Additional DRUG COVERAGE Additional prescription drug coverage Your plan includes extra coverage for certain drugs as shown below. These drugs are either not generally covered under Medicare Part D or are covered at a different tier or cost level than the one shown in your plan s formulary (drug list). This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call Customer Service using the information on the cover of this book. Lower-cost Medicare prescription drugs The following Medicare prescription drugs and supplies are available at a $0 or $45 co-pay. Your plan covers some of your Medicare prescription drugs and supplies at a lower drug tier or copay than in your formulary (drug list). If you have questions, see your Evidence of Coverage (EOC). These drugs and supplies are part of your Medicare prescription drug coverage. 1 $0 Co-Pay $45 Co-Pay Alendronate Tablet 10mg Alendronate Tablet 35mg Mirena IUD System Skyla IUD 13.5mg Alendronate Tablet 40mg Alendronate Tablet 5mg Alendronate Tablet 70mg Atenol/Chlorthalidone Tablet 100-25mg Atenol/Chlorthalidone Tablet 50-25mg Atenolol Tablet 100mg Atenolol Tablet 25mg Atenolol Tablet 50mg Benazepril Tablet 10mg Benazepril Tablet 20mg Benazepril Tablet 40mg Benazepril Tablet 5mg Benazepril/Hydrochlorothiazide Tablet 10-12.5 Y0066_160722_133902
$0 Co-Pay $45 Co-Pay Benazepril/Hydrochlorothiazide Tablet 20-12.5 Benazepril/Hydrochlorothiazide Tablet 20-25mg Benazepril/Hydrochlorothiazide Tablet 5-6.25 Bisoprolol/Hydrochlorothiazide Tablet 10-6.25 Bisoprolol/Hydrochlorothiazide Tablet 2.5-6.25 Bisoprolol/Hydrochlorothiazide Tablet 5-6.25mg Buproban Tablet 150mg Bupropion Tablet 100mg Bupropion Tablet 100mg ER Bupropion Tablet 100mg SR Bupropion Tablet 150mg ER Bupropion Tablet 150mg SR Bupropion Tablet 200mg ER Bupropion Tablet 200mg SR Bupropion Tablet 75mg Captopril Tablet 100mg Captopril Tablet 12.5mg Captopril Tablet 25mg Captopril Tablet 50mg Captopril/Hydrochlorothiazide Tablet 25-15mg Captopril/Hydrochlorothiazide Tablet 25-25mg Captopril/Hydrochlorothiazide Tablet 50-15mg Captopril/Hydrochlorothiazide Tablet 50-25mg Chlorthalidone Tablet 25mg Chlorthalidone Tablet 50mg Citalopram Tablet 10mg Citalopram Tablet 20mg
$0 Co-Pay $45 Co-Pay Citalopram Tablet 40mg Enalapril Tablet 10mg Enalapril Tablet 2.5mg Enalapril Tablet 20mg Enalapril Tablet 5mg Enalapril/Hydrochlorothiazide Tablet 10-25mg Enalapril/Hydrochlorothiazide Tablet 5-12.5mg Fluoxetine Capsule 10mg Fluoxetine Capsule 20mg Fluoxetine Capsule 40mg Fluoxetine Tablet 10mg Fluoxetine Tablet 20mg Glimepiride Tablet 1mg Glimepiride Tablet 2mg Glimepiride Tablet 4mg Glipizide ER Tablet 10mg Glipizide ER Tablet 2.5mg Glipizide ER Tablet 5mg Glipizide Tablet 10mg Glipizide Tablet 5mg Glipizide XL Tablet 10mg Glipizide XL Tablet 2.5mg Glipizide XL Tablet 5mg Glipizide/Metformin Tablet 2.5-250mg Glipizide/Metformin Tablet 2.5-500mg Glipizide/Metformin Tablet 5-500mg Hydrochlorothiazide Capsule 12.5mg
$0 Co-Pay $45 Co-Pay Hydrochlorothiazide Tablet 12.5mg Hydrochlorothiazide Tablet 25mg Hydrochlorothiazide Tablet 50mg Lisinopril Tablet 10mg Lisinopril Tablet 2.5mg Lisinopril Tablet 20mg Lisinopril Tablet 30mg Lisinopril Tablet 40mg Lisinopril Tablet 5mg Lisinopril/Hydrochlorothiazide Tablet 10-12.5 Lisinopril/Hydrochlorothiazide Tablet 20-12.5 Lisinopril/Hydrochlorothiazide Tablet 20-25mg Lovastatin Tablet 10mg Lovastatin Tablet 20mg Lovastatin Tablet 40mg Metformin Tablet 1000mg Metformin Tablet 500mg Metformin Tablet 500mg ER (generic Glucophage XR) Metformin Tablet 500mg ER 24 Hour (generic Fortamet) Metformin Tablet 850mg Metoprolol Tablet 100mg ER Metoprolol Tablet 25mg ER Metoprolol Tablet 50mg ER Metoprolol Tartrate Tablet 100mg Metoprolol Tartrate Tablet 25mg Metoprolol Tartrate Tablet 50mg
$0 Co-Pay $45 Co-Pay Mirtazapine Tablet 15mg Mirtazapine Tablet 15mg ODT Mirtazapine Tablet 30mg Mirtazapine Tablet 30mg ODT Mirtazapine Tablet 45mg Mirtazapine Tablet 45mg ODT Mirtazapine Tablet 7.5mg Paroxetine Tablet 10mg Paroxetine Tablet 20mg Paroxetine Tablet 30mg Paroxetine Tablet 40mg Pravastatin Tablet 10mg Pravastatin Tablet 20mg Pravastatin Tablet 40mg Pravastatin Tablet 80mg Simvastatin Tablet 10mg Simvastatin Tablet 20mg Simvastatin Tablet 40mg Simvastatin Tablet 5mg Simvastatin Tablet 80mg The amount you pay for these prescription drugs and supplies DO apply to your Medicare Part D out-of-pocket costs. Payments for these prescription drugs and supplies (made by you or the plan) 1) are treated the same as payments made for drugs in your plan s formulary. These drugs and supplies are part of your Medicare prescription drug coverage. 1 1 Information about the appeals and grievance process for these prescription drugs can be found in your Evidence of Coverage (EOC).
Bonus Drug List The State Health Benefit Plan has elected to offer 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 the 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 call 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 call 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 Phentermine 1 Maximum of 1 per day Dermatological agents - drugs to treat skin conditions Bold type = Brand name drug Plain type = Generic drug Y0066_160722_133902 BDL: U - GDCH
Drug Tier Quantity Limits Dry, Itchy Scalp Sulfacetamide Sodium 1 Sulfacetamide Sodium w/sulfur 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 3 Maximum of 12 tablets per month Edex 3 Maximum of 12 cartridges per month Levitra 3 Maximum of 12 tablets per month Bold type = Brand name drug Plain type = Generic drug
Drug Tier Quantity Limits Viagra 3 Maximum of 12 tablets per month Sexual Desire Disorder Addyi 3 Urinary Tract Infection Urogesic Blue 3 Ustell 1 Hormonal agents - hormone replacement/modifying drugs Menopausal Symptoms Osphena 3 Thyroid Supplement Armour Thyroid 3 Nutritional supplements - drugs to treat vitamin & mineral deficiencies Cyanocobalamin Injection (Vitamin B12) 1 Folgard Rx 3 Folic Acid 1mg (Rx only) 1 Galzin 3 Mephyton 3 Nephrocaps 3 NephPlex Rx 3 Rena-Vite Rx 1 Renal Cap 1 Vitamin D (Rx only) 1 Potassium Supplement K-Phos Tab 3 Bold type = Brand name drug Plain type = Generic drug
Drug Tier Quantity Limits 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 Brompheniramine/Pseudoephedrine/ Dextromethorphan Syrup 1 Guaifenesin/Codeine Syrup 1 Hydrocodone Polyst/Chlorphen CR Susp (generic for Tussionex) 1 Hydrocodone/Homatropine 1 Promethazine/Codeine Syrup 1 Promethazine/Dextromethorphan Syrup 1 Bold type = Brand name drug Plain type = Generic drug
This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits and/or co-payments/co-insurance may change each plan/benefit year. The formulary may change 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. Enrollment in the plan depends on the plan s contract renewal with Medicare. UHEX17PP3837365_000 BDL: U - GDCH