Enrollment Guide 2021

Take advantage of all your Medicare Advantage plan has to offer.

UnitedHealthcare Dual Complete® ONE (HMO D-SNP) H3113-005-000

Service area: New Jersey - Atlantic, Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union, Warren counties

Plan Year: January 1, 2021 through December 31, 2021 Get more for your Medicare dollar.

More choice and more guidance. Renew, our When it comes to Medicare, one size does not fit all. That’s why UnitedHealthcare® offers a broad range health and of Medicare products, so you have options to fit your wellness program. health care needs. UnitedHealthcare’s experienced advisors and licensed sales agents will guide you Renew can help by through choosing the plan that’s right for you. inspiring you to take charge of your health and wellness every day. Get the care you need when — It provides a wide variety and where — you need it. of useful resources and activities — including Whether it’s an appointment with your doctor brain games, healthy online, a call with a nurse at 3 a.m. or taking care recipes, learning of a wellness visit from the comfort of your home, courses, fitness activities, UnitedHealthcare makes it easier to connect you and more. All at no cost.1 with care so you can stay on top of your health — when, where, and how you need it.

One-on-one help using your Medicare plan. At UnitedHealthcare®, it’s not just customer service. It’s 1-on-1 support to help answer your questions and take the extra steps to understand your needs. It’s helping navigate your care during a health event. And it’s helping you get the most out of your plan, so you can be at your best health.

1Renew by UnitedHealthcare is not available in all plans. Resources may vary. Y0066_INTRO_2021_C CSEX21DU4776506_000 Table of Contents

Start with Medicare Basics...... 4 Eligibility and Helpful Resources

Plan Information Benefit Highlights...... 8 Explore Your Additional Services...... 11 My Additional Benefits...... 12 Over-the-Counter (OTC) Benefit Renew Active™ Summary of Benefits...... 17 Plan Ratings...... 44

Drug List Drug List...... 48 Alternative Covered Drugs...... 117

Ready to Enroll Plan Recap...... 120 How to Enroll...... 122 Scope of Appointment Confirmation Form...... 123 Enrollment Request Form...... 125 Enrollment Receipt...... 143 Take Advantage of What’s Next...... 144 Vendor Information...... 147

Questions? We're here to help.

Call toll-free 1-844-560-4944, TTY 711 www.UHCCommunityPlan.com 8 a.m. - 8 p.m. local time, 7 days a week

Y0066_EGTOC_2021_C UHEX21MP4713483_000 Start With Medicare Basics

Review the basics to make sure this plan is a good fit Original Medicare is provided by the federal government and covers some of the costs of hospital stays (Part A) and doctor visits (Part B), but doesn’t cover everything. It does not include prescription drug coverage (Part D). Depending on your needs, you may want to add on more coverage.

Original Medicare – Provided by the federal government

Part A Part B Helps pay for hospital stays Helps pay for doctor visits and inpatient care and outpatient care

Your options for more coverage:

Option 1 OR Option 2 Add one or both of the following Choose a Medicare Advantage plan: to Original Medicare:

Medicare Supplement Insurance Plan Medicare Advantage Plan Offered by private companies Offered by private companies

Medicare Supplement Helps pay some of the out- Part C of-pocket costs that come Combines Part A (hospital with Original Medicare insurance) and Part B (medical insurance) in one plan

Part D Medicare Part D Plan Usually includes prescription Offered by private companies drug coverage

Part D May offer additional Helps pay for prescription benefits not provided by drugs Original Medicare

Medicare Made ClearTM brought to you by UnitedHealthcare®

4 This is a Medicare Advantage Part C Health Maintenance Organization (HMO) plan Your plan is a Health Maintenance Organization (HMO) plan. That means you need to get healthcare services through a network of local doctors and hospitals. Here’s how your HMO plan works You will need to select a primary care provider (PCP). This health plan requires you to select a PCP from the network. Your PCP can oversee and help manage your care. You have coverage for emergency care. Emergency Services and Urgently Needed Services are covered no matter where you go. A network of providers for coordinated care The chart below shows what happens when you use network versus out-of-network resources with this plan. In-Network Out-of-Network Will the doctor or hospital Yes No accept my plan? Does this plan require a referral to see a Specialist or No No other providers? What will I pay for covered There is no copay or In most cases, you will have to services? coinsurance. pay the full cost for services.

You can find a complete listing of network providers and facilities within your plan on our website.

5 Are you eligible for this plan? You are eligible for this plan if you’re enrolled in Medicare Parts A and B and receive full state Medicaid benefits (such as New Jersey Family Care A or Managed Long Term Services and Supports). Enrollment is available once per calendar quarter during the first three quarters of the year (January – September) based on your qualifying election type. What are the levels of eligibility in New Jersey? · Qualified Medicare Beneficiary Plus (QMB Plus) · Full Benefit Dual Eligible (FBDE)

What are the income requirements for each eligibility level?

Federal Poverty Income Social Security Income Level Level Resources not more than two QMB Plus At or lower than times Based on Medical Need status, institutionalized income levels, FBDE home/community based waivers Helpful Resources

You may qualify for Extra Help Extra Help is a program for people with limited incomes who need help paying Part D premiums, deductibles and copays. To see if you qualify for Extra Help, call: · The Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778 · Your state Medicaid office

This information is not a complete description of benefits. Call 1-844-560-4944, TTY 711 for more information. Y0066_SWMB_2021_M H3113005000 UHNJ21HM4769854_000

6 Plan Information

UHEX21MP4713485_000

7 Beneﬁt Highlights

UnitedHealthcare Dual Complete® ONE (HMO D-SNP) As a UnitedHealthcare Dual Complete® ONE (HMO D-SNP) member, you have no out-of-pocket expenses. You will not be responsible for any copayments or coinsurance for drugs or other covered services provided by plan providers. This is a short description of your 2021 plan benefits. For complete information, please refer to your Evidence of Coverage. Limitations, exclusions and restrictions may apply. Plan Costs

Monthly plan premium $0

Medical Benefits

Your Cost Doctor’s office visit Primary Care Provider: $0 copay Specialist: $0 copay (no referral needed) Virtual medical visits: $0 copay Preventive services $0 copay Inpatient hospital care $0 copay per stay (no limit on days) Skilled nursing facility (SNF) $0 copay per stay (no limit on days) Outpatient hospital, including surgery $0 copay Mental health (outpatient and virtual) Group therapy: $0 copay Individual therapy: $0 copay Virtual visits: $0 copay Diabetes monitoring supplies $0 copay for covered brands Diagnostic radiology services (such as $0 copay MRIs, CT scans) Diagnostic tests and procedures (non- $0 copay radiological) Lab services $0 copay Outpatient x-rays $0 copay Ambulance $0 copay for ground or air Emergency care $0 copay (worldwide) Urgently needed services $0 copay (worldwide)

8 Benefits and Services Beyond Original Medicare Your cost Acupuncture $0 copay Chiropractic Services $0 copay Information Plan Dental Services $0 copay Durable Medical Equipment (DME) $0 copay Family Planning Services and Supplies $0 copay Federally Qualified Health Centers $0 copay (FQHC) Fitness program through Renew Standard membership to participating fitness Active™ locations with access to group fitness classes – depending on availability. Programs such as, online brain exercises, activities and an in-person fitness orientation at no cost to you. For the complete details about the program, please visit www.UHCRenewActive.com, and click the link in the footer entitled Terms and Conditions. Hearing services — hearing exams and $0 copay hearing aids Healthy Foods Benefit $50 credit per month to spend on healthy food items Managed Long Term Services and $0 copay Supports (MLTSS) Meal Benefit $0 copay for up to 42 meals for 21 days, two times per year after an inpatient hospital stay. Provider order required. Medical Day Care $0 copay Nurse Midwife Services $0 copay Nursing Facility (long term/custodial $0 copay care) NurseLine Speak with a registered nurse (RN) 24 hours a day, 7 days a week Over-the-Counter Debit Card $450 credit per quarter for approved products from the catalog or at network retail locations Personal Care Assistant $0 copay Personal Emergency Response $0 copay for emergency response services through System (PERS) an in-home electronic monitoring system 24 hours a day, 7 days a week. You must have a working landline and/or cellular phone coverage to take part in this benefit. Podiatry — routine $0 copay Private Duty Nursing $0 copay Transportation — routine $0 copay Vision Care Services $0 copay

9 Prescription Drugs 30-day supply from retail network pharmacy Generic (including brand drugs $0 copay treated as generic) Some covered drugs limited to a 30-day supply All other drugs $0 copay Some covered drugs limited to a 30-day supply

UnitedHealthcare Dual Complete® ONE (HMO D-SNP) is a Dual Eligible Special Needs Plan (D-SNP) with a Medicare contract and a contract with the New Jersey Medicaid program. Enrollment in UnitedHealthcare Dual Complete® ONE depends on contract renewal. This plan is available to anyone who has both Medicare and full New Jersey Medicaid benefits. This information is not a complete description of benefits. Contact the plan for more information. Premiums are covered for enrollees of UnitedHealthcare Dual Complete ONE (HMO D-SNP). Members must use network plan providers, pharmacies, DME (Durable Medical Equipment) suppliers, and follow the rules on referrals. Members will be enrolled into Medicare Part D prescription drug coverage under the plan and will be automatically disenrolled from any other Medicare Advantage or Medicare Part D prescription drug coverage. Y0066_MABH_2021_M H3113005000 UHNJ21HM4757825_000

10 Explore Your Additional Services Plan Information Plan Get all the benefits of Original Medicare – and more. With the UnitedHealthcare Dual Complete® ONE (HMO D-SNP) Plan, you get additional services designed to help you live a healthier life. Limitations, exclusions and restrictions may apply. For more detailed information, please contact Customer Service. A health and wellness program that comes to you With the UnitedHealthcare® HouseCalls program, you get a yearly in-home preventive health care visit from one of our licensed healthcare practitioners for no cost. A HouseCalls visit is designed to support, but not take the place of your regular doctor’s care.

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11 Over-the-Counter (OTC) Benefit

It’s time to take advantage of over-the-counter products at no cost to you.

Use your prepaid debit card and get up to $450 per quarter of over-the-counter health products at participating retail locations or delivered to your home at no cost. Choose from many brand and generic products, including pain management, over-the-counter medications, vitamins, supplements, and more.

Hundreds of over-the-counter products to choose from, including items for pain management, stomach remedies, incontinence, bath safety, vitamins, supplements, ibuprofen, bandages, antacids, cough drops, allergy relief, toothpaste, and more.

Order your health and wellness products through FirstLine Select, website or mobile app and enjoy home delivery at no cost.

Take advantage by using your debit card at participating Walgreens and other retailers.

How it works:

1 You will receive a welcome mailing with information about the program and debit card.

2 FirstLine Benefits™ will add credits to your debit card every three months. Credits expire yearly.

3 Purchase products in four different ways — by catalog, website, mobile app or at participating Walgreens and other retailers. The catalog will be mailed to you each quarter.

4 Use the website or mobile app to locate participating retail locations and determine if store items are approved for purchase with the debit card.

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12 NOTES

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13 Renew ActiveTM

Stay fit. Stay focused. Stay you.

Renew Active is the gold standard in Medicare fitness programs for body and mind — available at no cost. Stay active with a free gym membership, a personalized fitness plan, group fitness classes, an online brain health program and more. If you don’t want to go to the gym, there are ways for you to stay active at home. Renew Active includes:

A free gym membership with access to our extensive, nationwide network. It’s one of the largest of all Medicare fitness programs and includes many premium gyms and fitness locations.1

A one-on-one session with a personal trainer to set fitness-related goals and create a personalized fitness plan.

The ability to bring your caregiver to the gym with you, at no cost.

Access to Fitbit® PremiumTM, which includes thousands of workout videos of all levels, guided programs, personalized insights, mindfulness and more all from the comfort of home — no Fitbit device is needed.

Social activities at local health and wellness classes and events and through the online Fitbit Community for Renew Active — no Fitbit device is needed.

An online brain health program from AARP® Staying Sharp, including a brain health assessment and exclusive content for Renew Active members.

14 Plan Information Plan

How it works:

1 To learn more about all Renew Active has to offer, visitUHCRenewActive.com or contact your sales representative.

2 Once you become a member, you can explore all Renew Active has to offer. Sign into your plan website, go to Health & Wellness and look for Renew Active. Or you can call the Customer Service number on the back of your member ID card.

1Based on gym and fitness location network size. Participation in the Renew Active™ program is voluntary. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership. Equipment, classes, personalized fitness plans, caregiver access and events may vary by location. Certain services, classes and events are provided by affiliates of UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in AARP® Staying Sharp and the Fitbit® Community for Renew Active is subject to your acceptance of their respective terms and policies. AARP® Staying Sharp is the registered trademark of AARP®. UnitedHealthcare is not responsible for the services or information provided by third parties. The information provided through these services is for informational purposes only and is not a substitute for the advice of a doctor. The Renew Active program varies by plan/area. Access to gym and fitness location network may vary by location and plan. Renew Active premium gym and fitness location network only available with certain plans. Y0066_RENEW_2021_M CSNJ21DU4791406_000

15 NOTES

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16 Summary of Benefits 2021 Information Plan

UnitedHealthcare Dual Complete® ONE (HMO D-SNP) H3113-005-000

Look inside to learn more about the plan and the medical services and prescription drugs it covers. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m. – 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

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17 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 2 Introduction This document is a brief summary of the benefits and services covered by UnitedHealthcare Dual Complete® ONE (HMO D-SNP). It includes answers to frequently asked questions, important contact information, an overview of benefits and services offered, and information about your rights as a member of UnitedHealthcare Dual Complete® ONE. Key terms and their definitions appear in alphabetical order in the last chapter of the Evidence of Coverage.

Table of Contents A. Disclaimers �� 3 B. Frequently asked questions (FAQ) �� 5 C. Overview of Services �� 9 D. Additional services UnitedHealthcare Dual Complete® ONE covers ��19 E. Benefits covered outside of UnitedHealthcare Dual Complete® ONE ��20 F. Services not covered by UnitedHealthcare Dual Complete® ONE (exclusions) ��21 G. Your rights and responsibilities as a member of the plan ��22 H. How to file a complaint or appeal a denied service ��25 I. What to do if you suspect fraud ��25

If you have questions, please call UnitedHealthcare Dual Complete® ONE Customer Service at 1-800-514-4911, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week Oct – Mar, M – F, Apr – Sept. The call is free. For more information, visit www.UHCCommunityPlan.com.

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A. Disclaimers Information Plan This is a summary of health services covered by UnitedHealthcare Dual Complete® ONE (HMO D-SNP) for January 1, 2021 – December 31, 2021. This is only a summary. Read the Evidence of Coverage online at www.UHCCommunityPlan.com for the full list of benefits. • UnitedHealthcare Dual Complete® ONE (HMO D-SNP) is a Dual Eligible Special Needs Plan (D-SNP) with a Medicare contract and a contract with the New Jersey Medicaid program. Enrollment in UnitedHealthcare Dual Complete® ONE depends on contract renewal. This plan is available to anyone who has both Medicare and full New Jersey Medicaid benefits. • This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan at 1-800-514-4911 (TTY 711) or read the Evidence of Coverage. You can read and download it online at www.UHCCommunityPlan.com, or you can call Customer Service toll-free at 1-800-514-4911 (TTY 711) to request a copy. • ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Dual Complete® ONE Customer Service at the number listed at the bottom of this page. The call is free. • ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Dual Complete® ONE al número que aparece al final de esta página. La llamada es gratuita. • You can get this document for free in other formats, such as large print, braille, or audio. Call 1-844-560-4944 (TTY 711), 8 a.m. – 8 p.m. local time 7 days a week if you are not a member or 1-800-514-4911 (TTY 711), 8 a.m. – 8 p.m. 7 days a week from October to March, Monday – Friday from April to September if you are a member. The call is free. • You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future. • This information is available for free in other languages. Please call our customer service number located on the first page of this book. • Esta información esta disponible sin costo en otros idiomas. Comuníquese con nuestro número de Servicio al Cliente situado en la cobertura de este libro. • Benefits may change on January 1 of each year.

19 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 4

• Premiums are covered for enrollees of UnitedHealthcare Dual Complete ONE (HMO D-SNP). • Every year, Medicare evaluates plans based on a 5-star rating system. • The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. • Members must use network plan providers, pharmacies, DME (Durable Medical Equipment) suppliers, and follow the rules on referrals. Members will be enrolled into Medicare Part D prescription drug coverage under the plan and will be automatically disenrolled from any other Medicare Advantage or Medicare Part D prescription drug coverage. • OptumRx is an affiliate of UnitedHealthcare Insurance Company. You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. Prescriptions from OptumRx should arrive within 5 business days after we receive the complete order. Contact OptumRx anytime at 1-877-266-4832, TTY 711. • Participation in the Renew ActiveTM by UnitedHealthcare program is voluntary. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership. Equipment, classes, personalized fitness plans, and events may vary by location. Certain services, classes and events are provided by affiliates of UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in AARP® Staying Sharp and the Fitbit® Community for Renew Active is subject to your acceptance of their respective terms and policies. UnitedHealthcare is not responsible for the services or information provided by third parties. The information provided through these services is for informational purposes only and is not a substitute for the advice of a doctor. The Renew Active program varies by plan/area. • The NurseLine service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor’s care. Your health information is kept confidential in accordance with the law. Access to this service is subject to terms of use. You can read the Medicare & You handbook. 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 access it online at the Medicare website (www.medicare.gov) or request a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

20 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 5

B. Frequently asked questions (FAQ) Information Plan The following chart lists frequently asked questions. Frequently asked questions

Answers

What is a Fully Integrated Dual A NJ Fully Integrated Dual Eligible Special Needs Plan Eligible Special Needs Plan (FIDE (FIDE SNP) is a managed health care option for NJ SNP)? FamilyCare members with Medicare. A NJ FIDE SNP covers all of your Medicare, NJ FamilyCare (Medicaid) and prescription drug benefits, including Medicare Part D, and extra benefits, in one health plan, with one Member Identification (ID) Card, and no copays for medical services or prescription drugs. A FIDE SNP coordinates all of your care. If you join a FIDE SNP, you do not lose any of your NJ FamilyCare, Managed Long Term Services and Supports (MLTSS), or Medicare benefits. Every service you have with NJ FamilyCare and Medicare is still available, along with access to some additional services. To be eligible to enroll in a FIDE SNP in New Jersey, you must be entitled to Medicare Parts A and B and eligible for full NJ FamilyCare benefits. You must also live in the plan’s “service area” (the counties where that plan is offered). The counties that make up UnitedHealthcare Dual Complete® ONE’s service area are listed on page 7 of this document.

Will I get the same Medicare If you are coming to UnitedHealthcare Dual Complete® and NJ FamilyCare benefits in ONE from Original Medicare or another Medicare UnitedHealthcare Dual Complete® plan, you may get benefits or services differently. You ONE that I get now? (continued on will get almost all of your covered Medicare and NJ the next page) FamilyCare benefits directly from UnitedHealthcare Dual Complete® ONE.

21 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 6

Frequently asked questions

Answers

Will I get the same Medicare When you enroll in UnitedHealthcare Dual Complete® and NJ FamilyCare benefits in ONE, you and your Care Team will work together to UnitedHealthcare Dual Complete® develop an individualized Plan of Care to address your ONE that I get now? (continued from health and support needs, reflecting your personal the previous page) preferences and goals. If you are taking any Medicare Part D prescription drugs that UnitedHealthcare Dual Complete® ONE does not normally cover, you can get a temporary supply, and we will help you to transition to another drug or get an exception for UnitedHealthcare Dual Complete® ONE to cover your drug if medically necessary.

Can I go to the same health care That is often the case. If your providers (including providers I see now? doctors, therapists, pharmacies, and other health care providers) work with UnitedHealthcare Dual Complete® ONE and have a contract with us, you can keep going to them. • Providers with an agreement with us are “in- network.” You must use the providers in UnitedHealthcare Dual Complete® ONE’s network. • If you need urgent or emergency care or out- of-area dialysis services, you can use providers outside of UnitedHealthcare Dual Complete® ONE’s network. To find out if your providers are in the plan’s network, call Customer Service at the number in the footer of this document or read UnitedHealthcare Dual Complete® ONE’s Provider and Pharmacy Directory. You can also visit our website at UHCCommunityPlan.com for the most current listing. If UnitedHealthcare Dual Complete® ONE is new for you, we will work with you to develop an individualized Plan of Care to address your needs. You can keep seeing the providers you go to now for 90 days or until your individualized Plan of Care is completed.

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Frequently asked questions Plan Information Plan Answers

What is a Care Manager? A Care Manager is your main contact person at our plan. This person helps to manage all of your providers and services and make sure you get what you need.

What are Managed Long Term Managed Long Term Services and Supports Services and Supports (MLTSS)? (MLTSS) are help for people who need assistance to do everyday tasks like taking a bath, getting dressed, making food, and taking medicine. Often these services are provided at your home or in your community, but they could also be provided in a nursing home or hospital when necessary. MLTSS is available to members who meet certain clinical and financial requirements.

What happens if I need a service Most services will be provided by our network but no one in UnitedHealthcare providers. If you need a service that cannot be Dual Complete® ONE’s network can provided within our network, UnitedHealthcare Dual provide it? Complete® ONE will cover services provided by an out- of-network provider.

Where is UnitedHealthcare Dual The service area for this plan includes: Atlantic, Complete® ONE available? Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union, Warren Counties, NJ. You must live in one of these areas to join the plan.

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Frequently asked questions

Answers

What is prior authorization? Prior authorization means that you must get approval from UnitedHealthcare Dual Complete® ONE before UnitedHealthcare Dual Complete® ONE will cover a specific service, item, or drug or out-of-network provider. UnitedHealthcare Dual Complete® ONE may not cover the service, item or drug if you don’t get prior approval. If you need urgent or emergency care or out-of-area dialysis services, you don’t need to get approval first. UnitedHealthcare Dual Complete® ONE can provide you with a list of services or procedures that require you to get prior authorization from UnitedHealthcare Dual Complete® ONE before the service is provided. See Chapter 3, of the Evidence of Coverage to learn more about prior authorization. See the Benefits Chart in Chapter 4 of the Evidence of Coverage to learn which services require a prior authorization.

Do I pay a monthly amount No. You will not pay any monthly premiums to (also called a premium) under UnitedHealthcare Dual Complete® ONE for your health UnitedHealthcare Dual Complete® coverage. ONE? Additionally, Medicaid will pay your Medicare Part B premium for you.

Do I pay a deductible as a member No. You do not pay deductibles in UnitedHealthcare of UnitedHealthcare Dual Complete® Dual Complete® ONE. ONE?

What is the maximum out-of- There is no cost sharing for medical services in pocket amount that I will pay for UnitedHealthcare Dual Complete® ONE, so your medical services as a member of annual out-of-pocket costs will be $0. UnitedHealthcare Dual Complete® ONE?

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C. Overview of services Information Plan The following chart is a quick overview of what services you may need and rules about the benefits. Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need hospital Inpatient hospital care $0 Except in an emergency, your care health care provider must tell the plan of your hospital admission. Outpatient hospital $0 Your provider may need to services (including obtain prior authorization for outpatient treatment by services. a doctor or a surgeon) Ambulatory surgical $0 Your provider may need to center (ASC) services obtain prior authorization for services. You want to see Doctor visits (including $0 Your provider may need to a health care visits to Primary obtain prior authorization for provider Care Providers and Specialist services. specialists) Visits to treat an injury or $0 Your provider may need to illness obtain prior authorization for services. Preventive care (care $0 to keep you from getting sick, such as flu shots and other immunizations) Wellness visits, such as $0 a physical “Welcome to Medicare” $0 preventive visit (one time only)

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Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need Emergency room $0 You may go to any emergency emergency care services room if you reasonably believe you need emergency care. You do not need prior authorization and you do not have to be in-network. Emergency room services are covered outside of the U.S. and its territories except under certain circumstances. Contact the plan for details. Urgently needed $0 Urgently needed services are services not emergency care. You do not need prior authorization and you do not have to be in-network. Urgently needed care services are covered outside the U.S. and its territories except under certain circumstances. Contact the plan for details. You need medical Lab tests, such as blood $0 Your provider may need to tests work obtain prior authorization for services. X-rays or other pictures, $0 Your provider may need to such as CAT scans obtain prior authorization for services. Screenings, such as $0 Your provider may need to tests to check for cancer obtain prior authorization for services.

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Health need or concern Plan Information Plan Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need hearing/ Hearing screenings $0 Your provider may need to auditory services (including routine obtain prior authorization for hearing exams) services. Hearing aids (as well as $0 Your provider may need to fittings and associated obtain prior authorization for accessories and services. supplies) You need dental Dental services $0 Your provider may need to care (including, but not obtain prior authorization for limited to, routine services. exams and cleanings, X-rays, fillings, crowns, extractions, dentures, and endodontic and periodontal care) You need eye care Vision services $0 Your provider may need to (including annual eye obtain prior authorization for exams) services. Glasses or contact $0 lenses Other vision care $0 Your provider may need to (including diagnosis and obtain prior authorization for treatment for diseases services. and conditions of the eye)

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Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You have a mental Inpatient mental $0 All members are covered by health condition health care (long-term the plan for acute inpatient mental health services, hospitalization in a general including inpatient hospital, regardless of the services in a psychiatric admitting diagnosis or hospital, general treatment. Your provider hospital, psychiatric may need to obtain prior unit of an acute care authorization for services. hospital, Short Term Care Facility (STCF), or critical access hospital) Outpatient mental health $0 Services may be provided by care (including, but not a state-licensed psychiatrist or limited to, adult mental doctor, clinical psychologist, health rehabilitation clinical social worker, clinical in supervised group nurse specialist, nurse homes and apartments, practitioner, physician assistant, clinic and hospital Independent Practitioner services, partial Network (IPN) Psychiatrist, care, and medication Psychologist or Advanced management) Practice Nurse (APN), or other (Note: This is not a qualified mental health care complete list of the professional as allowed under plan’s expanded applicable state laws. Your outpatient mental health provider may need to obtain services. Call Customer prior authorization for services. Service at the number in the footer of this document or read the Evidence of Coverage for more information.)

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Health need or concern Plan Information Plan Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You have a Inpatient and outpatient $0 Your provider may need to substance use substance use disorder obtain prior authorization for disorder treatment services services. (including, but not limited to, detoxification and withdrawal management, short-term residential services, residential treatment center services, and methadone Medication Assisted Treatment) (Note: This is not a complete list of the plan’s expanded substance use disorder services. Call Customer Service at the number in the footer of this document or read the Evidence of Coverage for more information.) You need a place Skilled nursing care $0 Your provider will need to to live with people obtain prior authorization for available to help services. you Nursing home care $0 Your provider will need to obtain prior authorization for services. Custodial care $0 Services are covered for those (long-term care in a who meet nursing facility level Nursing Facility) of care and whose rehabilitation goals have been met or discontinued with no plan to discharge to the community within 180 days of admission.

29 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 14

Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need therapy Occupational, physical, $0 Your provider may need to after a stroke or or speech therapy obtain prior authorization for accident services. You need help Ambulance services $0 Your provider may need to getting to health obtain prior authorization for services non-emergency transportation. Emergency $0 No prior authorization is transportation needed. You need drugs to Medicare Part B $0 Read the Evidence of treat your illness prescription drugs Coverage for more information or condition (including those given on these drugs. Your provider (This service is by your provider in his may need to obtain prior continued on the or her office, some authorization for certain drugs. next page) oral anti-cancer drugs, and some drugs used with certain medical equipment) Medicare Part D $0 There may be limitations on prescription drugs the types of drugs covered. Tier 1 Generic and See UnitedHealthcare brand name drugs (all Dual Complete® ONE’s covered drugs are in this List of Covered Drugs at tier) UHCCommunityPlan.com for more information. UnitedHealthcare Dual Complete® ONE may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits.

30 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 15

Health need or concern Plan Information Plan Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need drugs to Your provider must get treat your illness prior authorization from or condition UnitedHealthcare Dual (continued) Complete® ONE for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, List of Covered Drugs, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on www.medicare. gov. An extended day supply is only available at a subset of the retail pharmacy network. Contact the Plan for details. Over-the-counter (OTC) $0 There may be limitations on the drugs types of drugs covered. Diabetes medications $0 There may be limitations on the types of drugs covered. Your provider may need to obtain prior authorization for certain drugs.

31 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 16

Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) You need foot Podiatry services $0 Your provider may need to care (including routine obtain prior authorization for exams) services. Orthotic services $0 Your provider may need to obtain prior authorization for services. You need Wheelchairs, nebulizers, $0 Your provider may need to durable medical crutches, rollabout knee obtain prior authorization for equipment (DME) walkers, walkers, and services/certain equipment. or supplies oxygen equipment and supplies, for example (Note: This is not a complete list of covered DME or supplies. Call Customer Service at the number in the footer of this document or read the Evidence of Coverage for more information.) You need Spoken language $0 interpreter interpreter services Sign language $0 interpreter Other covered Acupuncture $0 services (This Care coordination $0 service is Chiropractic services $0 Your provider may need to continued on the obtain prior authorization for next page) services.

32 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 17

Health need or concern Plan Information Plan Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) Other covered Diabetic supplies $0 We only cover Accu-Chek® services and OneTouch® brands. (continued) Covered glucose monitors include: OneTouch Verio Flex®, OneTouch Verio Reflect®, Accu-Chek® Guide Me, and Accu-Chek® Guide. Test strips: OneTouch Verio®, OneTouch Ultra®, Accu-Chek® Guide, Accu-Chek® Aviva Plus, and Accu-Chek® SmartView. Other brands are not covered by the plan. Your provider may need to obtain prior authorization for some services. Early and Periodic $0 EPSDT is for members under Screening Diagnosis 21 years of age. and Treatment (EPSDT) (including preventive screenings, medical examinations, vision and hearing screenings and services, immunizations, lead screening, and private duty nursing services) Family planning $0 Family planning services furnished by out-of-network providers are covered directly by Medicaid fee-for-service. Hospice care $0 Mammograms $0 Your provider may need to obtain prior authorization for some services.

33 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 18

Health need or concern

Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) Other covered Managed Long Term $0 MLTSS provides services for services Services and Supports members that need the level (continued) (MLTSS) (including, but of care typically provided in not limited to, assisted a Nursing Facility, and allows living services; cognitive, them to get necessary care speech, occupational, in a residential or community and physical therapy; setting. chore services; home- MLTSS is available to members delivered meals; residential who meet certain clinical modifications (such as requirements. the installation of ramps or grab bars); vehicle modifications; social adult day care; and non- medical transportation) Medical day care $0 Medical day care is provided to (including preventive, meet the needs of individuals diagnostic, therapeutic, with physical and/or cognitive and rehabilitative services impairments in order to support under medical and their community living. nursing supervision in an ambulatory care setting) Personal Care Assistance $0 Your provider may need to (PCA) (including health- obtain prior authorization for related tasks performed some services. by a qualified individual in a member’s home, under the supervision of a registered professional nurse, as certified by a physician in accordance with a member’s written plan of care)

34 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 19

Health need or concern Plan Information Plan Your costs for Limitations, exceptions, & Services you may need in-network benefit information (rules providers about benefits) Other covered Prosthetic services $0 Your provider may need to services obtain prior authorization for (continued) services. Services to help manage $0 Your provider may need to your disease obtain prior authorization for services. Read the Evidence of Coverage for more information. The above summary of benefits is provided for informational purposes only. For more information about your benefits, you can read UnitedHealthcare Dual Complete® ONE’s Evidence of Coverage. If you have questions, you can also call UnitedHealthcare Dual Complete® ONE Customer Service at the number in the footer of this document. D. Additional services UnitedHealthcare Dual Complete® ONE covers This is not a complete list. Call Customer Service at the number in the footer of this document or read the Evidence of Coverage to find out about other covered services. Additional services UnitedHealthcare Dual Complete® ONE covers

Your Costs Fitness Program through Renew Active $0 Health Products Catalog and Over The Counter Debit Card — $0 ($450 credit quarterly. Your credit amount expires at the end of the year. You can use your debit card at network retail locations or place an order online, over the phone, or by mail through your FirstLine Select+ Catalog that will be sent to you.) Healthy Food Benefit — $50 credit per month to spend on $0 healthy food items such as vegetables, fruit, bread, rice, milk, and more. You can use your debit card at network retail locations. Your credit amount expires at the end of the month. Meals Benefit — Up to 42 meals for 21 days, two times per $0 year after a hospital stay

35 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 20

Additional services UnitedHealthcare Dual Complete® ONE covers

Your Costs Personal Emergency Response System — We will install $0 the system in your home and cover the monthly monitoring charges. Virtual Medical Visits — Speak to network telehealth providers $0 using your computer or mobile device. Find participating doctors online at www.amwell.com Virtual mental health visits — Speak to network telehealth $0 providers using your computer or mobile device. Find participating doctors online at www.virtualvisitsmentalhealth.uhc.com. E. Benefits covered outside of UnitedHealthcare Dual Complete® ONE This is not a complete list. Call Customer Service at the number in the footer of this document to find out about other services not covered by UnitedHealthcare Dual Complete® ONE but available through Medicaid fee-for-service. Other services covered directly by Medicaid fee-for-service

Your Costs Non-Emergency (Routine) Transportation (including mobile $0 assistance vehicles (MAVs)); non-emergency basic life support (BLS) ambulance (stretcher); and livery transportation services (such as bus and train fare or passes, or car service and reimbursement for mileage) Targeted case management (chronic mental illness) $0 Behavioral Health Home (Care Management) $0 PACT (Program in Assertive Community Treatment) $0 CSS (Community Support Services) $0 Psychiatric Emergency Services (PES)/Affiliated $0 Emergency Services (AES)

36 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 21

F. Services not covered by UnitedHealthcare Dual Information Plan Complete® ONE (exclusions) The following services are not covered by our plan. This is not a complete list. Call Customer Service at the number in the footer of this document to find out about other excluded services.

Services not covered by UnitedHealthcare Dual Complete® ONE (exclusions) Services not considered “reasonable and necessary” according to standards of Medicare and NJ FamilyCare Experimental medical and surgical treatments, items, or drugs unless covered by Medicare or under a Medicare-approved clinical study Surgical treatment for morbid obesity except when medically necessary Elective or voluntary enhancement procedures Cosmetic surgery or other cosmetic work unless required criteria are met LASIK surgery

37 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 22 G. Your rights and responsibilities as a member of the plan As a member of UnitedHealthcare Dual Complete® ONE, you have certain rights concerning your health care. You also have certain responsibilities to the health care providers who are taking care of you. Regardless of your health condition, you cannot be refused medically necessary treatment. You can use these rights without losing your health care services. We will tell you about your rights at least once a year. For more information on your rights, read the Evidence of Coverage. Your rights include, but are not limited to, the following: • You have a right to respect, fairness, and dignity. This includes the right to: –– Get covered services without concern about race, ethnicity, national origin, color, religion, creed, sex (including sex stereotypes and gender identity), age, health status, mental, physical, or sensory disability, sexual orientation, genetic information, ability to pay, or ability to speak English. No health care provider should engage in any practice, with respect to any member that constitutes unlawful discrimination under any state or federal law or regulation. –– Ask for and get information in other formats (for example, large print, braille, audio) free of charge –– Be free from any form of physical restraint or seclusion –– Not be billed by network providers –– Have your questions and concerns answered completely and courteously –– Apply your rights freely without any negative effect on the way UnitedHealthcare Dual Complete® ONE or your provider treats you • You have the right to get information about your health care. This includes information on treatment and your treatment options, regardless of cost or benefit coverage. This information should be in a format and language you can understand. These rights include getting information on: –– UnitedHealthcare Dual Complete® ONE –– The services we cover –– How to get services –– How much services will cost you –– Names of health care providers and Care Managers –– Your rights and responsibilities • You have the right to make decisions about your care, including refusing treatment. This includes the right to: –– Choose a primary care provider (PCP). You can change your PCP at any time during the year. You can call 1-800-514-4911 if you want to change your PCP.

38 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 23

–– See a women’s health care provider without a referral –– Get your covered services and drugs quickly Information Plan –– Know about all treatment options, no matter what they cost or whether they are covered –– Refuse treatment as far as the law allows, even if your health care provider advises against it –– Stop taking medicine, even if your health care provider advises against it –– Ask for a second opinion about any health care that your PCP or your Care Team advises you to have. UnitedHealthcare Dual Complete® ONE will pay for the cost of your second opinion visit. –– Make your health care wishes known in an advance directive • You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to: –– Get timely medical care –– Get in and out of a health care provider’s office. This means barrier-free access for people with disabilities, in accordance with the Americans with Disabilities Act –– Have interpreters to help with communication with your doctors, other providers, and your health plan. Call 1-800-514-4911 if you need help with this service –– Have your Evidence of Coverage and any printed materials from UnitedHealthcare Dual Complete® ONE translated into your primary language, to have these materials read out loud to you if you have trouble seeing or reading. Oral interpretation services will be made available upon request and free of charge. –– Be free of any form of physical restraint or seclusion that would be used as a means of coercion, force, discipline, convenience, or retaliation • You have the right to seek emergency and urgent care when you need it. This means you have the right to: –– Get emergency and urgent care services, 24 hours a day, 7 days a week, without prior approval –– See an out-of-network urgent or emergency care provider, when necessary • You have a right to confidentiality and privacy.This includes the right to: –– Ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected –– Have your personal health information kept private. No personal health information will be released to anyone without your consent, unless required by law. –– Have privacy during treatment • You have the right to make complaints about your covered services or care. This includes the right to: –– Access an easy process to voice your concerns, and to expect follow-up by UnitedHealthcare Dual Complete® ONE

39 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 24

–– File a complaint or grievance against us or our providers. You also have the right to appeal certain decisions made by us or our providers –– Ask for a State Appeal (State Fair Hearing) –– Get a detailed reason why services were denied Your responsibilities include, but are not limited to, the following: • You have a responsibility to treat others with respect, fairness, and dignity. You should: –– Treat your health care providers with dignity and respect –– Keep appointments, be on time, and call in advance if you’re going to be late or have to cancel • You have the responsibility to give information about you and your health. You should: –– Tell your health care provider your health complaints clearly and provide as much information as possible –– Tell your health care provider about yourself and your health history –– Tell your health care provider that you are a UnitedHealthcare Dual Complete® ONE member –– Talk to your PCP, Care Manager, or other appropriate person about seeking the services of a specialist before you go to a hospital (except in cases of emergency) –– Tell your PCP, Care Manager, or other appropriate person within 24 hours of any emergency or out-of-network treatment –– Notify UnitedHealthcare Dual Complete® ONE Customer Service if there are any changes in your personal information, such as your address or phone number • You have the responsibility to make decisions about your care, including refusing treatment. You should: –– Learn about your health problems and any recommended treatment, and consider the treatment before it’s performed –– Partner with your Care Team and work out treatment plans and goals together –– Follow the instructions and plans for care that you and your health care provider have agreed to, and remember that refusing treatment recommended by your health care provider might harm your health • You have the responsibility to obtain your services from UnitedHealthcare Dual Complete® ONE. You should: –– Get all your health care from UnitedHealthcare Dual Complete® ONE, except in cases of emergency, urgent care, out-of-area dialysis services, or family planning services, unless UnitedHealthcare Dual Complete® ONE provides a prior authorization for out-of-network care –– Not allow anyone else to use your UnitedHealthcare Dual Complete® ONE Member ID Card to obtain healthcare services

40 UnitedHealthcare Dual Complete® ONE (HMO D-SNP): Summary of Benefits 2021 25

–– Notify UnitedHealthcare Dual Complete® ONE when you believe that someone has

purposely misused UnitedHealthcare Dual Complete® ONE benefits or services Information Plan For more information about your rights, you can read UnitedHealthcare Dual Complete® ONE’s Evidence of Coverage. If you have questions, you can also call UnitedHealthcare Dual Complete® ONE Customer Service at the number in the footer of this document.

H. How to file a complaint or appeal a denied service If you have a complaint or think UnitedHealthcare Dual Complete® ONE should cover something we denied, call UnitedHealthcare Dual Complete® ONE at 1-800-514-4911. You can file a complaint or appeal our decision. For questions about complaints and appeals, you can read Chapter 8 of UnitedHealthcare Dual Complete® ONE’s Evidence of Coverage. You can also call UnitedHealthcare Dual Complete® ONE Customer Service at the number in the footer of this document. You can also write us a letter about your grievance (complaint) or appeal. For complaints/grievances or medical appeals: UnitedHealthcare Appeals and Grievances Department PO Box 6103 MS CA124-0187 Cypress, CA 90630 For Part D or Medicaid drug appeals only: UnitedHealthcare Part D Appeal and Grievance Department PO Box 6103 MS CA124-0197 Cypress, CA 90630-0023

I. What to do if you suspect fraud Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who are dishonest. If you think a doctor, hospital or other pharmacy is doing something wrong, contact us.

• Call us at UnitedHealthcare Dual Complete® ONE Customer Service. Phone numbers are in the footer of this document • Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. • You can also contact New Jersey’s Medicaid Fraud Division (of the Office of the State Comptroller) by calling 1-609-292-1272. Calls to this number are free.

41 If you have general questions or questions about our plan, services, service area, billing, or Member ID Cards, please call UnitedHealthcare Dual Complete® ONE Customer Service: Call 1-800-514-4911 Calls to this number are free. 8 a.m. – 8 p.m., 7 days a week from October through March, Monday – Friday from April through September Customer Service also has free language interpreter services available for people who do not speak English. TTY 711 Calls to this number are free. 8 a.m. – 8 p.m. 7 days a week from October through March, Monday – Friday from April through September.

If you have questions about your health, please call the NurseLine: Call 1-877-440-9407 Calls to this number are free. 24 hours a day, 7 days a week. TTY 711 Calls to this number are free. 24 hours a day, 7 days a week.

If you need immediate behavioral health services, please call the Behavioral Health Crisis Line: Call 1-800-514-4911 Calls to this number are free. 24 hours a day, 7 days a week. TTY 711 Calls to this number are free. 24 hours a day, 7 days a week.

42 Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and Information Plan rules. If you have any questions, you can call and speak to a Customer Service Representative at the number listed on the back cover of this book.

Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Call us or go online to view a copy of the EOC. Our phone number and website are listed on the back cover of this book.

Review the Provider Directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the Pharmacy Directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

Benefits may change on January 1 of each year.

Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).

This plan is a Dual Eligible Special Needs Plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid.

Enrolling in this plan will automatically disenroll you from any Medicare and Medicaid plans you may currently be enrolled in.

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43 2020 Medicare Star Ratings*

UnitedHealthcare - H3113 The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan’s scores. 2. Summary Star Rating that focuses on our medical or our prescription drug services. Some of the areas Medicare reviews for these ratings include:

· How our members rate our plan’s services and care;

· How well our doctors detect illnesses and keep members healthy;

· How well our plan helps our members use recommended and safe prescription medications. For 2020, UnitedHealthcare received the following Overall Star Rating from Medicare. 4 stars We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:

Health Plan Services: 4 stars Drug Plan Services: 5 stars

The number of stars shows how well our plan performs.

5 stars – Excellent 4 stars – Above Average 3 stars – Average 2 stars – Below Average 1 star – Poor Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time at 888-834-3721 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Local time. Current members please call 800-514-4911 (toll-free) or 711 (TTY).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next. Y0066_H3113_C_PR2020_M UHPA20HM4621114_001 The company does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you Information Plan can send a complaint to the Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the member toll-free phone number listed in the front of this booklet.

You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed in the front of this booklet.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en la portada de esta guía.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打本手冊封面所列的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Xin vui lòng gọi số điện thoại miễn phí dành cho hội viên trên trang bìa của tập sách này.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 이 책자 앞 페이지에 기재된 무료 회원 전화번호로 문의하십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nakalista sa harapan ng booklet na ito.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русским (Russian). Позвоните по бесплатному номеру телефона, указанному на лицевой стороне данной брошюры.

تنبيه: إذا كنت تتحدث العربية (Arabic)، فإن خدمات المساعدة اللغوية المجانية متاحة لك. يرجى االتصال على رقم الھاتف المجاني للعضو الموجود في مقدمة ھذا الكتيب.

45 ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo telefòn gratis pou manm yo ki sou kouvèti ti liv sa a.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone sans frais pour les affiliés figurant au début de ce guide.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny członkowski numer telefonu podany na okładce tej broszury.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número do membro encontrado na frente deste folheto.

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Si prega di chiamare il numero verde per i membri indicato all'inizio di questo libretto.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer für Mitglieder auf der Vorderseite dieser Broschüre an.

注意事項：日本語 (Japanese) を話される場合、無料の言語支援サービスをご利用いただけます。本冊子の表紙に記載されているメンバー用フリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا ً با شماره تلفن رايگان اعضا که بر روی جلد اين کتابچه قيد شده تماس بگيريد . .

�यान द�: यिद आप िहदीं (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, िन:शु�क �पल�� ह�। कृ पया इस पु��तका के सामने के प��ृ पर सचीबद्धू सद�य टोल-फ्री फ़ोन नंबर पर कॉल कर�।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu tus tswv cuab xov tooj hu dawb teev nyob ntawm sab xub ntiag ntawm phau ntawv no.

ចំ㮶ប់讶រម䮘ណ៍ៈ េបើសិនអ䮓កនិ架យ徶羶ែខរ䮘 (Khmer) េស玶ជំនួយ徶羶េ⮶យឥតគិតៃថ䮛 គឺ掶នសំ殶ប់អ䮓ក។ សូមទូរស័ព䮑េ䟅េលខស掶ជិកឥតេចញៃថ䮛厶នកត់េ俅޶ងមុខៃនកូនេសៀវេ必េនះ។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Pakitawagan iti miyembro toll-free nga number nga nakasurat iti sango ti libro.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí díí naaltsoos bidáahgi t'áá jiik'eh naaltsoos báha'dít'éhígíí béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka xubinta ee telefonka bilaashka ah ee ku qoran xagga hore ee buugyaraha.

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46 Drug List

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47 Drug List

This is a complete alphabetical list of prescription drugs covered by the plan as of September 1, 2020. This list can change throughout the year. Call us at UnitedHealthcare or go online for the most up-to-date information. Our phone number and website are listed on the back cover of this book. · Brand name drugs are in ALL CAPS. Generic drugs are in lower-case italics · All covered drugs are in 1 tier · There are no out-of-pocket costs (cost sharing) such as copayments or coinsurance for covered, prescribed drugs when obtained from network pharmacies · See the Summary of Benefits in this book for a description of these drugs · Some drugs have coverage requirements, such as Prior Authorization or Step Therapy. For more information, please contact UnitedHealthcare or view the complete drug list on our website

A acetazolamide er (oral capsule extended release 12 hour), T1 abacavir sulfate (oral solution), T1 - QL acetic acid (otic solution), T1 abacavir sulfate (oral tablet), T1 - QL acetylcysteine (inhalation solution), T1 - B/D,PA abacavir sulfate-lamivudine (oral tablet), T1 - QL acitretin (oral capsule), T1 abacavir-lamivudine-zidovudine (oral tablet), T1 - DL; QL ACTHIB (INTRAMUSCULAR SOLUTION RECONSTITUTED), T1 - QL ABELCET (INTRAVENOUS SUSPENSION), T1 - B/D,PA ACTEMRA (SUBCUTANEOUS SOLUTION PREFILLED SYRINGE), T1 - PA; DL ABILIFY MAINTENA (INTRAMUSCULAR PREFILLED SYRINGE), T1 - DL ACTEMRA ACTPEN (SUBCUTANEOUS SOLUTION AUTO-INJECTOR), T1 - PA; DL ABILIFY MAINTENA (INTRAMUSCULAR SUSPENSION RECONSTITUTED ER), T1 - DL ACTIMMUNE (SUBCUTANEOUS SOLUTION), T1 - LA; DL abiraterone acetate (oral tablet), T1 - PA; DL; QL acyclovir (external ointment), T1 - QL acamprosate calcium (oral tablet delayed release), T1 acyclovir (oral capsule), T1 acarbose (oral tablet), T1 - QL acyclovir (oral suspension), T1 acebutolol hcl (oral capsule), T1 acyclovir (oral tablet), T1 acetaminophen-codeine (120-12mg/5ml oral acyclovir sodium (intravenous solution), T1 - B/ solution), T1 - 7D; MME; DL; QL D,PA acetaminophen-codeine (300-15mg oral tablet, ADACEL (INTRAMUSCULAR SUSPENSION), T1 300-30mg oral tablet, 300-60mg oral tablet), T1 - - QL 7D; MME; DL; QL adapalene (0.1% external gel), T1 acetazolamide (oral tablet), T1 adapalene (external cream), T1

T1= Tier 1 Covered Drugs H3113_DL_21_M

48 adefovir dipivoxil (oral tablet), T1 - DL ALPHAGAN P (0.1% OPHTHALMIC SOLUTION), ADEMPAS (ORAL TABLET), T1 - PA; LA; DL T1 ADVAIR DISKUS (INHALATION AEROSOL alprazolam (oral tablet immediate release), T1 - POWDER BREATH ACTIVATED), T1 - QL QL ADVAIR HFA (INHALATION AEROSOL), T1 - QL altavera (oral tablet), T1 AFINITOR (10MG ORAL TABLET), T1 - PA; DL ALUNBRIG (ORAL TABLET THERAPY PACK), AFINITOR DISPERZ (ORAL TABLET SOLUBLE), T1 - PA; LA; DL; QL T1 - PA; DL ALUNBRIG (ORAL TABLET), T1 - PA; LA; DL; AIMOVIG (SUBCUTANEOUS SOLUTION AUTO- QL INJECTOR), T1 - PA; QL alyacen 1/35 (oral tablet), T1 ala-cort (1% external cream), T1 alyq (oral tablet), T1 - PA; QL albendazole (oral tablet), T1 - DL; QL AMBISOME (INTRAVENOUS SUSPENSION albuterol sulfate (inhalation nebulization RECONSTITUTED), T1 - B/D,PA; DL solution), T1 - B/D,PA amantadine hcl (oral capsule), T1 albuterol sulfate (oral syrup), T1 amantadine hcl (oral syrup), T1 albuterol sulfate (oral tablet immediate release), amantadine hcl (oral tablet), T1 T1 ambrisentan (oral tablet), T1 - PA; LA; DL; QL albuterol sulfate hfa (108 (90 base)mcg/act amethia (oral tablet), T1 inhalation aerosol solution (generic proair), 108 amikacin sulfate (500mg/2ml injection solution), (90 base)mcg/act inhalation aerosol solution) T1 Drug List (generic proventil), T1 amiloride hcl (oral tablet), T1 alclometasone dipropionate (external cream), T1 amiloride-hydrochlorothiazide (oral tablet), T1 alclometasone dipropionate (external ointment), AMINOSYN II (INTRAVENOUS SOLUTION), T1 - T1 B/D,PA alcohol prep pads, T1 AMINOSYN-PF (7% INTRAVENOUS SOLUTION), ALECENSA (ORAL CAPSULE), T1 - PA; LA; DL; T1 - B/D,PA QL amiodarone hcl (200mg oral tablet), T1 alendronate sodium (10mg oral tablet, 35mg oral AMITIZA (ORAL CAPSULE), T1 - QL tablet, 70mg oral tablet), T1 - QL amitriptyline hcl (oral tablet), T1 alendronate sodium (oral solution), T1 amlodipine besylate (oral tablet), T1 alfuzosin hcl er (oral tablet extended release 24 hour), T1 amlodipine-atorvastatin (oral tablet), T1 - QL ALINIA (ORAL SUSPENSION amlodipine-benazepril (oral capsule), T1 - QL RECONSTITUTED), T1 - DL amlodipine-olmesartan (oral tablet), T1 - QL ALINIA (ORAL TABLET), T1 - DL amlodipine-valsartan (oral tablet), T1 - QL aliskiren fumarate (oral tablet), T1 - QL amlodipine-valsartan-hctz (oral tablet), T1 - QL allopurinol (oral tablet), T1 ammonium lactate (external cream), T1 ALOCRIL (OPHTHALMIC SOLUTION), T1 ammonium lactate (external lotion), T1 ALOMIDE (OPHTHALMIC SOLUTION), T1 amnesteem (oral capsule), T1 - PA alosetron hcl (oral tablet), T1 - PA; DL amoxapine (oral tablet), T1

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

49 amoxicillin (oral capsule), T1 PA amoxicillin (oral suspension reconstituted), T1 apri (oral tablet), T1 amoxicillin (oral tablet chewable), T1 APRISO (ORAL CAPSULE EXTENDED amoxicillin (oral tablet immediate release), T1 RELEASE 24 HOUR), T1 - QL amoxicillin-potassium clavulanate (oral APTIOM (ORAL TABLET), T1 - DL; QL suspension reconstituted), T1 APTIVUS (ORAL CAPSULE), T1 - DL; QL amoxicillin-potassium clavulanate (oral tablet APTIVUS (ORAL SOLUTION), T1 - DL; QL chewable), T1 ARALAST NP (1000MG INTRAVENOUS amoxicillin-potassium clavulanate (oral tablet SOLUTION RECONSTITUTED), T1 - PA; LA; DL immediate release), T1 aranelle (oral tablet), T1 amoxicillin-potassium clavulanate er (oral tablet ARANESP (ALBUMIN FREE) (100MCG/0.5ML extended release 12 hour), T1 INJECTION SOLUTION PREFILLED SYRINGE, amphetamine-dextroamphetamine (oral tablet), 150MCG/0.3ML INJECTION SOLUTION T1 - QL PREFILLED SYRINGE, 200MCG/0.4ML amphetamine-dextroamphetamine er (oral INJECTION SOLUTION PREFILLED SYRINGE, capsule extended release 24 hour), T1 - QL 300MCG/0.6ML INJECTION SOLUTION amphotericin b (intravenous solution PREFILLED SYRINGE, 500MCG/ML reconstituted), T1 - B/D,PA INJECTION SOLUTION PREFILLED SYRINGE), T1 - PA; DL ampicillin (oral capsule), T1 ARANESP (ALBUMIN FREE) (100MCG/ML ampicillin sodium (10gm intravenous solution INJECTION SOLUTION, 200MCG/ML reconstituted), T1 INJECTION SOLUTION, 300MCG/ML ampicillin sodium (125mg injection solution INJECTION SOLUTION), T1 - PA; DL reconstituted, 1gm injection solution ARANESP (ALBUMIN FREE) (10MCG/0.4ML reconstituted), T1 INJECTION SOLUTION PREFILLED SYRINGE, ampicillin-sulbactam sodium (15 (10-5)gm 25MCG/0.42ML INJECTION SOLUTION intravenous solution reconstituted), T1 PREFILLED SYRINGE, 40MCG/0.4ML ampicillin-sulbactam sodium (injection solution INJECTION SOLUTION PREFILLED SYRINGE, reconstituted), T1 60MCG/0.3ML INJECTION SOLUTION ANADROL-50 (ORAL TABLET), T1 - PA; DL PREFILLED SYRINGE), T1 - PA anagrelide hcl (oral capsule), T1 ARANESP (ALBUMIN FREE) (25MCG/ML anastrozole (oral tablet), T1 INJECTION SOLUTION, 40MCG/ML INJECTION SOLUTION, 60MCG/ML ANDRODERM (TRANSDERMAL PATCH 24 INJECTION SOLUTION), T1 - PA HOUR), T1 - QL ARCALYST (SUBCUTANEOUS SOLUTION ANORO ELLIPTA (INHALATION AEROSOL RECONSTITUTED), T1 - PA; LA; DL POWDER BREATH ACTIVATED), T1 - QL aripiprazole (10mg oral tablet, 15mg oral tablet, APOKYN (SUBCUTANEOUS SOLUTION 20mg oral tablet, 2mg oral tablet, 30mg oral CARTRIDGE), T1 - PA; LA; DL; QL tablet, 5mg oral tablet), T1 - QL apraclonidine hcl (ophthalmic solution), T1 aripiprazole (1mg/ml oral solution), T1 - QL aprepitant (oral therapy pack, oral capsule), T1 - aripiprazole odt (10mg oral tablet dispersible,

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

50 15mg oral tablet dispersible), T1 - DL; QL azelastine-fluticasone (nasal suspension), T1 ARISTADA (INTRAMUSCULAR PREFILLED azithromycin (intravenous solution SYRINGE), T1 - DL reconstituted), T1 ARISTADA INITIO (INTRAMUSCULAR azithromycin (oral suspension reconstituted), T1 PREFILLED SYRINGE), T1 - DL azithromycin (oral tablet), T1 armodafinil (oral tablet), T1 - PA; QL AZOPT (OPHTHALMIC SUSPENSION), T1 ARNUITY ELLIPTA (INHALATION AEROSOL aztreonam (1gm injection solution POWDER BREATH ACTIVATED), T1 - QL reconstituted), T1 ashlyna (oral tablet), T1 B aspirin-dipyridamole er (oral capsule extended BCG VACCINE (INJECTION), T1 - QL release 12 hour), T1 - QL BIVIGAM (INTRAVENOUS SOLUTION), T1 - PA; atazanavir sulfate (oral capsule), T1 - QL DL atenolol (oral tablet), T1 BRIVIACT (ORAL SOLUTION), T1 - PA; DL; QL atenolol-chlorthalidone (oral tablet), T1 BRIVIACT (ORAL TABLET), T1 - PA; DL; QL atomoxetine hcl (oral capsule), T1 - QL bacitracin (ophthalmic ointment), T1 atorvastatin calcium (oral tablet), T1 - QL bacitracin-polymyxin b (ophthalmic ointment), T1 atovaquone (oral suspension), T1 - DL baclofen (oral tablet), T1 atovaquone-proguanil hcl (oral tablet), T1 balsalazide disodium (oral capsule), T1 ATRIPLA (ORAL TABLET), T1 - DL; QL BALVERSA (ORAL TABLET), T1 - PA; LA; DL; Drug List ATROPINE SULFATE (1% OPHTHALMIC QL SOLUTION), T1 balziva (oral tablet), T1 ATROVENT HFA (INHALATION AEROSOL BANZEL (ORAL SUSPENSION), T1 - DL SOLUTION), T1 BANZEL (ORAL TABLET), T1 - DL AUBAGIO (ORAL TABLET), T1 - LA; DL; QL BAQSIMI TWO PACK (NASAL POWDER), T1 aubra eq (oral tablet), T1 BARACLUDE (ORAL SOLUTION), T1 - DL AURYXIA (ORAL TABLET), T1 - PA; DL BELSOMRA (ORAL TABLET), T1 - QL AUSTEDO (ORAL TABLET), T1 - PA; LA; DL; QL benazepril hcl (oral tablet), T1 - QL aviane (oral tablet), T1 benazepril-hydrochlorothiazide (oral tablet), T1 - AVONEX PEN (INTRAMUSCULAR AUTO- QL INJECTOR KIT), T1 - DL; QL BENLYSTA (SUBCUTANEOUS SOLUTION AVONEX PREFILLED (INTRAMUSCULAR AUTO-INJECTOR), T1 - PA; DL PREFILLED SYRINGE KIT), T1 - DL; QL BENLYSTA (SUBCUTANEOUS SOLUTION AYVAKIT (ORAL TABLET), T1 - PA; LA; DL; QL PREFILLED SYRINGE), T1 - PA; DL azathioprine (oral tablet), T1 - B/D,PA BENZNIDAZOLE (ORAL TABLET), T1 azelaic acid (external gel), T1 benzoyl peroxide-erythromycin (external gel), T1 azelastine hcl (0.1% nasal solution, 0.15% nasal benztropine mesylate (oral tablet), T1 solution), T1 BEPREVE (OPHTHALMIC SOLUTION), T1 azelastine hcl (ophthalmic solution), T1 BERINERT (INTRAVENOUS KIT), T1 - PA; LA;

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

51 DL BIKTARVY (ORAL TABLET), T1 - DL; QL BESIVANCE (OPHTHALMIC SUSPENSION), T1 bisoprolol fumarate (oral tablet), T1 betamethasone dipropionate (external cream), bisoprolol-hydrochlorothiazide (oral tablet), T1 - T1 QL betamethasone dipropionate (external lotion), T1 BLEPHAMIDE (OPHTHALMIC SUSPENSION), betamethasone dipropionate (external ointment), T1 T1 blephamide s.o.p. (ophthalmic ointment), T1 betamethasone dipropionate aug (external blisovi 24 fe (oral tablet), T1 cream), T1 blisovi fe 1.5/30 (oral tablet), T1 betamethasone dipropionate aug (external gel), BOOSTRIX (5-2.5-18.5 INTRAMUSCULAR T1 SUSPENSION, 5-2.5-18.5 (0.5ML SYRINGE) betamethasone dipropionate aug (external INTRAMUSCULAR SUSPENSION), T1 - QL lotion), T1 bosentan (oral tablet), T1 - PA; LA; DL; QL betamethasone dipropionate aug (external BOSULIF (ORAL TABLET), T1 - PA; DL; QL ointment), T1 BRAFTOVI (ORAL CAPSULE), T1 - PA; DL betamethasone valerate (external cream), T1 BREO ELLIPTA (INHALATION AEROSOL betamethasone valerate (external lotion), T1 POWDER BREATH ACTIVATED), T1 - QL betamethasone valerate (external ointment), T1 briellyn (oral tablet), T1 BETASERON (SUBCUTANEOUS KIT), T1 - DL; BRILINTA (ORAL TABLET), T1 - QL QL BRIMONIDINE TARTRATE (0.15% betaxolol hcl (ophthalmic solution), T1 OPHTHALMIC SOLUTION), T1 betaxolol hcl (oral tablet), T1 brimonidine tartrate (0.2% ophthalmic solution), bethanechol chloride (oral tablet), T1 T1 BETHKIS (INHALATION NEBULIZATION bromocriptine mesylate (oral capsule), T1 SOLUTION), T1 - B/D,PA; DL; QL bromocriptine mesylate (oral tablet), T1 BETIMOL (OPHTHALMIC SOLUTION), T1 BRUKINSA (ORAL CAPSULE), T1 - PA; LA; DL; BEVESPI AEROSPHERE (INHALATION QL AEROSOL), T1 - QL budesonide (inhalation suspension), T1 - B/D,PA bexarotene (oral capsule), T1 - PA; DL budesonide (oral capsule delayed release BEXSERO (INTRAMUSCULAR SUSPENSION particles), T1 PREFILLED SYRINGE), T1 - QL budesonide er (oral tablet extended release 24 BIDIL (ORAL TABLET), T1 - QL hour), T1 - ST; DL bicalutamide (oral tablet), T1 bumetanide (injection solution), T1 BICILLIN C-R (INTRAMUSCULAR bumetanide (oral tablet), T1 SUSPENSION), T1 buprenorphine (transdermal patch weekly), T1 - BICILLIN C-R 900/300 (INTRAMUSCULAR 7D; DL; QL SUSPENSION), T1 buprenorphine hcl (tablet sublingual), T1 - QL BICILLIN L-A (INTRAMUSCULAR buprenorphine hcl-naloxone hcl (sublingual film), SUSPENSION), T1 T1 - QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

52 buprenorphine hcl-naloxone hcl (tablet capsule), T1 sublingual), T1 - QL calcium acetate (phosphate binder) (oral tablet), bupropion hcl (oral tablet immediate release), T1 T1 bupropion hcl sr (150mg oral tablet extended CALQUENCE (ORAL CAPSULE), T1 - PA; DL; release 12 hour smoking-deterrent), T1 QL bupropion hcl sr (oral tablet extended release 12 camila (oral tablet), T1 hour), T1 camrese lo (oral tablet), T1 bupropion hcl xl (150mg oral tablet extended candesartan cilexetil (oral tablet), T1 - QL release 24 hour, 300mg oral tablet extended candesartan cilexetil-hctz (oral tablet), T1 - QL release 24 hour), T1 CAPLYTA (ORAL CAPSULE), T1 - ST; DL; QL buspirone hcl (oral tablet), T1 CAPRELSA (ORAL TABLET), T1 - PA; LA; DL butalbital-acetaminophen-caffeine (oral tablet), T1 - QL captopril (oral tablet), T1 - QL butalbital-aspirin-caffeine (oral capsule), T1 - QL captopril-hydrochlorothiazide (oral tablet), T1 - QL butorphanol tartrate (nasal solution), T1 - 7D; MME; DL; QL CARBAGLU (ORAL TABLET), T1 - LA; DL BYDUREON (SUBCUTANEOUS PEN- carbamazepine (oral suspension), T1 INJECTOR), T1 - QL carbamazepine (oral tablet chewable), T1 BYDUREON BCISE (SUBCUTANEOUS AUTO- carbamazepine (oral tablet immediate release), T1 INJECTOR), T1 - QL Drug List BYETTA 10MCG PEN (SUBCUTANEOUS carbamazepine er (oral capsule extended SOLUTION PEN-INJECTOR), T1 - QL release 12 hour), T1 BYETTA 5MCG PEN (SUBCUTANEOUS carbamazepine er (oral tablet extended release SOLUTION PEN-INJECTOR), T1 - QL 12 hour), T1 BYSTOLIC (ORAL TABLET), T1 - QL carbidopa (oral tablet), T1 C carbidopa-levodopa (oral tablet immediate release), T1 cabergoline (oral tablet), T1 carbidopa-levodopa er (oral tablet extended CABLIVI (INJECTION KIT), T1 - PA; LA; DL; QL release), T1 CABOMETYX (ORAL TABLET), T1 - PA; LA; DL; carbidopa-levodopa odt (oral tablet dispersible), QL T1 calcipotriene (external cream), T1 carbidopa-levodopa-entacapone (oral tablet), T1 calcipotriene (external ointment), T1 carteolol hcl (ophthalmic solution), T1 calcipotriene (external solution), T1 cartia xt (oral capsule extended release 24 hour), calcitonin salmon (nasal solution), T1 - QL T1 CALCITRIOL (EXTERNAL OINTMENT), T1 carvedilol (oral tablet), T1 calcitriol (oral capsule), T1 - B/D,PA CAYSTON (INHALATION SOLUTION calcitriol (oral solution), T1 - B/D,PA RECONSTITUTED), T1 - PA; LA; DL calcium acetate (phosphate binder) (oral caziant (oral tablet), T1

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

53 cefaclor (oral capsule), T1 cephalexin (250mg oral capsule, 500mg oral cefadroxil (oral capsule), T1 capsule), T1 cefadroxil (oral suspension reconstituted), T1 cephalexin (750mg oral capsule), T1 cefazolin sodium (10gm injection solution cephalexin (oral suspension reconstituted), T1 reconstituted, 1gm injection solution cetirizine hcl (1mg/ml oral solution), T1 reconstituted, 500mg injection solution CHANTIX (ORAL TABLET), T1 reconstituted), T1 CHANTIX CONTINUING MONTH PAK (ORAL cefdinir (oral capsule), T1 TABLET), T1 cefdinir (oral suspension reconstituted), T1 CHANTIX STARTING MONTH PAK (ORAL cefepime hcl (injection solution reconstituted), TABLET), T1 T1 CHEMET (ORAL CAPSULE), T1 - DL cefixime (oral capsule), T1 chenodal (oral tablet), T1 - PA; DL cefixime (oral suspension reconstituted), T1 chlordiazepoxide hcl (oral capsule), T1 cefotetan disodium (injection solution chlorhexidine gluconate (mouth solution), T1 reconstituted), T1 chloroquine phosphate (oral tablet), T1 - QL cefoxitin sodium (injection solution chlorpromazine hcl (oral tablet), T1 reconstituted), T1 chlorthalidone (oral tablet), T1 cefoxitin sodium (intravenous solution reconstituted), T1 chlorzoxazone (500mg oral tablet), T1 cefpodoxime proxetil (oral suspension CHOLBAM (ORAL CAPSULE), T1 - PA; DL reconstituted), T1 cholestyramine (oral packet), T1 cefpodoxime proxetil (oral tablet), T1 cholestyramine light (oral powder), T1 cefprozil (oral suspension reconstituted), T1 ciclopirox (external gel), T1 cefprozil (oral tablet), T1 ciclopirox (external shampoo), T1 ceftazidime (injection solution reconstituted), T1 ciclopirox (external solution), T1 ceftriaxone sodium (10gm intravenous solution ciclopirox olamine (external cream), T1 reconstituted), T1 ciclopirox olamine (external suspension), T1 ceftriaxone sodium (1gm injection solution cilostazol (oral tablet), T1 reconstituted, 250mg injection solution CILOXAN (OPHTHALMIC OINTMENT), T1 reconstituted, 2gm injection solution CIMDUO (ORAL TABLET), T1 - DL; QL reconstituted, 500mg injection solution reconstituted), T1 cimetidine (oral tablet), T1 cefuroxime axetil (oral tablet), T1 cimetidine hcl (oral solution), T1 cefuroxime sodium (injection solution CIMZIA (SUBCUTANEOUS KIT), T1 - PA; DL reconstituted), T1 CIMZIA PREFILLED (SUBCUTANEOUS KIT), T1 cefuroxime sodium (intravenous solution - PA; DL reconstituted), T1 cinacalcet hcl (30mg oral tablet), T1 - B/D,PA; celecoxib (oral capsule), T1 - QL QL CELONTIN (ORAL CAPSULE), T1 cinacalcet hcl (60mg oral tablet, 90mg oral tablet), T1 - B/D,PA; DL; QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

54 CINRYZE (INTRAVENOUS SOLUTION clobazam (oral tablet), T1 - PA; QL RECONSTITUTED), T1 - PA; LA; DL clobetasol propionate (external cream), T1 CIPRO HC (OTIC SUSPENSION), T1 clobetasol propionate (external gel), T1 ciprofloxacin hcl (100mg oral tablet immediate clobetasol propionate (external ointment), T1 release), T1 clobetasol propionate (external shampoo), T1 ciprofloxacin hcl (250mg oral tablet immediate clobetasol propionate (external solution), T1 release, 500mg oral tablet immediate release, 750mg oral tablet immediate release), T1 clobetasol propionate emollient base (external cream), T1 ciprofloxacin hcl (ophthalmic solution), T1 clomipramine hcl (oral capsule), T1 ciprofloxacin in d5w (200mg/100ml intravenous solution), T1 clonazepam (0.5mg oral tablet, 1mg oral tablet, 2mg oral tablet), T1 - QL citalopram hydrobromide (oral solution), T1 clonazepam odt (0.125mg oral tablet dispersible, citalopram hydrobromide (oral tablet), T1 0.25mg oral tablet dispersible, 0.5mg oral tablet claravis (oral capsule), T1 - PA dispersible, 1mg oral tablet dispersible, 2mg oral clarithromycin (oral suspension reconstituted), tablet dispersible), T1 - QL T1 clonidine (transdermal patch weekly), T1 clarithromycin (oral tablet immediate release), T1 clonidine hcl (oral tablet immediate release), T1 clarithromycin er (oral tablet extended release 24 clonidine hcl er (oral tablet extended release 12 hour), T1 hour), T1 - PA CLENPIQ (ORAL SOLUTION), T1 clopidogrel bisulfate (75mg oral tablet), T1 - QL Drug List CLIMARA PRO (TRANSDERMAL PATCH clorazepate dipotassium (oral tablet), T1 - QL WEEKLY), T1 clotrimazole (external cream), T1 clindacin-p (external swab), T1 clotrimazole (external solution), T1 clindamycin hcl (oral capsule), T1 clotrimazole (mouth/throat troche), T1 clindamycin palmitate hcl (oral solution clotrimazole-betamethasone (external cream), T1 reconstituted), T1 clotrimazole-betamethasone (external lotion), T1 clindamycin phosphate (300mg/2ml injection solution, 600mg/4ml injection solution, 900mg/ clovique (oral capsule), T1 - PA; DL; QL 6ml injection solution), T1 clozapine (100mg oral tablet, 200mg oral tablet, clindamycin phosphate (external gel), T1 - QL 25mg oral tablet, 50mg oral tablet), T1 clindamycin phosphate (external lotion), T1 clozapine odt (100mg oral tablet dispersible, 12.5mg oral tablet dispersible, 150mg oral tablet clindamycin phosphate (external solution), T1 dispersible, 200mg oral tablet dispersible, 25mg clindamycin phosphate (external swab), T1 oral tablet dispersible), T1 - QL clindamycin phosphate (vaginal cream), T1 COARTEM (ORAL TABLET), T1 clindamycin phosphate in d5w (intravenous CODEINE SULFATE (15MG ORAL TABLET), T1 - solution), T1 7D; MME; DL; QL clindamycin phosphate-benzoyl peroxide (1-5% codeine sulfate (30mg oral tablet, 60mg oral external gel), T1 tablet), T1 - 7D; MME; DL; QL clobazam (oral suspension), T1 - PA; QL COLCHICINE (0.6MG ORAL CAPSULE) (BRAND

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

55 EQUIVALENT MITIGARE), T1 - QL CRIXIVAN (ORAL CAPSULE), T1 - QL colchicine (0.6mg oral tablet) (generic colcrys), cromolyn sodium (inhalation nebulization T1 - QL solution), T1 - B/D,PA; DL colesevelam hcl (oral packet), T1 cromolyn sodium (ophthalmic solution), T1 colesevelam hcl (oral tablet), T1 cromolyn sodium (oral concentrate), T1 colestipol hcl (oral packet), T1 cryselle-28 (oral tablet), T1 colestipol hcl (oral tablet), T1 CUVPOSA (ORAL SOLUTION), T1 - PA colistimethate sodium (cba) (injection solution cyclafem 1/35 (oral tablet), T1 reconstituted), T1 - DL cyclafem 7/7/7 (oral tablet), T1 COMBIGAN (OPHTHALMIC SOLUTION), T1 cyclobenzaprine hcl (10mg oral tablet, 5mg oral COMBIVENT RESPIMAT (INHALATION tablet), T1 AEROSOL SOLUTION), T1 - QL cyclobenzaprine hcl (7.5mg oral tablet), T1 COMETRIQ (100MG DAILY DOSE) (ORAL KIT), cyclophosphamide (25mg oral capsule), T1 - B/ T1 - PA; LA; DL D,PA COMETRIQ (140MG DAILY DOSE) (ORAL KIT), cyclophosphamide (50mg oral capsule), T1 - B/ T1 - PA; LA; DL D,PA COMETRIQ (60MG DAILY DOSE) (ORAL KIT), CYCLOSET (ORAL TABLET), T1 - PA; QL T1 - PA; LA; DL cyclosporine (oral capsule), T1 - B/D,PA COMPLERA (ORAL TABLET), T1 - DL; QL cyclosporine modified (oral capsule), T1 - B/ compro (rectal suppository), T1 D,PA constulose (oral solution), T1 cyclosporine modified (oral solution), T1 - B/ COPIKTRA (ORAL CAPSULE), T1 - PA; DL; QL D,PA CORDRAN (EXTERNAL TAPE), T1 cyproheptadine hcl (oral syrup), T1 CORLANOR (ORAL SOLUTION), T1 - PA; QL cyproheptadine hcl (oral tablet), T1 CORLANOR (ORAL TABLET), T1 - PA; QL cyred eq (oral tablet), T1 cortisone acetate (oral tablet), T1 CYSTADANE (ORAL POWDER), T1 - DL CORTISPORIN (EXTERNAL CREAM), T1 CYSTAGON (ORAL CAPSULE), T1 - LA CORTISPORIN (EXTERNAL OINTMENT), T1 CYSTARAN (OPHTHALMIC SOLUTION), T1 - COSENTYX (300 MG DOSE) (SUBCUTANEOUS LA; DL SOLUTION PREFILLED SYRINGE), T1 - PA; D LA; DL DARAPRIM (ORAL TABLET), T1 - DL COSENTYX SENSOREADY (300 MG) dalfampridine er (oral tablet extended release 12 (SUBCUTANEOUS SOLUTION AUTO- hour), T1 - QL INJECTOR), T1 - PA; LA; DL DALIRESP (ORAL TABLET), T1 - PA; QL COTELLIC (ORAL TABLET), T1 - PA; LA; DL; QL DALVANCE (INTRAVENOUS SOLUTION CREON (ORAL CAPSULE DELAYED RELEASE RECONSTITUTED), T1 - PA; DL PARTICLES), T1 danazol (oral capsule), T1 CRINONE (VAGINAL GEL), T1 - PA dantrolene sodium (oral capsule), T1

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

56 dapsone (oral tablet), T1 dextroamphetamine sulfate (oral tablet), T1 - QL DAPTACEL (INTRAMUSCULAR SUSPENSION), dextroamphetamine sulfate er (oral capsule T1 - QL extended release 24 hour), T1 - QL daptomycin (intravenous solution reconstituted), dextrose (10% intravenous solution), T1 T1 - DL dextrose (5% intravenous solution), T1 - B/D,PA DAURISMO (ORAL TABLET), T1 - PA; LA; DL; DEXTROSE-NACL (10-0.2% INTRAVENOUS QL SOLUTION, 10-0.45% INTRAVENOUS deblitane (oral tablet), T1 SOLUTION, 2.5-0.45% INTRAVENOUS deferasirox (oral tablet soluble) (generic exjade), SOLUTION, 5-0.2% INTRAVENOUS T1 - PA; DL SOLUTION, 5-0.225% INTRAVENOUS deferasirox (oral tablet) (generic jadenu), T1 - SOLUTION, 5-0.45% INTRAVENOUS PA; DL SOLUTION), T1 DELSTRIGO (ORAL TABLET), T1 - DL; QL DEXTROSE-NACL (5-0.9% INTRAVENOUS SOLUTION), T1 - B/D,PA demeclocycline hcl (oral tablet), T1 diazepam (10mg oral tablet, 2mg oral tablet, DEMSER (ORAL CAPSULE), T1 - DL 5mg oral tablet), T1 - QL DEPEN TITRATABS (ORAL TABLET), T1 - DL diazepam (10mg rectal gel, 2.5mg rectal gel, depo-estradiol (intramuscular oil), T1 20mg rectal gel), T1 - QL DEPO-PROVERA (400MG/ML diazepam (5mg/5ml oral solution), T1 INTRAMUSCULAR SUSPENSION), T1 diazepam intensol (5mg/ml oral concentrate), T1 Drug List DESCOVY (ORAL TABLET), T1 - DL; QL - QL desipramine hcl (oral tablet), T1 diazoxide (oral suspension), T1 - DL desmopressin acetate (oral tablet), T1 diclofenac epolamine (transdermal patch), T1 - desmopressin acetate spray (nasal solution), T1 PA; QL desogestrel-ethinyl estradiol (oral tablet), T1 diclofenac potassium (oral tablet), T1 desonide (external ointment), T1 diclofenac sodium (1% transdermal gel), T1 desoximetasone (external cream), T1 - QL diclofenac sodium (3% transdermal gel), T1 - PA desvenlafaxine succinate er (oral tablet extended diclofenac sodium (ophthalmic solution), T1 release 24 hour) (generic pristiq), T1 - QL diclofenac sodium (oral tablet delayed release), dexamethasone (oral elixir), T1 T1 dexamethasone (oral tablet), T1 diclofenac sodium er (oral tablet extended dexamethasone intensol (oral concentrate), T1 release 24 hour), T1 dexamethasone sodium phosphate (ophthalmic dicloxacillin sodium (oral capsule), T1 solution), T1 dicyclomine hcl (oral capsule), T1 DEXILANT (ORAL CAPSULE DELAYED dicyclomine hcl (oral solution), T1 RELEASE), T1 - QL dicyclomine hcl (oral tablet), T1 dexmethylphenidate hcl (oral tablet), T1 - QL didanosine (250mg oral capsule delayed release, dexmethylphenidate hcl er (oral capsule 400mg oral capsule delayed release), T1 - QL extended release 24 hour), T1 DIFICID (ORAL TABLET), T1 - DL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

57 diflunisal (oral tablet), T1 dorzolamide hcl (ophthalmic solution), T1 digitek (oral tablet), T1 dorzolamide hcl-timolol maleate (ophthalmic digox (oral tablet), T1 solution), T1 digoxin (oral solution), T1 dorzolamide hcl-timolol maleate preservative free digoxin (oral tablet), T1 (ophthalmic solution), T1 dihydroergotamine mesylate (nasal solution), T1 DOVATO (ORAL TABLET), T1 - DL; QL - PA; DL; QL doxazosin mesylate (oral tablet), T1 dilantin (oral capsule), T1 doxepin hcl (external cream), T1 - PA; DL; QL dilantin infatabs (oral tablet chewable), T1 doxepin hcl (oral capsule), T1 dilt-xr (oral capsule extended release 24 hour), doxepin hcl (oral concentrate), T1 T1 doxercalciferol (oral capsule), T1 - B/D,PA diltiazem hcl (oral tablet immediate release), T1 doxy 100 (intravenous solution reconstituted), T1 diltiazem hcl er (oral capsule extended release doxycycline hyclate (100mg oral tablet 12 hour), T1 immediate release, 20mg oral tablet immediate diltiazem hcl er beads (360mg oral capsule release), T1 extended release 24 hour, 420mg oral capsule doxycycline hyclate (oral capsule), T1 extended release 24 hour), T1 doxycycline monohydrate (100mg oral capsule, diltiazem hcl er coated beads (120mg oral 50mg oral capsule), T1 capsule extended release 24 hour, 180mg oral doxycycline monohydrate (100mg oral tablet, capsule extended release 24 hour, 240mg oral 50mg oral tablet, 75mg oral tablet), T1 capsule extended release 24 hour, 300mg oral doxycycline monohydrate (oral suspension capsule extended release 24 hour), T1 reconstituted), T1 DIPENTUM (ORAL CAPSULE), T1 - DL DRIZALMA SPRINKLE (ORAL CAPSULE diphenoxylate-atropine (oral liquid), T1 DELAYED RELEASE SPRINKLE), T1 - ST; QL diphenoxylate-atropine (oral tablet), T1 dronabinol (oral capsule), T1 - PA DIPHTHERIA-TETANUS TOXOIDS DT drospirenone-ethinyl estradiol (oral tablet), T1 (INTRAMUSCULAR SUSPENSION), T1 - QL DROXIA (ORAL CAPSULE), T1 disulfiram (oral tablet), T1 DUAVEE (ORAL TABLET), T1 DIURIL (ORAL SUSPENSION), T1 DULERA (INHALATION AEROSOL), T1 - QL divalproex sodium (oral capsule delayed release duloxetine hcl (20mg oral capsule delayed sprinkle), T1 release particles, 30mg oral capsule delayed divalproex sodium (oral tablet delayed release), release particles, 60mg oral capsule delayed T1 release particles), T1 - QL divalproex sodium er (oral tablet extended DURAMORPH (INJECTION SOLUTION), T1 - DL release 24 hour), T1 dutasteride (oral capsule), T1 - QL dofetilide (oral capsule), T1 DYMISTA (NASAL SUSPENSION), T1 donepezil hcl (oral tablet), T1 - QL E donepezil hcl odt (oral tablet dispersible), T1 - QL E.E.S. GRANULES (ORAL SUSPENSION

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

58 RECONSTITUTED), T1 ENBREL SURECLICK (SUBCUTANEOUS econazole nitrate (external cream), T1 - QL SOLUTION AUTO-INJECTOR), T1 - PA; DL EDARBI (ORAL TABLET), T1 - QL endocet (10-325mg oral tablet, 5-325mg oral EDARBYCLOR (ORAL TABLET), T1 - QL tablet, 7.5-325mg oral tablet), T1 - 7D; MME; DL; QL EDURANT (ORAL TABLET), T1 - DL; QL ENGERIX-B (INJECTION SUSPENSION), T1 - B/ efavirenz (oral capsule), T1 - QL D,PA; QL efavirenz (oral tablet), T1 - QL enoxaparin sodium (subcutaneous solution), T1 - EGRIFTA (1MG SUBCUTANEOUS SOLUTION QL RECONSTITUTED), T1 - PA; LA; DL enpresse-28 (oral tablet), T1 EGRIFTA SV (2MG SUBCUTANEOUS enskyce (oral tablet), T1 SOLUTION RECONSTITUTED), T1 - PA; LA; DL entacapone (oral tablet), T1 ELESTRIN (TRANSDERMAL GEL), T1 entecavir (oral tablet), T1 ELIQUIS (ORAL TABLET), T1 - QL ENTRESTO (ORAL TABLET), T1 - QL ELIQUIS STARTER PACK (ORAL TABLET), T1 - QL enulose (oral solution), T1 ELMIRON (ORAL CAPSULE), T1 - DL ENVARSUS XR (ORAL TABLET EXTENDED RELEASE 24 HOUR), T1 - B/D,PA eluryng (vaginal ring), T1 EPCLUSA (ORAL TABLET), T1 - PA; DL; QL EMCYT (ORAL CAPSULE), T1 - DL EPIDIOLEX (ORAL SOLUTION), T1 - PA; DL

EMGALITY (120MG/ML SUBCUTANEOUS Drug List SOLUTION PREFILLED SYRINGE), T1 - PA; QL epinastine hcl (ophthalmic solution), T1 EMGALITY (300MG DOSE) (100MG/ML epinephrine (injection solution auto-injector), T1 - SUBCUTANEOUS SOLUTION PREFILLED QL SYRINGE), T1 - PA; QL epitol (oral tablet), T1 EMGALITY (SUBCUTANEOUS SOLUTION EPIVIR HBV (ORAL SOLUTION), T1 AUTO-INJECTOR), T1 - PA; QL eplerenone (oral tablet), T1 emoquette (oral tablet), T1 ergotamine-caffeine (oral tablet), T1 EMSAM (TRANSDERMAL PATCH 24 HOUR), T1 ERIVEDGE (ORAL CAPSULE), T1 - PA; LA; DL; - DL; QL QL EMTRIVA (ORAL CAPSULE), T1 - QL ERLEADA (ORAL TABLET), T1 - PA; DL; QL EMTRIVA (ORAL SOLUTION), T1 - QL erlotinib hcl (oral tablet), T1 - PA; DL; QL enalapril maleate (oral tablet), T1 - QL errin (oral tablet), T1 enalapril-hydrochlorothiazide (oral tablet), T1 - ertapenem sodium (injection solution QL reconstituted), T1 ENBREL (SUBCUTANEOUS SOLUTION ery (external pad), T1 PREFILLED SYRINGE), T1 - PA; DL erythrocin lactobionate (intravenous solution ENBREL (SUBCUTANEOUS SOLUTION reconstituted), T1 RECONSTITUTED), T1 - PA; DL erythromycin (external gel), T1 ENBREL MINI (SUBCUTANEOUS SOLUTION erythromycin (external solution), T1 CARTRIDGE), T1 - PA; DL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

59 erythromycin (ophthalmic ointment), T1 7.5mg oral tablet), T1 - PA; DL erythromycin base (oral capsule delayed release EVOTAZ (ORAL TABLET), T1 - DL; QL particles), T1 exemestane (oral tablet), T1 erythromycin base (oral tablet delayed release), ezetimibe (oral tablet), T1 - QL T1 ezetimibe-simvastatin (oral tablet), T1 - QL erythromycin base (oral tablet immediate F release), T1 erythromycin ethylsuccinate (200mg/5ml oral FML (OPHTHALMIC OINTMENT), T1 suspension reconstituted), T1 FML FORTE (OPHTHALMIC SUSPENSION), T1 erythromycin ethylsuccinate (oral tablet), T1 falmina (oral tablet), T1 ESBRIET (ORAL CAPSULE), T1 - PA; LA; DL; QL famciclovir (oral tablet), T1 - QL ESBRIET (ORAL TABLET), T1 - PA; LA; DL; QL famotidine (20mg oral tablet, 40mg oral tablet), escitalopram oxalate (oral solution), T1 T1 escitalopram oxalate (oral tablet), T1 famotidine (oral suspension reconstituted), T1 esomeprazole magnesium (oral capsule delayed FANAPT (10MG ORAL TABLET, 12MG ORAL release) (generic nexium), T1 - QL TABLET, 4MG ORAL TABLET, 6MG ORAL TABLET, 8MG ORAL TABLET), T1 - ST; DL; QL estarylla (oral tablet), T1 FANAPT (1MG ORAL TABLET, 2MG ORAL estradiol (oral tablet), T1 TABLET), T1 - ST; QL estradiol (transdermal patch weekly), T1 - QL FANAPT TITRATION PACK (ORAL TABLET), T1 estradiol (vaginal cream), T1 - ST estradiol (vaginal tablet), T1 - QL FARXIGA (ORAL TABLET), T1 - QL estradiol valerate (intramuscular oil), T1 FARYDAK (ORAL CAPSULE), T1 - PA; DL ESTRING (VAGINAL RING), T1 FASENRA (SUBCUTANEOUS SOLUTION ethacrynic acid (oral tablet), T1 PREFILLED SYRINGE), T1 - PA; LA; DL ethambutol hcl (oral tablet), T1 FASENRA PEN (SUBCUTANEOUS SOLUTION ethosuximide (oral capsule), T1 AUTO-INJECTOR), T1 - PA; LA; DL ethosuximide (oral solution), T1 fayosim (oral tablet), T1 ethynodiol diacetate-ethinyl estradiol (oral febuxostat (oral tablet), T1 - ST tablet), T1 felbamate (oral suspension), T1 - DL etodolac (oral capsule), T1 felbamate (oral tablet), T1 etodolac (oral tablet immediate release), T1 felodipine er (oral tablet extended release 24 etodolac er (oral tablet extended release 24 hour), T1 hour), T1 FEMRING (VAGINAL RING), T1 etonogestrel-ethinyl estradiol (vaginal ring), T1 femynor (oral tablet), T1 EUTHYROX (ORAL TABLET), T1 fenofibrate (145mg oral tablet, 48mg oral tablet), everolimus (0.25mg oral tablet, 0.5mg oral T1 tablet, 0.75mg oral tablet), T1 - B/D,PA; DL fenofibrate (160mg oral tablet, 54mg oral tablet), everolimus (2.5mg oral tablet, 5mg oral tablet, T1

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

60 fenofibrate micronized (134mg oral capsule), T1 fluconazole (oral suspension reconstituted), T1 fenofibrate micronized (200mg oral capsule, fluconazole (oral tablet), T1 67mg oral capsule), T1 fluconazole in sodium chloride (intravenous fenofibric acid (oral capsule delayed release), T1 solution), T1 fentanyl (100mcg/hr transdermal patch 72 hour, flucytosine (oral capsule), T1 - DL 12mcg/hr transdermal patch 72 hour, 25mcg/hr fludrocortisone acetate (oral tablet), T1 transdermal patch 72 hour, 50mcg/hr flunisolide (nasal solution), T1 transdermal patch 72 hour, 75mcg/hr transdermal patch 72 hour), T1 - 7D; MME; DL; fluocinolone acetonide (external cream), T1 QL fluocinolone acetonide (external ointment), T1 fentanyl citrate (1200mcg buccal lozenge on a fluocinolone acetonide (external solution), T1 handle, 1600mcg buccal lozenge on a handle, fluocinolone acetonide (otic oil), T1 400mcg buccal lozenge on a handle, 600mcg fluocinolone acetonide scalp (external oil), T1 buccal lozenge on a handle, 800mcg buccal fluocinonide (external gel), T1 lozenge on a handle), T1 - PA; DL; QL fluocinonide (external ointment), T1 fentanyl citrate (200mcg buccal lozenge on a handle), T1 - PA; DL; QL fluocinonide (external solution), T1 FERRIPROX (ORAL SOLUTION), T1 - PA; DL fluocinonide emulsified base (external cream), T1 FERRIPROX (ORAL TABLET), T1 - PA; DL fluorometholone (ophthalmic suspension), T1 FETZIMA (ORAL CAPSULE EXTENDED RELEASE 24 HOUR), T1 - ST; QL fluorouracil (5% external cream), T1 Drug List FETZIMA TITRATION (ORAL CAPSULE ER 24 fluorouracil (external solution), T1 HOUR THERAPY PACK), T1 - ST fluoxetine hcl (10mg oral capsule immediate FINACEA (EXTERNAL FOAM), T1 release, 20mg oral capsule immediate release, 40mg oral capsule immediate release), T1 finasteride (5mg oral tablet) (generic proscar), T1 fluoxetine hcl (20mg/5ml oral solution), T1 FIRMAGON (240MG DOSE) (120MG/VIAL fluoxetine hcl (90mg oral capsule delayed SUBCUTANEOUS SOLUTION release), T1 RECONSTITUTED), T1 - PA; DL fluphenazine decanoate (injection solution), T1 FIRMAGON (80MG SUBCUTANEOUS fluphenazine hcl (10mg oral tablet, 1mg oral SOLUTION RECONSTITUTED), T1 - PA tablet, 2.5mg oral tablet, 5mg oral tablet), T1 flac (otic oil), T1 fluphenazine hcl (2.5mg/5ml oral elixir), T1 FLAREX (OPHTHALMIC SUSPENSION), T1 fluphenazine hcl (2.5mg/ml injection solution), FLEBOGAMMA DIF (5GM/50ML INTRAVENOUS T1 SOLUTION), T1 - PA; DL fluphenazine hcl (5mg/ml oral concentrate), T1 flecainide acetate (oral tablet), T1 flurbiprofen (100mg oral tablet), T1 FLOVENT DISKUS (INHALATION AEROSOL flurbiprofen sodium (ophthalmic solution), T1 POWDER BREATH ACTIVATED), T1 - QL flutamide (oral capsule), T1 FLOVENT HFA (INHALATION AEROSOL), T1 - fluticasone propionate (external cream), T1 QL fluticasone propionate (external ointment), T1

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

61 fluticasone propionate (nasal suspension), T1 GAMMAGARD (2.5GM/25ML INJECTION fluticasone-salmeterol (inhalation aerosol powder SOLUTION), T1 - PA; DL breath activated), T1 - QL GAMMAGARD S/D LESS IGA (INTRAVENOUS fluvastatin sodium (oral capsule), T1 - QL SOLUTION RECONSTITUTED), T1 - PA; DL fluvoxamine maleate (oral tablet), T1 GAMMAKED (1GM/10ML INJECTION fondaparinux sodium (10mg/0.8ml SOLUTION), T1 - PA; DL subcutaneous solution, 5mg/0.4ml GAMMAPLEX (10GM/100ML INTRAVENOUS subcutaneous solution, 7.5mg/0.6ml SOLUTION, 10GM/200ML INTRAVENOUS subcutaneous solution), T1 - DL SOLUTION, 20GM/200ML INTRAVENOUS fondaparinux sodium (2.5mg/0.5ml SOLUTION, 5GM/50ML INTRAVENOUS subcutaneous solution), T1 SOLUTION), T1 - PA; DL FORTEO (SUBCUTANEOUS SOLUTION PEN- GAMUNEX-C (1GM/10ML INJECTION INJECTOR), T1 - PA; DL; QL SOLUTION), T1 - PA; DL fosamprenavir calcium (oral tablet), T1 - DL; QL GARDASIL 9 (INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE), T1 - QL fosinopril sodium (oral tablet), T1 - QL GARDASIL 9 (INTRAMUSCULAR fosinopril sodium-hctz (oral tablet), T1 - QL SUSPENSION), T1 - QL FREAMINE HBC (INTRAVENOUS SOLUTION), gatifloxacin (ophthalmic solution), T1 T1 - B/D,PA GATTEX (SUBCUTANEOUS KIT), T1 - PA; LA; furosemide (injection solution), T1 - B/D,PA DL furosemide (oral solution), T1 gauze (non-medicated 2x2 pad), T1 furosemide (oral tablet), T1 gavilyte-c (oral solution reconstituted), T1 FUZEON (SUBCUTANEOUS SOLUTION gavilyte-g (oral solution reconstituted), T1 RECONSTITUTED), T1 - DL; QL gavilyte-n with flavor pack (oral solution fyavolv (oral tablet), T1 reconstituted), T1 FYCOMPA (10MG ORAL TABLET, 12MG ORAL gemfibrozil (oral tablet), T1 TABLET, 4MG ORAL TABLET, 6MG ORAL TABLET, 8MG ORAL TABLET), T1 - DL; QL generlac (oral solution), T1 FYCOMPA (2MG ORAL TABLET), T1 - QL gengraf (oral capsule), T1 - B/D,PA FYCOMPA (ORAL SUSPENSION), T1 - DL; QL gengraf (oral solution), T1 - B/D,PA GENOTROPIN (SUBCUTANEOUS SOLUTION G RECONSTITUTED), T1 - PA; DL gabapentin (250mg/5ml oral solution), T1 GENOTROPIN MINIQUICK (SUBCUTANEOUS gabapentin (oral capsule), T1 SOLUTION RECONSTITUTED), T1 - PA; DL gabapentin (oral tablet), T1 gentak (ophthalmic ointment), T1 galantamine hydrobromide (oral solution), T1 - gentamicin sulfate (40mg/ml injection solution), QL T1 galantamine hydrobromide (oral tablet), T1 - QL gentamicin sulfate (external cream), T1 galantamine hydrobromide er (oral capsule gentamicin sulfate (external ointment), T1 extended release 24 hour), T1 - QL gentamicin sulfate (ophthalmic solution), T1

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

62 gentamicin sulfate-0.9% sodium chloride H (intravenous solution), T1 HAEGARDA (SUBCUTANEOUS SOLUTION GENVOYA (ORAL TABLET), T1 - DL; QL RECONSTITUTED), T1 - PA; LA; DL GEODON (INTRAMUSCULAR SOLUTION hailey 24 fe (oral tablet), T1 RECONSTITUTED), T1 halobetasol propionate (external cream), T1 gianvi (oral tablet), T1 halobetasol propionate (external ointment), T1 GILENYA (0.5MG ORAL CAPSULE), T1 - DL; QL haloperidol (oral tablet), T1 GILOTRIF (ORAL TABLET), T1 - PA; LA; DL haloperidol decanoate (intramuscular solution), GLASSIA (INTRAVENOUS SOLUTION), T1 - PA; T1 LA; DL haloperidol lactate (injection solution), T1 glatiramer acetate (subcutaneous solution haloperidol lactate (oral concentrate), T1 prefilled syringe), T1 - DL; QL HAVRIX (INTRAMUSCULAR SUSPENSION), T1 - glatopa (subcutaneous solution prefilled QL syringe), T1 - DL; QL heparin sodium (10000unit/ml injection solution, glimepiride (oral tablet), T1 - QL 20000unit/ml injection solution, 5000unit/ml glipizide (oral tablet immediate release), T1 - QL injection solution), T1 glipizide er (oral tablet extended release 24 heparin sodium (1000unit/ml injection solution), hour), T1 - QL T1 - B/D,PA glipizide-metformin hcl (oral tablet), T1 - QL HEPATAMINE (INTRAVENOUS SOLUTION), T1 - Drug List GLUCAGEN HYPOKIT (INJECTION SOLUTION B/D,PA RECONSTITUTED), T1 HETLIOZ (ORAL CAPSULE), T1 - PA; LA; DL; QL GLUCAGON (INJECTION KIT) (LILLY), T1 HIBERIX (INJECTION SOLUTION GLYXAMBI (ORAL TABLET), T1 - QL RECONSTITUTED), T1 - QL granisetron hcl (oral tablet), T1 - B/D,PA; QL HUMALOG (SUBCUTANEOUS SOLUTION GRANIX (SUBCUTANEOUS SOLUTION CARTRIDGE), T1 PREFILLED SYRINGE), T1 - ST; DL HUMALOG (SUBCUTANEOUS SOLUTION), T1 GRANIX (SUBCUTANEOUS SOLUTION), T1 - HUMALOG JUNIOR KWIKPEN ST; DL (SUBCUTANEOUS SOLUTION PEN- griseofulvin microsize (oral suspension), T1 INJECTOR), T1 griseofulvin microsize (oral tablet), T1 HUMALOG KWIKPEN (SUBCUTANEOUS griseofulvin ultramicrosize (oral tablet), T1 SOLUTION PEN-INJECTOR), T1 guanfacine hcl er (oral tablet extended release HUMALOG MIX 50/50 (SUBCUTANEOUS 24 hour), T1 SUSPENSION), T1 GUANIDINE HCL (ORAL TABLET), T1 HUMALOG MIX 50/50 KWIKPEN (SUBCUTANEOUS SUSPENSION PEN- GVOKE HYPOPEN 2-PACK (SUBCUTANEOUS INJECTOR), T1 SOLUTION AUTO-INJECTOR), T1 HUMALOG MIX 75/25 (SUBCUTANEOUS GVOKE PFS (SUBCUTANEOUS SOLUTION SUSPENSION), T1 PREFILLED SYRINGE), T1 HUMALOG MIX 75/25 KWIKPEN

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

63 (SUBCUTANEOUS SUSPENSION PEN- external cream), T1 INJECTOR), T1 hydrocortisone (1% external ointment, 2.5% HUMIRA (SUBCUTANEOUS PREFILLED external ointment), T1 SYRINGE KIT), T1 - PA; DL hydrocortisone (2.5% external lotion), T1 HUMIRA PEDIATRIC CROHNS START hydrocortisone (oral tablet), T1 (SUBCUTANEOUS PREFILLED SYRINGE KIT), hydrocortisone (rectal enema), T1 T1 - PA; DL hydrocortisone butyrate (external ointment), T1 HUMIRA PEN (SUBCUTANEOUS PEN- INJECTOR KIT), T1 - PA; DL hydrocortisone valerate (external cream), T1 HUMIRA PEN CROHNS DISEASE STARTER hydrocortisone valerate (external ointment), T1 (SUBCUTANEOUS PEN-INJECTOR KIT), T1 - hydrocortisone-acetic acid (otic solution), T1 PA; DL hydromorphone hcl (1mg/ml oral liquid), T1 - 7D; HUMIRA PEN PSORIASIS STARTER MME; DL; QL (SUBCUTANEOUS PEN-INJECTOR KIT), T1 - hydromorphone hcl (2mg oral tablet immediate PA; DL release, 4mg oral tablet immediate release, 8mg HUMULIN 70/30 (SUBCUTANEOUS oral tablet immediate release), T1 - 7D; MME; SUSPENSION), T1 DL; QL HUMULIN 70/30 KWIKPEN (SUBCUTANEOUS hydromorphone hcl er (oral tablet er 24 hour SUSPENSION PEN-INJECTOR), T1 abuse-deterrent), T1 - 7D; MME; DL; QL HUMULIN N (SUBCUTANEOUS SUSPENSION), hydromorphone hcl preservative free (10mg/ml T1 injection solution, 50mg/5ml injection solution), HUMULIN N KWIKPEN (SUBCUTANEOUS T1 - DL SUSPENSION PEN-INJECTOR), T1 hydroxychloroquine sulfate (oral tablet), T1 - QL HUMULIN R (INJECTION SOLUTION), T1 hydroxyurea (oral capsule), T1 HUMULIN R U-500 (CONCENTRATED) hydroxyzine hcl (oral syrup), T1 (SUBCUTANEOUS SOLUTION), T1 hydroxyzine hcl (oral tablet), T1 HUMULIN R U-500 KWIKPEN hydroxyzine pamoate (oral capsule), T1 (SUBCUTANEOUS SOLUTION PEN- I INJECTOR), T1 IDHIFA (ORAL TABLET), T1 - PA; LA; DL; QL hydralazine hcl (oral tablet), T1 IPOL (INJECTION), T1 - QL hydrochlorothiazide (oral capsule), T1 ibandronate sodium (oral tablet), T1 - QL hydrochlorothiazide (oral tablet), T1 IBRANCE (ORAL CAPSULE), T1 - PA; LA; DL; hydrocodone-acetaminophen (10-325mg oral QL tablet, 5-325mg oral tablet, 7.5-325mg oral tablet), T1 - 7D; MME; DL; QL IBRANCE (ORAL TABLET), T1 - PA; LA; DL; QL hydrocodone-acetaminophen (7.5-325mg/15ml ibu (600mg oral tablet, 800mg oral tablet), T1 oral solution), T1 - 7D; MME; DL; QL ibuprofen (400mg oral tablet, 600mg oral tablet, hydrocodone-ibuprofen (7.5-200mg oral tablet), 800mg oral tablet), T1 T1 - 7D; MME; DL; QL ibuprofen (oral suspension), T1 hydrocortisone (1% external cream, 2.5% icatibant acetate (subcutaneous solution), T1 -

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

64 PA; DL; QL HUMALOG), T1 ICLUSIG (ORAL TABLET), T1 - PA; LA; DL; QL INSULIN LISPRO (SUBCUTANEOUS ILEVRO (OPHTHALMIC SUSPENSION), T1 SOLUTION) (BRAND EQUIVALENT imatinib mesylate (oral tablet), T1 - PA; DL; QL HUMALOG), T1 IMBRUVICA (ORAL CAPSULE), T1 - PA; LA; DL; INSULIN LISPRO JUNIOR KWIKPEN QL (SUBCUTANEOUS SOLUTION PEN- INJECTOR) (BRAND EQUIVALENT IMBRUVICA (ORAL TABLET), T1 - PA; DL; QL HUMALOG), T1 imipenem-cilastatin (intravenous solution INSULIN LISPRO PROT & LISPRO reconstituted), T1 (SUBCUTANEOUS SUSPENSION PEN- imipramine hcl (oral tablet), T1 INJECTOR) (BRAND EQUIVALENT imipramine pamoate (oral capsule), T1 HUMALOG), T1 imiquimod (5% external cream), T1 - QL insulin syringes, needles, T1 IMIQUIMOD PUMP (3.75% EXTERNAL CREAM), INTELENCE (100MG ORAL TABLET, 200MG T1 - PA; DL ORAL TABLET), T1 - DL; QL IMOVAX RABIES (INTRAMUSCULAR INTELENCE (25MG ORAL TABLET), T1 - QL INJECTABLE), T1 - B/D,PA; QL INTRALIPID (INTRAVENOUS EMULSION), T1 - IMVEXXY MAINTENANCE PACK (VAGINAL B/D,PA INSERT), T1 - PA; QL INTRON A (INJECTION SOLUTION IMVEXXY STARTER PACK (VAGINAL INSERT), RECONSTITUTED), T1 - PA; LA; DL Drug List T1 - PA; QL INTRON A (INJECTION SOLUTION), T1 - PA; LA; incassia (oral tablet), T1 DL INCRELEX (SUBCUTANEOUS SOLUTION), T1 - introvale (oral tablet), T1 PA; LA; DL INVEGA SUSTENNA (117MG/0.75ML INCRUSE ELLIPTA (INHALATION AEROSOL INTRAMUSCULAR SUSPENSION PREFILLED POWDER BREATH ACTIVATED), T1 - QL SYRINGE, 156MG/ML INTRAMUSCULAR indapamide (oral tablet), T1 SUSPENSION PREFILLED SYRINGE, 234MG/ indomethacin (25mg oral capsule immediate 1.5ML INTRAMUSCULAR SUSPENSION release, 50mg oral capsule immediate release), PREFILLED SYRINGE, 78MG/0.5ML T1 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE), T1 - DL INFANRIX (INTRAMUSCULAR SUSPENSION), T1 - QL INVEGA SUSTENNA (39MG/0.25ML INTRAMUSCULAR SUSPENSION PREFILLED INGREZZA (ORAL CAPSULE THERAPY PACK), SYRINGE), T1 T1 - PA; DL; QL INVEGA TRINZA (INTRAMUSCULAR INGREZZA (ORAL CAPSULE), T1 - PA; DL; QL SUSPENSION PREFILLED SYRINGE), T1 - DL INLYTA (ORAL TABLET), T1 - PA; LA; DL; QL INVIRASE (ORAL TABLET), T1 - DL; QL INREBIC (ORAL CAPSULE), T1 - PA; DL; QL ipratropium bromide (inhalation solution), T1 - B/ INSULIN LISPRO (1 UNIT DIAL) D,PA (SUBCUTANEOUS SOLUTION PEN- ipratropium bromide (nasal solution), T1 INJECTOR) (BRAND EQUIVALENT

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

65 ipratropium-albuterol (inhalation solution), T1 - JANUMET (ORAL TABLET IMMEDIATE B/D,PA RELEASE), T1 - QL irbesartan (oral tablet), T1 - QL JANUMET XR (ORAL TABLET EXTENDED irbesartan-hydrochlorothiazide (oral tablet), T1 - RELEASE 24 HOUR), T1 - QL QL JANUVIA (ORAL TABLET), T1 - QL IRESSA (ORAL TABLET), T1 - PA; LA; DL; QL JARDIANCE (ORAL TABLET), T1 - QL ISENTRESS (100MG ORAL TABLET jasmiel (oral tablet), T1 CHEWABLE), T1 - QL JENTADUETO (ORAL TABLET IMMEDIATE ISENTRESS (25MG ORAL TABLET RELEASE), T1 - QL CHEWABLE), T1 - QL JENTADUETO XR (ORAL TABLET EXTENDED ISENTRESS (ORAL PACKET), T1 - QL RELEASE 24 HOUR), T1 - QL ISENTRESS (ORAL TABLET), T1 - DL; QL jinteli (oral tablet), T1 ISENTRESS HD (ORAL TABLET), T1 - DL; QL JUBLIA (EXTERNAL SOLUTION), T1 isibloom (oral tablet), T1 juleber (oral tablet), T1 ISOLYTE-P IN D5W (INTRAVENOUS JULUCA (ORAL TABLET), T1 - DL; QL SOLUTION), T1 junel 1.5/30 (oral tablet), T1 ISOLYTE-S (INTRAVENOUS SOLUTION), T1 junel 1/20 (oral tablet), T1 isoniazid (oral syrup), T1 junel fe 1.5/30 (oral tablet), T1 isoniazid (oral tablet), T1 junel fe 1/20 (oral tablet), T1 isosorbide dinitrate (10mg oral tablet immediate junel fe 24 (oral tablet), T1 release, 20mg oral tablet immediate release, JUXTAPID (ORAL CAPSULE), T1 - PA; LA; DL 30mg oral tablet immediate release, 5mg oral tablet immediate release), T1 K isosorbide mononitrate (oral tablet immediate KCL IN DEXTROSE-NACL (INTRAVENOUS release), T1 SOLUTION), T1 isosorbide mononitrate er (oral tablet extended KCL-LACTATED RINGERS-D5W release 24 hour), T1 (INTRAVENOUS SOLUTION), T1 isotretinoin (oral capsule), T1 - PA kaitlib fe (oral tablet chewable), T1 itraconazole (oral capsule), T1 - PA; QL KALETRA (100-25MG ORAL TABLET), T1 - QL itraconazole (oral solution), T1 - PA; DL KALETRA (200-50MG ORAL TABLET), T1 - DL; ivermectin (oral tablet), T1 QL IXIARO (INTRAMUSCULAR SUSPENSION), T1 - KALYDECO (ORAL PACKET), T1 - PA; LA; DL; QL QL KALYDECO (ORAL TABLET), T1 - PA; LA; DL; J QL JADENU SPRINKLE (ORAL PACKET), T1 - PA; kariva (oral tablet), T1 DL kelnor 1/35 (oral tablet), T1 JAKAFI (ORAL TABLET), T1 - PA; LA; DL; QL kelnor 1/50 (oral tablet), T1 jantoven (oral tablet), T1 ketoconazole (external cream), T1 - QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

66 ketoconazole (external shampoo), T1 larin fe 1.5/30 (oral tablet), T1 ketoconazole (oral tablet), T1 larin fe 1/20 (oral tablet), T1 ketoprofen (oral capsule immediate release), T1 labetalol hcl (oral tablet), T1 ketorolac tromethamine (ophthalmic solution), LACRISERT (OPHTHALMIC INSERT), T1 T1 lactulose (10gm/15ml oral solution), T1 KINERET (SUBCUTANEOUS SOLUTION lamivudine (100mg oral tablet), T1 PREFILLED SYRINGE), T1 - PA; DL lamivudine (10mg/ml oral solution), T1 - QL KINRIX (INTRAMUSCULAR SUSPENSION), T1 - lamivudine (150mg oral tablet, 300mg oral QL tablet), T1 - QL kionex (oral suspension), T1 lamivudine-zidovudine (oral tablet), T1 - QL KISQALI (200MG DOSE) (ORAL TABLET), T1 - lamotrigine (100mg oral tablet immediate PA; DL; QL release, 150mg oral tablet immediate release, KISQALI (400MG DOSE) (ORAL TABLET), T1 - 200mg oral tablet immediate release, 25mg oral PA; DL; QL tablet immediate release), T1 KISQALI (600MG DOSE) (ORAL TABLET), T1 - lamotrigine (25mg oral tablet chewable, 5mg PA; DL; QL oral tablet chewable), T1 KISQALI FEMARA (200MG DOSE) (ORAL LANOXIN (ORAL TABLET), T1 TABLET THERAPY PACK), T1 - PA; DL; QL lansoprazole (oral capsule delayed release), T1 - KISQALI FEMARA (400MG DOSE) (ORAL QL TABLET THERAPY PACK), T1 - PA; DL; QL lanthanum carbonate (oral tablet chewable), T1 - Drug List KISQALI FEMARA (600MG DOSE) (ORAL DL TABLET THERAPY PACK), T1 - PA; DL; QL LANTUS (SUBCUTANEOUS SOLUTION), T1 klor-con (oral packet), T1 LANTUS SOLOSTAR (SUBCUTANEOUS KLOR-CON 10 (ORAL TABLET EXTENDED SOLUTION PEN-INJECTOR), T1 RELEASE), T1 larissia (oral tablet), T1 KLOR-CON 8 (ORAL TABLET EXTENDED LASTACAFT (OPHTHALMIC SOLUTION), T1 RELEASE), T1 latanoprost (ophthalmic solution), T1 klor-con m10 (oral tablet extended release), T1 LATUDA (ORAL TABLET), T1 - DL; QL klor-con m15 (oral tablet extended release), T1 LAYOLIS FE (ORAL TABLET CHEWABLE), T1 klor-con m20 (oral tablet extended release), T1 leena (oral tablet), T1 KORLYM (ORAL TABLET), T1 - PA; LA; DL; QL leflunomide (oral tablet), T1 KOSELUGO (ORAL CAPSULE), T1 - PA; DL; QL LENVIMA 10MG DAILY DOSE (ORAL CAPSULE kurvelo (oral tablet), T1 THERAPY PACK), T1 - PA; LA; DL KUVAN (ORAL PACKET), T1 - LA; DL LENVIMA 12MG DAILY DOSE (ORAL CAPSULE KUVAN (ORAL TABLET SOLUBLE), T1 - LA; DL THERAPY PACK), T1 - PA; LA; DL L LENVIMA 14MG DAILY DOSE (ORAL CAPSULE larin 1.5/30 (oral tablet), T1 THERAPY PACK), T1 - PA; LA; DL larin 1/20 (oral tablet), T1 LENVIMA 18MG DAILY DOSE (ORAL CAPSULE THERAPY PACK), T1 - PA; LA; DL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

67 LENVIMA 20MG DAILY DOSE (ORAL CAPSULE levonest (oral tablet), T1 THERAPY PACK), T1 - PA; LA; DL levonorgestrel-ethinyl estradiol & ethinyl estradiol LENVIMA 24MG DAILY DOSE (ORAL CAPSULE (oral tablet), T1 THERAPY PACK), T1 - PA; LA; DL levonorgestrel-ethinyl estradiol (oral tablet), T1 LENVIMA 4MG DAILY DOSE (ORAL CAPSULE levonorgestrel-ethinyl estradiol 91-day (oral THERAPY PACK), T1 - PA; LA; DL tablet), T1 LENVIMA 8MG DAILY DOSE (ORAL CAPSULE levora 0.15/30 (28) (oral tablet), T1 THERAPY PACK), T1 - PA; LA; DL levorphanol tartrate (oral tablet), T1 - 7D; MME; lessina (oral tablet), T1 DL; QL letrozole (oral tablet), T1 levothyroxine sodium (oral tablet), T1 leucovorin calcium (10mg oral tablet, 15mg oral LEVOXYL (ORAL TABLET), T1 tablet, 5mg oral tablet), T1 LEXIVA (ORAL SUSPENSION), T1 - QL leucovorin calcium (25mg oral tablet), T1 lidocaine (5% external ointment), T1 - QL LEUKERAN (ORAL TABLET), T1 - DL lidocaine (5% external patch), T1 - PA; QL LEUKINE (INJECTION SOLUTION lidocaine hcl (4% external solution), T1 RECONSTITUTED), T1 - PA; DL lidocaine hcl (external gel), T1 leuprolide acetate (injection kit), T1 - PA lidocaine viscous (2% mouth/throat solution), T1 levalbuterol hcl (inhalation nebulization solution), T1 - B/D,PA lidocaine-prilocaine (external cream), T1 LEVEMIR (SUBCUTANEOUS SOLUTION), T1 linezolid (intravenous solution), T1 LEVEMIR FLEXTOUCH (SUBCUTANEOUS linezolid (oral suspension reconstituted), T1 - DL SOLUTION PEN-INJECTOR), T1 linezolid (oral tablet), T1 - QL levetiracetam (oral solution), T1 LINZESS (ORAL CAPSULE), T1 - QL levetiracetam (oral tablet immediate release), T1 liothyronine sodium (oral tablet), T1 levetiracetam er (oral tablet extended release 24 lisinopril (oral tablet), T1 - QL hour), T1 lisinopril-hydrochlorothiazide (oral tablet), T1 - LEVO-T (ORAL TABLET), T1 QL levobunolol hcl (ophthalmic solution), T1 LITHIUM (ORAL SOLUTION), T1 levocarnitine (1gm/10ml oral solution), T1 lithium carbonate (oral capsule), T1 LEVOCARNITINE (330MG ORAL TABLET), T1 lithium carbonate (oral tablet immediate levocetirizine dihydrochloride (oral tablet), T1 - release), T1 QL lithium carbonate er (oral tablet extended levofloxacin (0.5% ophthalmic solution), T1 release), T1 levofloxacin (250mg oral tablet, 500mg oral LITHOSTAT (ORAL TABLET), T1 - DL tablet, 750mg oral tablet), T1 LIVALO (ORAL TABLET), T1 - QL levofloxacin (25mg/ml intravenous solution), T1 LOKELMA (ORAL PACKET), T1 - QL levofloxacin (25mg/ml oral solution), T1 LONHALA MAGNAIR (INHALATION levofloxacin in d5w (500mg/100ml intravenous SOLUTION), T1 - DL; QL solution, 750mg/150ml intravenous solution), T1 LONSURF (ORAL TABLET), T1 - PA; LA; DL; QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

68 loperamide hcl (oral capsule), T1 M lopinavir-ritonavir (oral solution), T1 - QL M-M-R II (INJECTION SOLUTION lorazepam (oral tablet), T1 - QL RECONSTITUTED), T1 - QL lorazepam intensol (oral concentrate), T1 - QL magnesium sulfate (50% (10ml syringe) injection LORBRENA (ORAL TABLET), T1 - PA; LA; DL; solution), T1 QL MAGNESIUM SULFATE (50% INJECTION lorcet (oral tablet), T1 - 7D; MME; DL; QL SOLUTION), T1 lorcet hd (oral tablet), T1 - 7D; MME; DL; QL malathion (external lotion), T1 lorcet plus (7.5-325mg oral tablet), T1 - 7D; maprotiline hcl (oral tablet), T1 MME; DL; QL marlissa (oral tablet), T1 loryna (oral tablet), T1 MARPLAN (ORAL TABLET), T1 losartan potassium (oral tablet), T1 - QL MATULANE (ORAL CAPSULE), T1 - LA; DL losartan potassium-hctz (oral tablet), T1 - QL matzim la (oral tablet extended release 24 hour), LOTEMAX (OPHTHALMIC GEL), T1 T1 LOTEMAX (OPHTHALMIC OINTMENT), T1 MAVYRET (ORAL TABLET), T1 - PA; DL; QL LOTEMAX (OPHTHALMIC SUSPENSION), T1 MAYZENT (ORAL TABLET), T1 - LA; DL; QL LOTEMAX SM (OPHTHALMIC GEL), T1 meclizine hcl (oral tablet), T1 loteprednol etabonate (ophthalmic suspension), medroxyprogesterone acetate (10mg oral tablet,

T1 2.5mg oral tablet, 5mg oral tablet), T1 Drug List lovastatin (oral tablet), T1 - QL medroxyprogesterone acetate (150mg/ml low-ogestrel (oral tablet), T1 intramuscular suspension prefilled syringe), T1 loxapine succinate (oral capsule), T1 medroxyprogesterone acetate (150mg/ml intramuscular suspension), T1 LUMIGAN (OPHTHALMIC SOLUTION), T1 mefloquine hcl (oral tablet), T1 LUPANETA PACK (COMBINATION KIT), T1 - PA; DL megestrol acetate (40mg/ml oral suspension), T1 LUPRON DEPOT (1-MONTH) (INTRAMUSCULAR KIT), T1 - PA; DL megestrol acetate (625mg/5ml oral suspension), T1 LUPRON DEPOT (3-MONTH) (INTRAMUSCULAR KIT), T1 - PA; DL megestrol acetate (oral tablet), T1 LUPRON DEPOT (4-MONTH) MEKINIST (ORAL TABLET), T1 - PA; LA; DL (INTRAMUSCULAR KIT), T1 - PA; DL MEKTOVI (ORAL TABLET), T1 - PA; DL LUPRON DEPOT (6-MONTH) melodetta 24 fe (oral tablet chewable), T1 (INTRAMUSCULAR KIT), T1 - PA; DL meloxicam (oral tablet), T1 lutera (oral tablet), T1 memantine hcl (10mg oral tablet, 5mg oral LYNPARZA (ORAL TABLET), T1 - PA; LA; DL; tablet), T1 - PA; QL QL memantine hcl (2mg/ml oral solution), T1 - PA; LYSODREN (ORAL TABLET), T1 - DL QL lyza (oral tablet), T1 memantine hcl er (oral capsule extended release

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

69 24 hour), T1 - PA; QL methscopolamine bromide (oral tablet), T1 MEMANTINE HCL TITRATION PAK (ORAL methyldopa (oral tablet), T1 TABLET), T1 - PA methyldopa-hydrochlorothiazide (oral tablet), T1 MENACTRA (INTRAMUSCULAR INJECTABLE), methylphenidate hcl (oral solution), T1 - QL T1 - QL methylphenidate hcl (oral tablet immediate menest (oral tablet), T1 release) (generic ritalin), T1 - QL MENTAX (EXTERNAL CREAM), T1 methylphenidate hcl er (10mg oral tablet MENVEO (INTRAMUSCULAR SOLUTION extended release, 20mg oral tablet extended RECONSTITUTED), T1 - QL release), T1 - QL mercaptopurine (oral tablet), T1 methylprednisolone (oral tablet therapy pack), meropenem (intravenous solution reconstituted), T1 T1 methylprednisolone (oral tablet), T1 mesalamine (1.2gm oral tablet delayed release) metoclopramide hcl (5mg/5ml oral solution), T1 (generic lialda), T1 - QL metoclopramide hcl (oral tablet), T1 mesalamine (rectal enema), T1 - QL metolazone (oral tablet), T1 mesalamine (rectal suppository), T1 - QL metoprolol succinate er (oral tablet extended mesalamine er (0.375mg oral capsule extended release 24 hour), T1 release 24 hour) (generic apriso), T1 - QL metoprolol tartrate (100mg oral tablet, 25mg oral MESNEX (ORAL TABLET), T1 - DL tablet, 50mg oral tablet), T1 metaproterenol sulfate (oral syrup), T1 metoprolol-hydrochlorothiazide (oral tablet), T1 metformin hcl (1000mg oral tablet immediate metronidazole (0.75% external cream), T1 release, 500mg oral tablet immediate release, metronidazole (0.75% external gel, 1% external 850mg oral tablet immediate release), T1 - QL gel), T1 metformin hcl (500mg/5ml oral solution), T1 - QL metronidazole (0.75% external lotion), T1 metformin hcl er (oral tablet extended release 24 metronidazole (0.75% vaginal gel), T1 hour) (generic glucophage xr), T1 - QL metronidazole (250mg oral tablet, 500mg oral methadone hcl (oral solution), T1 - 7D; MME; DL; tablet), T1 QL metronidazole in nacl 0.79% (intravenous methadone hcl (oral tablet), T1 - 7D; MME; DL; solution), T1 QL mexiletine hcl (oral capsule), T1 methazolamide (oral tablet), T1 mibelas 24 fe (oral tablet chewable), T1 methenamine hippurate (oral tablet), T1 micafungin sodium (intravenous solution methimazole (oral tablet), T1 reconstituted), T1 methotrexate (oral tablet), T1 miconazole 3 (vaginal suppository), T1 methotrexate sodium (50mg/2ml injection microgestin 1.5/30 (oral tablet), T1 solution prefilled syringe), T1 microgestin 1/20 (oral tablet), T1 methotrexate sodium (50mg/2ml injection microgestin fe 1.5/30 (oral tablet), T1 solution), T1 microgestin fe 1/20 (oral tablet), T1 methoxsalen rapid (oral capsule), T1 - DL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

70 midodrine hcl (oral tablet), T1 vigamox), T1 migergot (rectal suppository), T1 - DL moxifloxacin hcl (oral tablet), T1 miglitol (oral tablet), T1 - QL moxifloxacin hcl in nacl (intravenous solution), miglustat (oral capsule), T1 - PA; LA; DL T1 mili (oral tablet), T1 MULTAQ (ORAL TABLET), T1 - QL minitran (transdermal patch 24 hour), T1 mupirocin (external ointment), T1 - QL minocycline hcl (oral capsule), T1 mupirocin calcium (external cream), T1 minocycline hcl (oral tablet immediate release), MYALEPT (SUBCUTANEOUS SOLUTION T1 RECONSTITUTED), T1 - PA; LA; DL minoxidil (oral tablet), T1 mycophenolate mofetil (oral capsule), T1 - B/ mirtazapine (oral tablet), T1 D,PA mirtazapine odt (oral tablet dispersible), T1 mycophenolate mofetil (oral suspension reconstituted), T1 - B/D,PA; DL MIRVASO (EXTERNAL GEL), T1 mycophenolate mofetil (oral tablet), T1 - B/D,PA misoprostol (oral tablet), T1 mycophenolate sodium (oral tablet delayed modafinil (oral tablet), T1 - PA; QL release), T1 - B/D,PA moexipril hcl (oral tablet), T1 - QL myorisan (oral capsule), T1 - PA molindone hcl (oral tablet), T1 MYRBETRIQ (ORAL TABLET EXTENDED mometasone furoate (external cream), T1 RELEASE 24 HOUR), T1 Drug List mometasone furoate (external ointment), T1 N mometasone furoate (external solution), T1 nabumetone (oral tablet), T1 mometasone furoate (nasal suspension), T1 nadolol (oral tablet), T1 montelukast sodium (oral packet), T1 - QL nafcillin sodium (10gm intravenous solution montelukast sodium (oral tablet chewable), T1 - reconstituted), T1 QL nafcillin sodium (1gm injection solution montelukast sodium (oral tablet), T1 - QL reconstituted, 2gm injection solution morphine sulfate (oral solution), T1 - 7D; MME; reconstituted), T1 DL; QL naftifine hcl (external cream), T1 morphine sulfate (oral tablet immediate release), NAFTIN (2% EXTERNAL GEL), T1 T1 - 7D; MME; DL; QL naloxone hcl (0.4mg/ml injection solution), T1 morphine sulfate er (100mg oral tablet extended naloxone hcl (injection solution cartridge), T1 release, 15mg oral tablet extended release, 30mg oral tablet extended release, 60mg oral naloxone hcl (injection solution prefilled syringe), tablet extended release) (generic ms contin), T1 - T1 7D; MME; DL; QL naltrexone hcl (oral tablet), T1 morphine sulfate er (200mg oral tablet extended NAMZARIC (ORAL CAPSULE ER 24 HOUR release) (generic ms contin), T1 - 7D; MME; DL; THERAPY PACK), T1 - PA; QL QL NAMZARIC (ORAL CAPSULE EXTENDED moxifloxacin hcl (ophthalmic solution) (generic RELEASE 24 HOUR), T1 - PA; QL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

71 naproxen (oral suspension), T1 - DL nevirapine (oral suspension), T1 - QL naproxen (oral tablet immediate release), T1 nevirapine (oral tablet immediate release), T1 - naproxen dr (oral tablet delayed release) QL (generic ec-naprosyn), T1 nevirapine er (oral tablet extended release 24 naratriptan hcl (oral tablet), T1 - QL hour), T1 - QL NARCAN (NASAL LIQUID), T1 NEXAVAR (ORAL TABLET), T1 - PA; LA; DL NATACYN (OPHTHALMIC SUSPENSION), T1 niacin er (antihyperlipidemic) (oral tablet nateglinide (oral tablet), T1 - QL extended release), T1 NATPARA (SUBCUTANEOUS CARTRIDGE), T1 niacor (oral tablet), T1 - PA; LA; DL nicardipine hcl (oral capsule), T1 NAYZILAM (NASAL SOLUTION), T1 - QL NICOTROL (INHALATION INHALER), T1 necon 0.5/35 (28) (oral tablet), T1 NICOTROL NS (NASAL SOLUTION), T1 nefazodone hcl (oral tablet), T1 nifedipine er (oral tablet extended release 24 neomycin sulfate (oral tablet), T1 hour), T1 - QL neomycin-bacitracin-polymyxin (5-400-10000 nifedipine er osmotic release (oral tablet ophthalmic ointment), T1 extended release 24 hour), T1 - QL neomycin-polymyxin-bacitracin-hydrocortisone nikki (oral tablet), T1 (ophthalmic ointment), T1 nilutamide (oral tablet), T1 - DL neomycin-polymyxin-dexamethasone nimodipine (oral capsule), T1 (3.5-10000-0.1 ophthalmic suspension), T1 NINLARO (ORAL CAPSULE), T1 - PA; DL; QL neomycin-polymyxin-dexamethasone nitisinone (oral capsule), T1 - DL (ophthalmic ointment), T1 nitro-bid (transdermal ointment), T1 neomycin-polymyxin-gramicidin (ophthalmic nitrofurantoin (oral suspension), T1 solution), T1 nitrofurantoin macrocrystal (100mg oral capsule, neomycin-polymyxin-hc (1% otic solution), T1 50mg oral capsule) (generic macrodantin), T1 neomycin-polymyxin-hc (ophthalmic suspension), nitrofurantoin monohydrate (generic macrobid), T1 T1 neomycin-polymyxin-hc (otic suspension), T1 nitroglycerin (tablet sublingual), T1 NEPHRAMINE (INTRAVENOUS SOLUTION), T1 nitroglycerin (transdermal patch 24 hour), T1 - B/D,PA nitroglycerin (translingual solution), T1 NERLYNX (ORAL TABLET), T1 - PA; LA; DL; QL NITROSTAT (TABLET SUBLINGUAL), T1 NEULASTA (SUBCUTANEOUS SOLUTION nizatidine (oral capsule), T1 PREFILLED SYRINGE), T1 - PA; DL nora-be (oral tablet), T1 NEUPOGEN (INJECTION SOLUTION PREFILLED SYRINGE), T1 - ST; DL norethindrone (0.35mg oral tablet), T1 NEUPOGEN (INJECTION SOLUTION), T1 - ST; norethindrone acetate (5mg oral tablet), T1 DL norethindrone acetate-ethinyl estradiol NEUPRO (TRANSDERMAL PATCH 24 HOUR), (0.5-2.5mg-mcg oral tablet, 1-20mg-mcg oral T1 tablet, 1-5mg-mcg oral tablet), T1

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

72 norethindrone acetate-ethinyl estradiol-fe nystatin (external ointment), T1 (0.4-35mg-mcg oral tablet chewable, 0.8-25mg- nystatin (external powder), T1 - QL mcg oral tablet chewable, 1-20mg-mcg(24) oral nystatin (mouth/throat suspension), T1 tablet chewable), T1 nystatin (oral tablet), T1 norgestimate-ethinyl estradiol (oral tablet), T1 nystop (external powder), T1 - QL norgestimate-ethinyl estradiol triphasic (oral tablet), T1 O NORMOSOL-M IN D5W (INTRAVENOUS OCALIVA (ORAL TABLET), T1 - PA; DL; QL SOLUTION), T1 ocella (oral tablet), T1 NORMOSOL-R (INTRAVENOUS SOLUTION), T1 OCTAGAM (1GM/20ML INTRAVENOUS NORTHERA (ORAL CAPSULE), T1 - PA; LA; DL; SOLUTION, 2GM/20ML INTRAVENOUS QL SOLUTION), T1 - PA; DL nortrel 0.5/35 (28) (oral tablet), T1 octreotide acetate (1000mcg/ml injection nortrel 1/35 (21) (oral tablet), T1 solution, 500mcg/ml injection solution), T1 - PA; DL nortrel 1/35 (28) (oral tablet), T1 octreotide acetate (100mcg/ml injection nortrel 7/7/7 (oral tablet), T1 solution, 200mcg/ml injection solution, 50mcg/ nortriptyline hcl (oral capsule), T1 ml injection solution), T1 - PA nortriptyline hcl (oral solution), T1 ODEFSEY (ORAL TABLET), T1 - DL; QL NORVIR (ORAL PACKET), T1 - QL ODOMZO (ORAL CAPSULE), T1 - PA; LA; DL; Drug List NORVIR (ORAL SOLUTION), T1 - QL QL NOXAFIL (ORAL SUSPENSION), T1 - DL; QL OFEV (ORAL CAPSULE), T1 - PA; LA; DL; QL NUBEQA (ORAL TABLET), T1 - PA; LA; DL; QL ofloxacin (ophthalmic solution), T1 NUCALA (SUBCUTANEOUS SOLUTION AUTO- ofloxacin (oral tablet), T1 INJECTOR), T1 - PA; LA; DL; QL ofloxacin (otic solution), T1 NUCALA (SUBCUTANEOUS SOLUTION olanzapine (10mg intramuscular solution PREFILLED SYRINGE), T1 - PA; LA; DL; QL reconstituted), T1 NUCALA (SUBCUTANEOUS SOLUTION olanzapine (10mg oral tablet, 15mg oral tablet, RECONSTITUTED), T1 - PA; LA; DL; QL 2.5mg oral tablet, 20mg oral tablet, 5mg oral NUCYNTA ER (ORAL TABLET EXTENDED tablet, 7.5mg oral tablet), T1 - QL RELEASE 12 HOUR), T1 - 7D; MME; DL; QL olanzapine odt (10mg oral tablet dispersible, NUEDEXTA (ORAL CAPSULE), T1 - PA; QL 15mg oral tablet dispersible, 20mg oral tablet NUPLAZID (ORAL CAPSULE), T1 - PA; DL; QL dispersible, 5mg oral tablet dispersible), T1 - QL NUPLAZID (ORAL TABLET), T1 - PA; DL; QL olmesartan medoxomil (oral tablet), T1 - QL NUTRILIPID (INTRAVENOUS EMULSION), T1 - olmesartan medoxomil-hctz (oral tablet), T1 - QL B/D,PA olmesartan-amlodipine-hctz (oral tablet), T1 - QL nyamyc (external powder), T1 - QL olopatadine hcl (ophthalmic solution), T1 NYMALIZE (6MG/ML ORAL SOLUTION), T1 - DL omega-3-acid ethyl esters (oral capsule) (generic nystatin (external cream), T1 lovaza), T1 - QL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

73 omeprazole (10mg oral capsule delayed oxandrolone (2.5mg oral tablet), T1 - PA; QL release), T1 - QL oxcarbazepine (150mg oral tablet, 300mg oral omeprazole (20mg oral capsule delayed release, tablet, 600mg oral tablet), T1 40mg oral capsule delayed release), T1 oxcarbazepine (300mg/5ml oral suspension), T1 ondansetron hcl (oral solution), T1 - B/D,PA oxybutynin chloride (oral syrup), T1 ondansetron hcl (oral tablet), T1 - B/D,PA oxybutynin chloride (oral tablet immediate ondansetron odt (oral tablet dispersible), T1 - B/ release), T1 D,PA oxybutynin chloride er (oral tablet extended OPSUMIT (ORAL TABLET), T1 - PA; LA; DL release 24 hour), T1 - QL ORENCIA (SUBCUTANEOUS SOLUTION oxycodone hcl (100mg/5ml oral concentrate), T1 PREFILLED SYRINGE), T1 - PA; DL - 7D; MME; DL; QL ORENCIA CLICKJECT (SUBCUTANEOUS oxycodone hcl (10mg oral tablet immediate SOLUTION AUTO-INJECTOR), T1 - PA; DL release, 15mg oral tablet immediate release, ORENITRAM (0.125MG ORAL TABLET 20mg oral tablet immediate release, 30mg oral EXTENDED RELEASE), T1 - PA; LA tablet immediate release, 5mg oral tablet ORENITRAM (0.25MG ORAL TABLET immediate release), T1 - 7D; MME; DL; QL EXTENDED RELEASE, 1MG ORAL TABLET oxycodone hcl (5mg/5ml oral solution), T1 - 7D; EXTENDED RELEASE, 2.5MG ORAL TABLET MME; DL; QL EXTENDED RELEASE, 5MG ORAL TABLET oxycodone-acetaminophen (10-325mg oral EXTENDED RELEASE), T1 - PA; LA; DL tablet, 2.5-325mg oral tablet, 5-325mg oral ORFADIN (20MG ORAL CAPSULE), T1 - LA; DL tablet, 7.5-325mg oral tablet), T1 - 7D; MME; DL; ORFADIN (ORAL SUSPENSION), T1 - LA; DL QL ORKAMBI (ORAL PACKET), T1 - PA; LA; DL; QL oxycodone-aspirin (oral tablet), T1 - 7D; MME; DL; QL ORKAMBI (ORAL TABLET), T1 - PA; LA; DL; QL OZEMPIC (0.25 OR 0.5MG/DOSE) orsythia (oral tablet), T1 (SUBCUTANEOUS SOLUTION PEN- oseltamivir phosphate (oral capsule), T1 - QL INJECTOR), T1 - QL oseltamivir phosphate (oral suspension OZEMPIC (1MG/DOSE) (SUBCUTANEOUS reconstituted), T1 - QL SOLUTION PEN-INJECTOR), T1 - QL OSPHENA (ORAL TABLET), T1 - PA; QL P OTEZLA (ORAL TABLET THERAPY PACK), T1 - peg-3350-electrolytes (oral solution) (generic PA; LA; DL golytely), T1 OTEZLA (ORAL TABLET), T1 - PA; LA; DL peg-3350-nacl-na bicarbonate-kcl (oral solution) oxacillin sodium (injection solution (generic nulytely), T1 reconstituted), T1 pacerone (200mg oral tablet), T1 oxacillin sodium (intravenous solution paliperidone er (oral tablet extended release 24 reconstituted), T1 hour), T1 - QL OXACILLIN SODIUM IN DEXTROSE pantoprazole sodium (oral tablet delayed (INTRAVENOUS SOLUTION), T1 release), T1 - QL oxandrolone (10mg oral tablet), T1 - PA; QL PANZYGA (INTRAVENOUS SOLUTION), T1 -

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

74 PA; DL PERSERIS (SUBCUTANEOUS PREFILLED paricalcitol (oral capsule), T1 - B/D,PA SYRINGE), T1 - DL paromomycin sulfate (oral capsule), T1 phenelzine sulfate (oral tablet), T1 paroxetine hcl (oral tablet immediate release), T1 phenobarbital (oral elixir), T1 paser (oral packet), T1 phenobarbital (oral tablet), T1 PAXIL (ORAL SUSPENSION), T1 phenoxybenzamine hcl (oral capsule), T1 - DL PAZEO (OPHTHALMIC SOLUTION), T1 phenytek (oral capsule), T1 PEDIARIX (INTRAMUSCULAR SUSPENSION), phenytoin (125mg/5ml oral suspension), T1 T1 - QL phenytoin (oral tablet chewable), T1 PEDVAX HIB (INTRAMUSCULAR phenytoin sodium extended (oral capsule), T1 SUSPENSION), T1 - QL PHOSLYRA (ORAL SOLUTION), T1 PEGANONE (ORAL TABLET), T1 PHOSPHOLINE IODIDE (OPHTHALMIC PEGASYS PROCLICK (SUBCUTANEOUS SOLUTION RECONSTITUTED), T1 SOLUTION), T1 - PA; DL PICATO (EXTERNAL GEL), T1 - QL PEMAZYRE (ORAL TABLET), T1 - PA; DL; QL PIFELTRO (ORAL TABLET), T1 - DL; QL penicillamine (250mg oral capsule), T1 - PA; DL pilocarpine hcl (ophthalmic solution), T1 penicillamine (250mg oral tablet), T1 - DL pilocarpine hcl (oral tablet), T1 penicillin g potassium (20000000unit injection pimecrolimus (external cream), T1 - ST; QL solution reconstituted), T1 pimozide (oral tablet), T1 Drug List penicillin g procaine (intramuscular suspension), pimtrea (oral tablet), T1 T1 pindolol (oral tablet), T1 penicillin g sodium (injection solution reconstituted), T1 - DL pioglitazone hcl (oral tablet), T1 - QL penicillin v potassium (oral solution pioglitazone hcl-glimepiride (oral tablet), T1 - QL reconstituted), T1 pioglitazone hcl-metformin hcl (oral tablet), T1 - penicillin v potassium (oral tablet), T1 QL pentamidine isethionate (inhalation solution piperacillin-tazobactam (intravenous solution reconstituted), T1 - B/D,PA; QL reconstituted), T1 pentamidine isethionate (injection solution PIQRAY (200MG DAILY DOSE) (ORAL TABLET reconstituted), T1 THERAPY PACK), T1 - PA; DL; QL PENTASA (ORAL CAPSULE EXTENDED PIQRAY (250MG DAILY DOSE) (ORAL TABLET RELEASE), T1 - QL THERAPY PACK), T1 - PA; DL; QL pentoxifylline er (oral tablet extended release), PIQRAY (300MG DAILY DOSE) (ORAL TABLET T1 THERAPY PACK), T1 - PA; DL; QL PERFOROMIST (INHALATION NEBULIZATION pirmella 1/35 (oral tablet), T1 SOLUTION), T1 - B/D,PA; QL piroxicam (oral capsule), T1 perindopril erbumine (oral tablet), T1 - QL PLASMA-LYTE 148 (INTRAVENOUS permethrin (external cream), T1 SOLUTION), T1 perphenazine (oral tablet), T1 PLASMA-LYTE A (INTRAVENOUS SOLUTION),

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

75 T1 praziquantel (oral tablet), T1 plenamine (intravenous solution), T1 - B/D,PA prazosin hcl (oral capsule), T1 podofilox (external solution), T1 PRED MILD (OPHTHALMIC SUSPENSION), T1 polymyxin b sulfate (injection solution PRED-G (OPHTHALMIC SUSPENSION), T1 reconstituted), T1 PRED-G S.O.P. (OPHTHALMIC OINTMENT), T1 polymyxin b-trimethoprim (ophthalmic solution), prednicarbate (external cream), T1 T1 prednicarbate (external ointment), T1 POMALYST (ORAL CAPSULE), T1 - PA; DL; QL prednisolone (oral solution), T1 portia-28 (oral tablet), T1 prednisolone acetate (ophthalmic suspension), posaconazole (oral tablet delayed release), T1 - T1 PA; DL; QL prednisolone sodium phosphate (1% ophthalmic POTASSIUM CHLORIDE (10MEQ/100ML solution), T1 INTRAVENOUS SOLUTION, 20MEQ/100ML prednisolone sodium phosphate (25mg/5ml oral INTRAVENOUS SOLUTION, 40MEQ/100ML solution, 6.7mg/5ml oral solution), T1 INTRAVENOUS SOLUTION), T1 - B/D,PA prednisone (10mg (21) oral tablet therapy pack, potassium chloride (2meq/ml intravenous 10mg (48) oral tablet therapy pack, 5mg (21) oral solution, 2meq/ml (20ml) intravenous solution), tablet therapy pack, 5mg (48) oral tablet therapy T1 - B/D,PA pack), T1 potassium chloride (oral packet), T1 prednisone (10mg oral tablet, 1mg oral tablet, potassium chloride (oral solution), T1 2.5mg oral tablet, 20mg oral tablet, 50mg oral potassium chloride cr (oral tablet extended tablet, 5mg oral tablet), T1 release), T1 prednisone (5mg/5ml oral solution), T1 potassium chloride er (oral capsule extended prednisone intensol (oral concentrate), T1 release), T1 pregabalin (oral capsule), T1 - QL POTASSIUM CHLORIDE IN DEXTROSE pregabalin (oral solution), T1 - QL (20MEQ/L INTRAVENOUS SOLUTION), T1 - B/ D,PA PREMARIN (ORAL TABLET), T1 - QL potassium chloride in nacl (20-0.45meq/l-% PREMARIN (VAGINAL CREAM), T1 intravenous solution), T1 - B/D,PA premasol (intravenous solution), T1 - B/D,PA POTASSIUM CHLORIDE IN NACL (20-0.9MEQ/ PREMPHASE (ORAL TABLET), T1 - QL L-% INTRAVENOUS SOLUTION, 40-0.9MEQ/L- PREMPRO (ORAL TABLET), T1 - QL % INTRAVENOUS SOLUTION), T1 - B/D,PA prevalite (oral packet), T1 potassium citrate er (oral tablet extended previfem (oral tablet), T1 release), T1 PREZCOBIX (ORAL TABLET), T1 - DL; QL PRALUENT (SUBCUTANEOUS SOLUTION PREZISTA (150MG ORAL TABLET, 600MG AUTO-INJECTOR), T1 - PA; LA; QL ORAL TABLET, 800MG ORAL TABLET), T1 - pramipexole dihydrochloride (oral tablet DL; QL immediate release), T1 PREZISTA (75MG ORAL TABLET), T1 - QL prasugrel hcl (oral tablet), T1 - QL PREZISTA (ORAL SUSPENSION), T1 - DL; QL pravastatin sodium (oral tablet), T1 - QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

76 PRIFTIN (ORAL TABLET), T1 QL PRILOSEC (ORAL PACKET), T1 - PA PROMACTA (ORAL TABLET), T1 - PA; LA; DL; primaquine phosphate (oral tablet), T1 QL primidone (oral tablet), T1 promethazine hcl (oral syrup), T1 PRIVIGEN (20GM/200ML INTRAVENOUS promethazine hcl (oral tablet), T1 SOLUTION), T1 - PA; DL promethazine hcl (rectal suppository), T1 PROAIR HFA (INHALATION AEROSOL promethegan (25mg rectal suppository), T1 SOLUTION), T1 propafenone hcl (oral tablet), T1 PROAIR RESPICLICK (INHALATION AEROSOL propafenone hcl er (oral capsule extended POWDER BREATH ACTIVATED), T1 release 12 hour), T1 PROQUAD (SUBCUTANEOUS SUSPENSION proparacaine hcl (ophthalmic solution), T1 RECONSTITUTED), T1 - QL propranolol hcl (oral solution), T1 probenecid (oral tablet), T1 propranolol hcl (oral tablet), T1 probenecid-colchicine (oral tablet), T1 propranolol hcl er (oral capsule extended release PROCALAMINE (INTRAVENOUS SOLUTION), 24 hour), T1 T1 - B/D,PA propranolol-hctz (oral tablet), T1 prochlorperazine (rectal suppository), T1 propylthiouracil (oral tablet), T1 prochlorperazine maleate (oral tablet), T1 PROSOL (INTRAVENOUS SOLUTION), T1 - B/ PROCRIT (10000UNIT/ML INJECTION D,PA Drug List SOLUTION, 2000UNIT/ML INJECTION protriptyline hcl (oral tablet), T1 SOLUTION, 3000UNIT/ML INJECTION SOLUTION, 4000UNIT/ML INJECTION PULMOZYME (INHALATION SOLUTION), T1 - SOLUTION), T1 - PA B/D,PA; DL; QL PROCRIT (20000UNIT/ML INJECTION PURIXAN (ORAL SUSPENSION), T1 - PA; DL SOLUTION, 40000UNIT/ML INJECTION pyrazinamide (oral tablet), T1 SOLUTION), T1 - PA; DL pyridostigmine bromide (60mg oral tablet procto-med hc (external cream), T1 immediate release), T1 procto-pak (external cream), T1 pyridostigmine bromide (oral solution), T1 - DL proctosol hc (external cream), T1 pyridostigmine bromide er (oral tablet extended proctozone-hc (external cream), T1 release), T1 PROCYSBI (ORAL PACKET), T1 - LA; DL pyrimethamine (oral tablet), T1 - DL progesterone micronized (oral capsule), T1 Q PROGRAF (ORAL PACKET), T1 - B/D,PA QINLOCK (ORAL TABLET), T1 - PA; DL; QL PROLASTIN-C (INTRAVENOUS SOLUTION QUADRACEL (INTRAMUSCULAR RECONSTITUTED), T1 - PA; LA; DL SUSPENSION), T1 - QL PROLENSA (OPHTHALMIC SOLUTION), T1 quetiapine fumarate (oral tablet immediate PROLIA (SUBCUTANEOUS SOLUTION release), T1 - QL PREFILLED SYRINGE), T1 - QL quetiapine fumarate er (oral tablet extended PROMACTA (ORAL PACKET), T1 - PA; LA; DL; release 24 hour), T1 - QL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

77 quinapril hcl (oral tablet), T1 - QL POWDER BREATH ACTIVATED), T1 - QL quinapril-hydrochlorothiazide (oral tablet), T1 - RELISTOR (ORAL TABLET), T1 - PA; DL; QL QL RELISTOR (SUBCUTANEOUS SOLUTION), T1 - quinidine gluconate er (oral tablet extended PA; DL release), T1 repaglinide (oral tablet), T1 - QL quinidine sulfate (oral tablet), T1 REPATHA (SUBCUTANEOUS SOLUTION quinine sulfate (oral capsule), T1 - PA PREFILLED SYRINGE), T1 - PA; QL R REPATHA PUSHTRONEX SYSTEM (SUBCUTANEOUS SOLUTION CARTRIDGE), RAVICTI (ORAL LIQUID), T1 - LA; DL; QL T1 - PA; QL RABAVERT (INTRAMUSCULAR SUSPENSION REPATHA SURECLICK (SUBCUTANEOUS RECONSTITUTED), T1 - B/D,PA; QL SOLUTION AUTO-INJECTOR), T1 - PA; QL rabeprazole sodium (oral tablet delayed release), RESTASIS SINGLE-USE VIALS (OPHTHALMIC T1 EMULSION), T1 - QL raloxifene hcl (oral tablet), T1 - QL RETACRIT (INJECTION SOLUTION), T1 - PA ramelteon (oral tablet), T1 - QL RETEVMO (ORAL CAPSULE), T1 - PA; DL; QL ramipril (oral capsule), T1 - QL REVLIMID (ORAL CAPSULE), T1 - PA; LA; DL; ranolazine er (oral tablet extended release 12 QL hour), T1 - QL REXULTI (ORAL TABLET), T1 - DL; QL rasagiline mesylate (oral tablet), T1 REYATAZ (ORAL PACKET), T1 - DL; QL RASUVO (SUBCUTANEOUS SOLUTION AUTO- RHOPRESSA (OPHTHALMIC SOLUTION), T1 - INJECTOR), T1 - PA ST RAYALDEE (ORAL CAPSULE EXTENDED ribavirin (oral tablet), T1 RELEASE), T1 - DL; QL RIDAURA (ORAL CAPSULE), T1 - DL REBIF (SUBCUTANEOUS SOLUTION PREFILLED SYRINGE), T1 - ST; DL; QL rifabutin (oral capsule), T1 REBIF REBIDOSE (SUBCUTANEOUS rifampin (150mg oral capsule, 300mg oral SOLUTION AUTO-INJECTOR), T1 - ST; DL; QL capsule), T1 REBIF REBIDOSE TITRATION PACK rifampin (600mg intravenous solution (SUBCUTANEOUS SOLUTION AUTO- reconstituted), T1 INJECTOR), T1 - ST; DL; QL riluzole (oral tablet), T1 REBIF TITRATION PACK (SUBCUTANEOUS rimantadine hcl (oral tablet), T1 SOLUTION PREFILLED SYRINGE), T1 - ST; DL; RIOMET ER (ORAL SUSPENSION QL RECONSTITUTED ER), T1 - QL reclipsen (oral tablet), T1 risedronate sodium (oral tablet immediate RECOMBIVAX HB (INJECTION SUSPENSION), release), T1 - QL T1 - B/D,PA; QL RISPERDAL CONSTA (12.5MG RECTIV (RECTAL OINTMENT), T1 - QL INTRAMUSCULAR SUSPENSION REGRANEX (EXTERNAL GEL), T1 - PA; DL RECONSTITUTED ER, 25MG INTRAMUSCULAR SUSPENSION RELENZA DISKHALER (INHALATION AEROSOL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

78 RECONSTITUTED ER), T1 RYTARY (ORAL CAPSULE EXTENDED RISPERDAL CONSTA (37.5MG RELEASE), T1 - ST INTRAMUSCULAR SUSPENSION S RECONSTITUTED ER, 50MG sps (oral suspension), T1 INTRAMUSCULAR SUSPENSION RECONSTITUTED ER), T1 - DL SSD (EXTERNAL CREAM), T1 risperidone (0.25mg oral tablet, 0.5mg oral SANCUSO (TRANSDERMAL PATCH), T1 - DL; tablet, 1mg oral tablet, 2mg oral tablet, 3mg oral QL tablet, 4mg oral tablet), T1 SANDIMMUNE (ORAL SOLUTION), T1 - B/D,PA; risperidone (1mg/ml oral solution), T1 DL risperidone odt (0.25mg oral tablet dispersible, SANTYL (EXTERNAL OINTMENT), T1 0.5mg oral tablet dispersible, 1mg oral tablet SAPHRIS (TABLET SUBLINGUAL), T1 - DL; QL dispersible, 2mg oral tablet dispersible, 3mg oral SAVELLA (ORAL TABLET), T1 tablet dispersible, 4mg oral tablet dispersible), SAVELLA TITRATION PACK (ORAL TABLET), T1 T1 ritonavir (oral tablet), T1 - QL scopolamine (transdermal patch 72 hour), T1 rivastigmine (transdermal patch 24 hour), T1 - SECUADO (TRANSDERMAL PATCH 24 HOUR), ST; QL T1 - PA; DL; QL rivastigmine tartrate (oral capsule), T1 - QL selegiline hcl (oral capsule), T1 rivelsa (oral tablet), T1

selegiline hcl (oral tablet), T1 Drug List rizatriptan benzoate (oral tablet), T1 - QL selenium sulfide (external lotion), T1 rizatriptan benzoate odt (oral tablet dispersible), SELZENTRY (150MG ORAL TABLET, 300MG T1 - QL ORAL TABLET, 75MG ORAL TABLET), T1 - ROCKLATAN (OPHTHALMIC SOLUTION), T1 - DL; QL ST SELZENTRY (25MG ORAL TABLET), T1 - QL ropinirole hcl (oral tablet immediate release), T1 SELZENTRY (ORAL SOLUTION), T1 - DL; QL rosuvastatin calcium (oral tablet), T1 - QL SEREVENT DISKUS (INHALATION AEROSOL ROTATEQ (ORAL SOLUTION), T1 - QL POWDER BREATH ACTIVATED), T1 - QL ROTARIX (ORAL SUSPENSION SEROSTIM (SUBCUTANEOUS SOLUTION RECONSTITUTED), T1 - QL RECONSTITUTED), T1 - PA; LA; DL roweepra (oral tablet immediate release), T1 sertraline hcl (oral concentrate), T1 roweepra xr (oral tablet extended release 24 sertraline hcl (oral tablet), T1 hour), T1 setlakin (oral tablet), T1 ROZLYTREK (ORAL CAPSULE), T1 - PA; DL; QL sevelamer carbonate (oral packet), T1 - DL RUBRACA (ORAL TABLET), T1 - PA; LA; DL; QL sevelamer carbonate (oral tablet) (generic RUCONEST (INTRAVENOUS SOLUTION renvela), T1 RECONSTITUTED), T1 - PA; LA; DL sharobel (oral tablet), T1 RYBELSUS (ORAL TABLET), T1 - QL SHINGRIX (INTRAMUSCULAR SUSPENSION RYDAPT (ORAL CAPSULE), T1 - PA; DL; QL RECONSTITUTED), T1 - PA; QL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

79 SIGNIFOR (SUBCUTANEOUS SOLUTION), T1 - sotalol hcl (oral tablet), T1 PA; LA; DL sotalol hcl af (oral tablet), T1 sildenafil citrate (20mg oral tablet) (generic SOVALDI (400MG ORAL TABLET), T1 - PA; DL; revatio), T1 - PA; QL QL silodosin (oral capsule), T1 - QL SOVALDI (ORAL PACKET), T1 - PA; DL; QL silver sulfadiazine (external cream), T1 SPIRIVA HANDIHALER (INHALATION SIMBRINZA (OPHTHALMIC SUSPENSION), T1 CAPSULE), T1 - QL SIMPONI (SUBCUTANEOUS SOLUTION AUTO- SPIRIVA RESPIMAT (INHALATION AEROSOL INJECTOR), T1 - PA; DL SOLUTION), T1 - QL SIMPONI (SUBCUTANEOUS SOLUTION spironolactone (oral tablet), T1 PREFILLED SYRINGE), T1 - PA; DL spironolactone-hctz (oral tablet), T1 simvastatin (oral tablet), T1 - QL sprintec 28 (oral tablet), T1 sirolimus (oral solution), T1 - B/D,PA; DL SPRITAM ODT (ORAL TABLET sirolimus (oral tablet), T1 - B/D,PA DISINTEGRATING SOLUBLE), T1 SIRTURO (100MG ORAL TABLET), T1 - PA; LA; SPRYCEL (ORAL TABLET), T1 - PA; DL; QL DL sronyx (oral tablet), T1 sodium chloride (0.45% intravenous solution), T1 stavudine (oral capsule), T1 - QL sodium chloride (0.9% intravenous solution, 3% STELARA (SUBCUTANEOUS SOLUTION intravenous solution), T1 - B/D,PA PREFILLED SYRINGE), T1 - PA; DL SODIUM CHLORIDE (5% INTRAVENOUS STELARA (SUBCUTANEOUS SOLUTION), T1 - SOLUTION), T1 - B/D,PA PA; DL SODIUM CHLORIDE (IRRIGATION SOLUTION), STIOLTO RESPIMAT (INHALATION AEROSOL T1 SOLUTION), T1 - QL sodium fluoride (oral tablet), T1 STIVARGA (ORAL TABLET), T1 - PA; LA; DL; QL sodium phenylbutyrate (oral powder), T1 - DL streptomycin sulfate (intramuscular solution sodium phenylbutyrate (oral tablet), T1 - DL reconstituted), T1 - DL sodium polystyrene sulfonate (oral powder), T1 STRIBILD (ORAL TABLET), T1 - DL; QL sodium polystyrene sulfonate (oral suspension), SUBOXONE (SUBLINGUAL FILM), T1 - QL T1 SUCRAID (ORAL SOLUTION), T1 - LA; DL sofosbuvir-velpatasvir (oral tablet), T1 - PA; DL; sucralfate (oral suspension), T1 QL sucralfate (oral tablet), T1 solifenacin succinate (oral tablet), T1 - QL sulfacetamide sodium (ophthalmic ointment), T1 SOLIQUA (SUBCUTANEOUS SOLUTION PEN- sulfacetamide sodium (ophthalmic solution), T1 INJECTOR), T1 - QL sulfacetamide-prednisolone (ophthalmic SOLTAMOX (ORAL SOLUTION), T1 - DL solution), T1 SOMATULINE DEPOT (SUBCUTANEOUS sulfadiazine (oral tablet), T1 SOLUTION), T1 - DL sulfamethoxazole-trimethoprim (oral SOMAVERT (SUBCUTANEOUS SOLUTION suspension), T1 RECONSTITUTED), T1 - PA; LA; DL; QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

80 sulfamethoxazole-trimethoprim (oral tablet), T1 SYNJARDY (ORAL TABLET IMMEDIATE SULFAMYLON (EXTERNAL CREAM), T1 RELEASE), T1 - QL sulfasalazine (oral tablet delayed release), T1 SYNJARDY XR (ORAL TABLET EXTENDED sulfasalazine (oral tablet immediate release), T1 RELEASE 24 HOUR), T1 - QL sulindac (oral tablet), T1 SYNRIBO (SUBCUTANEOUS SOLUTION RECONSTITUTED), T1 - PA; DL sumatriptan (nasal solution), T1 - QL SYNTHROID (ORAL TABLET), T1 sumatriptan succinate (100mg oral tablet, 25mg oral tablet, 50mg oral tablet), T1 - QL T sumatriptan succinate (4mg/0.5ml TDVAX (INTRAMUSCULAR SUSPENSION), T1 - subcutaneous solution auto-injector, 6mg/0.5ml QL subcutaneous solution auto-injector), T1 - QL TOBI PODHALER (INHALATION CAPSULE), T1 - sumatriptan succinate (6mg/0.5ml PA; DL; QL subcutaneous solution prefilled syringe), T1 - QL TPN ELECTROLYTES (INTRAVENOUS sumatriptan succinate (6mg/0.5ml CONCENTRATE), T1 subcutaneous solution), T1 - QL TABLOID (ORAL TABLET), T1 - PA sumatriptan succinate refill (subcutaneous TABRECTA (ORAL TABLET), T1 - PA; DL; QL solution cartridge), T1 - QL tacrolimus (external ointment), T1 - ST SUPRAX (500MG/5ML ORAL SUSPENSION tacrolimus (oral capsule), T1 - B/D,PA RECONSTITUTED), T1 tadalafil (pah) (20mg oral tablet), T1 - PA; QL SUPRAX (ORAL CAPSULE), T1 Drug List TAFINLAR (ORAL CAPSULE), T1 - PA; LA; DL suprax (oral tablet chewable), T1 TAGRISSO (ORAL TABLET), T1 - PA; LA; DL; QL SUPREP BOWEL PREP KIT (ORAL SOLUTION), TALZENNA (ORAL CAPSULE), T1 - PA; LA; DL; T1 QL SUTENT (ORAL CAPSULE), T1 - PA; DL; QL tamoxifen citrate (oral tablet), T1 syeda (oral tablet), T1 tamsulosin hcl (oral capsule), T1 SYLATRON (200MCG SUBCUTANEOUS KIT, TARGRETIN (EXTERNAL GEL), T1 - PA; DL; QL 300MCG SUBCUTANEOUS KIT), T1 - PA; DL tarina 24 fe (oral tablet), T1 SYMBICORT (INHALATION AEROSOL), T1 - QL tarina fe 1/20 eq (oral tablet), T1 SYMFI (ORAL TABLET), T1 - DL; QL TASIGNA (ORAL CAPSULE), T1 - PA; DL; QL SYMFI LO (ORAL TABLET), T1 - DL; QL tazarotene (external cream), T1 - PA SYMLINPEN 120 (SUBCUTANEOUS SOLUTION PEN-INJECTOR), T1 - PA; DL tazicef (injection solution reconstituted), T1 SYMLINPEN 60 (SUBCUTANEOUS SOLUTION taztia xt (oral capsule extended release 24 hour), PEN-INJECTOR), T1 - PA; DL T1 SYMPAZAN (10MG ORAL FILM, 20MG ORAL TAZVERIK (ORAL TABLET), T1 - PA; LA; DL; QL FILM), T1 - PA; DL; QL TECFIDERA (ORAL CAPSULE DELAYED SYMPAZAN (5MG ORAL FILM), T1 - PA; QL RELEASE), T1 - LA; DL; QL SYMTUZA (ORAL TABLET), T1 - DL; QL TECFIDERA STARTER PACK (ORAL), T1 - LA; DL SYNAREL (NASAL SOLUTION), T1 - DL

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

81 TEGSEDI (SUBCUTANEOUS SOLUTION hour), T1 PREFILLED SYRINGE), T1 - PA; LA; DL tiagabine hcl (oral tablet), T1 telmisartan (oral tablet), T1 - QL TIBSOVO (ORAL TABLET), T1 - PA; DL; QL telmisartan-amlodipine (oral tablet), T1 - QL tigecycline (intravenous solution reconstituted), telmisartan-hctz (oral tablet), T1 - QL T1 - DL temazepam (15mg oral capsule, 30mg oral timolol maleate (0.25% ophthalmic solution, capsule), T1 - QL 0.5% ophthalmic solution) (generic timoptic), T1 TENIVAC (INTRAMUSCULAR INJECTABLE), T1 timolol maleate (oral tablet), T1 - QL timolol maleate ophthalmic gel forming tenofovir disoproxil fumarate (oral tablet), T1 - QL (ophthalmic solution) (generic timoptic-xe), T1 terazosin hcl (oral capsule), T1 tinidazole (oral tablet), T1 terbinafine hcl (oral tablet), T1 TIVICAY (10MG ORAL TABLET), T1 - QL terconazole (vaginal cream), T1 TIVICAY (25MG ORAL TABLET, 50MG ORAL terconazole (vaginal suppository), T1 TABLET), T1 - DL; QL TERIPARATIDE (RECOMBINANT) tizanidine hcl (oral tablet), T1 (SUBCUTANEOUS SOLUTION PEN- TOBRADEX (OPHTHALMIC OINTMENT), T1 INJECTOR), T1 - PA; DL; QL TOBRADEX ST (OPHTHALMIC SUSPENSION), testosterone (20.25mg/1.25gm 1.62% T1 transdermal gel, 40.5mg/2.5gm 1.62% tobramycin (inhalation nebulization solution), T1 transdermal gel), testosterone pump (1.62% - B/D,PA; DL; QL transdermal gel), T1 tobramycin (ophthalmic solution), T1 testosterone (25mg/2.5gm 1% transdermal gel, tobramycin sulfate (10mg/ml injection solution, 50mg/5gm 1% transdermal gel), testosterone 80mg/2ml injection solution), T1 pump (1% transdermal gel), T1 tobramycin-dexamethasone (ophthalmic testosterone cypionate (intramuscular solution), suspension), T1 T1 TOBREX (OPHTHALMIC OINTMENT), T1 testosterone enanthate (intramuscular solution), T1 tolcapone (oral tablet), T1 - DL; QL tetrabenazine (oral tablet), T1 - PA; LA; DL; QL tolterodine tartrate er (oral capsule extended release 24 hour), T1 tetracycline hcl (oral capsule), T1 topiramate (oral capsule sprinkle immediate THALOMID (ORAL CAPSULE), T1 - PA; DL; QL release), T1 theophylline (oral solution), T1 topiramate (oral tablet), T1 theophylline er (300mg oral tablet extended toremifene citrate (oral tablet), T1 - DL release 12 hour), T1 torsemide (oral tablet), T1 theophylline er (oral tablet extended release 24 hour), T1 TOUJEO MAX SOLOSTAR (SUBCUTANEOUS SOLUTION PEN-INJECTOR), T1 thioridazine hcl (oral tablet), T1 TOUJEO SOLOSTAR (SUBCUTANEOUS thiothixene (oral capsule), T1 SOLUTION PEN-INJECTOR), T1 tiadylt er (oral capsule extended release 24 TRACLEER (ORAL TABLET SOLUBLE), T1 - PA;

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

82 LA; DL; QL tri-lo-sprintec (oral tablet), T1 TRADJENTA (ORAL TABLET), T1 - QL tri-mili (oral tablet), T1 tramadol hcl (50mg oral tablet immediate tri-previfem (oral tablet), T1 release), T1 - 7D; MME; DL; QL tri-sprintec (oral tablet), T1 tramadol hcl er (biphasic) (oral tablet extended tri-vylibra (oral tablet), T1 release 24 hour), T1 - 7D; MME; DL; QL tri-vylibra lo (oral tablet), T1 tramadol hcl er (oral tablet extended release 24 trilyte (oral solution reconstituted), T1 hour), T1 - 7D; MME; DL; QL triamcinolone acetonide (0.025% external tramadol-acetaminophen (oral tablet), T1 - 7D; ointment, 0.1% external ointment, 0.5% external MME; DL; QL ointment), T1 trandolapril (oral tablet), T1 - QL triamcinolone acetonide (dental paste), T1 tranexamic acid (oral tablet), T1 triamcinolone acetonide (external cream), T1 TRANSDERM-SCOP (1.5MG) (TRANSDERMAL triamcinolone acetonide (external lotion), T1 PATCH 72 HOUR), T1 triamterene (oral capsule), T1 tranylcypromine sulfate (oral tablet), T1 triamterene-hctz (oral capsule), T1 TRAVASOL (INTRAVENOUS SOLUTION), T1 - B/D,PA triamterene-hctz (oral tablet), T1 travoprost (bak free) (ophthalmic solution), T1 triderm (0.1% external cream), T1 trazodone hcl (100mg oral tablet, 150mg oral trientine hcl (oral capsule), T1 - PA; DL; QL tablet, 50mg oral tablet), T1 trifluoperazine hcl (oral tablet), T1 Drug List trazodone hcl (300mg oral tablet), T1 trifluridine (ophthalmic solution), T1 TRECATOR (ORAL TABLET), T1 trihexyphenidyl hcl (oral solution), T1 TRELEGY ELLIPTA (INHALATION AEROSOL trihexyphenidyl hcl (oral tablet), T1 POWDER BREATH ACTIVATED), T1 - QL trimethoprim (oral tablet), T1 TRELSTAR MIXJECT (INTRAMUSCULAR trimipramine maleate (oral capsule), T1 SUSPENSION RECONSTITUTED), T1 - PA; DL TRINTELLIX (ORAL TABLET), T1 - QL TRESIBA (SUBCUTANEOUS SOLUTION), T1 TRIUMEQ (ORAL TABLET), T1 - DL; QL TRESIBA FLEXTOUCH (SUBCUTANEOUS trivora (28) (oral tablet), T1 SOLUTION PEN-INJECTOR), T1 TROPHAMINE (10% INTRAVENOUS tretinoin (0.01% external gel, 0.025% external SOLUTION), T1 - B/D,PA gel), T1 - PA TRULICITY (SUBCUTANEOUS SOLUTION PEN- tretinoin (external cream), T1 - PA INJECTOR), T1 - QL tretinoin (oral capsule), T1 - DL TRUMENBA (INTRAMUSCULAR SUSPENSION tretinoin microsphere (external gel), T1 - PA PREFILLED SYRINGE), T1 - QL trexall (oral tablet), T1 TRUVADA (ORAL TABLET), T1 - DL; QL tri-estarylla (oral tablet), T1 TUKYSA (ORAL TABLET), T1 - PA; DL; QL tri-legest fe (oral tablet), T1 TURALIO (ORAL CAPSULE), T1 - PA; LA; DL; tri-lo-estarylla (oral tablet), T1 QL TWINRIX (INTRAMUSCULAR SUSPENSION

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

83 PREFILLED SYRINGE), T1 - QL THERAPY PACK), T1 - QL TYBOST (ORAL TABLET), T1 - QL VALTOCO 5 MG DOSE (NASAL LIQUID), T1 - QL TYKERB (ORAL TABLET), T1 - PA; LA; DL vancomycin hcl (10gm intravenous solution TYMLOS (SUBCUTANEOUS SOLUTION PEN- reconstituted, 1gm intravenous solution INJECTOR), T1 - PA; DL; QL reconstituted, 500mg intravenous solution TYPHIM VI (INTRAMUSCULAR SOLUTION), T1 - reconstituted, 750mg intravenous solution QL reconstituted), T1 VANCOMYCIN HCL (250MG INTRAVENOUS U SOLUTION RECONSTITUTED), T1 UDENYCA (SUBCUTANEOUS SOLUTION vancomycin hcl (oral capsule), T1 - QL PREFILLED SYRINGE), T1 - PA; DL VANDAZOLE (VAGINAL GEL), T1 UNITHROID (100MCG ORAL TABLET, 112MCG VARIVAX (SUBCUTANEOUS INJECTABLE), T1 - ORAL TABLET, 125MCG ORAL TABLET, QL 150MCG ORAL TABLET, 175MCG ORAL TABLET, 200MCG ORAL TABLET, 25MCG VARIZIG (INTRAMUSCULAR SOLUTION), T1 - ORAL TABLET, 300MCG ORAL TABLET, DL 50MCG ORAL TABLET, 75MCG ORAL VASCEPA (ORAL CAPSULE), T1 TABLET, 88MCG ORAL TABLET), T1 velivet (oral tablet), T1 ursodiol (oral capsule), T1 VELPHORO (ORAL TABLET CHEWABLE), T1 - ursodiol (oral tablet), T1 DL V VELTASSA (ORAL PACKET), T1 - DL; QL VEMLIDY (ORAL TABLET), T1 - DL; QL VAQTA (INTRAMUSCULAR SUSPENSION), T1 - QL VENCLEXTA (100MG ORAL TABLET, 50MG ORAL TABLET), T1 - PA; LA; DL; QL vp-pnv-dha (oral capsule), T1 VENCLEXTA (10MG ORAL TABLET), T1 - PA; valacyclovir hcl (oral tablet), T1 - QL LA; QL VALCHLOR (EXTERNAL GEL), T1 - PA; LA; DL; VENCLEXTA STARTING PACK (ORAL TABLET QL THERAPY PACK), T1 - PA; LA; DL valganciclovir hcl (450mg oral tablet), T1 - QL venlafaxine hcl (oral tablet immediate release), valganciclovir hcl (50mg/ml oral solution T1 reconstituted), T1 - DL; QL venlafaxine hcl er (oral capsule extended release valproic acid (oral capsule), T1 24 hour), T1 valproic acid (oral solution), T1 VENTAVIS (INHALATION SOLUTION), T1 - PA; valsartan (oral tablet), T1 - QL LA; DL; QL valsartan-hydrochlorothiazide (oral tablet), T1 - verapamil hcl (oral tablet immediate release), T1 QL VERAPAMIL HCL ER (100MG ORAL CAPSULE VALTOCO 10 MG DOSE (NASAL LIQUID), T1 - EXTENDED RELEASE 24 HOUR, 200MG QL ORAL CAPSULE EXTENDED RELEASE 24 VALTOCO 15 MG DOSE (NASAL LIQUID HOUR, 300MG ORAL CAPSULE EXTENDED THERAPY PACK), T1 - QL RELEASE 24 HOUR, 360MG ORAL CAPSULE VALTOCO 20 MG DOSE (NASAL LIQUID EXTENDED RELEASE 24 HOUR), T1

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

84 verapamil hcl er (120mg oral capsule extended ORAL CAPSULE), T1 - ST; DL; QL release 24 hour, 180mg oral capsule extended VRAYLAR (ORAL CAPSULE THERAPY PACK), release 24 hour, 240mg oral capsule extended T1 - ST release 24 hour), T1 vylibra (oral tablet), T1 verapamil hcl er (oral tablet extended release), vyfemla (oral tablet), T1 T1 VYNDAMAX (ORAL CAPSULE), T1 - PA; LA; DL; VERSACLOZ (ORAL SUSPENSION), T1 - DL QL VERZENIO (ORAL TABLET), T1 - PA; LA; DL; QL VYNDAQEL (ORAL CAPSULE), T1 - PA; LA; DL; VIBRAMYCIN (50MG/5ML ORAL SYRUP), T1 QL VICTOZA (SUBCUTANEOUS SOLUTION PEN- VYVANSE (ORAL CAPSULE), T1 INJECTOR), T1 - QL VYVANSE (ORAL TABLET CHEWABLE), T1 vienva (oral tablet), T1 VYZULTA (OPHTHALMIC SOLUTION), T1 vigabatrin (oral packet), T1 - PA; LA; DL; QL W vigabatrin (oral tablet), T1 - PA; LA; DL; QL wymzya fe (oral tablet chewable), T1 vigadrone (oral packet), T1 - PA; LA; DL; QL warfarin sodium (oral tablet), T1 VIIBRYD (ORAL TABLET), T1 - QL wixela inhub (inhalation aerosol powder breath VIIBRYD STARTER PACK (ORAL KIT), T1 - QL activated) (generic advair), T1 - QL VIMPAT (ORAL SOLUTION), T1 - QL X VIMPAT (ORAL TABLET), T1 - QL Drug List VIRACEPT (ORAL TABLET), T1 - DL; QL XALKORI (ORAL CAPSULE), T1 - PA; LA; DL VIREAD (150MG ORAL TABLET, 200MG ORAL XARELTO (ORAL TABLET), T1 - QL TABLET, 250MG ORAL TABLET), T1 - DL; QL XARELTO STARTER PACK (ORAL TABLET VIREAD (ORAL POWDER), T1 - DL; QL THERAPY PACK), T1 - QL VITRAKVI (ORAL CAPSULE), T1 - PA; LA; DL; XATMEP (ORAL SOLUTION), T1 - PA QL XCOPRI (100MG ORAL TABLET, 150MG ORAL VITRAKVI (ORAL SOLUTION), T1 - PA; LA; DL; TABLET, 50MG ORAL TABLET), T1 - PA; QL QL XCOPRI (14X12.5MG & 14X25MG ORAL VIVITROL (INTRAMUSCULAR SUSPENSION TABLET THERAPY PACK), T1 - PA; QL RECONSTITUTED), T1 - DL XCOPRI (14X150MG & 14X200MG ORAL VIZIMPRO (ORAL TABLET), T1 - PA; LA; DL; QL TABLET THERAPY PACK, 14X50MG & 14X100MG ORAL TABLET THERAPY PACK), voriconazole (intravenous solution T1 - PA; DL; QL reconstituted), T1 - DL XCOPRI (200MG ORAL TABLET), T1 - PA; DL; voriconazole (oral suspension reconstituted), T1 QL - DL XCOPRI (250 MG DAILY DOSE) (ORAL TABLET voriconazole (oral tablet), T1 THERAPY PACK), T1 - PA; DL; QL VOSEVI (ORAL TABLET), T1 - PA; DL; QL XCOPRI (350 MG DAILY DOSE) (ORAL TABLET VOTRIENT (ORAL TABLET), T1 - PA; LA; DL; QL THERAPY PACK), T1 - PA; DL; QL VRAYLAR (1.5MG ORAL CAPSULE, 3MG ORAL XELJANZ (ORAL TABLET IMMEDIATE CAPSULE, 4.5MG ORAL CAPSULE, 6MG

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

85 RELEASE), T1 - PA; DL; QL zarah (oral tablet), T1 XELJANZ XR (ORAL TABLET EXTENDED ZARXIO (INJECTION SOLUTION PREFILLED RELEASE 24 HOUR), T1 - PA; DL; QL SYRINGE), T1 - DL XGEVA (SUBCUTANEOUS SOLUTION), T1 - PA; ZEJULA (ORAL CAPSULE), T1 - PA; LA; DL; QL DL ZELAPAR ODT (ORAL TABLET DISPERSIBLE), XIFAXAN (ORAL TABLET), T1 - PA; DL T1 - DL XIGDUO XR (ORAL TABLET EXTENDED ZELBORAF (ORAL TABLET), T1 - PA; LA; DL; RELEASE 24 HOUR), T1 - QL QL XIIDRA (OPHTHALMIC SOLUTION), T1 - QL ZEMAIRA (INTRAVENOUS SOLUTION XOFLUZA (40 MG DOSE) (ORAL TABLET RECONSTITUTED), T1 - PA; LA; DL THERAPY PACK), T1 - QL zenatane (oral capsule), T1 - PA XOFLUZA (80 MG DOSE) (ORAL TABLET ZENPEP (ORAL CAPSULE DELAYED RELEASE THERAPY PACK), T1 - QL PARTICLES), T1 XOLAIR (SUBCUTANEOUS SOLUTION ZERBAXA (INTRAVENOUS SOLUTION PREFILLED SYRINGE), T1 - PA; LA; DL RECONSTITUTED), T1 - PA; DL XOLAIR (SUBCUTANEOUS SOLUTION zidovudine (oral capsule), T1 - QL RECONSTITUTED), T1 - PA; LA; DL zidovudine (oral syrup), T1 - QL XOSPATA (ORAL TABLET), T1 - PA; DL; QL zidovudine (oral tablet), T1 - QL XPOVIO (100MG ONCE WEEKLY) (ORAL zileuton er (oral tablet extended release 12 hour), TABLET THERAPY PACK), T1 - PA; LA; DL; QL T1 - ST; DL XPOVIO (60MG ONCE WEEKLY) (ORAL ziprasidone hcl (oral capsule), T1 - QL TABLET THERAPY PACK), T1 - PA; LA; DL; QL ziprasidone mesylate (intramuscular solution XPOVIO (80MG ONCE WEEKLY) (ORAL reconstituted), T1 TABLET THERAPY PACK), T1 - PA; LA; DL; QL ZIRGAN (OPHTHALMIC GEL), T1 XPOVIO (80MG TWICE WEEKLY) (ORAL ZOLINZA (ORAL CAPSULE), T1 - PA; DL TABLET THERAPY PACK), T1 - PA; LA; DL; QL zolpidem tartrate (oral tablet immediate release), XTAMPZA ER (ORAL CAPSULE ER 12 HOUR T1 - QL ABUSE-DETERRENT), T1 - 7D; MME; DL; QL zonisamide (oral capsule), T1 XTANDI (ORAL CAPSULE), T1 - PA; LA; DL; QL ZORBTIVE (SUBCUTANEOUS SOLUTION xulane (transdermal patch weekly), T1 RECONSTITUTED), T1 - PA; LA; DL XYREM (ORAL SOLUTION), T1 - PA; LA; DL; QL ZORTRESS (1MG ORAL TABLET), T1 - B/D,PA; Y DL YF-VAX (SUBCUTANEOUS INJECTABLE), T1 - ZOSTAVAX (19400UNT/0.65ML QL SUBCUTANEOUS SUSPENSION yuvafem (vaginal tablet), T1 - QL RECONSTITUTED), T1 - PA; QL zovia 1/35e (28) (oral tablet), T1 Z ZYCLARA PUMP (EXTERNAL CREAM), T1 - PA; zafirlukast (oral tablet), T1 - QL DL zaleplon (oral capsule), T1 - QL ZYDELIG (ORAL TABLET), T1 - PA; LA; DL; QL

T1 = Tier 1 Covered Drugs PA = Prior authorization QL = Quantity limits ST = Step therapy B/D = Medicare Part B or Part D LA = Limited access

86 ZYFLO (ORAL TABLET IMMEDIATE RELEASE), ZYPREXA RELPREVV (210MG T1 - ST; DL INTRAMUSCULAR SUSPENSION ZYKADIA (ORAL TABLET), T1 - PA; DL; QL RECONSTITUTED), T1 Drug List

Brand name drugs = CAPITILIZED Generic drugs = lowercase italics MME = Morphine milligram equivalent 7D = 7-Day limit DL = Dispensing limit

87 Over-the-counter Medicaid Drug List

Your plan covers some prescription over-the-counter (OTC) drugs that aren’t normally covered under our Medicare Part D benefit.

You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it’s available, unless otherwise prescribed or directed by your doctor.

Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.

The alphabetical list below shows the prescription OTC drugs covered by the plan.

# acetaminophen er (tablet) 12 hour decongestant (extended release tablet) acetaminophen extra strength (tablet) 12 hour nasal decongestant/maximum strength acetaminophen pm extra strength (tablet) (extended release tablet) acetaminophen/aspirin/caffeine (tablet) 12 hour nasal spray (solution) acetaminophen/diphenhydramine (tablet) 24hr allergy relief (tablet) acid control maximum strength (tablet) 3 day vaginal (cream) ACID GONE (CHEWABLE TABLET) 4-WAY FAST ACTING (SOLUTION) ACID GONE (SUSPENSION) 8 hour arthritis pain reliever (tablet) acid reducer (delayed release capsule) 8 hour pain relief (tablet) acid reducer (tablet) 8hr muscle aches & pain (tablet) acid reducer complete (chewable tablet) A acid reducer maximum strength (tablet) acne medication 10 (gel) ABREVA (CREAM) acne medication 10 (lotion) ACEPHEN (SUPPOSITORY) acne medication 5 (gel) ACETA-GESIC (TABLET) acne medication 5 (lotion) acetaminophen (liquid) actidose-aqua (liquid) acetaminophen (solution) ACTIDOSE/SORBITOL (LIQUID) acetaminophen (suppository) adult aspirin regimen (tablet) acetaminophen (suspension) adult suppository (suppository) acetaminophen (tablet) advanced hand sanitizer (gel) acetaminophen childrens (solution) advanced hand sanitizer/aloe (liquid) acetaminophen childrens (suspension) AFTERA (TABLET) acetaminophen congestion and pain (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

88 AHIST (TABLET) allfen dm (tablet) AKWA TEARS (OINTMENT) ALMACONE (CHEWABLE TABLET) ALA-HIST IR (TABLET) ALMACONE (SUSPENSION) ALA-HIST PE (TABLET) ALMACONE DOUBLE STRENGTH ALAHIST CF (TABLET) (SUSPENSION) ALAHIST DM (LIQUID) ALOE VESTA ANTIFUNGAL (OINTMENT) ALAWAY (SOLUTION) ALOE VESTA CLEAR ANTIFUNGAL ALAWAY CHILDRENS ALLERGY EYE ITCH (OINTMENT) RELIEF (SOLUTION) ALOE VESTA CLEAR BARRIER SPRAY alertness aid (tablet) (AEROSOL) alevazol (ointment) ALOE VESTA DAILY MOISTURIZER (LOTION) all day allergy (tablet) ALOE VESTA PROTECTIVE (OINTMENT) all day allergy childrens (solution) ALOE VESTA SKIN CONDITIONER (LOTION) all day allergy d (extended release tablet) ALOE VESTA SKIN PROTECTANT (AEROSOL) all day allergy-d (extended release tablet) aluminum acetate astringent (pack) all day pain relief (tablet) aluminum hydroxide (suspension) all day relief (tablet) ammonium lactate (cream) all-day allergy childrens (solution) ammonium lactate (lotion) all-nite cold & flu nighttime relief (liquid) antacid (chewable tablet) antacid (suspension) aller-chlor (tablet) Drug List aller-ease (tablet) antacid anti-gas maximum strength (suspension) allergy & congestion relief (extended release antacid calcium extra strength (chewable tablet) tablet) antacid calcium regular strength (chewable allergy (tablet) tablet) allergy childrens (liquid) antacid extra strength (chewable tablet) allergy childrens (syrup) antacid fast acting (suspension) allergy multi-symptom (tablet) antacid fast relief (suspension) allergy non-drowsy (tablet) antacid maximum strength (suspension) allergy relief (capsule) antacid plus anti-gas fast acting (suspension) allergy relief (suspension) antacid plus anti-gas relief (suspension) allergy relief (tablet) antacid plus anti-gas relief maximum strength (suspension) allergy relief 24hr (tablet) antacid regular strength (suspension) allergy relief childrens (liquid) anti-dandruff shampoo (shampoo) allergy relief d-24 (tablet) anti-diarrheal (capsule) allergy relief-d (tablet) anti-diarrheal (liquid) allergy relief/nasal decongestant (tablet) anti-diarrheal (tablet) allergy-time (tablet) anti-fungal powder (powder) allergy/congestion relief (tablet) anti-itch (cream) ALLERHIST (TABLET) anti-itch (lotion)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

89 anti-itch extra strength (cream) athletes foot powder spray (aerosol powder) anti-itch maximum strength (cream) athletes foot spray (aerosol) anti-itch maximum strength (solution) atuss da (liquid) anti-nausea (solution) B antifungal (cream) baby sunscreen spf50 (lotion) antifungal powder (powder) bacitracin (ointment) antihistamine/nasal decongestant (extended bacitracin zinc (ointment) release tablet) back & body extra strength (tablet) antiseptic mouthrinse (liquid) BANOPHEN (CAPSULE) antiseptic skin cleanser (solution) BANOPHEN (CREAM) anu-med (suppository) BANOPHEN (LIQUID) APRODINE (TABLET) BANOPHEN (TABLET) AQUAFRESH CAVITY PROTECTION (PASTE) baza antifungal (cream) AQUAFRESH EXTREME CLEAN (PASTE) BAZA CLEANSE & PROTECT (LOTION) AQUAFRESH FOR KIDS (PASTE) BAZA CLEAR (OINTMENT) AQUAFRESH SENSITIVE (PASTE) BAZA PROTECT (CREAM) AQUAFRESH TOOTHPASTE (PASTE) BEDSIDE-CARE (SOLUTION) AQUAFRESH WHITENING (PASTE) BENZEDREX INHALER (INHALANT) aquanaz (tablet) benzoin compound tincture (tincture) aromatic ammonia inhalant (inhalant) benzoyl peroxide (foam) arthritis pain relief (tablet) benzoyl peroxide (gel) arthritis pain relieving (cream) benzoyl peroxide cleanser (liquid) artificial tears (ointment) benzoyl peroxide wash (liquid) artificial tears (solution) BETADINE (SOLUTION) ASPIR-LOW (TABLET) BETADINE SKIN CLEANSER (SOLUTION) ASPIRIN TAB 325MG (TABLET) BETADINE SURGICAL SCRUB (SOLUTION) aspirin (chewable tablet) BETADINE SWABSTICKS (SWAB) aspirin (suppository) BETASEPT SURGICAL SCRUB (LIQUID) aspirin (tablet) BION TEARS (SOLUTION) aspirin 81 (tablet) BIOTENE DRY MOUTH (PASTE) aspirin adult low dose (chewable tablet) BIOTENE DRY MOUTH GENTLE FORMULA aspirin adult low dose (tablet) (PASTE) aspirin adult low strength (chewable tablet) BIOTENE PBF DRY MOUTH (PASTE) aspirin ec (tablet) BISAC-EVAC (SUPPOSITORY) aspirin ec low dose (tablet) bisacodyl (suppository) aspirin low dose (chewable tablet) bisacodyl ec (tablet) aspirin low dose (tablet) biscolax (suppository) aspirin low strength (chewable tablet) bismatrol (chewable tablet) athletes foot af cream (cream) bismatrol (suspension)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

90 bismatrol maximum strength (suspension) CEPACOL SORE THROAT & COUGH blue gel (gel) (LOZENGE) bpo foaming cloths CEPACOL SORE THROAT & COUGH EXTRA BRONKAID (TABLET) STRENGTH (LOZENGE) BROTAPP (LIQUID) CEPACOL SORE THROAT (LOZENGE) brotapp dm (liquid) CEPACOL SORE THROAT EXTRA STRENGTH (LOZENGE) budesonide nasal spray (suspension) CEPACOL SORE THROAT EXTRASTRENGTH burn relief (aerosol) (LOZENGE) butenafine hydrochloride (cream) cetirizine hcl (chewable tablet) C cetirizine hcl (tablet) caffeine (tablet) cetirizine hcl allergy childrens (solution) CAL-GEST ANTACID (CHEWABLE TABLET) cetirizine hcl childrens (chewable tablet) calamine (lotion) cetirizine hcl childrens (solution) calamine medicated (lotion) cetirizine hcl childrens allergy (solution) calcium antacid (chewable tablet) cetirizine hcl/pseudoephedrine hcl er (extended calcium antacid extra strength (chewable tablet) release tablet) calcium antacid ultra (chewable tablet) cetirizine hydrochloride (chewable tablet) calcium antacid ultra maximum strength cetirizine hydrochloride (tablet) (chewable tablet) cetirizine hydrochloride childrens allergy calcium antacid ultra strength (chewable tablet) (solution) Drug List calcium carbonate (suspension) cheratussin ac (syrup) calcium carbonate (tablet) chest congestion relief (tablet) calcium gluconate (tablet) chest rub (ointment) caldyphen (lotion) chewable acetaminophen childrens (chewable caldyphen clear (lotion) tablet) CALLERGY CLEAR (LOTION) chewable antacid (chewable tablet) CALPHRON (TABLET) children's chewable acetaminophen (chewable CAMPHO-PHENIQUE (GEL) tablet) capcof (syrup) childrens acetaminophen (suspension) capmist dm (tablet) childrens aspirin low strength (chewable tablet) capron dm (liquid) childrens cold & allergy (elixir) capron dmt (tablet) childrens ibuprofen (suspension) capsaicin (cream) childrens loratadine (solution) CARRINGTON ANTIFUNGAL (CREAM) childrens loratadine (syrup) CARRINGTON MOISTURE BARRIER (CREAM) childrens mucus relief cough (liquid) CARRINGTON MOISTURE BARRIER/ZINC childrens mucus relief expectorant (liquid) (CREAM) childrens pain relief plus multi-symptom cold castellani paint modified/color (liquid) (suspension) castellani paint modified/colorless (liquid) childrens pain relief plus multi-symptom flu relief

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

91 (suspension) cold relief/non-drowsy/daytime (tablet) childrens silapap (liquid) cold/cough childrens (liquid) childrens silfedrine (liquid) cold/flu daytime relief (capsule) chlo hist (solution) complete allergy medicine (capsule) CHLO TUSS (LIQUID) CONEX COLD/ALLERGY (SOLUTION) CHLORPHEN SR (TABLET) CONEX COLD/ALLERGY (TABLET) CITRUCEL (TABLET) CONGESTAC (TABLET) CITRUCEL FIBER LAXATIVE (POWDER) CONTAC COLD+FLU MAXIMUM STRENGTH clear anti-itch (lotion) (TABLET) CLEARLAX (PACK) CONTAC COLD/FLU DAY/NIGHT (TABLET) CLEARLAX (POWDER) CONTAC COLD/FLU MAXIMUM STRENGTH clotrimazole (cream) (TABLET) clotrimazole (solution) cool therapy pain gel (gel) clotrimazole 3 (cream) corn and callus remover (liquid) clotrimazole anti-fungal (cream) cough & chest congestion dm (syrup) clotrimazole antifungal (cream) cough & cold (tablet) COATS ALOE CREME (CREAM) cough & cold hbp (tablet) COATS ALOE GELLY (GEL) cough & sore throat day time (liquid) COATS ALOE LINIMENT (LOTION) cough & sore throat nighttime (liquid) COATS ALOE MOISTURIZING LOTION cough dm (suspension) (LOTION) cough dm childrens (suspension) codeine/guaifenesin (solution) cough drops (lozenge) COLACE (CAPSULE) cough syrup (syrup) COLACE 2-IN-1 (TABLET) CRITIC-AID CLEAR AF (OINTMENT) COLACE CLEAR (CAPSULE) CRITIC-AID CLEAR MOISTUREBARRIER cold & allergy (tablet) (OINTMENT) cold & allergy childrens (elixir) CRITIC-AID THICK MOISTUREBARRIER (PASTE) cold & cough childrens (liquid) cromolyn sodium (aerosol) cold & flu relief daytime/multi-symptom (capsule) cold & flu relief nighttime/multi-symptom D (capsule) DAY TIME COLD/FLU RELIEF (LIQUID) cold & sinus relief (tablet) day time cough (liquid) cold head congestion daytime (tablet) day time multi-symptom cold/flu relief (capsule) cold head congestion nighttime (tablet) day time/nite time cold & flu relief cold head congestion severe daytime (tablet) DAYCLEAR ALLERGY RELIEF (TABLET) cold multi-symptom daytime (tablet) DAYHIST ALLERGY 12 HOUR RELIEF (TABLET) cold multi-symptom nighttime (tablet) daytime cold & flu relief (capsule) cold multi-symptom severe daytime (tablet) daytime cold & flu relief (liquid) cold relief plus (tablet) daytime multi-symptom cold/flu relief (capsule)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

92 daytime pe multi-symptom cold/flu relief diphenhist (tablet) (capsule) diphenhydramine hcl (capsule) daytime severe cold & flu (liquid) diphenhydramine hcl/zinc acetate (cream) DECONEX DMX (TABLET) diphenhydramine hydrochloride (capsule) DECONEX IR (TABLET) diphenhydramine hydrochloride (liquid) decongestant 12hour maximum strength diphenhydramine hydrochloride (tablet) (extended release tablet) docqlace (capsule) DELSYM (SUSPENSION) docu (liquid) DELSYM COUGH + CHEST CONGESTION DM docusate sodium & senna stimulant laxative/ (LIQUID) stool softener (tablet) DELSYM COUGH + CHEST CONGESTION DM docusate sodium (capsule) CHILDRENS (LIQUID) docusate sodium (liquid) DELSYM COUGH + COLD DAYTIME (LIQUID) docusate sodium (tablet) DELSYM COUGH + COLD NIGHTTIME (LIQUID) DOCUSIL (CAPSULE) DELSYM COUGH + COLD NIGHTTIME DOCUSOL KIDS (ENEMA) CHILDRENS (LIQUID) DOCUSOL MINI (ENEMA) DELSYM COUGH CHILDRENS (SUSPENSION) DOCUSOL PLUS MINI-ENEMA (ENEMA) DELSYM COUGH+SOOTHING A CTION (LOZENGE) DOK (CAPSULE) DESENEX SHAKE POWDER (POWDER) DOK (TABLET)

DESENEX SPRAY LIQUID (AEROSOL) DOK PLUS (TABLET) Drug List DESENEX SPRAY POWDER (AEROSOL DOLOGESIC (TABLET) POWDER) double antibiotic (ointment) dextromethorphan polistirex (suspension) DR SMITHS ADULT BARRIER SPRAY dextromethorphan/guaifenesin/phenylephrine (AEROSOL) (liquid) DR SMITHS DIAPER (OINTMENT) DHS SAL (SHAMPOO) DR SMITHS DIAPER RASH SPRAY (AEROSOL) DHS TAR (SHAMPOO) DR SMITHS RASH + SKIN (AEROSOL) DHS TAR GEL (SHAMPOO) DRIMINATE (TABLET) DHS ZINC (SHAMPOO) dry eye relief drops (solution) diabetic siltussin das-na (liquid) dual action complete (chewable tablet) diabetic siltussin-dm (liquid) ducodyl (tablet) diabetic siltussin-dm maximum strength (liquid) DULCOLAX (SUPPOSITORY) diaper rash (ointment) DURAFLU (TABLET) dibucaine (ointment) dye-free allergy relief childrens (liquid) DIFFERIN (GEL) E dimaphen childrens (elixir) ear drops (solution) DIMAPHEN DM COLD & COUGH (LIQUID) ear dry (liquid) diphenhist (capsule) ear wax cleansing kit (kit) diphenhist (liquid) earwax removal kit (solution)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

93 earwax treatment drops (solution) F ECONTRA EZ (TABLET) FALLBACK SOLO (TABLET) ECONTRA ONE-STEP (TABLET) famotidine (tablet) ECPIRIN (TABLET) fast acting antacid plus anti-gas maximum ED A-HIST (LIQUID) strength (suspension) ED A-HIST (TABLET) FEVERALL ADULTS (SUPPOSITORY) ed a-hist dm (liquid) FEVERALL CHILDRENS (SUPPOSITORY) ed a-hist dm (tablet) FEVERALL INFANTS (SUPPOSITORY) ed a-hist pse (tablet) FEVERALL JUNIOR STRENGTH ed bron gp (liquid) (SUPPOSITORY) ED CHLORPED (LIQUID) fexofenadine hcl childrens allergy (suspension) ED CHLORPED D (LIQUID) fexofenadine hcl/pseudoephedrine hcl er (tablet) ed chlorped jr (syrup) fexofenadine hydrochloride (tablet) ed-apap (liquid) fexofenadine hydrochloride/pseudoephedrine ENDACOF-DM (LIQUID) hydrochloride er (extended release tablet) enema (enema) fexofenadine/pseudoephedrine (extended enema mineral oil ready-to-use (enema) release tablet) enema ready-to-use (enema) fiber laxative (capsule) ENEMEEZ MINI (ENEMA) fiber laxative (tablet) ENEMEEZ PLUS (ENEMA) fiber tabs (tablet) ephedrine sulfate (capsule) fiber-lax (tablet) eq aspirin ec (tablet) FLEET BISACODYL (ENEMA) esomeprazole magnesium (delayed release FLEET ENEMA (ENEMA) capsule) FLEET LIQUID GLYCERIN SUPPOSITORIES ethyl rubbing alcohol (solution) (ENEMA) EX-LAX (CHEWABLE TABLET) FLEET OIL (ENEMA) EX-LAX (TABLET) FLEET PEDIATRIC (ENEMA) EX-LAX MAXIMUM STRENGTH (TABLET) FLONASE ALLERGY RELIEF (SUSPENSION) EXCEDRIN EXTRA STRENGTH (TABLET) FLONASE ALLERGY RELIEF CHILDRENS (SUSPENSION) EXCEDRIN MIGRAINE (TABLET) FLONASE SENSIMIST (SUSPENSION) EXCEDRIN TENSION HEADACHE (TABLET) flu & severe cold daytime (pack) extra action cough (syrup) flu & sore throat (pack) extra strength pain relief (tablet) flu hbp (tablet) eye drops (solution) flu/severe cold & cough daytime (pack) eye irrigating solution (solution) fluticasone propionate (suspension) eye itch relief (solution) formula em (solution) EYE STREAM (SOLUTION) FRESHKOTE (SOLUTION) eye wash (solution) FRESHKOTE PF (SOLUTION) EZ CHAR FUNGOID TINCTURE (SOLUTION)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

94 G gnp 24 hour nasal allerg y spray (aerosol) gas relief (capsule) gnp 8 hour pain reliever (tablet) gas relief (chewable tablet) gnp acetaminophen (tablet) gas relief (suspension) gnp acetaminophen extra strength (capsule) gas relief extra strength (capsule) gnp acid control 150 maximum strength (tablet) gas relief maximum strength (chewable tablet) gnp acid reducer (tablet) gas relief ultra strength (capsule) gnp acid reducer maximum strength (tablet) GAS-X (CHEWABLE TABLET) gnp adult aspirin low strength (chewable tablet) GAS-X EXTRA STRENGTH (CAPSULE) gnp all day allergy (tablet) GAS-X EXTRA STRENGTH (CHEWABLE gnp all day allergy childrens (solution) TABLET) gnp all day allergy-d (extended release tablet) GAS-X ULTRA STRENGTH (CAPSULE) gnp all day pain relief (tablet) gavilax (powder) gnp allergy & congestion relief (tablet) GAVISCON (CHEWABLE TABLET) gnp allergy (capsule) GAVISCON (SUSPENSION) gnp allergy (tablet) GAVISCON EXTRA STRENGTH (CHEWABLE gnp allergy antihistaminechildrens (liquid) TABLET) gnp allergy multi-symptom (tablet) GAVISCON EXTRA STRENGTH (SUSPENSION) gnp allergy plus severe sinus headache GAVISCON EXTRA STRENGTH RELIEF maximum strength (tablet)

FORMULA (SUSPENSION) gnp allergy plus sinus headache (tablet) Drug List general protection sunscreen continuous spray gnp allergy relief (capsule) spf30 (aerosol) gnp allergy relief (chewable tablet) general protection sunscreen continuous spray gnp allergy relief (tablet) spf70 (aerosol) gnp allergy relief for kids (tablet) general protection sunscreen spf30 (lotion) gnp aloe vera/lidocaine (gel) general protection sunscreen spf50 (lotion) gnp antacid & anti-gas maximum strength GENTEAL SEVERE (GEL) (chewable tablet) GENTEAL TEARS LIQUID DROPS MODERATE gnp antacid & anti-gas/regular strength (SOLUTION) (suspension) GENTEAL TEARS MILD (SOLUTION) gnp antacid (chewable tablet) GENTEAL TEARS MODERATE PF (SOLUTION) gnp antacid and anti-gas/maximum strength GENTEAL TEARS MODERATE PF (SOLUTION) (suspension) gentle laxative (tablet) gnp antacid anti-gas (suspension) GERMBLOC HEALTH (FOAM) gnp antacid anti-gas/maximum strength GERMBLOC HEALTH HAND SANITIZER (suspension) (LOTION) gnp antacid extra strength (chewable tablet) glycerin adult (suppository) gnp antacid maximum strength (suspension) glycerin pediatric (suppository) gnp antacid/regular strength (suspension) GLYCOLAX (POWDER) gnp anti-diarrheal (capsule) gnp 12 hour nasal spray (solution) gnp anti-diarrheal (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

95 gnp anti-gas (capsule) gnp cold relief multi-symptom severe daytime gnp anti-itch (cream) (tablet) gnp anti-itch (lotion) gnp cough dm er (suspension) gnp antiseptic skin cleanser (solution) gnp cough gels (capsule) gnp arthricream (cream) gnp cough relief (liquid) gnp arthritis pain relief (tablet) gnp day time cold/flu (capsule) gnp artificial tears (solution) gnp day time cold/flu relief (liquid) gnp aspirin (tablet) gnp dayhist allergy (tablet) gnp aspirin low dose (tablet) gnp diaper rash (cream) gnp athlete's foot relief (aerosol powder) gnp docusate calcium (capsule) gnp athletes foot (cream) gnp ear systems (solution) gnp bacitracin zinc (ointment) gnp enema (enema) GNP BISA-LAX (TABLET) gnp enema mineral oil laxative (enema) gnp budesonide nasal spray (suspension) gnp epsom salt (granules) gnp burn relief spray aloe extra (aerosol) gnp esomeprazole magnesium (delayed release gnp calamine (lotion) capsule) gnp calamine phenolated (lotion) gnp eye drops (solution) gnp caldyphen (lotion) gnp fiber therapy (tablet) gnp caldyphen clear (lotion) gnp fiber-caps (tablet) gnp capsaicin (liquid) gnp flu & severe cold & cough nighttime (pack) gnp chest rub (ointment) gnp flu relief therapy severe cold nighttime (liquid) gnp childrens allergy (liquid) gnp fluticasone propionate (suspension) gnp childrens ibuprofen (suspension) gnp gas relief (chewable tablet) gnp childrens pain relief (suspension) gnp gas relief extra strength (capsule) gnp childrens pain relief plus cold (suspension) gnp gas relief extra strength (chewable tablet) GNP CLEARLAX (PACK) gnp gentle laxative (suppository) GNP CLEARLAX (POWDER) gnp headache pm (tablet) gnp clotrimazole 3 (cream) gnp headache relief (tablet) gnp cold & allergy childrens (elixir) gnp headache relief extra strength (tablet) gnp cold & allergy maximum strength (tablet) gnp heartburn relief (tablet) gnp cold & cough childrens (liquid) gnp hemorrhoidal (ointment) gnp cold & hot therapy balm extra strength (ointment) gnp hemorrhoidal cooling (gel) gnp cold head congestion day/night gnp hydro-lotion (lotion) gnp cold head congestion night time (tablet) gnp hydrocortisone (cream) gnp cold multi-symptom day/night gnp hydrocortisone maximum strength (ointment) gnp cold relief head congestion severe daytime (tablet) gnp hydrocortisone plus (cream) gnp cold relief multi-symptom daytime (tablet) gnp hydrocortisone/aloe (cream) gnp hydrogen peroxide (solution)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

96 gnp hygienic cleansing (pads) gnp miconazole 7 (cream) gnp ibuprofen (capsule) gnp miconazorb af (powder) gnp ibuprofen (tablet) gnp migraine relief (tablet) gnp ibuprofen cold/sinus (tablet) gnp milk of magnesia (suspension) gnp ibuprofen infants (suspension) gnp mineral oil heavy (oil) gnp ibuprofen junior strength (chewable tablet) gnp motion sickness relief (tablet) gnp ibuprofen pm (tablet) gnp mucus d 12 hr (extended release tablet) gnp infants gas relief (suspension) gnp mucus dm maximum strength (extended gnp infants pain relief (suspension) release tablet) gnp infants pain/fever (suspension) gnp mucus er (extended release tablet) gnp iodides tincture (tincture) gnp mucus relief childrens (liquid) gnp iodine tincture (tincture) gnp mucus relief cold & sinus (tablet) gnp isopropyl alcohol (solution) gnp mucus relief cold flu & sore throat (tablet) gnp itch relief extra strength (liquid) gnp mucus relief cough childrens (liquid) gnp lansoprazole (delayed release capsule) gnp mucus relief dm (tablet) gnp laxative (tablet) gnp mucus relief pe (tablet) gnp laxative pills (tablet) gnp mucus-er (extended release tablet) gnp lice solution kit (kit) gnp multi-symptom cold nighttime (liquid) gnp lice treatment (liquid) gnp muscle rub (cream) gnp lice treatment (shampoo) gnp naproxen sodium (capsule) Drug List gnp lidocaine pain relief (patch) gnp naproxen sodium (tablet) gnp loperamide hcl (suspension) gnp nasal decongestant (tablet) gnp loratadine (syrup) gnp nasal decongestant pemaximum strength gnp loratadine (tablet) (tablet) gnp loratadine childrens (solution) gnp nasal decongestant/maximum strength (tablet) gnp loratadine childrens (syrup) gnp nasal spray (solution) gnp loratadine-d 12hr (extended release tablet) gnp nasal spray extra moisturizing (solution) gnp loratadine-d 24 hour (tablet) gnp nasal spray fast actiing (solution) gnp lubricant pm (ointment) gnp natural fiber (powder) gnp lubricating plus eye drops (solution) gnp nausea relief (solution) gnp magnesium citrate (solution) gnp nicotine mini lozenge (lozenge) GNP MASANTI MAXIMUM STRENGTH (SUSPENSION) gnp nicotine polacrilex (gum) GNP MASANTI REGULAR STRENGTH gnp nicotine polacrilex (lozenge) (SUSPENSION) gnp nicotine polacrilex mini (lozenge) gnp medicated first aid spray (aerosol) gnp nicotine transdermal system (patch) gnp medicated wipes (pads) gnp nicotine transdermal system step 2 (patch) gnp miconazole 3 (kit) gnp night time cold & flu (capsule) gnp miconazole 3 combination pack (kit) gnp night time cold & flu multi-symptom (liquid)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

97 gnp night time cough (liquid) gnp stool softener (liquid) gnp nighttime sleep aid (tablet) gnp stool softener (syrup) gnp no drip nasal spray (solution) gnp stool softener extra strength (capsule) gnp nose drops extra strength (solution) gnp stool softener/stimulant laxative (tablet) gnp omeprazole (tablet) gnp tab tussin (tablet) gnp pain & fever childrens (suspension) gnp tab tussin dm (tablet) gnp pain relief (chewable tablet) gnp terbinafine hydrochloride (cream) gnp pain relief (tablet) gnp therapeutic blue gel (gel) gnp pain relief extra strength (liquid) gnp tioconazole 1 (ointment) gnp pain relief extra strength (tablet) gnp tolnaftate (cream) gnp pain relief pm extra strength (tablet) gnp triple antibiotic (ointment) gnp pink bismuth (chewable tablet) gnp triple antibiotic plus (ointment) gnp pink bismuth (tablet) gnp tussin (syrup) gnp povidone-iodine (solution) gnp tussin cf cough & cold (syrup) gnp pseudoephedrine hcl 12 hour (extended gnp tussin cf max multi-symptom cold (liquid) release tablet) gnp tussin cough long acting (syrup) gnp pseudoephedrine hcl er (extended release gnp tussin dm (liquid) tablet) gnp tussin dm cough (liquid) gnp redness relief (solution) gnp tussin dm max (liquid) gnp rubbing alcohol (solution) gnp tussin dm max cough & chest congestion gnp scalp relief (liquid) (liquid) gnp senna lax (tablet) gnp tussin mucus & chest congestion (liquid) gnp senna plus (tablet) gnp urinary pain relief (tablet) gnp senna-lax (tablet) gnp vitamin a & d (ointment) gnp sinus & allergy pe (tablet) gnp wart remover (liquid) gnp sinus & cold-d (extended release tablet) gnp womens gentle laxative (tablet) gnp sinus congestion & pain daytime (tablet) gnp womens laxative (tablet) gnp sinus relief congestion & pain daytime/ gnp zinc oxide (ointment) nighttime goodsense acid reducer (tablet) gnp sinus relief congestion & pain nighttime goodsense all day allergy (tablet) (tablet) goodsense all day allergychildrens (solution) gnp sinus relief pressure& pain (tablet) goodsense aller-ease (tablet) gnp sinus relief severe congestion relief (tablet) goodsense arthritis pain (tablet) gnp sleep aid (tablet) goodsense aspirin (chewable tablet) gnp sleep time (liquid) goodsense aspirin (tablet) gnp sore throat (liquid) goodsense aspirin adult low strength (chewable gnp sore throat spray (liquid) tablet) gnp stay awake (tablet) GOODSENSE CLEARLAX (POWDER) gnp stomach relief (suspension) goodsense cold & flu severe for adults (tablet) gnp stool softener (capsule)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

98 goodsense cough dm (suspension) strength (liquid) goodsense cough dm childrens (suspension) goodsense nighttime cough (liquid) goodsense day time cold &flu severe non-drowsy goodsense pain & fever childrens (suspension) (liquid) goodsense pain & fever infants (suspension) goodsense day time cold &flu severe non-drowsy goodsense pain relief (tablet) (tablet) goodsense pain relief extra strength (tablet) goodsense daytime cold & flu (capsule) goodsense pain relief pm extra strength (tablet) goodsense daytime cold & flu (liquid) goodsense severe sinus congestion (capsule) GOODSENSE ESOMEPRAZOLE MAGNESIUM goodsense sinus relief maximum strength (DELAYED RELEASE CAPSULE) (tablet) goodsense flu & severe cold & cough nighttime goodsense sleeptime (capsule) (pack) goodsense sleeptime (liquid) goodsense flu & severe cold daytime (pack) goodsense stomach relief (chewable tablet) goodsense headache pm (tablet) goodsense tussin cf (liquid) goodsense hemorrhoidal ointment (ointment) guaiatussin ac (syrup) goodsense hemorrhoidal (suppository) guaifenesin (liquid) goodsense ibuprofen (tablet) guaifenesin (solution) goodsense ibuprofen childrens (suspension) guaifenesin (tablet) goodsense ibuprofen infants (suspension) guaifenesin ac (syrup) goodsense ibuprofen junior strength (chewable

guaifenesin dac (solution) Drug List tablet) guaifenesin er (extended release tablet) goodsense ibuprofen pm (tablet) guaifenesin-dm (syrup) goodsense lansoprazole (delayed release capsule) guaifenesin/codeine (solution) goodsense lubricant eye drops (solution) guaifenesin/dextromethorphan hydrobromide (syrup) goodsense lubricating plus eye drops (solution) guaifenesin/pseudoephedrine hydrochloride goodsense miconazole 1 (kit) (extended release tablet) goodsense migraine formula (tablet) H goodsense mucus relief childrens (liquid) goodsense mucus-d (extended release tablet) hair regrowth treatment for men extra strength (solution) goodsense naproxen sodium (tablet) headache formula added strength (tablet) goodsense nasal allergy spray (aerosol) headache pm (tablet) goodsense nasoflow (suspension) headache pm formula (tablet) goodsense nicotine (lozenge) headache relief (tablet) goodsense nicotine gum (gum) headache relief pm (tablet) goodsense nicotine polacrilex (lozenge) headache relief/extra strength (tablet) goodsense nicotine polacrilex gum (gum) HEALTHYLAX (PACK) goodsense nighttime cold & flu (capsule) heartburn relief (tablet) goodsense nighttime cold & flu severe (liquid) heartburn relief 150 maximum strength (tablet) goodsense nighttime cold & flu severe maximum

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

99 heartburn relief maximum strength (tablet) hm aspirin ec low dose (tablet) heartburn treatment 24 hour (delayed release hm bacitracin (ointment) capsule) hm calamine (lotion) hemorrhoidal (cream) hm calcium antacid (chewable tablet) hemorrhoidal (ointment) hm calcium antacid extra strength (chewable hemorrhoidal (suppository) tablet) hemorrhoidal maximum strength/aloe (cream) hm calcium antacid smoothdissolve (chewable hemorrhoidal suppositories (suppository) tablet) HISTEX (SYRUP) hm calcium antacid smoothdissolve extra HISTEX PD (LIQUID) strength (chewable tablet) HISTEX-AC (SYRUP) hm calcium antacid ultra strength (chewable tablet) HISTEX-DM (SYRUP) hm castor oil (oil) HISTEX-PE (SYRUP) hm cetirizine hcl childrens (solution) hm acetaminophen childrens (chewable tablet) hm cetirizine hydrochloride (tablet) hm acid reducer (tablet) hm chest congestion relief (tablet) hm acid reducer maximum strength (tablet) hm chest congestion relief dm (tablet) hm advanced antacid maximum strength (suspension) hm chest rub (ointment) hm all day allergy (tablet) HM CLEARLAX (POWDER) hm all day allergy childrens (solution) hm cold & allergy childrens (elixir) hm allergy & congestion (extended release hm cold & cough childrens (liquid) tablet) hm cold & sinus relief (tablet) hm allergy complete-d (extended release tablet) hm cough dm (suspension) hm allergy relief & nasaldecongestant (tablet) hm day time liquid caps (capsule) hm allergy relief (capsule) hm daytime cold & flu (liquid) hm allergy relief (tablet) hm double antibiotic (ointment) hm allergy relief childrens (liquid) hm dry eye relief (solution) hm allergy relief nasal spray 24hr (suspension) hm earwax removal aid (solution) hm antacid (suspension) hm earwax removal kit (solution) hm antacid anti-gas extrastrength (suspension) hm enema (enema) hm antacid/antigas (suspension) hm enema mineral oil (enema) hm anti-diarrheal (tablet) hm enema ready-to-use (enema) hm anti-nausea (solution) hm enema saline laxative (enema) hm antiseptic skin cleanser (solution) hm epsom salt (granules) hm arthiritis creme (cream) hm esomeprazole magnesium delayed release hm arthritis pain relief (tablet) (delayed release capsule) hm aspirin (chewable tablet) hm eye drops (solution) hm aspirin (tablet) hm eye drops advanced relief (solution) hm aspirin ec (tablet) hm eye drops redness relief (solution) hm eye itch relief (solution)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

100 hm famotidine (tablet) hm milk of magnesia (suspension) hm fexofenadine hydrochloride (tablet) hm motion relief (tablet) hm fiber (capsule) hm motion sickness (tablet) hm fiber (powder) hm motion sickness relief (tablet) hm fiber (tablet) hm mucus relief d (extended release tablet) hm gas relief (chewable tablet) hm mucus relief dm maximum strength hm gas relief extra strength (capsule) (extended release tablet) hm gas relief infants (suspension) hm muscle rub (cream) hm glycerin (liquid) hm naproxen sodium (capsule) hm hemorrhoidal (ointment) hm naproxen sodium (tablet) hm hydrocortisone plus (cream) hm nasal decongestant (tablet) hm hydrocortisone/aloe maximum strength hm nasal decongestant 12 hour (extended (cream) release tablet) hm hydrogen peroxide (solution) hm nasal decongestant pe (tablet) hm ibuprofen (capsule) hm nasal spray (solution) hm ibuprofen (chewable tablet) hm nicotine polacrilex (gum) hm ibuprofen (tablet) hm nicotine polacrilex (lozenge) hm ibuprofen childrens (suspension) hm nicotine transdermal system (patch) hm ibuprofen ib (tablet) hm nicotine transdermal system (patch) hm nicotine transdermal system step 1 (patch) hm ibuprofen infants (suspension) Drug List hm ibuprofen pm (tablet) hm nicotine transdermal system step 2 (patch) hm iodides tincture (tincture) hm nicotine transdermal system step 3 (patch) hm iodine tincture (tincture) hm night time cold & flu (liquid) hm isopropyl rubbing alcool (solution) hm night time multi-symptom cold & flu (capsule) hm isoprpyl rubbing alcohol (solution) hm nighttime sleep aid (tablet) hm lansoprazole (delayed release capsule) hm nose drops extra strength (solution) hm laxative (tablet) hm omeprazole (tablet) hm lice killing maximum strength (shampoo) hm pain & fever childrens (suspension) hm lice treatment (liquid) hm pain & fever infants (suspension) hm loperamide hcl (capsule) hm pain relief (tablet) hm loperamide hcl (liquid) hm pain relief extra strength (tablet) hm loperamide hcl (suspension) hm pain relief therapy patch (patch) hm loratadine (tablet) hm pain reliever (tablet) hm loratadine childrens (syrup) hm pain reliever pm extrastrength (tablet) hm lubricating plus (solution) hm povidone-iodine (solution) hm lubricating tears (solution) hm rapid melts junior (tablet) hm magnesium citrate (solution) HM SALONPAS PAIN RELIEF PATCH (PATCH) hm medicated cooling pads (pads) hm senna (tablet) hm migraine relief (tablet) hm senna-s (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

101 hm severe cold & flu (tablet) ibuprofen infants (suspension) hm severe cold/cough/flu daytime (pack) ibuprofen junior strength (chewable tablet) hm sinus & cold-d (extended release tablet) ibuprofen pm (tablet) hm sinus nasal spray (solution) IFEREX 150 (CAPSULE) hm sleep aid (tablet) infants gas relief (suspension) hm stay awake (tablet) infants ibuprofen (suspension) hm stomach relief (chewable tablet) infants pain relief (suspension) hm stomach relief (suspension) infants simethicone (suspension) hm stomach relief maximumstrength iodides tincture (tincture) (suspension) ISAGEL (GEL) hm stool softener (capsule) isopropyl alcohol (solution) hm stool softener (tablet) ISOPTO TEARS (SOLUTION) hm stool softener maximum strength (capsule) itch relief extra strength (cream) hm stool softener/stimulant laxative (tablet) ITCH-X (GEL) hm triple antibiotic (ointment) ITCH-X (SOLUTION) hm triple antibiotic plus maximum strength J (ointment) J-MAX (SYRUP) hm tussin adult (liquid) J-TAN D PD (LIQUID) hm tussin adult cough & chest congestion dm (liquid) J-TAN PD (LIQUID) hm tussin adult multi-symptom cold (liquid) jock itch spray (aerosol powder) hm tussin cough/chest congestion dm max/ K adult (liquid) KAO-TIN (CAPSULE) hm witch hazel (liquid) KAO-TIN (SUSPENSION) hm z-sleep (capsule) KERR TRIPLE DYE (SWAB) hm z-sleep (liquid) ketotifen fumarate (solution) hydrocortisone (cream) kidkare cough/cold (liquid) hydrocortisone (ointment) kids sunscreen clear continuous spray spr50 hydrocortisone maximum strength (cream) (aerosol) hydrocortisone maximum strength plus 12 kids sunscreen continuousspray spf50 (aerosol) moisturizers (cream) KONSYL (CAPSULE) hydrocortisone/aloe (cream) KONSYL (PACK) I KONSYL (POWDER) ibu-200 (tablet) konsyl daily fiber (pack) ibuprofen (capsule) konsyl daily fiber (powder) ibuprofen (suspension) KONSYL FIBER (TABLET) ibuprofen (tablet) konsyl original formula daily fiber (powder) ibuprofen childrens (suspension) KONSYL-D (POWDER) ibuprofen cold & sinus (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

102 L LORTUSS LQ (LIQUID) LAMISIL ADVANCED (GEL) lubricant eye drops (solution) LAMISIL AF DEFENSE (AEROSOL POWDER) lubricating plus eye drops (solution) LAMISIL AT (CREAM) lubrifresh p.m. (ointment) LAMISIL AT JOCK ITCH (CREAM) LUMIFY (SOLUTION) LAMISIL AT SPRAY (SOLUTION) M lansoprazole (delayed release capsule) m-clear wc (solution) laxative (suppository) m-end dmx (liquid) laxative (tablet) M-END PE (LIQUID) laxative feminine (tablet) m-hist pd (liquid) levocetirizine dihydrochloride (tablet) mag-al (liquid) levonorgestrel (tablet) mag-al plus (liquid) lice killing maximum strength (shampoo) mag-al plus xs (liquid) lice killing shampoo (shampoo) MAGNEBIND 300 (TABLET) lice treatment (lotion) magnesium citrate (solution) LICEMD COMPLETE KIT (KIT) magnesium oxide (tablet) lidocaine (cream) MAJOR-PREP HEMORRHOIDAL (OINTMENT) lidocaine (kit) mapap (capsule) lidocaine 5% (cream) mapap (chewable tablet) lidocaine hydrochloride (cream) mapap (liquid) Drug List lidocaine/transparent dressing (kit) mapap (tablet) lip balm spf4 (stick) MAPAP ACETAMINOPHEN EXTRASTRENGTH liquitears (solution) (LIQUID) LODRANE D (CAPSULE) mapap arthritis pain (tablet) LOHIST-D (LIQUID) MAPAP CHILDRENS (CHEWABLE TABLET) lohist-dm (syrup) MAPAP CHILDRENS (SUSPENSION) loperamide hcl (liquid) MAPAP COLD FORMULA MULTI-SYMPTOM loperamide hcl (suspension) (TABLET) loperamide hydrochloride (tablet) MAPAP EXTRA STRENGTH (TABLET) loratadine (capsule) mapap pm (tablet) loratadine (tablet) MAPAP SINUS MAXIMUM STRENGTH CONGESTION AND PAIN (TABLET) loratadine childrens (chewable tablet) MAR-COF CG EXPECTORANT (LIQUID) loratadine childrens (solution) MAXIPHEN (TABLET) loratadine childrens (syrup) MAXIPHEN DM (TABLET) loratadine hives relief (solution) meclizine hcl (tablet) loratadine-d 12hr (extended release tablet) meclizine hydrochloride (chewable tablet) loratadine-d 24hr (tablet) medi pads (pads) LORTUSS DM (LIQUID) medicated callus removers (pads) LORTUSS EX (LIQUID)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

103 medicated corn removers (pads) MUCINEX CHILDRENS MULTI-SYMPTOM medicated feminine douche (solution) COLD (LIQUID) menstrual pain relief multi-symptom maximum MUCINEX CONGESTION & COUGH strength (tablet) CHILDRENS (LIQUID) MI-ACID (CHEWABLE TABLET) MUCINEX COUGH CHILDRENS (LIQUID) MI-ACID (SUSPENSION) MUCINEX COUGH FOR KIDS (PACK) mi-acid gas relief (chewable tablet) MUCINEX D (EXTENDED RELEASE TABLET) mi-acid maximum strength (suspension) MUCINEX D MAXIMUM STRENGTH miconazole (cream) (EXTENDED RELEASE TABLET) miconazole 1 (kit) MUCINEX DM (EXTENDED RELEASE TABLET) miconazole 3 (cream) MUCINEX DM MAXIMUM STRENGTH (EXTENDED RELEASE TABLET) miconazole 3 combination pack (kit) MUCINEX FAST-MAX COLD & SINUS (LIQUID) miconazole 3 combo pack (kit) MUCINEX FAST-MAX COLD & SINUS (TABLET) miconazole 7 (cream) MUCINEX FAST-MAX COLD FLU& SORE miconazole 7 (suppository) THROAT (LIQUID) miconazole nitrate (cream) MUCINEX FAST-MAX COLD FLU& SORE miconazole nitrate (suppository) THROAT (TABLET) MICRO GUARD (POWDER) MUCINEX FAST-MAX COLD FLU& SORE migraine formula (tablet) THROAT CLEAR & COOL (LIQUID) migraine relief (tablet) MUCINEX FAST-MAX COLD/FLU/SORE milk of magnesia (suspension) THROAT (CAPSULE) milk of magnesia concentrate (suspension) MUCINEX FAST-MAX COLD/FLU/SORE MINERAL ICE (GEL) THROAT (PACK) mineral oil (oil) MUCINEX FAST-MAX CONGESTION & HEADACHE (CAPSULE) minoxidil for men (solution) MUCINEX FAST-MAX DAY TIME/NIGHT TIME MINTOX (SUSPENSION) MUCINEX FAST-MAX DAY TIME/NIGHT TIME mintox maximum strength (suspension) (PACK) MINTOX PLUS (CHEWABLE TABLET) MUCINEX FAST-MAX DAY/NIGHT (CAPSULE) MOBISYL (CREAM) MUCINEX FAST-MAX DAY/NIGHT MAXIMUM MOISTUREL THERAPEUTIC (LOTION) STRENGTH motion sickness relief (tablet) MUCINEX FAST-MAX DAY/NITE M/S motion-time (chewable tablet) MUCINEX FAST-MAX DM MAX (LIQUID) MUCINEX (EXTENDED RELEASE TABLET) MUCINEX FAST-MAX NIGHT TIME COLD & FLU MUCINEX ALLERGY (TABLET) (CAPSULE) MUCINEX CHEST CONGESTION CHILDRENS MUCINEX FAST-MAX NIGHT TIME COLD & FLU (LIQUID) (LIQUID) MUCINEX CHILDRENS COLD COUGH & SORE MUCINEX FAST-MAX NIGHT TIME COLD & FLU THROAT (LIQUID) (PACK) MUCINEX CHILDRENS MULTI-SYMPTOM MUCINEX FAST-MAX NIGHT TIME COLD & FLU COLD & FEVER (LIQUID)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

104 (TABLET) mucosa dm (tablet) MUCINEX FAST-MAX SEVERE COLD & SINUS mucus & cough relief childrens (liquid) (CAPSULE) mucus d (extended release tablet) MUCINEX FAST-MAX SEVERE COLD (LIQUID) mucus relief (extended release tablet) MUCINEX FAST-MAX SEVERE COLD (PACK) mucus relief (tablet) MUCINEX FAST-MAX SEVERE COLD (TABLET) mucus relief chest congestion (tablet) MUCINEX FAST-MAX SEVERE CONGESTION & mucus relief childrens (liquid) COLD (TABLET) mucus relief cold & sinusmaximum strength MUCINEX FAST-MAX SEVERE CONGESTION & (tablet) COUGH (LIQUID) mucus relief cold flu & sore throat (tablet) MUCINEX FAST-MAX SEVERE CONGESTION & mucus relief cough childrens (liquid) COUGH (TABLET) mucus relief dm (extended release tablet) MUCINEX FAST-MAX SEVERE CONGESTION & mucus relief dm (tablet) COUGH CLEAR & COOL (LIQUID) mucus relief dm cough (tablet) MUCINEX FOR KIDS (PACK) mucus relief dm maximum strength (extended MUCINEX MAXIMUM STRENGTH (EXTENDED release tablet) RELEASE TABLET) mucus relief dm maximum strength (liquid) MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK mucus relief multi symptom cold childrens (liquid) MUCINEX MULTI-SYMPTOM COLD NIGHT mucus relief pe sinus congestion (tablet)

TIME CHILDRENS (LIQUID) Drug List MUCINEX SINUS-MAX DAY/NIGHT mucus relief severe cold maximum strength (tablet) MUCINEX SINUS-MAX DAY/NIGHT (CAPSULE) mucus-dm maximum strength (extended release MUCINEX SINUS-MAX FULL FORCE tablet) (SOLUTION) mucus-er (extended release tablet) MUCINEX SINUS-MAX MOISTURE SMART (SOLUTION) mucusrelief sinus (tablet) MUCINEX SINUS-MAX NIGHT TIME multi symptom flu & severe cold/daytime (pack) CONGESTION & COUGH (LIQUID) multi-symptom allergy (capsule) MUCINEX SINUS-MAX PRESSURE & PAIN MURO 128 (OINTMENT) (LIQUID) MURO 128 (SOLUTION) MUCINEX SINUS-MAX PRESSURE & PAIN muscle rub (cream) (TABLET) muscle rub ultra strength (cream) MUCINEX SINUS-MAX SEVERE CONGESTION MY CHOICE (TABLET) RELIEF (CAPSULE) MY WAY (TABLET) MUCINEX SINUS-MAX SEVERE CONGESTION mytab gas (chewable tablet) RELIEF (LIQUID) MUCINEX SINUS-MAX SEVERE CONGESTION N RELIEF (TABLET) NAPHCON-A (SOLUTION) MUCINEX STUFFY NOSE & COLD CHILDRENS naproxen sodium (capsule) (LIQUID) naproxen sodium (tablet) mucosa (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

105 nasal allergy 24 hour multi-symptom (aerosol) nighttime cold/flu relief (liquid) nasal decongestant (liquid) nighttime cold/flu reliefmulti-symptom (liquid) nasal decongestant (syrup) nighttime cold/flu/maximum strength (liquid) nasal decongestant (tablet) nighttime cough (liquid) nasal decongestant maximum strength (tablet) nighttime severe cold & flu/maximum strength nasal decongestant pe (tablet) (liquid) nasal decongestant pe maximum strength nighttime sinus congestion & pain (tablet) (tablet) nighttime sleep aid (tablet) nasal decongestant spray (solution) NINJACOF (LIQUID) nasal four (solution) NINJACOF-A (LIQUID) nasal relief (solution) NINJACOF-XG (LIQUID) nasal spray 12 hour (solution) NISEKO SUNSCREEN BROAD SPECTRUM nasal spray extra moisturizing 12 hour (solution) SPF25 (CREAM) NASOPEN PE (LIQUID) nite time cough (liquid) natural balance tears (solution) nite time multi-symptom cold/flu relief (liquid) natural fiber (powder) nite time multi-symptom cold/flu relief (capsule) natural fiber laxative (powder) nite time-d (liquid) natural fiber therapy (powder) nite-time multi-symptom cold/flu relief (liquid) natures tears (solution) NIVA-HIST DM (LIQUID) NEW DAY (TABLET) NIVANEX DMX (TABLET) NIACIN CAP 500MG SR (SUSTAINED RELEASE NO DOZ MAXIMUM STRENGTH (TABLET) CAPSULE) no drip nasal spray (solution) niacin sr (sustained release capsule) nohist-dm (liquid) NICODERM CQ (PATCH) nohist-lq (liquid) NICORELIEF (GUM) non-aspirin childrens (suspension) NICORETTE (GUM) NOREL AD (TABLET) NICORETTE (LOZENGE) nose drops extra strength (solution) NICORETTE MINI (LOZENGE) O NICORETTE STARTER KIT (GUM) omeprazole (tablet) nicotine polacrilex (gum) omeprazole magnesium (delayed release nicotine polacrilex (lozenge) capsule) nicotine transdermal system (kit) omeprazole odt (tablet) nicotine transdermal system (patch) OPCICON ONE-STEP (TABLET) nicotine transdermal system step 1 (patch) opti-clear (solution) nicotine transdermal system step 2 (patch) OPTION 2 (TABLET) nicotine transdermal system step 3 (patch) ORASEP (SOLUTION) night time multi-symptom cold/flu relief (capsule) organ-i nr (tablet) night time sleep aid (tablet) overnight ultra thin (pads) nighttime cold/flu relief (capsule) OXYTROL FOR WOMEN

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

106 P PHARBETOL EXTRA STRENGTH (TABLET) pain & fever (tablet) phenaseptic (liquid) pain & fever childrens (chewable tablet) phenylephrine hcl/pyrilamine maleate (tablet) pain & fever childrens (solution) pink bismuth (chewable tablet) pain & fever childrens (suspension) PLAN B ONE-STEP (TABLET) pain & fever childrens dye-free (suspension) poly bacitracin (ointment) pain & fever extra strength (tablet) POLY HIST FORTE (TABLET) pain & fever infants (suspension) poly-hist dm (liquid) pain relief (tablet) poly-hist pd (liquid) pain relief childrens (suspension) poly-tussin ac (liquid) pain relief extra strength (tablet) POLY-VENT DM (TABLET) pain relief pm extra strength (tablet) POLY-VENT IR (TABLET) pain reliever plus (tablet) polyethylene glycol 3350 (pack) pain reliever pm extra strength (tablet) polyethylene glycol 3350 (powder) pain relieving cream (cream) polytussin dm (syrup) pain relieving maximum strength (cream) potassium iodide (solution) pain relieving patch ultra strength (patch) povidone-iodine (ointment) PANOXYL (BAR) povidone-iodine (solution) PANOXYL (GEL) pramoxine hcl (foam) PANOXYL WASH (LIQUID) PREVACID 24HR (DELAYED RELEASE Drug List CAPSULE) PANOXYL-4 CREAMY WASH (LIQUID) PRO-RED AC (SYRUP) PARODONTAX (PASTE) PROSHIELD PLUS SKIN PROTECTANT PATADAY (SOLUTION) (CREAM) PEDI-BORO SOAK PAKS (PACK) PROVIL (TABLET) pedia relief cough/cold (liquid) PSEUDOEPHEDR TAB 60MG (TABLET) PEDIA-LAX (CHEWABLE TABLET) pseudoephedrine hcl (tablet) PEDIA-LAX (LIQUID) pseudoephedrine hcl er (extended release PEDIA-LAX (SUPPOSITORY) tablet) pediatric cough/cold (liquid) pseudoephedrine hydrochloride/ guaifenesin peg 3350 (pack) (tablet) peg 3350 (powder) PURALUBE (OINTMENT) peg3350 (powder) Q peptic relief (chewable tablet) qc 3 day vaginal cream (cream) peptic relief (suspension) qc acetaminophen 8 hour arthritis pain (tablet) PERDIEM OVERNIGHT RELIEF (TABLET) qc acetaminophen 8 hour muscle aches & pain PERI-COLACE (TABLET) (tablet) petrolatum (ointment) qc acetaminophen 8 hours (tablet) pharbedryl (capsule) qc acid controller (tablet) PHARBETOL (TABLET)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

107 qc acid controller maximum strength (tablet) qc iodides tincture (tincture) qc all day allergy (tablet) qc iodine tincture (tincture) qc allergy relief multi-symptom daytime (tablet) qc isopropyl rubbing alcohol (solution) qc allergy/sinus headache (tablet) qc isopropyl rubbing alcohol wintergreen qc antacid (chewable tablet) (solution) qc antacid (suspension) qc loratadine allergy relief (tablet) qc antacid/anti-gas (suspension) qc loratadine-d (tablet) qc anti-diarrheal (tablet) qc magnesium citrate (solution) qc anti-itch extra strength (cream) qc medifin 400 (tablet) qc antiseptic pain relief (liquid) qc medifin dm (tablet) qc arthritis pain relief (tablet) QC MEDIFIN PE (TABLET) qc aspirin (tablet) qc miconazole 7 (cream) qc aspirin low dose (tablet) qc milk of magnesia (suspension) qc calamine (lotion) qc mineral oil heavy (oil) qc castor oil (oil) qc mucus relief (extended release tablet) qc chewable aspirin low dose (chewable tablet) qc mucus relief er 12 hour maximum strength qc childrens allergy (solution) (extended release tablet) qc childrens ibuprofen (suspension) qc naproxen sodium (tablet) qc cold head congestion nighttime (tablet) qc natura-lax (powder) qc cold multi-symptom nighttime (tablet) qc natural vegetable laxative (tablet) qc cold multi-symptom severe daytime (tablet) qc non-aspirin childrens (suspension) qc complete allergy medicine (capsule) qc non-aspirin extra strength (tablet) qc cough & cold hbp (tablet) qc non-aspirin jr strength (tablet) qc daytime cold & flu (liquid) qc omeprazole magnesium (delayed release capsule) qc enema (enema) qc pain relief (tablet) qc enteric aspirin (tablet) qc pain relief childrens (suspension) qc fexofenadine hydrochloride (tablet) qc pain relief extra strength (tablet) qc fluticasone propionate (suspension) qc pain relief infants (suspension) qc gentle laxative (suppository) qc povidone iodine (solution) qc headache relief (tablet) qc ranitidine hcl (tablet) qc heartburn 150 maximum strength (tablet) qc severe cold & cough daytime (pack) qc hemorrhoidal (ointment) qc severe cold & cough nighttime (pack) qc hemorrhoidal (suppository) qc sinus congestion & pain severe daytime qc hydrogen peroxide (solution) (tablet) qc ibuprofen (capsule) qc sinus pain relief (tablet) qc ibuprofen (tablet) qc sore throat spray (liquid) qc ibuprofen cold/sinus (tablet) qc stool softener (capsule) qc ibuprofen ib (tablet) qc stool softener plus laxative (tablet) qc ibuprofen infants (suspension) qc stool softener plus stimulant laxative (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

108 qc suphedrine maximum strength (extended robafen (syrup) release tablet) robafen ac (solution) qc tolnaftate (cream) robafen cf multi-symptom cold (liquid) qc tussin cf (liquid) robafen cough (capsule) qc tussin dm cough & chest congestion/adult robafen dm (syrup) (liquid) ROBAFEN DM COUGH (LIQUID) qc tussin mucus + chest congestion adult (liquid) ROBAFEN DM COUGH CLEAR (SYRUP) qc witch hazel (liquid) ROBAFEN DM COUGH/CHEST CONGESTION R (LIQUID) ranitidine 150 maximum strength (tablet) ROBAFEN DM PEAK COLD COUGH/CHEST ranitidine 75 (tablet) CONGESTION (LIQUID) ranitidine maximum strength (tablet) ROBAFEN MUCUS/CHEST CONGESTION (LIQUID) REFRESH (SOLUTION) rondec-d (liquid) REFRESH CELLUVISC (GEL) ru-hist d (tablet) REFRESH LACRI-LUBE (OINTMENT) rulox (suspension) REFRESH LIQUIGEL (GEL) RYDEX (LIQUID) REFRESH OPTIVE (GEL) rymed (tablet) REFRESH OPTIVE (SOLUTION) rynex dm (liquid) REFRESH OPTIVE ADVANCED (SOLUTION) rynex pe (elixir) REFRESH OPTIVE ADVANCED SENSITIVE Drug List (SOLUTION) rynex pse (liquid) REFRESH OPTIVE MEGA-3 (SOLUTION) S REFRESH OPTIVE PRESERVATIVE FREE S2 (NEBULIZER SOLUTION) (SOLUTION) SAL-PLANT (GEL) REFRESH P.M. (OINTMENT) SALACTIC FILM (SOLUTION) REFRESH PLUS (SOLUTION) SANI-SUPP ADULT (SUPPOSITORY) REFRESH TEARS (SOLUTION) SANI-SUPP PEDIATRIC (SUPPOSITORY) REGULOID (POWDER) SARNA (LOTION) REMEDY ANTIFUNGAL (CREAM) SARNA SENSITIVE ANTI-ITCH (LOTION) REMEDY ANTIMICROBIAL CLEANSER (LIQUID) sb aspirin (tablet) REMEDY CLEANSING BODY LOTION (LOTION) sb cold multi-symptom day/night REMEDY DIMETHICONE MOISTURE BARRIER sb naproxen sodium (tablet) (CREAM) SCALPICIN 2 IN 1 (LIQUID) REMEDY NUTRASHIELD (CREAM) SCALPICIN MAXIMUM STRENGTH (SOLUTION) REMEDY SKIN REPAIR (CREAM) sebex (shampoo) RESCON (TABLET) senexon (tablet) RESCON DM (SYRUP) SENEXON-S (TABLET) RESCON-GG (LIQUID) senna (tablet) RESPAIRE-30 (CAPSULE) senna lax (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

109 senna laxative (tablet) simethicone (suspension) senna plus (tablet) sinus & allergy pe maximuum strength (tablet) SENNA PROMPT (CAPSULE) sinus & cold-d non-drowsy (extended release senna-lax (tablet) tablet) senna-s (tablet) sinus and headache daytime (tablet) senna-tabs (tablet) sinus congestion & pain daytime (tablet) senna-time (tablet) sinus congestion & pain severe daytime (tablet) senna-time s (tablet) sinus nasal spray (solution) SENNO (TABLET) sinus pressure/pain/adult (tablet) sennosides/docusate sodium (tablet) sinus relief extra strength (solution) SENOKOT (TABLET) sinus relief nasal spray 12 hour (solution) SENOKOT EXTRA STRENGTH (TABLET) sleep aid (capsule) SENOKOT S (TABLET) sleep aid (liquid) SENOKOT XTRA (TABLET) sleep aid (tablet) SENSI-CARE BODY CREAM (CREAM) sleep tabs (tablet) SENSI-CARE CLEAR ZINC DIAPER RASH SKIN sm 12 hour sinus decongestant (extended PROTECTANT (OINTMENT) release tablet) SENSI-CARE MOISTURIZING (CREAM) sm 3-day vaginal (cream) SENSI-CARE PROTECTIVE BARRIER sm 8 hour pain relief (tablet) (OINTMENT) sm acid reducer (tablet) SENSODYNE COMPLETE PROTECTION sm acid reducer maximum strength (tablet) (PASTE) sm advanced hand sanitizer (liquid) SENSODYNE MAXIMUM STRENGTH (PASTE) sm advanced hand sanitizer/aloe (liquid) SENSODYNE PRONAMEL (PASTE) sm alcohol (solution) SENSODYNE PRONAMEL FRESH BREATH sm alcohol prep pads/benzocaine (pads) (PASTE) sm all day allergy (tablet) SENSODYNE RAPID RELIEF (PASTE) sm all day allergy childrens (solution) SENSODYNE REPAIR & PROTECT WHITENING sm all day allergy-d (extended release tablet) (PASTE) sm allergy 4 hour (tablet) severe cold & cough nighttime (pack) sm allergy multi-symptom (tablet) severe cold & flu (tablet) sm allergy relief (capsule) silace (liquid) sm allergy relief (liquid) silace (syrup) sm allergy relief (tablet) siladryl allergy (liquid) sm allergy relief nasal spray (suspension) silphen cough (syrup) sm antacid advanced (suspension) siltussin dm das (liquid) sm antacid advanced maxi mum strength siltussin sa (syrup) (suspension) siltussin-dm (syrup) sm antacid/antigas (suspension) simethicone (capsule) sm anti-dandruff coal tartherapeutic (shampoo) simethicone (chewable tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

110 sm anti-diarrheal (capsule) sm cold & cough dm childrens (liquid) sm anti-diarrheal (tablet) sm cold & flu severe (tablet) sm anti-itch extra strength (cream) sm cold & sinus relief (tablet) sm antibiotic (ointment) sm cough drops (lozenge) sm antibiotic plus pain relief maximum strength sm day time cold & flu relief (liquid) (cream) sm day time liquid caps (capsule) sm antifungal clotrimazole (cream) sm daytime liquid caps (capsule) sm antifungal miconazole (cream) sm double antibiotic (ointment) sm antifungal tolnaftate (cream) sm ear drops (solution) sm arthricream rub (cream) sm enema (enema) sm arthritis pain relief (tablet) sm epsom salt (granules) sm arthritis pain reliever (tablet) sm esomeprazole magnesium (delayed release sm aspirin (tablet) capsule) sm aspirin adult low strength (chewable tablet) sm eye drops (solution) sm aspirin adult low strength (tablet) sm eye itch relief (solution) sm aspirin enteric coated (tablet) sm fexofenadine hcl (tablet) sm aspirin low dose (chewable tablet) sm fexofenadine hydrochloride (tablet) sm athletes foot (cream) sm fiber (powder) sm benzoin tincture (tincture) sm fiber (tablet)

sm calamine (lotion) sm fiber laxative (capsule) Drug List sm calamine phenolated (lotion) sm fiber laxative (tablet) sm calcium antacid (chewable tablet) sm gas relief (chewable tablet) sm calcium antacid extra strength (chewable sm gas relief antiflatuent (capsule) tablet) sm gas relief drops infants (suspension) sm calcium antacid ultra strength (chewable sm gas relief extra strength (capsule) tablet) sm gentle laxative (tablet) sm caldyphen (lotion) sm glycerin (liquid) sm caldyphen clear (lotion) sm hydrocortisone (cream) sm camphor spirit sm hydrocortisone maximum strength (ointment) sm castor oil (oil) sm hydrocortisone plus (cream) sm chest congestion relief (tablet) sm hydrogen peroxide (solution) sm chest congestion relief dm (tablet) sm ibuprofen (capsule) sm chest congestion relief pe (tablet) sm ibuprofen (tablet) sm childrens aspirin (chewable tablet) sm ibuprofen ib (chewable tablet) sm childrens ibuprofen (suspension) sm ibuprofen ib (tablet) sm childrens loratadine (syrup) sm ibuprofen pm (tablet) SM CLEARLAX (POWDER) sm infants ibuprofen (suspension) sm clotrimazole vaginal (cream) sm iodides tincture (tincture) sm cold & allergy childrens (elixir) sm isopropyl alcohol (solution)

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111 sm isopropyl alcohol rubbing (solution) sm nicotine (gum) sm lansoprazole (delayed release capsule) sm nicotine (lozenge) sm laxative maximum strength (tablet) sm nicotine polacrilex (gum) sm lice killing maximum strength (shampoo) sm nicotine polacrilex (lozenge) sm lice solution kit (kit) sm nicotine transdermal system (patch) sm lice treatment (lotion) sm nicotine transdermal system/step 1/clear sm loperamide hcl (suspension) (patch) sm lorata-dine d (tablet) sm nicotine transdermal system/step 2/clear sm loratadine (syrup) (patch) sm loratadine (tablet) sm nicotine transdermal system/step 3/clear (patch) sm loratadine d 12hr (extended release tablet) sm night time liquid caps (capsule) sm lubricant eye drops (solution) sm nighttime sleep aid (tablet) sm lubricating plus (solution) sm nite time cold & flu (liquid) sm lubricating tears (solution) sm nose drops nasal decongestant extra sm magnesium citrate (solution) strength (solution) sm medicated chest rub (ointment) sm omeprazole (tablet) sm miconazole 3 (kit) sm pain & fever childrens (suspension) sm miconazole 7 (cream) sm pain & fever infants (suspension) sm miconazole 7 (suppository) sm pain reliever (tablet) sm migraine relief (tablet) sm pain reliever extra strength (capsule) sm milk of magnesia (suspension) sm pain reliever extra strength (tablet) sm motion sickness (tablet) sm pain reliever pm extra strength (tablet) sm motion sickness relief (tablet) sm pain reliever pm extrastrength (tablet) sm mucus relief (extended release tablet) sm povidone-iodine (solution) sm mucus relief cough childrens (liquid) sm rapid melts junior (tablet) sm mucus relief d (extended release tablet) sm redness relief (solution) sm mucus relief maximum strength (extended sm senna laxative (tablet) release tablet) sm senna-s (tablet) sm mucus relief/12 hour (extended release tablet) sm sinus & cold-d (extended release tablet) sm muscle rub (cream) sm sleep aid (tablet) sm naproxen sodium (tablet) sm sleep aid night time (tablet) sm nasal decongestant maximum strength sm sore throat spray (liquid) (tablet) sm stay awake (tablet) sm nasal decongestant pe (tablet) sm stay awake maximum strength (tablet) sm nasal spray (solution) sm stomach relief (chewable tablet) sm nasal spray 12 hour (solution) sm stomach relief (tablet) sm nasal spray moisturizing (solution) sm stomach relief liquid (suspension) sm nasal spray sinus (solution) sm stool softener (capsule) sm stool softener (tablet)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

112 sm tioconazole-1 (ointment) TABLET) sm triple antibiotic (ointment) stahist ad (tablet) sm triple antibiotic original strength (ointment) stay awake (tablet) sm triple antibiotic plus maximum strength stay awake maximum strength (tablet) (ointment) stimulant laxative (tablet) sm tussin cf (liquid) stomach relief (chewable tablet) sm tussin dm (syrup) stomach relief (suspension) sm tussin dm cough/chest congestion (syrup) stomach relief maximum strength (suspension) sm tussin mucus + chest congestion adult stool softener (capsule) (liquid) stool softener extra strength (capsule) sm urinary pain relief (tablet) stool softener plus laxative (tablet) sm urinary pain relief maximum strength (tablet) SUDOGEST (TABLET) sodium bicarbonate (tablet) sudogest 12 hour (extended release tablet) sodium chloride (ointment) SUDOGEST PE (TABLET) sodium chloride (solution) SUDOGEST SINUS & ALLERGY (TABLET) SOLBAR AVO (LOTION) SWEEN 24 (CREAM) SOLBAR FIFTY (CREAM) SWIM EAR (LIQUID) SOLBAR PF LIQUID/GEL SPF30 (GEL) SYSTANE (SOLUTION) SOLBAR SHIELD SPF 40 (CREAM) SYSTANE BALANCE RESTORATIVE FORMULA SOLBAR ZINC SPF38 (CREAM) (SOLUTION) Drug List SOLUBLE FIBER (POWDER) SYSTANE COMPLETE (SOLUTION) SOOTHE & COOL BODY POWDER (POWDER) SYSTANE GEL (GEL) SOOTHE & COOL FREE MEDSEPTIC SYSTANE HYDRATION PF (SOLUTION) (OINTMENT) SYSTANE NIGHTTIME (OINTMENT) SOOTHE & COOL FREE MOISTURE BARRIER SYSTANE OVERNIGHT THERAPY LUBRICANT (OINTMENT) EYE (GEL) SOOTHE & COOL FREE SKIN PASTE SYSTANE PRESERVATIVE FREE (SOLUTION) (OINTMENT) SYSTANE ULTRA (SOLUTION) SOOTHE & COOL INZO ANTIFUNGAL CREAM SYSTANE ULTRA PRESERVATIVE FREE (CREAM) (SOLUTION) SOOTHE & COOL INZO BARRIER (CREAM) T SOOTHE & COOL PROTECT MOISTURE BARRIER (OINTMENT) tactinal (tablet) soothing - 12 hour nasal decongestant (solution) tactinal extra strength (tablet) sore throat (lozenge) TAKE ACTION (TABLET) sore throat spray (liquid) tension headache (tablet) sport sunscreen spf 50 (lotion) terbinafine hcl (cream) SPORT SUNSCREEN SPF30 (AEROSOL) tgt allergy relief non-drowsy (tablet) sport sunscreen spf50 (lotion) tgt nighttime sleep aid (tablet) ST JOSEPH LOW DOSE ASPIRIN (CHEWABLE THERA-GESIC (CREAM)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

113 THERA-GESIC PLUS (CREAM) CHILDRENS (SYRUP) THERAFLU EXPRESSMAX (LIQUID) TRIAMINIC COUGH & SORE THROAT THERAFLU EXPRESSMAX SEVERE COLD & (SUSPENSION) COUGH DAYTIME (TABLET) TRIAMINIC FEVER & COLD MULTI-SYMPTOM THERAFLU EXPRESSMAX SEVERE COLD & CHILDRENS (SUSPENSION) COUGH NIGHTTIME (TABLET) TRIAMINIC NIGHT TIME COLD & COUGH THERAFLU EXPRESSMAX SEVERE COLD & (SYRUP) COUGH/DAYTIME (LIQUID) triple antibiotic (ointment) THERAFLU EXPRESSMAX SEVERE COLD & triple antibiotic first aid (ointment) FLU (LIQUID) triple antibiotic plus (ointment) THERAFLU EXPRESSMAX SEVERE COLD & triprolidine hydrochloride (liquid) FLU (TABLET) trolamine salicylate (cream) THERAFLU POWERPODS DAYTIME SEVERE TUMS (CHEWABLE TABLET) COLD TUMS CHEWY BITES (CHEWABLE TABLET) THERAFLU POWERPODS NIGHTTIME SEVERE TUMS CHEWY DELIGHTS (CHEWABLE COLD TABLET) THERAFLU SEVERE COLD & COUGH TUMS E-X 750 (CHEWABLE TABLET) DAYTIME/NIGHTTIME TUMS EXTRA STRENGTH 750 (CHEWABLE THERAFLU SEVERE COLD & COUGH TABLET) NIGHTTIME (PACK) TUMS FRESHERS (CHEWABLE TABLET) THERAFLU SEVERE COLD MULTI SYMPTOM (PACK) TUMS GAS RELIEF CHEWY BITES (CHEWABLE TABLET) THERAFLU SEVERE COLD MULTI SYMPTOM NIGHTTIME (PACK) TUMS KIDS (CHEWABLE TABLET) therapeutic shampoo (shampoo) TUMS SMOOTHIES (CHEWABLE TABLET) tioconazole 1 (ointment) TUMS ULTRA 1000 (CHEWABLE TABLET) tioconazole-1 (ointment) TUSNEL (LIQUID) tippy toes diaper rash (ointment) TUSNEL (TABLET) tolnaftate (cream) TUSNEL C (SYRUP) tolnaftate (powder) tusnel diabetic (liquid) travel sickness (chewable tablet) TUSNEL PEDIATRIC (LIQUID) travel sickness (tablet) TUSNEL-DM PEDIATRIC (LIQUID) tri-buffered aspirin (tablet) tussin cf (liquid) triacting day time cold/cough childrens tussin cf cough & cold (liquid) (solution) tussin cf max multi-symptom (liquid) triacting nightime cold& cough childrens (liquid) tussin cf multi-symptom cold (liquid) triamcinolone acetonide (aerosol) tussin cf severe multi-symptom cough cold/flu TRIAMINIC COLD & ALLERGY (SYRUP) (liquid) TRIAMINIC COLD & COUGH DAY TIME tussin chest congestion (syrup) CHILDRENS (SYRUP) tussin cough (syrup) TRIAMINIC COUGH & CONGESTION tussin dm (liquid)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics

114 tussin dm (syrup) VANATAB AC (TABLET) tussin dm cough + chest congestion (liquid) VANATAB DM (TABLET) tussin dm max (liquid) vegetable laxative+stool softener (tablet) tussin dm max adult (liquid) virtussin a/c (solution) tussin dm maximum strength/adult (liquid) virtussin dac (solution) tussin mucus & chest congestion adult (liquid) vitamin a & d (ointment) tussin mucus + chest congestion (liquid) vitamin d3 (capsule) tussin mucus + chest congestion (syrup) VIVARIN (TABLET) tussin mucus + chest congestion adult (liquid) W tussin multi-symptom cold cf (liquid) wart remover maximum strength (liquid) U wart remover maximum strenth one-step (strip) ultra lubricant eye drops (solution) wee care (suspension) urinary pain relief (tablet) white petrolatum (ointment) urinary pain relief maximum strength (tablet) white petroleum jelly (gel) V womans laxative (tablet) VAGISTAT-3 (KIT) Z VANACLEAR PD (LIQUID) Z-BUM (CREAM) VANACOF (LIQUID) Z-TUSS AC (LIQUID) VANACOF AC (LIQUID) ZADITOR (SOLUTION) Drug List VANACOF DM (LIQUID) ZANTAC 75 (TABLET) VANACOF-8 (LIQUID) ZEASORB-AF (POWDER) VANAHIST PD (LIQUID) ZIKS ARTHRITIS PAIN RELIEF (CREAM) VANALICE (GEL) zinc oxide (ointment) VANAMINE PD (LIQUID)

Brand name drugs = CAPITALIZED Generic drugs = lower case italics UHNJ21MP4717060_000

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116 Alternative Covered Drugs

Your plan has a long list of covered drugs, but it doesn’t cover all drugs. Drugs not covered by your plan typically have alternative drugs that can be used instead. This is a partial list of drugs that aren’t covered and the alternative covered drug. Talk with your doctor or pharmacist to see if the alternative drugs listed here are appropriate for you.

Drugs not covered by the plan Alternative covered drugs – Tier Basaglar Lantus – 3 Levemir – 3 Toujeo – 3 Tresiba – 3 Cialis 2.5mg and 5mg (BPH Only) Alfuzosin Extended Release – 2 Doxazosin – 2 Tamsulosin – 1 Fluoxetine HCL Tablet Fluoxetine Immediate Release Capsule – 2 Invokana Farxiga – 3 Jardiance – 3 Invokamet and Synjardy and Synjardy XR – 3 Drug List Invokamet XR Xigduo XR – 3 Kombiglyze and Kombiglyze XR Janumet and Janumet XR – 3 Jentadueto and Jentadueto XR – 3 Metformin HCL Extended Release Metformin Extended Release (Osmotic) (Generic Glucophage XR) – 1 Movantik Lactulose Solution – 2 Amitiza – 3 Relistor – 5 Nexium Esomeprazole Magnesium (Generic Nexium) – 3 Lansoprazole 15mg and 30mg Capsule – 2 Omeprazole – 2 Pantoprazole Tablet – 1 Novolin Humulin – 3 Novolog Humalog – 3 Insulin Lispro – 3 Onglyza Januvia – 3 Tradjenta – 3 OxyContin Xtampza XR – 3 Pradaxa Eliquis – 3 Xarelto – 3

Bold type = Brand name drug Plain type = Generic drug

117 Drugs not covered by the plan Alternative covered drugs – Tier Proventil HFA Albuterol HFA (Generic Proair/Proventil HFA) – 2 Proair HFA – 3 Qvar Redihaler Arnuity – 3 Flovent – 3 Temazepam 7.5mg and 22.5mg Temazepam 15mg and 30mg – 2 Travatan Z Latanoprost – 1 Lumigan – 3 Travoprost – 3 Venlafaxine HCL Extended Release Venlafaxine HCL Extended Release Capsule – 2 Tablet Ventolin HFA Albuterol HFA (Generic Proair/Proventil HFA) – 2 Proair HFA – 3 Zolpidem Tartrate Extended Release Trazodone 50mg, 100mg, 150mg Tablet – 1 Zolpidem Immediate Release – 2 Belsomra – 3

Bold type = Brand name drug Plain type = Generic drug

Note: Alternatives are suggestions only and may or may not be appropriate depending on the specific illness being treated. Information is accurate as of August 1, 2020 and may be subject to change. Please refer to the drug list for details on drug coverage. The drug list may change at any time. You will receive notice when necessary. Y0066_ACD_21_M CSEX21MP4766511_000

118 Ready to Enroll

UHEX21MP4713487_000

119 Plan Recap

We want to make sure you know what to expect with the new plan you've chosen. Please fill out this plan recap with your Licensed Sales Representative (if applicable).

Plan Information Here are some details about your new plan. My new plan is a: Medicare Advantage plan Medicare Advantage Special Needs plan Medicare Supplement Insurance (Medigap) plan Medicare Part D plan The name of my new plan is: ______My plan type is a (circle one): HMO HMO-POS LPPO RPPO PFFS My plan type: Requires referrals Does not require referrals Includes a medical deductible unless the state or another third party pays it for me Does not include a medical deductible My plan will provide: all my Medicare health coverage all my Medicare prescription drug coverage I have purchased rider(s) as part of my plan: Yes No N/A Proposed effective date: M M – D D – Y Y Y Y I can cancel my enrollment in this plan before my coverage starts by calling Customer Service at . Once my coverage starts, I may have to wait until I have a valid election period to make a plan change. I must live in the plan's service area, which is . If I move out of the plan's service area for more than 6 months in a row, I will need to choose a new plan. I must (circle one) have Medicaid / have a qualifying chronic condition / live in an institution or assisted living facility to enroll in and/or remain enrolled in this plan. If the plan cannot verify my status, I understand that I may not be enrolled in or may be disenrolled from the plan. Circle the correct answer: I should / should not have a Medicare Advantage plan and a stand-alone Medicare Part D plan at the same time. (There is one exception: Medicare Advantage Private Fee-for-Service plans that do not include prescription drug coverage.)

Premium Information What you need to know about paying your monthly plan premium. My plan has a $ monthly premium that I must pay to stay in this plan. If I qualify for Extra Help, my premium may be less.* In addition, I must remain enrolled in Medicare Part A and Part B and must continue to pay my Medicare Part B premium, unless the state or another third party pays it for me. *Extra Help is a program for people with limited incomes who need help paying Part D premiums, deductibles and copays. To see if you qualify for Extra Help, call: • The Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778 • Your state Medicaid office

120 Network Information Understanding your network is important. Circle the correct answers: I need to get my care and services from network / out-of-network providers. I may have to pay the full cost for any care I get from network / out-of-network providers. But if I need emergency care, urgent care, or out-of-area dialysis, it will be covered wherever I need it. List the doctors and hospitals you use in this table. Be sure to note whether they are part of the provider network and if they require referrals. Provider Type Network Referral Provider Name (PCP/Specialist/ (Yes/No) (Yes/No) Hospital) HERE AR TE

Prescription Drug Coverage Know how prescription drugs are covered on your plan. My plan (circle one): does / does not have a prescription drug deductible. If I have a deductible, the amount is $ and it applies to drugs in (check the answer(s)): Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 or ALL tiers List the medications you use in this table. Be sure to note their tier level, whether there are any limits on the drug, and if the prescription drug deductible applies. Has Limits1 Deductible Medication Tier Level (Yes/No) (Yes/No)

HERE For medications that have limitations, I may need to contact the plan before I can fill my prescription. I can discuss alternatives by calling customer service to learn what other drugs might be on the drug list and by talking with my AR doctor or pharmacist. TE I have the option to access my plan documents, such as Explanation of Benefits (EOB), electronically.  I have opted to access documents electronically.  I have not opted to access documents electronically at this time, but can contact the plan in the future to activate this option. Enroll to Ready  I have provided an email address to provide the plan with various ways to reach me regarding important information.  I do not have an email address; should I get one in the future, I can provide it to the plan to provide other ways to reach me with important information.

Contact your Licensed Sales Representative. If I have questions about my plan, I will call my Licensed Sales Representative, at or Customer Service at . Y0066_PLRCMA_2021_C CSNJ21DU4780117_000

121 How to Enroll

You can enroll by phone, by mail or fax. Simply choose the way that is easiest for you and follow the directions below.

By phone Call one of our Licensed Sales Representatives toll-free at 1-844-560-4944, TTY 711 during 8 a.m. - 8 p.m. local time, 7 days a week to enroll over the phone or to schedule a face-to-face appointment with a licensed sales agent in your area.

By mail Fill out the Enrollment Request Form and mail it to: UnitedHealthcare P.O. Box 30769 Salt Lake City, UT 84130-0769

By fax Fill out the Enrollment Request Form and fax it to: Fax: 1-888-950-1169

Enrollment Request Form Checkpoints

Print your name exactly as it appears Sign and date where indicated on your red, white and blue Medicare card Verify your Date of Birth

Make sure you have chosen the plan Verify your providers accept the plan type that works best for you you are choosing Make sure your permanent address is Provide the name of your primary correct care provider (PCP)

Y0066_HE_2021_C UHNJ21HM4750105_000

122 Page 1 of 2 Scope of Appointment Confirmation Form

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary. Please check what you want to discuss with the Licensed Sales Representative:  Medicare Advantage Plans (Part C) and Cost Plans  Dental-Vision-Hearing Products  Stand-alone Medicare Prescription Drug Plan (Part D)  Hospital Indemnity Products  Medicare Supplement (Medigap) Plans By signing this form, you agree to meet with a Licensed Sales Representative to discuss the

HERE products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do NOT work directly for AR the federal government. TE Signing this form does NOT affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential. Beneficiary or Authorized Representative Signature and Signature Date: Signature of applicant/member/authorized representative Today’s Date MM-DD-YYYY

If you are the authorized representative, please sign above and print clearly and legibly below: Name (First_Last) Relationship to Beneficiary

To be completed by Licensed Sales Representative (please print clearly and legibly) Licensed Sales Representative Name Licensed Sales Representative Phone Licensed Sales (First_Last) Representative ID – – Beneficiary Name (First_Last) Beneficiary Phone Date Appointment

HERE will be Completed – – AR M M - D D - Y Y Y Y

TE Beneficiary Address

Initial Method of Contact Plan(s) the Licensed Sales Representative will Represent During the Meeting Ready to Enroll to Ready

Licensed Sales Representative Signature

123 Page 2 of 2 Medicare Advantage Plans (Part C) and Cost Plans 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 hospitals in the plan’s network (except in emergencies). Medicare HMO Point-of-Service (HMO-POS) Plans — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. HMO-POS plans may allow you to get some services out of network for a higher copayment or coinsurance. 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, providers and hospitals but you can also 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, 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 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 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. 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. 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 deductibles. Stand-alone Medicare Prescription Drug Plans (Part D) 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. Other Related Products Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and coinsurance amounts for Medicare approved services. Dental/Vision/Hearing Products — Plans offering additional benefits for consumers who are looking to cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare. Hospital Indemnity Products — Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.

Y0066_SOA_4489709_C UHEX21MP4752395_000

124 Page 1 of 9

2021 Enrollment Request Form

Please contact the plan if you need this information in another language or an accessible format (Braille). o UnitedHealthcare Dual Complete® ONE (HMO D-SNP) H3113-005-000 - UD1 HERE This plan is designed for people with both Medicare and Medicaid. We may need to contact you to AR ask for proof of eligibility. TE This is a Health Maintenance Organization (HMO) plan. It has a network of doctors, specialists, hospitals and other providers you must use.

Information about you. (Please type or print in black or blue ink) o Mr. Last Name First Name Middle Initial o Mrs. o Ms. Birth Date MM - DD - YYYY Sex ¨ Male ¨ Female Daytime Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number _ _ (Required for people who are enrolling in D-SNP plans): Permanent Residence Street Address (P.O. Box is not allowed)

City County State ZIP Code

Mailing Address (Only if it’s different from above. You can give a P.O. Box.) HERE

AR City County State ZIP Code TE Email Address Ready to Enroll to Ready

Enrollee Name Agent Name / ID No. Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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126 Page 2 of 9

Do you have other insurance that will cover your prescription drugs? ¨ Yes ¨ No (Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs.) If yes, what is it? Name of Other Insurance

Member Number Group Number Date Plan Started MM - DD - YYYY Information about your Medicare. HERE Please take out your red, white and blue Medicare card to complete this section. AR · Fill out this information as it appears on Name (as it appears on your Medicare card): TE your Medicare card. ______-OR- · Attach a copy of your Medicare card or Medicare Number:______your letter from Social Security or the Sex:______Railroad Retirement Board. Is Entitled to Effective Date Hospital (Part A) MM - DD - YYYY Medical (Part B) MM - DD - YYYY You must have Medicare Part A and Part B to join a Medicare Advantage plan. If your plan has a premium how do you want to pay? Response to these questions is optional. If you have a monthly plan premium (including any late enrollment penalty you may owe), you can choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. You can also pay from a bank account

HERE through Electronic Funds Transfer (EFT) or by mail.

AR If you need to pay a late enrollment penalty (LEP), please choose how you want to pay it. If you

TE don’t choose an option below, we’ll send a bill each month to your mailing address. ¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check. I get monthly benefits from: ¨ Social Security ¨ RRB Ready to Enroll to Ready

We will bill you directly until the Social Security Administration or Railroad Retirement Board approves the deduction. It could take up to 90 days after the approval for the first deduction to occur, so please continue to make payments. If the Social Security Administration or Railroad Retirement Board does not approve your request for automatic deduction, we will notify you and continue to send a paper bill for your monthly premiums. ¨ I want to pay directly from a bank account.

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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128 Page 3 of 9

· Please attach a blank check from the account you’d like to use. Write “VOID” across the front. Please DO NOT send a deposit slip or money order. · Please read the statement below. The bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents) (UHIC). The bank will pay the funds from a checking or savings account on or about the fifth of each month. The charges may include up to $200 of current retroactive charges plus the monthly premium amount. If I choose to stop paying directly from the account, I will tell both UHIC and the bank. I will give them a reasonable amount of time to change the method of

HERE payment.

AR Account Type □ Checking □ Savings TE Account Holder Name: ______Bank Routing Number Bank Account Number Signature ______Date MM - DD - YYYY ¨ I want to pay by mail. We’ll send a bill to your mailing address each month.

If you want to pay by credit card. After you become a member, you can call us to have your monthly payment automatically charged to a Visa, Mastercard or Discover credit card. Until then, we'll send you a bill each month. A few notes about your costs.

If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) Social Security (SS) will send you a letter and ask you how you want to pay it:

HERE · You can pay it from your SS check

AR · Medicare can bill you

TE · The Railroad Retirement Board (RRB) can bill you Please DO NOT pay the plan the Part D-IRMAA at this time. Need help with your prescription drug costs? Ready to Enroll to Ready If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify, Medicare could pay for 75% or more of your costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, you won’t have a coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only part of your premium, we will bill you for the amount that Medicare doesn’t cover.

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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130 Page 4 of 9

For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.

A few questions to help us manage your plan. Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out. ¨ ¨

HERE 1. Would you prefer plan information in another language or an accessible format? Yes No

AR Please check what you’d like: ¨ Spanish ¨ Other______

TE If you don’t see the language or format you want, please call us toll-free at 1-844-560-4944, TTY 711 during 8 a.m. - 8 p.m. local time, 7 days a week. Or visit www.UHCCommunityPlan.com for online help.

2. Are you enrolled in your State Medicaid program? ¨ Yes ¨ No If yes, please give us your Medicaid number: ______

3. Do you live in a nursing home or a long-term care facility? ¨ Yes ¨ No If yes, please give us information on the long-term care facility: Name

Address City State ZIP Code

Phone Number ( ) -- Date You Moved There MM - DD - YYYY 4. Do you have health insurance with an employer or union right now? ¨ Yes ¨ No If yes, you could lose that plan if you join this plan. Please talk to your employer or union. Ask

HERE how joining this plan could affect your current plan. You may also want to check your employer ’

AR or union s website, or read any information sent to you. If there is no information on whom to

TE contact, your benefits administrator or the office that answers questions about your coverage can help. Ready to Enroll to Ready

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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132 Page 5 of 9

5. Do you or your spouse work? ¨ Yes ¨ No Do you or your spouse have other health insurance that will cover medical services? (Examples: Other employer group coverage, LTD coverage, Workman’s Compensation, Auto Liability, or Veterans benefits) ¨ Yes ¨ No If yes, please complete the following: Name of Health Insurance Company

Subscriber Name Group Number HERE Member Number Effective Dates (if applicable) AR MM - DD - YYYY - MM - DD - YYYY TE 6. Please give us the name of your primary care provider (PCP), clinic or health center. You can find a list on the plan website or in the Provider Directory. Provider or PCP Full Name Phone Number ( ) - Provider/PCP Number: (Please enter the number exactly as it appears on the website or in the Provider Directory. It will be 10 to 12 digits. Don't include dashes.) Are you now seeing or have you recently seen this doctor? ¨ Yes ¨ No

To select paperless delivery complete and sign the application and provide your email address. You will get many of your required plan communications delivered electronically. We will send you an email when new communications (For example: Explanation of Benefits or the Annual Notice of Changes) are available online. You can access these communications through any device such as a computer, tablet, or mobile phone. If you would rather have hard copies of required materials mailed to you, please check here o

HERE Instead of paperless delivery, we will mail you hard copies of required materials. Please note that some communications are very large and may not fit in all mailboxes. You can change your AR preference for delivery at any time. TE

Please read and sign.

By completing this form, I agree to the following: Enroll to Ready · This is a Medicare Advantage plan. It has a contract with the federal government. This is not a Medicare Supplement plan. · I must keep both Part A and Part B to stay in UnitedHealthcare. I must keep paying my Part B premium if I have one, unless Medicaid or someone else pays for it.

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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134 Page 6 of 9

· I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan. · If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan. · I may have to pay a late enrollment penalty (LEP). This would only happen if I didn’t sign up for and keep creditable prescription drug coverage when I first qualified for Medicare. “Creditable” means the coverage is as good as a Medicare prescription drug plan. If I need to pay an LEP, the plan will tell me. · I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll HERE need to do so during the Annual Enrollment Period for Medicare Advantage AND Medicare AR prescription drug coverage between October 15 and December 7. There may be special TE situations that would allow me to leave the plan at other times. · This plan serves a specific service area. If I move out of the area that this plan serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of this plan I have the right to appeal plan decisions about payment or services if I disagree. · I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border. · I understand that when my UnitedHealthcare coverage begins, I must get all of my medical and prescription drug benefits from UnitedHealthcare. Benefits and services authorized by UnitedHealthcare and contained in my UnitedHealthcare “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Without authorization, neither Medicare nor UnitedHealthcare will pay for benefits or services. · I understand that I must get my health care coverage from doctors or providers that are in my plan’s network. I can go to any doctor or hospital in an emergency or for urgently needed services or out-of-area dialysis services. If I happen to pay full price for any network services, this plan provides refunds for all medically necessary covered benefits. · If I currently have Medicare Supplement Insurance (Medigap), I will cancel it in writing. I, not my agent, must cancel. I will cancel after my new plan tells me I’ve been accepted into the plan. HERE · Release of Information: By joining this Medicare Advantage Plan or Medicare Prescription

AR Drug Plan, I acknowledge that the plan will release my information to Medicare and other plans

TE as is necessary for treatment, payment, and health care operations. I also acknowledge that UnitedHealthcare will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes allowed by Federal law that

authorize the collection of this information (see Privacy Act Statement below). Enroll to Ready · I give UnitedHealthcare permission to share my protected health information with organizations or person(s) for permissible purposes under applicable law as required to administer my health plan. · I give consent for all entities under UnitedHealthcare and any outside vendor used by UnitedHealthcare to call the phone number(s) I have provided.

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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136 Page 7 of 9

· If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay that person for this help. · The information on this form is correct, to the best of my knowledge. I understand that if I intentionally provide false information on this form I will be disenrolled from the plan. · Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

When I sign below, it means that I have read and understand the information on this form. If I sign as an authorized representative, it means I have the legal right under state law to sign. I can show written proof (Power of attorney, guardianship, etc.) of this right if Medicare asks for it. I HERE understand that I will need to submit written proof of this right, to the plan, if I wish to take action on AR behalf of the member beyond this application. After this application has been approved and you TE have received your member ID card, please call Customer Service at the number on the back of your member ID card to update your authorization information on file. Signature of Applicant/Member/Authorized Representative Today’s Date MM - DD - YYYY

If you are the authorized representative, please sign above and complete the information below. *NOT A SALES AGENT Last Name First Name

Address

City State ZIP Code

Relationship to Applicant Phone Number ( ) -- HERE AR TE Ready to Enroll to Ready

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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138 Page 8 of 9 For licensed sales representative/agency use only. ¨ New Member Employer Group Name ¨ Plan Change

Employer Group ID Branch ID Licensed Sales Representative/Writing ID Initial Receipt Date MM - DD - YYYY Licensed Sales Representative/Agent Name Proposed Effective Date MM - DD - YYYY HERE Licensed Sales Representative Phone Number AR

TE Where did this application originate? ¨ National Retail/Mall Program ¨ Community Meeting ¨ Appointment ¨ Other

¨ Member Meeting ¨ Local Event Outreach ¨ Walmart Program

How was this application submitted? ¨ Mail ¨ Fax ¨ Online Agent must complete ¨ IEP (MA-PD ¨ ICEP (MA enrollees) ¨ IEP (MA-PD ¨ OEP (Jan1 – Mar enrollees) enrollees eligible for 31) 2nd IEP) ¨ OEP (newly eligible) ¨ SEP (Dual LIS ¨ SEP (change in ¨ SEP (loss of EGHP change of status) residence) coverage) ¨ SEP (Chronic) ¨ SEP (Dual LIS ¨ AEP (October 15- ¨ OEPI maintaining) December 7) ¨ SEP (SEP Reason) ¨ SEP Eligibility Date MM - DD - YYYY Licensed Sales Representative Signature (required) Date: MM - DD - YYYY HERE

AR Please mail or fax this completed form to: TE UnitedHealthcare P.O. Box 30769

Salt Lake City, UT 84130-0769 Enroll to Ready

Fax: 1-888-950-1169

Enrollee Name Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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140 Page 9 of 9 HERE AR TE HERE PRIVACY ACT STATEMENT: The Centers for Medicare & Medicaid Services (CMS) collects information from AR Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve

TE care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, Ready to Enroll to Ready failure to respond may affect enrollment in the plan. Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This information is available for free in other languages. Please call our customer service number located on the first page of this book. Esta información esta disponible sin costo en otros idiomas. Comuníquese con nuestro número de Servicio al Cliente situado en la cobertura de este libro. OMB No. 0938-1378 Expires: 7/31/2023 Y0066_ERFMA1_2021_M UHNJ21HM4752312_000

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142 2021 Enrollment Receipt

To be completed if enrolling with a Licensed Sales Representative. Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment and you receive your member ID card. This receipt is not a guarantee of enrollment. This copy is for your records only. Please do not resubmit enrollment.

HERE Applicant 1: Applicant 2 (if applicable): Name Name AR TE Application Date MM - DD - YYYY Application Date MM - DD - YYYY

Proposed Effective Date MM - DD - YYYY Proposed Effective Date MM - DD - YYYY

Plan Name Plan Name

Plan Type Plan Type

Health Plan/PBP No. Health Plan/PBP No.

Enrollment Tracking No. (if applicable) Enrollment Tracking No. (if applicable)

Call your Licensed Sales Representative if you have any RxBIN: 610097 questions: Licensed Sales Representative Name and ID Number Rx PCN: 9999 RxGRP: MPDACUNJ Licensed Sales Representative Phone No. HERE - - AR

TE We’re here to help. If you have additional questions you can call Customer Service toll-free at 1-844-560-4944, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Important Reminder - You don’t need a Medigap or supplement insurance plan with a Medicare Advantage plan. If you currently have a Medigap plan, contact the insurer to cancel your plan once Enroll to Ready your Medicare Advantage plan begins.

Y0066_ER_2021_C UHNJ21HM4750160_000

143 Take Advantage of What’s Next

Your enrollment application has been submitted, and we want to help you get ready to use your plan. Use this page to track your progress as you go. We’re here to help every step of the way.

Go online to manage your plan Once you receive your member ID card, you can use it to create You are Here your online account at Enrollment Submitted myuhc.com/communityplan to: • Find providers and pharmacies in your area. • Review your Drug List (Formulary). • Complete your Health Assessment. Welcome Letter • View plan documents.

Once your coverage begins • Call to schedule your Annual Quick Start Guide Physical and Wellness Visit to begin your preventive care. • Take advantage of a UnitedHealthcare® HouseCalls visit. Learn more at Member ID Card UHCHouseCalls.com. • We’ll provide an in-home nurse practitioner and nurse visits after a hospital admission. This includes an Individualized Care Plan focused on goal setting, education, monitoring Your plan coverage and evaluation. begins. You can start using your plan. Thank you for choosing UnitedHealthcare® If you have any questions, you can call the Customer Service number on the back of your member ID card.

Y0066_TAOWN_2021_C CSFL21DU4789218_000

144 NOTES

______

145 NOTES

______

146 Vendor Information

UnitedHealthcare Dual Complete® ONE (HMO D-SNP) Take advantage of your additional plan benefits, once you’re enrolled, by using the providers below or contacting Customer Service: 1-800-514-4911, TTY 711, 8am-8pm: 7 Days Oct-Mar; M-F Apr- Sept.

Benefit Type Vendor Name Contact Information

HERE NurseLine Nurseline 1-877-440-9407 www.myuhc.com/CommunityPlan AR

TE Over-the-Counter (OTC) FirstLine Benefits™ 1-844-368-7171 Products Card ShopFirstLineBenefits.com Healthy Foods

Personal Emergency Tunstall Americas 1-800-514-4911 Response System www.myuhc.com/CommunityPlan

Fitness Program Renew ActiveTM 1-800-514-4911 www.UHCRenewActive.com HERE AR TE

Y0066_VIS_2021_C H3113005000 UHNJ21HM4767918_000

147 For 1-on-1 support, please contact the plan or your Licensed Sales Representative.

Call toll-free 1-844-560-4944, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Important plan information. Y0066_EGCov_2021_C CSNJ21HM4743726_001