English - UHCCommunityPlan.com
Transcription
English - UHCCommunityPlan.com
2016 Enrollment Guide You could get more benefits than Original Medicare. Hospital Stays Doctor Visits Additional Benefits UnitedHealthcare Dual Complete® ONE (HMO SNP) H3113-005 Service area: New Jersey- Atlantic, Bergen, Burlington, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Union counties Prescription Drug Coverage Table of Contents Introduction............................................................................................................................. 3 Plan INFORMATION Benefit Highlights.................................................................................................................. 8 How Your Plan Works........................................................................................................10 Benefits and Services Beyond Original Medicare...................................................... 11 Summary of Benefits..........................................................................................................13 Plan Ratings......................................................................................................................... 31 Required Information......................................................................................................... 32 Drug LIST Drug List................................................................................................................................36 Ready to ENROLL Enrollment Instructions......................................................................................................86 Scope of Sales Appointment Confirmation Form.......................................................87 Enrollment Request Form.................................................................................................89 Enrollment Checklist........................................................................................................113 Enrollment Receipt.......................................................................................................... 115 What's Next........................................................................................................................ 123 It’s more than a health plan. IT’S A HEALTHY RELATIONSHIP. From preventive care to treating a chronic condition, there are many ways you may use your Medicare plan. We will work with you to help you live a healthier life and we strive to give you the best health care experience possible. Here are some reasons why this plan may be right for your needs. Doctor coverage Access your personal plan information online, anytime Worldwide ER coverage Care coordination Out-of-pocket maximums HouseCallsSM We are committed to providing the personal service that can help you get the most from your benefits. Your local licensed sales representative is ready to answer all your questions. Have any questions? We can help. Call: Toll-Free 1-888-834-3721, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week. Se habla español. Learn more online at www.UHCCommunityPlan.com CSNJ16HM3717096_000 3 Medicare EDUCATION Original Medicare Provided by the government What is Medicare? Medicare is a federal health insurance program for people age 65 and older and others with disabilities. Part A covers hospital stays Original Medicare is provided by the government and covers some of the costs of hospital stays (Part A) and doctor visits (Part B), but it does not cover everything — you don’t get coverage for prescription drugs or for routine vision, dental or hearing care. Part B covers doctor and outpatient visits What if you need more coverage beyond Original Medicare? Add one or both of the following to Original Medicare: OR Medicare Supplement Insurance* Add additional coverage by choosing a Medicare Advantage plan: Medicare Advantage (Part C)* Covers some of the costs not covered by Parts A and B Part C combines Parts A and B Often provides additional benefits Medicare Part D* Most plans cover prescription drugs Part D covers prescription drugs *Offered by private companies When can you enroll? It’s important to know your enrollment period so you always have health care coverage. You can enroll or change Medicare Advantage or Part D plans at least once a year, typically during your Initial Enrollment Period or the Open Enrollment Period. Medicare supplement plans have different rules about enrolling, please contact the Medicare Helpline for more information on enrolling. Initial Enrollment Period: For Medicare Advantage or Part D plans, this is the three months before and three months after the month you turn 65 or become Medicare eligible. For Medicare supplement plans, you must submit your application no later than six months after the date your Medicare Part B coverage takes effect. Special Election Period: Depending on certain circumstances, you may be able to enroll in a Medicare plan outside of the Initial Enrollment Period or Open Enrollment time frames. Open Enrollment Period: October 15 – December 7 Medicare Advantage Disenrollment Period: January 1 – February 14. If you disenroll from a Medicare Advantage plan during this time, you will return to Original Medicare and have a Special Election Period to enroll in a Medicare Part D plan. 4 Medicare EDUCATION What are the drug payment stages? If your plan includes prescription drug coverage, the amount you pay each time to fill a prescription depends on which payment stage you’re in. How do you know which stage you’re in? It depends on how much money you and your plan have paid for prescription drugs so far in the plan year. If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible amount. You then move to the initial coverage stage. The chart below shows the different payment stages you may go through in the plan year. Initial Coverage In this drug payment stage: • You pay a co-pay or co-insurance (percentage of a drug’s total cost). The plan pays the rest • You stay in this stage until your total drug costs reach $3,310 Coverage Gap (Donut Hole) Catastrophic Coverage After your total drug costs reach $3,310: After your total out-of-pocket costs reach $4,850: • You pay: • You pay a small co-pay or co-insurance amount – 45% of the cost of brand name drugs – 58% of the cost of generic drugs • You stay in this stage for the rest of the plan year • You stay in this stage until your total out‑of‑pocket costs reach $4,850 Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for prescription drugs starting on January 1, 2016. Out-of-Pocket Costs: The amount you pay (or others pay on your behalf) for prescription drugs starting on January 1, 2016. This does not include premiums. Do you qualify for Extra Help? If you have a limited income, you may be able to get Extra Help with your Medicare prescription drug plan premiums, deductibles and co-pays. Many people qualify and don’t even know it. To find out if you qualify, call the Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778, 7 a.m. – 7 p.m., Monday – Friday 5 Medicare EDUCATION Are you eligible for this plan? You are eligible for a Dual Special Needs Plan (DSNP) if you’re enrolled in Original Medicare Parts A and B and receive state Medicaid benefits. Your state Medicaid benefits vary based on your level of Medicaid eligibility. • DSNP enrollment is not limited to a specific • Based on your needs you may also qualify for time; you can enroll year-round Low Income Subsidy (LIS) assistance What are the levels of eligibility in most states? • Qualified Medicare Beneficiary Only (QMB Only) • Qualified Medicare Beneficiary Plus (QMB Plus) • Specified Low-Income Medicare Beneficiary Only (SLMB Only) • Specified Low-Income Medicare Beneficiary Plus (SLMB Plus) • Qualified Individual (QI) • Qualified Disabled and Working Individual (QDWI) • Full Benefit Dual Eligible (FBDE) What are the income requirements for each eligibility level? QMB Only QMB Plus SLMB Only SLMB Plus QI QDWI FBDE Federal Poverty Income Level Social Security Income Level At or lower than Resources not more than two times At or lower than Resources not more than two times Between 100% and 120% Resources not more than two times Between 100% and 120% Resources not more than two times Between 120% and 135% Resources not more than two times Below 200% Resources not more than two times Based on Medical Need status, institutionalized income levels, home/community based waivers What benefits does each eligibility level cover? Eligibility Level QMB Only QMB Plus SLMB Only SLMB Plus QI QDWI FBDE Part A Premium Yes Yes No No No Yes No Part B Premium Yes Yes Yes Yes Yes No Varies by state Part D Premium1 No2 No2 No2 No2 No2 No No Medicare Deductibles, Co-pays, Co-insurance Yes Yes No Varies by state No No Varies by state Full Medicaid Benefits No Yes No Yes No No Yes Low Income Subsidy may be available to help with Part D premium cost. QMBs, SLMBs and QIs are automatically enrolled in the low income subsidy program to cover Part D premium costs and will not have Part D premium expenses. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150728_100336 Accepted UHEX16MP3715078_000 1 2 6 UHEX16MP3700082_001 Benefit highlights UnitedHealthcare Dual Complete® ONE (HMO SNP) As a UnitedHealthcare Dual Complete® ONE (HMO SNP) member, you have no out-of-pocket expenses. You will not be responsible for any copayments or coinsurance for drugs or other covered services provided by plan providers. This is a short description of your 2016 Plan benefits. For complete information, please refer to your Summary of Benefits or Evidence of Coverage. Limitations, exclusions and restrictions may apply. Plan Costs Monthly Plan Premiums $0 Medical Benefits Doctor’s office visit Primary Care Provider: $0 copay Specialist: $0 copay (no referral needed) Preventive services $0 copay Inpatient hospital care $0 copay Skilled nursing facility (SNF) $0 copay Outpatient surgery $0 copay Diabetes monitoring supplies $0 copay for covered brands Home health care $0 copay Diagnostic radiology services (such as MRIs, CT scans) Diagnostic tests and procedures (non-radiological) $0 copay Lab services $0 copay Outpatient X-rays $0 copay Ambulance $0 copay Emergency care $0 copay Urgently needed services $0 copay $0 copay Benefits and Services beyond Original Medicare Health Products Catalog Routine transportation Personal Emergency Response System (PERS) NurseLineSM Covered $500 per year ($125 quarterly credit) $0 copay for 48 one-way trips per calendar year, includes Basic Life Support $0 copay for emergency response services through an electronic monitoring system 24 hours a day, seven days a week. Speak with a registered nurse (RN) 24 hours a day, 7 days a week H3113_150812_003144 Acccepted 8 Prescription Drugs Generic (including brand drugs treated as generic) $0 copay All other drugs $0 copay Benefits and Services covered by Medicaid Acupuncture You pay a $0 copayment Chiropractic Services You pay a $0 copayment Dental Services – preventive and routine You pay a $0 copayment Durable Medical Equipment (DME) You pay a $0 copayment Family Planning Services and Supplies You pay a $0 copayment Federally Qualified Health Centers (FQHC) You pay a $0 copayment Hearing services – hearing exams and hearing aids You pay a $0 copayment Medical Day Care You pay a $0 copayment You pay a $0 copayment Managed Long Term Services and Supports (MLTSS) Nurse Midwife Services You pay a $0 copayment Nursing Facility (long term/custodial care) You pay a $0 copayment Personal Care Assistant You pay a $0 copayment Podiatry – routine You pay a $0 copayment Private Duty Nursing You pay a $0 copayment Vision Care Services You pay a $0 copayment Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. H3113_150812_003144 Acccepted UHNJ16HM3699672_001 9 Plan INFORMATION Your cost of a 30-day supply from network retail pharmacy How your HMO PLAN WORKS Your plan is a Health Maintenance Organization (HMO) plan. That means you must receive care through a network of local doctors and hospitals. Your primary care provider (PCP) oversees your care and can suggest a specialist, if needed. In-Network Out-of-Network Will the doctor or hospital accept my plan? Yes No Do I need to choose a primary care provider (PCP)? Yes N/A Do I need a referral to see a specialist? No N/A Are emergency or urgently needed services covered? Yes Yes Do I have to pay the full cost for all covered doctor or hospital services? Plan co-pay or co‑insurance applies. In most cases, yes, you must pay the full cost for services. Is there a limit on my total out-of-pocket spending for the year? Yes N/A You’re part of a health care team. A team dedicated to increasing access to care, reducing costs and improving your health. Your primary care doctor is the leader, making sure everyone works together to improve your well-being. If you want help choosing a primary care provider (PCP), call Customer Service or your licensed sales representative. The website and Customer Service phone number are listed on the first page of this booklet. Plan co-pays and co-insurance apply. As a member, you will receive a Provider Directory listing all network providers and facilities within your plan. You can also find a complete listing on our website or you can request a Provider Directory from Customer Service. Please refer to the Summary of Benefits and Benefit Highlights for more complete plan information. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150612_074721 Accepted UHEX16HM3689579_000 10 Get all the benefits of Original Medicare – and more. With this plan, you get additional benefits and services designed to help you live a healthier life — most at little or no additional cost. More benefits mean more value. It also means more peace of mind for you, knowing you have access to a full range of services dedicated to your health and wellness. This is a short description of some of the 2016 plan benefits. For more information, please refer to your Summary of Benefits. Limitations, exclusions and restrictions may apply. A health and wellness program that comes to you SM With the HouseCalls program, you get an in-home clinical visit from one of our licensed health care practitioners for no additional cost. A HouseCalls visit is designed to support but not take the place of your regular doctor’s care. What to expect from a HouseCalls visit: • A knowledgeable health care practitioner will review your health history and medications, perform a health screening, identify health risks and provide health education • You can talk about health concerns and ask questions • You’ll get an Ask Your Doctor worksheet which you can bring to your next doctor visit We may call to talk to you about eligibility for the HouseCalls program or you can call 1-866-686-2504 TTY 711, Monday – Saturday 8:00AM – 8:00PM CST, to schedule your in-home visit. Health products benefit program Get credits to use for ordering over-the-counter health products from the FirstLine Medical catalog. You may order products one per quarter and the items will be delivered directly to you for no additional cost. Our product assortment offers a variety of health and wellness items such as: • Cough medicine, pain relievers, vitamins and supplements • Thermometers, blood pressure monitors and more For a full list of items visit the website at www.healthproductsbenefit.com. 11 Plan INFORMATION Benefits and services beyond ORIGINAL MEDICARE Benefits and services beyond ORIGINAL MEDICARE (CONTINUED) Transportation Get rides to and from plan-approved locations, like your doctor’s office. See your Summary of Benefits for the specific number of one-way or round trips included with this plan. NurseLineSM Whether you have questions about a medication or have a health concern in the middle of the night, with NurseLineSM a nurse is only a phone call away. A registered nurse can answer questions like: • Should I go to the emergency room or urgent care? • How do I find a doctor or specialist? Learn more about these extra benefits and services For more information, call the number on the first page of this booklet. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150612_074537_ Accepted UHNJ16HM3714324_000 12 BENEFITS UnitedHealthcare Dual Complete® ONE (HMO SNP) New Jersey Atlantic, Bergen, Burlington, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Union counties H3113_150729_150314 Accepted 13 Plan INFORMATION 2016 Summary of SUMMARY OF BENEFITS January 1, 2016 – December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You have choices about how to get your Medicare benefits • One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. • Another choice is to get your Medicare benefits by joining a Medicare health plan (such as UnitedHealthcare Dual Complete® ONE (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what UnitedHealthcare Dual Complete® ONE (HMO SNP) covers and what you pay. • If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. • If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633- 4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet • Things to Know About UnitedHealthcare Dual Complete® ONE (HMO SNP) • Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services • Covered Medical and Hospital Benefits • Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at 1-800-514-4911. Es posible que este documento esté disponible en otro idioma. Para información adicional llame al 1-800-514-4911. 14 Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. local time. UnitedHealthcare Dual Complete® ONE (HMO SNP) Phone Numbers and Website • If you are a member of this plan, call toll-free 1-800-514-4911. • If you are not a member of this plan, call toll-free 1-888-834-3721. • Our website: http://www.UHCCommunityPlan.com Who can join? To join UnitedHealthcare Dual Complete® ONE (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medicaid and live in our service area. Our service area includes the following counties in New Jersey: Atlantic, Bergen, Burlington, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, and Union. Which doctors, hospitals, and pharmacies can I use? UnitedHealthcare Dual Complete® ONE (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan’s provider and pharmacy directory at our website (www.UHCMedicareSolutions.com). Or, call us and we will send you a copy of the provider and pharmacy directories. 15 Plan INFORMATION THINGS TO KNOW ABOUT UNITEDHEALTHCARE DUAL COMPLETE® ONE (HMO SNP) What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers — and more. • Our plan members get all of the benefits covered by Original Medicare. • Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website http://www.UHCMedicareSolutions.com. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 16 SUMMARY OF BENEFITS MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $0 per month. How much is the deductible? This plan does not have a deductible. Is there any limit Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. on how much I will pay for my In this plan, you may pay nothing for Medicare-covered services, covered services? depending on your level of Medicaid eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Refer to the “Medicare & You” handbook for Medicare-covered services. For Medicaid-covered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 17 Plan INFORMATION January 1, 2016 – December 31, 2016 COVERED MEDICAL AND HOSPITAL BENEFITS OUTPATIENT CARE AND SERVICES Acupuncture Not covered However, please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Acupuncture benefits. Ambulance • Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): • Dental Services You pay nothing You pay nothing Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): • $0 copay Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Dental benefits. Diabetes Supplies Diabetes monitoring supplies: and Services • You pay nothing Diabetes self-management training: • You pay nothing Therapeutic shoes or inserts: • You pay nothing The plan covers the following brands of blood glucose monitors and test strips: OneTouch Ultra® 2 System, OneTouch Ultra Mini®, OneTouch Verio® Sync, OneTouch Verio® IQ, ACCU-CHEK® Nano SmartView, ACCU-CHEK® Aviva Plus. Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) Diagnostic radiology services (such as MRIs, CT scans): • You pay nothing Diagnostic tests and procedures: • You pay nothing Lab services: • You pay nothing Outpatient x-rays: • You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): • You pay nothing 18 Primary care physician visit: • You pay nothing Plan INFORMATION Doctor’s Office Visits Specialist visit: • You pay nothing Durable Medical Equipment (wheelchairs, oxygen, etc.) • You pay nothing Emergency Care • You pay nothing Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/ or meet certain conditions: Hearing Services Exam to diagnose and treat hearing and balance issues: • • You pay nothing $0 copay Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Hearing benefits. Home Health Care • Mental Health Care Inpatient visit: You pay nothing Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Home Health Care benefits. Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. • You pay nothing Outpatient group therapy visit: • You pay nothing Outpatient individual therapy visit: • You pay nothing Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Mental Health Care benefits. 19 Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): • You pay nothing Occupational therapy visit: • You pay nothing Physical therapy and speech and language therapy visit: • Outpatient Substance Abuse You pay nothing Group therapy visit: • You pay nothing Individual therapy visit: • You pay nothing Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Substance Abuse benefits. Outpatient Surgery Ambulatory surgical center: • You pay nothing Outpatient hospital: • You pay nothing Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items. Prosthetic Devices (braces, artificial limbs, etc.) Prosthetic devices: • You pay nothing Related medical supplies: • You pay nothing Renal Dialysis • You pay nothing Transportation • You pay nothing Urgently Needed Services • You pay nothing Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): • $0 copay Eyeglasses or contact lenses after cataract surgery: • $0 copay Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Vision Care Services benefits. 20 Preventive Care • You pay nothing • Abdominal aortic aneurysm screening • Alcohol misuse counseling • Bone mass measurement • Breast cancer screening (mammogram) • Cardiovascular disease (behavioral therapy) • Cardiovascular screenings • Cervical and vaginal cancer screening • Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) • Depression screening • Diabetes screenings • HIV screening • Medical nutrition therapy services • Obesity screening and counseling • Prostate cancer screenings (PSA) • Sexually transmitted infections screening and counseling • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) • Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots • “Welcome to Medicare” preventive visit (one-time) • Yearly “Wellness” visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam • Hospice You pay nothing You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Hospice benefits. 21 Plan INFORMATION Our plan covers many preventive services, including: INPATIENT CARE Inpatient Hospital Care Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. • You pay nothing Inpatient Mental Health Care For inpatient mental health care, see the “Mental Health Care” section of this booklet. Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. • You pay nothing Please see “Summary of Medicaid-Covered Benefits” after this section for Medicaid-covered Nursing Facility – Long Term Care benefits. 22 PRESCRIPTION DRUG BENEFITS For Part B drugs such as chemotherapy drugs: • You pay nothing Other Part B drugs: • You pay nothing As a member of UnitedHealthcare Dual Complete® ONE (HMO SNP), you have no cost sharing for covered, prescribed drugs. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: • $0 copay; or • $1.20 copay; or • $2.95 copay. For all other drugs, either: • $0 copay; or • $3.60 copay; or • $7.40 copay. You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Catastrophic Coverage • You pay nothing 23 Plan INFORMATION How much do I pay? SUMMARY OF MEDICAID-COVERED BENEFITS People who qualify for Medicare and Medicaid are known as dual eligibles. If you are a dual eligible, you are eligible for benefits under both the federal Medicare program and Medicaid. The following chart describes Medicaid benefits that are available to you under Medicaid and our Plan. As a member of this plan you have no cost-shares for covered medical services or Part D prescription drugs. Many of the services that are covered by Medicaid are also covered by Medicare through your Medicare Advantage SNP. These services are not listed below. Only the services that may continue when Medicare coverage ends, or which are not covered by Medicare, are shown. The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what Medicaid covers and what our plan covers. Benefit Category Medicaid UnitedHealthcare Dual Complete® ONE (HMO SNP) Acupuncture Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Clinical Trials Covered for services rendered beyond Medicare Part B limits. Covered for Medicaid approved services. Dental Services Includes diagnostic, preventive, restorative, endodontic, periodontal, prosthetic, and oral and maxillofacial surgical services, including routine dental exams, cleanings, dental X-rays, fillings, dentures and fixed prosthodontics. Diagnostic and Therapeutic Radiology and Laboratory Services Covered for services rendered beyond Medicare Part B limits. 24 Durable Medical Equipment Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Family Planning Services and Supplies Covered for services rendered beyond Medicare Part B limits. Out-of-Network services are covered through Medicaid Fee-for-Service. Hearing services Hearing aids and exams to fit hearing aids covered. Home Health Covered for services rendered beyond Medicare Parts A and B limits. Includes nursing services and home health aide services. Hospice Covered in the community as well as in institutional settings. Room and board services are included only when services are delivered in institutional (non-private residence) setting. Hospice care for children under 21 years of age shall cover both palliative and curative care. 25 Plan INFORMATION Covered for services rendered beyond Medicare Part B limits. Includes hearing aids. Managed Long Term Services and Supports (MLTSS) Managed Long Term Services and Supports (MLTSS) is a program that provides Home and Community Based services for members that require the level of care typically provided in a Nursing Facility, and allows them to receive necessary care in a residential or community setting. MLTSS services include (but are not limited to): assisted living services; cognitive, speech, occupational, and physical therapy; chore services; home-delivered meals; residential modifications (such as the installation of ramps or grab bars); vehicle modifications; social adult day care; and non-medical transportation. Covered - $0 copay Covered - $0 copay Covered – $0 copay Covered – $0 copay MLTSS is available to members who meet certain clinical and financial requirements. For more information on MLTSS, call Customer Service (phone numbers are printed on the back cover of this booklet). Medical Day Care Provides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community living. 26 Mental Health Care Nurse Midwife Service Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Nursing Facility – Long Term Care (also known as “custodial” care) Covered benefit for room and board and services rendered in a nursing facility for long-term care following exhaustion of Medicare days. Outpatient Mental Health Includes Mental Health (MH)/Substance Abuse (SA) services in hospital-based and community-based settings, as well as MH/SA screenings, referrals, and prescription drugs. Other services are covered directly through Medicaid Fee-for-Service. Outpatient Rehabilitation Covered for services rendered beyond Medicare Part B benefit limits. Includes physical therapy, occupational therapy, speech pathology, and cognitive rehabilitation. 27 Plan INFORMATION After Medicare coverage is exhausted, inpatient mental health services are covered via Medicaid Fee-for-Service other than State- or County-operated psychiatric facilities. The Medicaid Psychiatric Hospital Inpatient benefit applies to individuals under age 21 or over age 65. Inpatient hospital services and nursing facility services are covered for individuals 65 years of age or over in an institution for mental diseases. Inpatient psychiatric services in approved beds in a general hospital are covered for patients of any age. Outpatient Substance Abuse Methadone maintenance costs and administration are covered. Other services are covered via Medicaid Fee-for-Service. Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Covered – $0 copay Personal Care Assistant Covers health related tasks performed by a qualified individual in a beneficiary’s home, under the supervision of a registered professional nurse, as certified by a physician in accordance with a beneficiary’s written plan of care. Private Duty Nursing When authorized, available for members up to 21 years of age. This benefit is also available to Managed Long Term Services and Supports (MLTSS) members of any age. Transportation (routine) Covered by Medicaid fee-for-service for routine/non-emergent ground transportation to medically necessary services, including non-emergency basic life support (BLS). Vision Care Services Covers medically necessary eye care services for detection and treatment of disease or injury to the eye, including a comprehensive eye exam once per year. Optometric services and optical appliances are covered, including 1 pair of lenses/frames or contact lenses every 24 months, artificial eyes, low vision devices, vision training devices, and intraocular lenses. *For more information on plan benefits, please see the Evidence of Coverage. Authorization rules may apply. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. 28 Multi-language Interpreter Services Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, 1-800-514-4911 Alguien que hable español le podrá ayudar. Este es un por favor llame al 1-866-674-0491. servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务,帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务,请致电 1-800-514-4911 1-866-674-0491。我们的中文工作人员很乐意帮助您。 这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問,為此我們提供免費的翻譯 服務。如需翻譯服務,請致電 1-866-674-0491。我們講中文的人員將樂意為您提供幫助。 1-800-514-4911 這是一項免費服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-514-4911 1-866-674-0491. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-514-4911 1-866-674-0491. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-514-4911 1-866-674-0491 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-514-4911 1-866-674-0491. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-514-4911 1-866-674-0491 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. 29 Plan INFORMATION English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-514-4911 1-866-674-0491. Someone who speaks English/Language can help you. This is a free service. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, можете нашими бесплатными услугами Чтобы Russian:выЕсли у васвоспользоваться возникнут вопросы относительно страхового илипереводчиков. медикаментного воспользоваться переводчика, позвоните нам поуслугами телефонупереводчиков. 1-866-674-0491. Вам 1-800-514-4911 плана, вы можетеуслугами воспользоваться нашими бесплатными Чтобы окажет помощь сотрудник, который говорит по-pусски. услуга1-866-674-0491. бесплатная. воспользоваться услугами переводчика, позвоните нам Данная по телефону 1-800-514-4911 Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: ﻟﻠﺣﺻول ﻋﻠﻰ.إﻧﻧﺎ ﻧﻘدم ﺧدﻣﺎت اﻟﻣﺗرﺟم اﻟﻔوري اﻟﻣﺟﺎﻧﯾﺔ ﻟﻺﺟﺎﺑﺔ ﻋن أي أﺳﺋﻠﺔ ﺗﺗﻌﻠق ﺑﺎﻟﺻﺣﺔ أو ﺟدول اﻷدوﯾﺔ ﻟدﯾﻧﺎ اﻻﺗﺻﺎل ﺑﻧﺎ ﻋﻠﻰ ﻋﻠﯾك ﺳوى ﻟﯾس ،ﻓوري ﻣﺗرﺟم 1-866-674-0491 اﻟﻣﺟﺎﻧﯾﺔﯾﺗﺣدث ﺷﺧص ﻣﺎ اﻟﻣﺗرﺟمﺳﯾﻘوم . ﺧدﻣﺎت ھذه .ﺑﻣﺳﺎﻋدﺗك 1-800-514-4911 Arabic: ﻟﻠﺣﺻول اﻷدوﯾﺔ ﺟدول ﺑﺎﻟﺻﺣﺔ أو اﻟﻌرﺑﯾﺔأي أﺳﺋﻠﺔ ﺗﺗﻌﻠق ﻋن ﻟﻺﺟﺎﺑﺔ إﻧﻧﺎ ﻧﻘدم Russian:ﻋﻠﻰ Если у вас.ﻟدﯾﻧﺎ возникнут вопросы относительно страхового илиاﻟﻔوري медикаментного ﻣﺟﺎﻧﯾﺔ . ﺧدﻣﺔﺑﻧﺎ ﻋﻠﻰ اﻻﺗﺻﺎل ﺳوى ﻋﻠﯾك ﻟﯾس ،ﻓوري ﻣﺗرﺟم 1-866-674-0491 اﻟﻌرﺑﯾﺔ ﯾﺗﺣدث ﻣﺎ ﺷﺧص ﺳﯾﻘوم . ھذه . ﺑﻣﺳﺎﻋدﺗك 1-800-514-4911 плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы 1194-415-008-1 ﻣﺟﺎﻧﯾﺔ ﺧدﻣﺔ. воспользоваться услугами переводчика, позвоните нам по телефону 1-866-674-0491. 1-800-514-4911 Вам Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. domande sul nostro piano sanitario e farmaceutico.gratuito Per un per interprete, contattare il numero Italian: È disponibile un servizio di interpretariato rispondere a eventuali Hindi: हमारे स्वास्Un थ्यnostro या दवा की योजना केparla बारे Italianovi में आपके fornirà किसी भी प्रश्न केnecessaria. जवाब देने के लिए हमारे 1-866-674-0491. incaricato che l'assistenza 1-800-514-4911 domande nostro.ﻟدﯾﻧﺎ piano sanitario farmaceutico. unﻟﻺﺟﺎﺑﺔ interprete, il numero Arabic: ﻋﻠﻰsulﻟﻠﺣﺻول اﻷدوﯾﺔ أو ﺟدولeﺑﺎﻟﺻﺣﺔ أﺳﺋﻠﺔ ﺗﺗﻌﻠقPer ﻋن أي اﻟﻣﺟﺎﻧﯾﺔcontattare اﻟﻣﺗرﺟم اﻟﻔوري إﻧﻧﺎ ﻧﻘدم ﺧدﻣﺎت È1-800-514-4911 un ﺑﻧﺎ servizio gratuito. पास मुफ ्त दुभ ाषिया सेnostro वﻟﯾس ाएँ उपलब् ध हैं. 1-800-514-4911 एक parla दुभाषिया प्اﻟﻌرﺑﯾﺔ राप्तfornirà करने के लिए, ﺳﯾﻘوم बसnecessaria. हमे ं 1-800-514-4911 1-866-674-0491. Un incaricato che Italianovi ﻋﻠﻰ اﻻﺗﺻﺎل ﺳوى ﻋﻠﯾك ،ﻓوري ﻣﺗرﺟم 1-866-674-0491 ﯾﺗﺣدثl'assistenza ﺷﺧص ﻣﺎ . ھذه .ﺑﻣﺳﺎﻋدﺗك पर फोन करे . ं कोई व् य क् त ि जो हिन् द ी बोलता है आपकी मदद कर सकता है . यह एक मु फ्त सेवा है. È un servizio ﻣﺟﺎﻧﯾﺔ ﺧدﻣﺔ. gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão queDispomos tenha acerca do nossodeplano de saúde gratuitos ou de medicação. Para obter um intérprete, Portugués: deservizio serviços interpretação para responder a qualquer Italian: È disponibile un di interpretariato gratuito per rispondere a eventuali 1-800-514-4911 contacte-nos através do número 1-866-674-0491. encontrar alguém queobter fale oum idioma questão que nosso plano de saúdeIrá ou intérprete, domande sul tenha nostroacerca piano do sanitario e farmaceutico. Perdeunmedicação. interprete,Para contattare il numero Português para o ajudar. Este serviço é gratuito. 1-800-514-4911 contacte-nos através do número 1-866-674-0491. Irá encontrar que fale o idioma 1-866-674-0491. Un nostro incaricato che parla Italianovi forniràalguém l'assistenza necessaria. 1-800-514-4911 para o ajudar. Este serviço é gratuito. ÈPortuguês un servizio gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal wa dwòg an. Pou jwenn yon entèprèt, jis rele ou noutanan French Creole: Nou genyen sèvisnou entèprèt gratis pou reponn tout responder kesyon genyen Portugués: Dispomos de serviços de interpretação gratuitos para a qualquer 1-800-514-4911 1-866-674-0491. Yon moun ki pale Kreyòl kapab ede yon w. Sa a se yonjissèvis ki gratis. konsènan plan medikal wado dwòg nou an. Pou jwenn nan questão que tenha acerca nosso plano de saúde ou deentèprèt, medicação. rele Paranou obter um intérprete, 1-800-514-4911 1-866-674-0491. Yondo moun ki pale Kreyòl kapab ede Sa a se alguém yon sèvis ki gratis. 1-800-514-4911 contacte-nos através número 1-866-674-0491. Irá w. encontrar que fale o idioma Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w Português para o ajudar. Este serviço é gratuito. uzyskaniu odpowiedzi bezpłatne na temat planu zdrowotnego dawkowania leków. skorzystać Polish: Umożliwiamy skorzystanie z usługlub tłumacza ustnego, któryAby pomoże w z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-866-674-0491. Ta z 1-800-514-4911 uzyskaniu odpowiedzi na temat planu zdrowotnego dawkowania leków. skorzystać French Creole: Nou genyen sèvis entèprèt gratis poulub reponn tout kesyon ouAby ta genyen usługa bezpłatna. pomocyjest tłumacza znającego języknou polski, zadzwonić pod numer 1-866-674-0491. Ta konsènan plan medikal wa dwòg an. należy Pou jwenn yon entèprèt, jis rele nou nan 1-800-514-4911 1-800-514-4911 usługa jest bezpłatna. 1-866-674-0491. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Hindi: हमारे �वा��य या दवा क� योजना के बारे म� आपके �कसी भी ��न के जवाब दे ने के Polish: Umożliwiamy skorzystanie usług tłumacza ustnego, któryकेpomoże wने क �लए पास म� दभ वयोजना ाएँ उपल�ध ह� . म�एक दभ �ा�त करने केजवाब �लए, दे बस हम� Hindi:हमारे हमारे �वा��य या दवा क�से के zबारे आपक �कसी भी ��न े ु त bezpłatne ु ा�षया ु े ा�षया uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z 1-866-674-0491 . कोई �यि�त जो �ह�द� है आपक� मदद ककर सकता . 1-800-514-4911 �लए हमारे पास पर म� दभ ा�षया सेवाएँ उपल�ध ह� . एकबोलता दभ �ा�त करने े �लए, बस हैहम� ु तफोन ु कर� ु ा�षया pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-514-4911 1-866-674-0491. Ta यह एकjest म� त सेपर वा हैफोन . कर� . कोई �यि�त जो �ह�द� बोलता है आपक� मदद कर सकता है . 1-866-674-0491 1-800-514-4911 ु bezpłatna. usługa यह एक म� ु त सेवा है . Japanese:ᙜ♫ࡢᗣᗣಖ㝤⸆ရฎ᪉⸆ࣉࣛࣥ㛵ࡍࡿࡈ㉁ၥ࠾⟅࠼ࡍࡿࡓࡵ Hindi: हमारे �वा��य या दवा क� योजना के बारे म� आपके �कसी भी ��न के जवाब दे ने के ࠊ↓ᩱࡢ㏻ヂࢧ࣮ࣅࢫࡀ࠶ࡾࡲࡍࡈࡊ࠸ࡲࡍࠋ㏻ヂࢆࡈ⏝࡞ࡿࡣࠊ Japanese:ᙜ♫ࡢᗣᗣಖ㝤⸆ရฎ᪉⸆ࣉࣛࣥ㛵ࡍࡿࡈ㉁ၥ࠾⟅࠼ࡍࡿࡓࡵ �लए हमारे पास म� ु त दभ ु ा�षया सेवाएँ उपल�ध ह�. एक दभ ु ा�षया �ा�त करने के �लए, बस हम� 1-866-674-0491 ࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ 1-800-514-4911 ࠊ↓ᩱࡢ㏻ヂࢧ࣮ࣅࢫࡀ࠶ࡾࡲࡍࡈࡊ࠸ࡲࡍࠋ㏻ヂࢆࡈ⏝࡞ࡿࡣࠊ 1-866-674-0491 1-800-514-4911 पर फोन कर� . कोई �यि�त जो �ह�द� बोलता है आपक� मदद कर सकता है . ࡢࢧ࣮ࣅࢫ࡛ࡍࠋ 1-866-674-0491 1-800-514-4911 ࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ यह एक मु�त सेवा है . ࡢࢧ࣮ࣅࢫ࡛ࡍࠋ Japanese:ᙜ♫ࡢᗣᗣಖ㝤⸆ရฎ᪉⸆ࣉࣛࣥ㛵ࡍࡿࡈ㉁ၥ࠾⟅࠼ࡍࡿࡓࡵ ࠊ↓ᩱࡢ㏻ヂࢧ࣮ࣅࢫࡀ࠶ࡾࡲࡍࡈࡊ࠸ࡲࡍࠋ㏻ヂࢆࡈ⏝࡞ࡿࡣࠊ 1-866-674-0491 1-800-514-4911 ࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ ࡢࢧ࣮ࣅࢫ࡛ࡍࠋ UHNJ16HM3699674_001 30 UnitedHealthcare - H3113 2015 Medicare Star Ratings* 1. An Overall Star Rating that combines all of our plan’s scores. 2. Summary Star Rating that focuses on our medical or our prescription drug services. Some of the areas Medicare reviews for the ratings include: · How our members rate our plan’s services and care; · How well our doctors detect illnesses and keep members healthy; · How well our plan helps our members use recommended and safe prescription medications For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare: Not enough data available* We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services: Health Plan Services: Drug Plan Services: Not enough data available 3.5 stars The number of stars shows how well our plan performs. excellent above average average below average poor *Some contracts do not have enough data to rate performance. Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-834-3721 (toll-free) or 711 (TTY). Current members please call 800-514-4911 (toll-free) or 711 (TTY). *Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next. UHEX15HM3630278_001 Y0066_H3113_B_PR2015 CMS Accepted 31 Plan INFORMATION The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are: 2016 Required INFORMATION Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Members may enroll in the plan only during specific times of the year. Contact the plan for more information. You must have both Medicare Parts A and B to enroll in the plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. Premium and/or co- payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their dispensing policy or by the plan based on Quantity Limit requirements; if a prescription is in excess of a limit, co-pay amounts may be higher. Other pharmacies are available in our network. Members may use any pharmacy in the network, but may not receive Pharmacy Saver pricing. Pharmacies participating in the Pharmacy Saver program may not be available in all areas. You are not required to use OptumRx to obtain a 90 - day supply of your maintenance medications. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877-266-4832. OptumRx is an affiliate of UnitedHealthcare Insurance Company. For PPO and HMO-POS members, with the exception of emergency or out-of-area renal dialysis, it may cost more to get care from out-of-network providers. HMO members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor UnitedHealthcare® Medicare Advantage plans will be responsible for the costs. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. This information is available for free in other languages. Please call our customer service number located on the first page of this book. Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al número que se encuentra en la primera página de esta guía. Y0066_140728_115139_Accepted 32 UHEX16DU3720524_000 2016 Required INFORMATION (CONTINUED) NurseLineSM This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time. SilverSneakers® Consult a health care professional before beginning any exercise program. Availability of the SilverSneakers program varies by plan/market. Refer to your Evidence of Coverage for more details. SilverSneakers® is a registered trademark of Healthways, Inc. © 2014 Healthways, Inc. Y0066_140728_115139_Accepted 33 UHEX16DU3720524_000 Plan INFORMATION Your Plan may contain one or more of the following: NOTES _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ UHEX16MP3700083_001 0 2016 DRUG LIST This is an alphabetical list of Brand name and Generic drugs covered by the plan. · Brand name drugs appear in bold type · Generic drugs appear in plain type Your plan has one tier named “Covered Drugs”. All covered drugs are in this tier. · For a full description of the tier “Covered Drugs”, see the Summary of Benefits in this book Some drugs may need Prior Authorization, Step Therapy or other requirements. To find out if your drug has added coverage needs, please contact us or view the complete drug list on our website. Our contact information is on the first page of this book. This list was last updated August 1, 2015. # 8-Mop (Capsule), T1 A A-Hydrocort (Injection), T1 Abacavir (Tablet), T1 Abacavir Sulfate/Lamivudine/ Zidovudine (Tablet), T1 Abelcet (Injection), T1 Abilify Discmelt (Tablet Dispersible), T1 Abilify Maintena (Injection), T1 Abraxane (Injection), T1 Abstral (Tablet Sublingual), T1 Acamprosate Calcium DR (Tablet Delayed-Release), T1 Acarbose (Tablet), T1 Acebutolol HCl (Capsule), T1 Acetaminophen/Codeine (120mg-12mg/5ml Oral Solution, 300mg-15mg Tablet, 300mg-30mg Tablet, 300mg-60mg Tablet), T1 Acetazolamide (Tablet Immediate-Release), T1 Acetazolamide ER (Capsule Extended-Release 12 Hour), T1 Acetazolamide Sodium (Injection), T1 Acetic Acid (Otic Solution), T1 Acetylcysteine (Inhalation Solution), T1 Acitretin (Capsule), T1 ActHIB (Injection), T1 Actemra (162mg/0.9ml Injection, 200mg/10ml Injection), T1 Actimmune (Injection), T1 Actonel (150mg Tablet), T1 Acyclovir (200mg Capsule, 200mg/5ml Suspension), T1 Acyclovir (400mg Tablet, 800mg Tablet), T1 Acyclovir (5% Ointment), T1 Acyclovir Sodium (Injection), T1 Adacel (Injection), T1 Adagen (Injection), T1 Adapalene (0.1% Cream, 0.1% Gel), T1 T1 = Tier 1 Covered Drugs H3113_150616_121143_FINAL Accepted Adcirca (Tablet), T1 Adefovir Dipivoxil (Tablet), T1 Adempas (Tablet), T1 Adrucil (Injection), T1 Advair Diskus (Aerosol Powder), T1 Advair HFA (Aerosol), T1 Afeditab CR (Tablet Extended-Release 24 Hour), T1 Afinitor (Tablet), T1 Afinitor Disperz (Tablet Soluble), T1 Aggrenox (Capsule Extended-Release 12 Hour), T1 Ala Cort (Cream), T1 Albenza (Tablet), T1 Albuterol Sulfate (0.083% Nebulized Solution, 0.5% Nebulized Solution, 0.63mg/3ml Nebulized Solution, 1.25mg/3ml Nebulized Solution), T1 0 Bold type = Brand name drug Amikacin Sulfate (Injection), T1 Amiloride HCl (Tablet), T1 Amiloride/ Hydrochlorothiazide (Tablet), T1 Aminophylline (Injection), T1 Aminosyn 7%/Electrolytes (Injection), T1 Aminosyn 8.5%/ Electrolytes (Injection), T1 Aminosyn II (Injection), T1 Aminosyn II 8.5%/ Electrolytes (Injection), T1 Aminosyn M (Injection), T1 Aminosyn-HBC (Injection), T1 Aminosyn-PF (Injection), T1 Aminosyn-RF (Injection), T1 Amiodarone HCl (200mg Tablet), T1 Amiodarone HCl (50mg/ml Injection), T1 Amitiza (Capsule), T1 Amitriptyline HCl (Tablet), T1 Amlodipine Besylate (Tablet), T1 Amlodipine Besylate/ Atorvastatin Calcium (Tablet), T1 Amlodipine Besylate/ Benazepril HCl (Capsule), T1 Amlodipine Besylate/ Valsartan (Tablet), T1 Amlodipine/Valsartan/ Hydrochlorothiazide (Tablet), T1 Ammonium Chloride (Injection), T1 Ammonium Lactate (12% Cream, 12% Lotion), T1 Amoxapine (Tablet), T1 Amoxicillin (125mg Tablet Chewable, 250mg Tablet Chewable, 125mg/5ml Suspension, 200mg/5ml Suspension, 250mg/5ml Suspension, 400mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 500mg Tablet, 875mg Tablet), T1 Amoxicillin/Clavulanate Potassium (200mg-28.5mg Tablet Chewable, 400mg-57mg Tablet Chewable, 200mg-28.5mg/ 5ml Suspension, 250mg-62.5mg/5ml Suspension, 400mg-57mg/ 5ml Suspension, 600mg-42.9mg/5ml Suspension, 250mg-125mg Tablet Immediate-Release, 500mg-125mg Tablet Immediate-Release, 875mg-125mg Tablet Immediate-Release) (Generic Augmentin), T1 Amoxicillin/Clavulanate Potassium ER (Tablet Extended-Release 12 Hour), T1 Amphetamine/ Dextroamphetamine (Capsule Extended-Release 24 Hour), T1 Amphetamine/ Dextroamphetamine (Tablet Immediate-Release), T1 Amphotericin B (Injection), T1 Ampicillin (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Capsule, 500mg Capsule), T1 Plain type = Generic drug 37 Drug LIST Albuterol Sulfate (2mg Tablet Immediate-Release, 4mg Tablet Immediate-Release), T1 Alclometasone Dipropionate (0.05% Cream, 0.05% Ointment), T1 Alcohol Prep Pads, T1 Aldurazyme (Injection), T1 Alendronate Sodium (10mg Tablet, 35mg Tablet, 40mg Tablet, 5mg Tablet, 70mg Tablet), T1 Alendronate Sodium (70mg/ 75ml Oral Solution), T1 Alfuzosin HCl ER (Tablet Extended-Release 24 Hour), T1 Alimta (Injection), T1 Alinia (100mg/5ml Suspension, 500mg Tablet), T1 Allopurinol (Tablet), T1 Alocril (Ophthalmic Solution), T1 Alomide (Ophthalmic Solution), T1 Alora (Patch Twice Weekly), T1 Alosetron HCl (Tablet), T1 Aloxi (Injection), T1 Alphagan P (0.1% Ophthalmic Solution), T1 Alprazolam (Tablet Immediate-Release), T1 Altabax (Ointment), T1 AmBisome (Injection), T1 Amantadine HCl (100mg Capsule, 100mg Tablet, 50mg/5ml Syrup), T1 Amethia (Tablet), T1 Amethyst (Tablet), T1 Amifostine (Injection), T1 0 Ampicillin Sodium (10gm Injection, 125mg Injection, 1gm Injection), T1 Ampicillin-Sulbactam (10gm-5gm Injection, 1gm-0.5gm Injection, 2gm-1gm Injection), T1 Ampyra (Tablet ExtendedRelease 12 Hour), T1 Anadrol-50 (Tablet), T1 Anagrelide HCl (Capsule), T1 Anastrozole (Tablet), T1 Ancobon (Capsule), T1 Androderm (Patch 24 Hour), T1 Androgel (1.62% Packet), T1 Androgel Pump (1.62% Gel), T1 Anoro Ellipta (Aerosol Powder), T1 Anzemet (100mg Tablet, 50mg Tablet), T1 Apokyn (Injection), T1 Apraclonidine (Ophthalmic Solution), T1 Apri (Tablet), T1 Aptiom (200mg Tablet), T1 Aptiom (400mg Tablet, 600mg Tablet, 800mg Tablet), T1 Aptivus (100mg/ml Oral Solution, 250mg Capsule), T1 Aralast NP (Injection), T1 Aranelle (Tablet), T1 T1 = Tier 1 Covered Drugs Aranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 150mcg/0.3ml Injection, 200mcg/0.4ml Injection, 200mcg/ml Injection, 300mcg/0.6ml Injection, 300mcg/ml Injection, 500mcg/ml Injection, 60mcg/0.3ml Injection, 60mcg/ml Injection), T1 Aranesp Albumin Free (10mcg/0.4ml Injection, 25mcg/0.42ml Injection, 25mcg/ml Injection, 40mcg/0.4ml Injection, 40mcg/ml Injection), T1 Arcalyst (Injection), T1 Argatroban (Injection), T1 Aripiprazole (10mg Tablet, 15mg Tablet, 2mg Tablet, 5mg Tablet), T1 Aripiprazole (20mg Tablet, 30mg Tablet), T1 Arranon (Injection), T1 Arzerra (Injection), T1 Ashlyna (Tablet), T1 Atenolol (Tablet), T1 Atenolol/Chlorthalidone (Tablet), T1 Atgam (Injection), T1 Atorvastatin Calcium (Tablet), T1 Atovaquone (Suspension), T1 Atovaquone/Proguanil HCl (Tablet) (Generic Malarone), T1 Atripla (Tablet), T1 Atropine Sulfate (Injection), T1 Atrovent HFA (Aerosol Solution), T1 Aubagio (Tablet), T1 Aubra (Tablet), T1 Augmented Betamethasone Dipropionate (0.05% Cream), T1 Augmented Betamethasone Dipropionate (0.05% Gel, 0.05% Lotion, 0.05% Ointment), T1 Avandamet (Tablet), T1 Avandia (Tablet), T1 Avastin (Injection), T1 Avelox (400mg/250ml-0.8% Injection), T1 Aviane (Tablet), T1 Avita (0.025% Cream, 0.025% Gel), T1 Avonex (Injection), T1 Avonex Pen (Injection), T1 Azacitidine (Injection), T1 Azactam in Iso-Osmotic Dextrose (Injection), T1 Azasite (Ophthalmic Solution), T1 Azathioprine (Tablet), T1 Azelastine HCl (0.05% Ophthalmic Solution), T1 Azelastine HCl (0.1% Nasal Solution), T1 Azelastine HCl (0.15% Nasal Solution), T1 Azilect (Tablet), T1 Azithromycin (100mg/5ml Oral Suspension, 200mg/ 5ml Oral Suspension, 250mg Tablet, 500mg Tablet, 600mg Tablet), T1 Azithromycin (500mg Injection), T1 Azopt (Suspension), T1 Azor (Tablet), T1 Aztreonam (Injection), T1 0 Bold type = Brand name drug Betamethasone Dipropionate (0.05% Cream, 0.05% Lotion, 0.05% Ointment), T1 Betamethasone Valerate (0.1% Cream, 0.1% Lotion, 0.1% Ointment), T1 Betaseron (Injection), T1 Betaxolol HCl (0.5% Ophthalmic Solution), T1 Betaxolol HCl (10mg Tablet, 20mg Tablet), T1 Bethanechol Chloride (Tablet), T1 Bethkis (Nebulized Solution), T1 Betimol (Ophthalmic Solution), T1 Bexsero (Injection), T1 BiCNU (Injection), T1 BiDil (Tablet), T1 Bicalutamide (Tablet), T1 Bicillin C-R (Injection), T1 Bicillin L-A (Injection), T1 Biltricide (Tablet), T1 Binosto (Tablet Effervescent), T1 Bisoprolol Fumarate (Tablet), T1 Bisoprolol Fumarate/ Hydrochlorothiazide (Tablet), T1 Bleomycin Sulfate (Injection), T1 Blephamide (Suspension), T1 Blephamide S.O.P. (Ointment), T1 Boniva (3mg/3ml Injection), T1 Boostrix (Injection), T1 Bosulif (Tablet), T1 Botox (Injection), T1 Breo Ellipta (Aerosol Powder), T1 Briellyn (Tablet), T1 Brilinta (Tablet), T1 Brimonidine Tartrate (0.15% Ophthalmic Solution), T1 Brimonidine Tartrate (0.2% Ophthalmic Solution), T1 Brintellix (Tablet), T1 Bromocriptine Mesylate (2.5mg Tablet, 5mg Capsule), T1 Brovana (Nebulized Solution), T1 Budesonide (0.25mg/2ml Suspension, 0.5mg/2ml Suspension), T1 Budesonide (3mg Capsule Extended-Release 24 Hour), T1 Bumetanide (0.25mg/ml Injection), T1 Bumetanide (0.5mg Tablet, 1mg Tablet, 2mg Tablet), T1 Buprenorphine HCl (0.3mg/ ml Injection), T1 Buprenorphine HCl (2mg Tablet Sublingual, 8mg Tablet Sublingual), T1 Buprenorphine HCl/Naloxone HCl (Tablet Sublingual), T1 Buproban (Tablet ExtendedRelease 12 Hour), T1 Bupropion HCl (Tablet Immediate-Release), T1 Bupropion HCl SR (Tablet Extended-Release 12 Hour), T1 Bupropion HCl XL (Tablet Extended-Release 24 Hour), T1 Buspirone HCl (Tablet), T1 Busulfex (Injection), T1 Butorphanol Tartrate (10mg/ ml Nasal Solution), T1 Plain type = Generic drug 39 Drug LIST B BACiiM (Injection), T1 BCG Vaccine (Injection), T1 BIVIGAM (Injection), T1 Bacitracin (50000unit Injection), T1 Bacitracin (500unit/gm Ointment), T1 Bacitracin/Polymyxin B (Ointment), T1 Baclofen (Tablet), T1 Bactocill in Dextrose (1gm/ 50ml Injection), T1 Bactocill in Dextrose (2gm/ 50ml Injection), T1 Bactroban Nasal (Ointment), T1 Balsalazide Disodium (Capsule), T1 Balziva (Tablet), T1 Banzel (200mg Tablet, 400mg Tablet, 40mg/ml Suspension), T1 Baraclude (0.05mg/ml Oral Solution, 0.5mg Tablet, 1mg Tablet), T1 Beleodaq (Injection), T1 Belsomra (Tablet), T1 Benazepril HCl (Tablet), T1 Benazepril HCl/ Hydrochlorothiazide (Tablet), T1 Benicar (Tablet), T1 Benicar HCT (Tablet), T1 Benlysta (Injection), T1 Benztropine Mesylate (0.5mg Tablet, 1mg Tablet, 2mg Tablet), T1 Benztropine Mesylate (1mg/ ml Injection), T1 Bepreve (Ophthalmic Solution), T1 Berinert (Injection), T1 Besivance (Suspension), T1 0 Butorphanol Tartrate (1mg/ml Injection, 2mg/ml Injection), T1 Bydureon (Injection), T1 Byetta (Injection), T1 Bystolic (Tablet), T1 C Cabergoline (Tablet), T1 Calcipotriene (0.005% Cream, 0.005% External Solution), T1 Calcitonin-Salmon (Nasal Solution), T1 Calcitriol (0.25mcg Capsule, 0.5mcg Capsule, 1mcg/ml Oral Solution), T1 Calcitriol (1mcg/ml Injection), T1 Calcitriol (3mcg/gm Ointment), T1 Calcium Acetate (Capsule), T1 Camila (Tablet), T1 Canasa (Suppository), T1 Cancidas (Injection), T1 Candesartan Cilexetil (Tablet), T1 Candesartan Cilexetil/ Hydrochlorothiazide (Tablet), T1 Capastat Sulfate (Injection), T1 Caprelsa (Tablet), T1 Captopril (Tablet), T1 Captopril/Hydrochlorothiazide (Tablet), T1 Carac (Cream), T1 Carafate (1gm/10ml Suspension), T1 Carbaglu (Tablet), T1 T1 = Tier 1 Covered Drugs Carbamazepine (100mg Tablet Chewable, 100mg/ 5ml Suspension, 200mg Tablet Immediate-Release), T1 Carbamazepine ER (100mg Capsule Extended-Release 12 Hour, 200mg Capsule Extended-Release 12 Hour, 300mg Capsule ExtendedRelease 12 Hour, 200mg Tablet Extended-Release 12 Hour, 400mg Tablet Extended-Release 12 Hour), T1 Carbidopa (Tablet), T1 Carbidopa/Levodopa (Tablet Immediate-Release), T1 Carbidopa/Levodopa ER (Tablet Extended-Release), T1 Carbidopa/Levodopa ODT (Tablet Dispersible), T1 Carbidopa/Levodopa/ Entacapone (Tablet), T1 Carboplatin (Injection), T1 Cardene IV (Injection), T1 Carimune Nanofiltered (Injection), T1 Carteolol HCl (Ophthalmic Solution), T1 Cartia XT (Capsule ExtendedRelease 24 Hour), T1 Carvedilol (Tablet ImmediateRelease), T1 Cayston (Inhalation Solution), T1 Cefaclor (250mg Capsule Immediate-Release, 500mg Capsule ImmediateRelease), T1 Cefadroxil (250mg/5ml Suspension, 500mg/5ml Suspension, 500mg Capsule), T1 Cefazolin Sodium (10gm Injection, 1gm Injection, 500mg Injection, 1gm/50ml Injection), T1 Cefdinir (125mg/5ml Suspension, 250mg/5ml Suspension, 300mg Capsule), T1 Cefditoren Pivoxil (Tablet), T1 Cefepime (1gm Injection, 2gm Injection), T1 Cefepime (1gm/50ml Injection, 2gm/50ml Injection), T1 Cefixime (Suspension), T1 Cefotaxime Sodium (Injection), T1 Cefotetan (Injection), T1 Cefoxitin Sodium (10gm Injection, 1gm Injection, 2gm Injection), T1 Cefoxitin Sodium (1gm-4% Injection, 2gm-2.2% Injection), T1 Cefpodoxime Proxetil (100mg Tablet, 200mg Tablet, 100mg/5ml Suspension, 50mg/5ml Suspension), T1 Cefprozil (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Tablet, 500mg Tablet), T1 Ceftazidime (Injection), T1 Ceftazidime/Dextrose (Injection), T1 0 Bold type = Brand name drug Chlorpromazine HCl (100mg Tablet, 10mg Tablet, 200mg Tablet, 25mg Tablet, 50mg Tablet, 25mg/ml Injection), T1 Chlorthalidone (Tablet), T1 Cholestyramine Light (Packet), T1 Chorionic Gonadotropin (Injection), T1 Ciclopirox (0.77% Gel, 0.77% Suspension, 1% Shampoo), T1 Ciclopirox Nail Lacquer (External Solution), T1 Ciclopirox Olamine (Cream), T1 Cilostazol (Tablet), T1 Ciloxan (0.3% Ointment), T1 Cimetidine (Tablet), T1 Cimetidine HCl (Oral Solution), T1 Cimzia (Injection), T1 Cinryze (Injection), T1 Cipro HC (Suspension), T1 Ciprodex (Otic Suspension), T1 Ciprofloxacin (250mg/5ml Suspension, 500mg/5ml Suspension, 400mg/40ml Injection), T1 Ciprofloxacin ER (Tablet Extended-Release 24 Hour), T1 Ciprofloxacin HCl (0.3% Ophthalmic Solution, 100mg Tablet ImmediateRelease, 250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 750mg Tablet ImmediateRelease), T1 Ciprofloxacin I.V. in D5W (Injection), T1 Cisplatin (Injection), T1 Citalopram HBr (10mg Tablet, 20mg Tablet, 40mg Tablet), T1 Citalopram HBr (10mg/5ml Oral Solution), T1 Cladribine (Injection), T1 Claravis (Capsule), T1 Clarithromycin (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Tablet, 500mg Tablet), T1 Clarithromycin ER (Tablet Extended-Release 24 Hour), T1 Climara Pro (Patch Weekly), T1 Clindamycin HCl (Capsule Immediate-Release), T1 Clindamycin Palmitate HCl (Oral Solution), T1 Clindamycin Phosphate (1% External Solution, 1% Gel, 1% Lotion, 1% Swab), T1 Clindamycin Phosphate (2% Cream), T1 Clindamycin Phosphate AddVantage (Injection), T1 Clindamycin Phosphate in D5W (Injection), T1 Clindamycin/Benzoyl Peroxide (1%-5% Gel) (Generic BenzaClin), T1 Clinisol SF 15% (Injection), T1 Clobetasol Propionate (0.05% External Solution, 0.05% Gel, 0.05% Ointment), T1 Clobetasol Propionate (0.05% Shampoo), T1 Clobetasol Propionate E (Cream), T1 Clolar (Injection), T1 Clomipramine HCl (Capsule), T1 Plain type = Generic drug 41 Drug LIST Ceftriaxone Sodium (10gm Injection, 1gm Injection, 2gm Injection, 250mg Injection, 500mg Injection), T1 Cefuroxime Axetil (Tablet), T1 Cefuroxime Sodium (Injection), T1 Celecoxib (Capsule), T1 Cellcept (200mg/ml Suspension, 250mg Capsule, 500mg Tablet), T1 Cellcept Intravenous (Injection), T1 Celontin (Capsule), T1 Cephalexin (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 750mg Capsule), T1 Cerezyme (Injection), T1 Cervarix (Injection), T1 Cesamet (Capsule), T1 Cetirizine HCl (Syrup), T1 Chantix (Tablet), T1 Chantix Continuing Month Pak (Tablet), T1 Chantix Starting Month Pak (Tablet), T1 Chemet (Capsule), T1 Chenodal (Tablet), T1 Chloramphenicol Sodium Succinate (Injection), T1 Chlordiazepoxide HCl (Capsule), T1 Chlorhexidine Gluconate Oral Rinse (Solution), T1 Chloroquine Phosphate (Tablet), T1 Chlorothiazide (Tablet), T1 Chlorothiazide Sodium (Injection), T1 0 Clonazepam (Tablet Immediate-Release), T1 Clonazepam ODT (Tablet Dispersible), T1 Clonidine HCl (0.1mg Tablet Immediate-Release, 0.2mg Tablet Immediate-Release, 0.3mg Tablet ImmediateRelease), T1 Clonidine HCl (0.1mg/24hr Patch Weekly, 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly), T1 Clonidine HCl ER (Tablet Extended-Release 12 Hour), T1 Clopidogrel (75mg Tablet), T1 Clorazepate Dipotassium (Tablet), T1 Clorpres (Tablet), T1 Clotrimazole (1% Cream, 1% External Solution, 10mg Troche), T1 Clotrimazole/Betamethasone Dipropionate (1%-0.05% Cream), T1 Clotrimazole/Betamethasone Dipropionate (1%-0.05% Lotion), T1 Clozapine (Tablet ImmediateRelease), T1 Clozapine ODT (100mg Tablet Dispersible, 12.5mg Tablet Dispersible, 150mg Tablet Dispersible, 25mg Tablet Dispersible), T1 Clozapine ODT (200mg Tablet Dispersible), T1 Coartem (Tablet), T1 Codeine Sulfate (Tablet), T1 Colchicine (0.6mg Tablet) (Generic Colcrys), T1 T1 = Tier 1 Covered Drugs Colcrys (Tablet), T1 Colestipol HCl (1gm Tablet, 5gm Granules), T1 Colistimethate Sodium (Injection), T1 Colocort (Enema), T1 Coly-Mycin S (Suspension), T1 Combigan (Ophthalmic Solution), T1 Combivent Respimat (Aerosol Solution), T1 Combivir (Tablet), T1 Cometriq (Kit), T1 Complera (Tablet), T1 Compro (Suppository), T1 Comvax (Injection), T1 Constulose (Oral Solution), T1 Copaxone (Injection), T1 Cordran Tape (Tape), T1 Cormax Scalp Application (External Solution), T1 Cortisone Acetate (Tablet), T1 Cortisporin (0.5%-0.5% Cream, 1%-0.5% Ointment), T1 Cortisporin-TC (Suspension), T1 Cosmegen (Injection), T1 Coumadin (Tablet), T1 Creon (Capsule DelayedRelease), T1 Crestor (Tablet), T1 Crinone (Gel), T1 Crixivan (Capsule), T1 Cromolyn Sodium (100mg/ 5ml Concentrate), T1 Cromolyn Sodium (20mg/2ml Nebulized Solution), T1 Cromolyn Sodium (4% Ophthalmic Solution), T1 Cryselle-28 (Tablet), T1 Cubicin (Injection), T1 Cuprimine (Capsule), T1 Cuvposa (Oral Solution), T1 Cyclafem (Tablet), T1 Cyclobenzaprine HCl (7.5mg Tablet), T1 Cyclophosphamide (Capsule), T1 Cycloset (Tablet), T1 Cyclosporine (100mg Capsule, 25mg Capsule), T1 Cyclosporine (50mg/ml Injection), T1 Cyclosporine Modified (100mg Capsule, 25mg Capsule, 50mg Capsule, 100mg/ml Oral Solution), T1 Cyproheptadine HCl (4mg Tablet), T1 Cystadane (Powder), T1 Cystagon (Capsule), T1 Cystaran (Ophthalmic Solution), T1 Cytarabine Aqueous (Injection), T1 D DARAPRIM (Tablet), T1 Dacarbazine (Injection), T1 Dacogen (Injection), T1 Daliresp (Tablet), T1 Dalvance (Injection), T1 Danazol (Capsule), T1 Dantrolene Sodium (Capsule), T1 Dapsone (Tablet), T1 Daptacel (Injection), T1 DaunoXome (Injection), T1 Daunorubicin HCl (Injection), T1 Deblitane (Tablet), T1 Decitabine (Injection), T1 Delyla (Tablet), T1 Demeclocycline HCl (Tablet), T1 0 Bold type = Brand name drug Dexmethylphenidate HCl ER (Capsule Extended-Release 24 Hour), T1 Dexrazoxane (Injection), T1 Dextroamphetamine Sulfate (10mg Tablet ImmediateRelease, 5mg Tablet Immediate-Release), T1 Dextroamphetamine Sulfate ER (Capsule ExtendedRelease 24 Hour), T1 Dextrose 10% Flex Container (Injection), T1 Dextrose 10%/NaCl 0.2% (Injection), T1 Dextrose 10%/NaCl 0.45% (Injection), T1 Dextrose 2.5%/Sodium Chloride 0.45% (Injection), T1 Dextrose 5% (Injection), T1 Dextrose 5%/NaCl 0.2% (Injection), T1 Dextrose 5%/NaCl 0.225% (Injection), T1 Dextrose 5%/NaCl 0.33% (Injection), T1 Dextrose 5%/NaCl 0.45% (Injection), T1 Dextrose 5%/NaCl 0.9% (Injection), T1 Dextrose 5%/Potassium Chloride 0.15% (Injection), T1 Diastat AcuDial (Gel), T1 Diastat Pediatric (Gel), T1 Diazepam (10mg Gel, 2.5mg Gel, 20mg Gel), T1 Diazepam (10mg Tablet Immediate-Release, 2mg Tablet Immediate-Release, 5mg Tablet ImmediateRelease), T1 Diazepam (1mg/ml Oral Solution), T1 Diazepam Intensol (5mg/ml Concentrate), T1 Diclofenac Potassium (Tablet Immediate-Release), T1 Diclofenac Sodium (0.1% Ophthalmic Solution), T1 Diclofenac Sodium (3% Gel), T1 Diclofenac Sodium DR (Tablet Delayed-Release), T1 Diclofenac Sodium ER (Tablet Extended-Release 24 Hour), T1 Dicloxacillin Sodium (Capsule), T1 Dicyclomine HCl (10mg Capsule, 10mg/5ml Oral Solution, 20mg Tablet), T1 Didanosine (Capsule DelayedRelease), T1 Dificid (Tablet), T1 Diflunisal (Tablet), T1 Digitek (0.125mg Tablet), T1 Digitek (0.25mg Tablet), T1 Digoxin (0.05mg/ml Oral Solution), T1 Digoxin (0.25mg/ml Injection), T1 Digoxin (125mcg Tablet), T1 Digoxin (250mcg Tablet), T1 Dihydroergotamine Mesylate (1mg/ml Injection), T1 Dilantin (Capsule), T1 Dilantin INFATABS (Tablet Chewable), T1 Dilt-XR (Capsule ExtendedRelease 24 Hour), T1 Diltiazem CD (240mg Capsule Extended-Release 24 Hour) (Generic Cardizem CD), T1 Plain type = Generic drug 43 Drug LIST Demser (Capsule), T1 Denavir (Cream), T1 Depen Titratabs (Tablet), T1 Depo-Estradiol (Injection), T1 Depo-Medrol (20mg/ml Injection), T1 Depo-Provera (Injection), T1 Desipramine HCl (Tablet), T1 Desmopressin Acetate (0.01% Nasal Solution), T1 Desmopressin Acetate (0.01% Nasal Solution, 0.1mg Tablet, 0.2mg Tablet), T1 Desmopressin Acetate (4mcg/ml Injection), T1 Desogestrel/Ethinyl Estradiol (Tablet), T1 Desonide (0.05% Ointment), T1 Desoximetasone (0.05% Cream, 0.25% Cream), T1 Dexamethasone (0.5mg Tablet, 0.75mg Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 0.5mg/5ml Elixir), T1 Dexamethasone Intensol (1mg/ml Concentrate), T1 Dexamethasone Sodium Phosphate (0.1% Ophthalmic Solution), T1 Dexamethasone Sodium Phosphate (10mg/ml Injection, 120mg/30ml Injection), T1 Dexedrine (10mg Tablet, 5mg Tablet), T1 Dexilant (Capsule DelayedRelease), T1 Dexmethylphenidate HCl (Tablet Immediate-Release) (Generic Ritalin), T1 0 Diltiazem HCl (100mg Injection, 50mg/10ml Injection), T1 Diltiazem HCl (120mg Tablet, 30mg Tablet, 60mg Tablet, 90mg Tablet), T1 Diltiazem HCl ER (Capsule Extended-Release), T1 Dipentum (Capsule), T1 Diphenhydramine HCl (50mg/ml Injection), T1 Diphenoxylate/Atropine (2.5mg-0.025mg Tablet, 2.5mg-0.025mg/5ml Liquid), T1 Diphtheria/Tetanus Toxoids Adsorbed Pediatric (Injection), T1 Disulfiram (Tablet), T1 Diuril (Suspension), T1 Divalproex Sodium (Capsule Sprinkle), T1 Divalproex Sodium DR (Tablet Delayed-Release), T1 Divalproex Sodium ER (Tablet Extended-Release 24 Hour), T1 Docefrez (Injection), T1 Docetaxel (80mg/4ml Injection), T1 Docetaxel (80mg/8ml Injection), T1 Donepezil HCl (10mg Tablet Dispersible, 5mg Tablet Dispersible), T1 Donepezil HCl (10mg Tablet Immediate-Release, 23mg Tablet Immediate-Release, 5mg Tablet ImmediateRelease), T1 Doribax (Injection), T1 Dorzolamide HCl (Ophthalmic Solution), T1 T1 = Tier 1 Covered Drugs Dorzolamide HCl/Timolol Maleate (Ophthalmic Solution), T1 Doxazosin Mesylate (Tablet), T1 Doxepin HCl (100mg Capsule, 10mg Capsule, 150mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/ml Concentrate), T1 Doxercalciferol (0.5mcg Capsule, 1mcg Capsule, 2.5mcg Capsule), T1 Doxercalciferol (4mcg/2ml Injection), T1 Doxil (Injection), T1 Doxorubicin HCl (Injection), T1 Doxy 100 (Injection), T1 Doxycycline (150mg Capsule, 75mg Capsule), T1 Doxycycline (25mg/5ml Suspension), T1 Doxycycline Hyclate (100mg Capsule Immediate-Release, 50mg Capsule ImmediateRelease), T1 Doxycycline Hyclate (100mg Injection, 100mg Tablet Immediate-Release, 20mg Tablet Immediate-Release), T1 Doxycycline Monohydrate (100mg Capsule, 50mg Capsule, 100mg Tablet, 150mg Tablet, 50mg Tablet, 75mg Tablet), T1 Dronabinol (10mg Capsule), T1 Dronabinol (2.5mg Capsule, 5mg Capsule), T1 Drospirenone/Ethinyl Estradiol (Tablet), T1 Droxia (Capsule), T1 Dulera (Aerosol), T1 Duloxetine HCl (20mg Capsule Delayed-Release, 30mg Capsule DelayedRelease, 60mg Capsule Delayed-Release), T1 Duramorph (Injection), T1 Durezol (Emulsion), T1 Dymista (Suspension), T1 E E.E.S. 400 (Tablet), T1 E.E.S. Granules (Suspension), T1 Econazole Nitrate (Cream), T1 Edarbi (Tablet), T1 Edarbyclor (Tablet), T1 Edecrin (Tablet), T1 Edurant (Tablet), T1 Effient (Tablet), T1 Egrifta (Injection), T1 Elaprase (Injection), T1 Elelyso (Injection), T1 Elestrin (Gel), T1 Elidel (Cream), T1 Eliphos (Tablet), T1 Eliquis (Tablet), T1 Elitek (Injection), T1 Ellence (Injection), T1 Elmiron (Capsule), T1 Eloxatin (Injection), T1 Emcyt (Capsule), T1 Emend (Capsule), T1 Emoquette (Tablet), T1 Emsam (Patch 24 Hour), T1 Emtriva (10mg/ml Oral Solution, 200mg Capsule), T1 Enalapril Maleate (Tablet), T1 Enalapril Maleate/ Hydrochlorothiazide (Tablet), T1 Enbrel (Injection), T1 0 Bold type = Brand name drug Ery-Tab (Tablet DelayedRelease), T1 EryPed 200 (Suspension), T1 EryPed 400 (Suspension), T1 Erythrocin Lactobionate (Injection), T1 Erythromycin (2% External Solution), T1 Erythromycin (2% Gel), T1 Erythromycin (5mg/gm Ophthalmic Ointment), T1 Erythromycin Base (Tablet), T1 Erythromycin Ethylsuccinate (Tablet), T1 Erythromycin/Benzoyl Peroxide (Gel), T1 Esbriet (Capsule), T1 Escitalopram Oxalate (10mg Tablet, 20mg Tablet, 5mg Tablet), T1 Escitalopram Oxalate (5mg/ 5ml Oral Solution), T1 Esomeprazole Magnesium (Capsule Delayed-Release) (Generic Nexium), T1 Esomeprazole Sodium (Injection), T1 Estrace (0.1mg/gm Cream), T1 Estradiol (0.5mg Tablet, 1mg Tablet, 2mg Tablet) (Generic Estrace), T1 Estradiol Valerate (Injection), T1 Estring (Ring), T1 Ethambutol HCl (Tablet), T1 Ethosuximide (250mg Capsule, 250mg/5ml Oral Solution), T1 Etidronate Disodium (Tablet), T1 Etodolac (200mg Capsule, 300mg Capsule, 400mg Tablet Immediate-Release, 500mg Tablet ImmediateRelease), T1 Etodolac ER (Tablet Extended-Release 24 Hour), T1 Etopophos (Injection), T1 Etoposide (Injection), T1 Eurax (10% Cream, 10% Lotion), T1 Evotaz (Tablet), T1 Exelderm (1% Cream, 1% External Solution), T1 Exelon (13.3mg/24hr Patch 24 Hour, 4.6mg/24hr Patch 24 Hour, 9.5mg/ 24hr Patch 24 Hour), T1 Exemestane (Tablet), T1 Exjade (Tablet Soluble), T1 F FML (Ointment), T1 FML Forte (Suspension), T1 Fabrazyme (Injection), T1 Falmina (Tablet), T1 Famciclovir (Tablet), T1 Famotidine (20mg Tablet, 40mg Tablet), T1 Famotidine (20mg/2ml Injection, 40mg/5ml Suspension), T1 Famotidine Premixed (Injection), T1 Fanapt (10mg Tablet, 12mg Tablet, 6mg Tablet, 8mg Tablet), T1 Fanapt (1mg Tablet, 2mg Tablet, 4mg Tablet), T1 Fanapt Titration Pack (Tablet), T1 Fareston (Tablet), T1 Farydak (Capsule), T1 Plain type = Generic drug 45 Drug LIST Enbrel Sureclick (Injection), T1 Endocet (Tablet), T1 Engerix-B (Injection), T1 Enoxaparin Sodium (100mg/ ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection), T1 Enoxaparin Sodium (300mg/ 3ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection), T1 Enpresse-28 (Tablet), T1 Entacapone (Tablet), T1 Entecavir (Tablet), T1 Entocort EC (Capsule Extended-Release 24 Hour), T1 Enulose (Oral Solution), T1 Epaned (Oral Solution), T1 EpiPen (Injection), T1 Epinastine HCl (Ophthalmic Solution), T1 Epirubicin HCl (Injection), T1 Epitol (Tablet), T1 Epivir (10mg/ml Oral Solution), T1 Epivir HBV (5mg/ml Oral Solution), T1 Eplerenone (Tablet), T1 Eprosartan Mesylate (Tablet), T1 Epzicom (Tablet), T1 Equetro (Capsule ExtendedRelease 12 Hour), T1 Eraxis (Injection), T1 Erbitux (Injection), T1 Erivedge (Capsule), T1 Errin (Tablet), T1 Erwinaze (Injection), T1 Ery (2% Pad), T1 0 Faslodex (Injection), T1 Fazaclo (100mg Tablet Dispersible, 150mg Tablet Dispersible, 200mg Tablet Dispersible), T1 Felbamate (400mg Tablet, 600mg Tablet), T1 Felbamate (600mg/5ml Suspension), T1 Felbatol (600mg/5ml Suspension), T1 Felodipine ER (Tablet Extended-Release 24 Hour), T1 Femring (Ring), T1 Fenofibrate (145mg Tablet, 48mg Tablet) (Generic Tricor), (160mg Tablet, 54mg Tablet) (Generic Lofibra), T1 Fenofibrate Micronized (134mg Capsule, 200mg Capsule, 67mg Capsule) (Generic Lofibra), T1 Fenofibric Acid DR (Capsule Delayed-Release) (Generic Trilipix), T1 Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Hour), T1 Ferriprox (Tablet), T1 Fetzima (Capsule ExtendedRelease 24 Hour), T1 Fetzima Titration Pack (Capsule ExtendedRelease 24 Hour Therapy Pack), T1 Finasteride (5mg Tablet) (Generic Proscar), T1 Firazyr (Injection), T1 T1 = Tier 1 Covered Drugs Firmagon (120mg Injection), T1 Firmagon (80mg Injection), T1 Flarex (Suspension), T1 Flebogamma DIF (Injection), T1 Flecainide Acetate (Tablet), T1 Flector (Patch), T1 Flovent Diskus (Aerosol Powder), T1 Flovent HFA (Aerosol), T1 Fluconazole (100mg Tablet, 150mg Tablet, 200mg Tablet, 50mg Tablet, 10mg/ ml Suspension, 40mg/ml Suspension), T1 Fluconazole in Dextrose (Injection), T1 Flucytosine (Capsule), T1 Fludarabine Phosphate (Injection), T1 Fludrocortisone Acetate (Tablet), T1 Flunisolide (Nasal Solution), T1 Fluocinolone Acetonide (0.01% Cream, 0.025% Cream, 0.01% External Solution, 0.025% Ointment), T1 Fluocinolone Acetonide (0.01% Oil), T1 Fluocinolone Acetonide Body (Oil), T1 Fluocinonide (0.05% External Solution, 0.05% Gel, 0.05% Ointment), T1 Fluocinonide (0.1% Cream), T1 Fluocinonide-E (Cream), T1 Fluorometholone (Suspension), T1 Fluorouracil (2% External Solution, 5% External Solution, 5% Cream), T1 Fluorouracil (2.5gm/50ml Injection), T1 Fluoxetine DR (Capsule Delayed-Release), T1 Fluoxetine HCl (10mg Capsule Immediate-Release, 20mg Capsule ImmediateRelease, 40mg Capsule Immediate-Release, 20mg/ 5ml Oral Solution), T1 Fluphenazine Decanoate (Injection), T1 Fluphenazine HCl (10mg Tablet, 1mg Tablet, 2.5mg Tablet, 5mg Tablet), T1 Fluphenazine HCl (2.5mg/ 5ml Elixir, 5mg/ml Concentrate), T1 Fluphenazine HCl (2.5mg/ml Injection), T1 Flurbiprofen (Tablet), T1 Flurbiprofen Sodium (Ophthalmic Solution), T1 Flutamide (Capsule), T1 Fluticasone Propionate (0.005% Ointment, 0.05% Cream), T1 Fluticasone Propionate (50mcg/ACT Suspension), T1 Fluvastatin (Capsule Immediate-Release), T1 Fluvoxamine Maleate (Tablet), T1 Folotyn (Injection), T1 Fomepizole (Injection), T1 Fondaparinux Sodium (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection), T1 0 G Gabapentin (100mg Capsule, 300mg Capsule, 400mg Capsule, 600mg Tablet, 800mg Tablet), T1 Gabapentin (250mg/5ml Oral Solution), T1 Gabitril (12mg Tablet, 16mg Tablet), T1 Gablofen (10000mcg/20ml Injection, 50mcg/ml Injection), T1 Bold type = Brand name drug Gablofen (40000mcg/20ml Injection), T1 Galantamine HBr (12mg Tablet, 4mg Tablet, 8mg Tablet, 16mg Capsule Extended-Release 24 Hour, 24mg Capsule ExtendedRelease 24 Hour, 8mg Capsule Extended-Release 24 Hour, 4mg/ml Oral Solution), T1 Gamastan S/D (Injection), T1 Gammagard Liquid (Injection), T1 Gammaked (Injection), T1 Gammaplex (Injection), T1 Gamunex-C (Injection), T1 Ganciclovir (Injection), T1 Gardasil (Injection), T1 Gardasil 9 (Injection), T1 Gatifloxacin (Ophthalmic Solution), T1 Gattex (Injection), T1 Gauze (Non-medicated 2X2), T1 GaviLyte-C (Oral Solution), T1 GaviLyte-G (Oral Solution), T1 GaviLyte-N/Flavor Pack (Oral Solution), T1 Gemcitabine HCl (Injection), T1 Gemfibrozil (Tablet), T1 Gemzar (Injection), T1 Generlac (Oral Solution), T1 Gengraf (100mg Capsule, 25mg Capsule, 100mg/ml Oral Solution), T1 Genotropin (12mg Injection, 5mg Injection), T1 Genotropin Miniquick (0.2mg Injection), T1 Genotropin Miniquick (0.4mg Injection, 0.6mg Injection, 0.8mg Injection, 1.2mg Injection, 1.4mg Injection, 1.6mg Injection, 1.8mg Injection, 1mg Injection, 2mg Injection), T1 Gentak (Ointment), T1 Gentamicin Sulfate (0.1% Cream, 0.1% Ointment, 0.3% Ophthalmic Ointment, 0.3% Ophthalmic Solution), T1 Gentamicin Sulfate (10mg/ml Injection, 40mg/ml Injection), T1 Gentamicin Sulfate/0.9% Sodium Chloride (Injection), T1 Geodon (20mg Injection), T1 Gianvi (Tablet), T1 Giazo (Tablet), T1 Gildagia (Tablet), T1 Gildess 1.5/30 (Tablet), T1 Gildess 24 Fe (Tablet), T1 Gilenya (Capsule), T1 Gilotrif (Tablet), T1 Glassia (Injection), T1 Glatopa (Injection), T1 Gleevec (Tablet), T1 Glimepiride (Tablet), T1 Glipizide (Tablet ImmediateRelease), T1 Glipizide ER (Tablet Extended-Release 24 Hour), T1 Glipizide/Metformin HCl (Tablet), T1 Glucagen Hypokit (Injection), T1 Glucagon Emergency Kit (Injection), T1 Plain type = Generic drug 47 Drug LIST Fondaparinux Sodium (2.5mg/0.5ml Injection), T1 Fortaz (1gm Injection, 2gm Injection, 2gm Injection, 6gm Injection), T1 Forteo (Injection), T1 Foscarnet Sodium (Injection), T1 Fosinopril Sodium (Tablet), T1 Fosinopril Sodium/ Hydrochlorothiazide (Tablet), T1 Fosphenytoin Sodium (Injection), T1 Fosrenol (1000mg Packet, 750mg Packet, 1000mg Tablet Chewable, 500mg Tablet Chewable, 750mg Tablet Chewable), T1 FreAmine HBC 6.9% (Injection), T1 Furosemide (10mg/ml Injection), T1 Furosemide (10mg/ml Oral Solution, 8mg/ml Oral Solution), T1 Furosemide (20mg Tablet, 40mg Tablet, 80mg Tablet), T1 Fusilev (Injection), T1 Fuzeon (Injection), T1 Fycompa (Tablet), T1 0 Glycopyrrolate (4mg/20ml Injection), T1 Glyset (Tablet), T1 Granisetron HCl (0.1mg/ml Injection, 1mg/ml Injection), T1 Granisetron HCl (1mg Tablet), T1 Granix (Injection), T1 Griseofulvin Microsize (125mg/5ml Suspension, 500mg Tablet), T1 Griseofulvin Ultramicrosize (Tablet), T1 Guanidine HCl (Tablet), T1 H Halaven (Injection), T1 Halobetasol Propionate (0.05% Cream, 0.05% Ointment), T1 Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg Tablet, 20mg Tablet, 2mg Tablet, 5mg Tablet, 2mg/ml Concentrate), T1 Haloperidol Decanoate (Injection), T1 Haloperidol Lactate (Injection), T1 Harvoni (Tablet), T1 Havrix (Injection), T1 Hectorol (1mcg Capsule, 2.5mcg Capsule), T1 Heparin Sodium (Injection), T1 Heparin Sodium/D5W (Injection), T1 HepatAmine (Injection), T1 Hepsera (Tablet), T1 Herceptin (Injection), T1 Hetlioz (Capsule), T1 Hexalen (Capsule), T1 T1 = Tier 1 Covered Drugs Humalog Kwikpen (Injection), T1 Humalog Mix 50/50 Kwikpen (Injection), T1 Humalog Mix 50/50 Vial (Injection), T1 Humalog Mix 75/25 Kwikpen (Injection), T1 Humalog Mix 75/25 Vial (Injection), T1 Humalog Vial (Injection), T1 Humatrope (Injection), T1 Humatrope Combo Pack (Injection), T1 Humira (Injection), T1 Humira Pen-Crohns Diseasestarter (Injection), T1 Humulin 70/30 Kwikpen (Injection), T1 Humulin 70/30 Vial (Injection), T1 Humulin N Kwikpen (Injection), T1 Humulin N Vial (Injection), T1 Humulin R U-500 Vial (Concentrated) (Injection), T1 Humulin R Vial (Injection), T1 Hycamtin (Injection), T1 Hydralazine HCl (100mg Tablet, 10mg Tablet, 25mg Tablet, 50mg Tablet), T1 Hydralazine HCl (20mg/ml Injection), T1 Hydrochlorothiazide (12.5mg Capsule, 12.5mg Tablet, 25mg Tablet, 50mg Tablet), T1 Hydrocodone Bitartrate/ Acetaminophen (7.5mg-325mg/15ml Oral Solution), T1 Hydrocodone/ Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Tablet), T1 Hydrocodone/Ibuprofen (7.5mg-200mg Tablet), T1 Hydrocortisone (1% Cream, 2.5% Cream, 1% Ointment, 2.5% Ointment, 10mg Tablet, 20mg Tablet, 5mg Tablet, 2.5% Lotion), T1 Hydrocortisone (100mg/ 60ml Enema), T1 Hydrocortisone Butyrate (0.1% Ointment), T1 Hydrocortisone Valerate (0.2% Cream, 0.2% Ointment), T1 Hydrocortisone/Acetic Acid (Otic Solution), T1 Hydromorphone HCl (1mg/ml Liquid), T1 Hydromorphone HCl (2mg Tablet Immediate-Release, 4mg Tablet ImmediateRelease, 8mg Tablet Immediate-Release), T1 Hydromorphone HCl (500mg/50ml Injection), T1 Hydromorphone HCl ER (12mg Tablet ExtendedRelease 24 Hour AbuseDeterrent, 16mg Tablet Extended-Release 24 Hour Abuse-Deterrent), T1 0 Hydromorphone HCl ER (32mg Tablet ExtendedRelease 24 Hour AbuseDeterrent), T1 Hydromorphone HCl ER (8mg Tablet ExtendedRelease 24 Hour AbuseDeterrent), T1 Hydroxychloroquine Sulfate (Tablet), T1 Hydroxyurea (Capsule), T1 Hydroxyzine HCl (10mg/5ml Oral Solution, 25mg/ml Injection, 50mg/ml Injection), T1 Hydroxyzine Pamoate (Capsule), T1 Bold type = Brand name drug Irbesartan/ Hydrochlorothiazide (Tablet), T1 Irinotecan (Injection), T1 Isentress (100mg Packet, 100mg Tablet Chewable, 400mg Tablet), T1 Isentress (25mg Tablet Chewable), T1 Isolyte-P/Dextrose 5% (Injection), T1 Isolyte-S (Injection), T1 Isoniazid (100mg Tablet, 300mg Tablet, 50mg/5ml Syrup), T1 Isoniazid (100mg/ml Injection), T1 Isosorbide Dinitrate (Tablet Immediate-Release), T1 Isosorbide Dinitrate ER (Tablet Extended-Release), T1 Isosorbide Mononitrate (Tablet Immediate-Release), T1 Isosorbide Mononitrate ER (Tablet Extended-Release 24 Hour), T1 Isotonic Gentamicin (Injection), T1 Istodax (Injection), T1 Itraconazole (Capsule), T1 Ivermectin (Tablet), T1 Ixempra Kit (Injection), T1 Ixiaro (Injection), T1 J Jadenu (Tablet), T1 Jakafi (Tablet), T1 Jantoven (Tablet), T1 Janumet (Tablet), T1 Janumet XR (Tablet Extended-Release 24 Hour), T1 Plain type = Generic drug 49 Drug LIST I IPOL Inactivated IPV (Injection), T1 Ibandronate Sodium (150mg Tablet), T1 Ibandronate Sodium (3mg/ 3ml Injection), T1 Ibrance (Capsule), T1 Ibuprofen (100mg/5ml Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet), T1 Iclusig (15mg Tablet), T1 Iclusig (45mg Tablet), T1 Idamycin PFS (Injection), T1 Idarubicin HCl (Injection), T1 Ifosfamide (Injection), T1 Ilaris (Injection), T1 Ilevro (Suspension), T1 Ilotycin (Ointment), T1 Imbruvica (Capsule), T1 Imipenem/Cilastatin (Injection), T1 Imipramine HCl (Tablet), T1 Imipramine Pamoate (Capsule), T1 Imiquimod (Cream), T1 Imovax Rabies (H.D.C.V.) (Injection), T1 Increlex (Injection), T1 Indapamide (Tablet), T1 Infanrix (Injection), T1 Inlyta (Tablet), T1 Insulin Syringes, Needles, T1 Intelence (100mg Tablet, 200mg Tablet), T1 Intelence (25mg Tablet), T1 Intralipid (Injection), T1 Intron A (Injection), T1 Intron A w/Diluent (Injection), T1 Introvale (Tablet), T1 Invanz (Injection), T1 Invega (Tablet ExtendedRelease 24 Hour), T1 Invega Sustenna (117mg/ 0.75ml Injection, 156mg/ ml Injection, 234mg/1.5ml Injection, 78mg/0.5ml Injection), T1 Invega Sustenna (39mg/ 0.25ml Injection), T1 Invirase (200mg Capsule, 500mg Tablet), T1 Invokamet (Tablet), T1 Invokana (Tablet), T1 Ionosol-B/Dextrose 5% (Injection), T1 Ionosol-MB/Dextrose 5% (Injection), T1 Ipratropium Bromide (0.02% Inhalation Solution), T1 Ipratropium Bromide (0.03% Nasal Solution, 0.06% Nasal Solution), T1 Ipratropium Bromide/ Albuterol Sulfate (Inhalation Solution), T1 Irbesartan (Tablet), T1 0 Januvia (Tablet), T1 Jardiance (Tablet), T1 Jentadueto (Tablet), T1 Jevtana (Injection), T1 Jinteli (Tablet), T1 Jolivette (Tablet), T1 Junel 1.5/30 (Tablet), T1 Junel 1/20 (Tablet), T1 Junel Fe 1.5/30 (Tablet), T1 Junel Fe 1/20 (Tablet), T1 Junel Fe 24 (Tablet), T1 Juxtapid (Capsule), T1 K K-Tab (10meq Tablet Extended-Release, 8meq Tablet Extended-Release), T1 KCl 0.075%/D5W/NaCl 0.45% (Injection), T1 KCl 0.15%/D5W/LR (Injection), T1 KCl 0.15%/D5W/NaCl 0.2% (Injection), T1 KCl 0.15%/D5W/NaCl 0.225% (Injection), T1 KCl 0.15%/D5W/NaCl 0.9% (Injection), T1 KCl 0.3%/D5W/NaCl 0.45% (Injection), T1 KCl 0.3%/D5W/NaCl 0.9% (Injection), T1 Kadcyla (Injection), T1 Kaletra (100mg-25mg Tablet), T1 Kaletra (200mg-50mg Tablet, 400mg-100mg/5ml Oral Solution), T1 Kalydeco (150mg Tablet), T1 Kalydeco (50mg Packet, 75mg Packet), T1 Kariva (Tablet), T1 Kazano (Tablet), T1 T1 = Tier 1 Covered Drugs Kelnor 1/35 (Tablet), T1 Kenalog-10 (Injection), T1 Kenalog-40 (Injection), T1 Kepivance (Injection), T1 Ketoconazole (2% Cream, 2% Shampoo, 200mg Tablet), T1 Ketoprofen (Capsule Immediate-Release), T1 Ketorolac Tromethamine (0.4% Ophthalmic Solution, 0.5% Ophthalmic Solution), T1 Ketorolac Tromethamine (15mg/ml Injection, 30mg/ ml Injection), T1 Keytruda (Injection), T1 Kineret (Injection), T1 Kionex (Powder), T1 Klor-Con 10 (Tablet Extended-Release), T1 Klor-Con 8 (Tablet Extended-Release), T1 Klor-Con M15 (Tablet Extended-Release), T1 Klor-Con M20 (Tablet Extended-Release), T1 Kombiglyze XR (Tablet Extended-Release 24 Hour), T1 Korlym (Tablet), T1 Kuvan (100mg Tablet Soluble, 500mg Packet), T1 Kynamro (Injection), T1 L LARIN 1.5/30 (Tablet), T1 LARIN 1/20 (Tablet), T1 LARIN Fe 1.5/30 (Tablet), T1 LARIN Fe 1/20 (Tablet), T1 Labetalol HCl (100mg Tablet, 200mg Tablet, 300mg Tablet), T1 Labetalol HCl (5mg/ml Injection), T1 Lacrisert (Insert), T1 Lactated Ringers Dextrose 5% Viaflex (Injection), T1 Lactated Ringers Irrigation (Irrigation Solution), T1 Lactated Ringers Viaflex (Injection), T1 Lactulose (Oral Solution), T1 Lamisil (125mg Packet, 187.5mg Packet), T1 Lamivudine (100mg Tablet), T1 Lamivudine (10mg/ml Oral Solution, 150mg Tablet, 300mg Tablet), T1 Lamivudine/Zidovudine (Tablet), T1 Lamotrigine (100mg Tablet Immediate-Release, 150mg Tablet Immediate-Release, 200mg Tablet ImmediateRelease, 25mg Tablet Immediate-Release), T1 Lamotrigine (25mg Tablet Chewable, 5mg Tablet Chewable), T1 Lanoxin (125mcg Tablet, 62.5mcg Tablet), T1 Lanoxin (187.5mcg Tablet, 250mcg Tablet), T1 Lantus SoloStar (Injection), T1 Lantus Vial (Injection), T1 Lastacaft (Ophthalmic Solution), T1 Latanoprost (Ophthalmic Solution), T1 Latuda (Tablet), T1 Leena (Tablet), T1 Leflunomide (Tablet), T1 Lenvima (Capsule Therapy Pack), T1 0 Bold type = Brand name drug Levofloxacin (0.5% Ophthalmic Solution, 25mg/ ml Oral Solution), T1 Levofloxacin (250mg Tablet, 500mg Tablet, 750mg Tablet), T1 Levofloxacin (25mg/ml Injection), T1 Levofloxacin in D5W (Injection), T1 Levoleucovorin Calcium (Injection), T1 Levonest (Tablet), T1 Levonorgestrel and Ethinyl Estradiol (Tablet), T1 Levonorgestrel/Ethinyl Estradiol (Tablet), T1 Levora 0.15/30-28 (Tablet), T1 Levorphanol Tartrate (Tablet), T1 Levothyroxine Sodium (100mcg Injection), T1 Levothyroxine Sodium (100mcg Tablet, 112mcg Tablet, 125mcg Tablet, 137mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet), T1 Levoxyl (Tablet), T1 Lexiva (50mg/ml Suspension), T1 Lexiva (700mg Tablet), T1 Lialda (Tablet DelayedRelease), T1 Lidocaine (5% Ointment), T1 Lidocaine (5% Patch), T1 Lidocaine HCl (0.5% Injection, 2% Injection), T1 Lidocaine HCl (4% External Solution), T1 Lidocaine HCl (Gel), T1 Lidocaine Viscous (Solution), T1 Lidocaine/Prilocaine (2.5%-2.5% Cream), T1 Lincocin (Injection), T1 Lindane (1% Lotion, 1% Shampoo), T1 Linezolid (2mg/ml Injection), T1 Linezolid (600mg Tablet), T1 Linzess (Capsule), T1 Lioresal Intrathecal (0.05mg/ml Injection, 10mg/20ml Injection), T1 Lioresal Intrathecal (10mg/ 5ml Injection), T1 Liothyronine Sodium (10mcg/ ml Injection), T1 Liothyronine Sodium (25mcg Tablet, 50mcg Tablet, 5mcg Tablet), T1 Lisinopril (Tablet), T1 Lisinopril/Hydrochlorothiazide (Tablet), T1 Lithium (Oral Solution), T1 Lithium Carbonate (150mg Capsule Immediate-Release, 300mg Capsule ImmediateRelease, 600mg Capsule Immediate-Release, 300mg Tablet Immediate-Release), T1 Lithium Carbonate ER (Tablet Extended-Release), T1 Lithostat (Tablet), T1 Lomustine (Capsule), T1 Loperamide HCl (Capsule), T1 Lorazepam (Tablet Immediate-Release), T1 Lorazepam Intensol (2mg/ml Concentrate), T1 Plain type = Generic drug 51 Drug LIST Lessina (Tablet), T1 Letairis (Tablet), T1 Letrozole (Tablet), T1 Leucovorin Calcium (100mg Injection, 350mg Injection), T1 Leucovorin Calcium (10mg Tablet, 15mg Tablet, 25mg Tablet, 5mg Tablet), T1 Leukeran (Tablet), T1 Leukine (Injection), T1 Leuprolide Acetate (Injection), T1 Levalbuterol (Nebulized Solution), T1 Levemir FlexTouch (Injection), T1 Levemir Vial (Injection), T1 Levetiracetam (1000mg Tablet Immediate-Release, 250mg Tablet ImmediateRelease, 500mg Tablet Immediate-Release, 750mg Tablet Immediate-Release, 100mg/ml Oral Solution), T1 Levetiracetam (1000mg/ 100ml Injection, 1500mg/ 100ml Injection, 500mg/ 100ml Injection), T1 Levetiracetam (500mg/5ml Injection), T1 Levetiracetam ER (Tablet Extended-Release 24 Hour), T1 Levobunolol HCl (Ophthalmic Solution), T1 Levocarnitine (1gm/10ml Oral Solution, 330mg Tablet), T1 Levocarnitine (200mg/ml Injection), T1 Levocetirizine Dihydrochloride (5mg Tablet), T1 0 Lorcet (Tablet), T1 Lorcet HD (Tablet), T1 Lorcet Plus (Tablet), T1 Lortab (10mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Tablet), T1 Loryna (Tablet), T1 Losartan Potassium (Tablet), T1 Losartan Potassium/ Hydrochlorothiazide (Tablet), T1 Lotemax (0.5% Gel, 0.5% Ointment, 0.5% Suspension), T1 Lotronex (Tablet), T1 Lovastatin (Tablet ImmediateRelease), T1 Loxapine Succinate (10mg Capsule, 5mg Capsule), T1 Loxapine Succinate (25mg Capsule, 50mg Capsule), T1 Lumigan (0.01% Ophthalmic Solution), T1 Lumizyme (Injection), T1 Lupaneta Pack (Kit), T1 Lupron Depot (Injection), T1 Lupron Depot-PED (Injection), T1 Lutera (Tablet), T1 Lynparza (Capsule), T1 Lyrica (100mg Capsule, 150mg Capsule, 200mg Capsule, 225mg Capsule, 25mg Capsule, 300mg Capsule, 50mg Capsule, 75mg Capsule, 20mg/ml Oral Solution), T1 Lysodren (Tablet), T1 Lyza (Tablet), T1 T1 = Tier 1 Covered Drugs M M-M-R II w/Diluent 10 Dose (Injection), T1 Magnesium Sulfate (1gm/ 2ml-50% Injection), T1 Magnesium Sulfate (5gm/ 10ml-50% Injection), T1 Malathion (Lotion), T1 Maprotiline HCl (Tablet), T1 Marlissa (Tablet), T1 Marplan (Tablet), T1 Matulane (Capsule), T1 Matzim LA (180mg Tablet Extended-Release 24 Hour, 240mg Tablet ExtendedRelease 24 Hour, 300mg Tablet Extended-Release 24 Hour), T1 Matzim LA (360mg Tablet Extended-Release 24 Hour, 420mg Tablet ExtendedRelease 24 Hour), T1 Meclizine HCl (12.5mg Tablet), T1 Medroxyprogesterone Acetate (10mg Tablet, 2.5mg Tablet, 5mg Tablet), T1 Medroxyprogesterone Acetate (150mg/ml Injection), T1 Mefloquine HCl (Tablet), T1 Megace ES (Suspension), T1 Megestrol Acetate (20mg Tablet, 40mg Tablet, 40mg/ ml Suspension), T1 Mekinist (Tablet), T1 Meloxicam (15mg Tablet, 7.5mg Tablet), T1 Meloxicam (7.5mg/5ml Suspension), T1 Melphalan HCl (Injection), T1 Menactra (Injection), T1 Menest (Tablet), T1 Menomune-A/C/Y/W-135 (Injection), T1 Mentax (Cream), T1 Menveo (Injection), T1 Mepron (Suspension), T1 Mercaptopurine (Tablet), T1 Meropenem (Injection), T1 Mesalamine (Kit), T1 Mesna (Injection), T1 Mesnex (400mg Tablet), T1 Mestinon (60mg/5ml Syrup), T1 Mestinon Timespan (Tablet Extended-Release), T1 Metadate ER (Tablet Extended-Release), T1 Metaproterenol Sulfate (10mg Tablet, 20mg Tablet, 10mg/ 5ml Syrup), T1 Metformin HCl (Tablet Immediate-Release), T1 Metformin HCl ER (1000mg Tablet Extended-Release 24 Hour) (Generic Fortamet), (500mg Tablet ExtendedRelease 24 Hour, 700mg Tablet Extended-Release 24 Hour) (Generic Glucophage XR), T1 Methadone HCl (10mg Tablet, 5mg Tablet, 10mg/ 5ml Oral Solution, 5mg/5ml Oral Solution), T1 Methadone HCl (10mg/ml Injection), T1 Methazolamide (Tablet), T1 Methenamine Hippurate (Tablet), T1 Methimazole (Tablet), T1 Methotrexate (Tablet), T1 Methotrexate Sodium (Injection), T1 Methoxsalen (Capsule), T1 0 Bold type = Brand name drug Metoprolol Tartrate (100mg Tablet Immediate-Release, 25mg Tablet ImmediateRelease, 50mg Tablet Immediate-Release), T1 Metoprolol Tartrate (1mg/ml Injection), T1 Metoprolol/ Hydrochlorothiazide (Tablet), T1 Metronidazole (0.75% Cream, 0.75% Gel, 1% Gel, 0.75% Lotion), T1 Metronidazole (250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 375mg Capsule ImmediateRelease), T1 Metronidazole Vaginal (Gel), T1 Metronidazole in NaCl 0.79% (Injection), T1 Mexiletine HCl (Capsule), T1 Miacalcin (200unit/ml Injection), T1 Miconazole 3 (Suppository), T1 Microgestin 1.5/30 (Tablet), T1 Microgestin 1/20 (Tablet), T1 Microgestin Fe (Tablet), T1 Microgestin Fe 1.5/30 (Tablet), T1 Midodrine HCl (Tablet), T1 Migergot (Suppository), T1 Millipred (5mg Tablet), T1 Minitran (Patch 24 Hour), T1 Minocycline HCl (100mg Capsule Immediate-Release, 50mg Capsule ImmediateRelease, 75mg Capsule Immediate-Release), T1 Minocycline HCl (100mg Tablet Immediate-Release, 50mg Tablet ImmediateRelease, 75mg Tablet Immediate-Release), T1 Minoxidil (Tablet), T1 Mirtazapine (Tablet Immediate-Release), T1 Mirtazapine ODT (Tablet Dispersible), T1 Mirvaso (Gel), T1 Misoprostol (Tablet), T1 Mitomycin (Injection), T1 Mitoxantrone HCl (Injection), T1 Modafinil (Tablet), T1 Moexipril HCl (Tablet), T1 Moexipril/Hydrochlorothiazide (Tablet), T1 Mometasone Furoate (0.1% Cream, 0.1% External Solution, 0.1% Ointment), T1 Mononessa (Tablet), T1 Montelukast Sodium (10mg Tablet), T1 Montelukast Sodium (4mg Packet, 4mg Tablet Chewable, 5mg Tablet Chewable), T1 Morphine Sulfate (10mg/5ml Oral Solution, 20mg/5ml Oral Solution, 20mg/ml Oral Solution), T1 Morphine Sulfate (10mg/ml Injection, 2mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection), T1 Morphine Sulfate (15mg Tablet Immediate-Release, 30mg Tablet ImmediateRelease), T1 Plain type = Generic drug 53 Drug LIST Methscopolamine Bromide (Tablet), T1 Methyclothiazide (Tablet), T1 Methyldopa (Tablet), T1 Methyldopate HCl (Injection), T1 Methylergonovine Maleate (Tablet), T1 Methylphenidate HCl (10mg Tablet Immediate-Release, 20mg Tablet ImmediateRelease, 5mg Tablet Immediate-Release (Generic Ritalin), (10mg/5ml Oral Solution, 5mg/5ml Oral Solution), T1 Methylphenidate HCl ER (10mg Tablet ExtendedRelease, 20mg Tablet Extended-Release), T1 Methylprednisolone (Tablet), T1 Methylprednisolone Acetate (Injection), T1 Methylprednisolone Dose Pack (Tablet), T1 Methylprednisolone Sodium Succinate (Injection), T1 Metipranolol (Ophthalmic Solution), T1 Metoclopramide HCl (10mg Tablet, 5mg Tablet), T1 Metoclopramide HCl (5mg/ 5ml Oral Solution), T1 Metoclopramide HCl (5mg/ml Injection), T1 Metolazone (Tablet), T1 Metoprolol Succinate ER (Tablet Extended-Release 24 Hour), T1 0 Morphine Sulfate ER (Tablet Extended-Release) (Generic MS Contin), T1 Moxeza (Ophthalmic Solution), T1 Moxifloxacin HCl (Tablet), T1 Mozobil (Injection), T1 Multaq (Tablet), T1 Mupirocin (2% Cream), T1 Mupirocin (2% Ointment), T1 Mustargen (Injection), T1 Myalept (Injection), T1 Mycamine (Injection), T1 Mycophenolate Mofetil (200mg/ml Suspension), T1 Mycophenolate Mofetil (250mg Capsule, 500mg Tablet), T1 Mycophenolic Acid DR (Tablet Delayed-Release), T1 Myozyme (Injection), T1 Myrbetriq (Tablet ExtendedRelease 24 Hour), T1 N Nabumetone (Tablet), T1 Nadolol (Tablet), T1 Nadolol/Bendroflumethiazide (40mg-5mg Tablet), T1 Nadolol/Bendroflumethiazide (80mg-5mg Tablet), T1 Nafcillin Sodium (Injection), T1 Naftifine HCl (Cream), T1 Naftin (1% Cream, 2% Cream, 1% Gel, 2% Gel), T1 Naglazyme (Injection), T1 Nalbuphine HCl (Injection), T1 Nallpen/Dextrose (Injection), T1 Naloxone HCl (Injection), T1 Naltrexone HCl (Tablet), T1 T1 = Tier 1 Covered Drugs Namenda (10mg Tablet Immediate-Release, 5mg Tablet ImmediateRelease), T1 Namenda (10mg/5ml Oral Solution), T1 Namenda Titration Pak (Tablet), T1 Namenda XR (Capsule Extended-Release 24 Hour), T1 Namenda XR Titration Pack (Capsule ExtendedRelease 24 Hour), T1 Naphazoline HCl (Ophthalmic Solution), T1 Naproxen (125mg/5ml Suspension, 250mg Tablet Immediate-Release, 375mg Tablet Immediate-Release, 500mg Tablet ImmediateRelease), T1 Naproxen DR (Tablet Delayed-Release) (Generic EC-Naprosyn), T1 Naproxen Sodium (Tablet Immediate-Release), T1 Naratriptan HCl (Tablet), T1 Nasonex (Suspension), T1 Natacyn (Suspension), T1 Nateglinide (Tablet), T1 Natpara (Injection), T1 Nebupent (Inhalation Solution), T1 Necon 0.5/35-28 (Tablet), T1 Necon 1/35 (Tablet), T1 Necon 1/50-28 (Tablet), T1 Necon 10/11-28 (Tablet), T1 Necon 7/7/7 (Tablet), T1 Nefazodone HCl (Tablet), T1 Neomycin Sulfate (Tablet), T1 Neomycin/Bacitracin/ Polymyxin (Ointment), T1 Neomycin/Polymyxin B Sulfates (Irrigation Solution), T1 Neomycin/Polymyxin/ Bacitracin/Hydrocortisone (Ointment), T1 Neomycin/Polymyxin/ Dexamethasone (0.1% Ointment, 0.1% Suspension), T1 Neomycin/Polymyxin/ Gramicidin (Ophthalmic Solution), T1 Neomycin/Polymyxin/ Hydrocortisone (1% Ophthalmic Suspension), T1 Neomycin/Polymyxin/ Hydrocortisone (1% Otic Solution, 1% Otic Suspension), T1 Nephramine (Injection), T1 Nesina (Tablet), T1 Neulasta (Injection), T1 Neumega (Injection), T1 Neupogen (Injection), T1 Nevanac (Suspension), T1 Nevirapine (200mg Tablet Immediate-Release), T1 Nevirapine (50mg/5ml Suspension), T1 Nevirapine ER (Tablet Extended-Release 24 Hour), T1 Nexavar (Tablet), T1 Nexium (10mg Packet, 2.5mg Packet, 20mg Packet, 40mg Packet, 5mg Packet), T1 Niacin ER (Tablet ExtendedRelease), T1 Niacor (Tablet), T1 Nicardipine HCl (2.5mg/ml Injection), T1 0 Bold type = Brand name drug Norethindrone Acetate/ Ethinyl Estradiol/Ferrous Fumarate (Tablet), T1 Norlyroc (Tablet), T1 Normosol-M in D5W (Injection), T1 Normosol-R (Injection), T1 Normosol-R in D5W (Injection), T1 Northera (Capsule), T1 Nortrel 0.5/35 (28) (Tablet), T1 Nortrel 1/35 (Tablet), T1 Nortrel 7/7/7 (Tablet), T1 Nortriptyline HCl (10mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/5ml Oral Solution), T1 Norvir (100mg Capsule, 100mg Tablet, 80mg/ml Oral Solution), T1 Novarel (Injection), T1 Noxafil (100mg Tablet Delayed-Release), T1 Noxafil (40mg/ml Suspension), T1 Nucynta ER (Tablet Extended-Release 12 Hour), T1 Nuedexta (Capsule), T1 Nulojix (Injection), T1 NutreStore (Packet), T1 Nutrilipid (Injection), T1 Nutropin AQ (Injection), T1 NuvaRing (Ring), T1 Nyamyc (Powder), T1 Nystatin (Cream, Ointment, Powder, Suspension, Tablet), T1 Nystop (Powder), T1 O ONMEL (Tablet), T1 Ocella (Tablet), T1 Octagam (Injection), T1 Octreotide Acetate (1000mcg/ml Injection, 500mcg/ml Injection), T1 Octreotide Acetate (100mcg/ ml Injection, 200mcg/ml Injection, 50mcg/ml Injection), T1 Ofev (Capsule), T1 Ofloxacin (0.3% Ophthalmic Solution, 0.3% Otic Solution, 400mg Tablet), T1 Ogestrel (Tablet), T1 Olanzapine (10mg Injection), T1 Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 2.5mg Tablet ImmediateRelease, 20mg Tablet Immediate-Release, 5mg Tablet Immediate-Release, 7.5mg Tablet ImmediateRelease), T1 Olanzapine ODT (Tablet Dispersible), T1 Olysio (Capsule), T1 Omega-3-Acid Ethyl Esters (Capsule) (Generic Lovaza), T1 Omeprazole (10mg Capsule Delayed-Release, 40mg Capsule Delayed-Release), T1 Omeprazole (20mg Capsule Delayed-Release), T1 Omnitrope (Injection), T1 Oncaspar (Injection), T1 Ondansetron HCl (24mg Tablet, 4mg Tablet, 8mg Tablet), T1 Plain type = Generic drug 55 Drug LIST Nicardipine HCl (20mg Capsule, 30mg Capsule), T1 Nicotrol Inhaler, T1 Nifedical XL (Tablet ExtendedRelease 24 Hour), T1 Nifedipine ER (Tablet Extended-Release 24 Hour), T1 Nikki (Tablet), T1 Nilandron (Tablet), T1 Nimodipine (Capsule), T1 Nipent (Injection), T1 Nitro-Bid (Ointment), T1 Nitrofurantoin (Suspension), T1 Nitrofurantoin Macrocrystals (Capsule) (Generic Macrodantin), T1 Nitrofurantoin Monohydrate 100mg Capsule (Generic Macrobid), T1 Nitroglycerin (0.2mg/hr Patch 24 Hour, 0.4mg/hr Patch 24 Hour, 0.6mg/hr Patch 24 Hour), T1 Nitroglycerin (5mg/ml Injection), T1 Nitroglycerin Lingual (Translingual Solution), T1 Nitroglycerin Transdermal (Patch 24 Hour), T1 Nitrostat (Tablet Sublingual), T1 Nora-BE (Tablet), T1 Norditropin FlexPro (Injection), T1 Norditropin NordiFlex Pen (Injection), T1 Norethindrone & Ethinyl Estradiol Ferrous Fumarate (Tablet Chewable), T1 Norethindrone (Tablet), T1 Norethindrone Acetate (Tablet), T1 0 Ondansetron HCl (4mg/2ml Injection), T1 Ondansetron HCl (4mg/5ml Oral Solution), T1 Ondansetron ODT (Tablet Dispersible), T1 Onfi (10mg Tablet), T1 Onfi (2.5mg/ml Suspension), T1 Onfi (20mg Tablet), T1 Onglyza (Tablet), T1 Opana ER (Crush Resistant) (Tablet Extended-Release 12 Hour Abuse-Deterrent), T1 Opdivo (Injection), T1 Opsumit (Tablet), T1 Orap (Tablet), T1 Orencia (125mg/ml Injection, 250mg Injection), T1 Orenitram (0.125mg Tablet Extended-Release), T1 Orenitram (0.25mg Tablet Extended-Release, 1mg Tablet Extended-Release), T1 Orenitram (2.5mg Tablet Extended-Release), T1 Orfadin (Capsule), T1 Orphenadrine Citrate (Injection), T1 Orsythia (Tablet), T1 Oseni (Tablet), T1 Otezla (Tablet Therapy Pack, 30mg Tablet), T1 Oxacillin Sodium (10gm Injection), T1 Oxacillin Sodium (2gm Injection), T1 Oxaliplatin (Injection), T1 Oxandrolone (10mg Tablet), T1 T1 = Tier 1 Covered Drugs Oxandrolone (2.5mg Tablet), T1 Oxaprozin (Tablet), T1 Oxcarbazepine (150mg Tablet, 300mg Tablet, 600mg Tablet), T1 Oxcarbazepine (300mg/5ml Suspension), T1 Oxistat (1% Cream, 1% Lotion), T1 Oxsoralen Ultra (Capsule), T1 Oxybutynin Chloride (5mg Tablet Immediate-Release, 5mg/5ml Syrup), T1 Oxybutynin Chloride ER (Tablet Extended-Release 24 Hour), T1 Oxycodone HCl (100mg/5ml Concentrate, 5mg/5ml Oral Solution), T1 Oxycodone HCl (10mg Tablet Immediate-Release, 15mg Tablet Immediate-Release, 20mg Tablet ImmediateRelease, 30mg Tablet Immediate-Release, 5mg Tablet Immediate-Release), T1 Oxycodone/Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 5mg-325mg Tablet, 7.5mg-325mg Tablet), T1 Oxycodone/Aspirin (Tablet), T1 Oxycodone/Ibuprofen (Tablet), T1 P PEG-3350/Electrolytes (Oral Solution) (Generic GoLYTELY), T1 PRUDOXIN (Cream), T1 Pacerone (200mg Tablet), T1 Paclitaxel (Injection), T1 Pamidronate Disodium (Injection), T1 Panretin (Gel), T1 Pantoprazole Sodium (Tablet Delayed-Release), T1 Paricalcitol (1mcg Capsule, 2mcg Capsule), T1 Paricalcitol (2mcg/ml Injection, 5mcg/ml Injection), T1 Paricalcitol (4mcg Capsule), T1 Paromomycin Sulfate (Capsule), T1 Paroxetine HCl (Tablet Immediate-Release), T1 Paser (Packet), T1 Pataday (Ophthalmic Solution), T1 Patanol (Ophthalmic Solution), T1 Paxil (10mg/5ml Suspension), T1 Pedvax HIB (Injection), T1 PegIntron (Injection), T1 PegIntron Redipen (Injection), T1 Peganone (Tablet), T1 Pegasys (Injection), T1 Pegasys ProClick (Injection), T1 Penicillin G Potassium (Injection), T1 Penicillin G Procaine (Injection), T1 Penicillin G Sodium (Injection), T1 Penicillin V Potassium (125mg/5ml Oral Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Tablet), T1 Pentam 300 (Injection), T1 0 Bold type = Brand name drug Pilocarpine HCl (1% Ophthalmic Solution, 2% Ophthalmic Solution, 4% Ophthalmic Solution), T1 Pilocarpine HCl (5mg Tablet, 7.5mg Tablet), T1 Pimtrea (Tablet), T1 Pindolol (Tablet), T1 Pioglitazone HCl (Tablet), T1 Pioglitazone HCl/Glimepiride (Tablet), T1 Pioglitazone HCl/Metformin HCl (Tablet), T1 Piperacillin Sodium/ Tazobactam Sodium (Injection), T1 Pirmella 1/35 (Tablet), T1 Piroxicam (Capsule), T1 Plasma-Lyte A (Injection), T1 Plasma-Lyte-148 (Injection), T1 Plasma-Lyte-56/D5W (Injection), T1 Podofilox (External Solution), T1 Polyethylene Glycol 3350 Powder (Generic Miralax), T1 Polymyxin B Sulfate (Injection), T1 Polymyxin B Sulfate/ Trimethoprim Sulfate (Ophthalmic Solution), T1 Pomalyst (Capsule), T1 Portia-28 (Tablet), T1 Potassium Chloride (10meq/100ml Injection, 20meq/100ml Injection, 40meq/100ml Injection), T1 Potassium Chloride (2meq/ml Injection), T1 Potassium Chloride 0.15% / NaCl 0.45% Viaflex (Injection), T1 Potassium Chloride 0.15% D5W/NaCl 0.33% (Injection), T1 Potassium Chloride 0.15% D5W/NaCl 0.45% (Injection), T1 Potassium Chloride 0.15%/ NaCl 0.9% (Injection), T1 Potassium Chloride 0.22% D5W/NaCl 0.45% (Injection), T1 Potassium Chloride 0.3%/ NaCl 0.9% (Injection), T1 Potassium Chloride 0.3%/ D5W (Injection), T1 Potassium Chloride ER (10meq Capsule ExtendedRelease, 8meq Capsule Extended-Release, 8meq Tablet Extended-Release), T1 Potassium Chloride ER Microencapsulated (10meq Tablet Extended-Release, 20meq Tablet ExtendedRelease), T1 Potassium Citrate ER (Tablet Extended-Release), T1 Potiga (Tablet), T1 Pradaxa (Capsule), T1 Pramipexole Dihydrochloride (Tablet Immediate-Release), T1 PrandiMet (Tablet), T1 Pravastatin Sodium (Tablet), T1 Prazosin HCl (Capsule), T1 Pred Mild (Suspension), T1 Pred-G (Suspension), T1 Pred-G S.O.P. (Ointment), T1 Plain type = Generic drug 57 Drug LIST Pentasa (Capsule ExtendedRelease), T1 Pentoxifylline ER (Tablet Extended-Release), T1 Perforomist (Nebulized Solution), T1 Perindopril Erbumine (Tablet), T1 Periogard (Solution), T1 Perjeta (Injection), T1 Permethrin (Cream), T1 Perphenazine (Tablet), T1 Phenadoz (12.5mg Suppository), T1 Phenelzine Sulfate (Tablet), T1 Phenergan (12.5mg Suppository), T1 Phenobarbital (100mg Tablet, 15mg Tablet, 16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir), T1 Phenytek (Capsule), T1 Phenytoin (125mg/5ml Suspension, 50mg Tablet Chewable), T1 Phenytoin Sodium (Injection), T1 Phenytoin Sodium Extended (Capsule), T1 PhosLo (Capsule), T1 Phoslyra (Oral Solution), T1 Phospholine Iodide (Ophthalmic Solution), T1 Physiolyte (Irrigation Solution), T1 Physiosol Irrigation (Irrigation Solution), T1 Picato (Gel), T1 0 Prednicarbate (0.1% Cream), T1 Prednicarbate (0.1% Ointment), T1 Prednisolone Acetate (Suspension), T1 Prednisolone Sodium Phosphate (1% Ophthalmic Solution), T1 Prednisolone Sodium Phosphate (15mg/5ml Oral Solution, 25mg/5ml Oral Solution, 5mg/5ml Oral Solution), T1 Prednisone (10mg Tablet, 1mg Tablet, 2.5mg Tablet, 20mg Tablet, 50mg Tablet, 5mg Tablet), T1 Prednisone (5mg/5ml Oral Solution), T1 Prednisone Intensol (5mg/ml Concentrate), T1 Pregnyl w/Diluent Benzyl Alcohol/NaCl (Injection), T1 Premarin (Vaginal Cream), T1 Premasol (Injection), T1 Prevalite (Powder), T1 Previfem (Tablet), T1 Prezcobix (Tablet), T1 Prezista (100mg/ml Suspension, 150mg Tablet, 600mg Tablet, 800mg Tablet), T1 Prezista (75mg Tablet), T1 Priftin (Tablet), T1 Primaquine Phosphate (Tablet), T1 Primidone (Tablet), T1 Primsol (Oral Solution), T1 Pristiq (Tablet ExtendedRelease 24 Hour), T1 Privigen (Injection), T1 T1 = Tier 1 Covered Drugs ProAir HFA (Aerosol Solution), T1 ProAir RespiClick (Aerosol Powder), T1 ProQuad (Injection), T1 Probenecid (Tablet), T1 Probenecid/Colchicine (Tablet), T1 Procainamide HCl (Injection), T1 Procalamine (Injection), T1 Prochlorperazine (Suppository), T1 Prochlorperazine Edisylate (Injection), T1 Prochlorperazine Maleate (Tablet), T1 Procrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml Injection, 4000unit/ml Injection), T1 Procrit (20000unit/ml Injection, 40000unit/ml Injection), T1 Procto-Pak (Cream), T1 Proctosol HC (Cream), T1 Proctozone-HC (Cream), T1 Procysbi (Capsule DelayedRelease), T1 Progesterone (Capsule), T1 Proglycem (Suspension), T1 Prograf (5mg/ml Injection), T1 Prolastin-C (Injection), T1 Prolensa (Ophthalmic Solution), T1 Proleukin (Injection), T1 Prolia (Injection), T1 Promacta (Tablet), T1 Promethazine HCl (12.5mg Suppository, 12.5mg Tablet), T1 Propafenone HCl (Tablet), T1 Propafenone HCl ER (Capsule Extended-Release 12 Hour), T1 Proparacaine HCl (Ophthalmic Solution), T1 Propranolol HCl (10mg Tablet Immediate-Release, 20mg Tablet Immediate-Release, 40mg Tablet ImmediateRelease, 60mg Tablet Immediate-Release, 80mg Tablet Immediate-Release, 20mg/5ml Oral Solution, 40mg/5ml Oral Solution), T1 Propranolol HCl (1mg/ml Injection), T1 Propranolol HCl ER (Capsule Extended-Release 24 Hour), T1 Propranolol/ Hydrochlorothiazide (Tablet), T1 Propylthiouracil (Tablet), T1 Prosol (Injection), T1 Protriptyline HCl (Tablet), T1 Pulmicort (1mg/2ml Suspension), T1 Pulmozyme (Inhalation Solution), T1 Purixan (Suspension), T1 Pyrazinamide (Tablet), T1 Pyridostigmine Bromide (Tablet), T1 Q Quadracel (Injection), T1 Quasense (Tablet), T1 Quetiapine Fumarate (Tablet Immediate-Release), T1 Quinapril HCl (Tablet), T1 Quinapril/Hydrochlorothiazide (Tablet), T1 Quinidine Gluconate (Injection), T1 0 Quinidine Gluconate CR (Tablet Extended-Release), T1 Quinidine Sulfate (Tablet), T1 Quinine Sulfate (Capsule), T1 Bold type = Brand name drug Risperidone (0.25mg Tablet, 0.5mg Tablet, 1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Tablet), T1 Risperidone (1mg/ml Oral Solution), T1 Risperidone ODT (Tablet Dispersible), T1 Rituxan (Injection), T1 Rivastigmine Tartrate (Capsule ImmediateRelease), T1 Rizatriptan Benzoate (Tablet Immediate-Release), T1 Rizatriptan Benzoate ODT (Tablet Dispersible), T1 Ropinirole HCl (Tablet Immediate-Release), T1 RotaTeq (Oral Solution), T1 Rotarix (Suspension), T1 Roxicet (Oral Solution), T1 Rozerem (Tablet), T1 Ruconest (Injection), T1 S SFRowasa (Enema), T1 SSD (Cream), T1 Sabril (500mg Packet, 500mg Tablet), T1 Saizen (Injection), T1 Samsca (Tablet), T1 Sancuso (Patch), T1 Sandimmune (100mg Capsule), T1 Sandimmune (100mg/ml Oral Solution), T1 Sandostatin LAR Depot (Injection), T1 Santyl (Ointment), T1 Saphris (Tablet Sublingual), T1 Savella (Tablet), T1 Savella Titration Pack, T1 Plain type = Generic drug 59 Drug LIST R RAVICTI (Liquid), T1 Rabavert (Injection), T1 Raloxifene HCl (Tablet), T1 Ramipril (Capsule), T1 Ranexa (Tablet ExtendedRelease 12 Hour), T1 Ranitidine HCl (150mg Capsule, 300mg Capsule, 150mg/6ml Injection, 15mg/ml Syrup), T1 Ranitidine HCl (150mg Tablet, 300mg Tablet), T1 Rapaflo (Capsule), T1 Rapamune (1mg Tablet, 2mg Tablet, 1mg/ml Oral Solution), T1 Rebif (Injection), T1 Rebif Rebidose (Injection), T1 Rebif Rebidose Titration Pack (Injection), T1 Rebif Titration Pack (Injection), T1 Reclipsen (Tablet), T1 Recombivax HB (Injection), T1 Regranex (Gel), T1 Relenza Diskhaler (Aerosol Powder), T1 Relistor (Injection), T1 Remicade (Injection), T1 Remodulin (Injection), T1 Renagel (Tablet), T1 Renvela (0.8gm Packet, 2.4gm Packet, 800mg Tablet), T1 Repaglinide (Tablet), T1 Rescriptor (Tablet), T1 Restasis (Emulsion), T1 Retrovir IV Infusion (Injection), T1 Revatio (10mg/12.5ml Injection), T1 Revatio (20mg Tablet), T1 Revlimid (Capsule), T1 Reyataz (150mg Capsule, 200mg Capsule, 300mg Capsule, 50mg Packet), T1 Ribasphere (200mg Capsule), T1 Ribasphere (200mg Tablet, 400mg Tablet), T1 Ribasphere (600mg Tablet), T1 Ribavirin (200mg Capsule), T1 Ribavirin (200mg Tablet), T1 Ridaura (Capsule), T1 Rifabutin (Capsule), T1 Rifampin (150mg Capsule, 300mg Capsule), T1 Rifampin (600mg Injection), T1 Rifater (Tablet), T1 Rilutek (Tablet), T1 Riluzole (Tablet), T1 Rimantadine HCl (Tablet), T1 Ringers Injection (Injection), T1 Ringers Irrigation (Irrigation Solution), T1 Riomet (Oral Solution), T1 Risedronate Sodium (Tablet), T1 Risperdal Consta (12.5mg Injection, 25mg Injection), T1 Risperdal Consta (37.5mg Injection, 50mg Injection), T1 0 Selegiline HCl (5mg Capsule, 5mg Tablet), T1 Selenium Sulfide (Lotion), T1 Selzentry (Tablet), T1 Sensipar (30mg Tablet), T1 Sensipar (60mg Tablet, 90mg Tablet), T1 Serevent Diskus (Aerosol Powder), T1 Seroquel XR (Tablet Extended-Release 24 Hour), T1 Serostim (Injection), T1 Sertraline HCl (100mg Tablet, 25mg Tablet, 50mg Tablet), T1 Sertraline HCl (20mg/ml Concentrate), T1 Sharobel (Tablet), T1 Signifor (Injection), T1 Sildenafil (10mg/12.5ml Injection), T1 Sildenafil (20mg Tablet) (Generic Revatio), T1 Silver Sulfadiazine (Cream), T1 Simbrinza (Suspension), T1 Simponi (Injection), T1 Simponi Aria (Injection), T1 Simulect (Injection), T1 Simvastatin (Tablet), T1 Sirolimus (0.5mg Tablet), T1 Sirolimus (1mg Tablet, 2mg Tablet), T1 Sirturo (Tablet), T1 Sodium Chloride (0.9% Injection), T1 Sodium Chloride (2.5meq/ ml Injection, 3% Injection, 5% Injection), T1 Sodium Chloride 0.45% Viaflex (Injection), T1 Sodium Chloride 0.9% (Irrigation Solution), T1 T1 = Tier 1 Covered Drugs Sodium Fluoride (Tablet), T1 Sodium Lactate (Injection), T1 Sodium Phenylbutyrate (Powder), T1 Sodium Polystyrene Sulfonate (Suspension), T1 Sodium Sulfacetamide (Ophthalmic Solution), T1 Solaraze (Gel), T1 Soltamox (Oral Solution), T1 Solu-Cortef (Injection), T1 Solu-Medrol (2gm Injection), T1 Somatuline Depot (Injection), T1 Somavert (Injection), T1 Soriatane (Capsule), T1 Sotalol HCl (AF) (Tablet), T1 Sotalol HCl (Tablet), T1 Sovaldi (Tablet), T1 Spiriva HandiHaler (Capsule), T1 Spiriva Respimat (Aerosol Solution), T1 Spironolactone (Tablet), T1 Spironolactone/ Hydrochlorothiazide (Tablet), T1 Sporanox (10mg/ml Oral Solution), T1 Sprintec 28 (Tablet), T1 Sprycel (Tablet), T1 Sronyx (Tablet), T1 Stavudine (15mg Capsule, 20mg Capsule, 30mg Capsule, 40mg Capsule, 1mg/ml Oral Solution), T1 Stelara (Injection), T1 Sterile Water Irrigation (Irrigation Solution), T1 Stiolto Respimat (Aerosol Solution), T1 Stivarga (Tablet), T1 Strattera (Capsule), T1 Streptomycin Sulfate (Injection), T1 Stribild (Tablet), T1 Suboxone (Film), T1 Sucraid (Oral Solution), T1 Sucralfate (Tablet), T1 Sulfacetamide Sodium (Ointment), T1 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate (Ophthalmic Solution), T1 Sulfadiazine (Tablet), T1 Sulfamethoxazole/ Trimethoprim (200mg-40mg/5ml Suspension, 400mg-80mg Tablet), T1 Sulfamethoxazole/ Trimethoprim (400mg-80mg/5ml Injection), T1 Sulfamethoxazole/ Trimethoprim DS (Tablet), T1 Sulfamylon (85mg/gm Cream), T1 Sulfasalazine (Tablet), T1 Sulfazine EC (Tablet DelayedRelease), T1 Sulindac (Tablet), T1 Sumatriptan (Nasal Solution), T1 Sumatriptan Succinate (100mg Tablet, 25mg Tablet, 50mg Tablet), T1 Sumatriptan Succinate (6mg/ 0.5ml Injection), T1 Sumavel DosePro (Injection), T1 0 T TOBI (Nebulized Solution), T1 TOBI Podhaler (Capsule), T1 TPN Electrolytes (Injection), T1 TYPHIM Vi (Injection), T1 Tabloid (Tablet), T1 Tacrolimus (0.03% Ointment, 0.1% Ointment), T1 Tacrolimus (0.5mg Capsule, 1mg Capsule, 5mg Capsule), T1 Tafinlar (Capsule), T1 Bold type = Brand name drug Tamiflu (30mg Capsule, 45mg Capsule, 75mg Capsule, 6mg/ml Suspension), T1 Tamoxifen Citrate (Tablet), T1 Tamsulosin HCl (Capsule), T1 Tarceva (Tablet), T1 Targretin (1% Gel, 75mg Capsule), T1 Tarina Fe 1/20 (Tablet), T1 Tasigna (Capsule), T1 Tasmar (Tablet), T1 Taxotere (Injection), T1 Tazicef (Injection), T1 Tazorac (0.05% Cream, 0.1% Cream), T1 Taztia XT (Capsule ExtendedRelease 24 Hour), T1 Tecfidera (Capsule DelayedRelease), T1 Tecfidera Starter Pack, T1 Tegretol-XR (100mg Tablet Extended-Release 12 Hour), T1 Telmisartan (Tablet), T1 Telmisartan/Amlodipine (Tablet), T1 Telmisartan/ Hydrochlorothiazide (Tablet), T1 Tenivac (Injection), T1 Terazosin HCl (Capsule), T1 Terbinafine HCl (Tablet), T1 Terbutaline Sulfate (1mg/ml Injection), T1 Terconazole (0.4% Cream, 0.8% Cream, 80mg Suppository), T1 Testosterone Cypionate (Injection), T1 Testosterone Enanthate (Injection), T1 Tetanus/Diphtheria Toxoids-Adsorbed Adult (Injection), T1 Tetracycline HCl (Capsule), T1 Thalomid (Capsule), T1 Theophylline (Oral Solution), T1 Theophylline CR (Tablet Extended-Release 12 Hour), T1 Theophylline ER (300mg Tablet Extended-Release 12 Hour, 450mg Tablet Extended-Release 12 Hour, 400mg Tablet ExtendedRelease 24 Hour, 600mg Tablet Extended-Release 24 Hour), T1 Thioridazine HCl (Tablet), T1 Thiothixene (Capsule), T1 Thymoglobulin (Injection), T1 Thyrolar (Tablet), T1 Tiagabine HCl (2mg Tablet), T1 Tiagabine HCl (4mg Tablet), T1 Tikosyn (Capsule), T1 Timolol Maleate (0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution), T1 Timolol Maleate (10mg Tablet, 20mg Tablet, 5mg Tablet), T1 Timolol Maleate Ophthalmic Gel Forming (Gel Form Solution), T1 Tinidazole (Tablet), T1 Tivicay (Tablet), T1 Tizanidine HCl (2mg Tablet, 4mg Tablet), T1 Tobradex (0.3%-0.1% Ophthalmic Ointment), T1 Plain type = Generic drug 61 Drug LIST Suprax (100mg Tablet Chewable, 200mg Tablet Chewable, 100mg/5ml Suspension, 200mg/5ml Suspension), T1 Suprax (400mg Capsule, 500mg/5ml Suspension), T1 Suprep Bowel Prep (Oral Solution), T1 Surmontil (Capsule), T1 Sustiva (200mg Capsule, 600mg Tablet), T1 Sustiva (50mg Capsule), T1 Sutent (Capsule), T1 Sylatron (Injection), T1 Sylvant (Injection), T1 Symbicort (Aerosol), T1 SymlinPen 120 (Injection), T1 SymlinPen 60 (Injection), T1 Synagis (Injection), T1 Synarel (Nasal Solution), T1 Synercid (Injection), T1 Synribo (Injection), T1 Synthroid (Tablet), T1 Syprine (Capsule), T1 0 Tobradex ST (0.3%-0.05% Ophthalmic Suspension), T1 Tobramycin (Nebulized Solution), T1 Tobramycin Sulfate (0.3% Ophthalmic Solution), T1 Tobramycin Sulfate (10mg/ml Injection, 80mg/2ml Injection), T1 Tobramycin Sulfate/Sodium Chloride (Injection), T1 Tobramycin/Dexamethasone (Ophthalmic Suspension), T1 Tobrex (0.3% Ophthalmic Ointment), T1 Tolcapone (Tablet), T1 Topiramate (100mg Tablet Immediate-Release, 200mg Tablet Immediate-Release, 25mg Tablet ImmediateRelease, 50mg Tablet Immediate-Release, 15mg Capsule Sprinkle ImmediateRelease, 25mg Capsule Sprinkle ImmediateRelease), T1 Toposar (Injection), T1 Topotecan HCl (Injection), T1 Torisel (Injection), T1 Torsemide (Tablet), T1 Tracleer (Tablet), T1 Tradjenta (Tablet), T1 Tramadol HCl (Tablet Immediate-Release), T1 Tramadol HCl ER (100mg Tablet Extended-Release 24 Hour) (Generic Ultram ER), 200mg Tablet ExtendedRelease 24 Hour (Generic Ultram ER), T1 T1 = Tier 1 Covered Drugs Tramadol HCl ER (300mg Tablet Extended-Release 24 Hour) (Generic Ryzolt), T1 Tramadol HCl/ Acetaminophen (Tablet), T1 Trandolapril (Tablet), T1 Tranexamic Acid (100mg/ml Injection, 650mg Tablet), T1 Transderm-Scop (Patch 72 Hour), T1 Tranylcypromine Sulfate (Tablet), T1 Travasol (Injection), T1 Travatan Z (Ophthalmic Solution), T1 Travoprost (Ophthalmic Solution), T1 Trazodone HCl (Tablet), T1 Treanda (Injection), T1 Trecator (Tablet), T1 Trelstar Mixject (Injection), T1 Tretinoin (0.01% Gel, 0.025% Gel, 0.025% Cream, 0.05% Cream, 0.1% Cream), T1 Tretinoin (10mg Capsule), T1 Tretinoin Microsphere (Gel), T1 Trexall (Tablet), T1 Trezix (320.5mg-30mg-16mg Capsule), T1 Tri-Legest Fe (Tablet), T1 Tri-Previfem (Tablet), T1 Tri-Sprintec (Tablet), T1 TriLyte (Oral Solution), T1 Triamcinolone Acetonide (0.025% Cream, 0.1% Cream, 0.5% Cream, 0.025% Ointment, 0.1% Ointment, 0.5% Ointment), T1 Triamcinolone Acetonide (0.025% Lotion, 0.1% Lotion), T1 Triamcinolone Acetonide (55mcg/ACT Aerosol) (Generic Nasacort AQ), T1 Triamcinolone in Orabase (Paste), T1 Triamterene/ Hydrochlorothiazide (37.5mg-25mg Capsule, 50mg-25mg Capsule, 37.5mg-25mg Tablet, 75mg-50mg Tablet), T1 Tribenzor (Tablet), T1 Triderm (Cream), T1 Trifluoperazine HCl (Tablet), T1 Trifluridine (Ophthalmic Solution), T1 Trihexyphenidyl HCl (0.4mg/ ml Elixir), T1 Trimethoprim (Tablet), T1 Trinessa (Tablet), T1 Trisenox (Injection), T1 Triumeq (Tablet), T1 Trivora-28 (Tablet), T1 Trizivir (Tablet), T1 Trophamine (Injection), T1 Trulicity (Injection), T1 Trumenba (Injection), T1 Truvada (Tablet), T1 Twinrix (Injection), T1 Tybost (Tablet), T1 Tygacil (Injection), T1 Tykerb (Tablet), T1 Tysabri (Injection), T1 Tyvaso (Inhalation Solution), T1 Tyzeka (Tablet), T1 Tyzine Pediatric Nasal Drops (Nasal Solution), T1 0 U Uceris (9mg Tablet Extended-Release 24 Hour), T1 Uloric (Tablet), T1 Unithroid (Tablet), T1 Ursodiol (250mg Tablet, 500mg Tablet, 300mg Capsule), T1 Uvadex (Injection), T1 Bold type = Brand name drug Vfend (200mg Tablet, 50mg Tablet, 40mg/ml Suspension), T1 Vibramycin (50mg/5ml Syrup), T1 Victoza (Injection), T1 Vidaza (Injection), T1 Videx Pediatric (Oral Solution), T1 Vigamox (Ophthalmic Solution), T1 Viibryd (Kit, 10mg Tablet, 20mg Tablet, 40mg Tablet), T1 Vimpat (100mg Tablet, 150mg Tablet, 200mg Tablet, 50mg Tablet, 10mg/ml Oral Solution), T1 Vimpat (200mg/20ml Injection), T1 Vinblastine Sulfate (Injection), T1 Vincasar PFS (Injection), T1 Vincristine Sulfate (Injection), T1 Vinorelbine Tartrate (Injection), T1 Viracept (Tablet), T1 Viramune (50mg/5ml Suspension), T1 Viramune XR (100mg Tablet Extended-Release 24 Hour), T1 Viramune XR (400mg Tablet Extended-Release 24 Hour), T1 Virazole (Inhalation Solution), T1 Viread (150mg Tablet, 200mg Tablet, 250mg Tablet, 300mg Tablet, 40mg/gm Powder), T1 Vitekta (Tablet), T1 Plain type = Generic drug 63 Drug LIST V VAQTA (Injection), T1 VP-PNV-DHA (Capsule), T1 VPRIV (Injection), T1 Vagifem (Tablet), T1 Valacyclovir HCl (Tablet), T1 Valchlor (Gel), T1 Valcyte (450mg Tablet, 50mg/ml Oral Solution), T1 Valganciclovir (Tablet), T1 Valproate Sodium (100mg/ml Injection), T1 Valproic Acid (250mg Capsule, 250mg/5ml Syrup), T1 Valsartan (Tablet), T1 Valsartan/ Hydrochlorothiazide (Tablet), T1 Vancocin HCl (Capsule), T1 Vancomycin HCl (1000mg Injection, 10gm Injection, 500mg Injection), T1 Vancomycin HCl (125mg Capsule, 250mg Capsule), T1 Vandazole (Gel), T1 Varivax (Injection), T1 Varizig (Injection), T1 Vascepa (Capsule), T1 Vectibix (Injection), T1 Velcade (Injection), T1 Velivet (Tablet), T1 Velphoro (Tablet Chewable), T1 Venlafaxine HCl (Tablet Immediate-Release), T1 Venlafaxine HCl ER (150mg Capsule Extended-Release 24 Hour, 37.5mg Capsule Extended-Release 24 Hour, 75mg Capsule ExtendedRelease 24 Hour), T1 Ventavis (Inhalation Solution), T1 Verapamil HCl (120mg Tablet Immediate-Release, 40mg Tablet Immediate-Release, 80mg Tablet ImmediateRelease), T1 Verapamil HCl (2.5mg/ml Injection), T1 Verapamil HCl ER (100mg Capsule Extended-Release 24 Hour, 120mg Capsule Extended-Release 24 Hour, 180mg Capsule ExtendedRelease 24 Hour, 200mg Capsule Extended-Release 24 Hour, 240mg Capsule Extended-Release 24 Hour, 300mg Capsule ExtendedRelease 24 Hour), T1 Verapamil HCl ER (120mg Tablet Extended-Release, 180mg Tablet ExtendedRelease, 240mg Tablet Extended-Release), T1 Verapamil HCl SR (Capsule Extended-Release 24 Hour), T1 Versacloz (Suspension), T1 Vesicare (Tablet), T1 Vestura (Tablet), T1 Vexol (Suspension), T1 0 Vivitrol (Injection), T1 Voltaren (Gel), T1 Voriconazole (200mg Injection), T1 Voriconazole (200mg Tablet, 50mg Tablet, 40mg/ml Suspension), T1 Votrient (Tablet), T1 Vyfemla (Tablet), T1 Vytorin (Tablet), T1 Vyvanse (Capsule), T1 W WYMZYA Fe (Tablet Chewable), T1 Warfarin Sodium (Tablet), T1 Welchol (3.75gm Packet, 625mg Tablet), T1 X Xalkori (Capsule), T1 Xarelto (Tablet), T1 Xarelto Starter Pack (Tablet Therapy Pack), T1 Xeljanz (Tablet), T1 Xenazine (Tablet), T1 Xgeva (Injection), T1 Xifaxan (Tablet), T1 Xolair (Injection), T1 Xtandi (Capsule), T1 Xulane (Patch Weekly), T1 Xyrem (Oral Solution), T1 T1 = Tier 1 Covered Drugs Y YF-Vax (Injection), T1 Yervoy (Injection), T1 Z Zafirlukast (Tablet), T1 Zaleplon (Capsule), T1 Zaltrap (Injection), T1 Zanosar (Injection), T1 Zavesca (Capsule), T1 Zazole (0.4% Cream), T1 Zazole (0.8% Cream), T1 Zelapar (Tablet Dispersible), T1 Zelboraf (Tablet), T1 Zemaira (Injection), T1 Zemplar (2mcg/ml Injection, 5mcg/ml Injection), T1 Zenchent (Tablet), T1 Zenchent Fe (Tablet Chewable), T1 Zenpep (Capsule DelayedRelease), T1 Zerbaxa (Injection), T1 Zetia (Tablet), T1 Ziagen (20mg/ml Oral Solution), T1 Zidovudine (100mg Capsule, 300mg Tablet, 50mg/5ml Syrup), T1 Zinecard (Injection), T1 Ziprasidone HCl (Capsule), T1 Zirgan (Gel), T1 Zmax (Suspension), T1 Zoledronic Acid (4mg/5ml Injection), T1 Zoledronic Acid (5mg/100ml Injection), T1 Zolinza (Capsule), T1 Zolpidem Tartrate (Tablet Immediate-Release), T1 Zomacton (Injection), T1 Zometa (Injection), T1 Zonisamide (Capsule), T1 Zorbtive (Injection), T1 Zortress (Tablet), T1 Zostavax (Injection), T1 Zovia 1/35E (Tablet), T1 Zovia 1/50E (Tablet), T1 Zovirax (5% Cream), T1 Zovirax (5% Ointment), T1 Zyclara (Cream), T1 Zyclara Pump (Cream), T1 Zydelig (Tablet), T1 Zyflo (Tablet), T1 Zyflo CR (Tablet ExtendedRelease 12 Hour), T1 Zykadia (Capsule), T1 Zyprexa Relprevv (Injection), T1 Zytiga (Tablet), T1 Zyvox (100mg/5ml Suspension, 2mg/ml Injection), T1 Zyvox (600mg Tablet), T1 Over-the-counter Medicaid drug list This plan also covers selected over-the-counter (OTC) drugs not normally covered under our Medicare Part D benefit. The alphabetical OTC drugs listed below are covered only with a written prescription from your doctor. If your prescription is for a brand name drug, the generic version of the drug will be provided when available unless otherwise prescribed or directed by your physician. # 12 Hour Decongestant (Tablet Extended-Release 12 Hour) 12 Hour Nasal Spray (Nasal Solution) 3 Day Vaginal (Cream) Bold type = Brand name drug Plain type = Generic drug 65 All Day Allergy D (Tablet Extended-Release 12 Hour) All Day Allergy D-12 (Tablet Extended-Release 12 Hour) All Day Allergy-D (Tablet Extended-Release 12 Hour) All Day Pain Relief (Tablet) All Day Relief (Tablet) All-Nite Multi-Symptom Cold/ Flu Relief (Liquid) Aller-Chlor (2mg/5ml Syrup, 4mg Tablet) Aller-Ease (Tablet) Allergy & Congestion Relief (Tablet Extended-Release 12 Hour) Allergy (10mg Tablet Dispersible, 10mg Tablet, 25mg Tablet, 4mg Tablet, 25mg Capsule) Allergy Eye Drops (Ophthalmic Solution) Allergy Multi-Symptom (Tablet) Allergy Relief (10mg Tablet Dispersible, 10mg Tablet, 25mg Tablet) Allergy Relief Child (Syrup) Allergy Relief D-24 (Tablet Extended-Release 24 Hour) Allergy Relief/Nasal Decongestant (Tablet Extended-Release 24 Hour) Allergy Tablets (Tablet) Allergy-Time (Tablet) Drug LIST A Ace Aerosol Cloud Enhancer Acephen (Suppository) Acetaminophen (Suppository) Acid Gone (Suspension) Acid Reducer (Tablet) Acidophilus/Citrus Pectin (Tablet) Acidophilus/L-Sporogenes Extra Strength (Tablet) Acne Medication (Lotion) Acne Medication 5 (Lotion) Adult Mask Large Advil (200mg Capsule, 200mg Tablet) Advil Junior Strength (100mg Tablet, 100mg Tablet Chewable) AeroGear Asthma Action (Kit) Aerochamber MV Aerochamber Mini Aerosol Chamber (Device) Aerochamber Plus Flow Vu Aerochamber Plus Flow-Vu Aerochamber Plus Flow-Vu/ Large Mask Aerochamber Plus Flow-Vu/ Mask Aerochamber Plus Flow-Vu/ Medium Mask Aerochamber Plus Flow-Vu/ Small Mask Aerochamber Plus/Small Mask Aerochamber Z-Stat Plus Valved Holding Chamber w/ Flow Vu Aerochamber Z-Stat Plus/ Flowsignal Aerochamber Z-Stat Plus/ Large Mask Aerochamber Z-Stat Plus/ Medium Mask Aerochamber Z-Stat Plus/ Small Mask Aerochamber/Flowsignal Aerotrach Plus Aimsco Lubricated Airzone Peak Flow Meter (Device) Akwa Tears (Ointment) Alavert (Tablet Dispersible) Alavert Allergy/Sinus (Tablet Extended-Release 12 Hour) Alaway (Ophthalmic Solution) Alaway Childrens Allergy Eye Itch Relief (Ophthalmic Solution) Alevazol (Ointment) All Day Allergy (Tablet) All Day Allergy Childrens (Tablet Chewable) Allerhist-1 (Tablet) Almacone Double Strength (Suspension) Aloe Vesta Protective (Ointment) Alpha Lipoic Acid (100mg Capsule) Alpha Lipoic Acid (300mg Capsule) Aluminum Hydroxide (Suspension) Ameriphor (Ointment) Amlactin (Lotion) Amlactin Ultra (Cream) Animal Shapes (Tablet Chewable) Animal Shapes + Iron (Tablet Chewable) Antacid (Suspension) Antacid Anti-Gas Maximum Strength (Suspension) Antacid Fast Relief (Suspension) Antacid Maximum Strength (Suspension) Antacid Plus Anti-Gas Fast Acting (Suspension) Anti-Diarrheal (Tablet) Anti-Fungal Powder (Powder) Anti-Itch (Cream) Anti-Nausea (Oral Solution) Antifungal (Cream) Aprodine (Tablet) AquADEKs (Liquid) AquADEKs (Tablet Chewable, Capsule) Aqua-E (Liquid) Aquasol A Parenteral (Injection) Aquasol E (Oral Solution) Aqueous Vitamin D Infants (Liquid) Aqueous Vitamin E (Oral Solution) Bold type = Brand name drug Arginine (Tablet) Artificial Tears (Ointment, 15%-83% Ointment, 1.4% Ophthalmic Solution) Aspir-81 (Tablet DelayedRelease) Aspir-Low (Tablet DelayedRelease) Aspirin (325mg Tablet, 325mg Tablet DelayedRelease, 81mg Tablet Delayed-Release, 81mg Tablet Chewable) Aspirin Adult Low Strength (Tablet Chewable) Aspirin Childrens (Tablet Chewable) Aspirin EC (Tablet DelayedRelease) Aspirin EC Lo-Dose (Tablet Delayed-Release) Aspirin EC Low Dose (Tablet Delayed-Release) Aspirin Enteric Coated Adult Low Strength (Tablet Delayed-Release) Aspirin Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release) Aspirin Low Strength (Tablet Chewable) Assess Full Range Peak Flow Meter (Device) Asthma Check Meter-Zone System (Device) AsthmaMentor (Device) AsthmaPACK for Children (Kit) Athletes Foot AF Cream (Cream) Plain type = Generic drug B B-Complex Plus Vitamin C (Tablet) BBO Creamy Wash Complete Pack (Kit) Bacitracin (OTC Only) (500unit/gm Ointment) Bacitracin Zinc (OTC Only) (Ointment) Bacitracin/Neomycin/ Polymyxin (OTC Only) (Ointment) Bacteriostatic Water for Injection/Benzyl Alcohol (Injection) Banophen (12.5mg/5ml Liquid, 2%-0.1% Cream, 25mg Capsule, 50mg Capsule, 25mg Tablet) Baza Antifungal (Cream) Baza Protect (Cream) Benzoin Compound Tincture (Tincture) Benzonatate (Capsule) Benzoyl Peroxide (OTC Only) (10% Gel, 5% Gel, 2.5% Gel) Benzoyl Peroxide Cleanser (OTC Only) (Lotion) Benzoyl Peroxide Wash (OTC Only) (Liquid) Beta Care Betatar Gel (Shampoo) Beta HC (Lotion) Betadine Surgical Scrub (External Solution) Bion Tears (Ophthalmic Solution) Biotin (Capsule) Bisac-Evac (Suppository) Bisacodyl (Suppository) Bisacodyl EC (Tablet DelayedRelease) Biscolax (Suppository) Bismatrol (Suspension) Bismatrol Maximum Strength (Suspension) BreatheRite Valved MDI Chamber/Collapsible (Device) BreatheRite Valved MDI Chamber/Rigid (Device) Bromfed DM (Syrup) Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr (Syrup) Brotapp (Liquid) Brotapp DM (Liquid) Brovex PEB (Liquid) Brovex PSB (Liquid) Bold type = Brand name drug Plain type = Generic drug 67 Childrens Chewable Vitamins/Iron (Tablet Chewable) Childrens Cold & Allergy (Elixir) Childrens Ibuprofen (OTC Only) (40mg/ml Suspension) Childrens Loratadine (5mg/ 5ml Oral Solution, 5mg/5ml Syrup) Childrens Mucus Relief Cough (Liquid) Childrens Mucus Relief Expectorant (Liquid) Childrens Pain Relief Plus Multi-Symptom Cold (Suspension) Chlorpheniramine Maleate (OTC Only) (12mg Tablet Extended-Release, 4mg Tablet) Chromium Chloride (Injection) Citrus Calcium+D (Tablet) Citrus Calcium/Vitamin D (Tablet) Claritin (OTC Only) (10mg Capsule, 10mg Tablet, 5mg Tablet Chewable, 5mg/5ml Syrup) Claritin Reditabs (Tablet Dispersible) Claritin-D 12 Hour (Tablet Extended-Release 12 Hour) Claritin-D 24 Hour (Tablet Extended-Release 24 Hour) Clearlax (Powder) Clemastine Fumarate (OTC Only) (Tablet) Clotrimazole (OTC Only) (Cream) Co Q-10 (Capsule) Co Q-10 Plus (Capsule) Co-Enzyme Q-10 (Capsule) Drug LIST C Calcet Petites (Tablet) Calci-Chew (Tablet Chewable) Calci-Mix (Capsule) Calciferol (Oral Solution) Calcionate (Syrup) Calcitrate (Tablet) Calcium 600+D (Tablet) Calcium Carbonate (1250mg Tablet, 600mg Tablet, 1250mg/5ml Suspension) Calcium Carbonate (648mg Tablet) Calcium Citrate+D (Tablet) Calcium High Potency + Vitamin D (Tablet) Calcium Lactate (Tablet) Calcium Oyster Shell (Tablet) Calcium Plus Vitamin D3 (Capsule) Calcium+D3 (Tablet) Calcium/Vitamin D (Tablet) Calcium/Vitamin D/Minerals (Tablet Chewable) Calphron (Tablet) Caltrate 600+D Plus Minerals (Tablet Chewable) Calvite P&D (Tablet) Capcof (Syrup) Capmist DM (Tablet) Capron DM (Liquid) Carrington Antifungal (Cream) Castor Oil Centamin (Liquid) Centavite A-Z Complete Multivitamin/Minerals (Tablet) Centrum (Liquid) Centrum Adults (Tablet) Centrum Silver (Tablet) Centrum Ultra Womens (Tablet) Cerovite Advanced Formula (Tablet, Liquid) Cerovite Jr (Tablet Chewable) Certavite/Antioxidants (Tablet, Liquid) Cetirizine HCl (OTC Only) (10mg Tablet Chewable, 5mg Tablet Chewable, 10mg Tablet, 5mg Tablet) Cetirizine HCl/ Pseudoephedrine HCl ER (OTC Only) (Tablet Extended-Release 12 Hour) Cheratussin AC (Syrup) Cheratussin DAC (Oral Solution) Chest Congestion Relief (Tablet) Chewable Vite Childrens (Tablet Chewable) Chewable Vite with Iron/ Childrens (Tablet Chewable) Childrens Advil (Suspension) Childrens Aspirin (Tablet Chewable) Childrens Aspirin Low Strength (Tablet Chewable) Childrens Chewable Vitamins (Tablet Chewable) Codituss DM (Syrup) Cold Head Congestion Daytime (Tablet) Cold Head Congestion Nighttime (Tablet) Cold Head Congestion Severe Daytime (Tablet) Cold Multi-Symptom Daytime (Tablet) Cold Multi-Symptom Nighttime (Tablet) Cold Multi-Symptom Severe Daytime (Tablet) Cold/Allergy Childrens (Elixir) Cold/Cough Childrens (Elixir) Cold/Cough DM Childrens (Elixir) Cold/Cough/Sore Throat Childrens (Liquid) Complete (Tablet) Complete Allergy (25mg Capsule, 25mg Tablet) Complete Allergy Medicine (Capsule) Complete Lice Treatment Kit (Kit) Conex Cold/Allergy (1mg/ 5ml-30mg/5ml Oral Solution, 2mg-60mg Tablet) Copper Trace Metal (Injection) Coricidin HBP Nighttime Multi-Symptom Cold (Liquid) Cough & Sore Throat Day Time (Liquid) Cough DM (Liquid ExtendedRelease) Cough Syrup (Syrup) Coughtab (Tablet) Critic-Aid Clear AF (Ointment) Cromolyn Sodium (OTC Only) (Aerosol Solution) Cyanocobalamin (Injection) Cyto-Q Max (Liquid) Bold type = Brand name drug D D 5000 (Tablet) D-Vi-Sol (Liquid) D-Vita (Liquid) D3 High Potency (Capsule) D3 Super Strength (Capsule) D3-50 (Capsule) DHS Sal (Shampoo) DHS Tar (Shampoo) DHS Tar Gel (Shampoo) DHS Zinc (Shampoo) DOK (100mg Capsule, 250mg Capsule, 100mg Tablet) DOK PLUS (Tablet) Daily Multiple Vitamins (Tablet) Daily Vite (Tablet) Daily-Vite/Iron/Beta-Carotene (Tablet) Dallergy (Liquid) Day Time Cold/Flu Relief (Liquid) Day Time Cough (Liquid) Day Time Multi-Symptom Cold/Flu Relief (Capsule) Dayhist Allergy 12 Hour Relief (Tablet) Decongestant 12hour Maximum Strength (Tablet Extended-Release 12 Hour) Deep Sea Nasal Spray (Nasal Solution) Delsym (Liquid ExtendedRelease) Delsym Cough + Chest Congestion DM (Liquid) Delsym Cough + Chest Congestion DM Childrens (Liquid) Delsym Cough + Cold Daytime (Liquid) Delsym Cough + Cold Nighttime (Liquid) Plain type = Generic drug Delsym Cough + Cold Nighttime Childrens (Liquid) Delsym Night Time Cough/ Cold (Liquid) Delsym Night Time Cough/ Cold Childrens (Liquid) Delsym Night Time MultiSymptom (Liquid) Dermacerin (Cream) Dermamed (Ointment) Dermaphor (Ointment) Desenex Shake Powder (Powder) Dexferrum (Injection) Dextromethorphan Polistirex (Liquid Extended-Release) Dextromethorphan/ Guaifenesin (Oral Solution) Diabetic Siltussin DAS-Na (Liquid) Diabetic Siltussin-DM (Liquid) Diabetic Siltussin-DM Maximum Strength (Liquid) Diabetic Tussin (Liquid) Diabetic Tussin DM (Liquid) Diabetic Tussin Maximum Strength (Liquid) Dialyvite 800 (Tablet) Dialyvite Vitamin D3 Max (Tablet) Dimaphen Childrens (Elixir) Dimaphen DM Cold/Cough Childrens (Elixir) Dimenhydrinate (OTC Only) (Tablet) Dimetapp Cold & Allergy (Elixir) Dimetapp DM Cold & Cough (Liquid) Dimetapp Long Acting Cough Plus Cold (Syrup) Dimetapp Multi-Symptom Cold & Flu (Liquid) E E-Z Spacer (Device) ED A-Hist (Liquid) ED A-Hist DM (Liquid) ED A-Hist PSE (Tablet) ED Bron GP (Liquid) ED Chlorped (Liquid) ED Chlorped D (Liquid) ED Chlorped Jr (Syrup) ED Chlortan (Tablet) Ear Drops (Otic Solution) Bold type = Brand name drug Ear Wax Removal Drops (Otic Solution) Ear Wax Removal Kit (Otic Solution) Ear Wax Removal System (Ophthalmic Solution) Easivent Ecpirin (Tablet DelayedRelease) Endacof-DM (Liquid) Enema Ready-To-Use (Enema) Enemeez Mini (Enema) Enemeez Plus (Enema) Enfamil Enfalyte (Oral Solution) Enfamil Expecta Enteric Coated Aspirin (Tablet Delayed-Release) Ergocalciferol (Oral Solution) Exefen-IR (Tablet) Extra Action Cough (Syrup) Eye Drops Allergy Relief (Ophthalmic Solution) Ezfe Forte (Capsule) F Fallback Solo (Tablet) Famotidine (OTC Only) (10mg Tablet) Fantasy Lubricated Fantasy Lubricated/ Spermicide Fast Acting Antacid Plus AntiGas Maximum Strength (Suspension) Fer-In-Sol (Oral Solution) Fer-Iron (Oral Solution) Feraheme (Injection) Ferate (Tablet) Ferosul (Elixir) Ferrex 150 (Capsule) Ferrlecit (Injection) Ferrous Drops (Oral Solution) Plain type = Generic drug 69 Ferrous Gluconate (Tablet) Ferrous Sulfate (140mg Tablet Extended-Release, 220mg/5ml Liquid) Ferrous Sulfate (15mg/ml Oral Solution, 220mg/5ml Elixir, 325mg Tablet) Fever Reducer Childrens (Suppository) Feverall Adults (Suppository) Feverall Childrens (Suppository) Feverall Infants (Suppository) Feverall Junior Strength (Suppository) Fexofenadine HCl (Tablet) Fiber Laxative (Tablet) Fiber Tabs (Tablet) Fiber Therapy (Powder) Fiber-Lax (Tablet) Fish Oil (1000mg-300mg Capsule Delayed-Release, 1000mg-300mg Capsule, 1200mg-360mg Capsule, 1200mg Capsule, 120mg-180mg-1000mg-34 0mg-1unit Capsule, 144mg-180mg-1200mg Capsule, 144mg-216mg-1200mg Capsule, 1000mg-300mg Capsule, 1000mg Capsule) Fleet Bisacodyl (Enema) Fleet Enema (Enema) Fleet Enema Six Pack (Enema) Fleet Laxative (Tablet Delayed-Release) Fleet Oil (Enema) Fleet Pediatric (Enema) Folic Acid (5mg/ml Injection) Folic Acid (OTC Only) (800mcg Tablet) Drug LIST Dimetapp Nighttime Cold &congestion (Liquid) Diocto (50mg/5ml Liquid, 60mg/15ml Syrup) Diphenhist (OTC Only) (12.5mg/5ml Liquid, 25mg Capsule, 25mg Tablet) Diphenhydramine HCl (OTC Only) (25mg Capsule, 50mg Capsule, 25mg Tablet) Diphenhydramine HCl/Zinc Acetate (OTC Only) (Cream) Doc-Q-Lace (Capsule) Doc-Q-Lax (Tablet) Docu (Liquid) Docusate Calcium (Capsule) Docusate Sodium & Senna Stimulant Laxative/Stool Softener (Tablet) Docusate Sodium (Capsule) Docusil (Capsule) Docusol Mini (Enema) Double Antibiotic (Ointment) Driminate (Tablet) Drisdol (RX Only) (50000unit Capsule, 8000unit/ml Oral Solution) Dristan Cold (Tablet) Ducodyl (Tablet DelayedRelease) Duofer (Tablet) Folic Acid (RX Only) (1mg Tablet) Folitab 500 (Tablet ExtendedRelease) Formula EM (Oral Solution) Fosfree (Tablet) Freshkote (Ophthalmic Solution) Fungoid Tincture (External Solution) Fungoid-D (Cream) G GNP 12 Hour Nasal Spray (Nasal Solution) GNP Acid Reducer (Tablet) GNP Adult Aspirin Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release) GNP All Day Allergy (Tablet) GNP All Day Allergy-D (Tablet Extended-Release 12 Hour) GNP All Day Pain Relief (Tablet) GNP Allergy & Congestion Relief (Tablet ExtendedRelease 24 Hour) GNP Allergy (25mg Capsule, 25mg Tablet, 4mg Tablet) GNP Allergy Multi-Symptom (Tablet) GNP Allergy Plus Severe Sinus Headache Maximum Strength (Tablet) GNP Allergy Relief (10mg Tablet Dispersible, 180mg Tablet) GNP Allergy Relief for Kids (Tablet Dispersible) GNP Antacid Anti-Gas (Suspension) GNP Antacid Maximum Strength (Suspension) Bold type = Brand name drug GNP Anti-Diarrheal (Tablet) GNP Anti-Itch (Cream) GNP Artificial Tears (Ophthalmic Solution) GNP Aspirin (Tablet DelayedRelease) GNP Aspirin Low Dose (Tablet Delayed-Release) GNP Bacitracin Zinc (OTC Only) (Ointment) GNP Bisa-Lax (Tablet Delayed-Release) GNP Calcium 500+D3 (Tablet) GNP Calcium 500/D (Tablet) GNP Calcium 600+D (Tablet) GNP Calcium Citrate+D3 (Tablet) GNP Calcium Plus 600+D (Tablet) GNP Calcuim/Vitamin D/ Minerals (Tablet Chewable) GNP Capsaicin (Cream) GNP Castor Oil GNP Century (Tablet) GNP Century Adults 50+ Senior (Tablet) GNP Century Ultimate Mens Complete (Tablet) GNP Century Ultimate Mens Senior Formula (Tablet) GNP Century Ultimate Womens Complete (Tablet) GNP Century Ultimate Womens Senior Formula (Tablet) GNP Childrens Chewables/ Extra C (Tablet Chewable) GNP Childrens Chewables/ Iron (Tablet Chewable) GNP Childrens Pain Relief Plus Cold (Suspension) GNP Childrens Plus Cough & Sore Throat (Liquid) Plain type = Generic drug GNP Childrens Plus MultiSymptom Cold (Suspension) GNP Clearlax (Powder) GNP Clotrimazole 3 (OTC Only) (Cream) GNP Cold & Allergy Childrens (Elixir) GNP Cold & Allergy Maximum Strength (Tablet) GNP Cold & Cough Childrens (Elixir) GNP Cold Head Congestion Night Time (Tablet) GNP Cold Head Congestion Severe Daytime (Tablet) GNP Cold Multi-Symptom Daytime (Tablet) GNP Cold Multi-Symptom Nighttime (Tablet) GNP Cold Relief Head Congestion Severe Daytime (Tablet) GNP Cold Relief MultiSymptom Daytime (Tablet) GNP Cold Relief MultiSymptom Severe Daytime (Tablet) GNP Cold Severe Congestion/Daytime (Tablet) GNP Cough DM ER (Liquid Extended-Release) GNP Cough Relief (Liquid) GNP Daily Prenatal (OTC Only) (Tablet) GNP Day Time Cold & Flu (Capsule) GNP Day Time Cold/Flu (Capsule) GNP Day Time Cold/Flu Relief (Liquid) GNP Day Time Sinus (Capsule) GNP Dayhist Allergy (Tablet) Bold type = Brand name drug GNP Infants Gas Relief (Suspension) GNP Iron (200mg Tablet, 45mg Tablet ExtendedRelease) GNP Itchy Eye (Ophthalmic Solution) GNP K-Pec (Suspension) GNP Laxative (10mg Suppository, 5mg Tablet Delayed-Release) GNP Lice Solution Kit (Kit) GNP Lice Treatment (Liquid) GNP Little Ones Childrens (Tablet Chewable) GNP Loperamide HCl (OTC Only) (Suspension) GNP Loratadine (10mg Tablet, 5mg/5ml Syrup) GNP Loratadine Childrens (Syrup) GNP Loratadine-D 12 Hour (Tablet Extended-Release 12 Hour) GNP Loratadine-D 24 Hour (Tablet Extended-Release 24 Hour) GNP Lubricant Eye Drops (Ophthalmic Solution) GNP Lubricating Plus Eye Drops (Ophthalmic Solution) GNP Magnesium Citrate (Oral Solution) GNP Masanti Maximum Strength (Suspension) GNP Masanti Regular Strength (Suspension) GNP Miconazole 1 (Kit) GNP Miconazole 3 (Kit) GNP Miconazorb AF (Powder) GNP Milk of Magnesia (Suspension) GNP Mucus Relief (Tablet) Plain type = Generic drug 71 GNP Mucus Relief Cold & Sinus (Tablet) GNP Mucus Relief Cold Flu & Sore Throat (Tablet) GNP Mucus Relief Cough Childrens (Liquid) GNP Mucus Relief DM (Tablet) GNP Mucus Relief Severe Congestion & Cold (Tablet) GNP Mucus-ER (Tablet Extended-Release 12 Hour) GNP Multi-Symptom Cold Nighttime (Liquid) GNP Nasal Decongestant (Tablet) GNP Nasal Decongestant Pemaximum Strength (Tablet) GNP Nasal Spray (Nasal Solution) GNP Nasal Spray Extra Moisturizing (Nasal Solution) GNP Natural Fiber (Powder) GNP Niacin TR (OTC Only) (Tablet Extended-Release) GNP Nicotine Mini Lozenge (Lozenge) GNP Nicotine Polacrilex (2mg Gum, 4mg Gum, 2mg Lozenge, 4mg Lozenge) GNP Nicotine Polacrilex Mini (Lozenge) GNP Night Time Cold & Flu (Capsule) GNP Night Time Cold & Flu Multi-Symptom (Liquid) GNP Night Time Cold & Flu Multisymptom (Capsule) GNP Night Time Cold/Flu Relief (Liquid) GNP Night Time Cough (Liquid) Drug LIST GNP Docusate Calcium (Capsule) GNP Ear Drops (Otic Solution) GNP Ear Systems (Otic Solution) GNP Enema (Enema) GNP Essential One Daily (Tablet) GNP Eye Itch Relief (Ophthalmic Solution) GNP Fiber Therapy (Tablet) GNP Fiber-Caps (Tablet) GNP Fish Oil (1200mg Capsule Delayed-Release, 175mg-260mg-435mg Capsule) GNP Flu Relief Therapy Seere Cold Daytime (Liquid) GNP Flu Relief Therapy Severe Cold Nighttime (Liquid) GNP Foaming Antacid (80mg-20mg Tablet Chewable, 95mg/ 15ml-358mg/15ml Suspension) GNP Gas Relief (Tablet Chewable) GNP Gas Relief Extra Strength (Tablet Chewable) GNP Gas Relief Maximum Strength (Tablet Chewable) GNP Hemorrhoidal (14%-71.9%-0.25%-3% Ointment, 85.5%-0.25%-3% Suppository) GNP Hydrocortisone (OTC Only) (0.5% Cream) GNP Ibuprofen (OTC Only) (200mg Tablet) GNP Ibuprofen Junior Strength (OTC Only) (100mg Tablet Chewable) GNP Night Time Sinus (Capsule) GNP Nighttime Sleep Aid (Tablet) GNP No Drip Nasal Spray (Nasal Solution) GNP Nose Drops Extra Strength (Nasal Solution) GNP Omeprazole (OTC Only) (20 mg Tablet DelayedRelease) GNP One Daily Maximum (Tablet) GNP One Daily Plus Iron (Tablet) GNP Pediatric Electrolyte (Oral Solution) GNP Povidone-Iodine (External Solution) GNP Prenatal (OTC Only) (Tablet) GNP Pseudoephedrine HCl 12 Hour (Tablet ExtendedRelease 12 Hour) GNP Pseudoephedrine HCl ER (Tablet ExtendedRelease 12 Hour) GNP Senna Plus (Tablet) GNP Sinus Congestion & Pain Daytime (Tablet) GNP Sinus Congestion/Pain Nighttime (Tablet) GNP Sinus Relief Congestion & Pain Daytime/Nighttime GNP Sinus Relief Congestion & Pain Nighttime (Tablet) GNP Slow Release Iron (Tablet Extended-Release) GNP Stomach Relief (Suspension) GNP Stomach Relief Maximum Strength (Suspension) Bold type = Brand name drug GNP Stool Softener (100mg Capsule, 50mg/5ml Liquid, 60mg/15ml Syrup) GNP Stool Softener/Stimulant Laxative (Tablet) GNP Suphedrin (Liquid) GNP Tab Tussin (Tablet) GNP Tab Tussin DM (Tablet) GNP Terbinafine HCl (OTC Only) (Cream) GNP Tioconazole 1 (Ointment) GNP Tolnaftate (Cream) GNP Triacting Night Time Cold & Cough Childrens (Liquid) GNP Triple Antibiotic (Ointment) GNP Triple Antibiotic Plus (Ointment) GNP Tussin (Syrup) GNP Tussin CF Cough & Cold (Syrup) GNP Tussin CF Max MultiSymptom Cold (Liquid) GNP Tussin Cough Long Acting (Syrup) GNP Tussin DM (Liquid) GNP Tussin DM Cough (Liquid) GNP Tussin DM Max (Liquid) GNP Tussin DM Max Cough & Chest Congestion (Liquid) GNP Tussin Night Time (Liquid) GNP Ultra Lubricant Eye Drops (Ophthalmic Solution) Gas Relief (20mg/0.3ml Suspension, 80mg Tablet Chewable) Gas Relief Maximum Strength (Tablet Chewable) Gas-X Extra Strength (Tablet Chewable) Plain type = Generic drug Gavilax (Powder) Gaviscon (Suspension) GenTeal Mild to Moderate (Ophthalmic Solution) Genteal Mild (Ophthalmic Solution) Genteal PM (Ointment) Genteal Severe (Gel) Geravim (Liquid) Geriaton (Liquid) Glucose (Tablet Chewable) Glutose 15 (Gel) Glycerin (Liquid) Glycolax (Powder) Goodsense All Day Allergy (Tablet) Guaiatussin AC (Syrup) Guaifenesin (100mg/5ml Oral Solution, 200mg/10ml Oral Solution, 300mg/15ml Oral Solution, 200mg Tablet) Guaifenesin AC (Syrup) Guaifenesin DAC (Oral Solution) Guaifenesin ER (Tablet Extended-Release 12 Hour) Guaifenesin-DM (Syrup) Guaifenesin/Codeine (Oral Solution) H HM Advanced Antacid Maximum Strength (Suspension) HM All Day Allergy (Tablet) HM Allergy & Congestion (Tablet Extended-Release 12 Hour) HM Allergy (Tablet) HM Allergy Complete-D (Tablet Extended-Release 12 Hour) Bold type = Brand name drug HM Day Time (Capsule) HM Double Antibiotic (Ointment) HM Earwax Removal Aid (Otic Solution) HM Earwax Removal Kit (Otic Solution) HM Enema (Enema) HM Enema Mineral Oil (Enema) HM Eye Itch Relief (Ophthalmic Solution) HM Famotidine (OTC Only) (10mg Tablet) HM Fexofenadine HCl (Tablet) HM Fiber (0.52gm Capsule, 28.3% Powder, 30.9% Powder, 48.57% Powder, 58.6% Powder, 500mg Tablet) HM Fish Oil (Capsule Delayed-Release) HM Gas Relief (Tablet Chewable) HM Gas Relief Infants Drops (Suspension) HM Glucose (Tablet Chewable) HM Ibuprofen (OTC Only) (200mg Capsule, 200mg Tablet) HM Ibuprofen IB (OTC Only) (200mg Tablet) HM Ibuprofen Infants (OTC Only) (50mg/1.25ml Suspension) HM Laxative (Tablet DelayedRelease) HM Lice Killing Maximum Strength (Shampoo) HM Lice Treatment (Lotion) HM Loperamide HCl (OTC Only) (Suspension) Plain type = Generic drug 73 HM Loratadine Childrens (Syrup) HM Lubricating Plus (Ophthalmic Solution) HM Magnesium Citrate (Oral Solution) HM Milk of Magnesia (Suspension) HM Motion Sickness Relief (Tablet) HM Mucus ER (Tablet Extended-Release 12 Hour) HM Naproxen Sodium (OTC Only) (220mg Tablet Immediate-Release) HM Nasal Decongestant (Tablet) HM Nasal Decongestant 12 Hour (Tablet ExtendedRelease 12 Hour) HM Nasal Decongestant PE (Tablet) HM Nasal Spray (Nasal Solution) HM Niacin (Tablet ExtendedRelease) HM Nicotine Polacrilex (2mg Gum, 4mg Gum, 2mg Lozenge, 4mg Lozenge) HM Nicotine Transdermal System (Patch 24 Hour) HM Nicotine Transdermal System Step 3 (Patch 24 Hour) HM Night Time Cold & Flu (Liquid) HM Night Time Multi Symptom Cold & Flu (Capsule) HM Nose Drops Extra Strength (Nasal Solution) HM Omeprazole (OTC Only) (20 mg Tablet DelayedRelease) Drug LIST HM Allergy Relief & Nasaldecongestant (Tablet Extended-Release 24 Hour) HM Allergy Relief (10mg Tablet Dispersible, 10mg Tablet, 4mg Tablet) HM Allgery Multi Symptom (Capsule) HM Antacid Anti-Gas Extra Strength (Suspension) HM Antacid/Antigas (Suspension) HM Anti-Diarrheal (Tablet) HM Anti-Nausea (Oral Solution) HM Artificial Tears (Ophthalmic Solution) HM Aspirin (325mg Tablet, 81mg Tablet Chewable) HM Aspirin EC (Tablet Delayed-Release) HM Aspirin EC Low Dose (Tablet Delayed-Release) HM Bacitracin (OTC Only) (Ointment) HM Calcium/Vitamin D (Tablet) HM Castor Oil HM Chest Congestion Relief (Tablet) HM Chest Congestion Relief DM (Tablet) HM Clearlax (Powder) HM Cold & Allergy Childrens (Elixir) HM Cold & Cough Childrens (Elixir) HM Cold & Sinus Relief (Tablet) HM Complete (Tablet) HM Complete 50+ (Tablet) HM Cough DM (Liquid Extended-Release) HM Cough Relief (Liquid) HM One Daily/Iron (Tablet) HM Pediatric Electrolyte (Solution) HM Povidone-Iodine (External Solution) HM Saline Nasal Spray (Nasal Solution) HM Senna (Tablet) HM Senna-S (Tablet) HM Sinus Nasal Spray (Nasal Solution) HM Stomach Relief (Suspension) HM Stomach Relief Maximum Strength (Suspension) HM Stool Softener (Capsule) HM Stool Softener/Laxative (Tablet) HM Triple Antibiotic (Ointment) HM Tussin Adult (Liquid) HM Tussin Adult Cough & Chest Congestion DM (Liquid) HM Tussin Adult MultiSymptom Cold (Liquid) HM Vitamin B Complex/ Vitamin C (Tablet) Healthy Eyes (Tablet) Healthylax (Packet) Heartburn Relief (Tablet) Hem-Prep (Suppository) Hemorrhoid (Suppository) Hemorrhoidal (14%-71.9%-0.25%-3% Ointment, 14%-74.9%-0.25% Ointment, 85.5%-0.25%-3% Suppository) Hemorrhoidal Suppositories (Suppository) Hydro Skin Maximum Strength (Lotion) Bold type = Brand name drug Hydrocodone Bitartrate/ Homatropine Methylbromide (1.5mg-5mg Tablet, 1.5mg/ 5ml-5mg/5ml Syrup) Hydrocodone Polistirex/ Chlorpheniramine Polistirex (Liquid Extended-Release) Hydrocortisone (OTC Only) (0.5% Cream, 1% Cream, 0.5% Ointment) Hydrocortisone/Aloe (OTC Only) (Cream) Hydromet (Syrup) Hydroxocobalamin (Injection) I I-Caps (Capsule) I-Vite (Tablet) Ibu-Drops (OTC Only) (Suspension) Ibu-Drops Infants (OTC Only) (Suspension) Ibuprofen (OTC Only) (200mg Capsule, 200mg Tablet) Ibuprofen Junior Strength (OTC Only) (100mg Tablet Chewable) Iferex 150 (Capsule) In-Check Inspiratory Flowmeter/Nasal with Mask (Device) In-Check Inspiratory Flowmeter/Oral (Device) Infants Gas Relief (Suspension) Infants Ibuprofen (OTC Only) (50mg/1.25ml Suspension) Infants Simethicone (Suspension) Infed (Injection) Infuvite (Injection) Infuvite Adult (Injection) Infuvite Pediatric (Injection) Plain type = Generic drug InspiraChamber/Anti-Static Valved/Mouthpiece (Device) Inspirachamber/ Soothermask/Inspiramask/ Medium (Device) Inspirachamber/ Soothermask/Inspiramask/ Small (Device) Intense Cough Reliever Extra Strength (Liquid) Ionil-T (Shampoo) Iophen C-NR (Liquid) Iophen DM-NR (Liquid) Iophen-NR (Liquid) Iron (Tablet) Iron Chews Pediatric (Tablet Chewable) Isopto Tears (Ophthalmic Solution) Itch Relief Extra Strength (Cream) J J-TAN D PD (Liquid) Jock Itch Spray (Aerosol Powder) K Kao-Tin (240mg Capsule, 262mg/15ml Suspension) Ketotifen Fumarate (Ophthalmic Solution) Kidkare Cough/Cold (Liquid) Kimono Lubricated Kimono Micro Thin Kimono Micro Thin Plus Spermicide Lubricated Kimono Sensation Lubricated Kimono Sensation Plus Spermicide Lubricated Konsyl (28.3% Powder, 30.9% Powder, 520mg Capsule) Konsyl (60.3% Packet, 60.3% Powder, 71.67% Powder) Konsyl Fiber (Tablet) Konsyl-D (Powder) Bold type = Brand name drug M M-Clear WC (Oral Solution) M-End PE (Liquid) M-End WC (Liquid) M.V.I. 12 without Vitamin K (Injection) M.V.I. Adult (Injection) M.V.I. Pediatric (Injection) MYTAB GAS (Tablet Chewable) MYTAB GAS Maximum Strength (Tablet Chewable) Maalox Advanced (Suspension) Maalox Advanced Maximum Strength (Suspension) Mag-Delay (Tablet ExtendedRelease) Mag-G (Tablet) Mag-Tab SR (Tablet Extended-Release) Magnebind 300 (Tablet) Magnesium Citrate (Oral Solution) Magnesium Oxide (241.3mg Tablet) Magonate (1000mg/5ml Liquid) Magonate (500mg Tablet) Major-Prep Hemorrhoidal (Ointment) Plain type = Generic drug 75 Manganese Trace Metal (Injection) Mapap Sinus Maximum Strength Congestion and Pain (Tablet) Maximum D3 (Capsule) Maxx Lubricated Meclizine HCl (OTC Only) (Tablet Chewable) Medi-Cortisone (Cream) Mephyton (Tablet) Meribin (Capsule) Metamucil (Powder) Metamucil Multihealth Fiber (Powder) Metamucil Original Texture (Powder) Metamucil Smooth Texture (Powder) Metamucil Smooth Texture Sugar Free (Powder) Mi-Acid (Suspension) Mi-Acid Gas Relief (Tablet Chewable) Mi-Acid Maximum Strength (Suspension) Miconazole (Cream) Miconazole 1 (Kit) Miconazole 3 Combo Pack (Kit) Miconazole 7 (100mg Suppository, 2% Cream) Miconazole Nitrate (100mg Suppository, 2% Cream) Miconazorb AF (Powder) Micro Guard (Powder) Microchamber Microlife Digital Peak Flow Meter (Device) Microspacer Milantex (Suspension) Milantex Extra Strength (Suspension) Drug LIST L L-Arginine (Powder) L-Citrulline (Powder) L-Glutamine (Powder) Lactrase (Capsule) Lamisil AF Defense (Aerosol Powder) Lamisil AT (Cream) Lamisil AT Spray (External Solution) Lamisil Advanced (Gel) Laxative (10mg Suppository, 5mg Tablet DelayedRelease) Levonorgestrel (OTC Only) (Tablet) Lice Killing Maximum Strength (Shampoo) Lice Solution Kit (Kit) Lice Treatment Creme Rinse (Liquid) Lidocaine (OTC Only) (Cream) Lidocream (Cream) Liq-10 (Syrup) Liquituss GG (Liquid) Liteaire (Device) LoHist-D (Liquid) LoHist-DM (Syrup) LoHist-PEB (Liquid) Long Acting Nasal Spray (Nasal Solution) Loperamide HCl (OTC Only) (1mg/5ml Liquid, 1mg/ 7.5ml Suspension) Loratadine (Tablet) Loratadine Childrens (5mg/ 5ml Oral Solution, 5mg/5ml Syrup) Loratadine Hives Relief (Oral Solution) Loratadine-D 12 Hour (Tablet Extended-Release 12 Hour) Loratadine-D 24 Hour (Tablet Extended-Release 24 Hour) Lortuss EX (Liquid) Lotrimin AF (Powder) Lotrimin Ultra (Cream) Lubricant Eye Drops Dry Eye Therapy (Ophthalmic Solution) Lubricating Plus Eye Drops (Ophthalmic Solution) Milk of Magnesia (Suspension) Milk of Magnesia Concentrate (Suspension) Minerin (Cream) Mini Wright AFS Peak Flowmeter Low Range (Device) Mini Wright Peak Flow Meter (Device) Miniprin Low Dose (Tablet Delayed-Release) Mintox (Suspension) Mintox Maximum Strength (Suspension) Miralax (Packet, Powder) Moisturizing Cream (Cream) Motion Sickness (Tablet) Motion-Time (Tablet Chewable) Mucinex (Tablet ExtendedRelease 12 Hour) Mucinex Allergy (Tablet) Mucinex Chest Congestion Childrens (Liquid) Mucinex Childrens Cold Cough & Sore Throat (Liquid) Mucinex Childrens MultiSymptom Cold & Fever (Liquid) Mucinex Childrens MultiSymptom Cold (Liquid) Mucinex Cold for Kids (Liquid) Mucinex Congestion & Cough Childrens (Liquid) Mucinex Cough Childrens (Liquid) Mucinex D (Tablet ExtendedRelease 12 Hour) Mucinex DM (Tablet Extended-Release 12 Hour) Bold type = Brand name drug Mucinex DM Maximum Strength (Tablet ExtendedRelease 12 Hour) Mucinex Fast-Max Cold & Sinus (Tablet) Mucinex Fast-Max Cold Flu& Sore Throat (Liquid) Mucinex Fast-Max Cold Flu& Sore Throat (Tablet) Mucinex Fast-Max DM Max (Liquid) Mucinex Fast-Max Night Time Cold & Flu (Tablet, Liquid) Mucinex Fast-Max Severe Cold (325mg-10mg-200mg-5mg Tablet) Mucinex Fast-Max Severe Cold (Liquid) Mucinex Fast-Max Severe Congestion & Cold (Tablet) Mucinex Fast-Max Severe Congestion & Cough (Liquid) Mucinex Maximum Strength (Tablet Extended-Release 12 Hour) Mucinex Multi-Symptom Cold Night Time Childrens (Liquid) Mucinex Nasal Spray Full Force (Nasal Solution) Mucinex Nasal Spray Moisture Smart (Nasal Solution) Mucinex Sinus-Max Full Force (Nasal Solution) Mucinex Sinus-Max Pressure & Pain (Tablet) Mucinex Sinus-Max Severe Congestion Relief (Tablet) Mucinex Stuffy Nose & Cold Childrens (Liquid) Mucinex for Kids (Packet) Plain type = Generic drug Mucosa (Tablet) Mucosa DM (Tablet) Mucus Relief (Tablet) Mucus Relief Childrens (Liquid) Mucus Relief Cold/Sinus Maximum Strength (Liquid) Mucus Relief Cough Childrens (Liquid) Mucus Relief DM (Tablet) Mucus Relief Severe Congestion/Cough (Liquid) Mucus-DM (Tablet ExtendedRelease 12 Hour) Mucus-DM Max (Tablet Extended-Release 12 Hour) Mucus-ER (Tablet ExtendedRelease 12 Hour) Multi-Delyn (Liquid) Multi-Delyn/Iron (Liquid) Multi-Symptom Allergy (Capsule) Multi-Vitamins (Tablet) Multilex (Tablet) Multilex T&M (Tablet) Muro 128 (5% Ointment, 5% Ophthalmic Solution) My Way (OTC Only) (Tablet) MyKidz Iron 10 (Suspension) Mykidz Iron (Suspension) N NRS Nasal Relief (Nasal Solution) Nail Scrub (Liquid) Naproxen Sodium (OTC Only) (220mg Tablet ImmediateRelease) Nasal Decongestant (1% Nasal Solution, 30mg Tablet) Nasal Decongestant (30mg/ 5ml Liquid, 30mg/5ml Syrup) Bold type = Brand name drug Nicorette (2mg Gum, 4mg Gum, 2mg Lozenge, 4mg Lozenge) Nicorette Mini (Lozenge) Nicorette Starter Kit (Gum) Nicotine (Patch 24 Hour) Nicotine Polacrilex (2mg Gum, 4mg Gum, 2mg Lozenge, 4mg Lozenge) Nicotine Transdermal System (Patch 24 Hour) Night Time Multi-Symptom Cold/Flu Relief (Capsule) Nighttime Sinus Congestion & Pain (Tablet) Nighttime Sleep Aid (Tablet) Nite Time Cough (Liquid) Nite Time Multi-Symptom Cold/Flu Relief (Liquid) Nite-Time Cold/Flu (Capsule) Nite-Time Multi-Symptom Cold/Flu Relief (Liquid) Nohist-DM (Liquid) Nohist-LQ (Liquid) Novaferrum 125 (Liquid) Novaferrum 50 (Capsule) Novaferrum Pediatric Drops (Liquid) Nutraplus (10% Cream, 10% Lotion) O ORA-Blend SF (Suspension) ORA-Sweet SF (Syrup) Ocean Nasal Spray (Nasal Solution) Ocean for Kids (Nasal Solution) Ocuvite Adult 50+ (Capsule) Omega-3 Fish Oil (Capsule) Omeprazole (OTC Only) (20mg Tablet DelayedRelease) Once Daily (Tablet) Plain type = Generic drug 77 Once Daily/Iron (Tablet) One Daily (Tablet) One Daily Mens (Tablet) Opcicon One-Step (Tablet) Operand Scrub (External Solution) Opti-Clear (Ophthalmic Solution) Optichamber Diamond Optichamber Diamond/ Largeface Mask (Device) Optichamber Diamond/ Medium Face Mask Optichamber Diamond/Small Face Mask Ora-Blend (Suspension) Ora-Plus (Liquid) Oralyte (Oral Solution) Oralyte Freezer Pops (Oral Solution) Organ-I NR (Tablet) Oysco 500+D (Tablet Chewable) Oyster Shell Calcium (Tablet) Oyster Shell Calcium+Vitamin D (Tablet) Oyster Shell Calcium/Vitamin D (Tablet) P PRO-RED AC (Syrup) Pain Relief Cold Severe Congestion (Tablet) Pain Relief Sinus PE Daytime (Tablet) Panoxyl Wash (Liquid) Panoxyl-4 Creamy Wash (Liquid) Peak Air Peak Flow Meter Adult/Pediatric (Device) Pedi-Boro Soak Paks (Packet) Pedia Relief Cough/Cold (Liquid) Pedia-Lax (Liquid) Drug LIST Nasal Decongestant PE (Tablet) Nasal Decongestant PE Maximum Strength (Tablet) Nasal Decongestant Spray (Nasal Solution) Nasal Spray 12 Hour (Nasal Solution) Nasal Spray Anti-Drip (Nasal Solution) Nasal Spray X-Moist (Nasal Solution) Natural Coenzyme Q10 (Capsule) Natural Fiber Laxative (Powder) Natural Fiber Therapy (Powder) Nephro-Vite (Tablet) Nessi Spacer/Large Mask (Device) Nessi Spacer/Mouthpiece (Device) Nessi Spacer/Small/Med Mask (Device) Next Choice One Dose (OTC Only) (Tablet) Niacin ER (OTC Only) (Capsule Extended-Release) Niacin Flush Free Formula (OTC Only) (Capsule) Niacin SR (OTC Only) (Capsule Extended-Release) Niacin TR (OTC Only) (250mg Capsule ExtendedRelease, 500mg Capsule Extended-Release, 500mg Tablet Extended-Release, 750mg Tablet ExtendedRelease) Nicoderm CQ (Patch 24 Hour) Nicorelief (Gum) Pedialyte (Oral Solution) Pedialyte Advanced Care (Solution) Pedialyte Freezer Pops (Oral Solution) Pediatric Cough/Cold (Liquid) Pediatric Electrolyte (Oral Solution) Pediatric Electrolyte Freezer Pops (Oral Solution) Pediatric Electrolyte/Zinc (Oral Solution) Pediatric Medium Mask Pediatric Small Mask Peleverus (Ointment, 0.25% Liquid) Peleverus Clear (Ointment) Peleverus Gold (Ointment) Peptic Relief (Suspension) Periguard (Ointment) Permethrin (OTC Only) (Lotion) Personal Best Full Range (Device) Personal Best Low Range (Device) Petrolatum (Ointment) Pharbechlor (Tablet) Pharbedryl (Capsule) Phenylhistine DH (Liquid) Phos-NaK Powder Concentrate (Packet) Piko 1 Electronic (Device) Pink Bismuth Maximum Strength (Suspension) Plan B One-Step (OTC Only) (Tablet) Pocket Chamber (Device) Pocket Peak Flow Meter (Device) Poly Vitamin (Tablet Chewable) Poly-Iron 150 (Capsule) Bold type = Brand name drug Polyvitamin (Oral Solution) Polyvitamin/Iron (Oral Solution, Tablet Chewable) Povidone-Iodine (10% External Solution, 10% Ointment) Premium Condoms Lubricated Prenatal (OTC Only) (Tablet) Preparation H (Ointment) Preservision Areds 2 (Capsule) Prilosec OTC (Tablet DelayedRelease) Primeaire Dual-Valved Holding Chamber (Device) Pro-Clear AC (Syrup) Profe (Capsule) Profe Forte (Capsule) Promethazine VC/Codeine (Syrup) Promethazine-DM (Syrup) Promethazine/Codeine (Syrup) Promethazine/ Dextromethorphan (Syrup) Provil (Tablet) Pseudoephedrine HCl (Tablet) Pseudoephedrine HCl ER (Tablet Extended-Release 12 Hour) Puralube (Ointment) Pure & Gentle Lubricant (Ophthalmic Solution) Q Q-Dryl (Capsule) Q-Gel Mega (Capsule) Q-Tapp (Elixir) Q-Tapp DM (Elixir) Q-Tussin (Syrup) Q-Tussin DM (Syrup) Plain type = Generic drug QC 3 Day Vaginal Cream (Cream) QC AZO (Tablet) QC Acid Controller (Tablet) QC All Day Allergy (Tablet) QC Allergy Relief (Tablet Dispersible) QC Allergy Relief MultiSymptom Daytime (Tablet) QC Antacid (Suspension) QC Antacid/Anti-Gas (Suspension) QC Antacid/Anti-Gas Maximum Strength (Suspension) QC Anti-Diarrheal (Tablet) QC Aspirin (325mg Tablet, 325mg Tablet DelayedRelease) QC Aspirin Low Dose (Tablet Delayed-Release) QC Athletes Foot (Cream) QC Bacitracin (OTC Only) (Ointment) QC Castor Oil QC Childrens Aspirin (Tablet Chewable) QC Childrens Chewable Vitamins/Extra C (Tablet Chewable) QC Childrens Chewable Vitamins/Iron (Tablet Chewable) QC Chlor-Pheniramine (Tablet) QC Cold Relief Plus MultiSymptom Childrens (Suspension) QC Complete Allergy Medicine (Tablet) QC Cough Relief (Liquid) QC Cough/Sore Throat Nighttime (Liquid) Bold type = Brand name drug QC Nighttime Cold/Flu Relief (Liquid) QC Nighttime Cough (Liquid) QC No Drip Nasal Relief (Nasal Solution) QC Pink Bismuth (Suspension) QC Prenatal (OTC Only) (Tablet) QC Senna (Tablet) QC Senna-S (Tablet) QC Sinus Pain Relief (Tablet) QC Stool Softener (Capsule) QC Stool Softener Plus Laxative (Tablet) QC Suphedrine (Tablet) QC Suphedrine Maximum Strength (Tablet ExtendedRelease 12 Hour) QC Suphedrine PE (Tablet) QC Therin-M (Tablet) QC Tolnaftate (Cream) QC Tussin CF (Liquid) QC Womens Daily Multivitamin (Tablet) R Reeses Pinworm Medicine (Suspension) Refresh Celluvisc (Ophthalmic Solution) Refresh P.M. (Ointment) Refresh Plus (Ophthalmic Solution) Reguloid (0.52gm Capsule, 28.3% Powder, 48.57% Powder, 58.6% Powder) Relcof C (Oral Solution) Remedy Antifungal (2% Cream, 2% Powder) Remedy Nutrashield (Cream) Remedy Skin Repair (Cream) Rena-Vite (Tablet) Rescon DM (Syrup) Plain type = Generic drug 79 Rescon-GG (Liquid) Respaire-30 (Capsule) Rhinaris (Gel) Risabal-pH (Cream) Risacal-D (Tablet) Riteflo (Device) Robafen (Syrup) Robafen CF Cough & Cold (Syrup) Robafen DM (Syrup) Robafen DM Cough Clear (Syrup) Robitussin Childrens Cough & Cold CF (Liquid) Robitussin Childrens Cough Long-Acting (Syrup) Robitussin Childrens Cough/ Cold Long-Acting (Liquid) Robitussin Cold+flu Daytime (Capsule) Robitussin Cold+flu Nighttime (Capsule) Robitussin Lingering Coldlong-Acting Cough (Liquid) Robitussin Mucus+chest Congestion (Liquid) Robitussin Peak Cold Cough + Chest Congestion DM (Liquid) Robitussin Peak Cold Cough + Chest Congestion DM Max Strength (Liquid) Robitussin Peak Cold DM (Syrup) Robitussin Peak Cold MultiSymptom Cold (Liquid) Robitussin Peak Cold MultiSymptom Cold Maximum Strength (Liquid) Robitussin Peak Cold Nasal Relief (Tablet) Drug LIST QC Daily Multivitamins/Iron (Tablet) QC Docusate Calcium (Capsule) QC Ear Wax Removal Drops (Otic Solution) QC Enema (Enema) QC Ferrous Sulfate (Tablet) QC Fiber Laxative (Capsule) QC Gas Relief (Tablet Chewable) QC Gas Relief Extra Strength (Tablet Chewable) QC Gentle Laxative (10mg Suppository, 5mg Tablet Delayed-Release) QC Hemorrhoidal (Suppository) QC Ibuprofen (OTC Only) (200mg Tablet) QC Ibuprofen IB (OTC Only) (200mg Tablet) QC Loratadine Allergy Relief (Tablet) QC Loratadine-D (Tablet Extended-Release 24 Hour) QC Magnesium Citrate (Oral Solution) QC Maximum Daily Multivitamin/Multimineral (Tablet) QC Medifin Mucus Relief Childrens (Liquid) QC Milk of Magnesia (Suspension) QC Multi-Vite (Tablet) QC Multi-Vite 50 & Over (Tablet) QC Naproxen Sodium (OTC Only) (220mg Tablet Immediate-Release) QC Natural Vegetable (Powder) Robitussin Peak Cold Nighttime Multi-Symptom Cold (Liquid) Robitussin Peak Cold Nighttime Nasal Relief (Tablet) Rulox (Suspension) Rydex (Liquid) Rynex DM (Liquid) Rynex PE (Elixir) Rynex PSE (Liquid) S SB Allergy (Tablet) SB Antacid Anti-Gas (Suspension) SB Anti-Itch Maximum Strength (Cream) SB Aspirin (81mg Tablet Delayed-Release) SB Bismuth (Suspension) SB Cold & Cough HBP (Tablet) SB Cold Head Congestion Severe Daytime (Tablet) SB Cold Multi-Symptom Severe Daytime (Tablet) SB Cough Control CF (Liquid) SB Cough Control DM (Liquid) SB Cough Control DM Max (Liquid) SB Cough Relief (Liquid) SB Coughtab (Tablet) SB Flu Maximum Strength HBP (Tablet) SB Ibuprofen (OTC Only) (200mg Tablet) SB Lice Killing Maximum Strength (Shampoo) SB Loratadine (Tablet) SB Naproxen Sodium (OTC Only) (220mg Tablet Immediate-Release) Bold type = Brand name drug SB Sinus & Allergy Maximum Strength (Tablet) SB Sinus Congestion & Pain Daytime (Tablet) SB Sinus Congestion & Pain Daytime/Nighttime SB Sinus Congestion & Pain Severe Daytime (Tablet) SM 12 Hour Sinus Decongestant (Tablet Extended-Release 12 Hour) SM 12-Hour No Drip (Nasal Solution) SM 3-Day Vaginal (Cream) SM Acid Reducer (Tablet) SM All Day Allergy (Tablet) SM All Day Allergy-D (Tablet Extended-Release 12 Hour) SM All Day Pain Relief (220mg Tablet ImmediateRelease) SM Allergy 4 Hour (Tablet) SM Allergy Multi-Symptom (Tablet) SM Allergy Relief (1.34mg Tablet, 25mg Tablet, 10mg Tablet Dispersible, 25mg Capsule) SM Allergy Relief Loratadine (Tablet) SM Antacid Advanced Maximum Strength (Suspension) SM Antacid Anti-Gas (Suspension) SM Antacid Maximum Strength (Suspension) SM Anti-Diarrheal (1mg/5ml Liquid, 2mg Tablet) SM Anti-Itch Extra Strength (Cream) SM Antifungal Miconazole (Cream) Plain type = Generic drug SM Antifungal Tolnaftate (Cream) SM Artificial Tears (Ophthalmic Solution) SM Aspirin Adult Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release) SM Aspirin Enteric Coated (Tablet Delayed-Release) SM Aspirin Low Dose (Tablet Delayed-Release) SM Athletes Foot (Cream) SM Calcium Citrate w/Vitamin D3 (Tablet) SM Castor Oil SM Childrens Aspirin (Tablet Chewable) SM Childrens Loratadine (Syrup) SM Childrens Pain Relief Plus Multi-Symptom Cold (Suspension) SM Clearlax (Powder) SM Clotrimazole Vaginal (OTC Only) (Cream) SM Cold & Allergy Childrens (Elixir) SM Cold & Cough DM Childrens (Elixir) SM Cold Head Congestion Severe Day Time (Tablet) SM Complete Advanced Formula (Tablet) SM Complete Senior Formula (Tablet) SM Cough Relief (Syrup) SM Day Time Cold & Flu Relief (Liquid) SM Day Time PE Cold & Flurelief (Capsule) SM Docusate Calcium (Capsule) Bold type = Brand name drug SM Loratadine Allergy Relief (Tablet Dispersible) SM Loratadine-D 12 Hour (Tablet Extended-Release 12 Hour) SM Lubricant Eye Drops (Ophthalmic Solution) SM Miconazole 7 (OTC Only) (100mg Suppository, 2% Cream) SM Milk of Magnesia (Suspension) SM Mucus ER (Tablet Extended-Release 12 Hour) SM Mucus Relief Cough Childrens (Liquid) SM Naproxen Sodium (OTC Only) (220mg Capsule Immediate-Release) SM Nasal Decongestant Maximum Strength (Tablet) SM Nasal Decongestant PE (Tablet) SM Nasal Spray Moisturizing (Nasal Solution) SM Nasal Spray Saline (Nasal Solution) SM Nasal Spray Sinus (Nasal Solution) SM Natural Laxative Plus Stool Softener (Tablet) SM Nicotine (14mg/24hr Patch 24 Hour, 21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour, 2mg Lozenge, 4mg Gum) SM Nicotine Polacrilex (2mg Gum, 4mg Gum, 4mg Lozenge) SM Nite Time Cold & Flu (Liquid) Plain type = Generic drug 81 SM Nite Time Cold & Flu Relief (325mg-15mg-6.25mg Capsule, 500mg/ 15ml-15mg/15ml-6.25mg/ 15ml Liquid) SM Nite Time Cough (Liquid) SM Nose Drops Nasal Decongestant Extra Strength (Nasal Solution) SM Omega-3 Fish Oil (Capsule) SM Omeprazole (OTC Only) (20mg Tablet DelayedRelease) SM Oral Saline Laxative (Oral Solution) SM Pediatric Electrolyte (Oral Solution) SM Stomach Relief (Suspension) SM Stomach Relief Maximum Strength (Suspension) SM Stool Softener (Capsule) SM Stool Softener Plus Laxative (Tablet) SM Tioconazole-1 (Ointment) SM Triple Antibiotic (Ointment) SM Tussin (Syrup) SM Tussin CF (Liquid) SM Tussin DM (Syrup) SM Tussin DM Cough/Chest Congestion (Syrup) SM Tussin DM Max Cough/ Chest Congestion (Liquid) SM Womans Laxative (Tablet Delayed-Release) Sal-Plant (Gel) Salactic Film (External Solution) Saline Mist (Nasal Solution) Saline Nasal Spray (Nasal Solution) Drug LIST SM Double Antibiotic (Ointment) SM Enema (Enema) SM Eye Itch Relief (Ophthalmic Solution) SM Fexofenadine HCl (Tablet) SM Fiber (Powder) SM Fiber Laxative (0.52gm Capsule, 500mg Tablet, 625mg Tablet) SM Flu Relief Therapy Severe Cold Nighttime (Liquid) SM Foaming Antacid (Tablet Chewable) SM Gas Relief (Tablet Chewable) SM Gas Relief Drops Infants (Suspension) SM Gas Relief Infants Drops (Suspension) SM Gentle Laxative (Tablet Delayed-Release) SM Glucose (Tablet Chewable) SM Hemorrhoidal (Ointment) SM Hydrocortisone (OTC Only) (Cream) SM Ibuprofen (OTC Only) (200mg Tablet) SM Ibuprofen IB (OTC Only) (200mg Tablet) SM Infants Ibuprofen (OTC Only) (50mg/1.25ml Suspension) SM Iron (Tablet) SM Laxative (Suppository) SM Lice Killing Maximum Strength (Shampoo) SM Lice Treatment (Lotion) SM Loperamide HCl (OTC Only) (Suspension) SM Lorata-Dine D (Tablet Extended-Release 24 Hour) SM Loratadine (Syrup) Sea Soft Nasal Mist (Nasal Solution) Sea-Omega 30 (Capsule) Sea-Omega 50 (Capsule) Senexon (8.6mg Tablet, 8.8mg/5ml Liquid) Senexon-S (Tablet) Senna (8.6mg Tablet, 8.8mg/ 5ml Syrup) Senna Lax (Tablet) Senna Plus (Tablet) Senna Prompt (Capsule) Senna-S (Tablet) Senna-Tabs (Tablet) Senna-Time (Tablet) Sennalax-S (Tablet) Senno (Tablet) Sennosides/Docusate Sodium (Tablet) Sensi-Care Protective Barrier (Ointment) Sentry (Tablet) Sentry Senior (Tablet) Sesame Oil Sidestream Pediatric Facemask/Tucker the Turtle Silace (150mg/15ml Liquid, 60mg/15ml Syrup) Siladryl Allergy (Liquid) Silicone Mask for Breatherite Chamber/Infant Silicone Mask for Breatherite Chamber/Pediatric Siltussin SA (Syrup) Siltussin-DM (Syrup) Simethicone (40mg/0.6ml Suspension, 80mg Tablet Chewable) Sinus Congestion & Pain Daytime (Tablet) Sinus Nasal Spray (Nasal Solution) Bold type = Brand name drug Slo-Niacin (OTC Only) (250mg Tablet ExtendedRelease) Slo-Niacin (OTC Only) (500mg Tablet ExtendedRelease, 750mg Tablet Extended-Release) Slow-Mag (Tablet DelayedRelease) Sodium Bicarbonate (Tablet) Sodium Chloride (OTC Only) (5% Ointment, 5% Ophthalmic Solution) Soothe & Cool Free Moisture Barrier (Ointment) Soothe & Cool INZO Antifungal Cream (Cream) Soothe & Cool Protect Moisture Barrier (Ointment) Sterile Water for Injection (Injection) Stimulant Laxative (Tablet Delayed-Release) Stomach Relief (Suspension) Stomach Relief Maximum Strength (Suspension) Stool Softener (Capsule) Stool Softener Extra Strength (Capsule) Stool Softener Laxative DC (Capsule) Stress Formula (Tablet) Stress Formula w/Iron (Tablet) Stress Formula/Zinc (OTC Only) (Tablet) Stuart One (Capsule) Sudogest (Tablet) Sudogest 12 Hour (Tablet Extended-Release 12 Hour) Sudogest PE (Tablet) Sudogest Sinus & Allergy (Tablet) Superplex-T (Tablet) Systane (Ophthalmic Solution) Plain type = Generic drug Systane Balance Restorative Formula (Ophthalmic Solution) Systane Gel (Gel) Systane Nighttime (Ointment) Systane Overnight Therapy Lubricant Eye (Gel) Systane Ultra (Ophthalmic Solution) T TAB-A-VITE (Tablet) TAB-A-VITE Womens (Tablet) TAB-A-VITE w/Beta Carotene (Tablet) TAB-A-VITE/Iron (Tablet) TGT Glucose (Tablet Chewable) Take Action (Tablet) Tears Naturale (Ophthalmic Solution) Tears Naturale Forte (Ophthalmic Solution) Tears Naturale II (Ophthalmic Solution) Tears Pure (Ophthalmic Solution) Terbinafine HCl (OTC Only) (Cream) Tessalon Perles (Capsule) Thera (Tablet) Thera M Plus (Tablet) Thera-M (Tablet) Thera/Beta-Carotene (Tablet) Therems (Tablet) Therems-H (Tablet) Therems-M (Tablet) Thiamine HCl (Injection) Tinactin (Aerosol) Tioconazole-1 (Ointment) Tolnaftate (1% Cream, 1% External Solution, 1% Powder) Bold type = Brand name drug Truzone Peak Flow Meter (Device) Tusnel (Liquid) Tusnel Diabetic (Liquid) Tusnel Pediatric (Liquid) Tussi-Pres PE Pediatric (Liquid) Tussigon (Tablet) Tussin (Syrup) Tussin CF (Liquid) Tussin CF Cough & Cold (Liquid) Tussin CF Max MultiSymptom (Liquid) Tussin Chest Congestion (Syrup) Tussin Cough (Syrup) Tussin DM (10mg-100mg/ 5ml Liquid, 10mg/ 5ml-100mg/5ml Syrup) Tussin DM Max (Liquid) Tussin Mucus + Chest Congestion (Syrup) Tussionex Pennkinetic Extended-Release (Liquid Extended-Release) Vita-Bee/C (Tablet) Vitamin B Complex-C (Capsule) Vitamin C (Tablet) Vitamin D (RX Only) (1000unit Capsule, 2000unit Capsule, 400unit/ml Liquid, 50000unit Capsule) Vitamin D3 (OTC Only) (10000unit Capsule, 50000unit Capsule, 5000unit Capsule, 1000unit Tablet, 5000unit Tablet, 400unit/ml Liquid) Vitamin D3 Super Strength (OTC Only) (Tablet) Vitamin K1 (10mg/ml Injection) Vitamin K1 (1mg/0.5ml Injection) Vortex Holding Chamber/ Mask/Childs (Device) Vortex Holding Chamber/ Mask/Toddler (Device) Vortex Valved Holding Chamber (Device) U Unicomplex-M (Tablet) Urea (10% Cream, 10% Lotion) Ureacin-10 (Lotion) W Watchhaler (Device) Womans Laxative (Tablet Delayed-Release) V Vagistat-1 (Ointment) Vagistat-3 (Kit) Valved Holding Chamber (Device) Vanahist PD (Liquid) Venofer (Injection) Vicks Dayquil Mucus Control DM (Liquid) Virtussin A/C (Oral Solution) Virtussin DAC (Oral Solution) Plain type = Generic drug 83 Z Zaditor (Ophthalmic Solution) Zeasorb-AF (Powder) Ziks Arthritis Pain Relief (Cream) Zinc Sulfate (OTC Only) (220mg Capsule) Zinc Trace Metal (Injection) Zonatuss (Capsule) Zoo Friends (Tablet Chewable) Zoo Friends Complete (Tablet Chewable) Drug LIST Travel Sickness (25mg Tablet Chewable, 50mg Tablet) Tri-Vita (Oral Solution) Tri-Vitamin (Oral Solution) Triacting Nightime Cold& Cough Childrens (Liquid) Triaminic Cold & Allergy (Syrup) Triaminic Cold & Cough Day Time Childrens (Syrup) Triaminic Cough & Congestion Childrens (Syrup) Triaminic Cough & Sore Throat (Suspension) Triaminic Multi-Symptom Fever (Syrup) Triaminic Night Time Cold & Cough (Syrup) Triple Antibiotic (Ointment) Trixaicin (Cream) Trixaicin HP (Cream) Trustex Lubricated Trustex Lubricated Extra Large Trustex Lubricated Extra Strength Trustex Lubricated/Ribbed/ Studded Trustex Lubricated/ Spermicide Trustex Lubricated/ Spermicide Extra Large Trustex Lubricated/ Spermicide Extra Strength Trustex Non-Lubricated Trustex with Nonoxynol-9/ Ribbed/Studded Trustex/Ria Lubricated Trustex/Ria Lubricated Spermicide Trustex/Ria Lubricated/ Spermicide Trustex/Ria Non-Lubricated Zoo Friends Gummies (Tablet Chewable) Zoo Friends Plus Extra C (Tablet Chewable) Zoo Friends Plus Iron (Tablet Chewable) Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. UHNJ16MP3700480_000 Ready to ENROLL UHEX16MP3700084_001 Enrollment INSTRUCTIONS We want to make your health care experience as easy as possible right from the start. Below we’ve described the forms you need to fill out to enroll in your plan. Questions? Ask your licensed sales representative or call the number on the first page of this booklet. Sales Appointment Confirmation Form (use only with a licensed sales representative) If you are meeting with a licensed sales representative, you will need to fill out this form completely before your appointment can begin. On this form, you’ll select which products and services you’d like to discuss during your appointment. Enrollment request form We need certain information to complete your enrollment. This form gathers that information. Two copies of the form are included. Fill out only one form for each applicant. For Dual Special Needs Plans, you have to provide your Social Security number so we can verify your Medicaid eligibility. Please sign your application, then return the completed enrollment form. By mail: UnitedHealthcare Attn: Enrollment Department 3315 Central AVE Hot Springs, AR, 71913 By fax: 1-501-262-7070 Enrollment checklist (use only with a licensed sales representative) This checklist helps ensure that your licensed sales representative explains the plan clearly to you and that you fully understand the plan you’ve chosen. Enrollment receipt (use only with a licensed sales representative) Your licensed sales representative will help you fill out this receipt. You can use the completed receipt as your temporary proof of coverage until you receive your permanent membership materials. If you received this kit through the mail, not from a licensed sales representative, you will not receive an enrollment receipt. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150608_140046 Accepted CSAL16HM3709721_000 86 TEAR HERE Scope of Sales Appointment Confirmation Form Page 1 of 2 The Centers for Medicare and Medicaid Services requires Licensed Sales Representatives to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the Licensed Sales Representative and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative. Please initial below beside the type of product(s) you want the Licensed Sales Representative to discuss. (Refer to page 2 for product type descriptions) Stand-alone Medicare Prescription Drug Plans (Part D) Hospital Indemnity Products Medicare Advantage Plans (Part C) and Cost Plans Medicare Supplement (Medigap) Products Dental/Vision/Hearing Products By signing this form, you agree to a meeting with a Licensed Sales Representative to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. Beneficiary or Authorized Representative Signature and Signature Date: Signature Signature Date If you are the authorized representative, please sign above and print clearly and legibly below: Name (First_Last) Relationship to Beneficiary To be completed by Licensed Sales Representative (please print clearly and legibly) Licensed Sales Representative Name (First_Last) Licensed Sales Representative Phone Licensed Sales Representative ID Beneficiary Name (First_Last) Beneficiary Phone (Optional) Date Appointment will be Completed Initial Method of Contact Plan(s) the Licensed Sales Representative will represent during the meeting Licensed Sales Representative Signature Scope of appointment (SOA) is subject to CMS Record Retention Requirements Licensed Sales Representative, if the form was not signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: Please check all that apply Unplanned Attendee Walk-in New SOA required (consumer requested other Health Product information) Other (please explain): Y0066_140611_154714 Approved 87 Ready to ENROLL TEAR HERE Beneficiary Address (Optional) Page 2 of 2 Fax to: 1-866-994-9659 Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-For-Service Plans, and Medicare Medical Savings Account Plans. Medicare Advantage Plans (Part C) and Cost Plans Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies). Medicare HMO Point-of-Service (HMO-POS) Plans — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. HMOPOS plans may allow you to get some services out of network for a higher copayment or coinsurance. Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors, providers and hospitals but you can also use out-of-network providers, usually at a higher cost. Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you — not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-ofnetwork providers. Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles. Other Related Products Dental/Vision/Hearing Products — Plans offering additional benefits for consumers who are looking to cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare. Hospital Indemnity Products — Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are not affiliated or connected to Medicare. Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and co-insurance amounts for Medicare approved services. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. UHEX16MP3693102_000 88 2016 Enrollment Request Form Page 1 of 6 Please contact the Plan if you need information in another language or format (Braille). TEAR HERE □ UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-005 - UDO This plan is designed for people with both Medicare and Medicaid. We may need to contact you to ask for proof. If we can't get proof before the enrollment deadline, you won’t be able to join the plan. This is a Health Maintenance Organization (HMO) plan. It has a network of doctors, specialists, hospitals and other providers you must use. Information about you. Please type or print in black or blue ink. o Mr. Last Name o Mrs. o Ms. First Name Middle Initial Birth Date M M / D D / Y Y Y Y Sex ¨ Male ¨ Female Main Phone Number ( Other Phone Number ( ) - Social Security Number (Required for people who are enrolling in D-SNP plans): _ ) - _ Permanent Street Address (P.O. BOX IS NOT ALLOWED) City County State ZIP TEAR HERE Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.) City State ZIP Email Address Copy 1 Enrollee name 89 This page intentionally left blank. 90 Page 2 of 6 Information about your Medicare Please use the information from your red, white and blue Medicare card. Remember, you need to have both Medicare Part A and Part B to join this plan. You can simply fill in the blanks so they match your card. TEAR HERE Or, you can attach a copy of the card or your letter from Social Security or the Railroad Retirement Board. How do you want to pay? You can pay your monthly plan premium if one applies, (including any late enrollment penalty you may owe) by mail or from your bank account through Electronic Funds Transfer (EFT). You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month. This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late enrollment penalty (LEP), we’ll add it to your premium. If you don’t choose an option, we’ll send a bill each month to your mailing address. ¨ I want to pay by mail. We’ll send a bill to your mailing address each month. ¨ I want to pay directly from my bank account. Please attach a blank check from the account you’d like to use. Write “VOID” across the front. Please DO NOT send a deposit slip or money order. · Please read the statement below. My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my checking account on or about the fifth of each month. If I choose to stop paying directly from my account, I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of payment. TEAR HERE · Account Type □ Checking □ Savings Account Holder Name: _________________________________________________________________ Bank Routing Number Copy 1 Bank Account Number · Sign here: ¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check. We’ll set it up. It may take a few months before payment starts, so the first payment may include more than one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the Enrollee name 91 This page intentionally left blank. 92 Page 3 of 6 first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums. A few notes about your costs. TEAR HERE If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) Social Security (SS) will send you a letter and ask you how you want to pay it: · · · You can pay it from your SS check Medicare can bill you The Railroad Retirement Board (RRB) can bill you Please DO NOT pay the plan the Part D-IRMAA at this time. Need help with your prescription drug costs? If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify, Medicare could pay for 75% or more of your costs, including your monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only part of your premium, we will bill you for the amount that Medicare doesn’t cover. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. A few questions to help us manage your plan. ¨ Yes ¨ No 1. Do you want plan information in another language or format? Please check what you’d like: ¨ Spanish ¨ Chinese ¨ Other TEAR HERE If you don’t see the language or format you want, please call us at 1-888-834-3721, (TTY 711) during 8 a.m. to 8 p.m. local time, 7 days a week. Or visit www.UHCCommunityPlan.com for online help. ¨ Yes ¨ No 2. Do you have end stage renal disease? If you have had a successful kidney transplant and/or you don’t need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information. ¨ Yes ¨ No If “yes,” are you currently a member of a health care company? Name of Company Member ID ¨ Yes ¨ No 3. Do you have Medicaid? If yes, please give us your Medicaid number: Enrollee name 93 _ Copy 1 _ This page intentionally left blank. 94 Page 4 of 6 ¨ Yes ¨ No 4. Do you live in a nursing home or a long-term care facility? If yes, please give us: Name City Address TEAR HERE Phone Number ( ) -- State Date you moved there ZIP M M/D D/Y Y Y Y ¨ Yes ¨ No 5. Do you have health insurance with an employer or union right now? If yes, you could lose that plan if you join this plan. Please talk to your employer or union. Ask how joining our plan could affect your current plan. You may also want to check your employer or union’s website, or read any information sent to you. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. ¨ Yes ¨ No 6. Do you or your spouse work? Do you or your spouse have other health insurance that will cover medical services? (Examples: Other employer group coverage, LTD coverage, Workman’s Compensation, Auto Liability, or Veterans benefits) If yes, please complete the following: ¨ Yes ¨ No Name of Health Insurance Company Subscriber Name Group ID Member ID Effective Dates (if applicable) M M/D D/Y Y Y Y - M M/D D/Y Y ¨ Yes ¨ No 7. Do you have other insurance that will cover your prescription drugs? TEAR HERE Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs. If yes, what is it? Name of other insurance Member ID number Group ID number Date plan started M M/D D/Y Y Y Y 8. Please give us the name of your primary care provider (PCP), clinic or health center. You can find a list on the plan website or in the provider directory. Provider/PCP ID number: Phone number: ( ) - (Please enter the number exactly as it appears on the website or in the directory. It will be 10 to 12 digits. Don't include dashes.) Are you now seeing or have you recently seen this doctor? Enrollee name 95 ¨ Yes ¨ No Copy 1 Provider or PCP full name This page intentionally left blank. 96 Page 5 of 6 Please read and sign. TEAR HERE TEAR HERE By completing this form, I agree to the following: · This is a Medicare Advantage plan. It has a contract with the federal government. This is not a Medicare Supplement plan. · I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless Medicaid or someone else pays for it. · I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan. · If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan. · I may have to pay a late enrollment penalty (LEP). This would only happen if I didn’t sign up for and keep creditable prescription drug coverage when I first qualified for Medicare. “Creditable” means the coverage is as good as a Medicare prescription drug plan. If I need to pay a LEP, the plan will tell me. · I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do so during the Open Enrollment Period for Medicare Advantage AND Medicare prescription drug coverage between October 15 and December 7. There may be special situations that would allow me to leave the plan at other times. · This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in the new area. Medicare may not cover me when I’m out of the country. However, I have some limited coverage near the U.S. border. · I will get an Evidence of Coverage (EOC). (The EOC is also known as a member contract or subscriber agreement.) The EOC will list services the plan covers, as well as the plan’s terms and conditions. The plan will cover services it approves, as well as services listed in the EOC. If a service isn’t listed in the EOC or approved by the plan, Medicare and the plan won’t pay for it. If I disagree with how the plan covers my care, I have the right to make an appeal. · I understand that I must get my health care coverage from doctors or providers that are in my plan’s network. I can go to any doctor or hospital in an emergency or urgently needed services or out-of-area dialysis services. · If I currently have Medicare Supplement Insurance (Medigap), I will cancel it in writing. I, not my agent, must cancel. I will cancel after my new plan tells me I’ve been accepted into the plan. · My plan will give my information to Medicare and other plans when needed for treatment, payment and health care operations. This may include my prescription drug information. Medicare uses the information to understand how my care was handled or billed. Other plans may need my information when they help pay for my care. Medicare may also give my information for research and other purposes. All federal laws and rules protecting my privacy will be followed. · If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay that person for this help. · The information on this form is correct, to the best of my knowledge. I understand that if I put information on this form that I know is not true, I will lose the plan. When I sign below, it means that I have read and understand the information on this form. Signature of applicant / member / authorized representative: Enrollee name 97 Today’s date: M M / D D / Y Y Y Y Copy 1 If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show written proof of this right if Medicare asks for it. This page intentionally left blank. 98 Page 6 of 6 If you are the authorized representative, please sign above and complete the information below. First Name Last Name Address State TEAR HERE City Phone Number ( ) ZIP Code Relationship to Applicant -- For licensed sales representative/agency use only. New Member Plan Change Employer Group Name Branch ID Employer Group ID Where did this application originate? □ Retail/Mall Program □ Member Meeting □ Local Event Outreach □ Community Meeting How was this application submitted? Appointment Other □ Local B2B Outreach □ Other Mail In Licensed Sales Representative/Writing ID Initial Receipt Date M M/D D/Y Y Y Y Licensed Sales Representative/Agent Name Proposed Effective Date M M/D D/Y Y Y Y Licensed Sales Representative Phone Number ( ) -- TEAR HERE Agent must complete AEP OEPI ICEP (MA enrollees) SEP (SEP Reason) SEP (Chronic) IEP (MA-PD enrollees) SEP (Full Dual Eligible) IEP (MA-PD enrollees eligible for 2nd IEP) SEP (Partial Dual Eligible) SEP Eligibility Date M M / D D / Y Y Y Y Licensed Sales Representative Signature (required) Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-888-834-3721, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana 本資訊也有其他語言的免費版本。請撥打 1-888-834-3721 聯絡我們的客戶服務部, 聽語障專線711, 每 週7天, 當地時間上午8 時至晚上8 時 Y0066_150729_133227 Approved CSNJ16HM3724996_002 99 Copy 1 This information is available for free in other languages. Please call our customer service number at 1-888-834-3721, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. This page intentionally left blank. 100 2016 Enrollment Request Form Page 1 of 6 Please contact the Plan if you need information in another language or format (Braille). TEAR HERE □ UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-005 - UDO This plan is designed for people with both Medicare and Medicaid. We may need to contact you to ask for proof. If we can't get proof before the enrollment deadline, you won’t be able to join the plan. This is a Health Maintenance Organization (HMO) plan. It has a network of doctors, specialists, hospitals and other providers you must use. Information about you. Please type or print in black or blue ink. o Mr. Last Name o Mrs. o Ms. First Name Middle Initial Birth Date M M / D D / Y Y Y Y Sex ¨ Male ¨ Female Main Phone Number ( Other Phone Number ( ) - Social Security Number (Required for people who are enrolling in D-SNP plans): _ ) - _ Permanent Street Address (P.O. BOX IS NOT ALLOWED) City County State ZIP TEAR HERE Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.) City State ZIP Email Address Copy 2 Enrollee name 101 This page intentionally left blank. 102 Page 2 of 6 Information about your Medicare Please use the information from your red, white and blue Medicare card. Remember, you need to have both Medicare Part A and Part B to join this plan. You can simply fill in the blanks so they match your card. TEAR HERE Or, you can attach a copy of the card or your letter from Social Security or the Railroad Retirement Board. How do you want to pay? You can pay your monthly plan premium if one applies, (including any late enrollment penalty you may owe) by mail or from your bank account through Electronic Funds Transfer (EFT). You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month. This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late enrollment penalty (LEP), we’ll add it to your premium. If you don’t choose an option, we’ll send a bill each month to your mailing address. ¨ I want to pay by mail. We’ll send a bill to your mailing address each month. ¨ I want to pay directly from my bank account. Please attach a blank check from the account you’d like to use. Write “VOID” across the front. Please DO NOT send a deposit slip or money order. · Please read the statement below. My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my checking account on or about the fifth of each month. If I choose to stop paying directly from my account, I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of payment. TEAR HERE · Account Type □ Checking □ Savings Account Holder Name: _________________________________________________________________ Bank Routing Number Copy 2 Bank Account Number · Sign here: ¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check. We’ll set it up. It may take a few months before payment starts, so the first payment may include more than one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the Enrollee name 103 This page intentionally left blank. 104 Page 3 of 6 first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums. A few notes about your costs. TEAR HERE If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) Social Security (SS) will send you a letter and ask you how you want to pay it: · · · You can pay it from your SS check Medicare can bill you The Railroad Retirement Board (RRB) can bill you Please DO NOT pay the plan the Part D-IRMAA at this time. Need help with your prescription drug costs? If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify, Medicare could pay for 75% or more of your costs, including your monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only part of your premium, we will bill you for the amount that Medicare doesn’t cover. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. A few questions to help us manage your plan. ¨ Yes ¨ No 1. Do you want plan information in another language or format? Please check what you’d like: ¨ Spanish ¨ Chinese ¨ Other TEAR HERE If you don’t see the language or format you want, please call us at 1-888-834-3721, (TTY 711) during 8 a.m. to 8 p.m. local time, 7 days a week. Or visit www.UHCCommunityPlan.com for online help. ¨ Yes ¨ No 2. Do you have end stage renal disease? If you have had a successful kidney transplant and/or you don’t need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information. ¨ Yes ¨ No If “yes,” are you currently a member of a health care company? Name of Company Member ID ¨ Yes ¨ No 3. Do you have Medicaid? If yes, please give us your Medicaid number: Enrollee name 105 _ Copy 2 _ This page intentionally left blank. 106 Page 4 of 6 ¨ Yes ¨ No 4. Do you live in a nursing home or a long-term care facility? If yes, please give us: Name City Address TEAR HERE Phone Number ( ) -- State Date you moved there ZIP M M/D D/Y Y Y Y ¨ Yes ¨ No 5. Do you have health insurance with an employer or union right now? If yes, you could lose that plan if you join this plan. Please talk to your employer or union. Ask how joining our plan could affect your current plan. You may also want to check your employer or union’s website, or read any information sent to you. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. ¨ Yes ¨ No 6. Do you or your spouse work? Do you or your spouse have other health insurance that will cover medical services? (Examples: Other employer group coverage, LTD coverage, Workman’s Compensation, Auto Liability, or Veterans benefits) If yes, please complete the following: ¨ Yes ¨ No Name of Health Insurance Company Subscriber Name Group ID Member ID Effective Dates (if applicable) M M/D D/Y Y Y Y - M M/D D/Y Y ¨ Yes ¨ No 7. Do you have other insurance that will cover your prescription drugs? TEAR HERE Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs. If yes, what is it? Name of other insurance Member ID number Group ID number Date plan started M M/D D/Y Y Y Y 8. Please give us the name of your primary care provider (PCP), clinic or health center. You can find a list on the plan website or in the provider directory. Provider/PCP ID number: Phone number: ( ) - (Please enter the number exactly as it appears on the website or in the directory. It will be 10 to 12 digits. Don't include dashes.) Are you now seeing or have you recently seen this doctor? Enrollee name 107 ¨ Yes ¨ No Copy 2 Provider or PCP full name This page intentionally left blank. 108 Page 5 of 6 Please read and sign. TEAR HERE TEAR HERE By completing this form, I agree to the following: · This is a Medicare Advantage plan. It has a contract with the federal government. This is not a Medicare Supplement plan. · I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless Medicaid or someone else pays for it. · I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan. · If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan. · I may have to pay a late enrollment penalty (LEP). This would only happen if I didn’t sign up for and keep creditable prescription drug coverage when I first qualified for Medicare. “Creditable” means the coverage is as good as a Medicare prescription drug plan. If I need to pay a LEP, the plan will tell me. · I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do so during the Open Enrollment Period for Medicare Advantage AND Medicare prescription drug coverage between October 15 and December 7. There may be special situations that would allow me to leave the plan at other times. · This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in the new area. Medicare may not cover me when I’m out of the country. However, I have some limited coverage near the U.S. border. · I will get an Evidence of Coverage (EOC). (The EOC is also known as a member contract or subscriber agreement.) The EOC will list services the plan covers, as well as the plan’s terms and conditions. The plan will cover services it approves, as well as services listed in the EOC. If a service isn’t listed in the EOC or approved by the plan, Medicare and the plan won’t pay for it. If I disagree with how the plan covers my care, I have the right to make an appeal. · I understand that I must get my health care coverage from doctors or providers that are in my plan’s network. I can go to any doctor or hospital in an emergency or urgently needed services or out-of-area dialysis services. · If I currently have Medicare Supplement Insurance (Medigap), I will cancel it in writing. I, not my agent, must cancel. I will cancel after my new plan tells me I’ve been accepted into the plan. · My plan will give my information to Medicare and other plans when needed for treatment, payment and health care operations. This may include my prescription drug information. Medicare uses the information to understand how my care was handled or billed. Other plans may need my information when they help pay for my care. Medicare may also give my information for research and other purposes. All federal laws and rules protecting my privacy will be followed. · If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay that person for this help. · The information on this form is correct, to the best of my knowledge. I understand that if I put information on this form that I know is not true, I will lose the plan. When I sign below, it means that I have read and understand the information on this form. Signature of applicant / member / authorized representative: Enrollee name 109 Today’s date: M M / D D / Y Y Y Y Copy 2 If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show written proof of this right if Medicare asks for it. This page intentionally left blank. 110 Page 6 of 6 If you are the authorized representative, please sign above and complete the information below. First Name Last Name Address State TEAR HERE City Phone Number ( ) ZIP Code Relationship to Applicant -- For licensed sales representative/agency use only. New Member Plan Change Employer Group Name Branch ID Employer Group ID Where did this application originate? □ Retail/Mall Program □ Member Meeting □ Local Event Outreach □ Community Meeting How was this application submitted? Appointment Other □ Local B2B Outreach □ Other Mail In Licensed Sales Representative/Writing ID Initial Receipt Date M M/D D/Y Y Y Y Licensed Sales Representative/Agent Name Proposed Effective Date M M/D D/Y Y Y Y Licensed Sales Representative Phone Number ( ) -- TEAR HERE Agent must complete AEP OEPI ICEP (MA enrollees) SEP (SEP Reason) SEP (Chronic) IEP (MA-PD enrollees) SEP (Full Dual Eligible) IEP (MA-PD enrollees eligible for 2nd IEP) SEP (Partial Dual Eligible) SEP Eligibility Date M M / D D / Y Y Y Y Licensed Sales Representative Signature (required) Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-888-834-3721, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana 本資訊也有其他語言的免費版本。請撥打 1-888-834-3721 聯絡我們的客戶服務部, 聽語障專線711, 每 週7天, 當地時間上午8 時至晚上8 時 Y0066_150729_133227 Approved CSNJ16HM3724996_002 111 Copy 2 This information is available for free in other languages. Please call our customer service number at 1-888-834-3721, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. This page intentionally left blank. 112 2016 Enrollment CHECKLIST Your Licensed Sales Representative has given you a lot of information about the plan you have chosen. TEAR HERE For each topic, please fill out information on this sheet and check each box to confirm you understand what you and your Licensed Sales Representative have reviewed. If you have any questions, please ask. PLAN INFORMATION Here are some details about your plan and coverage. My new plan is (circle one): Medicare supplement insurance (Medigap) policy Medicare Advantage plan Medicare Part D plan The name of my new plan is: . My plan coverage begins (effective date): M M / D D / Y Y Y Y My plan type is (circle): HMO HMO-POS My plan type: Requires referrals LPPO RPPO PFFS Does not require referrals I have purchased a rider(s) as part of my plan: Yes No N/A I must have Medicare Part A and Part B to enroll in this plan. My plan is available only in the plan’s service area, which is: . If I move outside of the service area, I will ask my Licensed Sales Representative or Customer Service to help me choose a new plan. My plan will now provide all my Medicare health coverage and prescription drug coverage. TEAR HERE I can cancel this plan before it goes into effect by calling Customer Service at If my plan coverage starts and I want to leave the plan, I will generally need to wait until the Open Enrollment Period, unless I qualify for a Special Election Period. Y0066_150708_012328A Accepted 113 . Ready to ENROLL I should not have a Medicare Advantage plan and a Medicare supplement insurance (Medigap) policy at the same time. If I have a Medicare supplement policy right now, once I receive confirmation of my enrollment in my new Medicare Advantage plan, I will write to that insurance company, , to cancel my Medicare supplement policy. I cannot have a Medicare Advantage plan and a stand-alone Medicare Part D plan at the same time. (There is one exception: Medicare Advantage Private Fee-for-Service plans that do not include prescription drug coverage.) PREMIUM INFORMATION What you need to know about paying a monthly premium. I need to continue to pay my Medicare Part B premium unless the state or another third party pays this premium for me. My plan: Does not have a premium (monthly payment). Has a $ monthly premium (this would include the cost of any riders if applicable). I must pay this monthly premium to stay in this plan. NETWORK INFORMATION Understanding your network is important. My current Primary Care Provider (PCP) is: . My specialists are: . My Licensed Sales Representative has confirmed that my PCP and my other providers are part of my plan’s network, and has explained whether or not my plan requires provider referrals. He/She has explained how provider referrals work. I need to get my care and services from network providers. The only exceptions are emergencies, urgent care or out‑of-area dialysis services. I may have to pay the full cost for any care I get outside of the network. PRESCRIPTION DRUG COVERAGE Know what is covered by your prescription drug plan. My prescription drug plan will cover only those drugs included on my plan’s list of covered drugs. My Licensed Sales Representative helped me confirm whether my current medications are on my plan’s drug list, and showed me how to look up any medications I am prescribed in the future. My current medications are: I understand how my prescription drug plan works, including: • T he cost difference between network pharmacies and out-of-network pharmacies • Tier levels • Prior authorizations • Quantity limits • Step therapy • Coverage gap drug stages and how they impact my costs • Late Enrollment Penalty Remember that plans can change each year. We’ll send you an Annual Notice of Changes prior to the Open Enrollment Period. It will tell you about any changes to your plan for the next year. If your needs change throughout the year or you have questions about your plan, please call your Licensed Sales Representative or Customer Service. A few examples of when to call are: getting a new prescription, changing your doctor, or moving. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan's contract renewal with Medicare. UHEX16HM3710668_000 114 TEAR HERE 2016 Enrollment Receipt To be completed if enrolling with a licensed Sales Representative. Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and you have received your permanent membership materials. You will receive a copy of your original Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your local licensed Sales Representative. This copy is for your records only. Please do not resubmit enrollment. Applicant 1: Applicant 2 (if applicable): Name ____________________________________ Name ____________________________________ Application Date MM / D D / Y Y Y Y Application Date MM / D D / Y Y Y Y Proposed Effective Date M M / D D / Y Y Y Y Proposed Effective Date M M / D D / Y Y Y Y Plan Name ________________________________ Plan Name _____________________________ Plan Type _________________________________ Plan Type _________________________________ Health Plan/PBP No. _______________________ Health Plan/PBP No. _____________________ Enrollment Tracking No. (if applicable) _________ Enrollment Tracking No. (if applicable) _________ If you have any questions, please contact your local Licensed Sales Representative: RxBIN: 610097 Licensed Sales Representative Name _______________________________ Rx PCN: 8500 Licensed Sales Representative Phone No. ____________________________ RxGRP: MPDACUNJ Licensed Sales Representative ID __________________________________ Questions? We’re always here to help. Simply call the Customer Service number listed on the first page of this booklet. Important Reminder - Once you have received confirmation of enrollment in your new Medicare Advantage plan, if you are currently enrolled in a Medicare Supplement plan you must contact the plan in writing with your intention to cancel your policy. TEAR HERE Copy 1 Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150629_142455 Accepted CSNJ16DU3707322_000 115 This page left intentionally blank. 116 TEAR HERE 2016 Enrollment Receipt To be completed if enrolling with a licensed Sales Representative. Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and you have received your permanent membership materials. You will receive a copy of your original Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your local licensed Sales Representative. This copy is for your records only. Please do not resubmit enrollment. Applicant 1: Applicant 2 (if applicable): Name ____________________________________ Name ____________________________________ Application Date MM / D D / Y Y Y Y Application Date MM / D D / Y Y Y Y Proposed Effective Date M M / D D / Y Y Y Y Proposed Effective Date M M / D D / Y Y Y Y Plan Name ________________________________ Plan Name _____________________________ Plan Type _________________________________ Plan Type _________________________________ Health Plan/PBP No. _______________________ Health Plan/PBP No. _____________________ Enrollment Tracking No. (if applicable) _________ Enrollment Tracking No. (if applicable) _________ If you have any questions, please contact your local Licensed Sales Representative: RxBIN: 610097 Licensed Sales Representative Name _______________________________ Rx PCN: 8500 Licensed Sales Representative Phone No. ____________________________ RxGRP: MPDACUNJ Licensed Sales Representative ID __________________________________ Questions? We’re always here to help. Simply call the Customer Service number listed on the first page of this booklet. Important Reminder - Once you have received confirmation of enrollment in your new Medicare Advantage plan, if you are currently enrolled in a Medicare Supplement plan you must contact the plan in writing with your intention to cancel your policy. TEAR HERE Copy 2 Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150629_142455 Accepted CSNJ16DU3707322_000 117 This page left intentionally blank. 118 NOTES _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 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_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TEAR HERE What’s next? Thank you for choosing UnitedHeathcare. Here’s what you can expect soon. Verification Letter We got your application and are reviewing it. Welcome Letter and Member ID Card Great news – your application has been approved. Getting Started Guide and Plan Details Learn how you can make the most of your plan. Welcome Call We’ll call you to welcome you and answer your questions. Get ready to work together for better health. Our commitment. We’ll reach out to you throughout the year to help make sure you are taking advantage of all the programs your plan has to offer. + Your commitment. Taking action is your first step to managing your health. We’ll give you resources and support you in taking those steps. Schedule your Annual Wellness Visit. Preventive care is vital to staying healthy. Call to schedule your visit after your plan coverage begins. Take advantage of a HouseCalls visit. Learn more about this in-home visit with a health care practitioner at www.uhchousecalls.com. Complete your Health Survey. Once your coverage begins, answering a few short questions will help us connect you to programs and services. TEAR HERE Questions? Give us a call. Helpful information: Toll-Free 1-800-514-4911, TTY 711 8 a.m- 8 p.m. local time, 7 days a week Y0066_150701_144908_FINAL_13 Accepted UHEX16DU3700230_000 123 MAPD This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. The provider network may change at any time. You will receive notice when necessary. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Y0066_150619_112614A_FINAL_5 Accepted This is an advertisement. CSNJ16HM3701820_003