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 on your plan s drug list (formulary). 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 are available at a $0 copay. Your plan covers some of your Medicare prescription drugs at a lower drug tier or copay than in your drug list (formulary). If you have questions, see your Evidence of Coverage. The amount you pay for these prescription drugs does apply to your Medicare Part D out-ofpocket costs. 1 These drugs are part of your Medicare prescription drug coverage. 1 $0 Copay Alendronate Tablet 10mg Alendronate Tablet 35mg 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 10-12.5mg Benazepril/Hydrochlorothiazide Tablet 20-12.5mg Benazepril/Hydrochlorothiazide Tablet 20-25mg $0 Copay Benazepril/Hydrochlorothiazide Tablet 5-6.25mg Bisoprolol/Hydrochlorothiazide Tablet 10-6.25mg Bisoprolol/Hydrochlorothiazide Tablet 2.5-6.25mg 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 Y0066_170630_180428
$0 Copay 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 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 (for depression or mood disorders) Fluoxetine Tablet 20mg (for depression or mood disorders) 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 Hydrochlorothiazide Tablet 12.5mg $0 Copay 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 10-12.5mg Lisinopril/Hydrochlorothiazide Tablet 20-12.5mg 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 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
$0 Copay Pravastatin Tablet 20mg Pravastatin Tablet 40mg Pravastatin Tablet 80mg Simvastatin Tablet 10mg $0 Copay Simvastatin Tablet 20mg Simvastatin Tablet 40mg Simvastatin Tablet 5mg Simvastatin Tablet 80mg 1) 1 Information about the appeals and grievance process for these prescription drugs can be found in your Evidence of Coverage.
Bonus Drug List The State Health Benefit Plan has elected to offer a bonus drug list. The prescription drugs on this list are covered in addition to the drugs on the plan s drug list (formulary). The cost tier for each prescription drug is shown on the list. Although you pay the same copay for these drugs as shown in the Summary of Benefits and Evidence of Coverage, the amounts you pay for these additional prescription drugs does 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 on the bonus drug list is in addition to your Part D drug coverage. Unlike your Part D drug coverage, you are unable to file a Medicare appeal or grievance for drugs on 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 on 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. If you have questions about drug coverage, 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 Dry, Itchy Scalp Bold type = Brand name drug Plain type = Generic drug Y0066_170630_180428
Drug Tier Quantity Limits 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 (10 mg, 20 mg) 3 Maximum of 12 tablets per 30 days Edex 3 Maximum of 12 cartridges per 30 days Levitra 3 Maximum of 12 tablets per 30 days Viagra 3 Maximum of 12 tablets per 30 days Sexual Desire Disorder Bold type = Brand name drug Plain type = Generic drug
Drug Tier Quantity Limits 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 Potassium Bicarbonate & Chloride Effervescent Tablet 1 Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions Cough and Cold Bold type = Brand name drug Plain type = Generic drug
Drug Tier Quantity Limits Benzonatate 1 Brompheniramine/Pseudoephedrine/ Dextromethorphan Syrup 1 Guaifenesin/Codeine Syrup 1 Hydrocodone Polyst/Chlorphen ER 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 BDL: U - GDCH
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change each plan/benefit year. The drug list 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. Enrollment in the plan depends on the plan s contract renewal with Medicare. UHEX18PP4081686_000