Download 3-Tier Medication Guide

2004: 3-Tier Medication Guide of Commonly Prescribed Drugs
The designation of drugs in the following categories is for reference only and is not a clinical comparison.
Drug placement does not establish clinical comparability of products in individual situations.
This list provides examples within categories and is not comprehensive.
DRUG CLASS
Tier 1
Tier 2
(lowest member co-payment)
ALLERGY
Antihistamines (Oral)
Antihistamine/
Decongestant
Combinations
Intranasal: Steroids/
Antihistamines/
Miscellaneous
ALZHEIMER’S
ARTHRITIS
ASTHMA
Inhaled Beta Agonists/
Inhaled Respiratory
Agents (miscellaneous)
Inhaled Steroids
Leukotriene Inhibitors
Respiratory Drugs (oral)
ATTENTION DEFICIT
DISORDER
BLOOD
Anticoagulants
Antiplatelet
Anemia
CANCER
CARDIOVASCULAR / HEART
ACE Inhibitors
(high blood pressure)
Angiotensin II Receptor
Blockers
Tier 3
(highest member co-payment)
clemastine, cyproheptadine,
diphenhydramine, hydroxyzine
Numerous generics
No drugs listed at this time
Allegra, Clarinex, Zyrtec
No drugs listed at this time
Allegra-D, Optimine, Rynatan SA, Semprex-D,
Trinalin, Zyrtec-D
flunisolide, ipratropium nasal
spray
Beconase AQ, Flonase, Nasonex,
Rhinocort AQ
No drugs listed at this time
Aricept
Astelin, Atrovent Nasal Spray, Nasacort,
Nasacort AQ, Nasarel, Nasalide, Tri-Nasal,
Vancenase, Vancenase AQ, Vancenase DS
Cognex, Exelon, Reminyl
azathioprine, cyclophosphamide,
gold, hydroxychloroquine,
methotrexate, penicillamine,
sulfasalazine
No drugs listed at this time
Arava§, Enbrel§, Humira§, Kineret§, Rheumatrex
albuterol, cromolyn sodium,
metaproterenol solution
Atrovent Inhaler, Combivent, Intal,
Pulmozyme, Serevent Diskus
Advair, Foradil, Maxair, Maxair Autohaler, Proventil,
Proventil HFA, Tilade, Tornalate, Ventolin, Xopenox
No drugs listed at this time
Azmacort, Beclovent, Flovent,
Pulmicort
Singulair (Tier 2 if history criteria met)
No drugs listed at this time
Advair, Aerobid, Aerobid M, QVAR, Vanceril,
Vanceril DS
Accolate, Zyflo
Alupent, Brethine, Proventil SA, T-Phyl, Theo-Dur,
Uniphyl, Volmax
Adderall, Adderall XR, Concerta, Dexedrine,
Dexedrine Spansules, Dextrostat, Focalin,
Metadate CD, Ritalin, Ritalin LA, Strattera§
No drugs listed at this time
albuterol, metaproterenol,
theophylline
dextroamphetamine, methylin,
methylin ER, methylphenidate
No drugs listed at this time
heparin, warfarin
dipyridamole
No drugs listed at this time
methotrexate, tamoxifen
Coumadin
Agrylin, Plavix
Epogen§, Neupogen,Procrit§
All brands are Tier 2
Arixtra, Fragmin, Inohep, Lovenox
Aggrenox, Pletal, Ticlid, Trental
Aranesp§
No drugs listed at this time
captopril, enalapril, lisinopril,
moexepril
Altace
No drugs listed at this time
Avapro\, Diovan
Accupril§, Aceon§, Capoten§, Lotensin§, Mavik§,
Monopril§\, Prinivil§, Univasc§, Vasotec§, Zestril§
Atacand§, Benicar§, Cozaar§, Micardis§, Teveten§
amiodarone, digoxin,
disopyramide, mexiletine,
procainamide, quinidine, sotalol
cholestyramine, clofibrate,
gemfibrozil, lovastatin
Betapace AF, Lanoxin, Rythmol,
Tonocard
(high blood pressure)
Antiarrhythmics
(for normal heart rhythm)
Antihyperlipidemics
(high cholesterol)
Antihypertensive
Combinations
(high blood pressure)
Beta Blockers
(high blood pressure)
Calcium Channel Blockers
1
bisoprolol/hydrochlorothiazide,
captopril/ hydrochlorothiazide
enalapril/hydrocholrothiazide
lisinopril/hydrochlorothiazide
acebutolol, atenolol, bisoprolol,
labetolol, metoprolol, nadolol,
propranolol, propranolol solution,
pindolol, timolol
diltiazem, diltiazem-XR,
nicardipine, nifedipine,
Taztia XT, verapamil, verapamil
(SR)
Lipitor\, Lofibra, Niaspan,
Pravachol\, Tricor,
Zetia (Tier 2 if history criteria are met)
Avalide, Diovan HCT
Coreg,
Toprol XL 25mg, 50mg\, 100mg,
200mg
Norvasc: Tier 2 if age 55 or older and
on concurrent ACE/ARB therapy or on
nitrate therapy
Betapace, Cordarone, Mexitil, Norpace CR, Procan,
Procanbid, Pronestyl, Quinidex, Quiniglute,
Tambocor, Tikosyn
Altocor, Advicor, Colestid, Crestor, Crestor 10mg\,
20mg\, 40mg\§, Lescol§, Lescol XL§, Mevacor,
Pravigard, Questran, Welchol, Zocor\§
Accuretic§, Atacand HCT§, Benicar HCT§,
Capozide§, Hyzaar§, Lexxel, Lopressor HCT,
Lotensin HCT§, Lotrel, Micardis HCT§,
Monopril HCT§, Prinzide§, Tarka, Teczem,
Tenoretic, Tevetan HCT§, Uniretic§, Vaseretic§,
Zestoretic§, Ziac
Corgard, Inderal LA, Innopran XL, Kerlone, Levatol,
Lopressor, Sectral, Tenormin, Trandate, Visken,
Zebeta
Adalat CC, Calan, Calan SR, Cardene, Cardene SR,
Cardizem, Cardizem CD, Cardizem LA , Covera,
Covera HS, Dilacor XR, Dynacirc, Dynacirc CR,
Plendil, Procardia XL, Sular, Tiazac, Verelan,
Verelan PM
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
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Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
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DRUG CLASS
Diuretics
Nitrates (angina)
Tier 1
(lowest member co-payment)
amiloride, furosemide,
hydrochlorothiazide (HCTZ),
indapamide, spironolactone,
triamterene/HCTZ
Numerous generics
Tier 2
Tier 3
No drugs listed at this time
(highest member co-payment)
Aldactone, Bumex, Demadex, Dyazide, Dyrenium,
Hydrodiuril, Hygroton, Lozol, Maxzide, Zaroxolyn
No drugs listed at this time
Deponit, Imdur, Ismo, Monoket, Nitrek, Nitrodisk,
Nitro-Dur, Transderm-Nitro
K-Dur, K-Lyte, K-Tab, Micro-K, Slow K
Cylert, Desoxyn, Dexedrine, Dexedrine Spansules,
Provigil 100mg§, Provigil 200mg§\, Xyrem§
Potassium Supplements
CENTRAL NERVOUS
SYSTEM
COUGH / COLD
Antitussives and
Expectorants
potassium chloride generics
pemoline
Urocit-K
No drugs listed at this time
benzonatate, guiafenesin
products, hydrocodone products
No drugs listed at this time
Amibid LA, Duratuss G, Humabid LA, Tussionex
Antitussive Combinations
gauifenesin/codeine,
hydrocodone/homatropine,
promethazine/codeine
No drugs listed at this time
Genesin DM, Guaituss AC, Histussin, Histussin HC,
Hycodan, Hycotuss, Phenergan w/codeine,
Rondec-DM
benzoyl peroxide, clindamycin,
erythromycin,
erythromycin/benzoyl peroxide,
isotretinoin, sulfacetamide,
tretinoin products, tetracycline,
others
bacitracin/polymyxin,
erythromycin, gentamycin,
neomycin/polymyxin, tobramycin,
others
ketoconazole cream, mycostatin,
triamcinolone/nystatin,
betamethasone/clotrimazole
betamethasone, clobetasol,
dexamethasone, fluocinolone,
fluocinonide, hydrocortisone,
triamcinolone
Metrocream, Metrogel
Accutane, A/T/S, Avita, Azelex, BenzaClin,
Benzamycin, Cleocin T, Desquam E, Differin, Emgel,
Finacea, Finevin, Klaron, Novacet, Retin-A,
Sulfacet-R, T-stat
Bactroban
Emgel, Noritate, Silvadene
Nizoral Shampoo
Exelderm, Loprox, Lotrimin, Lotrisone, Mentax,
Mycelex, Mycolog II, Naftin, Nizoral Cream, Oxistat,
Spectazole
Aclovate, Cloderm, Cordran, Cordran Tape,
Cutivate, Cyclocort, Decadron, Desowen,
Diprolene/AF, Elocon, Florone/E, Halog/E, Locoid,
Medrol Dose Pack, Pandel, Temovate, Psorcon/E,
Topicort, Ultravate, Uticort
selenium sulfide
Dovonex, Drithocreme
DERMATOLOGY
Topical/Oral Acne
Products
Topical Antibiotics
Topical/Combination
Antifungals
Topical/ Oral Steroids
Topicals:
Psoriasis/Eczema
DIABETES
Blood Glucose Supplies
Insulin
Capex Shampoo, Florinef
Capitrol, Elidel, Protopic, Selsun,
Soriatane (oral), Tazorac
Diabetic benefit and/or DME benefit applies: Preferred Meters are: Accu-check Active, Accu-check Advantage,
Accu-check Compact, Accu-check Complete, One Touch Sure Step, One Touch Ultra
DIABETIC BENEFIT APPLIES FOR ALL INSULINS
If Diabetic benefit DOES NOT apply please refer to the following tier classifications:
No drugs listed at this time
Oral Hypoglycemics
Humalog, Humulin, Lantus, Novolin,
No drugs listed at this time
Novolog
DIABETIC BENEFIT APPLIES FOR ALL ORAL HYPOGYLCEMICS
If Diabetic benefit DOES NOT apply, please refer to the following tier classifications:
glipizide, glyburide, metformin
Actos, Amaryl, Avandia, Glyset,
Prandin, Precose, Starlix,
Glucotrol XL
Cipro HC and Floxin Otic only for
children <11 years of age
Avandamet, Diabeta, Glucophage, Glucophage XR,
Glucotrol, Glucovance, Glynase, Metaglip,
Micronase
Aurulgan, Cerumenex, Cortisporin, Pediotic, Vosol,
Vosol HC
EAR
Numerous generics
ENTERAL FORMULAS
EYE
Ophthalmic
Anti-Inflammatory
Multiple products available§
PKU Formulas§
All branded enteral products§
dexameth, dexa/neo,
fluorometholone, flurbiprofen,
prednisolone
cromolyn sodium
Lotemax, Voltaren, PredForte
FML Forte, Ocufen, Vexol
Optivar, Zaditor, Acular, Acular PF
Ciloxan, Ocuflox
Alamast, Alocril, Alomide, Alrex, Emadine, Livostin,
Opticrom, Patanol
Chibroxin, Quixin, Vigamox, Zymar
Vira A, Viroptic
FML-S, Poly-Pred
Vitrasert, Vitravene
HMS, Pred-G, TobradexV
Ophthalmic Antiallergics
Ophthalmic Antiinfectives
Ophthalmic Antivirals
Ophthalmic Combinations
2
bacitracin, bac/poly/neo,
neosporin, polysporin, erythro,
gent, sodium sulfacetamide,
TMP/pol, tobra, others
No drugs listed at this time
neomycin, neomycin/polymixin,
dexamethasone sodium
phosphate solution, etc.
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
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Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
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DRUG CLASS
Glaucoma
Tier 1
Tier 2
(lowest member co-payment)
carbachol, carteolol, dipivefrin,
levobunolol, pilocarpine, timolol,
timolol XE
Alphagan P, Lumigan, Trusopt,
Xalatan
No drugs listed at this time
GROWTH HORMONES
allopurinol, colchicine,
colchicine/probenecid,
probenecid, sulfinpyrazone
No drugs listed at this time
HEPATITIS
No drugs listed at this time
HIV
No drugs listed at this time
IMMUNE SYSTEM
azathioprine, cyclosporine
Copegus§, Peg Intron§, Pegasys§,
Rebetol§
All brands are Tier 2- Combivir,
Crixivan, Epivir, Fortovase, Norvir,
Viracept, Viramune, Zerit
Cellcept, Neoral, Prograf,
Rapamune, Sandimmune,
Sandostatin
GOUT
INFECTIONS: BACTERIAL, FUNGAL, VIRAL
amoxicillin,
Antibiotics
amoxicillin/clavulanate,
ampicillin, dicloxacillin, cefaclor,
cefadroxil, cefuroxime tablets,
cephalexin, doxycycline,
erythromycins, ofloxacin,
penicillin, others
griseofulvin, nystatin
Antifungal Drugs (Oral)
Antiviral Drugs
MALARIA
MEN’S HEALTH
BPH Agents (prostate)
Erectile Dysfunction
Hormones
Oral Androgens
MENTAL HEALTH
Antidepressants
acyclovir, amantadine,
rimantadine
chloroquine, hydroxychloroquine,
quinine
Nutropin§, Nutropin AQ§, Protropin§
Tier 3
(highest member co-payment)
Azopt, Betagan, Betimol, Betoptic, Betoptic-S,
Cosopt, Iopidine, Ocupress, Optipranolol,
Pilopine gel, Propine, Rescula, Timoptic,
Timoptic XE, Travatan
Zyloprim
Genotropin§, Humatrope§, Norditropin§, Saizen§,
Serostim§, Tev-tropin§
Infergen, Intron-A, Rebetron, Roferon A
No drugs listed at this time
Imuran
Any brand when prescribed for
patients <11 years of age
Augmentin, Augmentin XR, Avelox, Biaxin, Ceclor
CD, Cedax, Ceftin, Cefzil, Cipro, Cipro XR, Cleocin,
Dynabac, Floxin, Levaquin, Lorabid, Macrobid,
Maxaquin, Monurol, Noroxin, Omnicef, PCE,
Penetrax, Spectracef, Suprax, Tequin, Tobi, Trovan,
Vantin, Vancocin, Zagam, Zithromax, Zyvox§
Diflucan 150mg, Griseofulvin
Suspension, Lamisil tablets§
Hepsera, Valtrex
Cytovene (Tier 2 for CMV retinitis only)
Lariam
Diflucan, Penlac§, Sporanox§, Vfend
doxazosin, prazocin, terazosin
Flomax (Tier 2 after failure to generic)
yohimbine
testosterone
No drugs listed at this time
Viagra§
Android, Depo-Testosterone
Casodex, Eulexin
amitriptyline, amoxipine,
desipramine, doxepin, fluoxetine,
imipramine, nortriptyline,
paroxetine, protriptyline,
trazodone
Celexa 40mg\, Zoloft 100mg\,
Paxil 30mg, 40mg\,
Paxil suspension
Effexor, Effexor XR: Tier 2 only if
Denavir, Famvir, Flumadine, Relenza§, Symmetrel,
Tamiflu, Valcyte, Zovirax
Daraprim, Fansidar, Malarone, Plaquenil
Avodart, Cardura, Hytrin, Proscar
Caverject, Edex, Levitra§, Muse
Androderm, Androgel, Testoderm
No drugs listed at this time
Celexa 10mg, 20mg\, Desyrel, Elavil, Lexapro\,
Luvox, Nardil, Pamelor, Parnate,
Paxil 10mg, 20mg\, Paxil CR, Prozac§,
Prozac Weekly§, Remeron, Sarafem§, Sinequan,
Surmontil, Tofranil, Zoloft 25mg, 50mg
Serzone, Surmontil, Wellbutrin
history criteria are met
Wellbutrin SR, Welllbutrin XL: Tier 2
only if <13 years of age or history
criteria are met
Antipsychosis
Sedatives/Hypnotics/
Anxiety
MIGRAINE
clozapine, haloperidol,
trifluoperazine, thioridazine,
others
benzodiazepines (alprazolam,
clonazepam, diazepam,
triazolam), hydroxyzine
ergotamine,
isometheptene/dichlor/APAP
MULTIPLE SCLEROSIS
No drugs listed at this time
OSTEOPOROSIS
No drugs listed at this time
3
Abilify, Geodon, Risperdal,
Seroquel, Zyprexa
Clozaril, Haldol, Mellaril, Navane, Prolixin, Stelazine,
Thorazine, Trilafon
High dose requires prior
authorization
Ambien (only for aged >65)
Ativan, Buspar, Serax, Sonata, Valium, Xanax
Depakote ER, Maxalt, Maxalt MLT,
Migranal,
Imitrex 100mg & 50mg tablets,
Imitrex nasal spray and injection
Amerge, Axert, Frova, Imitrex 25mg tablets, Relpax,
Zomig, Zomig ZMT
Betaseron, Copaxone
Actonel, Actonel Weekly, Evista,
Fosamax, Fosamax Weekly
Avonex, Rebif
Didronel, Forteo§, Skelid, Miacalcin Nasal
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
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DRUG CLASS
Tier 1
Tier 2
(lowest member co-payment)
PAIN / INFLAMMATION
Muscle Relaxants
NSAIDs
Pain Relievers (narcotic)
PARKINSON’S
SEIZURE / PAIN
SMOKING DETERRENTS
STOMACH / INTESTINAL
Antiemetics
(for nausea)
Antispasmotic Drugs
Digestants
Inflammatory Bowel
Irritable Bowel Syndrome
Ulcer/Heartburn
baclofen, methocarbamol,
carisoprodol, cyclobenzaprine,
others
diclofenac, fenoprofen,
flurbiprofen, ibuprofen,
indomethacin, ketoprofen,
nabumetone, naproxen,
naproxen sodium, oxaprozin,
piroxicam, salsalate, sulindac,
tolmetin
No drugs listed at this time
acetaminophen/codeine,
acetaminophen/propoxyphene,
hydrocodone combinations,
methadone, morphine
(immediate & sustained release),
others
amantadine, anticholinergics,
bromocriptine,
carbidopa/levodopa, selegiline
carbamazepine, clonazepam,
phenytoin, valproic acid
(highest member co-payment)
No drugs listed at this time
Norflex, Skelaxin, Zanaflex
No drugs listed at this time
Step Therapy applies:
Arthrotec, Cataflam, Daypro, EC-Naprosyn,
Lodine XL, Mobic, Naprelan, Oruvail, Ponstel,
Relafen, Toradol, Voltaren XR
No drugs listed at this time
Step Therapy applies:
Vioxx \, Vioxx Suspension, Bextra\, Celebrex
(Patient must have failed a trial of Vioxx or Bextra
prior to Celebrex approval)
Avina, Avinza, Duragesic, Kadian, MS Contin, MSIR,
Norco, Oramorph SR, OxyIR, Ultram, Zydone
Duragesic, Oxycontin
(Tier 2 for chronic, intractable pain)
Comtan, Permax, Requip
Cogentin, Dopar, Eldepryl, Larodopa, Lodosyn,
Mirapex, Parlodel, Sinemet CR, Tasmar
Depakote, Dilantin, Felbatol,
Gabitril, Keppra, Klonopin,
Neurontin, Tegretol XR, Trileptal,
Zonegran, Zarontin, others
No drugs listed at this time
No drugs listed at this time
No drugs listed at this time
No drugs listed at this time
Habitrol, Nicotrol , Zyban
meclizine, prochlorperazine,
others
clidinium products, dicyclomine,
hyoscyamine, oxybutynin, others
pancrealipase
Zofran
Anzemet, Kytril, Marinol, Transderm-SC
Urecholine
Detrol, Detrol LA, Ditropan, Ditropan XL, Levsin,
Levsinex, Oxytrol Patch, Urispas
No drugs listed at this time
sulfasalazine,
hydrocortisone enema
No drugs listed at this time
cimetidine, famotidine, ranitidine
No drugs listed at this time
WEIGHT MANAGEMENT
omeprazole§, Prilosec OTC
metoclopramide, sucralfate
levothyroxine, levoxyl,
levothroid, PTU
diethylpropion
WOMEN’S HEALTH
Hormones
Oral
Transdermal
Fertility Drugs*
cycrin, estradiol,
medroxyprogesterone
estradiol patch
clomiphene citrate
THYROID
Tier 3
*Not all prescription drug benefits
provide coverage
Cotazym, Cotazym S, Creon,
Kutrase, Pancrease, Pancrease MT,
Ultrase MT, Viokase, Zymase
Asacol, Canasa, Cortenema,
Pentasa, Rowasa enema
No drugs listed at this time
No drugs listed at this time
No drugs listed at this time
Prevacid, Protonix
Cytotec
Cytomel, Synthroid, Tapazole
LamictalV , TopamaxV, ZonegranV
Azulfidine (enteric coated), Colazal, Dipentum,
Entocort EC
Lotronex§, Zelnorm§
Axid, Pepcid, Tagamet, Zantac
Helidac, Prevpac, Tritec
Aciphex§ Nexium§, Prilosec§
Carafate
Armour Thyroid, Thyrolar, Unithroid
No drugs listed at this time
Adipex-P, Adipost, Bontril-SR, Didrex, Meridia§,
phentermine, Xenical§
Estratest, Estratest HS, Premarin,
Premphase, Prempro, Prometrium
Climara
No drugs listed at this time
Activella, Cenestin, Estrace, Estratab, FemHRT,
Menest, Ogen, Ortho-Prefest
Alora, Combipatch, Estraderm, Vivelle/Dot,
Clomid, Crinone, Fertinex§, Follistim§, Gonal-F§,
Humegon§, Metrodin§, Ovidrel§, Pergonal§,
Repronex§
Alesse, Brevicon, Cylessa, Demulen, Desogen,
Estrostep, Estrostep FE, Jenest, Loestrin,
Loestrin FE, Lo-Ovral, Mircette, Nordette, Norinyl,
Nor QD, NuvaRing, Ovcon, Ovral, TriNessa,
Trinorinyl, Triphasil, Tri-Sprintec
Apri, Aviane, Camila, Cryselle,
Levlen, Levlite, Modicon,
Enpresse, Jolivette, Kariva,
Ortho-Cept, Ortho-Cyclen,
*Not all prescription drug benefits
Lessina, Levora, Low-Ogestrel,
Ortho Evra, Ortho Micron,
provide coverage
Microgestin FE, Necon, Nelova,
Ortho-Novum, Ortho Tri-Cyclen Lo,
Nora B, Nortrel, Ogestrel,
Tri-Levlen, Yasmin
Ortho Tri-Cyclen, Portia,
Sprintec, Trivora, Zovia
Miscellaneous Tier 2 agents: DDAVP tablets, Diamox Sequels, Elmiron, Epipen, Epipen Jr., Evoxac, Glucagen, Mestinon, Metrogel Vaginal, Metrolotion,
Phoslo, Premarin Vaginal, Pulmozyme, Renagel, Rilutek, Salagen, Stimate, Synarel
Oral Contraceptives*
4
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
ƒ
ƒ
B-1530y4 Rev. 1/21/04
4