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September 3, 2002

ENLOE MEDICAL CENTER
EMPLOYEE PRESCRIPTION
PLAN PROGRAM
ENLOE PHARMACY
Locations, phone numbers and hours of operation OUTPATIENT CENTER (EOC)
ESPLANADE SITE
The Esplanade site serves as a pick-up and drop-
Best location for immediate fills
off point for medications. If you need your prescription

Location:
fil ed immediately, take it directly to the EOC pharmacy. With advance notice, prescriptions can be couriered to the Esplanade Location: 1531 Esplanade
REFILLS:
Be sure to include the following information in your REFILLS:
You may phone the EOC site (332-6470) for your Say and spell your name (and name of person
refil and request a prescription pick up at either  Prescription number (upper left side of label)
Medication name
How many days you are requesting (up to
90 day supply)
Pickup point … EOC or Esplanade
Method of payment - payroll deduction or cash
Enloe Pharmacy Copays
CLASSIC PLAN MEMBERS:
VALUE PLAN MEMBERS:
This formulary is reviewed regularly for quality and efficacy, and is designed to offer drugs in the majority of drug classes. If you wish to save money, often a generic drug is available for a brand name prescription your physician may prescribe. Keep this formulary available for your reference, and bring it to your doctor’s appointment when you may be receiving a new prescription. You may only fill prescriptions for generic or brand name drugs listed on this Enloe formulary. (If special circumstances
warrant, you may request your physician to work with Express Scripts to request prior authorization for a substitute Non-formulary prescription. To determine if prior authorization can be obtained, the physician may contact Express Scripts at 1-800-753-2851). You may only fill prescriptions at Enloe Pharmacy (332-6470). If you are fil ing an urgent (non-maintenance) prescription when
Enloe Pharmacy is closed, you may use an Express Scripts network pharmacy. Call Express Scripts for urgent fil s when traveling and an Express Scripts network pharmacy is not available. You may only fill prescriptions for generic or brand name drugs listed on this Enloe formulary. (If special circumstances
warrant, you may request your physician to work with Express Scripts to request prior authorization for a substitute Non-formulary prescription. To determine if prior authorization can be obtained, the physician may contact Express Scripts at 1-800-753-2851). You have a lower co-pay when you fill prescriptions at Enloe Pharmacy. You may use an Express Scripts network pharmacy,
but at a higher co-pay. Cal Express Scripts when traveling and an Express Scripts network pharmacy is not available. How to transfer a prescription to Enloe Pharmacy
You wil need the prescription name and number located on your prescription bottle, the physician’s name, the current Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site at pharmacy’s name and telephone number. Then cal Enloe Pharmacy at 332-6470 with your name, date of birth, he document lists all active medications that are formulary on this formulary with the exception of compound powders and f medication needed (30, 60, 90) and employee ID#. Enloe Pharmacy wil coo rdinate the transfer. 2014 Express Scripts High Performance Formulary List
The 2014 High Performance Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes.
PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available
during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your
benefit materials for the specific drugs covered and the copayments for your prescription drug benefit
program. For specific questions about your coverage, please call the phone number printed on your
member ID card.

KEY
The symbol [INJ] next to a drug name indicates that the drug is an Injectable.
The symbol [OTC] next to a drug name indicates that the drugs is available Over-the-Counter.
The symbol [SP] next to a drug name indicates the drug is a specialty drug.
The symbol [PA] next to a drug name indicates that a prior authorization is required before coverage.
The symbol [ST] next to a drug name indicates that a less expensive alternative is required first.

For the member:
Generic medications contain the same active ingredients as their corresponding brand name
medications, although they may look different in color or shape. They have been FDA-approved under strict
standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
Brand name drugs are listed in CAPITAL letters. Example: CELEBREX
Generic drugs are listed in lower case letters. Example: ibuprofen
This is a list of formulary products only.
Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site at he document lists all active medications that are formulary on this formulary with the exception of compound powders and acetaminophen/phenyltoloxamine citrate alclometasone acetaminophen/phenyltoloxamine citrate ALDURAZYME [INJ] [SP] acetic acid/hydrocortisone ear solution allopurinol sodium [INJ] antipyrine/benzocaine/polycosanol ear azithromycin [INJ] alprazolam orally disintegrating tablets aluminum chloride 20% topical solution APOKYN [INJ] [SP] bupropion ext-release (12 hour) smoking calcitriol betamethasone acetate/betamethasone bromocriptine betamethasone dipropionate augmented brompheniramine/pseudoephedrine/ Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound chloroxylenol/benzocaine/hydrocortisone colchicine/probenecid carbidopa/levodopa orally disintegrating cholestryramine choline salicylate/magnesium salicylate corvita cromolyn sodium nebulization solution diazepam clindamycin phosphate/benzoyl peroxide danazol clonazepam orally disintegrating tablets daunorubicin [INJ] desloratadine orally disintegrating tablets donepezil orally disintegrating tablets Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound doxycycline hyclate delayed-release [ST] ERIVEDGE [SP] esterified estrogens/methyltestosterone FIRST-LANSOPRAZOLE Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound hydrocodone/chlorpheniramine polistirex infed [INJ] hydrocortisone sodium succinate [INJ] ipratropium bromide nebulization ipratropium/albuterol sulfate nebulization labetalol [INJ] hydrocortisone/pramoxine ear solution irbesartan/hydrochlorothiazide hydrocortisone/pramoxine/chloroxylenol irinotecan [INJ] halobetasol + ammonium lactate combo hydroxyzine hcl hyoscyamine orally disintegrating tablets IXIARO [INJ] Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound mirtazapine orally disintegrating tablets natalvirt flt LUPRON DEPOT 3.75 MG, 11.25 MG methocarbamol Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound NOVOFINE 30G, 32G NEEDLES [OTC] oxytocin [INJ] pancrelipase delayed-release 5000 units PNEUMOVAX 23 [INJ] olanzapine orally disintegrating tablets penicil in g sodium [INJ] potassium chloride effervescent tablets PROCRIT [INJ] [SP] ondansetron orally disintegrating tablets perphenazine potassium chloride powder packets for PROFERRIN-FORTE potassium chloride/sodium chloride [INJ] PROGRAF [INJ] opium/belladona alkaloids suppositories phenelzine Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound risperidone orally disintegrating tablets SOMAVERT [INJ] [SP] rizatriptan orally disintegrating tablets sulfacetamide/prednisolone eye solution thiothixene Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound trypsin/balsam peru/castor oil ointment VIAGRA zolmitriptan orally disintegrating tablets venatal complete dha prenatal vitamins VUMON [INJ] water for injection, bacteriostatic [INJ] Created 11/2013. Please note this document is subject to change. Any changes/updates to this document can viewed at Express-Script's web site ahe document lists all active medications that are formulary on this formulary with the exception of compound

Source: http://www.enloe.org/for_our_employees/documents/2014EnloeFormulary_000.pdf

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