**EXPRESS SCRIPTS, INC.**

**PHARMACY AGREEMENT\
APPLICABLE TO THE PHARMACY CARE ALLIANCE, INC.\
MEDICARE APPROVED DRUG DISCOUNT CARD PROGRAM**

**This Pharmacy Agreement (the "Agreement") is effective as of the
\_\_\_\_ day of \_\_\_\_\_\_\_\_\_, 2004 (the "Effective Date"), by and
between Express Scripts, Inc., a Delaware corporation and the pharmacy
or dispensary set forth on the signature page hereto ("Provider"). The
provisions of this Agreement apply only to the PCA Medicare Approved
Discount Card Program ("PCA Drug Card Program").**

This Agreement, together with [Exhibits A, B and C]{.underline} attached
hereto and the Provider Manual, will govern service components,
requirements, and reimbursement to the Provider for adhering to the
provisions of the PCA Drug Card Program.

Participation in the PCA Drug Card Program will continue until December
31, 2005. After December 31, 2005, in accordance with transition rules
specified by the Secretary of Health and Human Services, participation
will continue until the last day of the initial enrollment period for
Part D of Title XVIII of the Social Security Act or, if Congress amends
such Act so that the duration of the Medicare Approved Drug Discount
Card Program is no longer tied to the initial enrollment period for
Medicare Part D, such other date mutually agreed upon by the parties.

**1. Definitions**. For purposes of this Agreement:

> **ESI:** Express Scripts, Inc., the pharmacy benefit manager for the
> PCA Drug Card.
>
> **Indian:** Has the meaning given that term in Sec. 4 of the Indian
> Health Care Improvement Act, 25 U.S.C. §1603.
>
> **Indian Health Service ("IHS"):** The agency of that name within the
> U.S. Department of Health and Human Services established by Sec. 601
> of the Indian Health Care Improvement Act, 25 U.S.C. §1661.
>
> **Indian Tribe:** Has the meaning given that term in Sec. 4 of the
> Indian Health Care Improvement Act, 25 U.S.C. §1603.
>
> **I/T/U Endorsement:** A special endorsement from CMS to administer a
> Medicare Approved Drug Discount Card Program at pharmacies or
> dispensaries operated by the Indian Health Service, Indian tribes,
> tribal organizations, and urban Indian organizations.
>
> **Medicare Approved Drug Discount Card Program:** A program under
> section 1860D-31 of the Social Security Act that is made available for
> Medicare beneficiaries entitled to benefits, or enrolled under Part A
> or enrolled under Part B, excluding beneficiaries entitled to medical
> assistance for outpatient prescription drugs under Medicaid, including
> section 1115 waiver demonstrations, to provide assistance in the
> purchase of covered discount card drugs pursuant to the MedicareRx
> Rule.
>
> **Medicare Formulary:** List of discount card drugs covered under the
> PCA Drug Card Program.
>
> **MedicareRx Rule:** The final rules of CMS implementing the Medicare
> Prescription Drug Discount Card Program, and codified at 42 C.F.R.
> 403, et. seq.
>
> **On-Line System:** The telecommunications and data transfer systems
> existing between ESI and Pharmacies for claim processing.
>
> **PCA:** Pharmacy Care Alliance, Inc., sponsor of the PCA Drug Card
> Program.
>
> **PCA Drug Card:** The prescription drug discount card sponsored by
> PCA and approved by CMS pursuant to the MedicareRx Rule.
>
> **Pharmacy:** Each pharmacy and dispensary operated by Provider and
> licensed by the appropriate state board of pharmacy or other
> applicable regulatory authority set forth on [Exhibit B]{.underline}.
> If Provider operates only one Pharmacy, then "Provider" and "Pharmacy"
> shall be used interchangeably in this Agreement.
>
> **Provider Manual:** A written description of practices, policies,
> rules and procedures provided by ESI. This Agreement shall be the
> overriding document in the event of a contradiction between the
> Provider Manual as amended from time to time by ESI and this
> Agreement. The Provider Manual will not impose obligations and
> responsibilities on Provider.
>
> **Transitional Assistance:** A subsidy of \$600 a year provided by CMS
> to certain eligible Enrollees to be applied towards the purchase of
> the covered discount card drugs.
>
> **Tribal Organization:** Has the meaning given that term in Sec. 4 of
> the Indian Health Care Improvement Act, 25 U.S.C. §1603.
>
> **Urban Indian Organization:** Has the meaning given that term in Sec.
> 4 of the Indian Health Care Improvement Act, 25 U.S.C. §1603.
>
> Capitalized terms used, and not otherwise defined, herein shall have
> the meanings ascribed to such terms in the MedicareRx Rule.

**[Description of Service Components]{.underline}**

1.  **[Information and Outreach Services]{.underline}**

PCA, as an endorsed sponsor of a Medicare drug discount card, is
required under the MedicareRx Rule to provide certain information and
outreach materials to Medicare beneficiaries. In connection with PCA's
information and outreach activities, Provider may choose, but is under
no obligation, to provide any of the following information and outreach
services on behalf of PCA (the "Information and Outreach Services")
during the term of the PCA Drug Card Program. Provider is not required
to provide any Information and Outreach Services in order to participate
in the PCA Drug Card Program, and neither ESI nor PCA will directly or
indirectly compensate Provider for any Information and Outreach Services
that Provider elects to provide. Any materials used by Provider to
provide such services must be materials approved by CMS and/or PCA, or
developed under the IHS/CMS inter-agency agreement, and shall include
the PCA Drug Card Program enrollment form and eligibility determination
notice (the "Card Enrollment Materials"):

-   Make Card Enrollment Materials generally available for Medicare
    beneficiaries in Provider's facility by displaying Card Enrollment
    Materials and distributing informational flyers.

-   Make available trained staff persons to answer Medicare
    beneficiaries' questions about the features of the PCA Drug Card
    Program and the enrollment process. The "features of the PCA Drug
    Card Program" means the following information: (1) the enrollment
    fee, (2) negotiated prices offered under the PCA Drug Card Program
    for covered discount card drugs as communicated to Provider by ESI
    at the time of inquiry, (3) any other agreed upon products or
    services offered under the PCA Drug Card Program, and (4) any other
    information that CMS has determined is necessary for a full
    description of the PCA Drug Card Program. ESI will provide Provider
    with information to assist Provider with the provision of this
    service. The services described in this paragraph must be provided
    in accordance with the "Program Requirements" section of this
    Agreement.

2.  **[Enrollment and Re-Enrollment Services]{.underline}**

**[Enrollment Services]{.underline}.** PCA, as an endorsed sponsor of a
Medicare drug discount card, is required under the MedicareRx Rule to
make preliminary eligibility determinations and to conduct enrollment
activities with respect to the PCA Drug Card Program. PCA\'s enrollment
and eligibility authority does not extend to making eligibility
determinations regarding who may be treated at Provider\'s facility,
regardless of whether the individual is eligible for the PCA Drug Card
Program. In connection with PCA's eligibility determination and
enrollment activities, Provider may choose, but is under no obligation,
to provide the following services (the "Enrollment Services"). Provider
is not required to provide any Enrollment Services in order to
participate in the PCA Drug Card Program, and neither ESI nor PCA will
directly or indirectly compensate Provider for any Enrollment Services
that Provider elects to provide:

-   When and where Provider chooses to conduct Enrollment Services,
    Provider will accept on behalf of PCA, at applicable Provider's
    facilities, enrollment forms submitted by Medicare beneficiaries who
    are applying to enroll in the PCA Drug Card Program (each, an
    "applicant").

-   For each PCA Drug Card Program enrollment form (or "application")
    submitted to Provider, take the following actions:

    -   Verify that the application is complete and, if necessary,
        assist the applicant in completing the application;

    -   Visually verify that the application responses indicate
        eligibility for the PCA Drug Card Program, based on criteria set
        forth in the Card Application Materials and, if necessary,
        inform the applicant if the responses indicate that he or she is
        not eligible for the PCA Drug Card Program; and

    -   Use commercially reasonable efforts to transmit the application
        to ESI by electronic or manual submission within 48 hours of
        receipt from the applicant.

-   Forward to ESI on a weekly basis, using a secure delivery method,
    all physical documents, including applications, received from
    applicants in connection with the PCA Drug Card Program and not
    already forwarded to PCA by facsimile or mail.

-   In lieu of collecting applications, Provider may direct the
    applicant to utilize the envelope provided with the enrollment
    booklet.

**[Re-Enrollment Services]{.underline}.** PCA Drug Card Program
enrollees are permitted under the MedicareRx Rule to elect to disenroll
from the PCA Drug Card Program and elect enrollment in another Medicare
drug discount card program during the annual coordinated election period
established by CMS (November 15, 2004 through December 31, 2004) (the
"Annual Coordinated Election Period"). CMS has established as a matter
of policy that an enrollee eligible for services from an I/T/U pharmacy
may elect to disenroll from a drug card program without an I/T/U
endorsement and elect enrollment in a drug card program with an I/T/U
endorsement at any time during the life of the Medicare Approved Drug
Discount Card Program (the "I/T/U" Election Period"). In connection with
the Annual Coordinated Election Period or the I/T/U Election Period,
Provider may choose, but is under no obligation, to provide the
following information and outreach services (the "Re-Enrollment
Services"). Provider is not required to provide any Re-Enrollment
Services in order to participate in the PCA Drug Card Program, and
neither ESI nor PCA will directly or indirectly compensate Provider for
any Re-Enrollment Services that Provider elects to provide:

-   When and where Provider chooses to provide Re-Enrollment Services,
    Provider will make available during the Annual Coordinated Election
    Period, at applicable Provider's facilities, trained staff persons
    to answer PCA Drug Card Program enrollees' questions about the
    decisions to be made by them during Annual Coordinated Election
    Period and the features of the PCA Drug Card Program for 2005
    (including the 2005 enrollment fee). To ensure that PCA Drug Card
    Program enrollees' questions are answered correctly, Provider will
    provide educational materials and appropriate training to Provider's
    staff persons regarding the features of the PCA Drug Card Program
    for 2005 and the Annual Coordinated Election Period. ESI will
    provide Provider with information to assist Provider with the
    provision of this service. The services described in this paragraph
    must be provided in accordance with the provisions of the "Program
    Requirements" section of this Addendum.

Additional information and instructions relating to the Information and
Outreach Services and Enrollment and Re-Enrollment Services to be
provided by Provider, if any, will be provided by ESI and set forth in
other PCA Drug Card Program documents made available by ESI to
participating Providers from time to time.

> **[Program Requirements]{.underline}**

1.  Card Application Materials will be provided to Provider pursuant to
    the following:

  --------------------- ---------------- --------------------------------
  **Application         **Charge Per     **Notes**
  Material**            Application      
                        Package**        

  Standard I/T/U        No Charge        ESI will provide a base quantity
  Application Package                    of standard application packages
                                         at no charge
  --------------------- ---------------- --------------------------------

2.  Enrollment Fees:

-   Enrollees eligible for Transitional Assistance will not be charged
    an enrollment fee. PCA will bill, and collect from, CMS any
    enrollment fee applicable to Enrollees eligible for Transitional
    Assistance.

3.  All services will be provided in accordance with CMS regulations
    applicable to the Medicare Approved Drug Discount Card Program,
    including without limitation, with respect to the Information and
    Outreach Services, 42 CFR 403.806(g), 42 CFR 403.813(a) and the
    Information and Outreach Guidelines published by CMS.

4.  Provider will examine the PCA Drug Card presented by the enrollee
    and, to the extent available, use the On-Line System to determine
    that the holder of the PCA Drug Card is eligible for benefits under
    the PCA Drug Card Program. ESI or PCA shall provide, to any Provider
    without an On-Line System, information the Provider may use in
    acquiring an On-Line System. In the event an On-Line System is not
    available, the pharmacist may contact PCA by telephone for
    eligibility verification and may utilize a paper claim form, Exhibit
    C, provided by ESI or PCA to submit claims via facsimile.

5.  Card Application Materials may not be modified without the prior
    written consent of PCA and Provider will not use any materials
    relating to the PCA Drug Card Program other than those furnished or
    authorized by ESI or PCA. Notwithstanding the foregoing, Provider
    may provide to Enrollees materials to assist Enrollees with the
    Medicare Approved Drug Discount Card Program provided that any such
    materials (i) do not include the phrase "Medicare-approved", (ii) do
    not include either the Medicare or PCA logos, (iii) clearly indicate
    the author (sponsoring entity) of the material, and (iv) provide
    that neither PCA nor CMS has reviewed or approved the materials.
    Provider will not commingle materials not related to the Medicare
    Approved Drug Discount Card Program with materials described in this
    Section.

6.  Provider agrees to facilitate generic substitution in accordance
    with Provider's policy The parties, by entering into this Agreement,
    do not intend to affect Provider's formulary and Provider shall not
    be required to comply with the Medicare Formulary, drug utilization
    review, generic equivalent substitution, and notification of price
    differentials.

7.  ESI will provide to Providers with an On-Line System the
    Transitional Assistance balance remaining at the point of sale. This
    balance will be returned to the Provider in the NCPDP version 5.1
    Response Transaction by ESI in the Remaining Benefit Amount (514-FE)
    field. In the event Provider does not adjudicate claims through an
    On-Line System, Provider may contact ESI by telephone to obtain an
    enrollee's Transitional Assistance Balance remaining as of the time
    of such communication; provided, however neither PCA nor ESI can
    guarantee that the reported balance will be available at the time a
    paper claim for such enrollee is adjudicated. The Provider Manual
    supplies guidance relating to claims processing and submission, but
    no provision of the Provider Manual shall be a basis for denial of a
    claim that contains all required information on the claim form,
    attached at Exhibit C.

8.  Provider may not collect any fees from Enrollees or potential
    Enrollees in connection with the PCA Drug Card except as (i)
    specifically authorized by PCA or ESI, or (ii) consistent with IHS
    policy.

9.  PCA Drug Card Enrollee data may not be used to market or sell any
    other goods or services.

10. Provider will comply with HIPAA, the MedicareRx Rule, CMS
    regulations relating to the Medicare Approved Drug Discount Card
    Program, all applicable state and federal laws, including, but not
    limited to, applicable privacy and security requirements. In
    addition to the foregoing, Provider and ESI acknowledge the
    applicability of the following laws: (i) The Indian Health Care
    Improvement Act, 25 U.S.C. §1601, et seq., (ii) The Federal Privacy
    Act of 1974, 5 U.S.C. §552a and regulations at 42 CFR Part 2, (iii)
    The Federal Tort Claims Act 28 U.S.C. §2671-2680 with respect to
    Indian Tribes, Tribal Organizations and Urban Indian Organizations
    (to the extent the Urban Indian Organization is a Federally
    Qualified Health Center, and (iv) The Indian Self-Determination and
    Education Assistance Act, 25 U.S.C. §450 et seq. with respect to
    Indian Tribes and Tribal Organizations.

11. Provider will not (i) offer or pay bonuses or other financial
    incentives to any pharmacist, pharmacy technician or other pharmacy
    staff based on the number of persons who enroll for the PCA Drug
    Card, or (ii) prohibit or otherwise discourage any pharmacist,
    pharmacy technician or other pharmacy staff from providing
    information or advice to a potential Enrollee regarding other
    available Medicare approved drug discount cards.

12. To the extent Provider provides Information and Outreach Services
    and/or Enrollment or Re-Enrollment Services, Provider will use
    commercially reasonable efforts to inform pharmacists, pharmacy
    technicians and other pharmacy staff that any guidance given to
    potential Enrollees regarding the PCA Drug Card and/or other
    available discount cards should be based on their understanding of
    the patient's interests.

13. Any and all records pertaining to the PCA Drug Card Program must be
    retained for 6 years from the last date of activity under the PCA
    Drug Card Program as it relates to Provider. Upon fourteen (14)
    days' prior written notice, Provider shall permit, and shall cause
    the Pharmacies owned or under control of Provider to permit, ESI or
    a third party authorized by ESI and acceptable to Provider to
    inspect, review, audit and reproduce on-site at the location of the
    records at ESI's expense, during regular business hours and without
    charge, any prescription records maintained by Provider or any
    pharmacy pertaining to ESI, PCA Drug Card enrollees or this
    Agreement to determine compliance with the terms of this Agreement.

14. Provider will apply the correct coinsurance amount, if applicable.

15. Provider will only waive or reduce coinsurance amounts for Enrollees
    eligible for Transitional Assistance in a manner consistent with the
    MedicareRx Rules and Provider's operational authority.

16. Provider represents to ESI that it is a non-taxable entity and is
    therefore not required to collect or remit any Federal, State or
    local tax applicable to the services it performs under this
    Agreement.

17. Provider and ESI are obligated to abide by all regulations and
    guidelines published by CMS applicable to the Medicare Approved Drug
    Discount Card Program and waivers issued thereunder.

18. Provider agrees that all Pharmacies set forth on [Exhibit
    B]{.underline} shall provide services to PCA Drug Card enrollees in
    accordance with (i) the terms of this Agreement, (ii) the MedicareRx
    Rule, (iii) Sec. 813 of the Indian Health Care Improvement Act, 25
    U.S.C. §1680c, (iv) Part 136 of Title 42, Code of Federal
    Regulations, and (v) the terms of the contract, compact or grant
    issued to Provider by IHS for operation of a health program,
    including one or more pharmacies or dispensaries, a copy of which
    will be provided to ESI upon request. Provider is solely responsible
    for ensuring that the enrollee is entitled to utilize the services
    offered by Provider.

19. This Agreement, including the Exhibits, constitutes the entire
    understanding of the parties hereto with respect to the subject
    matter hereof and, upon execution by the parties, supersedes all
    prior oral or written agreements between the parties with respect to
    the subject matter hereof. No modification, alteration or waiver of
    any term, covenant or condition of this Agreement shall be valid
    unless agreed to in writing by both parties, except as hereinafter
    set forth. Notwithstanding the foregoing, Provider and ESI agree to
    amend this Agreement to comply with any changes required by the
    appropriate regulatory authorities in the course of discharging
    their responsibilities under applicable laws and regulations.

20. Provider acknowledges, on its behalf and on behalf of each Pharmacy,
    that in the performance of services to be rendered hereunder,
    Provider and each Pharmacy will have access to certain confidential
    business information regarding ESI and PCA, which includes ESI's
    Pharmacy Manual, customer lists, technology, business processes and
    procedures, business strategies and copies of materials relating
    thereto (collectively, the "Confidential Information"). Provider
    shall not disclose or use or enable anyone else to disclose or use,
    in whole or in part, any such Confidential Information other than
    for the purpose of providing the services to be provided hereunder
    and shall promptly return all Confidential Information to ESI upon
    request. Notwithstanding anything to the contrary herein, the
    following information is not considered confidential information
    hereunder: (i) information that is or becomes known generally within
    the relevant industry (except as a result of a breach by a party of
    its obligations under this Agreement or as a result of an improper
    or unlawful disclosure by another person), (ii) information which
    the receiving party was in the possession of or was known by such
    party prior to its receipt from the other party (and such
    information was not obtained from a person who improperly or
    unlawfully disclosed such information), or (iii) information that is
    rightfully disclosed to the receiving party by another person or
    entity not in violation of the proprietary or other rights of the
    disclosing party or any other person or entity. Further, if a party
    becomes legally obligated to disclose the other party's Confidential
    Information, such party must promptly notify the other party and
    cooperate with the other party as reasonably requested under the
    circumstances, in contesting such disclosure.

21. To the extent not superceded by applicable Federal law, this
    Agreement shall be construed and governed in all respects according
    to the internal laws of the State of Missouri. The parties agree
    that by entering into this Agreement, they have not availed
    themselves of the jurisdiction of courts situated in the State of
    Missouri.

22. The relationship created hereunder is that of independent
    contractors and nothing herein shall create or be deemed to create
    an agency, partnership or joint venture relationship between the
    parties. No provision of this Agreement or any part of the PCA Drug
    Card Program shall be construed to require any pharmacist to
    dispense any covered discount card drug to any enrollee if, in the
    pharmacist\'s reasonable professional judgment, such medication
    should not be dispensed to such person.

23. No waiver of a breach of any covenant or condition shall be
    construed to be a waiver of any subsequent breach. No act, delay or
    omission done, suffered, or permitted by the parties shall be deemed
    to exhaust or impair any right, remedy or power of the parties
    hereunder.

24. Should any provision of this Agreement be held or ruled
    unenforceable or ineffective under the law, such a ruling will in no
    way affect the validity or enforceability of any other clause or
    provision contained herein.

25. Each party hereto agree that prior to instituting any action to
    enforce any provision of this Agreement against the other party
    through arbitration or judicial order, each party shall meet and
    confer in good faith to resolve any disputes arising hereunder.

26. The parties, by entering into this Agreement, do not intend to
    affect Provider's acquisition of pharmaceuticals from any source,
    including the Federal Supply Schedule and participation in the Drug
    Pricing Program of Section 340B of the Public Health Service Act.
    Provider is not obligated to purchase from ESI, and ESI is not
    obligated to sell to Provider, any pharmaceuticals.

27. Provider is responsible for establishing hours of service for its
    Pharmacies.

28. This Agreement shall not be assigned, in whole or in part, by either
    party without the prior written consent of the other.

29. The performance by either party hereunder will be excused to the
    extent of circumstances beyond such party's reasonable control, such
    as flood, tornado, earthquake, or other natural disaster, epidemic,
    war, material destruction of facilities, fire, acts of God, etc. In
    such event, the parties will use their commercially reasonable
    efforts to resume performance as soon as reasonably possible under
    the circumstances giving rise to the party's failure to perform.
    Both ESI and Provider will use joint communication and resources to
    assist the other party in the event of a Force Majeure.

30. Provider reserves the right to participate in other health care or
    prescription programs and to accept other Medicare approved drug
    discount cards and nothing contained herein will prohibit or limit
    Provider's right to provide prescriptions services to other third
    parties.

**\[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK\]**

IN WITNESS WHEREOF, the undersigned have executed this Agreement as of
the Effective Date.

> **EXPRESS SCRIPTS, INC.**
>
> By: Elizabeth S. Wingate By:
>
> Title: Vice President, Provider Relations Title:
>
> Date: Date:
>
> The Provider executing this Agreement is (please check one):
>
> /\_/ An Indian Tribe that operates a health program, including one or
> more pharmacies or dispensaries, under a contract or compact with IHS
> issued pursuant to the Indian Self-Determination and Education
> Assistance Act, 25 U.S.C. §450 *et seq*. Provider represents to ESI
> that it is not required to obtain or maintain general liability,
> professional liability or other insurance, as such Provider is covered
> by the Federal Tort Claims Act pursuant to Federal law (Pub. L.
> 101-512, Title III, §314, Nov. 5, 1990, 104 Stat. 1959, as amended by
> Publ. L. 103-138, Title III §308, Nov. 11, 1993, 107 Stat. 1416
> (codified at 25 U.S.C. §450f note); and regulations at 25 CFR Part
> 900, Subpt. M.
>
> /\_/ A Tribal Organization authorized by one or more Indian Tribes to
> operate a health program, including one or more pharmacies or
> dispensaries, under a contract or compact with IHS issued pursuant to
> the Indian Self-Determination and Education Assistance Act, 25 U.S.C.
> §450 *et seq*. Provider represents to ESI that it is not required to
> obtain or maintain general liability, professional liability or other
> insurance, as such Provider is covered by the Federal Tort Claims Act
> pursuant to Federal law (Pub. L. 101-512, Title III, §314, Nov. 5,
> 1990, 104 Stat. 1959, as amended by Publ. L. 103-138, Title III §308,
> Nov. 11, 1993, 107 Stat. 1416 (codified at 25 U.S.C. §450f note); and
> regulations at 25 CFR Part 900, Subpt. M.
>
> /\_/ An Urban Indian Organization that operates a health program,
> including one or more pharmacies or dispensaries, under a grant from
> IHS issued pursuant to Title V of the Indian Health Care Improvement
> Act. Provider represents to ESI that it holds a designation as a
> Federally Qualified Health Center and is therefore not required to
> obtain or maintain general liability, professional liability or other
> insurance as such Provider is covered by the Federal Tort Claims Act
> pursuant to such designation.
>
> **EXHIBIT A**

**[Prescription Pricing Schedule]{.underline}**

+-------------+--------------------------+-----------------------------+
| **I/T/U     |                          |                             |
| P           |                          |                             |
| rescription |                          |                             |
| Re          |                          |                             |
| imbursement |                          |                             |
| Rate by     |                          |                             |
| State**     |                          |                             |
+-------------+--------------------------+-----------------------------+
| *           | **[INGREDIENT            | **[DISPENSING               |
| *[STATE]{.u | COST]{.underline}**      | FEE]{.underline}**          |
| nderline}** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Alabama** | **AWP - 10%**            | **\$6.40**                  |
+-------------+--------------------------+-----------------------------+
| **Alaska**  | **AWP - 5%**             | **\$4.45**                  |
+-------------+--------------------------+-----------------------------+
| **Arizona** | **AWP - 15%**            | **\$3.00**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 20% (generic);   | **\$6.51**                  |
| *Arkansas** | AWP - 14% (brand)**      |                             |
+-------------+--------------------------+-----------------------------+
| **C         | **AWP - 10%**            | **\$5.05**                  |
| alifornia** |                          |                             |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 35% (generic);   | **\$5.00**                  |
| *Colorado** | AWP - 13.5% (brand)**    |                             |
+-------------+--------------------------+-----------------------------+
| **Co        | **AWP - 40% (generic);   | **\$4.60**                  |
| nnecticut** | AWP - 12% (brand)**      |                             |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 14%**            | **\$4.65**                  |
| *Delaware** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **DC**      | **AWP - 10%**            | **\$5.50**                  |
+-------------+--------------------------+-----------------------------+
| **Florida** | **AWP - 13.25%**         | **\$5.23**                  |
+-------------+--------------------------+-----------------------------+
| **Georgia** | **AWP - 10%**            | **\$5.33**                  |
+-------------+--------------------------+-----------------------------+
| **Hawaii**  | **AWP - 10.5%**          | **\$5.67**                  |
+-------------+--------------------------+-----------------------------+
| **Idaho**   | **AWP - 12%**            | **\$5.94**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 25% (generic);   | **\$5.60 (generic); \$4.40  |
| *Illinois** | AWP - 12% (brand)**      | (brand)**                   |
+-------------+--------------------------+-----------------------------+
| **Indiana** | **AWP - 20% (generic);   | **\$5.90**                  |
|             | AWP - 13.5% (brand)**    |                             |
+-------------+--------------------------+-----------------------------+
| **Iowa**    | **AWP - 12%**            | **\$5.26**                  |
+-------------+--------------------------+-----------------------------+
| **Kansas**  | **AWP - 27% (generic);   | **\$4.40**                  |
|             | AWP - 13% (brand)**      |                             |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 12%**            | **\$5.51**                  |
| *Kentucky** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **          | **AWP - 15%**            | **\$6.77**                  |
| Louisiana** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Maine**   | **AWP - 15%**            | **\$4.35**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 12%**            | **\$5.69 (generic); \$4.69  |
| *Maryland** |                          | (brand)**                   |
+-------------+--------------------------+-----------------------------+
| **Mass      | **AWP - 14%**            | **\$4.50 (brand), \$6       |
| achusetts** |                          | (generic)**                 |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 15.1%**          | **\$4.77**                  |
| *Michigan** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **          | **AWP - 11%**            | **\$4.65**                  |
| Minnesota** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Mi        | **AWP - 12%**            | **\$4.91**                  |
| ssissippi** |                          |                             |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 10.43%**         | **\$5.09**                  |
| *Missouri** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Montana** | **AWP - 15%**            | **\$5.70**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 11%**            | **\$4.27**                  |
| *Nebraska** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Nevada**  | **AWP - 15%**            | **\$5.76**                  |
+-------------+--------------------------+-----------------------------+
| **New       | **AWP - 16%**            | **\$2.75**                  |
| Hampshire** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **New       | **AWP - 12.5%**          | **\$4.73**                  |
| Jersey**    |                          |                             |
+-------------+--------------------------+-----------------------------+
| **New       | **AWP - 12.5%**          | **\$4.65**                  |
| Mexico**    |                          |                             |
+-------------+--------------------------+-----------------------------+
| **New       | **AWP - 12%**            | **\$5.50 (generic); \$4.50  |
| York**      |                          | (brand)**                   |
+-------------+--------------------------+-----------------------------+
| **North     | **AWP - 10%**            | **\$6.60 (generic); \$5.00  |
| Carolina**  |                          | (brand)**                   |
+-------------+--------------------------+-----------------------------+
| **North     | **AWP - 10%**            | **\$6.60 (generic); \$5.60  |
| Dakota**    |                          | (brand)**                   |
+-------------+--------------------------+-----------------------------+
| **Ohio**    | **AWP - 12.8%**          | **\$4.70**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 12%**            | **\$5.15**                  |
| *Oklahoma** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Oregon**  | **AWP - 15%**            | **\$4.50**                  |
+-------------+--------------------------+-----------------------------+
| **Pen       | **AWP - 10%**            | **\$5.00**                  |
| nsylvania** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Rhode     | **AWP - 14%**            | **\$4.40**                  |
| Island**    |                          |                             |
+-------------+--------------------------+-----------------------------+
| **South     | **AWP - 10%**            | **\$5.05**                  |
| Carolina**  |                          |                             |
+-------------+--------------------------+-----------------------------+
| **South     | **AWP - 10.5%**          | **\$5.75**                  |
| Dakota**    |                          |                             |
+-------------+--------------------------+-----------------------------+
| **          | **AWP - 13%**            | **\$6.00**                  |
| Tennessee** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Texas**   | **AWP - 15%**            | **\$6.14**                  |
+-------------+--------------------------+-----------------------------+
| **Utah**    | **AWP - 15%**            | **\$5.40**                  |
+-------------+--------------------------+-----------------------------+
| **Vermont** | **AWP - 11.9%**          | **\$5.25**                  |
+-------------+--------------------------+-----------------------------+
| *           | **AWP - 10.25%**         | **\$4.75**                  |
| *Virginia** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **W         | **AWP - 14%**            | **\$5.20**                  |
| ashington** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **West      | **AWP - 12%**            | **\$4.90**                  |
| Virginia**  |                          |                             |
+-------------+--------------------------+-----------------------------+
| **          | **AWP - 11.25%**         | **\$5.88**                  |
| Wisconsin** |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Wyoming** | **AWP - 11%**            | **\$6.00**                  |
+-------------+--------------------------+-----------------------------+
|             |                          |                             |
+-------------+--------------------------+-----------------------------+
| **AWP =     |                          |                             |
| average     |                          |                             |
| wholesale   |                          |                             |
| price**     |                          |                             |
+-------------+--------------------------+-----------------------------+
| **Source:   |                          |                             |
| Adapted     |                          |                             |
| from        |                          |                             |
| Medicaid    |                          |                             |
| P           |                          |                             |
| rescription |                          |                             |
| Re          |                          |                             |
| imbursement |                          |                             |
| Information |                          |                             |
| by State -- |                          |                             |
| Qtr Ending  |                          |                             |
| June 2004** |                          |                             |
|             |                          |                             |
| **\         |                          |                             |
| *Dispensing |                          |                             |
| fee         |                          |                             |
| includes    |                          |                             |
| one dollar  |                          |                             |
| adm         |                          |                             |
| inistrative |                          |                             |
| fee to be   |                          |                             |
| retained by |                          |                             |
| Express     |                          |                             |
| Scripts,    |                          |                             |
| Inc.**      |                          |                             |
+-------------+--------------------------+-----------------------------+

**EXHIBIT B**

**[Pharmacy Location]{.underline}**

**Please provide the following information for each pharmacy or
dispensary participating in the I/T/U Special Endorsed Medicare Discount
Drug Card and Transitional Assistance Program:**

**Facility Name:**

**Seven-Digit NCPDP Number: (If a dispensary, write in the word
"DISPENSARY")**

**Pharmacy Contact:**

**Contact's Position:**

**Mailing Address:**

**P.O. Box:**

**City:**

**State:**

**Zip Code:**

**Phone Number:**

**Fax Number (optional):**

**E-Mail Address (optional):**

**Authorized Contracting Official:**

**Authorized Contracting Official's Signature:**

**On-Line System Availability:**

**Date:**

**EXHIBIT C**

**[Universal Claim Form]{.underline}**

![](media/image1.jpeg){width="7.11875in" height="8.13125in"}

**EXHIBIT C**

**[Universal Claim Form]{.underline}**

![](media/image2.jpeg){width="7.11875in" height="8.13125in"}