Additional DRUG COVERAGE
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1 Additional DRUG COVERAGE Bonus Drug List Your plan sponsor (employer, union or trust) offers a bonus drug list. The prescription drugs in this list are covered in addition to the drugs in the plan s formulary (drug list). The cost tier for each prescription drug is shown in the list. Although you pay the same co-pay or co-insurance for these drugs as shown in your Summary of Benefits and Evidence of Coverage, the amounts you pay for these additional prescription drugs do not apply to your Medicare Part D out-of-pocket costs. Payments for these additional prescription drugs (made by you or the plan) are treated differently from payments made for other prescription drugs. Coverage for the prescription drugs in the bonus drug list is in addition to your Part D drug coverage. Unlike your Part D drug coverage, you are unable to file an appeal or grievance for drugs in the bonus drug list. If you have questions, please contact Customer Service using the information on the cover of this book. If you get Extra Help from Medicare to pay for your prescription drugs, it will not apply to the drugs in this bonus drug list. This is not a complete list of the prescription drugs available to you or the restrictions and limitations that may apply through the bonus drug list. For a complete list, please contact Customer Service using the information on the cover of this book. Drug Tier Quantity Limits Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions Inflammation Choline & Magnesium Salicylates 1 Salsalate 1 Urinary Tract Pain Phenazopyridine 1 Anesthetics - drugs for numbing Lidocaine Cream 3% 1 Central nervous system agents - anxiolytics, sedatives, hypnotics Weight Loss Y0066_150612_125125
2 Phentermine 1 Maximum of 1 per day Dermatological agents - drugs to treat skin conditions Sulfacetamide Sodium 1 Dry Skin Urea 40% Cream 1 Fungal Infections Alcortin A 3 Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions Irritable Bowel Clidinium & Chlordiazepoxide 1 Hyoscyamine Sulfate 1 Levbid 3 Irritable Bowel or Ulcers Donnatal 3 Hemorrhoids Analpram-HC 3 Hydrocortisone Acetate Suppository 1 Lidocaine/Hydrocortisone Acetate 1 Pramoxine/Hydrocortisone 1 Genitourinary agents - drugs to treat bladder, genital and kidney conditions Erectile Dysfunction Cialis (10 mg, 20 mg) 3 Maximum of 6 tablets per 30 days Edex 3 Maximum of 6 cartridges per 30 days Levitra 3 Maximum of 6 tablets per 30 days Viagra 3 Maximum of 6 tablets per 30 days Urinary Tract Infection
3 Urogesic Blue 3 Ustell 1 Hormonal agents - hormone replacement/modifying drugs Thyroid Supplement Armour Thyroid 3 Nutritional supplements - drugs to treat vitamin & mineral deficiencies Cyanocobalamin (Vitamin B12) Injection 1 Folgard Rx 3 Folic Acid (Rx only) 1 Mephyton 3 Nephrocaps 3 NephPlex Rx 3 Rena-Vite Rx 1 Renal Cap 1 Vitamin D (Rx only) 1 Zinc Sulfate 1 Potassium Supplement Potassium Bicarbonate & Chloride Effervescent Tablet 1 Otic agents - drugs to treat ear conditions Ear Pain Antipyrine/Benzocaine Otic Solution 1 Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions Cough and Cold Benzonatate 1 Bromfed DM Syrup 1 Cheratussin AC 1
4 Hydrocodone Polyst/Chlorphen CR Susp (generic for Tussionex) 1 Hydrocodone/Homatropine 1 Promethazine/Codeine Syrup 1 Promethazine/Dextromethorphan Syrup 1
5 The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change from time to time during each plan year. 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 plan depends on the plan s contract renewal with Medicare. UHEX16HM _000 BDL: U
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