UPDATED 1/20/2005CONTRACT CONTRACT_NAME ROLE STREET_ADDRESS STREET_ADDRESS2 CITY STATE ZIP CONTRACT_PLAN_TYPEH0104 BLUE CROSS AND BLUE SHIELD OF ALABAMA Formulary Contact 450 Riverchase Parkway East Birmingham AL 35244 PPOH0104 BLUE CROSS AND BLUE SHIELD OF ALABAMA MA Claims Processing 450 Riverchase Parkway East Birmingham AL 35244 PPOH0150 HEALTHSPRING OF ALABAMA, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 HMOH0150 HEALTHSPRING OF ALABAMA, INC. MA Claims Processing 44 Vantage Way Suite 300 Nashville TN 37228 HMOH0151 UNITED HEALTHCARE OF ALABAMA, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH0151 UNITED HEALTHCARE OF ALABAMA, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH0154 VIVA HEALTH, INC. Formulary Contact 1400 21st Place South Birmingham AL 35205 HMOH0154 VIVA HEALTH, INC. MA Claims Processing 1400 21st Place South Birmingham AL 35205 HMOH0302 SUN HEALTH MEDISUN, INC. Formulary Contact P.O. Box 1489 13632 N. 99th Ave, Suite B Sun City AZ 85372 HMOH0302 SUN HEALTH MEDISUN, INC. MA Claims Processing P.O. Box 1489 13632 N. 99th Ave Suite B Sun City AZ 85372 HMOH0303 PACIFICARE OF ARIZONA, INC Formulary Contact 3515 Harbor Boulevard Costa Mesa CA 92626 HMOH0303 PACIFICARE OF ARIZONA, INC MA Claims Processing 4601 E Hilton Avenue, Mail Stop: AZ74-149 Phoenix AZ 85034 HMOH0307 HUMANA HEALTH PLAN, INC. Formulary Contact 500 West Main Street Louisville KY 40202 HMOH0307 HUMANA HEALTH PLAN, INC. MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH0315 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH0315 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH0316 UNITEDHEALTHCARE OF ARIZONA INC Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH0316 UNITEDHEALTHCARE OF ARIZONA INC MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH0317 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH0317 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH0318 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH0318 AETNA HEALTH INC. MA Claims Processing 1 FarrView Drive Cranbury NJ 8512 HMOH0319 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH0319 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH0320 ARCADIAN HEALTH PLAN, INC. Formulary Contact 825 Washington St. Suite 300 Oakland CA 94607 HMOH0320 ARCADIAN HEALTH PLAN, INC. MA Claims Processing 858 858 Oak Park Road, Suite 250 Covina CA 91724 HMOH0321 ARIZONA PHYSICIANS IPA, INC. Formulary Contact 8045 Leesburg Pike Suite 600 Vienna VA 22182 HMOH0321 ARIZONA PHYSICIANS IPA, INC. MA Claims Processing Mail Route AZ060-S225 3141 North Third Avenue Phoenix AZ 85013 HMOH0322 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH0322 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH0351 HEALTH NET OF ARIZONA, INC. Formulary Contact 10834 International Dr., Ste. 200 Rancho Cordova CA 95670 HMOH0351 HEALTH NET OF ARIZONA, INC. MA Claims Processing 950 N. Finance Center Dr. Tucson AZ 85710-1362 HMOH0354 CIGNA HEALTHCARE OF ARIZONA, INC. Formulary Contact 8826 N 23rd Ave Phoenix AZ 85021 HMOH0354 CIGNA HEALTHCARE OF ARIZONA, INC. MA Claims Processing 11001 N. Black Canyon Highway Phoenix AZ 85029 HMOH0401 UNITEDHEALTHCARE OF ARKANSAS, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH0401 UNITEDHEALTHCARE OF ARKANSAS, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH0502 CONTRA COSTA HEALTH PLAN MA Claims Processing 595 Center Ave Suite 100 Martinez CA 94553 1876 CostH0504 CA PHYSICIANS SERV/DBA BLUE SHIELD OF CALIF Formulary Contact 4205 Town Center Blvd El Dorado Hills CA 95762 HMOH0504 CA PHYSICIANS SERV/DBA BLUE SHIELD OF CALIF MA Claims Processing 6300 Canoga Avenue Woodland Hills CA 91367 HMOH0523 AETNA HEALTH OF CALIFORNIA,INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH0523 AETNA HEALTH OF CALIFORNIA,INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH0524 KAISER FOUNDATION HP, INC. Formulary Contact 12254 Bellflower Blvd Downey CA 90242 HMOH0524 KAISER FOUNDATION HP, INC. MA Claims Processing 393 E. Walnut Street, Floor 5 Pasadena CA 91188 HMOH0532 WESTERN HEALTH ADVANTAGE Formulary Contact 1331 Garden Hwy., Ste. 100 Sacramento CA 95833 HMOH0532 WESTERN HEALTH ADVANTAGE MA Claims Processing 1331 Garden Hwy., Ste. 100 Sacramento CA 95833 HMOH0538 UNIVERSAL CARE Formulary Contact 1600 East Hill Street Signal Hill CA 90755 HMOH0538 UNIVERSAL CARE MA Claims Processing 1600 E. Hill Street Signal Hill CA 90755 HMOH0540 UNICARE LIFE & HEALTH INS. COMPANY Formulary Contact 8407 Fallbrook Avenue AF5 West Hills CA 91304 PFFSH0540 UNICARE LIFE & HEALTH INS. COMPANY MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 PFFSH0542 ALTAMED HEALTH SERVICES CORPORATION Formulary Contact PO Box 3242 La Habra CA 90632 National PACEH0542 ALTAMED HEALTH SERVICES CORPORATION MA Claims Processing 5425 E. Pomona Blvd. Los Angeles CA 90022 National PACEH0543 PACIFICARE OF CALIFORNIA/SECURE HORIZONS Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH0543 PACIFICARE OF CALIFORNIA/SECURE HORIZONS MA Claims Processing 10801 Walker Drive M/S CY48-117 Cypress CA 90630 HMOH0544 CALIFORNIA HEALTH PLAN Formulary Contact 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 PSO (State License)H0544 CALIFORNIA HEALTH PLAN MA Claims Processing 18000 Studebaker Road, Suite 100 Cerritos CA 90703 PSO (State License)H0545 INTER VALLEY HEALTH PLAN, INC. Formulary Contact 300 S. Park Avenue Suite 300 PO Box 6002 Pomona CA 91769-6002 HMOH0545 INTER VALLEY HEALTH PLAN, INC. MA Claims Processing PO Box 6002 300 South Park Ave, Suite 300 Pomona CA 91769-6002 HMOH0562 HEALTH NET_OF CA Formulary Contact 10834 International Dr., STe. 200 Rancho Cordova CA 95670 HMOH0562 HEALTH NET_OF CA MA Claims Processing 21281 Burbank Blvd. Building B3 Woodland Hills CA 91367 HMOH0564 BLUE CROSS OF CALIFORNIA Formulary Contact 8407 Fallbrook Avenue AF-5 West Hills CA 91304 HMOH0564 BLUE CROSS OF CALIFORNIA MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 HMOH0571 CHINESE COMMUNITY HEALTH PLAN Formulary Contact 170 Columbus Avenue, Suite 210 San Francisco CA 94133 HMOH0571 CHINESE COMMUNITY HEALTH PLAN MA Claims Processing 170 Columbus Avenue, Suite 210 San Francisco CA 94133 HMOH0602 ROCKY MOUNTAIN HEALTH PLANS Formulary Contact PO Box 10600 Grand Junction CO 81502 1876 CostH0602 ROCKY MOUNTAIN HEALTH PLANS MA Claims Processing PO Box 10600 Grand Junction CO 81502 1876 CostH0609 PACIFICARE OF COLORADO, INC Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH0609 PACIFICARE OF COLORADO, INC MA Claims Processing 4601 E Hilton Avenue Phoenix AZ 85034 HMOH0613 TOTAL LONGTERM CARE, INC. Formulary Contact 200 E. 9th Ave Denver CO 80203 National PACEH0613 TOTAL LONGTERM CARE, INC. MA Claims Processing 610 Garrison St, Suite F Lakewood, CO 80215 National PACEH0620 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH0620 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH0621 COLORADO ACCESS Formulary Contact 10065 E. Harvard Ave Ste 600 Denver CO 80231 HMOH0621 COLORADO ACCESS MA Claims Processing 10065 E. Harvard Ave. Suite 600 Denver CO 80231 HMOH0623 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH0623 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH0624 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH0624 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH0630 KAISER FOUNDATION HP OF CO Formulary Contact 16601 E. Centretech Parkway Aurora CO 80011 HMOH0630 KAISER FOUNDATION HP OF CO MA Claims Processing 10350 East Dakota Avenue Denver CO 80247 HMOH0657 HMO HEALTH PLANS, INC. MA Claims Processing 700 Main Street, Suite 100 Alamosa CO 81101 1876 CostH0710 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH0710 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH0712 WELLCARE OF CONNECTICUT, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH0712 WELLCARE OF CONNECTICUT, INC. MA Claims Processing 8735 Henderson Rd. Ren 2 Tampa FL 33634 HMOH0752 OXFORD HEALTH PLANS (CT), INC. Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH0752 OXFORD HEALTH PLANS (CT), INC. MA Claims Processing 44 South Broadway 14th Floor White Plains NY 10601 HMOH0755 HEALTH NET OF CONNECTICUT Formulary Contact 10834 International Dr., Ste. 200 Rancho Cordova CA 95670 HMOH0755 HEALTH NET OF CONNECTICUT MA Claims Processing 313A Towne Place King of Prussia PA 19406 HMOH0901 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH0901 AETNA HEALTH INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMO

H0902 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH0902 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH1013 VISTA HEALTHPLAN OF SOUTH FLORIDA, INC. Formulary Contact 1340 Concord Terrace Sunrise FL 33323 HMOH1013 VISTA HEALTHPLAN OF SOUTH FLORIDA, INC. MA Claims Processing 300 S. Park Road Hollywood FL 33021 HMOH1016 AVMED, INC Formulary Contact AvMed Health Plans 4300 N.W. 89th Blvd. Gainesville FL 32606 HMOH1016 AVMED, INC MA Claims Processing 4300 NW 89 Boulevard Gainesville FL 32606 HMOH1019 CARE PLUS HEALTH PLAN Formulary Contact 500 West Main Street Louisville KY 40202 HMOH1019 CARE PLUS HEALTH PLAN MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH1026 HEALTH OPTIONS, INC Formulary Contact 4800 Deerwood Campus Pkwy Bldg 3, Floor 6 Jacksonville FL 32246 HMOH1026 HEALTH OPTIONS, INC MA Claims Processing 4800 Deerwood Campus Pkwy Jacksonville FL 32246 HMOH1032 WELL CARE OF FLORIDA, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH1032 WELL CARE OF FLORIDA, INC. MA Claims Processing 8735 Henderson Rd. Ren 2 Tampa FL 33634 HMOH1034 AMERICA'S HEALTH CHOICE MEDICAL PLAN Formulary Contact 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 HMOH1034 AMERICA'S HEALTH CHOICE MEDICAL PLAN MA Claims Processing 1175 South US Highway 1 Vero Beach FL 32962 HMOH1035 FLORIDA HEALTH CARE PLAN, INC. Formulary Contact 1340 Ridgewood Avenue Holly Hill FL 32117 HMOH1035 FLORIDA HEALTH CARE PLAN, INC. MA Claims Processing 1340 Ridgewood Avenue Holly Hill FL 32117 HMOH1036 HUMANA MEDICAL PLAN, INC Formulary Contact 500 West Main Street Louisville KY 40202 HMOH1036 HUMANA MEDICAL PLAN, INC MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH1037 CHOICE CARE HEALTH PLAN, INC. MA Claims Processing P.O. Box 1980 Melbourne FL 32902 HCPP - 1833 CostH1043 FLORIDA PACE CENTERS, INC. Formulary Contact 5200 NE 2nd Avenue Miami FL 33137 National PACEH1043 FLORIDA PACE CENTERS, INC. MA Claims Processing 5200 Ne 2nd Avenue Miami FL 33137 National PACEH1045 PREFERRED CARE PARTNERS INC. Formulary Contact 9100 S. Dadeland Blvd. Suite 1250 Miami FL 33156 PSO (State License)H1045 PREFERRED CARE PARTNERS INC. MA Claims Processing 9100 S. Dadeland Blvd. Suite 1250 Miami FL 33156 PSO (State License)H1076 VISTA HEALTHPLAN, INC. Formulary Contact 1340 Concord Terrace Sunrise FL 33323 HMOH1076 VISTA HEALTHPLAN, INC. MA Claims Processing 1340 Concord Terrace Sunrise FL 33323 HMOH1080 UNITED HEALTHCARE OF FL, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH1080 UNITED HEALTHCARE OF FL, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH1099 HEALTH FIRST HEALTH PLANS, INC. Formulary Contact 6450 US Highway 1 Rockledge FL 32955 HMOH1099 HEALTH FIRST HEALTH PLANS, INC. MA Claims Processing 6450 US Highway 1 Rockledge FL 32955 HMOH1108 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH1108 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH1109 AETNA HEALTH INC.(GEORGIA) Formulary Contact 5250 148th Place Wellborn FL 32094-2362 HMOH1109 AETNA HEALTH INC.(GEORGIA) MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH1110 AETNA LIFE INSURANCE COMPANY Formulary Contact 5250 148th Place Wellborn FL 32094-2362 PPOH1110 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH1111 UNITED HEALTHCARE OF GEORGIA, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH1111 UNITED HEALTHCARE OF GEORGIA, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH1112 WELLCARE OF GEORGIA, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH1112 WELLCARE OF GEORGIA, INC. MA Claims Processing 8735 Henderson Rd Ren 2 Tampa FL 33634 HMOH1170 KAISER FOUNDATION HP OF GA, INC. Formulary Contact Nine Piedmont Center, 3495 Piedmont Road N.E. Atlanta GA 30305 HMOH1170 KAISER FOUNDATION HP OF GA, INC. MA Claims Processing 3495 Piedmont Road NE Atlanta GA 30305 HMOH1200 KAISER FOUNDATION HP, INC. MA Claims Processing 711 Kapiolani Blvd. Honolulu HI 96813 1876 CostH1230 KAISER FOUNDATION HP, INC. Formulary Contact Kaiser Permanente - Pharmacy Services 501 Alakawa Street Honolulu HI 96817 HMOH1230 KAISER FOUNDATION HP, INC. MA Claims Processing Affiliated Care - Claims 80 Mahalani Street Wailuku HI 96793 HMOH1251 HAWAII MED. SRVC. ASSN. Formulary Contact 550B - PM 818 Keeaumoku St Honolulu HI 96814 1876 CostH1251 HAWAII MED. SRVC. ASSN. MA Claims Processing 8 - CA 818 Keeaumoku St Honolulu HI 96814 1876 CostH1302 BLUE CROSS OF IDAHO HLTH SERVICES INC Formulary Contact 10201 East 92nd Street North Owasso OK 74055 PPOH1302 BLUE CROSS OF IDAHO HLTH SERVICES INC MA Claims Processing 3000 E. Pine Ave. Meridian ID 83642 PPOH1303 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH1303 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH1304 REGENCE BLUE SHIELD OF IDAHO Formulary Contact 200 SW Market St M/S 2P Portland OR 97201 PPOH1304 REGENCE BLUE SHIELD OF IDAHO MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 PPOH1349 REGENCE BLUESHIELD OF IDAHO. MA Claims Processing 201 High Street SE Salem OR 97309-0625 1876 CostH1350 BLUE CROSS OF IDAHO HEALTH SERVICES, INC Formulary Contact 10201 East 92nd Street North Owasso OK 74055 HMOH1350 BLUE CROSS OF IDAHO HEALTH SERVICES, INC MA Claims Processing 3000 E. Pine Ave. Meridian ID 83642 HMOH1406 HUMANA HEALTH PLAN, INC. Formulary Contact 500 West Main Street Louisville KY 40202 HMOH1406 HUMANA HEALTH PLAN, INC. MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH1407 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PFFSH1407 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PFFSH1415 HEALTHSPRING, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 HMOH1415 HEALTHSPRING, INC. MA Claims Processing 44 Vantage Way Suite 300 Nashville TN 37228 HMOH1416 HARMONY HEALTH PLAN OF ILLINOIS, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH1416 HARMONY HEALTH PLAN OF ILLINOIS, INC. MA Claims Processing 8735 Henderson Rd. Ren 2 Tampa FL 33634 HMOH1417 HEALTH ALLIANCE MEDICAL PLANS Formulary Contact 301 S. Vine St Urbana IL 61801 PPOH1417 HEALTH ALLIANCE MEDICAL PLANS MA Claims Processing 301 S Vine St Urbana IL 61801 PPOH1418 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH1418 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH1419 AETNA HEALTH OF ILLINOIS, INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH1419 AETNA HEALTH OF ILLINOIS, INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH1420 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH1420 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH1463 HEALTH ALLIANCE MEDICAL PLANS Formulary Contact 301 S. Vine St Urbana IL 61801 HMOH1463 HEALTH ALLIANCE MEDICAL PLANS MA Claims Processing 301 S Vine St Urbana IL 61801 HMOH1468 OSF HEALTHPLANS, INC. Formulary Contact 7915 N. Hale Ave., Ste. D Peoria IL 61615 HMOH1468 OSF HEALTHPLANS, INC. MA Claims Processing 7915 N. Hale Ave., Ste D Peoria IL 61615 HMOH1472 JOHN DEERE HEALTH PLAN, INC. MA Claims Processing 3800 Avenue of the Cities, Suite 200 Moline IL 61265 1876 CostH1509 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH1509 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH1510 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH1510 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH1511 ANTHEM INSURANCE COMPANIES, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 HMOH1511 ANTHEM INSURANCE COMPANIES, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 HMOH1553 THE M PLAN, INC. MA Claims Processing 8802 N. Meridian St. Suite 100 Indianapolis IN 46260 1876 CostH1555 ARNETT HMO MA Claims Processing PO BOX 6108 Lafayette IN 46903 1876 CostH1558 WELBORN HEALTH PLAN MA Claims Processing 421 Chestnut Street Evansville IN 47713 1876 CostH1607 ANTHEM INSURANCE COMPANIES, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 PPOH1607 ANTHEM INSURANCE COMPANIES, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 PPOH1608 COVENTRY HEALTH AND LIFE INS COMPANY Formulary Contact 6705 Rockledge Dr., Suite 900 Bethesda MD 20817 PPOH1608 COVENTRY HEALTH AND LIFE INS COMPANY MA Claims Processing 4320 114th Street Urbandale IA 50322 PPOH1609 COVENTRY HEALTH CARE OF IOWA, INC. Formulary Contact 6705 Rockledge Dr., Suite 900 Bethesda MD 20817 HMOH1609 COVENTRY HEALTH CARE OF IOWA, INC. MA Claims Processing 4320 114th Street Urbandale IA 50322 HMOH1651 MEDICAL ASSOCIATES HEALTH PLAN, INC. MA Claims Processing 1605 Associates Drive, Suite 101 P.O. Box 5002 Dubuque IA 52001 1876 Cost

H1714 VIA CHRISTI HEALTHCARE OUTREACH PROGRAM FOR ELDERS Formulary Contact 935 S Glendale Wichita KS 67218 National PACEH1714 VIA CHRISTI HEALTHCARE OUTREACH PROGRAM FOR ELDERS MA Claims Processing 935 S. Glendale Wichita KS 67218 National PACEH1716 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH1716 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH1717 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH1717 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH1804 HUMANA INSURANCE COMPANY Formulary Contact 500 West. Main Street Louisville KY 40202 PFFSH1804 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40201 PFFSH1806 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH1806 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH1807 UNIVERSITY HEALTH CARE, INC. Formulary Contact 200 Stevens Drive Philadelphia PA 19113 HMOH1807 UNIVERSITY HEALTH CARE, INC. MA Claims Processing 305 W. Broadway Louisville KY 40202 HMOH1849 ANTHEM HEALTH PLANS OF KENTUCKY, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 HMOH1849 ANTHEM HEALTH PLANS OF KENTUCKY, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 HMOH1903 WELLCARE OF LOUISIANA, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH1903 WELLCARE OF LOUISIANA, INC. MA Claims Processing 8735 Henderson Rd. Ren 2 Tampa FL 33634 HMOH1904 PACE GREATER NEW ORLEANS Formulary Contact 4201 N RAMPART ST NEW ORLEANS LA 70117 National PACEH1905 HUMANA HLTH BENEFIT PLN OF LOUISIANA Formulary Contact 500 West Main Street Louisville KY 40202 PPOH1905 HUMANA HLTH BENEFIT PLN OF LOUISIANA MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH1906 HUMANA HEALTH BENEFIT PLAN OF LA, INC. Formulary Contact 500 West Main Street Louisville KY 40202 PFFSH1906 HUMANA HEALTH BENEFIT PLAN OF LA, INC. MA Claims Processing 500 West Main Street Louisville KY 40202 PFFSH1951 HUMANA HEALTH BENEFIT PLAN OF LOUISIANA INC Formulary Contact 500 West Main Street Louisville KY 40202 HMOH1951 HUMANA HEALTH BENEFIT PLAN OF LOUISIANA INC MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH1961 TENET CHOICES, INC. / PEOPLES HEALTH NETWORK Formulary Contact 200 W Esplanade Avenue Suite 600 Kenner LA 70065 HMOH1961 TENET CHOICES, INC. / PEOPLES HEALTH NETWORK MA Claims Processing 200 W Esplanade Ave Suite 600 Kenner LA 70065 HMOH2001 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East Minnetonka MN 55343 PPOH2001 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH2003 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East,MN008-T500 Minnetonka MN 55343 PPOH2003 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN-008-W130 Minnetonka MN 55343 PPOH2108 ELDER HEALTH MID-ATLANTIC, INC. Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 HMOH2108 ELDER HEALTH MID-ATLANTIC, INC. MA Claims Processing 3601 O'Donnell Street Baltimore MD 21224 HMOH2109 JOHNS HOPKINS HEALTH SYSTEM, INC. Formulary Contact 4940 Eastern Avenue, Mason Lord Bldg., East Tower, First Floor Baltimore MD 21224 National PACEH2109 JOHNS HOPKINS HEALTH SYSTEM, INC. MA Claims Processing 4940 Eastern Avenue, Mason Lord Bldg., East Tower, First Floor Baltimore MD 21224 National PACEH2111 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH2111 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH2112 AETNA HEALTH INC. (MARYLAND) Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH2112 AETNA HEALTH INC. (MARYLAND) MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH2150 KAISER FNDN HP OF THE MID-ATLANTIC STS Formulary Contact 11445 Sunset Hills Road Suite300 Reston VA 20190 1876 CostH2150 KAISER FNDN HP OF THE MID-ATLANTIC STS MA Claims Processing 2101 East Jefferson Street, 7th floor East Rockville MD 20852 1876 CostH2204 HARVARD PILGRIM HEALTH CARE OF NEW ENGLAND Formulary Contact 93 Worcester Street Wellesley MA 2481 HMOH2204 HARVARD PILGRIM HEALTH CARE OF NEW ENGLAND MA Claims Processing 1600 Crown Colony Drive Quincy MA 2169 HMOH2206 HARVARD PILGRIM HEALTH CARE Formulary Contact 93 Worcester Street Wellesley MA 2481 HMOH2206 HARVARD PILGRIM HEALTH CARE MA Claims Processing 1600 Crown Colony Drive Quincy MA 2169 HMOH2218 HARBOR HEALTH SERVICES Formulary Contact 2216 Dorchester Avenue Dorchester MA 2124 National PACEH2218 HARBOR HEALTH SERVICES MA Claims Processing 2216 Dorchester Avenue Dorchester MA 2124 National PACEH2219 FALLON COMMUNITY HEALTH PLAN Formulary Contact One Chestnut Place 10 Chestnut Street Worcester MA 01608-2810 National PACEH2219 FALLON COMMUNITY HEALTH PLAN MA Claims Processing One Chestnut Place 10 Chestnut Street Worcester MA 1608 National PACEH2220 UPHAMS CORNER HEALTH COMMITTEE, INC. Formulary Contact 1140 Dorchester Ave. Dorchester MA 2125 National PACEH2220 UPHAMS CORNER HEALTH COMMITTEE, INC. MA Claims Processing 1140 Dorchester Ave. Dorchester MA 2125 National PACEH2221 ELDER SRVC PLN/CAMBRIDGE HEALTH ALLIANCE Formulary Contact 270 Green Street Cambridge MA 2139 National PACEH2221 ELDER SRVC PLN/CAMBRIDGE HEALTH ALLIANCE MA Claims Processing 270 Green Street Cambridge MA 2139 National PACEH2222 ELDER SERVICE PLAN OF THE NORTH SHORE Formulary Contact None None MA 1901 National PACEH2222 ELDER SERVICE PLAN OF THE NORTH SHORE MA Claims Processing 37 Friend Street Lynn MA 1902 National PACEH2223 ELDER SVC PLN/E BOSTON HEALTH CENTER Formulary Contact 10 Gove Street East Boston MA 2128 National PACEH2223 ELDER SVC PLN/E BOSTON HEALTH CENTER MA Claims Processing 10 Gove St East Boston MA 2128 National PACEH2224 SENIOR WHOLE HEALTH, LLC Formulary Contact 58 Charles Street, 2nd Floor Cambridge MA 2141 MA Health Senior Care OptionsH2224 SENIOR WHOLE HEALTH, LLC MA Claims Processing 58 Charles Street, 2nd Floor Cambridge MA 2141 MA Health Senior Care OptionsH2225 COMMONWEALTH CARE ALLIANCE, INC. Formulary Contact 30 Winter Street, 7th Floor Boston MA 2108 MA Health Senior Care OptionsH2225 COMMONWEALTH CARE ALLIANCE, INC. MA Claims Processing 30 Winter Street, 7th Floor Boston MA 2108 MA Health Senior Care OptionsH2226 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 MA Health Senior Care OptionsH2226 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 MA Health Senior Care OptionsH2228 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH2228 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH2229 TUFTS ASSOCIATED HMO, INC. Formulary Contact 705 mt auburn street watertown MA 2472 PPOH2229 TUFTS ASSOCIATED HMO, INC. MA Claims Processing 705 Mt Auburn Street Watertown MA 2471 PPOH2230 BLUE CROSS AND BLUE SHIELD OF MA HMO BLUE, INC. Formulary Contact Landmark Center 401 Park Drive Boston MA 2215 PPOH2230 BLUE CROSS AND BLUE SHIELD OF MA HMO BLUE, INC. MA Claims Processing 1 Enterprise Drive Mail Stop 02-03 North Quincy MA 2171 PPOH2256 TUFTS ASSOCIATED HMO, INC. Formulary Contact 705 mt. auburn street watertown MA 2472 HMOH2256 TUFTS ASSOCIATED HMO, INC. MA Claims Processing 705 Mt Auburn Street Watertown MA 2471 HMOH2261 BLUE CROSS & BLUE SHIELD OF MA HMO BLUE, INC. Formulary Contact Landmark Center 401 Park Drive Boston MA 2215 HMOH2261 BLUE CROSS & BLUE SHIELD OF MA HMO BLUE, INC. MA Claims Processing 1 Enterprise Drive Mail Stop 02-03 North Quincy MA 2171 HMOH2312 HEALTH ALLIANCE PLAN OF MICHIGAN Formulary Contact 2850 West Grand Blvd Detroit MI 48202 HMOH2312 HEALTH ALLIANCE PLAN OF MICHIGAN MA Claims Processing 2850 West Grand Boulevard Detroit MI 48375 HMOH2318 HENRY FORD HEALTH SYSTEM Formulary Contact 7800 W. Outer Dr., Suite 240 Detroit MI 48235 National PACEH2318 HENRY FORD HEALTH SYSTEM MA Claims Processing 7800 W. Outer Dr., Suite 240 Detroit MI 48235 National PACEH2319 BLUE CROSS BLUE SHIELD OF MICHIGAN Formulary Contact 27000 W. 11 Mile Road MC B773 Southfield MI 48034 PFFSH2319 BLUE CROSS BLUE SHIELD OF MICHIGAN MA Claims Processing 27000 W. Eleven Mile Road MC H404 Southfield MI 48034 PFFSH2320 PRIORITY HEALTH Formulary Contact 1231 East Beltline, NE Grand Rapids MI 49525 HMOH2320 PRIORITY HEALTH MA Claims Processing 1231 East Beltline Ave NE Grand Rapids MI 49525 HMOH2322 ALLIANCE HEALTH AND LIFE INSURANCE, CO Formulary Contact 2850 W. Grand Blvd. Detroit MI 48202 PPOH2322 ALLIANCE HEALTH AND LIFE INSURANCE, CO MA Claims Processing 2850 W. Grand Blvd. Detroit MI 48202 PPOH2323 FIDELIS SECURECARE OF MICHIGAN Formulary Contact 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH2323 FIDELIS SECURECARE OF MICHIGAN MA Claims Processing 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH2354 HEALTHPLUS OF MICHIGAN Formulary Contact 2050 S. Linden Road P.O. BOX 1700 Flint MI 48501-1700 HMOH2354 HEALTHPLUS OF MICHIGAN MA Claims Processing 2050 S. Linden Road P.O. Box 1700 Flint MI 48501-1700 HMOH2406 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH2406 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH2407 UCARE MINNESOTA Formulary Contact PO Box 52 Minneapolis MN 55440 MN Disability Health OptionsH2407 UCARE MINNESOTA MA Claims Processing UCare Minnesota 2000 Summer St. NE Mpls MN 55413 MN Disability Health OptionsH2408 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PFFSH2408 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PFFSH2409 MEDICA HEALTH PLAN S OF WISCONSIN Formulary Contact 401 Carlson Parkway Minnetonka MN 55305 PFFS

H2409 MEDICA HEALTH PLAN S OF WISCONSIN MA Claims Processing 401 Carlson Parkway Minnetonka MN 55305 PFFSH2410 MEDICA HEALTH PLANS Formulary Contact 401 Carlson Parkway Minnetonka MN 55305 PFFSH2410 MEDICA HEALTH PLANS MA Claims Processing 401 Carlson Parkway Minnetonka MN 55305 PFFSH2411 FALLON COMMUNITY HEALTH PLAN Formulary Contact One Chestnut Place 10 Chestnut Street Worcester MA 1608 PPOH2411 FALLON COMMUNITY HEALTH PLAN MA Claims Processing One Chestnut Place 10 Chestnut Street Worcester MA 1608 PPOH2416 PRIMEWEST HEALTH SYSTEM Formulary Contact Prime Therapeutics, LLC PO Box 64812, Mail Route PWEST St. Paul MN 55164 MN Senior Health OptionsH2416 PRIMEWEST HEALTH SYSTEM MA Claims Processing PrimeWest Health System 822 South 3rd St., Suite 150 Minneapolis MN 55415 MN Senior Health OptionsH2417 ITASCA MEDICAL CARE Formulary Contact 9501 East Shea Boulevard Scottsdale AZ 85260-6719 MN Senior Health OptionsH2417 ITASCA MEDICAL CARE MA Claims Processing 1209 SE 2nd Ave. Grand Rapids MN 55744 MN Senior Health OptionsH2419 SOUTH COUNTRY HEALTH ALLIANCE Formulary Contact Prime Therapeutics Inc. 1020 Discovery Road No. 100 Eagan MN 55121 MN Senior Health OptionsH2419 SOUTH COUNTRY HEALTH ALLIANCE MA Claims Processing 110 W Fremont Street Owatonna MN 55060 MN Senior Health OptionsH2422 HEALTHPARTNERS Formulary Contact 8100 34th Avenue South, PO Box 1309 Minneapolis MN 55440 MN Senior Health OptionsH2422 HEALTHPARTNERS MA Claims Processing 8100 34th Avenue South Minneapolis MN 55110 MN Senior Health OptionsH2424 FIRST PLAN OF MINNESOTA Formulary Contact 3400 Yankee Drive Eagan MN 55122 MN Senior Health OptionsH2424 FIRST PLAN OF MINNESOTA MA Claims Processing 525 S. Lake Ave, Suite 222 Duluth MN 55802 MN Senior Health OptionsH2425 BLUE PLUS Formulary Contact 3400 Yankee Drive Eagan MN 55122 MN Senior Health OptionsH2425 BLUE PLUS MA Claims Processing 1020 Discovery Rd Eagan MN 55121-2095 MN Senior Health OptionsH2450 MEDICA INSURANCE COMPANY Formulary Contact 401 Carlson Parkway Minnetonka MN 55305 1876 CostH2450 MEDICA INSURANCE COMPANY MA Claims Processing 401 Carlson Parkway Minnetonka MN 55305 1876 CostH2456 UCARE MINNESOTA Formulary Contact PO Box 52 Minneapolis MN 55440 MN Senior Health OptionsH2456 UCARE MINNESOTA MA Claims Processing UCare Minnesota 2000 Summer St. NE Mpls MN 55413 MN Senior Health OptionsH2457 METROPOLITAN HEALTH PLAN Formulary Contact 822 S 3rd St. #140 Minneapolis MN 55415 MN Senior Health OptionsH2457 METROPOLITAN HEALTH PLAN MA Claims Processing 822 S. Third St. Minneapolis MN 55415 MN Senior Health OptionsH2458 MEDICA HEALTH PLANS Formulary Contact 401 Carlson Parkway Minnetonka MN 55305 MN Senior Health OptionsH2458 MEDICA HEALTH PLANS MA Claims Processing 401 Carlson Parkway Minnetonka MN 55305 MN Senior Health OptionsH2459 UCARE MINNESOTA Formulary Contact 2000 Summer St. NE Mpls MN 55413 HMOH2459 UCARE MINNESOTA MA Claims Processing 2000 Summer St. NE Mpls MN 55413 HMOH2461 BLUE CROSS BLUE SHIELD OF MINNESOTA MA Claims Processing 3400 Yankee Drive Eagan MN 55122 1876 CostH2462 HEALTHPARTNERS Formulary Contact 8100 34th Avenue South PO Box 1309 Minneapolis MN 55440 1876 CostH2462 HEALTHPARTNERS MA Claims Processing 8100 34th Avenue South PO Box 1309 Minneapolis MN 55440 1876 CostH2609 ALEXIAN BROTHERS COMMUNITY SERVICES Formulary Contact 3900 S. Grand St. Louis MO 63118 National PACEH2609 ALEXIAN BROTHERS COMMUNITY SERVICES MA Claims Processing 3900 S. Grand St. Louis MO 63118 National PACEH2610 ESSENCE INC. Formulary Contact 12655 Olive St. Louis MO 63141 HMOH2610 ESSENCE INC. MA Claims Processing 12655 Olive 4th Floor saint louis MO 63141 HMOH2611 PREMIER HEALTH INSURANCE COMPANY, INC. Formulary Contact 14528 S. Outer 40, Ste. 300 Chesterfield MO 63017 PPOH2611 PREMIER HEALTH INSURANCE COMPANY, INC. MA Claims Processing 1949 E. Sunshine One Corporate Centre, Ste. 200 Springfield MO 65804 PPOH2613 HEALTHY ALLIANCE LIFE INS COMPANY Formulary Contact 8407 Fallbrook Avenue AF-5 West Hills CA 91304 PFFSH2613 HEALTHY ALLIANCE LIFE INS COMPANY MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 PFFSH2649 HUMANA HEALTH PLAN, INC. Formulary Contact 500 West Main Street Louisville KY 40202 HMOH2649 HUMANA HEALTH PLAN, INC. MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH2654 UNITED HEALTHCARE OF THE MIDWEST, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T005 Minnetonka MN 55343 HMOH2654 UNITED HEALTHCARE OF THE MIDWEST, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH2663 GROUP HEALTH PLAN, INC. Formulary Contact 111 Corporate Office Dr., Suite 400 Earth City MO 63045 HMOH2663 GROUP HEALTH PLAN, INC. MA Claims Processing 111 Corporate Office Drive Suite 400 Earth City MO 63045 HMOH2667 MERCY HEALTH PLANS OF MISSOURI INC. Formulary Contact 14528 S. Outer 40, Ste. 300 Chesterfield MO 63017 HMOH2667 MERCY HEALTH PLANS OF MISSOURI INC. MA Claims Processing 1949 E. Sunshine One Corporate Centre, Ste. 200 Springfield MO 65804 HMOH2672 COVENTRY HEALTH CARE OF KANSAS, INC. Formulary Contact 4300 Cox Road Glen Allen VA 23060 HMOH2672 COVENTRY HEALTH CARE OF KANSAS, INC. MA Claims Processing 8320 Ward Parkway Kansas City MO 64114 HMOH2701 NEW WEST HEALTH SERVICES Formulary Contact 130 Neill Avenue Helena MT 59634 PPOH2701 NEW WEST HEALTH SERVICES MA Claims Processing 1203 Highway 2 West, Suite 45 Kalispell MT 59901 PPOH2802 UNITED HEALTHCARE OF THE MIDLANDS, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH2802 UNITED HEALTHCARE OF THE MIDLANDS, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH2803 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH2803 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH2905 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Formulary Contact 2716 N. Tenaya Way Las Vegas NV 89128 PPOH2905 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. MA Claims Processing 2716 N. Tenaya Way Las Vegas NV 89128 PPOH2906 HOMETOWN HEALTH PLAN Formulary Contact 830 Harvard Way Reno NV 89502 PPOH2906 HOMETOWN HEALTH PLAN MA Claims Processing 830 Harvard Way Reno NV 89502 PPOH2931 HEALTH PLAN OF NEVADA, INC. Formulary Contact 2716 N. Tenaya Way Las Vegas NV 89128 HMOH2931 HEALTH PLAN OF NEVADA, INC. MA Claims Processing 2716 N. Tenaya Way Las Vegas NV 89128 HMOH2949 PACIFICARE OF NEVADA, INC Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH2949 PACIFICARE OF NEVADA, INC MA Claims Processing 4601 E Hilton Ave M/S AZ74-149 Phoenix AZ 85034 HMOH2960 HOMETOWN HEALTH PLAN Formulary Contact 830 Harvard Way Reno NV 89502 HMOH2960 HOMETOWN HEALTH PLAN MA Claims Processing 830 Harvard Way Reno NV 89502 HMOH2961 HEALTH PLAN OF NEVADA, INC. Formulary Contact 2716 N. Tenaya Way Las Vegas NV 89128 SHMOH2961 HEALTH PLAN OF NEVADA, INC. MA Claims Processing 2716 N. Tenaya Way Las Vegas NV 89128 SHMOH3107 OXFORD HEALTH PLANS (NJ), INC. Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3107 OXFORD HEALTH PLANS (NJ), INC. MA Claims Processing 44 South Broadway 14th Floor White Plains NY 10601 HMOH3112 AMERIHEALTH HMO_INC Formulary Contact 200 Stevens Drive Philadelphia PA 19113 HMOH3112 AMERIHEALTH HMO_INC MA Claims Processing 925 Chestnut Street - C4 Philadelphia PA 19107 HMOH3113 OXFORD HEALTH PLANS OF NEW JERSEY, INC Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3113 OXFORD HEALTH PLANS OF NEW JERSEY, INC MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH3152 AETNA HEALTH, INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH3152 AETNA HEALTH, INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH3154 HORIZON HEALTHCARE OF NEW JERSEY, INC. Formulary Contact 3 Penn Plaza East - PP 13Q Newark NJ 07105-2200 HMOH3154 HORIZON HEALTHCARE OF NEW JERSEY, INC. MA Claims Processing 3 Penn Plaza East PP02Q Newark NJ 07105-2200 HMOH3156 AMERIHEALTH HMO_INC Formulary Contact Independence Blue Cross 1700 Market Street Philadelphia PA 19103 HMOH3156 AMERIHEALTH HMO_INC MA Claims Processing 925 Chestnut Street - C4 Philadelphia PA 19107 HMOH3164 AMERICHOICE OF NEW JERSEY, INC Formulary Contact 8045 Leesburg Pike Vienna VA 22182 HMOH3164 AMERICHOICE OF NEW JERSEY, INC MA Claims Processing 100 Penn Square East, Suite 900 The Wanamaker Building Philadelphia PA 19107 HMOH3204 PRESBYTERIAN HEALTH PLAN Formulary Contact P.O. Box 27489 Albuquerque NM 87125-7489 HMOH3204 PRESBYTERIAN HEALTH PLAN MA Claims Processing P.O. Box 27489 Albuquerque NM 87125-7489 HMOH3206 PRESBYTERIAN INSURANCE COMPANY, INC. Formulary Contact P.O. Box 26267 Albuquerque NM 87125-6267 PPOH3206 PRESBYTERIAN INSURANCE COMPANY, INC. MA Claims Processing P.O. Box 26267 Albuquerque NM 87125-6267 PPOH3207 LOVELACE INSURANCE COMPANY Formulary Contact 4101 Indian School R. NE Suite 110S Albuquerque NM 87111 PPOH3207 LOVELACE INSURANCE COMPANY MA Claims Processing 4101 Indian School Rd. NE Albuquerque NM 87110 PPOH3208 HCSC INSURANCE SERVICES COMPANY Formulary Contact 300 E. Randolph Chicago IL 60601 PPOH3208 HCSC INSURANCE SERVICES COMPANY MA Claims Processing HCSC Insurance Services Company 901 S. Central Expressway Richardson TX 76051 PPOH3209 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH3209 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH3251 LOVELACE HEALTH PLAN, INC. Formulary Contact 4101 Indian School Rd. NE Suite 110S Albuquerque NM 87111 HMOH3251 LOVELACE HEALTH PLAN, INC. MA Claims Processing 4101 Indian School Rd. NE Albuquerque NM 87110 HMO

H3304 EXCELLUS HEALTH PLAN, INC. Formulary Contact 165 Court Street Rochester NY 14647 1876 CostH3304 EXCELLUS HEALTH PLAN, INC. MA Claims Processing 344 South Warren Syracuse NY 13331 1876 CostH3305 ROCHESTER AREA HMO/ DBA PREFERRED CARE Formulary Contact 259 Monroe Ave. Rochester NY 14607 HMOH3305 ROCHESTER AREA HMO/ DBA PREFERRED CARE MA Claims Processing 259 Monroe Ave. Rochester NY 14607 HMOH3307 OXFORD HEALTH PLANS (NY) INC. Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3307 OXFORD HEALTH PLANS (NY) INC. MA Claims Processing 44 South Broadway 14th Floor White Plains NY 10601 HMOH3312 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH3312 AETNA HEALTH INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH3321 INDEPENDENT LIVING SRVCS OF CENTRAL NY Formulary Contact 100 Malta Lane North Syracuse NY 13212 National PACEH3321 INDEPENDENT LIVING SRVCS OF CENTRAL NY MA Claims Processing 100 Malta Lane North Syracuse NY 13212 National PACEH3322 SENIOR CARE CONNECTION, INC. Formulary Contact Royal Care Pharmacy 100 Saratoga Village Boulevard Malta NY 12020 National PACEH3322 SENIOR CARE CONNECTION, INC. MA Claims Processing 504 State Street Schenectady NY 12305 National PACEH3327 TOUCHSTONE HEALTH PARTNERSHIP Formulary Contact 1130 Ten Rod Road Building D, Suite 206 North Kingston RI 2852 PSO (Federal Waiver of State License)H3327 TOUCHSTONE HEALTH PARTNERSHIP MA Claims Processing 14 Wall Street New York NY 10005 PSO (Federal Waiver of State License)H3328 NEW YORK STATE CATHOLIC HLTH PLAN INC Formulary Contact 95-25 Queens Blvd. 8th Fl Rego Park NY 11374 HMOH3328 NEW YORK STATE CATHOLIC HLTH PLAN INC MA Claims Processing 40 John Glenn Amherst NY 14228 HMOH3329 COMPREHENSIVE CARE MANAGEMENT CORP. Formulary Contact 2401 White Plains Rd. Bronx NY 10467 National PACEH3329 COMPREHENSIVE CARE MANAGEMENT CORP. MA Claims Processing 100 Parsons Pond Dr. Franklin Lakes NJ 7417 National PACEH3330 HIP OF GREATER NEW YORK Formulary Contact 55 Water Street New York NY 11401 HMOH3330 HIP OF GREATER NEW YORK MA Claims Processing 55 Water Street New York NY 10041 HMOH3331 INDEPENDENT LIVING FOR SENIORS, INC. Formulary Contact 2066 Hudson Avenue Rochester NY 14617 National PACEH3331 INDEPENDENT LIVING FOR SENIORS, INC. MA Claims Processing 2066 Hudson Avenue Rochester NY 14617 National PACEH3333 AMERICAN PROGRESSIVE LIFE/HLTH INS. MA Claims Processing 201 Lackawanna Avenue Suite 400 Scrantan PA 18503 PFFSH3335 EXCELLUS HEALTH PLAN, INC. Formulary Contact 165 Court Street Rochester NY 14647 PPOH3335 EXCELLUS HEALTH PLAN, INC. MA Claims Processing 205 Park Club Lane Buffalo NY 14221 PPOH3336 NEIGHBORHOOD HEALTH PROVIDERS LLC Formulary Contact 521 Fifth Avenue 3rd Floor New York NY 10175 HMOH3336 NEIGHBORHOOD HEALTH PROVIDERS LLC MA Claims Processing 1377 Motor Parkway Suite 400 Islandia NY 11749 HMOH3337 LIBERTY HEALTH ADVANTAGE, INC. Formulary Contact 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 HMOH3337 LIBERTY HEALTH ADVANTAGE, INC. MA Claims Processing 50 Charles Lindbergh Blvd., Suite 400 Uniondale NY 11553 HMOH3340 GROUP HEALTH INCORPORATED Formulary Contact 441 Ninth Ave New York NY 10001 PPOH3340 GROUP HEALTH INCORPORATED MA Claims Processing 789 Grant Ave. Lake Katrine NY 12449 PPOH3342 EMPIRE HEALTHCHOICE ASSURANCE, INC. Formulary Contact 15 Metrotech Center, 2nd floor Brooklyn NY 11201 PPOH3342 EMPIRE HEALTHCHOICE ASSURANCE, INC. MA Claims Processing 11 Corporate Woods Blvd Loudonville NY 12211 PPOH3344 INDEPENDENT HEALTH BENEFITS CORP Formulary Contact 511 Farber Lakes Drive Buffalo NY 14221 PPOH3344 INDEPENDENT HEALTH BENEFITS CORP MA Claims Processing 511 Farber Lakes Drive Buffalo NY 14221 PPOH3345 HIP INSURANCE COMPANY OF NEW YORK Formulary Contact 55 Water Street New York NY 10041-8190 PPOH3345 HIP INSURANCE COMPANY OF NEW YORK MA Claims Processing 55 Water Street New York NY 10041 PPOH3346 ROCHESTER AREA HEALTH MAINTENANCE ORG. Formulary Contact 259 Monroe Ave. Rochester NY 14607 PPOH3346 ROCHESTER AREA HEALTH MAINTENANCE ORG. MA Claims Processing 259 Monroe Ave. Rochester NY 14607 PPOH3347 ELDERPLAN, INC. Formulary Contact 745 64th Street Brooklyn NY 11220 HMOH3347 ELDERPLAN, INC. MA Claims Processing 745 64th Street Brooklyn NY 11220 HMOH3351 EXCELLUS HEALTH PLAN, INC. Formulary Contact 165 Court Street Rochester NY 14647 HMOH3351 EXCELLUS HEALTH PLAN, INC. MA Claims Processing 205 Park Club Lane Buffalo NY 14221 HMOH3356 EXCELLUS HEALTH PLAN, INC. Formulary Contact 165 Court Street Rochester NY 14647 1876 CostH3356 EXCELLUS HEALTH PLAN, INC. MA Claims Processing 205 Park Club Lane Buffalo NY 14221 1876 CostH3359 MANAGED HEALTH, INC. Formulary Contact 25 Broadway, 9th Floor New York NY 10004 HMOH3359 MANAGED HEALTH, INC. MA Claims Processing 25 Broadway, 9th Floor New York NY 10004 HMOH3361 WELLCARE_OF NEW YORK, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 HMOH3361 WELLCARE_OF NEW YORK, INC. MA Claims Processing 8735 Henderson Blvd. Ren 2 Tampa FL 33634 HMOH3362 INDEPENDENT HEALTH ASSOCIATION, INC. Formulary Contact 511 Farber Lakes Drive Buffalo NY 14221 HMOH3362 INDEPENDENT HEALTH ASSOCIATION, INC. MA Claims Processing 511 Faber Lakes Drive Buffalo NY 14221 HMOH3366 HEALTH NET OF NY Formulary Contact 10834 International Dr., Ste. 200 Rancho Cordova CA 95670 HMOH3366 HEALTH NET OF NY MA Claims Processing 313A Towne Place King of Prussia PA 19406 HMOH3370 EMPIRE HEALTHCHOICE HMO, INC. Formulary Contact 15 Metrotech Center, 2nd floor Brooklyn NY 11201 HMOH3370 EMPIRE HEALTHCHOICE HMO, INC. MA Claims Processing 15 Metrotech Center, 2nd Floor Brooklyn NY 11201 HMOH3379 UNITED HEALTHCARE OF NEW YORK, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3379 UNITED HEALTHCARE OF NEW YORK, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH3384 HEALTHNOW NEW YORK INC Formulary Contact 10201 East 92nd Street North Owasso OK 74055 HMOH3384 HEALTHNOW NEW YORK INC MA Claims Processing 1901 Main Street Buffalo NY 13905 HMOH3387 AMERICHOICE OF NEW YORK, INC Formulary Contact 8045 Leesburg Pike Vienna VA 22182 HMOH3387 AMERICHOICE OF NEW YORK, INC MA Claims Processing 8045 Leesburg Pike Vienna VA 22182 HMOH3388 CAPITAL DISTRICT PHYSICIANS' HP, INC. Formulary Contact 500 Patroon Creek Blvd Albany NY 12206 HMOH3388 CAPITAL DISTRICT PHYSICIANS' HP, INC. MA Claims Processing 500 Patroon Creek Blvd Albany NY 12206 HMOH3404 PARTNERS NATIONAL HEALTH PLANS OF NC INC Formulary Contact PO Box 2291 Durham NC 27702 PPOH3404 PARTNERS NATIONAL HEALTH PLANS OF NC INC MA Claims Processing 5635 Hanes Mill Rd Winston-Salem NC 27105 PPOH3405 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH3405 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH3449 PARTNERS NATIONAL HEALTH PLANS OF NC, INC. Formulary Contact PO Box 2291 Durham NC 27702 HMOH3449 PARTNERS NATIONAL HEALTH PLANS OF NC, INC. MA Claims Processing 5635 Hanes Mill Rd Winston-Salem NC 27105 HMOH3456 UNITED HEALTHCARE OF NORTH CAROLINA Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3456 UNITED HEALTHCARE OF NORTH CAROLINA MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH3613 CONCORDIA CARE Formulary Contact 2373 Euclid Heights Blvd Cleveland Heights OH 44106 National PACEH3613 CONCORDIA CARE MA Claims Processing 2373 Euclid Heights Blvd. Cleveland Heights OH 44106 National PACEH3614 TRIHEALTH SENIORLINK Formulary Contact 4750 Wesley Ave. Suite J Cincinnati OH 45212 National PACEH3614 TRIHEALTH SENIORLINK MA Claims Processing 619 0ak Street Cincinnati OH 45206 National PACEH3619 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisvile KY 40202 PPOH3619 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH3620 MCKINLEY LIFE INSURANCE COMPANY Formulary Contact 214 Dartmouth Ave SW Canton OH 44710 PPOH3620 MCKINLEY LIFE INSURANCE COMPANY MA Claims Processing 214 Dartmouth Avenue SW Canton OH 44710 PPOH3621 SUMMACARE, INC. Formulary Contact P.O. Box 3620 Akron OH 44309-3620 PPOH3621 SUMMACARE, INC. MA Claims Processing P.O. Box 3620 Akron OH 44309-3620 PPOH3622 QUALCHOICE HEALTH PLAN, INC. Formulary Contact 6000 Parkland Blvd. Cleveland OH 44124 PPOH3622 QUALCHOICE HEALTH PLAN, INC. MA Claims Processing 6000 Parkland Boulevard Cleveland OH 44124 PPOH3623 AETNA HEALTH OF (OHIO) Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH3623 AETNA HEALTH OF (OHIO) MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH3624 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 21094-2362 PPOH3624 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH3653 PARAMOUNT CARE, INC Formulary Contact 1901 Indian Wood Circle Maumee OH 43537 HMOH3653 PARAMOUNT CARE, INC MA Claims Processing 1901 Indian Wood Circle Maumee OH 43537 HMOH3655 COMMUNITY INSURANCE COMPANY Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 HMOH3655 COMMUNITY INSURANCE COMPANY MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 HMOH3657 QUALCHOICE HEALTH PLAN Formulary Contact 6000 Parkland Boulevard Cleveland OH 44124 HMO

H3657 QUALCHOICE HEALTH PLAN MA Claims Processing 6000 Parkland Boulevard Cleveland OH 44124 HMOH3659 UNITED HEALTHCARE OF OHIO, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH3659 UNITED HEALTHCARE OF OHIO, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH3660 SUMMACARE INC. Formulary Contact P.O. Box 3620 Akron OH 44309-3620 HMOH3660 SUMMACARE INC. MA Claims Processing P.O. Box 3620 Akron OH 44309-3620 HMOH3664 MCKINLEY LIFE INSURANCE COMPANY Formulary Contact 2600 Sixth Street SW Canton OH 44710 HMOH3664 MCKINLEY LIFE INSURANCE COMPANY MA Claims Processing 214 Dartmouth Avenue SW Canton OH 44710 HMOH3668 MT. CARMEL HEALTH PLAN, INC. Formulary Contact 495 Cooper Road Suite 200 Westerville OH 43081 HMOH3668 MT. CARMEL HEALTH PLAN, INC. MA Claims Processing 495 Cooper Road Suite 200 Westerville OH 43081 HMOH3672 HOMETOWN HEALTH PLAN Formulary Contact The Health Plan 52160 National Road East St. Clairsville OH 43950 HMOH3672 HOMETOWN HEALTH PLAN MA Claims Processing The Health Plan 52160 National Road East St. Clairsville OH 43950 HMOH3706 GLOBALHEALTH, INC. Formulary Contact 701 NE 10th Street Suite 300 Oklahoma City OK 73104 HMOH3706 GLOBALHEALTH, INC. MA Claims Processing 701 NE 10th Street Suite 300 Oklahoma City OK 73104 HMOH3708 SELECTCARE OF OKLAHOMA, INC. Formulary Contact 4888 Loop Central Drive Suite 800 Houston TX 77081 HMOH3708 SELECTCARE OF OKLAHOMA, INC. MA Claims Processing 4888 Loop Central Drive Suite 700 Houston TX 77081 HMOH3709 BLUE CROSS AND BLUE SHIELD OF OKLAHOMA Formulary Contact 10201 East 92nd St. North Owasso OK 74055 PPOH3709 BLUE CROSS AND BLUE SHIELD OF OKLAHOMA MA Claims Processing 218 W. 6th Street Tulsa, OK 74119 PPOH3749 PACIFICARE OF OKLAHOMA, INC. Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH3749 PACIFICARE OF OKLAHOMA, INC. MA Claims Processing 6200 Northwest Parkway San Antonio TX 78249 HMOH3755 COMMUNITY CARE HMO, INC Formulary Contact 10201 East 92nd Street North Owasso OK 74055 HMOH3755 COMMUNITY CARE HMO, INC MA Claims Processing 218 W.6TH STREET TULSA OK 74119 HMOH3805 PACIFICARE OF OREGON, INC. Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH3805 PACIFICARE OF OREGON, INC. MA Claims Processing 10801 Walker Dr Cypress CA 90630 HMOH3809 PROVIDENCE HEALTH SYSTEM - OREGON Formulary Contact 1235 NE 47th Ave, Suite 148 Portland OR 97213 National PACEH3809 PROVIDENCE HEALTH SYSTEM - OREGON MA Claims Processing 13007 NE Glisan Street Portland OR 97230 National PACEH3810 MID ROGUE INDEPENDENT PHYSICIAN ASSOCIATION Formulary Contact 820 NE 7th Street Grants Pass OR 97526 HMOH3810 MID ROGUE INDEPENDENT PHYSICIAN ASSOCIATION MA Claims Processing 820 NE 7th Street Grants Pass OR 97526 HMOH3811 SAMARITAN HEALTH PLANS, INC. Formulary Contact PO Box M Corvallis OR 97339 HMOH3811 SAMARITAN HEALTH PLANS, INC. MA Claims Processing PO Box M Corvallis OR 97339 HMOH3812 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH3812 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH3813 ODS HEALTH PLAN, INC. Formulary Contact 601 S.W. Second Avenue Portland OR 97204 PPOH3813 ODS HEALTH PLAN, INC. MA Claims Processing 601 S.W. Second Avenue Portland OR 97204 PPOH3814 ATRIO HEALTH PLANS Formulary Contact 500 SE Cass Ave Suite 230 Roseburg OR 97470 HMOH3814 ATRIO HEALTH PLANS MA Claims Processing 500 SE CASS Ave Suite 230 Roseburg OR 97470 HMOH3815 CITIZENS CHOICE HEALTHPLAN Formulary Contact 5400 E. Olympic Blvd. Suite 130 Los Angeles CA 90022 HMOH3815 CITIZENS CHOICE HEALTHPLAN MA Claims Processing 5400 E. Olympic Blvd., Suite 130 Los Angeles CA 90022 HMOH3817 REGENCE BLUECROSS BLUESHIELD OF OR Formulary Contact 200 SW Market Street M/S 2P Portland OR 97201 PPOH3817 REGENCE BLUECROSS BLUESHIELD OF OR MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 PPOH3818 FAMILYCARE HEALTH PLANS, INC. Formulary Contact 2121 SW Broadway #300 Portland OR 97201 HMOH3818 FAMILYCARE HEALTH PLANS, INC. MA Claims Processing 2121 SW Broadway #300 Portland OR 97201 HMOH3851 REGENCE BLUE CROSS BLUE SHIELD OF OREGON MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 1876 CostH3856 REGENCE BLUE CROSS BLUE SHIELD OF OREGON Formulary Contact 200 SW Market Street M/S 2P Portland OR 97201 HMOH3856 REGENCE BLUE CROSS BLUE SHIELD OF OREGON MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 HMOH3864 CENTRAL OREGON INDPDNT HLTH SVCS, INC. Formulary Contact 2650 NE Courtney Dr. Bend OR 97701 HMOH3864 CENTRAL OREGON INDPDNT HLTH SVCS, INC. MA Claims Processing 2650 NE Courtney Dr. Bend OR 97701 HMOH3907 UNIVERSITY OF PITTSBURGH MEDICAL CENTER Formulary Contact 112 Washington Place Suite 800 Pittsburgh PA 15219 HMOH3907 UNIVERSITY OF PITTSBURGH MEDICAL CENTER MA Claims Processing 112 Washington Place Suite 800 Pittsburgh PA 15219 HMOH3908 TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA Formulary Contact 4101 Woodland Avenue Philadelphia PA 19104 National PACEH3908 TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA MA Claims Processing 4101 Woodland Avenue Philadelphia PA 19104 National PACEH3909 INDEPENDENCE BLUE CROSS Formulary Contact 1700 Market Street Philadelphia PA 19103 PPOH3909 INDEPENDENCE BLUE CROSS MA Claims Processing 925 Chestnut Street - C4 Philadelphia PA 19107 PPOH3912 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH3912 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH3916 HIGHMARK, INC. Formulary Contact 120 Fifth Avenue Place Suite 1812 Pittsburgh PA 15222-3099 PPOH3916 HIGHMARK, INC. MA Claims Processing 120 Fifth Avenue, Ste. FAP 1835 Pittsburgh PA 15222 PPOH3917 PITTSBURGH CARE PARTNERSHIP, INC. Formulary Contact SUITE # 700 2400 ARDMORE BOULEVARD PITTSBURGH PA 15221 National PACEH3917 PITTSBURGH CARE PARTNERSHIP, INC. MA Claims Processing Suite # 700, 2400 Ardmore Boulevard Pittsburgh PA 15221 National PACEH3918 LIVING INDEPENDENCE FOR THE ELDERLY Formulary Contact 875 Greentree Road One Parkway Center, Suite 200 Pittsburgh PA 15220 National PACEH3918 LIVING INDEPENDENCE FOR THE ELDERLY MA Claims Processing 875 Greentree Road One Parkway Center, Suite 200 Pittsburgh PA 15220 National PACEH3919 ST AGNES MEDICAL CENTER Formulary Contact 1900 S. Broad Street Philadelphia PA 19145 National PACEH3919 ST AGNES MEDICAL CENTER MA Claims Processing 1900 S. Broad St. Philadelphia PA 19145 National PACEH3920 UNISON HEALTH PLAN OF PENNSYLVANIA, INC. Formulary Contact Unison Administrative Services, LLC 300 Oxford Drive Monroeville PA 15146 HMOH3920 UNISON HEALTH PLAN OF PENNSYLVANIA, INC. MA Claims Processing Building 801, 4th Floor 1388 Beulah Road Monroeville PA 15146 HMOH3921 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH3921 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH3923 CAPITAL ADVANTAGE INSURANCE COMPANY Formulary Contact 2500 Elmerton Avenue Harrisburg PA 17177 PPOH3923 CAPITAL ADVANTAGE INSURANCE COMPANY MA Claims Processing 2500 Elmerton Avenue Harrisburg PA 17177 PPOH3924 GEISINGER INDEMNITY INSURANCE COMPANY Formulary Contact 100 North Academy Avenue Danville PA 17822-3045 PPOH3924 GEISINGER INDEMNITY INSURANCE COMPANY MA Claims Processing 100 North Academy Avenue Danville PA 17822-3020 PPOH3925 PENNSYLVANIA PACE, INC. Formulary Contact N/A N/A PA 12345 National PACEH3925 PENNSYLVANIA PACE, INC. MA Claims Processing 209 Sigma Drive Pittsburgh PA 15238 National PACEH3931 AETNA HEALTH INC Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH3931 AETNA HEALTH INC MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH3949 ELDER HEALTH PENNSYLVANIA, INC. Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 HMOH3949 ELDER HEALTH PENNSYLVANIA, INC. MA Claims Processing 3601 O'Donnell Street Baltimore MD 21224 HMOH3952 KEYSTONE HEALTH PLAN EAST, INC. Formulary Contact 1700 Market Street Philadelphia PA 19103 HMOH3952 KEYSTONE HEALTH PLAN EAST, INC. MA Claims Processing 925 Chestnut Street - C4 Philadelphia PA 19107 HMOH3954 GEISINGER HEALTH PLAN Formulary Contact 100 N. Academy Ave. Danville PA 17822-3045 HMOH3954 GEISINGER HEALTH PLAN MA Claims Processing 100 North Academy Avenue Danville PA 17821-3020 HMOH3957 KEYSTONE HEALTH PLAN WEST, INC. Formulary Contact 120 Fifth Avenue Place Suite 1812 Pittsburgh PA 15222-3099 HMOH3957 KEYSTONE HEALTH PLAN WEST, INC. MA Claims Processing 120 Fifth Avenue, Ste. FAP 1835 Pittsburgh PA 15222 HMOH3959 HEALTHAMERICA PENNSYLVANIA, INC. Formulary Contact 3721 TecPort Drive Harrisburg PA 17106 HMOH3959 HEALTHAMERICA PENNSYLVANIA, INC. MA Claims Processing 11 Stanwix Street Suite 2300 Pittsburgh PA 15222 HMOH3962 KEYSTONE HEALTH PLAN CENTRAL,INC. Formulary Contact 2500 Elmerton Avenue Harrisburg PA 17177-9799 HMOH3962 KEYSTONE HEALTH PLAN CENTRAL,INC. MA Claims Processing 2500 Elmerton Avenue Harrisburg PA 17177 HMOH3964 HEALTH PARTNERS OF PHILADELPHIA INC Formulary Contact 833 Chestnut Street Suite 900 Philadelphia PA 19107 HMOH3964 HEALTH PARTNERS OF PHILADELPHIA INC MA Claims Processing 833 Chestnut Street Suite 900 Philadelphia PA 19107 HMOH3972 ELDER HEALTH PENNSYLVANIA, INC Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 HMOH3972 ELDER HEALTH PENNSYLVANIA, INC MA Claims Processing 3601 O'Donnell Street Baltimore MD 21224 HMOH4003 MMM HEALTHCARE, INC. Formulary Contact 350 Chardon Avenue Suite 500 San Juan PR 918 HMOH4003 MMM HEALTHCARE, INC. MA Claims Processing 350 Chardon Ave Suite 500 San Juan PR 918 HMO

H4004 PREFERRED MEDICARE CHOICE, INC. Formulary Contact 1551 Calle Alda Urb. Caribe Suite 201 San Juan PR 00926-2709 HMOH4004 PREFERRED MEDICARE CHOICE, INC. MA Claims Processing 1551 Calle Alda Urb. Caribe Suite 201 San Juan PR 00926-2709 HMOH4005 TRIPLE-S, INC. Formulary Contact PO Box 363628 San Juan PR 00936-3628 PPOH4005 TRIPLE-S, INC. MA Claims Processing PO Box 363628 San Juan PR 00936-3628 PPOH4006 MCS LIFE INSURANCE COMPANY Formulary Contact PO box 191720 San Juan PR 00919-1720 HMOH4006 MCS LIFE INSURANCE COMPANY MA Claims Processing PMB 152 Suite 75 255 Ponce de Leon Ave. San Juan PR 00917-1919 HMOH4007 HUMANA HEALTH PLANS OF PUERTO RICO INC Formulary Contact 500 West Main Street Louisville KY 40202 HMOH4007 HUMANA HEALTH PLANS OF PUERTO RICO INC MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH4008 HUMANA INSURANCE OF PUERTO RICO, INC Formulary Contact 500 West Main Street Louisville KY 40202 PFFSH4008 HUMANA INSURANCE OF PUERTO RICO, INC MA Claims Processing 500 West Main Street Louisville KY 40202 PFFSH4009 SDM HEALTHCARE MANAGEMENT, INC. Formulary Contact P.O. Box 3078 Bayamon PR 00960-3078 HMOH4009 SDM HEALTHCARE MANAGEMENT, INC. MA Claims Processing P.O. Box 3078 Bayamon PR 00960-3078 HMOH4011 FIRST MEDICAL HEALTH PLAN, INC. Formulary Contact P.O. Box 9950 Cotto Station Arecibo PR 613 PPOH4011 FIRST MEDICAL HEALTH PLAN, INC. MA Claims Processing P.O. Box 195559 San Juan PR 919 PPOH4012 TRIPLE-S, INC. Formulary Contact PO Box 363628 San Juan PR 00936-3628 HMOH4012 TRIPLE-S, INC. MA Claims Processing PO Box 363628 San Juan PR 00936-3628 HMOH4102 UNITED HEALTH PLANS OF NEW ENGLAND, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH4102 UNITED HEALTH PLANS OF NEW ENGLAND, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH4105 PACE ORGANIZATION OF RHODE ISLAND Formulary Contact 225 Chapman Street, Box 7 Providence RI 2905 National PACEH4105 PACE ORGANIZATION OF RHODE ISLAND MA Claims Processing 225 Chapman Street, Box 7 Providence RI 2905 National PACEH4106 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH4106 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH4152 BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND Formulary Contact 10201 East 92nd Street North Owasso OK 74055 HMOH4152 BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND MA Claims Processing 444 Westminster Street Attn: Product Marketing Providence RI 2903 HMOH4203 PALMETTO HEALTH ALLIANCE Formulary Contact 15 Richland Medical Park Drive, Suite 203 NA Columbia SC 29203 National PACEH4203 PALMETTO HEALTH ALLIANCE MA Claims Processing 15 Richland Medical Park Drive, Suite 203 Columbia SC 29203 National PACEH4204 INSTIL HEALTH INSURANCE COMPANY MA Claims Processing InStil Health Insurance Company 17 Technology Circle Columbia SC 29203 PFFSH4205 BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA MA Claims Processing 2401 Faraway Drive Columbia SC 29223 PFFSH4206 INSTIL HEALTH INSURANCE COMPANY Formulary Contact InStil Health Insurance Company 17 Technology Circle Columbia SC 29203 PPOH4206 INSTIL HEALTH INSURANCE COMPANY MA Claims Processing InStil Health Insurance Company 17 Technology Circle Columbia SC 29203 PPOH4207 BLUECHOICE HEALTHPLAN OF SOUTH CAROLINA, INC. Formulary Contact 3060 Alpine Road AX-400 Columbia SC 29260 PPOH4207 BLUECHOICE HEALTHPLAN OF SOUTH CAROLINA, INC. MA Claims Processing 3060 Alpine Road AX-415 Columbia SC 29223 PPOH4208 CAROLINA CARE PLAN, INC. Formulary Contact 201 Executive Center Dr. Columbia SC 29210 HMOH4208 CAROLINA CARE PLAN, INC. MA Claims Processing 201 Executive Center Drive Columbia SC 29210 HMOH4209 BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA Formulary Contact 2401 Faraway Drive Columbia SC 29223 PPOH4209 BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA MA Claims Processing 2401 Faraway Drive Columbia SC 29223 PPOH4402 ALEXIAN BROTHERS COMMUNITY SERVICES Formulary Contact 425 Cumberland Street Suite 110 Chattanoga TN 37404 National PACEH4402 ALEXIAN BROTHERS COMMUNITY SERVICES MA Claims Processing 425 Cumberland Street Suite 110 Chattanooga TN 37404 National PACEH4406 UNITED HEALTHCARE OF TENNESSEE, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH4406 UNITED HEALTHCARE OF TENNESSEE, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH4407 HEALTHSPRING OF TENNESSEE, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 HMOH4407 HEALTHSPRING OF TENNESSEE, INC. MA Claims Processing 44 Vantage Way Suite 300 Nashville TN 37228 HMOH4408 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH4408 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH4454 HEALTHSPRING OF TENNESSEE, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 HMOH4454 HEALTHSPRING OF TENNESSEE, INC. MA Claims Processing 44 Vantage Way Suite 300 Nashville TN 37228 HMOH4456 JOHN DEERE HEALTH PLAN, INC. Formulary Contact John Deere Health 1300 River Drive, Suite 200 Moline IL 61265 HMOH4456 JOHN DEERE HEALTH PLAN, INC. MA Claims Processing 3800 Avenue of the Cities, Suite 200 Moline IL 61265 HMOH4461 CARITEN HEALTH PLAN IN Formulary Contact 1420 Centerpoint Blvd Knoxville TN 37932 HMOH4461 CARITEN HEALTH PLAN IN MA Claims Processing 1420 Centerpoint Blvd Knoxville TN 37932 HMOH4506 SELECTCARE OF TEXAS, L.L.C. Formulary Contact 4888 Loop Central Drive Suite 800 Houston TX 77081 PSO (State License)H4506 SELECTCARE OF TEXAS, L.L.C. MA Claims Processing 4888 Loop Central Drive Suite 700 Houston TX 77081 PSO (State License)H4510 HUMANA HEALTH PLAN OF TEXAS,INC. Formulary Contact 500 West Main Street Louisville KY 40202 HMOH4510 HUMANA HEALTH PLAN OF TEXAS,INC. MA Claims Processing 500 West Main Street Louisville KY 40202 HMOH4513 TEXAS HEALTHSPRING I, LLC Formulary Contact 44 Vantage Way - Suite 300 Nashville TN 37228 HMOH4513 TEXAS HEALTHSPRING I, LLC MA Claims Processing 44 Vantage Way - Suite 300 Nashville TN 37228 HMOH4514 EVERCARE OF TEXAS, LLC Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH4514 EVERCARE OF TEXAS, LLC MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH4517 AMARILLO MULTISVC CTR FR THE AGING INC Formulary Contact 3108 S Fillmore Amarillo TX 79110 National PACEH4517 AMARILLO MULTISVC CTR FR THE AGING INC MA Claims Processing 3108 S Fillmore Amarillo TX 79110 National PACEH4518 BIENVIVIR SENIOR HEALTH SERVICES Formulary Contact 2300 McKinley street El Paso TX 79930 National PACEH4518 BIENVIVIR SENIOR HEALTH SERVICES MA Claims Processing 2300 McKinley El Paso TX 79930 National PACEH4520 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH4520 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH4521 VALLEY BAPTIST HEALTH PLAN, INC. Formulary Contact 2005 Ed Carey Drive Harlingen TX 78550 HMOH4521 VALLEY BAPTIST HEALTH PLAN, INC. MA Claims Processing 2005 Ed Carey Drive Harlingen TX 78550 HMOH4522 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH4522 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire MI 54701 PPOH4523 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH4523 AETNA HEALTH INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH4524 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH4524 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH4525 SHA, L.L.C Formulary Contact 12940 North Highway 183 Austin TX 78750 HMOH4525 SHA, L.L.C MA Claims Processing 12940 North Highway 183 Austin TX 78750 HMOH4526 EL PASO FIRST HEALTH PLANS, INC. Formulary Contact 2501 N. Mesa St. El Paso TX 79902 HMOH4526 EL PASO FIRST HEALTH PLANS, INC. MA Claims Processing 2501 N. Mesa St. El Paso TX 79902 HMOH4527 PSO HEALTH SERVICES, LLC Formulary Contact 8637 FREDERICKSBURG RD STE 400 SAN ANTONIO TX 78240 HMOH4527 PSO HEALTH SERVICES, LLC MA Claims Processing 8637 FREDERICKSBURG RD STE 400 SAN ANTONIO TX 78240 HMOH4528 ELDER HEALTH TEXAS, INC. Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 HMOH4528 ELDER HEALTH TEXAS, INC. MA Claims Processing 3601 O'Donnell Street Baltimore MD 21224 HMOH4529 ARCADIAN HEALT PLAN, INC. Formulary Contact 825 Washington St. Suite 300 Oakland CA 94607 HMOH4529 ARCADIAN HEALT PLAN, INC. MA Claims Processing 858 Oak Park Road, Suite 250 Covina CA 91724 HMOH4531 HCSC INSURANCE SERVICES COMPANY Formulary Contact 300 E. Randolph Chicago IL 60601 PPOH4531 HCSC INSURANCE SERVICES COMPANY MA Claims Processing HCSC Insurance Services Company 901 S. Central Expressway Richardson TX 76051 PPOH4564 SCOTT AND WHITE HEALTH PLAN Formulary Contact 2601 Thornton Lane, Suite A Temple TX 76502 1876 CostH4564 SCOTT AND WHITE HEALTH PLAN MA Claims Processing 2401 South 31st Street Temple TX 76508 1876 CostH4590 PACIFICARE OF TEXAS, INC. Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH4590 PACIFICARE OF TEXAS, INC. MA Claims Processing 6200 Northwest Parkway San Antonio TX 78249 HMOH4604 UNITEDHEALTHCARE OF UTAH, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH4604 UNITEDHEALTHCARE OF UTAH, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH4605 REGENCE BLUECROSS BLUESHIELD OF UT Formulary Contact 200 SW Market Street M/S 2P Portland OR 97201 PPOH4605 REGENCE BLUECROSS BLUESHIELD OF UT MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 PPO

H4606 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH4606 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH4906 C & O EMPLOYEES' HOSPITAL ASSOCIATION MA Claims Processing 511 Main Street, 2nd Floor Clifton Forge VA 24422 HCPP - 1833 CostH4908 OPTIMA HEALTH INSURANCE COMPANY Formulary Contact 4417 Corporation Lane Virginia Beach VA 23462 PPOH4908 OPTIMA HEALTH INSURANCE COMPANY MA Claims Processing 4417 Corporation Lane Virginia Beach VA 23462 PPOH4909 ANTHEM HEALTH PLANS OF VIRGINIA, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 PPOH4909 ANTHEM HEALTH PLANS OF VIRGINIA, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 PPOH4910 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH4910 AETNA HEALTH INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH4911 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH4911 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5005 PACIFICARE OF WASHINGTON, INC. Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 HMOH5005 PACIFICARE OF WASHINGTON, INC. MA Claims Processing 10801 Walker Dr Cypress CA 90630 HMOH5006 STERLING LIFE INSURANCE COMPANY MA Claims Processing 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 PFFSH5007 PROVIDENCE HEALTH SYSTEM Formulary Contact 425 Pontius Ave. N. Ste. 300 Seattle WA 98108 National PACEH5007 PROVIDENCE HEALTH SYSTEM MA Claims Processing 4515 Martin Luther King Jr. Way S. Ste. 100 Seattle WA 98108 National PACEH5008 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH5008 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH5009 REGENCE BLUESHIELD Formulary Contact 200 SW Market St M/S 2P Portland OR 97201 PPOH5009 REGENCE BLUESHIELD MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 PPOH5010 ASURIS NORTHWEST HEALTH Formulary Contact 200 SW Market St M/S 2P Portland OR 97201 PPOH5010 ASURIS NORTHWEST HEALTH MA Claims Processing 201 High Street, SE PO Box 12625 Salem OR 97309-0625 PPOH5050 GROUP HEALTH COOPERATIVE Formulary Contact Group Health Cooperative 521 Wall Street, ACC-1 Seattle WA 98121 HMOH5050 GROUP HEALTH COOPERATIVE MA Claims Processing Group Health Cooperative 521 Wall Street, ACC-1 Seattle WA 98121 HMOH5102 HEALTH PLAN OF THE UPPER OHIO VALLEY MA Claims Processing The Health Plan 52160 National Road East St. Clairsville OH 43950 1876 CostH5106 MOUNTAIN STATE BLUE CROSS BLUE SHIELD Formulary Contact 700 Market Square PO Box 1948 Parkersburg WV 26102 PPOH5106 MOUNTAIN STATE BLUE CROSS BLUE SHIELD MA Claims Processing 700 Market Square PO Box 1948 Parkersburg WV 26101 PPOH5151 HEALTH PLAN OF THE UPPER OHIO VALLEY Formulary Contact The Health Plan 52160 National Road East St. Clairsville OH 43950 HMOH5151 HEALTH PLAN OF THE UPPER OHIO VALLEY MA Claims Processing The Health Plan 52160 National Road East St. Clairsville OH 43950 HMOH5204 COMMUNITY LIVING ALLIANCE Formulary Contact 1414 MacArthur Road PO Box 8028 Madison WI 53708-8028 WI Partnership ProgramH5204 COMMUNITY LIVING ALLIANCE MA Claims Processing 1414 MacArthur Road PO Box 8028 Madison WI 53708-8028 WI Partnership ProgramH5206 COMMUNITY HEALTH PARTNERSHIP, INC. Formulary Contact 2240 Eastridge Center Eau Claire WI 54701 WI Partnership ProgramH5206 COMMUNITY HEALTH PARTNERSHIP, INC. MA Claims Processing 2240 EastRidge Center Eau Claire WI 54701 WI Partnership ProgramH5207 COMMUNITY CARE HEALTH PLAN, INC Formulary Contact 1555 S. Layton Blvd. Milwaukee WI 53215 WI Partnership ProgramH5207 COMMUNITY CARE HEALTH PLAN, INC MA Claims Processing 1555 S. Layton Blvd. Milwaukee WI 53215 WI Partnership ProgramH5209 ELDER CARE HEALTH PLAN, INC. Formulary Contact 2802 International Lane Madison WI 53704 WI Partnership ProgramH5209 ELDER CARE HEALTH PLAN, INC. MA Claims Processing 2802 International Lane Madison WI 53704 WI Partnership ProgramH5211 SECURITY HEALTH PLAN OF WISCONSIN, INC Formulary Contact 1515 Saint Joseph Avenue PO Box 8000 Marshfield WI 54449-8000 HMOH5211 SECURITY HEALTH PLAN OF WISCONSIN, INC MA Claims Processing 1515 Saint Joseph Avenue Marshfield WI 54449 HMOH5212 COMMUNITY CARE ORGANIZATION, INC. Formulary Contact 1555 S. Layton Blvd. Milwaukee WI 53215 National PACEH5212 COMMUNITY CARE ORGANIZATION, INC. MA Claims Processing 1555 S. Layton Blvd. Milwaukee WI 53215 National PACEH5213 TOTAL COMMUNITY CARE, L.L.C. Formulary Contact 1555 S. Layton Blvd. Milwaukee WI 53215 National PACEH5213 TOTAL COMMUNITY CARE, L.L.C. MA Claims Processing 1555 S. Layton Blvd. Milwaukee WI 53215 National PACEH5214 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH5214 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH5215 NETWORK HEALTH INSURANCE CORPORATION Formulary Contact 1570 Midway Place P.O. Box 120 Menasha WI 54952 PPOH5215 NETWORK HEALTH INSURANCE CORPORATION MA Claims Processing 1570 Midway Place Menasha WI 54952 PPOH5216 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PPOH5216 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH5253 UNITED HEALTHCARE OF WISCONSIN, INC Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH5253 UNITED HEALTHCARE OF WISCONSIN, INC MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH5254 NETWORK HEALTH PLAN MA Claims Processing 1570 Midway Place P.O. Box 120 Menasha WI 54952 1876 CostH5256 MEDICAL ASSOCIATES CLINIC HEALTH PLAN MA Claims Processing 1605 Associates Drive, Suite 101 P.O. Box 5002 Dubuque IA 52001 1876 CostH5262 GUNDERSEN LUTHERAN HEALTH PLAN Formulary Contact 1900 South Avenue Mail Stop NCA2-01 La Crosse WI 54601 HMOH5262 GUNDERSEN LUTHERAN HEALTH PLAN MA Claims Processing 1900 South Avenue Mail Stop NCA2-01 La Crosse WI 54601 HMOH5264 DEAN HEALTH PLAN, INC. MA Claims Processing 1277 Deming Way Madison WI 53717 1876 CostH5402 QUALITY HEALTH PLANS, INC. Formulary Contact 2435 US Hwy 19 Suite 470 Holiday FL 34691 HMOH5402 QUALITY HEALTH PLANS, INC. MA Claims Processing 2435 US Hwy 19 Suite 470 Holiday FL 34691 HMOH5403 ON LOK SENIORHEALTH Formulary Contact 1333 Bush Street San Francisco CA 94109 National PACEH5403 ON LOK SENIORHEALTH MA Claims Processing 1333 Bush Street San Francisco CA 94109 National PACEH5404 UNIVERSAL HEALTH CARE, INC. Formulary Contact 150 SECOND AVE NORTH SUITE 400 ST. PETERSBURG FL 33701 HMOH5404 UNIVERSAL HEALTH CARE, INC. MA Claims Processing 150 SECOND AVE NORTH SUITE 400 ST. PETERSBURG FL 33701 HMOH5405 CENTER FOR ELDERS INDEPENDENCE Formulary Contact N/A N/A CA 94612 National PACEH5405 CENTER FOR ELDERS INDEPENDENCE MA Claims Processing 510-17th St., Suite 400 Oakland CA 94612 National PACEH5406 SUTTER HEALTH SACRAMENTO SIERRA REGION Formulary Contact 1234 U Street Sacramento CA 95818 National PACEH5406 SUTTER HEALTH SACRAMENTO SIERRA REGION MA Claims Processing 1234 U Street Sacramento CA 95818 National PACEH5407 CITRUS HEALTH CARE, INC. Formulary Contact 5420 Bay Center Drive Suite 250 Tampa FL 33609 HMOH5407 CITRUS HEALTH CARE, INC. MA Claims Processing 5420 Bay Center Drive Suite 250 Tampa FL 33609 HMOH5410 LEON MEDICAL CENTERS HEALTH PLANS, INC Formulary Contact 11501 SW 40th Street Miami FL 33165 HMOH5410 LEON MEDICAL CENTERS HEALTH PLANS, INC MA Claims Processing 11501 SW 40th Street Miami FL 33165 HMOH5411 DOCTORCARE, INC. Formulary Contact 3001 Ponce De Leon, Suite 101 Coral Gables FL 33134 PSO (State License)H5411 DOCTORCARE, INC. MA Claims Processing 3001 Ponce de Leon Blvd. Suite 101 Coral Gables FL 33134 PSO (State License)H5414 AETNA HEALTH INC. Formulary Contact 5350 148th Place Wellborn FL 32094-2362 HMOH5414 AETNA HEALTH INC. MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 HMOH5415 HUMANA HEALTH INSURANCE COMPANY OF FL, INC. Formulary Contact 500 West Main Street Louisville KY 40202 PPOH5415 HUMANA HEALTH INSURANCE COMPANY OF FL, INC. MA Claims Processing 500 West Main Street Louisville KY 40202 PPOH5416 ARCADIAN HEALTH PLAN Formulary Contact 825 Washington Street, Suite 300 Oakland CA 94607 HMOH5416 ARCADIAN HEALTH PLAN MA Claims Processing 858 Oak Park Road, Ste 250 Covina CA 91724 HMOH5417 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road MN008-T500 Minnetonka MN 55343 PPOH5417 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 PPOH5418 CALIFORNIA HEALTH PLAN Formulary Contact 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 PPOH5418 CALIFORNIA HEALTH PLAN MA Claims Processing 18000 Studebaker Road, Suite 100 Cerritos CA 90703 PPOH5419 BLUE CROSS OF CALIFORNIA Formulary Contact 8407 Fallbrook Avenue West Hills CA 91304 PFFSH5419 BLUE CROSS OF CALIFORNIA MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 PFFSH5420 MEDICA HEALTHCARE PLANS, INC. Formulary Contact 4000 Ponce de Leon Blvd. Suite 650 Coral Gables FL 33146 PSO (State License)H5420 MEDICA HEALTHCARE PLANS, INC. MA Claims Processing 4000 Ponce De Leon Blvd. Suite 650 Coral Gables FL 33146 PSO (State License)H5421 PYRAMID LIFE INSURANCE COMPANY MA Claims Processing 201 Lackawanna Avenue Suite 400 Scranton PA 18503 PFFSH5422 BLUE CROSS BLUE SHIELD OF GEORGIA Formulary Contact 8407 Fallbrook Avenue AF5 West Hills CA 91304 HMOH5422 BLUE CROSS BLUE SHIELD OF GEORGIA MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 HMOH5424 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5424 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5425 SCAN HEALTH PLAN Formulary Contact 3800 Kilroy Aiport Way Suite 100 Long Beach CA 90806 HMO

H5425 SCAN HEALTH PLAN MA Claims Processing 3800 Kilroy Aiport Way Suite 100 Long Beach CA 90806 HMOH5426 METCARE HEALTH PLANS, INC. Formulary Contact 11 Scott Street, Suite 150 Wausau WI 54403-4808 HMOH5426 METCARE HEALTH PLANS, INC. MA Claims Processing 250 South Australian Avenue, Suite 400 West Palm Beach FL 33401 HMOH5427 FREEDOM HEALTH, INC. Formulary Contact 5501 49th Street N St. Petersburg FL 33709 HMOH5427 FREEDOM HEALTH, INC. MA Claims Processing 5501 49th Street N St. Petersburg FL 33709 HMOH5428 SAN MATEO HEALTH COMMISSION Formulary Contact 701 Gateway Blvd, Ste 400 South San Francisco CA 94080 HMOH5428 SAN MATEO HEALTH COMMISSION MA Claims Processing 701 Gateway Blvd, Ste 400 South San Francisco CA 94080 HMOH5429 UNIVERSAL HEALTH CARE, INC. Formulary Contact 14301 First Bank Parkway Suite 200 Omaha FL 68154 PPOH5429 UNIVERSAL HEALTH CARE, INC. MA Claims Processing 150 2nd Avenue North Suite 400 Saint Petersburg FL 33716 PPOH5430 CARE1ST HEALTH PLAN OF ARIZONA Formulary Contact 2355 E. Camelback Rd., Ste. 300 Phoenix AZ 85016 HMOH5430 CARE1ST HEALTH PLAN OF ARIZONA MA Claims Processing 2355 E. Camelback, Rd. Ste. 300 Phoenix AZ 85016 HMOH5431 HEALTHSUN HEALTH PLANS, INC. Formulary Contact 2181 East Aurora Rd 201 Twinsburg OH 44087 HMOH5431 HEALTHSUN HEALTH PLANS, INC. MA Claims Processing 1205 SW 37th Avenue Miami FL 33135 HMOH5433 ORANGE COUNTY HEALTH AUTHORITY Formulary Contact 1120 West La Veta Avenue Orange CA 92868 HMOH5433 ORANGE COUNTY HEALTH AUTHORITY MA Claims Processing 1120 W. La Veta Avenue Orange CA 92868 HMOH5434 BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. Formulary Contact 4800 Deerwood Campus Pkwy Bldg 3, Floor 6 Jacksonville, FL 32246 PPOH5434 BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. MA Claims Processing 4800 Deerwood Campus Pkwy Jacksonville FL 32246 PPOH5435 PACIFICARE LIFE AND HEALTH INSURANCE COMPANY MA Claims Processing 3100 Lake Center Dr M/S LC03-377 Santa Ana CA 92704 PFFSH5436 AVMED, INC. Formulary Contact AvMed Health Plans 4300 N.W. 89th Blvd Gainesville FL 32606 PPOH5436 AVMED, INC. MA Claims Processing 4300 NW 89 Blvd. Gainesville FL 32606 PPOH5437 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH5437 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5439 HEALTH NET LIFE INSURANCE COMPANY Formulary Contact 10834 International Dr., Ste. 200 Rancho cordova CA 95670 PPOH5439 HEALTH NET LIFE INSURANCE COMPANY MA Claims Processing 21281 Burbank Blvd. Building B Woodland Hills CA 91367 PPOH5440 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 HMOH5440 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 HMOH5500 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5500 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5501 TENET CHOICES, INC. / PEOPLES HEALTH NETWORK Formulary Contact 200 W Esplanade Ave Suite 600 Kenner LA 70065 PPOH5501 TENET CHOICES, INC. / PEOPLES HEALTH NETWORK MA Claims Processing 200 W Esplanade Ave Suite 600 Kenner LA 70065 PPOH5506 COVENTRY HEALTH AND LIFE INS. COMPANY Formulary Contact 111 Corporate Office Dr., Suite 400 Earth City MO 63045 PPOH5506 COVENTRY HEALTH AND LIFE INS. COMPANY MA Claims Processing 111 Corporate Office Dr., Suite 400 Earth City MO 63045 PPOH5507 UNITED HEALTHCARE INS. COMPANY, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5507 UNITED HEALTHCARE INS. COMPANY, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5508 ADVANTAGE HEALTH SOLUTIONS, INC. Formulary Contact 9490 Priority Way West Drive Indianapolis IN 46240 PPOH5508 ADVANTAGE HEALTH SOLUTIONS, INC. MA Claims Processing 9490 Priority Way West Drive Indianapolis IN 46240 PPOH5509 COVENTRY HEALTH AND LIFE INS. COMPANY Formulary Contact 4300 Cox Road Glen Allen VA 23060 PPOH5509 COVENTRY HEALTH AND LIFE INS. COMPANY MA Claims Processing 8320 Ward Parkway Kansas City MO 64114 PPOH5510 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH5510 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5512 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH5512 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5514 MANAGED HEALTH INC. Formulary Contact 25 Broadway, 9th Floor New York NY 10004 PPOH5514 MANAGED HEALTH INC. MA Claims Processing 25 Broadway, 9th Floor New York NY 10004 PPOH5515 UNITED HEALTHCARE INS. COMPANY OF NY, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5515 UNITED HEALTHCARE INS. COMPANY OF NY, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5516 UNITED HEALTHCARE INS. COMPANY, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5516 UNITED HEALTHCARE INS. COMPANY, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5517 COVENTRY HEALTH AND LIFE INS. COMPANY Formulary Contact 2751 Centerville Road Wilmington DE 19808 PPOH5517 COVENTRY HEALTH AND LIFE INS. COMPANY MA Claims Processing 11 Stanwix Street Pittsburgh PA 15222 PPOH5518 UNITED HEALTHCARE INS. COMPANY, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5518 UNITED HEALTHCARE INS. COMPANY, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5520 HEALTH NET LIFE INSURANCE COMPANY Formulary Contact 10834 International Dr., Ste. 200 Rancho Cordova CA 95670 PPOH5520 HEALTH NET LIFE INSURANCE COMPANY MA Claims Processing 21281 Burbank Blvd. Building B3 Woodland Hills CA 91367 PPOH5521 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH5521 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5522 HEALTH ASSURANCE PENNSYLVANIA, INC. Formulary Contact 3721 TecPort Drive Harrisburg PA 17106 PPOH5522 HEALTH ASSURANCE PENNSYLVANIA, INC. MA Claims Processing 11 Stanwix Street Suite 2300 Pittsburgh PA 15222 PPOH5523 CARITEN INSURANCE COMPANY Formulary Contact 1420 Centerpoint Blvd Knoxville TN 37932 PPOH5523 CARITEN INSURANCE COMPANY MA Claims Processing 1420 Centerpoint Blvd. Knoxville TN 37932 PPOH5524 HEALTHSPRING OF TENNESSEE, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 PPOH5524 HEALTHSPRING OF TENNESSEE, INC. MA Claims Processing 44 Vantage Way - Suite 300 Nashville TN 37228 PPOH5525 OSF HEALTHPLANS, INC. Formulary Contact 7915 N. Hale Ave., Ste. D Peoria IL 61615 PPOH5525 OSF HEALTHPLANS, INC. MA Claims Processing 7915 N. Hale Ave., Ste D Peoria IL 61615 PPOH5526 HEALTHNOW NEW YORK INC. Formulary Contact 10201 East 92nd Street North Owasso OK 74055 PPOH5526 HEALTHNOW NEW YORK INC. MA Claims Processing 1901 Main Street Buffalo NY 14208 PPOH5527 UNITED HEALTHCARE INS. COMPANY, INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5527 UNITED HEALTHCARE INS. COMPANY, INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5528 GROUP HEALTH INCORPORATED Formulary Contact 441 Ninth Ave New York NY 10001 PPOH5528 GROUP HEALTH INCORPORATED MA Claims Processing 789 Grant Ave. Lake Katrine NY 12449 PPOH5529 COMMUNITY INSURANCE COMPANY Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 PPOH5529 COMMUNITY INSURANCE COMPANY MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 PPOH5530 ANTHEM HEALTH PLANS OF KENTUCKY, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 PPOH5530 ANTHEM HEALTH PLANS OF KENTUCKY, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 PPOH5531 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PPOH5531 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PPOH5532 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 PPOH5532 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 PPOH5533 UPMC HEALTH NETWORK Formulary Contact 112 Washington Place Suite 800 Pittsburgh PA 15219 PPOH5533 UPMC HEALTH NETWORK MA Claims Processing 112 Washington Place Suite 800 Pittsburgh PA 15219 PPOH5575 FIDELIS SECURECARE OF NORTH CAROLINA Formulary Contact 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH5575 FIDELIS SECURECARE OF NORTH CAROLINA MA Claims Processing 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH5580 SOUTHWEST CATHOLIC HEALTH NETWORK CORPORATION Formulary Contact 4645 E Cotton Center Blvd Building 1, Suite 200 Phoenix AZ 85040 HMOH5580 SOUTHWEST CATHOLIC HEALTH NETWORK CORPORATION MA Claims Processing 4645 E Cotton Center Blvd Phoenix AZ 85040 HMOH5586 SOUTH DAKOTA STATE MEDICAL HOLDING COMPANY, INC. Formulary Contact 1323 S Minnesota Avenue Sioux Falls SD 57105 HMOH5586 SOUTH DAKOTA STATE MEDICAL HOLDING COMPANY, INC. MA Claims Processing 1323 S Minnesota Avenue Sioux Falls SD 57105 HMOH5587 HEALTH CHOICE ARIZONA, INC. Formulary Contact 1600 W. Broadway Suite 260 Tempe AZ 85282 HMOH5587 HEALTH CHOICE ARIZONA, INC. MA Claims Processing 1600 W Broadway, Ste 110 Tempe AZ 85282 HMOH5598 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East,MN008-T500 Minnetonka MN 55343 ESRD IIH5598 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 ESRD IIH5602 STERLING LIFE INSURANCE COMPANY (PA) Formulary Contact 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 PFFSH5602 STERLING LIFE INSURANCE COMPANY (PA) MA Claims Processing 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 PFFS

H5604 AVETA HEALTH ILLINOIS, INC. Formulary Contact 4415 West Harrison Street Suite 300 Hillside IL 60162 HMOH5604 AVETA HEALTH ILLINOIS, INC. MA Claims Processing 4415 W. Harrsion Street Suite 300 Hillside IL 60162-1953 HMOH5606 STERLING LIFE INSURANCE COMPANY MA Claims Processing 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 ESRD IH5608 DENVER HEALTH MEDICAL PLAN, INC. Formulary Contact 9501 East Shea Blvd MC 005 Scottsdale AZ 85260-6719 HMOH5608 DENVER HEALTH MEDICAL PLAN, INC. MA Claims Processing 777 Bannock St Mail Code 6000 Denver CO 80204 HMOH5628 MOLINA HEALTHCARE OF UTAH, INC. Formulary Contact ONE GOLDEN SHORE DRIVE LONG BEACH CA 90802 HMOH5628 MOLINA HEALTHCARE OF UTAH, INC. MA Claims Processing One Golden Shore Dr. Long Beach CA 90802 HMOH5637 FIDELIS SECURECARE OF COLORADO Formulary Contact 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH5637 FIDELIS SECURECARE OF COLORADO MA Claims Processing 1700 East Golf Road Suite 1115 Schaumburg IL 60173 HMOH5649 CENTRAL HEALTH PLAN OF CALIFORNIA, INC. Formulary Contact 1051 Park View Drive Suite 120 Covina CA 91724 HMOH5649 CENTRAL HEALTH PLAN OF CALIFORNIA, INC. MA Claims Processing 1051 Park View Drive Suite 120 Covina CA 91724 HMOH5652 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Continuing Care Retirement CommunityH5652 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 Continuing Care Retirement CommunityH5665 CARE IMPROVEMENT ASSOCIATES OF MARYLAND Formulary Contact 351 W Camden St Suite 100 Baltimore MD 21201 HMOH5665 CARE IMPROVEMENT ASSOCIATES OF MARYLAND MA Claims Processing 351 W Camden St Suite 100 Baltimore MD 21201 HMOH5678 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Continuing Care Retirement CommunityH5678 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East Minnetonka MN 55343 Continuing Care Retirement CommunityH5683 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 PFFSH5683 HUMANA INSURANCE COMPANY MA Claims Processing 500 W. Main Street Louisville KY 40202 PFFSH5685 MIDWEST HEALTH PLAN, INC. Formulary Contact 5050 SCHAEFER ROAD DEARBORN MI 48126 HMOH5685 MIDWEST HEALTH PLAN, INC. MA Claims Processing 5050 Schaefer Road Dearborn MI 48126 HMOH5696 PHYSICIANS UNITED PLAN, INC. Formulary Contact 14301 First National Bank Parkway Suite 200 Omaha NE 68154 HMOH5696 PHYSICIANS UNITED PLAN, INC. MA Claims Processing 1124 First Street South Winter Haven FL 33880 HMOH5697 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Continuing Care Retirement CommunityH5697 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East Minnetonka MN 55343 Continuing Care Retirement CommunityH5698 WINDSOR HEALTH PLAN OF TN INC. Formulary Contact 7100 Commerce Way, Ste 285 Brentwood TN 37027 HMOH5698 WINDSOR HEALTH PLAN OF TN INC. MA Claims Processing 7100 Commerce Way, Ste 285 Brentwood TN 37027 HMOH5700 ARKANSAS COMMUNITY CARE Formulary Contact 825 Washington St., Suite 300 Oakland CA 94607 HMOH5700 ARKANSAS COMMUNITY CARE MA Claims Processing 858 Oak Park Rd. Suite 250 Covina CA 91724 HMOH5703 SOUTH COUNTRY HEALTH ALLIANCE Formulary Contact Prime Therapeutics Inc. 1020 Discovery Road No. 100 Eagan MN 55121 HMOH5703 SOUTH COUNTRY HEALTH ALLIANCE MA Claims Processing 110 W Fremont Street Owatonna MN 55060 HMOH5729 CAREONE HEALTH PLAN, INC. Formulary Contact 5501 West Waters Ave. Suite 401 Tampa FL 33634 HMOH5729 CAREONE HEALTH PLAN, INC. MA Claims Processing 5501 West Waters Ave. Suite 401 Tampa FL 33634 HMOH5732 AUXILIO PLATINO, INC. Formulary Contact 200 W Esplanade Ave Suite 600 Kenner LA 70065 HMOH5732 AUXILIO PLATINO, INC. MA Claims Processing 200 W Esplanade Ave Suite 600 Kenner LA 70065 HMOH5736 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 PFFSH5736 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 PFFSH5750 METROPOLITAN HEALTH PLAN Formulary Contact 822 SOUTH THIRD STREET, SUITE 140 MINNEAPOLIS MN 55415 HMOH5750 METROPOLITAN HEALTH PLAN MA Claims Processing 822 SOUTH THIRD STREET, SUITE 140 MINNEAPOLIS MN 55415 HMOH5754 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Continuing Care Retirement CommunityH5754 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55343 Continuing Care Retirement CommunityH5757 RED MEDICA DE PUERTO RICO, INC. Formulary Contact 293 Arterial Hostos Ave. Capital Center Building South Tower Suite 704 San Juan PR 918 HMOH5757 RED MEDICA DE PUERTO RICO, INC. MA Claims Processing 293 Arterial Hostos Ave. Capital Center Building South Tower Suite 704 San Juan PR 918 HMOH5760 COOPERATIVA DE SEGUROS DE VIDA DE PUERTO RICO Formulary Contact PO Box 363428 San Juan PR 936 HMOH5760 COOPERATIVA DE SEGUROS DE VIDA DE PUERTO RICO MA Claims Processing PO BOX 363428 SAN JUAN PR 00936-3428 HMOH5774 AMERICAN HEALTH, INC. Formulary Contact American Health Medicare PO Box 11320 San JUan PR 00922-9907 HMOH5774 AMERICAN HEALTH, INC. MA Claims Processing American Health Medicare PO BOx 11320 Caparra PR 00922-9907 HMOH5810 MOLINA HEALTHCARE OF CALIFORNIA Formulary Contact One Golden Shore Drive Long Beach CA 90802 HMOH5810 MOLINA HEALTHCARE OF CALIFORNIA MA Claims Processing One Golden Shore Dr. Long Beach CA 90802 HMOH5811 MEDCORE HP Formulary Contact 509 West Weber Avenue Suite 200 Stockton CA 95203 HMOH5811 MEDCORE HP MA Claims Processing 509 West Weber Avenue Suite 200 Stockton CA 95203 HMOH5812 GEISINGER INDEMNITY INSURANCE COMPANY Formulary Contact 100 North Academy Avenue Danville PA 17822-3020 PFFSH5812 GEISINGER INDEMNITY INSURANCE COMPANY MA Claims Processing 100 North Academy Avenue Danville PA 17822-3029 PFFSH5817 AMERIGROUP TEXAS, INC. Formulary Contact AMERIGROUP Corporation 4425 Corporation Lane, #300 Virginia Beach, VA 23462 HMOH5817 AMERIGROUP TEXAS, INC. MA Claims Processing AMERIGROUP Corporation 4425 Corporation Lane Virginia Beach VA 23462 HMOH5821 MAPFRE LIFE INSURANCE COMPANY Formulary Contact PO Box 70297 San Juan PR 00936-8297 HMOH5821 MAPFRE LIFE INSURANCE COMPANY MA Claims Processing PO Box 70297 San Juan PR 00936-8297 HMOH5823 MOLINA HEALTHCARE OF WASHINGTON, INC. Formulary Contact ONE GOLDEN SHORE DRIVE LONG BEACH CA 90802 HMOH5823 MOLINA HEALTHCARE OF WASHINGTON, INC. MA Claims Processing One Golden Shore Dr Long Beach CA 90802 HMOH5838 COMMONWEALTH CARE ALLIANCE Formulary Contact 30 Winter Street, 7th Floor Boston MA 2108 HMOH5838 COMMONWEALTH CARE ALLIANCE MA Claims Processing 30 Winter Street, 7th Floor Boston MA 2108 HMOH5839 STERLING LIFE INSURANCE COMPANY (MT) Formulary Contact 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 PFFSH5839 STERLING LIFE INSURANCE COMPANY (MT) MA Claims Processing 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 PFFSH5842 BC LIFE & HEALTH INSURANCE COMPANY Formulary Contact 8407 Fallbrook Avenue AF5 West Hills CA 91304 PFFSH5842 BC LIFE & HEALTH INSURANCE COMPANY MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 PFFSH5850 SUMMIT HEALTH PLAN, INC. Formulary Contact 1340 Concord Terrace Sunrise FL 33323 HMOH5850 SUMMIT HEALTH PLAN, INC. MA Claims Processing 300 South Park Road Hollywood FL 33021 HMOH5852 AIDS HEALTHCARE FOUNDATION Formulary Contact 1001 N. MARTEL AVE. LOS ANGELES CA 90046 HMOH5852 AIDS HEALTHCARE FOUNDATION MA Claims Processing 1001 NORTH MARTEL AVE LOS ANGELES CA 90046 HMOH5859 HEALTH PLAN OF CAREOREGON, INC. Formulary Contact CareOregon Advantage 522 SW Fifth Avenue, Suite 200 Portland OR 97204 HMOH5859 HEALTH PLAN OF CAREOREGON, INC. MA Claims Processing CareOregon Advantage 522 SW Fifth Avenue, Suite 200 Portland OR 97204 HMOH5883 BLUE CARE NETWORK OF MICHIGAN Formulary Contact 20500 Civic Center Drive Southfield MI 48076 HMOH5883 BLUE CARE NETWORK OF MICHIGAN MA Claims Processing 611 Cascade W. Parkway Grand Rapids MI 49546 HMOH5884 BLUECROSS BLUESHIELD OF TENNESSEE Formulary Contact 801 Pine Street Chattanooga TN 37402 PFFSH5884 BLUECROSS BLUESHIELD OF TENNESSEE MA Claims Processing 801 Pine Street Chattanooga TN 37402 PFFSH5893 ELDER CARE HEALTH PLAN, INC. Formulary Contact 2802 International Lane Madison WI 53704 HMOH5893 ELDER CARE HEALTH PLAN, INC. MA Claims Processing 2802 International Lane Madison WI 53704 HMOH5908 SUN HEALTH MEDISUN, INC. MA Claims Processing P.O. Box 1489 13632 N. 99th Ave, Suite B Sun City AZ 85372 PFFSH5909 AMERICAN PROGRESSIVE LIFE & HEALTH OF NEW YORK MA Claims Processing 4888 Loop Central Drive Suite 700 Houston TX 77081 ESRD IH5918 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East MN008-T500 Minnetonka MN 55347 Continuing Care Retirement CommunityH5918 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 9900 Bren Road East MN008-W130 Minnetonka MN 55347 Continuing Care Retirement CommunityH5926 MOLINA HEALTHCARE OF MICHIGAN Formulary Contact ONE GOLDEN SHORE DRIVE LONG BEACH CA 90802 HMOH5926 MOLINA HEALTHCARE OF MICHIGAN MA Claims Processing One Golden Shore Drive Long Beach CA 90802 HMOH5932 GATEWAY HEALTH PLAN, INC. Formulary Contact 600 GRANT STREET US STEEL BUILDING, 41ST FLOOR PITTSBURGH PA 15219-2704 HMOH5932 GATEWAY HEALTH PLAN, INC. MA Claims Processing 600 Grant Street - 41st Floor Pittsburgh PA 15219 HMOH5936 AMERICAN PIONEER LIFE INSURANCE COMPANY Formulary Contact 4888 Loop Central Drive Suite 800 Houston TX 77081 HMOH5936 AMERICAN PIONEER LIFE INSURANCE COMPANY MA Claims Processing 4888 Loop Central Drive Suite 700 Houston TX 77081 HMOH5938 CAPITAL HEALTH PLAN Formulary Contact 2140 Centerville Place Tallahassee FL 32308 HMOH5938 CAPITAL HEALTH PLAN MA Claims Processing P.O. Box 15349 Tallahassee FL 32317 HMOH5942 SUNCOAST PHYSICIANS HEALT PLAN, INC. Formulary Contact 330 North Andrews Avenue Ft. Lauderdale FL 33301 HMOH5942 SUNCOAST PHYSICIANS HEALT PLAN, INC. MA Claims Processing 2900 Glades Circle Suite 250 Weston FL 33327 HMOH5943 SCAN HEALTH PLAN Formulary Contact 3800 Kilroy Airport Way Suite 100 Long Beach CA 90806 ESRD II

H5943 SCAN HEALTH PLAN MA Claims Processing 3800 Kilroy Airport Way Suite 100 Long Beach CA 90806 ESRD IIH5962 STERLING LIFE INSURANCE COMPANY MA Claims Processing 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 ESRD IH5969 ALOHACARE Formulary Contact 1357 Kapiolani Blvd., Suite 1250 Honolulu HI 96814 HMOH5969 ALOHACARE MA Claims Processing 1357 Kapiolani Blvd., Suite 1250 Honolulu HI 96814 HMOH5985 ABRAZO ADVANTAGE HEALTH PLAN Formulary Contact 7878 N. 16th St. Suite 105 Phoenix AZ 85020 HMOH5985 ABRAZO ADVANTAGE HEALTH PLAN MA Claims Processing 7878 N. 16th St., #105 Phoenix AZ 85020 HMOH5995 MARION POLK COMMUNITY HEALTH PLAN ADVANTAGE, INC. Formulary Contact 198 Commercial St. SE, Ste. 240 Salem OR 97301 HMOH5995 MARION POLK COMMUNITY HEALTH PLAN ADVANTAGE, INC. MA Claims Processing 198 Commercial St. SE, Ste. 240 Salem OR 97301 HMOH6360 KAISER FOUNDATION HP OF OHIO Formulary Contact 5420 Lancaster Drive Pharmacy Administration Brooklyn Heights OH 44131 1876 CostH6360 KAISER FOUNDATION HP OF OHIO MA Claims Processing 5420 Lancaster Drive Pharmacy Administration Brooklyn Heights OH 44131 1876 CostH9001 FALLON COMMUNITY HEALTH PLAN Formulary Contact One Chestnut Place 10 Chestnut Street Worcester MA 1608 HMOH9001 FALLON COMMUNITY HEALTH PLAN MA Claims Processing One Chestnut Place 10 Chestnut Street Worcester MA 1608 HMOH9003 KAISER FOUNDATION HP OF THE N W Formulary Contact 5725 NE 138th Avenue Portland OR 97230 HMOH9003 KAISER FOUNDATION HP OF THE N W MA Claims Processing 7201 N Interstate Ave Portland OR 97232 HMOH9005 GROUP HEALTH PLAN, INC. Formulary Contact 8100 34th Avenue South PO Box Minneapolis MN 55440 HMOH9005 GROUP HEALTH PLAN, INC. MA Claims Processing 8100 34th Avenue South PO Box Minneapolis MN 55440 HMOH9011 UNITED HEALTHCARE OF FLORIDA INC. Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minneatonka MN 55343 HMOH9011 UNITED HEALTHCARE OF FLORIDA INC. MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 HMOH9016 UHP HEALTHCARE Formulary Contact 3405 Imperial Hwy Inglewood CA 90303 HMOH9016 UHP HEALTHCARE MA Claims Processing 3405 West Imperial Hwy Inglewood CA 90303 HMOH9047 PROVIDENCE HEALTH PLAN Formulary Contact PO BOX 3125 PORTLAND OR 97208-3125 HMOH9047 PROVIDENCE HEALTH PLAN MA Claims Processing 3601 SW Murray Blvd Beaverton OR 97005 HMOH9101 ELDERPLAN, INC. - SHMO Formulary Contact 745 64th Street Brooklyn NY 11220 SHMOH9101 ELDERPLAN, INC. - SHMO MA Claims Processing Elderplan, Inc 745 64th Street Brooklyn NY 11220-4713 SHMOH9103 KAISER FOUNDATION HP OF THE N W Formulary Contact 5725 NE 138th Avenue Portland OR 97230 SHMOH9103 KAISER FOUNDATION HP OF THE N W MA Claims Processing 7201 N Interstate Ave Portland OR 97232 SHMOH9104 SCAN HEALTH PLAN Formulary Contact 3800 Kilroy Airport Way Suite 100 Long Beach CA 90806 SHMOH9104 SCAN HEALTH PLAN MA Claims Processing 3800 Kilroy Airport Way Suite 100 Long Beach CA 90806 SHMOR3175 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact 9900 Bren Road East Minnetonka MN 55343 Regional PPOR3175 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 Regional PPOR3175 UNITED HEALTHCARE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1417 Lake Cook Road Deerfield IL 60015 Regional PPOR5287 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Regional PPOR5287 UNITED HEALTHCARE INSURANCE COMPANY MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 Regional PPOR5287 UNITED HEALTHCARE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1417 Lake Cook Road MS L457 Deerfield IL 60015 Regional PPOR5342 UNITED HEALTHCARE INSURANCE COMPANY OF NEW YORK Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Regional PPOR5342 UNITED HEALTHCARE INSURANCE COMPANY OF NEW YORK MA Claims Processing 2725 Mall Drive Eau Claire WI 54701 Regional PPOR5342 UNITED HEALTHCARE INSURANCE COMPANY OF NEW YORK Pharmacy Benefit Manager Contact 1 1417 Lake Cook Road MS L457 Deerfield IL 60015 Regional PPOR5553 INSTIL HEALTH INSURANCE COMPANY Formulary Contact 17 Technology Circle Columbia SC 29203 Regional PPOR5553 INSTIL HEALTH INSURANCE COMPANY MA Claims Processing 17 Technology Circle Columbia SC 29203 Regional PPOR5553 INSTIL HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 MedImpact Healthcare Systems, Inc 10680 Treena Street San Diego CA 92131 Regional PPOR5566 BLUE CROSS BLUE SHIELD NORTHERN PLAINS ALLIANCE Formulary Contact Blue Cross and Blue Shield of Minnesota 3400 Yankee Drive Eagan MN 55122 Regional PPOR5566 BLUE CROSS BLUE SHIELD NORTHERN PLAINS ALLIANCE MA Claims Processing Wellmark Blue Cross and Blue Shield 636 Grand Avenue, Sta. 94 Des Moines IA 50309 Regional PPOR5566 BLUE CROSS BLUE SHIELD NORTHERN PLAINS ALLIANCE Pharmacy Benefit Manager Contact 1 1020 Discovery Road Eagan MN 55121-2095 Regional PPOR5595 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2362 Regional PPOR5595 AETNA LIFE INSURANCE COMPANY MA Claims Processing 1 Farr View Drive Cranbury NJ 8512 Regional PPOR5595 AETNA LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 11100 Wayzata Blvd., Ste. 400 Mail Stop F615 Minnetonka MN 55305 Regional PPOR5674 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Formulary Contact 2716 N. Tenaya Way Las Vegas NV 89128 Regional PPOR5674 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. MA Claims Processing 2716 N. Tenaya Way Las Vegas NV 89128 Regional PPOR5674 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Pharmacy Benefit Manager Contact 1 2716 N. Tenaya Way Las Vegas NV 89128 Regional PPOR5826 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 Regional PPOR5826 HUMANA INSURANCE COMPANY MA Claims Processing 500 West Main Street Louisville KY 40202 Regional PPOR5826 HUMANA INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 500 West Main Street Louisville KY 40202 Regional PPOR5863 HEALTH NET LIFE INSURANCE COMPANY Formulary Contact 10843 International Dr., Ste. 200 Rancho Cordova CA 95670 Regional PPOR5863 HEALTH NET LIFE INSURANCE COMPANY MA Claims Processing 1230 W. Washington St. Tempe AZ 85281 Regional PPOR5863 HEALTH NET LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 10843 International Dr., Ste. 200 Rancho Cordove CA 95670 Regional PPOR5941 ANTHEM INSURANCE COMPANIES, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 Regional PPOR5941 ANTHEM INSURANCE COMPANIES, INC. MA Claims Processing 4361 Irwin Simpson Road OH12C-535 Mason OH 45040-9498 Regional PPOR5941 ANTHEM INSURANCE COMPANIES, INC. Pharmacy Benefit Manager Contact 1 11365 Westwood Road Alden NY 14004 Regional PPOR9943 BC LIFE & HEALTH INSURANCE COMPANY Formulary Contact 8407 Fallbrook Avenue AF5 West Hills CA 91304 Regional PPOR9943 BC LIFE & HEALTH INSURANCE COMPANY MA Claims Processing 2100 Corporate Center Drive - NQ01E Newbury Park CA 91320 Regional PPOR9943 BC LIFE & HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1651 Christy Drive St. Charles MO 63303 Regional PPOS0043 PREFERRED MEDICARE CHOICE, INC. Formulary Contact 1551 Calle Alda Urb. Caribe Suite 201 San Juan PR 00926-2709 Medicare Prescription Drug PlanS0043 PREFERRED MEDICARE CHOICE, INC. Pharmacy Benefit Manager Contact 1 1551 Calle Alda Urb. Caribe Suite 201 San Juan PR 00926-2709 Medicare Prescription Drug PlanS0197 CAMBRIDGE LIFE INSURANCE COMPANY Formulary Contact 501 Corporate Centre Drive Franklin TN 37067 Medicare Prescription Drug PlanS0197 CAMBRIDGE LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 501 Corporate Centre Drive Franklin TN 37067 Medicare Prescription Drug PlanS0654 IBT VOLUNTARY EMPLOYEE BENEFITS TRUST Formulary Contact 3515 Harbor Boulevard Costa Mesa CA 92626 Employer Sponsored PDPS0654 IBT VOLUNTARY EMPLOYEE BENEFITS TRUST Pharmacy Benefit Manager Contact 1 3515 Harbor Boulevard Costa Mesa CA 92626 Employer Sponsored PDPS1539 THE PORT OF AUTHORITY OF NEW YORK AND NEW JERSEY Formulary Contact 711 Ridgedale Avenue East Hanover NJ 7936 Employer Sponsored PDPS1539 THE PORT OF AUTHORITY OF NEW YORK AND NEW JERSEY Pharmacy Benefit Manager Contact 1 711 Ridgedale Avenue East Hanover NJ 7936 Employer Sponsored PDPS1566 ELDER HEALTH TEXAS, INC Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 Medicare Prescription Drug PlanS1566 ELDER HEALTH TEXAS, INC Pharmacy Benefit Manager Contact 1 3601 O'Donnell Street Baltimore MD 21224 Medicare Prescription Drug PlanS2321 QCC INS CO D/B/A AMERIHEALTH INS CO Formulary Contact 1700 Market Street Philadelphia PA 19103 Medicare Prescription Drug PlanS2321 QCC INS CO D/B/A AMERIHEALTH INS CO Pharmacy Benefit Manager Contact 1 1700 Market Street Philadelphia PA 19103 Medicare Prescription Drug PlanS2332 NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION Formulary Contact 7334 Woodgrove Court Castle Rock CO 80108 Employer Sponsored PDPS2332 NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION Pharmacy Benefit Manager Contact 1 4301 Wilson Blvd Arlington VA 22203 Employer Sponsored PDPS2468 CA PHYSICIANS' SERVICE DBA BLUE SHIELD OF CA Formulary Contact 4205 Town Center Drive El Dorado Hills El Dorado Hills CA 95762 Medicare Prescription Drug PlanS2468 CA PHYSICIANS' SERVICE DBA BLUE SHIELD OF CA Pharmacy Benefit Manager Contact 1 50 Beale Street San Francisco CA 94105 Medicare Prescription Drug PlanS2630 C & O EMPLOYEES HOSPITAL ASSOCIATION Formulary Contact 511 Main Street, 2nd Floor Clifton Forge VA 24422 Employer Sponsored PDPS2630 C & O EMPLOYEES HOSPITAL ASSOCIATION Pharmacy Benefit Manager Contact 1 26 Harbor Park Drive Port Washington NY 11050 Employer Sponsored PDPS2770 QCC INS CO D/B/A AMERIHEALTH INS CO Formulary Contact 200 Stevens Drive Philadelphia PA 19113 Medicare Prescription Drug PlanS2770 QCC INS CO D/B/A AMERIHEALTH INS CO Pharmacy Benefit Manager Contact 1 1700 Market Street, MK 12 Philadelphia PA 19103 Medicare Prescription Drug PlanS2868 CARPENTER'S HEALTH & WELFARE TRUST FUND OF STL Formulary Contact 1061 Peruque Crossing Ct. Ofallon MO 63366 Employer Sponsored PDPS2868 CARPENTER'S HEALTH & WELFARE TRUST FUND OF STL Pharmacy Benefit Manager Contact 1 11467 Huebner Rd. Ste 260 San Antonio TX 78230 Employer Sponsored PDPS2893 BLUE CROSS BLUE SHIELD NEW ENGLAND ALLIANCE Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 Medicare Prescription Drug PlanS2893 BLUE CROSS BLUE SHIELD NEW ENGLAND ALLIANCE Pharmacy Benefit Manager Contact 1 11365 Westwood Road Alden NY 14004 Medicare Prescription Drug PlanS3014 PSERS HOP PROGRAM Formulary Contact 168 Franklin Corner Rd. Building 2, Suite 201 Lawrenceville NJ 8109 Employer Sponsored PDPS3014 PSERS HOP PROGRAM Pharmacy Benefit Manager Contact 1 168 Franklin Corner Rd. Bldg 2, Suite 201 Lawrenceville NJ 8648 Employer Sponsored PDPS3389 UPMC HEALTH PLAN Formulary Contact 112 Washington Place Pittsburgh PA 15219 Medicare Prescription Drug PlanS3389 UPMC HEALTH PLAN Pharmacy Benefit Manager Contact 1 112 Washington Place Pittsburgh PA 15219 Medicare Prescription Drug PlanS3521 EXCELLUS HEALTH PLAN, INC Formulary Contact 165 Court Street Rochester NY 14647 Medicare Prescription Drug PlanS3521 EXCELLUS HEALTH PLAN, INC Pharmacy Benefit Manager Contact 1 165 Court Street Rochester NY 14647 Medicare Prescription Drug PlanS4167 HARRIS CORPORATION Formulary Contact 4301 North Fairfax Drive Suite 600 Arlington VA 22203 Employer Sponsored PDP

S4167 HARRIS CORPORATION Pharmacy Benefit Manager Contact 1 1025 West Nasa Blvd Melbourne FL 32919 Employer Sponsored PDPS4231 UNIVERSAL HEALTH CARE, INC. Formulary Contact 14301 First Bank Parkway Suite 200 Omaha NE 68154 Medicare Prescription Drug PlanS4231 UNIVERSAL HEALTH CARE, INC. Pharmacy Benefit Manager Contact 1 14301 First Bank Parkway Suite 200 Omaha NE 68154 Medicare Prescription Drug PlanS4744 MO DOT & MSHP MEDICAL AND LIFE INS PLAN Formulary Contact 1061 Peruque Crossing Ct. Ofallon MO 63366 Employer Sponsored PDPS4744 MO DOT & MSHP MEDICAL AND LIFE INS PLAN Pharmacy Benefit Manager Contact 1 11467 Huebner Rd. Ste 260 San Antonio TX 78230 Employer Sponsored PDPS4802 STERLING LIFE INSURANCE COMPANY Formulary Contact 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 Medicare Prescription Drug PlanS4802 STERLING LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 9501 E Shea Boulevard Scottsdale AZ 85260 Medicare Prescription Drug PlanS5540 BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA Formulary Contact Blue Cross and Blue Shield of North Carolina 5901 Chapel Hill Road Durham NC 27707 Medicare Prescription Drug PlanS5540 BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA Pharmacy Benefit Manager Contact 1 Medco Health Solutions, Inc. 100 Parsons Pond Drive Franklin Lakes NJ 7417 Medicare Prescription Drug PlanS5552 HUMANA INSURANCE COMPANY OF NEW YORK Formulary Contact 500 West Main Street Louisville KY 40202 Medicare Prescription Drug PlanS5552 HUMANA INSURANCE COMPANY OF NEW YORK Pharmacy Benefit Manager Contact 1 500 West Main Street Louisville KY 40202 Medicare Prescription Drug PlanS5555 MCS LIFE INSURANCE COMPANY (H4006) Formulary Contact Suite 201 255 Ponce De Leon Avenue San Juan PR 917 Medicare Prescription Drug PlanS5555 MCS LIFE INSURANCE COMPANY (H4006) Pharmacy Benefit Manager Contact 1 East Shea Boulevard 9501 MC032 Scottsdale AR 85260-6719 Medicare Prescription Drug PlanS5557 FOX INSURANCE COMPANY Formulary Contact 6263 North Scottsdale Road Suite 200 Scottsdale AZ 85250 Medicare Prescription Drug PlanS5557 FOX INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 45 Commerce Drive, Suite 5, PO Box 1090 Augusta ME 4332 Medicare Prescription Drug PlanS5566 GROUP HEALTH SERVICES OF OKLAHOMA, INC. Formulary Contact 1400 S. Boston Tulsa OK 74119 Medicare Prescription Drug PlanS5566 GROUP HEALTH SERVICES OF OKLAHOMA, INC. Pharmacy Benefit Manager Contact 1 1020 Discover Road Eagan MN 55121 Medicare Prescription Drug PlanS5569 CAMBRIDGE LIFE INSURANCE COMPANY Formulary Contact 4300 Cox Road Glenn Allen VA 23060 Medicare Prescription Drug PlanS5569 CAMBRIDGE LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 4300 Cox Road Glenn Allen VA 23060 Medicare Prescription Drug PlanS5578 HEALTHSPRING, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 Medicare Prescription Drug PlanS5578 HEALTHSPRING, INC. Pharmacy Benefit Manager Contact 1 1300 Washginton St Kansas MO 64105 Medicare Prescription Drug PlanS5580 FIRST UNITED AMERICAN LIFE INSURANCE COMPANY Formulary Contact 3700 S. Stonebridge Drive McKinney TX 75070 Medicare Prescription Drug PlanS5580 FIRST UNITED AMERICAN LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 3700 S. Stonebridge Drive McKinney TX 75070 Medicare Prescription Drug PlanS5581 MARQUETTE NATIONAL LIFE INSURANCE COMPANY Formulary Contact 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5581 MARQUETTE NATIONAL LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5584 BLUE CROSS BLUE SHIELD OF MICHIGAN Formulary Contact 27000 W. Eleven MIle Road MC B773 Southfield MI 48034 Medicare Prescription Drug PlanS5584 BLUE CROSS BLUE SHIELD OF MICHIGAN Pharmacy Benefit Manager Contact 1 27000 W. Eleven Mile Road MC B775 Southfield MI 48034 Medicare Prescription Drug PlanS5585 HEALTHNOW NEW YORK INC. Formulary Contact 10201 East 92nd Street North Owasso OK 74055 Medicare Prescription Drug PlanS5585 HEALTHNOW NEW YORK INC. Pharmacy Benefit Manager Contact 1 1651 Christy Drive St. Charles MO 63303 Medicare Prescription Drug PlanS5588 PROMEDICA LIFE INS D/B/A PARAMOUNT INS CO Formulary Contact 1901 Indian Wood Circle Maumee OH 43537 Medicare Prescription Drug PlanS5588 PROMEDICA LIFE INS D/B/A PARAMOUNT INS CO Pharmacy Benefit Manager Contact 1 1901 Indian Wood Circle Maumee OH 43537 Medicare Prescription Drug PlanS5593 HIGHMARK SENIOR RESOURCES INC. Formulary Contact 120 Fifth Avenue Ste. 1812 Pittsburgh PA 15222 Medicare Prescription Drug PlanS5593 HIGHMARK SENIOR RESOURCES INC. Pharmacy Benefit Manager Contact 1 3 Gateway Center, Suite 250 401 Liberty Avenue Pittsburgh PA 15222 Medicare Prescription Drug PlanS5596 ANTHEM INSURANCE COMPANIES, INC. Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 Medicare Prescription Drug PlanS5596 ANTHEM INSURANCE COMPANIES, INC. Pharmacy Benefit Manager Contact 1 11365 Westwood Road Alden NY 14004 Medicare Prescription Drug PlanS5597 PENNSYLVANIA LIFE INSURANCE COMPANY Formulary Contact 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5597 PENNSYLVANIA LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5601 SILVERSCRIPT INSURANCE COMPANY Formulary Contact 11311 McCormick Rd. Hunt Valley Bldg 75, Ste 230 Hunt Valley MD 21031 Medicare Prescription Drug PlanS5601 SILVERSCRIPT INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 9501 E. Shea Blvd Scottsdale AZ 85260 Medicare Prescription Drug PlanS5609 ASURIS NORTHWEST HEALTH Formulary Contact 200 SW Market St M/S 2P Portland OR 97201 Medicare Prescription Drug PlanS5609 ASURIS NORTHWEST HEALTH Pharmacy Benefit Manager Contact 1 1300 Washington Street Kansas City MO 64105 Medicare Prescription Drug PlanS5617 CONNECTICUT GENERAL LIFE INSURANCE COMPANY Formulary Contact 8826 N 23rd Ave Phoenix AZ 85021 Medicare Prescription Drug PlanS5617 CONNECTICUT GENERAL LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 900 Cottage Grove Rd Bloomfield, CT CT 6002 Medicare Prescription Drug PlanS5644 RXAMERICA, LLC Formulary Contact 221 N Charles Lindbergh Dr Salt Lake City UT 84116 Medicare Prescription Drug PlanS5644 RXAMERICA, LLC Pharmacy Benefit Manager Contact 1 221 N. Charles Lindbergh Dr. Salt Lake City UT 84116 Medicare Prescription Drug PlanS5650 SELECT HEALTH OF SOUTH CAROLINA, INC. Formulary Contact 200 Stevens Drive Philadelphia PA 19113 Medicare Prescription Drug PlanS5650 SELECT HEALTH OF SOUTH CAROLINA, INC. Pharmacy Benefit Manager Contact 1 200 Stevens Drive Philadelphia PA 19113 Medicare Prescription Drug PlanS5660 MEDCO CONTAINMENT LIFE INSURANCE COMPANY Formulary Contact 100 Parsons Pond Drive Franklin Lakes NJ 7417 Medicare Prescription Drug PlanS5660 MEDCO CONTAINMENT LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 100 Parsons Pond Drive E2-7 Franklin Lakes NJ 7417 Medicare Prescription Drug PlanS5670 COVENTRY HEALTH AND LIFE INSURANCE COMPANY Formulary Contact 501 Corporate Centre Drive Franklin TN 37067 Medicare Prescription Drug PlanS5670 COVENTRY HEALTH AND LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 501 Corporate Cente Drive Franklin TN 37067 Medicare Prescription Drug PlanS5674 FIRST HEALTH LIFE AND HEALTH INSURANCE COMPANY Formulary Contact 501 Corporate Centre Drive Franklin TN 37067 Medicare Prescription Drug PlanS5674 FIRST HEALTH LIFE AND HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 501 Corporate Centre Drive Franklin TN 37067 Medicare Prescription Drug PlanS5678 HEALTH NET LIFE INS CO/HEALTH NET INS OF NY Formulary Contact 10540 White Rock Rd.., Ste. 200 Rancho Cordova CA 95670 Medicare Prescription Drug PlanS5678 HEALTH NET LIFE INS CO/HEALTH NET INS OF NY Pharmacy Benefit Manager Contact 1 10540 White Rock Rd.., Ste. 200 Mail Stop: CA-175-02-02 Rancho Cordova CA 95670 Medicare Prescription Drug PlanS5704 GLOBALHEALTH, INC. Formulary Contact 3001 South Priest Drive Tempe AZ 85282 Medicare Prescription Drug PlanS5704 GLOBALHEALTH, INC. Pharmacy Benefit Manager Contact 1 3001 South Priest Drive Tempe AZ 85282 Medicare Prescription Drug PlanS5715 HCSC INSURANCE SERVICES COMPANY Formulary Contact 300 East Randolph Chicago IL 60601 Medicare Prescription Drug PlanS5715 HCSC INSURANCE SERVICES COMPANY Pharmacy Benefit Manager Contact 1 901 S. Central Expressway, North Building Richardson TX 75080 Medicare Prescription Drug PlanS5726 BLUE CROSS BLUE SHIELD OF KANSAS Formulary Contact 5350 Bevis Avenue Sherman Oaks CA 91411 Medicare Prescription Drug PlanS5726 BLUE CROSS BLUE SHIELD OF KANSAS Pharmacy Benefit Manager Contact 1 11365 Westwood Road Alden NY 14004 Medicare Prescription Drug PlanS5740 TEXAS HEALTHSPRING I, LLC Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 Medicare Prescription Drug PlanS5740 TEXAS HEALTHSPRING I, LLC Pharmacy Benefit Manager Contact 1 1300 Washington Street Kansas City MO 64105 Medicare Prescription Drug PlanS5741 HIP HEALTH PLAN OF NEW YORK Formulary Contact 55 Water Street New York NY 10041-8190 Medicare Prescription Drug PlanS5741 HIP HEALTH PLAN OF NEW YORK Pharmacy Benefit Manager Contact 1 55 Water Street New York NY 10041 Medicare Prescription Drug PlanS5743 BLUE CROSS BLUE SHIELD NORTHERN PLAINS ALLIANCE Formulary Contact Blue Cross Blue Shield of Minnesota 3400 Yankee Drive Eagan MN 55122 Medicare Prescription Drug PlanS5743 BLUE CROSS BLUE SHIELD NORTHERN PLAINS ALLIANCE Pharmacy Benefit Manager Contact 1 1020 Discovery Road Eagan MN 55121-2095 Medicare Prescription Drug PlanS5753 WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION Formulary Contact 1717 W. Broadway PO Box 8190 Madison WI 53708 Medicare Prescription Drug PlanS5753 WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION Pharmacy Benefit Manager Contact 1 1717 West Broadway PO Box 8190 Madison WI 53708 Medicare Prescription Drug PlanS5755 UNITED AMERICAN INSURANCE COMPANY Formulary Contact 3700 S. Stonebridge Drive McKinney TX 75070 Medicare Prescription Drug PlanS5755 UNITED AMERICAN INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 3700 S. Stonebridge Drive McKinney TX 75070 Medicare Prescription Drug PlanS5766 FIRST CARE, INC. Formulary Contact 100 S. Charles Street Baltimore MD 21201 Medicare Prescription Drug PlanS5766 FIRST CARE, INC. Pharmacy Benefit Manager Contact 1 1300 Washington Street Kansas City MO 64105 Medicare Prescription Drug PlanS5768 FIRST HEALTH LIFE & HEALTH INSURANCE COMPANY Formulary Contact 4300 Cox Road Glenn Allen VA 23060 Medicare Prescription Drug PlanS5768 FIRST HEALTH LIFE & HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 4300 Cox Road Glenn Allen VA 23060 Medicare Prescription Drug PlanS5775 PHARMACY INSURANCE CORPORATION OF AMERICA Formulary Contact PO Box 70232 San Juan PR 00936-8232 Medicare Prescription Drug PlanS5775 PHARMACY INSURANCE CORPORATION OF AMERICA Pharmacy Benefit Manager Contact 1 PO Box 70232 San Juan PR 00936-8232 Medicare Prescription Drug PlanS5783 QCC INS CO D/B/A AMERIHEALTH INS CO Formulary Contact 200 Stevens Drive Philadelphia PA 19113 Medicare Prescription Drug PlanS5783 QCC INS CO D/B/A AMERIHEALTH INS CO Pharmacy Benefit Manager Contact 1 1700 Market Street Philadelphia PA 19103 Medicare Prescription Drug PlanS5795 ARKANSAS BCBS, A MUTUAL INS CO Formulary Contact 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5795 ARKANSAS BCBS, A MUTUAL INS CO Pharmacy Benefit Manager Contact 1 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5803 MEMBERHEALTH, INC. Formulary Contact 29100 Aurora Rd., Ste. 301 Solon OH 44139 Medicare Prescription Drug PlanS5803 MEMBERHEALTH, INC. Pharmacy Benefit Manager Contact 1 29100 Aurora Rd., Ste. 301 Solon OH 44139 Medicare Prescription Drug PlanS5805 UNITED HEALTHCARE INSURANCE COMPANY OF NEW YORK Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Medicare Prescription Drug PlanS5805 UNITED HEALTHCARE INSURANCE COMPANY OF NEW YORK Pharmacy Benefit Manager Contact 1 1417 Lake Cook Road MS L457 Deerfield IL 60015 Medicare Prescription Drug PlanS5810 AETNA LIFE INSURANCE COMPANY Formulary Contact 5350 148th Place Wellborn FL 32094-2352 Medicare Prescription Drug PlanS5810 AETNA LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 11100 Wayzata Blvd., Ste. 400 Mail Stop F615 Minnetonka MN 55305 Medicare Prescription Drug PlanS5815 HEALTHSPRING, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 Medicare Prescription Drug PlanS5815 HEALTHSPRING, INC. Pharmacy Benefit Manager Contact 1 1300 Washington Street Kansas MO 64105 Medicare Prescription Drug PlanS5820 UNITED HEALTHCARE INSURANCE COMPANY Formulary Contact UnitedHealth Group 9900 Bren Road East MN008-T500 Minnetonka MN 55343 Medicare Prescription Drug PlanS5820 UNITED HEALTHCARE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1417 Lake Cook Road MS L457 Deerfield IL 60015 Medicare Prescription Drug PlanS5822 ELDER HEALTH MID-ATLANTIC, INC. Formulary Contact 3601 O'Donnell Street Baltimore MD 21224 Medicare Prescription Drug Plan

S5822 ELDER HEALTH MID-ATLANTIC, INC. Pharmacy Benefit Manager Contact 1 3601 O'Donnell Street Baltimore MD 21224 Medicare Prescription Drug PlanS5825 AMERICAN PROGRESSIVE LIFE AND HEALTH INS CO NY Formulary Contact 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5825 AMERICAN PROGRESSIVE LIFE AND HEALTH INS CO NY Pharmacy Benefit Manager Contact 1 695 George Washington Highway Lincoln RI 2865 Medicare Prescription Drug PlanS5857 PRIORITY HEALTH INSURANCE COMPANY Formulary Contact 1231 East Beltline NE Grand Rapids MI 49525 Medicare Prescription Drug PlanS5857 PRIORITY HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1300 Washington St. Kansas City MO 64105-1433 Medicare Prescription Drug PlanS5860 ROCKY MOUNTAIN HEALTH MAINTENANCE ORGANIZATION Formulary Contact PO Box 10600 Grand Junction CO 81502-5600 Medicare Prescription Drug PlanS5860 ROCKY MOUNTAIN HEALTH MAINTENANCE ORGANIZATION Pharmacy Benefit Manager Contact 1 PO Box 10600 Grand Junction CO 81502-5600 Medicare Prescription Drug PlanS5877 EDUCATORS MUTUAL INSURANCE ASSOCIATION Formulary Contact 852 East Arrowhead Lane Murray UT 84107 Medicare Prescription Drug PlanS5877 EDUCATORS MUTUAL INSURANCE ASSOCIATION Pharmacy Benefit Manager Contact 1 852 East Arrowhead Lane Murray UT 84107 Medicare Prescription Drug PlanS5884 HUMANA INSURANCE COMPANY Formulary Contact 500 West Main Street Louisville KY 40202 Medicare Prescription Drug PlanS5884 HUMANA INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 500 West Main Street Louisville KY 40202 Medicare Prescription Drug PlanS5902 PRESBYTERIAN INSURANCE COMPANY, INC. Formulary Contact P.O. Box 26267 New Mexico NM 87125-6267 Medicare Prescription Drug PlanS5902 PRESBYTERIAN INSURANCE COMPANY, INC. Pharmacy Benefit Manager Contact 1 P.O. Box 26267 New Mexico NM 87125-6267 Medicare Prescription Drug PlanS5904 BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. Formulary Contact 4800 Deerwood Campus Pkwy Bldg 3, Floor 6 Jacksonville FL 32246 Medicare Prescription Drug PlanS5904 BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. Pharmacy Benefit Manager Contact 1 4800 Deerwood Campus Pkwy Bldg 3, Floor 6 Jacksonville FL 32246 Medicare Prescription Drug PlanS5907 TRIPLE-S, INC. Formulary Contact PO BOX 363628 San Juan PR 00936-3628 Medicare Prescription Drug PlanS5907 TRIPLE-S, INC. Pharmacy Benefit Manager Contact 1 Angora Industrial Park Lot #1 RD #1 Km. 33.3 Bairoa Caguas PR 725 Medicare Prescription Drug PlanS5915 SCOTT AND WHITE HEALTH PLAN Formulary Contact 2601 Thornton Lane, Suite A Temple TX 76502 Medicare Prescription Drug PlanS5915 SCOTT AND WHITE HEALTH PLAN Pharmacy Benefit Manager Contact 1 2601 Thornton Lane, Suite A Temple TX 76502 Medicare Prescription Drug PlanS5916 REGENCE LIFE AND HEALTH INSURANCE COMPANY Formulary Contact 200 SW Market St M/S 2P Portland OR 97201 Medicare Prescription Drug PlanS5916 REGENCE LIFE AND HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 1300 Washington St Kansas City MO 64105 Medicare Prescription Drug PlanS5917 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Formulary Contact 2716 N. Tenaya Way Las Vegas NV 89128 Medicare Prescription Drug PlanS5917 SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Pharmacy Benefit Manager Contact 1 2716 N. Tenaya Way Las Vegas NV 89128 Medicare Prescription Drug PlanS5921 PACIFICARE LIFE AND HEALTH INSURANCE COMPANY Formulary Contact 3515 Harbor Blvd. Costa Mesa CA 92626 Medicare Prescription Drug PlanS5921 PACIFICARE LIFE AND HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 3515 Harbor Blvd. Costa Mesa CA 92626 Medicare Prescription Drug PlanS5932 HEALTHSPRING INC. HEALTHSPRING OF ALABAMA, INC. Formulary Contact 44 Vantage Way Suite 300 Nashville TN 37228 Medicare Prescription Drug PlanS5932 HEALTHSPRING INC. HEALTHSPRING OF ALABAMA, INC. Pharmacy Benefit Manager Contact 1 1300 Washington Street Kansas City MO 64105 Medicare Prescription Drug PlanS5937 LOUISIANA HEALTH SERVICE & INDEMNITY COMPANY Formulary Contact 5525 Reitz Avenue Baton Rouge LA 70809 Medicare Prescription Drug PlanS5937 LOUISIANA HEALTH SERVICE & INDEMNITY COMPANY Pharmacy Benefit Manager Contact 1 6625 West 78th Street Bloomington MN 55439 Medicare Prescription Drug PlanS5946 INSTIL HEALTH INSURANCE COMPANY Formulary Contact 17 Technology Circle Columbia SC 29203 Medicare Prescription Drug PlanS5946 INSTIL HEALTH INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 MedImpact Health Systems, Inc 10680 Treena Street, 5th Floor San Diego CA 92131 Medicare Prescription Drug PlanS5953 BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA Formulary Contact 2401 Faraway Drive Columbia SC 29223 Medicare Prescription Drug PlanS5953 BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA Pharmacy Benefit Manager Contact 1 3011 NE 40th St Fort Lauderdale FL 33308 Medicare Prescription Drug PlanS5954 DEAN HEALTH INSURANCE, INC. Formulary Contact 1277 Deming Way Madison WI 53717 Medicare Prescription Drug PlanS5954 DEAN HEALTH INSURANCE, INC. Pharmacy Benefit Manager Contact 1 999 Fourier Drive, Suite 301 Madison WI 53717 Medicare Prescription Drug PlanS5960 UNICARE Formulary Contact 8407 Fallbrook Avenue AF5 West Hills CA 91304 Medicare Prescription Drug PlanS5960 UNICARE Pharmacy Benefit Manager Contact 1 8407 Fallbrook Ave West Hills CA 91304 Medicare Prescription Drug PlanS5966 GROUP HEALTH INCORPORATED Formulary Contact 441 Ninth Ave New York NY 10001 Medicare Prescription Drug PlanS5966 GROUP HEALTH INCORPORATED Pharmacy Benefit Manager Contact 1 441 Ninth Avenue New York NY 10001 Medicare Prescription Drug PlanS5967 WELLCARE PRESCRIPTION INSURANCE, INC. Formulary Contact PO Box 25858 Tampa FL 33622-5858 Medicare Prescription Drug PlanS5967 WELLCARE PRESCRIPTION INSURANCE, INC. Pharmacy Benefit Manager Contact 1 PO Box 25858 Tampa FL 33622-5858 Medicare Prescription Drug PlanS5975 ODS HEALTH PLAN, INC. Formulary Contact 601 S.W. Second Avenue Portland OR 97204 Medicare Prescription Drug PlanS5975 ODS HEALTH PLAN, INC. Pharmacy Benefit Manager Contact 1 601 S.W. Second Avenue Portland OR 97204 Medicare Prescription Drug PlanS5983 MEDCO CONTAINMENT INSURANCE COMPANY OF NEW YORK Formulary Contact 100 Parsons Pond Drive Franklin Lakes NJ 7417 Medicare Prescription Drug PlanS5983 MEDCO CONTAINMENT INSURANCE COMPANY OF NEW YORK Pharmacy Benefit Manager Contact 1 100 Parsons Pond Drive E2-7 Franklin Lakes NJ 7417 Medicare Prescription Drug PlanS5993 HORIZON HEALTHCARE SERVICES DBA HORIZON BCBS NJ Formulary Contact Three Penn Plaza East PP-13Q Newark NJ 7105 Medicare Prescription Drug PlanS5993 HORIZON HEALTHCARE SERVICES DBA HORIZON BCBS NJ Pharmacy Benefit Manager Contact 1 Three Penn Plaza East PP-13Q Newark NJ 7105 Medicare Prescription Drug PlanS6875 QCC INS CO D/B/A AMERIHEALTH INS CO Formulary Contact 1700 Market Street Philadelphia PA 19103 Medicare Prescription Drug PlanS6875 QCC INS CO D/B/A AMERIHEALTH INS CO Pharmacy Benefit Manager Contact 1 1700 Market Street Philadelphia PA 19103 Medicare Prescription Drug PlanS7316 UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS Formulary Contact 3795 Kiesel Ave. Ogden UT 84405 Employer Sponsored PDPS7316 UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS Pharmacy Benefit Manager Contact 1 3795 Kiesel Ave. Ogden UT 84405 Employer Sponsored PDPS7848 OKLAHOMA STATE & EDUCATION EMP GRP INSURANCE BOARD Formulary Contact 3545 N.W. 58th Street Suite 1000 Oklahoma City OK 73112 Employer Sponsored PDPS7848 OKLAHOMA STATE & EDUCATION EMP GRP INSURANCE BOARD Pharmacy Benefit Manager Contact 1 775 Prairie Center Drive Suite 350 Eden Prairie MN 55344 Employer Sponsored PDPS8067 AVALON HEALTH, LTD Formulary Contact 2500 Elmerton Avenue mail drop 9846 Harrisburg PA 17177 Medicare Prescription Drug PlanS8067 AVALON HEALTH, LTD Pharmacy Benefit Manager Contact 1 2500 Elmerton Avenue Harrisburg PA 17177 Medicare Prescription Drug PlanS9086 AMERICA'S HEALTHCHOICE Formulary Contact 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 Medicare Prescription Drug PlanS9086 AMERICA'S HEALTHCHOICE Pharmacy Benefit Manager Contact 1 14301 First National Bank Parkway, Suite 200 Omaha NE 68154 Medicare Prescription Drug PlanS9264 STERLING LIFE INSURANCE COMPANY Formulary Contact 2219 Rimland Drive PO Box 5348 Bellingham WA 98227-5348 Medicare Prescription Drug PlanS9264 STERLING LIFE INSURANCE COMPANY Pharmacy Benefit Manager Contact 1 16 International Way Warwick RI 2886 Medicare Prescription Drug Plan