ORDER NO. 31201 KERR COUNTY INDIGENT HEALTH PROGRAM CONTRACT FOR PHARMACEUTICAL PROVIDER Came to be heard this the 13th day of February, 2009, with a motion made by Commissioner Letz, seconded by Commissioners Williams/Oehler, the Court unanimously approved by a vote of 4-0-0 to: Award Kerr County Indigent Health Program Prescription Drug Contract to HEB Pharmacy for the balance of fiscal year 2009 and fiscal year 2010. 3/~ 0 / COMMISSIONERS' COURT AGENDA REQUEST PLEASE FURNISH ONE ORIGINAL AND TEN (10) COPIES OF THIS REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT MADE BY: Dawn Lantz & Rosa Lavender OFFICE: Indigent Health MEETING DATE: February 13, 2009 TIME PREFERRED: SUBJECT: Consider, discuss and take appropriate action to award contract for pharmaceutical provider for Kerr County Indigent Health program for the balance of 2009 fiscal year and FY 2010. EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) NAME OF PERSON ADDRESSING THE COURT: Dawn Lantz & Rosa Lavender ESTIMATED LENGTH OF PRESENTATION: IF PERSONNEL MATTER -NAME OF EMPLOYEF,: Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter 551 and 552, Government Code, is as follows: Meeting scheduled for Mondays: 5:00 PM previous Tuesday THIS REQUEST RECEIVED BY: 'THIS RQUFST RECEIVED ON: @ .M. All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be appreciated and contribute towards your request being addressed at the earliest opportunity. See Agenda Request Rules Adopted by Co-nmissioners' Court. r~ . • > ~'~ ~,~ : ~p~ ~~~' 31 January 12, 2009 KERR COUI`ITY II`IDICI~ItiIT HEALTH CARE PROGRAM 700 Main Street BA-108 ti• Kerrville, Texas 78028 ~s (830} 792-2239 • Fax (830)257-8194 To: Prospective Bidders for the Kerr County Indigent Health Program Pharmaceuticals Enclosed are: 1. Copy of Notice to Bidder published in the Kerrville Daily Times (Notice that the deadline. for hid suhmi.~~sion is Feh. 6 at 4:30 p. m.) 2. Copy of Texas Department of State Health Services guidelines for prescription Drugs. 3. ON CD: a. Copy of Kerr County Indigent Health Care Policy adopted in December 2008 b. Copy of list of prescription drugs dispensed to indigent health clients from September 1 to December 31, 2008 with NCR codes with dosage information c. Copy of Top 20 NDC Usage reports for Kerr County IHC for September, October and November, 2008 (December is not available yet) We suggest you make copies of this information because of the format it was scanned into. 4. Additional information that may be of interest to you in your bid decision. 5. Form to he returned with bid package and your bid letter. Please fcel free to give us a call if you have any questions about this bid package. Dawn Lantz IHC Coordinator 792-2239 ~~~G(,w Rosa Lavender IHC Supervisor 792-2297 Notice to Bidder: Kerr County is accepting proposals from qualified pharmaceutical providers to provide prescriptions for persons approved for the Kerr County Indigent Health program for the balance of the 2008-2009 fiscal year plus FY Z01 O. Bid packages will be available in the Kerr County Indigent Health Care office in the lower level of the courthouse annex beginning January 12. Proposals are to be submitted as unit pricing based on a list of commonly prescribed medications that will be provided with the bid package. The county's method of payment will be based on monthly billing from the provider. No bond will be required from the bidder. Proposals are to be submitted as one original complete Proposal set (marked "original") and three copies of the Proposal (marked "copy"). All proposals must be returned in a sealed envelope with the Firm's name, address, Proposal name, and the wording "SEALED BID" clearly marked on the outside of the envelope. Sealed proposals may behand-delivered or mailed to the Kerr County Clerk, 700 Main St., #122, Kerrville, TX 78028. The proposals must be received in the County Clerk's Office on or before February 6, at 4:30 p.m. The bids will be opened on February 9 at 9 a.m. in the Kerr County Commissioners' Court. ~~~ I ~ s ~' eo~- Jcvr- ~ ~ ~~ ~ ~ I ~ ~- SECTION FOUR SERVICE DELIVERY Page 12 Basic Health Care Services (continued) Prescription This service includes up to three prescription drugs per month. New and Drugs refilled prescriptions count equally toward this three prescription drugs per month total. Drugs must be prescribed by a physician or other practitioner within the scope of practice under law. The quantity of each prescription depends on the prescribing practice of the physician and the needs of the patient. Payment Standard. Use the following information and formula. • Use the drug's 11-digit National Drug Code (NDC) number and the quantity dispensed to select the average wholesale price (AWP) in the Red BooicO. In addition to the annual Red Books the monthly Red Book® Update may be used. Red Book® products may be obtained by contacting Thomson Healthcare at 1-800-678-5689. • Net Cost is: o Red Booker AWP minus 40% for generic prescription drugs o Red Book® AWP minus 13% for name brand prescription drugs • The drug dispensing fee is $5.60. • The formula for computing the TDSHS Payable is: Net Cost plus drug dispensing fee =TDSHS Payable Example: Red Book®AWP for 25 tablets is $100.00. 1. $100.00 divided by 25 = $4.00 per tablet 2. $4.00 per tablet x 34 tablets (prescribed quantity) _ $136.00 3. $136.00 - $54.40 (a0% for generic} _ $81.60 4. $81.60 + $5.60 (dispensing fee) _ $87.20 TDSHS Payable • A payment amount may be negotiated with the provider for: o Prescription compound drugs, o Prescription drugs not listed in the Red Book®, or o Prescription drugs that do not have an NDC number. Rural Health RHC services must be provided in a freestanding or - sed rural Clinic (RHC) health cl~ ~ d provided by a physicia physician assistant, an Services advanced practice a (includin rse practitioner, a clinical nurse specialist, and a certified n Idwife), or a visiting nurse. Pa ment St ard: Use the Rate Per Visl ~ he "Medicare-Approved Rural Healt Clinic Rates" included in Section Four, rvice Delivery. CIHCP 05-5 September 2005 KERR COUNTY INDIGENT HEALTH PROGRAM PRESCRIPTION DRUGS March 1, 2009 to August 31, 2010 Return this form with the Bid proposal attached. • NET COST to be computed in accordance with Department of State Health Services, County Indigent Health Care Program Handbook, Payment Standard for Prescription Drugs. (Page 12 excerpted from current DHS Handbook attached -Handbook was scheduled to be updated in January 2009.) ADDITIONAL DISCOUNT TO BE APPLIED TO THE NET COST OF GENERIC PRESCRIPTION DRUGS ADDITIONAL DISCOUNT TO BE APPLIED TO THE NET COST OF NAME BRAND PRESCRLPTION DRUGS ~l charges must be included in the bid rice No other char c m y he added to the bid urice when invoiced unless noted as an ~~,g~tion in the bid form. ADDITIONAL INFORMATION: CVS Pharmacy has been the county's indigent health pharmaceuticals provider for the past several years. From January 1, 2008 to December 31, 2008 Kerr County paid out $86,609 to CVS Pharmacy. State law requires that- any county expenditure exceeding $25,000 annually must be put up for bid at least every three years. Ackman Pharmacy provided the pharmaceuticals for the Kerr County Jail during that same period, but this budget year the county contracted with a company to provide the prescriptions for the prisoners as part of a comprehensive health care contract. for inmates. 2008-2009 KERR COUNTY INDIGENT HEALTH CARE POLICY (This policy, adopted by Kerr County Commissioners' Court at the regular meeting in December, 2008, shall become effective January 31, 2009, and remain in effect until August 31, 2009) The Kerr County Indigent Health Program is established with an application, documentation, and verification process based on Texas Department of State Health Services (TDSHS) guidelines established Chapter 61 of the Health and Safety Code. Chapter 61, the Indigent Health Care and Treatment Act was passed in 1986 by the 69`" Texas Legislature. The Kerr County Indigent Health Program will be referred to as KCIHP in the remainder of this policy document. KCIHP is a county-based program providing basic services according to the TDSHS guidelines and does not offer any optional services. KCIHP has a maximum county liability per client for each state fiscal year (September 1 to August 31) for health services provided by all assistance providers, including hospital and skilled nursing facility. Eligibility must (by law) be determined within 14 days of application completion date. KCIHP will consider four eligibility criteria for determination of eligibility: Residence, Household, Income and Resources. KCIHP Residency Requirements (may include but are not limited to): • Mail addressed and delivered to the applicant's physical address. No post office box addresses are acceptable. • Texas driver's license or other official identification showing current Kerr County address. • Rent or mortgage payment showing applicant's name and address of property and date signed. • Kerr County property tax receipt for the most recent tax year • Kerr County voter registration card showing current address • School enrollment records KCIHP Household Requirements (may include but are not limited to): • A KCIHP household may be a person living alone or two or more persons living together where legal responsibility for support exists, excluding disqualified persons. Verification of household is required. • Legal responsibility for support exists between persons who are legally married, a legal parent and a minor child, or a managing conservator and a minor child. KCIHP Income Requirements • A household must pursue and accept all income to which the household is legally entitled. • The income of all household members is considered in determining eligibility. • Monthly Income Standards will be based on the annual Federal Poverty Guidelines • Verification of income may include but is not limited to requests for paycheck stubs, statements from employers, W-2 forms, verification of cash contributions, business records, award letters, court orders or public decrees, sales records, income tax returns or statements completed, signed and dated by the self- employed person. KCIHP Resources Requirements • A household must pursue all resources to which the household is legally entitled unless it is unreasonable to pursue the resource. Indigent health care should be considered the source of last resort. • The resources of all household members are considered. Proof of resources may be required. KCIHP Policies All applicants for KCIHP will be required to visit the county's indigent health office in the basement of the Kerr County Courthouse annex for an interview. If the applicant misses the interview appointment the application will be denied and applicant will have to reapply. If approved, a photo identification card will be generated for the applicant. Persons already on the program will be photographed and an identification card generated when they are reviewed. Reviews must be done every 6 months but can be required at any interval of time less than the 6 months, as determined by KCIHP. Beginning Feb. 1, 2009, persons covered under the Kerr County Indigent Health Program will be asked to share in the costs of their health care. $50 co-pay per hospital visit, $25 co-pay per doctor visit and $5 co-pay per prescription will be requested. Program participants will be encouraged to seek information on other low-cost prescription plans that are available through their providers. • Persons on KCIHP or new applicants will have 14 days to report changes in address, in income or resources, people living in the household, or any application for or receipt of Medicaid, TANF, or SSI to our office. Failure to do so will jeopardize eligibility and could lead to criminal charges. • Applicants will be required to sign an affidavit swearing to the accuracy of information provided in the application process and the affidavit will be notarized at no cost to the applicant. A person who provides false information will be banned from re-applying for indigent health care in Kerr County for a period of two years. Giving false information on an application could lead to criminal charges. • Applicants will be subject to background checks to include screening under www.yourtexasbenefits.com and http://bestssa.800 • The filing of an application for Kerr County IHP or the receipt of services constitutes an assignment of the applicant's or recipient's right of recovery from personal insurance, other sources, or another person for personal injury caused by another person's negligence or wrong doing. An applicant or recipient shall inform the county at the time of application or any time during eligibility, of any unsettled tort claim that may affect medical needs and of any private accident or sickness insurance coverage that is or may become available. Notice must be given to KCIHP within 10 days of the date the person learns of the insurance coverage, tort claim or potential cause of action. • If an applicant is denied coverage, the person will have 90 days to file a written appeal with KCIHP. A form will be provided. An appeals committee will review the application and written appeal and set up a hearing with the applicant. The review committee will be made up of the IHC Coordinator (non-voting) and two unbiased members. • Kerr County may, by state law, designate providers for indigent health care recipients. Out-of-county care will require prior approval and a referral in writing from a Kerr County physician or meet one of three criteria (an emergency situation, when medical care is not available in Kerr County, or when care in Kerr County would be medically inappropriate). • KCIHP requires dispensing of generic prescriptions, if there is a generic available. A physician can request the name-brand as part of the prescription but the IHC recipient cannot make the choice. Medications that are available in an over-the-counter form will not be covered. Prescriptions are limited to a total of three per month for each IHC recipient. If a physician writes the prescription for a 90 day supply then the prescription will count as one of the three for each of the three months. Dosage verification will be required for all prescriptions. • Persons on KCIHP may be required to register with the Workforce Solutions Alamo for job eligibility or training. They may also be advised to seek services from the Texas Rehabilitation Commission or ask Social Security to determine whether they are eligible for Social Security Disability Insurance/Medicare. • For claim payments to be considered, a claim must be received in the KCIHP office no later than 95 days from (I) the date of service, for services provided after the date of approval, or (2) the date of approval, for services provided before the household was approved. 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C' O N N O ~ ~ C +- ~ N ~ E E .~ '6 ', 'D -O N .~ Y , fn N ~ Q.', Q N (~ (~ .~ U CA CZ ~E U~ U~ ~ O ~ ~ r- ' ~ N ~ O M T ~ ~ O ' ~ r- In Lf~ ~ 1 0 ~ ~' M ' ~ r- op ~ 0 0 0 ~ 0 O N r- O j 0 CD lf') O O' ~ 0 0 07 O' er O O O N O' N ~' M N' CO' N'' O ~ O' O' H I` 00' O~ ~'' M', o0 M ~ O M ~ M M ~ O CO ~ f~ O I~ ' ti 07 ~ O ~ N O ~ O' CO ~ N O ' ~ ~ ti ti M N' ~- O O' CO M N' M ~' O N CO CO' s CO O' O' f~ ~ ~ O, O O O M N ~ ~ ~, N' ~ O O Cfl ~.(~ O' O O O N O O' M CO O' ~, ~ O O O I~ ~ M N M CO C~ C~ ~ 00 00 ~ N O In 00 N N d' M ~ ' ~ M M ~ M l.(7 O CO ' N O ~ M ti ', ti O ~ CO '~, 00 O CO O Cfl ' f~ f` f~ Cfl O~ O ~ ~ I~ N ~ ', I` ', ~ M N ~ ~ ~ r- 00 I` r- ~ ~, 07, , N M, ~ x'' 00 O ~ O'~ N ~ ~ ~ ~ N Cfl' CflI O, ~' ~' I ~ __ _ _ _ U •i O ' N' M , ~ ~ O O ~ Q' Q ~ (6 O p) N In O O, O ~ O Oi O O U O OL ~ W O, 0 0 ~ U O~ O ~ ~ ~ ~ '' O O ~ E, ' ~' ~ ~ ' O ~', ~ O J U ' ~ `~ , ~' ~ ~ , O N ~ ~ ~ ~ N ~' M O, 00 O ~ ', O, ltd 00 ' CO ~ M', 00 ' O M O r 2 , d- O M O , N ', •: ~ ~ ~ O ~ + W ~ , r- L, ~', ~ '' N C ~ N, N N ' ~ ~ O O (6' X ' ~ ~' - 'i p' p ~ ~ ~ O ~ O ~ O X ~ U ~ ~ ~ ~ ~ Oi, ~i U U O ~- X N ! .~ O ~ N ~ ' N ~ (6 (a ~ N (B ~ O ~ ~ O O' O Q Q~~ ~ ~ >+, >+ N p O L i i i ' L ' i ' i C6 O O O (n (n Cn (~ ' (n (n (n (n ', (n H F- ' I- H ' I- F- H f- I- H > > ~ N ', N N A.'f\'~'~ ly~ L KERR COUNTY INDIGENT HEALTH PROGRAM PRESCRIPTION DRUGS March 1, 2009 to August 31, 2010 Return this form with the Bid proposal attached. • NET COST to be computed in accordance with Department of State Health Services, County Indigent Health Care Program Handbook, Payment Standard for Prescription Drugs. (Page 12 excerpted from current DHS Handbook attached -Handbook was scheduled to be updated in January 2009.) ADDITIONAL DISCOUNT TO BE APPLIED TO THE NET COST OF GENERIC PRESCRIPTION DRUG5 rr~~.,, C ^~ `p (~ ~~J (.~ ADDITIONAL D SCOUNT TO BE APPLIED TO THE NET COST OF NAME BRAND PRESCRIPTION DRUGS ~l charges mint be included in the bid price. No other charges may bgadded to the bid price when invoiced unless noted as an exception in the bid form. February 4, 2009 H-E-B Pharmacy 646 S. Main Avenue San Antonio, TX 78204 c/o Sandra Barsenas 2]0-938-7423 Kerr County Prescription Drug Bid Indigent Health Care Pharmaceuticals Due Date: February 6, 2009 Opening Date: February 9, 2009 * Generics (must be at least 40% discount) Minimum of 40% off of AWP with access to the list of 500 generics for $5 each. Plus a dispensing fee of $5.00 per prescription. (There is no dispense fee for prescriptions on the 500 generic list). * Brands Minimum of 13% off AWP. Plus a dispensing fee of $5.00 per prescription. Please note, that the 500 generic list covers a wide variety of medications, which includes medications for both acute and maintenance conditions. Such medications include but are not limited to: • Cardiac, • Asthma, • Penicillins, • Ulcer, • Allergy, Cough, and Cold, • Anxiety, • Seizures, • Hornone, • Cholesterol, • Antibiotics, • Antidepressants, • Diabetes, • Contraceptives, • Thyroid, • and Gastrointestinal • Plus others as noted on the attached list (., ~' ~~ ~ ~-+ a L V V .O V ~+ V 0 .~..+i 0 V ~_ V -~~-+ ca Q i ~-+ x 4~ s -~+ .~ •-+ t C~- 4~ V ._ O U .~ O U 0 .~ O U 0 U ~~ ~--• U .~ 4~ 0 0 0 a~ 0 c!~ U U c~ a~ .> O w U L C~ c~ m J J Q O 0 U .~ ~\ U C~ S.. C~ U cis a~ ~+ a~ O O :~-_~ .~ .~ .~ a~ -~ 4~ L ~~ L Q U U ca a~ m 0 0 N U Q ~--- 4~ O w z z ._ v «s .~ .~ a~ .~ C~ ~-- O a~ .>_ 4~ A ~--+ O U a~ m L 0 O CrS U ~--+ a~ C .~ V A .~ O V Q ~~ N CCS -~-. O ~ ~ C~ N ~ L O N N }' ~ ~ ~ ~~ ~ Ca U O ° ~ ~ ~ - ~ ~ M N ~ ~ Y.~ _ ~ _ U O~ ~ L ~~ ~ O O ~ O Q O O ~--~ } ~ .~ , ~ f~ CB O ~ ~ - ~ U W Q ~ Q C1) i N -,.:~ 0 O _N Q X O O N ~ ~ > ~ O U Q. ~ ~ Q N _~ ~ O to _ O ~ "~ ~ Q ~ ~ ~ O ~ ~ Z ~ ~ V U ~~~ (n U ~ .~ ~ ~ ~~ ~ ~ Q .~ i O . ~ 0 O CB ~ ~ U O +_• i ~ ~ O i ~ O ~ ~ ~ ca U ~ O ~ ~ o O 'O - ~ J ~ ~ ~ _ ~ ~ _ C~ W v W ~ U ~ = J ~ ~ ~ U ~ ~ ~ V . U ~ ~ ~ ~ ~ O v ~ ~ V ~ Q V ~ ~ . ~ ~ ~ Q v O U O ~ ~ ~ ~ -Q ~ ~ ~ ~ ~ ~ _~ ~ ~ ~ U J ~ U ~ Q O Q ~ ~ C!~ ca ~ FLURBIPROFEN TAB 100MG 60 CICLOPIP,O}; CRE 0 i i% 30 llh~~OLOL h1AL SOL 0 5°~-, OP 15 BENZONATATE CAP 100MG 30 IBUPROFEN' 3US 100; 5ML 120 CICLOPIROY 5US 1,.77°~~ 30 (OBPnh1YCiN SOt (' 3% OP 5 CERON SYP 2a0 IBUPROFEN TAB 4JOMG 90 CLOTRIMA,'_OLE CRE 1'~~ 15 CLEMASTINE SYP 0.5i5ML 120 IBUPROFEN TAB 600MG 60 CLOTRIMAZOLE LOZ IOMG 70 COLDAMINE TAB 8 90 25 60 IBUPROFEN TAB 800MG 30 ECONAZOLE CRE 1°% 15 ACEBUTOLOL CAP 200MG 30 DEHISTINE SYP 240 INDOMETHACIN CAP 25MG 60 FLUCONAZOLE IOOMGTABLETS 30 AMILOR/HCTZ TAB 5 50 30 DEX PC SYP 120 KETOPROFEN CAP 75MG 60 FLUCONAZOLE 150MG TABLETS 1 AMLODIPiNE TAB 2.5MG 30 DURADRYL SR TAB 30 KETOPROFEN CAP 200MG ER 30 FLUCONAZOLE 200MG TABLETS 2 ATENOL/CHLOR TAB 50-25MG 30 FLUNISOLIDE SPR 0.025% 25 MELOXICAM TAB 7.5MG 30 KETOCONAZOLE CRE 2% 15 ATENOL/CHLOR TAB 100-25MG 30 GANI-TUBS DM LIQ 100-10/5 240 MELOXICAM TAB 15MG 30 NYSTAT/TRIAM CRE 15 ATENOLOL TAB 25MG 30 IPRATROPIUM SPR 0.03°% 30 METHOCARBAM TAB 500MG 60 NYSTAT/TRIAM CRE 30 ATENOLOL iAB 50MG 30 IPRATROPIUM SPR 0.06% 15 MST 600 TAB 60 NYSTAT/TRIAM CRE 60 ATEPJOLOL TAB 100MG 30 PROMETHAZINE SYP 6.25/5ML 120 NAPROXEN TAB 250MG 60 NYSTAT/TRIAM OIN 15 BENAZEP; HCTZ TAB 5-6.25 30 PROMETHAZINE SYP DM 120 NAPROXEN TAB 375MG 60 NYSTAT/TRIAM OIN 30 BENAZFPRIL TAB 5MG 30 PROMETHAZINE TAB 25MG 30 NAPROXEN TAB 500MG 60 NYSTATIN CRE 100000 30 BENAZEPRII TAB IOMG 30 PSE/DM/GG SYP 40 15 10 120 ORPHEN CPD TAB DS 30 NYSTATIN OIN 100000 15 BENAZFPRIL TAB 20MG 30 PIROXICAM CAP 20MG 30 NYSTATIN OIN 100000 30 BENAZFPRIL TAB 40MG 30 SALSALATE TAB 500MG 60 NYSTATIN SUS 100000 60 BISOPRL/HCTZ TAB 2.5/6.25 30 AMOX/K CLAV CHW 200MG 20 SALSALATE TAB 750MG 60 NYSTATIN TAB 500000 60 BISOPRL/HCTZ TAB 5/6.25 30 AMOX/K CLAV SUS 200/5ML 50 TRAMADOL HCLTAB 50MG 60 TERBINAFlNE TAB 250MG 30 BISOPRL/HCTZ TAB 10/6.25 30 AMOXICILLIN CAP 250MG 30 BISOPROL FUM TAB lOMG 30 AMOXICILLIN CAP 500MG 30 I BUMETANIDE TAB 0.5h1G 30 AMOXICILLIN SUS 125/5ML 80 ALBUTEROL NEB 0.083% 75 BELLA ALK/PB TAB 16.2MG 60 BUMETANIDE TAB IMG 30 AMOXICILLIN SUS 125/5ML 100 ALBUTEROL NEB 0.5% 20 CIMETIDINE TAB 300MG 60 BUMETANIDE TAB 2MG 30 AMOXICIWN SUS 125/5ML 150 ALBUTEROL SYP 2MG/5ML 120 CIMETIDINE TAB 400MG 60 CAPTOPR/HCTZ TAB 25 15MG 60 AMOXICILLIN SUS 200,i5M1 50 ALBUTEROL TAB 2MG 60 CIMETIDINE TAB 800MG 30 CAPTOPRIL TAB 12.5MG 60 AMOXICILLIN SUS 250/5ML 80 ALBUTEROLTAB 4MG 60 CYTRA 2 SOL 473 CAPTOPRIL TAB 25MG 60 AMOXICIILIN SUS 250/5ML 100 IPRATROPIUM SOL INHAL 63 DICYCIOMiNE CAP IOMG 90 CAPTOPRIL TAB 50MG 60 AMOXICILLIN SUS 250/5ML 150 THEOPHYLLINE TAB 100MG CR 30 DICYCLOMINE TAB 20MG 30 CAPTOPRIL TAB 100MG 60 AMOXICILLIN SUS 400/5ML 50 THEOPHYLLINE TAB 200MG CR 30 DIPHEN/ATROP TAB 25MG 30 CARVEDILOL TAB 3.125MG 60 AMOXICILLIN SUS 400/5ML 75 THEOPHYLLINE TAB 200MG ER 60 FAMOTIDINE TAB 20MG 60 CARVEDILOL TAB 6.25MG 60 AMOXICILLIN SUS 400,i5ML 100 THEOPHYLLINE TAB 300MG ER 60 FAMOTIDINE TAB 40MG 30 CARVEDILOL iA8 125MG 60 CEFPROZIL SUS 125/5ML 50 HYOSYNE DRO 0.125/ML 15 CARVEDILOL TAB 25MG 60 CEFUROXIME TAB 250MG 20 LACTULOSE SOL IOGM/15 946 CHLORTHALID TAB 25MG 30 CEFUROXIME TAB 500MG 20 CHOLESTYRAM POW 4GM 378 LOPERAMIDE CAP 2MG 30 CHLORTHALID TAB 50MG 30 CEPHALEXIN CAP 250MG 40 CHOLESTYRAM POW 4GM LITE 210 METOCLOPRAM SOL 5MG/5ML 60 CLONIDINE TAB O.1MG 60 CEPHALEXIN CAP 500MG 30 LOVASTATIN TAB IOMG 30 METOCLOPRAM TAB lOh1G 120 CLONIDINE TAB 0.2MG 60 CEPHALEXIN SUS 125/5ML 100 LOVASTATIN TAB 20MG 30 MISOPROSTOL TAB 200MCG 60 DIGOXIN TAB 0.125MG 30 CIPROFLOXACN TAB 250MG 14 PRAVASTATIN TAB IOMG 30 OMEPRAZOLE CAP lOMG 30 DIGOXIN TAB 0.25MG 30 CIPROFLOXACN TAB 500MG 20 PRAVASTATIN TAB 20MG 30 ONDANSETRON TAB 4MG ODT 10 DILTIAZEM TAB 30MG 60 CLARITHROMYC SUS 125/5ML 50 PRAVASTATIN TAB 40MG 30 RANITIDINE TAB 150MG 60 DILTIAZEM iAB 60MG 60 DOXYCYCL HYC CAP 50MG 30 SIMVASTATIN TAB 5MG 30 RANITIDINE TAB 300MG 30 DILTIAZEM TAB 90MG 60 DOXYCYCL HYC CAP 100MG 20 SIMVASTATIN TAB IOMG 30 SUCRALFATE TAB 1GM 60 DILTIAZEM CAP 120MG ER 30 DOXYCYCL HYC TAB 100MG 20 DILTIAZEM TAB 120MG 30 ERYFHROCIN TAB 250MG 40 ~~ DIPYRIDAMOLE TAB 50MG 60 ERYTHROMYCIN CAP 250MG EC 40 CHLORPROPAM TAB 100MG 30 ATROPINE SUL OIN 1°% OP 4 DOXAZOSIN TAB 1MG 30 METRONIDAZOL TAB 250MG 28 CHLORPROPAM TAB 250MG 30 ATROPINE SUL SOL 1% OP 15 DOXAZOSIN TAB 7MG 30 METRONIDAZOLTAB 500MG 14 GLIMEPIRIDE TAB iMG 30 BACIT/POLVMY OIN OP 4 DOXAZOSIN TAB 4MG 30 PENICILLN VK SOL 125/5ML 100 GLIMEPIRIDE iA6 2MG 30 BACITRACIN OIN OP 4 DOXAZOSIN TAB 8MG 30 PENICILLN VK SOL 250/5ML 100 GLIPIZIDE TAB 5MG 60 CYCLOPENTOL SOL 1% OP 2 ENALAPR/HCTZ TAB 512.5MG 30 PENICILLN VK SOL 250/5ML 200 GLIPIZIDE TAB lOMG 60 CYCLOPENTOL SOL 1°~° OP 15 ENALAPRIL TAB 25MG 30 PENICILLN VK TAB 250MG 30 GLVB,~METFORM TAB 1.25-250 60 DEXAMETH PHO SOL 0.1°i° OP 5 ENALAPRIL TAB 5MG 30 SMZ/TMP DS TAB 800-160 20 GLYBURID MCR TAB 3MG 60 ERYTHROMYCIN OIN OP 4 ENALAPRIL TA8 lOMG 30 SMZ-TMP SUS 200-40/5 100 GLYBURID MCR TAB 6MG 60 GENTAK OIN 0.3°~ OP 4 ENALAPRIL TAB 20MG 30 SMZ-TMP TAB 400-SOMG 30 GLYBURIDE TAB L25MG 30 GENTAMICIN SOL 0.3°~o OP 5 FUROSEMIDE SOL IOMG/ML 60 TETRACYCLINE CAP 250MG 60 GLYBURIDE TAB 25MG 30 LEVOBUNOLOL SOL 0.5% OP 5 FUROSEMIDE TAB 20MG 30 TETRACYCLINE CAP 500MG 60 GLYBURIDE TAB 5MG (BLUE) 60 NEO,~POIY/DEX OIN 0.1% OP 4 FUROSEMIDE TAB 40MG 30 TRIMETHOPRIM TAB 100MG 60 GLYBURIDE TAB 5MG (GREEN) 60 NEO/POLYJDEX SUS 0.1°i° OP 5 FUROSEMIDE TAB SOMG 30 METFORMIN TAB 1000MG 60 OFLOXACIN OPTH SOL 0.3% 5 GUANFACINE TAB 1MG 30 . .. METFORMIN TAB 500MG 60 PILOCARPINE SOL 1°% OP 15 GUANFACINE TAB 2MG 30 ALLOPURINOL TAB 100MG 30 METFORMIN TAB 500MG ER 60 PILOCARPINE SOL 2°%° OP 15 HCTZ TAB 25MG 30 ALLOPURINOL TAB 300MG 30 MEfFORMIN TAB 850MG 60 PILOCARPINE SOL 4% OP 15 HCTZ TAB 50MG 30 BACLOFEN TAB IOMG 90 POLYMVXIN B TRIMETHOPRIM OS 10 HYDRALAZINE TAB IOMG 60 CHLORZOXAZON TAB 500MG 120 PRED SOD PHO SOL 1°% OP 15 HYDRALAZINE TAB 25MG 60 COLCHICINE TAB 0.6MG 30 ANTIPY/BENZO SOL OTIC 10 PREDNISOLONE SUS 1°i° OP 5 HYDROCHLOROT CAP 12.5MG 30 CYCLOBENZAPR TAB 5MG 30 EAR-GESIC DRO OTIC 15 PREDNISOLONE SUS 1°io OP 10 INDAPAMIDE TAB L25MG 30 CYCIOBENZAPR TAB IOMG 30 OTICAINE SOL 20% OTIC 15 SULFACET SOD SOL 10°6 OP 15 INDAPAMIDE TAB 25MG 30 DICLOFENAC TAB 50MG EC 60 TIMOLOL MAL SOL 0.25% OP 5 ISOSORB DIN TAB 40MG ER 60 DICLOFENAC TAB 75MG DR 60 _. - TIMOLOL MAL SOL 0.5°i° OP 5 ISOSORB MONO iA6 30MG ER 30 EiODOLAC CAP 300MG 60 CICLOPIROX CRE 0.77% 15 TIMOLOL MAL SOL 0.5% OP 10 ISOSORB MONO TAB 60MG ER 30 ~ r ISOSORB!~10N0 i4B 120MG ER 30 BUSPIRONC TAB 5N1G 60 METHY'LPRED PAK 4MG 21 LEVOTH4ROXIN TAB 75MCG 30 LABETALOL TAB 100h1G 60 BUSPIRONE U13 10~11i~ 60 OXYBUTYNIPJ lAB 5MG 60 LEVO(Hl"ROXIN TAB 88rv9CG 30 LISINOP/HCi~ TAB 10 12.5 30 CARBAMAZEPiN TAB 200MG 6C PHENAZOPYRID IAB 100MG o L"tV01HYROXIN TAB 100MCG 30 LISINOP/HCTZ TAB 20 125 30 CITALOPRAA4 TAB lOMG 30 PHENAZOPYRID TAB 200MG 30 IEVOTHYROXIN TAB 112MCG 30 LISINOP/HCTZ TAB 20-25MG 30 CITALOPRAM TAB 20MG 30 PREDNISONE TAB 25MG 30 LEVOTHYROXIN TAB 125MCG 30 LISINOPRIL TAB 25MG 30 CITALOPRAh9 TAB 40MG 30 PREDNISONE TAB 5MG 30 LEVOTHYROXIN TAB 137MCG 30 LISINOPRIL TAB 5MG 30 CLOMIPRAMINE CAP 25MG 30 PREDNISONE PAK 5MG 21 LEVOTHYROXIN TAB 150MCG 30 LISINOPRIL TAB IOMG 30 DESIPRAMINE TAB 50MG 60 PREDNISONE TAB lOMG 30 LEVOTHVROXIN TAB 175MCG 30 LISINOPRIL TAB 20MG 30 DOXEPIN HCL CAP lOMG 30 PREDNISONE PAK IOMG 48 LEVOTHYROXIN TAB 200MCG 30 LISINOPRIL TAB 30MG 30 DOXEPIN HCL CAP 25MG 30 PREDNISONETAB 20MG 30 THYROID TAB 325MG 30 METHYLDOPA TAB 250MG 60 DOXEPIN HCL CAP 50MG 30 THYROID TAB 65MG 30 METHYLDOPA TAB 500MG 60 DOXEPIN HCL CAP 75MG 30 METOPROLOL TAR 25MG TAB 60 DOXEPIN HCL CAP 100MG 30 ALCLOMETASON CRE 0.05% 15 METOPROLOLTAR 50MG TAB 60 FLUOXETINE CAP lOMG 30 ALCLOMETASON CRE 0.05% 45 ACYCLOVIR CAP 200MG 60 METOPROLOLTAR 100MG TAB 60 FLUOXETINE CAP 20MG 30 AMMONIUM LAC LOT 12% 400 MINOXIDIL TAB 25MG 30 FLUOXETINE CAP 40MG 30 AUG BETAMET CRE 0-05% 15 NADOLOL TAB 20MG 30 FLUOXETINE TAB lOMG 30 AUG BETAMET OIN 0.05°io 15 CYANOCOBALAM INJ 1000MCG 30 NADOLOL TAB 40MG 30 FLUOXETINE TAB 20MG 30 AUG BETAMET GEL 0.05°ia 50 ETHEDENT CHW Q25MG 30 NIFEDIPINE CAP lOMG 90 FLUPHENAZINE TAB 1MG 30 BETAMETH DIP CRE 0.05°a 15 ETHEDENT CHW 0.5MG 30 NITROGLVCER CAP 25MG ER 60 HALOPERIDOL TAB 0.5MG 30 BETAMETH DIP CRE 0.05°6 45 FER-IRON DRO 15; 0,6ML 50 NITROGLYCER CAP 6.5MG CR 60 HALOPERIDOL TAB 1 MG 30 BETAMETH VAL CRE 0.1°io 15 FERROUS GLUC TAB 246MG 30 NITROGLYCER CAP 6,5MG ER 60 HALOPERIDOL TAB 2MG 30 BETAMETH VAL CRE O. L% 45 FERROUS SULF TAB 325MG 60 NITROGLYCERI DIS 0.6MG/HR 30 HALOPERIDOL TAB 5MG 30 BETAMETH VAL OIN 0.1% 30 FOLIC ACID TAB 1MG 30 NITROQUICK SUB 0.3MG 100 HYDROXYZ HCL SYP IOMG/5ML 120 BETAMETH VAL OIN 0.1% 45 HEMATINIC PL TAB VIT/MIN 30 NITROQUICK SUB 0.4MG 100 HYDROXYZ PAM CAP 25MG 30 CLINDAMYCIN SOL 19a 30 KLOR-CON M10 TAB IOMEQ ER 30 PINDOLOL TAB 5MG 30 HYDROXYZ PAM CAP 50MG 30 CLINDAMYCIN SOL 1% 60 KLOR-CON 10 TAB 10MEQ ER 30 PINDOLOL TAB IOMG 30 IMIPRAM HCL TAB 10MG 30 CLOBETASOL CRE 0.05% 15 KLOR-CON 8 TAB 8MEQ ER 30 PRAZOSIN HCL CAP 1MG 60 LITHIUM CARB CAP 300MG 90 CLOBETASOL CRE 0.05°% 30 KLOR-CON/EF TAB 25MEQ FR 30 PRAZOSIN HCL CAP 2MG 30 MIRTAZAPINE TAB 45MG 30 CLOBETASOL OIN 0.05% 30 MAG64 TAB 64MG 60 PRAZOSIN HCL CAP 5MG 30 NEFAZODONE TAB 100MG 30 CLOBETASOL OIN 0.05°% 45 MULTI VIT/FL CHW 0.25MG 30 PROPRANOLOL TAB IOMG 60 NEFAZODONE TAB 150MG 30 CLOBETASOL E CRE 0.059a 30 MULTI-VIT/FL CHW iMG 30 PROPRANOLOL TAB 20MG 60 NEFAZODONE TAB 200MG 60 DESONIDE CRE 0.05% 15 POLY-VIT/FE DRO /FL 0.25 50 PROPRANOLOL TAB 40MG 60 NORTRIPTYLIN CAP IOMG 30 ERYTHROMYCIN GEL 2% 60 POLY-VIT/FL DRO 0.25MG 50 PROPRANOLOL TAB 60MG 60 NORTRIPTYLIN CAP 25MG 30 ERYTHROMYCIN SOL 2% 60 POT CHLORIDE LIQ 10°6 473 PROPRANOLOL TAB 80MG 60 NORTRIPTYLIN CAP 50MG 30 FLUOCIN ACET CRE 0.025% 15 POT CHLORIDE LIQ 20% 473 QNAPRIL/HCTZ TAB 20-25MG 30 NORTRIP~IYLIN CAP 75MG 30 FLUOCIN ACET SOL 0-01°ro 60 QUINAPRIL TAB 5MG 30 PAROXETINE TAB IOMG 30 FLUOCINONIDE CRE 0.05% 15 ~ QUINAPRIL TAB IOMG 30 PAROXETINE TAB 20MG 30 FLUOCINONIDE CRE 0.05°io 30 ESTRADIOL DIS 0.025MG 4 SOTALOL HCE TAB 80MG 60 PERPHENAZINE TAB 4MG 30 FLUOCINONIDE CRE 0.05% 60 ESTRADIOL DIS 0.0375MG 4 SOTALOL HCL TAB 120MG 60 PROCHLORPER TAB lOMG 30 FLUOCINONIDE OIN 0.05°6 15 ESTRADIOLTAB 0.5MG 30 SPIRONOLACT TAB 25MG 30 THIORIDAZINE TAB 25MG 60 FLUOCINONIDE OIN 0.05% 30 ESTRADIOLTAB 1MG 30 TERAZOSIN CAP 1MG 30 THIORIDAZINE TAB 50MG 60 FLUOCINONIDE OIN 0.05°% 60 ESTRADIOL TAB 2MG 30 TERAZOSIN CAP 2MG 30 THIOTHIXENE CAP 2MG 120 FLUOCINONIDE SOL 0.05% 60 ESTROPIPATE TAB 0.75MG 30 TERAZOSIN CAP 5MG 30 TRAZODONE TAB 50MG 30 GENTAMICIN CRE 0.1% 15 ESTROPIPATE TAB 1.5MG 30 TERAZOSIN CAP lOMG 30 TRAZODONE TAB 100MG 30 GENTAMICIN OIN 0.1°% 15 LEENATAB 28 TICLOPIDINE TAB 250MG 60 TRAZODONE TAB 150MG 30 HALOBEIASOL CRE 0.05°/a 15 MEDROXYPR AC TAB 2.5MG 30 TORSEMIDE TAB lOMG 30 TRIHEXYPHEN TAB 2MG 60 HALOBETASOL OIN 0.054% 15 MEDROXYPR AC TAB 5MG 30 TRIAMj HCTZ CAP 37.5-25 30 TRIHEXYPHEN TAB 5MG 60 HC VALERATE OIN 0.2°/ 15 MEDROXYPR AC TAB lOMG 30 TRIAM,iHCTZ TAB 37.5 25 30 VALPROIC ACD SYP 250/5ML 473 HYDROCORT CRE 1°~0 28 NATACAPS CAP 30 TRIAM/HCTZ TAB 75 50 30 HYDROCORT CRE Z5% 28 NATATAB RXTAB 29 1MG 30 VERAPAMIL TAB 80MG 90 HYDROCORT LOT 1°io 118 SRONYX TAB 28 VERAPAMIL TAB 120MG 30 AMANTADINE SYP 50MG/5ML 100 LAVOCLEN 4 LIQ CREM WSH 170 VELIVET PAK 28 WARFARIN TAB 1 MG 30 ANUCORT HC SUP 25MG 12 METRONIDAZOL LOT 0.7590 59 ZOVIA 1; 50E TAB 28 WARFARIN TAB 2MG 30 BETHANECHOL TAB 25MG 90 MOMETASONE OIN 0.1°6 15 WARFARIN TAB 2.5MG 30 CARB!LEVO TAB 10 100MG 30 SELENIUM SUL SHA 259% 118 ~ WARFARIN TAB 3MG 30 CHLORHEX GLU SOL 0.12°6 473 SILVER SULFA CRE i°% 400 WARFARIN TAB 4MG 30 DEXAMETHASON ELX 0.5i5ML 240 SSD CRE 1°io 85 Influenza (Flu) WARFARIN TAB 5MG 30 DEXAMETHASON TAB 0.5MG 30 TRIAMCINOLON CRE 0.025% 15 Pneumococcal (Pneumonia) WARFARIN TAB 6MG 30 DEXAMETHASON TAB 0.75MG 10 TRIAMCINOLON CRE 0.1°% 30 Zostavax (Vaccine for Shingles) WARFARIN TAB 25MG 30 DEXAMETHASON TAB 4MG 10 TRIAMCINOLON CRE 0.1"% 80 Gardasil (Vaccine for Cervical Cancer) WARFARIN TAB lOMG 30 DIVALPROEX TAB 125MG EC 60 TRIAMCINOLON CRE 0.5°ro 15 HEMORRHOIDAL SUP -HC 25MG 12 TRIAMCINOLON OIN 0.02540 g0 Tetanus /Diptheria / Pertussis HYDROCORT TAB 20MG 45 TRIAh-1CINOLON OIN 0.1 . 454 Tetanus /Diptheria AMITRIPTYLIN TAB IOMG 30 HYDROCORTAC SUP 25MG 12 Hepatitus A and B AMITRIPTYLIN TAB 25MG 30 ISONIAZID TAB 300MG 30 - ° Meningococcal (Meningitis) AMITRIPIYLIN TAB 50MG 30 LIDOCAINE GEL 2 io JELLY 30 LEVOTHROID TAB 50MCG 30 AMITRIPTYLIN TAB 75MG 30 LIDOCAINEOIN 5°~0 35 LEVOTHROID TAB 125MCG 30 ..~, AMITRIPTYLIN TAB 100MG 30 LIDOCAINE SOL 2°~ VISC 100 LEVOTHROID TAB 150MCG 30 BENZTROPINE TAB 1MG 30 MEGESTROL AC TAB 20MG 30 LEVOTHYROXIN TAB 25MCG 30 Foltabs BENZTROPINE TAB 2MG 30 METHYLPRED TAB 4MG 30 LEVOTHYROXIN TAB 50MCG 30 Vinate GT Prenatal Plus `"``'?' i~4 ~-`~:" -.3":h ~r'ld :~~3 s ;°-;'" .t ,' ,: 4 `C t ;~ , x,. r3.g w r Y~ .~ ~ -, _~ Better Service. He~e>s` Care. ~ ti. _ r~.~ .- ~. ' `Better. Value ,~:~ ^~ ~l ,~ 1 It pays to go ~ _u ~ ~ I ~ L ~ ~; ~ .~~ .~~ l • ~. , . ~ generic nleications for s -~ (for up tea 30-clay supplY)* -~ ~~~ generic r~ae~ications for $~~ e_ ,fora 90daY supPRY?* '"` - I~is~ounts on ALL immunizations ~i~~unts on ALL pet medications m FREE health screenings** f~-, FREE prenatal Vitamins* One time enro(Iment fee of ~5 for the entire family! r. ~ Visit your H-E-B Pharmacy for details, j k. S .~ ~'~~~'. tS~ rY'f I N - ~ i i 1 ~w M s~"'~;; ~ '}. ~~ E ~ .y"' .3.. r ,~.. 3 .~ o- _ v ~. ~ -G i zt .~ r ~ ..t. -a1~,~ "~-., r r~ ` ally,--e i` o- e~~sT'~`~ ?~t _,}^ r ~~ f '~- 3 t r ~ J,} r~ . - -..fir'' • 'k~ ;<"r r ~ :: ~, fi~ , ,^ ,t r r~ r ~, r i ": y, ~ ~ ~~ I 1. Is there a minimum age requirement for enrollment? Yes. Customers must be 18 years or older to enroll. 2. Is there a limit to the number of family members on one card? No. If customers need extra fields to include the entire family, they can add on the back of the form. 3. Can college age students enroll separately from their parents? Yes. Anyone age 18 and older can enroll in the program individually. 4. Is the My H-E-B Rx Rewards Platinum program a substitute for prescription insurance? No. This program is not an insur- ance policy and does not provide insurance coverage. 5. Can I use My H-E-B Rx Rewards Platinum card along with my prescription coverage plan? No. H-E-B Rx Rewards Platinum members choose to either purchase their prescription drugs through the My H-E-B Rx Rewards Platinum program OR pay the applicable cost-sharing amount under their insurance or other third party payer program. No claims will be submitted to a third party payer for prescriptions processed using the H E-B Rx Rewards Platinum card. 6. Does a prescription purchased through the My H-E-B Rx Rewards Platinum program count towards my insurance deductible? Customers should consult their prescription coverage plans to determine if their purchases using the My H E-B Rx Rewards Platinum program count toward the customer's total drug spend for calculating deductibles or other patient payment responsibilities. Savings under the My H-E-B Rx Rewards Platinum program will NOT be used to discount or waive any co-pay. coinsurance or deductible amounts. 7. How will I know if my drug is available on the 500 for $5 list? Customers can visit www.heb.com/pharmacy to determine individual pricing on specific medications. Or, customers can call 1-866-286-8098 for assistance. The pharmacy staff and selected store partners will be available to answer questions too. 8. What if I am an existing Rx Rewards member? You can upgrade to the preferred My H-E-B Rx Rewards Platinum program by paying the one time $5.00 enrollment fee. There is no need for membership in both programs as the Platinum program includes the Rx Rewards benefits plus so much more! If you are interested in upgrading to the My H-E-B Rx Rewards Platinum program, you will need to fill out a new enrollment form. You will be provided a new card to use for this new program. 9. Can I add my pet to the My H-E-B Rx Reward Platinum program at a later date than when I sign myself up? Yes, you can add a pet at any time by calling 1-866-286-8098. 10. What discounted prescriptions are available for pets? Most veterinarians use a combination of human, veterinary-only, and compounded medications for your pet's medical condition. More than 600 drugs used to treat pets are human drugs and can be purchased at your local H-E-B Pharmacy with a prescription from your veterinarian. H-E-B does not stock or provide discounts on veterinary-only medication used for the treatment of fleas, ticks, heartworms or other medical conditions. 11. What quantity is included in the $5.00 price? The $5.00 price is for commonly prescribed dosages up to a 30 day supply.* 12. What quantity is included in the $9.99 price? The $9.99 price is for commonly prescribed dosages at a 90 day supply.* 13. Is there a fee for the Platinum program? Yes, there is a one time $5.00 enrollment fee. 14. How does the Prenatal Vitamin program work? Participating Prenatal vitamins are available at no cost for 30-day supply (up to 12 refills).* 15. What discounts on immunizations are available on the My H-E-B RX Rewards Platinum program? Visit www.heb.com, call 866-286-8098, or visit your H-E-B Pharmacist for more information. 16. How do I find out the cost of medicines that are not on the 500 for $5 list? Visit www.heb.com, call 866-286-8098, or visit your H-E-B Pharmacist for more information. 1~~•J . 4f,_ SC ~I PT~AVE~ *The day supply is based upon the average dispensing patterns for the specific drug and strength. The program, as well as. the prices and the list of covered drugs can be modified by H-E-B Pharmacy at any time without notice and at H-E-B Pharmacy's discretion. **See your H E B Pharmacy for more details. DISCOUNT ONLY -NOT INSURANCE Discounts are available exclusively through participating pharmacies. You may cancel your registration under the My H-E-B Rx Rewards Platinum Program at any time by contacting 1-86&286-8098.