Pharmacy benefit comparison : state health benefit plan, July 1, 2004 - June 30, 2005

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STATE HEALTH BENEFIT PLAN JULY 1 , 2 004 - JUNE 3 0 , 2005

PHARMACY BENEFIT COMPARISON

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~ GEORGIA DEPARTMENT OF COMMUNITY HEALTH

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NEW PPO & INDEMNITY OPTIONS:
PPO BASIC PPO PREMIER PPO CHOICE BASIC PPO CHOI CE PREMIER INDEMN ITY BASIC INDEMNITY PREMI ER

HMO OPTIONS: BLUECHOICE
CIGNA
KAI SER PERMANENTE U N ITEDHEALTHCARE

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IMPORTANT ENROLLMENT INFORMATION
r If you do not submit your choice by May 14, 2004 and you are participating in the Current PPO, PPO Choice or
Indemnity Options, your coverage will default to the New PPO Basic, New PPO Choice Basic or New Indemnity Basic Option. Failure to respond will not allow you to retain your current level of pharmacy coverage. '-- -
1. Review yom 2003-2004 coverage. 2. Determine the 2004-2005 benefit option that best fits your needs and budget. 3. Submit your 2004-2005 benefit elections using www.statehealth.org for agencies that do not participate in the State Flexible
Benefit Program (FBP) offered by the Georgia Me rit System and www.gabenefits.org for agencies participating in the State FBP or via paper bv Mav 14. 2004. 4.You can go online to www.dch.state.ga.us and follow the pharmacy links to the Express Choice tool to calculate your estimated out-of-pocket costs for the Basic and Premier Plan Options.

IMPORTANT MESSAGE FROM THE STATE HEALTH BENEFIT PLAN (SHBP)
You have heard in the media how medical and pharmacy costs contilrne to i11crease. Our pharmacy costs are increasing at rates higher than the national average because, as a group, SliBP members use a high number of prescription medications. SHBP and Express Scripts (our pharmacy benefit manager) want to help you manage your prescription expenses. Our goal is to provide you with quality pharmacy benefits at a reasonable cost to you and the Plan.

Effective July 1, 2004, the current PPO, PPO Choice and Indemnity Options will no longer be available. The New PPO, PPO Choice and 11ldemnity Options are:

PPO Basic

PPO Choice Basic

Indemnity Basic

PJ;>O Premier

PPO Choice Premier

Indemnity Premier

OVERVIEW OF MY PHARMACY BENEFIT OPTIONS
What Are the Differences Between the Basic and Premier Pharmacy Options? There are three differences between the Basic and Premier prescription benefits.
The Basic Preferred Drug List (PDL) is not as extensive as the Premier Drug List; The co-payments are different (see Pharmacy Benefit Comparison Chart); and There are no Maximum Out-of-Pocket (MOP) limits for the Basic pharmacy options (see Pharmacy Benefit Cornparison Chart).
During Open Enrollment, you can select the health be nefit coverage best suited for you and your family. Before making your choice, review the PPO, PPO Choice and Inde mnity Option Overviews and the Pharmacy Benefit Comparison Chart.

PLAN PROVISIONS FOR THE BASIC AND PREMIER OPTIONS
New Progressive Drug Management Program (PDMP) - This program has been designed to assist your doctor in finding the most appropriate drug treatment for you and your family.The first step in the program is usually a proven less e,xpensive treatment known to be safe and effective for most people. U the drug does not work for you, your doctor may progress to another drug.A Prior Authorization may be required as the next step in the program to obtain the drug that is best suited for you . Progressive Drng Management belps to ensure that you are receiving the most appropriate and costeffective drug for your condition.The PDMP is in effect for the following therapeutic categories:ACE Inhibitors, Brand NSAlD, Elidel/Protopic and Glucophage XR.Note:This list is subject to change during the Plan year.
Note: If you should go to t he pharmacy and are told that your prescription cannot be filled because a prior authorization is required, please have your doctor call Express Scripts, lnc.'s (ESI's) prior authorization unit w ith your clinical information.The prior authorization process is a telephonic process where your doctor can give your clinical information over the phone for review. Uthe information provided by your doctor does not meet the criteria for the drug requested, you Hre entitled to appeal. Your physician will need to fax a written request to ESI's appeals unit that should include your medical history and all previously used drugs to treat your particular condition.
HEALTH MAINTl!NANCE ORGANIZATIONS (HMOs) Generic co-payments are different from the PPO and Indemnity Options No Maximum Out-of-Pocket (MOP) limit feature Maintenance Drngs may be obtained for up to a 90-day supply of your prcscription(s) for two (2) co-payments.
Note: (Kaiser: one co-payment per 30-day supply) Contact respective HMO for further Plan provisions
ALL PLA~ O1'TI 0NS
Re1nember: No co-payments for drugs that are covered by SHBP will be changed or overridden on an individual basis. The SHBP defines Maintenance Drugs as medications for specified chronic conditions where you may obtain up to a 90-day
supply of your prescription(s) at one time for three (3) co-payments.Your co-payments are based on supplies of up to 30 days as this is the industry standard. However, some drugs are limited to a standard other than the 30-day supply for one co-payment. Note:This applies only to the PPO Basic, PPO Premier, PPO Choice Basic, PPO Choice Premier, Indemnity Basic and Indemnity Premier Options. In addition, many drugs listed as non-preferred have a generic or preferred brand-name drug alternative. Preferred drug alternatives are therapeutically equivalent while being more cost effective. If the drug cost is less than the co-payment, you do not pay the co-payment but the lesser of,which is the actual cost of the drug. For example, if the preferred drug cost is $18.23, and the preferred drug co-payment is $25.00, you will only pay $18.23.

PHARMACY BENEFIT COMPARISON CHART

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PLAN T ,YPE ,

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PPOBasic -

Basic

$10

$25

PPO Choice Basic

(see page 4 for

abbreviated PDL)

$40

Does not apply

Indemnity Basic

Basic

S10

$25

$40

Does not apply

(see page 4 for

abbreviated POL)

PPO Premier -

Premier

Sl5

PPO Choice Premier (see page 5 for

abbreviated PDL)

$25

20% of cost;

$450 per

minimum $40 -

member/

maximum Sl 00

S1,300 family

Indemnity Premier

Premier

$15

(see page 5 for

abbreviated POL)

$25

20% of cost;

$450 per

minimum $40 -

member/

maximum $100

$1 ,300 family

HMOs-
BlueChoice
CIGNA
United.Healthcare
Kaiser Permanente

HMO Drug Lists

$10

$25

$40

(see telephone

numbers below)

Kaiser Drug List (see telephone number below)

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Kaiser : Eckerd's

Facility Drugs

$10

$16

Kaiser Facility
$25

Eckerd 's Drugs $3 1

Does not apply

Does not apply Does nm apply

Note: Please:: contact each HMO regarding pharmacy lists - IllueChoice: (800) 464-1367; CIGNA: (800) 564-7642; Kaiser Permanente: (800) 611-1811 ; UniteclHealthcare: (866) 527-9599.

BASTC A '\0 PltE\.lll':R DRUG LISTS
The pharmacy drug lists are created, revie wed and continually updated by a team of health care professionals, including physicians and pharmacists.
A medication becomes a preferred drug bas<.:d first on safety, then efficacy and last on cost-effectiveness.
Your doctor can use the list associated w ith your chosen option to select mc.:dications for your healthcare needs, while helping you maximize your prescription drug benefit.The choice of medications is strictly between you and your doctor.
Preferred Drug Lists for SHBP members arc subject to d1ange. Prior to p urchasing your medication(s) you may view the drug lists at www.clch.state.ga. us or contact Express Scripts by phone at (877) 650-9342 or TDD (800) 842-5754 to get the most current status on any covered cl.rug. Included in this brochure is an abbreviated version of the two drug lists for comparison. Use these lists to help you determine what your co-payments will be and to evaluate which cl.rug benefit will best meet your needs.

GEORGIA BASIC PREFERRED DRUG LIST (ABBREVIATED)

PA - prior authorization re9uired QLL - quantity or therapy limits exist

EFFECTIVE JULY 1, 2004
f0R STATE HEALTH BENEFIT PLAN - PPO AND INDEMN ITY H EALTH PLANS
All generics are considered preferred drugs (examples listed in each category). If at any time during the Plan year a brand has a generic equivalent become available, that brand will automatically b<:: moved to the non-preferred status.

.\ l.l.F.RGY/ RESPTRATORY ADVAIR DISKUS albuterol generic ALLEGRA, -D CO M B IVENT FLOVENT ROTADISK FORADIL INTAL ipratropiL11n generic PROVENTIL 1-IFA QVAR SEREVENT DISKUS SINGULAIR
A:-il"l -L',FECTIVES
acyclovir generic amoxicillin generic amoxicillin/clavulanic generic ampicillin generic AUGMENnN ES AUGMENTIN XR AVELOX, ABC PACK cefuroxime generic cephalexin generic CIPRO DIFLUCAN doxycycline generic erythromycin generic ketoconazole generic nitrofurnatoi n generic penic illin generic SPORANOX TEQUIN tetracycline generic timethoprim generic tmp/smx generic ZITHROMAX
Al/ rONO/IUC & C:-iS AMB IEN amitriptyline generic CELEXA CONCERTA ciextroamphetamine generic EFFEXOR, -XR fluoxetine generic IMITREX LEXAPRO

METADATE CD m~thylpl~enidate seneric rrnrtazapme generic paroxeti ne generic PAXIL CR REMERON soltab SONATA ST RATTERA temazepam generic trazodone generic WELLBUTRIN SR ZOMIG, -ZMT
GASTROINTST1l\A_L ASACOL cimetici ine generic fa motidine generic nizatidine generic omeprazole generic PENTASA PREVACI D PREVPAC ranitidine generic sulfasalazine generic
C.\HDIOVASCI 11.Alt ADVICOR atenolol generic AVALI DE AVAPRO bisoprolol generic bisoprolol w/hclZ generic chlorthaliclone generic c lonidine generic COR EG CRESTOR diltiazem, er generic DIOVAN, HCT enalapril generic enak1pri l w/hctz generic gemfibrozil generic nydrochloroihiazide generic INNOPRAN XL LIPITOR l isinopril generic lisinopril w/hctz generic LOTENSIN HCT LOTREL

lovastatin generic metoprolof tartrate generic moexipril generic NIASPAN nifedipine er generic NORVASC
propranolol generic terzosin generic verapamn generic verapamil, xr generic ZAROXO LYN ZETIA

EAR - 1 \ 0 S .' f H RO AT ASTELIN FLONASE NASONEX
llllO l.()GICAT. DETROL, -LA oxybL1lynin generic AVODART EDEX FLOMAX VIAGRA

MUSCUI.OS K EUffAI.
diclofenac sodium generic ibuprofen generic indomethacin generic nabumetone generic naproxen generic VIOXX chol ine mag trisa licylate
generi c d iflunisal generic salsalate generic

E:-.DOCRlNE
ACTONEL ACTOS AVANDAMET AVANDIA D IDRONEL EVISTA FORTEO FOSAMAX glipizide generic glyburide generic f-lUMALOC HUMULIN LANTUS metformin generic NOVOLIN NOVOI.OG PRANDIN PRECOSE STARLIX tolazamide generic tolbutamide generic
OHSTETRICAI./ GY:\ECO I.OGICAI. ESCLIM estracliol generic FEMHRT medroxyprogesterone generic O RTHO ORTHO EVRA PREMARIN PREMPt-IASE PREMPRO TRI-CYCLEN LO YASMIN

ALTERNATIVE PRODUCT LISTING FOR NON-PREFERRED BRANDS

NON-PRCFERRED BRAND

SELECTED ALlERNATIVE BRA'Ill~

Accolate ... . ....... . .. . . . . .. .. . .. . . Singulair

AccupriI . .. . . . . . . . ...... . . . . ... . . . . lisinopril

Aciphex ... .. .. . ...... .... omeprazole, Prevacid

Act1vel la . . ... . . .. . . FemHRT, Prempro, Premphase

Altace . .. . . .. .. .. . . .. . . . .. .. ....... lisinopril

Atacand ... .. . . ... . .. . . ... ... . Avapro, Diovan

Biaxin, -XL ... ... ..... . . erythromycin, Zithromax

Clarinex . . ... .. . . .. . . . . .... . ... ... .. Allergra

Cozaar. . ... .. . ... . . ...... . . . . : Avapro, Diovan

Hyzaar ... . ... . .. . . , .. . ... Avahde, D 1ovan HCT

Maxalt, -MLT . ... . . . ..... .. . lmi trex, Zom ig, -ZMT

Mabie .. .... ..... . .. . . ... . . .. . generic NSAIDs

Nexium . . .. . . .. , . .. , .. . . . omeprazole, Prevacid

Plencii l .. . . . . . . . . . ...... . . . ni tedipine, Norvasc

Protonix .... . . . . . . .. ..... . omeprazole, Prevacid

Pulmicort ... . . . . .. . . . . . ... .... . Flovent, QVAR

Sular . . . . . . . .

. ... . ..... nifed ipine, Norvasc

Zocor . . .. . . . .. .. .. . ... lovastatin, Crestor, Lipitor

Zoloft . . .... ftuoxetine, paroxetine, Lexapro, Paxil CR

Zyrtec. . . . ...... . ....... .. ... .. . .... . Allegra

( For Prior Authorizations (PA), Quantity Level Limits (QLL) or any questions rcg;irding specific coverage rules or co-payment i.tlformation for drugs not Usted on this document, please contact Express Scripts, Inc. at 1-877-650-9342.

f'cbruary I 8, 2004 This list is subject to cb(mse al the discretion of tin l}eJ}(/r/menl ofCo1111111111ity f/e(l/tb.

GEORGIA PREMIER PREFERRED DRUG LIST (ABBREVIATED)

PA - prior authorization re9uired QLL - quantity or therapy hmits exist

EFFECTIVE JULY 1, 2004
FOR STATE HEALTH BENEFIT PLANS - PPO AND INDEMNITY HEALTH PLANS
All generics are considered preferred drugs (examples listed in each category). If at any time during the Plan year a brand has a generic equivalent become available, that brand w ill automatically be moved to the non-preferred status.

A I. LERGY / R E S P I R A T O R Y ADVAIR D ISKUS QLL albuterol generic Q LL ALLEGRA, -D Q LL COMBIVENT QLL crornolyn sodium generic FLOVENT, - ROTADISK Q LL FORADIL QLL ipratropi um generic MAXAIR AUTOHALER Q LL metapro terenol generic QLL PROVENTIL I-IFA QLL PU LMICORT RESPS Q LL SI N G U LAIR TI LADE QLL ZYRTEC Q LL
ANTI-INFECTIVES acyclovir generic amoxic il l in generi c arnoxicill in/c lavulanic generic ampicillin generic AUGMENTIN ER AUGMENTIN XR QLL AVELOX cefuroxirne generi c C EFZI L cephalexin generic CIPRO CIPRO XR Q LL D IFLUCAN lSOMG QLL D IFLUCAN PA cloxycyc li n~ generi ~ erythromyc1 n generic GANTRISIN PEDIATRIC gri seofulv in generic l<etoconazole generic LAMISIL PA MACROBID penicillin generic SPECTRACEF SPORANOX QLL , PA tetracycl ine generic tmp/ srnx generic VALTREX QLL ZITI-IROMAX Q LL
AUTONOMIC & CNS alprazolarn generic AMBIEN Qll amitriptyline generic bupropion generic

b uspiro ne generic clcsipramine generic diazeparn generic EFFEXOR, -XR fl uoxetine generic irniprarn ine generic IMITREX QLL LEXAPRO lorazepam generic M IGRANAL QLL nortriptyline generic oxazepam generic paroxetine generic trazodone generic triazolam generic WELLBUTRI N -SR ZOLOFT ZOMIG, -ZMT QLL
GASTROINTESTINAL ASACOL AZU LFIDINE EN-TAB c imetidine generic CREON famotidine generic orneprazo le generic Q LL, PA PA N CREASE pancre lipase generic PENTASA PREVACID Q LL, PA PREVPAC QLL PROCTOFOAM- I-IC ranitidine generic ROWASA sucralfate generic URSO VIO KASE ZANTAC SYRUP
CARDIOVASCULAR ADVICOR ALTACE atenolol generic captopri I generic CARDIZEM LA CATAPRES-TTS QLL cholestyramine generic COREG COZAAR diltiazem, sa generic DIOVAN, -t-lCT enalapri l generi c

f urosemide generic gemfibrozil generic hydrochloro(haizide generic HYZAAR LEVATO L LEXXEL LIPITO R l isinopri l generi c lisinopri l w/hctz generic LOTENSIN, -I-ICT LOTRE L lovastatin generic metoprolol generic NIAS PAN n ica rclipine generic n ifed ip ine, er, x i generic N IMOTO P NORVASC PRAVACHOL prazosin generic propranorol generic spi rono lactone generi c terazosin generic TOPROL )(L torsemicle generic TRIC O R veraparnil, xr generic ZAROXOLYN ZOCOR
ENDOCRINE ACTOS QLL AMARYL AVANDIA QLL DDAVP NASAL PA EVISTA FOSAMAX QLL G LUCOTROL XL glyburide m icron ized generic GLYSET H UMALOG H UMULIN LANT US metforrnin MIACALCIN N O V OLI N NOVOLOG PRANDIN PRECOSE STARLIX to lazamide generic to lbutarnide generic

February 5, 2004 This list is subject to change at the discretion of the Department <?( Co ,mrmnity Hea//h.

ORSTETRlCAL/ GYNECOLOGICAL C O M B IPATCH ESTRADERM PATCH Q LL ESTRATEST, - HS estradiol patch generic QLL estropipate generic ESTROSTEP FE FEMHRT medroxyprogesterone generic MENEST NUVARING ORTHO EVRA Q LL ORTI-IO T RI-CYCLEN PREMARIN PREM PHASE PREM PRO VIVELLE, -DOT QLL
EAR-NOSE-THROAl' ASTELIN QLL FLONASE AQ QLL NASONEX Q LL

UROLOGICAL DETRO L, -LA D ITROPAN XL EDEX Q LL, PA FLOMAX oxybutynin generic PROSCAR VIAGRA Q LL, PA
MUSCUI.OSKEI.ETAt ARTHROTEC CELEBREX QLL dic lofenac generic fenoprofen generic flu rbiprofen generic i ndomethac in generic ketoprofen generic mecl ofenarnate generic nabumetone generic naproxen generic p iroxicam generic sulindac generic tolmetin generic VIOXX QlL

ALTERNATIVE PRODUCT LISTING FOR NON-PREFERRED BRANDS

NON-PREFERRED BRAND

SELECTED ALTERNATIVE BRAND$

Accon .. . .... . . .. .. ... l isinopri l, A ltace, Lotensin

Aciphex . . . . . .. . . . . . . . . . . omcprazole, Prevacid

Accolate .. .. . .. . . .. ... . .. ... ..... . . Singulair

Accupri l .. . .. . .... .. . .. l isi nopri l, A ltace, Lotensin

Activella... . . . . . . ....... . Prempro, Premp hase

Actonel . . .. . . . . . ... . . . . ... Fosamax, Miacalc in

Atacand . .. ... .. .. ... ... .... . .. Cozaar, Diovan

Biaxi n, -XL ... . ... ... .. .. erythromyc in, Z ith romax

Celexa .. .. ... fluoxeti nc, paroxetine, Lexapro, Zoloft

Clari nex . . ...... . . . . .. . .... . ... Al lergra, Zyrtcc

Lesco!, -XL . . . . . . lovastatin, Lipitor, Pravachol, Zocor

Mavik. .. ... . . . .. . . .. .. lisinopril, A ltace, Lotensin

Max~lt, -MLT . . . . . . . . . . lrn1trex, Zom1g, : ZMT Mob1c. . . . . . . . . . . . . . . generic N1SAIDs

Nex1u_111 . . . . .. . ... omeprazole, P1evacid

Plendil . . .

. . . 111fccl1p111e, Norvasc

Protonix .. .. . .. . .. . .. ... orneprazole, Prevacid

Pulmicort ..... . . .. ... . ... . ... . .. .. .. . Flovent

Serevent . .. . . . . . . . ... . . .. . . . . . .. . . . ForadiI

Sular .. . . .. . . .. . . . . . .. . . . . n ii edipine, Norvasc

Teveten .. ... . ... . . . .. .. . . . .. . . Cozaar, D iova n

For Prior Authorizations (PA) or any questions regarding preferred status ofdrugs not listed on this document, please contact Express Scripts, Lnc. at 1877-650-9342.