(i) that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary's prescriber;

(ii) the prescriber approved the therapeutic interchange;

(iii) the names of the originally prescribed drug and the drug dispensed pursuant to the therapeutic interchange;

(iv) the difference in copayments or coinsurance to be paid by the beneficiary to obtain the drug dispensed pursuant to the therapeutic interchange;

(v) the circumstances under which the originally prescribed drug will be covered;

(vi) the circumstances under and the extent to which health care costs related to the therapeutic interchange will be compensated; and

(vii) that the beneficiary may decline the therapeutic interchange if the originally prescribed drug remains on the beneficiary's formulary, and the beneficiary is willing to pay any difference in the copayment or coinsurance; and

(i) a patient package insert about potential side effects; and

(ii) a toll-free telephone number to communicate with the pharmacy benefits manager.