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AdvantraRx Formulary - Prescription Drug

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					  Prescription Drug
2007 COMPREHENSIVE FORMULARY

                               P LEASE R EAD :


                               This Document

                               Contains

                               Information

                               About The

                               Drugs We Cover

                               In This Plan

                               Note to Existing
                               Members:
                               This formulary has
                               changed since last year.
                               Please review this
                               document to make sure
                               that it still contains the
                               drugs you take.
                         Important Information
          If you have

    general questions

     about Medicare

    prescription drug

coverage, please call

         Medicare at

    1-800 -MEDICARE

  (1-800 -633-4227),

     24 hours a day,

     7 days a week.

TTY/TDD users should

call 1-877-486 -2048,

              or visit

  www.medicare.gov
  THE ADVANTRARX COMPREHENSIVE FORMULARY GUIDE
  Provides important information
  on your AdvantraRx prescription benefits plan!

     • Questions and Answers about how the plan works

     • The list of covered prescription drugs

     • The copayment level for each drug

     • Special instructions for certain types of drugs


  The AdvantraRx Comprehensive Formulary List covers thousands
  of brand name, generic and specialty drugs. To decide which
  AdvantraRx plan is best for you, take out the medications you
  take today and look for them on the Comprehensive Formulary
  List. Add up your monthly drug costs and consider the monthly
  premium as well. You should also take into account additional
  opportunities to save by switching to lower cost generic drugs
  (if your doctor agrees) and by using our mail order option for
  maintenance drugs.

  You can also use our online Cost Calculator at
  www.AdvantraRx.com site to evaluate which AdvantraRx plan fits
  your monthly budget and prescription needs.

  For more detailed information about AdvantraRx prescription
  drug coverage, please review the Summary of Benefits and other
  plan materials. If you have questions about AdvantraRx please
  call a Customer Service representative at 1-800-882-3822,
  8 a.m.- 8 p.m., local time, 7 days a week. TTY/TDD users should
  call 1-800-508-9548 or visit www.AdvantraRx.com.




C0002_ENRPDP_Comprehensive Formulary_2007 v6    CMS Approved: 09/01/2006
                           ADVANTRARX COMPREHENSIVE FORMULARY GUIDE

                           What is the AdvantraRx formulary?

                           The AdvantraRx Comprehensive Formulary List is a list of drugs selected
                           by AdvantraRx, in consultation with a team of health care providers,
                           which represents the prescription therapies believed to be a necessary
                           part of a quality treatment program. AdvantraRx will generally cover the
                           drugs listed in our AdvantraRx Comprehensive Formulary List:

                              • As long as the drug is medically necessary,
                              • The prescription is filled at an AdvantraRx network pharmacy, and
                              • Other plan rules are followed.

                           For more information on how to fill your prescriptions, please review your
                           Evidence of Coverage.


                           How much will I pay for AdvantraRx covered drugs?

                           The AdvantraRx Comprehensive Formulary List covers all medications
                           required by Medicare Part D and has been approved by CMS. The
                           amount you pay depends on which drug tier your drug is in under our
                           plan. (You can find out which drug tier your drug is in by looking in the
                           Comprehensive Formulary List that begins on page 7.) There are four
                           copayment tiers for covered prescription drugs:

         For more            Copayment Tier                       Type of Drug
                             Tier 1 (lowest copayment)            Preferred generic and certain
    information on                                                  preferred brand name drugs
                             Tier 2 (middle copayment)            Preferred brand name and certain
   how to fill your                                                 preferred generic drugs
                             Tier 3 (highest copayment)           Non-preferred drugs
     prescriptions,
                             Tier 4 (coinsurance)                 Specialty drugs

please review your         A generic drug has the same active ingredient formula as the brand
                           name drug. Generic drugs usually cost less than brand name drugs and
      Evidence of          are approved by the Food and Drug Administration (FDA). Generic drugs
                           are listed in lower-case italics (e.g., digoxin) within the Comprehensive
                           Formulary List on page 7. Brand name drugs are capitalized in the
        Coverage.          Comprehensive Formulary List (e.g., CLARINEX).


                      2.   C0002_ENRPDP_Comprehensive Formulary_2007 v6   CMS Approved: 09/01/2006
The amount you pay also depends on whether you fill your
prescription at a retail pharmacy or at a mail order pharmacy.
Generally, when you go to a retail pharmacy you will pay for a 30-day
supply. If you fill your prescription through our mail order pharmacy,
you can get a 90-day supply for two copayments.
                                                                               Questions?
If you qualified for extra help with your drug costs, your costs for your
drugs may be different than those described below. Please refer to             CALL: 1-800-882-3822,
your Evidence of Coverage or call a Customer Service representative
to find out your specific costs.                                               8 a.m.- 8 p.m.,

Can the Comprehensive Formulary List change?                                   local time,

Yes, AdvantraRx may add or remove drugs from our Comprehensive                 7 days a week.
Formulary List during the year. The enclosed Comprehensive
Formulary List is current as of September 12, 2006. To get updated             TTY/TDD users should
information about the drugs covered by AdvantraRx, please visit our
website at www.AdvantraRx.com or call Customer Service at 1-800-               call 1-800-508-9548
882-3822, 8 a.m.- 8 p.m., local time, 7 days a week. TTY/TDD users
should call 1-800-508-9548.                                                    or visit

You will be notified at least 60 days in advance, or at the time of refill,    www.AdvantraRx.com.
of any of the following changes to the Comprehensive Formulary List:
1) The drug is removed from our Comprehensive Formulary List; 2)
Prior Authorization, quantity limits and/or step therapy restrictions are
now required on a drug; or 3) The drug is moved to a higher cost-
sharing tier. If you need a refill, you will receive a 60-day supply of the
drug. You should then ask your doctor to prescribe an alternate
medication.

If the Food and Drug Administration determines that a drug on our
Comprehensive Formulary List is unsafe or the drug's manufacturer
removes the drug from the market, we will immediately remove the
drug from our Comprehensive Formulary List and notify members who
take the drug.




C0002_ENRPDP_Comprehensive Formulary_2007 v6    CMS Approved: 09/01/2006      3.
                             ADVANTRARX COMPREHENSIVE FORMULARY GUIDE

                             What if my drug is not on the Comprehensive Formulary List?

                             If your drug is not included in this Comprehensive Formulary List, you
                             should first contact Customer Service and ask if your drug is covered. If
                             you learn that AdvantraRx does not cover your drug, you have two
                             options:

                                • You can ask Customer Service for a list of similar drugs that are
                                  covered by AdvantraRx. When you receive the list, show it to your
                                  doctor and ask him or her to prescribe a similar drug that is
                                  covered by AdvantraRx.

                                • You can ask AdvantraRx to make an exception and cover your drug.
                                  See below for information about how to request an exception.


                             Can I get a Transition Supply of my prescription drugs?

                             If you recently joined AdvantraRx and learned that AdvantraRx does not
Note to existing members:    cover a drug you were taking when you joined our plan, you are entitled
                             to a one time fill of that prescription up to a 30-day supply.
                    This
                             This one time fill will permit up to 30-days of a non-formulary or prior
        formulary has        authorized medication to allow you to transition to a formulary
                             medication where appropriate, or to provide time for a formulary
                             exception request. This one time fill will be allowed during the first
       changed since         90-days of coverage with AdvantraRx.
             last year.
                             How do I request an exception to AdvantraRx’s Comprehensive
   Please review this        Formulary List?

  document to make           You can ask AdvantraRx to make an exception to our coverage rules.
                             There are several types of exceptions that you can ask us to make:
      sure that it still
                                • You can ask us to cover your drug even if it is not on our
          contains the            Comprehensive Formulary List.

      drugs you take.           • You can ask us to waive coverage restrictions or limits on your drug.
                                  For example, for certain drugs, AdvantraRx limits the amount of the
                                  drug that we will cover. If your drug has a quantity limit, you can
                                  ask us to waive the limit and cover more.


                        4.   C0002_ENRPDP_Comprehensive Formulary_2007 v6   CMS Approved: 09/01/2006
                                                                                  Questions?
                                                                                  CALL: 1-800-882-3822
                                                                                  (TDD 1-800-508-9548)
                                                                                  8 am to 8 pm, local time,
                                                                                  7 days a week




Generally, AdvantraRx will only approve your request for an exception if the alternative drugs
included on the plan’s Comprehensive Formulary List, the low-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects. You should contact us to ask us for an initial coverage decision for a
Comprehensive Formulary, tiering or utilization restriction exception. When you are requesting a
Comprehensive Formulary, tiering or utilization restriction exception, you should submit a statement
from your physician supporting your request. Generally, we must make our decision within 72
hours of your request.


Are there any other restrictions on coverage?

Some covered drugs may have additional requirements or limits on coverage and may include:

Prior Authorization (indicated on the Comprehensive Formulary List by PA): AdvantraRx requires you to get
prior authorization for certain drugs. (You may need prior authorization for drugs that are on the
Comprehensive Formulary List or drugs that are not on the Comprehensive Formulary List and were
approved for coverage through our exceptions process.) This means that your doctor must request
and receive approval from AdvantraRx before you fill your prescriptions. Without this approval,
AdvantraRx may not cover the drug.

Quantity Limits (indicated on the Comprehensive Formulary List by QL): For certain drugs, AdvantraRx limits
the amount of the drug that AdvantraRx will cover. For example, AdvantraRx provides 4 units per
prescription for FOSAMAX 70 mg per 30 days. This may be in addition to a standard 30- or 90-day
supply. This means that your doctor must request and receive approval from AdvantraRx before
you fill your prescriptions. Without this approval, AdvantraRx may not cover the drug.

Step Therapy (indicated on the Comprehensive Formulary List by ST): In some cases, AdvantraRx requires
you to first try certain drugs to treat your medical condition before we will cover another drug for
that condition. For example, if Drug A and Drug B both treat your medical condition, AdvantraRx
may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AdvantraRx will
then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the
Comprehensive Formulary List that begins on page 7. You can ask AdvantraRx to make an
exception to these restrictions or limits. See the section, “How do I request an exception to
AdvantraRx’s Comprehensive Formulary List?” for information about how to request an exception.




C0002_ENRPDP_Comprehensive Formulary_2007 v6     CMS Approved: 09/01/2006        5.
                                  FOR MORE INFORMATION

                                  For more detailed information about your AdvantraRx prescription drug
                                  coverage, please review your Summary of Benefits and other plan
                                  materials. If you have questions about AdvantraRx, please call Customer
                                  Service at 1-800-882-3822, 8 a.m.- 8 p.m., local time, 7 days a week.
                                  TTY/TDD users should call 1-800-508-9548 or visit
                                  www.AdvantraRx.com. If you have general questions about Medicare
                                  prescription drug coverage, please call Medicare at 1-800-MEDICARE
                                  (1-800-633-4227), 24 hours a day/7 days a week. TTY/TDD users should
                                  call 1-877-486-2048, or visit www.medicare.gov.


                                  AdvantraRx’s Comprehensive Formulary List

                                  The Comprehensive Formulary List that begins on page 7 provides
                                  coverage information about all of the drugs covered by AdvantraRx. The
                                  first column of the chart lists the drug names in alphabetical order. Brand
                                  name drugs are capitalized (e.g., CLARINEX) and generic drugs are listed
                                  in lower-case italics (e.g., digoxin). The information in the
                                  Requirements/Limits column tells you if AdvantraRx has any special
                                  requirements for coverage of your drug.

                                  As described above, the following abbreviations may be used in the
        Questions?                Requirements/Limits column:

                                     • PA–Prior Authorization: AdvantraRx requires you to get prior
 CALL: 1-800-882-3822,                 authorization for certain drugs.
          8 a.m.- 8 p.m.,
                                     • QL–Quantity Limits: For certain drugs, AdvantraRx limits the amount
              local time,              of the drug that AdvantraRx will cover.
          7 days a week.
                                     • ST–Step Therapy: In some cases, AdvantraRx requires you to first try
TTY/TDD users should call              certain drugs to treat your medical condition before we will cover
        1-800-508-9548                 another drug for that condition.

                  or visit
   www.AdvantraRx.com.



                             6.   C0002_ENRPDP_Comprehensive Formulary_2007 v6   CMS Approved: 09/01/2006
Therapeutic Class              Definition
ALS                            LOU GEHRIG'S DISEASE
ALZHEIMERS                     ALZHEIMERS DISEASE
ANTIMYCOBACT                   ANTIMYCOBACTERIALS
BPH                            PROSTATE
CNS                            CENTRAL NERVOUS SYSTEM AGENTS
CHF                            CONGESTIVE HEART FAILURE
COAG DISORDER                  COAGULATION DISORDER
COPD                           CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DENT CAV PREV                  DENTAL CAVITY PREVENTION
ENZYME REPLACE                 ENZYME REPLACEMENTS
ED                             ERECTILE DYSFUNCTION
GAUCHERS                       GAUCHERS DISEASE
GROWTH DEF                     GROWTH DEFICIENCY
HORMONE IMBAL                  HORMONE IMBALANCE
IMMUNE SYSTEM                  IMMUNE SYSTEM DISORDERS
IBS                            IRRITABLE BOWEL SYNDROME
MIG HEADACHE                   MIGRAINE HEADACHE
MS                             MULTIPLE SCLEROSIS
PRENATAL VITS                  PRENATAL VITAMINS
PSYCHOTHERAP                   PSYCHOTHERAPEUTICS
PAH                            PULMONARY ARTERIAL HYPERTENSION
RESPIRATORY TRA                RESPIRATORY TRACT AGENTS
RA                             RHEUMATOID ARTHRITIS
ALLERGIC REACT                 SEVERE ALLERGIC REACTION
SJOGRENS SYND                  SJORGRENS SYNDROME
SMOKING CESSA                  SMOKING CESSATION
NUTR/MINER/ELEC                THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES
ULCERAT COLITIS                ULCERATIVE COLITIS
URINARY INCONT                 URINARY INCONTINENCE
URINARY INFECT                 URINARY INFECTION
VITAMIN DEF                    VITAMIN DEFICIENCY

        C0002_ENRPDP_Comprehensive Formulary_2007 v6   CMS Approved: 09/01/2006
                                            7
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
amnesteem                          ACNE                           1          1                QL
AZELEX                            ACNE                            2          2
BENZACLIN                         ACNE                            3          3
BENZAMYCINPAK                     ACNE                            3          3
BENZASHAVE                        ACNE                            3          3
claravis                           ACNE                           1          1                QL
clindamax cream                    ACNE                1          1          1
CLINDAMAX GEL                     ACNE                 2          2          2
CLINDAMAX LOTION                  ACNE                 2          2          2
clindamycin                        ACNE                1          1          1
DIFFERIN                          ACNE                            3          3
erythromycin                       ACNE                1          1          1
EVOCLIN                           ACNE                            3          3
SOTRET                            ACNE                            3          3
ADDERALL XR                       ADHD                            2          2                QL
amphetamine                       ADHD                 1          1          1
CONCERTA                          ADHD                            2          2                QL
dextroamphet                      ADHD                 1          1          1
FOCALIN                           ADHD                 2          3          3                QL
metadate                          ADHD                 1          1          1                QL
METADATE CD                       ADHD                            3          3                QL
methylin                          ADHD                 1          1          1
methylphenidate                   ADHD                 1          1          1
methylphenidate hcl sr            ADHD                 1          1          1                QL
RITALIN LA                        ADHD                            3          3                QL
STRATTERA                         ADHD                            3          3                QL
*loratadine                      ALLERGY               1          1          1                QL
ALLEGRA-D                        ALLERGY               3          3          3                QL
ASTELIN NASL                     ALLERGY               2          2          2
BECONASE AQ                      ALLERGY                                     3
chlorphenir                      ALLERGY               1          1          1
CLARINEX                         ALLERGY               3          3          3                QL
CLARINEX-D                       ALLERGY               3          3          3                QL
clemastine                       ALLERGY               1          1          1
cyproheptad                      ALLERGY               1          1          1
dexchlorphen                     ALLERGY               1          1          1
ed chlorped                      ALLERGY               1          1          1
ed-chlor-tan                     ALLERGY               1          1          1
fexofenadine                     ALLERGY               1          1          1                QL
flunisolide                      ALLERGY               1          1          1
fluticasone inhaler              ALLERGY               1          1          1
ipratropium nasal inh            ALLERGY                          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                      8
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
NASACORT AQ                     ALLERGY                2          3          3                QL
NASAREL                         ALLERGY                           2          2                QL
NASONEX                         ALLERGY                2          2          2                QL
promethegan                     ALLERGY                1          1          1
RHINOCORT AQUA                  ALLERGY                3          3          3
SEMPREX-D                       ALLERGY                           3          3
ZYRTEC                          ALLERGY                3          3          3                QL
ZYRTEC-D                        ALLERGY                3          3          3                QL
RILUTEK                           ALS                  4          4          4                PA
ARICEPT                       ALZHEIMERS               2          2          2                QL
ARICEPT ODT                   ALZHEIMERS               2          2          2                QL
COGNEX                        ALZHEIMERS                          3          3
ergoloid mesylates             ALZHEIMERS              1          1          1
EXELON                        ALZHEIMERS               2          2          2
NAMENDA                       ALZHEIMERS               2          2          2                QL
RAZADYNE                      ALZHEIMERS               3          3          3                QL
RAZADYNE ER                   ALZHEIMERS               3          3          3                QL
ARANESP                          ANEMIA                4          4          4                PA
PROCRIT                          ANEMIA                4          4          4                PA
DILATRATE SR                     ANGINA                           2          2
isosorbide dinitrate             ANGINA                1          1          1
isosorbide mononitrate           ANGINA                1          1          1                QL
NITROBID                         ANGINA                           2          2
NITRO-DUR                        ANGINA                1          1          1                QL
nitroglycerin caps               ANGINA                1          1          1
nitroglycerin spr                ANGINA                1          1          1
nitroglycerin tabs               ANGINA                1          1          1
nitrolingual                     ANGINA                1          1          1
nitroquik sl                     ANGINA                1          1          1
NITROSTAT SL                     ANGINA                2          2          2
nitro-time                       ANGINA                1          1          1
RANEXA                           ANGINA                2          2          2              PA QL
neo/bac/poly                 ANTIBACTERIALS            1          1          1
neo/poly b                   ANTIBACTERIALS            1          1          1
neo/poly b/gram              ANTIBACTERIALS            1          1          1
neom/poly/bacitr             ANTIBACTERIALS            1          1          1
neo/poly/dexame              ANTIBACTERIALS            1          1          1
neo/poly/gramic              ANTIBACTERIALS            1          1          1
neo/poly/hc                  ANTIBACTERIALS            1          1          1
PASER                        ANTIMYCOBACT                         3          3
PRIFTIN                      ANTIMYCOBACT                         3          3
RIFATER                      ANTIMYCOBACT                         3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                      9
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
FANSIDAR                     ANTIPARASITICS                       3          3
LIDODERM                       ANTISEPTIC              2          2          2
*alprazolam tabs                 ANXIETY                                     1                QL
*clonazepam tabs                 ANXIETY                                     1                QL
*lorazepam tabs                  ANXIETY                                     1                QL
buspirone                        ANXIETY               1          1          1
hydroxyz pam                     ANXIETY               1          1          1
hydroxyzine hcl                  ANXIETY               1          1          1
LEXAPRO                         ANXIETY                2          2          2                QL
meprobamate                      ANXIETY               1          1          1
amiodarone                     ARRYTHMIA               1          1          1
disopyramide                   ARRYTHMIA               1          1          1
flecainide                     ARRYTHMIA               1          1          1
mexiletine                     ARRYTHMIA               1          1          1
NORPACE CAPS                  ARRYTHMIA                           2          2
PACERONE                      ARRYTHMIA                           2          2
pacerone 200mg;400mg           ARRYTHMIA               1          1          1
procainamide                   ARRYTHMIA               1          1          1
propafenone                    ARRYTHMIA               1          1          1
quinidine gl                   ARRYTHMIA               1          1          1
quinidine su                   ARRYTHMIA               1          1          1
RYTHMOL SR                    ARRYTHMIA                2          2          2                QL
sorine                         ARRYTHMIA               1          1          1
sotalol af                     ARRYTHMIA               1          1          1
sotalol hcl                    ARRYTHMIA               1          1          1
TIKOSYN                       ARRYTHMIA                3          2          2
a-methapred                     ARTHRITIS              1          1          1
ARISTOCORT                     ARTHRITIS                          3          3
ARISTOSPAN                     ARTHRITIS               3          3          3
ARTHROTEC                      ARTHRITIS                          3          3
CELESTONE                      ARTHRITIS                          2          2
CORTEF                         ARTHRITIS                          2          2
cortisone ac                    ARTHRITIS              1          1          1
dexamethasone phos              ARTHRITIS              1          1          1
DEXPAK                         ARTHRITIS                          2          2
ENTOCORT EC                    ARTHRITIS                          3          3
flurbiprofen                    ARTHRITIS              1          1          1
hydrocort                       ARTHRITIS              1          1          1
KENALOG VIAL                   ARTHRITIS                          3          3
ketorolac inj                   ARTHRITIS              1          1          1              PA QL
methotrexate                    ARTHRITIS              1          1          1
methylpr ss                     ARTHRITIS              1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     10
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
methylprednisolone              ARTHRITIS              1          1          1
methylprednisolone acetat       ARTHRITIS              1          1          1
methylprednisolone sod          ARTHRITIS              1          1          1
prednisone                      ARTHRITIS              1          1          1
RIDAURA                         ARTHRITIS                         2          2
ACCOLATE                         ASTHMA                2          2          2
ACCUNEB 0.21MG                   ASTHMA                           2          2                PA
ADVAIR DISKUS                    ASTHMA                           2          2                QL
AEROBID                          ASTHMA                           3          3                QL
AEROBID-M                        ASTHMA                           3          3                QL
albuterol                        ASTHMA                1          1          1
albuterol inh                    ASTHMA                1          1          1                QL
albuterol soln                   ASTHMA                1          1          1                PA
ALUPENT                          ASTHMA                           2          2
aminophylline                    ASTHMA                1          1          1
ASMANEX                          ASTHMA                2          2          2                QL
BRONCOMAR-1                      ASTHMA                           3          3
cromolyn sodium neb              ASTHMA                1          1          1                PA
DIFIL-G                          ASTHMA                           3          3
DIFIL-G FORTE                    ASTHMA                           3          3
DILEX-G                          ASTHMA                           3          3
DUONEB                           ASTHMA                           3          3                PA
DYFLEX-G                         ASTHMA                           3          3
DY-G LIQUID                      ASTHMA                           3          3
DYLIX                            ASTHMA                           3          3
DYPHYLLINE GG                    ASTHMA                           3          3
ELIXOPHYLLIN                     ASTHMA                           3          3
ELIXOPHYLLIN GG                  ASTHMA                           3          3
epinephrine                      ASTHMA                1          1          1
FLOVENT                          ASTHMA                           2          2                QL
FLOVENT HFA                      ASTHMA                           2          2                QL
FLOVENT ROTA                     ASTHMA                           2          2                QL
FORADIL                          ASTHMA                2          2          2
INTAL 112                        ASTHMA                2          2          2
INTAL INH                        ASTHMA                2          2          2
ipratropium nebs                 ASTHMA                1          1          1                PA
MAXAIR AUTOH                     ASTHMA                           3          3                QL
metaproteren neb                 ASTHMA                1          1          1                PA
proair hfa                       ASTHMA                1          1          1                QL
PROVENTIL HFA                    ASTHMA                3          3          3                QL
PULMICORT INHALER                ASTHMA                           3          3
PULMICORT NEBS                   ASTHMA                           2          2              PA QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     11
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
QUIBRON                        ASTHMA                             3          3
QUIBRON-300                    ASTHMA                             3          3
QUIBRON-T                      ASTHMA                  2          3          3
QVAR                           ASTHMA                  2          2          2
SEREVENT                       ASTHMA                             3          3
SINGULAIR                      ASTHMA                  2          2          2             PA QL ST
terbutaline                     ASTHMA                 1          1          1
THEO-24                        ASTHMA                  2          2          2                QL
theochron                       ASTHMA                 1          1          1
THEOMAR GG                     ASTHMA                  3          3
theophylline                    ASTHMA                 1          1          1
theophylline cr                 ASTHMA                 1          1          1
TILADE (104)                   ASTHMA                  2          2          2
VOSPIRE ER                     ASTHMA                  3          2          2
XOLAIR                         ASTHMA                  4          4          4                PA
XOPENEX MDI                    ASTHMA                  2          2          2
ZYFLO                          ASTHMA                  2          2          2
GUANIDINE HCL              AUTONOMIC AGENTS            2          3          3
EXJADE                     BLOOD DISORDERS             4          4          4                PA
LEUKINE                    BLOOD DISORDERS             4          4          4                PA
NEULASTA                   BLOOD DISORDERS             4          4          4                PA
NEUPOGEN                   BLOOD DISORDERS             4          4          4                PA
SYPRINE                    BLOOD DISORDERS             3          3          3
acebutolol                  BLOOD PRESSURE             1          1          1
ACEON                      BLOOD PRESSURE              3          2          2                QL
ALTACE                     BLOOD PRESSURE              3          3          3                QL
amiloride                   BLOOD PRESSURE             1          1          1
amiloride hcl w/hctz        BLOOD PRESSURE             1          1          1
ATACAND                    BLOOD PRESSURE              3          3          3                QL
ATACAND HCT                BLOOD PRESSURE              3          3          3                QL
atenol/chlor                BLOOD PRESSURE             1          1          1
atenolol                    BLOOD PRESSURE             1          1          1
AVALIDE                    BLOOD PRESSURE              2          2          2                QL
AVAPRO                     BLOOD PRESSURE              2          2          2                QL
benazep/hctz                BLOOD PRESSURE             1          1          1
benazepril                  BLOOD PRESSURE             1          1          1
BENICAR                    BLOOD PRESSURE              3          3          3                QL
BENICAR HCT                BLOOD PRESSURE              3          3          3                QL
betaxolol                   BLOOD PRESSURE             1          1          1
bisoprl/hctz                BLOOD PRESSURE             1          1          1
bisoprolol fumarate         BLOOD PRESSURE             1          1          1
bumetanide                  BLOOD PRESSURE             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     12
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
captopr/hctz                BLOOD PRESSURE             1          1          1
captopril                   BLOOD PRESSURE             1          1          1
CARDIZEM LA                 BLOOD PRESSURE             2          2          2                QL
cartia xt                   BLOOD PRESSURE             1          1          1                QL
CATAPRES-TTS                BLOOD PRESSURE                        3          3                QL
chlorothiaz                 BLOOD PRESSURE             1          1          1
chlorthalid                 BLOOD PRESSURE             1          1          1
clonidine                   BLOOD PRESSURE             1          1          1
CLORPRES                    BLOOD PRESSURE                        2          2
COREG                       BLOOD PRESSURE                        2          2
COVERA-HS                   BLOOD PRESSURE                        3          3
COZAAR                      BLOOD PRESSURE             3          3          3                QL
DIBENZYLINE                 BLOOD PRESSURE                        2          2
diltia xt                   BLOOD PRESSURE             1          1          1
diltiazem                   BLOOD PRESSURE             1          1          1                QL
diltiazem cd                BLOOD PRESSURE             1          1          1                QL
diltiazem er                BLOOD PRESSURE             1          1          1                QL
diltiazem xr                BLOOD PRESSURE             1          1          1                QL
dilt-xr                     BLOOD PRESSURE             1          1          1
DIOVAN                      BLOOD PRESSURE             3          3          3                QL
DIOVAN HCT                  BLOOD PRESSURE             3          3          3                QL
doxazosin                   BLOOD PRESSURE             1          1          1                QL
DYNACIRC CR                 BLOOD PRESSURE             3          3          3                QL
EDECRIN                     BLOOD PRESSURE                        3          3
enalapr/hctz                BLOOD PRESSURE             1          1          1                QL
enalapril                   BLOOD PRESSURE             1          1          1
felodipine                  BLOOD PRESSURE             1          1          1
fosinopril sodium           BLOOD PRESSURE             1          1          1
fosinopril-hctz             BLOOD PRESSURE             1          1          1
furosemide                  BLOOD PRESSURE             1          1          1
guanabenz                   BLOOD PRESSURE             1          1          1
guanfacine                  BLOOD PRESSURE             1          1          1
hydral/hctz                 BLOOD PRESSURE             1          1          1
hydralazine                 BLOOD PRESSURE             1          1          1
hydra-zide                  BLOOD PRESSURE             1          1          1
hydrochlorot                BLOOD PRESSURE             1          1          1
HYDROCHL SOLN               BLOOD PRESSURE             2          2          2
HYZAAR                      BLOOD PRESSURE             3          3          3                QL
indapamide                  BLOOD PRESSURE             1          1          1
INDERAL LA                  BLOOD PRESSURE             3          3          3                QL
INNOPRAN XL                 BLOOD PRESSURE             2          2          2                QL
INSPRA                      BLOOD PRESSURE                        3          3                QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     13
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
INVERSINE                   BLOOD PRESSURE                        3          3
isradipine                  BLOOD PRESSURE             3          3          3
labetalol                   BLOOD PRESSURE             1          1          1
LEVATOL                     BLOOD PRESSURE                        1          1
LEXXEL                      BLOOD PRESSURE                        3          3
lisinop/hctz                BLOOD PRESSURE             1          1          1                QL
lisinopril                  BLOOD PRESSURE             1          1          1
LOTREL                      BLOOD PRESSURE             2          2          2                QL
MAVIK                       BLOOD PRESSURE             2          2          2                QL
methyclothiazide            BLOOD PRESSURE             1          1          1
methyld/hctz                BLOOD PRESSURE             1          1          1
methyldopa                  BLOOD PRESSURE             1          1          1
metolazone                  BLOOD PRESSURE             1          1          1
metoprl/hctz                BLOOD PRESSURE             1          1          1
metoprolol tartrate         BLOOD PRESSURE             1          1          1
MICARDIS                    BLOOD PRESSURE             2          2          2                QL
MICARDIS HCT                BLOOD PRESSURE             2          2          2                QL
midodrine                   BLOOD PRESSURE             1          1          1
minoxidil                   BLOOD PRESSURE             1          1          1
nadolol                     BLOOD PRESSURE             1          1          1
nicardipine                 BLOOD PRESSURE             1          1          1
nifediac cc                 BLOOD PRESSURE             1          1          1                QL
nifediac cc 60mg            BLOOD PRESSURE             1          1          1
nifedical xl                BLOOD PRESSURE             1          1          1                QL
nifedical xl 60mg           BLOOD PRESSURE             1          1          1
nifedipine cap              BLOOD PRESSURE                        3          3
nifedipine tab              BLOOD PRESSURE             1          1          1                QL
NIMOTOP                     BLOOD PRESSURE                        2          2
NORVASC                     BLOOD PRESSURE             3          3          3                QL
pindolol                    BLOOD PRESSURE             1          1          1
prazosin                    BLOOD PRESSURE             1          1          1
propranolol                 BLOOD PRESSURE             1          1          1
propranolol hcl w/hctz      BLOOD PRESSURE             1          1          1
quinapril                   BLOOD PRESSURE             1          1          1                QL
quinapril/hctz              BLOOD PRESSURE             1          1          1                QL
quinaretic                  BLOOD PRESSURE             1          1          1                QL
reserpine                   BLOOD PRESSURE             1          1          1
spirono/hctz                BLOOD PRESSURE             1          1          1
spironolactone              BLOOD PRESSURE             1          1          1
SULAR                       BLOOD PRESSURE             2          2          2                QL
TARKA                       BLOOD PRESSURE             3          3          3
taztia xt                   BLOOD PRESSURE             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     14
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
terazosin                   BLOOD PRESSURE             1          1          1                QL
TEVETEN                     BLOOD PRESSURE             3          3          3                QL
THALITONE                   BLOOD PRESSURE                        2          2
TIAZAC                      BLOOD PRESSURE             2          2          2
TIMOLIDE                    BLOOD PRESSURE                        3          3
timolol mal                 BLOOD PRESSURE             1          1          1
TOPROL XL                   BLOOD PRESSURE             2          2          2                QL
torsemide                   BLOOD PRESSURE             1          1          1
triamt/hctz                 BLOOD PRESSURE             1          1          1
UNIRETIC                    BLOOD PRESSURE             2          2          2
UNIVASC                     BLOOD PRESSURE             2          2          2                QL
verapamil                   BLOOD PRESSURE             1          1          1                QL
verapamil er                BLOOD PRESSURE             1          1          1                QL
VERELAN PM                  BLOOD PRESSURE                        3          3
SKELID                      BONE DISORDERS                        3          3
AVODART                          BPH                              3          3                QL
finasteride                      BPH                   1          1          1                QL
FLOMAX                           BPH                   2          2          2                QL
UROXATROL                        BPH                   2          2          2                QL
ALKERAN                        CANCER                  2          2          2                PA
ARIMIDEX                       CANCER                  2          2          2                QL
AROMASIN                       CANCER                  2          2          2                QL
AVASTIN                        CANCER                  4          4          4                PA
BEXXAR                         CANCER                             3          3                PA
CARAC                          CANCER                             3          3
CASODEX                        CANCER                  2          2          2                QL
CEENU                          CANCER                  2          2          2
cisplatin                       CANCER                 1          1          1                PA
cyclophosphamide                CANCER                 1          1          1                PA
DROXIA                         CANCER                  2          3          3
EFUDEX                         CANCER                  2          2          2
EMCYT                          CANCER                  2          2          2
FARESTON                       CANCER                  2          2          2
FASLODEX                       CANCER                  4          4          4                PA
FEMARA                         CANCER                  2          2          2
FLUOROPLEX                     CANCER                             2          2
fluorouracil                    CANCER                 1          1          1
flutamide                       CANCER                 1          1          1
GLEEVEC                        CANCER                  4          4          4                PA
HERCEPTIN                      CANCER                  4          4          4                PA
HEXALEN                        CANCER                  4          4          4                PA
HYCAMTIN                       CANCER                  4          4          4                PA
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     15
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
hydroxyurea                     CANCER                 1          1          1
INTRON A                        CANCER                 4          4          4                PA
IRESSA                          CANCER                 4          4          4              PA QL
leucovorin                      CANCER                 1          1          1                PA
LEUKERAN                        CANCER                 2          2          2
LUPRON                          CANCER                 4          4          4                PA
LYSODREN                        CANCER                 4          4          4                PA
MATULANE                        CANCER                 2          2          2
megestrol ac                    CANCER                 1          1          1
mercaptopur                     CANCER                 1          1          1
mesna                           CANCER                 1          1          1                PA
MESNEX                          CANCER                 4          4          4               PA
NEXAVAR                         CANCER                 4          4          4              PA QL
NILANDRON                       CANCER                 2          2          2
PANRETIN                        CANCER                 3          3          3                QL
ROFERON-A                       CANCER                 4          4          4                PA
SOLARAZE                        CANCER                 2          2          2
SUTENT                          CANCER                 4          4          4              PA QL
tamoxifen                       CANCER                 1          1          1
TARCEVA                         CANCER                 4          4          4              PA QL
TARGRETIN                       CANCER                 4          4          4              PA QL
TESLAC                          CANCER                 2          2          2
THALOMID                        CANCER                 4          4          4                PA
THIOGUANINE                     CANCER                 2          2          2
THIOTEPA                        CANCER                 3          3          3                PA
VESANOID                        CANCER                 2          2          2                PA
methamphetamine hcl               CNS                             3          3
MYOBLOC                           CNS                  4          4          4                PA
digitek                           CHF                  1          1          1
digoxin                           CHF                  1          1          1
LANOXICAPS                        CHF                  2          2          2
LANOXIN                           CHF                  2          2          2
LANOXIN PED                       CHF                  2          2          2
ADVICOR                       CHOLESTEROL                         2          2
ALTOPREV                      CHOLESTEROL              1          1          1                QL
ANTARA                        CHOLESTEROL                         3          3
CADUET                        CHOLESTEROL                         3          3                QL
cholestyram                   CHOLESTEROL              1          1          1
COLESTID GRAN;TAB             CHOLESTEROL                         2          2
colestipol pkt                CHOLESTEROL              3          3          3
CRESTOR                       CHOLESTEROL              2          2          2                QL
fenofibrate                   CHOLESTEROL              1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     16
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
gemfibrozil                   CHOLESTEROL              1          1          1
LESCOL                        CHOLESTEROL                         3          3                QL
LESCOL XL                     CHOLESTEROL                         3          3                QL
LIPITOR                       CHOLESTEROL              3          3          3                QL
lovastatin                    CHOLESTEROL              1          1          1                QL
NIASPAN                       CHOLESTEROL              2          2          2
OMACOR                        CHOLESTEROL              2          2          2                PA
pravastatin                   CHOLESTEROL              3          3          3                QL
prevalite                     CHOLESTEROL              1          1          1
simvastatin                   CHOLESTEROL              1          1          1                QL
TRICOR                        CHOLESTEROL                         3          3
TRIGLIDE                      CHOLESTEROL                         3          3
VYTORIN                       CHOLESTEROL              2          2          2                QL
WELCHOL                       CHOLESTEROL                         3          3
ZETIA                         CHOLESTEROL              2          2          2                QL
anagrelide                     CIRCULATION             1          1          1
cilostazol                     CIRCULATION             1          1          1
dipyridamole                   CIRCULATION             1          1          1
papaverine hcl                 CIRCULATION             1          1          1
para-time                      CIRCULATION             1          1          1
pentopak                       CIRCULATION             1          1          1
pentoxifylline                 CIRCULATION             1          1          1
ARIXTRA                      COAG DISORDER             4          4          4                PA
COUMADIN                     COAG DISORDER             2          2          2
FRAGMIN                      COAG DISORDER             4          4          4                PA
heparin sod                  COAG DISORDER             1          1          1
heparin sod/d5w              COAG DISORDER             1          1          1
heparin sod/sod chl          COAG DISORDER             1          1          1
INNOHEP                      COAG DISORDER             4          4          4                PA
jantoven                     COAG DISORDER             1          1          1
LOVENOX                      COAG DISORDER             4          4          4              PA QL
warfarin                     COAG DISORDER             1          1          1
constulose                    CONSTIPATION             1          1          1
enulose                       CONSTIPATION             1          1          1
generlac                      CONSTIPATION             1          1          1
glycolax                      CONSTIPATION             1          1          1
KRISTALOSE                    CONSTIPATION                        2          2
lactulose                     CONSTIPATION             1          1          1
polyeth glyc                  CONSTIPATION             1          1          1
apri                         CONTRACEPTION             1          1          1
aranelle                     CONTRACEPTION             1          1          1
aviane                       CONTRACEPTION             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     17
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
camila                      CONTRACEPTION              1          1          1
cesia                       CONTRACEPTION              1          1          1
cryselle-28                 CONTRACEPTION              1          1          1
enpresse-28                 CONTRACEPTION              1          1          1
errin                       CONTRACEPTION              1          1          1
ESTROSTEP FE                CONTRACEPTION              2          2          2
jolivette                   CONTRACEPTION              1          1          1
junel                       CONTRACEPTION              1          1          1
junel fe                    CONTRACEPTION              1          1          1
kariva                      CONTRACEPTION              1          1          1
leena                       CONTRACEPTION              1          1          1
lessina-28                  CONTRACEPTION              1          1          1
levora-28                   CONTRACEPTION              1          1          1
LOESTRIN 24 FE              CONTRACEPTION              3          3          3
low-ogestrel                CONTRACEPTION              1          1          1
lutera                      CONTRACEPTION              1          1          1
medroxypr ac                CONTRACEPTION              1          1          1
microgestin                 CONTRACEPTION              1          1          1
mononessa                   CONTRACEPTION              1          1          1
necon                       CONTRACEPTION              1          1          1
nora-be                     CONTRACEPTION              1          1          1
nortrel                     CONTRACEPTION              1          1          1
ogestrel                    CONTRACEPTION              1          1          1
ORTHO EVRA                  CONTRACEPTION              2          2          2
ORTHO TRI-CY                CONTRACEPTION              2          2          2
OVCON-35 21                 CONTRACEPTION              3          2          2
OVCON-35 28                 CONTRACEPTION              3          2          2
OVCON-50/28                 CONTRACEPTION              2          2          2
PLAN B                      CONTRACEPTION              2          2          2
portia-28                   CONTRACEPTION              1          1          1
previfem                    CONTRACEPTION              1          1          1
solia                       CONTRACEPTION              1          1          1
sprintec                    CONTRACEPTION              1          1          1
trinessa                    CONTRACEPTION              1          1          1
tri-previfem                CONTRACEPTION              1          1          1
tri-sprintec                CONTRACEPTION              1          1          1
trivora-28                  CONTRACEPTION              1          1          1
velivet                     CONTRACEPTION              1          1          1
YAZ                         CONTRACEPTION              3          3          3
zovia                       CONTRACEPTION              1          1          1
acetylcyst                      COPD                   1          1          1                PA
ATROVENT                        COPD                   2          2          2
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     18
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
ATROVENT HFA                     COPD                  2          2          2
COMBIVENT                        COPD                  2          2          2                QL
SPIRIVA                          COPD                  2          2          2                QL
REMICADE                    CROHNS DISEASE             4          4          4                PA
PULMOZYME                   CYSTIC FIBROSIS            4          4          4                PA
TOBI 300/5ML NEBS           CYSTIC FIBROSIS            4          4          4              PA QL
chlorhexidine                   DENTAL                 1          1          1
triamcinolone dental            DENTAL                 1          1          1
ethedent                     DENT CAV PREV             1          1          1
fluorabon                    DENT CAV PREV             1          1          1
fluor-a-day                  DENT CAV PREV             1          1          1
fluoride                     DENT CAV PREV             1          1          1
fluoritab                    DENT CAV PREV             1          1          1
flura-drops                  DENT CAV PREV             1          1          1
amitriptyline                 DEPRESSION               1          1          1
amitriptyline/chlordiazep     DEPRESSION               1          1          1
AMOXAPINE                     DEPRESSION               2          2          2
budeprion                     DEPRESSION               1          1          1
budeprion sr                  DEPRESSION               1          1          1
bupropion er                  DEPRESSION               1          1          1
bupropion sr                  DEPRESSION               1          1          1
chlordiazepoxide/amitript     DEPRESSION               1          1          1
citalopram                    DEPRESSION               1          1          1                QL
clomipramine                  DEPRESSION               1          1          1
CYMBALTA                      DEPRESSION               3          3          3              QL ST
desipramine                   DEPRESSION               1          1          1
doxepin hcl                   DEPRESSION               1          1          1
EFFEXOR XR                    DEPRESSION               2          2          2              QL ST
EMSAM                         DEPRESSION               3          3          3              PA QL
fluoxetine                    DEPRESSION               1          1          1
fluvoxamine                   DEPRESSION               1          1          1                QL
imipram hcl                   DEPRESSION               1          1          1
LEXAPRO                       DEPRESSION               2          2          2                QL
maprotiline                   DEPRESSION               1          1          1
MARPLAN                       DEPRESSION               2          3          3
mirtazapine                   DEPRESSION               1          1          1                QL
mirtazapine odt               DEPRESSION               3          3          3                QL
NARDIL                        DEPRESSION               2          2          2
nefazodone hcl                DEPRESSION               1          1          1
nortriptyline                 DEPRESSION               1          1          1
paroxetine                    DEPRESSION               1          1          1               QL
PAXIL CR                      DEPRESSION                          3          3              QL ST
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     19
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
PAXIL SUSP                     DEPRESSION              2          2          2
perphen/amit                   DEPRESSION              1          1          1
PEXEVA                         DEPRESSION              3          3          3
PROZAC WEEKLY                  DEPRESSION                         3          3              QL ST
RAPIFLUX                       DEPRESSION                         3          3                QL
sertraline                     DEPRESSION              1          1          1                QL
SYMBYAX                        DEPRESSION                         3          3              PA QL
tranlycypromine                DEPRESSION              1          1          1
trazodone                      DEPRESSION              1          1          1
venlafaxine                    DEPRESSION              1          1          1
VIVACTIL                       DEPRESSION              2          2          2
WELLBUTRIN XL                  DEPRESSION                         3          3              QL ST
ACCUZYME                     DERMATOLOGICAL            2          2          2
AKNE-MYCIN                   DERMATOLOGICAL                       3          3
ala-cort                     DERMATOLOGICAL            1          1          1
alclometasone dipropionate   DERMATOLOGICAL            1          1          1
ALDARA                       DERMATOLOGICAL            2          2          2
amcinonide                   DERMATOLOGICAL            1          1          1
aug betamet                  DERMATOLOGICAL            1          1          1
bac/neo/poly                 DERMATOLOGICAL            1          1          1
BACTROBAN CREAM              DERMATOLOGICAL                       2          2
BACTROBAN OINT               DERMATOLOGICAL            2          2          2
BENSAL HP                    DERMATOLOGICAL                       3          3
betameth dip                 DERMATOLOGICAL            1          1          1
betameth val                 DERMATOLOGICAL            1          1          1
CAPEX                        DERMATOLOGICAL                       2          2
CAPITROL                     DERMATOLOGICAL                       2          2
centany                      DERMATOLOGICAL            1          1          1
ciclopirox                   DERMATOLOGICAL                       3          3
CLENIA CREAM                 DERMATOLOGICAL            3          3          3
CLENIA FOAMING WASH          DERMATOLOGICAL            3          3          3
clobetasol                   DERMATOLOGICAL            1          1          1
clobetasol e                 DERMATOLOGICAL            1          1          1
CLOBEX                       DERMATOLOGICAL                       3          3
CLODERM                      DERMATOLOGICAL                       3          3
clotrim/beta                 DERMATOLOGICAL            1          1          1
clotrimazole                 DERMATOLOGICAL            1          1          1
CONDYLOX                     DERMATOLOGICAL                       2          2
CORDRAN                      DERMATOLOGICAL                       3          3
CORDRAN SP                   DERMATOLOGICAL                       3          3
del-beta                     DERMATOLOGICAL            1          1          1
DENAVIR                      DERMATOLOGICAL            2          3          3                QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     20
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
DERMA-SMOOTH            DERMATOLOGICAL                            2          2
DERMATOP                DERMATOLOGICAL                            3          3
desonide                DERMATOLOGICAL                 1          1          1
desoximetas             DERMATOLOGICAL                 1          1          1
diflorasone             DERMATOLOGICAL                 1          1          1
econazole nitrate       DERMATOLOGICAL                 1          1          1
ELIDEL                  DERMATOLOGICAL                 3          3          3             PA QL ST
erythromycin-benz perox DERMATOLOGICAL                 3          3
EURAX                   DERMATOLOGICAL                            2          2
EXELDERM                DERMATOLOGICAL                            2          2
FIRST-HYDROCORT         DERMATOLOGICAL                            3          3
fluocinolone            DERMATOLOGICAL                 1          1          1
fluocinonide            DERMATOLOGICAL                 1          1          1
fluticasone propionate  DERMATOLOGICAL                 1          1          1
gentamicin              DERMATOLOGICAL                 1          1          1
granul-derm             DERMATOLOGICAL                 1          1          1
HALOBETASOL PROP DERMATOLOGICAL                        3          3
HALOG                   DERMATOLOGICAL                            3          3
hc pramoxine            DERMATOLOGICAL                 1          1          1
hc valerate             DERMATOLOGICAL                 1          1          1
hydrocortiso            DERMATOLOGICAL                 1          1          1
hydrocortisone          DERMATOLOGICAL                 1          1          1
hydrocortisone butyrate DERMATOLOGICAL                 1          1          1
ketoconazole            DERMATOLOGICAL                 1          1          1
KLARON                  DERMATOLOGICAL                            2          2
LACTIC ACID E           DERMATOLOGICAL                 3          3          3               QL
LEVULAN KERASTICK DERMATOLOGICAL                       2                                    PA QL
LIDAMANTLE HC           DERMATOLOGICAL                            3          3
lidoc/priloc            DERMATOLOGICAL                 1          1          1
lidocaine               DERMATOLOGICAL                 1          1          1
LINDANE LOTION          DERMATOLOGICAL                 2          2          2                QL
lindane shamp           DERMATOLOGICAL                 1          1          1                QL
LOCOID                  DERMATOLOGICAL                 2          2          2
MENTAX                  DERMATOLOGICAL                            3          3
METHOXSALANE (8-MOP) DERMATOLOGICAL                    2
metronidazole           DERMATOLOGICAL                 1          1          1
metronidazole lotion    DERMATOLOGICAL                 1          1          1
mometasone              DERMATOLOGICAL                 1          1          1
mupirocin               DERMATOLOGICAL                 1          1          1
NAFTIN                  DERMATOLOGICAL                            3          3
NAFTIN-MP               DERMATOLOGICAL                            3          3
NORITATE                DERMATOLOGICAL                            3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     21
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
nystat/triam               DERMATOLOGICAL              1          1          1
nystatin                   DERMATOLOGICAL              1          1          1
nystop                     DERMATOLOGICAL              1          1          1
OVIDE                      DERMATOLOGICAL                         3          3
OXISTAT                    DERMATOLOGICAL                         3          3
PANAFIL                    DERMATOLOGICAL              2          2          2
PANAFIL-WHITE              DERMATOLOGICAL              2          2          2
PANFIL G                   DERMATOLOGICAL                         3          3
PEDI-DRI                   DERMATOLOGICAL              2          2          2
PENLAC                     DERMATOLOGICAL                         3          3                QL
permethrin                 DERMATOLOGICAL              1          1          1
PODOCON-25                 DERMATOLOGICAL                         3          3                PA
podofilox                  DERMATOLOGICAL              1          1          1
PROTOPIC                   DERMATOLOGICAL                         3          3                ST
PRUDOXIN                   DERMATOLOGICAL                         3          3
PSORCON E                  DERMATOLOGICAL              2          2          2
REGRANEX                   DERMATOLOGICAL              4          4          4                PA
RETIN-A                    DERMATOLOGICAL              2          2          2
RETIN-A MICR               DERMATOLOGICAL              2          2          2
rosaderm                   DERMATOLOGICAL              1          1          1
ROZEX                      DERMATOLOGICAL                         3          3
SANTYL                     DERMATOLOGICAL                         3          3
SEBIZON                    DERMATOLOGICAL                         2          2
selenium sul               DERMATOLOGICAL              1          1          1
SILVER NITRATE             DERMATOLOGICAL              2          2          2
silver sulfa               DERMATOLOGICAL              1          1          1
sod sul/sulf               DERMATOLOGICAL              1          1          1
ssd                        DERMATOLOGICAL              1          1          1
ssd af                     DERMATOLOGICAL              1          1          1
SULFAMYLON                 DERMATOLOGICAL                         3          3
tbc aer                    DERMATOLOGICAL              1          1          1
tetracycline               DERMATOLOGICAL              1          1          1
TEXACORT TOP               DERMATOLOGICAL                         2          2
tretinoin                  DERMATOLOGICAL              1          1          1
triamcinolon               DERMATOLOGICAL              1          1          1
triamcinolone acetonide    DERMATOLOGICAL              1          1          1
triamcinolone/nystatin     DERMATOLOGICAL              1          1          1
triderm                    DERMATOLOGICAL              1          1          1
VANOS                      DERMATOLOGICAL                         3          3
VANOXIDE-HC                DERMATOLOGICAL                         3          3
XENADERM                   DERMATOLOGICAL              2          2          2
ZOVIRAX OINT               DERMATOLOGICAL              2                                      QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     22
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
ANTABUSE                       DETERRENTS              2          2          2
CAMPRAL                        DETERRENTS              3                                      QL
naltrexone                     DETERRENTS              1          1          1
ACTOS                           DIABETES               2          2          2              QL ST
AVANDAMET                       DIABETES               2          2          2                ST
AVANDARYL                       DIABETES               2          2          2              QL ST
AVANDIA                         DIABETES               2          2          2              QL ST
BYETTA                          DIABETES               2          2          2              PA QL
chlorpropam                     DIABETES               1          1          1
glimepiride                     DIABETES               1          1          1
glipizide                       DIABETES               1          1          1
glipizide er                    DIABETES               1          1          1
glipizide xl                    DIABETES               1          1          1
glipizide/metformin             DIABETES               3          3          3
GLUCAGEN HYPOKIT                DIABETES               2          2          2
GLUCAGON                        DIABETES               2          2          2                QL
glyburid mcr                    DIABETES               1          1          1
glyburide                       DIABETES               1          1          1
glyburide-metformin             DIABETES               1          1          1
glycron                         DIABETES               1          1          1
GLYCRON 4.5MG                   DIABETES                          3          3
HUMALOG                         DIABETES                          3          3              PA PEN
HUMALOG 5'S                     DIABETES                          3          3              PA PEN
HUMALOG MIX                     DIABETES                          3          3              PA PEN
HUMULIN 5'S                     DIABETES                          3          3              PA PEN
HUMULIN L VIAL                  DIABETES               3          3          3
HUMULIN N 5                     DIABETES                          3          3              PA PEN
HUMULIN N VIAL                  DIABETES                          3          3
HUMULIN R VIAL                  DIABETES                          3          3
HUMULIN U VIAL                  DIABETES                          3          3
HUMULIN VIAL                    DIABETES                          3          3
ILETIN II RG VIAL               DIABETES                          2          2
ILETIN II VIAL                  DIABETES                          2          2
LANTUS VIAL                     DIABETES               2          2          2
mcr glyburid                    DIABETES               1          1          1
metformin                       DIABETES               1          1          1
metformin hcl er                DIABETES               1          1          1
NOVOLIN 70/30                   DIABETES               2          2          2              PA PEN
NOVOLIN N                       DIABETES               2          2          2              PA PEN
NOVOLIN R                       DIABETES               2          2          2              PA PEN
NOVOLOG                         DIABETES               2          2          2              PA PEN
NOVOLOG MIX 70/30               DIABETES               2          2          2              PA PEN
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     23
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
PRANDIN                        DIABETES                2          2          2
PRECOSE                        DIABETES                2          2          2
PROGLYCEM                      DIABETES                3          3          3
RIOMET                         DIABETES                2          2          2
STARLIX                        DIABETES                           3          3
SYMLIN                         DIABETES                2          2          2              PA QL
tolazamide                     DIABETES                1          1          1
tolbutamide                    DIABETES                1          1          1
alcohol swabs              DIABETIC SUPPLIES           1          1          1
GAUZE PADS                 DIABETIC SUPPLIES           1          1          1
INSULIN SYRG               DIABETIC SUPPLIES           2          2          2
PEN NEEDLES                DIABETIC SUPPLIES           2          2          2
STER NEEDLES               DIABETIC SUPPLIES           2          2          2
TERUMO INS                 DIABETIC SUPPLIES           2          2          2
diphen/atrop                   DIARRHEA                1          1          1
lofene                         DIARRHEA                1          1          1
lonox                          DIARRHEA                1          1          1
MOTOFEN                        DIARRHEA                           3          3
CREON                         DIGESTION                           2          2
DYGASE                        DIGESTION                2          2          2
KU-ZYME HP                    DIGESTION                           2          2
lapase                         DIGESTION               1          1          1
lipram 4500                    DIGESTION               1          1          1
lipram-cr10                    DIGESTION               1          1          1
lipram-cr20                    DIGESTION               1          1          1
lipram-cr5                     DIGESTION               1          1          1
lipram-pn10                    DIGESTION               1          1          1
lipram-pn16                    DIGESTION               1          1          1
lipram-pn20                    DIGESTION               1          1          1
lipram-ul12                    DIGESTION               1          1          1
lipram-ul18                    DIGESTION               1          1          1
lipram-ul20                    DIGESTION               1          1          1
PALCAPS 10                    DIGESTION                           3          3
PALCAPS 20                    DIGESTION                           3          3
PANCREASE                     DIGESTION                2          2          2
PANCRECARB MS-16              DIGESTION                           3          3
PANCRECARB MS-4               DIGESTION                           3          3
PANCRECARB MS-8               DIGESTION                           3          3
pancrelipase                   DIGESTION               1          1          1
pancron 10                     DIGESTION               1          1          1
pancron 20                     DIGESTION               1          1          1
panges cn 10                   DIGESTION               1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     24
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
panges cn 20                    DIGESTION              1          1          1
panges mt 16                    DIGESTION              1          1          1
panges ul 12                    DIGESTION              1          1          1
panges ul 18                    DIGESTION              1          1          1
panges ul 20                    DIGESTION              1          1          1
pangestym ec                    DIGESTION              1          1          1
PANOCAPS                        DIGESTION                         3          3
PANOCAPS MT 16                  DIGESTION                         3          3
PANOCAPS MT 20                  DIGESTION                         3          3
panokase                        DIGESTION              1          1          1
panokase-16                     DIGESTION              1          1          1
plaretase                       DIGESTION              1          1          1
ULTRACAPS MT 20                 DIGESTION                         3          3
ULTRASE                         DIGESTION              2          2          2
ULTRASE MT12                    DIGESTION              2          2          2
ULTRASE MT18                    DIGESTION              2          2          2
ULTRASE MT20                    DIGESTION              2          2          2
VIOKASE 16                      DIGESTION              2          2          2
VIOKASE-8                       DIGESTION              2          2          2
bacteriostatic water for         DILUENT               1          1          1
bacteriostatic water inj         DILUENT               1          1          1
bacteriostatic water para        DILUENT               1          1          1
NATURETIN-5                     DIURETIC                          3          3
a/b ear drops                      EAR                 1          1          1
a/b otic                           EAR                 1          1          1
ace acd/alum                       EAR                 1          1          1
acetasol hc                        EAR                 1          1          1
acetic acid                        EAR                 1          1          1
acetic acid/hydrocort              EAR                 1          1          1
antiben                            EAR                 1          1          1
antibiot ear                       EAR                 1          1          1
antipyrine/benzocaine              EAR                 1          1          1
aurodex                            EAR                 1          1          1
auroto                             EAR                 1          1          1
balagan                            EAR                 1          1          1
benzotic                           EAR                 1          1          1
CIPRO HC                           EAR                            3          3
CIPRODEX                           EAR                 2          2          2
COLY-MYCIN S                       EAR                 2          3          3
CORTANE-B                          EAR                            3          3
cortic                             EAR                 1          1          1
cortomycin                         EAR                 1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     25
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
dolotic                           EAR                  1          1          1
ear drops                         EAR                  1          1          1
ear-gesic                         EAR                  1          1          1
FLOXIN OTIC                       EAR                  2          2          2
neo/poly/hc                       EAR                  1          1          1
oticin hc                         EAR                  1          1          1
otimar                            EAR                  1          1          1
otirx                             EAR                  1          1          1
OTOGESIC                          EAR                             2          2
OTOMAR-HC                         EAR                             3          3
otozone                           EAR                  1          1          1
otra nr                           EAR                  1          1          1
pro-otic                          EAR                  1          1          1
tri-otic                          EAR                  1          1          1
uni-otic                          EAR                  1          1          1
ZOTANE HC                         EAR                             3          3
ZOTO-HC                           EAR                             3          3
K+ POTASSIUM                  ELECTROLYTE              1          1          1
KAON-CL-10                    ELECTROLYTE              2          2          2
KLOR-CON                      ELECTROLYTE              2          2          2
klor-con 10                   ELECTROLYTE              1          1          1
klor-con 8                    ELECTROLYTE              1          1          1
klor-con m15                  ELECTROLYTE              1          1          1
klor-con m20                  ELECTROLYTE              1          1          1
KLOTRIX                       ELECTROLYTE              2          2          2
K-LYTE DS OR                  ELECTROLYTE              2          2          2
K-LYTE/CL-50                  ELECTROLYTE              2          2          2
KTABS                         ELECTROLYTE              2          2          2
MICRO K                       ELECTROLYTE              2          2          2
MICRO-K                       ELECTROLYTE              2          2          2
0.45% normal saline           ELECTROLYTE              1          1          1
0.9% normal saline            ELECTROLYTE              1          1          1
AMINOSYN                      ELECTROLYTE              3          3          3                PA
AMINOSYN 7%                   ELECTROLYTE              3          3          3                PA
AMINOSYN II                   ELECTROLYTE              3          3          3                PA
AMINOSYN II 3.5%              ELECTROLYTE              3          3          3                PA
AMINOSYN II 4.25%             ELECTROLYTE              3          3          3                PA
AMINOSYN II 5%                ELECTROLYTE              3          3          3                PA
AMINOSYN II 8.5%              ELECTROLYTE              3          3          3                PA
AMINOSYN II M 3.5%            ELECTROLYTE              3          3          3                PA
AMINOSYN II M 4.25%           ELECTROLYTE              3          3          3                PA
AMINOSYN M                    ELECTROLYTE              3          3          3                PA
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     26
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
AMINOSYN-HBC                  ELECTROLYTE              3          3          3                PA
AMINOSYN-HF                   ELECTROLYTE              3          3          3                PA
AMINOSYN-PF                   ELECTROLYTE              3          3          3                PA
AMINOSYN-PF 7%                ELECTROLYTE              3          3          3                PA
AMINOSYN-RF                   ELECTROLYTE              3          3          3                PA
citric acid/sod citr soln     ELECTROLYTE              1          1          1
cytra k crystals              ELECTROLYTE              1          1          1
cytra-2                       ELECTROLYTE              1          1          1
cytra-3                       ELECTROLYTE              1          1          1
cytra-k                       ELECTROLYTE              1          1          1
ed k+10                       ELECTROLYTE              1          1          1
effervescent potassium        ELECTROLYTE              1          1          1
KAOCHLOR                      ELECTROLYTE              2          2          2
KAY CIEL                      ELECTROLYTE              2          2          2
kcal/d5w/nacl 0.224/0.45      ELECTROLYTE              1          1          1
kcl 0.075%/d5w/0.225          ELECTROLYTE              1          1          1
kcl 0.15%/d5w/lr              ELECTROLYTE              1          1          1
kcl 0.15%/d5w/0.45%           ELECTROLYTE              1          1          1
kcl 0.224%/d5w/0.2%           ELECTROLYTE              1          1          1
kcl 0.224%/d5w/0.45%          ELECTROLYTE              1          1          1
kcl 0.3%/d5w/lr               ELECTROLYTE              1          1          1
kcl 20meq/d5.45nacl           ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.15/0.2         ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.15/0.33%       ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.15/0.9         ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.224/0.2        ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.224/0.33       ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.3/0.2%         ELECTROLYTE              1          1          1
kcl/d5w/nacl 0.3/0.45         ELECTROLYTE              1          1          1
k-effervesce                  ELECTROLYTE              1          1          1
klor-con/ef                   ELECTROLYTE              1          1          1
K-PHOS M.F.                   ELECTROLYTE                         2          2
K-PHOS NO.2                   ELECTROLYTE                         2          2
K-PHOS ORIGINAL               ELECTROLYTE                         2          2
k-vescent                     ELECTROLYTE              1          1          1
lactated ringers              ELECTROLYTE              1          1          1
magnesium sulfate             ELECTROLYTE              1          1          1
ORACIT                        ELECTROLYTE                         2          2
phospha 250 neutral           ELECTROLYTE              1          1          1
POLYCITRA                     ELECTROLYTE              2          3          3
POLYCITRA-LC                  ELECTROLYTE              2          3          3
pot bicar/cl                  ELECTROLYTE              1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     27
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
pot bicarb                      ELECTROLYTE            1          1          1
pot chloride                    ELECTROLYTE            1          1          1
POT CHLORIDE PKT               ELECTROLYTE             2          2          2
pot efferves                    ELECTROLYTE            1          1          1
potassium chloride              ELECTROLYTE            1          1          1
potassium chloride cr           ELECTROLYTE            1          1          1
potassium chloride er           ELECTROLYTE            1          1          1
potassium chloride sa           ELECTROLYTE            1          1          1
potassium chloride sr           ELECTROLYTE            1          1          1
potassium citrate extende       ELECTROLYTE            1          1          1
potassium citrate/citric acid   ELECTROLYTE            1          1          1
ringer's injection              ELECTROLYTE            1          1          1
sod poly sul                    ELECTROLYTE            1          1          1
sodium chloride 0.9%            ELECTROLYTE            1          1          1
sodium chloride 0.45% v         ELECTROLYTE            1          1          1
sodium polystyrene sulfon       ELECTROLYTE            1          1          1
sps                             ELECTROLYTE            1          1          1
sterile water for inj           ELECTROLYTE            1          1          1
sterile water irrig             ELECTROLYTE            1          1          1
TPN ELECTROLYTES               ELECTROLYTE             3          3          3
BUPHENYL                         ENDOCRINE             4          4          4                PA
cabergoline                      ENDOCRINE                        1          1
CYSTADANE                        ENDOCRINE             3          3          3                PA
CYTADREN                         ENDOCRINE             2          2          2
DHT                              ENDOCRINE                        2          2
octreotide acetate               ENDOCRINE             4          4          4                PA
SENSIPAR                         ENDOCRINE             4          4          4               PA ST
SOMAVERT                         ENDOCRINE             4          4          4                PA
SYNAREL                          ENDOCRINE             2          2          2
ZEMPLAR                          ENDOCRINE                        3          3              PA QL
ZOMETA                           ENDOCRINE             4          4          4                PA
ZORBTIVE                         ENDOCRINE             4          4          4                PA
FABRAZYME                     ENZYME REPLACE           4          4          4                PA
ORFADIN                       ENZYME REPLACE                      3          3
*phenobarbital tabs               EPILEPSY                                   1                QL
carbamazepine                     EPILEPSY             1          1          1
CARBATROL                         EPILEPSY             2          2          2
CELONTIN                          EPILEPSY             2          2          2
DEPAKOTE                          EPILEPSY             2          2          2
DEPAKOTE ER                       EPILEPSY             2          2          2
DEPAKOTE SPR                      EPILEPSY             2          2          2
DILANTIN                          EPILEPSY             2          2          2
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     28
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
DILANTIN-125                   EPILEPSY                2          2          2
epitol                          EPILEPSY               1          1          1
ethosuximide                    EPILEPSY               1          1          1
FELBATOL                       EPILEPSY                2          2          2                QL
gabapentin                      EPILEPSY               1          1          1
GABITRIL                       EPILEPSY                2          3          3                QL
KEPPRA                         EPILEPSY                2          2          2                QL
LAMICTAL                       EPILEPSY                2          3          3              PA ST
lamotrigine                     EPILEPSY               1          3          3                PA
LYRICA                         EPILEPSY                3          3          3              PA QL
NEURONTIN                      EPILEPSY                2          2          2
PEGANONE                       EPILEPSY                2          3          3
PHENYTEK                       EPILEPSY                2          2          2
phenytoin                       EPILEPSY               1          1          1
primidone                       EPILEPSY               1          1          1
TEGRETOL                       EPILEPSY                2          2          2
TEGRETOL XR                    EPILEPSY                2          2          2
TOPAMAX                        EPILEPSY                2          3          3                PA
TRILEPTAL                      EPILEPSY                2          3          3              PA QL
valproate sodium                EPILEPSY               1          1          1
valproic acid                   EPILEPSY               1          1          1
zonisamide                      EPILEPSY               1          1          1                QL
*LEVITRA                           ED                                        1                QL
acetazolamid                 EYE DISORDERS             1          1          1
ACULAR                       EYE DISORDERS             3          3
ACULAR LS                    EYE DISORDERS             3          3          3
ACULAR PF                    EYE DISORDERS                        3          3
ak-con                       EYE DISORDERS             1          1          1
ak-poly-bac                  EYE DISORDERS             1          1          1
ak-tob                       EYE DISORDERS             1          1          1
ALAMAST                      EYE DISORDERS                        2          2
ALOCRIL                      EYE DISORDERS                        2          2
ALOMIDE                      EYE DISORDERS                        2          2
ALPHAGAN P                   EYE DISORDERS             3          3          3
ALREX                        EYE DISORDERS             2          2          2                QL
atropin-care                 EYE DISORDERS             1          1          1
atropine sul                 EYE DISORDERS             1          1          1
AZOPT                        EYE DISORDERS             2          2          2
bac/neo/poly                 EYE DISORDERS             1          1          1
bacit/poly b                 EYE DISORDERS             1          1          1
bacitracin                   EYE DISORDERS             1          1          1
betaxolol                    EYE DISORDERS             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     29
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
BETIMOL                      EYE DISORDERS             2          2          2
BETOPTIC-S                   EYE DISORDERS             3          2          2
BLEPHAMIDE                   EYE DISORDERS             2          2          2
BOTOX                        EYE DISORDERS             4          4          4                PA
brimonidine                  EYE DISORDERS             1          1          1
carboptic                    EYE DISORDERS             1          1          1
carteolol hcl                EYE DISORDERS             1          1          1
CILOXAN                      EYE DISORDERS                        2          2
ciprofloxacin                EYE DISORDERS             1          1          1
COSOPT                       EYE DISORDERS             3          3          3
cromolyn sod                 EYE DISORDERS             1          1          1
dexamethasone phos           EYE DISORDERS             1          1          1
DIAMOX SEQUE                 EYE DISORDERS             2          2          2
dipivefrin                   EYE DISORDERS             1          1          1
ELESTAT                      EYE DISORDERS                        3          3
EMADINE                      EYE DISORDERS                        3          3
FLAREX                       EYE DISORDERS                        3          3
fluoromethol                 EYE DISORDERS             1          1          1
FML                          EYE DISORDERS                        2          2
FML FORTE                    EYE DISORDERS                        2          2
FML-S LIQUIF                 EYE DISORDERS                        2          2
gentak                       EYE DISORDERS             1          1          1
gentamicin                   EYE DISORDERS             1          1          1
gentasol                     EYE DISORDERS             1          1          1
homatropaire                 EYE DISORDERS             1          1          1
INFLAM MILD                  EYE DISORDERS             2          2          2
IOPIDINE                     EYE DISORDERS                        2          2
ISOPTO HOMATROPINE           EYE DISORDERS                        3          3
ketotifen                    EYE DISORDERS             3          3          3
LACRISERT                    EYE DISORDERS             2          2          2
levobunolol                  EYE DISORDERS             1          1          1
LOTEMAX                      EYE DISORDERS             2          2          2                QL
LUMIGAN                      EYE DISORDERS             2          2          2                QL
MAXIDEX                      EYE DISORDERS             2          2          2
methazolamid                 EYE DISORDERS             1          1          1
metipranolol                 EYE DISORDERS             1          1          1
MYDFRIN                      EYE DISORDERS                        3          3
naphazoline                  EYE DISORDERS             1          1          1
NATACYN                      EYE DISORDERS             2          2          2
neo/poly/dex                 EYE DISORDERS             1          1          1
neo/poly/gra                 EYE DISORDERS             1          1          1
neocin-pg                    EYE DISORDERS             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     30
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
neo/poly/dexame              EYE DISORDERS             1          1          1
NEVANAC                      EYE DISORDERS             3          3          3
ocusulf-10                   EYE DISORDERS             1          1          1
ocutricin                    EYE DISORDERS             1          1          1
ofloxacin                    EYE DISORDERS             1          1          1
OPTIVAR                      EYE DISORDERS             3          3          3
parcaine                     EYE DISORDERS             1          1          1
PATANOL                      EYE DISORDERS             3          3          3
PHOSPHOLINE                  EYE DISORDERS             2          2          2
pilocarpine                  EYE DISORDERS             1          1          1
PILOPINE HS                  EYE DISORDERS             2          2          2
piloptic-1                   EYE DISORDERS             1          1          1
piloptic-1/2                 EYE DISORDERS             1          1          1
piloptic-2                   EYE DISORDERS             1          1          1
piloptic-3                   EYE DISORDERS             1          1          1
piloptic-4                   EYE DISORDERS             1          1          1
piloptic-6                   EYE DISORDERS             1          1          1
polycin b                    EYE DISORDERS             1          1          1
poly-dex                     EYE DISORDERS             1          1          1
poly-pred                    EYE DISORDERS             2          2          2
pred acetate                 EYE DISORDERS             1          1          1
PRED MILD                    EYE DISORDERS             2          2          2
pred sod pho                 EYE DISORDERS             1          1          1
PRED-G                       EYE DISORDERS             2          2          2
prednisolone                 EYE DISORDERS             1          1          1
proparacaine                 EYE DISORDERS             1          1          1
QUIXIN                       EYE DISORDERS                        3          3
RESTASIS                     EYE DISORDERS             3          3          3
romycin                      EYE DISORDERS             1          1          1
sod sulfacet                 EYE DISORDERS             1          1          1
sodium sulfacetamide         EYE DISORDERS             1          1          1
sulf/pred na                 EYE DISORDERS             1          1          1
sulfacet sod                 EYE DISORDERS             1          1          1
TOBRADEX                     EYE DISORDERS             2          2          2
tobramycin                   EYE DISORDERS             1          1          1
tobrasol                     EYE DISORDERS             1          1          1
TOBREX                       EYE DISORDERS             2          2          2
TRAVATAN                     EYE DISORDERS             2          2          2                QL
trifluridine                 EYE DISORDERS             1          1          1
trimet/polym                 EYE DISORDERS             1          1          1
trimethoprim                 EYE DISORDERS             1          1          1
tropicamide                  EYE DISORDERS             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     31
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
TRUSOPT                      EYE DISORDERS             3          3          3
VEXOL                        EYE DISORDERS                        2          2
VIGAMOX                      EYE DISORDERS             2          2          2                QL
VOLTAREN                     EYE DISORDERS             2          2          2
XALATAN                      EYE DISORDERS             3          3          3                QL
ZYLET                        EYE DISORDERS                        3          3
ZYMAR                        EYE DISORDERS             3          3          3
LIPOSYN II                    FAT EMULSION             3          3          3                PA
LIPOSYN III                   FAT EMULSION             3          3          3                PA
CEREZYME                        GAUCHERS               4          4          4                PA
ZAVESCA                         GAUCHERS               4          4          4                PA
GOLYTELY                     GI DIAGNOSTICS            2          2          2
HALFLYTELY                   GI DIAGNOSTICS            3          3          3
NULYTELY                     GI DIAGNOSTICS            2          2          2
peg 3350                     GI DIAGNOSTICS            1          1          1
trilyte                      GI DIAGNOSTICS            1          1          1
VISICOL                      GI DIAGNOSTICS            3          3          3
CANTIL                        GI DISORDERS                        3          3
colidrops                     GI DISORDERS             1          1          1
COLYTROL DROPS                GI DISORDERS                        2          2
COLYTROL SUSP                 GI DISORDERS                        3          3
dicyclomine                   GI DISORDERS             1          1          1
DIPENTUM                      GI DISORDERS             2          3          3
GASTROCROM                    GI DISORDERS             2          2          2
glycopyrrolate                GI DISORDERS                        3          3
hyoscyamine                   GI DISORDERS             1          1          1
hyosyne                       GI DISORDERS             1          1          1
LOTRONEX                      GI DISORDERS             2          2          2                PA
metoclopramide hcl            GI DISORDERS             1          1          1
PAMINE                        GI DISORDERS                        3          3
PAMINE FORTE                  GI DISORDERS                        3          3
PRO-BANTHINE                  GI DISORDERS                        2          2
propantheline bromide         GI DISORDERS             1          1          1
SAL-TROPINE                   GI DISORDERS                        3          3
spasdel                       GI DISORDERS             1          1          1
SUCRAID                       GI DISORDERS                        3          3
sulfasalazin                  GI DISORDERS             1          1          1
sulfazine                     GI DISORDERS             1          1          1
sulfazine ec                  GI DISORDERS             1          1          1
URSO                          GI DISORDERS                        3          3
URSO FORTE                    GI DISORDERS                        3          3
ursodiol                      GI DISORDERS             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     32
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
allopurinol                      GOUT                  1          1          1
colchicine                       GOUT                  1          1          1
proben/colch                     GOUT                  1          1          1
probenecid                       GOUT                  1          1          1
NORDITROPIN                   GROWTH DEF               4          4          4                PA
NORDITROPIN NORDIFLEX         GROWTH DEF               4          4          4                PA
TEV-TROPIN                    GROWTH DEF               4          4          4                PA
ANALPRAM-HC                  HEMMORHOIDS               2          2          2
ANALPRAM-HC                  HEMMORHOIDS                          3          3
ANUSOL-HC                    HEMMORHOIDS               2          2          2
CORTIFOAM                    HEMMORHOIDS                          2          2
hc cream                     HEMMORHOIDS               1          1          1
hemorrhoidal-hc cream        HEMMORHOIDS               1          1          1
lidazone                     HEMMORHOIDS               1          1          1
PROCTOFOAM                   HEMMORHOIDS               2          2          2
proctosol hc                 HEMMORHOIDS               1          1          1
proctozone                   HEMMORHOIDS               1          1          1
BARACLUDE                      HEPATITIS B             4          4          4              PA QL
HEPSERA                        HEPATITIS B             4          4          4             PA QL ST
INFERGEN                       HEPATITIS C             4          4          4                PA
PEGASYS                        HEPATITIS C             4          4          4                PA
PEG-INTRON                     HEPATITIS C             4          4          4                PA
REBETOL                        HEPATITIS C             2          2          2              PA QL
REBETRON 1200                  HEPATITIS C             4          4          4                PA
RIBASPHERE                     HEPATITIS C             4          4          4                PA
RIBATAB                        HEPATITIS C             4          4          4                PA
RIBAVIRIN                      HEPATITIS C             4          4          4                PA
fluoxymester                   HORMONAL                1          1         PA
ACTIVELLA                   HORMONE IMBAL              2          3          3                QL
ALORA                       HORMONE IMBAL                         3          3                QL
ANADROL-50                  HORMONE IMBAL                         3          3                PA
ANDRODERM                   HORMONE IMBAL                         3          3              PA QL
ANDROID                     HORMONE IMBAL                         2          2                PA
CENESTIN                    HORMONE IMBAL              3          3          3                QL
COMBIPATCH                  HORMONE IMBAL                         3          3                QL
danazol                     HORMONE IMBAL              1          1          1
DEPO-TESTOSTERONE           HORMONE IMBAL                         3          3                PA
ENJUVIA                     HORMONE IMBAL              3          3          3                QL
ESCLIM                      HORMONE IMBAL                         2          2
ESTRACE VAG                 HORMONE IMBAL              2          2          2
ESTRADERM                   HORMONE IMBAL                         2          2                QL
estradiol                   HORMONE IMBAL              1          1          1                QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     33
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
ESTRASORB                   HORMONE IMBAL                         3          3                QL
ESTRING                     HORMONE IMBAL              3          3          3
ESTROGEL                    HORMONE IMBAL                         3          3                QL
estropipate                 HORMONE IMBAL              1          1          1
FEMHRT                      HORMONE IMBAL              3          3          3                QL
FEMHRT LOW DOSE             HORMONE IMBAL              3          3          3
FEMRING                     HORMONE IMBAL                         3          3                QL
FIRST-TESTOSTERONE          HORMONE IMBAL                         3          3                PA
GYNODIOL                    HORMONE IMBAL                         3          3
MENEST                      HORMONE IMBAL                         2          2
MENOSTAR                    HORMONE IMBAL                         3          3
norethin ace                HORMONE IMBAL              1          1          1
OXANDRIN                    HORMONE IMBAL              4          4          4                PA
PREFEST                     HORMONE IMBAL              3          3          3                QL
PREMARIN                    HORMONE IMBAL              2          2          2                QL
PREMARIN VAG                HORMONE IMBAL              2          2          2
PREMPHASE                   HORMONE IMBAL              2          2          2                QL
PREMPRO                     HORMONE IMBAL              2          2          2                QL
PROMETRIUM                  HORMONE IMBAL                         2          2
TESTIM 1%                   HORMONE IMBAL              2          2          2                PA
testosterone                HORMONE IMBAL              1          1          1                PA
testosterone cypionate      HORMONE IMBAL              1          1          1                PA
testosterone enanthate      HORMONE IMBAL              1          1          1                PA
testosterone propionate     HORMONE IMBAL              1          1          1                PA
TESTRED                     HORMONE IMBAL                         2          2                PA
VAGIFEM                     HORMONE IMBAL              3          3          3
VIVELLE                     HORMONE IMBAL              2          2          2                QL
VIVELLE-DOT                 HORMONE IMBAL              2          2          2                QL
ACTIMMUNE                   IMMUNE SYSTEM              4          4          4                PA
acid jelly                    INFECTION                1          1          1
acidic vaginal jelly          INFECTION                1          1          1
acyclovir                     INFECTION                1          1          1
ADOXA                         INFECTION                           3          3
AGENERASE                     INFECTION                2          2          2
ALBENZA                       INFECTION                           3          3
ALINIA                        INFECTION                           3          3                QL
amikacin                      INFECTION                1          1          1
amino acid cervical           INFECTION                1          1          1
amox/k clav                   INFECTION                1          1          1
amoxicillin                   INFECTION                1          1          1
amoxicillin/clavulanate       INFECTION                1          1          1
amoxil                        INFECTION                1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     34
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
ampicillin                      INFECTION              1          1          1
ampicillin-sulbactam            INFECTION              1          1          1
ANCOBON                         INFECTION                         3          3
APTIVUS                         INFECTION              3          4          4                QL
AUGMENTIN XR                    INFECTION                         2          2
AVELOX SOLN                     INFECTION              2          2          2
AVELOX TAB                      INFECTION              2          2          2                QL
AZACTAM                         INFECTION              2          2          2                PA
AZACTAM/DEXT                    INFECTION              2          2          2                PA
azithromycin                    INFECTION              1          1          1                QL
BILTRICIDE                      INFECTION                         3          3
BIO-STATIN                      INFECTION                         2          2
CEDAX                           INFECTION              2          2          2
cefaclor                        INFECTION              1          1          1
cefaclor er                     INFECTION              1          1          1
cefadroxil                      INFECTION              1          1          1
cefazolin                       INFECTION              1          1          1
cefotaxime                      INFECTION              1          1          1
cefoxitin                       INFECTION              1          1          1
cefpodoxime proxetil            INFECTION              1          1          1
cefprozil                       INFECTION              1          1          1
CEFTIN SUSP                     INFECTION              2          2          2
ceftriaxone                     INFECTION              1          1          1
cefuroxime                      INFECTION              1          1          1
cephalexin                      INFECTION              1          1          1
chloramphen                     INFECTION              1          1          1
chloroquine                     INFECTION              1          1          1
CIPRO SUSP                      INFECTION                         2          2
CIPRO XR                        INFECTION                         3          3                QL
ciprofloxacin                   INFECTION              1          1          1
clarithromycin                  INFECTION              1          1          1
CLEOCIN                         INFECTION                         2          2
CLEOCIN PED                     INFECTION                         2          2
CLEOCIN VAG                     INFECTION                         2          2
clindamycin phosphate           INFECTION              1          1          1
CLINDESSE                       INFECTION                         3          3
colistimethate sodium           INFECTION              3          3          3                PA
COMBIVIR                        INFECTION              2          2          2
CRIXIVAN                        INFECTION              2          2          2
CUBICIN                         INFECTION              4          4          4
DAPSONE                         INFECTION              2          2          2
DARAPRIM                        INFECTION              2          2          2
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     35
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
demeclocycline hcl              INFECTION              4          4          4
dicloxacillin                   INFECTION              1          1          1
didanosine                      INFECTION              1          1          1
DISPERMOX                       INFECTION                         3          3
DORYX                           INFECTION                         3          3                PA
doxy-caps                       INFECTION              1          1          1
doxycycline hyclate             INFECTION              1          1          1
doxycycline monohydrate         INFECTION                         3          3
DYNABAC                         INFECTION                         3          3
E.E.S.                          INFECTION              1          1          1
ees/sulfisox                    INFECTION              1          1          1
EMTRIVA                         INFECTION              2          2          2                QL
E-MYCIN                         INFECTION              2          2          2
EPIVIR                          INFECTION              2          2          2
EPIVIR HBV                      INFECTION              2          2          2
EPZICOM                         INFECTION              2          2          2
ERYPED                          INFECTION              2          2          2
ERY-TAB                         INFECTION              2          2          2
ERY-TAB EC                      INFECTION              2          2          2
erythro base                    INFECTION              1          1          1
erythro stea                    INFECTION              1          1          1
erythrocin                      INFECTION              1          1          1
ERYTHROCIN SOLN                 INFECTION              2          2          2
erythrocin tablet               INFECTION              1          1          1
erythrom eth                    INFECTION              1          1          1
ERYTHROMYCIN LACTO              INFECTION              2          2          2
ethambutol                      INFECTION              1          1          1
FACTIVE                         INFECTION                         3          3
FAMVIR                          INFECTION                         2          2                QL
fluconazole                     INFECTION              1          1          1                QL
fluconazole in dextrose         INFECTION              1          1          1
FLUMADINE                       INFECTION              2          3          3
FORTOVASE                       INFECTION              2          2          2
FOSCAVIR                        INFECTION              2                                      PA
FUZEON                          INFECTION              4          4          4                PA
ganciclovir                     INFECTION              1          1          1
GANTRIS PED                     INFECTION                         2          2
gentamicin sulfate              INFECTION              1          1          1
gentamicin sulfate/0.9% s       INFECTION              1          1          1
gentamicin sulfate/sodium       INFECTION              1          1          1
GEOCILLIN                       INFECTION              3          3          3
griseofulvin                    INFECTION                         3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     36
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
griseofulvin microsize          INFECTION                         3          3
GRIS-PEG                        INFECTION              2          2          2
GYNAZOLE-1                      INFECTION                         3          3
HIVID                           INFECTION              2          2          2
hydroxychlor                    INFECTION              1          1          1
INVIRASE                        INFECTION              2          2          2
isoniazid                       INFECTION              1          1          1
isotonic gentamicin             INFECTION              1          1          1
itraconazole                    INFECTION              1          1          1                PA
KALETRA                         INFECTION              2          2          2
KETEK                           INFECTION              2          2          2
LAMISIL                         INFECTION              2          2          2              PA QL
LEVAQUIN                        INFECTION              3          3          3                QL
LEXIVA                          INFECTION              2          2          2
LORABID CAPS                    INFECTION                         3          3
LORABID SUSP                    INFECTION              2          2          2
MAXIPIME                        INFECTION              2          2          2
mefloquine                      INFECTION              1          1          1
MEPRON                          INFECTION              4          4          4                PA
metronidazole 500mg pb          INFECTION              1          1          1
metronidazole gel               INFECTION              1          1          1
minocycline                     INFECTION                         3          3
MINTEZOL                        INFECTION              2          2          2
MYCOBUTIN                       INFECTION              2          2          2
nafcillin                       INFECTION              1          1          1
NEBUPENT                        INFECTION              2          2          2                PA
NEGGRAM                         INFECTION                         3          3
NEO-FRADIN                      INFECTION              2          3          3
neomycin                        INFECTION              1          1          1
NORVIR                          INFECTION              2          2          2
nystatin vag                    INFECTION              1          1          1
OMNICEF                         INFECTION              2          2          2
OMNI-PAC                        INFECTION              2          2          2
oxacillin                       INFECTION              1          1          1
PANIXINE                        INFECTION              2          2          2
paromomycin                     INFECTION              1          1          1
PCE                             INFECTION              2          2          2
pen g sod                       INFECTION              1          1          1
penicillin g potassium          INFECTION              1          1          1
penicillin vk                   INFECTION              1          1          1
pentamidine isethionate         INFECTION              1          1          1
piperacillin sodium vial        INFECTION              3          3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     37
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
PIPRACIL/D5W                    INFECTION              2          2          2
PRIMAQUINE                      INFECTION                         2          2
PRIMAXIN                        INFECTION              3          3          3
pyrazinamide                    INFECTION              1          1          1
quinine sulf                    INFECTION              1          1          1
RANICLOR                        INFECTION                         3          3
RELENZA                         INFECTION                         3          3
RESCRIPTOR                      INFECTION              2          2          2
RETROVIR IV                     INFECTION              3          3          3
REYATAZ                         INFECTION              2          2          2                QL
RIFAMATE                        INFECTION                         2          2
rifampin                        INFECTION              1          1          1
rimantadine hcl                 INFECTION              1          1          1
SEROMYCIN                       INFECTION                         3          3
smz-tmp                         INFECTION              1          1          1
smz-tmp ds                      INFECTION              1          1          1
SPECTRACEF                      INFECTION                         2          2
SPORANOX SOLN                   INFECTION                         2          2                PA
STROMECTOL                      INFECTION                         3          3
sulfac                          INFECTION              1          1          1
sulfadiazine                    INFECTION              1          1          1
sulfamethoxazole/trimetho       INFECTION              1          1          1
sulfatrim                       INFECTION              1          1          1
sulfisoxazol                    INFECTION              1          1          1
sumycin                         INFECTION              1          1          1
SUMYCIN 250                     INFECTION                         3          3
SUMYCIN 500                     INFECTION                         3          3
SUPRAX                          INFECTION                         2          2
SUSTIVA                         INFECTION              2          2          2
TAMIFLU                         INFECTION              3          3          3
TEQUIN                          INFECTION              3          3          3
TERAZOL 3 SUPP                  INFECTION                         3          3
terconazole                     INFECTION              1          1          1
TINDAMAX                        INFECTION                         3          3                QL
tobramycin sulfate              INFECTION              1          1          1
TRECATOR                        INFECTION                         3          3
TRECATOR-SC                     INFECTION                         3          3
trimethoprim/polymyxin b        INFECTION              1          1          1
TRIZIVIR                        INFECTION              2          2          2
TRUVADA                         INFECTION              2          3          3
TYGACIL                         INFECTION              3          3          3                PA
VALCYTE                         INFECTION              4          4          4
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     38
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
VALTREX                      INFECTION                 3          3          3                QL
VANCOCIN HCL                 INFECTION                 4          4          4             PA ST QL
vancomycin hcl               INFECTION                 1          1          1
vandazole                    INFECTION                 1          1          1
VANTIN                       INFECTION                 2          2          2
VELOSEF                      INFECTION                 2          2          2
VFEND                        INFECTION                 4          4          4                PA
VFEND IV                     INFECTION                 4          4          4                PA
VIBRAMYCIN                   INFECTION                            3          3
VIDEX                        INFECTION                 2          2          2
VIDEX BUFFER                 INFECTION                 2          2          2
VIDEX EC                     INFECTION                 2          2          2
VIDEX PED                    INFECTION                 2          2          2
VIRACEPT                     INFECTION                 2          2          2
VIRAMUNE                     INFECTION                 2          2          2
VIRAZOLE                     INFECTION                            3          3                PA
VIREAD                       INFECTION                 2          2          2
XIFAXAN                      INFECTION                 2          2          2
YODOXIN                      INFECTION                 2          2          2
ZERIT                        INFECTION                 2          2          2
ZIAGEN                       INFECTION                 2          2          2
zidovudine                   INFECTION                 1          1          1
ZYVOX                        INFECTION                 4          4          4              PA QL
ZELNORM                         IBS                    3          3          3              PA ST
calcitriol               KIDNEY DISORDERS              1          1          1
CYSTAGON                 KIDNEY DISORDERS                         3          3                PA
FOSRENOL                 KIDNEY DISORDERS                         3          3
HECTOROL                 KIDNEY DISORDERS              2          2          2
PHOSLO                   KIDNEY DISORDERS              2          2          2
RENAGEL                  KIDNEY DISORDERS              3          3          3
THIOLA                   KIDNEY DISORDERS              3          3          3
tricitrates              KIDNEY DISORDERS              1          1          1
ARALAST                  LUNG DISORDERS                4          4          4
PROLASTIN                LUNG DISORDERS                4          4          4                PA
AMERGE                    MIG HEADACHE                            3          3                QL
AXERT                     MIG HEADACHE                            3          3                QL
AXERT                     MIG HEADACHE                            3          3
dihydroergotamine mesylat MIG HEADACHE                 3          3          3                PA
ERGOMAR                   MIG HEADACHE                            2          2
ergotamine-caffeine        MIG HEADACHE                1          1          1
FROVA                     MIG HEADACHE                            3          3                QL
IMITREX                   MIG HEADACHE                 2          2          2                QL
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     39
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
IMITREX NASL                 MIG HEADACHE              2          2          2
IMITREX STATDOSE             MIG HEADACHE              2          2          2                QL
MAXALT                       MIG HEADACHE              2          2          2                QL
MAXALT- MLT                  MIG HEADACHE              2          2          2                QL
migergot                     MIG HEADACHE              1          1          1
MIGRANAL                     MIG HEADACHE              2          2          2              PA QL
RELPAX                       MIG HEADACHE              2          2          2                QL
ZOMIG                        MIG HEADACHE                         3          3                QL
ZOMIG ZMT                    MIG HEADACHE                         3          3                QL
AVONEX                             MS                  4          4          4                PA
BETASERON                          MS                  4          4          4                PA
COPAXONE                           MS                  4          4          4                PA
REBIF                              MS                  4          4          4                PA
baclofen                    MUSCLE RELAXANTS           1          1          1
carisopr/asa                MUSCLE RELAXANTS           1          1          1
carisoprodol                MUSCLE RELAXANTS           1          1          1
carisoprodol comp/codeine   MUSCLE RELAXANTS           1          1          1
chlorzoxazone               MUSCLE RELAXANTS           1          1          1
cyclobenzaprine             MUSCLE RELAXANTS           1          1          1
dantrolene sodium           MUSCLE RELAXANTS           1          1          1
methocarbam                 MUSCLE RELAXANTS           1          1          1
orphenadrine citrate        MUSCLE RELAXANTS                      3          3
orphenadrine comp           MUSCLE RELAXANTS                      3          3
orphenadrine comp forte     MUSCLE RELAXANTS                      3          3
orphengesic                 MUSCLE RELAXANTS                      3          3
orphengesic forte           MUSCLE RELAXANTS                      3          3
SKELAXIN                    MUSCLE RELAXANTS                      3          3
tizanidine                  MUSCLE RELAXANTS           1          1          1
MESTINON                      MYASTHENIA                          2          2
MESTINON TS                   MYASTHENIA                          2          2
MYTELASE                      MYASTHENIA                          3          3
pyridostigmine bromide        MYASTHENIA               1          1          1
PROVIGIL                      NARCOLEPSY               3          3          3              PA QL
XYREM                         NARCOLEPSY               4          4          4                PA
ANZEMET                         NAUSEA                 3          3          3              PA QL
EMEND                           NAUSEA                 2          2          2              PA QL
KYTRIL                          NAUSEA                            2          2              PA QL
MARINOL                         NAUSEA                 4          4          4                PA
meclizine                       NAUSEA                 1          1          1
phenadoz                        NAUSEA                 1          1          1
promethazine hcl                NAUSEA                 1          1          1
SCOPACE                         NAUSEA                            3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     40
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
ZOFRAN                           NAUSEA                2          2          2              PA QL
ACTONEL                       OSTEOPOROSIS             3          3          3                QL
ACTONEL W/CALCIUM             OSTEOPOROSIS             3          3          3                QL
BONIVA                        OSTEOPOROSIS             3          3          3                QL
etidronate                    OSTEOPOROSIS                        3          3
EVISTA                        OSTEOPOROSIS             2          2          2
FORTEO                        OSTEOPOROSIS             4          4          4                PA
fortical                      OSTEOPOROSIS             1          1          1
FOSAMAX                       OSTEOPOROSIS             2          2          2                QL
FOSAMAX PLUS D                OSTEOPOROSIS             2          2          2                QL
MIACALCIN                     OSTEOPOROSIS             2          2          2
pamidronate                   OSTEOPOROSIS             4          4          4                PA
REVATIO                           PAH                  4          4          4              PA QL
acetaminophen/hydrocod            PAIN                 1          1          1
acetaminophen-codeine             PAIN                 1          1          1
ACTIQ                             PAIN                 4          4          4                PA
amigesic                          PAIN                 1          1          1
ANABAR                            PAIN                            3          3
asa/codeine                       PAIN                 1          1          1
ascomp/codeine                    PAIN                            3          3
aspirin/codeine #3                PAIN                 1          1          1
AVINZA                            PAIN                            3          3                QL
but/apap/caf codeine              PAIN                            3          3
but/asa/caf codeine               PAIN                            3          3
butorphanol tartrate              PAIN                 1          1          1
CAPITAL/COD                       PAIN                            2          2
CELEBREX                          PAIN                 3          3          3             PA QL ST
cho mag tris                      PAIN                 1          1          1
cmt                               PAIN                 1          1          1
CODEINE PHOS SOLN                 PAIN                            2          2
CODEINE PHOSP INJ                 PAIN                 2          2          2
CODEINE SULF TAB                  PAIN                 2          2          2
DARVON-N                          PAIN                            2          2
diclofenac                        PAIN                 1          1          1
diclofenac potassium              PAIN                 1          1          1
diclofenac sodium ec              PAIN                 1          1          1
diclofenac sodium sr              PAIN                 1          1          1
diflunisal                        PAIN                 1          1          1
DOLOGESIC                         PAIN                            3          3
dolorex fort                      PAIN                 1          1          1
DURABAC                           PAIN                 3          3          3
ED-FLEX                           PAIN                            3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     41
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
endocet                             PAIN               1          1          1
endodan                             PAIN               1          1          1
etodolac                            PAIN               1          1          1
fenoprofen                          PAIN               1          1          1
fentanyl                            PAIN               1          1          1
fludrocort                          PAIN               1          1          1
hydrocodone bitartrate/ap           PAIN               1          1          1
hydrocodone bit-ibuprofen           PAIN                          3          3
hydrocodone/acetaminophen           PAIN               1          1          1
hydromorphone hcl                   PAIN               1          1          1
ibuprofen                           PAIN               1          1          1
INDOCIN SUPP                        PAIN                          3          3
INDOCIN SUSP                        PAIN                          2          2
indomethacin                        PAIN               1          1          1
KADIAN                              PAIN               2          2          2
ketoprofen                          PAIN               1          1          1
ketoprofen 200mg                    PAIN               3          3          3
ketorolac tablet                    PAIN               1          1          1                QL
LEVACET                             PAIN                          3          3
LEVORPHANOL TARTRATE                PAIN                          3          3
margesic-h                          PAIN               1          1          1
meclofen sod                        PAIN               1          1          1
meloxicam                           PAIN               1          1          1               QL ST
meperidine                          PAIN               1          1          1
methadone                           PAIN               1          1          1
methadone hcl                       PAIN               1          1          1
methadone intensol                  PAIN               1          1          1
METHADONE SOLN                      PAIN               2          2          2
methadose                           PAIN               1          1          1
METHADOSE 40MG                      PAIN               2          2          2
morphine sulfate                    PAIN               1          1          1
morphine sulfate inj                PAIN               1          1          1
MORPHINE TAB 10MG                   PAIN               2          2          2
MORPHINE TAB 15MG                   PAIN               2          2          2
MORPHINE TAB 30MG                   PAIN               2          2          2
NABUMETONE                          PAIN               3          3          3
NALFON                              PAIN               2          2          2
naproxen                            PAIN               1          1          1
naproxen dr                         PAIN               1          1          1
naproxen ec                         PAIN               1          1          1
naproxen sod                        PAIN               1          1          1
NUMORPHAN                           PAIN                          3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     42
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
oramorph sr                       PAIN                 1          1          1
oxaprozin                         PAIN                            3          3
oxycod/asa                        PAIN                 1          1          1
oxycodone                         PAIN                 1          1          1
oxycodone/acetaminophen           PAIN                 1          1          1
oxydose                           PAIN                 1          1          1
pentazocine/acetamin              PAIN                 1          1          1
pentazocine/naloxone              PAIN                 1          1          1
piroxicam                         PAIN                 1          1          1
PREVACID NAPRAPAC                 PAIN                            3          3              PA QL
propo-n/apap                      PAIN                 1          1          1
propoxacet-n                      PAIN                 1          1          1
propoxy hcl                       PAIN                 1          1          1
propoxy/apap                      PAIN                 1          1          1
ROXANOL                           PAIN                 2          2          2
roxicet                           PAIN                 1          1          1
ROXICODONE                        PAIN                 2          2          2
salflex                           PAIN                 1          1          1
salsalate                         PAIN                 1          1          1
STAGESIC-10                       PAIN                            2          2
SUBOXONE                          PAIN                 3          3          3              PA QL
SUBUTEX                           PAIN                 3          3          3                PA
sulindac                          PAIN                 1          1          1
tolmetin sod                      PAIN                 1          1          1
tramado/apap                      PAIN                            3          3
tramadol hcl                      PAIN                 1          1          1
tricosal                          PAIN                 1          1          1
vanacet                           PAIN                 1          1          1
VOPAC                             PAIN                            3          3
amantadine                     PARKINSONS              1          1          1
APOKYN                         PARKINSONS              4          4          4                PA
atamet                         PARKINSONS              1          1          1
benztropine mesylate           PARKINSONS              1          1          1
bromocriptine                  PARKINSONS              1          1          1
carb/levo                      PARKINSONS              1          1          1
carb/levo er                   PARKINSONS              1          1          1
carb/levo sr                   PARKINSONS              1          1          1
COMTAN                         PARKINSONS              2          2          2
KEMADRIN                       PARKINSONS                         3          3
LODOSYN                        PARKINSONS                         3          3
MIRAPEX                        PARKINSONS              2          2          2
PARCOPA                        PARKINSONS              2          2          2
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     43
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
pergolide                     PARKINSONS               1          1          1
REQUIP                        PARKINSONS               2          2          2
selegiline                    PARKINSONS               1          1          1
STALEVO 100                   PARKINSONS               2          2          2
STALEVO 150                   PARKINSONS               2          2          2
STALEVO 50                    PARKINSONS               2          2          2
TASMAR                        PARKINSONS                          3          3
trihexyphen                   PARKINSONS               1          1          1
anemagen ob                  PRENATAL VITS             1          1          1
CO-NATAL FA                  PRENATAL VITS                        2          2
DUET                         PRENATAL VITS                        2          2
DUET DHA                     PRENATAL VITS                        2          2
ICAR PRENATA                 PRENATAL VITS             2          2          2
INATAL ADV                   PRENATAL VITS             2          2          2
INATAL GT                    PRENATAL VITS             2          2          2
INATAL ULTRA                 PRENATAL VITS             2          2          2
maternity                    PRENATAL VITS             1          1          1
MYNATAL                      PRENATAL VITS             2          2          2
MYNATAL PLUS                 PRENATAL VITS             2          2          2
MYNATAL-Z                    PRENATAL VITS             2          2          2
NATACAPS                     PRENATAL VITS             2          2          2
natafolic-pn                 PRENATAL VITS             1          1          1
NATAFORT                     PRENATAL VITS             2          2          2
natalcare                    PRENATAL VITS             1          1          1
natalcare 3                  PRENATAL VITS             1          1          1
natalcare rx                 PRENATAL VITS             1          1          1
NATALVIT                     PRENATAL VITS             2          2          2
natatab cfe                  PRENATAL VITS             1          1          1
natatab fa                   PRENATAL VITS             1          1          1
natatab rx                   PRENATAL VITS             1          1          1
nu-natal                     PRENATAL VITS             1          1          1
nutrinate                    PRENATAL VITS             1          1          1
OBSTETRIX                    PRENATAL VITS             2          2          2
O-CAL                        PRENATAL VITS             2          2          2
o-cal fa                     PRENATAL VITS             1          1          1
original                     PRENATAL VITS             1          1          1
perry prenat                 PRENATAL VITS             1          1          1
PRECARE                      PRENATAL VITS                        2          2
PREMESIS RX                  PRENATAL VITS                        2          2
PRENA-CAP                    PRENATAL VITS                        2          2
prenafirst                   PRENATAL VITS             1          1          1
prenatab cbf                 PRENATAL VITS             1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     44
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
prenatabs                     PRENATAL VITS            1          1          1
prenatabs fa                  PRENATAL VITS            1          1          1
prenatabs rx                  PRENATAL VITS            1          1          1
prenatal 1                    PRENATAL VITS            1          1          1
prenatal 19                   PRENATAL VITS            1          1          1
prenatal mtr                  PRENATAL VITS            1          1          1
prenatal nf                   PRENATAL VITS            1          1          1
prenatal pls                  PRENATAL VITS            1          1          1
prenatal rx                   PRENATAL VITS            1          1          1
prenatal sta                  PRENATAL VITS            1          1          1
prenatal z                    PRENATAL VITS            1          1          1
prenatal-h                    PRENATAL VITS            1          1          1
prenatal-u                    PRENATAL VITS            1          1          1
STRONGSTART                  PRENATAL VITS             2          2          2
trinate                       PRENATAL VITS            1          1          1
ultra natal                   PRENATAL VITS            1          1          1
ultra-natal                   PRENATAL VITS            1          1          1
vinate                        PRENATAL VITS            1          1          1
vinate 90                     PRENATAL VITS            1          1          1
vinate gt                     PRENATAL VITS            1          1          1
vinate ii                     PRENATAL VITS            1          1          1
vinate m                      PRENATAL VITS            1          1          1
vinate ultra                  PRENATAL VITS            1          1          1
VITAFOL-OB                   PRENATAL VITS             2          2          2
VYNATAL FA                   PRENATAL VITS             2          2          2
anthralin                       PSORIASIS              1          1          1
DOVONEX                         PSORIASIS              2          2          2
OXSORALEN                       PSORIASIS              2          2          2
OXSORALEN-UL                    PSORIASIS              2          2          2
RAPTIVA                         PSORIASIS              4          4          4                PA
SORIATANE                       PSORIASIS              4          4          4
TAZORAC                         PSORIASIS              2          2          2
ABILIFY                      PSYCHOTHERAP              3          3          3              PA QL
chlorpromazine               PSYCHOTHERAP              1          1          1
clozapine                    PSYCHOTHERAP              1          1          1
CLOZAPINE 12.5MG             PSYCHOTHERAP              2          2          2
CLOZAPINE 200MG              PSYCHOTHERAP              2          2          2
COMPAZINE SYRP               PSYCHOTHERAP                         2          2
FAZACLO                      PSYCHOTHERAP              2          2          2
fluphenazine                 PSYCHOTHERAP              1          1          1
GEODON                       PSYCHOTHERAP              3          3          3              PA QL
haloperidol                  PSYCHOTHERAP              1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     45
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
lithium                       PSYCHOTHERAP             1          1          1
LITHOBID                     PSYCHOTHERAP              2          2          2
loxapine                      PSYCHOTHERAP             1          1          1
MOBAN                        PSYCHOTHERAP              2          2          2
NAVANE                       PSYCHOTHERAP              2          2          2
ORAP                         PSYCHOTHERAP              2          3          3
perphenazine                  PSYCHOTHERAP             1          1          1
prochlorper                   PSYCHOTHERAP             1          1          1
RISPERDAL                    PSYCHOTHERAP              2          2          2                QL
RISPERDAL CONSTA             PSYCHOTHERAP              2          2          2                QL
SEROQUEL                     PSYCHOTHERAP              2          2          2                QL
thioridazine                  PSYCHOTHERAP             1          1          1
thiothixene                   PSYCHOTHERAP             1          1          1
THORAZINE SUPP               PSYCHOTHERAP              3          3          3                QL
trifluoperaz                  PSYCHOTHERAP             1          1          1
ZYPREXA                      PSYCHOTHERAP              3          3          3              PA QL
ZYPREXA ZYDIS                PSYCHOTHERAP              3          3          3              PA QL
TRACLEER                           PAH                 4          4          4                PA
ED-BRON G                   RESPIRATORY TRA                       3          3
CUPRIMINE                           RA                 2          2          2
DEPEN TITRA                         RA                 2          2          2
ENBREL                              RA                 4          4          4                PA
HUMIRA                              RA                 4          4          4                PA
KINERET                             RA                 4          4          4                PA
leflunomide                         RA                 1          1          1                QL
ADRENALIN                    ALLERGIC REAC                        2          2
EPIPEN                       ALLERGIC REAC             2          2          2                QL
EPIPEN-JR                    ALLERGIC REAC             2          2          2                QL
EVOXAC                       SJOGRENS SYND             2          2          2
*temazepam caps             SLEEP DISORDERS                                  1                QL
AMBIEN                      SLEEP DISORDERS            2          3          3                QL
AQUACHLORAL                 SLEEP DISORDERS                       3          3
chloral hydrate             SLEEP DISORDERS            1          1          1
LUNESTA                     SLEEP DISORDERS            3          3          3                QL
SOMNOTE                     SLEEP DISORDERS                       1          1
SONATA                      SLEEP DISORDERS                       3          3                QL
buproban                     SMOKING CESSA             1          1          1
NICOTROL NS                  SMOKING CESSA             2          2          2                QL
AGGRENOX                         STROKE                3          3          3
PLAVIX                           STROKE                2          2          2                QL
ticlopidine                      STROKE                1          1          1
dextrose 10%/nacl 0.45%     NUTR/MINER/ELEC            1          1          1
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     46
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
dextrose 2.5%               NUTR/MINER/ELEC            1          1          1
dextrose 2.5%/lactated       NUTR/MINER/ELEC           1          1          1
dextrose 5%                 NUTR/MINER/ELEC            1          1          1
dextrose 10%                NUTR/MINER/ELEC            1          1          1
dextrose 10%/nacl 0.2%      NUTR/MINER/ELEC            1          1          1
dextrose 10%/nacl 0.9%      NUTR/MINER/ELEC            1          1          1
dextrose 10%/sodium chl     NUTR/MINER/ELEC            1          1          1
dextrose 2.5%               NUTR/MINER/ELEC            1          1          1
dextrose 2.5%/nacl 0.45%    NUTR/MINER/ELEC            1          1          1
dextrose 2.5%/sodium chl    NUTR/MINER/ELEC            1          1          1
dextrose 5%/lactated         NUTR/MINER/ELEC           1          1          1
dextrose 5%/nacl 0.2%       NUTR/MINER/ELEC            1          1          1
dextrose 5%/potas cl        NUTR/MINER/ELEC            1          1          1
dextrose 5%/ringer's        NUTR/MINER/ELEC            1          1          1
dextrose 5%/sodium cl       NUTR/MINER/ELEC            1          1          1
dextrose 5%-0.25% sal       NUTR/MINER/ELEC            1          1          1
dextrose 5%-0.33% sal       NUTR/MINER/ELEC            1          1          1
dextrose 5%-0.45% sal       NUTR/MINER/ELEC            1          1          1
dextrose 5%-0.9% sal        NUTR/MINER/ELEC            1          1          1
dextrose 5%-1/2ns-kcl       NUTR/MINER/ELEC            1          1          1
dextrose 50%                NUTR/MINER/ELEC            1          1          1
dextrosr 5%-1/4ns-kcl       NUTR/MINER/ELEC            1          1          1
lactated ringer's dext       NUTR/MINER/ELEC           1          1          1
lactated ringer's viaflex    NUTR/MINER/ELEC           1          1          1
lactated rinse soln         NUTR/MINER/ELEC            1          1          1
potassium cl 0.075%         NUTR/MINER/ELEC            1          1          1
potassium cl 0.15%          NUTR/MINER/ELEC            1          1          1
potassium cl 0.15%          NUTR/MINER/ELEC            1          1          1
potassium cl 0.224%         NUTR/MINER/ELEC            1          1          1
potassium cl 0.3%/          NUTR/MINER/ELEC            1          1          1
potassium cl 0.3%/d         NUTR/MINER/ELEC            1          1          1
potassium cl 0.3%/n         NUTR/MINER/ELEC            1          1          1
triamcin/ora                THROAT INFECTION           1          1          1
ARMOUR THYROID                  THYROID                2          2          2
CYTOMEL                         THYROID                2          2          2
LEVOTHROID                      THYROID                2          2          2
levothyroxine                   THYROID                1          1          1
levoxyl                         THYROID                1          1          1
methimazole                     THYROID                1          1          1
NATURE-THROI                    THYROID                           2          2
propylthiour                    THYROID                1          1          1
SYNTHROID                       THYROID                2          2          2
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     47
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
thyroid                         THYROID                1          1          1
THYROLAR-1                      THYROID                           3          3
THYROLAR-1/2                    THYROID                           3          3
THYROLAR-1/4                    THYROID                           3          3
THYROLAR-2                      THYROID                           3          3
THYROLAR-3                      THYROID                           3          3
westhroid                       THYROID                1          1          1
depade                       TOXICOLOGIC               1          1          1
azathioprine                  TRANSPLANT               1          1          1
CELLCEPT                      TRANSPLANT               3          3          3               PA
cyclosporine                  TRANSPLANT               1          1          1                PA
gengraf                       TRANSPLANT               1          1          1                PA
MYFORTIC                      TRANSPLANT               4          4          4               PA
PROGRAF                       TRANSPLANT               4          4          4               PA
RAPAMUNE                      TRANSPLANT               4          4          4               PA
*prilosec otc                    ULCER                 1          1          1               QL
ACIPHEX                          ULCER                            3          3              PA QL
AXID SOLN                        ULCER                            3          3
CARAFATE SUSP                    ULCER                            2          2
cimetidine                       ULCER                 1          1          1
famotidine                       ULCER                 1          1          1
HELIDAC                          ULCER                            3          3
misoprostol                      ULCER                 1          1          1
NEXIUM                           ULCER                 2          2          2                QL
nizatidine                       ULCER                            3          3
omeprazole                       ULCER                 1          1          1                QL
PEPCID SUSP                      ULCER                            2          2
PREVACID SOLUTAB                 ULCER                            3          3             PA QL ST
PREVPAC                          ULCER                            2          2                QL
PROTONIX                         ULCER                 2          2          2                QL
PROTONIX INJECTION               ULCER                 4          4          4                PA
ranitidine                       ULCER                 1          1          1
sucralfate                       ULCER                 1          1          1
ZANTAC SYRP                      ULCER                 2          2          2
ZEGERID                          ULCER                 2          2          2                QL
ASACOL                      ULCERAT COLITIS            2          2          2
CANASA                      ULCERAT COLITIS            2          2          2
COLAZAL                     ULCERAT COLITIS            2          2          2
mesalamine                  ULCERAT COLITIS            1          1          1
PENTASA                     ULCERAT COLITIS                       3          3
desmopressin                URINARY INCONT             1          1          1
DETROL                      URINARY INCONT                        3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     48
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
DETROL LA                   URINARY INCONT                        3          3                QL
DITROPAN XL                 URINARY INCONT             3          3          3                QL
ENABLEX                     URINARY INCONT             2          2          2                QL
oxybutynin                  URINARY INCONT             1          1          1
OXYTROL                     URINARY INCONT                        3          3
SANCTURA                    URINARY INCONT             2          2          2
VESICARE                    URINARY INCONT                        3          3
FURADANTIN                  URINARY INFECT                        2          2
methenam                    URINARY INFECT             1          1          1
mhp-a                       URINARY INFECT             1          1          1
MONUROL                     URINARY INFECT                        3          3
nitro macro                 URINARY INFECT             1          1          1
nitrofurantn                URINARY INFECT             1          1          1
phenazopyrid                URINARY INFECT             1          1          1
TRAC                        URINARY INFECT                        2          2
urimar t                    URINARY INFECT             1          1          1
uritact ds                  URINARY INFECT             1          1          1
urogesic-blue               URINARY INFECT             1          1          1
UROQID-ACID NO.2            URINARY INFECT                        3          3
usept                       URINARY INFECT             1          1          1
UTA                         URINARY INFECT             2          2          2
UTIRA                       URINARY INFECT             2          2          2
ELMIRON                       URINARY PAIN                        2          2
bethanechol                  URINARY SPASMS            1          1          1
flavoxate                    URINARY SPASMS            1          1          1
hyospaz                      URINARY SPASMS            1          1          1
ACTHIB                        VACCINATION              3          3          3
ADACEL                        VACCINATION              3          3          3                QL
ATTENUVAX VACCINE             VACCINATION              3          3          3
BOOSTRIX                      VACCINATION              3          3          3                QL
COMVAX                        VACCINATION              3          3          3                PA
DIPTHERIA/TETANUS TOX         VACCINATION              2          2          2
ENGERIX-B 10 MCG PEDI         VACCINATION              2          2          2                PA
ENGERIX-B 10 MCG SYR          VACCINATION              2          2          2                PA
ENGERIX-B 20 MCG SYR          VACCINATION              2          2          2                PA
ENGERIX-B 20 MCG VIAL         VACCINATION              2          2          2                PA
HAVRIX 1,440 UNITS/ML         VACCINATION              3          3          3
HAVRIX 720 UNITS VIAL         VACCINATION              3          3          3
HIBTITER                      VACCINATION              3          3          3
INFANRIX                      VACCINATION              3          3          3
IPOL                          VACCINATION              2          2          2
JE-VAX                        VACCINATION              3          3          3
*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     49
                                AdvantraRx Value/Premier/Premier Plus
                                                Value Premier Premier Requirements/Limits
Drug Name                      Therapeutic                          Plus Prior Authorization (PA)
                                                Drug      Drug      Drug
                                  Class                                    Step Therapy (ST)
                                                 Tier     Tier      Tier  Quantity Limits (QL)
MENACTRA                      VACCINATION              3          3          3                QL
MENOMUNE-A/C/Y/W-135          VACCINATION              2          2          2
MERUVAX II VACCINE            VACCINATION              3          3          3
M-M-R II VACCINE              VACCINATION              2          2          2
M-R-VAX II VACCINE            VACCINATION              3          3          3
MUMPSVAX                      VACCINATION              2          2          2                QL
PEDIARIX                      VACCINATION              3          3          3
PROQUAD                       VACCINATION              2          3          3                QL
REVLIMID                      VACCINATION              4          4          4                PA
TETANUS TOXOID                VACCINATION              2          2          2
TETANUS TOXOID ABSOR          VACCINATION              2          2          2
TETANUS/DIPH TOX              VACCINATION                         2          2                 2
TRIHIBIT                      VACCINATION                         3          3
TWINRIX VIAL                  VACCINATION              3          3          3
TYPHIM VI                     VACCINATION              3          3          3
VARICELLA                     VACCINATION              2          2          2
ZOSTAVAX                      VACCINATION              3          3          3              PA QL
*folic acid tabs               VITAMIN DEF                                   1                QL
mult vit-bet                   VITAMIN DEF             1          1          1
multi vit/fl                   VITAMIN DEF             1          1          1
multi vita-bets/fluoride       VITAMIN DEF             1          1          1
multiple vitamins/fluorid      VITAMIN DEF             1          1          1
multi-vit/fe                   VITAMIN DEF             1          1          1
multivit/fl                    VITAMIN DEF             1          1          1
multi-vit/fluoride             VITAMIN DEF             1          1          1
multi-vit/fluoride 1/2 st      VITAMIN DEF             1          1          1
multi-vit/fluoride/iron        VITAMIN DEF             1          1          1
multivitamin drops/fluori      VITAMIN DEF             1          1          1
multi-vitamin/fluoride         VITAMIN DEF             1          1          1
POLY-VI-FLOR                  VITAMIN DEF              2          2          2
poly-vi-flor/fe                VITAMIN DEF             1          1          1
poly-vit fl                    VITAMIN DEF             1          1          1
poly-vit/fe                    VITAMIN DEF             1          1          1
poly-vit/fl                    VITAMIN DEF             1          1          1
poly-vitamin                   VITAMIN DEF             1          1          1
polyvitamin/fluoride           VITAMIN DEF             1          1          1
poly-vitamin/iron/fluorid      VITAMIN DEF             1          1          1
tri-vit/fe                     VITAMIN DEF             1          1          1
tri-vit/fl                     VITAMIN DEF             1          1          1
tri-vita bet                   VITAMIN DEF             1          1          1



*Drugs marked with an asterisk "*" do not count toward your total out-of-pocket expenditure and if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.
            C0002_ENRPDP_Comprehensive Formulary_2007 v6                 CMS Approved: 09/01/2006

                                                     50
                         CONTACT US AT:

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C0002_ENRPDP_Comprehensive Formulary_2007 v6   CMS Approved: 09/01/2006

				
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