Additional Drug Coverage Additional prescription drug coverage Your plan includes extra coverage for certain drugs and supplies 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 Alendronate 10mg Alendronate 35mg Alendronate 40mg Alendronate 5mg Alendronate 70mg Atenolol 100mg Atenolol 25mg Atenolol 50mg Atenolol/Chlorthalidone 100-25mg Atenolol/Chlorthalidone 50-25mg Benazepril 10mg Benazepril 20mg Benazepril 40mg Benazepril 5mg Benazepril/Hydrochlorothiazide 10-12.5mg Benazepril/Hydrochlorothiazide 20-12.5mg Benazepril/Hydrochlorothiazide 20-25mg Benazepril/Hydrochlorothiazide 5-6.25mg Bisoprolol/Hydrochlorothiazide 10-6.25mg Bisoprolol/Hydrochlorothiazide 2.5-6.25mg Bisoprolol/Hydrochlorothiazide 5-6.25mg Bupropion 100mg (SR) Bupropion 150mg SR Bupropion 150mg (for tobacco cessation) Bupropion 200mg SR Bupropion 75mg Captopril 100mg Captopril 12.5mg Captopril 25mg Captopril 50mg Captopril/Hydrochlorothiazide 25-15mg Captopril/Hydrochlorothiazide 25-25mg Captopril/Hydrochlorothiazide 50-15mg Captopril/Hydrochlorothiazide 50-25mg Y0066_180628_025340
Chlorthalidone 25mg Chlorthalidone 50mg Citalopram 10mg Citalopram 20mg Citalopram 40mg Enalapril 10mg Enalapril 2.5mg Enalapril 20mg Enalapril 5mg Enalapril/Hydrochlorothiazide 10-25mg Enalapril/Hydrochlorothiazide 5-12.5mg Fluoxetine 10mg Capsule Fluoxetine 10mg (for depression or mood disorders) Fluoxetine 20mg Capsule Fluoxetine 20mg (for depression or mood disorders) Fluoxetine 40mg Capsule Glimepiride 1mg Glimepiride 2mg Glimepiride 4mg Glipizide 10mg Glipizide 5mg Glipizide ER & XL 10mg Glipizide ER & XL 2.5mg Glipizide ER & XL 5mg Glipizide/Metformin 2.5-250mg Glipizide/Metformin 2.5-500mg Glipizide/Metformin 5-500mg Hydrochlorothiazide 12.5mg Capsule & Hydrochlorothiazide 25mg Hydrochlorothiazide 50mg Lisinopril 10mg Lisinopril 2.5mg Lisinopril 20mg Lisinopril 30mg Lisinopril 40mg Lisinopril 5mg Lisinopril/Hydrochlorothiazide 10-12.5mg Lisinopril/Hydrochlorothiazide 20-12.5mg Lisinopril/Hydrochlorothiazide 20-25mg Lovastatin 10mg Lovastatin 20mg Lovastatin 40mg Metformin 1000mg Metformin 500mg ER 24 Hour (generic Fortamet) Metformin 500mg ER (generic Glucophage XR) Metformin 500mg Metformin 850mg Metoprolol Succinate 100mg ER Metoprolol Succinate 25mg ER Metoprolol Succinate 50mg ER Metoprolol Tartrate 100mg Metoprolol Tartrate 25mg Metoprolol Tartrate 50mg Mirtazapine 15mg (ODT) Mirtazapine 30mg (ODT) Mirtazapine 45mg (ODT) Mirtazapine 7.5mg Paroxetine 10mg Paroxetine 20mg Paroxetine 30mg Paroxetine 40mg Pravastatin 10mg Pravastatin 20mg Pravastatin 40mg Pravastatin 80mg Simvastatin 10mg Simvastatin 20mg Simvastatin 40mg
Simvastatin 5mg Simvastatin 80mg 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 drug 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 amount 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 your drug has any coverage rules or limits, there will be code(s) in the Coverage Rules or Limits on use column of the chart. The codes and what they mean are shown below. If you have questions about drug coverage, please call Customer Service using the information on the cover of this book. QL Quantity limits DL Dispensing limit The plan only covers a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. Dispensing limits apply to this drug. This drug is limited to a one month s supply per prescription. Drug Tier Coverage Rules or Limits on use Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions Inflammation Choline & Magnesium Salicylates 1 Salsalate 1 Urinary Tract Pain Phenazopyridine 1 Anorexiants - drugs to promote weight loss Bold type = Brand name drug Plain type = Generic drug Y0066_180628_025340
Drug Tier Coverage Rules or Limits on use Phentermine 1 QL (maximum of 1 capsule/tablet per day) Dermatological agents - drugs to treat skin conditions Dry, Itchy Scalp Sulfacetamide Sodium 1 Sulfacetamide Sodium w/sulfur 1 Dry Skin Urea 40% Cream 1 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 Genitourinary agents - drugs to treat bladder, genital and kidney conditions Erectile Dysfunction Cialis 3 Edex 3 Levitra 3 QL (maximum of 12 tablets per month) QL (maximum of 12 cartridges per month) QL (maximum of 12 tablets per month) Bold type = Brand name drug Plain type = Generic drug
Drug Tier Coverage Rules or Limits on use Sildenafil (25 mg, 50 mg, 100 mg) 1 QL (maximum of 12 tablets per month) Sexual Desire Disorder Addyi 3 QL (maximum of 1 tablet per day) Urinary Tract Infection 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 Injection (Vitamin B12) 1 Folgard Rx 3 Folic Acid 1mg (Rx only) 1 Galzin 3 Mephyton 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 1 Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions Cough and Cold Benzonatate 1 Bold type = Brand name drug Plain type = Generic drug
Drug Tier Coverage Rules or Limits on use Brompheniramine/Pseudoephedrine/ Dextromethorphan Syrup 1 Guaifenesin/Codeine Syrup 1 DL Hydrocodone Polst/Chlorpheniramine ER Susp (generic for Tussionex) 1 DL Hydrocodone/Homatropine 1 DL Promethazine/Codeine Syrup 1 DL 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. UHEX19PP4281665_000