscar, 21 Restoril, 8 Prosed EC, 21 Retin-A, 13 Prostigmin, 8 Retrovir, 5 Protonix, 15 Reyataz, 4 Proventil, 19 ribavirin, 4 Proventil HFA, 21 Rifadin, 4 Provera, 17 rifampin, 4 Prozac, 7 Rifater, 4 pseudoephedrine/ rimantadine, 4 brompheniramine, 21 Risperdal, 8 pseudoephedrine/ Ritalin, SR, 7 chlorpheniramine, 21 Robaxin, 16 pseudoephedrine/cpm/codeine, 21 Rocaltrol, 14 pseudoephedrine/ Rowasa, 15 guaifenesin ER, 21 Roxicet, 8 Psorcon, 12 Rynatan, 19 Psoriatec, 11 Rythmol, 10 Pulmicort Respules, Turbuhaler, 21 S Pulmozyme, 21 Salagen, 22 Purinethol, 5 salsalate, 8, 16 pyrazinamide, 4 Sandimmune, 5 34 Seasonale, 17 sulfisoxazole, 4 Sebizon, 13 sulindac, 8, 17 Sectral, 9 Sumycin, 4 selegiline HCl, 8 Sustiva, 4 selenium sulfide, 12 Symlin, 14 Selsun Rx, 12 Symmetrel, 3, 6 Selzentry, 4 Synalar, 12 Sensipar, 14 Synthroid, 14 Septra DS, 4 Serax, 8 T Serevent Diskus, 21 Tagamet, 15 Seroquel, 8 Tambocor, 10 sertraline, 8 Tamiflu, 4 Silvadene, 13 tamoxifen, 5 silver sulfadiazine, 13 Tapazole, 14 simvastatin, 10 Targretin, 5 Sinemet, CR, 6 Tegretol, 6 Sinequan, 6 Tegretol XR, 8 Singulair, 21 temazepam, 8 Skelaxin, 16 Temodar, 5 sodium fluoride, 22 Temovate, 12 sodium sulfacetamide lotion, 13 Tenex, 10 sodium sulfacetamide/sulfur, 13 Tenoretic, 9 Soma, 16 Tenormin, 9 Sonata, 8 Terazol 3, 18 sotalol HCl, 10 terazosin, 10, 22 Spectazole, 12 terbinafine, 4 Spiriva, 21 terbutaline sulfate, 21 spironolactone, 10 terconazole, 18 spironolactone/HCTZ, 10 Tessalon Perles, 19 Sporonax, 4 tetracycline, 4 Starlix, 14 Theo-24, 21 Strattera, 8 Theochron, 21 Stuartnatal Plus, 22 theophylline extended release, 21 sucralfate, 15 thioguanine, 5 Sular, 10 thioridazine, 8 sulfacetamide, 19 thiothixene, 8 sulfacetamide sodium, 13 Tiazac, 9 sulfacetamide sodium/urea, 13 Ticlid, 10 Sulfacet-R, 13 ticlopidine HCl, 10 sulfamethoxazole/tmp, 4 Tigan, 15 sulfasalazine, 15, 16 Tilade, 21 sulfinpyrazone, 17 timolol, XE, 11, 19 35 Timoptic, XE, 19 U tizanidine, 17 Ultram, 8 Tobi, 4 Uniphyl, 21 Tobradex, 19 Uniretic, 10 tobramycin, 19 urea cream, 13 Tobrex, 19 Urecholine, 21 Tofranil, 7 Urex, 4 tolbutamide, 14 Urimar, 4 tolmetin, 8, 17 Urised, 21 Topicort, 12 Urispas, 21 Toprol XL, 10 Urocit-K, 22 Toradol, 7, 16 ursodiol, 15 torsemide, 11 Tracleer, 21 V tramadol, 8 Valcyte, 4 Trandate, 10 Valium, 6, 16 trandolapril, 11 valproic acid, 8 tranycypromine sulfate, 8 Valtrex, 4 trazodone, 8 Vaseretic, 10 Trental, 10 Vasocidin oint, 19 tretinoin, 13 Vasotec, 9 triamcinolone, 13, 14 Veetids, 4 triamcinolone acetonide, 13 venlafaxine, 8 triamterene/HCTZ, 11 Ventolin, 19 Tricor, 11 VePesid, 5 trifluoperazine, 8 verapamil extended trifluridine, 19 release, PM, 11 trihexyphenidyl, 8 verapamil, SR, 11 Trileptal, 8 Verelan, PM, 11 trimethobenzamide, 15 Vermox, 4 trimethoprim sulfate/ Vexol, 19 polymyxin B, 19 Vfend, 4 Triphasil, 17 Viagra, 22 Tri-Vi-Flor, 22 Vibramycin, 3 Trizivir, 4 Vicodin, ES, 7 tropicamide, 19 Vicoprofen, 7 Trusopt, 19 Videx, EC, 3, 5 Truvada, 4 Vigamox, 19 Tylenol with Codeine #2, #3, #4, 6 Viracept, 5 Tylox, 8 Viramune, 5 Viread, 5Viroptic, 19 Vistaril, 20 vitamin D, 22 36 Vivelle, Dot, 18 Voltaren, 19 Voltaren XR, 6, 16 Vospire ER, 21 W warfarin, 11 Wellbutrin, SR, XL, 6 Westcort, 12 X Xalatan, 19 Xanax, 6 Xeloda, 5 Xifaxan, 5 Xylocaine, 12 Z Zanaflex, 17 Zantac, 15 Zarontin, 6 Zaroxolyn, 10 Zavesca, 14 Zephrex LA, 21 Zerit, 5 Zetia, 11 Ziac, 9 Ziagen, 5 zidovudine, 5 Zithromax, 3 Zocor, 10 Zoderm, 11 Zofran, 15 Zoloft, 8 zolpidem tartrate, 8 Zomig, Zomig ZMT, 8 Zovirax, 3, 13 Zyloprim, 16 Zyprexa, 8

37 Prescription Drug Program Provider Payment Information A pharmacy benefits management company (PBM), which is affiliated with Independence Administrators, administers our prescription drug program, and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. Independence Administrators anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment.

Copyright©2008 Independence Administrators. All rights reserved. No part of this publication may be reproduced or distributed without the prior written permission of Independence Administrators. Independence Administrators is an independent licensee of the Blue Cross and Blue Shield Association.

012838 (2008-0088) 07/08 IA