2019 Northeast Medicare Advantage Sales Kit by dksutton

2018 MEDICARE PPO

NORTHEAST WISCONSIN

Where you’re more than a Medicare member

Richard C., Grand Chute • Campground owner • Family man • Network Health Medicare member

800 - 9 8 3 - 7 5 87

TT Y 800-947-3529

N e two rkHe alt hMe dic are . c o m

My Guide to Choosing a Medicare Advantage Plan Agent name ______________________________________________________________________________________________________ Agent phone number _____________________________________________________________________________________

OCONTO SHAWANO

How do I know if I can join a Network Health Medicare Advantage (PPO) Plan?

WAUPACA

q You must live in our service area. q You must be eligible for Part A and enrolled in Part B

PORTAGE KEWAUNEE OUTAGAMIE WINNEBAGO

(approaching age 65 or older).

BROWN

MANITOWOC

WAUSHARA CALUMET MARQUETTE GREEN FOND DU LAC LAKE SHEBOYGAN

q You must continue to pay your Medicare Part B premium. q You must not be diagnosed with end-stage renal disease (ESRD).

DODGE

I can enroll in a Medicare Advantage Plan at the following times.

q The Medicare Annual Enrollment Period (October 15 - December 7). q The seven-month period around my 65th birthday.

(Example, if you turn 65 on April 10, you can enroll in a Medicare Advantage Plan from January 1 through July 31.)

My birthday is

_________________________________________

I can enroll in a Medicare Advantage Plan from

________________________________

through

_____________________________________

q A special situation (see page 10 to see if this applies to you). Note – If you don’t enroll in a plan with prescription drug coverage when you are first eligible, it could result in a penalty or fee. Avoid this late enrollment penalty by making sure you have creditable drug coverage as soon as you are eligible.

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What should I consider when choosing a plan? Do I need prescription drug coverage? List the medications you are currently taking below. Check the Research Rx section of this information book for a list of the most common covered drugs. You can find a full list at NetworkHealthMedicare.com.

DRUG NAME

SUPPLY (circle your day’s supply) 30 90 30 90 30 90 30 90 30 90 30 90 30 90

PAGE #

TIER (circle your drug’s tier) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

COPAYMENT $ $ $ $ $ $ $

Which doctors can I see? All Network Health Medicare Advantage Plans in this book are PPO plans, which means you can see any doctor who accepts Medicare beneficiaries. List your doctors below. My doctors_____________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

How can I enroll?

• Work with an agent, at no additional cost to you, to get your questions answered in person and your application submitted. Call 800-983-7587, and we can match you with an agent. • You can apply online at NetworkHealthMedicare.com or use the application in the back pocket of this guide. • Come into our office at 1570 Midway Pl., Menasha, WI. We’ll walk you through the process one step at a time. Call 800-983-7587 to set up an appointment.

My notes_______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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Table of Contents

Getting Started Everything you need to join a Network Health Medicare Advantage PPO plan is in this book. We’ve organized it into five simple sections to make it easy to find the information you need. You can learn about the basics of Medicare and how it works, compare our plans and discover all the extras we offer our members at no additional cost.

A Few Helpful Tips • Look at the table of contents to see what you can learn in each section.

• Look on the right side for easy-to-understand definitions of common terms.

• If you have questions about anything, don’t hesitate to call. That’s what we’re here for, and our number and hours are listed on the bottom of every page. You can also visit us at NetworkHealthMedicare.com.

My Guide to Choosing a Medicare Advantage Plan...........1 Understanding Medicare....................................................5 • What is Medicare? • Your Medicare Coverage Choices • Medicare’s Four Parts • Types of Medicare Plans • When You Can Enroll • Special Times You Can Enroll • We Speak Your Language Why Network Health......................................................... 12 • Your Local Health Insurance Partner • Personal Service with No Jargon • Quality Coverage Close to Home • Large Provider Network • Being a Member Has It’s Perks • Support to Get and Stay Healthy Available Plans................................................................. 21 • Choosing a Medicare Plan • Our Newest Plan • Our PPO Plans • Tools to Help You Choose at NetworkHealthMedicare.com Research Rx...................................................................... 25 • Understanding Drug Costs • How the Coverage Gap Works • How to Look Up Drugs and Pharmacies • Our Plan Drug Costs • Formulary Is Located in the Back Pocket of This Book Enroll Now......................................................................... 29 • Three Ways You Can Enroll • What Happens After You Enroll • Common Enrollment Questions • Notice of Privacy Practices • Grievance and Appeals Process for Medicare Part C • Coverage Determinations, Exceptions, Grievance and Appeal Procedures for Medicare Part D Summary Information

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PPO

YOUR PLAN | YOUR PROVIDER | YOUR CHOICE

Dear Neighbor: We understand you have many choices when it comes to Medicare insurance. For 35 years, Network Health has offered a different kind of health insurance that puts customers first. We are more than your typical health plan, bringing value to our relationship through exceptional one-on-one service that helps you live a healthier life while reducing your health care costs. Our mission is to enhance the life, health and wellness of the people we serve. Co-owned by Froedtert Health and Ministry Health Care, part of Ascension, we understand the importance of quality health care, and believe it should be convenient. With roots in northeast Wisconsin and a growing presence in southeast Wisconsin, we are able to offer access to a large network of high-quality providers. Plus, we have a variety of Medicare Advantage plans to fit your needs. We hope you choose to experience the Network Health difference, because here, you are more than a Medicare member. Sincerely,

Coreen Dicus-Johnson, J.D. President and CEO 4

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Karen S., Brillion

UNDERSTANDING MEDICARE In This Section WHAT IS MEDICARE? YOUR MEDICARE COVERAGE CHOICES MEDICARE’S FOUR PARTS TYPES OF MEDICARE PLANS WHEN YOU CAN ENROLL SPECIAL TIMES YOU CAN ENROLL WE SPEAK YOUR LANGUAGE

UNDERSTANDING MEDICARE

• Watercolor artist • Grandmother • Network Health Medicare member

Understanding Medicare

what’s that

We believe in making your insurance simple. We’ll explain Medicare in understandable, straightforward terms and help you find the Medicare plan that is best for you.

MEDICARE ADVANTAGE

Also called Part C, this is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with your Part A and Part B benefits. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare.

First things first...

WHAT IS MEDICARE?

Medicare is health insurance for people age 65 and older or some people under age 65 with disabilities.

WHAT IS ORIGINAL MEDICARE?

This is a plan made up of Medicare Parts A and B and managed by the federal government.

PART D

WHEN SHOULD I APPLY FOR MEDICARE?

The government allows you to apply for Medicare three months before you turn 65, or as soon as you are eligible.

HOW DO I APPLY FOR MEDICARE?

You can apply for Medicare online at https://www.ssa.gov or in person at your local Social Security office.

Dianne D., Appleton

Part D is the part of Medicare that helps pay for prescription drugs. It can be structured as part of a Medicare Advantage Plan or a Stand Alone Drug Plan.

•Acrylic artist •Grandmother •Network Health Medicare member 800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Understanding Medicare Your Medicare Coverage Choices Original Medicare Part A

Medicare Advantage Plan Part C

Part B

Hospital Insurance

Medical Insurance

Part D

You can add

Medicare Supplement Insurance (Medigap Policy)

Combines Part A and Part B

Part D

Prescription Drug Coverage

Prescription Drug Coverage (Most Part C plans cover prescription drugs. You may be able to add drug coverage to some plan types, if itâ&#x20AC;&#x2122;s not already included)

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Understanding Medicare MEDICARE’S FOUR PARTS

Nobody wants to pay more than they need to for health care. Some people may only need what is provided by the government, while others might need a more comprehensive insurance plan. Take a look at the chart below to identify the differences in coverage. PART A HOSPITAL

PART B MEDICAL

Part B covers doctor visits and outpatient services.

PART C MEDICARE ADVANTAGE Part C covers what both Parts A and B cover. Part C is also referred to as a Medicare Advantage Plan and sometimes includes Part D.

PART D DRUG COVERAGE Part D covers prescription drugs only.

COVERAGE

Part A covers hospital stays, home health, hospice and skilled nursing care.

COST

Typically, there is no cost The cost is set by the to you. government and varies from year to year. It may also vary based on your income.

The cost varies depending on which private health plan you select and what services are covered.

The cost varies, and Part D can be purchased as a stand Stand Alone Prescription Drug Plan (PDP) or as part of a Medicare Advantage Plan (Part C).

HOW TO ENROLL

You are automatically enrolled at age 65, if you are collecting Social Security. If you are 65 and not collecting Social Security, you must enroll online at https://www. ssa.gov or at your local Social Security office.

You enroll through a private insurance company, like Network Health.

Typically, you enroll during the seven month period around your 65th birthday or during the annual enrollment period, October 15– December 7.

You can enroll during the seven month period around your 65th birthday. If you do not enroll at that time, you will have to wait until January 1 March 31, and you may have to pay a penalty.

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Understanding Medicare TYPES OF MEDICARE PLANS

There are several types of Medicare plans including Original Medicare, PPO, MSA, SNP and HMO. What does it all mean? Let us translate.

ORIGINAL MEDICARE

Original Medicare is made up of Parts A and B, and is managed by the federal government.

MEDICARE ADVANTAGE

This plan covers Medicare Parts A and B, and some Medicare Advantage Plans cover Part D prescription drug coverage. Medicare Advantage may also be called Part C.

Preferred Provider Organization (PPO) This type of Medicare Advantage Plan has contracts with doctors, but it allows you to choose any doctor who accepts Medicare beneficiaries. Doctors and other providers are divided into in-network or out-of-network based on if they have a contract with Network Health.

Medical Savings Account (MSA) This is a unique plan that combines a high-deductible health insurance plan with a medical savings account. You can use the medical savings account to pay for health care services, while the high-deductible plan limits your out-of-pocket costs. If you think an MSA plan may be a good fit for you, call us for more information.

Special Needs Plan (PPO SNP) This Medicare Advantage Plan is specifically designed for people who are eligible for both Medicare and Medicaid, (called dual eligible). If you think a SNP plan may be a good fit for you, call us for more information.

Health Maintenance Organization (HMO) This type of Medicare Advantage Plan requires you to use doctors that are contracted by your plan. That means you’ll have to use certain doctors and hospitals for your health care to be covered. Network Health does not offer this type of Medicare Advantage Plan.

MEDICARE SUPPLEMENT

Also called Medigap insurance, this type of plan helps pay for the gap between Original Medicare and what you would pay out-of-pocket. It covers some additional medical care that Original Medicare doesn’t cover, but it does not include drug coverage. Network Health does not offer this type of coverage.

STAND ALONE PRESCRIPTION DRUG PLAN

This plan helps cover the cost of prescription drugs only. You must have Medicare Part A or Part B coverage to enroll in this type of plan, and you can combine it with Original Medicare or a Medicare Supplement plan. You cannot combine it with a PPO or HMO Medicare Advantage Plan. Network Health does not offer this type of coverage.

Network Health offers PPO, MSA and SNP plans. The plans in this book are PPO plans.

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Understanding Medicare

Annual Enrollment Period Example - 2017

WHEN YOU CAN ENROLL IN A MEDICARE ADVANTAGE PLAN

It’s important to understand when you can enroll, because there are only specific times of the year when you can join or leave a Medicare Advantage Plan. Here are the dates you need to know.

Initial Enrollment Period Example - 2018

ANNUAL ENROLLMENT PERIOD

Every year from October 15 to December 7, you can make changes to your Medicare coverage. This is generally the only time during the year when you can switch plans. Any changes you make will be effective January 1 of the following year. See the 2017 calendar.

INITIAL ENROLLMENT PERIOD

This is a seven-month window when you can decide if you want to enroll in Medicare. You have • Three months before your 65th birthday • The month of your birthday • Three months after your birthday For Example: If your birthday is April 10, you are eligible to sign up from January 1 through July 31. See the 2018 calendar.

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Understanding Medicare

what’s that

SPECIAL TIMES YOU CAN ENROLL AND LEAVE A PLAN

LOW-INCOME SUBSIDY

Call us to find out if you can enroll because of a special situation. Here are a few examples of when you can make plan changes.

Money the government gives to Medicare beneficiaries who can’t afford their part of the fee for prescription drugs, copayments, coinsurance and deductibles.

SPECIAL ENROLLMENT PERIODS

You can make changes to your plan in the following special situations. • You lose coverage through your employer. • You move outside of your plan’s service area. • Your current Medicare Advantage Plan is discontinued. • Your income changes and you qualify for a low-income subsidy.

MEDICAID

MEDICARE ADVANTAGE DISENROLLMENT PERIOD

From January 1 to February 14, you can drop your Medicare Advantage Plan (Part C) and return to Original Medicare (Parts A and B). This disenrollment period does not apply to MSA Medicare Advantage Plans. If you chose to return to Original Medicare during this period, you may also enroll in a Stand Alone Prescription Drug Plan.

John K., Germantown

A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

• Football fan • Volunteer • Network Health Medicare member

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Understanding Medicare WE SPEAK YOUR LANGUAGE

We don’t believe in bombarding customers with health insurance lingo, which is typically the norm in our industry. At Network Health, we break down the barriers to understanding health insurance, so the facts are explained in plain language. Still, as you review your plan options, you’ll want to understand the differences between plans. Let’s look at some common terms you’ll read in this book. For more help with insurance language, visit NetworkHealthMedicare.com, select Understanding Medicare and click Glossary.

CLAIM – What gets sent to the insurance company asking them to pay for care, medications or medical equipment.

COINSURANCE – The amount you pay for specific services,

according to your plan. For example, an insurance company may cover 80 percent of a service. The remaining 20 percent is the coinsurance, or the amount you pay.

COPAYMENT – A fixed fee you pay for some covered services,

INPATIENT HOSPITAL CARE – Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term care hospital or inpatient care as part of a qualifying research study and mental health care. MAXIMUM OUT-OF-POCKET – The total, maximum amount, not

including monthly premiums, that your health insurance plan requires you to pay during the year toward the cost of your health care services.

COVERED SERVICES – All services covered by your health plan.

OUT-OF-NETWORK – Doctors, pharmacies or health care facilities that aren’t part of your plan. It may cost more to use out-of-network providers.

DEDUCTIBLE – The amount of money you must pay (not including

OUTPATIENT – When you go to the hospital for a procedure or service

usually at a doctor visit or for a prescription.

premiums) before the insurance company begins paying for services. It’s different and separate from a copayment which is usually paid at office visits or the pharmacy.

IN-NETWORK – Doctors, hospitals, pharmacies and other health

care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network providers.

but don’t stay overnight.

PREMIUM – What you pay (per month, usually) to keep your

insurance active.

PREVENTIVE CARE – Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include pap tests, flu shots and screening mammograms).

INITIAL COVERAGE PERIOD – Refers to the first period of your Medicare Part D drug coverage. During this period, you will pay the copayment for the drug cost and your health plan pays the rest. This continues until your total drug costs reach $3,750, and you enter the coverage gap. 11

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Bob D., Appleton

WHY NETWORK HEALTH? In This Section YOUR LOCAL HEALTH INSURANCE PARTNER PERSONAL SERVICE WITH NO JARGON QUALITY COVERAGE CLOSE TO HOME LARGE PROVIDER NETWORK BEING A MEMBER HAS ITS PERKS SUPPORT TO GET AND STAY HEALTHY

WHY NET WORK HEALTH?

• Golfer • Grandfather • Network Health Medicare member

Why Network Health? YOUR LOCAL HEALTH INSURANCE PARTNER

We’re a locally owned, Wisconsin-based company that’s been around for more than three decades. We partner with and live in the communities we serve.

OUR VALUES

Innovation Bringing ideas to life

Service Excellence Providing exceptional service at the right time, right place and with the right attitude

Integrity

Collaboration

Accountability

Demonstrating honesty in every action

Working as one team toward a common goal

Honoring and respecting the trust people place in us

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Why Network Health? PERSONAL SERVICE WITH NO JARGON

L I F E , H E A LT H & W E L LNESS

A PUBLICATION OF

FA L L 2 016

We put things simply and you can always count on us to answer your questions in an easy and understandable way.

Hitting the Road

LOCAL HEALTH CARE CONCIERGE SERVICE

Follow along as one Network Health agent becomes a Medicare memb er

Dealing with health insurance can be stressful and confusing. So, we’re glad to provide friendly, local and personal service to every one of our members. These caring professionals help with any concerns you may have and get your questions answered. LIFE,

Our health care concierges are just a phone call away and all are based in Wisconsin. Or, if you’d prefer, you can visit our Menasha office and talk face to face.

H E A LT

H & W ELLNE S

inside

A PUB LICAT ION O Breaking Down Obstacles F to Care

LIFE

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Ensuring the Service You Deserve

HIGHLY-TRAINED AGENTS

WEL LNES S

When deciding what plan to choose, you can always get the help you need by sitting down with one of our experienced agents. Our agents attend quarterly, in-person meetings, so they can give you expert advice on what plan will best fit your needs and pocketbook.

Join Us for Network Health ’s Member Appreciation Events

Important 2017 Benefits

Information Begins on Pag e 20

Good News About Our Provi

der Network

MEMBER ADVISORY BOARD

We value our members and we want to hear what they have to say. That’s why we invite members from around the area to serve on our member advisory board. This group of members helps shape our decisions, so we can offer the quality service and plans you need and want.

MEMBER NEWSLETTER

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Through our Medicare Advantage member newsletter, Concierge, we keep our members informed and provide education on important topics. The newsletter includes helpful tips and advice for your life, health and wellness as well as feature stories about members. Plus, it gives tips and highlights the best ways to use your plan and get the most from your Medicare coverage. 13

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Why Network Health? QUALITY COVERAGE CLOSE TO HOME HIGHLY RATED

Our members appreciate our service and coverage–that’s why 94 percent stayed with us last year.* And CMS (the government agency that oversees Medicare) rates us 4.5 out of 5 stars.** Network Health’s Medicare Advantage Plans also received a 4.5 out of 5 rating from the National Committee for Quality Assurance’s (NCQA) Medicare Health Insurance Plan Ratings 2016-2017. This prestigious status reflects the hard work we put into designing our plans and caring for our members.

WHAT ARE THE ADVANTAGES OF HAVING A NETWORK HEALTH MEDICARE ADVANTAGE PPO PLAN?

MORE CHOICE

THE RIGHT TO CHOOSE YOUR DOCTOR

Network Health contracts with a vast system of in-network doctors, hospitals and facilities, and, in 2018, you will pay the same costs for both in- and out-of-network providers. With a PPO plan, you have the right to choose in-network or out-of-network doctors. This means you can select any doctor who accepts Medicare beneficiaries.

*Based on the percentage of Network Health Medicare Advantage (PPO) members who stayed in the plan for 2017, for coverage starting January 1, 2017. **Network Health Medicare Advantage PPO plans received an overall rating of 4.5 out of 5 stars for 2017 from the federal Medicare program. 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.

We have a strong reputation for one-on-one, quality service and members rate us highly.

AFFORDABLE COPAYMENTS PERSON-TO-PERSON SERVICE PAY THE SAME INOR OUT-OF-NETWORK

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Why Network Health?

OCONTO SHAWANO

LARGE PROVIDER NETWORK With a PPO plan, you can use both in- and out-of-network providers. Our broad network of in-network providers covers 21 counties and includes more than ...

• 1,654 Primary Care Providers • 11,157 Specialists • 50 Hospitals • 1,270 Ancillary Service Providers

PORTAGE

WAUPACA OUTAGAMIE

WAUSHARA WINNEBAGO

CALUMET

MARQUETTE FOND DU LAC

DODGE

SHEBOYGAN

WASHINGTON

Hospital

OZAUKEE WAUKESHA

Provider-owned, we offer a fully integrated provider network.

KEWAUNEE

MANITOWOC

GREEN LAKE

Counties in Network Health’s service area

BROWN

MILWAUKEE

RACINE

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Why Network Health? BEING A MEMBER HAS ITS PERKS A COMPLETE FITNESS PROGRAM AT NO COST* TO YOU

Improve your health and live the life you want with SilverSneakers® Fitness. The program is included in most* Network Health Medicare Advantage PPO Plan benefits and gives you membership at 13,000+ gyms nationwide. * Not available with Network PlatinumSelect (PPO) This program is designed for all fitness levels and abilities, providing the fitness support you need. Try the signature group classes, use the fitness equipment or workout in a pool. With coed and women-only classes, you can socialize and maintain or improve your fitness. If you’re new to fitness, that’s okay. Nearly half of SilverSneakers members had never been to a fitness location before joining SilverSneakers. On your first day, remember to wear comfortable workout clothes, wear athletic shoes with good support and bring your SilverSneakers member ID card to get started. Visit silversneakers.com to find a location near you.

John and Diane H., Oshkosh •RV travelers •Grandparents •Network Health Medicare members

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Why Network Health? SUPPORT TO GET AND STAY HEALTHY You’ll have access to a variety of programs to help you get and stay well, manage health conditions and take care of yourself.

COVERAGE FOR YOUR SMILE

Protect your teeth and gums with routine preventive dental care. We partner with Delta Dental to include dental care with many* of our Medicare Advantage Plans. For a $30 copayment, you can receive one cleaning and one exam per year. Add a dental rider to all of our plans for more comprehensive coverage, for $35 per month. Refer to the Summary of Benefits for more details. * Not available with Network PlatinumSelect (PPO). For other plans must use in-network provider.

PREVENTIVE CARE BENEFITS

You’re always covered for preventive care that can help you avoid getting sick. This includes coverage for immunizations, preventive screenings and an annual wellness visit to your doctor.

as an alternative to expensive urgent care visits or waiting to get an appointment with your primary care physician for non-emergency medical conditions. Virtual visits are provided at no cost to you as part of your plan.

COVERAGE THAT TRAVELS WITH YOU

When visiting another U.S. state, you can get care at the same cost you would back home. Regardless of which state you visit, every provider who accepts Medicare beneficiaries is considered in-network. When you travel outside the U.S., you have coverage up to $100,000 for emergency situations only. Refer to the Summary of Benefits for more details.

MDLIVE® VIRTUAL VISITS

In-network when you travel

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Why Network Health? SUPPORT TO GET AND STAY HEALTHY

“I picked up so many hints. It was well If you have certain health conditions, you’ll have accessgreat to a team of registered nurses who can provide information and educational resources to help you manage worth the time.’’ HEALTH MANAGEMENT your condition.

Self-Management

WORKSHOPS

Lois P., Fond du Lac

• Promote healthy lifestyle behaviors such as exercise and eating right. • Review medications, treatments and answer your questions. • Offer educational workshops, like Healthy Living with Diabetes, Living Well with Chronic Conditions and Stepping On (a falls prevention program). • Help to monitor your disease and offer opportunities for you to successfully manage your health. networkhealth.com • Support communication between you and your doctor. NetworkHealthMedicare.com • With your permission, work with a caregiver or family member to educate them about your condition so they can best care for you. HMO plans underwritten by Network Health Plan. POS Plans underwritten by Network Health Insurance Corporation, or HEARING AID Network Health Insurance Corporation and Network Health For 2018, Network Health will offer a hearing aid discount program with Plan. Self-funded plans administered by Network Health Administrative Services, LLC. Network Health Medicare Simpli Hearing, LLC. Members will find quality brand name discounted Advantagehearing plans includeaids MSA and PPO plans with ato Medicare Cares is athree PPO SNPoffice plan with visits, a Medicare contract. Network $1,220-$1,985. The discount program includes a one-year warranty, contract and a contract with the Forward Health Wisconsin one pack of batteries and one year of loss and damage insurance. For details Medicaid program. Enrollment in Network visit Health Medicare Advantage Plans depends on contract renewal. NeworkHealthMedicare.com/hearingaid. g-cnm-smwbro-0316 SAL-134-03-07/15

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Why Network Health? SUPPORT TO GET AND STAY HEALTHY HOME TELEMONITORING

At Network Health, we understand managing an on-going medical condition like heart failure is challenging. That’s why we offer the home telemonitoring benefit. If you’ve been diagnosed with heart failure, this benefit can help you track your health with an easyto-use monitoring system and phone calls from a member of the home health care team. Your doctor will be involved throughout your care.

IN-HOME HEALTH ASSESSMENTS

Network Health offers in-home health assessments where a doctor or nurse comes to your home to review your medications and talk about any health concerns you may have. The health care professional can also refer you to our care management teams for health plan services that can help you stay healthy. We provide these visits at no cost to members who qualify.

NURSE LINE

Kay and Reg F., Winneconne

Network Health’s Nurse Line is available when you have health care questions any time of the day or night. This free 24-hour phone service is available 365 days a year through Health Dialog. The nurse advice line can be accessed by calling 888-879-8960 (TTY 888-833-4271). Health Dialog has been providing services for more than 20 years, and the nurses you speak with can help answer your medical questions.

•Gym members •Card and domino players •Network Health Medicare members

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Why Network Health? SUPPORT TO GET AND STAY HEALTHY

Richard C., Grand Chute • Cyclist • Outdoorsman • Network Health Medicare member

For members with chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD), Network Health offers extra help with Breathe at Ease.

How does the program work?

A respiratory therapist conducts the program in the outpatient pulmonary rehabilitation department at St. Elizabeth Hospital, Mercy Medical Center, Affinity Medical Group New London, Calumet Medical Center and Holy Family Memorial.

Once enrolled in the program, here’s what you’ll experience.

• Receive a thorough assessment from the respiratory therapist • Develop an individualized action plan to follow at home • Receive education on medication and proper use of inhalers and rescue inhalers • Get exercise recommendations • Be screened for quality of life, depression and sleep disturbances • Receive monthly follow-up calls to track your progress and address any new issues

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Sue L., New London

AVAILABLE PLANS In This Section CHOOSING A MEDICARE PLAN OUR NEWEST PLAN

OUR PPO PLANS

(FOR MORE PLAN DETAILS, SEE THE SUMMARY OF BENEFITS IN THE BACK POCKET OF THIS BOOK)

TOOLS TO HELP YOU CHOOSE AT NetworkHealthMedicare.com

AVAILABLE PLANS

• Fitness devotee • Great grandmother • Network Health Medicare member

Available Plans CHOOSING A MEDICARE PLAN

Depending on your health care needs, one plan may be a better fit for you than another. Ask yourself the three questions below for help choosing a plan.

1. AM I ELIGIBLE FOR A NETWORK HEALTH MEDICARE ADVANTAGE PLAN?

You must have both Medicare Part A and Part B and live in our service area. See the checklist and map on the first page of this book.

2. WHAT DOCTORS CAN I GO TO?

3. ARE MY DRUGS COVERED?

This depends on what plan you choose, because some plans do not include prescription drug coverage. To learn more about your drug costs and what drugs are covered, see our drug list (also called a formulary) located in the back pocket of this book.

whatâ&#x20AC;&#x2122;s that PPO A specific kind of health insurance plan in which you can see any doctor that accepts Medicare beneficiaries, in- or out-of-network. In 2018, our members in northeast Wisconsin will pay the same to see in- and out-of-network providers.

PREMIUM The set monthly amount you pay for your plan.

MAXIMUM OUTOF-POCKET This is the yearly limit on your total costs for medical services. Your deductible, copayments and coinsurance contribute towards your maximum out-of-pocket. 21

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NEW PLAN

NETWORK PLATINUMCHOICE INCLUDES

Available Plans OUR NEWEST PLAN

NETWORK PLATINUMCHOICE (PPO) This new plan is a great new choice for anyone looking for excellent coverage at a low price.

Prescription drug coverage

Network PlatinumChoice has a low monthly premium and offers low copayments for doctor visits and the most common medical services. Plus, it includes prescription drug coverage, dental coverage and SilverSneakers to keep you healthy and control your out-of-pocket costs.

Dental coverage

If you’re looking for a plan with comprehensive coverage that will save you money long term, this plan is a great fit.

WHY CHOOSE NETWORK PLATINUMCHOICE?

SilverSneakers And many more benefits

• The monthly premium is only $22 a month, less than a gym membership. • This plan includes SilverSneakers. • One annual dental exam and cleaning is included, with a $30 copayment. Without insurance, your average out-of-pocket cost could be more than $120. • Network PlatinumChoice’s maximum out-of-pocket is more than $2,000 less than our Network PlatinumSelect plan. • Primary care visit, urgent care and hospital stay copayments are all lower than Network PlatinumSelect. • You’ll have a lower pharmacy deductible than the Network PlatinumSelect plan. See the next page for a full comparison of Network PlatinumChoice with our other plans.

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Available Plans

All Network Health Medicare Advantage Plans have concierge customer service and the flexibility to see any doctor you want.

OUR PPO PLANS

Review the chart below to compare our plans. Make sure to review the drug coverage, too. Itâ&#x20AC;&#x2122;s included with our Network PlatinumChoice Network PlatinumSelect, Network PlatinumPlus Pharmacy and Network PlatinumPremier Pharmacy plans (see the Research Rx section). You can find more details in our Summary of Benefits located in the back pocket of this book.

A QUICK SUMMARY

NEW PLAN

Network PlatinumSelect (PPO)

Network PlatinumChoice (PPO)

Network PlatinumPlus (PPO) Network PlatinumPlus Pharmacy (PPO)

Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO)

YOU PAY THE SAME IN- AND OUT-OF-NETWORK (EXCLUDES DENTAL) $0 per month (Includes drug coverage) Maximum Out-of-Pocket $6,700 per year combined Primary Care Office Visit $25 per visit $50 per visit Specialist Visit $50 copayment Urgent Care $450 copayment for days 1-4. You Hospital Stays pay nothing for days 5 and beyond. Emergency Room $80 copayment per visit Ambulance $300 copayment Outpatient Services $395 copayment per visit Annual Wellness Visit $0 copayment with Lab Tests Plan covers all Medicare-covered Preventive Services preventive services at $0 $0 copayment for days 1-20, $167 Skilled Nursing Facility copayment for days 21-57 $30 copayment X-rays

Premium

MRI/CT Scan Annual Dental Exam and Cleaning SilverSneakers 23

$150 copayment

$22 per month (Includes drug coverage) $4,500 per year combined $10 per visit $50 per visit $45 copayment $425 copayment for days 1-4. You pay nothing for days 5 and beyond. $80 copayment per visit $275 copayment $395 copayment per visit $0 copayment

$89 per month With drug coverage: $117 per month $3,400 per year combined $10 per visit $40 per visit $25 copayment $375 copayment for days 1-4. You pay nothing for days 5 and beyond. $100 copayment per visit $250 copayment $350 copayment per visit $0 copayment

$195 per month With drug coverage: $292 per month $3,400 per year combined $5 per visit $10 per visit $0 per visit $50 copayment for days 1-5. You pay nothing for days 6 and beyond. $100 copayment per visit $0 copayment $0 per visit $0 copayment

Plan covers all Medicare-covered preventive services at $0 $0 copayment for days 1-20, $160 copayment for days 21-49 $30 copayment

Plan covers all Medicare-covered preventive services at $0 $20 copayment for days 1-20, $167 copayment for days 21-54 $25 copayment

Plan covers all Medicare-covered preventive services at $0 $0 copayment for days 1-100

$125 copayment

$100 copayment

$0 copayment

$30 copayment in-network only

Dental and SilverSneakers $30 copayment in-network only not included with Network $0 PlatinumSelect

$0 copayment

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Available Plans TOOLS TO HELP YOU CHOOSE AT NETWORKHEALTHMEDICARE.COM Visit our website to find the information you need to pick the plan that is best for you. • Find a Plan. Scroll down on our home page, and you’ll find three simple questions to match you with the plan that best fits your needs and preferences. • Attend a Community Meeting. If you prefer to speak with someone in person, you can attend a no-cost, no pressure Network Health Medicare Advantage meeting hosted by a highly trained agent. These informational meetings are held throughout our service area year round. Dates, locations and registration information can be found online at NetworkHealthMedicare.com. • Find a Doctor. Find doctors, hospitals and facilities in your area. • Search Drugs and Pharmacies. Look up medications and search for in-network pharmacies in your area.

ENROLL ONLINE Enroll today on our website at NetworkHealthMedicare.com. Click Enroll Now, and we’ll walk you through each step.

QUESTIONS? It’s our job to make Medicare as easy to understand as possible. If you have questions, call 800-983-7587 (TTY 800-947-3529). We’re available Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re available to assist you seven days a week, 8 a.m. to 8 p.m.

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Richard C., Grand Chute • • •

Campground owner Family man Network Health Medicare member

Where you’re more than a Medicare member

2018 NORTHEAST WISCONSIN

SUMMARY OF BENEFITS

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800- 983- 7587 T T Y 800- 947- 3529 N e two rkH e alt h M e dic are . c o m

Contact Network Health By Phone

Sales Department – 800-983-7587 Health Care Concierge Customer Service – 800-378-5234 TTY/TDD Users – 800-947-3529

Online

NetworkHealthMedicare.com

By Mail or In Person Network Health 1570 Midway Pl. Menasha, WI 54952

Hours of Operation

Normal business hours are Monday–Friday, 8 a.m to 5 p.m. Network Health is closed on major holidays. From October 1–February 14, you can call us seven days a week from 8 a.m. to 8 p.m., Central Time. From February 15–September 30, you can call us Monday–Friday from 8 a.m. to 8 p.m., Central Time.

Additional Resources

Medicare – Available 24 hours a day, seven days a week If you want to learn more about the coverage and costs of Original Medicare, use your current “Medicare & You” handbook, available from Medicare. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this booklet, you can get it at the Medicare website (https://www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048), 24 hours a day, seven days a week.

Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year. Out-of-network/non-contracted providers are under no obligation to treat Network Health Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. As an enrollee of our plan, you can get a long-term supply (up to 90 days) of drugs shipped to your home using our plans network mail order delivery program. Usually you will receive your mail order prescriptions within 14 calendar days. If your order does not arrive within the estimated time frame, call Express Scripts Customer Service at 800-316-3107 (TTY 800-899-2114), 24 hours a day, seven days a week. The products and services described include value-added discounts that are only available to Network Health Medicare Advantage plan members. These discounts are value-added and not part of our Medicare contract or your plan coverage. H5215_1164_080917 Accepted 08142017

Table of Contents

What Is a Summary of Benefits?................................................... 2 Supplemental Benefits and Additional Programs........................ 2 Understanding the Difference—PPO vs. HMO.............................. 3 Service Area and Eligibility............................................................ 4 Glossary—We Speak Your Language............................................. 5 A Quick Summary of Our Newest Plan Network PlatinumChoice (PPO) .................................................... 7 Summary of Benefits..................................................................... 8 Part D Pharmacy Coverage Information.....................................26 Optional Supplemental Dental Benefit.......................................36 Multi-Language Interpreter Services..........................................37

Sue L., New London

• Fitness devotee • Great grandmother • Network Health Medicare member

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What Is a Summary of Benefits?

MDLIVE® Virtual Visits

A Summary of Benefits is a summary document that describes Network Health’s Medicare Advantage Plans. In this booklet, you will find information on Network PlatinumChoice (PPO), Network PlatinumSelect (PPO), Network PlatinumPlus (PPO), Network PlatinumPlus Pharmacy (PPO), Network PlatinumPremier (PPO) and Network PlatinumPremier Pharmacy (PPO). A complete list of services can be found in your Evidence of Coverage. The Evidence of Coverage for each plan is available at NetworkHealthMedicare.com. Contact customer service for a printed copy. Additional Medicare Advantage Plan options offered by Network Health include NetworkPrime (MSA) and NetworkCares (PPO SNP) plans. Summary of Benefits materials for these plan options are available by contacting the Network Health Sales Department at 800-983-7587.

Consult with a board-certified doctor by phone, secure video or MDLIVE App—anytime, from anywhere. Virtual visits are a convenient, no cost way to get care for covered health services that include the diagnosis and treatment of non-urgent medical conditions through electronic means. MDLIVE offered through Network Health, was designed as an alternative to expensive urgent care visits or waiting to get an appointment with your primary care physician for non-emergency medical conditions. Virtual visits are provided at no cost to you as part of your plan.

Hearing Aid

Supplemental Benefits and Additional Programs

For 2018, Network Health will offer a hearing aid discount program with Simpli Hearing, LLC. Members will find quality brand name hearing aids discounted to $1,000-$1,985. The discount program includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. For details visit NeworkHealthMedicare.com/hearingaid.

SilverSneakers® Fitness

Understanding the Difference – PPO vs. HMO

In addition to the plan benefits outlined in the pages ahead, Network Health offers many supplemental benefits at no cost to you. Improve your health and live the life you want with SilverSneakers Fitness. The program is included in most* Network Health Medicare Advantage PPO Plan benefits and gives you membership at 13,000+ gyms nationwide. This program is designed for all fitness levels and abilities, providing the fitness support you need. Visit SilverSneakers.com to find a location near you. *Not available with Network PlatinumSelect (PPO)

Preferred Provider Organization (PPO)

Preventive Screenings

In 2018, Network Health has the same in- and out-of-network costs for Medicare members in northeast Wisconsin. All the plans in this book are PPO plans.

The plans contained within this booklet cover preventive care and an Annual Wellness Visit. Although it’s not required by Medicare, Network Health also covers preventive screenings including a lipid profile, fasting blood sugar and complete blood count with your Annual Wellness Visit or Routine Physical. For a full list of preventive services, visit NetworkHealthMedicare.com, select Member’s Corner and click Preventive Health Checklist. A printed copy of the Preventive Health Checklist is available by calling customer service.

Travel Benefit

With Network Health’s Medicare Advantage Plans, your coverage travels with you when you travel outside of Wisconsin but within the United States. When you’re traveling, you can see any provider who accepts Medicare beneficiaries, and you’ll be covered as though you’re seeing an in-network provider. For international coverage, refer to your Evidence of Coverage for more information.

This type of Medicare Advantage Plan has contracts with doctors, but it allows you to choose any doctor who accepts Medicare beneficiaries. Doctors and other providers are divided into in-network or out-of-network based on if they have a contract with Network Health.

Health Maintenance Organization (HMO)

This type of Medicare Advantage Plan requires you to use doctors that are contracted by your plan. That means you’ll have to use certain doctors and hospitals for your health care to be covered. Network Health does not offer this type of Medicare Advantage Plan.

In-Network

Doctors, hospitals, pharmacies, and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network providers.

Nurse Line

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Service Area and Eligibility

To be eligible to join Network Health’s Medicare Advantage Plans described in this booklet, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, live in the service area and not be diagnosed with end-stage renal disease (ESRD). This Summary of Benefits applies to plans offered in the following counties in Wisconsin–Brown, Calumet, Dodge, Fond du Lac, Green Lake, Kewaunee, Manitowoc, Marquette, Oconto, Outagamie, Portage, Shawano, Sheboygan, Waupaca, Waushara and Winnebago.

We Speak Your Language We don’t believe in bombarding customers with health insurance lingo, which is typically the norm in our industry. At Network Health, we break down the barriers to understanding health insurance, so the facts are explained in plain language.

OCONTO

Still, as you review your plan options, you’ll want to understand the differences between plans. Let’s look at some common terms you’ll read in this Summary of Benefits.

SHAWANO

Claim

What gets sent to the insurance company asking them to pay for care, medications or medical equipment.

PORTAGE KEWAUNEE

WAUPACA OUTAGAMIE WINNEBAGO

BROWN

MANITOWOC

WAUSHARA CALUMET MARQUETTE GREEN FOND DU LAC LAKE SHEBOYGAN

Do You Live Outside Our Service Area?

DODGE

Coinsurance

The amount you pay for specific services, according to your plan. For example, an insurance company may cover 80 percent of a service. The remaining 20 percent is the coinsurance, the amount you pay.

Copayment

A fixed fee you pay for some covered services, usually at a doctor visit or for a prescription.

Covered Services

All services covered by your health plan.

Deductible

The amount of money you must pay (not including premiums) before the insurance company begins paying for services. It’s different and separate from a copayment which is a fee paid at office visits or the pharmacy.

Inpatient Hospital Care

Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term care hospital or inpatient care as part of a qualifying research study and mental health care.

Maximum Out-of-Pocket

Network Health offers other Medicare Advantage Plans in Wisconsin, including a statewide Medicare Medical Savings Account (MSA) Plan and additional PPO plans in southeast Wisconsin. For more information, contact Network Health’s Sales Department at 800-983-7587 or visit NetworkHealthMedicare.com.

This is the yearly limit on your total costs for medical services. Your deductible, copayments and coinsurance contribute toward your maximum out-of-pocket.

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Doctors, pharmacies or health care facilities that aren’t part of your plan. It may cost more to use out-of-network providers.

Outpatient

When you go to the hospital for a procedure or service but don’t stay overnight.

Premium

What you pay (per month, usually) to keep your insurance active.

Preventive Care

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include pap tests, flu shots and screening mammograms).

Prior Authorizations

A prior authorization is an approval from a Medicare plan that may be required before you have certain procedures done or prescriptions filled to be sure they are covered by your plan. With most services, Network Health does not require prior authorization for Medicare-covered services.

For more help with insurance language, visit NetworkHealthMedicare.com, select Understanding Medicare and click Glossary.

A QUICK SUMMARY OF OUR NEWEST PLAN

Out-of-Network

NETWORK PLATINUMCHOICE (PPO)

This new plan is a great new choice for anyone looking for excellent coverage at a low price. Network PlatinumChoice has a low monthly premium and offers low copayments for doctor visits and the most common medical services. Plus, it includes prescription drug coverage, dental coverage and SilverSneakers to keep you healthy and control your out-of-pocket costs.

If you’re looking for a plan with comprehensive coverage that will save you money long term, this plan is a great fit.

TAKE A LOOK AT JUST SOME OF THE HIGHLIGHTS. • The monthly premium is only $22 a month, less than a gym membership. • This plan includes SilverSneakers. • One annual dental exam and cleaning is included, with a $30 copayment. Without insurance, your average out-of-pocket cost could be more than $120. • Network PlatinumChoice’s maximum out-of-pocket is over $2,000 less than our Network PlatinumSelect plan. • Primary care visit, urgent care and hospital stay copayments are all lower than Network PlatinumSelect. • You’ll have a lower pharmacy deductible than the Network PlatinumSelect plan.

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Bob and Dianne D., Appleton • Acrylic artist • Golfer • Network Health Medicare members

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SECTION II - SUMMARY OF BENEFITS BENEFIT How much is the monthly premium?

Network PlatinumSelect (PPO) Network PlatinumChoice (PPO) $0 per month. In addition, you must keep paying $22 per month. In addition, you must keep your Medicare Part B premium. paying your Medicare Part B premium.

Network PlatinumPlus (PPO) $89 per month. In addition, you must keep paying your Medicare Part B premium.

Network PlatinumPlus Pharmacy (PPO) $117 per month. In addition, you must keep paying your Medicare Part B premium.

How much is the deductible?

This plan does not have a medical deductible. This plan has a $395 per year deductible for Part D prescription drugs on tiers 3, 4 and 5. The deductible does not apply for drugs on tiers 1 and 2. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care.

This plan does not have a medical deductible. This plan has a $260 per year deductible for Part D prescription drugs on tiers 3, 4 and 5. The deductible does not apply for drugs on tiers 1 and 2. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care.

This plan does not have a deductible.

This plan does not have a medical deductible. This plan This plan does not have a deductible. has a $260 per year deductible for Part D prescription drugs except for drugs on tiers 3, 4 and 5. The deductible does not apply for drugs on tiers 1 and 2.

This plan does not have a medical deductible. This plan has a $260 per year deductible for Part D prescription drugs except for drugs on tiers 3, 4 and 5. The deductible does not apply for drugs on tiers 1 and 2.

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care.

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.

Your yearly limit(s) in this plan:

$4,500 combined maximum out-of-pocket for $3,400 combined maximum out-of-pocket for $6,700 combined maximum out-of-pocket for services received from both in-network and out- services received from both in-network and out- services received from both in-network and outof-network providers. of-network providers. of-network providers.

$3,400 combined maximum out-of-pocket for services received from both in-network and out-of-network providers.

If you reach the limit on out-of-pocket costs, we will pay the full cost of covered services for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Please note that you will still need to pay your monthly premiums.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Please note that you will still need to pay your monthly premiums.

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 Our plan has a coverage limit every year for much the plan will pay? certain in-network benefits. Contact us for the services that apply.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.

Our plan has a coverage limit every year for certain benefits Our plan has a coverage limit every year for certain benefits Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. from any provider. Contact us for services that apply. from any provider. Contact us for services that apply.

Is there any limit on how much I will pay for my covered services?

Network PlatinumPremier (PPO) $195 per month. In addition, you must keep paying your Medicare Part B premium.

Network PlatinumPremier Pharmacy (PPO) $292 per month. In addition, you must keep paying your Medicare Part B premium.

NOTE: Services with a 1 may require prior authorization.

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BENEFIT Network PlatinumSelect (PPO) Network PlatinumChoice (PPO) Inpatient Hospital Care1 The copayments for hospital and skilled nursing The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re periods. A benefit period begins the day you’re admitted as an inpatient and ends when you admitted as an inpatient and ends when you MONTHLY PREMIUM, DEDUCTIBLE, LIMITS care ON (or HOW MUCHhaven’t YOU PAY FORany COVERED SERVICES haven’t receivedAND any inpatient skilled received inpatient care (or skilled care in a SNF) for 60 days in a row. If you go care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You has ended, a new benefit period begins. You must pay the inpatient hospital deductible for must pay the inpatient hospital deductible for each benefit period. There’s no limit to the each benefit period. There’s no limit to the number of benefit periods. number of benefit periods.

Outpatient Surgery1

Doctor’s Office Visits

Network PlatinumPlus (PPO) The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Network PlatinumPlus Pharmacy (PPO) The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Network PlatinumPremier (PPO) The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Network PlatinumPremier Pharmacy (PPO) The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers an unlimited number of days for an inpatient hospital stay: In-network: $375 copayment per day for days 1 through 4 $0 copayment for additional days Out-of-network: $375 copayment per day for days 1 through 4 $0 copayment for additional days

Our plan covers an unlimited number of days for an inpatient hospital stay: In-network: $50 copayment per day for days 1 through 5 $0 copayment for additional days Out-of-network: $50 copayment per day for days 1 through 5 $0 copayment for additional days

For inpatient mental health care, see the “Mental Health Care” section of this booklet.

Ambulatory surgical center: In-network: $350 copayment Out-of-network: $350 copayment Outpatient hospital: In-network: $350 copayment Out-of-network: $350 copayment

Ambulatory surgical center: In-network: $0 copayment Out-of-network: $0 copayment Outpatient hospital: In-network: $0 copayment Out-of-network: $0 copayment

Our plan covers an unlimited number of days for an inpatient hospital stay: In-network: $450 copayment per day for days 1 through 4 $0 copayment per day for days 5 and beyond Out-of-network: $450 copayment per day for days 1 through 4 $0 copayment per day for days 5 and beyond

Our plan covers an unlimited number of days for an inpatient hospital stay: In-network: $425 copayment per day for days 1 through 4 $0 copayment per day for days 5 and beyond Out-of-network: $425 copayment per day for days 1 through 4 $0 copayment per day for days 5 and beyond

For inpatient mental health care, see the “Mental Health Care” section of this booklet. Ambulatory surgical center: In-network: $395 copayment Out-of-network: $395 copayment

For inpatient mental health care, see the “Mental Health Care” section of this booklet. Ambulatory surgical center: In-network: $350 copayment Out-of-network: $350 copayment

Outpatient hospital: In-network: $395 copayment Out-of-network: $395 copayment Primary care physician visit: In-network: $25 copayment Out-of-network: $25 copayment

Outpatient hospital: In-network: $395 copayment Out-of-network: $395 copayment Primary care physician visit: In-network: $10 copayment Out-of-network: $10 copayment

Outpatient hospital: In-network: $350 copayment Out-of-network: $350 copayment Primary care physician visit: In-network: $10 copayment Out-of-network: $10 copayment

Primary care physician visit: In-network: $10 copayment Out-of-network: $10 copayment

Primary care physician visit: In-network: $5 copayment Out-of-network: $5 copayment

Specialist visit: In-network: $50 copayment Out-of-network: $50 copayment

Specialist visit: In-network: $40 copayment Out-of-network: $40 copayment

Specialist visit: In-network: $10 copayment Out-of-network: $10 copayment

Specialist visit: In-network: $50 copayment Out-of-network: $50 copayment NOTE: Services with a 1 may require prior authorization.

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BENEFIT Preventive Care

Network PlatinumSelect (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumChoice (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumPlus (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumPlus Pharmacy (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumPremier (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumPremier Pharmacy (PPO) In-network: $0 copayment Out-of-network: $0 copayment

Our plan covers many preventive services, including: 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. $80 copayment

Any additional preventive services approved by Medicare during the contract year will be covered. $100 copayment

Any additional preventive services approved by Medicare during the contract year will be covered.

$100 copayment

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs. 1 NOTE: Services with a may require prior authorization.

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.

Emergency Care

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BENEFIT Emergency Care (Continued)

Network PlatinumPlus Pharmacy (PPO) When Emergency care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost per incident.

Network PlatinumPremier (PPO) When Emergency care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost per incident.

Network PlatinumPremier Pharmacy (PPO) When Emergency care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost per incident.

Network Health will pay the remaining 75% of the cost up to the maximum of $100,000 every year. Urgent Care Walk-In Clinic: In-network: $25 copayment Out-of-network: $25 copayment

Network Health will pay the remaining 75% of the cost up to the maximum of $100,000 every year. Urgent Care Walk-In Clinic: In-network: $0 copayment Out-of-network: $0 copayment

Primary Care Physician Visit: In-network: $10 copayment Out-of-network: $10 copayment Diagnostic radiology services (such as MRIs, CT scans): In-network: $100 copayment Out-of-network: $100 copayment

Primary Care Physician Visit: In-network: $5 copayment Out-of-network: $5 copayment Diagnostic radiology services (such as MRIs, CT scans): In-network: $0 copayment Out-of-network: $0 copayment

Lab services: In-network: $5 copayment Out-of-network: $5 copayment

Lab services: In-network: $0 copayment Out-of-network: $0 copayment

Outpatient X-rays: In-network: $25 copayment Out-of-network: $25 copayment

Outpatient X-rays: In-network: $0 copayment Out-of-network: $0 copayment

Therapeutic radiology services (such as radiation treatment for cancer): In-network: $60 copayment Out-of-network: $60 copayment

Therapeutic radiology services (such as radiation treatment for cancer): In-network: $0 copayment Out-of-network: $0 copayment

Ultrasounds, EKGs, EEGs and stress tests: In-network: $40 copayment Out-of-network: $40 copayment

Ultrasounds, EKGs, EEGs and stress tests: In-network: $35 copayment Out-of-network: $35 copayment

Ultrasounds, EKGs, EEGs and stress tests: In-network: $25 copayment Out-of-network: $25 copayment

Other diagnostic tests, procedures and lab services: In-network: $20 copayment Out-of-network: $20 copayment NOTE: Services with a 1 may require prior authorization.

Other diagnostic tests, procedures and lab services: In-network: $15 copayment Out-of-network: $15 copayment

Other diagnostic tests, procedures and lab services: In-network: $5 copayment Out-of-network: $5 copayment

Ultrasounds, EKGs, EEGs and stress tests: In-network: $25 copayment Out-of-network: $25 copayment

Ultrasounds, EKGs, EEGs and stress tests: In-network: $0 copayment Out-of-network: $0 copayment

Other diagnostic tests, procedures and lab services: In-network: $5 copayment Out-of-network: $5 copayment

Other diagnostic tests, procedures and lab services: In-network: $0 copayment Out-of-network: $0 copayment

Urgently Needed Services

Network PlatinumSelect (PPO) When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for a $75 copayment per incident.

Network PlatinumChoice (PPO) When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for a $75 copayment per incident.

Network PlatinumPlus (PPO) When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost per incident.

Network Health will pay the remainder of the cost up to the maximum $100,000 every year. Urgent Care Walk-In Clinic: In-network: $50 copayment Out-of-network: $50 copayment

Network Health will pay the remainder of the cost up to the maximum $100,000 every year. Urgent Care Walk-In Clinic: In-network: $45 copayment Out-of-network: $45 copayment

Network Health will pay the remaining 75% of the cost up to the maximum $100,000 every year. Urgent Care Walk-In Clinic: In-network: $25 copayment Out-of-network: $25 copayment

Primary Care Physician Visit: In-network: $25 copayment Out-of-network: $25 copayment Diagnostic radiology services (such as MRIs, CT scans): In-network: $150 copayment Out-of-network: $150 copayment

Primary Care Physician Visit: In-network: $10 copayment Out-of-network: $10 copayment Diagnostic radiology services (such as MRIs, CT scans): In-network: $125 copayment Out-of-network: $125 copayment

Primary Care Physician Visit: In-network: $10 copayment Out-of-network: $10 copayment Diagnostic radiology services (such as MRIs, CT scans): In-network: $100 copayment Out-of-network: $100 copayment

Lab services: In-network: $15 copayment Out-of-network: $15 copayment

Lab services: In-network: $5 copayment Out-of-network: $5 copayment

Outpatient X-rays: In-network: $30 copayment Out-of-network: $30 copayment

Therapeutic radiology services (such as radiation treatment for cancer): In-network: 20% of the cost Out-of-network: 20% of the cost

Diagnostic Tests, Lab and Radiology Services and X-rays (Costs for these services may be Lab services: different if received in an 1 In-network: $20 copayment outpatient surgery setting) Out-of-network: $20 copayment

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BENEFIT Hearing Services

Dental Services1

Vision Services

Network PlatinumSelect (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $15 copayment Out-of-network: $15 copayment

Network PlatinumChoice (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $10 copayment Out-of-network: $10 copayment

Network PlatinumPlus (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumPlus Pharmacy (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumPremier (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $0 copayment Out-of-network: $0 copayment

Network PlatinumPremier Pharmacy (PPO) Exam to diagnose and treat hearing and balance issues: In-network: $0 copayment Out-of-network: $0 copayment

Routine hearing exam (1 every year): In-network: $0 copayment Out-of-network: $0 copayment

Routine hearing exam (1 every year): In-network: $0 copayment Out-of-network: $0 copayment Hearing aid: In-network: Our plan will reimburse up to $75 per year for the purchase of hearing aids Out-of-network: Our plan will reimburse up to $75 per year for the purchase of hearing aids Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth): In-network: $0 copayment Out-of-network: $0 copayment

Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth): In-network: $50 copayment Out-of-network: $50 copayment

Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth): In-network: $25 copayment Out-of-network: $25 copayment

Hearing aid: In-network: Our plan will reimburse up to $75 per year for the purchase of hearing aids Out-of-network: Our plan will reimburse up to $75 per year for the purchase of hearing aids Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth): In-network: $0 copayment Out-of-network: $0 copayment

Additional rider available see page 36

One exam and cleaning per year: $30 copayment, no coverage out-of-network

Exam to diagnose and treat diseases and conditions of the eye: In-network: $50 copayment Out-of-network: $50 copayment

Additional rider available see page 36 Exam to diagnose and treat diseases and conditions of the eye: In-network: $50 copayment Out-of-network: $50 copayment

Additional rider available see page 36 Exam to diagnose and treat diseases and conditions of the eye: In-network: $25 copayment Out-of-network: $25 copayment

Additional rider available see page 36 Exam to diagnose and treat diseases and conditions of the eye: In-network: $0 copayment Out-of-network: $0 copayment

Eyeglasses or contact lenses after cataract surgery: In-network: $0 copayment Out-of-network: $0 copayment

Eyeglasses or contact lenses after cataract surgery: In-network: $15 copayment Out-of-network: $15 copayment

Eyeglasses or contact lenses after cataract surgery: In-network: $0 copayment Out-of-network: $0 copayment

Medicare-covered eye exam: In-network: $50 copayment Out-of-network: $50 copayment

Medicare-covered eye exam: In-network: $25 copayment Out-of-network: $25 copayment

Medicare-covered eye exam: In-network: $0 copayment Out-of-network: $0 copayment

CMS-defined preventive glaucoma screenings: In-network: $0 copayment Out-of-network: $0 copayment

CMS-defined preventive glaucoma screenings: In-network: $0 copayment Out-of-network: $0 copayment 1 NOTE: Services with a may require prior authorization.

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BENEFIT Mental Health Care1

Network PlatinumSelect (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $395 copayment per day for days 1 through 4 $0 copayment per day for days 5 through 190 including “lifetime reserve days” Out-of-network: $395 copayment per day for days 1 through 4 $0 copayment per day for days 5 through 190 including “lifetime reserve days” Outpatient group therapy visit: In-network: $40 copayment Out-of-network: $40 copayment Outpatient individual therapy visit: In-network: $40 copayment Out-of-network: $40 copayment 1 NOTE: Services with a may require prior authorization.

Network PlatinumChoice (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $295 copayment per day for days 1 through 4 $0 copayment per day for days 5 through 190 including “lifetime reserve days” Out-of-network: $295 copayment per day for days 1 through 4 $0 copayment per day for days 5 through 190 including “lifetime reserve days” Outpatient group therapy visit: In-network: $40 copayment Out-of-network: $40 copayment Outpatient individual therapy visit: In-network: $40 copayment Out-of-network: $40 copayment

Network PlatinumPlus (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $150 copayment per day for days 1 through 10 $0 copayment per day for days 11 through 190 including “lifetime reserve days” Out-of-network: $150 copayment per day for days 1 through 10 $0 copayment per day for days 11 through 190 including “lifetime reserve days” Outpatient group therapy visit: In-network: $35 copayment Out-of-network: $35 copayment Outpatient individual therapy visit: In-network: $35 copayment Out-of-network: $35 copayment

Network PlatinumPlus Pharmacy (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $150 copayment per day for days 1 through 10 $0 copayment per day for days 11 through 190 including “lifetime reserve days” Out-of-network: $150 copayment per day for days 1 through 10 $0 copayment per day for days 11 through 190 including “lifetime reserve days” Outpatient group therapy visit: In-network: $35 copayment Out-of-network: $35 copayment Outpatient individual therapy visit: In-network: $35 copayment Out-of-network: $35 copayment

Network PlatinumPremier (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $0 copayment Out-of-network: $0 copayment Outpatient group therapy visit: In-network: $0 copayment Out-of-network: $0 copayment Outpatient individual therapy visit: In-network: $0 copayment Out-of-network: $0 copayment

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Network PlatinumPremier Pharmacy (PPO) Inpatient visit: 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. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay in a psychiatric hospital. 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, up to a total of 190 lifetime days. In-network: $0 copayment Out-of-network: $0 copayment Outpatient group therapy visit: In-network: $0 copayment Out-of-network: $0 copayment Outpatient individual therapy visit: In-network: $0 copayment Out-of-network: $0 copayment

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BENEFIT Skilled Nursing Facility (SNF)1

Outpatient Rehabilitation1

Ambulance Transportation Medicare Part B Drugs

Network PlatinumSelect (PPO) Our plan covers up to 100 days in a SNF: In-network: $0 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 57 $0 copayment per day for days 58 through 100 Out-of-network: $0 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 57 $0 copayment per day for days 58 through 100 Prior 3 day inpatient hospital stay NOT required Cardiac (heart) rehab services: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumChoice (PPO) Our plan covers up to 100 days in a SNF: In-network: $0 copayment per day for days 1 through 20 $160 copayment per day for days 21 through 49 $0 copayment per day for days 50 through 100 Out-of-network: $0 copayment per day for days 1 through 20 $160 copayment per day for days 21 through 49 $0 copayment per day for days 50 through 100 Prior 3 day inpatient hospital stay NOT required Cardiac (heart) rehab services: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumPlus (PPO) Our plan covers up to 100 days in a SNF: In-network: $20 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 54 $0 copayment per day for days 55 through 100 Out-of-network: $20 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 54 $0 copayment per day for days 55 through 100 Prior 3 day inpatient hospital stay NOT required Cardiac (heart) rehab services: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumPlus Pharmacy (PPO) Our plan covers up to 100 days in a SNF: In-network: $20 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 54 $0 copayment per day for days 55 through 100 Out-of-network: $20 copayment per day for days 1 through 20 $167 copayment per day for days 21 through 54 $0 copayment per day for days 55 through 100 Prior 3 day inpatient hospital stay NOT required Cardiac (heart) rehab services: In-network: $25 copayment Out-of-network: $25 copayment

Network PlatinumPremier (PPO) Our plan covers up to 100 days in a SNF: In-network: $0 copayment per day for days 1 through 100 Out-of-network: $0 copayment per day for days 1 through 100 Prior 3 day inpatient hospital stay NOT required

Network PlatinumPremier Pharmacy (PPO) Our plan covers up to 100 days in a SNF: In-network: $0 copayment per day for days 1 through 100 Out-of-network: $0 copayment per day for days 1 through 100 Prior 3 day inpatient hospital stay NOT required

Cardiac (heart) rehab services: In-network: $0 copayment Out-of-network: $0 copayment

Occupational therapy visit: In-network: $40 copayment Out-of-network: $40 copayment

Occupational therapy visit: In-network: $0 copayment Out-of-network: $0 copayment

Physical therapy and speech and language therapy visit: In-network: $40 copayment Out-of-network: $40 copayment In-network: $300 copayment Out-of-network: $300 copayment Not covered For Part B drugs such as chemotherapy drugs: In-network: 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 20% of the cost Out-of-network: 20% of the cost

Physical therapy and speech and language therapy visit: In-network: $40 copayment Out-of-network: $40 copayment In-network: $275 copayment Out-of-network: $275 copayment Not covered For Part B drugs such as chemotherapy drugs: In-network: 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 20% of the cost Out-of-network: 20% of the cost

Physical therapy and speech and language therapy visit: In-network: $40 copayment Out-of-network: $40 copayment In-network: $250 copayment Out-of-network: $250 copayment Not covered For Part B drugs such as chemotherapy drugs: In-network: 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 20% of the cost Out-of-network: 20% of the cost

Physical therapy and speech and language therapy visit: In-network: $40 copayment Out-of-network: $40 copayment

Physical therapy and speech and language therapy visit: In-network: $0 copayment Out-of-network: $0 copayment

In-network: $250 copayment Out-of-network: $250 copayment Not covered For Part B drugs such as chemotherapy drugs: In-network: 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 20% of the cost Out-of-network: 20% of the cost

In-network: $0 copayment Out-of-network: $0 copayment Not covered For Part B drugs such as chemotherapy drugs: In-network: 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 20% of the cost Out-of-network: 20% of the cost

NOTE: Services with a 1 may require prior authorization.

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BENEFIT

Network PlatinumSelect (PPO)

Network PlatinumChoice (PPO)

Network PlatinumPlus (PPO)

ADDITIONAL BENEFITS Acupuncture Chiropractic Care

Diabetes Supplies and Services1

Durable Medical Equipment (wheelchairs, oxygen, etc.) Foot Care (podiatry services)

Network PlatinumPlus Pharmacy (PPO)

Network PlatinumPremier (PPO)

Network PlatinumPremier Pharmacy (PPO)

ADDITIONAL BENEFITS

Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $15 copayment Out-of-network: $15 copayment One Touch™ and Accu-Chek™ (All other brands are not covered) Diabetes monitoring supplies: In-network: $10 copayment Out-of-network: $10 copayment

Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $15 copayment Out-of-network: $15 copayment

Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $0 copayment Out-of-network: $0 copayment

One Touch™ and Accu-Chek™ (All other brands are not covered) Diabetes monitoring supplies: In-network: $10 copayment Out-of-network: $10 copayment

One Touch™ and Accu-Chek™ (All other brands are not covered) Diabetes monitoring supplies: In-network: $0 copayment Out-of-network: $0 copayment

Diabetes self-management training: In-network: $0 copayment Out-of-network: $0 copayment

Therapeutic shoes or inserts: In-network: $10 copayment Out-of-network: $10 copayment

Therapeutic shoes or inserts: In-network: $0 copayment Out-of-network: $0 copayment

Copayments for diabetes monitoring supplies apply up to a 90-day supply In-network: 20% of the cost Out-of-network: 20% of the cost

Copayments for diabetes monitoring supplies apply up to a 90-day supply In-network: $0 copayment Out-of-network: $0 copayment

Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: In-network: $40 copayment Out-of-network: $40 copayment In-network: $0 copayment Out-of-network: $0 copayment

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copayment Out-of-network: $40 copayment

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $0 copayment Out-of-network: $0 copayment

In-network: $0 copayment Out-of-network: $0 copayment

Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: In-network: $50 copayment Out-of-network: $50 copayment 1 Home Health Care In-network: $0 copayment Out-of-network: $0 copayment 1 NOTE: Services with a may require prior authorization.

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BENEFIT PREVENTIVE CARE Hospice

Network PlatinumSelect (PPO) 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. Group therapy visit: In-network: $40 copayment Out-of-network: $40 copayment

Network PlatinumChoice (PPO) 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. Group therapy visit: In-network: $40 copayment Out-of-network: $40 copayment

Network PlatinumPlus (PPO) 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. Group therapy visit: In-network: $20 copayment Out-of-network: $20 copayment

Network PlatinumPlus Pharmacy (PPO) 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.

Network PlatinumPremier (PPO) 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.

Network PlatinumPremier Pharmacy (PPO) 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.

Group therapy visit: In-network: $20 copayment Out-of-network: $20 copayment

Group therapy visit: In-network: $0 copayment Out-of-network: $0 copayment

Individual therapy visit: In-network: $40 copayment Out-of-network: $40 copayment Prosthetic devices: In-network: 20% of the cost Out-of-network: 20% of the cost

Individual therapy visit: In-network: $20 copayment Out-of-network: $20 copayment Prosthetic devices: In-network: 20% of the cost Out-of-network: 20% of the cost

Individual therapy visit: In-network: $0 copayment Out-of-network: $0 copayment Prosthetic devices: In-network: $0 copayment Out-of-network: $0 copayment

Related medical supplies: In-network: 20% of the cost Out-of-network: 20% of the cost 1 Renal Dialysis In-network: 20% of the cost Out-of-network: 20% of the cost 1 NOTE: Services with a may require prior authorization.

Related medical supplies: In-network: 20% of the cost Out-of-network: 20% of the cost In-network: $30 copayment Out-of-network: $30 copayment

Related medical supplies: In-network: 20% of the cost Out-of-network: 20% of the cost In-network: $25 copayment Out-of-network: $25 copayment

Related medical supplies: In-network: $0 copayment Out-of-network: $0 copayment In-network: $0 copayment Out-of-network: $0 copayment

Outpatient Substance Abuse1

Prosthetic Devices (braces, artificial limbs, etc.)1

HOSPICE

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Part D Pharmacy Coverage Information Medicare Part D Prescription Drug coverage adds another layer of complexity to insurance. Let’s take a look at how Medicare Part D coverage works in general, before we get into the details of Network Health’s pharmacy coverage.

Part D Pharmacy Coverage Information

What is a drug tier?

A drug tier is the cost category a drug belongs to. It determines what you pay for the drug, and usually the higher the tier the more you pay. Network Health’s plans divide drugs into five tiers.

What is a copayment?

A copayment is the set fee you pay for a prescription drug. Your copayment will vary based on the drug tier and whether you are in initial coverage, the coverage gap or the catastrophic coverage period. You pay less when you use a preferred pharmacy.

What is the difference between brand name and generic drugs?

A brand name drug is a drug that is protected by a patent. The drug can only be made or sold by the company that holds the patent. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredients as a brand name drug, but generally, the generic drug will cost less. Generic drugs are just as good as the brand name because they are approved by the FDA as meeting the same standards.

What is the Initial Coverage Period?

Refers to the first period of your Medicare Part D drug coverage. During this period, you will pay the copayment for the drug cost and your health plan pays the rest. This continues until total drug costs reach $3,750, and you enter the coverage gap.

What is the coverage gap (a.k.a. donut hole)?

The coverage gap is a period of time, after the initial coverage period, in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage.

Tom and Beverly R., Greenville

The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

• Greeting card maker • Fisherman • Network Health Medicare members

For more help with insurance language, visit NetworkHealthMedicare.com, select Understanding Medicare and click Glossary. 26 N e tw o r k He a l t h M e d i c are. c om

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Understanding Part D Prescription Drug Coverage Medicare Part D, or prescription drug coverage, has four different periods of coverage—deductible, initial coverage, the coverage gap and catastrophic coverage. Refer to the graphic for a general example of how it all works.

Remember, this image is an example only. Your deductible, drug tiers, pharmacy choice and other factors will determine your actual drug costs.

You pay Network Health pays Drug manufacturer pays

Drug Deductible

Preferred Pharmacy – A preferred pharmacy is a network pharmacy where drugs are covered at a lower cost.

Standard Pharmacy – A standard pharmacy is a network pharmacy where drugs are covered, but at a higher cost.

3.3

INITIAL COVERAGE

260

5 $ 8.3 $

You enter the coverage gap when total drug costs reach $3,750.

What is the difference between a preferred pharmacy and a standard pharmacy?

You leave the coverage gap and enter catastrophic coverage when the amount you pay reaches $5,000.

8 12 Generic ($20) $ $

58 Brand ($100) $

DRUG INITIAL COVERAGE DEDUCTIBLE You pay copayments. Your If your plan has a health plan pays the rest. deductible, you’ll pay the full cost of drugs up to that amount first. Network Health’s drug deductibles apply to medications on tiers 3, 4 and 5 only.

8.8

11.20 Generic ($20) $

50 Brand ($100) $

COVERAGE GAP You pay 44 percent of the cost for generic drugs and 35 percent for brand name drugs.

16.65 Generic ($20) $

$91.65 Brand ($100)

CATASTROPHIC COVERAGE You pay the greater of $3.35 or 5% of the cost for generic drugs and $8.35 or 5% of the cost for brand name drugs. Catastrophic coverage continues until December 31.

When your coverage starts, you pay a deductible and copayments until total drug costs (what you and Network DRUG DEDUCTIBLE Health pay) reach $3,750 $395 30-Day Supply 30-Day Supply Network For tiers 3, 4 Preferred Pharmacy Standard Pharmacy PlatinumSelect and 5 only $4 for Tier 1 $2 for Tier 1 $14 for Tier 2 $8 for Tier 2 $260 Network $47 for Tier 3 For tiers 3, 4 $42 for Tier 3 PlatinumChoice $91 for Tier 4 $84 for Tier 4 and 5 only Network PlatinumSelect is 25% for Tier 5 All other plans are 27% for Tier 5 $260 Network For tiers 3, 4 90-Day Supply PlatinumPlus 90-Day Supply and 5 only Pharmacy Standard Preferred $10 for Tier 1 $5 for Tier 1 $35 for Tier 2 $20 for Tier 2 $260 Network $118 for Tier 3 PlatinumPremier For tiers 3, 4 $105 for Tier 3 $228 for Tier 4 $210 for Tier 4 and 5 only Pharmacy Tier 5 is not available Tier 5 is not available

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COVERAGE GAP

You enter the coverage gap when total drug costs reach $3,750

You pay 44% and Network Health pays 56% for generic drugs. For brand name drugs, you pay 35%, Network Health pays 15% and the drug company pays 50%.

CATASTROPHIC COVERAGE

You enter catastrophic coverage when what you pay reaches $5,000

You pay the greater of $3.35 or 5% of the cost for generic drugs and $8.35 or 5% of the cost for brand name drugs.

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PRESCRIPTION DRUG BENEFITS How much do I pay?

Network PlatinumSelect (PPO) Network PlatinumChoice (PPO) Network PlatinumPlus (PPO) Part D Prescription Drug Coverage includes a $395 Part D Prescription Drug Coverage includes a $260 Our plan does not cover Part D prescription drugs. deductible for drugs listed on Tiers 3, 4 and 5 deductible for drugs listed on Tiers 3, 4 and 5

Network PlatinumPlus Pharmacy (PPO) Part D Prescription Drug Coverage includes a $260 deductible for drugs listed on Tiers 3, 4 and 5

Initial Coverage

Network PlatinumSelect (PPO) After you pay your yearly drug deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

Network PlatinumChoice (PPO) After you pay your yearly drug deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

Network PlatinumPlus Pharmacy (PPO) After you pay your yearly drug deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

Network PlatinumPremier Pharmacy (PPO) After you pay your yearly drug deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies and mail order pharmacies.

BENEFIT

Preferred Retail Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $2 copayment Tier 2 (Generic) $8 copayment Tier 3 (Preferred Brand) $42 copayment Tier 4 (Non-Preferred Brand) $84 copayment Tier 5 (Specialty Tier) 25% of the cost Standard Retail Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $4 copayment Tier 2 (Generic) $14 copayment Tier 3 (Preferred Brand) $47 copayment Tier 4 (Non-Preferred Brand) $91 copayment Tier 5 (Specialty Tier) 25% of the cost

90-Day supply $5 copayment $20 copayment $105 copayment $210 copayment Not offered

90-Day supply $10 copayment $35 copayment $118 copayment $228 copayment Not offered

Standard Retail Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $4 copayment Tier 2 (Generic) $14 copayment Tier 3 (Preferred Brand) $47 copayment Tier 4 (Non-Preferred Brand) $91 copayment Tier 5 (Specialty Tier) 27% of the cost

90-Day supply $5 copayment $20 copayment $105 copayment $210 copayment Not offered 90-Day supply $10 copayment $35 copayment $118 copayment $228 copayment Not offered

Network PlatinumPremier (PPO) Our plan does not cover Part D prescription drugs.

90-Day supply $5 copayment $20 copayment $105 copayment $210 copayment Not offered

Standard Retail Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $4 copayment

90-Day supply $10 copayment

Tier 2 (Generic)

$14 copayment

$35 copayment

Tier 3 (Preferred Brand)

$47 copayment

$118 copayment

Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier)

$91 copayment 27% of the cost

$228 copayment Not offered

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Network PlatinumPremier Pharmacy (PPO) Part D Prescription Drug Coverage includes a $260 deductible for drugs listed on Tiers 3, 4 and 5

Preferred Retail Cost-Sharing Tier 30-Day supply 90-Day supply Tier 1 (Preferred Generic) $2 copayment $5 copayment Tier 2 (Generic)

$8 copayment

$20 copayment

Tier 3 (Preferred Brand)

$42 copayment

$105 copayment

Tier 4 (Non-Preferred Brand)

$84 copayment

$210 copayment

Tier 5 (Specialty Tier)

27% of the cost

Not offered

Standard Retail Cost-Sharing Tier 30-Day supply 90-Day supply Tier 1 (Preferred Generic) $4 copayment $10 copayment Tier 2 (Generic) $14 copayment $35 copayment Tier 3 (Preferred Brand) $47 copayment $118 copayment Tier 4 (Non-Preferred Brand) $91 copayment $228 copayment Tier 5 (Specialty Tier) 27% of the cost Not offered

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BENEFIT How much do I pay? (Continued)

Coverage Gap

Network PlatinumSelect (PPO) Mail Order Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $2 copayment Tier 2 (Generic) $8 copayment Tier 3 (Preferred Brand) $42 copayment Tier 4 (Non-Preferred Brand) $84 copayment Tier 5 (Specialty Tier) 25% of the cost

90-Day supply $5 copayment $20 copayment $105 copayment $210 copayment Not offered

Network PlatinumChoice (PPO) Mail Order Cost-Sharing Tier 30-Day supply 90-Day supply Tier 1 (Preferred Generic) $2 copayment $5 copayment Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier)

$8 copayment $42 copayment $84 copayment 27% of the cost

$20 copayment $105 copayment $210 copayment Not offered

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use an in-network pharmacy. If it is necessary to use an out-of-network pharmacy, please check first with customer service as you may pay more than you pay at an in-network pharmacy.

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750.

After you enter the coverage gap, you pay 35% of the plan’s cost for covered brand name drugs and 44% of the plan’s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Network PlatinumPlus Pharmacy (PPO) Mail Order Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $2 copayment Tier 2 (Generic) $8 copayment Tier 3 (Preferred Brand) $42 copayment Tier 4 (Non-Preferred Brand) $84 copayment Tier 5 (Specialty Tier) 27% of the cost

90-Day supply $5 copayment $20 copayment $105 copayment $210 copayment Not offered

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

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Network PlatinumPremier Pharmacy (PPO) Mail Order Cost-Sharing Tier 30-Day supply Tier 1 (Preferred Generic) $2 copayment Tier 2 (Generic) $8 copayment Tier 3 (Preferred Brand) $42 copayment Tier 4 (Non-Preferred Brand) $84 copayment Tier 5 (Specialty Tier) 27% of the cost

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BENEFIT Catastrophic Coverage

Network PlatinumSelect (PPO) After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the following: Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Generic) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Generic) Tier 5 (Specialty Brand)

Your Cost $3.35 copayment or 5% of (whichever costs more) $3.35 copayment or 5% of (whichever costs more) $3.35 copayment or 5% of (whichever costs more) $8.35 copayment or 5% of (whichever costs more) $3.35 copayment or 5% of (whichever costs more) $8.35 copayment or 5% of (whichever costs more) $3.35 copayment or 5% of (whichever costs more) $8.35 copayment or 5% of (whichever costs more)

Network PlatinumChoice (PPO) After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the following: Tier

the cost

Tier 1 (Preferred Generic)

the cost

Tier 2 (Generic)

the cost

Tier 3 (Non-Preferred Generic)

the cost

Tier 3 (Preferred Brand)

the cost

Tier 4 (Non-Preferred Generic)

the cost

Tier 4 (Non-Preferred Brand)

the cost

Tier 5 (Specialty Generic)

the cost

Tier 5 (Specialty Brand)

Tier

Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier Pharmacy (PPO) After your yearly out-of-pocket drug costs (including drugs purchased through your retail After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the following: pharmacy and through mail order) reach $5,000, you pay the following:

the cost the cost the cost the cost the cost the cost the cost the cost

Tier 1 (Preferred Generic)

Your Cost

$3.35 copayment or 5% of (whichever costs more) Tier 2 (Generic) $3.35 copayment or 5% of (whichever costs more) Tier 3 (Non-Preferred Generic) $3.35 copayment or 5% of (whichever costs more) Tier 3 (Preferred Brand) $8.35 copayment or 5% of costs more) Tier 4 (Non-Preferred Generic) $3.35 copayment or 5% of (whichever costs more) Tier 4 (Non-Preferred Brand) $8.35 copayment or 5% of costs more) Tier 5 (Specialty Generic) $3.35 copayment or 5% of (whichever costs more) Tier 5 (Specialty Brand) $8.35 copayment or 5% of costs more)

the cost the cost the cost the cost (whichever the cost the cost (whichever the cost the cost (whichever

34 N e tw o r k He a l t h M e d i c are. c om

Tier Tier 1 (Preferred Generic)

Your Cost

$3.35 copayment or 5% of (whichever costs more) Tier 2 (Generic) $3.35 copayment or 5% of (whichever costs more) Tier 3 (Non-Preferred $3.35 copayment or 5% of Generic) (whichever costs more) $8.35 copayment or 5% of Tier 3 (Preferred Brand) costs more) Tier 4 (Non-Preferred $3.35 copayment or 5% of Generic) (whichever costs more) $8.35 copayment or 5% of Tier 4 (Non-Preferred Brand) costs more) Tier 5 (Specialty Generic) $3.35 copayment or 5% of (whichever costs more) Tier 5 (Specialty Brand) $8.35 copayment or 5% of costs more)

the cost the cost the cost the cost (whichever the cost the cost (whichever the cost the cost (whichever

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Nondiscrimination

OPTIONAL SUPPLEMENTAL BENEFIT The dental optional supplemental benefit package is available for a monthly premium of $35.

BENEFIT

Dental Optional Supplemental Benefit

Network Network PlatinumSelect PlatinumChoice (PPO) (PPO) Annual Maximum: $1,000 Comprehensive Deductible: $100

Network PlatinumPlus (PPO)

Network PlatinumPlus (PPO) Pharmacy

Network PlatinumPremier (PPO)

Network PlatinumPremier Pharmacy (PPO)

In-network: 0% of the cost for non-Medicare covered preventive and diagnostic dental services. Deductible does not apply. 50% of the cost for non-Medicare covered basic and major dental services after the deductible. Out-of-network: 20% of the cost for non-Medicare covered preventive and diagnostic dental services. Deductible does not apply. 50% of the cost for non-Medicare covered basic and major dental services after the deductible.

Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Network Health does notNondiscrimination exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Network Health does not exclude people or treat them differently because of race, color, national Network Health: origin, age, disability, or sex. • Provides free aids and services to people with disabilities to communicate effectively with us, such as: Network Health: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) •• Provides and services disabilities communicate effectively withas: us, such as: Provides free free aids language servicestotopeople peoplewith whose primary to language is not English, such o language interpreters o Qualified Qualified sign interpreters o Written information in other other languages formats (large print, audio, accessible electronic formats, other formats) o Information written in • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters If you need these services, contact Network Health’s discrimination complaints coordinator at 800-378-5234 (TTY 800-947-3529). o Information written in other languages If you believe that Network Health has failed to provide these services or discriminated in another way on the basis of race, color, If you need these services, contact Network Health’s discrimination complaints coordinator at 800-378-5234 (TTY 800-947-3529). national origin, age, disability, or sex, you can file a grievance with Network Health’s discrimination complaints coordinator, 1570 Midway Place, Menasha, WI 54952, phone number 800-378-5234, TTY 800-947-3529, Fax 920-720-1907, If you believe that Network Health You has can failed these servicesororbydiscriminated in another way on help the basis race, color, compliance@networkhealth.com. filetoaprovide grievance in person mail, fax, or email. If you need filing of a grievance, national age, disability, orcomplaints sex, you can file a grievance with Network Health’s discrimination complaints coordinator, Network origin, Health’s discrimination coordinator is available to help you. You can also file a civil rights complaint with1570 the Midway Place, Menasha, WI 54952, phone number 800-378-5234, TTY 800-947-3529, Fax 920-720-1907, U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint compliance@networkhealth.com. You can file a grievance in person or or by by mail mail,orfax, or email. If you need help a grievance, Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, phone at U.S. Department offiling Health and Human Network Health’s discrimination complaints coordinator is available to help you. You can also file a civil rights complaint with the Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint (TDD). Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, Independence SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 Complaint200 forms are availableAvenue at https://www.hhs.gov/ocr/office/file/index.html. (TDD).

Multi-language Interpreter Services

Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your Multi-language Interpreter Services language at no cost. To talk to an interpreter, call 800-378-5234 (TTY 800-947-3529). If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234 (TTY 800-947-3529). m-cmp-ndmulti-general-0617

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Albanian: Nëse ju, ose dikush që po ndihmoni, ka pyetje për Network Health, keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 800-378-5234 (TTY 800-947-3529). Arabic: ‫ ﻟﻠﺗﺣدث ﻣﻊ ﻣﺗر‬.‫ ﻟدﯾك اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة واﻟﻣﻌﻠوﻣﺎت ﺑﺎﻟﻠﻐﺔ اﻟﺧﺎﺻﺔ ﺑك دون أي ﺗﻛﻠﻔﺔ‬،Health Network ‫ أﺳﺋﻠﺔ ﺣول‬،‫إذا ﻛﺎن ﻟدﯾك أو ﻟدى ﺷﺧص ﻛﻧت ﻣﺳﺎﻋدة‬ .(3529-947-800 TTY) 5234-378-800 ‫ ﻗم ﺑﺎﺳﺗدﻋﺎء‬،‫ﺟم ﻓوري‬

Pennsylvania Dutch: “Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Network Health, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 800-378-5234 (TTY 800-947-3529) uffrufe. Polish: Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Network Health, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 800-378-5234 (TTY 800-947-3529).

Chinese: 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Network Health 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字800-378-5234 (TTY 800-947-3529).

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Network Health, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 800-378-5234 (TTY 800-947-3529).

French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Network Health, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 800-378-5234 (TTY 800-947-3529).

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-378-5234 (TTY 800-947-3529).

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Network Health haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 800-378-5234 (TTY 800-947-3529) an.

Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Network Health, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 800-378-5234 (TTY 800-947-3529).

Hindi: य"द आप, या (कसी को आप क- मदद कर रहे ह2, के बारे म4 सवाल है Network Health, आप कोई भी क-मत पर अपनी भाषा म4 मदद

Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Network Health, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 800-378-5234 (TTY 800-947-3529).

और जानकार@ AाBत करने का अCधकार है । एक दभ ु ाHषया के Iलए बात करने के Iलए, 800-378-5234 (TTY 800-947-3529) कहते ह2।.

Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-378-5234 (TTY 800-947-3529). Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Network Health 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는800-378-5234 (TTY 800-947-3529).로 전화하십시오. Laotian: ຖ້າທ່ານ, ຫຼືຄົນທ່ທ່ານກໍາລັງຊ່ວຍເຫຼືອ, ມຄໍາຖາມກ່ຽວກັບ Network Health, ທ່ານມ ສິດທ່ ຈະໄດ້ຮັບການຊ່ວຍເຫຼືອແລະຂໍ້ມູນຂ່າວສານທ່ເປັນພາສາຂອງທ່ານບໍ່ມ ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 800-378-5234 (TTY 800-947-3529).

38 N e tw o r k He a l t h M e d i c are. c om

39 800-983-7 5 87 | Mo n day– Fr i day, 8 a .m . t o 8 p.m .

8 0 0 -9 8 3 -7 5 87 | Mo n day– Fr i day, 8 a .m . t o 8 p . m .

N e t w o r kH e a l t h M e d i c a r e . c o m

Contact Network Health By Phone

Sales Department – 800-983-7587 Health Care Concierge Customer Service – 800-378-5234 TTY/TDD Users – 800-947-3529

Online

NetworkHealthMedicare.com

By Mail or In Person Network Health 1570 Midway Pl. Menasha, WI 54952

Hours of Operation

Additional Resources

Richard C., Grand Chute • • •

Campground owner Family man Network Health Medicare member

Where you’re more than a Medicare member

2018 NORTHEAST WISCONSIN

SUMMARY OF BENEFITS

800-983-7587 TT Y 800-947-3529 N e twork Heal t h Med i care.com

800- 983- 7587 T T Y 800- 947- 3529 N e two rkH e alt h M e dic are . c o m

RESEARCH RX In This Section UNDERSTANDING DRUG COSTS HOW THE COVERAGE GAP WORKS HOW TO LOOK UP DRUGS AND PHARMACIES OUR PLAN DRUG COSTS

Tom and Beverly R., Greenville

FORMULARY IS LOCATED IN THE BACK POCKET OF THIS BOOK

• Fisherman • Greeting card maker • Network Health Medicare members

RESEARCH Rx

Research Rx

Karen S., Brillion •Snowbird •Book club leader •Network Health Medicare member

UNDERSTANDING DRUG COSTS WHAT IS A DRUG TIER? A drug tier is the cost category a drug belongs to. It determines what you pay for the drug, and usually the higher the tier the more you pay. You can find out what tier a drug is on by looking it up in our drug list, called the formulary.

WHAT IS A COPAYMENT? A copayment is the set fee you pay for a prescription drug. Your copayment will vary based on the drug tier and whether you are in initial coverage, the coverage gap or the catastrophic coverage period. You pay less when you use a preferred pharmacy.

OUR PLANS HAVE FIVE DRUG TIERS

Tier 1 Preferred generic

Tier 2 Generic

Tier 3 Preferred brand

Tier 4 Non-preferred brand

Tier 5 Specialty drugs

WHAT IS THE DIFFERENCE BETWEEN BRAND NAME AND GENERIC DRUGS? A brand name drug is a drug that is protected by a patent. The drug can only be made or sold by the company that holds the patent. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredients as a brand name drug, but generally, the generic drug will cost less.

IS A GENERIC DRUG AS GOOD AS A BRAND NAME DRUG? Yes, generic drugs are just as good as the brand name because they are approved by the FDA as meeting the same standards. 25

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Research Rx

You leave the coverage gap and enter catastrophic coverage when the amount you pay reaches $5,000.

HOW THE COVERAGE GAP WORKS Medicare Part D, or prescription drug coverage, has four different periods of coverage—deductible, initial coverage, the coverage gap and catastrophic coverage. Refer to the graphic for a general example of how it all works.

Remember, this image is an example only. Your deductible, drug tiers, pharmacy choice and other factors will determine your actual drug costs. You pay Network Health pays Drug manufacturer pays

You enter the coverage gap when total drug costs reach $3,750. $

260

Drug Deductible

8 12 Generic ($20) $ $

58 Brand ($100) $

8.8

11.20 Generic ($20) $

8.3

3.3

50 Brand ($100) $

COVERAGE GAP You pay 44 percent of the cost for generic drugs and 35 percent for brand name drugs.

16.65 Generic ($20) $

$91.65 Brand ($100)

CATASTROPHIC COVERAGE You pay the greater of $3.35 or 5% of the cost for generic drugs and $8.35 or 5% of the cost for brand name drugs. Catastrophic coverage continues until December 31.

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Research Rx

HOW TO LOOK UP DRUGS AND PHARMACIES DRUGS Covered drugs are listed in our drug list, called the formulary. A printed copy of the most common drugs on this list is included in the back pocket of this book. You can also search the full, most up-to-date list at NetworkHealthMedicare.com.

HOW DO I USE THE FORMULARY? 1.

Find your drug. • Drugs are listed by category or alphabetically in the index at the end.

Find the drug’s tier. • The tier will be a number 1–5. Generally, the higher the tier, the more you’ll pay for the drug.

Look at the plan drug costs table on the next page to find the tier’s cost. • The table lists the cost (copayment) for each tier.

PHARMACIES Our pharmacy directory lists network pharmacies where you can get your prescriptions. For your prescriptions to be covered, you must use one of these pharmacies. In addition, if you use a preferred pharmacy, your copayment will be lower. Preferred pharmacies are marked with an asterisk (*) in the pharmacy directory. A few of our preferred pharmacies in your neighborhood include ShopKo®, Walgreens and Pick 'n Save® locations.

HOW DO I USE THE PHARMACY DIRECTORY? You can search for pharmacies by visiting NetworkHealthMedicare.com. Click Find a Pharmacy under Research Rx. If you’d like a printed copy of our pharmacy directory, call us. To find an in-network pharmacy while traveling, please call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re available seven days a week, 8 a.m. to 8 p.m.

what’s that NETWORK PHARMACIES PREFERRED PHARMACY

A preferred pharmacy is a network pharmacy where drugs are covered at a lower cost. STANDARD PHARMACY

A standard pharmacy is a network pharmacy where drugs are covered, but at a higher cost.

PRIOR AUTHORIZATION

Prior authorization is an approval from your plan that may be required before you have certain procedures done or prescriptions filled to be sure they are safe and appropriate.

CAN I HAVE MY PRESCRIPTION MEDICATIONS MAILED TO ME? Yes, you can save even more with a 90-day supply of your medications sent to you in the mail. Visit Express-Scripts.com and sign up for home delivery. Or call 800-316-3107 (TTY 800-899-2114), 24 hours a day, seven days a week. 27

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Research Rx

OUR PLAN DRUG COSTS INITIAL COVERAGE

When your coverage starts, you pay a deductible and copayments until total drug costs (what you and Network DRUG DEDUCTIBLE Health pay) reach $3,750 $395 30-Day Supply 30-Day Supply Network For tiers 3, 4 Preferred Pharmacy Standard Pharmacy PlatinumSelect and 5 only $4 for Tier 1 $2 for Tier 1 $14 for Tier 2 $8 for Tier 2 $260 Network $47 for Tier 3 $42 for Tier 3 For tiers 3, 4 PlatinumChoice $91 for Tier 4 $84 for Tier 4 and 5 only Select is 25% for Tier 5 All other plans are 27% for Tier 5 $260 Network For tiers 3, 4 90-Day Supply PlatinumPlus 90-Day Supply and 5 only Pharmacy Standard Preferred $10 for Tier 1 $5 for Tier 1 $35 for Tier 2 $20 for Tier 2 $260 Network $118 for Tier 3 $105 for Tier 3 PlatinumPremier For tiers 3, 4 $228 for Tier 4 $210 for Tier 4 and 5 only Pharmacy Tier 5 is not available Tier 5 is not available

COVERAGE GAP

You enter the coverage gap when total drug costs reach $3,750

You pay 44% and Network Health pays 56% for generic drugs. For brand name drugs, you pay 35%, Network Health pays 15% and the drug company pays 50%

CATASTROPHIC COVERAGE

You enter catastrophic coverage when what you pay reaches $5,000

You pay the greater of $3.35 or 5% of the cost for generic drugs and $8.35 or 5% of the cost for brand name drugs

REMINDERS • If you do not add prescription drug coverage when you are first eligible (and you do not have coverage that’s as good as or better than Medicare Part D coverage) and you choose to add it later, you may have to pay a penalty. • You can only be enrolled in one Part D prescription drug plan at a time. If you are enrolled in a Medicare Advantage PPO Plan, you must receive your Part D coverage through that plan. • If you enroll in a Stand Alone Prescription Drug Plan, you will automatically be disenrolled from the Medicare Advantage (PPO) or (HMO) plan and returned to Original Medicare. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You must continue to pay your Medicare Part B premium. 28

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Network Health Insurance Corporation 1570 Midway Place Menasha, WI 54952 800-378-5234 TTY 800-947-3529 Monday â&#x20AC;&#x201C; Friday, 8 a.m. to 8 p.m. NetworkHealthMedicare.com

Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier Pharmacy (PPO) Network PlatinumChoice (PPO) Network PlatinumSelect (PPO) Network Health Medicare Go (PPO) Network Health Medicare Anywhere ( PPO)

RX OPEN

2018 ABRIDGED FORMULARY

(LIST OF COVERED DRUGS) Please read. This document contains information about the drugs we cover in this plan. This abridged formulary was updated on 9/08/2017. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Network Health Medicare Advantage plans customer service at 800-316-3107 or, for TTY users, 800-899-2114, 24 hours a day/seven days a week, or visit NetworkHealthMedicare.com.

800- 378- 5234 T T Y 800-947- 3529 N e t w o r k H e a l t h Me d i c a r e . c o m H5215_1112r2p3_080817 Accepted 09082017

FormularyOpenCover2018.indd 1

9/6/17 4:14 PM

2018 Part D Formulary (Abridged)

Network Health Medicare Advantage Plans Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier Pharmacy (PPO) Network PlatinumSelect (PPO) Network Health Medicare Go (PPO) Network Health Medicare Anywhere (PPO) Network Health Medicare Choice (PPO)

2018 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 18156, 8 This abridged formulary was updated on 09/08/2017. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Network Health Medicare Advantage plans customer service at 800-316-3107 or, for TTY users, 800-899-2114, 24 hours a day/seven days a week, or visit NetworkHealthMedicare.com. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Network Health Insurance Corporation. When it refers to “plan” or “our plan,” it means Network Health Medicare Advantage plans. This document includes a partial list of the drugs (formulary) for our plan which is current as of 09/08/2017. For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. H5215_1112r2p3_080817 Accepted 09082017

2018 Part D Formulary (Abridged) You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.

What is the Network Health Medicare Advantage Plans Abridged Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Network Health Medicare Advantage plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by Network Health Medicare Advantage plans. For a complete listing of all prescription drugs covered by our plan, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugâ&#x20AC;&#x2122;s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/08/2017. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In limited instances, our plan may make changes to the formulary during the year which would reduce or discontinue coverage of a drug. Examples of this include removing dosage forms from the formulary, changing a preferred drug to a non-preferred drug even though a less expensive generic drug is not available and adding new prior authorization. If this occurs, a corrected formulary page will be mailed to you listing the updated formulary status of the affected drug.

How do I use the Formulary? There are two ways to find your drug within the formulary: 2

2018 Part D Formulary (Abridged) Medical Condition The formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on� page 97. The Index provides an alphabetical list of all of the drugs included in this� document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find� your drug. Next to your drug, you will see the page number where you can find coverage information.� Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Network Health Medicare Advantage plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: ·

Prior Authorization: Network Health Medicare Advantage plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug.

Quantity Limits: For certain drugs, Network Health Medicare Advantage plans limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for Actos. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Network Health Medicare Advantage plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our web site. We have posted on line documents that explain our prior authorization and 3

2018 Part D Formulary (Abridged) step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Network Health Medicare Advantage plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Network Health Medicare Advantage plans’ formulary?” on page 4 for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. This document includes only a partial list of covered drugs, so Network Health Medicare Advantage plans may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Network Health Medicare Advantage plans does not cover your drug, you have two options: ·

You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Network Health Medicare Advantage Plans’ Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. · · ·

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Network Health Medicare Advantage plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you 4

2018 Part D Formulary (Abridged) should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriberâ&#x20AC;&#x2122;s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a level of care change (for example, if you are admitted to or discharged from a hospital or long-term care facility), you may need additional supplies of medications. If this occurs, your pharmacy can get an override for this situation to allow for early refills. We will not limit your access to appropriate and necessary Part D medication refills if you experience a level of care change

For more information For more detailed information about your Network Health Medicare Advantage plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Network Health Medicare Advantage plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. 5

2018 Part D Formulary (Abridged)

Network Health Medicare Advantage Plan’s Formulary The abridged formulary below provides coverage information about some of the drugs covered by our plan.� If you have trouble finding your drug in the list, turn to the Index that begins on page 97. Remember: This is only a partial list of drugs covered by our plan. If your prescription is not in this partial� formulary, please contact us. Our contact information, along with the date we last updated the formulary,� appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and� generic drugs are listed in lower-case italics (e.g.,� warfarin). The information in the Requirements/Limits column tells you if Network Health Medicare Advantage plans� has any special requirements for coverage of your drug.

2018 Part D Formulary (Abridged)

Legend PA

Prior Authorization

STEP

Step Therapy

Quantity Limit

B/D PA

This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call customer service at 800-316-3107, 24 hours a day/seven days a week. TTY users should call 800-899-2114.

2018 Part D Formulary (Abridged)

Network PlatinumPlus Pharmacy, Network PlatinumPremier Pharmacy, Network Health Medicare Go and Network Health Medicare Choice

This table defines the standard copay structure during the initial coverage phase, which is what you pay after your deductible is met.* Depending on your income level, your actual cost-share may be less. For more information, consult your Evidence of Coverage. Initial Coverage Phase PREFERRED PHARMACY DRUG TIER

STANDARD PHARMACY

One Month

Three Months

One Month

Three Months

Tier 1

$10

Tier 2

$20

$14

$35

Tier 3*

$42

$105

$47

$118

Tier 4*

$84

$210

$91

$228

Tier 5*

27%

N/A

27%

N/A

*During the deductible stage, you pay the full cost of drugs in Tier 3, Tier 4 and Tier 5 until you have paid $260.

Network Health Medicare Anywhere

STANDARD PHARMACY

One Month

Three Months

One Month

Three Months

Tier 1

$10

Tier 2

$20

$14

$35

Tier 3

$42

$105

$47

$118

Tier 4

$84

$210

$91

$228

Tier 5

27%

N/A

27%

N/A 8

2018 Part D Formulary (Abridged) *During the deductible stage, you pay the full cost of your drugs. You stay in this stage until you have paid $200 for your drugs. Depending on your income level, your actual deductible and cost-share amounts may be less.

Network PlatinumSelect

This table defines the standard copay structure during the initial coverage phase, which is what you pay after your deductible is met.* Depending on your income level, you will pay the following cost-share. For more information, consult your Evidence of Coverage. Initial Coverage Phase PREFERRED PHARMACY DRUG TIER

STANDARD PHARMACY

One Month

Three Months

One Month

Three Months

Tier 1

$10

Tier 2

$20

$14

$35

Tier 3

$42

$105

$47

$118

Tier 4

$84

$210

$91

$228

Tier 5

25%

N/A

25%

N/A

*During the deductible stage, you pay the full cost of your drugs. You stay in this stage until you have paid $395 for your drugs. Depending on your income level, your actual deductible and cost-share amounts may be less.

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

ANTI - INFECTIVES

griseofulvin ultramicrosize

ANTIFUNGAL AGENTS

itraconazole

2 2

ABELCET

B/D PA

AMBISOME

B/D PA

ketoconazole 200 mg tablet

amphotericin b

B/D PA

LAMISIL

ANCOBON

MYCAMINE

CANCIDAS

clotrimazole 10 mg troche

NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET)

CRESEMBA (186 MG CAPSULE, 372 MG VIAL)

nystatin (100,000 unit/ml susp, 500,000 unit oral tab)

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

ONMEL

ORAVIG

SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE)

terbinafine hcl

ERAXIS (WATER DILUENT)

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

VFEND (40 MG/ML SUSPENSION, 50 MG TABLET, 200 MG TABLET) VFEND IV

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mg tablet)

fluconazole-nacl

flucytosine

voriconazole 200 mg vial

GRIS-PEG

ANTIVIRALS

griseofulvin (125 mg/5 ml susp, micro 500 mg tab)

abacavir

abacavir-lamivudine

B/D PA

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 10

Drug Name

Drug Tier

abacavir-lamivudinezidovudine

acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mg tablet, 800 mg tablet)

acyclovir sodium

adefovir dipivoxil

amantadine (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule)

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)

ATRIPLA

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)

entecavir

EPCLUSA

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET)

EPIVIR HBV 25 MG/5 ML SOLN

EPIVIR HBV 100 MG TABLET

EPZICOM

EVOTAZ

BARACLUDE 0.05 MG/ML SOLUTION

famciclovir 125 mg tablet

QL (10 PER 5 DAYS)

BARACLUDE (0.5 MG TABLET, 1 MG TABLET)

famciclovir 250 mg tablet

QL (60 PER 30 DAYS)

cidofovir

famciclovir 500 mg tablet

QL (30 PER 10 DAYS)

COMBIVIR

FLUMADINE

COMPLERA

FUZEON

COPEGUS

ganciclovir sodium

CRIXIVAN

GENVOYA

CYTOVENE

B/D PA

HARVONI

DAKLINZA

HEPSERA

DESCOVY

didanosine

INTELENCE (100 MG TABLET, 200 MG TABLET)

EDURANT

INTELENCE 25 MG TABLET

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 11

Drug Name

Drug Tier

INVIRASE (200 MG CAPSULE, 500 MG TABLET)

ISENTRESS (100 MG POWDER PACKET, 100 MG TABLET CHEW, 400 MG TABLET)

ISENTRESS 25 MG TABLET CHEW

Requirements/ Limits

Drug Name

Drug Tier

nevirapine er 400 mg tablet

NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)

ODEFSEY

oseltamivir phosphate

KALETRA (80 MG-20 MG/ML SOLN, 200-50 MG TABLET)

PREZCOBIX

5 5

KALETRA 100-25 MG TABLET

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mg tablet)

PREZISTA (100 MG/ML SUSPENSION, 600 MG TABLET, 800 MG TABLET)

lamivudine hbv

PREZISTA (75 MG TABLET, 150 MG TABLET)

lamivudinezidovudine

REBETOL

RELENZA

LEXIVA 50 MG/ML SUSPENSION

LEXIVA 700 MG TABLET

RESCRIPTOR (100 MG TABLET, 200 MG TABLET)

lopinavir-ritonavir

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE)

MODERIBA (200 MG TABLET, 400-400 MG DOSEPACK)

RETROVIR 200 MG/20 ML VIAL

MODERIBA 600-600 MG DOSEPACK

nevirapine (50 mg/5 ml susp, 200 mg tablet)

REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)

nevirapine er 100 mg tablet

RIBASPHERE 200 MG CAPSULE RIBASPHERE (200 MG TABLET, 400 MG TABLET)

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 12

Drug Name

Drug Tier

RIBASPHERE 600 MG TABLET

RIBASPHERE RIBAPAK

ribavirin (200 mg capsule, 200 mg tablet)

rimantadine hcl

SELZENTRY (75 MG TABLET, 150 MG TABLET, 300 MG TABLET)

SELZENTRY 25 MG TABLET

SOVALDI

stavudine

STRIBILD

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

TRIZIVIR

TRUVADA

TYBOST

valacyclovir hcl 1 gram tablet

QL (30 PER 30 DAYS)

valacyclovir hcl 500 mg tablet

QL (60 PER 30 DAYS)

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET)

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet)

VALTREX 1 GM CAPLET

QL (30 PER 30 DAYS)

VALTREX 500 MG CAPLET

QL (60 PER 30 DAYS)

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET)

VEMLIDY

VIDEX

SYNAGIS

VIDEX EC

TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE)

VIEKIRA PAK

VIEKIRA XR

VIRACEPT

TAMIFLU 6 MG/ML SUSPENSION

TECHNIVIE

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET)

TIVICAY (25 MG TABLET, 50 MG TABLET)

VIRAMUNE XR

4 5

TIVICAY 10 MG TABLET

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)

TRIUMEQ

ZEPATIER

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 13

Drug Name

Drug Tier

ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET)

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) ZOVIRAX (200 MG/5 ML SUSP, 200 MG CAPSULE, 800 MG TABLET)

Requirements/ Limits

Drug Name

Drug Tier

cefotetan

cefoxitin (1 gm vial, 10 gm vial)

cefoxitin 2 gm vial

4 2

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100 mg/5 ml susp, 200 mg tablet)

cefprozil (125 mg/5 ml susp, 250 mg/5 ml susp, 250 mg tablet, 500 mg tablet) ceftazidime (1 gm vial, 6 gm vial)

ceftazidime 2 gm vial

CEPHALOSPORINS AVYCAZ

CEFTIN

cefaclor (125 mg/5 ml susp, 250 mg/5 ml susp, 250 mg capsule, 375 mg/5 ml suspen, 500 mg capsule)

ceftriaxone (1 gm vial, 2 gm add vial, 10 gm vial, 250 mg vial, 500 mg vial)

cefuroxime

cefaclor er

cefuroxime sodium

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg/5 ml susp, 500 mg capsule)

cefazolin sodium

cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule)

cephalexin (125 mg/5 ml susp, 250 mg tablet, 250 mg capsule, 250 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 750 mg capsule)

cefepime hcl

FORTAZ (1 GM TWISTVIAL, 2 GM TWISTVIAL, 6 GM VIAL)

cefixime

MAXIPIME

cefotaxime sodium

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 14

Drug Name

Drug Tier

SUPRAX (100 MG/5 ML SUSPENSION, 100 MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION)

TAZICEF

TEFLARO

ZERBAXA

ZINACEF

Requirements/ Limits

ERYTHROMYCINS / OTHER MACROLIDES

Drug Name

Drug Tier

ERYPED 200

ERYPED 400

ERYTHROCIN LACTOBIONATE

ERYTHROCIN STEARATE

erythromycin (ec 250 mg cap, 500 mg filmtab)

erythromycin 250 mg filmtab

erythromycin ethylsuccinate (200 mg/5 ml gran, es 400 mg tab)

PCE

ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP, 200 MG/5 ML SUSP, 250 MG Z-PAK TABLET, 250 MG TABLET, 500 MG TABLET, 600 MG TABLET, I.V. 500 MG VIAL)

ZITHROMAX TRIPAK

ZMAX

Requirements/ Limits

azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200 mg/5 ml susp, 250 mg tablet, 500 mg tablet, 600 mg tablet, i.v. 500 mg vial)

clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet)

clarithromycin er

DIFICID

E.E.S. 200

MISCELLANEOUS ANTIINFECTIVES

E.E.S. 400

ALBENZA

ERY-TAB EC 250 MG TABLET

ERY-TAB EC 333 MG TABLET

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) amikacin sulfate

ERY-TAB EC 500 MG TABLET

atovaquone

PA; QL (20 PER 10 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 15

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

atovaquoneproguanil hcl

clindamycin phosphate-d5w

AZACTAM-ISOOSMOT 1 GM/50 ML

COARTEM

AZACTAM-ISOOSMOT 2 GM/50 ML

colistimethate

CUBICIN

aztreonam

DALVANCE

BACIIM

dapsone

bacitracin 50,000 unit vial

daptomycin

BETHKIS

DARAPRIM

DORIBAX

BILTRICIDE

EMVERM

CAPASTAT SULFATE

ethambutol hcl

CAYSTON

chloramphenicol sod succinate

FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET)

chloroquine phosphate

gentamicin sulfate (10 mg/ml vial, 80 mg/2 ml vial)

CLEOCIN HCL

CLEOCIN PALMITATE

gentamicin sulfate in ns

CLEOCIN PHOSPHATE

hydroxychloroquine sulfate

CLEOCIN PHOSPHATE IN D5W

imipenem-cilastatin sodium INVANZ

clindamycin hcl

clindamycin pediatric

clindamycin phosphate (300 mg/2 ml vl, 600 mg/4 ml vl, 900 mg/6 ml vl)

isoniazid (50 mg/5 ml solution, 100 mg/ml vial, 100 mg tablet, 300 mg tablet) ivermectin

LINCOCIN

B/D PA; QL (224 PER 28 DAYS)

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 16

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

lincomycin hcl

quinine sulfate

linezolid (100 mg/5 ml susp, 600 mg tablet, 600 mg/300 ml iv sol)

rifabutin

RIFADIN

MALARONE

RIFAMATE

mefloquine hcl

MEPRON

rifampin (150 mg capsule, 300 mg capsule, iv 600 mg vial)

meropenem

RIFATER

MERREM

SIRTURO

metronidazole (250 mg tablet, 375 mg capsule, 500 mg/100 ml, 500 mg tablet)

SIVEXTRO (200 MG VIAL, 200 MG TABLET)

MYAMBUTOL

streptomycin sulfate

MYCOBUTIN

STROMECTOL

NEBUPENT

SYNERCID

neomycin sulfate

tigecycline

ORBACTIV

TINDAMAX

paromomycin sulfate

tinidazole

PASER

TOBI

B/D PA; QL (280 PER 28 DAYS)

PENTAM 300

TOBI PODHALER

PLAQUENIL

QL (224 PER 28 DAYS)

polymyxin b sulfate

tobramycin 300 mg/5 ml ampule

B/D PA; QL (280 PER 28 DAYS)

PRIFTIN

tobramycin sulfate

primaquine

TRECATOR

PRIMAXIN

TYGACIL

pyrazinamide

QUALAQUIN

XIFAXAN 200 MG TABLET

B/D PA

QL (9 PER 3 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 17

Drug Name

Drug Tier

XIFAXAN 550 MG TABLET

ZYVOX (100 MG/5 ML SUSPENSION, 600 MG/300 ML IV SOLN, 600 MG TABLET)

PENICILLINS

Requirements/ Limits

Drug Name

Drug Tier

BICILLIN L-A

dicloxacillin sodium

nafcillin 1 gm vial

nafcillin 10 gm vial

oxacillin 1 gm/ 50 ml inj

oxacillin 2 gm/ 50 ml inj

oxacillin 10 gm vial

oxacillin 2 gm vial

penicillin g potassium

penicillin g procaine

penicillin g sodium

penicillin gk-iso-osm dextrose

penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet)

piperacillintazobactam

UNASYN

ZOSYN (2.25 GM/50 ML GALAXY BAG, 3.375 GM/50 ML GALAXY, 40.5 GRAM BULK VIAL)

amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 875 mg tablet)

amoxicillinclavulanate pot er

amoxicillinclavulanate potass (200-28.5 mg tab chew, 200-28.5 mg/5 ml sus, 250-62.5 mg/5 ml sus, 250125 mg tablet, 40057 mg/5 ml susp, 400-57 mg tab chew, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

ampicillin sodium

ampicillin trihydrate (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule)

ampicillin-sulbactam

AVELOX

AUGMENTIN

AVELOX IV

BICILLIN C-R

Requirements/ Limits

QUINOLONES

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 18

Drug Name

Drug Tier

CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG TABLET, 500 MG TABLET)

CIPRO I.V.

Requirements/ Limits

Drug Name

Drug Tier

TETRACYCLINES demeclocycline 150 mg tablet

demeclocycline 300 mg tablet

ciprofloxacin (250 mg/5 ml susp, 400 mg/40 ml vl, 500 mg/5 ml susp)

DORYX

DORYX MPC

ciprofloxacin er

DOXY 100

ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab)

doxycycline hyclate (20 mg tab, 50 mg cap, 100 mg tab, 100 mg cap)

ciprofloxacin-d5w

LEVAQUIN

doxycycline hyclate (dr 50 mg tab, dr 200 mg tab)

levofloxacin (25 mg/ml solution, 250 mg tablet, 500 mg/20 ml vial, 500 mg tablet, 750 mg tablet)

doxycycline hyclate (dr 75 mg tab, dr 100 mg tab, dr 150 mg tab)

levofloxacin-d5w

doxycycline mono 75 mg capsule

moxifloxacin

moxifloxacin hcl

ofloxacin (300 mg tablet, 400 mg tablet)

doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg tablet, mono 100 mg tablet, mono 100 mg cap, mono 150 mg cap, mono 150 mg tablet) MINOCIN

minocycline hcl (50 mg capsule, hcl 50 mg tablet, 75 mg capsule, hcl 75 mg tablet, 100 mg capsule, hcl 100 mg tablet)

SULFA'S / RELATED AGENTS BACTRIM

BACTRIM DS

sulfadiazine

sulfamethoxazoletrimethoprim (ds tablet, inj vial, ss tablet, susp)

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 19

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

trimethoprim

Requirements/ Limits

minocycline er 90 mg tablet

minocycline hcl er (er 45 mg tablet, er 135 mg tablet)

MORGIDOX

ORACEA

SOLODYN

TARGADOX

tetracycline 250 mg capsule

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

tetracycline 500 mg capsule

ADJUNCTIVE AGENTS

VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE)

URINARY TRACT AGENTS

VANCOMYCIN VANCOCIN HCL

vancomycin hcl (125 mg capsule, 250 mg capsule)

vancomycin hcl (1 gm vial, hcl 10 gm vial, 500 mg vial)

dexrazoxane

ELITEK

FUSILEV

KEPIVANCE

leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab, 100 mg vial, 350 mg vial)

levoleucovorin calcium

mesna

MESNEX 400 MG TABLET

MESNEX 1 GRAM/10 ML VIAL

XGEVA

5 5

FURADANTIN

HIPREX

MACROBID

MACRODANTIN

methenamine hippurate

MONUROL

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mg cap, mcr 100 mg cap)

nitrofurantoin monomacro

ZINECARD

PRIMSOL

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 20

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

ADRIAMYCIN

B/D PA

BUSULFEX

B/D PA

ADRUCIL

B/D PA

CABOMETYX

PA; LA

AFINITOR

CAMPTOSAR

B/D PA

AFINITOR DISPERZ

CAPRELSA

ALECENSA

carboplatin

B/D PA

ALIMTA

B/D PA

CASODEX

ALKERAN

B/D PA

ALUNBRIG

PA; LA

CELLCEPT (250 MG CAPSULE, 500 MG VIAL)

anastrozole

B/D PA

ARIMIDEX

CELLCEPT (200 MG/ML ORAL SUSP, 500 MG TABLET)

AROMASIN

cisplatin

B/D PA

ARRANON

B/D PA

cladribine

B/D PA

ASTAGRAF XL

B/D PA

clofarabine

AVASTIN

B/D PA

CLOLAR

azacitidine

B/D PA

COMETRIQ

AZASAN

B/D PA

COSMEGEN

B/D PA

azathioprine

B/D PA

COTELLIC

PA; LA

azathioprine sodium

B/D PA

cyclophosphamide

B/D PA

BAVENCIO

B/D PA

BELEODAQ

B/D PA

bexarotene

cyclosporine (25 mg capsule, 50 mg/ml ampul, 100 mg capsule, 100 mg/ml soln)

bicalutamide

B/D PA

BICNU

B/D PA

cyclosporine modified

bleomycin sulfate

B/D PA

CYRAMZA

B/D PA

BOSULIF

cytarabine

B/D PA

busulfan

dacarbazine

B/D PA

DACOGEN

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 21

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

DARZALEX

B/D PA; LA

FASLODEX

B/D PA

daunorubicin hcl

B/D PA

FEMARA

decitabine

B/D PA

FIRMAGON

B/D PA

docetaxel

B/D PA

DOXIL

B/D PA

fludarabine phosphate

doxorubicin hcl

B/D PA

fluorouracil 2,500 mg/50 ml vl

B/D PA

doxorubicin hcl liposome

B/D PA

flutamide

DROXIA

FOLOTYN

B/D PA

ELIGARD (7.5 MG SYRINGE KIT, 22.5 MG SYRINGE KIT, 30 MG SYRINGE KIT)

gemcitabine hcl

B/D PA

GEMZAR

B/D PA

ELIGARD 45 MG SYRINGE KIT

B/D PA

GENGRAF (25 MG CAPSULE, 50 MG CAPSULE)

B/D PA

ELLENCE

B/D PA

GENGRAF (100 MG/ML SOLUTION, 100 MG CAPSULE)

EMCYT

GILOTRIF

EMPLICITI

B/D PA

GLEEVEC

ENVARSUS XR

B/D PA

GLEOSTINE

epirubicin hcl

B/D PA

HALAVEN

B/D PA

ERBITUX

B/D PA

HERCEPTIN

B/D PA

ERIVEDGE

HEXALEN

ERWINAZE

B/D PA

HYCAMTIN

ETOPOPHOS

B/D PA

HYDREA

etoposide

B/D PA

hydroxyurea

exemestane

IBRANCE

FARESTON

ICLUSIG

FARYDAK

IDAMYCIN PFS

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 22

Drug Name

Drug Tier

Requirements/ Limits

idarubicin hcl

B/D PA

IFEX

B/D PA

ifosfamide

B/D PA

imatinib mesylate

IMBRUVICA

IMFINZI

IMURAN

B/D PA

INLYTA

IRESSA

irinotecan hcl

B/D PA

ISTODAX

B/D PA

JAKAFI

JEVTANA

B/D PA

KADCYLA

KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)

KISQALI

Drug Name

Drug Tier

Requirements/ Limits

LUPRON DEPOTPED

B/D PA

LYNPARZA

LYSODREN

MATULANE

MEGACE

MEGACE ES

megestrol acetate (20 mg tablet, acet 40 mg/ml susp, 40 mg tablet, 625 mg/5 ml susp)

MEKINIST

melphalan hcl

B/D PA

mercaptopurine

B/D PA

methotrexate (1 gm vial, 2.5 mg tablet)

B/D PA

methotrexate sodium

B/D PA

mitomycin

B/D PA

mitoxantrone hcl

B/D PA

KISQALI FEMARA CO-PACK

MUSTARGEN

B/D PA

KYPROLIS

B/D PA

mycophenolate 200 mg/ml susp

B/D PA

LARTRUVO

B/D PA; LA

B/D PA

LENVIMA

letrozole

mycophenolate mofetil (250 mg capsule, 500 mg vial, 500 mg tablet)

LEUKERAN

mycophenolic acid

B/D PA

leuprolide acetate

B/D PA

MYFORTIC

B/D PA

LONSURF

LUPRON DEPOT

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 23

Drug Name

Drug Tier

Requirements/ Limits

NEORAL (25 MG GELATIN CAPSULE, 100 MG/ML SOLUTION, 100 MG GELATIN CAPSULE)

B/D PA

NEXAVAR

Drug Tier

Requirements/ Limits

RAPAMUNE (1 MG TABLET, 2 MG TABLET)

B/D PA

RAPAMUNE 0.5 MG TABLET

B/D PA

NILANDRON

REVLIMID

nilutamide

RITUXAN

B/D PA

NINLARO

RUBRACA

NIPENT

B/D PA

RYDAPT

NULOJIX

B/D PA

SANDIMMUNE (25 MG CAPSULE, 50 MG/ML AMPUL, 100 MG/ML SOLN, 100 MG CAPSULE)

B/D PA

octreotide acetate (0.05 mg/ml vl, 100 mcg/ml vl, 200 mcg/ml vl)

SANDOSTATIN (0.05 MG/ML AMPUL, 0.5 MG/ML AMPUL)

octreotide acetate (acet 500 mcg/ml vl, 1,000 mcg/ml vial)

SANDOSTATIN 0.1 MG/ML AMPUL

ODOMZO

OPDIVO

B/D PA

SANDOSTATIN LAR DEPOT

oxaliplatin

B/D PA

SIGNIFOR

paclitaxel

B/D PA

SIGNIFOR LAR

PERJETA

B/D PA

SIMULECT

B/D PA

POMALYST

sirolimus

B/D PA

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG/ML AMPULE, 5 MG CAPSULE)

SOLTAMOX

SOMATULINE DEPOT

PURIXAN

SPRYCEL

RAPAMUNE 1 MG/ML ORAL SOLN

STIVARGA

SUTENT

SYLVANT

PA; LA

B/D PA

Drug Name

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 24

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

SYNRIBO

B/D PA

VELCADE

B/D PA

TABLOID

PA; LA

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)

B/D PA

VENCLEXTA (10 MG TABLET, 50 MG TABLET) VENCLEXTA 100 MG TABLET

PA; LA

TAFINLAR

PA; LA

TAGRISSO

PA; LA

VENCLEXTA STARTING PACK

tamoxifen citrate

VIDAZA

B/D PA

TARCEVA

vinblastine sulfate

B/D PA

TARGRETIN (1% GEL, 75 MG CAPSULE)

VINCASAR PFS

B/D PA

vincristine sulfate

B/D PA

TASIGNA

vinorelbine tartrate

B/D PA

TAXOTERE

B/D PA

VOTRIENT

TECENTRIQ

B/D PA; LA

XALKORI

THALOMID

XERMELO

thiotepa

B/D PA

XTANDI

TOPOSAR

B/D PA

YERVOY

B/D PA

topotecan hcl

B/D PA

YONDELIS

B/D PA

TORISEL

B/D PA

ZALTRAP

B/D PA

TREANDA

B/D PA

ZANOSAR

B/D PA

TRELSTAR

B/D PA

ZEJULA

PA; LA

tretinoin 10 mg capsule

ZELBORAF

ZOLINZA

TREXALL

B/D PA

ZORTRESS

TRISENOX

B/D PA

ZYDELIG

TYKERB

PA; LA

ZYKADIA

VECTIBIX

B/D PA

ZYTIGA

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 25

Drug Name

Drug Tier

Requirements/ Limits

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS QL (30 PER 30 DAYS); STEP

Drug Name

Drug Tier

Requirements/ Limits

clonazepam (0.125 mg dis tab, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg tablet, 1 mg tablet, 1 mg dis tablet, 2 mg odt, 2 mg tablet)

DEPACON

STEP

DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION)

STEP

DEPAKOTE

STEP

DEPAKOTE ER

STEP STEP

APTIOM (200 MG TABLET, 400 MG TABLET)

APTIOM (600 MG TABLET, 800 MG TABLET)

QL (60 PER 30 DAYS); STEP

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET)

STEP

BANZEL 400 MG TABLET

STEP

DEPAKOTE SPRINKLE

BRIVIACT (10 MG/ML ORAL SOLN, 10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)

STEP

DIASTAT

DIASTAT ACUDIAL

4 3

STEP

BRIVIACT 50 MG/5 ML VIAL

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) DILANTIN-125

STEP

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mg tablet)

carbamazepine er (er 100 mg cap, er 100 mg tablet, er 200 mg tablet, er 200 mg cap, er 300 mg cap, er 400 mg tablet)

divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mg tab, sod dr 250 mg tab, sod dr 500 mg tab) divalproex sodium er

EPITOL

CARBATROL

STEP

EQUETRO

CELONTIN

STEP

CEREBYX

STEP

ethosuximide (250 mg/5 ml soln, 250 mg capsule) felbamate (600 mg tablet, 600 mg/5 ml susp)

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 26

Drug Name

Drug Tier

Requirements/ Limits

felbamate 400 mg tablet

FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP)

fosphenytoin sodium

FYCOMPA 0.5 MG/ML ORAL SUSP

STEP

FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)

STEP

gabapentin (100 mg capsule, 250 mg/5 ml soln, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet)

GABITRIL

GRALISE

KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET)

KEPPRA XR

STEP

KLONOPIN

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

STEP

Drug Name

Drug Tier

Requirements/ Limits

LAMICTAL (BLUE)

STEP

LAMICTAL (GREEN)

STEP

LAMICTAL (ORANGE)

STEP

LAMICTAL ODT

STEP

LAMICTAL XR

STEP

LAMICTAL XR (BLUE)

STEP

LAMICTAL XR (GREEN)

STEP

LAMICTAL XR (ORANGE)

STEP

lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

lamotrigine er (er 25 mg tablet, er 50 mg tablet, er 100 mg tablet, er 200 mg tablet)

lamotrigine er (er 250 mg tablet, er 300 mg tablet)

lamotrigine odt

levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg/5 ml vial, 500 mg tablet, 750 mg tablet, 1,000 mg tablet)

levetiracetam er

levetiracetam-nacl

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 27

Drug Name

Drug Tier

Requirements/ Limits

LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)

MYSOLINE

STEP

NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE, 400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET)

STEP

ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET)

oxcarbazepine (150 mg tablet, 300 mg/5 ml susp, 300 mg tablet, 600 mg tablet)

OXTELLAR XR

PEGANONE

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet)

PHENYTEK

phenytoin (50 mg tablet chew, 125 mg/5 ml susp)

phenytoin sodium

STEP

Drug Name

Drug Tier

Requirements/ Limits

phenytoin sodium extended

primidone

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE)

QUDEXY XR 150 MG CAPSULE

ROWEEPRA

SABRIL (500 MG TABLET, 500 MG POWDER PACKET)

SPRITAM

STEP

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET)

STEP

TEGRETOL XR

STEP

tiagabine hcl

TOPAMAX (15 MG SPRINKLE CAP, 25 MG TABLET, 25 MG SPRINKLE CAP, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET)

topiramate (15 mg sprinkle cap, 25 mg sprinkle cap, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

topiramate er

TRILEPTAL (150 MG TABLET, 300 MG/5 ML SUSP, 300 MG TABLET, 600 MG TABLET)

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 28

Drug Name

Drug Tier

Requirements/ Limits

TROKENDI XR

valproate sodium

valproic acid (250 mg capsule, 250 mg/5 ml soln)

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET)

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION)

STEP

ZONEGRAN

zonisamide

Drug Name

Drug Tier

carbidopa-levodopa (carbidopa-levo 10100 mg odt, carbidopa-levo 25250 mg odt, carbidopa-levo 25100 mg odt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa 25-250 tab, carbidopa-levodopa 25-100 tab)

carbidopa-levodopa er

carbidopa-levodopaentacapone

COGENTIN

COMTAN

DUOPA

ELDEPRYL

STEP

ANTIPARKINSONISM AGENTS APOKYN

AZILECT

entacapone

benztropine mesylate (mes 0.5 mg tab, mes 1 mg tablet, mes 2 mg tablet, 2 mg/2 ml ampule)

LODOSYN

MIRAPEX

MIRAPEX ER

bromocriptine 5 mg capsule

NEUPRO

bromocriptine 2.5 mg tablet

PARLODEL (2.5 MG TABLET, 5 MG CAPSULE)

carbidopa

pramipexole dihydrochloride

pramipexole er (er 0.375 mg tablet, er 0.75 mg tablet, er 2.25 mg tablet, er 3 mg tablet, er 3.75 mg tablet, er 4.5 mg tablet)

Requirements/ Limits

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 29

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier 4

Requirements/ Limits

pramipexole er 1.5 mg tablet

ZELAPAR

rasagiline mesylate

MIGRAINE / CLUSTER HEADACHE THERAPY

REQUIP

almotriptan malate

REQUIP XL

QL (9 PER 30 DAYS)

ropinirole er (er 2 mg tablet, er 4 mg tablet, er 6 mg tablet, er 8 mg tablet)

AMERGE

QL (9 PER 30 DAYS); STEP

AXERT

QL (9 PER 30 DAYS); STEP

ropinirole hcl er 12 mg tablet

CAFERGOT

ropinirole hcl

dihydroergotamine 1 mg/ml am

RYTARY

selegiline hcl (5 mg tablet, 5 mg capsule)

dihydroergotamine 4 mg/ml spry ergotamine-caffeine

SINEMET 10-100

FROVA

SINEMET 25-100

QL (27 PER 28 DAYS); STEP

SINEMET 25-250

frovatriptan succinate

QL (27 PER 28 DAYS)

SINEMET CR

STALEVO 100

QL (8 PER 28 DAYS); STEP

STALEVO 125

IMITREX (4 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML VIAL, 6 MG/0.5 ML CARTRIDGES)

STALEVO 150

STALEVO 200

IMITREX 20 MG NASAL SPRAY

QL (12 PER 30 DAYS); STEP

STALEVO 50

IMITREX 5 MG NASAL SPRAY

QL (36 PER 30 DAYS); STEP

STALEVO 75

TASMAR

QL (9 PER 30 DAYS); STEP

tolcapone

IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg tablet)

MAXALT

QL (36 PER 28 DAYS); STEP

MAXALT MLT

QL (36 PER 28 DAYS); STEP

QL (8 PER 28 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 30

Drug Name

Drug Tier

Requirements/ Limits

MIGERGOT

MIGRANAL

QL (8 PER 28 DAYS)

naratriptan hcl

QL (9 PER 30 DAYS)

ONZETRA XSAIL

RELPAX

Drug Name

Drug Tier

Requirements/ Limits

zolmitriptan odt

QL (9 PER 30 DAYS)

ZOMIG (2.5 MG SPRAY, 5 MG SPRAY)

QL (18 PER 28 DAYS); STEP

QL (32 PER 28 DAYS); STEP

ZOMIG (2.5 MG TABLET, 5 MG TABLET)

QL (9 PER 30 DAYS); STEP

ZOMIG ZMT

QL (9 PER 30 DAYS); STEP

rizatriptan (5 mg tablet, 5 mg odt, 10 mg odt, 10 mg tablet)

QL (36 PER 28 DAYS)

MISCELLANEOUS NEUROLOGICAL THERAPY

sumatriptan 20 mg nasal spray

QL (12 PER 30 DAYS)

sumatriptan 5 mg nasal spray

QL (36 PER 30 DAYS)

sumatriptan succinate (4 mg/0.5 ml cart, 6 mg/0.5 ml vial, 6 mg/0.5 ml refill, 6 mg/0.5 ml inject, 6 mg/0.5 ml syrng)

QL (8 PER 28 DAYS)

sumatriptan 4 mg/0.5 ml inject

QL (8 PER 28)

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)

QL (9 PER 30 DAYS)

SUMAVEL DOSEPRO

QL (8 PER 28 DAYS); STEP

TREXIMET

QL (18 PER 28 DAYS); STEP

ZEMBRACE SYMTOUCH

STEP

zolmitriptan

QL (9 PER 30 DAYS)

AMPYRA

PA; LA

ARICEPT (5 MG TABLET, 10 MG TABLET, 23 MG TABLET)

STEP

AUBAGIO

AUSTEDO

PA; LA

COPAXONE

donepezil hcl (5 mg tablet, 10 mg tablet)

donepezil hcl 23 mg tablet

donepezil hcl odt

EXELON

STEP

EXONDYS 51

galantamine er

galantamine hbr

galantamine hydrobromide

GILENYA

GLATOPA

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 31

Drug Name

Drug Tier

Requirements/ Limits

HORIZANT

STEP

INGREZZA

KEVEYIS

memantine hcl (2 mg/ml solution, 5 mg tablet, 10 mg tablet)

memantine 5-10 mg titration pk

NAMENDA (2 MG/ML SOLUTION, 5-10 MG TITRATION PK, 5 MG TABLET, 10 MG TABLET)

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK)

NAMZARIC (7 MG10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK)

NUEDEXTA

RAZADYNE

STEP

RAZADYNE ER

STEP

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr ptch)

TECFIDERA

tetrabenazine

Drug Name

Drug Tier

Requirements/ Limits

TYSABRI

PA; LA

XENAZINE

PA; LA

ZINBRYTA

STEP

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY AMRIX

baclofen

carisoprodol

carisoprodol-aspirin

carisoprodol-aspirincodeine

PA; QL (240 PER 30 DAYS)

chlorzoxazone

cyclobenzaprine hcl

DANTRIUM

dantrolene sodium

FEXMID

GABLOFEN

B/D PA

LIORESAL INTRATHECAL

B/D PA

LORZONE

MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG TIMESPAN)

METAXALL

metaxalone

methocarbamol (500 mg tablet, 750 mg tablet, 1,000 mg/10 ml)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 32

Drug Name

Drug Tier

Requirements/ Limits

orphenadrine er 100 mg tablet

orphenadrine 30 mg/ml vial

pyridostigmine bromide

pyridostigmine bromide er

SKELAXIN

SOMA

tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg tablet, 4 mg capsule)

tizanidine hcl 6 mg capsule

ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, 6 MG CAPSULE)

Drug Tier

Requirements/ Limits

ASCOMP WITH CODEINE

QL (360 PER 30 DAYS)

BELBUCA (75 MCG FILM, 150 MCG FILM, 300 MCG FILM, 450 MCG FILM, 600 MCG FILM)

QL (60 PER 30 OVER TIME)

BELBUCA (750 MCG FILM, 900 MCG FILM)

QL (60 PER 30 OVER TIME)

BUPAP

QL (360 PER 30 DAYS)

BUPRENEX

QL (266 PER 30 OVER TIME)

buprenorphine

QL (4 PER 28 OVER TIME)

buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syring)

QL (266 PER 30 OVER TIME)

buprenorphine 2 mg tablet sl

QL (100 PER 30 OVER TIME)

buprenorphine 8 mg tablet sl

QL (25 PER 30 OVER TIME)

butalb-acetaminophcaff-codein

QL (360 PER 30 DAYS)

butalb-caffacetaminoph-codein

QL (360 PER 30 DAYS)

butalbital compoundcodeine

QL (360 PER 30 DAYS)

butalbitalacetaminophen

QL (360 PER 30 DAYS)

NARCOTIC ANALGESICS ABSTRAL

PA; QL (120 PER 30 OVER TIME)

acetaminop-codeine 120-12 mg/5

QL (4500 PER 30 OVER TIME)

acetaminophen-cod #4 tablet

QL (180 PER 30 OVER TIME)

acetaminophencodeine (#2 tablet, #3 tablet)

QL (360 PER 30 OVER TIME)

ACTIQ

PA; QL (120 PER 30 OVER TIME)

ALLZITAL

QL (360 PER 30 DAYS)

Drug Name

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 33

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

butalbitalacetaminophen-caffe (butalb-acetamin-caff 50-325-40, butalbacetamin-caff 50300-40, butalbitacetaminophen-caff cp)

QL (360 PER 30 DAYS)

EMBEDA (ER 60-2.4 MG CAPSULE, ER 80-3.2 MG CAPSULE, ER 100-4 MG CAPSULE)

QL (90 PER 30 OVER TIME)

EMBEDA ER 50-2 MG CAPSULE

QL (90 PER 30 OVER TIME)

butalbital-aspirincaffeine

QL (360 PER 30 DAYS)

ENDOCET

QL (360 PER 30 OVER TIME)

BUTRANS

QL (4 PER 28 OVER TIME)

ESGIC

QL (360 PER 30 DAYS)

codeine sulfate

QL (180 PER 30 OVER TIME)

EXALGO (ER 16 MG TABLET, ER 32 MG TABLET)

QL (60 PER 30 OVER TIME)

DILAUDID 5 MG/5 ML ORAL LIQUID

QL (1500 PER 30 DAYS)

EXALGO (ER 8 MG TABLET, ER 12 MG TABLET)

QL (60 PER 30 OVER TIME)

DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET)

QL (180 PER 30 OVER TIME)

fentanyl (12 mcg/hr patch, 50 mcg/hr patch, 75 mcg/hr patch, 100 mcg/hr patch)

QL (10 PER 30 OVER TIME)

DOLOPHINE HCL 10 MG TABLET

QL (120 PER 30 OVER TIME)

DOLOPHINE HCL 5 MG TABLET

QL (240 PER 30 OVER TIME)

fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch)

QL (10 PER 30 OVER TIME)

DURAGESIC (12 MCG/HR PATCH, 25 MCG/HR PATCH, 50 MCG/HR PATCH)

QL (10 PER 30 OVER TIME)

fentanyl 25 mcg/hr patch

QL (10 PER 30 DAYS)

DURAGESIC (75 MCG/HR PATCH, 100 MCG/HR PATCH)

QL (10 PER 30 OVER TIME)

fentanyl 87.5 mcg/hr patch

QL (10 PER 30 OVER TIME)

fentanyl citrate

QL (2000 PER 30 OVER TIME)

PA; QL (120 PER 30 OVER TIME)

DURAMORPH 10 MG/10 ML AMPUL

FENTORA

QL (4000 PER 30 OVER TIME)

PA; QL (120 PER 30 OVER TIME)

DURAMORPH 5 MG/10 ML AMPUL

FIORICET

QL (90 PER 30 OVER TIME)

QL (360 PER 30 DAYS)

EMBEDA (ER 20-0.8 MG CAPSULE, ER 30-1.2 MG CAPSULE)

FIORICET WITH CODEINE

QL (360 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 34

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

FIORINAL

QL (360 PER 30 DAYS)

hydromorphone hcl (10 mg/ml vial, 50 mg/5 ml vial)

QL (240 PER 30 OVER TIME)

FIORINAL WITH CODEINE #3

QL (360 PER 30 DAYS)

HYSINGLA ER (ER 30 MG TABLET, ER 40 MG TABLET, ER 60 MG TABLET)

QL (60 PER 30 OVER TIME)

HYCET

QL (5550 PER 30 OVER TIME)

hydrocodonacetamin 7.5-325/15

QL (5550 PER 30 OVER TIME)

HYSINGLA ER (ER 80 MG TABLET, ER 100 MG TABLET, ER 120 MG TABLET)

QL (60 PER 30 OVER TIME)

hydrocodoneacetaminophen (hydrocodonacetaminoph 2.5325, hydrocodonacetaminoph 7.5300, hydrocodonacetaminoph 7.5325, hydrocodonacetaminophen 5325, hydrocodonacetaminophen 5300, hydrocodonacetaminophn 10300, hydrocodonacetaminophn 10325)

QL (360 PER 30 OVER TIME)

HYSINGLA ER 20 MG TABLET

QL (150 PER 30 OVER TIME)

IBUDONE

QL (50 PER 30 OVER TIME)

KADIAN

QL (90 PER 30 OVER TIME)

LAZANDA 100 MCG NASAL SPRAY

PA; QL (45 PER 30 OVER TIME)

LAZANDA 300 MCG NASAL SPRAY

PA; QL (23 PER 30 OVER TIME)

hydrocodoneibuprofen

QL (50 PER 30 OVER TIME)

LAZANDA 400 MCG NASAL SPRAY

PA; QL (30 PER 30 OVER TIME)

hydromorphone er (er 16 mg tab, er 32 mg tab)

QL (60 PER 30 OVER TIME)

levorphanol tartrate

QL (120 PER 30 OVER TIME)

LORCET

QL (360 PER 30 OVER TIME)

hydromorphone er (er 8 mg tab, er 12 mg tab)

QL (60 PER 30 OVER TIME)

LORCET HD

QL (360 PER 30 OVER TIME)

hydromorphone 1 mg/ml solution

QL (2400 PER 30 OVER TIME)

LORCET PLUS

QL (360 PER 30 OVER TIME)

hydromorphone 2 mg/ml isecure

QL (1200 PER 30 OVER TIME)

LORTAB

QL (360 PER 30 OVER TIME)

hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet)

QL (180 PER 30 OVER TIME)

methadone 10 mg/5 ml solution

QL (600 PER 30 OVER TIME)

methadone 5 mg/5 ml solution

QL (1200 PER 30 OVER TIME)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 35

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

methadone hcl 10 mg tablet

QL (120 PER 30 OVER TIME)

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet, er 200 mg tablet)

QL (120 PER 30 OVER TIME)

methadone hcl 5 mg tablet

QL (240 PER 30 OVER TIME)

methadone hcl 10 mg/ml vial

QL (150 PER 30 OVER TIME)

MS CONTIN

QL (120 PER 30 OVER TIME)

morphine sulfate (10 mg/5 ml soln, 20 mg/5 ml soln, 100 mg/5 ml soln)

QL (900 PER 30 OVER TIME)

NORCO

QL (360 PER 30 OVER TIME)

OPANA 10 MG TABLET

QL (360 PER 30 OVER TIME)

morphine 10 mg/ml isecure syrg

QL (200 PER 30 OVER TIME)

OPANA 5 MG TABLET

QL (180 PER 30 OVER TIME)

morphine 2 mg/ml isecure syr

QL (1000 PER 30 OVER TIME)

OPANA ER

QL (90 PER 30 OVER TIME)

morphine 4 mg/ml isecure syr

QL (500 PER 30 OVER TIME)

oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet, 100 mg/5 ml soln)

QL (180 PER 30 OVER TIME)

morphine 8 mg/ml isecure syrng

QL (250 PER 30 OVER TIME)

morphine sulfate (ir 15 mg tab, ir 30 mg tab)

QL (180 PER 30 OVER TIME)

oxycodone hcl 5 mg/5 ml soln

QL (1200 PER 30 OVER TIME)

morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, er 80 mg cap, er 100 mg cap)

QL (90 PER 30 OVER TIME)

oxycodone hcl (5 mg capsule, 5 mg tablet)

QL (360 PER 30 OVER TIME)

oxycodone hcl er (er 10 mg tablet, er 20 mg tablet, er 40 mg tablet)

QL (90 PER 30 DAYS)

morphine sulfate er (sulf er 100 mg tablet, sulfate er 30 mg cap, sulfate er 60 mg cap, sulfate er 90 mg cap, sulfate er 120 mg cap)

oxycodone hcl er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet)

QL (90 PER 30 OVER TIME)

morphine sulfate er (er 45 mg cap, er 75 mg cap)

oxycodone hcl er 80 mg tablet

QL (60 PER 30 DAYS)

oxycodone hclaspirin

QL (360 PER 30 OVER TIME)

oxycodone hclibuprofen

QL (28 PER 30 OVER TIME)

QL (60 PER 30 OVER TIME)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 36

Drug Name

Drug Tier

Requirements/ Limits

oxycodoneacetaminophn 5325/5

QL (1860 PER 30 OVER TIME)

oxycodoneacetaminophen (oxycodonacetaminophen 2.5325, oxycodonacetaminophen 7.5325, oxycodoneacetaminophen 5325, oxycodoneacetaminophen 10325)

QL (360 PER 30 OVER TIME)

OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET)

Drug Tier

Requirements/ Limits

ROXICODONE 5 MG TABLET

QL (360 PER 30 OVER TIME)

SUBSYS

PA; QL (120 PER 30 OVER TIME)

SYNALGOS-DC

QL (300 PER 30 OVER TIME)

TENCON

QL (360 PER 30 DAYS)

TREZIX

QL (300 PER 30 OVER TIME)

TYLENOL-CODEINE NO.3

QL (360 PER 30 OVER TIME)

TYLENOL-CODEINE NO.4

QL (180 PER 30 OVER TIME)

VANATOL LQ

QL (5550 PER 30 DAYS)

OXYCONTIN 80 MG TABLET

QL (60 PER 30 OVER TIME)

VICODIN

QL (360 PER 30 OVER TIME)

oxymorphone hcl 10 mg tablet

QL (360 PER 30 OVER TIME)

VICODIN ES

QL (360 PER 30 OVER TIME)

oxymorphone hcl 5 mg tablet

QL (180 PER 30 OVER TIME)

VICODIN HP

QL (360 PER 30 OVER TIME)

oxymorphone hcl er (er 15 mg tab, er 20 mg tab, er 30 mg tab)

QL (90 PER 30 OVER TIME)

XODOL 10-300

QL (360 PER 30 OVER TIME)

oxymorphone hcl er (er 5 mg tablet, er 7.5 mg tab, er 10 mg tab, er 40 mg tab)

QL (90 PER 30 OVER TIME)

XODOL 5-300

QL (360 PER 30 OVER TIME)

XODOL 7.5-300

QL (360 PER 30 OVER TIME)

PERCOCET

QL (360 PER 30 OVER TIME)

XTAMPZA ER

QL (90 PER 30 OVER TIME)

PRIMLEV

QL (360 PER 30 OVER TIME)

ZAMICET

QL (5550 PER 30 OVER TIME)

ROXICODONE (15 MG TABLET, 30 MG TABLET)

QL (180 PER 30 OVER TIME)

ZEBUTAL

QL (360 PER 30 DAYS)

QL (90 PER 30 OVER TIME)

Drug Name

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 37

Drug Name ZOHYDRO ER

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

QL (90 PER 30 OVER TIME)

Requirements/ Limits

ANAPROX DS

diclofenac sodium (sod ec 25 mg tab, sod ec 50 mg tab, sodium 1% gel, 1.5% topical soln, sod ec 75 mg tab)

ARTHROTEC 50

diclofenac sodium er

ARTHROTEC 75

BUNAVAIL (4.2-0.7 MG FILM, 6.3-1 MG FILM)

diclofenac sodiummisoprostol diflunisal

BUNAVAIL 2.1-0.3 MG FILM

QL (30 PER 30 DAYS)

DUEXIS

EC-NAPROSYN

buprenorphinnaloxon 8-2 mg sl

QL (90 PER 30 DAYS)

buprenorphn-naloxn 2-0.5 mg sl

QL (360 PER 30 DAYS)

etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet)

butorphanol 10 mg/ml spray

QL (5 PER 28 OVER TIME)

etodolac er

EVZIO

butorphanol 1 mg/ml vial

QL (857 PER 30 OVER TIME)

FELDENE

butorphanol 2 mg/ml vial

fenoprofen 400 mg capsule

CAMBIA

fenoprofen 600 mg tablet

FLECTOR

flurbiprofen

ibuprofen (100 mg/5 ml susp, 400 mg tablet, 600 mg tablet, 800 mg tablet)

INDOCIN

indomethacin

indomethacin er

NON-NARCOTIC ANALGESICS

CELEBREX

celecoxib

CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)

DAYPRO

diclofenac potassium

QL (60 PER 30 DAYS)

QL (428 PER 30 OVER TIME) QL (9 PER 30 DAYS)

QL (30 PER 30 OVER TIME)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 38

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

NUCYNTA 50 MG TABLET

QL (362 PER 30 OVER TIME)

NUCYNTA 75 MG TABLET

QL (242 PER 30 OVER TIME)

NUCYNTA ER

QL (60 PER 30 OVER TIME)

oxaprozin

PENNSAID

pentazocinenaloxone hcl

piroxicam

PONSTEL

ketoprofen (50 mg capsule, 75 mg capsule, er 200 mg capsule)

LODINE

meclofenamate 100 mg capsule

meclofenamate 50 mg capsule

mefenamic acid

meloxicam

MOBIC

nabumetone

nalbuphine 100 mg/10 ml vial

QL (200 PER 30 OVER TIME)

SUBOXONE (4 MG-1 MG FILM, 8 MG-2 MG FILM)

QL (90 PER 30 DAYS)

nalbuphine 200 mg/10 ml vial

QL (100 PER 30 OVER TIME)

SUBOXONE 12 MG-3 MG SL FILM

QL (60 PER 30 DAYS)

naloxone hcl (0.4 mg/ml vial, 2 mg/2 ml syringe)

SUBOXONE 2 MG0.5 MG SL FILM

QL (360 PER 30 DAYS)

naltrexone hcl

sulindac

NAPRELAN

TALWIN

QL (541 PER 30 DAYS)

NAPROSYN

TIVORBEX

naproxen (125 mg/5 ml suspen, 250 mg tablet, dr 375 mg tablet, 375 mg tablet, 500 mg tablet, dr 500 mg tablet)

tolmetin sodium (400 mg cap, 600 mg tab)

tramadol hcl

QL (240 PER 30 OVER TIME)

naproxen sodium

QL (30 PER 30 OVER TIME)

naproxen sodium er

tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er 300 mg capsule)

NARCAN

NUCYNTA 100 MG TABLET

tramadol hcl er (er 300 mg tablet, hcl er 100 mg tablet, hcl er 200 mg tablet)

QL (30 PER 30 OVER TIME)

QL (181 PER 30 OVER TIME)

QL (325 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 39

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

tramadol hclacetaminophen

QL (240 PER 30 OVER TIME)

ALPRAZOLAM INTENSOL

ULTRACET

QL (240 PER 30 OVER TIME)

alprazolam odt

ULTRAM

QL (240 PER 30 OVER TIME)

AMBIEN

STEP

AMBIEN CR

STEP

VIMOVO

amitriptyline hcl

VIVITROL

amoxapine

VIVLODEX

ANAFRANIL

VOLTAREN

APLENZIN

ZIPSOR

APTENSIO XR

ZORVOLEX

aripiprazole

ZUBSOLV (1.4-0.36 MG TABLET, 5.7-1.4 MG TABLET)

QL (90 PER 30 DAYS)

aripiprazole odt

ARISTADA

ZUBSOLV (2.9-0.71 MG TABLET, 11.4-2.9 MG TABLET)

QL (30 PER 30 DAYS)

armodafinil

ATIVAN

ZUBSOLV 8.6-2.1 MG TABLET SL

QL (60 PER 30 DAYS)

atomoxetine hcl

BELSOMRA

BRISDELLE

bupropion hcl

bupropion hcl sr

bupropion xl

PSYCHOTHERAPEUTIC DRUGS

STEP

ABILIFY

ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER 400 MG SYR)

ADDERALL

buspirone hcl

ADDERALL XR

BUTISOL SODIUM

ADZENYS XR-ODT

CELEXA

alprazolam

chlordiazepoxide hcl

alprazolam er

chlordiazepoxideamitriptyline

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 40

Drug Name

Drug Tier

Requirements/ Limits

chlorpromazine hcl (25 mg/ml amp, 100 mg tablet)

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 200 mg tablet)

citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20 mg tablet, 40 mg tablet)

clomipramine 75 mg capsule

clomipramine hcl (25 mg capsule, 50 mg capsule)

clonidine hcl er

clorazepate dipotassium

clozapine

clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt 100 mg tablet)

clozapine odt (odt 150 mg tablet, odt 200 mg tablet)

CLOZARIL

CONCERTA

CYMBALTA

DAYTRANA

desipramine hcl

DESOXYN

desvenlafaxine er

QL (30 PER 30 DAYS)

Drug Name

Drug Tier

Requirements/ Limits

desvenlafaxine succinate er

DEXEDRINE

dexmethylphenidate hcl

dexmethylphenidate hcl er (er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp)

dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 20 mg cp)

dextroamphetamine sulfate

d-amphetamine er 5 mg capsule

dextroamphetamine sulfate er (er 10 mg capsule, er 15 mg capsule)

dextroamphetamineamphet er

dextroamphetamineamphetamine

diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)

doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

duloxetine hcl

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 41

Drug Name

Drug Tier

Requirements/ Limits

EDLUAR

STEP

EFFEXOR XR

EMSAM

ergoloid mesylates

escitalopram oxalate (oxalate 5 mg/5 ml, 5 mg tablet, 10 mg tablet, 20 mg tablet)

estazolam

eszopiclone

STEP

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET, TITRATION PACK)

STEP

FAZACLO

Drug Name

Drug Tier

fluphenazine hcl (1 mg tablet, 2.5 mg/ml vial, 2.5 mg tablet, 2.5 mg/5 ml elix, 5 mg/ml conc, 5 mg tablet, 10 mg tablet)

flurazepam hcl

fluvoxamine maleate

fluvoxamine maleate er

FOCALIN

FOCALIN XR

FORFIVO XL

GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE)

GEODON 20 MG/ML VIAL

FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE)

guanfacine hcl er

guanidine hcl

HALCION

fluoxetine dr

HALDOL

fluoxetine hcl (hcl 10 mg tablet, hcl 10 mg capsule, hcl 20 mg tablet, hcl 20 mg capsule, 20 mg/5 ml solution, hcl 40 mg capsule)

HALDOL DECANOATE 100

HALDOL DECANOATE 50

haloperidol

fluoxetine hcl 60 mg tablet

haloperidol decanoate

fluphenazine decanoate

haloperidol lactate (2 mg/ml conc, 5 mg/ml vial)

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 42

Drug Name

Drug Tier

Requirements/ Limits

HETLIOZ

maprotiline hcl

imipramine hcl

MARPLAN

imipramine pamoate

METADATE CD

INTERMEZZO

PA; QL (20 PER 30 DAYS)

METADATE ER

INTUNIV

methamphetamine hcl

INVEGA

METHYLIN

INVEGA SUSTENNA (78 MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML)

methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mg tab, er 54 mg tab)

INVEGA SUSTENNA 39 MG/0.25 ML

methylphenidate er (er 10 mg tab, er 20 mg tab)

INVEGA TRINZA

KAPVAY

methylphenidate 10 mg/5 ml sol

KHEDEZLA

LATUDA

LEXAPRO

lithium

methylphenidate hcl (2.5 mg chew tb, 5 mg/5 ml soln, 5 mg tablet, 5 mg chew tab, 10 mg chew tab, 10 mg tablet, 20 mg tablet)

lithium carbonate (150 mg cap, 300 mg tab, 300 mg cap, 600 mg cap)

methylphenidate hcl cd

methylphenidate hcl er

lithium carbonate er

methylphenidate la

LITHOBID

lorazepam

LORAZEPAM INTENSOL

mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg odt, 30 mg tablet, 30 mg odt, 45 mg tablet, 45 mg odt)

loxapine

modafinil

LUNESTA

NARDIL

nefazodone hcl

STEP

Drug Name

Drug Tier

Requirements/ Limits

QL (30 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 43

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

NORPRAMIN

PAXIL CR

nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap)

perphenazine

perphenazineamitriptyline

NUPLAZID

PEXEVA

NUVIGIL

phenelzine sulfate

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet)

STEP

pimozide

PRISTIQ

PROCENTRA

olanzapine 10 mg vial

protriptyline hcl

PROVIGIL

olanzapine odt

STEP

PROZAC

olanzapine-fluoxetine hcl (3-25 mg, 12-25 mg)

STEP

quetiapine fumarate

2 2

olanzapine-fluoxetine hcl (6-25 mg, 6-50 mg, 12-50 mg)

quetiapine fumarate er QUILLICHEW ER

ORAP

QUILLIVANT XR

oxazepam

paliperidone er

STEP

PAMELOR

PARNATE

REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG TABLET, 30 MG SOLTAB, 45 MG TABLET, 45 MG SOLTAB)

paroxetine er

RESTORIL

paroxetine hcl

REXULTI

STEP

PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET)

RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 1 MG/ML SOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 44

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

SYMBYAX

STEP

temazepam

thioridazine hcl

thiothixene

RISPERDAL CONSTA (12.5 MG SYR, 25 MG SYR)

RISPERDAL CONSTA (37.5 MG SYR, 50 MG SYR)

RISPERDAL M-TAB

TOFRANIL

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet)

TRANXENE T-TAB

tranylcypromine sulfate

trazodone hcl

risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt)

triazolam

trifluoperazine hcl

risperidone odt (3 mg odt, 4 mg odt)

trimipramine maleate

RITALIN

TRINTELLIX

RITALIN LA

VALIUM

ROZEREM

venlafaxine hcl

SAPHRIS

SARAFEM

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150 mg cap)

SEROQUEL

SEROQUEL XR

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50 mg tablet, hcl 100 mg tablet)

venlafaxine hcl er (er 37.5 mg tab, er 75 mg tab, er 150 mg tab, er 225 mg tab) VERSACLOZ

5 3

SILENOR

SONATA

VIIBRYD (10 MG TABLET, 10-20 MG STARTER PACK, 20 MG TABLET, 40 MG TABLET)

STRATTERA

VRAYLAR 1.5 MG-3 MG PACK

SURMONTIL

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 45

Drug Name

Drug Tier

Requirements/ Limits

VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE)

STEP

VYVANSE (10 MG CAPSULE, 10 MG CHEWABLE TABLET, 20 MG CAPSULE, 20 MG CHEWABLE TABLET, 30 MG CAPSULE, 30 MG CHEWABLE TABLET, 40 MG CHEWABLE TABLET, 40 MG CAPSULE, 50 MG CAPSULE, 50 MG CHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLE TABLET, 70 MG CAPSULE)

WELLBUTRIN SR

WELLBUTRIN XL

XANAX

XANAX XR

XYREM

PA; LA

zaleplon

STEP

ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET)

ZENZEDI (5 MG TABLET, 10 MG TABLET)

ziprasidone hcl

Drug Name

Drug Tier

Requirements/ Limits

ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

zolpidem tartrate (5 mg tablet, 10 mg tablet)

STEP

zolpidem tartrate (1.75 mg tab, 3.5 mg tablet)

PA; QL (20 PER 30 DAYS)

zolpidem tartrate er

STEP

ZYPREXA (15 MG TABLET, 20 MG TABLET)

STEP

ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET)

STEP

ZYPREXA 10 MG TABLET

STEP

ZYPREXA 10 MG VIAL

ZYPREXA RELPREVV

ZYPREXA ZYDIS (15 MG TABLET, 20 MG TABLET)

STEP

ZYPREXA ZYDIS 10 MG TABLET

STEP

ZYPREXA ZYDIS 5 MG TABLET

STEP

CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 46

Drug Name

Drug Tier

Requirements/ Limits

amiodarone 150 mg/3 ml vial

B/D PA

BETAPACE AF

disopyramide phosphate

dofetilide

Drug Name

Drug Tier

Requirements/ Limits

ANTIHYPERTENSIVE THERAPY ACCUPRIL

ACCURETIC

acebutolol hcl

ADALAT CC

flecainide acetate

AFEDITAB CR

mexiletine hcl

ALDACTAZIDE

STEP

MULTAQ

ALDACTONE

STEP

NEXTERONE

ALTACE

NORPACE

amiloride hcl

NORPACE CR

PACERONE

amiloridehydrochlorothiazide

procainamide hcl

amlodipine besylate

propafenone hcl

amlodipine besylatebenazepril

propafenone hcl er (er 325 mg cap, er 425 mg cap)

amlodipineolmesartan

propafenone hcl er 225 mg cap

amlodipine-valsartan

2 4

quinidine gluconate (80 mg/ml vial, er 324 mg tab)

amlodipinevalsartan-hctz (10160-25 mg, 10-16012.5mg, 10-320-25 mg)

quinidine sulfate

RYTHMOL SR

SORINE

amlodipinevalsartan-hctz (5160-12.5 mg, 5-16025 mg)

sotalol

ATACAND

sotalol af

ATACAND HCT

SOTYLIZE

atenolol

TIKOSYN

atenololchlorthalidone

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 47

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

AVALIDE

CARDENE I.V.

AVAPRO

CARDIZEM

AZOR

CARDIZEM CD

benazepril hcl

CARDIZEM LA

benazeprilhydrochlorothiazide

CARDURA

BENICAR

CARDURA XL

BENICAR HCT

CARTIA XT

betaxolol hcl (10 mg tablet, 20 mg tablet)

carvedilol

CATAPRES

BIDIL

CATAPRES-TTS 1

bisoprolol fumarate

CATAPRES-TTS 2

bisoprololhydrochlorothiazide

CATAPRES-TTS 3

bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

chlorothiazide

chlorothiazide sodium

BYSTOLIC

chlorthalidone

BYVALSON

CALAN

clonidine (0.1 mg/day patch, 0.2 mg/day patch)

CALAN SR

clonidine 0.3 mg/day patch

candesartan cilexetil

clonidine hcl

candesartanhydrochlorothiazid

COREG

captopril (12.5 mg tablet, 50 mg tablet, 100 mg tablet)

COREG CR

CORGARD

captopril 25 mg tablet

CORZIDE

captoprilhydrochlorothiazide

COZAAR

DEMADEX

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 48

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits STEP

DEMSER

eplerenone

DIBENZYLINE

eprosartan mesylate

DILT-XR

ethacrynate sodium

diltiazem 12hr er

EXFORGE

diltiazem 24hr cd

EXFORGE HCT

diltiazem 24hr er (24hr er 180 mg cap, 24hr er 120 mg cap, 24hr er 300 mg cap, 24hr er 420 mg cap, 24hr er 360 mg cap)

felodipine er

fosinopril sodium

fosinoprilhydrochlorothiazide

diltiazem hcl (30 mg tablet, 50 mg/10 ml vial, 60 mg tablet, 90 mg tablet, hcl 100 mg vial, 120 mg tablet)

DIOVAN

furosemide (10 mg/ml solution, 20 mg tablet, 40 mg/4 ml syringe, 40 mg/5 ml soln, 40 mg tablet, 80 mg tablet, 100 mg/10 ml vial)

DIOVAN HCT

guanfacine hcl

DIURIL

doxazosin mesylate

DUTOPROL

hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet)

DYAZIDE

DYRENIUM 100 MG CAPSULE

hydrochlorothiazide (12.5 mg tb, 12.5 mg cp, 25 mg tab, 50 mg tab)

DYRENIUM 50 MG CAPSULE

HYZAAR

EDARBI

indapamide

EDARBYCLOR

INDERAL LA

EDECRIN

INNOPRAN XL

enalapril maleate

INSPRA

enalaprilhydrochlorothiazide

irbesartan

irbesartanhydrochlorothiazide

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 49

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

isradipine

MICROZIDE

labetalol hcl (100 mg tablet, 100 mg/20 ml vl, 200 mg tablet, 300 mg tablet)

MINIPRESS

minoxidil

LASIX

moexipril hcl

lisinopril

moexiprilhydrochlorothiazide

lisinoprilhydrochlorothiazide

nadolol (20 mg tablet, 40 mg tablet)

LOPRESSOR

nadolol 80 mg tablet

LOPRESSOR HCT

losartan potassium

nadololbendroflumethiazide

losartanhydrochlorothiazide

LOTENSIN

nicardipine hcl (20 mg capsule, 25 mg/10 ml vial, 30 mg capsule)

LOTREL

nifedipine er

MATZIM LA

nimodipine

MAXZIDE

MAXZIDE-25 MG

methyclothiazide

metolazone

nisoldipine (er 8.5 mg tablet, er 17 mg tablet, er 25.5 mg tablet, er 30 mg tablet, er 34 mg tablet, er 40 mg tablet)

metoprolol succinate

nisoldipine er 20 mg tablet

metoprolol tartrate (1 mg/ml carpuject, tart 5 mg/5 ml vial, tartrate 25 mg tab, tartrate 50 mg tab, tartrate 100 mg tab)

NORVASC

olmesartan medoxomil

2 2

metoprololhydrochlorothiazide

olmesartanamlodipine-hctz

MICARDIS

olmesartanhydrochlorothiazide

MICARDIS HCT

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 50

Drug Name

Drug Tier

ORENITRAM ER (ER 0.25 MG TABLET, ER 1 MG TABLET, ER 2.5 MG TABLET, ER 5 MG TABLET)

ORENITRAM ER 0.125 MG TABLET

perindopril erbumine

phenoxybenzamine hcl

pindolol

prazosin hcl

Requirements/ Limits

Drug Name

Drug Tier

SULAR

TARKA

TAZTIA XT

TEKTURNA

TEKTURNA HCT

telmisartan

telmisartanamlodipine

telmisartanhydrochlorothiazid

PRINIVIL

TENORETIC 100

PROCARDIA XL

TENORETIC 50

propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg/5 ml soln, 20 mg tablet, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mg tablet)

TENORMIN

terazosin hcl

TIAZAC

4 2

propranolol hcl er

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)

propranololhydrochlorothiazid

TOPROL XL

QBRELIS

torsemide

quinapril hcl

trandolapril

quinaprilhydrochlorothiazide

trandolaprilverapamil er

ramipril

REMODULIN

SODIUM DIURIL

triamterenehydrochlorothiazid (37.5-25 mg cp, 37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab)

spironolactone

TRIBENZOR

spironolactone-hctz

TWYNSTA

B/D PA; LA

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 51

Drug Name

Drug Tier

Requirements/ Limits

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)

valsartan

valsartanhydrochlorothiazide

VASERETIC

VASOTEC

verapamil er (er 120 mg capsule, er 120 mg tablet, er 180 mg tablet, er 180 mg capsule, er 240 mg capsule, er 240 mg tablet)

verapamil er pm

verapamil hcl (2.5 mg/ml vial, 40 mg tablet, 80 mg tablet, 120 mg tablet, 360 mg cap pellet)

VERELAN

Drug Name

Drug Tier

digoxin (0.05 mg/ml solution, 125 mcg tablet, 250 mcg tablet, 500 mcg/2 ml ampule)

LANOXIN (125 MCG TABLET, 250 MCG TABLET, 500 MCG/2 ML AMPULE)

LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET)

COAGULATION THERAPY AGGRENOX

argatroban

argatroban-0.9% nacl

ARIXTRA (5 MG/0.4 ML SYRINGE, 7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE)

ARIXTRA 2.5 MG/0.5 ML SYRINGE

aspirin-dipyridamole er

BRILINTA

VERELAN PM

cilostazol

ZESTORETIC

clopidogrel

ZESTRIL

COUMADIN

ZIAC

CYKLOKAPRON

CARDIAC GLYCOSIDES

dipyridamole

DIGITEK

EFFIENT

ELIQUIS

Requirements/ Limits

QL (15 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 52

Drug Name

Drug Tier

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial)

fondaparinux 2.5 mg/0.5 ml syr

fondaparinux sodium (5 mg/0.4 ml syr, 7.5 mg/0.6 ml syr, 10 mg/0.8 ml syr)

FRAGMIN (10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 ML VL)

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR)

FRAGMIN 7,500 UNITS/0.3 ML SYR

heparin sodium

heparin sodium-d5w

JANTOVEN

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL)

Requirements/ Limits

QL (15 PER 30 DAYS)

QL (6 PER 30 DAYS)

QL (9 PER 30 DAYS)

Drug Name

Drug Tier

pentoxifylline

PLAVIX

PRADAXA

PROMACTA

SAVAYSA

tranexamic acid 1,000 mg/10 ml

warfarin sodium

XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, STARTER PACK)

YOSPRALA

ZONTIVITY

Requirements/ Limits

PA; LA

LIPID/CHOLESTEROL LOWERING AGENTS ALTOPREV

amlodipineatorvastatin (2.5-10 mg, 2.5-40 mg)

amlodipineatorvastatin (2.5-20 mg, 5-20 mg, 5-80 mg, 5-10 mg, 5-40 mg, 10-40 mg, 10-20 mg, 10-10 mg, 10-80 mg)

ANTARA

atorvastatin calcium

CADUET

cholestyramine

cholestyramine light

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 53

Drug Name

Drug Tier

COLESTID (1 GM TABLET, GRANULES)

colestipol hcl (1 gm tablet, granules)

CRESTOR

ezetimibe

ezetimibesimvastatin

fenofibrate (40 mg tablet, 50 mg capsule, 120 mg tablet, 150 mg capsule)

fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet, 67 mg capsule, 130 mg capsule, 134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mg capsule)

fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mg tablet, dr 135 mg cap)

FENOGLIDE

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

LIPOFEN

LIVALO

LOPID

lovastatin

LOVAZA

niacin er

NIACOR

NIASPAN

omega-3 acid ethyl esters

PRALUENT 150 MG/ML PEN

PA; QL (2 PER 28 DAYS)

PRALUENT 75 MG/ML PEN

PA; QL (4 PER 28 DAYS)

PRAVACHOL

pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab)

pravastatin sodium 80 mg tab

PREVALITE

FIBRICOR

QUESTRAN

fluvastatin er

QUESTRAN LIGHT

fluvastatin sodium

gemfibrozil

REPATHA PUSHTRONEX

PA; QL (3.5 PER 28 DAYS)

JUXTAPID

PA; LA

REPATHA SURECLICK

PA; QL (3 PER 30 DAYS)

KYNAMRO

PA; LA

REPATHA SYRINGE

LESCOL XL

PA; QL (3 PER 30 DAYS)

LIPITOR

rosuvastatin calcium

simvastatin

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 54

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

TRICOR

MINITRAN

TRIGLIDE

NITRO-BID

TRILIPIX

NITRO-DUR

VASCEPA

VYTORIN

WELCHOL (3.75G PACKET, 625 MG TABLET)

nitroglycerin (0.3 mg tablet sl, lingual 0.4 mg, 0.4 mg tablet sl, 0.6 mg tablet sl) nitroglycerin 5 mg/ml vial

ZETIA

nitroglycerin patch

ZOCOR

NITROMIST

NITROSTAT

MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR

ENTRESTO

ethacrynic acid

RANEXA

VECAMYL

NITRATES

Requirements/ Limits

B/D PA

DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin

calcipotriene 0.005% cream

calcipotriene (ointment, solution)

calcipotrienebetamethasone dp

GONITRO

ISORDIL

ISORDIL TITRADOSE

calcitriol 3 mcg/g ointment

isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, er 40 mg tablet)

COSENTYX (2 SYRINGES)

COSENTYX PEN (2 PENS)

isosorbide mononitrate

DOVONEX

DUPIXENT

isosorbide mononitrate er

ENSTILAR

selenium sulfide

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 55

Drug Name

Drug Tier

Requirements/ Limits

SILIQ

SORIATANE

SORILUX

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE, 130 MG/26 ML VIAL)

TACLONEX (0.005%0.064% SUSPENS, OINTMENT)

TALTZ AUTOINJECTOR

TALTZ SYRINGE

VECTICAL

BURN THERAPY

Drug Name

Drug Tier

fluorouracil (2% topical soln, 5% top solution, 5% cream)

fluorouracil 0.5% cream

imiquimod

methoxsalen

OXSORALENULTRA

PANRETIN

PICATO

podofilox

PROTOPIC

PRUDOXIN

SILVADENE

REGRANEX

silver sulfadiazine

SOLARAZE

SSD

tacrolimus (0.03%, 0.1%)

TOLAK

VALCHLOR

VEREGEN

MISCELLANEOUS DERMATOLOGICALS ALDARA

ammonium lactate (cream, lotion)

CARAC

ZONALON

CONDYLOX

diclofenac sodium 3% gel

ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM)

doxepin 5% cream

EFUDEX

ELIDEL

EUCRISA

PA; QL (100 PER 30 DAYS)

Requirements/ Limits

THERAPY FOR ACNE ABSORICA

ACANYA

ACZONE

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 56

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

adapalene (cream, gel)

CLINDESSE

adapalene 0.3% gel

ATRALIN

DIFFERIN (0.1% LOTION, 0.1% GEL, 0.1% CREAM, 0.3% GEL PUMP)

AVITA 0.025% CREAM

DUAC

AVITA 0.025% GEL

EPIDUO

AZELEX

EPIDUO FORTE

BENZACLIN

ERY

BENZAMYCIN

ERYGEL

CLARAVIS (10 MG CAPSULE, 30 MG CAPSULE)

erythromycin (gel, solution)

2 2

CLARAVIS (20 MG CAPSULE, 40 MG CAPSULE)

erythromycinbenzoyl peroxide EVOCLIN

CLEOCIN T (GEL, LOION, PLEDGES, SOLUION)

FABIOR

FINACEA (FOAM, GEL)

CLINDACIN P

METROCREAM

CLINDAGEL

METROGEL

clindamax

METROLOTION

clindamycin phosbenzoyl perox

clindamycin phostretinoin

metronidazole (0.75% cream, topical 0.75% gl, 0.75% lotion, topical 1% gel)

clindamycin phosphate 1% foam

MIRVASO

clindamycin phosphate (ph gel, ph solution, phos pledget, phosp lotion)

MYORISAN

NEUAC

NORITATE

clindamycin-benzoyl peroxide

ONEXTON

Requirements/ Limits PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 57

Drug Name

Drug Tier

Requirements/ Limits

RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% CREAM, 0.1% CREAM)

RETIN-A MICRO

RETIN-A MICRO PUMP

SOOLANTRA

tazarotene

TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL, 0.1% CREAM)

tretinoin (0.01% gel, 0.025% gel, 0.025% cream, 0.05% gel, 0.05% cream, 0.1% cream)

tretinoin microsphere

ZENATANE (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)

ZENATANE 10 MG CAPSULE

ZIANA

Drug Name

Drug Tier

Requirements/ Limits

lidocaine-prilocaine

LIDODERM

4 4

XYLOCAINE (2% VIAL, 4% SOLUTION)

TOPICAL ANTIBACTERIALS

BACTROBAN

CORTISPORIN (CREAM, OINTMENT)

gentamicin sulfate (cream, ointment)

KLARON

mupirocin (cream, ointment)

NEO-SYNALAR

sulfacetamide sod 10% top susp

SULFAMYLON (8.5% CREAM, POWDER PACKET)

TOPICAL ANTIFUNGALS PA

TOPICAL ANESTHETICS lidocaine 5% patch

lidocaine 5% ointment

QL (110 PER 30 DAYS)

lidocaine hcl (0.5% vial, 1% ampul, 2% vial, 2% jelly, 4% solution)

lidocaine hcl viscous

ciclopirox (0.77% gel, 0.77% cream, 0.77% topical susp, 1% shampoo, 8% solution)

clotrimazole (cream, solution)

clotrimazolebetamethasone (crm, lot)

econazole nitrate

ERTACZO

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 58

Drug Name

Drug Tier

EXELDERM (CREAM, SOLUTION)

EXTINA

JUBLIA

KERYDIN

ketoconazole (cream, foam, shampoo)

LOPROX 1% SHAMPOO

LOTRISONE

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

TOPICAL ANTIVIRALS acyclovir 5% ointment

DENAVIR

XERESE

ZOVIRAX (CREAM, OINTMENT)

TOPICAL CORTICOSTEROIDS ALA-CORT

ALA-SCALP

LUZU

MENTAX

alclometasone dipropionate (dipr oint, dipro crm)

naftifine hcl 1% cream

amcinonide (cream, lotion, ointment)

naftifine hcl 2% cream

APEXICON E

NAFTIN (1% GEL, 2% CREAM, 2% GEL)

NIZORAL

betamethasone dipropionate (aug crm, aug gel, aug lot, aug oin, crm, lot, oint)

NYAMYC

NYATA

betamethasone valer 0.12% foam

nystatin (unit/gm cream, unit/gm powd, units/gm oint)

betamethasone valerate (va cream, va lotion, valer ointm)

nystatintriamcinolone (cream, ointm)

CAPEX SHAMPOO

clobetasol emollient

NYSTOP

oxiconazole nitrate

clobetasol propionate (gel, prop spray, solution)

OXISTAT (CREAM, LOTION)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 59

Drug Name

Drug Tier

clobetasol propionate (ointment, prop foam, shampoo, topical lotn)

CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION)

CLODAN

CLODERM

CORDRAN

CORMAX

CUTIVATE

DERMATOP

DESONATE

desonide (cream, lotion)

desonide 0.05% ointment

DESOWEN (CREAM, LOTION)

Requirements/ Limits

Drug Name

Drug Tier

fluocinolone acetonide (0.01% solution, 0.01% cream, 0.01% body oil, 0.025% cream, 0.025% ointment)

fluocinonide (0.05% gel, 0.05% ointment, 0.05% solution, 0.1% cream)

fluocinonide-e

flurandrenolide (cream, lotion)

flurandrenolide 0.05% ointment

fluticasone propionate (0.005% oint, 0.05% cream)

fluticasone prop 0.05% lotion

4 2

halobetasol propionate (cream, ointmnt)

desoximetasone (0.05% ointment, 0.05% cream, 0.25% ointment)

HALOG (CREAM, OINTMENT)

4 2

desoximetasone (0.05% gel, 0.25% cream)

hydrocortisone (1% ointment, 1% cream, 2.5% cream, 2.5% ointment, 2.5% lotion)

diflorasone diacetate (cream, ointment)

hydrocort buty 0.1% lipo cream

DIPROLENE

hydrocortisone butyrate (oint, soln)

DIPROLENE AF

ELOCON (CREAM, OINTMENT)

hydrocortisone valerate (cream, ointmt) KENALOG

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 60

Drug Name

Drug Tier

Requirements/ Limits

Drug Name SANTYL

Drug Tier

LOCOID (CREAM, LOTION, OINTMENT, SOLUTION)

lokara

ELIMITE

mometasone furoate (cream, oint, soln)

EURAX (CREAM, LOTION)

NOLIX

lindane

OLUX

malathion

PANDEL

OVIDE

prednicarbate (cream, ointment)

permethrin

PSORCON

SKLICE

TOPICORT (0.05% GEL, 0.05% OINTMENT, 0.05% CREAM, 0.25% CREAM, 0.25% SPRAY, 0.25% OINTMENT)

triamcinolone acetonide (0.025% lotion, 0.025% oint, 0.025% cream, 0.1% ointment, 0.1% cream, 0.1% lotion, 0.147 mg/g spray, 0.5% ointment, 0.5% cream)

TRIANEX

TRIDERM

TRIDESILON

TOPICAL SCABICIDES / PEDICULICIDES

DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation

neomycin-polymyxin b

PHYSIOLYTE

PHYSIOSOL

ringers irrigation

MISCELLANEOUS AGENTS acamprosate calcium

ACTONEL 30 MG TABLET

ULTRAVATE (CREAM, LOTION, OINTMENT)

ADAGEN

AGRYLIN

VANOS

alendronate sodium 40 mg tab

anagrelide hcl

TOPICAL ENZYMES

Requirements/ Limits

QL (30 PER 30 DAYS); STEP

QL (30 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 61

Drug Name

Drug Tier

Requirements/ Limits

ANTABUSE

ARALAST NP

AURYXIA

BUPHENYL (500 MG TABLET, POWDER)

CARBAGLU

CARNITOR (1 GM/5 ML VIAL, 100 MG/ML ORAL SOLN, 330 MG TABLET)

cevimeline hcl

CHEMET

CLINIMIX 4.25%-5% SOLUTION

B/D PA

CLINIMIX E (2.75%5% SOLUTION, 2.75%-10% SOLUTION)

B/D PA

dextrose 10%-0.2% nacl

dextrose 10%-0.45% nacl

dextrose 2.5%-0.45% nacl

dextrose 5%-0.2% nacl

dextrose 5%-0.225% nacl

dextrose 5%-0.33% nacl

dextrose 5%-0.45% nacl

dextrose 5%-0.9% nacl

Drug Name

Drug Tier

Requirements/ Limits

dextrose in lactated ringers

dextrose in water

disulfiram

etidronate disodium

EVOXAC

EXJADE

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET)

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER PACK, 1,000 MG TABLET CHEW)

GLASSIA

INCRELEX

JADENU

JADENU SPRINKLE

KAYEXALATE

KIONEX

levocarnitine (1 g/10 ml soln, 330 mg tablet)

LITHOSTAT

midodrine hcl

NORTHERA

NUTRESTORE

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 62

Drug Name

Drug Tier

Requirements/ Limits

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG CAPSULE, 10 MG CAPSULE)

pilocarpine hcl (5 mg tablet, 7.5 mg tablet)

PROLASTIN C

RAVICTI

RECLAST

RENAGEL

RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET, 800 MG TABLET)

RILUTEK

riluzole

risedronate sodium 30 mg tab

QL (30 PER 30 DAYS); STEP

SALAGEN

sevelamer carbonate

sodium chloride (irrig., solution)

sodium phenylbutyrate

sodium polystyrene sulfonate

SPS

SYPRINE

THIOLA

VELPHORO

VELTASSA

Drug Name

Drug Tier

water

ZEMAIRA

zoledronic acid 5 mg/100 ml

Requirements/ Limits LA

SMOKING DETERRENTS LA

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET, STARTING MONTH BOX)

NICOTROL

NICOTROL NS

ZYBAN

EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO

QL (60 PER 30 DAYS)

azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray)

QL (60 PER 30 DAYS)

BACTROBAN NASAL

chlorhexidine gluconate

ipratropium 0.03% spray

QL (60 PER 30 DAYS)

ipratropium 0.06% spray

QL (45 PER 30 DAYS)

olopatadine 665 mcg nasal spry

QL (61 PER 30 DAYS)

PATANASE

QL (61 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 63

Drug Name

Drug Tier

PERIOGARD

triamcinolone 0.1% paste

Requirements/ Limits

MISCELLANEOUS OTIC PREPARATIONS ACETASOL HC

acetic acid

FLOXIN

fluocinolone acetonide oil

hydrocortisone-acetic acid

ofloxacin 0.3% ear drops

Drug Name

Drug Tier

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

DEXAMETHASONE INTENSOL

dexamethasone sodium phosphate (10 mg/ml vial, 120 mg/30 ml vl)

DEXPAK

fludrocortisone acetate

H.P. ACTHAR

5 2

CIPRO HC

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet)

CIPRODEX

KENALOG-10

COLY-MYCIN S

KENALOG-40

neomycin-polymyxinhc ear susp

neomycin-polymyxinhydrocort

OTOVEL

MEDROL (2 MG TABLET, 4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) methylprednisolone (4 mg tablet, 4 mg dosepk, 8 mg tab, 16 mg tab, 32 mg tab)

methylprednisolone acetate

methylprednisolone sodium succ

OTIC STEROID / ANTIBIOTIC

ENDOCRINE/DIABETES ADRENAL HORMONES CORTEF

cortisone acetate

DEPO-MEDROL

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 64

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

acarbose 100 mg tablet

QL (90 PER 30 DAYS)

acarbose 25 mg tablet

QL (360 PER 30 DAYS)

MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION)

ORAPRED ODT

prednisolone odt 10 mg tablet

acarbose 50 mg tablet

QL (180 PER 30 DAYS)

prednisolone sodium phos odt (odt 15 mg tablet, odt 30 mg tablet)

ACTOPLUS MET

QL (90 PER 30 DAYS)

prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5 ml soln, 15 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25 mg/5 ml)

ACTOPLUS MET XR 15-1,000 MG TB

QL (60 PER 30 DAYS)

ACTOPLUS MET XR 30-1,000 MG TB

QL (30 PER 30 DAYS)

ACTOS

QL (30 PER 30 DAYS)

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mg tablet, 20 mg tablet, 50 mg tablet)

ADLYXIN

QL (6 PER 28 DAYS); STEP

AFREZZA

alogliptin

QL (30 PER 30 DAYS); STEP

PREDNISONE INTENSOL

alogliptin-metformin

QL (60 PER 30 DAYS); STEP

RAYOS

alogliptinpioglitazone

QL (30 PER 30 DAYS); STEP

SOLU-CORTEF

SOLU-MEDROL

AMARYL 1 MG TABLET

QL (240 PER 30 DAYS)

VERIPRED 20

AMARYL 2 MG TABLET

QL (120 PER 30 DAYS)

ANTITHYROID AGENTS

AMARYL 4 MG TABLET

QL (60 PER 30 DAYS)

APIDRA

APIDRA SOLOSTAR

AVANDIA

QL (60 PER 30 DAYS)

methimazole

propylthiouracil

TAPAZOLE

DIABETES THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 65

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

glipizide-metformin (2.5-500 mg, 5-500 mg)

QL (120 PER 30 DAYS)

glipizide-metformin 2.5-250 mg

QL (240 PER 30 DAYS)

GLUCAGEN

BASAGLAR KWIKPEN U-100

BYDUREON

QL (4 PER 28 DAYS); STEP

BYDUREON PEN

QL (4 PER 28 DAYS); STEP

BYETTA 10 MCG DOSE PEN INJ

QL (2.4 PER 30 DAYS); STEP

GLUCAGON EMERGENCY KIT

BYETTA 5 MCG DOSE PEN INJ

QL (1.2 PER 30 DAYS); STEP

GLUCOPHAGE 1,000 MG TABLET

QL (75 PER 30 DAYS)

CYCLOSET

QL (180 PER 30 DAYS)

GLUCOPHAGE 500 MG TABLET

QL (150 PER 30 DAYS)

DUETACT

QL (30 PER 30 DAYS)

GLUCOPHAGE 850 MG TABLET

QL (90 PER 30 DAYS)

FARXIGA 10 MG TABLET

QL (30 PER 30 DAYS)

GLUCOPHAGE XR 500 MG TAB

QL (120 PER 30 DAYS)

FARXIGA 5 MG TABLET

QL (60 PER 30 DAYS)

GLUCOPHAGE XR 750 MG TAB

QL (75 PER 30 DAYS)

glimepiride 1 mg tablet

QL (240 PER 30 DAYS)

GLUCOTROL 10 MG TABLET

QL (120 PER 30 DAYS)

glimepiride 2 mg tablet

QL (120 PER 30 DAYS)

GLUCOTROL 5 MG TABLET

QL (240 PER 30 DAYS)

glimepiride 4 mg tablet

QL (60 PER 30 DAYS)

GLUCOTROL XL 10 MG TABLET

QL (60 PER 30 DAYS)

glipizide 10 mg tablet

QL (120 PER 30 DAYS)

GLUCOTROL XL 2.5 MG TABLET

QL (240 PER 30 DAYS)

glipizide 5 mg tablet

QL (240 PER 30 DAYS)

GLUCOTROL XL 5 MG TABLET

QL (120 PER 30 DAYS)

glipizide er 10 mg tablet

QL (60 PER 30 DAYS)

GLYSET 100 MG TABLET

QL (90 PER 30 DAYS)

glipizide er 2.5 mg tablet

QL (240 PER 30 DAYS)

GLYSET 25 MG TABLET

QL (360 PER 30 DAYS)

glipizide er 5 mg tablet

QL (120 PER 30 DAYS)

GLYSET 50 MG TABLET

QL (180 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 66

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

GLYXAMBI

QL (30 PER 30 DAYS); STEP

INVOKAMET XR (50-1,000 MG TAB, 150-1,000 MG TAB, 150-500 MG TABLET)

QL (60 PER 30 DAYS)

HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL)

INVOKAMET XR 50500 MG TABLET

QL (120 PER 30 DAYS)

HUMALOG KWIKPEN U-100

INVOKANA 100 MG TABLET

QL (90 PER 30 DAYS)

HUMALOG KWIKPEN U-200

INVOKANA 300 MG TABLET

QL (30 PER 30 DAYS)

HUMALOG MIX 5050

JANUMET

QL (60 PER 30 DAYS)

HUMALOG MIX 5050 KWIKPEN

JANUMET XR (50500 MG TABLET, 100-1,000 MG TABLET)

QL (30 PER 30 DAYS)

HUMALOG MIX 7525

HUMALOG MIX 7525 KWIKPEN

JANUMET XR 501,000 MG TABLET

QL (60 PER 30 DAYS)

HUMULIN 70-30

JANUVIA

HUMULIN 70/30 KWIKPEN

QL (30 PER 30 DAYS)

JARDIANCE

HUMULIN N

PA; QL (30 PER 30 DAYS)

HUMULIN N KWIKPEN

JENTADUETO

QL (60 PER 30 DAYS); STEP

HUMULIN R

JENTADUETO XR 2.5 MG-1,000 MG

QL (60 PER 30 DAYS); STEP

HUMULIN R U-500

HUMULIN R U-500 KWIKPEN

JENTADUETO XR 5 MG-1,000 MG TB

QL (30 PER 30 DAYS); STEP

KAZANO

INVOKAMET (501,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MG TABLET)

QL (60 PER 30 DAYS)

QL (60 PER 30 DAYS); STEP

KOMBIGLYZE XR (5-1,000 MG TAB, 5500 MG TABLET)

QL (30 PER 30 DAYS)

INVOKAMET 50-500 MG TABLET

QL (120 PER 30 DAYS)

KOMBIGLYZE XR 2.5-1,000 MG TAB

QL (60 PER 30 DAYS)

LANTUS

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 67

Drug Name

Drug Tier

Requirements/ Limits

LANTUS SOLOSTAR

LEVEMIR

STEP

LEVEMIR FLEXTOUCH

STEP

metformin hcl 1,000 mg tablet

QL (75 PER 30 DAYS)

metformin hcl 500 mg tablet

QL (150 PER 30 DAYS)

metformin hcl 850 mg tablet

QL (90 PER 30 DAYS)

metformin hcl er 500 mg tablet

QL (120 PER 30 DAYS)

metformin hcl er 750 mg tablet

QL (75 PER 30 DAYS)

miglitol 100 mg tablet

QL (90 PER 30 DAYS)

miglitol 25 mg tablet

QL (360 PER 30 DAYS)

miglitol 50 mg tablet

QL (180 PER 30 DAYS)

nateglinide 120 mg tablet

QL (90 PER 30 DAYS)

nateglinide 60 mg tablet

QL (180 PER 30 DAYS)

NESINA

QL (30 PER 30 DAYS); STEP

NOVOLIN 70-30

NOVOLIN N

NOVOLIN R

NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL)

NOVOLOG FLEXPEN

Drug Name

Drug Tier

Requirements/ Limits

NOVOLOG MIX 7030

NOVOLOG MIX 7030 FLEXPEN

ONGLYZA

QL (30 PER 30 DAYS)

OSENI

QL (30 PER 30 DAYS); STEP

pioglitazone hcl

QL (30 PER 30 DAYS)

pioglitazoneglimepiride

QL (30 PER 30 DAYS)

pioglitazonemetformin

QL (90 PER 30 DAYS)

PRANDIN 1 MG TABLET

QL (480 PER 30 DAYS)

PRANDIN 2 MG TABLET

QL (240 PER 30 DAYS)

PRECOSE 100 MG TABLET

QL (90 PER 30 DAYS)

PRECOSE 25 MG TABLET

QL (360 PER 30 DAYS)

PRECOSE 50 MG TABLET

QL (180 PER 30 DAYS)

PROGLYCEM

repaglinide 0.5 mg tablet

QL (960 PER 30 DAYS)

repaglinide 1 mg tablet

QL (480 PER 30 DAYS)

repaglinide 2 mg tablet

QL (240 PER 30 DAYS)

repaglinidemetformin hcl

QL (150 PER 30 DAYS)

RIOMET

QL (765 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 68

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

SOLIQUA 100-33

QL (15 PER 25 DAYS)

XIGDUO XR (10 MG1,000 MG TAB, 10 MG-500 MG TABLET)

QL (30 PER 30 DAYS)

STARLIX 120 MG TABLET

QL (90 PER 30 DAYS)

STARLIX 60 MG TABLET

QL (180 PER 30 DAYS)

XIGDUO XR (5 MG1,000 MG TABLET, 5 MG-500 MG TABLET)

QL (60 PER 30 DAYS)

SYMLINPEN 120

QL (18.9 PER 30 DAYS)

SYMLINPEN 60

QL (10.5 PER 30 DAYS)

SYNJARDY (5-1,000 MG TABLET, 12.5500 MG TABLET, 12.5-1,000 MG TABLET)

PA; QL (60 PER 30 DAYS)

SYNJARDY 5-500 MG TABLET

PA; QL (120 PER 30 DAYS)

TANZEUM

QL (4 PER 28 DAYS); STEP

tolazamide 250 mg tablet

QL (120 PER 30 DAYS)

tolazamide 500 mg tablet

QL (60 PER 30 DAYS)

tolbutamide

QL (180 PER 30 DAYS)

TOUJEO SOLOSTAR

TRADJENTA

QL (30 PER 30 DAYS); STEP

TRESIBA FLEXTOUCH U-100

STEP

TRESIBA FLEXTOUCH U-200

STEP

TRULICITY

QL (2 PER 28 DAYS); STEP

VICTOZA 3-PAK

QL (9 PER 30 DAYS); STEP

MISCELLANEOUS HORMONES ALDURAZYME

ANADROL-50

ANDRODERM

ANDROGEL (1%(5G) GEL PACKET, 1%(2.5G) GEL PACKET, 1.62%(1.25G) GEL PCKT, 1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT)

AVEED

AXIRON

cabergoline

calcitonin-salmon

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution, 1 mcg/ml ampul)

CERDELGA

CEREZYME

chorionic gonadotropin

danazol (50 mg capsule, 100 mg capsule)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 69

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

KUVAN (100 MG TABLET, 100 MG POWDER PACKET, 500 MG POWDER PACKET)

LUMIZYME

METHITEST

methyltestosterone

MIACALCIN

MYALEPT

PA; LA

NAGLAZYME

NATPARA

PA; LA

NOVAREL

oxandrolone 10 mg tablet

oxandrolone 2.5 mg tablet

danazol 200 mg capsule

DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 MG TABLET, 4 MCG/ML AMPUL, 4 MCG/ML VIAL, 10 MCG/0.1 ML SOLUTION)

DEPOTESTOSTERONE

desmopressin 0.01% solution

desmopressin acetate (acetate 0.1 mg tb, 0.1 mg/ml sol, acetate 0.2 mg tb, 40 mcg/10 ml vial)

doxercalciferol (1 mcg capsule, 2.5 mcg cap, 4 mcg/2 ml amp)

doxercalciferol 0.5 mcg cap

pamidronate disodium

ELAPRASE

ELELYSO

paricalcitol (1 mcg capsule, 4 mcg capsule)

FABRAZYME

FORTESTA

paricalcitol (2 mcg/ml vial, 2 mcg capsule, 10 mcg/2 ml vial)

HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE, 4 MCG/2 ML VIAL)

PREGNYL

4 4

KANUMA

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORAL SOLN)

KORLYM

SAMSCA

SENSIPAR (60 MG TABLET, 90 MG TABLET)

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 70

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

SENSIPAR 30 MG TABLET

B/D PA; QL (60 PER 30 DAYS)

CYTOMEL

SOMAVERT

STIMATE

STRENSIQ

STRIANT

SYNAREL

TESTIM

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

testosterone (10 mg gel pump, 12.5 mg/1.25 gram, 50 mg/5 gram pkt)

levothyroxine 100 mcg vial

LEVOXYL

testosterone 25 mg/2.5 gm pkt

testosterone cypionate

liothyronine sodium (5 mcg tab, 10 mcg/ml vl, 25 mcg tab, 50 mcg tab)

testosterone enanthate

SYNTHROID

THYROLAR-1

VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL PACKT)

THYROLAR-1/2

THYROLAR-1/4

VPRIV

THYROLAR-2

ZAVESCA

THYROLAR-3

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE, 2 MCG/ML VIAL, 10 MCG/2 ML VIAL)

TIROSINT

TRIOSTAT

UNITHROID

zoledronic acid 4 mg/5 ml vial

B/D PA

GASTROENTEROLOGY

ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML VIAL)

B/D PA

ANTIDIARRHEALS / ANTISPASMODICS

atropine 0.05 mg/ml syringe

Requirements/ Limits

THYROID HORMONES

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 71

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

BENTYL (10 MG CAPSULE, 10 MG/ML AMPUL)

ANZEMET 100 MG TABLET

B/D PA; QL (4 PER 28 DAYS)

CUVPOSA

ANZEMET 50 MG TABLET

B/D PA; QL (8 PER 28 DAYS)

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg/2 ml vial, 20 mg tablet)

aprepitant 125-80-80 mg pack

B/D PA; QL (12 PER 28 DAYS)

diphenoxylateatropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025)

aprepitant 125 mg capsule

B/D PA; QL (4 PER 28 DAYS)

aprepitant 40 mg capsule

B/D PA

aprepitant 80 mg capsule

B/D PA; QL (8 PER 28 DAYS)

glycopyrrolate (1 mg tablet, 2 mg tablet, 4 mg/20 ml vial)

APRISO

ASACOL HD

LOMOTIL

loperamide

AZULFIDINE (500 MG TABLET, ENTAB 500 MG)

methscopolamine bromide

balsalazide disodium

MYTESI

budesonide ec

propantheline bromide

CANASA

CESAMET

B/D PA

ROBINUL

CHENODAL

ROBINUL FORTE

CHOLBAM

5 5

STEP

ACTIGALL

CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT)

alosetron hcl

COLAZAL

ALOXI

COLOCORT

AMITIZA

ANUSOL-HC

COLYTE WITH FLAVOR PACKETS COMPRO

MISCELLANEOUS GASTROINTESTINAL AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 72

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

CONSTULOSE

GAVILYTE-G

CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE, DR 12,000 CAPSULE, DR 24,000 CAPSULE)

GAVILYTE-H AND BISACODYL

GAVILYTE-N

CREON DR 36,000 UNITS CAPSULE

GENERLAC

GIAZO

cromolyn 100 mg/5 ml oral conc

CYSTADANE

GOLYTELY (PACKET, SOLUTION)

DELZICOL

granisetron hcl 1 mg tablet

DIPENTUM

dronabinol (2.5 mg capsule, 5 mg capsule)

granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 mg/4 ml vial)

dronabinol 10 mg capsule

B/D PA

hydrocortisone 100 mg/60 ml INFLECTRA

EMEND TRIPACK

B/D PA; QL (12 PER 28 DAYS)

KRISTALOSE

EMEND (125 MG POWDER PACKET, 125 MG CAPSULE)

B/D PA; QL (4 PER 28 DAYS)

lactulose

LIALDA

EMEND 40 MG CAPSULE

B/D PA

LINZESS

LOTRONEX

EMEND 80 MG CAPSULE

B/D PA; QL (8 PER 28 DAYS)

B/D PA

EMEND 150 MG VIAL

MARINOL (5 MG CAPSULE, 10 MG CAPSULE)

B/D PA

ENTOCORT EC

MARINOL 2.5 MG CAPSULE

ENULOSE

meclizine hcl

GASTROCROM

mesalamine 4 gm/60 ml kit

GATTEX

GAVILYTE-C

mesalamine 800 mg dr tablet

B/D PA

STEP

B/D PA; QL (56 PER 28 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 73

Drug Name

Drug Tier

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mg/2 ml vial, 10 mg tablet)

metoclopramide hcl odt

MICORT-HC

Requirements/ Limits

Drug Name

Drug Tier

PERTZYE DR 16,000 UNITS CAPS

polyethylene glycol 3350

PREPOPIK

prochlorperazine

MOVANTIK

MOVIPREP

prochlorperazine edisylate

NULYTELY WITH FLAVOR PACKS

prochlorperazine maleate

OCALIVA

PROCTO-MED HC

ondansetron hcl (4 mg/5 ml solution, hcl 4 mg tablet, hcl 8 mg tablet, hcl 24 mg tablet)

B/D PA

PROCTO-PAK

PROCTOSOL-HC

PROCTOZONE-HC

ondansetron hcl (hcl 4 mg/2 ml vial, 4 mg/2 ml isecure)

RECTIV

REGLAN

ondansetron odt

OSMOPREP

PANCREAZE (DR 2,600 CAP, DR 4,200 CAP, DR 10,500 CAP, DR 16,800 CAP)

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL, 150 MG TABLET) REMICADE

PANCREAZE DR 21,000 UNIT CAP

SANCUSO

peg 3350-electrolyte

SFROWASA

peg-3350 and electrolytes

SUCRAID

sulfasalazine

PENTASA

sulfasalazine dr

PERTZYE (DR 4,000 UNIT CAPSULE, DR 8,000 UNITS CAPSULE)

SUPREP

TRANSDERM-SCOP

B/D PA

Requirements/ Limits

QL (4 PER 28 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 74

Drug Name

Drug Tier

Requirements/ Limits

TRILYTE WITH FLAVOR PACKETS

UCERIS 2 MG RECTAL FOAM

UCERIS 9 MG ER TABLET

URSO

URSO FORTE

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)

VARUBI

VIBERZI

VIOKACE

ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE)

ZENPEP DR 40,000 UNITS CAPSULE

ZOFRAN (4 MG/5 ML ORAL SOLN, 4 MG TABLET, 8 MG TABLET)

B/D PA

ZOFRAN ODT

B/D PA

ZUPLENZ

B/D PA

B/D PA; QL (4 PER 28 DAYS)

ULCER THERAPY ACIPHEX

ACIPHEX SPRINKLE

Drug Name

Drug Tier

CARAFATE (1 GM/10 ML SUSP, 1 GM TABLET)

cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 800 mg tablet)

CYTOTEC

DEXILANT

esomeprazole magnesium

esomeprazole sodium

famotidine (20 mg tablet, 20 mg piggyback, 20 mg/2 ml vial, 40 mg/5 ml susp, 40 mg tablet)

lansoprazol-amoxicilclarithro

lansoprazole

misoprostol

NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG PACKET, DR 20 MG PACKET, DR 20 MG CAPSULE, DR 40 MG CAPSULE, DR 40 MG PACKET)

NEXIUM I.V.

nizatidine (150 mg capsule, 300 mg capsule)

nizatidine 15 mg/ml solution

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 75

Drug Name

Drug Tier

omeprazole (dr 20 mg capsule, dr 40 mg capsule)

omeprazole dr 10 mg capsule

omeprazole-bicarb 40-1,100 cap

omeprazole-sodium bicarbonate (201,680 pkt, 20-1,100 cap, 40-1,680 pkt)

Requirements/ Limits

Drug Name

Drug Tier

ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 ml vial, 150 mg tablet, 150 mg capsule, 300 mg capsule, 300 mg tablet)

sucralfate

ZANTAC (150 MG TABLET, 300 MG TABLET, 1,000 MG/40 ML VIAL)

pantoprazole sodium (sod dr 20 mg tab, sod dr 40 mg tab, sodium 40 mg vial)

PEPCID (20 MG TABLET, 40 MG/5 ML ORAL SUSP, 40 MG TABLET)

ZEGERID (20 MG PACKET, 20 MG CAPSULE, 40 MG PACKET, 40 MG CAPSULE)

PREVACID (DR 15 MG CAPSULE, 15 MG SOLUTAB, 30 MG SOLUTAB, DR 30 MG CAPSULE)

PREVPAC

PRILOSEC

PROTONIX 40 MG SUSPENSION

PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET)

PROTONIX IV

PYLERA

rabeprazole sodium

QL (30 PER 30 DAYS)

Requirements/ Limits

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE

B/D PA

ARANESP (10 MCG/0.4 ML SYRINGE, 40 MCG/0.4 ML SYRINGE)

PA; QL (1.6 PER 28 DAYS)

ARANESP (150 MCG/0.3 ML SYRINGE, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)

ARANESP 100 MCG/0.5 ML SYRINGE

PA; QL (2 PER 28 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 76

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

ARANESP 25 MCG/0.42 ML SYRING

PA; QL (1.68 PER 28 DAYS)

GENOTROPIN (MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE)

ARANESP 60 MCG/0.3 ML SYRINGE

PA; QL (1.2 PER 28 DAYS)

ARANESP (25 MCG/ML VIAL, 40 MCG/ML VIAL)

PA; QL (4 PER 28 DAYS)

ARANESP (60 MCG/ML VIAL, 100 MCG/ML VIAL)

PA; QL (4 PER 28 DAYS)

GENOTROPIN MINIQUICK 0.2 MG

ARCALYST

GRANIX

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT)

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, 24 MG CARTRIDGE)

AVONEX PEN

BETASERON

ILARIS

PA; LA

EGRIFTA

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL)

B/D PA

EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL)

PA; QL (12 PER 28 DAYS)

EPOGEN 20,000 UNITS/2 ML VIAL

PA; QL (24 PER 28 DAYS)

LEUKINE

MIRCERA

EPOGEN 20,000 UNITS/ML VIAL

PA; QL (12 PER 28 DAYS)

MOZOBIL

EXTAVIA

NEULASTA

NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)

NORDITROPIN FLEXPRO

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 77

Drug Name

Drug Tier

Requirements/ Limits

NUTROPIN AQ NUSPIN

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG)

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)

PEGASYS PROCLICK

PLEGRIDY

PLEGRIDY PEN

PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL)

PROCRIT (20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)

PROCRIT 10,000 UNITS/ML VIAL

PA; QL (12 PER 28 DAYS)

PROLEUKIN

PA; B/D PA

REBIF

REBIF REBIDOSE

SAIZEN (5 MG VIAL, 8.8 MG VIAL, 8.8 MG CLICK.EASY CARTG)

SEROSTIM

SYLATRON

ZARXIO

Drug Name

Drug Tier

Requirements/ Limits

ZOMACTON 10 MG VIAL

ZOMACTON 5 MG VIAL

ZORBTIVE

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

PA; QL (12 PER 28 DAYS)

ACTHIB

ADACEL TDAP

ATGAM

bcg vaccine (tice strain)

BEXSERO

BIVIGAM

BOOSTRIX TDAP (SYRINGE, VIAL)

BOTOX

CARIMUNE NF NANOFILTERED

DAPTACEL DTAP

diphtheria-tetanus toxoids-ped

DYSPORT

ENGERIX-B ADULT

B/D PA

ENGERIX-B PEDIATRICADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN)

B/D PA

FLEBOGAMMA DIF

fomepizole

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 78

Drug Name

Drug Tier

Requirements/ Limits

GAMASTAN S-D VIAL (RXCUI 1809038)

GAMMAGARD LIQUID

GAMMAGARD S-D

GAMMAKED

Drug Name

Drug Tier

MENVEO A-C-Y-W135-DIP

OCTAGAM

ORALAIR

PEDIARIX

PEDVAXHIB

GAMMAPLEX

PRIVIGEN

GAMUNEX-C

PROQUAD

GARDASIL 9 (9 VIAL, 9 SYRINGE)

QUADRACEL DTAPIPV

GRASTEK

RABAVERT

HAVRIX (720 UNIT/0.5 ML SYRINGE, 1,440 UNITS/ML VIAL)

RAGWITEK

4 3

HIBERIX

HYPERRAB S-D

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL)

IMOGAM RABIESHT

ROTARIX

ROTATEQ

IMOVAX RABIES VACCINE

TENIVAC

INFANRIX DTAP

tetanus diphtheria toxoids

IPOL

THYMOGLOBULIN

IXIARO

TRUMENBA

KINRIX (TIP-LOK SYRINGE, VIAL)

TWINRIX

M-M-R II VACCINE

MENACTRA

TYPHIM VI (25 MCG/0.5 ML SYRNG, 25 MCG/0.5 ML AL)

MENOMUNE-A-C-YW-135

VAQTA

VARIVAX VACCINE

VARIZIG

Requirements/ Limits

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 79

Drug Name

Drug Tier

Requirements/ Limits

XEOMIN

YF-VAX

ZINPLAVA

ZOSTAVAX

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY

Drug Name

Drug Tier

Requirements/ Limits

alendronate sodium (35 mg tab, 70 mg tab)

QL (5 PER 30 DAYS)

alendronate sodium (5 mg tablet, 10 mg tab)

QL (30 PER 30 DAYS)

ATELVIA

QL (5 PER 30 DAYS); STEP

BINOSTO

QL (5 PER 30 DAYS); STEP

BONIVA 3 MG/3 ML SYRINGE

STEP QL (1 PER 30 DAYS); STEP

allopurinol

allopurinol sodium

ALOPRIM

BONIVA 150 MG TABLET

colchicine (0.6 mg capsule, 0.6 mg tablet)

EVISTA

FORTEO

STEP

COLCRYS

FOSAMAX

MITIGARE

QL (5 PER 30 DAYS); STEP

probenecid

FOSAMAX PLUS D

QL (5 PER 30 DAYS); STEP

probenecidcolchicine

ibandronate sodium 150 mg tab

QL (1 PER 30 DAYS); STEP

ULORIC

STEP

ZURAMPIC

ibandronate 3 mg/3 ml vial

ZYLOPRIM

PROLIA

STEP

raloxifene hcl

risedronate sodium 150 mg tab

QL (1 PER 30 DAYS); STEP

risedronate sodium 35 mg tab

QL (5 PER 30 DAYS); STEP

risedronate sodium 5 mg tablet

QL (30 PER 30 DAYS); STEP

risedronate sodium dr

QL (5 PER 30 DAYS); STEP

OSTEOPOROSIS THERAPY ACTONEL 150 MG TABLET

QL (1 PER 30 DAYS); STEP

ACTONEL 35 MG TABLET

QL (5 PER 30 DAYS); STEP

ACTONEL 5 MG TABLET

QL (30 PER 30 DAYS); STEP

alendronate sod 70 mg/75 ml

QL (375 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 80

Drug Name TYMLOS

Drug Tier

Requirements/ Limits

STEP

OTHER RHEUMATOLOGICALS PA

Drug Name

Drug Tier

Requirements/ Limits

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE, 250 MG VIAL)

ORENCIA CLICKJECT

ACTEMRA (80 MG/4 ML VIAL, 162 MG/0.9 ML SYRINGE, 200 MG/10 ML VIAL, 400 MG/20 ML VIAL)

ARAVA

BENLYSTA

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET)

CUPRIMINE

OTREXUP

DEPEN

RASUVO

ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)

RIDAURA

5 3

HUMIRA (10 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE)

PA; QL (2 PER 28 DAYS)

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, TITRATION PACK)

HUMIRA 40 MG/0.8 ML SYRINGE

PA; QL (4 PER 28 DAYS)

SIMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE)

PA; QL (1 PER 28 DAYS)

HUMIRA PEDIATRIC CROHN'S

PA; QL (6 PER 28 DAYS)

PA; QL (0.5 PER 28 DAYS)

HUMIRA PEN

PA; QL (4 PER 28 DAYS)

SIMPONI (50 MG/0.5 ML SYRINGE, 50 MG/0.5 ML PEN INJEC) SIMPONI ARIA

XELJANZ

XELJANZ XR

HUMIRA PEN CROHN-UC-HS STARTER

PA; QL (6 PER 28 DAYS)

HUMIRA PEN PSORIASIS-UVEITIS

PA; QL (4 PER 28 DAYS)

KEVZARA

ESTROGENS / PROGESTINS

KINERET

ACTIVELLA

leflunomide

ALORA

AMABELZ

OBSTETRICS / GYNECOLOGY

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 81

Drug Name

Drug Tier

ANGELIQ

AYGESTIN

CAMILA

CLIMARA

CLIMARA PRO

COMBIPATCH

CRINONE

DEBLITANE

Requirements/ Limits

Drug Name

Drug Tier

estradiol (tds 0.025 mg/day, 0.025 mg patch, tds 0.0375 mg/day, 0.0375 mg patch, 0.05 mg patch, tds 0.05 mg/day, tds 0.06 mg/day, tds 0.075 mg/day, 0.075 mg patch, 0.1 mg patch, tds 0.1 mg/day, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

estradiol valerate

DELESTROGEN

DEPO-ESTRADIOL

estradiolnorethindrone acetat

DEPO-PROVERA

ESTRING

DEPO-SUBQ PROVERA 104

estropipate

EVAMIST

DIVIGEL

FEMHRT

DUAVEE

FEMRING

ELESTRIN

FYAVOLV

2 5

ERRIN

hydroxyprogesterone caproate

ESTRACE 0.01% CREAM

JINTELI

JOLIVETTE

ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET)

LYZA

MAKENA

medroxyprogesteron e acetate (2.5 mg tab, 5 mg tab, 10 mg tab, 150 mg/ml)

MENEST

MENOSTAR

MIMVEY

QL (30 PER 30 DAYS)

QL (52 PER 30 DAYS)

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 82

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

MIMVEY LO

MISCELLANEOUS OB/GYN

MINIVELLE

AVC

NORA-BE

norethindron-ethinyl estradiol (norethineth 1 mg-5 mcg, norethind-eth 0.52.5)

CLEOCIN (2% CREAM, 100 MG OVULE) clindamycin 2% vaginal cream

norethindrone

GYNAZOLE 1

norethindrone acetate

LUPANETA PACK

LYSTEDA

NORLYROC

ORTHO MICRONOR

METROGELVAGINAL

PREFEST

metronidazole vaginal 0.75% gl

PREMARIN VAGINAL CREAMAPPL

miconazole 3

NUVARING

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, 25 MG VIAL)

NUVESSA

TERAZOL 7

terconazole (0.4% cream, 0.8% cream, 80 mg suppository)

PREMPHASE

PREMPRO

tranexamic acid 650 mg tablet

progesterone

VANDAZOLE

PROMETRIUM

XULANE

PROVERA

zazole

SHAROBEL

ORAL CONTRACEPTIVES / RELATED AGENTS

VAGIFEM

ALYACEN

VIVELLE-DOT

AMETHIA

YUVAFEM

AMETHIA LO

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 83

Drug Name

Drug Tier

APRI

ARANELLE

ASHLYNA

AUBRA

AVIANE

BALZIVA

BEKYREE

BEYAZ

BLISOVI 24 FE

BLISOVI FE

BREVICON

BRIELLYN

CAMRESE LO

CAZIANT

CRYSELLE

CYCLAFEM

CYCLESSA

DELYLA

DESOGEN

desogestr-eth estrad eth estra

drospirenone-eth estra-levomef

drospirenone-ethinyl estradiol

EMOQUETTE

ENPRESSE

Requirements/ Limits

Drug Name

Drug Tier

ethynodiol-ethinyl estradiol

FALMINA

FAYOSIM

FEMYNOR

GENERESS FE

GIANVI

GILDAGIA

INTROVALE

JULEBER

JUNEL

JUNEL FE

JUNEL FE 24

KAITLIB FE

KARIVA

KELNOR 1-35

KIMIDESS

LARIN

LARIN FE

LARISSIA

LAYOLIS FE

LEENA

LESSINA

LEVONEST

levonorg-eth estrad eth estrad

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 84

Drug Name

Drug Tier

levonorgestrel-eth estradiol (estra 0.090.02 mg, estrad 0.10.02 mg, estrad 0.150.03, estrad triphasic)

LEVORA-28

LO LOESTRIN FE

LOESTRIN

Requirements/ Limits

Drug Name

Drug Tier

NORINYL 1-35

NORTREL

OCELLA

OGESTREL

ORSYTHIA

ORTHO TRICYCLEN

LOESTRIN FE

LOMEDIA 24 FE

ORTHO TRICYCLEN LO

LORYNA

ORTHO-CYCLEN

LOSEASONIQUE

ORTHO-NOVUM

LOW-OGESTREL

OVCON-35

LUTERA

PIMTREA

MARLISSA

PIRMELLA

MIBELAS 24 FE

PORTIA

MICROGESTIN

PREVIFEM

MICROGESTIN FE

QUARTETTE

MINASTRIN 24 FE

QUASENSE

MONONESSA

RECLIPSEN

NATAZIA

RIVELSA

NECON

SAFYRAL

NIKKI

SEASONIQUE

norethin-eth estraferrous fum

SETLAKIN

SPRINTEC

norethind-eth estrad 1-0.02 mg

SRONYX

norgestimate-ethinyl estradiol

TARINA FE

TRI-LEGEST FE

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 85

Drug Name

Drug Tier

TRI-LO-ESTARYLLA

TRI-LO-SPRINTEC

TRI-NORINYL

TRI-PREVIFEM

TRI-SPRINTEC

TRINESSA

Requirements/ Limits

Drug Name

Drug Tier

CILOXAN 0.3% EYE DROPS

CILOXAN 0.3% OINTMENT

ciprofloxacin 0.3% eye drop

erythromycin 0.5% eye ointment

TRIVORA-28

gatifloxacin

VELIVET

GENTAK

VESTURA

VIENVA

gentamicin 0.3% eye drops

VYFEMLA

levofloxacin 0.5% eye drops

WYMZYA FE

MOXEZA

YASMIN 28

NATACYN

YAZ

ZARAH

neomycin-bacitracinpolymyxin

ZENCHENT

neomycin-polymyxingramicidin

ZENCHENT FE

NEOSPORIN

ZOVIA 1-35E

OCUFLOX

ZOVIA 1-50E

ofloxacin 0.3% eye drops

polymyxin b sultrimethoprim

OPHTHALMOLOGY ANTIBIOTICS AZASITE

POLYTRIM

bacitracin 500 unit/gm ophth

tobramycin 0.3% eye drops

bacitracin-polymyxin

TOBREX (DROPS, OINTMENT)

BESIVANCE

VIGAMOX

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 86

Drug Name

Drug Tier

ZYMAXID

Requirements/ Limits

VIROPTIC

ZIRGAN

Drug Tier

ISOPTO CARPINE

pilocarpine hcl (1% drops, 2% drops, 4% drops)

MISCELLANEOUS OPHTHALMOLOGICS

BETA-BLOCKERS

ALOCRIL

ALOMIDE

azelastine hcl 0.05% drops

BEPREVE

cromolyn 4% eye drops

CYSTARAN

ELESTAT

metipranolol

EMADINE

timolol maleate (0.25% gfs gelsolution, 0.25% eye drops, 0.5% eye drops, 0.5% gelsolution)

epinastine hcl

LACRISERT

LASTACAFT

TIMOPTIC OCUDOSE

STEP

olopatadine hcl (0.1% drops, 0.2% drop)

TIMOPTIC-XE

STEP

PATADAY

PATANOL

PAZEO

RESTASIS

XIIDRA

BETAGAN

betaxolol hcl 0.5% eye drop

BETIMOL

STEP

BETOPTIC S

STEP

carteolol hcl

ISTALOL

levobunolol hcl

CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE

CYCLOPLEGIC MYDRIATICS atropine 1% eye drops

Requirements/ Limits

DIRECT ACTING MIOTICS

ANTIVIRALS trifluridine

Drug Name

STEP

NON-STEROIDAL ANTIINFLAMMATORY AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 87

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

ACULAR

COSOPT

STEP

ACULAR LS

COSOPT PF

STEP

ACUVAIL

dorzolamide hcl

bromfenac sodium

dorzolamide-timolol

diclofenac 0.1% eye drops

latanoprost

flurbiprofen sodium

LUMIGAN

ILEVRO

SIMBRINZA

ketorolac tromethamine (0.4% solution, 0.5% solution)

TRAVATAN Z

TRUSOPT

XALATAN

STEP

NEVANAC

ZIOPTAN

STEP

OCUFEN

STEROID-ANTIBIOTIC COMBINATIONS

PROLENSA

MAXITROL (DROPS, OINTMENT)

ORAL DRUGS FOR GLAUCOMA acetazolamide (125 mg tablet, 250 mg tablet, er 500 mg cap)

neomycin-bacitracinpoly-hc

2 2

acetazolamide sodium

DIAMOX SEQUELS

neomycin-polymyxindexameth (neomycpolym-dexamet ointm, neomycpolym-dexameth drop)

methazolamide 25 mg tablet

neomycin-poly-hc eye drops

methazolamide 50 mg tablet

PRED-G (1% DROPS, S.O.P. OINTMENT)

TOBRADEX (DROPS, OINTMENT)

TOBRADEX ST

tobramycindexamethasone

OTHER GLAUCOMA DRUGS AZOPT

bimatoprost

STEP

COMBIGAN

STEP

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 88

Drug Name ZYLET

Drug Tier 4

STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE

BLEPHAMIDE S.O.P.

sulfacetamideprednisolone

STEROIDS ALREX

dexamethasone 0.1% eye drop

DUREZOL

FLAREX

fluorometholone

FML

FML FORTE

Requirements/ Limits

Drug Name sulfacetamide sodium (drops, ointment)

Drug Tier 2

SYMPATHOMIMETICS ALPHAGAN P

apraclonidine hcl

brimonidine tartrate

IOPIDINE (0.5% DROPS, 1% DROPS)

RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ADRENALIN

AUVI-Q

5 3

carbinoxamine maleate (4 mg/5 ml liquid, maleate 4 mg tab)

FML S.O.P.

cetirizine hcl

LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL)

CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET)

MAXIDEX

CLARINEX-D 12 HOUR

OMNIPRED

clemastine fumarate

PRED FORTE

PRED MILD

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet)

prednisolone acetate

prednisolone sod 1% eye drop

desloratadine (2.5 mg odt, 5 mg tablet, 5 mg odt) diphenhydramine hcl

epinephrine 0.15 mg auto-inject (mylan)

SULFONAMIDES BLEPH-10

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 89

Drug Name

Drug Tier

epinephrine 0.3 mg auto-inject (mylan)

EPIPEN 2-PAK

EPIPEN JR 2-PAK

hydroxyzine hcl (hcl 10 mg tablet, 10 mg/5 ml soln, hcl 25 mg tablet, hcl 50 mg tablet)

hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial)

hydroxyzine pamoate

KARBINAL ER

levocetirizine dihydrochloride (2.5 mg/5 ml sol, 5 mg tablet)

PHENADOZ

PHENERGAN (12.5 MG, 25 MG, 50 MG)

PHENERGAN (25 MG/ML VIAL, 50 MG/ML VIAL)

promethazine hcl (12.5 mg suppos, 25 mg suppository, 50 mg suppository)

promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg tablet, 25 mg tablet, 50 mg tablet)

promethazine hcl (25 mg/ml vial, 50 mg/ml vial)

PROMETHEGAN

Requirements/ Limits

Drug Name

Drug Tier

RYVENT

SEMPREX-D

VISTARIL

XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET)

Requirements/ Limits

PULMONARY AGENTS

ACCOLATE

acetylcysteine

B/D PA

ADCIRCA

ADEMPAS

PA; LA

ADVAIR DISKUS

QL (120 PER 30 DAYS)

ADVAIR HFA

QL (24 PER 30 DAYS)

AEROSPAN

QL (17.8 PER 30 DAYS)

AIRDUO RESPICLICK

QL (60 PER 30 DAYS)

albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate 2 mg tab, sulfate er 4 mg tab, sulfate er 8 mg tab)

albuterol sulfate 4 mg tab

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sul 2.5 mg/3 ml soln, 5 mg/ml solution)

B/D PA

ALVESCO

QL (12.2 PER 30 DAYS)

aminophylline

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 90

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

ANORO ELLIPTA

QL (60 PER 30 DAYS)

cromolyn 20 mg/2 ml neb soln

B/D PA

ARCAPTA NEOHALER

QL (60 PER 30 DAYS)

DALIRESP

ARNUITY ELLIPTA

QL (60 PER 30 DAYS)

DULERA

QL (26 PER 30 DAYS)

ASMANEX (110 MCG, 220 MCG)

QL (60 PER 30 DAYS)

DYMISTA

QL (46 PER 30 DAYS); STEP

ASMANEX TWISTHALER 220 MCG #60

QL (120 PER 30 DAYS)

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET)

ASMANEX TWISTHALR 220 MCG #120

QL (240 PER 30 DAYS)

FIRAZYR

FLOVENT 250 MCG DISKUS

QL (240 PER 30 DAYS)

ASMANEX HFA

QL (26 PER 30 DAYS)

FLOVENT DISKUS (50 MCG, 100 MCG)

QL (120 PER 30 DAYS)

ATROVENT HFA

QL (38.7 PER 30 DAYS)

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER)

QL (24 PER 30 DAYS)

BECONASE AQ

QL (50 PER 30 DAYS); STEP

BERINERT

FLOVENT HFA 44 MCG INHALER

QL (21.2 PER 30 DAYS)

BEVESPI AEROSPHERE

QL (21.4 PER 30 DAYS)

flunisolide

QL (50 PER 30 DAYS)

BREO ELLIPTA

QL (60 PER 30 DAYS)

fluticasone prop 50 mcg spray

QL (32 PER 30 DAYS)

BROVANA

B/D PA; QL (120 PER 30 DAYS)

fluticasonesalmeterol

QL (60 PER 30 DAYS)

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2 ml inh susp)

B/D PA

INCRUSE ELLIPTA

QL (60 PER 30 DAYS)

budesonide 32 mcg nasal spray

QL (17.2 PER 30 DAYS); STEP

ipratropium br 0.02% soln

B/D PA

CINRYZE

ipratropium-albuterol

B/D PA

COMBIVENT RESPIMAT

QL (8 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 91

Drug Name

Drug Tier

Requirements/ Limits

KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET)

LETAIRIS

levalbuterol concentrate

levalbuterol 1.25 mg/3 ml sol

Drug Tier

Requirements/ Limits

PROAIR HFA

QL (17 PER 30 DAYS)

PROAIR RESPICLICK

QL (2 PER 30 DAYS)

PROVENTIL HFA

QL (13.4 PER 30 DAYS)

B/D PA

PULMICORT

B/D PA

PULMICORT 180 MCG FLEXHALER

QL (3 PER 30 DAYS)

levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3 ml sol)

B/D PA

PULMICORT 90 MCG FLEXHALER

QL (2 PER 30 DAYS)

PULMOZYME

B/D PA

levalbuterol tartrate hfa

QNASL

QL (17.4 PER 30 DAYS); STEP

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet)

QNASL CHILDREN

QL (9.8 PER 30 DAYS); STEP

QVAR

mometasone furoate 50 mcg spry

QL (26.1 PER 30 DAYS)

montelukast sodium (4 mg granules, 4 mg tab chew, 5 mg tab chew, 10 mg tablet)

REVATIO (10 MG/12.5 ML VIAL, 10 MG/ML ORAL SUSP, 20 MG TABLET)

NASONEX

QL (34 PER 30 DAYS); STEP

RUCONEST

SEREVENT DISKUS

NUCALA

PA; LA

QL (120 PER 30 DAYS)

OFEV

sildenafil

OMNARIS

QL (25 PER 30 DAYS); STEP

sildenafil citrate

OPSUMIT

PA; LA

ORKAMBI

SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG TABLET CHEW, 10 MG TABLET)

PERFOROMIST

B/D PA

SPIRIVA

QL (45 PER 30 DAYS)

QL (34 PER 30 DAYS); STEP

Drug Name

QL (60 PER 30 DAYS)

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 92

Drug Name

Drug Tier

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

SPIRIVA RESPIMAT

QL (8 PER 30 DAYS)

ZETONNA

QL (12.2 PER 30 DAYS); STEP

STIOLTO RESPIMAT

QL (8 PER 30 DAYS)

zileuton er

STRIVERDI RESPIMAT

QL (8 PER 30 DAYS)

ZYFLO

ZYFLO CR

SYMBICORT

QL (20.4 PER 30 DAYS); STEP

terbutaline sulfate (sulf 1 mg/ml vial, sulfate 2.5 mg tab, sulfate 5 mg tab)

THEO-24

theophylline (80 mg/15 ml soln, er 400 mg tablet, er 600 mg tablet)

theophylline anhydrous

TRACLEER

triamcinolone 55 mcg nasal spr

STEP

TUDORZA PRESSAIR

QL (2 PER 30 DAYS)

VENTAVIS

B/D PA

VENTOLIN HFA

QL (36 PER 30 DAYS)

XOLAIR

PA; LA

XOPENEX

B/D PA

XOPENEX CONCENTRATE

B/D PA

XOPENEX HFA

zafirlukast

UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

QL (45 PER 30 DAYS)

darifenacin er

DETROL

DETROL LA

DITROPAN XL

ENABLEX

flavoxate hcl

GELNIQUE

MYRBETRIQ

oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet)

oxybutynin chloride er

OXYTROL

tolterodine tartrate

tolterodine tartrate er

TOVIAZ

trospium chloride

trospium chloride er

VESICARE

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 93

Drug Name

Drug Tier

Requirements/ Limits

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Drug Name

Drug Tier

calcium acetate (667 mg capsule, 667 mg tablet)

dextrose 5%-0.2% nacl-kcl

dextrose 5%-0.33% nacl-kcl

dextrose 5%-0.45% nacl-kcl

2 2

alfuzosin hcl er

AVODART

dutasteride

dutasteridetamsulosin

finasteride

FLOMAX

dextrose 5%-1/2nskcl

JALYN

dextrose 5%-ns-kcl

PROSCAR

RAPAFLO

dextrose 5%potassium chloride

tamsulosin hcl

ELIPHOS

UROXATRAL

K-TAB ER (ER 10 TABLET, ER 20 TABLET)

CHOLINERGIC STIMULANTS bethanechol chloride

K-TAB ER 8 MEQ TABLET

URECHOLINE

KLOR-CON 10

MISCELLANEOUS UROLOGICALS

KLOR-CON 8

CIALIS

KLOR-CON M10

KLOR-CON M15

KLOR-CON M20

KLOR-CON SPRINKLE

lactated ringers injection

magnesium sulfate (syringe, vial)

NORMOSOL-R AND DEXTROSE

CYSTAGON

ELMIRON

potassium citrate er

PROCYSBI

UROCIT-K

PA; QL (30 PER 30 DAYS)

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

Requirements/ Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 94

Drug Name

Drug Tier

PHOSLYRA

potassium chl-normal saline

potassium chloride (2 meq/ml vial, er 8 meq capsule, er 8 meq tablet, er 10 meq tablet, 10 meq/100 ml sol, er 10 meq capsule, 10% (20 meq/15 ml, 20% (40 meq/15 ml, er 20 meq tablet, 20 meq/100 ml sol, 40 meq/20 ml conc, 40 meq/100 ml sol)

potassium chloride in d5lr

potassium chloridenacl

Requirements/ Limits

Drug Name

Drug Tier

Requirements/ Limits

AMINOSYN-PF

B/D PA

AMINOSYN-RF

B/D PA

CLINIMIX (2.75%-5% SOLUTION, 4.25%25% SOLUTION, 4.25%-20% SOLUTION, 4.25%10% SOLUTION, 5%20% SOLUTION, 5%25% SOLUTION, 5%15% SOLUTION)

B/D PA

CLINIMIX E (4.25%25% SOLUTION, 4.25%-5% SOLUTION, 5%-15% SOLUTION, 5%-25% SOLUTION, 5%-20% SOLUTION)

B/D PA

CLINIMIX E 4.25%10% SOLUTION

B/D PA

ringers injection

CLINISOL

B/D PA

sodium chloride (0.45% soln, 3% iv soln, 5% iv soln, 50 meq/20 ml)

FREAMINE HBC

B/D PA

HEPATAMINE

B/D PA

sodium lactate

INTRALIPID 20% IV FAT EMUL

B/D PA

TPN ELECTROLYTES

INTRALIPID 30% IV FAT EMUL

B/D PA

MISCELLANEOUS NUTRITION PRODUCTS

IONOSOL MBDEXTROSE 5%

AMINO ACIDS

B/D PA

AMINOSYN II

B/D PA

ISOLYTE P WITH DEXTROSE

AMINOSYN II WITH ELECTROLYTES

B/D PA

ISOLYTE S

NEPHRAMINE

AMINOSYN WITH ELECTROLYTES

B/D PA

NORMOSOL-M AND DEXTROSE

AMINOSYN-HBC

B/D PA

NORMOSOL-R PH 7.4

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 95

Drug Name

Drug Tier

Requirements/ Limits

NUTRILIPID

B/D PA

PLASMA-LYTE 148

PLASMA-LYTE A PH 7.4

PREMASOL 10% IV SOLUTION

B/D PA

PREMASOL 6% IV SOLUTION

B/D PA

PROCALAMINE

B/D PA

PROSOL

B/D PA

TRAVASOL

B/D PA

TROPHAMINE

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page 7. 96

Alphabetical Listing

abacavir 10 abacavir-lamivudine 10 abacavir-lamivudinezidovudine 11 ABELCET 10 ABILIFY 40 ABILIFY MAINTENA 40 ABRAXANE 20 ABSORICA 56 ABSTRAL 33 acamprosate calcium 61 ACANYA 56 acarbose 65 ACCOLATE 90 ACCUPRIL 47 ACCURETIC 47 acebutolol hcl 47 acetaminophen-codeine 33 ACETASOL HC 64 acetazolamide 88 acetazolamide sodium 88 acetic acid 64 acetylcysteine 90 ACIPHEX 75 ACIPHEX SPRINKLE 75 acitretin 55 ACTEMRA 81 ACTHIB 78 ACTIGALL 72 ACTIMMUNE 76 ACTIQ 33 ACTIVELLA 81 ACTONEL 61,80 ACTOPLUS MET 65 ACTOPLUS MET XR 65 ACTOS 65 ACULAR 88 ACULAR LS 88 ACUVAIL 88

acyclovir 11,59 acyclovir sodium 11 ACZONE 56 ADACEL TDAP 78 ADAGEN 61 ADALAT CC 47 adapalene 57 ADCIRCA 90 ADDERALL 40 ADDERALL XR 40 adefovir dipivoxil 11 ADEMPAS 90 ADLYXIN 65 ADRENALIN 89 ADRIAMYCIN 21 ADRUCIL 21 ADVAIR DISKUS 90 ADVAIR HFA 90 ADZENYS XR-ODT 40 AEROSPAN 90 AFEDITAB CR 47 AFINITOR 21 AFINITOR DISPERZ 21 AFREZZA 65 AGGRENOX 52 AGRYLIN 61 AIRDUO RESPICLICK 90 ALA-CORT 59 ALA-SCALP 59 ALBENZA 15 albuterol sulfate 90 alclometasone dipropionate 59 ALDACTAZIDE 47 ALDACTONE 47 ALDARA 56 ALDURAZYME 69 ALECENSA 21 alendronate sodium 61,80 alfuzosin hcl er 94 ALIMTA 21 ALINIA 15

ALKERAN allopurinol allopurinol sodium ALLZITAL almotriptan malate ALOCRIL alogliptin alogliptin-metformin alogliptin-pioglitazone ALOMIDE ALOPRIM ALORA alosetron hcl ALOXI ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL alprazolam odt ALREX ALTACE ALTOPREV ALUNBRIG ALVESCO ALYACEN AMABELZ amantadine AMARYL AMBIEN AMBIEN CR AMBISOME amcinonide AMERGE AMETHIA AMETHIA LO amikacin sulfate amiloride hcl amiloridehydrochlorothiazide AMINO ACIDS aminophylline

21 80 80 33 30 87 65 65 65 87 80 81 72 72 89 40 40 40 40 89 47 53 21 90 83 81 11 65 40 40 10 59 30 83 83 15 47 47 95 90

AMINOSYN II 95 AMINOSYN II WITH ELECTROLYTES 95 AMINOSYN WITH ELECTROLYTES 95 AMINOSYN-HBC 95 AMINOSYN-PF 95 AMINOSYN-RF 95 amiodarone hcl 46,47 AMITIZA 72 amitriptyline hcl 40 amlodipine besylate 47 amlodipine besylatebenazepril 47 amlodipine-atorvastatin 53 amlodipine-olmesartan 47 amlodipine-valsartan 47 amlodipine-valsartan-hctz 47 ammonium lactate 56 amoxapine 40 amoxicillin 18 amoxicillin-clavulanate pot er 18 amoxicillin-clavulanate potass 18 amphotericin b 10 ampicillin sodium 18 ampicillin trihydrate 18 ampicillin-sulbactam 18 AMPYRA 31 AMRIX 32 ANADROL-50 69 ANAFRANIL 40 anagrelide hcl 61 ANAPROX DS 38 anastrozole 21 ANCOBON 10 ANDRODERM 69 ANDROGEL 69 ANGELIQ 82 ANORO ELLIPTA 91 ANTABUSE 62

ANTARA 53 ANUSOL-HC 72 ANZEMET 72 APEXICON E 59 APIDRA 65 APIDRA SOLOSTAR 65 APLENZIN 40 APOKYN 29 apraclonidine hcl 89 aprepitant 72 APRI 84 APRISO 72 APTENSIO XR 40 APTIOM 26 APTIVUS 11 ARALAST NP 62 ARANELLE 84 ARANESP 76,77 ARAVA 81 ARCALYST 77 ARCAPTA NEOHALER 91 argatroban 52 argatroban-0.9% nacl 52 ARICEPT 31 ARIMIDEX 21 aripiprazole 40 aripiprazole odt 40 ARISTADA 40 ARIXTRA 52 armodafinil 40 ARNUITY ELLIPTA 91 AROMASIN 21 ARRANON 21 ARTHROTEC 50 38 ARTHROTEC 75 38 ASACOL HD 72 ASCOMP WITH CODEINE 33 ASHLYNA 84 ASMANEX 91 ASMANEX HFA 91 aspirin-dipyridamole er 52

ASTAGRAF XL 21 ASTEPRO 63 ATACAND 47 ATACAND HCT 47 ATELVIA 80 atenolol 47 atenolol-chlorthalidone 47 ATGAM 78 ATIVAN 40 atomoxetine hcl 40 atorvastatin calcium 53 atovaquone 15 atovaquone-proguanil hcl 16 ATRALIN 57 ATRIPLA 11 atropine sulfate 71,87 ATROVENT HFA 91 AUBAGIO 31 AUBRA 84 AUGMENTIN 18 AURYXIA 62 AUSTEDO 31 AUVI-Q 89 AVALIDE 48 AVANDIA 65 AVAPRO 48 AVASTIN 21 AVC 83 AVEED 69 AVELOX 18 AVELOX IV 18 AVIANE 84 AVITA 57 AVODART 94 AVONEX 77 AVONEX PEN 77 AVYCAZ 14 AXERT 30 AXIRON 69 AYGESTIN 82 azacitidine 21

AZACTAM-ISO-OSMOTIC DEXTROSE 16 AZASAN 21 AZASITE 86 azathioprine 21 azathioprine sodium 21 azelastine hcl 63,87 AZELEX 57 AZILECT 29 azithromycin 15 AZOPT 88 AZOR 48 aztreonam 16 AZULFIDINE 72

BACIIM 16 bacitracin 16,86 bacitracin-polymyxin 86 baclofen 32 BACTRIM 19 BACTRIM DS 19 BACTROBAN 58 BACTROBAN NASAL 63 balsalazide disodium 72 BALZIVA 84 BANZEL 26 BARACLUDE 11 BASAGLAR KWIKPEN U100 66 BAVENCIO 21 bcg vaccine (tice strain) 78 BECONASE AQ 91 BEKYREE 84 BELBUCA 33 BELEODAQ 21 BELSOMRA 40 benazepril hcl 48 benazeprilhydrochlorothiazide 48 BENICAR 48

BENICAR HCT 48 BENLYSTA 81 BENTYL 72 BENZACLIN 57 BENZAMYCIN 57 benztropine mesylate 29 BEPREVE 87 BERINERT 91 BESIVANCE 86 BETAGAN 87 betamethasone dipropionate 59 betamethasone valerate 59 BETAPACE AF 47 BETASERON 77 betaxolol hcl 48,87 bethanechol chloride 94 BETHKIS 16 BETIMOL 87 BETOPTIC S 87 BEVESPI AEROSPHERE 91 bexarotene 21 BEXSERO 78 BEYAZ 84 bicalutamide 21 BICILLIN C-R 18 BICILLIN L-A 18 BICNU 21 BIDIL 48 BILTRICIDE 16 bimatoprost 88 BINOSTO 80 bisoprolol fumarate 48 bisoprololhydrochlorothiazide 48 BIVIGAM 78 bleomycin sulfate 21 BLEPH-10 89 BLEPHAMIDE 89 BLEPHAMIDE S.O.P. 89 BLISOVI 24 FE 84 BLISOVI FE 84

BONIVA 80 BOOSTRIX TDAP 78 BOSULIF 21 BOTOX 78 BREO ELLIPTA 91 BREVICON 84 BRIELLYN 84 BRILINTA 52 brimonidine tartrate 89 BRISDELLE 40 BRIVIACT 26 bromfenac sodium 88 bromocriptine mesylate 29 BROVANA 91 budesonide 91 budesonide ec 72 bumetanide 48 BUNAVAIL 38 BUPAP 33 BUPHENYL 62 BUPRENEX 33 buprenorphine 33 buprenorphine hcl 33 buprenorphine-naloxone 38 bupropion hcl 40 bupropion hcl sr 40 bupropion xl 40 buspirone hcl 40 busulfan 21 BUSULFEX 21 butalb-acetaminoph-caffcodein 33 butalb-caff-acetaminophcodein 33 butalbital compound-codeine 33 butalbital-acetaminophen 33 butalbital-acetaminophencaffe 34 butalbital-aspirin-caffeine 34 BUTISOL SODIUM 40 butorphanol tartrate 38

BUTRANS BYDUREON BYDUREON PEN BYETTA BYSTOLIC BYVALSON

34 66 66 66 48 48

cabergoline 69 CABOMETYX 21 CADUET 53 CAFERGOT 30 CALAN 48 CALAN SR 48 calcipotriene 55 calcipotriene-betamethasone dp 55 calcitonin-salmon 69 calcitriol 55,69 calcium acetate 94 CAMBIA 38 CAMILA 82 CAMPTOSAR 21 CAMRESE LO 84 CANASA 72 CANCIDAS 10 candesartan cilexetil 48 candesartanhydrochlorothiazid 48 CAPASTAT SULFATE 16 CAPEX SHAMPOO 59 CAPRELSA 21 captopril 48 captopril-hydrochlorothiazide 48 CARAC 56 CARAFATE 75 CARBAGLU 62 carbamazepine 26 carbamazepine er 26 CARBATROL 26 carbidopa 29

carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopaentacapone carbinoxamine maleate carboplatin CARDENE I.V. CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA CARDURA XL CARIMUNE NF NANOFILTERED carisoprodol carisoprodol-aspirin carisoprodol-aspirin-codeine CARNITOR carteolol hcl CARTIA XT carvedilol CASODEX CATAPRES CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 CAYSTON CAZIANT cefaclor cefaclor er cefadroxil cefazolin sodium cefdinir cefepime hcl cefixime cefotaxime sodium cefotetan cefoxitin cefpodoxime proxetil cefprozil ceftazidime

100

29 CEFTIN 29 ceftriaxone cefuroxime 29 cefuroxime sodium 89 CELEBREX 21 celecoxib 48 CELEXA 48 CELLCEPT 48 CELONTIN 48 cephalexin 48 CERDELGA 48 CEREBYX CEREZYME 78 CESAMET 32 cetirizine hcl 32 cevimeline hcl 32 CHANTIX 62 CHEMET 87 CHENODAL 48 chloramphenicol sod 48 succinate 21 chlordiazepoxide hcl 48 chlordiazepoxide48 amitriptyline 48 chlorhexidine gluconate 48 chloroquine phosphate 16 chlorothiazide 84 chlorothiazide sodium 14 chlorpromazine hcl 14 chlorthalidone 14 chlorzoxazone 14 CHOLBAM 14 cholestyramine 14 cholestyramine light 14 chorionic gonadotropin 14 CIALIS 14 ciclopirox 14 cidofovir 14 cilostazol 14 CILOXAN 14 cimetidine

14 14 14 14 38 38 40 21 26 14 69 26 69 72 89 62 63 62 72 16 40 40 63 16 48 48 41 48 32 72 53 53 69 94 58 11 52 86 75

CIMZIA 72 CINRYZE 91 CIPRO 19 CIPRO HC 64 CIPRO I.V. 19 CIPRODEX 64 ciprofloxacin 19 ciprofloxacin er 19 ciprofloxacin hcl 19,86 ciprofloxacin-d5w 19 cisplatin 21 citalopram hbr 41 cladribine 21 CLARAVIS 57 CLARINEX 89 CLARINEX-D 12 HOUR 89 clarithromycin 15 clarithromycin er 15 clemastine fumarate 89 CLEOCIN 83 CLEOCIN HCL 16 CLEOCIN PALMITATE 16 CLEOCIN PHOSPHATE 16 CLEOCIN PHOSPHATE IN D5W 16 CLEOCIN T 57 CLIMARA 82 CLIMARA PRO 82 CLINDACIN P 57 CLINDAGEL 57 clindamax 57 clindamycin hcl 16 clindamycin pediatric 16 clindamycin phos-benzoyl perox 57 clindamycin phos-tretinoin 57 clindamycin phosphate 16,57,83 clindamycin phosphate-d5w 16 clindamycin-benzoyl peroxide 57 CLINDESSE 57

CLINIMIX 62,95 CLINIMIX E 62,95 CLINISOL 95 clobetasol emollient 59 clobetasol propionate 59,60 CLOBEX 60 CLODAN 60 CLODERM 60 clofarabine 21 CLOLAR 21 clomipramine hcl 41 clonazepam 26 clonidine 48 clonidine hcl 48 clonidine hcl er 41 clopidogrel 52 clorazepate dipotassium 41 clotrimazole 10,58 clotrimazole-betamethasone 58 clozapine 41 clozapine odt 41 CLOZARIL 41 COARTEM 16 codeine sulfate 34 COGENTIN 29 COLAZAL 72 colchicine 80 COLCRYS 80 COLESTID 54 colestipol hcl 54 colistimethate 16 COLOCORT 72 COLY-MYCIN S 64 COLYTE WITH FLAVOR PACKETS 72 COMBIGAN 88 COMBIPATCH 82 COMBIVENT RESPIMAT 91 COMBIVIR 11 COMETRIQ 21 COMPLERA 11

101

COMPRO 72 COMTAN 29 CONCERTA 41 CONDYLOX 56 CONSTULOSE 73 CONZIP 38 COPAXONE 31 COPEGUS 11 CORDRAN 60 COREG 48 COREG CR 48 CORGARD 48 CORLANOR 55 CORMAX 60 CORTEF 64 cortisone acetate 64 CORTISPORIN 58 CORZIDE 48 COSENTYX (2 SYRINGES) 55 COSENTYX PEN (2 PENS) 55 COSMEGEN 21 COSOPT 88 COSOPT PF 88 COTELLIC 21 COUMADIN 52 COZAAR 48 CREON 73 CRESEMBA 10 CRESTOR 54 CRINONE 82 CRIXIVAN 11 cromolyn sodium 73,87,91 CRYSELLE 84 CUBICIN 16 CUPRIMINE 81 CUTIVATE 60 CUVPOSA 72 CYCLAFEM 84 CYCLESSA 84 cyclobenzaprine hcl 32 cyclophosphamide 21

CYCLOSET cyclosporine cyclosporine modified CYKLOKAPRON CYMBALTA cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine CYTOMEL CYTOTEC CYTOVENE

dacarbazine DACOGEN DAKLINZA DALIRESP DALVANCE danazol DANTRIUM dantrolene sodium dapsone DAPTACEL DTAP daptomycin DARAPRIM darifenacin er DARZALEX daunorubicin hcl DAYPRO DAYTRANA DDAVP DEBLITANE decitabine DELESTROGEN DELYLA DELZICOL DEMADEX demeclocycline hcl

66 21 21 52 41 89 21 73 94 87 21 71 75 11

21 21 11 91 16 69,70 32 32 16 78 16 16 93 22 22 38 41 70 82 22 82 84 73 48 19

DEMSER 49 DENAVIR 59 DEPACON 26 DEPAKENE 26 DEPAKOTE 26 DEPAKOTE ER 26 DEPAKOTE SPRINKLE 26 DEPEN 81 DEPO-ESTRADIOL 82 DEPO-MEDROL 64 DEPO-PROVERA 82 DEPO-SUBQ PROVERA 104 82 DEPO-TESTOSTERONE 70 DERMATOP 60 DESCOVY 11 desipramine hcl 41 desloratadine 89 desmopressin acetate 70 DESOGEN 84 desogestr-eth estrad eth estra 84 DESONATE 60 desonide 60 DESOWEN 60 desoximetasone 60 DESOXYN 41 desvenlafaxine er 41 desvenlafaxine succinate er 41 DETROL 93 DETROL LA 93 dexamethasone 64 DEXAMETHASONE INTENSOL 64 dexamethasone sodium phosphate 64,89 DEXEDRINE 41 DEXILANT 75 dexmethylphenidate hcl 41 dexmethylphenidate hcl er 41 DEXPAK 64

102

dexrazoxane 20 dextroamphetamine sulfate 41 dextroamphetamine sulfate er 41 dextroamphetamine-amphet er 41 dextroamphetamineamphetamine 41 dextrose 10%-0.2% nacl 62 dextrose 10%-0.45% nacl 62 dextrose 2.5%-0.45% nacl 62 dextrose 5%-0.2% nacl 62 dextrose 5%-0.2% nacl-kcl 94 dextrose 5%-0.225% nacl 62 dextrose 5%-0.33% nacl 62 dextrose 5%-0.33% nacl-kcl 94 dextrose 5%-0.45% nacl 62 dextrose 5%-0.45% nacl-kcl 94 dextrose 5%-0.9% nacl 62 dextrose 5%-1/2ns-kcl 94 dextrose 5%-ns-kcl 94 dextrose 5%-potassium chloride 94 dextrose in lactated ringers 62 dextrose in water 62 DIAMOX SEQUELS 88 DIASTAT 26 DIASTAT ACUDIAL 26 diazepam 41 DIBENZYLINE 49 diclofenac potassium 38 diclofenac sodium 38,56,88 diclofenac sodium er 38 diclofenac sodiummisoprostol 38 dicloxacillin sodium 18 dicyclomine hcl 72 didanosine 11 DIFFERIN 57 DIFICID 15 diflorasone diacetate 60

DIFLUCAN diflunisal DIGITEK digoxin dihydroergotamine mesylate DILANTIN DILANTIN-125 DILAUDID DILT-XR diltiazem 12hr er diltiazem 24hr cd diltiazem 24hr er diltiazem hcl DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoidsped DIPROLENE DIPROLENE AF dipyridamole disopyramide phosphate disulfiram DITROPAN XL DIURIL divalproex sodium divalproex sodium er DIVIGEL docetaxel dofetilide DOLOPHINE HCL donepezil hcl donepezil hcl odt DORIBAX DORYX DORYX MPC dorzolamide hcl dorzolamide-timolol DOVONEX

10 38 52 52 30 26 26 34 49 49 49 49 49 49 49 73 89 72 78 60 60 52 47 62 93 49 26 26 82 22 47 34 31 31 16 19 19 88 88 55

doxazosin mesylate 49 EDECRIN 49 doxepin hcl 41,56 EDLUAR 42 doxercalciferol 70 EDURANT 11 DOXIL 22 EFFEXOR XR 42 doxorubicin hcl 22 EFFIENT 52 doxorubicin hcl liposome 22 EFUDEX 56 DOXY 100 19 EGRIFTA 77 doxycycline hyclate 19 ELAPRASE 70 doxycycline monohydrate 19 ELDEPRYL 29 dronabinol 73 ELELYSO 70 drospirenone-eth estraELESTAT 87 levomef 84 ELESTRIN 82 drospirenone-ethinyl ELIDEL 56 estradiol 84 ELIGARD 22 DROXIA 22 ELIMITE 61 DUAC 57 ELIPHOS 94 DUAVEE 82 ELIQUIS 52 DUETACT 66 ELITEK 20 DUEXIS 38 ELLENCE 22 DULERA 91 ELMIRON 94 duloxetine hcl 41 ELOCON 60 DUOPA 29 EMADINE 87 DUPIXENT 55 EMBEDA 34 DURAGESIC 34 EMCYT 22 DURAMORPH 34 EMEND 73 DUREZOL 89 EMOQUETTE 84 dutasteride 94 EMPLICITI 22 dutasteride-tamsulosin 94 EMSAM 42 DUTOPROL 49 EMTRIVA 11 DYAZIDE 49 EMVERM 16 DYMISTA 91 ENABLEX 93 DYRENIUM 49 enalapril maleate 49 DYSPORT 78 enalapril-hydrochlorothiazide 49 ENBREL 81 ENDOCET 34 E.E.S. 200 15 ENGERIX-B ADULT 78 E.E.S. 400 15 ENGERIX-B PEDIATRICEC-NAPROSYN 38 ADOLESCENT 78 econazole nitrate 58 enoxaparin sodium 53 EDARBI 49 ENPRESSE 84 EDARBYCLOR 49 ENSTILAR 55

103

entacapone 29 entecavir 11 ENTOCORT EC 73 ENTRESTO 55 ENULOSE 73 ENVARSUS XR 22 EPCLUSA 11 EPIDUO 57 EPIDUO FORTE 57 epinastine hcl 87 epinephrine 0.15 mg auto-inject (mylan) 89 epinephrine 0.3 mg auto-inject (mylan) 90 EPIPEN 2-PAK 90 EPIPEN JR 2-PAK 90 epirubicin hcl 22 EPITOL 26 EPIVIR 11 EPIVIR HBV 11 eplerenone 49 EPOGEN 77 eprosartan mesylate 49 EPZICOM 11 EQUETRO 26 ERAXIS (WATER DILUENT) 10 ERBITUX 22 ergoloid mesylates 42 ergotamine-caffeine 30 ERIVEDGE 22 ERRIN 82 ERTACZO 58 ERWINAZE 22 ERY 57 ERY-TAB 15 ERYGEL 57 ERYPED 200 15 ERYPED 400 15 ERYTHROCIN LACTOBIONATE 15 ERYTHROCIN STEARATE 15

erythromycin 15,57,86 erythromycin ethylsuccinate 15 erythromycin-benzoyl peroxide 57 ESBRIET 91 escitalopram oxalate 42 ESGIC 34 esomeprazole magnesium 75 esomeprazole sodium 75 estazolam 42 ESTRACE 82 estradiol 82 estradiol valerate 82 estradiol-norethindrone acetat 82 ESTRING 82 estropipate 82 eszopiclone 42 ethacrynate sodium 49 ethacrynic acid 55 ethambutol hcl 16 ethosuximide 26 ethynodiol-ethinyl estradiol 84 etidronate disodium 62 etodolac 38 etodolac er 38 ETOPOPHOS 22 etoposide 22 EUCRISA 56 EURAX 61 EVAMIST 82 EVISTA 80 EVOCLIN 57 EVOTAZ 11 EVOXAC 62 EVZIO 38 EXALGO 34 EXELDERM 59 EXELON 31 exemestane 22 EXFORGE 49

104

EXFORGE HCT EXJADE EXONDYS 51 EXTAVIA EXTINA ezetimibe ezetimibe-simvastatin

FABIOR FABRAZYME FALMINA famciclovir famotidine FANAPT FARESTON FARXIGA FARYDAK FASLODEX FAYOSIM FAZACLO felbamate FELBATOL FELDENE felodipine er FEMARA FEMHRT FEMRING FEMYNOR fenofibrate fenofibric acid FENOGLIDE fenoprofen calcium fentanyl fentanyl citrate FENTORA FERRIPROX FETZIMA FEXMID FIBRICOR FINACEA

49 62 31 77 59 54 54

57 70 84 11 75 42 22 66 22 22 84 42 26,27 27 38 49 22 82 82 84 54 54 54 38 34 34 34 62 42 32 54 57

finasteride 94 FIORICET 34 FIORICET WITH CODEINE 34 FIORINAL 35 FIORINAL WITH CODEINE #3 35 FIRAZYR 91 FIRMAGON 22 FLAGYL 16 FLAREX 89 flavoxate hcl 93 FLEBOGAMMA DIF 78 flecainide acetate 47 FLECTOR 38 FLOMAX 94 FLOVENT DISKUS 91 FLOVENT HFA 91 FLOXIN 64 fluconazole 10 fluconazole-nacl 10 flucytosine 10 fludarabine phosphate 22 fludrocortisone acetate 64 FLUMADINE 11 flunisolide 91 fluocinolone acetonide 60 fluocinolone acetonide oil 64 fluocinonide 60 fluocinonide-e 60 fluorometholone 89 fluorouracil 22,56 fluoxetine dr 42 fluoxetine hcl 42 fluphenazine decanoate 42 fluphenazine hcl 42 flurandrenolide 60 flurazepam hcl 42 flurbiprofen 38 flurbiprofen sodium 88 flutamide 22 fluticasone propionate 60,91

fluticasone-salmeterol 91 fluvastatin er 54 fluvastatin sodium 54 fluvoxamine maleate 42 fluvoxamine maleate er 42 FML 89 FML FORTE 89 FML S.O.P. 89 FOCALIN 42 FOCALIN XR 42 FOLOTYN 22 fomepizole 78 fondaparinux sodium 53 FORFIVO XL 42 FORTAZ 14 FORTEO 80 FORTESTA 70 FOSAMAX 80 FOSAMAX PLUS D 80 fosinopril sodium 49 fosinopril-hydrochlorothiazide49 fosphenytoin sodium 27 FOSRENOL 62 FRAGMIN 53 FREAMINE HBC 95 FROVA 30 frovatriptan succinate 30 FURADANTIN 20 furosemide 49 FUSILEV 20 FUZEON 11 FYAVOLV 82 FYCOMPA 27

gabapentin GABITRIL GABLOFEN galantamine er galantamine hbr galantamine hydrobromide

105

27 27 32 31 31 31

GAMASTAN S-D VIAL (RXCUI 1809038) 79 GAMMAGARD LIQUID 79 GAMMAGARD S-D 79 GAMMAKED 79 GAMMAPLEX 79 GAMUNEX-C 79 ganciclovir sodium 11 GARDASIL 9 79 GASTROCROM 73 gatifloxacin 86 GATTEX 73 GAVILYTE-C 73 GAVILYTE-G 73 GAVILYTE-H AND BISACODYL 73 GAVILYTE-N 73 GELNIQUE 93 gemcitabine hcl 22 gemfibrozil 54 GEMZAR 22 GENERESS FE 84 GENERLAC 73 GENGRAF 22 GENOTROPIN 77 GENTAK 86 gentamicin sulfate 16,58,86 gentamicin sulfate in ns 16 GENVOYA 11 GEODON 42 GIANVI 84 GIAZO 73 GILDAGIA 84 GILENYA 31 GILOTRIF 22 GLASSIA 62 GLATOPA 31 GLEEVEC 22 GLEOSTINE 22 glimepiride 66 glipizide 66

glipizide er glipizide-metformin GLUCAGEN GLUCAGON EMERGENCY KIT GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL glycopyrrolate GLYSET GLYXAMBI GOLYTELY GONITRO GRALISE granisetron hcl GRANIX GRASTEK GRIS-PEG griseofulvin griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er guanidine hcl GYNAZOLE 1

66 heparin sodium 53 66 heparin sodium-d5w 53 66 HEPATAMINE 95 HEPSERA 11 66 HERCEPTIN 22 66 HETLIOZ 43 66 HEXALEN 22 66 HIBERIX 79 66 HIPREX 20 72 HORIZANT 32 66 HUMALOG 67 67 HUMALOG KWIKPEN U-100 67 73 HUMALOG KWIKPEN U-200 67 55 HUMALOG MIX 50-50 67 27 HUMALOG MIX 50-50 73 KWIKPEN 67 77 HUMALOG MIX 75-25 67 79 HUMALOG MIX 75-25 10 KWIKPEN 67 10 HUMATROPE 77 10 HUMIRA 81 49 HUMIRA PEDIATRIC 42 CROHN'S 81 42 HUMIRA PEN 81 83 HUMIRA PEN CROHN-UC-HS STARTER 81 HUMIRA PEN PSORIASISH.P. ACTHAR 64 UVEITIS 81 HALAVEN 22 HUMULIN 70-30 67 HALCION 42 HUMULIN 70/30 KWIKPEN 67 HALDOL 42 HUMULIN N 67 HALDOL DECANOATE 100 42 HUMULIN N KWIKPEN 67 HALDOL DECANOATE 50 42 HUMULIN R 67 halobetasol propionate 60 HUMULIN R U-500 67 HALOG 60 HUMULIN R U-500 haloperidol 42 KWIKPEN 67 haloperidol decanoate 42 HYCAMTIN 22 haloperidol lactate 42 HYCET 35 HARVONI 11 hydralazine hcl 49 HAVRIX 79 HYDREA 22 HECTOROL 70 hydrochlorothiazide 49

106

hydrocodoneacetaminophen 35 hydrocodone-ibuprofen 35 hydrocortisone 60,64,73 hydrocortisone butyrate 60 hydrocortisone valerate 60 hydrocortisone-acetic acid 64 hydromorphone er 35 hydromorphone hcl 35 hydroxychloroquine sulfate 16 hydroxyprogesterone caproate 82 hydroxyurea 22 hydroxyzine hcl 90 hydroxyzine pamoate 90 HYPERRAB S-D 79 HYSINGLA ER 35 HYZAAR 49

ibandronate sodium IBRANCE IBUDONE ibuprofen ICLUSIG IDAMYCIN PFS idarubicin hcl IFEX ifosfamide ILARIS ILEVRO imatinib mesylate IMBRUVICA IMFINZI imipenem-cilastatin sodium imipramine hcl imipramine pamoate imiquimod IMITREX IMOGAM RABIES-HT IMOVAX RABIES VACCINE

80 22 35 38 22 22 23 23 23 77 88 23 23 23 16 43 43 56 30 79 79

IMURAN 23 INCRELEX 62 INCRUSE ELLIPTA 91 indapamide 49 INDERAL LA 49 INDOCIN 38 indomethacin 38 indomethacin er 38 INFANRIX DTAP 79 INFLECTRA 73 INGREZZA 32 INLYTA 23 INNOPRAN XL 49 INSPRA 49 INTELENCE 11 INTERMEZZO 43 INTRALIPID 95 INTRON A 77 INTROVALE 84 INTUNIV 43 INVANZ 16 INVEGA 43 INVEGA SUSTENNA 43 INVEGA TRINZA 43 INVIRASE 12 INVOKAMET 67 INVOKAMET XR 67 INVOKANA 67 IONOSOL MB-DEXTROSE 5% 95 IOPIDINE 89 IPOL 79 ipratropium bromide 63,91 ipratropium-albuterol 91 irbesartan 49 irbesartanhydrochlorothiazide 49 IRESSA 23 irinotecan hcl 23 ISENTRESS 12

ISOLYTE P WITH DEXTROSE ISOLYTE S isoniazid ISOPTO CARPINE ISORDIL ISORDIL TITRADOSE isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er isradipine ISTALOL ISTODAX itraconazole ivermectin IXIARO

JADENU JADENU SPRINKLE JAKAFI JALYN JANTOVEN JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JEVTANA JINTELI JOLIVETTE JUBLIA JULEBER JUNEL JUNEL FE JUNEL FE 24 JUXTAPID

K-TAB ER

95 95 16 87 55 55 55 55 55 50 87 23 10 16 79

62 62 23 94 53 67 67 67 67 67 67 23 82 82 59 84 84 84 84 54

107

KADCYLA 23 KADIAN 35 KAITLIB FE 84 KALETRA 12 KALYDECO 92 KANUMA 70 KAPVAY 43 KARBINAL ER 90 KARIVA 84 KAYEXALATE 62 KAZANO 67 KELNOR 1-35 84 KENALOG 60 KENALOG-10 64 KENALOG-40 64 KEPIVANCE 20 KEPPRA 27 KEPPRA XR 27 KERYDIN 59 ketoconazole 10,59 ketoprofen 39 ketorolac tromethamine 88 KEVEYIS 32 KEVZARA 81 KEYTRUDA 23 KHEDEZLA 43 KIMIDESS 84 KINERET 81 KINRIX 79 KIONEX 62 KISQALI 23 KISQALI FEMARA COPACK 23 KLARON 58 KLONOPIN 27 KLOR-CON 10 94 KLOR-CON 8 94 KLOR-CON M10 94 KLOR-CON M15 94 KLOR-CON M20 94 KLOR-CON SPRINKLE 94

KOMBIGLYZE XR KORLYM KRISTALOSE KUVAN KYNAMRO KYPROLIS

67 70 73 70 54 23

labetalol hcl 50 LACRISERT 87 lactated ringers 61,94 lactulose 73 LAMICTAL 27 LAMICTAL (BLUE) 27 LAMICTAL (GREEN) 27 LAMICTAL (ORANGE) 27 LAMICTAL ODT 27 LAMICTAL XR 27 LAMICTAL XR (BLUE) 27 LAMICTAL XR (GREEN) 27 LAMICTAL XR (ORANGE) 27 LAMISIL 10 lamivudine 12 lamivudine hbv 12 lamivudine-zidovudine 12 lamotrigine 27 lamotrigine er 27 lamotrigine odt 27 LANOXIN 52 lansoprazol-amoxicil-clarithro 75 lansoprazole 75 LANTUS 67 LANTUS SOLOSTAR 68 LARIN 84 LARIN FE 84 LARISSIA 84 LARTRUVO 23 LASIX 50 LASTACAFT 87 latanoprost 88 LATUDA 43

LAYOLIS FE 84 LAZANDA 35 LEENA 84 leflunomide 81 LENVIMA 23 LESCOL XL 54 LESSINA 84 LETAIRIS 92 letrozole 23 leucovorin calcium 20 LEUKERAN 23 LEUKINE 77 leuprolide acetate 23 levalbuterol concentrate 92 levalbuterol hcl 92 levalbuterol tartrate hfa 92 LEVAQUIN 19 LEVEMIR 68 LEVEMIR FLEXTOUCH 68 levetiracetam 27 levetiracetam er 27 levetiracetam-nacl 27 levobunolol hcl 87 levocarnitine 62 levocetirizine dihydrochloride 90 levofloxacin 19,86 levofloxacin-d5w 19 levoleucovorin calcium 20 LEVONEST 84 levonorg-eth estrad eth estrad 84 levonorgestrel-eth estradiol 85 LEVORA-28 85 levorphanol tartrate 35 levothyroxine sodium 71 LEVOXYL 71 LEXAPRO 43 LEXIVA 12 LIALDA 73 lidocaine 58 lidocaine hcl 58

108

lidocaine hcl viscous 58 lidocaine-prilocaine 58 LIDODERM 58 LINCOCIN 16 lincomycin hcl 17 lindane 61 linezolid 17 LINZESS 73 LIORESAL INTRATHECAL 32 liothyronine sodium 71 LIPITOR 54 LIPOFEN 54 lisinopril 50 lisinopril-hydrochlorothiazide 50 lithium 43 lithium carbonate 43 lithium carbonate er 43 LITHOBID 43 LITHOSTAT 62 LIVALO 54 LO LOESTRIN FE 85 LOCOID 61 LODINE 39 LODOSYN 29 LOESTRIN 85 LOESTRIN FE 85 lokara 61 LOMEDIA 24 FE 85 LOMOTIL 72 LONSURF 23 loperamide 72 LOPID 54 lopinavir-ritonavir 12 LOPRESSOR 50 LOPRESSOR HCT 50 LOPROX 59 lorazepam 43 LORAZEPAM INTENSOL 43 LORCET 35 LORCET HD 35 LORCET PLUS 35

LORTAB LORYNA LORZONE losartan potassium losartan-hydrochlorothiazide LOSEASONIQUE LOTEMAX LOTENSIN LOTREL LOTRISONE LOTRONEX lovastatin LOVAZA LOVENOX LOW-OGESTREL loxapine LUMIGAN LUMIZYME LUNESTA LUPANETA PACK LUPRON DEPOT LUPRON DEPOT-PED LUTERA LUZU LYNPARZA LYRICA LYSODREN LYSTEDA LYZA

M-M-R II VACCINE MACROBID MACRODANTIN magnesium sulfate MAKENA MALARONE malathion maprotiline hcl MARINOL MARLISSA

35 85 32 50 50 85 89 50 50 59 73 54 54 53 85 43 88 70 43 83 23 23 85 59 23 28 23 83 82

79 20 20 94 82 17 61 43 73 85

MARPLAN MATULANE MATZIM LA MAXALT MAXALT MLT MAXIDEX MAXIPIME MAXITROL MAXZIDE MAXZIDE-25 MG meclizine hcl meclofenamate sodium MEDROL medroxyprogesterone acetate mefenamic acid mefloquine hcl MEGACE MEGACE ES megestrol acetate MEKINIST meloxicam melphalan hcl memantine hcl MENACTRA MENEST MENOMUNE-A-C-Y-W-135 MENOSTAR MENTAX MENVEO A-C-Y-W-135-DIP MEPRON mercaptopurine meropenem MERREM mesalamine mesna MESNEX MESTINON METADATE CD METADATE ER metaproterenol sulfate

109

43 23 50 30 30 89 14 88 50 50 73 39 64 82 39 17 23 23 23 23 39 23 32 79 82 79 82 59 79 17 23 17 17 73 20 20 32 43 43 92

METAXALL 32 metaxalone 32 metformin hcl 68 metformin hcl er 68 methadone hcl 35,36 methamphetamine hcl 43 methazolamide 88 methenamine hippurate 20 methimazole 65 METHITEST 70 methocarbamol 32 methotrexate 23 methotrexate sodium 23 methoxsalen 56 methscopolamine bromide 72 methyclothiazide 50 METHYLIN 43 methylphenidate er 43 methylphenidate hcl 43 methylphenidate hcl cd 43 methylphenidate hcl er 43 methylphenidate la 43 methylprednisolone 64 methylprednisolone acetate 64 methylprednisolone sodium succ 64 methyltestosterone 70 metipranolol 87 metoclopramide hcl 74 metoclopramide hcl odt 74 metolazone 50 metoprolol succinate 50 metoprolol tartrate 50 metoprololhydrochlorothiazide 50 METROCREAM 57 METROGEL 57 METROGEL-VAGINAL 83 METROLOTION 57 metronidazole 17,57,83 mexiletine hcl 47

MIACALCIN 70 MIBELAS 24 FE 85 MICARDIS 50 MICARDIS HCT 50 miconazole 3 83 MICORT-HC 74 MICROGESTIN 85 MICROGESTIN FE 85 MICROZIDE 50 midodrine hcl 62 MIGERGOT 31 miglitol 68 MIGRANAL 31 MILLIPRED 65 MIMVEY 82 MIMVEY LO 83 MINASTRIN 24 FE 85 MINIPRESS 50 MINITRAN 55 MINIVELLE 83 MINOCIN 19 minocycline hcl 19 minocycline hcl er 20 minoxidil 50 MIRAPEX 29 MIRAPEX ER 29 MIRCERA 77 mirtazapine 43 MIRVASO 57 misoprostol 75 MITIGARE 80 mitomycin 23 mitoxantrone hcl 23 MOBIC 39 modafinil 43 MODERIBA 12 moexipril hcl 50 moexipril-hydrochlorothiazide50 mometasone furoate 61,92 MONONESSA 85 montelukast sodium 92

MONUROL MORGIDOX morphine sulfate morphine sulfate er MOVANTIK MOVIPREP MOXEZA moxifloxacin moxifloxacin hcl MOZOBIL MS CONTIN MULTAQ mupirocin MUSTARGEN MYALEPT MYAMBUTOL MYCAMINE MYCOBUTIN mycophenolate mofetil mycophenolic acid MYFORTIC MYORISAN MYRBETRIQ MYSOLINE MYTESI

nabumetone nadolol nadolol-bendroflumethiazide nafcillin sodium naftifine hcl NAFTIN NAGLAZYME nalbuphine hcl naloxone hcl naltrexone hcl NAMENDA NAMENDA XR NAMZARIC NAPRELAN

110

20 20 36 36 74 74 86 19 19 77 36 47 58 23 70 17 10 17 23 23 23 57 93 28 72

39 50 50 18 59 59 70 39 39 39 32 32 32 39

NAPROSYN 39 naproxen 39 naproxen sodium 39 naproxen sodium er 39 naratriptan hcl 31 NARCAN 39 NARDIL 43 NASONEX 92 NATACYN 86 NATAZIA 85 nateglinide 68 NATPARA 70 NEBUPENT 17 NECON 85 nefazodone hcl 43 NEO-SYNALAR 58 neomycin sulfate 17 neomycin-bacitracin-poly-hc 88 neomycin-bacitracinpolymyxin 86 neomycin-polymyxin b 61 neomycin-polymyxindexameth 88 neomycin-polymyxingramicidin 86 neomycin-polymyxin-hc 64,88 neomycin-polymyxinhydrocort 64 NEORAL 24 NEOSPORIN 86 NEPHRAMINE 95 NESINA 68 NEUAC 57 NEULASTA 77 NEUPOGEN 77 NEUPRO 29 NEURONTIN 28 NEVANAC 88 nevirapine 12 nevirapine er 12 NEXAVAR 24

NEXIUM 75 NEXIUM I.V. 75 NEXTERONE 47 niacin er 54 NIACOR 54 NIASPAN 54 nicardipine hcl 50 NICOTROL 63 NICOTROL NS 63 nifedipine er 50 NIKKI 85 NILANDRON 24 nilutamide 24 nimodipine 50 NINLARO 24 NIPENT 24 nisoldipine 50 NITRO-BID 55 NITRO-DUR 55 nitrofurantoin 20 nitrofurantoin mono-macro 20 nitroglycerin 55 nitroglycerin patch 55 NITROMIST 55 NITROSTAT 55 nizatidine 75 NIZORAL 59 NOLIX 61 NORA-BE 83 NORCO 36 NORDITROPIN FLEXPRO 77 norethin-eth estra-ferrous fum 85 norethindron-ethinyl estradiol 83,85 norethindrone 83 norethindrone acetate 83 norgestimate-ethinyl estradiol 85 NORINYL 1-35 85 NORITATE 57

NORLYROC 83 NORMOSOL-M AND DEXTROSE 95 NORMOSOL-R AND DEXTROSE 94 NORMOSOL-R PH 7.4 95 NORPACE 47 NORPACE CR 47 NORPRAMIN 44 NORTHERA 62 NORTREL 85 nortriptyline hcl 44 NORVASC 50 NORVIR 12 NOVAREL 70 NOVOLIN 70-30 68 NOVOLIN N 68 NOVOLIN R 68 NOVOLOG 68 NOVOLOG FLEXPEN 68 NOVOLOG MIX 70-30 68 NOVOLOG MIX 70-30 FLEXPEN 68 NOXAFIL 10 NUCALA 92 NUCYNTA 39 NUCYNTA ER 39 NUEDEXTA 32 NULOJIX 24 NULYTELY WITH FLAVOR PACKS 74 NUPLAZID 44 NUTRESTORE 62 NUTRILIPID 96 NUTROPIN AQ NUSPIN 78 NUVARING 83 NUVESSA 83 NUVIGIL 44 NYAMYC 59 NYATA 59 nystatin 10,59

111

nystatin-triamcinolone NYSTOP

59 59

OCALIVA 74 OCELLA 85 OCTAGAM 79 octreotide acetate 24 OCUFEN 88 OCUFLOX 86 ODEFSEY 12 ODOMZO 24 OFEV 92 ofloxacin 19,64,86 OGESTREL 85 olanzapine 44 olanzapine odt 44 olanzapine-fluoxetine hcl 44 olmesartan medoxomil 50 olmesartan-amlodipine-hctz 50 olmesartanhydrochlorothiazide 50 olopatadine hcl 63,87 OLUX 61 omega-3 acid ethyl esters 54 omeprazole 76 omeprazole-sodium bicarbonate 76 OMNARIS 92 OMNIPRED 89 OMNITROPE 78 ondansetron hcl 74 ondansetron odt 74 ONEXTON 57 ONFI 28 ONGLYZA 68 ONMEL 10 ONZETRA XSAIL 31 OPANA 36 OPANA ER 36 OPDIVO 24

OPSUMIT ORACEA ORALAIR ORAP ORAPRED ODT ORAVIG ORBACTIV ORENCIA ORENCIA CLICKJECT ORENITRAM ER ORFADIN ORKAMBI orphenadrine citrate ORSYTHIA ORTHO MICRONOR ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CYCLEN ORTHO-NOVUM oseltamivir phosphate OSENI OSMOPREP OTEZLA OTOVEL OTREXUP OVCON-35 OVIDE oxacillin oxacillin sodium oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole nitrate OXISTAT OXSORALEN-ULTRA OXTELLAR XR oxybutynin chloride oxybutynin chloride er oxycodone hcl

92 20 79 44 65 10 17 81 81 51 63 92 33 85 83 85 85 85 85 12 68 74 81 64 81 85 61 18 18 24 70 39 44 28 59 59 56 28 93 93 36

oxycodone hcl er oxycodone hcl-aspirin oxycodone hcl-ibuprofen oxycodone-acetaminophen OXYCONTIN oxymorphone hcl oxymorphone hcl er OXYTROL

PACERONE paclitaxel paliperidone er PAMELOR pamidronate disodium PANCREAZE PANDEL PANRETIN pantoprazole sodium paricalcitol PARLODEL PARNATE paromomycin sulfate paroxetine er paroxetine hcl PASER PATADAY PATANASE PATANOL PAXIL PAXIL CR PAZEO PCE PEDIARIX PEDVAXHIB peg 3350-electrolyte peg-3350 and electrolytes PEGANONE PEGASYS PEGASYS PROCLICK penicillin g potassium

112

36 36 36 37 37 37 37 93

47 24 44 44 70 74 61 56 76 70 29 44 17 44 44 17 87 63 87 44 44 87 15 79 79 74 74 28 78 78 18

penicillin g procaine 18 penicillin g sodium 18 penicillin gk-iso-osm dextrose 18 penicillin v potassium 18 PENNSAID 39 PENTAM 300 17 PENTASA 74 pentazocine-naloxone hcl 39 pentoxifylline 53 PEPCID 76 PERCOCET 37 PERFOROMIST 92 perindopril erbumine 51 PERIOGARD 64 PERJETA 24 permethrin 61 perphenazine 44 perphenazine-amitriptyline 44 PERTZYE 74 PEXEVA 44 PHENADOZ 90 phenelzine sulfate 44 PHENERGAN 90 phenobarbital 28 phenoxybenzamine hcl 51 PHENYTEK 28 phenytoin 28 phenytoin sodium 28 phenytoin sodium extended 28 PHOSLYRA 95 PHOSPHOLINE IODIDE 87 PHYSIOLYTE 61 PHYSIOSOL 61 PICATO 56 pilocarpine hcl 63,87 pimozide 44 PIMTREA 85 pindolol 51 pioglitazone hcl 68 pioglitazone-glimepiride 68

pioglitazone-metformin 68 piperacillin-tazobactam 18 PIRMELLA 85 piroxicam 39 PLAQUENIL 17 PLASMA-LYTE 148 96 PLASMA-LYTE A PH 7.4 96 PLAVIX 53 PLEGRIDY 78 PLEGRIDY PEN 78 podofilox 56 polyethylene glycol 3350 74 polymyxin b sul-trimethoprim 86 polymyxin b sulfate 17 POLYTRIM 86 POMALYST 24 PONSTEL 39 PORTIA 85 potassium chl-normal saline 95 potassium chloride 95 potassium chloride in d5lr 95 potassium chloride-nacl 95 potassium citrate er 94 PRADAXA 53 PRALUENT PEN 54 pramipexole dihydrochloride 29 pramipexole er 29,30 PRANDIN 68 PRAVACHOL 54 pravastatin sodium 54 prazosin hcl 51 PRECOSE 68 PRED FORTE 89 PRED MILD 89 PRED-G 88 prednicarbate 61 prednisolone acetate 89 prednisolone sodium phos odt 65 prednisolone sodium phosphate 65,89

prednisone PREDNISONE INTENSOL PREFEST PREGNYL PREMARIN PREMASOL PREMPHASE PREMPRO PREPOPIK PREVACID PREVALITE PREVIFEM PREVPAC PREZCOBIX PREZISTA PRIFTIN PRILOSEC primaquine PRIMAXIN primidone PRIMLEV PRIMSOL PRINIVIL PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide hcl PROCALAMINE PROCARDIA XL PROCENTRA prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTO-MED HC PROCTO-PAK PROCTOSOL-HC PROCTOZONE-HC

113

65 65 83 70 83 96 83 83 74 76 54 85 76 12 12 17 76 17 17 28 37 20 51 44 79 92 92 80 80 47 96 51 44 74 74 74 78 74 74 74 74

PROCYSBI progesterone PROGLYCEM PROGRAF PROLASTIN C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl PROMETHEGAN PROMETRIUM propafenone hcl propafenone hcl er propantheline bromide propranolol hcl propranolol hcl er propranololhydrochlorothiazid propylthiouracil PROQUAD PROSCAR PROSOL PROTONIX PROTONIX IV PROTOPIC protriptyline hcl PROVENTIL HFA PROVERA PROVIGIL PROZAC PRUDOXIN PSORCON PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN PYLERA pyrazinamide pyridostigmine bromide pyridostigmine bromide er

94 83 68 24 63 88 78 80 53 90 90 83 47 47 72 51 51 51 65 79 94 96 76 76 56 44 92 83 44 44 56 61 92 92 92 24 76 17 33 33

QBRELIS 51 QNASL 92 QNASL CHILDREN 92 QUADRACEL DTAP-IPV 79 QUALAQUIN 17 QUARTETTE 85 QUASENSE 85 QUDEXY XR 28 QUESTRAN 54 QUESTRAN LIGHT 54 quetiapine fumarate 44 quetiapine fumarate er 44 QUILLICHEW ER 44 QUILLIVANT XR 44 quinapril hcl 51 quinapril-hydrochlorothiazide 51 quinidine gluconate 47 quinidine sulfate 47 quinine sulfate 17 QVAR 92

RABAVERT rabeprazole sodium RAGWITEK raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RASUVO RAVICTI RAYOS RAZADYNE RAZADYNE ER REBETOL REBIF

79 76 79 80 51 55 76 94 24 30 81 63 65 32 32 12 78

REBIF REBIDOSE 78 RECLAST 63 RECLIPSEN 85 RECOMBIVAX HB 79 RECTIV 74 REGLAN 74 REGRANEX 56 RELENZA 12 RELISTOR 74 RELPAX 31 REMERON 44 REMICADE 74 REMODULIN 51 RENAGEL 63 RENVELA 63 repaglinide 68 repaglinide-metformin hcl 68 REPATHA PUSHTRONEX 54 REPATHA SURECLICK 54 REPATHA SYRINGE 54 REQUIP 30 REQUIP XL 30 RESCRIPTOR 12 RESTASIS 87 RESTORIL 44 RETIN-A 58 RETIN-A MICRO 58 RETIN-A MICRO PUMP 58 RETROVIR 12 REVATIO 92 REVLIMID 24 REXULTI 44 REYATAZ 12 RIBASPHERE 12,13 RIBASPHERE RIBAPAK 13 ribavirin 13 RIDAURA 81 rifabutin 17 RIFADIN 17 RIFAMATE 17 rifampin 17

114

RIFATER RILUTEK riluzole rimantadine hcl ringers injection ringers irrigation RIOMET risedronate sodium risedronate sodium dr RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB risperidone risperidone odt RITALIN RITALIN LA RITUXAN rivastigmine RIVELSA rizatriptan ROBINUL ROBINUL FORTE ROCALTROL ropinirole er ropinirole hcl rosuvastatin calcium ROTARIX ROTATEQ ROWEEPRA ROXICODONE ROZEREM RUBRACA RUCONEST RYDAPT RYTARY RYTHMOL SR RYVENT

SABRIL SAFYRAL

17 63 63 13 95 61 68 63,80 80 44 45 45 45 45 45 45 24 32 85 31 72 72 70 30 30 54 79 79 28 37 45 24 92 24 30 47 90

28 85

SAIZEN SALAGEN SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SARAFEM SAVAYSA SAVELLA SEASONIQUE selegiline hcl selenium sulfide SELZENTRY SEMPREX-D SENSIPAR SEREVENT DISKUS SEROQUEL SEROQUEL XR SEROSTIM sertraline hcl SETLAKIN sevelamer carbonate SFROWASA SHAROBEL SIGNIFOR SIGNIFOR LAR sildenafil sildenafil citrate SILENOR SILIQ SILVADENE silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT simvastatin

78 63 70 74 24 24 24 61 45 45 53 81 85 30 55 13 90 70,71 92 45 45 78 45 85 63 74 83 24 24 92 92 45 56 56 56 88 81 81 24 54

SINEMET 10-100 30 SINEMET 25-100 30 SINEMET 25-250 30 SINEMET CR 30 SINGULAIR 92 sirolimus 24 SIRTURO 17 SIVEXTRO 17 SKELAXIN 33 SKLICE 61 sodium chloride 63,95 SODIUM DIURIL 51 sodium lactate 95 sodium phenylbutyrate 63 sodium polystyrene sulfonate 63 SOLARAZE 56 SOLIQUA 100-33 69 SOLODYN 20 SOLTAMOX 24 SOLU-CORTEF 65 SOLU-MEDROL 65 SOMA 33 SOMATULINE DEPOT 24 SOMAVERT 71 SONATA 45 SOOLANTRA 58 SORIATANE 56 SORILUX 56 SORINE 47 sotalol 47 sotalol af 47 SOTYLIZE 47 SOVALDI 13 SPIRIVA 92 SPIRIVA RESPIMAT 93 spironolactone 51 spironolactone-hctz 51 SPORANOX 10 SPRINTEC 85 SPRITAM 28 SPRYCEL 24

115

SPS 63 SRONYX 85 SSD 56 STALEVO 100 30 STALEVO 125 30 STALEVO 150 30 STALEVO 200 30 STALEVO 50 30 STALEVO 75 30 STARLIX 69 stavudine 13 STELARA 56 STIMATE 71 STIOLTO RESPIMAT 93 STIVARGA 24 STRATTERA 45 STRENSIQ 71 streptomycin sulfate 17 STRIANT 71 STRIBILD 13 STRIVERDI RESPIMAT 93 STROMECTOL 17 SUBOXONE 39 SUBSYS 37 SUCRAID 74 sucralfate 76 SULAR 51 sulfacetamide sodium 58,89 sulfacetamide-prednisolone 89 sulfadiazine 19 sulfamethoxazoletrimethoprim 19 SULFAMYLON 58 sulfasalazine 74 sulfasalazine dr 74 sulindac 39 sumatriptan 31 sumatriptan succinate 31 SUMAVEL DOSEPRO 31 SUPRAX 15 SUPREP 74

SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMBICORT SYMBYAX SYMLINPEN 120 SYMLINPEN 60 SYNAGIS SYNALGOS-DC SYNAREL SYNERCID SYNJARDY SYNRIBO SYNTHROID SYPRINE

45 13 24 78 24 93 45 69 69 13 37 71 17 69 25 71 63

TABLOID 25 TACLONEX 56 tacrolimus 25,56 TAFINLAR 25 TAGRISSO 25 TALTZ AUTOINJECTOR 56 TALTZ SYRINGE 56 TALWIN 39 TAMIFLU 13 tamoxifen citrate 25 tamsulosin hcl 94 TANZEUM 69 TAPAZOLE 65 TARCEVA 25 TARGADOX 20 TARGRETIN 25 TARINA FE 85 TARKA 51 TASIGNA 25 TASMAR 30 TAXOTERE 25 tazarotene 58

TAZICEF TAZORAC TAZTIA XT TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEGRETOL TEGRETOL XR TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartanhydrochlorothiazid temazepam TENCON TENIVAC TENORETIC 100 TENORETIC 50 TENORMIN TERAZOL 7 terazosin hcl terbinafine hcl terbutaline sulfate terconazole TESTIM testosterone testosterone cypionate testosterone enanthate tetanus diphtheria toxoids tetrabenazine tetracycline hcl THALOMID THEO-24 theophylline theophylline anhydrous THIOLA thioridazine hcl thiotepa thiothixene

116

15 58 51 25 32 13 15 28 28 51 51 51 51 51 45 37 79 51 51 51 83 51 10 93 83 71 71 71 71 79 32 20 25 93 93 93 63 45 25 45

THYMOGLOBULIN 79 THYROLAR-1 71 THYROLAR-1/2 71 THYROLAR-1/4 71 THYROLAR-2 71 THYROLAR-3 71 tiagabine hcl 28 TIAZAC 51 tigecycline 17 TIKOSYN 47 timolol maleate 51,87 TIMOPTIC OCUDOSE 87 TIMOPTIC-XE 87 TINDAMAX 17 tinidazole 17 TIROSINT 71 TIVICAY 13 TIVORBEX 39 tizanidine hcl 33 TOBI 17 TOBI PODHALER 17 TOBRADEX 88 TOBRADEX ST 88 tobramycin 17,86 tobramycin sulfate 17 tobramycin-dexamethasone 88 TOBREX 86 TOFRANIL 45 TOLAK 56 tolazamide 69 tolbutamide 69 tolcapone 30 tolmetin sodium 39 tolterodine tartrate 93 tolterodine tartrate er 93 TOPAMAX 28 TOPICORT 61 topiramate 28 topiramate er 28 TOPOSAR 25 topotecan hcl 25

TOPROL XL 51 TORISEL 25 torsemide 51 TOUJEO SOLOSTAR 69 TOVIAZ 93 TPN ELECTROLYTES 95 TRACLEER 93 TRADJENTA 69 tramadol hcl 39 tramadol hcl er 39 tramadol hcl-acetaminophen 40 trandolapril 51 trandolapril-verapamil er 51 tranexamic acid 53,83 TRANSDERM-SCOP 74 TRANXENE T-TAB 45 tranylcypromine sulfate 45 TRAVASOL 96 TRAVATAN Z 88 trazodone hcl 45 TREANDA 25 TRECATOR 17 TRELSTAR 25 TRESIBA FLEXTOUCH U100 69 TRESIBA FLEXTOUCH U200 69 tretinoin 25,58 tretinoin microsphere 58 TREXALL 25 TREXIMET 31 TREZIX 37 TRI-LEGEST FE 85 TRI-LO-ESTARYLLA 86 TRI-LO-SPRINTEC 86 TRI-NORINYL 86 TRI-PREVIFEM 86 TRI-SPRINTEC 86 triamcinolone acetonide 61,64,93

triamterenehydrochlorothiazid TRIANEX triazolam TRIBENZOR TRICOR TRIDERM TRIDESILON trifluoperazine hcl trifluridine TRIGLIDE trihexyphenidyl hcl TRILEPTAL TRILIPIX TRILYTE WITH FLAVOR PACKETS trimethoprim trimipramine maleate TRINESSA TRINTELLIX TRIOSTAT TRISENOX TRIUMEQ TRIVORA-28 TRIZIVIR TROKENDI XR TROPHAMINE trospium chloride trospium chloride er TRULICITY TRUMENBA TRUSOPT TRUVADA TUDORZA PRESSAIR TWINRIX TWYNSTA TYBOST TYGACIL TYKERB TYLENOL-CODEINE NO.3 TYLENOL-CODEINE NO.4

117

TYMLOS 51 TYPHIM VI 61 TYSABRI 45 51 55 UCERIS 61 ULORIC 61 ULTRACET 45 ULTRAM 87 ULTRAVATE 55 UNASYN 30 UNITHROID 28 UPTRAVI 55 URECHOLINE UROCIT-K 75 UROXATRAL 20 URSO 45 URSO FORTE 86 ursodiol 45 71 25 VAGIFEM 13 valacyclovir 86 VALCHLOR 13 VALCYTE 29 valganciclovir hcl 96 VALIUM 93 valproate sodium 93 valproic acid 69 valsartan 79 valsartan88 hydrochlorothiazide 13 VALTREX 93 VANATOL LQ 79 VANCOCIN HCL 51 vancomycin hcl 13 VANDAZOLE 17 VANOS 25 VAQTA 37 VARIVAX VACCINE 37 VARIZIG

81 79 32

75 80 40 40 61 18 71 52 94 94 94 75 75 75

83 13 56 13 13 45 29 29 52 52 13 37 20 20 83 61 79 79 79

VARUBI VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX VECTICAL VELCADE VELIVET VELPHORO VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl venlafaxine hcl er VENTAVIS VENTOLIN HFA verapamil er verapamil er pm verapamil hcl VEREGEN VERELAN VERELAN PM VERIPRED 20 VERSACLOZ VESICARE VESTURA VFEND VFEND IV VIBERZI VIBRAMYCIN VICODIN VICODIN ES VICODIN HP VICTOZA 3-PAK VIDAZA VIDEX VIDEX EC VIEKIRA PAK

75 55 52 52 55 25 56 25 86 63 63 13 25 25 45 45 93 93 52 52 52 56 52 52 65 45 93 86 10 10 75 20 37 37 37 69 25 13 13 13

VIEKIRA XR VIENVA VIGAMOX VIIBRYD VIMOVO VIMPAT vinblastine sulfate VINCASAR PFS vincristine sulfate vinorelbine tartrate VIOKACE VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VIROPTIC VISTARIL VIVELLE-DOT VIVITROL VIVLODEX VOGELXO VOLTAREN voriconazole VOTRIENT VPRIV VRAYLAR VYFEMLA VYTORIN VYVANSE

warfarin sodium water WELCHOL WELLBUTRIN SR WELLBUTRIN XL WYMZYA FE

13 86 86 45 40 29 25 25 25 25 75 13 13 13 13 87 90 83 40 40 71 40 10 25 71 45,46 86 55 46

53 63 55 46 46 86

XANAX 46 XANAX XR 46 XARELTO 53 XELJANZ 81 XELJANZ XR 81 XENAZINE 32 XEOMIN 80 XERESE 59 XERMELO 25 XGEVA 20 XIFAXAN 17,18 XIGDUO XR 69 XIIDRA 87 XODOL 10-300 37 XODOL 5-300 37 XODOL 7.5-300 37 XOLAIR 93 XOPENEX 93 XOPENEX CONCENTRATE 93 XOPENEX HFA 93 XTAMPZA ER 37 XTANDI 25 XULANE 83 XYLOCAINE 58 XYREM 46 XYZAL 90

YASMIN 28 YAZ YERVOY YF-VAX YONDELIS YOSPRALA YUVAFEM

zafirlukast zaleplon 88 ZALTRAP 25 ZAMICET

XALATAN XALKORI

118

86 86 25 80 25 53 83

93 46 25 37

ZANAFLEX ZANOSAR ZANTAC ZARAH ZARONTIN ZARXIO ZAVESCA zazole ZEBUTAL ZEGERID ZEJULA ZELAPAR ZELBORAF ZEMAIRA ZEMBRACE SYMTOUCH ZEMPLAR ZENATANE ZENCHENT ZENCHENT FE ZENPEP ZENZEDI ZEPATIER ZERBAXA ZERIT ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN ZIANA zidovudine zileuton er ZINACEF ZINBRYTA ZINECARD ZINPLAVA ZIOPTAN ziprasidone hcl ZIPSOR ZIRGAN

33 25 76 86 29 78 71 83 37 76 25 30 25 63 31 71 58 86 86 75 46 13 15 14 52 52 55 93 52 14 58 14 93 15 32 20 80 88 46 40 87

ZITHROMAX ZITHROMAX TRI-PAK ZMAX ZOCOR ZOFRAN ZOFRAN ODT ZOHYDRO ER zoledronic acid ZOLINZA zolmitriptan zolmitriptan odt ZOLOFT zolpidem tartrate zolpidem tartrate er ZOMACTON ZOMETA ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOSTAVAX ZOSYN ZOVIA 1-35E ZOVIA 1-50E ZOVIRAX ZUBSOLV ZUPLENZ ZURAMPIC ZYBAN ZYCLARA ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET ZYLOPRIM

119

15 15 15 55 75 75 38 63,71 25 31 31 46 46 46 78 71 31 31 56 29 29 53 78 25 40 80 18 86 86 14,59 40 75 80 63 56 25 93 93 25 89 80

ZYMAXID ZYPREXA ZYPREXA RELPREVV ZYPREXA ZYDIS ZYTIGA ZYVOX

87 46 46 46 25 18

2018 Part D Formulary (Abridged)

Network Health Medicare Advantage plans are PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. The benefit information is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year. The formulary and pharmacy network may change at any time. You will receive notice when necessary. As an enrollee of our plan, you can get a long-term supply (up to 90 days) of drugs shipped to your home using our planâ&#x20AC;&#x2122;s network mail order delivery program. Usually you will receive your mail order prescriptions within 14 calendar days. If your order does not arrive within the estimated timeframe, call Express Scripts Customer Service at 800-316-3107 (TTY 800-899-2114), 24 hours a day/7 days a week. This abridged formulary was updated on 09/08/2017. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Network Health Medicare Advantage plans customer service at 800-316-3107 or, for TTY users, 800-899-2114, 24 hours a day/seven days a week, or visit NetworkHealthMedicare.com.

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Nondiscrimination Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Network Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Network Health: 



Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact Network Health’s discrimination complaints coordinator at 800-378-5234 (TTY 800-947-3529). If you believe that Network Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Network Health’s discrimination complaints coordinator, 1570 Midway Place, Menasha, WI 54952, phone number 800-378-5234, TTY 800-947-3529, Fax 920-720-1907, compliance@networkhealth.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Network Health’s discrimination complaints coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Multi-language Interpreter Services If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234 (TTY 800-947-3529).

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Albanian: Nëse ju, ose dikush që po ndihmoni, ka pyetje për Network Health, keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 800-378-5234 (TTY 800-947-3529). Arabic: ‫ لديك الحق في الحصول على المساعدة‬،Health Network ‫ أسئلة حول‬،‫إذا كان لديك أو لدى شخص كنت مساعدة‬ ‫ قم باستدعاء‬،‫ للتحدث مع مترجم فوري‬.‫والمعلومات باللغة الخاصة بك دون أي تكلفة‬ .(3529-947-800 TTY) 5234-378-800 Chinese: 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Network Health 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字800-378-5234 (TTY 800-947-3529). French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Network Health, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 800-378-5234 (TTY 800-9473529). German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Network Health haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 800-378-5234 (TTY 800-947-3529) an. Hindi: यिद आप, या िकसी को आप की मदद कर रहे ह, के बारे म सवाल है Network Health, आप कोई भी कीमत पर अपनी भाषा म मदद और जानकारी प्रा त करने का अिधकार है । एक दभ ु ािषया के िलए बात करने के िलए, 800-378-5234 (TTY 800-947-3529) कहते ह।. Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-3785234 (TTY 800-947-3529). Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Network Health 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는800-378-5234 (TTY 800-947-3529).로 전화하십시오. Laotian: ຖ ຼ ຄ ້ າທ ່ ານ, ືຫ ່ ທ ່ ານກ ໍ າລັງຊ ່ ວຍເຫ ໍ າຖາມກ ່ ຽວກັບ Network Health, ທ ່ ານມ ື ຼ ອ, ມຄ ົ ນທ ່ໍ ມ ຄ ູ ນຂ ັ ນພາສາຂອງທ ່ ຈະໄດ ້ ຮັບການຊ ່ ວຍເຫ ໍ້ ມ ່ າວສານທ ່ ເປ ່ ານບ ່ າໃຊ ້ ຈ ່ າຍ. ິສດທ ື ຼ ອແລະຂ ການໂອ ້ ລ ້ ໂທຫາ 800-378-5234 (TTY 800-947-3529). ົ ມກັບນາຍພາສາ, ໃຫ Pennsylvania Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Network Health, hoscht du es Recht fer Hilf un Information in deinre eegne

Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 800-378-5234 (TTY 800-947-3529) uffrufe. Polish: Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Network Health, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 800-378-5234 (TTY 800-947-3529). Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Network Health, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 800-378-5234 (TTY 800-947-3529). Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-378-5234 (TTY 800-947-3529). Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Network Health, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 800-3785234 (TTY 800-947-3529). Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Network Health, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 800-378-5234 (TTY 800-9473529).

ENROLL NOW In This Section THREE WAYS YOU CAN ENROLL WHAT HAPPENS AFTER YOU ENROLL COMMON ENROLLMENT QUESTIONS NOTICE OF PRIVACY PRACTICES GRIEVANCE AND APPEALS PROCESS FOR MEDICARE PART C

Ron and Janet V., Kaukauna • Community advocates • Grandparents • Network Health Medicare members

COVERAGE DETERMINATIONS, EXCEPTIONS, GRIEVANCE AND APPEAL PROCEDURES FOR MEDICARE PART D SUMMARY INFORMATION

ENROLL NOW

Enroll Now THREE WAYS YOU CAN ENROLL 1. SET UP AN APPOINTMENT w Call 800-983-7587 or 920-720-1280 to set up a time to meet with a knowledgeable and helpful agent. All of our agents go through extensive training to ensure the best service to you. If you’d like, our agents will even come to your home. w You can also visit our main office in Menasha for one-on-one help. Walk-ins are welcome. If you prefer to make an appointment, call 800-983-7587 or 920-720-1280.

Network Health 1570 Midway Pl. Menasha, WI 54952 Normal business hours are Monday–Friday, 8 a.m. to 5 p.m.

2. SIGN UP ONLINE w Visit NetworkHealthMedicare.com, and click Enroll Now. Simple instructions will appear and guide you through the enrollment process.

3. SIGN UP BY MAIL w Fill out the enrollment form in the back pocket of this book and mail it to us in the envelope provided.

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Tom and Beverly R., Greenville •Outdoor enthusiast •Flower gardener •Network Health Medicare members

Enroll Now WHAT HAPPENS AFTER YOU ENROLL •We’ll confirm the date your coverage will start. If you sign up during the Annual Enrollment Period, your coverage will probably start January 1. •Your member ID card will be mailed to your home. Your ID card will come separately from the rest of your member materials. •You’ll get your member welcome kit which includes details about your benefits. This includes a magnet for your fridge with our health care concierge team picture and contact information and a guide called “How to Use Your Health Plan.” In it, you’ll find tips on how to make sure you’re getting the most out of your coverage.

COMMON ENROLLMENT QUESTIONS WHEN CAN I ENROLL? You can enroll or switch plans between October 15 and December 7 every year. And, you can enroll three months before, during the month of, and three months after you turn 65. For more information on special circumstances, see page 10.

HOW CAN I PAY MY MONTHLY PREMIUM? Once you’re a member, you can choose to pay your monthly premium by using an automatic bank withdrawal, sending a check or by withholding your premiums from your Social Security or U.S. Railroad Retirement Board checks. If you have questions about your monthly premium, please call us at 800-983-7587.

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Notice of Privacy Practices YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES. Network Health Insurance Corporation (NHIC) is committed to protecting the privacy of your confidential health information. This includes all oral, written and electronic protected health information across our organization. This Notice of Privacy Practices will be followed by all associates of our workforce, regardless of geographical location. It describes how medical and financial information about you may be used and disclosed and how you can get access to or limit sharing of this information. Please review it carefully.

OUR RESPONSIBILITIES • We are required by law to maintain the privacy and security of your protected health and non-public personal information. • We must follow either Federal or State law, whichever is more protective of your privacy rights. • We will let you know promptly if a breach occurs which may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here, unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html and https://www.ftc.gov/tips-advice/business-center/privacy-and-security/gramm-leach-bliley-act.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide you with a copy or summary of your health and claims records within 30 days of your request. We may charge a reasonable, cost-based fee. • If we need an extension, we will let you know in writing the reason and a date when we will provide the records. • We may say “no” to your request, but we’ll tell you why in writing within 30 days with additional information on how you can have the decision reviewed. Ask us to correct health and claims records • You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days and include information on how you can appeal this decision. 31

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Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what health information we use or share • You can ask us not to use or share certain health information. Your request must be made in writing. • We are not required to agree to your request, and we may say “no” if it would affect your care. Get a list of those with whom we’ve shared health information • You can ask for a list showing the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why. • We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one list per year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. You may also print a copy at any time from our website, NetworkHealthMedicare.com. Choose someone to act for you • If you have given someone durable power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the Privacy Manager, at 800-378-5234 (TTY 800-947-3529). Complaints may also be made in writing to: Network Health Insurance Corporation Attn: Compliance 1570 Midway Pl. Menasha, WI 54952 • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 877-696-6775 or visiting https://www.hhs.gov/ocr/privacy/hipaa/complaints/ • We will not retaliate against you for filing a complaint. YOUR CHOICES For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do and we will follow your instructions.

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends or others involved in payment for your care • Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Use or share information related to psychotherapy notes, substance abuse, developmental disability, alcohol and other drug abuse (AODA) and HIV testing • Marketing purposes, except for health-related benefits and services (see Health-Related Benefits and Services below) • Sale of your information • Research • Fundraising purposes and any other uses and disclosures not described in this notice OUR USES AND DISCLOSURES How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. For example – A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization We can use and disclose your information to run our organization and contact you when necessary. For example – We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. For example – We may need to disclose your health information with our contracted pharmacy benefit manager to coordinate payment for any prescriptions you may need. Administer your plan We can disclose your health information to a third party claims payor for enrollment and claims processing. For example – We contract with a third party vendor to conduct enrollment and claims processing functions. Therefore, we may disclose your health information to conduct necessary functions to process your enrollment and health care claims. Business Associates We may disclose your health information to persons or organizations which perform a service for us that requires the use or sharing of health information. Such persons or organizations are our contracted business associates, and they are held to the same privacy standards as our organization. 33

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

For example – We may need to disclose your health information to a mailing and fulfillment vendor for them to print and mail a letter to you about our diabetes program. Health-Related Products, Benefits and Services We may contact you to give you information about certain health-related benefits and services which may be of interest to you. We may also contact you to recommend alternative treatments, health care providers or care settings. For example – If we think you could benefit from an annual health assessment in your home, we may send you a letter with information about it. HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION? We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information about this visit https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing or controlling disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Notification and communication with family and friends We may share health information about you with family members, friends or others you identify as being involved in your health care or payment for your health care. We will disclose only the health information relevant to the person’s involvement. If you are unable or unavailable to agree or object to a disclosure to such a person, we will use our best professional judgment in communicating with your family or friends. Compliance with the law We will share information about you if State or Federal laws require it, including with the Department of Health and Human Services if they want to see that we’re complying with federal privacy law. Respond to organ, eye and tissue donation and transplantation requests and work with a medical examiner or funeral director • We can share health information about you with organ, eye and tissue procurement and transplantation organizations. • We can share health information with a coroner, medical examiner or funeral director when an individual dies. Address workers’ compensation, law enforcement and other government requests We can use or share health information about you for the following. • Workers’ compensation claims • Law enforcement purposes or with a law enforcement official • Health oversight agencies for activities authorized by law, such as audits and investigations related to the oversight of government benefit programs (like Medicare) • Special government functions such as military, national security and presidential protective services 34

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Disaster relief We may use or disclose your name and location to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. CHANGES TO THE TERMS OF THIS NOTICE This notice takes effect July 1, 2017, and it will remain in effect until we replace it. We can change the terms of this notice, and the changes will apply to all information we have about you. Any changes to the notice will be effective for all of your records created or maintained in the past, as well as any records we create or maintain in the future. The new notice will be available upon request, on our website, and we will mail a copy to you. If there are no changes to the notice, you will be notified at least every three years that this notice is available to you. FINANCIAL INFORMATION PRIVACY Network Health Insurance Corporation is committed to maintaining the confidentiality of your personal financial information. We collect personal and financial information about you to perform functions such as premium payment transactions and establishing bank accounts for members who elect the Medicare Medical Savings Account (MSA) plan. We do not disclose personal financial information about past, present or future members to any third party, except as required or permitted by law. Access to your personal financial information is restricted only to employees, affiliates and service providers who are involved in administering your health care coverage or providing services to you. We maintain physical, electronic and procedural safeguards that comply with Federal standards to guard your personal financial information. We may disclose personal financial information to financial institutions which perform services for us, such as electronic fund transfer for payment of premiums and establishment of MSAs. We may begin disclosing this information as soon as you submit an application to become a member of Network Health. Once you’re no longer a member, we may continue to share this information as described in this notice. In limited circumstances, you can ask us to limit sharing of this information by calling customer service at 800-378-5234 (TTY 800-947-3529), or submitting a written request to: Network Health Insurance Corporation Attn: Compliance 1570 Midway Pl. Menasha, WI 54952 OTHER INSTRUCTIONS FOR NOTICE If you have questions about any part of this notice or would like to request a copy, you may call the Medicare customer service department at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re here every day, 8 a.m. to 8 p.m.

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

Grievance and Appeals Process for Medicare Part C Summary Information MEDICAL SERVICES AND BENEFITS YOUR RIGHT TO APPEAL

You can appeal if you do not agree with Network Health Insurance Corporation’s decisions about your health care. You must file your appeal in writing within 60 calendar days after the date of the denial. We can give you more time if you have a good reason for missing the deadline. You have the right to appeal if you believe the following. •Network Health Insurance Corporation will not approve or give you care it should cover. •Network Health Insurance Corporation is stopping care you still need. •Network Health Insurance Corporation has denied payment for services or items you have received that are not covered and you think they should be covered.

WHO MAY FILE AN APPEAL?

You or someone you name to act for you (called your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. Also, others may be authorized under State law to act for you. To learn how to name your authorized representative, you can call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re here every day, 8 a.m. to 8 p.m. If you want someone to act for you, you and the person you choose must sign, date and send us a statement naming that person to act for you.

HOW DO I FILE AN APPEAL?

To file a grievance or appeal, you can call us at 800-378-5234 (TTY 800 947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–February 14, we’re here every day, 8 a.m. to 8 p.m. Or, you can send it to us in writing by faxing to 920-720-1832 or mailing to: Network Health Insurance Corporation P. O. Box 120 Menasha, WI 54952

800-983- 7587 | Mo n day–Friday, 8 a .m . t o 8 p.m . | N e t wo r k H ea l t h Medi ca r e.co m

THERE ARE THREE KINDS OF APPEALS 1. A Standard Appeal (30 days) If your request is for medical coverage or services that you haven’t received yet, you can ask for a standard appeal. We must give you a decision no later than 30 days after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.) 2. A Fast Appeal (72 hour review) You can ask for a fast appeal on services that you haven’t received yet if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.) • If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically give you a fast appeal. • If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within 30 day. • We will make a decision on your appeal and notify you within the above timelines. However, if our decision is not fully in your favor, we will automatically forward your appeal request to the CMS contractor (MAXIMUS Federal Services) for an independent review. MAXIMUS will send you a letter with their decision within three working days of receipt of your case from Network Health Insurance Corporation. 3. A Standard Appeal (60 days) If your request is for payment of services you already received, you can ask for a standard appeal. We must give you a decision no later than 60 days after we get your appeal.

INFORMATION TO SUBMIT TO SUPPORT YOUR APPEAL

You are not required to submit additional information to support your request for services or payment for services already received. Network Health Insurance Corporation is responsible for gathering all necessary medical information, however, it may be helpful to you to include additional information to clarify or support your position. For example, you may want to include in your appeal request information such as medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your Primary Care Physician. If your medical records from specialist physicians are not included in your medical record from your Primary Care Physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you.

WHAT HAPPENS NEXT?

If you submit an appeal to Network Health, we will complete a full and fair review to determine if our original denial of the requested services or payment for services can be changed. After we complete our review, we will notify you of our decision. If our decision is not in your favor, we will automatically forward your appeal request to the CMS Contractor (MAXIMUS Federal Services) for an independent review. This is provided by Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. 37

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Coverage Determinations, Exceptions, Grievance and Appeal Procedures for Medicare Part D Summary Information PRESCRIPTION DRUG BENEFITS COVERAGE DETERMINATION

Whenever you ask for a Part D prescription drug benefit coverage determination, the first step is called “requesting a coverage determination.” When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. You must contact us if you would like to request a coverage determination. You cannot request an appeal if we have not issued a coverage determination. There are two types of coverage determinations; standard or fast. A decision about whether we will cover a Part D prescription drug can be a standard coverage determination. This is made within the standard time frame of 72 hours. You can only request a fast decision if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Part D drugs that you have not received yet. For a fast decision, we will give you our decision within 24 hours or sooner if your health requires.

EXCEPTIONS

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make, such as: • Asking us to cover your drug even if it is not on our formulary • Asking us to waive coverage restrictions or limits on your drug • Asking us to provide a higher level of coverage for your drug If you request an exception, your physician must provide a statement to support your request. Generally, we will only approve your request for an exception if the alternative drugs included in the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects. If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition, and you are still enrolled in Network Health’s Medicare Advantage plan. If we deny your exception request you can appeal our decision. 38

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WHAT IS A GRIEVANCE?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have a problem with Network Health Insurance Corporation’s Medicare Advantage pharmacy plans or one of our network pharmacies that relates to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as: •Waiting times when you fill a prescription •The way your network pharmacist or others behave •Not being able to reach someone by phone or get the information you need •The cleanliness or condition of a network pharmacy If you have a grievance, we encourage you to first call customer service at the number listed in your Evidence of Coverage. We will try and resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you.

APPEAL (ALSO CALLED A REDETERMINATION):

If you are unhappy with the coverage determination, you can ask for an appeal. You may also appeal our decision: • Not to cover a drug, vaccine or other Part D benefit • Not to reimburse you for a Part D drug that you paid for • If you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay • If we deny your exception request You must send your appeal to Network Health in writing within 60 calendar days after the date of the denial. We can give you more time if you have a good reason for missing the deadline, such as being in the hospital.

THERE ARE TWO KINDS OF APPEALS Standard Appeal If your request is about reimbursement for a Part D drug you already paid for and received, or about a part D drug that has been denied, you can ask for a standard appeal. We must give you a decision no later than seven (7) calendar days from the date we receive your appeal, but will make it sooner if your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to the second level of appeal where an independent organization will review your case.

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Fast Appeal You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case. If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for seven calendar days could seriously harm your health, we will automatically give you a fast appeal. If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within seven calendar days. If we deny any part of your appeal, you or your appointed representative have the right to ask for an independent review organization to review your case. This independent review organization contracts with the federal government and is not part of Network Health Insurance Corporation Medicare Advantage pharmacy plans. You must make your request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal. You must send your written request to the independent review organization whose name and address is included in the level 1 redetermination.

HOW TO FILE A GRIEVANCE OR APPEAL (PART C OR D):

This document provides summary details about your grievance and appeal rights. You will obtain the full procedures when you enroll in Network Health’s Medicare Advantage plan. If you have questions about the grievance or appeal process, you can call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m.; although from October 1–February 14, we’re available Monday–Sunday, 8 a.m. to 8 p.m. To submit a grievance or appeal, you can send it to: Network Health Insurance Corporation Attn: Grievance and Appeals Department P. O. Box 120 Menasha, WI 54952 You can also fax a grievance or appeal to Network Health at 920-720-1832.

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Scope Scope of of Sales Sales Appointment Appointment Confirmation Confirmation Form Form The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales The Centers for Medicare and Medicaid Services requires agents 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 agent and the Medicare beneficiary (or their authorized representative). All meeting to ensure understanding of what will be discussed between the agent 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. 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 agent to discuss. Please initial below beside the type of product(s) you want the agent to discuss.

Stand-alone Stand-alone Medicare Medicare Prescription Prescription Drug Drug Plans Plans (Part (Part D) D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some 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 Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Dental Dental Medicare Medicare Advantage Advantage Plans Plans (Part (Part C) C) and and Cost Cost Plans Plans

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that provides all Original Medicare Part A and Part 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 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). hospitals in the plan’s network (except in emergencies). Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and 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 and hospitals but you can also Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost. 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, 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 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 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-of- network providers. pay more to see out-of- network providers. Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health 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 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. 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 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. 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 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 network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles. deductibles. By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who By signing this form, you agree to a meeting with a sales agent 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 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

Signature Date

If you are the authorized representative, please sign above and print below: Representativeâ&#x20AC;&#x2122;s Name:

Your Relationship to the Beneficiary:

To be completed by Agent: Date Appointment Completed:

Agent Name:

Beneficiary Name(s):

Beneficiary Phone (Optional):

Agent Phone:

Beneficiary Address (Optional): Initial Method of Contact:

(Indicate here if beneficiary was a walk-in.)

Agentâ&#x20AC;&#x2122;s Signature: Plan(s) the agent represented during this meeting: [Plan Use Only:] *Scope of Appointment documentation is subject to CMS record retention requirements * Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. NetworkCares is a PPO SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage plans depends on contract renewal. Y0108_1136_071317

Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. As an enrollee of our plan, you can get a long-term supply (up to 90 days) of drugs shipped to your home using our planâ&#x20AC;&#x2122;s network mail order delivery program. Usually you will receive your mail order prescriptions within 14 calendar days. If your order does not arrive within the estimated timeframe, call Express Scripts Customer Service at 800-316-3107 (TTY 800-899-2114), 24 hours a day, seven days a week. Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. m-sls-nekit-0717 H5215_1138r2_071717 Approved 08182017

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