2019 Prescription Drug List Advantage Three-Tier

Your 2019 Prescription Drug List Advantage Three-Tier

EffectiveEffective January Jan. 1, 1, 2019 2019

This Prescription Drug List (PDL) is accurate as of Jan. 1 2019 and is subject to change after this date. The next anticipated update will be July 1, 2019. This PDL applies to members of our UnitedHealthcare, Neighborhood Health Plan, River Valley, All Savers and Oxford medical plans with a pharmacy benefit subject to the Advantage Three-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan. Table of Contents

Understanding your Prescription Gastrointestinal Drug List...... 3 Acid Suppression...... 16 Nausea/Vomiting...... 16 Medication tips ...... 5 Other...... 17 Reading your PDL...... 6 Gout ...... 17 Questions...... 8 Hepatitis C...... 17 Drugs by category ...... 9 HIV/AIDS...... 17 Anti-Infectives Infertility...... 18 Antibiotics ...... 9 Antifungals...... 9 Inflammatory Conditions: Rheumatoid Antivirals ...... 9 Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis...... 18 Cancer ...... 9 Medications for Sexual Dysfunction. . 18 Cardiovascular/Heart Disease Coagulation Therapy...... 10 Men’s Health Prostate...... 19 High Blood Pressure...... 10 Testosterone Therapy...... 19 High Cholesterol ...... 11 Other...... 11 Miscellaneous...... 19 Central Nervous System Musculoskeletal Attention Deficit Disorder...... 11 Muscle Spasms...... 19 Depression ...... 12 Osteoporosis...... 20 Migraine...... 12 Pain Relief...... 20 Multiple Sclerosis...... 12 Overactive Bladder...... 20 Other...... 12 Sedatives/Hypnotics...... 13 Respiratory Seizure Disorders ...... 13 Allergies...... 20 Asthma/COPD...... 20 Dermatology ...... 13 Pulmonary Arterial Hypertension...... 21 Diabetes Smoking Cessation...... 21 Blood Glucose Monitoring...... 14 Insulin ...... 14 Transplant ...... 21 Non-Insulin ...... 15 Vitamins/Electrolytes...... 22 Endocrine Women’s Health Growth Hormone...... 15 Contraceptives...... 22 Other...... 16 Hormone Replacement...... 24 Thyroid Hormone Replacement. . . . . 16 Miscellaneous...... 24 Eye Conditions Prenatal Vitamins ...... 24 Allergies...... 16 Index...... 25 Antibiotics ...... 16 Dry Eye Disease...... 16 Glaucoma ...... 16 2 Understanding your Prescription Drug List (PDL)

What is a PDL? This document is a list of the most commonly About this PDL prescribed medications. It includes both brand-name Where differences exist between and generic prescription medications approved by the this PDL and your benefit plan Food and Drug Administration (FDA). Medications are documents, the benefit plan listed by common categories or classes and placed documents rule. This PDL is not in tiers that represent the cost you pay out-of-pocket. a complete list of medications, They are then listed in alphabetical order. and not all medications listed may be covered by your plan. How do I use my PDL? Please look at the benefit plan You and your doctor can consult the PDL to help you documents provided by your select the most cost-effective prescription medications. employer or health plan to see This guide tells you if a medication is generic or a which medications are covered brand-name, and if there are coverage requirements or under your plan. limits. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the toll-free member phone number on your health plan ID card.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your employer or benefit plan. This is how much you will pay when you fill a prescription. See page 6 for additional information.

When does the PDL change? PDL changes typically occur twice per year. However, changes that have a positive impact for you — such as coverage for new medications or cost savings — may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options.

3 Understanding your Prescription Drug List (continued)

Why are some medications excluded from coverage? We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)1 if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications2). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over- the-counter medications available.

Who decides which medications are covered? Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL Management Committee, which includes senior UnitedHealth Group® physicians and business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for all medications.

1. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2. For New York and New Jersey plans, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it is determined to be medically necessary. 4 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter Generic medications contain the same active (OTC) medications ingredients (what makes the medication work) as An OTC medication may be brand-name medications, but they often cost less. the right treatment option for Once the patent for a brand-name medication ends, some conditions. Talk to your the FDA can approve a generic version with the same doctor about available OTC active ingredients. These types of medications are options. Even though these known as generic medications. Sometimes, the same medications may not be company that makes a brand-name medication also covered by your pharmacy makes the generic version. benefit, they may cost less than a prescription medication. What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and the generic equivalent.

What if I am taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free phone number on your ID card to learn more. Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.

5 Reading your PDL

The PDL gives you choices so you and your doctor can determine your best course of treatment. In this PDL, brand-name medications are shown in bold type and generic medications in plain type.

Tier information. Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible.

Drug Tier Includes Helpful Tips Tier 1 $ Lower-cost Medications that provide the highest Use Tier 1 drugs for the overall value. Mostly generic drugs. Some lowest out-of-pocket costs. brand-name drugs may also be included. Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of Medications that provide good overall value. Tier 3, to help reduce your A mix of brand-name and generic drugs. out-of-pocket costs. Tier 3 $$$ Highest-cost Medications that provide the lowest Ask your doctor if a Tier 1 or Tier 2 overall value. Mostly brand-name drugs, option could work for you. as well as some generics.

6 Reading your PDL (continued)

Drug list information. In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York. (Referred to as First Start in New Jersey) Lower-cost options are available and covered.

H Health Care Reform Preventive This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.

H-PA Health Care Reform Preventive with Prior Authorization May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.

PA Prior Authorization (sometimes referred to as Precertification)3 Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.

RS Refill and Save Program4 Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.

SP Specialty Medication Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.

ST Step Therapy (referred to as First Start in New Jersey) Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.

SL Supply Limits Specifies the largest quantity of medication covered per copayment or in a defined period of time.

3. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 4. Not applicable to Neighborhood Health Plan and Oxford plans. 7 Questions

For the most current list of covered medications or if you have questions:

Call the toll-free member phone number on your health plan ID card.

Visit your plan’s member website listed And, if home delivery services on your health plan ID card to: are included in your pharmacy benefit, you can also: • View your pharmacy benefit and coverage information, including prescription history • Refill prescriptions • View medication interactions and side effects • Check the status of your order • Locate a participating retail pharmacy • Set up reminders for refills by ZIP code • Manage your account • Look up possible lower-cost medication alternatives • Compare medication pricing and options

8 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Anti-Infectives: Antibiotics Anti-Infectives: Antifungals Amoxicillin Capsule, Chewable 1 Cresemba 3 Tablet Econazole Cream 3 SL Amoxicillin/Potassium Clavulanate 1 Chewable Tablet, Tablet Fluconazole Tablet 1 Azithromycin Tablet 1 Itraconazole Capsule 1 SL Cefadroxil Capsule, Tablet 1 Ketoconazole Cream 1 SL Cefdinir Capsule 1 Noxafil Tablet, Suspension 2 Cefixime Suspension 3 Nystatin Cream, Ointment 1 Cefprozil Tablet 1 Terbinafine Tablet 1 SL Cefuroxime Tablet 1 Anti-Infectives: Antivirals Cephalexin Capsule 1 Acyclovir Ointment 3 PA, SL, ST Ciprodex 3 Acyclovir Tablet 1 Ciprofloxacin Tablet 1 Famciclovir Tablet 2 Clarithromycin Tablet 1 Oseltamivir Capsule, Suspension 2 SL Clindamycin Capsule 1 Valacyclovir Tablet 1 SL Dificid 3 SL Valganciclovir 1 SL Doxycycline Hyclate 50, 100 mg 2 Cancer Capsule, Tablet Alunbrig 2 PA, SL, SP Doxycycline Monohydrate 1 50, 100 mg Capsule Bexarotene Capsule 3 E, SP Levofloxacin Tablet 1 Bicalutamide 1 Metronidazole Tablet 1 Bosulif 2 PA, SL, SP, ST Minocycline Capsule 1 Braftovi 3 PA, SL, SP Moxifloxacin Tablet 3 Calquence 2 PA, SL, SP Nitrofurantoin Capsule 1 Cyclophosphamide Capsule 2 Nitrofurantoin Macrocrystal 1 Erleada 3 PA, SL, SP Capsule Hydroxyurea Capsule 1 Ofloxacin Otic Solution 2 Ibrance 2 PA, SL, SP Ofloxacin Tablet 1 Idhifa 2 PA, SL, SP Penicillin V Potassium Tablet 1 Imatinib Tablet 1 PA, SL, SP Sulfamethoxazole-Trimethoprim 1 Tablet Imbruvica 2 PA, SL, SP Suprax Capsule, Chewable 3 Leucovorin Calcium Tablet 1 Tablet, Tablet

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 9 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Mektovi 3 PA, SL, SP Bisoprolol-Hydrochlorothiazide 1 Mercaptopurine Tablet 1 Bystolic 2 Nerlynx 2 PA, SL, SP Byvalson 2 SL Revlimid 2 PA, SL, SP Cartia XT 2 Carvedilol Immediate-Release Rydapt 2 PA, SL, SP 1 Tablet Sutent 2 PA, SL, SP Chlorthalidone 1 Targretin Capsule 2 SP Clonidine Tablet 1 Targretin Gel 3 SL Diltiazem 24 Hour CD 2 Tasigna 2 PA, SL, SP, ST Diltiazem Sustained-Release 2 Verzenio 2 PA, SL, SP Capsule Diltiazem Sustained-Release Xeloda 1 SL, SP 2 Tablet Zykadia 2 PA, SL, SP Doxazosin 1 Zytiga 2 PA, SL, SP Edarbi 3 SL Cardiovascular/Heart Disease: Coagulation Therapy Edarbyclor 3 SL Bevyxxa 3 SL Enalapril 1 Brilinta 3 SL Furosemide 1 Clopidogrel 1 Guanfacine 1 Eliquis 3 SL Hydralazine 1 Enoxaparin Sodium 2 SL Hydrochlorothiazide 1 Pradaxa 2 SL Irbesartan 1 Prasugrel 3 SL Labetalol 1 Savaysa 3 SL Lisinopril 1 Warfarin Sodium 1 Lisinopril-Hydrochlorothiazide 1 Xarelto 2 SL Losartan 1 Cardiovascular/Heart Disease: High Blood Pressure Losartan-Hydrochlorothiazide 1 Amlodipine 1 Metoprolol Succinate Extended- 2 Amlodipine-Benazepril 1 Release 50, 100, 200 mg Metoprolol Tartrate 25, 50, Amlodipine-Valsartan 2 1 100 mg Atenolol 1 Nadolol 1 Atenolol-Chlorthalidone 1 Nifedipine Extended-Release 1 Benazepril 1 Olmesartan 2 SL Benazepril-Hydrochlorothiazide 1 Olmesartan-Hydrochlorothiazide 2 SL Bidil 2 Propranolol Extended-Release 2 Bisoprolol 1 Capsule

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 10 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Propranolol Tablet 1 Vascepa 3 PA Welchol Packet for Suspension, Quinapril 1 2 Tablet Ramipril 1 Cardiovascular/Heart Disease: Other Spironolactone 1 Amiodarone 1 Telmisartan 2 Corlanor 3 PA, SL Telmisartan-Hydrochlorothiazide 2 Digoxin 1 Terazosin 1 Entresto 3 PA, SL Triamterene-Hydrochlorothiazide 1 Flecainide 1 Valsartan 2 Isosorbide Mononitrate ER 1 Valsartan-Hydrochlorothiazide 1 Multaq 3 PA Verapamil 1 Nitroglycerin Sublingual Tablet 1 Verapamil Sustained-Release 3 Ranexa 2 Cardiovascular/Heart Disease: High Cholesterol Sotalol 1 Atorvastatin 1 H-PA, SL Central Nervous System: Attention Deficit Disorder Colesevelam Packet for Suspension, Tablet (generic 3 E Adderall XR 2 PA, SL Welchol) Amphetamine Salt Combo 1 PA Ezetimibe Tablet 3 SL Atomoxetine 3 SL Ezetimibe/Simvastatin 3 SL Concerta 2 PA, SL Fenofibrate 54, 160 mg Tablet 2 Dexmethylphenidate Immediate- 1 PA Fluvastatin Extended-Release Release Tablet 3 SL, ST Tablet Dextroamphetamine- Gemfibrozil 1 Amphetamine Immediate-Release 1 PA Tablet Lovastatin 1 H Dextroamphetamine Sulfate 3 PA Niacin Extended-Release Tablet 3 Immediate-Release Tablet Niaspan 2 Guanfacine Extended-Release 2 SL Omega-3-Acid Ethyl Esters Methylphenidate Chewable Tablet 3 PA 3 PA Capsule Methylphenidate Extended- Praluent 2 PA, SL, SP, ST Release Capsule (generic 2 PA, SL ) Pravastatin 1 Metadate CD, Ritalin LA Methylphenidate Extended- Repatha 3 PA, SL, SP, ST Release Tablet (generic 3 E, PA, SL Rosuvastatin 2 SL Concerta) Simvastatin 1 H-PA

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 11 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Methylphenidate Extended- Rizatriptan ODT, Tablet 1 SL Release Tablet (Metadate ER, 3 PA, SL generic Ritalin SR) Sumatriptan Nasal Spray 2 SL Methylphenidate Immediate- Sumatriptan Succinate Tablet, 1 PA 1 SL Release Tablet Injection Vyvanse 2 PA, SL Central Nervous System: Multiple Sclerosis Central Nervous System: Depression Ampyra 2 PA, SL, SP Amitriptyline Tablet 1 Aubagio 3 PA, SL, SP Bupropion Extended-Release Avonex 2 PA, SL, SP 1 Tablet Betaseron 2 PA, SL, SP Bupropion Sustained-Release 1 Tablet Gilenya 3 PA, SL, SP Glatiramer (generic Copaxone) Bupropion Tablet 1 2 PA, SL, SP [Mylan version only] Citalopram Tablet 1 Plegridy 3 PA, SL, SP Desvenlafaxine Extended- 2 SL Release Tablet (generic Pristiq) Rebif 3 PA, SL, SP, ST Doxepin 1 Tecfidera 2 PA, SL, SP Duloxetine Capsule 3 SL Central Nervous System: Other Alprazolam Extended-Release Escitalopram Tablet 1 1 Tablet Fetzima 3 SL, ST Alprazolam Tablet 1 Fluoxetine Capsule (generic 1 Prozac) Aripiprazole Tablet 2 SL Fluvoxamine Tablet 1 Armodafinil 3 PA, SL Mirtazapine Tablet 1 Austedo 2 PA, SL, SP Nortriptyline Capsule 1 Buprenorphine Sublingual Tablet 1 Paroxetine Tablet 1 Buspirone Tablet 1 Sertraline Tablet 1 Carbidopa-Levodopa 1 Trazodone Tablet 1 Diazepam Tablet 1 Trintellix 3 SL, ST Donepezil 5, 10 mg ODT, Tablet 1 Venlafaxine Extended-Release Latuda 3 SL 1 Capsule Lithium Capsule 1 Venlafaxine Tablet 1 Lorazepam Tablet 1 Viibryd 3 SL Memantine Immediate-Release 2 Central Nervous System: Migraine Tablet Acetaminophen/Butalbital/ Modafinil 3 PA, SL 1 SL Caffeine 325 mg/50 mg/40 mg Naloxone Vials 1 Eletriptan 2 SL Narcan Nasal Spray 2 SL Frovatriptan 3 SL Naratriptan 1 SL

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 12 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Lamotrigine Immediate-Release Olanzapine Tablet 1 SL 1 Tablet Pramipexole Tablet 1 Levetiracetam Extended-Release Quetiapine Extended-Release 2 3 SL Tablet Tablet Levetiracetam Immediate-Release Quetiapine Immediate-Release 1 1 Tablet Tablet Lyrica 3 SL, ST Risperidone Tablet 1 Lyrica CR 3 E, SL, ST Ropinirole Tablet 1 Oxcarbazepine Tablet 1 Suboxone Film 3 E, PA, SL Phenytoin Capsule, Suspension 1 Tolcapone 2 Topiramate Immediate-Release 1 Xyrem 3 PA, SL, SP Tablet Zelapar 3 Zonisamide Capsule 1 Ziprasidone Capsule 2 SL Dermatology Zubsolv 2 SL Aczone 3 SL Central Nervous System: Sedatives/Hypnotics Betamethasone Dipropionate 0.05% Augmented Lotion, 3 Eszopiclone Tablet 2 SL Ointment Temazepam Capsule 1 Betamethasone Dipropionate 2 0.05% Cream, Ointment Triazolam Tablet 1 Calcipotriene/Betamethasone 3 SL Zaleplon Capsule 1 SL Ointment Zolpidem Immediate-Release 1 SL Carac 2 Tablet Ciclopirox Cream, Gel, Lotion, 1 Central Nervous System: Seizure Disorders Solution Carbamazepine Extended- 2 Claravis 2 PA Release Capsule Clindamycin 1.2%/Benzoyl Carbamazepine Extended- 3 SL 3 Peroxide 5% Gel Release Tablet Clindamycin Gel 3 SL Carbamazepine Immediate- 1 Release Tablet Clindamycin Lotion 3 Clonazepam Tablet 1 Clindamycin Solution 1 SL Diazepam Tablet 1 Clindamycin Swabs 1 Divalproex Delayed-Release Clobetasol Propionate Cream, 1 2 SL Tablet Ointment Divalproex Extended-Release 2 Clobetasol Propionate Solution 1 SL Tablet Clotrimazole-Betamethasone 1 SL Gabapentin Capsule, Tablet 1 Cream

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 13 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Clotrimazole-Betamethasone 1 Tretinoin Cream 3 PA, SL Lotion Triamcinolone Acetonide Cream, 1 Dapsone 5% Gel 3 E, SL Lotion, Ointment Desonide 0.05% Cream, Lotion, 3 SL Vectical 3 SL Ointment Diabetes: Blood Glucose Monitoring5 Desoximetasone Gel, Ointment 3 SL Accu-Chek Test Strips 3 E, SL Diflorasone Diacetate 0.05% 3 SL Cream, Ointment Contour Next EZ Meter 2 Dupixent 3 PA, SL, SP, ST Contour Next Meter 2 Elidel 3 SL, ST Contour Next One Meter 2 Enstilar Foam 3 SL Contour Next Test Strips 2 SL Eucrisa 3 SL, ST Contour Test Strips 3 E, SL Finacea 3 FreeStyle Test Strips 3 E, SL Fluocinolone Cream, Oil, Solution 3 SL OneTouch Ultra 2 Meter 1 Fluocinolone Ointment 2 SL OneTouch Ultra Test Strips 1 SL Fluocinonide 0.05% Cream 1 OneTouch UltraMini Meter 1 Fluorouracil 0.5% Cream 3 SL OneTouch Verio Flex Meter 1 Halobetasol Ointment 2 SL OneTouch Verio IQ Meter 1 Hydrocortisone 2.5% Cream, 1 OneTouch Verio Meter 1 Ointment OneTouch Verio Sync Meter 1 Imiquimod 5% Cream 1 SL OneTouch Verio Test Strips 1 SL Metronidazole 0.75% Topical Gel 1 5 Diabetic supplies and prescription medications may Minocycline Extended-Release 3 E, PA be subject to different cost-share arrangements for (generic Solodyn) Oxford plans. Please see your Summary of Benefits and Mirvaso 3 SL Coverage (SBC) for specifics. Medications that require Mometasone Furoate Cream, step therapy may require prior authorization (sometimes 1 referred to as precertification) if covered under another Lotion, Ointment benefit. Mupirocin Ointment 1 SL Diabetes: Insulin5 Oracea 3 Admelog SoloStar, Vials 3 E, SL Oxsoralen-Ultra 2 Apidra SoloStar, Vials 3 E, SL Picato 3 SL Basaglar 1 SL Regranex 2 PA, SL Fiasp FlexTouch, Vials 3 E, SL 3 PA, SL Rhofade Humalog KwikPens 2 SL Taclonex Suspension 3 SL (all formulations) Tacrolimus Ointment 2 SL, ST Humalog Vials (all formulations) 1 SL Tazarotene 0.1% Cream (generic Humulin KwikPens 3 E, PA, SL 2 SL Tazorac) (all formulations) Tazorac 3 PA, SL Humulin Vials (all formulations) 1 SL

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 14 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Lantus SoloStar 3 E, SL Metformin 1 Metformin Extended-Release Lantus Vials 3 E, SL 1 Tablet (generic Glucophage XR) Levemir FlexTouch, Vials 3 SL Nesina 2 SL Novolin Vials (all formulations) 3 E, SL Onglyza 2 SL Novolog FlexPen, Vials 3 E, SL (all formulations) Oseni 2 SL Tresiba FlexTouch 2 SL Ozempic 3 SL 5 Diabetic supplies and prescription medications may Pioglitazone 1 SL be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Qtern 3 E, SL, ST Coverage (SBC) for specifics. Medications that require Segluromet 3 E, SL, ST step therapy may require prior authorization (sometimes referred to as precertification) if covered under another Soliqua 2 PA, SL benefit. Steglatro 3 E, SL, ST Diabetes: Non-Insulin5 Steglujan 3 E, SL, ST Adlyxin 3 SL Synjardy, Synjardy XR 2 SL Bydureon, Bydureon Bcise 2 SL Tradjenta 2 SL Byetta 2 SL Trulicity 3 SL Farxiga 3 E, SL, ST Victoza 2-Pak 2 SL Glimepiride 1 Victoza 3-Pak 3 SL Glipizide 1 Xigduo XR 3 E, SL, ST Glipizide Extended-Release 1 5 Diabetic supplies and prescription medications may Glyburide 1 be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Glyxambi 2 SL, ST Coverage (SBC) for specifics. Medications that require Invokamet, Invokamet XR 2 SL step therapy may require prior authorization (sometimes referred to as precertification) if covered under another Invokana 2 SL, ST benefit. Janumet 3 SL, ST Endocrine: Growth Hormone6 Januvia 3 SL, ST Nutropin, Nutropin AQ 2 PA, SL, SP Jardiance 2 SL, ST 6 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents Jentadueto 2 SL regarding benefit coverage and cost-share. Prior Jentadueto XR 2 SL authorization (sometimes referred to as precertification) may be required for Oxford plans. Kazano 2 SL Kombiglyze XR 2 SL

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 15 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Endocrine: Other Eye Conditions: Dry Eye Disease Calcitriol Capsule 1 Restasis Single Use Vials 3 PA, SL Desmopressin Tablet 1 Xiidra 3 PA, SL Dexamethasone Tablet 1 Eye Conditions: Glaucoma Methylprednisolone Tablet 1 Alphagan P 0.1% 2 SL Prenisolone Oral Solution 1 Azopt 2 SL Prednisone Tablet 1 Combigan 2 SL Latanoprost 0.005% Ophthalmic Endocrine: Thyroid Hormone Replacement 1 Solution Armour Thyroid 3 Lumigan 2 SL Levothyroxine Sodium Tablet 1 Timolol 0.25%, 0.5% Ophthalmic 1 Liothyronine Sodium Tablet 2 Solution (generic Timoptic) Methimazole Tablet 1 Travatan Z 2 SL NP Thyroid Tablet 1 Gastrointestinal: Acid Suppression Synthroid 2 Dexilant 3 SL Eye Conditions: Allergies Omeclamox-Pak 3 SL Azelastine 0.05% Ophthalmic Omeprazole Capsule 1 1 Solution Pantoprazole Tablet 1 Lastacaft 3 SL Pylera 3 SL Olopatadine 0.1% Ophthalmic 3 SL Solution Ranitadine Syrup 1 Eye Conditions: Antibiotics Rabeprazole Tablet 3 SL Erythromycin 0.5% Ophthalmic 1 Sucralfate Tablet 1 Ointment Gastrointestinal: Nausea/Vomiting Gentamicin Ophthalmic Ointment, 1 Solution Akynzeo 3 SL Moxeza 3 Aprepitant Capsule 2 SL Moxifloxacin Ophthalmic Solution 3 Emend Suspension 2 SL Ofloxacin 0.3% Ophthalmic 1 Ondansetron 1 Solution Scopolamine Transdermal Patch 3 Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic 2 Varubi 2 SL Suspension Tobramycin Ophthalmic Solution 1

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 16 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Gastrointestinal: Other Gout Amitiza 3 PA, SL, ST Allopurinol Tablet 1 Apriso 2 Duzallo 3 PA, SL Budesonide Extended-Release 3 E Mitigare 2 Tablet (generic Uceris) Uloric 3 SL, ST Canasa 2 Zurampic 3 PA, SL Clenpiq 3 Hepatitis C Cortifoam 2 Daklinza 3 PA, SL, SP, ST Creon 2 Epclusa 2 PA, SL, SP Diphenoxylate-Atropine Tablet 1 Harvoni 2 PA, SL, SP Golytely 2 Mavyret 2 PA, SL, SP Hyoscyamine Tablet 1 Ribavirin Tablet 1 SP Lialda 2 Sovaldi 3 PA, SL, SP, ST Linzess 2 PA, SL Technivie 3 PA, SL, SP, ST Mesalmine Delayed-Release 3 E Tablet (generic Lialda) Viekira Pak 3 PA, SL, SP, ST Metoclopramide Tablet 1 Viekira XR 3 PA, SL, SP, ST Movantik 3 E, PA, SL Vosevi 2 PA, SL, SP Moviprep 3 Zepatier 3 PA, SL, SP, ST Polyethylene Glycol 3350 2 HIV/AIDS Prepopik 3 Abacavir-Lamivudine 2 SP Sulfasalazine Tablet 1 Atazanavir Capsule 2 SP Suprep 3 Atripla 3 E, SP Symproic 2 PA, SL Cimduo 2 SP Uceris Foam 2 Complera 3 SP Uceris Tablet 3 Descovy 3 SP Viberzi 3 PA, SL Efavirenz 2 SP Zenpep 2 Evotaz 2 SP Genvoya 3 SP Intelence 2 SP

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 17 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Isentress 2 SP Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis Juluca 2 SP Actemra 3 PA, SL, SP, ST Kaletra Tablet 2 SP Cimzia 2 PA, SL, SP Lamivudine-Zidovudine 1 SP Cosentyx 3 PA, SL, SP, ST Lopinavir-Ritonavir Oral Solution 2 SP Enbrel 3 PA, SL, SP, ST Nevirapine 1 SP Humira 2 PA, SL, SP Nevirapine Extended-Release 3 E, SP Hydroxychloroquine Sulfate 1 Odefsey 3 SP Kevzara 3 PA, SL, SP, ST Prezcobix 2 SP Leflunomide 1 Prezista 2 SP Methotrexate Tablet 1 Ritonavir Tablet 2 SP Orencia 3 PA, SL, SP, ST Selzentry 2 PA, SP Otezla 2 PA, SL, SP Stribild 3 SP Rasuvo 3 SL, ST Symfi 2 SP Siliq 3 PA, SL, SP, ST Symfi Lo 2 SP Simponi 2 PA, SL, SP Tenofovir Tablet 2 SP Stelara 2 PA, SL, SP Tivicay 3 SP Taltz 3 PA, SL, SP, ST Triumeq 2 SP Tremfya 2 PA, SL, SP Truvada 3 SP Xeljanz, Xeljanz XR 3 PA, SL, SP, ST Tybost 2 SP Medications for Sexual Dysfunction6 Vitekta 2 SP Addyi 3 PA, SL Infertility6, 7 Cialis 3 SL Cetrotide 2 PA, SP Intrarosa 3 SL Clomiphene 1 PA Levitra 3 SL Endometrin 2 PA Osphena 3 SL Gonal-F 2 PA, SP Sildenafil Tablet (genericViagra ) 3 SL Gonal-F RFF 2 PA, SP Stendra 3 PA, SL Ovidrel 3 PA, SP 6 Coverage is determined by the consumer’s prescription 6 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) authorization (sometimes referred to as precertification) may be required for Oxford plans. may be required for Oxford plans. 7 This is not a covered benefit for Neighborhood Health Plan.

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 18 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Lidocaine Transdermal Patch Men’s Health: Prostate 3 PA, SL (generic Lidoderm) Alfuzosin Tablet 1 Nityr 2 PA, SP Doxazosin Tablet 1 Nuedexta 2 PA Dutasteride Capsule 3 Obredon 3 PA, SL, ST Finasteride Tablet 1 Pegasys 2 PA, SP, SL Rapaflo 3 Phenazopyridine 1 Tamsulosin Capsule 1 Procrit 2 SL, SP Terazosin Capsule, Tablet 1 Promethazine/Codeine 1 PA, SL Men’s Health: Testosterone Therapy Promethazine/Dextromethorphan 1 Androderm 2 PA, SL Pulmozyme 2 PA, SL, SP Androgel 3 E, PA, SL Rectiv 3 SL Methyltestosterone Capsule 2 Rezira 3 Testim 2 PA, SL Sevelamer 2 Testosterone 1% Topical Gel 3 E, PA, SL Syprine 3 PA, SP Testosterone Cypionate Injection 1 Tobi Podhaler 3 PA, SL, SP Miscellaneous Trientine (generic Syprine) 3 E, PA, SP Anastrozole Tablet 1 Velphoro 2 Aranesp 2 SL, SP Veltassa 3 PA, SL Auryxia 3 Zarxio 2 SP Bethkis 2 PA, SL, SP Musculoskeletal: Muscle Spasms Cayston 2 PA, SL, SP Baclofen Tablet 1 Cerdelga 2 PA, SP Carisoprodol 350 mg Tablet 1 Chlorhexidine Gluconate 1 Cyclobenzaprine 1 Chlorpheniramine/Hydrocodone/ 2 PA, SL Pseudoephedrine Solution Metaxalone Tablet 3 Epinephrine (generic EpiPen/ 2 SL Methocarbamol Tablet 1 EpiPen-Jr.) Tizanidine Tablet 1 EpiPen/EpiPen-Jr. 3 E, SL Hydrocodone/Chlorpheniramine 3 PA, SL Suspension Lanthanum Chewable Tablet 3 Letrozole Tablet 1

Bold type = Brand-name drug [Plain type = Generic drug] PA = Prior authorization required E = May be excluded from coverage RS = May be eligible for the refill and save program H = May be part of health care reform preventive SL = Supply limit H-PA = May be part of health care reform preventive with SP = Specialty medication prior authorization ST = Step therapy Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 19 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Oxycodone/Acetaminophen Musculoskeletal: Osteoporosis 1 SL 5/325, 7.5/325, 10/325 mg Tablet Alendronate Sodium Tablet 1 Oxycontin 3 E, PA, SL, ST Forteo 3 PA, SP Sprix 3 Ibandronate Tablet 2 SL Tramadol-Acetaminophen 1 SL Raloxifene Tablet 2 Tramadol Immediate-Release 1 Risedronate Sodium Tablet 3 SL Tablet Tramadol Sustained-Release Tymlos 3 PA, SP 2 SL Tablet Musculoskeletal: Pain Relief Trezix 3 SL Acetaminophen/Codeine Tablet 1 SL Vicodin 5/300, 7.5/300, 3 E, SL Belbuca 3 PA, SL 10/300 mg Tablet Celecoxib 2 SL Voltaren Gel 2 Diclofenac Tablet 1 Xtampza ER 2 PA, SL Etodolac Capsule 1 Zohydro ER 3 PA, SL, ST Fentanyl 12, 25, 50, 75, 100 mcg Overactive Bladder 2 PA, SL, ST Patch Dicyclomine Tablet 1 Fentanyl Citrate Lozenge 2 PA, SL Oxybutynin Extended-Release Hydrocodone/Acetaminophen 2 1 SL Tablet 5/325, 7.5/325, 10/325 mg Tablet Oxybutynin Tablet 1 Hydrocodone/Ibuprofen Tablet 1 Toviaz 3 Hydromorphone Immediate- 1 Release Tablet Respiratory: Allergies Ibuprofen Tablet 1 Azelastine 0.1% Nasal Spray 3 Indomethacin Capsule 1 Fluticasone Nasal Spray 2 SL Ketorolac Tablet 1 Zetonna 3 SL Lazanda 3 PA, SL Respiratory: Asthma/COPD Meloxicam Tablet 1 Advair Diskus/HFA 3 RS, SL Methadone Tablet, Oral Solution, Albuterol Nebs 1 1 PA, SL Concentrate Solution Alvesco 1 SL Morphine Sulfate Extended- 1 PA, SL Release Tablet Anoro Ellipta 3 SL Morphine Sulfate Oral Solution 1 Arnuity Ellipta 3 SL Nabumetone Tablet 1 Asmanex TwistHaler, HFA 1 SL Naproxen Tablet 1 Bevespi Aerosphere 2 SL Nucynta 3 SL Breo Ellipta 3 RS, SL Nucynta ER 3 PA, SL Budesonide Nebs 2 SL Oxycodone Tablet 1 Combivent Respimat 3 SL

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 20 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Flovent Diskus/HFA 3 SL Tadalafil (genericAdcirca ) 3 PA, SL, SP Fluticasone/Salmeterol RespiClick 2 SL Tracleer 2 PA, SL, SP (generic AirDuo RespiClick) Tyvaso 2 PA, SP Incruse Ellipta 2 SL Uptravi 3 PA, SL, SP Ipratropium-Albuterol Nebs 2 Smoking Cessation Ipratropium Nebs 1 Bupropion Sustained-Release Montelukast Chewable Tablet, 1 H-PA 1 Tablet Tablet Chantix Tablet 3 H-PA Montelukast Granules 2 Nicoderm CQ 3 H-PA Perforomist 3 SL Nicorette Gum 3 H-PA ProAir HFA/RespiClick 3 SL Nicorette Lozenge 2 H-PA Proventil HFA 3 SL Nicorette Mini-Lozenge 2 H-PA Pulmicort Flexhaler 3 SL, ST Nicotine Gum 1 H-PA QVAR Redihaler 1 SL Nicotine Lozenge 1 H-PA Seebri Neohaler 3 SL, ST Nicotine Patch 1 H-PA Serevent Diskus 3 SL Nicotrol Inhaler 3 H-PA Spiriva Handihaler/Respimat 2 SL Nicotrol Nasal Spray 3 H-PA Striverdi Respimat 2 SL Transplant Symbicort 3 RS, SL Azathioprine Tablet 1 Trelegy Ellipta 3 RS, SL Cyclosporine Modified Capsule 1 SP Tudorza 2 SL Mycophenolate Capsule, 1 SP Ventolin HFA 2 SL Suspension Xopenex HFA 3 SL Mycophenolic Acid Tablet 2 SP Respiratory: Pulmonary Arterial Hypertension Sirolimus Tablet 1 SP Adempas 2 PA, SL, SP Tacrolimus Capsule 1 SP Letairis 2 PA, SL, SP Opsumit 2 PA, SL, SP Orenitram 3 PA, SL, SP Sildenafil Tablet (genericRevatio ) 1 PA, SL, SP

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 22 Drug Requirements Drug Requirements Drug Name Drug Name Tier & Limits Tier & Limits Microgestin 2 Reclipsen 1 H Microgestin Fe 1 H Setlakin 2 H Mono-Linyah 1 H Sharobel 1 H MonoNessa 1 H Solia 1 H My Choice 1 H Sprintec 1 H My Way 1 H Sronyx 1 H Myzilra 1 H Take Action 1 H Natazia 2 Tarina Fe 1 H Necon 7/7/7, 0.5/35, 1/35, 1/50, 1 H Tri Femynor 1 H 10/11 Tri-Estarylla 1 H Next Choice One Choice 1 H Tri-Linyah 1 H Nora BE 1 H Tri-Lo-Estarylla 2 Norethindrone 0.35 mg 1 H Tri-Lo-Marzia 2 Norethindrone-Ethinyl Estradiol- 1 H Ferrous Fumarate Tri-Lo-Sprintec 2 Norgestimate-Ethinyl Estradiol Tri-Previfem 1 H (generic Ortho-Cyclen, Ortho 1 H Tri-Cyclen) Tri-Sprintec 1 H Norgestimate-Ethinyl Estradiol Lo Tri-Vylibra 1 H 2 (generic Ortho Tri-Cyclen Lo) Trinessa 1 H Norlyda 1 H Trinessa Lo 2 Norlyroc 1 H Trivora-28 1 H Nortrel 7/7/7, 0.5/35, 1/35 1 H Velivet 1 H Nuvaring 2 H Vestura 3 Opcicon One Step 1 H Vienva 1 H Option 2 1 H Viorele 2 Orsythia 1 H Vylibra 1 H Pirmella 7/7/7, 1/35 1 H Wera 1 H Plan B One Step 1 H Xulane 3 H Portia 1 H Yasmin 28 2 Previfem 1 H Yaz 2 Quasense 2 H Zovia 1/35E, 1/50E 1 H Rajani 3 E React 1 H

Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY. 24 Index

A Ampyra...... 12 Betamethasone Dipropionate Abacavir-Lamivudine...... 17 Anastrozole Tablet...... 19 0.05% Augmented Lotion, Accu-Chek Test Strips...... 14 Androderm...... 19 Ointment...... 13 Acetaminophen/Butalbital/Caffeine Androgel...... 19 Betamethasone Dipropionate 325 mg/50 mg/40 mg...... 12 Anoro Ellipta...... 20 0.05% Cream, Ointment...... 13 Acetaminophen/Codeine Tablet..... 20 Apidra SoloStar, Vials...... 14 Betaseron...... 12 Actemra...... 18 Aprepitant Capsule...... 16 Bethkis...... 19 Acyclovir Ointment...... 9 Apri...... 22 Bevespi Aerosphere...... 20 Acyclovir Tablet...... 9 Apriso...... 17 Bevyxxa...... 10 Aczone...... 13 Aranelle...... 22 Bexarotene Capsule...... 9 Adcirca...... 21 Aranesp...... 19 Bicalutamide...... 9 Adderall XR...... 11 Aripiprazole Tablet...... 12 Bidil...... 10 Addyi...... 18 Armodafinil...... 12 Bisoprolol...... 10 Adempas...... 21 Armour Thyroid...... 16 Bisoprolol-Hydrochlorothiazide...... 10 Adlyxin...... 15 Arnuity Ellipta...... 20 Blisovi Fe...... 22 Admelog SoloStar, Vials...... 14 Asmanex TwistHaler, HFA...... 20 Bosulif...... 9 Advair Diskus/HFA...... 20 Atazanavir Capsule...... 17 Braftovi...... 9 Aftera...... 22 Atenolol...... 10 Brand Prenatal Vitamins...... 24 AirDuo RespiClick...... 21 Atenolol-Chlorthalidone...... 10 Breo Ellipta...... 20 Akynzeo...... 16 Atomoxetine...... 11 Brilinta...... 10 Albuterol Nebs...... 20 Atorvastatin...... 11 Budesonide Extended-Release Alendronate Sodium Tablet...... 20 Atripla...... 17 Tablet...... 17 Alesse...... 22 Aubagio...... 12 Budesonide Nebs...... 20 Alfuzosin Tablet...... 19 Aubra...... 22 Buprenorphine Sublingual Tablet... 12 Allopurinol Tablet...... 17 Auryxia...... 19 Bupropion Extended-Release Alphagan P 0.1%...... 16 Austedo...... 12 Tablet...... 12 Alprazolam Extended-Release Aviane...... 22 Bupropion Sustained-Release Tablet...... 12 Avonex...... 12 Tablet...... 12, 21 Alprazolam Tablet...... 12 Azathioprine Tablet...... 21 Bupropion Tablet...... 12 Altavera...... 22 Azelastine 0.05% Ophthalmic Buspirone Tablet...... 12 Alunbrig...... 9 Solution...... 16 Bydureon, Bydureon Bcise...... 15 Alvesco...... 20 Azelastine 0.1% Nasal Spray...... 20 Byetta...... 15 Alyacen 7/7/7, 1/35...... 22 Azithromycin Tablet...... 9 Bystolic...... 10 Amiodarone...... 11 Azopt...... 16 Byvalson...... 10 Amitiza...... 17 Azurette...... 22 Amitriptyline Tablet...... 12 C Amlodipine...... 10 B Calcipotriene/Betamethasone Amlodipine-Benazepril...... 10 Baclofen Tablet...... 19 Ointment...... 13 Amlodipine-Valsartan...... 10 Basaglar...... 14 Calcitriol Capsule...... 16 Amoxicillin Capsule, Chewable Belbuca...... 20 Calquence...... 9 Tablet...... 9 Benazepril...... 10 Camila...... 22 Amoxicillin/Potassium Clavulanate Benazepril-Hydrochlorothiazide..... 10 Canasa...... 17 Chewable Tablet, Tablet...... 9 Carac...... 13 Amphetamine Salt Combo...... 11

25 Carbamazepine Extended-Release Clindamycin Swabs...... 13 Desoximetasone Gel, Ointment..... 14 Capsule...... 13 Clobetasol Propionate Cream, Desvenlafaxine Extended-Release Carbamazepine Extended-Release Ointment...... 13 Tablet...... 12 Tablet...... 13 Clobetasol Propionate Solution...... 13 Dexamethasone Tablet...... 16 Carbamazepine Immediate-Release Clomiphene...... 18 Dexilant...... 16 Tablet...... 13 Clonazepam Tablet...... 13 Dexmethylphenidate Immediate- Carbidopa-Levodopa...... 12 Clonidine Tablet...... 10 Release Tablet...... 11 Carisoprodol 350 mg Tablet...... 19 Clopidogrel...... 10 Dextroamphetamine Sulfate Cartia XT...... 10 Clotrimazole-Betamethasone Immediate-Release Tablet...... 11 Carvedilol Immediate-Release Cream...... 13 Dextroamphetamine-Amphetamine Tablet...... 10 Clotrimazole-Betamethasone Immediate-Release Tablet...... 11 Cayston...... 19 Lotion...... 14 Diazepam Tablet...... 12, 13 Caziant...... 22 Colesevelam Packet for Diclofenac Tablet...... 20 Cefadroxil Capsule, Tablet...... 9 Suspension, Tablet...... 11 Dicyclomine Tablet...... 20 Cefdinir Capsule...... 9 Combigan...... 16 Dificid...... 9 Cefixime Suspension...... 9 Combivent Respimat...... 20 Diflorasone Diacetate 0.05% Cefprozil Tablet...... 9 Complera...... 17 Cream, Ointment...... 14 Cefuroxime Tablet...... 9 Concerta...... 11 Digoxin...... 11 Celecoxib...... 20 Contour Next EZ Meter...... 14 Diltiazem 24 Hour CD...... 10 Cephalexin Capsule...... 9 Contour Next Meter...... 14 Diltiazem Sustained-Release Cerdelga...... 19 Contour Next One Meter...... 14 Capsule...... 10 Cetrotide...... 18 Contour Next Test Strips...... 14 Diltiazem Sustained-Release Chantix Tablet...... 21 Contour Test Strips...... 14 Tablet...... 10 Chateal...... 22 Copaxone...... 12 Diphenoxylate-Atropine Tablet...... 17 Chlorhexidine Gluconate...... 19 Corlanor...... 11 Divalproex Delayed-Release Chlorpheniramine/Hydrocodone/ Cortifoam...... 17 Tablet...... 13 Pseudoephedrine Solution...... 19 Cosentyx...... 18 Divalproex Extended-Release Chlorthalidone...... 10 Creon...... 17 Tablet...... 13 Cialis...... 18 Cresemba...... 9 Divigel...... 24 Ciclopirox Cream, Gel, Lotion, Cryselle...... 22 Donepezil 5, 10 mg ODT, Tablet.... 12 Solution...... 13 Cyclafem 7/7/7, 1/35...... 22 Doxazosin...... 10, 19 Cimduo...... 17 Cyclobenzaprine...... 19 Doxazosin Tablet...... 19 Cimzia...... 18 Cyclophosphamide Capsule...... 9 Doxepin...... 12 Ciprodex...... 9 Cyclosporine Modified Capsule..... 21 Doxycycline Hyclate 50, 100 mg Ciprofloxacin Tablet...... 9 Cyred...... 22 Capsule, Tablet...... 9 Citalopram Tablet...... 12 Doxycycline Monohydrate Claravis...... 13 D 50, 100 mg Capsule...... 9 Clarithromycin Tablet...... 9 Daklinza...... 17 Duavee...... 24 Clenpiq...... 17 Dapsone 5% Gel...... 14 Duloxetine Capsule...... 12 Climara...... 24 Dasetta 7/7/7, 1/35...... 22 Dupixent...... 14 Climara Pro...... 24 Deblitane...... 22 Dutasteride Capsule...... 19 Clindamycin 1.2%/Benzoyl Delyla...... 22 Duzallo...... 17 Peroxide 5% Gel...... 13 Descovy...... 17 Clindamycin Capsule...... 9 Desmopressin Tablet...... 16 E Clindamycin Gel...... 13 Desogestrel-Ethinyl Estradiol...... 22 Econazole Cream...... 9 Clindamycin Lotion...... 13 Desonide 0.05% Cream, Lotion, Econtra EZ...... 22 Clindamycin Solution...... 13 Ointment...... 14 Edarbi...... 10

26 Edarbyclor...... 10 F Glucophage XR...... 15 Efavirenz...... 17 Fallback...... 22 Glyburide...... 15 Eletriptan...... 12 Falmina...... 22 Glyxambi...... 15 Elidel...... 14 Famciclovir Tablet...... 9 Golytely...... 17 Elinest...... 22 Farxiga...... 15 Gonal-F...... 18 Eliquis...... 10 Fenofibrate 54, 160 mg Tablet...... 11 Gonal-F RFF...... 18 Ella...... 22 Fentanyl 12, 25, 50, 75, 100 mcg Guanfacine...... 10, 11 Emend Suspension...... 16 Patch...... 20 Guanfacine Extended-Release...... 11 Emoquette...... 22 Fentanyl Citrate Lozenge...... 20 Enalapril...... 10 Fetzima...... 12 H Enbrel...... 18 Fiasp FlexTouch, Vials...... 14 Halobetasol Ointment...... 14 Endometrin...... 18 Finacea...... 14 Harvoni...... 17 Enoxaparin Sodium...... 10 Finasteride Tablet...... 19 Heather...... 22 Enpresse...... 22 Flecainide...... 11 Humalog KwikPens...... 14 Enskyce...... 22 Flovent Diskus/HFA...... 21 Humalog Vials...... 14 Enstilar Foam...... 14 Fluconazole Tablet...... 9 Humira...... 18 Entresto...... 11 Fluocinolone Cream, Oil, Humulin KwikPens...... 14 Epclusa...... 17 Solution...... 14 Humulin Vials...... 14 Epinephrine...... 19 Fluocinolone Ointment...... 14 Hydralazine...... 10 EpiPen/EpiPen-Jr...... 19 Fluocinonide 0.05% Cream...... 14 Hydrochlorothiazide...... 10 Erleada...... 9 Fluoride...... 22 Hydrocodone/Acetaminophen Errin...... 22 Fluorouracil 0.5% Cream...... 14 5/325, 7.5/325, 10/325 mg Erythromycin 0.5% Ophthalmic Fluoxetine Capsule...... 12 Tablet...... 20 Ointment...... 16 Fluticasone Nasal Spray...... 20 Hydrocodone/Chlorpheniramine Escitalopram Tablet...... 12 Fluticasone/Salmeterol Suspension...... 19 Estarylla...... 22 RespiClick...... 21 Hydrocodone/Ibuprofen Tablet...... 20 Estrace...... 24 Fluvastatin Extended-Release Hydrocortisone 2.5% Cream, Estrace Cream...... 24 Tablet...... 11 Ointment...... 14 Estradiol Cream...... 24 Fluvoxamine Tablet...... 12 Hydromorphone Immediate-Release Estradiol Tablet...... 24 Folic Acid...... 22 Tablet...... 20 Estradiol Twice-Weekly Forteo...... 20 Hydroxychloroquine Sulfate...... 18 Transdermal Patch...... 24 FreeStyle Test Strips...... 14 Hydroxyurea Capsule...... 9 Estradiol Weekly Transdermal Frovatriptan...... 12 Hyoscyamine Tablet...... 17 Patch...... 24 Furosemide...... 10 Estradiol/Norethindrone Acetate I Tablet...... 24 G Ibandronate Tablet...... 20 Estring...... 24 Gabapentin Capsule, Tablet...... 13 Ibrance...... 9 Estrogen/Methyltestosterone Gemfibrozil...... 11 Ibuprofen Tablet...... 20 Tablet...... 24 Gentamicin Ophthalmic Ointment, Idhifa...... 9 Eszopiclone Tablet...... 13 Solution...... 16 Imatinib Tablet...... 9 Etodolac Capsule...... 20 Genvoya...... 17 Imbruvica...... 9 Eucrisa...... 14 Gilenya...... 12 Imiquimod 5% Cream...... 14 Evamist...... 24 Glatiramer...... 12 Incruse Ellipta...... 21 Evotaz...... 17 Glimepiride...... 15 Indomethacin Capsule...... 20 Ezetimibe Tablet...... 11 Glipizide...... 15 Intelence...... 17 Ezetimibe/Simvastatin...... 11 Glipizide Extended-Release...... 15 Intrarosa...... 18

27 Introvale...... 22 Larissia...... 22 M Invokamet, Invokamet XR...... 15 Lastacaft...... 16 Marlissa...... 22 Invokana...... 15 Latanoprost 0.005% Ophthalmic Mavyret...... 17 Ipratropium Nebs...... 21 Solution...... 16 Medroxyprogesterone...... 22, 24 Ipratropium-Albuterol Nebs...... 21 Latuda...... 12 Medroxyprogesterone Acetate...... 22 Irbesartan...... 10 Lazanda...... 20 Mektovi...... 10 Isentress...... 18 Leena...... 22 Meloxicam Tablet...... 20 Isibloom...... 22 Leflunomide...... 18 Memantine Immediate-Release Isosorbide Mononitrate ER...... 11 Lessina...... 22 Tablet...... 12 Itraconazole Capsule...... 9 Letairis...... 21 Mercaptopurine Tablet...... 10 Letrozole Tablet...... 19 Mesalmine Delayed-Release J Leucovorin Calcium Tablet...... 9 Tablet...... 17 Janumet...... 15 Levemir FlexTouch, Vials...... 15 Metadate CD...... 11 Januvia...... 15 Levetiracetam Extended-Release Metadate ER...... 12 Jardiance...... 15 Tablet...... 13 Metaxalone Tablet...... 19 Jencycla...... 22 Levetiracetam Immediate-Release Metformin...... 15 Jentadueto...... 15 Tablet...... 13 Metformin Extended-Release Jentadueto XR...... 15 Levitra...... 18 Tablet...... 15 Jolessa...... 22 Levofloxacin Tablet...... 9 Methadone Tablet, Oral Solution, Jolivette...... 22 Levonest...... 22 Concentrate Solution...... 20 Juleber...... 22 Levonorgestrel 1.5 mg...... 22 Methimazole Tablet...... 16 Juluca...... 18 Levonorgestrel-Ethinyl Estradiol.... 22 Methocarbamol Tablet...... 19 Junel...... 22 Levora-28...... 22 Methotrexate Tablet...... 18 Junel Fe...... 22 Levothyroxine Sodium Tablet...... 16 Methylphenidate Chewable Lialda...... 17 Tablet...... 11 Lidocaine Transdermal Patch...... 19 K Methylphenidate Extended-Release Lidoderm...... 19 Kaletra Tablet...... 18 Capsule...... 11 Lillow...... 22 Kazano...... 15 Methylphenidate Extended-Release Linzess...... 17 Kelnor 1/35...... 22 Tablet...... 11, 12 Liothyronine Sodium Tablet...... 16 Ketoconazole Cream...... 9 Methylphenidate Immediate-Release Lisinopril...... 10 Ketorolac Tablet...... 20 Tablet...... 12 Lisinopril-Hydrochlorothiazide...... 10 Kevzara...... 18 Methylprednisolone Tablet...... 16 Lithium Capsule...... 12 Klor-Con M10...... 22 Methyltestosterone Capsule...... 19 Lo Loestrin Fe...... 22 Klor-Con M20...... 22 Metoclopramide Tablet...... 17 Lopinavir-Ritonavir Oral Solution.... 18 Kombiglyze XR...... 15 Metoprolol Succinate Extended- Lorazepam Tablet...... 12 Kurvelo...... 22 Release 50, 100, 200 mg...... 10 Loryna...... 22 Metoprolol Tartrate 25, 50, Losartan...... 10 100 mg...... 10 L Losartan-Hydrochlorothiazide...... 10 Metronidazole 0.75% Topical Gel... 14 Labetalol...... 10 Lovastatin...... 11 Metronidazole Tablet...... 9 Lamivudine-Zidovudine...... 18 Low-Ogestrel...... 22 Microgestin...... 23 Lamotrigine Immediate-Release Lumigan...... 16 Microgestin Fe...... 23 Tablet...... 13 Lutera...... 22 Minivelle...... 24 Lanthanum Chewable Tablet...... 19 Lyrica...... 13 Minocycline Capsule...... 9 Lantus SoloStar...... 15 Lyrica CR...... 13 Minocycline Extended-Release...... 14 Lantus Vials...... 15 Lyza...... 22 Mirtazapine Tablet...... 12 Larin Fe...... 22 Mirvaso...... 14

28 Mitigare...... 17 Nicotine Gum...... 21 Omega-3-Acid Ethyl Esters Modafinil...... 12 Nicotine Lozenge...... 21 Capsule...... 11 Mometasone Furoate Cream, Nicotine Patch...... 21 Omeprazole Capsule...... 16 Lotion, Ointment...... 14 Nicotrol Inhaler...... 21 Ondansetron...... 16 Mono-Linyah...... 23 Nicotrol Nasal Spray...... 21 OneTouch Ultra 2 Meter...... 14 MonoNessa...... 23 Nifedipine Extended-Release...... 10 OneTouch Ultra Test Strips...... 14 Montelukast Chewable Tablet, Nitrofurantoin Capsule...... 9 OneTouch UltraMini Meter...... 14 Tablet...... 21 Nitrofurantoin Macrocrystal OneTouch Verio Flex Meter...... 14 Montelukast Granules...... 21 Capsule...... 9 OneTouch Verio IQ Meter...... 14 Morphine Sulfate Extended-Release Nitroglycerin Sublingual Tablet...... 11 OneTouch Verio Meter...... 14 Tablet...... 20 Nityr...... 19 OneTouch Verio Sync Meter...... 14 Morphine Sulfate Oral Solution...... 20 Nora BE...... 23 OneTouch Verio Test Strips...... 14 Movantik...... 17 Nordette...... 22 Onglyza...... 15 Moviprep...... 17 Norethindrone 0.35 mg...... 23 Opcicon One Step...... 23 Moxeza...... 16 Norethindrone-Ethinyl Estradiol- Opsumit...... 21 Moxifloxacin Ophthalmic Solution.. 16 Ferrous Fumarate...... 23 Option 2...... 23 Moxifloxacin Tablet...... 9 Norgestimate-Ethinyl Estradiol...... 23 Oracea...... 14 Multaq...... 11 Norgestimate-Ethinyl Estradiol Orencia...... 18 Mupirocin Ointment...... 14 Lo...... 23 Orenitram...... 21 My Choice...... 23 Norlyda...... 23 Orsythia...... 23 My Way...... 23 Norlyroc...... 23 Ortho Tri-Cyclen...... 23 Mycophenolate Capsule, Nortrel 7/7/7, 0.5/35, 1/35...... 23 Ortho Tri-Cyclen Lo...... 23 Suspension...... 21 Nortriptyline Capsule...... 12 Ortho-Cept...... 22 Mycophenolic Acid Tablet...... 21 Novolin Vials...... 15 Ortho-Cyclen...... 23 Myzilra...... 23 Novolog FlexPen, Vials...... 15 Oseltamivir Capsule, Suspension.... 9 Noxafil Tablet, Suspension...... 9 Oseni...... 15 N NP Thyroid Tablet...... 16 Osphena...... 18 Nabumetone Tablet...... 20 Nucynta...... 20 Otezla...... 18 Nadolol...... 10 Nucynta ER...... 20 Ovidrel...... 18 Naloxone Vials...... 12 Nuedexta...... 19 Oxcarbazepine Tablet...... 13 Naproxen Tablet...... 20 Nutropin, Nutropin AQ...... 15 Oxsoralen-Ultra...... 14 Naratriptan...... 12 Nuvaring...... 23 Oxybutynin Extended-Release Narcan Nasal Spray...... 12 Nystatin Cream, Ointment...... 9 Tablet...... 20 Natazia...... 23 Oxybutynin Tablet...... 20 Necon 7/7/7, 0.5/35, 1/35, O Oxycodone Tablet...... 20 1/50, 10/11...... 23 Obredon...... 19 Oxycodone/Acetaminophen 5/325, Nerlynx...... 10 Odefsey...... 18 7.5/325, 10/325 mg Tablet...... 20 Nesina...... 15 Ofloxacin 0.3% Ophthalmic Oxycontin...... 20 Nevirapine...... 18 Solution...... 16 Ozempic...... 15 Nevirapine Extended-Release...... 18 Ofloxacin Otic Solution...... 9 Next Choice One Choice...... 23 Ofloxacin Tablet...... 9 P Niacin Extended-Release Tablet.....11 Olanzapine Tablet...... 13 Pantoprazole Tablet...... 16 Niaspan...... 11 Olmesartan...... 10 Paroxetine Tablet...... 12 Nicoderm CQ...... 21 Olmesartan-Hydrochlorothiazide... 10 Pegasys...... 19 Nicorette Gum...... 21 Olopatadine 0.1% Ophthalmic Penicillin V Potassium Tablet...... 9 Nicorette Lozenge...... 21 Solution...... 16 Perforomist...... 21 Nicorette Mini-Lozenge...... 21 Omeclamox-Pak...... 16 Phenazopyridine...... 19

29 Phenytoin Capsule, Suspension.... 13 Quinapril...... 11 Sharobel...... 23 Picato...... 14 QVAR Redihaler...... 21 Sildenafil Tablet...... 18, 21 Pioglitazone...... 15 Siliq...... 18 Pirmella 7/7/7, 1/35...... 23 R Simponi...... 18 Plan B One Step...... 23 Rabeprazole Tablet...... 16 Simvastatin...... 11 Plegridy...... 12 Rajani...... 23 Sirolimus Tablet...... 21 Polyethylene Glycol 3350...... 17 Raloxifene...... 20, 24 Solia...... 23 Portia...... 23 Raloxifene Tablet...... 20 Soliqua...... 15 Potassium Chloride...... 22 Ramipril...... 11 Solodyn...... 14 Potassium Citrate...... 22 Ranexa...... 11 Sotalol...... 11 Pradaxa...... 10 Ranitadine Syrup...... 16 Sovaldi...... 17 Praluent...... 11 Rapaflo...... 19 Spiriva Handihaler/Respimat...... 21 Pramipexole Tablet...... 13 Rasuvo...... 18 Spironolactone...... 11 Prasugrel...... 10 React...... 23 Sprintec...... 23 Pravastatin...... 11 Rebif...... 12 Sprix...... 20 Prednisone Tablet...... 16 Reclipsen...... 23 Sronyx...... 23 Premarin...... 24 Rectiv...... 19 Steglatro...... 15 Premphase...... 24 Regranex...... 14 Steglujan...... 15 Prempro...... 24 Repatha...... 11 Stelara...... 18 Prenisolone Oral Solution...... 16 Restasis Single Use Vials...... 16 Stendra...... 18 Prepopik...... 17 Revatio...... 21 Stribild...... 18 Previfem...... 23 Revlimid...... 10 Striverdi Respimat...... 21 Prezcobix...... 18 Rezira...... 19 Suboxone Film...... 13 Prezista...... 18 Rhofade...... 14 Sucralfate Tablet...... 16 Pristiq...... 12 Ribavirin Tablet...... 17 Sulfamethoxazole-Trimethoprim ProAir HFA/RespiClick...... 21 Risedronate Sodium Tablet...... 20 Tablet...... 9 Procrit...... 19 Risperidone Tablet...... 13 Sulfasalazine Tablet...... 17 Progesterone Micronized Ritalin LA...... 11 Sumatriptan Nasal Spray...... 12 Capsule...... 24 Ritalin SR...... 12 Sumatriptan Succinate Tablet, Promethazine/Codeine...... 19 Ritonavir Tablet...... 18 Injection...... 12 Promethazine/Dextromethorphan.. 19 Rizatriptan ODT, Tablet...... 12 Suprax Capsule, Chewable Tablet, Propranolol Extended-Release Ropinirole Tablet...... 13 Tablet...... 9 Capsule...... 10 Rosuvastatin...... 11 Suprep...... 17 Propranolol Tablet...... 11 Rydapt...... 10 Sutent...... 10 Proventil HFA...... 21 Symbicort...... 21 Prozac...... 12 Symfi...... 18 S Pulmicort Flexhaler...... 21 Symfi Lo...... 18 Savaysa...... 10 Pulmozyme...... 19 Symproic...... 17 Scopolamine Transdermal Patch... 16 Pylera...... 16 Synjardy, Synjardy XR...... 15 Seasonale...... 22 Synthroid...... 16 Seebri Neohaler...... 21 Q Syprine...... 19 Segluromet...... 15 Qtern...... 15 Selzentry...... 18 T Quasense...... 23 Serevent Diskus...... 21 Quetiapine Extended-Release Sertraline Tablet...... 12 Taclonex Suspension...... 14 Tablet...... 13 Setlakin...... 23 Tacrolimus Capsule...... 21 Quetiapine Immediate-Release Sevelamer...... 19 Tacrolimus Ointment...... 14 Tablet...... 13 Tadalafil...... 21

30 Take Action...... 23 Tremfya...... 18 Velivet...... 23 Taltz...... 18 Tresiba FlexTouch...... 15 Velphoro...... 19 Tamoxifen...... 24 Tretinoin Cream...... 14 Veltassa...... 19 Tamsulosin Capsule...... 19 Trezix...... 20 Venlafaxine Extended-Release Targretin Capsule...... 10 Tri Femynor...... 23 Capsule...... 12 Targretin Gel...... 10 Tri-Estarylla...... 23 Venlafaxine Tablet...... 12 Tarina Fe...... 23 Tri-Linyah...... 23 Ventolin HFA...... 21 Tasigna...... 10 Tri-Lo-Estarylla...... 23 Verapamil...... 11 Tazarotene 0.1% Cream...... 14 Tri-Lo-Marzia...... 23 Verapamil Sustained-Release...... 11 Tazorac...... 14 Tri-Lo-Sprintec...... 23 Verzenio...... 10 Tecfidera...... 12 Tri-Previfem...... 23 Vestura...... 23 Technivie...... 17 Tri-Sprintec...... 23 Viagra...... 18 Telmisartan...... 11 Tri-Vylibra...... 23 Viberzi...... 17 Telmisartan-Hydrochlorothiazide....11 Triamcinolone Acetonide Cream, Vicodin 5/300, 7.5/300, 10/300 mg Temazepam Capsule...... 13 Lotion, Ointment...... 14 Tablet...... 20 Tenofovir Tablet...... 18 Triamterene-Hydrochlorothiazide....11 Victoza 2-Pak...... 15 Terazosin...... 11, 19 Triazolam Tablet...... 13 Victoza 3-Pak...... 15 Terazosin Capsule, Tablet...... 19 Trientine...... 19 Viekira Pak...... 17 Terbinafine Tablet...... 9 Trinessa...... 23 Viekira XR...... 17 Testim...... 19 Trinessa Lo...... 23 Vienva...... 23 Testosterone 1% Topical Gel...... 19 Trintellix...... 12 Viibryd...... 12 Testosterone Cypionate Injection... 19 Triphasil...... 22 Viorele...... 23 Timolol 0.25%, 0.5% Ophthalmic Triumeq...... 18 Vitekta...... 18 Solution...... 16 Trivora-28...... 23 Vivelle-Dot...... 24 Timoptic...... 16 Trulicity...... 15 Voltaren Gel...... 20 Tivicay...... 18 Truvada...... 18 Vosevi...... 17 Tizanidine Tablet...... 19 Tudorza...... 21 Vylibra...... 23 Tobi Podhaler...... 19 Tybost...... 18 Vyvanse...... 12 Tobramycin Ophthalmic Solution.... 16 Tymlos...... 20 Tobramycin/Dexamethasone Tyvaso...... 21 W 0.3%-0.1% Ophthalmic Warfarin Sodium...... 10 Suspension...... 16 U Welchol...... 11 Tolcapone...... 13 Uceris...... 17 Welchol Packet for Suspension, Topiramate Immediate-Release Uceris Foam...... 17 Tablet...... 11 Tablet...... 13 Uceris Tablet...... 17 Wera...... 23 Toviaz...... 20 Uloric...... 17 Tracleer...... 21 Uptravi...... 21 X Tradjenta...... 15 Xarelto...... 10 Tramadol Immediate-Release V Xeljanz, Xeljanz XR...... 18 Tablet...... 20 Valacyclovir Tablet...... 9 Xeloda...... 10 Tramadol Sustained-Release Valganciclovir...... 9 Xigduo XR...... 15 Tablet...... 20 Valsartan...... 11 Xiidra...... 16 Tramadol-Acetaminophen...... 20 Valsartan-Hydrochlorothiazide...... 11 Xopenex HFA...... 21 Travatan Z...... 16 Varubi...... 16 Xtampza ER...... 20 Trazodone Tablet...... 12 Vascepa...... 11 Xulane...... 23 Trelegy Ellipta...... 21 Vectical...... 14 Xyrem...... 13

31 Y Yasmin 28...... 23 Yaz...... 23 Yuvafem...... 24

Z Zaleplon Capsule...... 13 Zarxio...... 19 Zelapar...... 13 Zenpep...... 17 Zepatier...... 17 Zetonna...... 20 Ziprasidone Capsule...... 13 Zohydro ER...... 20 Zolpidem Immediate-Release Tablet...... 13 Zonisamide Capsule...... 13 Zovia 1/35E, 1/50E...... 23 Zubsolv...... 13 Zurampic...... 17 Zykadia...... 10 Zytiga...... 10

32 Nondiscrimination notice and access to communication services

UnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you 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, UT 84130

You must send the complaint within 60 days of your experience. 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 toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

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, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

33 Multi-language interpreter services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. 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 su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡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. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: 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 nasa iyong identification card. ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте. تنبيه: إذا كنت تتحدث العربية (Arabic ،) فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّمعرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises 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。健康保険証に記載されている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 رايگانی که روی کارت شناسايی شما قيد شده تماس بگيريد. ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej. ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo. 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 ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ ę́› t’áá jíík’ehgo 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 telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

This document applies to commercial group members of UnitedHealthcare and Oxford New York and New Jersey plans. Insurance coverage provided by or through UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of New York, or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates. UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners.