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Home My WebLink About20040849.tiff 2004 Client's Copy PACIFICARE OF COLORADO, INC. MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT MID/LARGE COVER SHEET (This Cover Sheet is an integral part of this Agreement) GROUP NAME: Weld County Government GROUP CODE: D6600 SIC CODE: 9111 GROUP COVERAGE EFFECTIVE DATE: January 1, 2004 through December 31, 2004 PLAN CODE: PLAN DESCRIPTION: 10734 Medical Plan 19DW4 Pharmacy Plan E1174 Vision Plan HEALTH PLAN PREMIUMS: EE $269.33 EE + Spouse $538.65 EE + Child(ren) $517.10 EE+Family $857.84 PREMIUMS DUE ON OR BEFORE (refer to Section 3.06): The first of the month of coverage to be paid within 15 days ANNUAL OUT OF POCKET MAXIMUM PER INDIVIDUAL: $5,000 ANNUAL OUT OF POCKET MAXIMUM PER FAMILY: $10,000 CONTINUATION OF BENEFITS ELECTIONS: Yes ELIGIBILITY: Group Eligibility(refer to Section 2) This health plan is available only to employer groups who have 51 or more eligible employees. If at the anniversary date of the Agreement the number of eligible employees is less than 51, this Agreement may not be renewed. However, the Subscribing Group may be offered the small employer health benefit plan(s) as defined by Colorado Insurance Law. Dependent Member Eligibility Dependent children are Eligible through age: (minimum up to age 19) end of the month in which they reach age 26 Students are Eligible through age: (minimum up to age 24) end of the month in which they reach age 26 Start and End date of coverage (e.g. waiting period for Employee, full-time requirement, and termination of coverage date): PC0 1531 (lam --, 2004-0849 Waiting Period: First day of the month following first full pay period _ Full-Time Requirement: 20 hours per week Termination of Coverage: Termination of coverage varies by date of termination. If term occurs from the 1St through the 14`h of the month, coverage terms end of current month. If term occurs on the 15th through end of month, coverage terms at the end of the following month. Eligibility: A retiree who retired from employment with Weld County on or after December 16, 1998, after at least 10 years of service; or was an elected official of Weld County, Colorado, for at least one full four-year term; has attained the age of 55 years; and is now drawing benefits from the Weld County Retirement Plan and on the date of his or her retirement or end of office, retiree and/or his dependents was (were) enrolled and in good standing with Weld County's health insurance program. Continuation: A retiree can continue the health insurance plan until the retiree attains the Normal Retirement Age for Social Security(NRA), or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. Such insurance shall be the same as that offered to regular, full-time, current employees of Weld County, through the same health insurance provider. New spouse or children are eligible as set forth in the PacifiCare Combined Evidence of Coverage and Disclosure Form. ATTACHMENTS: (The following Attachments are an integral part of this Agreement) A- Schedule of Benefits, PacifiCare Combined Evidence of Coverage and Disclosure Form B - Schedule of Supplemental Benefits (If Purchased) C- Chiropractic Services (If Purchased) E - Eye Refraction Benefits (Standard Medical) H - Hearing Aid (If Purchased) PAN - Personal Assistant Network (If Purchased) R- Outpatient Prescription Drug Benefit (If Purchased) V- Vision Care (If Purchased) PCO1531 2004 PACIFICARE OF COLORADO, INC. MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT PCO1531 MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT This Medical and Hospital Group Subscriber Agreement (the "Agreement") is entered into between PACIFICARE OF COLORADO, INC., a Colorado corporation, hereinafter called "PacifiCare," and the employer, association or other entity specified as "GROUP" on the Cover Sheet, hereinafter called "Group." RECITAL OF FACTS PacifiCare is a health care service plan which arranges for the provision of medical, hospital and preventive medical services to persons enrolled as Members through contracts with associations of licensed physicians, hospitals and other health care providers, Group is an employer, union, trust, organization, or association which desires to provide such health care for its eligible Subscribers and family Dependents. PacifiCare desires to contract with Group to arrange for the provision of such health care services to Subscribers and family Dependents of Group, and Group desires to contract with PacifiCare to arrange for the provision of such services to its Subscribers and family Dependents. AGREEMENT NOW THEREFORE, in consideration of the application of Group for the benefits provided under this Agreement, and in consideration of the periodic payment of Health Plan Premiums on behalf of Members in advance as they become due, PacifiCare agrees to arrange or provide medical, surgical, hospital, and related health care benefits subject to all terms and conditions of this Medical and Hospital Group Subscriber Agreement, including the Cover Sheet and Attachments. 1. DEFINITIONS 1.01 Agreement is this Medical and Hospital Group Subscriber Agreement, including, but not limited to, the Combined Evidence of Coverage and Disclosure Form, the Cover Sheet, Attachments and any amendments thereto. 1.02 COBRA Continuation Member is any individual who is enrolled and eligible to receive COBRA benefits under Agreement. 1.03 Coinsurance are fees payable to a health care provider by the Member enrolled in a Point-of- Service (PLUS) plan, at the time of provision of services which are in addition to the Health Plan Premiums paid by the Group. Such fees are a pre-determined percentage of eligible charges that the Member pays after a deductible has been met, as specified under in the Summary of Benefits, depending on the type of service. 1.04 Combined Evidence of Coverage and Disclosure Form is the document issued to prospective and enrolled Subscribers disclosing and setting forth the benefits and terms and conditions of coverage to which Members of the Health Plan are entitled as set forth in the summary of benefits. 1.05 Copayments are fees payable to a health care provider by the Member at the time of provision of services which are in addition to the Health Plan Premiums paid by the Group. Such fees may be a specific dollar amount or a percentage of total fees as specified herein, depending on the type of services provided. PCO1531 1 1.06 Cover Sheet is the Medical and Hospital Group Subscriber Agreement Cover Sheet which is attached to and an integral part of this Agreement. 1.07 Dependent is any spouse, including those as defined as common-law spouse under the state, or unmarried child (including a step-child, court ordered Dependent, or adopted child or child placed for adoption) of a Subscriber who is enrolled hereunder, who meets all the eligibility requirements and definitions as set forth in the PacifiCare Combined Evidence of Coverage and Disclosure Form attached to this Agreement and for whom applicable Health Plan Premiums are received by PacifiCare. 1.08 Eligible Dependent is any spouse or unmarried child (including a step-child, court ordered coverage, or adopted child or child placed for adoption) of an Eligible Employee who works or resides within the HMO Service Area and who is eligible for Enrollment as a Dependent in the Health Plan as defined in the PacifiCare Combined Evidence of Coverage and Disclosure Form. 1.09 Eligible Employee is a Group employee who works a fixed number of hours per week as established by the Group, meets any applicable waiting period required by the Group, and meets the following additional criteria: (a) Is defined as an employee under state and federal law; (b) Consultants, temporary labor, suppliers or contractors are not Eligible Employees. 1.10 Enrollment is the execution of a PacifiCare Enrollment Application form, or a non-standard Enrollment Application form approved by PacifiCare, by the Subscriber on behalf of the Subscriber and his or her Dependents, and acceptance thereof by PacifiCare, conditioned upon the execution of this Agreement by PacifiCare, and either the execution of this Agreement by Group or the timely payment of applicable Health Plan Premiums by Group. In its discretion and subject to specific protocols, PacifiCare may accept Enrollment through an electronic submission from Group. 1.11 Group is the single employer, labor union, trust, organization, or association identified on the Cover Sheet. 1.12 Group Contribution is the amount of the Health Plan Premium applicable to each Subscriber which is paid solely by the Group or employer and which is not paid by the Subscriber either through payroll deduction or otherwise. 1.13 Group Participation is the number of individuals in the Group who are enrolled as Subscribers expressed as a percentage of the number of individuals in the Group who are eligible to enroll as Subscribers. 1.14 Health Plan is the Health Plan described in this PacifiCare Medical and Hospital Group Subscriber Agreement, Cover Sheet and Attachments, subject to modification pursuant to the terms of this Agreement. 1.15 Health Plan Premiums are pre-determined amounts established by PacifiCare to be made on a pre-paid basis to PacifiCare by Group on behalf of Members in consideration of the benefits provided under this Health Plan; such amounts are set forth in the Cover Sheet of this Agreement. PCO1531 2 1.16 Member is any Subscriber or Dependent. 1.17 Open Enrollment Period is the period of not less than 30 days agreed upon by PacifiCare and Group, during which all eligible and prospective Group Subscribers and their Eligible Dependents may enroll in this Health Plan. 1.18 PacifiCare Enrollment Packet is the packet of information supplied by PacifiCare to prospective Members which discloses plan policy and procedure and provides information about Plan benefits. The PacifiCare Enrollment Packet contains the PacifiCare Enrollment Application Form or a non-standard Enrollment Application Form approved by PacifiCare. 1.19 Standard Leave of Absence is the period of time when you are voluntarily absent from work, including but not limited to, sabbaticals and The Family and Medical Leave Act of 1993 (FMLA). 1.20 Subscriber is the individual enrolled in the Health Plan for whom the appropriate Health Plan Premium has been received timely by PacifiCare, and whose employment or other status, except for family dependency, is the basis for enrollment eligibility. 1.21 USERRA Continuation Member is any individual who is enrolled and eligible to receive USERRA benefits as outlined under this Agreement. 2. ELIGIBILITY AND ENROLLMENT 2.01 Enrollment Procedure 2.01.01 Application Form. A properly completed, signed application for Enrollment on a form provided by PacifiCare, or on a non-standard form approved by PacifiCare, must be submitted to PacifiCare by Group for each eligible and/or prospective Subscriber, on behalf of the eligible and/or prospective Subscriber and any Eligible Dependents. PacifiCare may, in its discretion and subject to specific protocols, accept Enrollment through an electronic submission from Group. 2.01.02 Time of Enrollment. All applications for Enrollment shall be submitted by prospective Subscribers to the Group during Open Enrollment Periods, except that prospective Subscribers and their Eligible Dependents who were not eligible during the previous Open Enrollment Period may apply for Enrollment within 31 days after becoming eligible. All applications for Enrollment which are not received by PacifiCare within the 31 days from the first day the prospective Subscriber or Dependent becomes eligible shall be subject to rejection by PacifiCare. Prospective Subscribers and their Eligible Dependents may reapply at the next Open Enrollment Period in the event an application was not received by PacifiCare within such 31 day period. Group shall provide notice to Members of the applicable Open Enrollment Periods. PCO1531 3 2.01.03 Notice and Certification. Group shall provide a written notice and certification, prepared by PacifiCare, as part of the PacifiCare Enrollment Packet to Eligible Employees at the commencement of the initial Open Enrollment Period. The written notice and certification section of the PacifiCare application for Enrollment shall provide notice of the availability of coverage under the Health Plan and indicate that an Eligible Employee's failure to elect coverage, on his or her behalf or on behalf of his or her Eligible Dependents during the initial Open Enrollment Period, permits PacifiCare to exclude coverage for a period of 12 months from the date the Eligible Employee subsequently elects coverage under the Health Plan. Group shall require any Eligible Employee declining coverage under the Health Plan on behalf of himself or herself or any Eligible Dependent, to certify on the written notice and certification prepared by PacifiCare, the reason for declining Enrollment in the Health Plan and that he or she has reviewed the notice and certification and understands the consequences of declining coverage under the Health Plan. Group agrees to submit all completed notices and certifications to PacifiCare for: a. Each Eligible Employee and/or his or her Eligible Dependents who declined coverage at renewal of this Agreement; and, b. Each Eligible Employee and/or his or her Eligible Dependents who became eligible during the term of this Agreement specified on the Cover Sheet of this Agreement and who have declined coverage. 2.01.04 Late Enrollment: Please refer to the section of this Agreement entitled Combined Evidence of Coverage and Disclosure Form for a complete description of Late Enrollment procedures. 2.02 Commencement of Coverage. The commencement date of coverage under this Health Plan shall be effective in accordance with the terms of the Cover Sheet and this Agreement. PacifiCare's acceptance of each Member's Enrollment is contingent upon receipt of the applicable Health Plan Premium payment. 2.03 PacifiCare's Liability in the Event of Conversion From a Prior Carrier. In the event PacifiCare replaces a prior carrier responsible for the payment of benefits or provision of services under a Group contract within a period of 60 days from the date of discontinuation of the prior contract or policy, PacifiCare will immediately cover all employees and Dependents who were validly covered under the previous contract or policy at the date of discontinuation, and who are eligible for Enrollment under this Agreement, without regard to health status. 2.04 Standard Leave of Absence. A Member who elects to take a Standard Leave of Absence shall be eligible for coverage for six months from the first day the Standard Leave of Absence begins. The Family Medical Leave Act of 1993 (FMLA) allows a worker up to 12 weeks of leave under certain circumstances. All time taken by a Member under FMLA shall be applied to the six month limit under this section, Standard Leave of Absence. PCO1531 4 3. GROUP OBLIGATIONS, HEALTH PLAN PREMIUMS AND COPAYMENTS 3.01 Non-Discrimination. Group shall offer PacifiCare an opportunity to market this Health Plan to its employees and shall offer its employees an opportunity to enroll in this Health Plan under no less favorable terms or conditions than Group offers enrollment in other health care service plans or employee health benefit plans. 3.02 Notices to PacifiCare. Group shall forward to PacifiCare all completed or amended Enrollment forms for each Member within 31 days of the Member's initial eligibility. Group acknowledges that any Enrollment applications not forwarded to PacifiCare within such 31 day period may be rejected by PacifiCare. Group further agrees to transmit to PacifiCare any Enrollment application amendments pursuant to the Administrative Manual described in Section 8.07 below. Group shall forward all notices of termination to PacifiCare within 31 days after Member loses eligibility or elects to terminate membership under this Agreement. Group agrees to pay any applicable Member Health Plan Premiums through the last day of the month in which notice of termination is received by PacifiCare. Any errors in termination by the Group will not afford a refund to the Group in Member premium, as premium payment will be required up to last day of the month in which notice of termination is received by PacifiCare, whether in practice or in error. 3.03 Notices to Member. If Group or PacifiCare terminates this Agreement pursuant to Section 7 below, Group shall promptly notify all Members enrolled through Group of the termination of their coverage in this Health Plan. Group shall provide such notice by delivering to each Subscriber a true, legible copy of the notice of termination sent from PacifiCare to Group at the Subscriber's then current address. Group shall promptly provide PacifiCare with a copy of the notice of termination delivered to each Subscriber, along with evidence of the date the notice was provided. If, pursuant to this Agreement, PacifiCare increases Health Plan Premiums payable by the Subscriber, or if PacifiCare increases Copayments or reduces Covered Services provided under this Agreement, Group shall promptly notify all Members enrolled through Group of the increase or reduction. In addition, Group shall promptly notify Members enrolled through Group of any other changes in the terms or conditions of this Agreement affecting the Members' benefits or obligations under the Health Plan. Group shall provide such notice by delivering to each Subscriber a true, legible copy of the notice of the Health Plan Premium or Copayment increase or reduction in Covered Services sent from PacifiCare to Group at the Subscriber's then current address. Group shall promptly provide PacifiCare with a copy of the notice of Health Plan Premium or Copayment increase or reduction in Covered Services delivered to each Subscriber, along with evidence of the date the notice was provided. PacifiCare shall have no responsibility to Members in the event Group fails to provide the notices required by this section. 3.04 Indemnification. Group agrees to indemnify, defend and hold PacifiCare harmless and accept all legal and financial responsibility for any liability arising out of Group's failure to perform its obligations as set forth in this Section 3. 3.05 Rates (Prepayment Fees). The Health Plan Premium rates are set forth in the Health Plan Premiums section of the Cover Sheet and supplemental Health Plan Premium notices. PCO1531 5 3.06 Due Date. Health Plan Premiums are due in full on a monthly basis by check or electronic transfer and must be paid directly by Group to PacifiCare on or before the last business day of the month prior to the month for which the premium applies. Failure to provide payment on or before the due date may result in termination of Group, as set forth under this Agreement. 3.07 Modification of Rates and Benefits. 3.07.01 Modification of Health Plan Premium Rates. The Health Plan Premium rates set forth on the Cover Sheet and the PacifiCare Enrollment Packet may be modified by PacifiCare in its sole discretion upon 31 days written notice mailed postage prepaid to Group. Any such modification shall take effect commencing the first full month following the expiration of the 31 day notice period. Modifications may be made for any reason including but not limited to: • Changes to the terms of the Health Plan, including any changes required by federal or state law that affect PacifiCare's liability under the Health Plan or • Failure of the Group maintain any applicable participation or enrollment requirements; or • PacifiCare may adjust premiums, in lieu of terminating coverage, for misstatements of the age, family status, employee status or geographic location of a Member and/or Dependent. If a state or any other taxing authority imposes upon PacifiCare a tax, assessment or license fee which is levied upon or measured by the monthly amount of Health Plan Premiums, membership, claims, or by PacifiCare's gross receipts or any portions of either, then upon 30 days written notice to Group, Group shall remit to PacifiCare, with the appropriate payment, a pro rata amount sufficient to cover all such taxes, assessments and license fees, rounded to the nearest cent. 3.07.02 Modification of Benefits or Terms. The Covered Services set forth in the Combined Evidence of Coverage and Disclosure Form, the Schedule of Benefits, and the Schedule of Supplemental Benefits in the PacifiCare Enrollment Packet, as well as other terms of this Agreement, may be modified by PacifiCare in its sole discretion upon 31 days written notice mailed postage prepaid to Group. Any such modification shall take effect commencing the first full month following the expiration of the 31 day notice period. 3.08 Effect of Payment. Except as otherwise provided in this Agreement, only Members for whom Health Plan Premiums are received by PacifiCare are entitled to health care benefits as described in this Agreement, and then only for the period for which such payment is received. Group agrees to pay entire portion of premium on behalf of the Subscriber to PacifiCare for the first month of coverage for newborn or adopted children who become eligible as provided in the Combined Evidence of Coverage and Disclosure Form of this Agreement. PCO1531 6 3.09 Continuation of Benefits and Conversion Coverage. 3.09.01 Notice Regarding Continuation Coverage. Upon the occurrence of a qualifying event, as defined by the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99- 272), as amended by the 1986 Tax Reform Act(P.L. 99-514) and the 1986 Omnibus Budget Reconciliation Act (P.L. 99-509) ("COBRA"), Group shall provide affected Members with written notice of available continuation coverage as required by and in accordance with COBRA and amendments thereto. Group shall be solely responsible for collecting Health Plan Premiums from Members who elect to continue benefits under COBRA and shall transmit such Health Plan Premiums to PacifiCare along with the Group's Health Plan Premiums otherwise due under this Agreement. Group shall maintain accurate records regarding Health Plan Premiums for Members who elect to continue benefits, including qualifying events, terminating events, and other information necessary to administer this continuation of benefits. Group may contract with a third party to perform the obligations set forth in this section. However, Group remains liable to PacifiCare for any failure of the third party to fulfill any such duties. 3.09.02 Notice of Individual Conversion Rights. Within 15 days after a Member's coverage terminates, Group shall notify the Subscriber on behalf of the Subscriber and his or her Dependents or, if no Subscriber is available, any terminated Dependent, of the availability, terms, and individual conversion rights as set forth in the Combined Evidence of Coverage and Disclosure Form. 3.09.03 Conversion From Federal COBRA Plan: If a Member is covered under COBRA, the Group and PacifiCare must notify the Member of the option to enroll in all available conversion plans no later than 180 days prior to the expiration date of the Members coverage under COBRA. Notification must include, at a minimum, availability, terms, and individual conversion rights. 3.09.04 USERRA (Uniformed Services Employment and Reemployment Rights Act). Continuation coverage under this Health Plan shall be available to Members through Group under the Uniform Services Employment and Reemployment Rights Act of 1994, as amended ("USERRA"). The continuation coverage under this section shall be equal to, and subject to the same limitations as, the benefits provided to other Members regularly enrolled in this Health Plan and shall be made available to eligible Members absent from employment with Group by reason of service in the United States uniformed services ("USERRA Continuation Members"). Such coverage, including, but not limited to, the maximum period of USERRA coverage, will be provided to USERRA Continuation Members pursuant to the requirements set forth in USERRA. For HMO Coverage Only: To obtain coverage, all care must be provided or arranged in the HMO Service Area by the designated Participating Medical Group, except for Emergency and Urgently Needed Services. Group shall provide written notice to each Member eligible for USERRA continuation coverage of the continuation coverage available to such Member under USERRA. PCO1531 7 The Health Plan Premium for USERRA Continuation Members shall be equal to the Health Plan Premium for similarly situated regular Group Members plus any additional surcharge or administrative fee that can be charged to the USERRA Continuation Member as allowed by law. Group shall be solely responsible for collecting Health Plan Premiums from USERRA Continuation Members and shall transmit such Health Plan Premiums to PacifiCare along with the Group's Health Plan Premiums otherwise due under this Agreement. Group shall maintain accurate records regarding USERRA Continuation Member Health Plan Premium, qualifying events, terminating events and other information necessary to administer this continuation benefit. 4. BENEFITS AND CONDITIONS FOR COVERAGE The attached PacifiCare Combined Evidence of Coverage and Disclosure Form included at the end of this Agreement, is an integral part of this Agreement, and it includes a complete description of the Benefits and Conditions of Coverage of this Health Plan. 5. PARTIES AFFECTED BY THIS AGREEMENT; RELATIONSHIPS BETWEEN PARTIES 5.01 Relationship of Parties. Group is not the agent or representative of PacifiCare and shall not be liable for any acts or omissions of PacifiCare, its agents, employees or providers, or any other person or organization with which PacifiCare has made, or hereafter shall make, arrangements for the performance of services under this Health Plan. Member is not the agent or representative of PacifiCare and shall not be liable for any acts or omissions of PacifiCare, its agents or employees. 5.02 Compliance with the Health Insurance Portability and Accountability Act of 1996. PacifiCare agrees to furnish written certification of prior creditable coverage ("Certificates") to all eligible Members, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PacifiCare and Group acknowledge that PacifiCare's agreement to issue Certificates to all eligible Members relieves Group of its obligation under HIPAA to furnish Certificates. Further, Group acknowledges that PacifiCare must rely completely on eligibility information and data(including, but not limited to, Member's name and current address) furnished by Group in issuing Certificates to Members. Group agrees to notify PacifiCare of all terminations within 30 days of the termination, and to provide PacifiCare with eligibility information and data within 30 days of its receipt or change. Group agrees to indemnify, defend and hold PacifiCare harmless and accept all legal, financial and regulatory responsibility for any liability arising out of PacifiCare's furnishing Certificates to eligible Members under HIPAA. 6. TERM OF AGREEMENT; RENEWAL PROVISIONS Term; Automatic Renewal. The term of this Agreement shall be one year, commencing on the Group Coverage Effective Date set out in the Cover Sheet, unless otherwise indicated on the Cover Sheet or unless this Agreement is terminated as provided herein. This Agreement shall automatically renew for a one year term on each anniversary of the date of commencement of this Agreement or as indicated on the Cover Sheet, unless terminated as provided herein. Renewal of this Agreement shall be subject to modification of rates and benefits pursuant to Section 3.07 and subject to Group underwriting and eligibility criteria as set forth by PacifiCare. PCO1531 8 7. TERMINATION 7.01 Termination by Group. Group may terminate this Agreement by giving a minimum of 30 days written notice of termination to PacifiCare. Group termination must always be effective on the first day of the month. Group shall continue to be liable for Health Plan Premiums for all Members enrolled in this Health Plan through Group until the date of termination and as required under section 3.02 of this Agreement. 7.02 Termination by PacifiCare. 7.02.01 For Nonpayment of Health Plan Premiums. PacifiCare may terminate this Agreement on the last day of the month for which premiums were paid if the Group or its designee fails to remit Health Plan Premiums in full by the required date. Nonpayment of Health Plan Premiums includes payments returned due to non- sufficient funds (NSF) and post-dated checks. In the event premiums are not received, PacifiCare will send the Group a notice of premiums due. Such notice shall specify that payment of all unpaid Health Plan Premiums must be received by PacifiCare within 15 days of the date of issuance of the notice, and that if payment of all unpaid Health Plan Premiums is received within the 15 days of the date specified in the notice, coverage will continue uninterrupted. If premiums are not received within that time period, all coverage will be terminated. PacifiCare will give written notice of final termination of the Agreement via First Class Mail to the Group. In the event PacifiCare has provided notice of non-payment of premium to Group on a prior occasion, and Group again fails to remit payment by the required due date, PacifiCare, at its discretion, reserves the right to immediately terminate Group for non-payment of premium. Termination will be retroactive to the last day of the month for which PacifiCare received full payment of premiums. Notwithstanding the forgoing, Members who receive services beyond their termination date or that of the Group, including but not limited to, cases of retro-termination, confinement or other instances as required under the law, such coverage will continue only to the extent as required under the law, and premiums must be remitted in full by the Group for any month in which services were provided for said Members. 7.02.02 Partial Payment of Premium. If Group submits partial month's premium for the final coverage month, PacifiCare shall have the sole discretion to terminate Group coverage at the end of the previous month as outlined above under section 7.02.01,and refund the partial payment or terminate Group coverage at the end of the final month and pursue collection of the outstanding premium. Negotiation of said partial payment shall not be construed as full payment, nor shall it provide any of the benefits under this Agreement. 7.02.03 Nonliability After Termination. Except as required by law, upon termination of this Agreement for any reason, PacifiCare shall have no further liability to provide benefits to any Member, including, without limitation, those Members hospitalized or undergoing treatment for an ongoing condition. Member's rights to receive benefits hereunder shall cease upon the effective date of termination. PCO1531 9 If a Member is receiving continuing care pursuant to this Agreement at the time Group is terminated, Member shall be responsible for the monthly payment of Health Plan Premiums at the Group rate. Any person receiving benefits or services for which he or she is not entitled will be responsible for all billed charges. PacifiCare and its contracted providers will not be responsible for any portion of the charges incurred during any period for which the Group has not paid premiums. PacifiCare has the right to pend any claims and non- urgent medical authorizations during any period for which premiums have not been received. Pended claims will be subsequently denied if premiums are not paid within the time frames set forth above, except as required by law, and in instances in which premium payment is due as described above in section 7.02.01. Any extension of the time frame in which payment must be made will not be deemed a waiver of PacifiCare's rights under this provision. If PacifiCare agrees to provide coverage during any time period in which the Group is provided to remit payments, the Group will be responsible for premiums during that period even if this Agreement subsequently terminates. Any such agreement to provide coverage must be in writing and signed by both PacifiCare and the Group or its designee. 7.02.04 Reinstatement Following Non-Payment of Premium. Requests for Reinstatement of this Agreement must be received by PacifiCare within 15 days from the date set out on the final termination notice. The termination date will be shown on the Group termination notice sent out by PacifiCare. Group shall be liable for any unpaid Health Plan Premiums. Group shall also pay the current month's premiums. All future premium must be remitted to PacifiCare by the premium due date through an electronic payment. PacifiCare reserves the right to assess an administrative fee of five percent of the monthly premium prorated on a 30 day month for each day premium payment is delinquent thereafter. This fee will be assessed solely at PacifiCare's discretion. Any requests for Reinstatement beyond the period set forth above will not be granted and the Group must submit a new application and undergo underwriting as a new Group. PCO1531 10 7.02.05 Termination for Breach of Material Term. PacifiCare may terminate this Agreement if Group breaches any material term, covenant or condition of this Agreement and fails to cure such breach within 30 days of receiving written notice of such breach from PacifiCare. For purposes of this section, material terms of this Agreement specifically include, but are not limited to, the Sections 3.01, Non-Discrimination and 8.03, Assignment. PacifiCare's written notice of breach shall make specific reference to Group's action causing such breach. If Group fails to cure its breach subject to PacifiCare's satisfaction within 30 days of receiving notice of the breach from PacifiCare,PacifiCare may terminate this Agreement at the end of the 30 day notice period. 7.02.06 For Providing Misleading or Fraudulent Information. PacifiCare may terminate this Agreement upon 30 days written notice to Group if Group provides materially misleading or fraudulent information to PacifiCare in any Group questionnaires or is aware that materially misleading or fraudulent information has been provided on membership enrollment forms. 7.02.07 For Ceasing to Meet Group Eligibility Criteria. PacifiCare may terminate Group upon 30 days written notice to Group if Group fails to meet any of the following Group eligibility requirements: a. Group fails to maintain active Group Participation percentage of 75%; b. For Subscribers without Dependents, Group fails to maintain a Group Contribution equal to 75% of the Health Plan Premium; c. For Subscribers with Dependents, Group fails to maintain a Group Contribution at a minimum of 75% of the employee's cost, or 50% of the employee and Dependent(s) combined premium; d. Group fails to abide by and enforce the conditions of Subscriber Enrollment set forth in this Agreement. 7.02.08 For Changing the Nature of Group's Business. PacifiCare may terminate Group upon 30 days written notice to Group if Group materially alters the nature of its business. "Materially Alters," for the purposes of this section, means a significant change in the business conducted by Group after the commencement of this Agreement. 7.02.09 For Loss of Group's Office Location within Geographic Area of Licensure. PacifiCare may terminate Group if Group no longer maintains an office location within the area in which PacifiCare is licensed as a health care service plan. PacifiCare shall provide Group with 30 days written notice prior to such termination, if possible. Group must notify PacifiCare of changes of the Group's office location provided on the Group application within 30 days of the change. PCO1531 11 7.03 Return of Prepayment Premium Fees Following Termination. In the event of termination by either PacifiCare (except in the case of fraud or deception in the use of PacifiCare services or facilities, or . knowingly permitting such fraud or deception by another) or Group, PacifiCare will, within 30 days, return to Group the pro-rata portion of money paid to PacifiCare which corresponds to any unexpired period for which payment has been received, together with amounts due on claims, if any, less any amounts due to PacifiCare. 8. MISCELLANEOUS PROVISIONS 8.01 Governing Law. This Agreement is subject to the laws of the State in which this coverage is sold and to applicable Federal laws including the Employee Retirement Income Security Act of 1974, as amended, (codified at Chapter 18 of Title 29 of the United States Code) and the regulations promulgated thereunder by the United States Department of Labor (codified at Chapter XXV of Title 29 of the Code of Federal Regulations) and title II subtitle F section 261-264 of the Health Insurance Portability and Accountability Act 1996, Public law 104-191, or as amended. Any provisions required to be in this Agreement by any applicable laws and regulations shall bind PacifiCare, Group and Member whether or not expressly provided in this Agreement. Any provisions in this Agreement which, on its effective date, is in conflict with the applicable statutes of the jurisdiction in which is it is delivered, is hereby amended to conform with the minimum requirements of such statutes. 8.01.01 Relationship Of Parties. Group is not the agent or representative of PacifiCare, and shall not be liable for any acts or omissions of PacifiCare, its agents, or employees, or Providers. Member is not the agent or representative of PacifiCare, and shall not be liable for any acts or omissions of PacifiCare, its agents, or employees. Providers, Primary Care Physicians and Contracting Medical Groups are independent contractors and are not the agents, employees or servants of PacifiCare. 8.01.02 PacifiCare Non-Liability As A Health Care Provider. Member and Group agree that PacifiCare is not a Provider. PacifiCare is not responsible for the professional negligence of any Provider, Primary Care Physician or Contracting Medical Group. 8.01.03 Access to Books and Records. PacifiCare and Group shall have the right to access the others books and records for audit of compliance with the terms and conditions of this Agreement. Any such access shall be in compliance with all state and federal laws governing the privacy and security of individual protected health information including HIPAA. Group's access to PacifiCare Member specific data will be limited to de-identified information unless Group uses a third-party auditor who signs a confidentiality statement prior to access and the auditor agrees that all Member specific data or information: a. provided by PacifiCare will be used for auditing purposes only; b. will not be provided to Group or any other party; c. will only be used in a manner and to the extent permitted under federal or state laws, including HIPAA. PCO1531 12 8.01.04 Disclosure of Protected Health Information to Group. In compliance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA," found at Public Law 94-191) and certain regulations promulgated by the U.S. Department of Health and Human Services to implement certain provisions of HIPAA (the "HIPAA Privacy Regulations," found at 45 CFR, Parts 160 through 164), PacifiCare shall disclose Summary Health Information (as defined at 45 CFR § 164.504) to Group if Group requests such Summary Health Information and only for the limited purpose of(i) obtaining premium bids from health plans for providing health insurance coverage to Group; or(ii) modifying, amending or terminating the Group's Health Plan coverage. PacifiCare shall not disclose Protected Health Information (as defined at 45 CFR § 164.504) to Group unless Group executes an addendum to this Agreement, acceptable to PacifiCare, regarding the disclosure and use of such Protected Health Information. Such addendum will, at a minimum, comply with the requirements set forth at 45 CFR § 164.504(f). 8.02 PacifiCare Names, Logos and Service Marks. PacifiCare reserves the right to control all use of its name, product names, symbols, logos, trademarks, and service marks currently existing or later established. Group shall not use PacifiCare's name, product names, symbols, logos, trademarks, or service marks without obtaining the prior written approval of PacifiCare. 8.03 Assignment. This Agreement and the rights, interests and benefits hereunder shall not be assigned, transferred, pledged, or hypothecated in any way by either party and shall not be subject to execution, attachment or similar process, nor shall the duties imposed herein be subcontracted or delegated without the approval of the other party. Notwithstanding the above, if PacifiCare assigns, sells or otherwise transfers substantially all of its assets and business to another corporation, firm or person, with or without recourse, this Agreement will continue in full force and effect as if such corporation, firm or person were a party to this Agreement, provided such corporation, firm or person continues to provide prepaid health services. Notwithstanding the foregoing, Group acknowledges and agrees that PacifiCare may delegate certain functions, including, but not limited to medical management, utilization review, credentialing and/or claims payment, to provider groups or other certified organizations which contract with PacifiCare and that PacifiCare may contract with its corporate affiliates to perform certain management and administrative services for PacifiCare. 8.04 Validity. The unenforceability or invalidity of any part of this Agreement shall not affect the enforceability and validity of the balance of this Agreement. 8.05 Confidentiality. PacifiCare agrees to maintain and preserve the confidentiality of any and all medical records of Member in accordance with all applicable State and federal laws, including HIPAA. However, Member authorizes the release of information and access to any and all of Member's medical records for purposes of utilization review, quality review, processing of any claim, financial audit, coordination of benefits, or for any other purpose reasonably related to the provision of benefits under this Agreement to PacifiCare, its agents and employees, Member's participating medical group, and appropriate governmental agencies. PacifiCare shall not release any information to Group which would directly or indirectly indicate to the Group that a Member is receiving or has received Covered Services, unless authorized to do so by the Member. 8.06 Amendments. This Agreement may be modified by PacifiCare as set forth in Section 3.07, above, or it may be amended upon the mutual written consent of the parties. PCO1531 13 8.07 Group Use of Administrative Manual. Group agrees to comply with and conform to policies and . procedures in the Administrative Manual provided by PacifiCare. PacifiCare agrees to provide 30 days notice to Group of any changes in the Administrative Manual. In the event of conflict between this Agreement and the Administrative Manual, the terms of this Agreement shall prevail. 8.08 Attachments. The Cover Sheet and Attachments to this Agreement, the Combined Evidence of Coverage and Disclosure Form, and all terms and conditions set forth therein, as they are from time-to-time amended by parties, are incorporated by reference herein and made an integral part of this Agreement. 8.09 Use of Gender. The use of masculine gender in this Agreement includes the feminine gender and the singular includes the plural. 8.10 Waiver of Default. The waiver by PacifiCare of any one or more defaults by Group or Member shall not be construed as a waiver of any other or future defaults under the same or different terms, conditions or covenants contained in this Agreement. 8.11 Notices. Any notice required or permitted under this Agreement shall be in writing and either delivered personally or by regular, registered, or certified mail, U.S. Postal Service Express Mail, or overnight courier, postage prepaid, or at the addresses set forth below: If to PacifiCare: PacifiCare of Colorado P.O. Box 6770 Englewood, CO 80155 If to Group or Member: Group's or Member's last address known to PacifiCare. Any notice sent by registered or certified mail, return receipt requested, shall be deemed given on the date of delivery shown on the receipt card, or if no delivery date is shown, the postmark date. If sent by regular mail, the notice shall be deemed given 48 hours after the notice is addressed and mailed with postage prepaid. Notices delivered by U.S. Postal Service Express mail or overnight courier that guarantees next day delivery shall be deemed given 24 hours after delivery of the notice to the United State Postal Service or courier. If any notice is transmitted by facsimile transmission or similar means, the notice shall be deemed served or delivered upon telephone confirmation of receipt of the transmission, provided a copy is also delivered via delivery or mail. 8.12 Acceptance of Agreement. Group accepts the terms and conditions of this Agreement by making its initial payment to PacifiCare of Health Plan Premiums on or before the due date specified on the Cover Sheet or by executing this Agreement. If acceptance is made by payment of the first premium, Group must still execute a copy of the Agreement to keep coverage in force. Failure to execute this Agreement may result in termination of coverage. All Members accepts the terms, conditions and provisions of this Agreement upon completion and execution of the Enrollment form. Acceptance by any of these methods shall render all terms and provisions of this Agreement binding on PacifiCare, Group and Members. PC01531 14 8.13 Entire Agreement. This Agreement, including all exhibits, attachments, and amendments, contains the entire understanding of Group and PacifiCare with respect to the subject matter hereof and it incorporates all of the covenants, conditions, promises, and agreements exchanged by the parties hereto with respect to such matter. This Agreement supersedes any and all prior or contemporaneous negotiations, agreements, representations, or communications, whether written or oral, between Group and PacifiCare with respect to the subject matter of this Agreement. This Agreement may be executed in two or more counterparts, each of which shall constitute an original, but all of which shall constitute one and the same document. 8.14 Contracting Provider Termination. PacifiCare will provide written notice to Group within a reasonable time if it receives notice that any contracting provider terminates or breaches its contract with PacifiCare, or is unable to perform such contract, if the termination, breach, or inability to perform may materially and adversely affect Group. 8.15 Headings. The headings of the various sections of this Agreement are inserted merely for the purpose of convenience and do not expressly, or by implication, limit or define or extend the specific terms of the section so designated. 8.16 No Third Party Beneficiaries. Except as otherwise expressly indicated in this Agreement, this Agreement shall not create any rights in any third parties who have not entered into this Agreement, nor shall this Agreement entitle any such third party to enforce any rights or obligations that may be possessed by such third party. 9. ARBITRATION 9.01 Member Appeals and Grievances. The attached PacifiCare Combined Evidence of Coverage and Disclosure Form includes complete description of the PacifiCare appeals and grievance procedures and dispute resolution processes for Members. 9.02 Disputes Between PacifiCare and Group. All disputes between Group and PacifiCare shall be resolved by binding arbitration before the Commercial Arbitration Rules of the American Arbitration Association unless both PacifiCare and the Group agree in writing to use another form of alternative dispute resolution (e.g., mediation). The parties will seek to mutually agree on the appointment of an arbitrator; however, if an agreement cannot be reached within 30 days following the date demanding arbitration, the parties will use the arbitrator appointment procedures in the Rules. Arbitration hearings will be held at the neutral administrator's offices in Denver, Colorado, or at another location agreed upon in writing by the parties. The results of the binding arbitration shall be final, with no further recourse in a court of law or otherwise will be available to either PacifiCare or the Group. The arbitrator(s) will prepare in writing an award that includes the legal and factual reasons for the decision. Judgement upon the award rendered by the arbitrator(s) shall be entered into any court having jurisdiction. PacifiCare and the Group shall equally share the costs of arbitration; however, each party shall be individually responsible for the expenses related to its attorney, experts and evidence. The Federal Arbitration Act, 9 U.S.C. §§ 1-4, will also apply to the arbitration. 9.03 Mandatory Arbitration. Group and PacifiCare agree and understand that any and all disputes, including claims of medical malpractice, shall be determined by submission to binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as Colorado law provides for judicial review of arbitration proceedings. Each party to this agreement is giving up the constitutional right to have any such dispute decided in a court of law before a jury, and instead is accepting the use of binding arbitration. PCO1531 15 IN WITNESS WHEREOF, the parties hereto have executed this Agreement in G1 Z€ € , Colorado, on re A , 20 GROUP: Weld County Government PACIFICARE OF COLORADO, INC. BY: l�l BY: NAME: J�U oh ibt �14 d C�YU}} NAME: Brian Crary TITLE: 12, � (,1)p r� 4, (,//n miss' u)IEfSTITLE: President of PacifiCare of Colorado DATE: c--,2/7`/ V DATE: February 9, 2004 PCO1531 16 See original booklet in file 2004-0649 PacifiCare SignatureValue- A select gmuP of physicians Appendix A Attachment A—Schedule of Benefits Colorado Health Plan Description Form PacifiCare of Colorado Commercial HMO Percentage Plan 10734, 30-50/600a PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Health Maintenance Organization(HMO). 2. OUT-OF-NETWORK CARE COVERED?t Only for emergency care. 3. AREAS OF COLORADO Plan is available only in the following counties: Adams,Arapahoe, WHERE PLAN IS AVAILABLE Boulder, Broomfield,Clear Creek,Denver, Douglas,El Paso, Elbert, Fremont,Gilpin,Jefferson, Larimer,Lincoln,Logan,Morgan,Park, Teller,Washington and Weld. PART B: SUMMARY OF BENEFITS Important Note:This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the policy,which contains all terms,covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses,or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed(e.g.,plans may require prior authorization,a referral from your primary care physician,or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage.Coinsurance options reflect the amount the carrier will pay. IN-NETWORK ONLY (out-of-network care is not covered except as noted) 4. ANNUAL DEDUCTIBLE No deductibles. a) Individual b) Family 5. OUT-OF-POCKET ANNUAL MAXIMUM2 a) Individual $5,000(per contract year) b) Family $10,000(per contract year) 6. LIFETIME OR BENEFIT MAXIMUM No lifetime maximum. PAID BY THE PLAN FOR ALL CARE 7a. COVERED PROVIDERS PacifiCare of Colorado HMO Network. See provider directory for complete list of current providers. 7b. With respect to network plans,are all Yes. the providers listed in 7a accessible to me through my primary care physician? 8. ROUTINE MEDICAL OFFICE $30 copayment per visit with PCP; VISITS $50 copayment per visit with specialist. "Network"refers to a specified group of physicians,hospitals,medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan,or that the plan may encourage you to use because it pays more of your bill if you use their network providers(i.e.,go in-network)than if you don't(i.e.,go out-of-network). 2 Out-of-pocket maximum. The maximum amount you will have to pay for allowable covered expenses under a health plan,which may or may not include the deductible or copayments,depending on the contract for that plan. PCO10734 10734 00 • IN-NETWORK ONLY (out-of-network care is not covered except as noted) 9. PREVENTIVE CARE a) Children's services $30 copayment per visit with PCP; $50 copayment per visit with specialist. b) Adults' services $30 copayment per visit with PCP; $50 copayment per visit with specialist. 10. MATERNITY a) Prenatal care $30 copayment; one copayment per pregnancy. b) Delivery& inpatient well baby care $600 with a 30%of allowable charges copayment per admission. Plan pays 70%,excluding applicable copayment. 11. PRESCRIPTION DRUGS Available as separate pharmacy plan or as an optional benefit if Level of coverage and restrictions purchased by your employer,see benefit schedule attached(if on prescriptions applicable). 12. INPATIENT HOSPITAL $600 with a 30%of allowable charges copayment per admission. Plan pays 70%,excluding applicable copayment. 13. OUTPATIENT/AMBULATORY $300 with a 30%of allowable charges copayment per visit. Plan pays SURGERY 70%,excluding applicable copayment. 14. LABORATORY&X-RAY No copayment(100%covered)including mammograms; MRI,CT, SPECT and PET Scan$300 copayment per procedure. 15. EMERGENCY CARES Emergency room setting inside and outside the service area: $200 copayment per visit. Urgent Care and Follow-up care to emergency services received outside the HMO service area is covered to a maximum of$400 per contract year. 16. AMBULANCE $75 copayment per episode inside and outside the service area. 17. URGENT,NON-ROUTINE, $200 copayment in emergency room setting inside and outside the AFTER HOURS CARE service area;otherwise$100 copayment per visit. Urgent Care and Follow-up care to emergency services received outside the HMO service area is covered to a maximum of$400 per contract year. 18. BIOLOGICALLY-BASED Coverage is no less extensive than the coverage provided for any other physical MENTAL ILLNESS°CARE illness. 19. OTHER MENTAL HEALTH CARE a) Inpatient care $50 copayment per day,$25 copayment per partial day;coverage for maximum of 45 full or 90 partial days per contract year. b) Outpatient care $50 copayment per visit. 20. ALCOHOL&SUBSTANCE Inpatient:$50 copayment per day,$25 copayment per partial day; ABUSE coverage for maximum of 45 full or 90 partial days per contract year. Outpatient:$50 copayment per visit. Limited to one course of treatment per contract year,two courses of treatment during the member's lifetime. 21. PHYSICAL,OCCUPATIONAL,& PhysicaUOccupational: $30 copayment per visit,coverage for maximum of SPEECH THERAPY 20 sessions per acute condition. Speech Therapy:$30 copayment per visit, coverage for maximum of 20 sessions for certain acute conditions.For children born with congenital defects or birth abnormalities up to age 5,20 visits each of physical,occupational and speech therapy per contract year; $30 copayment per visit. 22. DURABLE MEDICAL 70%. Maximum of$2,000 per member per contract year,including oxygen. EQUIPMENT Coverage is limited to certain items. Orthopedic Braces and Podiatric Shoe Inserts are covered at 100%and are limited to a separate combined$500 maximum.Surgical bras meeting criteria are covered at 100%up to$500 per contract year. Prosthetic arms and legs will not be limited to the DME maximum;80%. 23. OXYGEN Covered as durable medical equipment. (see#22) 9"Emergency care"means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. °"Biologically based mental illnesses"means schizophrenia,schizoaffective disorder,bipolar affective disorder,major depressive disorder,specific obsessive-compulsive disorder,and panic disorder. PCO10734 1073400 IN-NETWORK ONLY (out-of-network care is not covered except as noted) 24. ORGAN TRANSPLANTS Bone marrow(for certain conditions),cornea,liver(for children)and kidney transplants,and skin grafts,are covered based on criteria. Heart,heart/lung (combined),lung,kidney/pancreas(combined),and adult liver transplants,are covered based on criteria,subject to pre-existing condition limitations(see #32). 25. HOME HEALTH CARE $50 copayment per day 26. HOSPICE CARE No copayment(100%covered). 27. SKILLED NURSING FACILITY CARE 70%. Covered up to 100 days per contract year. 28. DENTAL CARE Available as a separate dental care plan or as an optional benefit. 29. VISION CARE $30 copayment per visit; one visit per 12 months. 30. CHIROPRACTIC CARE Available as a separate chiropractic care plan or as an optional benefit. 31. SIGNIFICANT ADDITIONAL Allergy injections,$10 copayment;well-woman exam,$30 copayment; COVERED SERVICES(list up to 5) injectables for home use,$75 copayment; cardiac rehabilitation covered to$1,000 within a 90-day period. PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING Six months for selected transplants only;no pre-existing CONDITIONS ARE NOT COVERED.5 limitation for all other conditions. See policy for details. 33. EXCLUSIONARY RIDERS. Can an No. individual's specific,pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A A pre-existing condition is a condition for which medical advice, "PRE-EXISTING CONDITION"? diagnosis, care,or treatment was recommended or received within the last 6 months immediately preceding the date of enrollment or,if earlier,the first day of the waiting period;except that pre-existing condition exclusions may not be imposed on a newly adopted child,a child placed for adoption,a newborn, other special enrollees,or for pregnancy. 35. WHAT TREATMENTS AND CONDITIONS Exclusions vary by policy. A list of exclusions is available ARE EXCLUDED UNDER THIS POLICY? immediately upon request from your carrier,agent, or plan sponsor(e.g.,employer).Review them to see if a service or treatment you may need is excluded from the policy. 3 Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor(e.g.,employer)for details. PCO10734 1013400 PART D: USING THE PLAN IN-NETWORK ONLY (out-of-network care is not covered except as noted) 36. Does the enrollee have to obtain a referral and/or prior Yes. authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical Yes. procedures and hospital care(except in an emergency)? 38. If the provider charges more for a covered service No. than the plan normally pays,does the enrollee have to pay the difference? 39. What is the main customer service number? Please call Customer Service at(800)877-9777 40. Whom do I write/call if I have a complaint or want to Write to: PacifiCare of Colorado Member Appeals Team, file a grievance?6 P.O.Box 6770, Englewood,CO 80155 41. Whom do I contact if I am not satisfied with the Write to: Colorado Division of Insurance,ICARE resolution of my complaint or grievance? Section, 1560 Broadway, Suite 850,Denver,CO 80202 42. To assist in filing a grievance,indicate the form Policy Form#: 10734, Large Group number of this policy;whether it is individual,small group,or large group;and if it is a short-term policy. 43. Does the plan have a binding arbitration clause? Yes. PART E: COST 44. What is the cost of this plan? Contact your agent,this insurance company, or your employer,as appropriate,to find out the premium for this plan. In some cases,plan costs are included with this form. PART F: PHYSICIAN PAYMENT METHODS,AND PLAN EXPENDITURES FOR HEALTH EXPENSES, ADMINISTRATION AND PROFIT Any person interested in applying for coverage,or who is covered by,or who purchased coverage under this plan may request answers to the questions listed below. The request may be made orally or in writing to the agent marketing the plan or directly to the insurance company and shall be answered within five(5)working days of the receipt of the request: • What are the three most frequently used methods of payment for primary care physicians? • What are the three most frequently used methods of payment for physician specialists? • What other financial incentives determine physician payment? • What percentage of total Colorado premiums are spent on health care expenses as distinct from administration and profit? NOTE: If you would like a copy of the directions used in filling out this form,which includes choices of answers and definitions of terms,please write the Colorado Division of Insurance,Rates and Forms Section, 1560 Broadway,Suite 850,Denver,CO 80202. An Access Plan detailing the managed care network is available upon request Please call Customer Service at(800) 877-9777 for more information. Second opinions are covered when medically appropriate. In order to obtain a second opinion,you must obtain the necessary referrals from your Primary Care Provider. 6 Grievances. Insurance regulation 4-2-17 establishes carrier grievance procedures and appeals process requirements. A copy of the regulation is available from the Colorado Division of Insurance. PCO10734 10714 011 COLORADO PacifiCare ATTACHMENT E - EYE REFRACTION BENEFITS EYE EXAM SUMMARY OF BENEFITS 12-MONTH Your employer has elected to offer coverage for routine eye examinations. Routine eye examinations other than the annual visual acuity exam under your medical plan are available Not Covered: under this Rider. These include refractions for Fitting of contact lenses, vision therapy and/or radial prescription lenses, and are covered once every 12 months. Services must be obtained from a Participating keratotomy, keratomilieusis and excimer laser surgery. Eye Specialists,A Block Vision Company® Provider. This information contains only highlights of the eye Using Eye Specialists,A Block Vision Company® is as examination benefit and is not intended to contain the easy as 1, 2, 3. First, locate an Eye Specialists,A Block complete provisions of these benefits. Please refer to Vision Company® Provider near you by checking your your Combined Evidence of Coverage and Disclosure Form for a complete description of this benefit. PacifiCare Provider Directory, by visiting Eye Specialists,A Block Vision Company's Web site at www.eyespec.com or by calling Eye Specialists, A Block Vision Company® at 1-800-879-6901. Second, call your doctor and make an appointment. Third, keep your scheduled appointment.A referral from your Primary Care Physician is not required for this benefit. Customer Service: 800-877-9777 ©2004 PacifiCare of Colorado 6455 S.Yosemite St. 800-659-2656 (TDD) CM-104-58132 Greenwood Village, CO 80111 www.pacificare.com PCO6004-001 Rev.1/04 i ATTACHMENT PAN - PERSONAL ASSISTANT NETWORK PACIFICARE OF COLORADO ATTACHMENT TO THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM TI IIS ATIACIIMENT is made part of the PacifiCare of Colorado ("PacifiCare") Combined Evidence of Coverage and Disclosure Form (the "EOC"). Please review this attachment as it contains valuable information regarding important changes to your EOC. Unless otherwise indicated herein, all terms initially capitalized herein shall have the same meaning attributed to such terms in the EOC and references to section numbers are to section of the EOC. "PERSONAL ASSISTANT NETWORK" You and your Eligible Dependents are entitled to the following additional benefits under the PacifiCare Personal Assistant Program ("PAN"). Accessing Personal Assistant Network The following services are available 24 hours per day, every day, by calling 1-866-331-3975. Our staff will listen carefully to your concerns and direct you to a wealth of informational resources. Information and resources are also available online at www.pbhi.com. Included Services The Personal Assistant Network offers you access to the resources and information you may need to reduce stress associated with balancing family life, childcare, and legal and financial issues with work. With one toll-free phone call, you can access resources, and receive information and referrals for professional advice to help you to reduce these stresses. These services and resources include: 1. Financial Planning Consultation with a Certified Financial Advisor: 30 minutes per topic at no charge. (You may request additional services which will be provided at a discounted rate for which you will he financially responsible.) • Debt management • Budgeting • Financial Planning • Investment planning • Retirement Planning • Estate Planning 2. Legal Assistance Consultation with an attorney: 30 minutes per topic at no charge. (You may request additional services at a discount rate for which you will be financially responsible.) • Divorce • Landlord/Tenant Conflicts • Wills • Consumer Issues • Referrals to Legal Specialists PacifiCare 3. Resources for Seniors You may receive information concerning a number of items of particular concern to the elderly. You may access this informational service as frequently as you wish, without limitation. Information on the following services is provided to you at no additional cost. • Senior housing options • Assisted living options • Adult day care • Meal services • Transportation services • Community services and resources 4. Community Support Services You may receive access to information concerning other community support services of general interest. You may access this informational service as frequently as you wish, without limitation. This information is provided to you at no additional cost. • Career development • Various support groups • Food programs • Special needs programs 5. Parenting, Child Care and Schools You may receive access to information concerning childcare issues at no additional cost. • Parenting/Exploring Adoption • Strategies for working parents • Day care options • Nursery and Pre-Kindergarten options • Public and private schools • College planning 6. Convenience Services You may receive access to information concerning other services of convenience at no additional cost. • Assistance locating services such as home remodeling and repair, pet care, house sitting, relocation assistance, funeral services and more. • Information and assistance locating personal enrichment programs such as dance lessons, music training, physical fitness and massage therapy • Research and information concerning restaurants, parks, entertainment and sporting events THE INFORMATION OR SERVICE PROVIDED TO MEMBERS UNDER THE PERSONAL ASSISTANT NETWORK PROGRAM DO NOT IMPLY, AND SHALL NOT BE CONSTRUED TO Bli AN ENDORSEMENT, RECOMMENDATION OR APPROVAL OF THAT PARTICULAR INFORMATION OR SERVICE BY PACIFICARE. Please keep this Attachment with your PacifiCare EOC for future reference. If you have any questions or need further information regarding this Attachment, please call PacifiCare Customer Service Department at 1.800-877-9777. Representatives are available to help you Monday through Friday, from 7:00 a.m. to 8:00 p.m. ©2003 by PacifiCare Health Systems. Inc. CM-403-43445 PacifiCare SignatuleVaiue- A select group of physicians Selected Benefit Descriptions Attachment R—Outpatient Prescription Drug Benefit Colorado Health Plan Description Form Addendum PacifiCare of Colorado Pharmacy Plan 19DW4, Weld County BENEFIT BENEFIT LEVEL 11. PRESCRIPTION DRUGS $15 formulary generic,$40 formulary brand-name,$60 non-formulary. If Level of coverage and restrictions on brand-name is dispensed when a generic equivalent is available and listed on prescriptions the drug formulary,member pays the non-formulary copayment for the brand name medication. Prepackaged units will have one applicable copayment apply per prepackaged unit. A 90-day supply of maintenance medications,or a three-cycle maximum of oral contraceptives, is available through the mail-order prescription pharmacy for two applicable copayments. Prepackaged units dispensed through the mail-order prescription pharmacy will have one applicable copayment apply per two prepackaged units. For more information on the mail-order prescription drug program,or for information on drugs on our approved formulary list,call Customer Service at(800) 877-9777. NOTE: PacifiCare's prescription drug coverage relies on a framework provided by a drug formulary. Quite simply,a formulary is a list of preferred or recommended drugs that have been carefully selected by physicians and pharmacists based upon the safety and effectiveness of those drugs. You pay your applicable copayment for prescriptions filled at network pharmacies: • Formulary Generic • Formulary Brand • Non-Formulary Pml9DW4 1 19DW41p ATTACHMENT R- YOUR OUTPATIENT PRESCRIPTION DRUG BENEFIT Pharmacy Schedule of Benefits Pharmacy Plan 19DW4 Summary of Benefits Generic Brand Formulary Non-Formulary Formulary Retail Pharmacy Copayment(per Prescription Unit or up to 30 $15 $40 $60 days) Retail Pharmacy Pre-Packaged Unit Copayment(per Defined or $15 $40 $60 Pre-Packaged Unit;up to a 30 day supply max) Mail Service Pharmacy Copayment(up to 3 Prescription Units or $30 $80 $120 up to 90 days) Mail Service Pharmacy Pre-Packaged Unit Copayment(per two $15 $40 $60 [2] Defined or Pre-Packaged Units;up to a 90 day supply max) This Schedule of Benefits provides specific details about your • Diabetic Supplies:Insulin,insulin syringes,glucagon kits prescription drug benefit,as well as the exclusions and and glucose testing strips on the Formulary. Insulin is limitations that apply.Together this document and the limited to two(2)vials of the same kind of insulin per Supplement to the Combined Evidence of Coverage and applicable Copayment at a Participating Retail Pharmacy. Disclosure Form as well as the medical Combined Evidence of Insulin is limited to three(3)vials of the same kind of Coverage and Disclosure Form determine the exact terms and insulin per applicable Copayment at a participating mail conditions of your prescription drug coverage. order pharmacy. What Do I Pay When I Fill a Prescription? Glucose and Ketone test strips and lancets on the Formulary are dispensed in pre-packaged units and are You will pay a Copayment every time a prescription is filled. subject to the applicable Copayment per pre-packaged Your benefits are shown in the above grid.If you choose a unit. brand-name medication when an equivalent generic is available,you will pay your non-formulary Copayment for the Coverage of glucose and ketone test strips is limited to brand-name medication. 200 strips per thirty(30)days. Clinical Review for Selected Drugs Coverage of lancets is limited to 200 units per thirty(30) days. Selected medications require clinical review. The Clinical Review process uses criteria based upon FDA approved • Federal Legend Drugs:Any medicinal substance which indications,medical findings and the current availability of the bears the legend: "Caution: Federal law prohibits medication. PacifiCare reviews requests for these selected dispensing without a prescription." medications to ensure that they are Medically Necessary, • Immunosuppressants to prevent organ rejections. being prescribed according to treatment guidelines consistent with standard professional practice and are not otherwise • Miscellaneous Prescription Drug Coverage:For the excluded from coverage. purposes of determining coverage,the following items are considered prescription drug benefits:glucagon insulin, For a list of the selected medications that require PacifiCare's insulin syringes,blood glucose test strips, lancets, inhaler clinical review,please contact PacifiCare's Customer Service extender devices urine test strips,and anaphylaxis Department. prevention kits(including,but not limited to,EpiPen®, Medication Covered By Your Benefit Ana-Kits®and Ana-Guard®). See the medical benefit portion of the Combined Evidence of Coverage and When prescribed by your Participating Physician or Disclosure Form for coverage of other injectable Authorized Non-Plan Physician as Medically Necessary and medications. filled at a Participating Pharmacy,subject to all the other terms and conditions of this outpatient prescription drug benefit,the • Oral contraceptives:Federal Legend oral contraceptives, prescription diaphragms,cervical caps and oral following medications are covered. medications for emergency contraception. • State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to State law. 20030108 9/03 1 PCO1482 Exclusions and Limitations • Infertility: All forms of prescription medication for the treatment of infertility are not covered. If your employer While the prescription drug benefit covers most medications, has purchased coverage for infertility treatment, there are some that are not covered or limited. These drugs are prescription medications for the treatment of infertility listed below. Some of the following excluded drugs may be may be covered under that benefit. covered under your medical benefit. Please refer to Section Five of your Combined Evidence of Coverage and Disclosure • Injectable Medications are not covered except as listed Form in this Schedule of Benefits in the section entitled "Medication Covered By Your Benefit". Injectable • Allergy serum is not covered. Allergy serum may be Medications including but not limited to self-injectables, available under your medical benefits. Refer to your infusion therapy,allergy serum, immunization agents and medical Combined Evidence of Coverage and Disclosure blood products may be covered under your medical Form. benefit.Injectable medications may be subject to • Administered Drugs:Drugs or medicines delivered or PacifiCare's pre-authorization requirements. Refer to your administered to the Member by the prescriber or the medical Combined Evidence of Coverage and Disclosure prescriber's staff is not covered. Injectable drugs is Form. covered under your medical benefit when administered • Inpatient Medications:Medications administered to a during the course of a physician's office visit or self- Member while an inpatient receiving skilled care in a administered pursuant to training by an appropriate health medical facility,hospital,rest home,nursing home, care professional. Please refer to Section Five of your sanitarium,skilled nursing facility,or extended care Combined Evidence of Coverage and Disclosure Form. facility not covered. Inpatient pharmacy benefits are • Compounded Medication: Compounded medication(s) covered as a basic medical benefit. Refer to your medical that are made up of at least one prescription drug.(All Combined Evidence of Coverage and Disclosure Form for compounded medications require preauthorization). additional information. • Diagnostic Drugs:Drugs used for diagnostic purposes • Investigational or Experimental Drugs:Medication are not covered. prescribed for experimental or investigational therapies are not covered.For non-Food and Drug Administration • Dietary or nutritional products and food supplements, approved indications,see Off Label Drug exclusion. whether prescription or non-prescription, including Further information about Investigation and Experimental vitamins(except prenatal),and fluoride supplements, therapies can be found in the medical Combined Evidence health or beauty aids,herbal supplements and/or of Coverage and Disclosure Form. alternative medicine are not covered. • Medications dispensed by a non-Participating • Diabetic supplies: All diabetic supplies such as insulin Pharmacy are not covered except for prescriptions pens,penfills,pumps and associated supplies,are not required as a result of an Emergency or Urgently Needed covered except those supplies specifically covered in this Service for an acute condition. Pharmacy Schedule of Benefits in the section entitled Medication Covered By Your Benefit. • Medications prescribed by non-Participating Physicians are not covered except for prescriptions • Drugs prescribed by a dentist or drugs used for dental required as a result of an Emergency or Urgently Needed treatment. Service for an acute condition. • Elective or voluntary enhancement procedures, • New procedures,services,supplies,and medications services,supplies and medications including but not until they are reviewed for safety,efficacy and cost limited to: weight loss, hair growth,sexual performance, effectiveness and approved by PacifiCare are not covered. athletic performance,cosmetic purposes,anti-aging, • Non-Covered Services:Any prescription drug prescribed discolored nails and mental performance. Examples of these drugs include but are not limited to: Penlac®,Retin- in connection with a service excluded under your Health A®,Renova®,Vaniqa®,Propecia®,Lustra®,Xenical®, Plan is not covered. or Meridia®. This provision does not exclude Medically • Non covered medical condition:Prescription medication Necessary medications directly related to non-covered for the treatment of a non-covered medical condition. services when complications exceed routine follow-up care such as life-threatening complications of cosmetic • Non-Approved Drugs: Drugs determined by the surgery. PacifiCare Pharmacy and Therapeutics Committee to be ineffective,duplicative or to have preferred therapeutic • Immunizations are not covered. Immunizations except alternatives available are not covered. oral typhoid. 20030108 9/03 2 PC01482 • Off-Label Drug Use.Off Label Drug Use means that the • Sexual dysfunction Medication:All forms of Provider has prescribed a drug approved by the Food and medications prescribed for the treatment of sexual Drug Administration(FDA)for a use that is different than dysfunction,which includes,but is not limited to erectile that for which the FDA approved the drug. PacifiCare dysfunction, impotence and anorgasmy or hyporgasmy. excludes coverage for Off Label Drug Use, including off An example of such medications would include Viagra. label self-injectable drugs,except as described in the Combined Evidence of Coverage and Disclosure Form • Smoking cessation products including,but not limited and any applicable Attachments. If a drug is prescribed to,nicotine gum,nicotine patches,and nicotine nasal spray are not covered unless such products are available for Off-Label Drug Use,the drug and its administration will be covered only if it satisfies all of the following through and the member is enrolled in,a smoking criteria: (1)The drug is approved by the FDA. (2)The cessation program approved by PacifiCare. drug is prescribed by a participating licensed health care • Take Home Use From a Facility: Drugs received from a professional for the treatment of a life-threatening hospital,Skilled Nursing facility,convalescent home or condition or for a chronic and seriously debilitating similar facility for take home use are not covered. condition. (3)The drug is Medically Necessary to treat the condition. (4)The drug has been recognized for treatment • Therapeutic devices or appliances including but not of the life-threatening or chronic and seriously debilitating limited to support garments and other non-medical condition by one of the following:The American Medical substances,insulin pumps and related supplies(these Association Drug Evaluations,The American Hospital services are provided as durable medical equipment) Formulary Service Drug Information,and The United hypodermic needles and syringes not related to diabetic States Pharmacopoeia Dispensing Information. (5)The needs,penfills,pen needles or cartridges. Birth control drug is administered as part of a core medical benefit as devices,supplies or preparations that do not require a determined by PacifiCare. See Section Five of your Participating Physician's or Authorized non-Plan Combined Evidence of Coverage and Disclosure Form for Physician's prescription by law are also not covered,even a description of your medical benefits. Nothing in this if prescribed by a Participating Physician or Authorized section shall prohibit PacifiCare from use of a Formulary, non-Plan Physician. Copayment,pre-authorization process,technology • Unit/Convenience Dosage Forms:Unit dose,pre- assessment panel,or similar mechanism as a means for packaged medications, individual packets,etc are not appropriately controlling the utilization of a drug that is covered. prescribed for a use that is prescribed for a use that is different from the use for which that drug has been • Worker's Compensation:Medication for which the cost approved for marketing by the FDA. is recoverable under any Workers' Compensation or Occupational Disease Law or any state or government • Over the Counter Drugs: Medications(except insulin) agency,or medication furnished by any other drug or available without a prescription(over-the-counter)or for medical service for which no charge is made to the patient which there is a non-prescription equivalent available, are not covered. even if ordered by a physician are not covered. All non- prescription(over-the-counter)contraceptive jellies, • Work-Related Medications: Medications recommended ointments,foams,or devices are not covered. because of increased risk due to type of employment are • Progesterone and Estrogen Products: Specially not covered. compounded progesterone and estrogen products • Other Exclusions and Limitations:All exclusions and including progesterone suppositories are not covered. limitations as listed in this Supplement or in your Evidence of Coverage and Disclosure Form, Section Five, • Prior to Effective Date:Drugs or medicines purchased Your Medical Benefits are not covered. and received prior to the Member's effective date or subsequent to the Member's termination are not covered. PacifiCare reserves the right to expand the prior authorization • Recreation or travel:Medications when used for the requirement for any drug product. purpose(s)of recreation and/or travel,other than those Note: PacifiCare may determine medical necessity by using medications recommended for travel by guidelines pre-authorization programs as deemed appropriate by established by the Centers for Disease Control are not PacifiCare. Coverage is based on PacifiCare criteria.If you covered. have any questions, please contact our Customer Service Department at 1-800-877-9777 or 1-800-360-]797(TDHI). • Replacement of lost, stolen,or destroyed medications are not covered. • Saline and irrigation solutions are not covered. 20030108 9/03 3 PCO1482 ATTACHMENT R-YOUR OUTPATIENT PRESCRIPTION DRUG BENEFIT SUPPLEMENT TO THE COMBINED EVIDENCE OF COVERAGE and DISCLOSURE FORM Understanding Your Outpatient Prescription Formulary Drugs Drug Benefit What is a Formulary? This brochure contains important information for our A Formulary is a list of medications that are covered members about the PacifiCare outpatient prescription under your prescription drug benefit. drug benefit.As part of PacifiCare's commitment to you, we want to provide you with the tools that will help you Are there different types of Formularies? better understand and utilize your Pharmacy and Prescription Drug Plan. In an effort to eliminate PacifiCare uses one Formulary for our prescription drug confusion,PacifiCare has provided you with answers for benefits. Your coverage for Formulary and non- Formulary drugs depends on the level of pharmacy your pharmacy questions such as: benefits purchased by your employer. Certain pharmacy • What is a Formulary? benefit plans provide coverage only for Formulary drugs and non-Formulary drugs when Medically Necessary and • What is the difference between a name brand and approved by PacifiCare through the pre-authorization generic drug? process described in this document and your Schedule of • Who can write my prescription? Benefits. Please refer to your Pharmacy Schedule of Benefits to determine how the Formulary applies to your • What happens in emergency situations? benefits. • What is the Mail Service Pharmacy Program? Why are Formularies necessary? • What is pre-authorization? Medication costs continue to rise. Formularies list those What Else Should I Read To Understand My medications that offer value while maintaining quality of Pharmacy Benefits? care to help reduce health care and premium costs. We want our members to get the most from their Who decides which medications are on the prescription drug benefit plan,so please read this Formulary? Supplement to the Combined Evidence of Coverage and Medications are added or deleted from the Formulary Disclosure Form("Supplement")carefully.You need to only after careful review by a committee of Practicing become familiar with the terms used for explaining your Physicians and pharmacists.This committee,called a coverage,because understanding these terms is essential pharmacy and Therapeutics(P&T)Committee,has the to understanding your benefit. Along with reading this responsibility of reviewing new and existing drugs.This publication,be sure to review your Pharmacy Schedule of committee decides which drugs provide quality treatment Benefits.Your Pharmacy Schedule of Benefits provides at the best value. Updates occur quarterly; however,in the details of your particular pharmacy benefit plan, certain situations,drugs may be added to or removed from including the exclusions and limitations,applicable the Formulary more frequently. You may obtain a copy Copayments and PacifiCare's pre-authorization process. of the formulary by contacting Customer Service or from Together,these documents explain your coverage.These PacifiCare's web site at www.pacificare.com. documents should be read completely and carefully for a comprehensive understanding of your medical and Please remember that the inclusion of a specific drug on pharmacy benefits. the Formulary does not guarantee that your Participating Physician or Authorized non-Plan Physician will Your medical Combined Evidence of Coverage and prescribe that drug for treatment of a particular condition. Disclosure Form and Medical Schedule of Benefits together with this Supplement to the Combined Evidence of Coverage and Disclosure Form and the Pharmacy What if my outpatient prescription Schedule of Benefits provide the terms and conditions of medication is not on the Formulary? your benefit coverage.All applicants have a right to view these documents prior to enrollment. Formularies list alternative medications,which are safe and effective. These medications often have the same PacifiCare does not coordinate benefits for outpatient action on your body. If your medication is not listed,ask prescription drugs. your Participating Physician or Authorized non-Plan Physician or Participating Pharmacist for an alternative. 20030109 9/03 1 PCO1549 How is a medication added or deleted from Therapeutic substitution of medication the Formulary? If there is no generic equivalent available for a specific A medication must first demonstrate safety and brand name drug,your physician may prescribe a effectiveness to be added to the Formulary. Only after this 'therapeutic substitute'instead. Unlike a generic,which is determined is the cost of the medication considered. has the identical active ingredient as the brand name Some medications have similar safety and effectiveness, version,a therapeutic substitute has a chemical however,are available at a lower cost.In these cases,the composition that is different but acts similarly in clinical least costly medications are added to the Formulary. and therapeutic ways when compared to competing brand name counterparts. When does the Formulary change? If a change occurs, will I have to pay more to use Filling Your Prescription: a drug I had been using? Who can write my prescription? The National Pharmacy and Therapeutics Committee Generally,to be eligible for coverage,your prescription meets regularly to review the Formulary and add or must be written by a Participating Physician. There are remove medications.Our Formulary books are printed two exceptions to this rule. The first is when the and distributed to Participating Physicians or Authorized prescription is written by a non-Participating Physician non-Plan Physicians on a regular basis and any changes to who has been pre-approved by PacifiCare to treat you. the Formulary are also communicated to your The second exception is when a drug is prescribed for Participating Physician or Authorized non-Plan Physician Emergency or Urgently Needed Services when you are non a regular basis. We also make available on our web out of the area. Emergency Service or Urgently Needed site a listing of the most recent Formulary changes. See Service is defined in your medical Combined Evidence of the section"Recent Formulary Changes"on the pharmacy Coverage and Disclosure Form. page of our Web site.Refer to your Pharmacy Schedule of Benefits to find out if your Copayments are dependent How Do I Use My Prescription Drug Benefit? on Formulary status. Your outpatient prescription drug benefit helps to cover Generic Prescription Drugs the cost for some of the outpatient medications prescribed by a PacifiCare Participating Physician or Authorized What is the Difference Between Generic and non-Plan Physician.Using your benefit is simple. Brand Name Drugs? • Obtain your prescription from your PacifiCare When a new drug is put on the market,for many years it Participating Physician or Authorized non-Plan is typically available only under a manufacturer's brand Physician. name. At first,this new drug is protected by a patent. • Present your prescription for a covered outpatient Only after the patent expires are competing manufacturers medication and PacifiCare Member ID card at any allowed to offer the very same drug. This type of drug is PacifiCare Participating Pharmacy. If ordering by called a generic drug. phone,be sure to mention that you are a PacifiCare While the name of the drug may not be familiar to you,a Member. Note that some prescription medications generic drug has the same medicinal benefits as its brand must be pre-authorized by PacifiCare. name competitor. In fact,a manufacturer must provide • pay the Copayment for a Prescription Unit or its proof to the Food and Drug Administration(FDA)that a retail cost,whichever is less. generic drug has the identical active chemical compound as the brand name product. A generic product must meet • Receive your medication. rigid FDA standards for strength,quality,purity,and potency. Where do I go to fill a prescription? Only when a generic drug meets these standards is it PacifiCare has a well-established network of pharmacies considered the brand name drug's equivalent. When the including most major pharmacy and supermarket chains as well as many independent pharmacies.A complete FDA approves a new generic drug,PacifiCare may choose to replace the brand name drug on the Formulary listing of Participating pharmacies is available in your with the generic drug. Provider Directory. Contact our Customer Service Department at 1-800-877-9777 or TDHI 1-800-360-1797 NOTE:If you have a question about our Formulary or a to help locate a Participating Pharmacy near you or visit particular drug,please contact PacifiCare's Customer our web site at www.pacificare.com for an up-to-date list. Service Department at 1-800-877-9777 TDHI 1-800-360- 1797 or visit PacifiCare's web site at www.pacificare.com. 20030109 9/03 2 PCO1549 When Do I Request a Refill? Call the Customer Service Department at 1-800-877- 9777,TDHI 1-800-360-1797 or visit PacifiCare's web site You may refill a prescription when a minimum of 75%of at www.pacificare.com to obtain the Direct the quantity is consumed based on the days supply. Reimbursement form. Provide the following:Direct I take medication on a continuing basis. How Member Reimbursement form,copies of the prescription can I have my prescriptions filled when I am receipts showing the prescription number,name of the medication,date filled,pharmacy name,name of the on vacation? member for whom the prescription was written,proof of The most convenient and affordable way to do this is to payment and a description of why a PacifiCare take advantage of our mail service program(for additional Participating Pharmacy was not available. Send these details refer to the Mail Service section in this document). documents to:PacifiCare Pharmacy Department,P.O. It is important to plan ahead,because it takes Box 6037,Cypress,CA 90630. approximately seven days to receive your 90 day supply You must submit the Direct Reimbursement Form within from the mail service program.Vacation overrides are 12 months from the date of service. Payment will be also available in certain circumstances—talk with your forwarded to you once your request for reimbursement is pharmacist about obtaining a vacation override. Our determined by PacifiCare to be appropriate. Customer Service Associates can also help you with planning for your medication needs while traveling call 1- Emergency After Hours 800-877-9777,TDHI 1-800-360-1797. PacifiCare will cover a one time only emergency after What if I am sick and need a prescription hours prescription without pre-authorization in the when I'm away from home? following situations: • The prescription is for medication in conjunction If you are sick and need an outpatient prescription with a hospital discharge,emergency room,or urgent medication filled when away from home,you may visit one of our Participating Pharmacies within our national care facility visit limited to a seven day supply except pharmacy network and receive the medication for the for antibiotics which may be dispensed in up to a 14 applicable Copayment.For the nearest network pharmacy, day supply. contact the Customer Service Department at 1-800-877- • Medications used for acute treatment and immediate 9777,TDHI 1-800-360-1797 or visit our web site at use is required. www.pacificare.com. • Any time the prescribing physician states that failure What happens in an Emergency Situation? to supply the medication will result in a severe medical event or hospital admission. If you receive an outpatient prescription medication out of the Pharmacy Network due to an emergency or urgent Note: After hours pre-authorization will not be approved situation,you must pay for the total cost of the for any of the following situations: prescription at the time of service.For possible • Continuation of a restricted medication based solely reimbursement,you must submit a Direct Member on a previous authorization or previous use. Reimbursement Form.You are only eligible for reimbursement for prescriptions related to urgent or • A change to an existing pre-authorization to extend emergency situations as defined by PacifiCare(refer to the days'supply. your medical Combined Evidence of Coverage and Disclosure Form). • A change to an existing pre-authorization to correct erroneous information. Remember: You should only fill a prescription at a Non- Participating Pharmacy-when absolutely necessary. • Early refills of maintenance medications. How do I obtain reimbursement? • Early refills for signature changes or dosage changes. 20030109 9/03 3 PCO1549 When I Fill a Prescription,How Much Here's how to fill prescriptions through the Mail Service Medication Do I Receive? Pharmacy Program. For a single Copayment,Members receive one I. Call your Participating Physician or Authorized non- Prescription Unit which represents a maximum of one Plan Physician to obtain a new prescription for each month's(30 days supply)fill of outpatient prescription medication. When you call,ask the physician to medication that can be obtained at one time. For most write the prescription for a 90 day supply which oral medications,a Prescription Unit is up to a 30 day represents three Prescription Units with up to three supply of medication. additional refills. The doctor will tell you when to pick up the written prescription. (Note:Prescription Medications dispensed in quantities other than the 30 day Solutions must have a new prescription to process supply maximum are listed below: any new mail service request.) • Medications with quantity limitations: The 2. After picking up the prescription,complete the Mail Prescription Unit for some medications may be set at a Service Form included in your enrollment materials. smaller quantity to promote appropriate medication (To obtain additional forms or for assistance in use and patient safety. These quantity limits are based completing the form,call PacifiCare's Customer on generally accepted pharmaceutical practices and Service Department at 1-800-877-9777,TDHI 1-800- the manufacturer's labeling.For example,antibiotics 360-1797. You can also find the form at the web site typically require less than a 30 day supply;and certain address www.rxsolutions.com.) drugs such as controlled substances and migraine 3. Enclose the prescription and appropriate Copayment medications may be limited due to the expectation of via check,money order,or credit card.Your patient need and in accordance with manufacturer's Pharmacy Schedule of Benefits will have the recommended dosages. Drugs with quantity applicable Copayment for the Mail Service Pharmacy limitations may be dispensed in greater quantities if Program. Make the check or money order payable to Medically Necessary and pre-authorized by Prescription Solutions. No cash please. PacifiCare. When you receive your prescription,you'll get detailed • Defined or pre-packaged units of medications: instructions that tell you how to take the medication, Prescriptions such as vials,eye drops,creams or other possible side effects and any other important information types of medications that are normally dispensed in pre-packaged or defined units of 30 day or less will be about the medication.If you have questions,registered pharmacists are available to help you by calling considered a single Prescription Unit. Prescription Solutions at 1-800-562.6223 or TDHI 1-800- • Medication obtained through PacifiCare's Mail 498-5425. Service Program: If you use the PacifiCare Mail Note: Medications such as antibiotics,drugs used for Service Pharmacy Program,you will receive three short-term or acute illnesses,and drugs that require Prescription Units or up to a 90 day supply of special packaging,are not available through our Mail maintenance medications(except for pre-packaged Service Pharmacy Program. medications as described above). Important Tip:If you are starting a new medication, Pacificare's Mail Service Program please request two prescriptions from your Participating What is the Mail Service Pharmacy Physician or Authorized non-Plan Physician. Have one filled immediately at a Participating Pharmacy while program? mailing the second prescription to PacifiCare's Mail PacifiCare offers a Mail Service Pharmacy Program Service Pharmacy. Once you receive your medication through Prescription Solutions®. The Mail Service through the mail service,you should stop filling the Pharmacy Program provides convenient service and prescription at the Participating Pharmacy. savings on maintenance medications that you may take on a regular basis by allowing you to purchase certain drugs for receipt by mail. You get high quality medications mailed directly to your home or address of your choice within the United States,in a discreetly labeled envelope to ensure privacy and safety. Shipping and handling is at no additional charge. If you use our Mail Service Pharmacy Program,you will generally get your maintenance medication within seven working days after receipt of your order. All orders are shipped in discreetly labeled envelopes for privacy and safety. 20030]09 9/03 4 PC01549 What is pre-authorization? What do I do if I need pre-authorization? While your prescription drug benefit covers most We understand that situations may arise in which it may medications,there are some medications that are excluded be medically necessary to take a medication above the or require pre-authorization. For example,medications preset limits or for a particular condition/circumstance.In used for cosmetic purposes such as wrinkle creams are these instances,since your Participating Physician or not generally covered.Medication quantities may also be Authorized non-Plan Physician understands your medical limited to ensure that they are being used safely and history and health conditions,he/she can request pre- effectively.Copayments,exclusions and restrictions vary, authorization.We have made the process simple and easy. so be sure to read your Pharmacy Schedule of Benefits for Your Participating Physician or Authorized non-Plan additional details.Prescriptions that require pre- Physician can call or fax the pre-authorization request to authorization will be charged at the applicable Copayment Prescription Solutions®,PacifiCare's pharmacy benefit if approved. manager.The pre-authorization staff of qualified pharmacists and technicians is available Monday through We want to make sure our members receive optimal care Friday from 6:00 a.m.to 6:00 p.m. to assist Participating and appropriate medication use is a big part of Physicians or Authorized non-Plan Physicians.Most maintaining your overall health.That is why we have authorizations are completed within 24 hours.The most systems in place to make sure your medication is common reason for delay in the authorization process is prescribed according to treatment guidelines consistent insufficient information.Your Participating Physician or with standard professional practice.We want to make Authorized non-Plan Physician may need to provide sure you are not taking more medication or medication for information on diagnosis and medication history and/or a longer period of time than is necessary,as well as evidence in the form of documents,records or lab tests receiving follow-up care.PacifiCare reserves the right to which establish that the use of the requested medication require pre-authorization and/or limit the quantity of any meets plan criteria. prescription to ensure that the following coverage criteria are met. Does this plan limit or exclude certain drugs • The prescription is for the treatment of a covered my health care provider may prescribe or medical condition and the expected beneficial effects encourage substitutions for some drugs? of the prescription outweigh the harmful effects. Your PacifiCare pharmacy benefit provides you access to • There is sufficient evidence to draw conclusions a wide range of FDA-approved brand and generic about the effect of the prescription on the medical medications.The Formulary is developed with the input condition being treated and on your health outcome. from Participating Physicians,Authorized non-Plan Physicians and pharmacists and is based on assessment of • The expected beneficial effects of the prescription the drug's quality,safety,effectiveness and cost.When outweigh the expected harmful effects. we don't include a medication,it's usually because an • The prescription represents the most cost-effective approved alternative can be prescribed for the same method to treat the medical condition. condition.For example,PacifiCare may cover the generic product,rather than its brand-name equivalent.It is also • The prescription drug is prescribed according to important to remember there may be other options established,documented and approved indications available for treating a particular medical condition. that are supported by the weight of scientific evidence. What should I do if I want a change from PacifiCare understands that situations arise in which an limitations, eXClUS1OUS, substitutions or cost exception to pre-authorization requirements may be increases for drugs specified in this plan? Medically Necessary. In these instances,your In some cases,your provider may request an exception to Participating Physician Authorized non-Plan Physician an exclusion,limitation or substitution through the pre- may request an exception by calling or faxing the request authorization process.In addition,as a PacifiCare to PacifiCare. The Participating Physician or Authorized member you have the right to appeal any coverage non-Plan Physician may need to provide evidence to determination. Contact Customer Service at 1-800-877- PacifiCare in the form of documents,lab results,records 9777,TDHI 1-800-360-1797 for details on the pre- or clinical trials which establish that use of the requested authorization or appeals process. All appeals are handled medication meets plan criteria for coverage. Prescriptions within 30 days;however;emergency requests are that require pre-authorization will be charged at the processed within three business days. Please refer to your applicable Copayment if approved. medical Combined Evidence of Coverage and Disclosure Form for more details on the appeals process. 20030109 9/03 5 PCO1549 • What is covered,what is not? Participating Provider-Any Physician,Physician specialist,hospital,Skilled Nursing Facility,extended PacifiCare covers most FDA-approved generics and a care facility, individual,organization,agency or other • broad selection of brand name drugs. Refer to your Provider who/which has entered into a contractual Pharmacy Schedule of Benefits for a listing of covered arrangement with PacifiCare to provide health services to medications as well as limitations and exclusions for Member. PacifiCare may contract with a Provider for a certain medications. specified Member,a specified period of time and/or a Helpful tips: specified services. In that case,the Provider is a Participating Provider only for the services(s)contracted • Take your medications list with you to the doctor's and/or for the designated period. office. Participating Pharmacy-A pharmacy that has • Ask your doctor before leaving his office if the drug contracted with PacifiCare to provide outpatient he prescribed is on the PacifiCare Formulary. prescription drugs to our members. • Talk with your doctor about Formulary alternative Participating Physician -A physician that has contracted medications to treat your medical condition. with PacifiCare to provide health care services to our members. • You and your practitioner can access the most current Formulary information on our Web site at Pre-authorization-PacifiCare's review process that www.pacificare.com including information on determines the coverage of a prescription drug prior to the Formulary alternatives. member receiving the prescription drug. Definitions Prescription Unit-The maximum amount(quantity)of prescription medication that may be dispensed per single Contract or Plan Year-The twelve-month period that Copayment. For most oral medications,a Prescription begins on the first day of the month the Agreement Unit represents up to.a 30 day supply of medication. The becomes effective Prescription Unit for some medications may be set at a Calendar Year-The time period beginning on January smaller quantity to promote appropriate medication use l'and ending on December 31". and patient safety. Quantity limits are based on generally accepted pharmaceutical practices and the manufacturer's Formulary-A list of prescription medications covered labeling. Prescriptions that are normally dispensed in pre- by PacifiCare for use in the member's treatment.The packaged or commercially available units of 30 days or Formulary contains a broad range of FDA approved less will be considered a single Prescription Unit generic and some brand name medications that under including but not limited to,one inhaler,one vial of State or Federal law are to be dispensed by a prescription ophthalmic medication,one tube of topical ointment or only. The Formulary does not include all prescription cream. medications. Selected Brands List-The brand-name drugs included Non-Participating Pharmacy-A pharmacy that has on the PacifiCare Formulary in place of their generic NOT contracted with PacifiCare to provide outpatient equivalents. These drugs are available at the generic drug prescription drugs to our members. Copayment amount. Non-Participating Physician-A physician that has NOT Non-Formulary Preferred Drug:Non-Formulary drug contracted with PacifiCare to provide health care services that is more cost effective than a similar non-Formulary to our members. drug. Non-Participating Providers-A hospital or other health care entity,a Physician or other health care professional, or a health care vendor that has not entered into a written agreement to provide Covered Services to PacifiCare's members. 20030109 9/03 6 PCO1549 PHARMACY LISTING For the most up to date list visit the web site at www.pacificare.com • AI.BERTSONS PHARMACY • CITY MARKET PHARMACY • CUB PHARMACY • GOOD DAY PHARMACY • HOFFMAN DRUGS • K MART PHARMACY • KING SOOPERS PHARMACY • LONGS DRUG STORE • MEDICINE SHOPPE PHARMACY • PHAR-MOR • RITE AID PHARMACY • SAFEWAY PHARMACY • SAMS PHARMACY • SHOPKO PHARMACY • TARGET • WALGREEN DRUG STORE • WAL-MART PHARMACY Questions? Call Paci'Ware's Customer Service Department at 1-800-877-9777, 1-800-360-1797 (TM). PacifiCare® 6455 South Yosemite Street Greenwood Village,Colorado 80111 M-F,7 a.m.to 8 p.m. www.pacificare.com 20030109 9/03 7 PCO1549 PacifiCare of Colorado Formulary ft_tvzirr _Bracd`Name�.:.. , 4=a7 Gi eNaName r ;_-_;Sfre<apetfffW'ClaSE;_4,--. rCssverage RAW A/r/S erythromycin .H .e- Dermatologic Agents Generic Accolate zafidukast Respiratory Agents Brand Accutane isotretinoin Dermatologic Agents Brand Achromycin tetracycline Anti-Infective Agents Generic Aciphex rabeprazole Gastrointestinal Agents Brand Aclovate alclometasone dipropionate Dermatologic Agents Brand Actigall ursodiol Gastrointestinal Agents Generic Acular ketorolac tromethamine ophthalmic Ophthalmic/Otic Agents Brand Adalat CC nifedipine Cardiovascular Agents Brand Adapin doxepin Central Nervous System Agents Generic Adderall amphetamine/dexamphetamine Central Nervous System Agents Generic Adderall 7.5mg amphetamine/dexamphetamine 7.5mg Central Nervous System Agents Brand Adderall XR Amphetamine-Dextroamphetamine Central Nervous System Agents Brand Advair Diskus salmeterol xinafoate&fluticasone propionate Respiratory Agents Brand Advicor lovastatin&niacin SR Cardiovascular Agents Brand Aerochamber respiratory device Respiratory Agents Brand Aerochamber w/Mask respiratory device Respiratory Agents Brand Agenerase amprenavir Anti-Infective Agents Brand Agrylin anagrelide hd Cardiovascular Agents Brand Albalon naphazoline Ophthalmic/Otic Agents Generic Aldactazide 25mg/25mg spironolactone/hydrochlorothiazide 25mg/25mg Cardiovascular Agents Generic Aldactazide 50mg/50mg spironolactone/hydrochlorothiazide Cardiovascular Agents Brand Aldactone spironolactone Cardiovascular Agents Generic Aldara imiquimad Dermatologic Agents Brand Aldomet methyldopa Cardiovascular Agents Genenc Aldoril-15 methyldopa/HCTZ Cardiovascular Agents Generic Aldoril-25 methyldopa/HCTZ Cardiovascular Agents Generic Alesse levonorgestrel-ethinyl estradiol Metabolic/Endocrine Agents Brand Antineoplastics and Alkeran melphalan Immunosuppressants Brand Allegra 180 MG fexofenadine rid Respiratory Agents Brand Allegra 30mg,60mg fexofenadine 30mg,60mg Respiratory Agents Brand Alora estradiol transdermal patch Metabolic/Endocrine Agents Brand Alphagan brimonidine tartrate Ophthalmic/Otic Agents Brand Alupent Inhalation Solution metaproterenol inhalation solution Respiratory Agents Generic Alupent Inhaler metaproterenol inhaler Respiratory Agents Brand Amoxil(not 200mg) amoxicillin(not 200mg) Anti-Infective Agents Generic Amoxil 400mg/5ml suspension amoxicillin 400mg/5m1 suspension Anti-Infective Agents Brand Amoxil 875mg amoxicillin 875mg Anti-Infective Agents Brand Anafranii domipramine Central Nervous System Agents Generic Analpram HC hydrocortisone acetate/pramoxine Gastrointestinal Agents Brand Anaprox naproxen sodium Musculoskeletal Agents Generic Androderm testosterone transdermal patches Metabolic/Endocrine Agents Brand Antabuse disulfiram Miscellaneous Agents Generic Anusol-HC cream,suppository hydrocortisone acetate cream,suppository Gastrointestinal Agents Generic Anzemet dolasetron mesylate Gastrointestinal Agents Brand Apresoline hydralazine Cardiovascular Agents Generic Aralen 500mg chloroquin phosphate 500mg Anti-Infective Agents Generic Antineoplastics and Arimidex anastrozole Immunosuppressants Brand Aristocort tablet tnamcinolone tablet Metabolic/Endocrine Agents Brand Armour Thyroid thyroid Metabolic/Endocrine Agents Generic Antineoplastics and Aromasin exemestane Immunosuppressants Brand Artane lrihexyphenidyl Central Nervous System Agents Generic Asacol mesalamine Gastrointestinal Agents Brand Astelin azelastine Respiratory Agents Brand Atarax 100mg tablet hydroxyzine 100mg tablet Respiratory Agents Brand Atarax 10mg,25mg,50mg tablet hydroxyzine 10mg,25mg,50mg tablet Respiratory Agents Generic Atarax Syrup hydroxyzine Respiratory Agents Generic Ativan Iorazepam Central Nervous System Agents Generic Atropine Sulfate atropine sulfate Gastrointestinal Agents Generic Atrovent Inhalation Solution ipratropium inhalation solution Respiratory Agents Generic Atrovent Inhaler ipratropium inhaler Respiratory Agents Brand 20030111 9/03 Page 1 of 13 PC01541 Wad Nalw e' .m t, :---= 1:Geh l m_ `'..._ ,'-. herageutioallgs :.Coverage:Flag:, Augmentin amoxicillin&K clavulanate Anti-Infective Agents Brand Augmentin XR amoxicillin&K clavulanate SR Anti-Infective Agents Brand Auralgan benzocaine-antipyrine Ophthalmic/Otic Agents Generic Avelox moxifloxacin Anti-Infective Agents Brand Aventyl capsule nortriptyline capsule Central Nervous System Agents Generic Azopt brinzolamide Ophthalmic/Otic Agents Brand Azulfdine sulfasalazine Gastrointestinal Agents Generic B-D Insulin Syringes B-D Insulin Syringes Diabetic Testing Supplies Brand Bacitracin bacitracin Ophthalmic/Otic Agents Generic Bactrim irimethoprim/sulfamethoxazole Anti-Infective Agents Generic Bactrim DS trimethoprim/sulfamethoxazole Anti-Infective Agents Generic Bactroban mupirocin Dermatologic Agents Brand BD Ultrafne Lancets lancets Diabetic Testing Supplies Brand Beconase AO beclomethasone nasal spray Respiratory Agents Brand Benemid probenecid Metabolic/Endocrine Agents Genenc Bentyl dicyclomine Gastrointestinal Agents Generic Bentyl syrup dicyclomine syrup Gastrointestinal Agents Brand Benzamycin erythromycin/benzoyl peroxide Dermatologic Agents Brand Betagan levobunolol Ophthalmic/Otic Agents Generic Betapace sotalol Cardiovascular Agents Generic Betapace AF sotalol Cardiovascular Agents Brand Betimol [imolol hemihydrate Ophthalmic/Otic Agents Brand Betoptic betaxolol Ophthalmic/Otic Agents Generic Betoptic S betaxolol OphthalmiciOtic Agents Brand Biaxin clarithromycin Anti-Infective Agents Brand Biaxin XL clarithromycin SR Anti-Infective Agents Brand Biltricide praziquantel Anti-Infective Agents Brand Bleph-10 sulfacetamide Ophthalmic/Otic Agents Generic Blephamide sulfacetamide/prednisolone Ophthalmic/Otic Agents Brand Brethine terbutaline Respiratory Agents Brand Brethine terbutaline Metabolic/Endocrine Agents Brand Bromodiphenhydramine/codeine bromodiphenhydramine/codeine Respiratory Agents Brand Bronchia Saline sodium chloride for inhalation Respiratory Agents Brand Bumex bumetanide Cardiovascular Agents Generic Buspar buspirone Central Nervous System Agents Generic Buspar 30mg buspirone 30mg Central Nervous System Agents Generic Cafatine PB ergolamine/pentobarbital/belladonna/caffeine Central Nervous System Agents Brand Cafergot tablet ergotamine tartrate/caffeine tablet Central Nervous System Agents Brand Celan SR tablet verapamil CR,ER,SR tablet Cardiovascular Agents Generic Celan tablet verapamil tablet Cardiovascular Agents Generic Canasa suppository mesalamine suppository Gastrointestinal Agents Brand Capoten captopril Cardiovascular Agents Generic Capozide captopril/hydrochlorothiazide Cardiovascular Agents Generic Antineoplastics and Carac fluorouracit Immunosuppressants Brand Carafate suspension sucralfate suspension Gastrointestinal Agents Brand Carafate tablet sucralfate tablet Gastrointestinal Agents Generic Cardene nicardipene Cardiovascular Agents Generic Cardene SR nicardipene SR Cardiovascular Agents Brand Cardizem(not CD) diltiazem Cardiovascular Agents Generic Cardizem SR diltiazem SR Cardiovascular Agents Generic Cardura doxazosin mesylate Cardiovascular Agents Generic Cardura doxazosin mesylate Genitourinary Agents Generic Antineoplastics and Casodex bicalutamide Immunosuppressants Brand Catapres tablet clonidine tablet Cardiovascular Agents Generic Antineoplastics and CeeNu lomustine Immunosuppressants Brand Cefzil cefprozil Anti-Infective Agents Brand Cephulac lactulose Gastrointestinal Agents Generic Cerespan papaverine CR Cardiovascular Agents Generic Chemstrip UG&UGK Strips Chemstrip UG&UGK Strips Diabetic Testing Supplies Brand Chloroptic chloramphenicol Ophthalmic/Otic Agents Brand Chloroquin Phosphate(250mg) chloroquin phosphate(250mg) Anti-Infective Agents Brand 20030111 9/03 Page 2 of 13 PCO1541 r _Bt?a thiS:_' r' er Sttraef0sse- x 17 a Chlorpheniramine/Pyrilamine/Ph enylephrine 8/25/25 chlorpheniramine/pyrilamine/phenylephrine Respiratory Agents Generic Chlorpromazine concentrate 30mg/ml chlorpromazine concentrate Central Nervous System Agents Brand Chromagen-OB Prenatal Vitamin Nutritional Supplements Brand Chronulac lactulose Gastrointestinal Agents Generic Cipro tablet ciprofloxacin tablet Anti-Infective Agents Brand Clarinex desloratadine Respiratory Agents Brand Cleocin 75mg capsule clindamycin(75mg capsule) Anti-Infective Agents Brand Cleocin capsule clindamycin capsule Anti-Infective Agents Generic Cleocin vaginal cream,vaginal suppository clindamycin vaginal cream,vaginal suppository Anti-Infective Agents Brand Cleocin-T clindamycin Dermatologic Agents Generic Cleocin-T lotion clindamycin lotion Dermatologic Agents Generic Clinoril sulindac Musculoskeletal Agents Generic Clorpres clonitline/chlorthalidone Cardiovascular Agents Brand Codeine sulfate codeine sulfate Musculoskeletal Agents Brand Codimal-DH phenylephrine/pyrilamine/hydrocodone Respiratory Agents Generic Cogentin benztropine mesylate Central Nervous System Agents Generic Colazal balsalazide Gastrointestinal Agents Brand Colchicine calchicine Metabolic/Endocrine Agents Generic Colestid colestipol Cardiovascular Agents Brand CoLyte polyethylene glycol/electrolyte solution Gastrointestinal Agents Generic Combipres 0.1mg/15mg, 0.2mg/15mg clonitline/chlorthalidone Cardiovascular Agents Generic Combivent Inhaler albuterol/ipratropium Respiratory Agents Brand Combivir lamivudine/zidevudine Anti-Infective Agents Brand Compazine prochlorperazine Gastrointestinal Agents Generic Concerta methylphenidate hcl er Central Nervous System Agents Brand Condylox gel podofilox gel Dermatologic Agents Brand Condylox solution podofilox solution Dermatologic Agents Generic Cordarone amiodarone Cardiovascular Agents Generic Coreg carvedilol Cardiovascular Agents Brand Corgard nadolol Cardiovascular Agents Generic Cortef 20mg hydrocortisone 20mg Metabolic/Endocrine Agents Generic Cortef 5mg,10mg hydrocortisone 5mg,10mg Metabolic/Endocrine Agents Brand Cortenema hydrocortisone Gastrointestinal Agents Generic Cortisporin otic neomycin/potymixin b/hydrocortisone Ophthalmic/Otic Agents Generic Cotazym pancrelipase Gastrointestinal Agents Brand Coumadin warfarin Cardiovascular Agents Generic Creon pancrelipase Gastrointestinal Agents Generic Crixivan indinavir sulfate Anti-Infective Agents Brand Crolom cromolyn sodium Ophthalmic/Otic Agents Generic Cuprimine penicillamine Musculoskeletal Agents Brand Cutivate fluticasone propionate Dermatologic Agents Brand Cyclessa desogestrel-ethinyl estradiol Metabolic/Endocrine Agents Brand Cyclogyl cyclopentolate Ophthalmic/Otic Agents Generic Cystospaz hyoscyamine Gastrointestinal Agents Generic Cytomel liothyronine Metabolic/Endocrine Agents Brand Cytotec misoprostol Gastrointestinal Agents Generic Antineoplastics and Cytoxan cyclophosphamide Immunosuppressants Generic Dalmane flurazepam Central Nervous System Agents Generic Danocrine danazol Metabolic/Endocrine Agents Generic Dantrium dantrolene Musculoskeletal Agents Brand Dapsone dapsone Anti-Infective Agents Brand Daraprim pyrimethamine Anti-Infective Agents Brand Darvocet-N 100 propoxyphene napsylate/acetaminophen Musculoskeletal Agents Generic Darvocet-N 50 propoxyphene napsylate/acetaminophen Musculoskeletal Agents Brand Darvon propoxyphene Musculoskeletal Agents Generic Darvon Compound propoxyphene/aspirin/caffeine Musculoskeletal Agents Generic DDAVP nasal solution desmopressin nasal solution Metabolic/Endocrine Agents Generic DDAVP oral desmopressin tablet Metabolic/Endocrine Agents Brand Decadron ophthalmic dexamethasone Ophthalmic/Otic Agents Generic Decadron oral dexamethasone Metabolic/Endocrine Agents Generic Declomycin demeclocycline hcl Metabolic/Endocrine Agents Brand Deltasone prednisone Metabolic/Endocrine Agents Generic 20030111 9/03 Page 3 of 13 PCO1541 a..Bral5`dNam. .=v -'= = ekt ti .gaM ::-. :„...,;.;.,'Lti letitleas ' —Berta " Demerol meperidine Musculoskeletal Agents Generic Demulen ethynodiol diacetate/ethinyl estradiol Metabolic/Endocrine Agents Brand Depakene valproic acid Central Nervous System Agents Generic Depakote divalproex sodium Central Nervous System Agents Brand Depakote divalproex sodium Central Nervous System Agents Brand Depakote divalproex sodium Central Nervous System Agents Brand Depakote ER divalproex sodium SR Central Nervous System Agents Brand Desogen desogestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Desyrel trazodone Central Nervous System Agents Genenc Dexedrine dextroamphetamine Central Nervous System Agents Generic Dexedrine SR dextroamphetamine SR Central Nervous System Agents Brand Dexstrostat Dextroamphetamine Sulfate 5mg tablet Central Nervous System Agents Generic DHT dihydrotachysterol Nutritional Supplements Brand Diabeta glyburide Metabolic/Endocrine Agents Generic Diabinese chtorpropamide Metabolic/Endocrine Agents Generic Diamox acetazolamide Ophthalmic/Otic Agents Generic Diaphragms Diaphragms Miscellaneous Agents Brand Dibenzyline phenoxybenzamine Cardiovascular Agents Brand Diflucan 150mg fluconazole 150mg Anti-Infective Agents Brand Digitek Digitek Cardiovascular Agents Generic Dilacor XR diltiazem ER Cardiovascular Agents Generic Dilantin phenytoin Central Nervous System Agents Brand Dilaudid hydromorphone Musculoskeletal Agents Generic Diltiazem ER(24 HR)capsule diltiazem ER(24 HR)capsule Cardiovascular Agents Generic Diprolene augmented betamethasone Dermatologic Agents Generic Diprolene AF augmented betamethasone dipropionate Dermatologic Agents Brand Diprolene lotion augmented betamethasone lotion Dermatologic Agents Brand Diprosone betamethasone dipropionate Dermatologic Agents Generic Disalcid tablet salsalate tablet Musculoskeletal Agents Genenc Ditropan(not XL) oxybutynin Genitourinary Agents Generic Dolobid diflunisal r.Musculoskeletal Agents Generic Dolophine methadone Musculoskeletal Agents Generic Donnatal phenobarbital/belladonna alkaloids Gastrointestinal Agents Generic Donnatal Extentab phenobarbital/belladonna alkaloids CR Gastrointestinal Agents Brand Drisdol ergocalciferol(vitamin D) Nutritional Supplements Generic Drithocreme anthralin Dermatologic Agents Brand Drithocreme HP 1% anthralin Dermatologic Agents Generic Dura-Vent/DA chlorpheniramine/phenylephrine/methscopolamine Respiratory Agents Generic Duragesic fentanyl Musculoskeletal Agents Brand Duratuss G guiafenesin 1200mg Respiratory Agents Generic Duratuss HD pseudoephedrine/hydrocodone/guiafenesin Respiratory Agents Generic Duricef 500mg capsule,1gm tablet cefadroxi1500mg capsule,1gm tablet Anti-Infective Agents Generic Duricef suspension cefadroxil suspension Anti-Infective Agents Brand Dyazide triamterene/hydrochlorothiazide Cardiovascular Agents Generic Dymelor acetohexamide Metabolic/Endocrine Agents Generic Dynacin minocycline Anti-Infective Agents Generic DynaCirc(not CR) isradipine Cardiovascular Agents Brand Dynapen dicloxacillin Anti-Infective Agents Generic Dynapen suspension dicloxacillin suspension Anti-Infective Agents Brand E-Z Spacer respiratory device Respiratory Agents Brand Easivent respiratory device Respiratory Agents Brand EES erythromycin ethylsuccinate Anti-Infective Agents Generic Effexor venlafaxine Central Nervous System Agents Brand Effexor XR venlafaxine XR Central Nervous System Agents Brand Antineoplastics and Efudex fluorouracil Immunosuppressants Brand Elavil amitriptyline Central Nervous System Agents Generic Eldepryl tablet selegiline tablet Central Nervous System Agents Generic Simile permethrin Dermatologic Agents Generic Elixophyllin theophylline Respiratory Agents Generic Elmiron pentosan polysulfate sodium Genitourinary Agents Brand Elocon Cream&Lotion mometasone Dermatologic Agents Brand Elocon ointment mometasone Dermatologic Agents Generic Antineoplastics and Emcyt estramustine phosphate sodium Immunosuppressants Brand Emgel erythromycin Dermatologic Agents Generic 20030111 9/03 Page 4 of 13 PCO1541 -re Ti_6.ai'rle,-_: ._: f. 414,`014_,_ NI*O ._.. .:.. € :4. r erapeud WK oVetagelfla Empwn w/Codeine aspirin/codeine Musculoskeletal Agents Generic Epifrin epinephrine Ophthalmic/Otic Agents Brand Epivir lamivudine Anti-Infective Agents Brand Ergomar ergotamine tartrate Central Nervous System Agents Brand Ery-Tab Erythromycin base Anti-Infective Agents Generic Erythromycin Stearate erythromycin stearate Anti-Infective Agents Generic Esgic acetaminophen/caffeine/butalbital Central Nervous System Agents Generic Esgic Plus tablet acetaminophen/caffeine/butalbital tablet Central Nervous System Agents Generic Eskalith 300mg capsule lithium carbonate 300mg capsule Central Nervous System Agents Generic Estrace tablet estradiol tablet Metabolic/Endocrine Agents Generic Estrace Vaginal Cream estradiol vaginal cream Metabolic/Endocrine Agents Brand Estraderm estradiol transdermal patch Metabolic/Endocrine Agents Brand Estratab esterilied estrogen Metabolic/Endocrine Agents Brand Estratest esterified estrogen/methyltestosterone Metabolic/Endocrine Agents Brand Estratest HS esterified estrogen/methyltestosterone Metabolic/Endocrine Agents Brand Ethmozine moncizine Cardiovascular Agents Brand Antineoplastics and Eulexin flutamide Immunosuppressants Generic Eurax crotamiton Dermatologic Agents Brand chlorpheniramine/phenylephrine/methscopolami ne Exlendryl(plain) (plain) Respiratory Agents Generic Fansidar pyrimethamine/sulfadoxine Anti-Infective Agents Brand Antineoplastics and Fareston toremifine citrate Immunosuppressants Brand FastTake Test Strips test strips Diabetic Testing Supplies Brand Feldene piroxicam Musculoskeletal Agents Generic Antineoplastics and Femara letrozole Immunosuppressants Brand Fioncet acetaminophen/caffeine/butalbital Central Nervous System Agents Generic Fioncet w/codeine acetaminophen/caffeine/butalbital w/codeine Central Nervous System Agents Generic Fiorinal aspirin/caffeine/butalbital Central Nervous System Agents Generic Flagyl tablet metronidazole tablet Anti-Infective Agents Generic Flexenl cyclobenzaprine Musculoskeletal Agents Generic Flonase fluticasone propionate Respiratory Agents Brand Flonnef fudrocortisone Metabolic/Endocrine Agents Generic Flovent fluticasone propionate Respiratory Agents Brand Floxin Otic ofloxacin otic Ophthalmic/Otic Agents Brand Fluorabon Basic Drops pediatric vitamin ACD w/fluoride Nutritional Supplements Brand FML Forte fluorometholone Ophthalmic/Ohc Agents Brand FML Liquifilm fluorometholone OphthalmiaOtic Agents Generic FML S.O.P. fluorometholone Ophthalmic/Otic Agents Brand Folic Acid folic acid Nutritional Supplements Generic Fortovase saquinavir Anti-Infective Agents Brand Fulvicin P/G griseofulvin ultramicrosize Anti-Infective Agents Brand Fulvicin U/F griseofulvin microsize Anti-Infective Agents Brand Furadantin suspension nitrofurantoin suspension Anti-Infective Agents Brand Furoxone furazolidone Anti-Infective Agents Brand Gantrisin suspension sulfisoxazole suspension Anti-Infective Agents Brand Garamycin Ophthalmic ointment,solution gentamicin ophthalmic ointment,solution Ophthalmic/Otic Agents Generic Garamycin topical gentamicin sulfate Dermatologic Agents Generic Glucophage metformin Metabolic/Endocrine Agents Generic Glucotrol(not XL) glipizide Metabolic/Endocrine Agents Generic Glynase PresTab glyburide micronized Metabolic/Endocrine Agents Generic Golytely polyethylene glycol/electrolyte solution Gastrointestinal Agents Brand Granulex trypsin/balsam pew/castor oil Dermatologic Agents Generic Grifulvin V griseofulvin microsize Anti-Infective Agents Brand Gns-Peg griseofulvin ultramicrosize Anti-Infective Agents Brand Grisactin 500mg tablet griseofulvin microsize 500mg tablet Anti-Infective Agents Brand Gynodiol 0.5mg,1mg,2mg estradiol 0.5mg,1mg,2mg Metabolic/Endocrine Agents Generic Gynodiol 1.5mg estradiol 1.5mg Metabolic/Endocrine Agents Brand Halcion triazolam Central Nervous System Agents Genenc Haldol haloperidol Central Nervous System Agents Generic Haldol 10mg haloperidol 10mg Central Nervous System Agents Brand Halotestin fluoxymesterone Metabolic/Endocrine Agents Brand Helidac bismuth/metronidazole/tetracycline Gastrointestinal Agents Brand 20030111 9/03 Page 5 of 13 PCO1541 ,_ thO! __ ' _. Ls' Gil ::. — 8tt-Gla - C6verag Flag , Antineoplastics and Hexalen altretamine Immunosuppressants Brand Histussin MC pheylephrine/chlorpheniramine/hydrocodone Respiratory Agents Generic Hivid ddC/dideoxycytidine Anti-Infective Agents Brand Humalog human insulin lispro MetabolidEndocrine Agents Brand Humalog Mix human insulin lispro&lispro prolamine Metabolic/Endocrine Agents Brand Humibid LA guaifenesin CR Respiratory Agents Generic Humulin Insulin human insulin Metabolic/Endocrine Agents Brand Hycodan syrup hydrocodone/homatropine syrup Respiratory Agents Generic Antineoplastics and Hydrea hyroxyurea Immunosuppressants Generic Hydrodiuril hydrochlorothiazide Cardiovascular Agents Generic Hygroton chlorthalidone Cardiovascular Agents Generic Hytone hydrocortisone Dermatologic Agents Generic Hytrin terazosin Cardiovascular Agents Generic Hytrin terazosin Genitourinary Agents Generic Ilotycin erythromycin Ophthalmic/Otic Agents Generic Imdur isosorbide mononitrate Cardiovascular Agents Generic Imitrex tablet sumatriptan succinate tablet Central Nervous System Agents Brand Antineoplastics and Imuran azathioprine Immunosuppressants Generic Inderal propranolol Cardiovascular Agents Generic Inderal propranolol Central Nervous System Agents Generic Inderal LA propranolol CR Central Nervous System Agents Brand Inderal LA propranolol CR Cardiovascular Agents Brand Inderide propranolol/hydrochlorothiazide Cardiovascular Agents Generic Indocin indomethacin Metabolic/Endocrine Agents Generic Indocin indomethacin Musculoskeletal Agents Generic Inflamase Forte prednisolone phosphate Ophthalmic/Otic Agents Generic Inflamase Mild prednisolone phosphate Ophthalmic/Otic Agents Brand Inspirease respiratory device Respiratory Agents Brand Intal Inhalation Solution cromolyn sodium Respiratory Agents Generic Intal Inhaler cromolyn sodium Respiratory Agents Brand Invirase saquinavir mesylate Anti-Infective Agents Brand lodoquinol powder iodoquinol powder Anti-Infective Agents Generic Isoniazid(INH) isoniazid Anti-Infective Agents Generic Isoptin SR tablet verapamil CR,ER,SR tablet Cardiovascular Agents Generic Isoptin tablet verapamil tablet Cardiovascular Agents Generic Isopto Atropine atropine OphthalmidOtic Agents Generic Isopto Carbachol carbachol Ophthalmic/Otic Agents Brand Isopto Carpine pilocarpine OphthalmidOtic Agents Generic Isopto Carpine 0.25%,8% pilocarpine 0.25%,8% Ophthalmic/Otic Agents Brand Isopto Homatropine homatropine Ophthalmic/Otic Agents Brand Isopto Homatropine 5% homatropine 5% OphthalmidOtic Agents Generic Isordil 40mg tablet isosorbide dinitrate 40mg tablet Cardiovascular Agents Brand Isordil SL tablet isosorbide dinitrate 10mg SL tablet Cardiovascular Agents Brand Isordil SL tablet isosorbide dinitrate SL tablet Cardiovascular Agents Generic Isordil SR tablet isosorbide dinitrate SR tablet Cardiovascular Agents Generic Isordil tablet isosorbide dinitrate tablet Cardiovascular Agents Generic K-Dur potassium chloride CR Nutritional Supplements Brand K-Lyte(25 meq) potassium bicarbonate(25 meq) Nutritional Supplements Generic K-Lyte/CL 25 meq potassium bicarbonate/chloride effer 25 meq Nutritional Supplements Generic Kaletra lopinavir-ritonavir Anti-Infective Agents Brand Karidium Sodium Fluoride Miscellaneous Agents Generic Kayexalate sodium polystyrene sulfonate powder Miscellaneous Agents Generic Keflex cephalexin Anti-Infective Agents Generic Kenalog triamcinolone Dermatologic Agents Generic Kedone betaxolol Cardiovascular Agents Generic Klonopin clonazepam Central Nervous System Agents Generic Lamictal lamotrigine Central Nervous System Agents Brand Lanoxin elixir digoxin elixir Cardiovascular Agents Generic lanoxin tablet digoxin tablet Cardiovascular Agents Brand Lantus insulin glargine Metabolic/Endocrine Agents Brand Lanam mefloquine Anti-Infective Agents Brand Larodopa levodopa Central Nervous System Agents Brand Lasix furosemide Cardiovascular Agents Generic 20030111 9/03 Page 6 of 13 PCO1541 . _ i t " = nee14 rp . ' .An Mat€ '" ._raSuticsciiisieoveragkEratit Antineoplastics and Leucovorin 10mg leucovorin 10mg Immunosuppressants Brand Antineoplastics and Leucovorin 5mg,15mg,25mg leucovorin 5mg,15mg,25mg Immunosuppressants Generic Antineoplastics and Leukeran chlorambucil Immunosuppressants Brand Levatol penbutolol Cardiovascular Agents Brand Levothyroxine levothyroxine Metabolic/Endocrine Agents Generic Levoxyl levothyroxine Metabolic/Endocrine Agents Brand Levsin hyoscamine sulfate Gastrointestinal Agents Generic Levsinex L-hyoscamine sulfate Gastrointestinal Agents Generic Lexapro escitalopram oxalate Central Nervous System Agents Brand Librium chlordiazepoxide Central Nervous System Agents Generic Lidex fluocinonide Dermatologic Agents Generic LifeScan Lancets lancets Diabetic Testing Supplies Brand Lioresal baclofen Musculoskeletal Agents Generic Liquid Pred prednisone Metabolic/Endocrine Agents Brand Lithium carbonate(not 300mg capsule) lithium carbonate(not 300mg capsule) Central Nervous System Agents Brand Livostin levocabastine Ophthalmic/Otic Agents Brand Lo/Ovral norgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Locoid hydrocortisone butyrate Dermatologic Agents Brand Lodine etodolac Musculoskeletal Agents Generic Lomotil diphenoxylate/atropine sulfate Gastrointestinal Agents Generic Loniten minoxidil Cardiovascular Agents Generic Lopid gemlbrozil Cardiovascular Agents Generic Lopressor metoprolol Cardiovascular Agents Generic Loprox ciclopirox olamine Dermatologic Agents Brand Lorcet hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Lortab hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Lotensin benazepril Cardiovascular Agents Brand Lotensin HCT benazepril/hydrochlorothiazide Cardiovascular Agents Brand Loxitane capsule loxapine capsule Central Nervous System Agents Generic Loxitane-C concentrate loxapine concentrate Central Nervous System Agents Brand Lozol indapamide Cardiovascular Agents Generic Ludiomil maprotiline Central Nervous System Agents Generic Lumigan bimatoprost Ophthalmic/Otic Agents Brand Luride sodium fluoride Miscellaneous Agents Generic Antineoplastics and Lysodren mitotane Immunosuppressants Brand Macrobid nitrofurantoin monohydrate macrocrystalline- Anti-Infective Agents Brand Macrodantin nitrofurantoin macrocrystaltine Anti-Infective Agents Generic Marmot dronabinol Gastrointestinal Agents Brand Antineoplastics and Matulane procarbazine Immunosuppressants Brand Maxair Autohaler pirbuterol acetate Respiratory Agents Brand Maxitrol neomycin/polymixin b/dexamethasone Ophthalmic/Otic Agents Generic Maxzide triamterene/hydrochlorothiazide Cardiovascular Agents Generic Mebaral mephobarbital Central Nervous System Agents Brand Meclomen meclofenamate Musculoskeletal Agents Generic Medrol methylprednisolone Metabolic/Endocrine Agents Generic Antineoplastics and Megace megestrol acetate Immunosuppressants Generic Antineoplastics and Megace(suspension) megestrol acetate(suspension) Immunosuppressants Generic Mellaril thioridazine Central Nervous System Agents Generic Menest esterified estrogen Metabolic/Endocrine Agents Brand Mepergan Fortis meperidine/promethazine Musculoskeletal Agents Generic Mephyton phytonadione(vitamin K) Nutritional Supplements Brand Mestinon syrup,CR tablet pyridostigmine bromide syrup,CR tablet Central Nervous System Agents Brand Metaprel metaproterenol Respiratory Agents Generic Metaprel Inhalation Solution metaproterenol inhalation solution Respiratory Agents Generic Methergine methylergonovine realeste Metabolic/Endocrine Agents Brand Methilest methyltestosterone Metabolic/Endocrine Agents Brand Antineoplastics and Methotrexate methotrexate Immunosuppressants Generic Metimyd sulfacetamide/prednisolone Ophthalmic/Otic Agents Generic Metrocream metronidazole Dermatologic Agents Brand 20030111 9/03 Page 7 of 13 PCO1541 `" ' B[ar'1d N#,ne,. n 7" 17 _n_S elirTh.:. .0 lis?apeettic War ===Coverage F*1r,. Metrogel metronidazole Dermatologic Agents Brand MetroGel-Vaginal metronidazole Anti-Infective Agents Brand Metrolotion Metronidazole Lotion 0.75% Dermatologic Agents Brand Mevacor lovastatin Cardiovascular Agents Generic Mexitil mexiletine Cardiovascular Agents Generic Micro-K 8mEq potassium chloride 8mEq Nutritional Supplements Brand Micronase glyburide Metabolic/Endocrine Agents Generic Micronor norethindrone Metabolic/Endocrine Agents Brand Microzide hydrochlorothiazide Cardiovascular Agents Generic Midamor amiloride Cardiovascular Agents Generic Midrin acetaminophen/isometheptane/dichloralphenazone Central Nervous System Agents Generic Minipress prazosin Genitourinary Agents Generic Minipress prazosin Cardiovascular Agents Generic Minocin minocycline Anti-Infective Agents Generic Mintezol thiabendazole Anti-Infective Agents Brand Mircette desogestrel/ethinyl estradiol/ethinyl estradiol Metabolic/Endocrine Agents Brand Moduretic amiloride/hydrochlorothiazide Cardiovascular Agents Generic Monoket isosorbide mononitrate Cardiovascular Agents Generic Motrin ibuprofen Musculoskeletal Agents Generic MS Conlin morphine sulfate SR Musculoskeletal Agents Genenc MSIR solution,tablets morphine sulfate solution,tablets Musculoskeletal Agents Generic Mucomyst acetylcysteine inhalant solution 20% Respiratory Agents Generic Mucomyst-10 acetylcysteine inhalant solution 10% Respiratory Agents Generic Myambutol ethambutol Anti-Infective Agents Generic Mycelex Troche clotrimazole Anti-Infective Agents Brand Mycifradrin neomycin sulfate Anti-Infective Agents Generic Mycobutin nfabutin Anti-Infective Agents Brand Mycolog II nystatin/triamcinolone Dermatologic Agents Generic Mycostatin oral nystatin Anti-Infective Agents Generic Mycostatin topical nystatin Dermatologic Agents Generic Mydriacil tropicamide Ophthalmic/Otic Agents Generic Antineoplastics and Myleran busulfan Immunosuppressants Brand Antineoplastics and Mylocel hydroxyurea Immunosuppressants Brand Mysoline primidone Central Nervous System Agents Generic Nalfon fenoprofen Musculoskeletal Agents Generic Nalfon capsule fenoprofen capsule Musculoskeletal Agents Brand Naprosyn naproxen Musculoskeletal Agents Generic Nardi) phenelzine sulfate Central Nervous System Agents Brand Nasatide fiunisolide Respiratory Agents Generic Nasarel fiunisolide Respiratory Agents Generic Nasonex mometasone furoate Respiratory Agents Brand Natacyn natamycin Ophthalmic/Otic Agents Brand Navane thiothixene Central Nervous System Agents Generic Navane 20mg capsule thiothixene 20mg capsule Central Nervous System Agents Brand NebuPent pentamidine Anti-Infective Agents Brand Neo-Synephrine phenylephnne Ophthalmic/Otic Agents Generic NeoDecadron dexamethasone/neomycin/polysorbate Ophthalmic/Otic Agents Brand Antineoplastics and Neoral capsule cyclosporine modified capsule Immunosuppressants Generic Antineoplastics and Neoral solution cyclosporine solution Immunosuppressants Brand Neosporin ophthalmic ointment bacitracin/neomycin/polymyxin b ophthalmic ointment Ophthalmic/Olic Agents Generic Neosporin ophthalmic solution gramicidin/neomycin/polymixin b ophthalmic solution Ophthalmic/Otic Agents Generic Neptazane methazolamide OphthalmiciOtic Agents Generic Neurontin gabapentin Central Nervous System Agents Brand Niaspan niacin extended release Cardiovascular Agents Brand Antineoplastics and Nilandron nilutamide Immunosuppressants Brand Nitro-Bid nitroglycerin Cardiovascular Agents Generic Nitro-Dur nitroglycerin transdermal patches Cardiovascular Agents Brand Nitroglycerin Ointment Nitroglycerin Ointment Cardiovascular Agents Generic Nitrostat nitroglycerin Cardiovascular Agents Generic Nizoral 2%Cream ketoconazole 2%cream Dermatologic Agents Generic Nizoral 2%Shampoo ketoconazole 2%shampoo Dermatologic Agents Brand Nizoral oral ketoconazole Anti-Infective Agents Generic 20030111 9/03 Page 8 of 13 PCO1541 t. e71/10Wd Nam "* .Stitt. t Trtieatreciasor. to7Sagc-Fiartv, Noclec chloral hydrate Central Nervous System Agents Brand Antineoplastics and Nolvadex tamoxifen citrate Immunosuppressants Brand Nordette levonorgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Norflex orphenadnne citrate Musculoskeletal Agents Generic Norgesic orphenadrine/aspirin/caffeine Musculoskeletal Agents Generic Norgesic Forte orphenadrine/aspirin/caffeine Musculoskeletal Agents Generic Normodyne labetalol Cardiovascular Agents Generic Norpace disopyramide Cardiovascular Agents Generic Norpace CR 100mg disopyramide CR 100mg Cardiovascular Agents Brand Norpace CR 150mg disopyramide CR 150mg Cardiovascular Agents Generic Norpramin desipramine Central Nervous System Agents Generic Norvir ritonavir Anti-Infective Agents Brand Nulytely polyethylene glycol/electrolyte solution Gastrointestinal Agents Brand NuvaRing etonogestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Ocufen flurbiprofen Ophthalmic/Otic Agents Generic Ocuflox ofloxacin Ophthalmic/Otic Agents Brand Ogen estropipate Metabolic/Endocrine Agents Generic Omnicef cefdinir Anti-Infective Agents Brand OneTouch Test Strips test strips Diabetic Testing Supplies Brand Ophthetic proparacaine Ophthalmic/Otic Agents Generic Optichamber respiratory device Respiratory Agents Brand Optihaler respiratory device Respiratory Agents Brand OptiPranolol metipranolol hcl Ophthalmic/Olio Agents Generic Optivar azelastine Ophthalmic/Otic Agents Brand Oramorph SR morphine sulfate SR Musculoskeletal Agents Brand Orinase tolbutamide Metabolic/Endocrine Agents Generic Ortho Evra norelgestromin/ethinyl estradiol transdermal patch Metabolic/Endocrine Agents Brand Ortho Tri-Cyclen norgestimate/ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Cyclen norgestimate&ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Novum 1/35 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Novum 1/50 norethindrone/mestranol Metabolic/Endocrine Agents Brand Ortho-Novum 10/11 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Novum 7/717 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Orudis ketoprofen Musculoskeletal Agents Generic Otobiotic polymixin b/hydrocortisone Ophthalmic/Otic Agents Brand Ovral norgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Pacerone 400mg amiodarone Cardiovascular Agents Brand Pamelor capsule nortriptyline capsule Central Nervous System Agents Generic Pancrease pancrelipase Gastrointestinal Agents Generic Pancrease MT pancrelipase Gastrointestinal Agents Generic Panmist-LA pseudoephedrine/guiafenesin Respiratory Agents Generic Padodel capsule bromocriptine capsule Central Nervous System Agents Brand Parnate tranylcypromine sulfate Central Nervous System Agents Brand Patanol Ophthalmic Solution olopatadine hcl Ophthalmic/Otic Agents Brand Paxil paroxetine Central Nervous System Agents Brand Paxil CR paroxetine CR Central Nervous System Agents Brand Pediazole erythromycin/sulfisoxazole Anti-Infective Agents Generic Pen VK penicillin VK Anti-Infective Agents Generic Percocet(not 2.5mg/325mg) oxycodone/acetaminophen(not 2.5mg/325mg) Musculoskeletal Agents Generic Percodan oxycodone/aspirin Musculoskeletal Agents Generic Periactin cyproheptadine Central Nervous System Agents Generic Periactin cyproheptadine Respiratory Agents Generic Persantine dipyridamole Cardiovascular Agents Generic Phenergan promethazine Gastrointestinal Agents Generic Phenergan 12.5mg suppository promethazine 12.5mg suppository Gastrointestinal Agents Brand Phenergan 25mg.50mg suppository promethazine 25mg.50mg suppository Gastrointestinal Agents Generic Phenergan DM promethazine-dextromethorphan Respiratory Agents Generic Phenergan w/Codeine promethazine-codeine Respiratory Agents Generic Phenobarbital phenobarbital Central Nervous System Agents Generic Phoslo calcium acetate Nutritional Supplements Brand Phospholine echothiophate iodide Ophthalmic/Otic Agents Brand Phrenilin Forte acetaminophen/butalbital Central Nervous System Agents Generic Pilocar pilocarpine Ophthalmic/Otic Agents Generic Plaquenil hydroxychloroquine Anti-Infective Agents Generic 20030111 9/03 Page 9 of 13 PCO1541 =8 atikNamf .. 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'tc"averageF.ag€ Plendil felodipine Cardiovascular Agents Brand Polaramine dexchlorpheniramine maleate CR Respiratory Agents Generic Polaramine 2mg dexchlorpheniramine maleate 2mg Respiratory Agents Brand Poly-Histine pheniramine-pyrilamine-phenyltoloxamine Respiratory Agents Brand Poly-Vi-Flor pediatric multiple vitamin with fluoride Nutritional Supplements Generic Poly-Vi-Flor w/Iron pediatric multiple vitamin with fluoride and iron Nutritional Supplements Generic Poly-Vi-Flor w/Iron(0.25mg tablets) pediatric multiple vitamin with FL/FE Nutritional Supplements Brand Polycitra potassium/sodium citrates/citric acid Nutntional Supplements Generic Polycitra-K potassium citrate/citric acid Nutritional Supplements Generic Polycitra-LC potassium/sodium citrates/citric acid Nutritional Supplements Generic Polysporin polymyxin b/bacitracin Ophthalmic/Otic Agents Generic Polytrim tdmethoprim/polymixin b Ophthalmic/Otic Agents Generic Potassium Chloride potassium chloride Nutritional Supplements Generic Pravachol pravastatin Cardiovascular Agents Brand Pred Forte prednisolone acetate 0.1% Ophthalmic/Otic Agents Generic Pred Mild prednisolone acetate 0.12% Ophthalmic/Otic Agents Brand Prednisone concentrate prednisone concentrate Metabolic/Endocrine Agents Brand Prednisone solution Prednisone solution Metabolic/Endocrine Agents Brand Prelone prednisolone Metabolic/Endocrine Agents Generic Premarin conjugated estrogen Metabolic/Endocrine Agents Brand Premphase estrogen/medroxyprogesterone Metabolic/Endocrine Agents Brand Prempro estrogen/medroxyprogesterone Metabolic/Endocrine Agents Brand Prenatal Vitamins wth Folic Acid 1mg All generic prenatal vitamins are covered. Nutritional Supplements Generic PrevPac amoxicillin/clarithromyciMansoprazole CR Gastrointestinal Agents Brand Primaquine primaquine phosphate Anti-Infective Agents Brand Principen ampicillin Anti-Infective Agents Generic Pro-Banthine 15mg probantheline bromide 15mg Gastrointestinal Agents Generic Procainamide 500mg capsule procainamide 500mg capsule Cardiovascular Agents Brand Proctofoam HC hydrocortisone/pramoxine Gastrointestinal Agents Brand Prolixin fluphenazine Central Nervous System Agents Generic Pronestyl 250mg,375mg capsule procainamide 250mg,375mg capsule Cardiovascular Agents Generic Pronestyt SR procainamide CR Cardiovascular Agents Generic Propine dipivefrin Ophthalmic/Otic Agents Generic Propylthiouracil propylthiouracil Metabolic/Endocrine Agents Generic Protonix pantoprazole Gastrointestinal Agents Brand Proventil Inhalation Solution albuterol inhalation solution Respiratory Agents Generic Proventil Inhaler albuterol Respiratory Agents Generic Proventil Repetabs albuterol CR Respiratory Agents Brand Proventil syrup,tablet albuterot syrup,tablet Respiratory Agents Generic Provera medroxyprogesterone Metabolic/Endocrine Agents Generic Prozac(not Prozac Weekly) fluoxetine Central Nervous System Agents Generic Antineaplastics and Punnethol mercaptopurine,6-MP Immunosuppressants Brand Pyrazinamide pyrazinamide Anti-Infective Agents Generic Pyndium phenazopyridine Genitourinary Agents Generic Questran cholestyramine Cardiovascular Agents Generic Questran Light cholestyramine Cardiovascular Agents Generic Quibron-T 300mg tablet theophylline 300mg tablet Respiratory Agents Brand Quinaglute quinidine gluconate Cardiovascular Agents Generic Quinidex quinidine sulfate SR Cardiovascular Agents Generic Quinidine Sulfate quinidine sulfate Cardiovascular Agents Generic Quinine Sulfate quinine sulfate Anti-Infective Agents Generic Quixin levofloxacin Ophthalmic/Otic Agents Brand QVAR beclomethasone dipropionate Respiratory Agents Brand Reglan metoclopramide Gastrointestinal Agents Generic Remeron Soltab mirtazapine Central Nervous System Agents Brand Rescriptor delavirdine mesylate Anti-Infective Agents Brand Reston) temazepam Central Nervous System Agents Generic Reston)7.5mg temazepam 7.5mg Central Nervous System Agents Brand Reim-A cream,gel tretinoin cream,gel Dermatologic Agents Generic Retin-A liquid tretinoin liquid Dermatologic Agents Brand Retin-A Micro tretinoin microsphere Dermatologic Agents Brand Retrovir AZT/zidovudine Anti-Infective Agents Brand Rheumatrex methotrexate Musculoskeletal Agents Generic 20030111 9/03 Page 10 of 13 PCO1541 Rnti4. „- r A _ _and— Na `="-' T1 las C`fath Flan_ Rhinocorl Aqua budesonide Aqua i,Respiratory Agents Brand Ridaura auranofin Musculoskeletal Agents Brand Rifadin rifampin Anti-Infective Agents Genenc Risperdal risperidone Central Nervous System Agents Brand Ritalin methylphenidate Central Nervous System Agents Generic Ritalin SR methylphenidate SR Central Nervous System Agents Generic RMS morphine sulfate Musculoskeletal Agents Generic Robaxin methocarbamol Musculoskeletal Agents Generic Robitussin AC guaifenesin/codeine Respiratory Agents Generic Robitussin DAC pseudoephedrine/codeine/guaifenesin Respiratory Agents Generic Rocaltrol calcitriol Nutritional Supplements Brand Rocaltrol Solution calcitrol solution Nutritional Supplements Brand Rondec brompheniramine or carbinoxamine/pseutloephedrine Respiratory Agents Generic brompheniramine or Rondec DM carbinoxamine/pseudoephedrine/dextromethorphan Respiratory Agents Generic Rowasa enema mesalamine Gastrointestinal Agents Brand Roxanol,Roxanol-T morphine sulfate Musculoskeletal Agents Generic Roxicodone tablet oxycodone tablet Musculoskeletal Agents Generic Rynatan 1-120mg azatadine/pseudoephedrine cr Respiratory Agents Brand Rynatan-S Chlorpheniramine/phenylephrine/pyrilamine Respiratory Agents Generic Rythmol propafenone Cardiovascular Agents Generic Salagen pilocarpine hcl Miscellaneous Agents Brand Antineoplastics and Sandimmune solution cyclosporine solution Immunosuppressants Brand Sansert methysergide Central Nervous System Agents Brand Sebizon sodium sulfacetamide Dermatologic Agents Brand Sectral acebutolol Cardiovascular Agents Generic - Sedapap acetaminophen/butalbital Central Nervous System Agents Generic Selsun selenium sulfide Dermatologic Agents Generic Serax oxazepam Central Nervous System Agents Generic Serevent Diskus DPI salmeterol xinafoate Respiratory Agents Brand Serevent Inhaler salmeterol Respiratory Agents Brand Seaone nefazodone Central Nervous System Agents Brand Silvadene silver sulfadiazine Dermatologic Agents Generic Sinemet carbidopa/levodopa Central Nervous System Agents Generic Sinemet CR carbidopa/levodopa CR Central Nervous System Agents Generic Sinequan doxepin Central Nervous System Agents Generic Singulair montelukast sodium Respiratory Agents Brand Slo-Bid theophylline SR Respiratory Agents Generic Slo-Bid 50mg,75mg theophylline SR 50mg,75mg Respiratory Agents Brand Slo-Phyllin theophylline Respiratory Agents Brand Slo-Phyllin Solution theophylline Respiratory Agents Generic Soft Touch Lancets lancets Diabetic Testing Supplies Brand Softclix Lancets lancets Diabetic Testing Supplies Brand — Somnote chloral hydrate Central Nervous System Agents Brand Sorbitrate chewable tablet isosorbide dinitrate chewable tablet Cardiovascular Agents Brand Soriatane acitretin Dermatologic Agents Brand Spectazole econazole nitrate 1%cream Dermatologic Agents Brand SSKI potassium iodide Respiratory Agents Brand Stelazine concentrate trifluoperazine concentrate Central Nervous System Agents Brand Stelazine tablet trifluoperazine tablet Central Nervous System Agents Generic Sular nisoldipine Cardiovascular Agents Brand Sulfacet-R sulfacetamide sodium/sulfur Dermatologic Agents Generic Sultrin vaginal cream triple sulfa Anti-Infective Agents Generic Suredose Insulin Syringes Suredose Insulin Syringes Diabetic Testing Supplies Brand SureStep Test Strips test strips Diabetic Testing Supplies Brand Sustiva efavirenz Anti-Infective Agents Brand Symmetrel amantadine Anti-Infective Agents Generic Symmetrel amantadine Central Nervous System Agents Generic Syn-Rx pesudoephedrine/guiafenesin 8 guiafenesin Respiratory Agents Generic Synalar fluocinolone Dermatologic Agents Generic Synarel nafarelin Metabolic/Endocrine Agents Brand Synthroid levothyroxine Metabolic/Endocrine Agents Generic T-Star erythromycin Dermatologic Agents Generic Tagamet cimetidine Gastrointestinal Agents Generic Tambocor flecainide Cardiovascular Agents Generic 20030111 9/03 Page 11 of 13 PCO1541 _ B[au_ `'tl -Bert aiti ' .._.±:E.::.:,,, ,-.aliefaR u6s Ia` _..., ove agt Fla Antineoplastics and Tamoxifen tamoxifen citrate Immunosuppressants Brand Tapazole methimazole MetabolidEndocrine Agents Generic Tapazole 20mg tab methimazole Metabolic/Endocrine Agents Brand Antineoplastics and Targretin capsule bexarotene capsule Immunosuppressants Brand Tavist demastine Respiratory Agents Generic Tegretol suspension carbamazepine suspension Central Nervous System Agents Brand Tegretol tablet,chewable tablet carbamazepine Central Nervous System Agents Both Tegretol XR carbamazepine Central Nervous System Agents Brand Antineoplastics and Temodar temozolomide Immunosuppressants Brand Temovate clobetasol propionate Dermatologic Agents Generic Tenex guanfacine Cardiovascular Agents Generic Tenoretic atenolol/chlorthalidone Cardiovascular Agents Generic Tenormin atenolol Cardiovascular Agents Genenc Terramycin oxytetracycline/polymixin b Ophthalmic/Otic Agents Generic Terumo Insulin Syringes Terumo Insulin Syringes Diabetic Testing Supplies Brand Antineoplastics and Testae testolactone Immunosuppressants Brand Tessalon Perles 100mg capsule benzonatate 100mg capsule Respiratory Agents Generic Testred methyltestosterone Metabolic/Endocrine Agents Brand Theo-24 theophylline SR Respiratory Agents Brand Theo-Dur theophylline SR Respiratory Agents Generic Antineoplastics and Thioguanine thioguanine Immunosuppressants Brand Thorazine chlorpromazine Central Nervous System Agents Generic Tigan trimethobenzamide Gastrointestinal Agents Generic Tigan 100mg,300mg capsule trimethobenzamide 100mg,300mg capsule Gastrointestinal Agents Brand Tilade nedocromil sodium Respiratory Agents Brand Timoptic timolot maleate Ophthalmic/Otic Agents Generic Tobradex dexamethasone/tobramycin OphthalmidOtic Agents Brand Tobrex ophthalmic ointment tobramycin ophthalmic ointment OphthalmidOtic Agents Brand Tobrex ophthalmic solution tobramycin ophthalmic solution OphthalmidOtic Agents Generic Tofranil imipramine Central Nervous System Agents Generic Tolectin tolmetin Musculoskeletal Agents Generic Tolectin DS tolmetin Musculoskeletal Agents Generic Tolinase tolazamide Metabolic/Endocrine Agents Generic Tonocard tocainide Cardiovascular Agents Brand Topicort desoximetasone Dermatologic Agents Generic Toradol ketorolac Musculoskeletal Agents Generic Torecan thiethylperazine Gastrointestinal Agents Brand Trandate labetalol Cardiovascular Agents Generic Tranxene Garazepate Central Nervous System Agents Generic Trental pentoxifylline CR Cardiovascular Agents Generic Antineoplastics and Trexall methotrexale Immunosuppressants Brand Tri-Vi-Flor pediatric vitamin ACD with fluoride Nutritional Supplements Generic Tri-Vi-Flor w/Iron pediatric vitamin ACD with fluoride and iron Nutritional Supplements Generic Triavil perphenazine/amitriptyline Central Nervous System Agents Generic Tridesilon desonide Dermatologic Agents Generic Trilafon perphenazine Central Nervous System Agents Generic Trilafon concentrate perphenazine concentrate Central Nervous System Agents Generic Trilisate liquid salicylate combination liquid Musculoskeletal Agents Brand Trilisate tablet salicylate combination tablet Musculoskeletal Agents Generic Trimpex trimelhoprim Anti-Infective Agents Generic Trinalin pseudoephedrine/azatadine Respiratory Agents Brand Triphasil levonorgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Trizivir abacavir sulfate-lamivudine-zidovudine Anti-Infective Agents Brand Tylenol w/Codeine acetaminophen/codeine Musculoskeletal Agents Generic Tympagesic benzocaine/phenylephrine/antipyrine OphthalmidOtic Agents Generic Uniphyl theophylline Respiratory Agents Brand Uniretic moexipril/HCTZ Cardiovascular Agents Brand Univasc moexipril Cardiovascular Agents Generic Urecholine bethanechol Genitourinary Agents Brand Urocit-K potassium citrate Genitourinary Agents Brand 20030111 9/03 Page 12 of 13 PCO1541 .yam, :�Ge ET:rfen*Me 1': =;r> ieFaPeuiraCie atnetag nig:, Valisone betamethasone valerate Dermatologic Agents Generic Valium diazepam Musculoskeletal Agents Generic Valium diazepam Central Nervous System Agents Generic Velosef cephradine Anti-Infective Agents Brand Velosulin BR human regular insulin buffered Metabolic/Endocrine Agents Brand Ventolin Inhalation Solution albuterol inhalation solution Respiratory Agents Generic Ventolin Inhaler albuterol Respiratory Agents Generic Ventolin syrup,tablet albuterol syrup,tablet Respiratory Agents Generic Antineoplastics and VePesid etoposide Immunosuppressants Brand Vermox mebendazole Anti-Infective Agents Generic Antineoplastics and Vesanoid tretinoin Immunosuppressants Brand Vibramycin doxycycline Anti-Infective Agents Generic Vicodin hydrocodone bitarirate/acetaminophen Musculoskeletal Agents Generic Vicodin ES hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Videx ddl/dideoxyinosine Anti-Infective Agents Brand Videx EC ddl/dideoxyinosine delayed release Anti-Infective Agents Brand Viokase pancrelipase Gastrointestinal Agents Generic Viokase 16 pancrelipase Gastrointestinal Agents Brand Vira A vidarabine OphthalmidOtic Agents Brand Viracept nelfinavir mesylate Anti-Infective Agents Brand Viramune nevirapine Anti-Infective Agents Brand Viread tenofovir disoproxil fumarate Anti-Infective Agents Brand Viroptic trifluridine Ophthalmic/Otic Agents Generic Visken pindolol Cardiovascular Agents Generic Vistaril hydroxyzine pamoate Respiratory Agents Generic Vivelle estradiol transdermal patch Metabolic/Endocrine Agents Brand Vivelle-DOT estradiol transdermal patch Metabolic/Endocrine Agents Brand Volmax albuterol CR Respiratory Agents Brand Voltaren diclofenac Musculoskeletal Agents Generic Voltaren ophthalmic diclofenac ophthalmic OphthalmidOtic Agents Brand VoSol acetic acid Ophthalmic/Otic Agents Generic VoSol HC acetic acid/hydrocortisone OphthalmidOtic Agents Generic Vytone iodoquinol/hydrocortisone Dermatologic Agents Generic Wellbutrin bupropion Central Nervous System Agents Generic Wellbutrin SR bupropion CR Central Nervous System Agents Brand Wylensin guanabenz acetate Cardiovascular Agents Generic xalatan latanoprost OphthalmidOtic Agents Brand Xanax alprazolam Central Nervous System Agents Generic Antineoplastics and Xeloda capecitabine Immunosuppressants Brand Xylocaine 2%gel lidocaine 2%gel Dermatologic Agents Generic Xylocaine 5%ointment lidocaine 5%ointment Dermatologic Agents Generic Xylocaine Viscous lidocaine viscuous Miscellaneous Agents Generic Yasmin drospirenone/ethinyl estradiol MetabolidEndocrine Agents Brand Yodoxin tablet iodoguinol tablet Anti-Infective Agents Brand Zantac syrup ranitidine Gastrointestinal Agents Brand Zantac tablet ranitidine Gastrointestinal Agents Generic Zaronlin ethosuximide Central Nervous System Agents Brand Zaroxolyn metolazone Cardiovascular Agents Brand Zephrex LA pseudoephedrine/guaifenesin Respiratory Agents Generic Zerit stavudine Anti-Infective Agents Brand Zestoretic Iisinopril/hydrochlorolhiazide Cardiovascular Agents Generic Zestril lisinopril Cardiovascular Agents Generic Ziagen abacavir sulfate Anti-Infective Agents Brand Zithromax azithromycin Anti-Infective Agents Brand Zocor simvastatin Cardiovascular Agents Brand Zofran ODT ondansetron Gastrointestinal Agents Brand Zofran solution ondansetron Gastrointestinal Agents Brand Zofran tablet ondansetron tablet Gastrointestinal Agents Brand Zomig zolmitriptan Central Nervous System Agents Brand Zomig ZMT zolmitriptan Central Nervous System Agents Brand Zovirax oral acyclovir Anti-Infective Agents Generic Zovirax topical acyclovir Dermatologic Agents Brand Zyloprim allopurinol MetaboliGEndocrine Agents Generic Zyprexa olanzapine Central Nervous System Agents Brand 20030111 9/03 Page 13 of 13 PCO1541 Hello