2011 Enrollment Kit

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2011 Enrollment Kit
Hospitals Doctors Rx Drugs

convenient
$0 monthly plan premium

OnE

plan

AARP® MedicareComplete ® Plus (HMO-POS)
H2182-001

Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton counties

Y0004Y0066_100707_142434 CMS Approved 08202010

What You’ll Find in this Booklet
Cover Letter.........................................................................1 Medicare Advantage Explained............................................3 Benefits at a Glance.............................................................4 Passport Brochure...............................................................6 Ready to Enroll.................................................................... 8 Summary of Benefits............................................................9 Additional Plan Information .....................................33 - Appeals & Grievances............................................35 - Plan Ratings.......................................................... 37 - Dental Platinum Rider............................................39 - Fitness Rider..........................................................41 - Disclaimers............................................................43 Pharmacy Options Enrollment Materials - Outbound Education & Verification Call Checklist (See back of Enrollment Materials Divider) - Scope of Appointment Form Enrollment Form Roadmap After Enrollment ..........................................45 - Drug List................................................................47

Health Care to Fit Your Needs…

now that is peace of mind

At UnitedHealthcare we realize more than ever the importance of affordable health care coverage. We are dedicated to helping you make the right choices by providing quality, costeffective health care solutions. As one of the largest and most recognized health carriers in the United States, you can be confident we will be here when you need us.

We Make Health Care Simple…
and provide the answers you need
INSIDE THIS BOOKLET:
• Understand the basics of Medicare Advantage • Learn how our plans can benefit you • View plan details and how they compare to your Original Medicare

use our Medicare Advantage Programs
• Start your application process • Continue on your path to good health

ONE out of FIVE Medicare members

• Look up your medications

We’re Here For You
Y0035Y0066_100624_153203 CMS Approved 08032010
Talk with your local sales agent. Health care is personal. Your agent will answer your questions and help you enroll.

If you don’t have a local sales agent, call SecureHorizons toll-free: x-xxx-xxx-xxxx, <8 a.m.– 1-800-547-5514, 8a.m. – 8 p.m. local time, 7 days a week>. week. TTY users, call 711.
Go online: www.AARPMedicarePlans.com. <WebsiteAddress>. Thank you for your interest in this plan. The world of Medicare can be confusing, but we’re here to help. Together we’ll find a plan that’s right for you. Sincerely,

Thomas S. Paul Chief Executive Officer, UnitedHealthcare Medicare Solutions

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You may contact 1-800-MEDICARE (1-800-633-4227) and TTY users should call 1-877-486-2028, 24 hours a day, 7 days a week or visit www.medicare.gov for more information about Medicare benefits and services including general information regarding health and Part D benefit. The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related products, services, insurance or programs. You are strongly encouraged to evaluate your needs. This document is available in alternative formats. You must have both Medicare Part A and B, and must reside in the service area of the plan. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Your ability to enroll may be limited certain times of the year. For more information contact Customer Service at 1-800-547-5514 7 days a week, between 8:00 a.m. and 8:00 p.m. local time. TTY users can call 711 or write us at P.O. Box 29675, Hot Springs, AR 71903-9675, or go to www.AARPMedicarePlans.com. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor AARP MedicareComplete RX plans will be responsible for the costs. For PPO and HMO-POS members, with the exception of emergency or urgent care or out-of-area renal dialysis, it may cost more to get care from out-of-network providers. For PPO members, reimbursement is provided for all covered benefits regardless of whether they are received in network. Out of network services may cost more than in network services. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid Office. The Medicare Prescription Drug benefit is only available to members of the Medicare Advantage with Prescription Drug (MA-PD) plans. By enrolling in an MA-PD you will automatically be disenrolled from any existing Medicare Prescription Drug coverage. To receive the highest level of benefit you must use contracted network pharmacies to access your prescription drug benefit except in the case of emergency. The pharmacy network includes retail, mail order, long-term care, home infusion and I/T/U (Indian Health Service, Tribes, or Urban Indian) pharmacy services. You may obtain your prescriptions from pharmacies outside the contracted network at a reduced benefit. Quantity limitations and restrictions may apply. For more information about mail order, names and addresses of network pharmacies or for more information call 1-800-547-5514, or TTY 711, Monday through Friday, 8:00 a.m. to 8:00 p.m. local times. Or write us at P.O. Box 29675, Hot Springs, AR 71903-9675, or go to www.AARPMedicarePlans.com. The AARP ® MedicareComplete® benefit packages, plan premiums, copayments/coinsurance may vary by county, and service areas are all subject to change annually at the Medicare Advantage contract renewal time with the Centers for Medicare & Medicaid Services (January 1). Availability of coverage beyond the end of the current year is not guaranteed.

2

Medicare Advantage Explained
Medicare is health insurance for people 65 and older and others with certain disabilities. You have choices about how you get your Medicare coverage. You can choose Original Medicare (Parts A and B) or a Medicare Advantage plan. Many people with Original Medicare find there are expenses that are not covered. To help pay for some of these additional costs, many people choose to enroll in a Medicare Advantage plan.

Original Medicare consists of Medicare Parts A and B
• Part A helps with hospital costs • Part B helps with doctor services and outpatient care • Part D (optional add-on) stand-alone prescription drug plans can be added to help with the cost of prescription drugs • Most preventive care services are not covered – expect to pay additional costs for these services • Original Medicare has unpredictable out-of-pocket expenses

Original Medicare (Parts A and B) Operated by the Federal government. Medicare pays fees for your care directly to the doctors and hospitals you visit

=

PAR T

A

PAR T

B

+

PAR T

D

Original Medicare

Optional Plan You Can Add

Medicare Advantage (Part C) Combines Your Coverage into ONE Plan
[CMSCODE] Y0004Y0066_100722_192352 File & Use 08092010 • Medicare Advantage plans cover at least the same services as Parts A and B • Prescription drug coverage (Part D) is included in many Medicare Advantage plans • Preventive care services like dental, vision, hearing and foot care may be included at no extra charge • Medicare Advantage plans have predictable out-of-pocket expenses

Operated by private companies approved by Medicare. Individuals must have both Parts A and B to enroll. You pay a low or no additional monthly plan premium beyond the Medicare Part B premium

=

PA R T

C

+

PA R T

D

+
Other Services May Be Included

Prescription Drug Coverage

Medicare Advantage plans may be a lower-cost alternative to Original Medicare. Medicare Advantage can offer extra preventive benefits and prescription drugs all in ONE convenient plan. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage Organization with a Medicare contract. OVEX11MP3244608_000 3 3

Benefits at a Glance
This plan is a Health Maintenance Organization (HMO) with a Point-of-Service (POS) option plan or HMO-POS. HMO-POS plans provide care through a network of local doctors and hospitals, and the POS plans may provide covered services out-of-network. HMO-POS plans may be a good fit for someone looking for predictable cost shares, benefits above Original Medicare, and the freedom to receive out-of-network services.

Benefit
Monthly plan premium Deductible

In-Network
$0 None $0 copay $0 copay $0 copay $10 copay $35 copay (No Referral Needed) $295 copay per day: days 1-7. $0 thereafter. 20% coinsurance $30 copay $50 copay $200 copay $0 copay $100 copay per day: days 1-34. $0 copay $10 copay 0% - 20% coinsurance 20% coinsurance $16 copay $3380 $0 31-day retail supply $5 $45 $85 33% No Coverage

Out-of-Network

Medical Coverage
Annual physical Preventive services (Medicare-covered) Immunizations (pneumonia and flu) Primary Care Physician (PCP) office visit Specialist office visit Inpatient hospitalization Outpatient surgery and hospital services Urgently needed care Emergency care Ambulance services Home health care Skilled nursing facility (SNF) care Lab services: HIV & cardiovascular screenings All other lab services Diagnostic testing: EKG & AAA screenings All other diagnostic tests X-rays Annual out-of-pocket maximum $15 copay 30% coinsurance $0 copay $15 copay $40 copay $325 copay per day for unlimited days. 30% coinsurance $40 copay $50 copay $200 copay 30% coinsurance $175 copay per day: days 1-40. $0 - $10 copay $10 copay 30% coinsurance 30% coinsurance $21 copay Unlimited

Prescription Drugs
Prescription drug deductible Initial coverage stage n Tier 1: n Tier 2: n Tier 3: n Tier 4: Coverage gap stage (after prescription costs paid reach $2840) Catastrophic coverage stage (after you have paid $4550 out-of-pocket) 90-day mail order supply $10 $125 $245 33%

The greater of $2.50 for generic, $6.30 for brand-name, or 5%

4

To verify your provider is in the plan’s network or for additional plan information visit us online at www.AARPMedicarePlans.com

Y0004Y0066_100622_141023 CMS Approved 08032010

Also included in this plan
Foot care Vision services

In-Network

Out-of-Network

Hearing services

UnitedHealth Passport® Program NurselineSM

$35 copay for 6 visits per year* $40 copay for 6 visits per year* $0 copay for Medicare-covered $40 copay for Medicare-covered glaucoma screening glaucoma screening $35 copay for routine exams; 1 $40 copay for routine exams; 1 per year* per year* $30 copay for coverage up to No coverage for eyewear $70 every 2 years for frames (standard lenses included) or $105 for contact lenses $0 copay for Epic Hearing $40 copay for annual hearing Healthcare provider or $35 test* copay for other network provider No coverage for hearing aids for annual hearing test* $300 hearing aids allowance every 2 years Included in this plan. See the Passport brochure in this booklet for more information. Speak with a registered nurse (RN) 24 hours a day $32 additional monthly premium See the “Additional Information” section for more information $13 additional monthly premium See the “Additional Information” section for more information

Optional additional plan coverage
Dental Platinum Rider Fitness Rider

* Benefit combined in and out-of-network The benefit information provided here in is a brief summary, not a comprehensive description of benefits. For more information contact the plan or review the Summary of Benefits provided within this booklet for more benefit information.

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage Organization with a Medicare contract. To verify your provider is in the plan’s network or for additional plan information visit us online at www.AARPMedicarePlans.com 5

The 2011 UnitedHealth Passport Program
®

The UnitedHealth Passport® Program is Included in Your Plan.
You pay no additional charge (beyond your monthly health plan premium) for health care coverage while you travel within the UnitedHealth Passport® service area. Simply pay the same copay or coinsurance as you would at home to receive non‑emergency care benefit coverage when traveling within the service area, including preventive care, specialist care and hospitalizations. Emergency care is covered worldwide. The gray states on the map to the right show the states in which there are UnitedHealth Passport® service areas. If you are a plan member who resides within one of the counties in this list, you are eligible to participate in the UnitedHealth Passport Program. If you travel to any of the counties on this list, you will be able to use the Passport benefit to access routine and preventive care as needed. Alabama Autauga, Baldwin, Bibb, Blount, Chilton, Elmore, Jefferson, Lowndes, Macon, Mobile, Montgomery, Russell, Shelby, St. Clair, Walker Arizona Cochise, Graham, Maricopa, Pima, Pinal, Santa Cruz, Yavapai Arkansas Benton, Carroll, Crawford, Sebastian, Washington Connecticut1 All Counties in the State of Connecticut Florida All Counties in the State of Florida Georgia Chatham, Cherokee, Clayton, Cobb, Columbia, DeKalb, Forsyth, Fulton, Harris, Muscogee, Rich‑ mond Hawaii All Counties in the State of Hawaii Idaho Ada, Canyon Illinois Bureau, Carroll, Cook, Henderson, Henry, Jersey, Jo Daviess, Kane, Knox, Madison, Marshall, Mercer, Monroe, Peoria, Putnam, Rock Island, Stark, St. Clair, Tazewell, Warren, Whiteside, Will, Woodford Indiana Adams, Allen, Boone, Fulton, Hamilton, Hancock, Hendricks, Huntington, Johnson, Kosciusko, Madi‑ son, Marion, Noble, Posey, St. Joseph, Vanderburgh, Warrick, Wells, Whitley

Kansas Johnson, Sedgwick

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To verify your provider is in the plan’s network or for additional plan information visit us online at www.AARPMedicarePlans.com

Y0066_100716_122643 File & Use 08032010

Iowa Appanoose, Benton, Black Hawk, Boone, Bremer, Buchanan, Butler, Cedar, Chickasaw, Clarke, Clayton, Clinton, Crawford, Dallas, Davis, Delaware, Des Moines, Dubuque, Fayette, Floyd, Greene, Grundy, Guthrie, Hamilton, Hardin, Henry, Iowa, Jackson, Jasper, Jefferson, Johnson, Jones, Keokuk, Lee, Linn, Louisa, Lucas, Madison, Mahaska, Marion, Marshall, Monroe, Muscatine, Page, Polk, Pottawattamie, Poweshiek, Scott, Shelby, Story, Tama, Van Buren, Wapello, Warren, Washington, Wayne

Kentucky Boone, Campbell, Kenton Maine Cumberland, Kennebec, Sagadahoc, York Massachusetts All Counties in the State of Massachusetts Michigan Allegan, Kent, Ottawa Missouri Barry, Cass, Christian, Cole, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Jackson, Jefferson, Laclede, Lafayette, Lawrence, Lincoln, McDonald, Polk, St. Charles, St. Louis, St. Louis City, Stone, Texas, Warren, Washington, Webster, Wright Nebraska Burt, Cass, Douglas, Otoe, Sarpy, Washington New Mexico Dona Ana, Grant, Hidalgo, Luna, Sierra New York1 All Counties in the State of New York North Carolina Alamance, Caswell, Catawba, Chatham, Cumberland, Davidson, Davie, Durham, Forsyth, Guilford, Haywood, Henderson, Iredell, Mecklenburg, Orange, Person, Randolph, Rockingham, Rowan, Stokes, Surry, Wake, Wilkes, Yadkin Ohio Butler, Clark, Clermont, Cuyahoga, Delaware, Franklin, Greene, Hamilton, Madison, Mahoning, Montgomery, Preble, Stark, Summit, Trumbull, Warren Oregon2 Clackamas, Lane, Marion, Multnomah, Washington, Yamhill Pennsylvania Erie, Lancaster, Lehigh, Northampton, York

Rhode Island All Counties in the State of Rhode Island South Carolina Beaufort, Charleston, Greenville, York Tennessee Anderson, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Davidson, DeKalb, Fayette, Grainger, Greene, Hamblen, Hamilton, Hancock, Hawkins, Hickman, Jefferson, Johnson, Knox, Loudon, McMinn, Meigs, Monroe, Morgan, Roane, Rutherford, Scott, Sevier, Shelby, Sullivan, Tipton, Unicoi, Union, Washington Texas Austin, Brazoria, El Paso, Fort Bend, Hardin, Harris, Jefferson, Liberty, Montgomery Utah Box Elder, Cache, Davis, Morgan, Salt Lake, Summit, Tooele, Utah, Wasatch, Weber Vermont All Counties in the State of Vermont Virginia Bland, Botetourt, Bristol City, Buchanan, Chester‑ field, Craig, Dickenson, Floyd, Franklin, Goochland, Grayson, Lee, Hanover, Henrico, Montgomery, Newport News City, Norfolk City, Norton City, Ports‑ mouth City, Radford City, Richmond City, Roanoke, Roanoke City, Russell, Salem City, Scott, Smyth, Tazewell, Washington, Wise, Wythe Washington Skagit, Spokane, Whatcom Wisconsin Brown, Calumet, Dodge, Fond Du Lac, Green Lake, Kewaunee, La Crosse, Manitowoc, Milwaukee, Monroe, Oconto, Outagamie, Ozaukee, Racine, Shawano, Sheboygan, Trempeleau, Vernon, Washington, Waukesha, Waupaca, Waushara, Winnebago

1

Members of HMO plans H3307 in New York as well as Point of Service plans H0752 in Connecticut and H3107 in New Jersey may access Passport services in the state of Florida only. The H3805 HMO plans in the Oregon counties of Clackamas, Lane, Marion, Multnomah and Washington do not participate in UnitedHealth Passport. Therefore, members of these plans are not eligible to participate in the program. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract. 3 7

2

Ready to Enroll?
Things to Do Before You Enroll:
Review the benefit information in this booklet. You may choose to contact your doctor to confirm if he or she is in the network or you may ask your sales agent to check for you. For a complete list of plan providers, visit our Web site.

an informed

makE

CHOICE

Check the Drug List in this booklet to see if your medications are included. Visit our Web site for a detailed listing of prescription medications. (for MAPD plans) Have your Original Medicare ID card ready or other proof that states you are eligible for Medicare. This information will help you fill out the Enrollment Form.

I’m a Member…What’s Next?
Enjoy Peace of Mind with One Convenient Plan
After Medicare approves your enrollment you will receive your Welcome Letter, New Member Kit and your Member ID card.

This is a sample card; your card may look different.

Customer service phone number is located on the back of your card. Please secure your Original Medicare card in a safe place.

www.myaaRPmedicare.com
Register online to view your personal information, plan details, coverage summaries, payment history, options and claims. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

8

Y0066_100720_090630 File & Use 08102010

Summary of

Benefits
H2182-001

January 1, 2011 — December 31, 2011

AARP® MedicareComplete® Plus (HMO-POS)
Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton counties

AAGA11PO3240581_000 H0755Y0066_100816EA01_SB_MAMAPD CMS Approved 09082010

Section I - Introduction to Summary of Benefits
Thank you for your interest in AARP MedicareComplete Plus (HMO-POS). Our plan is offered by UNITEDHEALTHCARE INSURANCE COMPANY/SecureHorizons by UnitedHealthcare, a Medicare Advantage Health Maintenance Organization (HMO), with a point-of-service option (POS). This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call AARP MedicareComplete Plus (HMO-POS) and ask for the "Evidence of Coverage".

You Have Choices in Your Health Care
As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like AARP MedicareComplete Plus (HMO-POS). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call AARP MedicareComplete Plus (HMO-POS) at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

How Can I Compare My Options?
You can compare AARP MedicareComplete Plus (HMO-POS) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

Where is AARP MedicareComplete Plus (HMO-POS) Available?
The service area for this plan includes: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton Counties, GA. You must live in one of these areas to join the plan.

Who is Eligible to Join AARP MedicareComplete Plus (HMO-POS)
You can join AARP MedicareComplete Plus (HMO-POS) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in AARP MedicareComplete Plus (HMO-POS) unless they are members of our organization and have been since their dialysis began.

Can I Choose My Doctors?
AARP MedicareComplete Plus (HMO-POS) has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. In some cases, you may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory or for an up-to-date list visit us at www.AARPMedicarePlans.com Our customer service number is listed at the end of this introduction.

10

What Happens if I go to a Doctor Who's Not in Your Network?
You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. For more information, please call the customer service number at the end of this introduction.

Where can I Get My Prescriptions if I Join This Plan?
AARP MedicareComplete Plus (HMO-POS) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at www.AARPMedicarePlans.com Our customer service number is listed at the end of this introduction. AARP MedicareComplete Plus (HMO-POS) has a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or co-insurance. You may go to a non-preferred pharmacy, but you may have to pay more for your prescription drugs.

Does My Plan Cover Medicare Part B or Part D Drugs?
AARP MedicareComplete Plus (HMO-POS) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs.

What is a Prescription Drug Formulary?
AARP MedicareComplete Plus (HMO-POS) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at www.AARPMedicarePlans.com If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra Help With Other Medicare Costs?
You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: * 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources' in the publication Medicare & You. * The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or * Your State Medicaid Office.

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What Are My Protections in This Plan?
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact AARP MedicareComplete Plus (HMO-POS) for more details.

What Types of Drugs May be Covered Under Medicare Part B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact AARP MedicareComplete Plus (HMO-POS) for more details. Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

12

Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most injectable drugs administered incident to a physician's service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and Infusion Drugs provided through DME.

Where Can I Find Information on Plan Ratings?
The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call SecureHorizons by UnitedHealthcare for more information about AARP MedicareComplete Plus (HMO-POS). Visit us at www.AARPMedicarePlans.com or, call us: Customer Service Hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m - 8:00 p.m Eastern Current members should call toll-free 1-800-643-4845 for questions related to the Medicare Advantage Program and Medicare Part D Prescription Drug program. TTY/TDD: 711 Prospective members should call toll-free 1-800-547-5514 for questions related to the Medicare Advantage and Medicare Part D Prescription Drug Program. TTY/TDD: 711 For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov on the web. This document may be available in a different format or language. For additional information, call customer service at the phone number listed above. Este documento puede estar disponible en diferentes formatos e idiomas. Por favor, llame al número de Servicio al Cliente dado anteriormente si necesita obtener más información. 本資訊可以不同形式或語言提供。如需更多資訊,請撥打上文所列的電話號碼,與客戶服 務部聯絡。 If you have special needs, this document may be available in other formats.

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Section II - Summary Of Benefits
If you have any questions about this plan's benefits or costs, please contact SecureHorizons by UnitedHealthcare for details.
Benefit Important Information Original Medicare AARP MedicareComplete Plus (HMO-POS)

1 Premium and Other In 2010 the monthly Part B Premium General
Important Information was $96.40 and may change for 2011 and the yearly Part B deductible amount was $155 and may change for 2011.

$0 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard If a doctor or supplier does not accept monthly Part B premium in addition to assignment, their costs are often their MA plan premium. However, higher, which means you pay more. some people will pay higher Part B and Part D premiums because of their Most people will pay the standard yearly income (over $85,000 for monthly Part B premium. However, some people will pay a higher premium singles, $170,000 for married because of their yearly income (over couples). For more information about Part B and Part D premiums based on $85,000 for singles, $170,000 for married couples). For more information income, call Medicare at 1-800-MEDICARE (1-800-633-4227). about Part B premiums based on TTY users should call 1-877-486-2048. income, call Medicare at 1-800-MEDICARE (1-800-633-4227). You may also call Social Security at TTY users should call 1-877-486-2048. 1-800-772-1213. TTY users should call 1-800-325-0778. You may also call Social Security at 1-800-772-1213. TTY users should call This plan covers all Medicare-covered 1-800-325-0778. preventive services with zero cost sharing. In-Network $3,380 out-of-pocket limit. This limit includes only Medicare-covered services.

2 Doctor and Hospital You may go to any doctor, specialist
Choice or hospital that accepts Medicare. (For more information, see Emergency Care #15 and Urgently Needed Care - #16.)

In-Network No referral required for network doctors, specialists, and hospitals. Out of Service Area Plan covers you when you travel in the U.S.

Inpatient Care

14

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Inpatient Care (continued)

3 Inpatient Hospital

In 2010 the amounts for each benefit Care period were: (includes Substance Days 1 - 60: $1100 deductible Abuse and Days 61 - 90: $275 per day Rehabilitation Days 91 - 150: $550 per lifetime reserve day These amounts will Services) change for 2011. Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A "benefit period" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

In-Network No limit to the number of days covered by the plan each benefit period. For Medicare-covered hospital stays: Days 1 - 7: $295 copay per day Days 8 - 90: $0 copay per day $0 copay for each additional hospital day.

4 Inpatient Mental
Health Care

In-Network Same deductible and copay as inpatient hospital care (see "Inpatient You get up to 190 days in a Psychiatric Hospital Care" above). Hospital in a lifetime. 190 day lifetime limit in a Psychiatric For Medicare-covered hospital stays: Hospital. Days 1 - 7: $295 copay per day Days 8 - 90: $0 copay per day

5 Skilled Nursing

Facility (SNF) (in a Medicare-certified skilled nursing facility)

In 2010 the amounts for each benefit In-Network period after at least a 3-day covered Plan covers up to 100 days each hospital stay were: benefit period Days 1 - 20: $0 per day No prior hospital stay is required. Days 21 - 100: $137.50 per day These amounts will change for 2011. For Medicare-covered SNF stays: Days 1 - 34: $100 copay per day 100 days for each benefit period. Days 35 - 100: $0 copay per day A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you

15

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Inpatient Care (continued) go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

6 Home Health Care $0 copay.
(includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

In-Network $0 copay for each Medicare-covered home health visit.

7 Hospice

You pay part of the cost for outpatient General drugs and inpatient respite care. You must get care from a Medicare-certified hospice. You must get care from a Medicare-certified hospice.

Outpatient Care

8 Doctor Office Visits 20% coinsurance

In-Network $10 copay for each primary care doctor visit for Medicare-covered benefits. $30 copay for each in-area, network urgent care Medicare-covered visit. $35 copay for each specialist visit for Medicare-covered benefits.

9 Chiropractic
Services

Routine care not covered 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

In-Network 50% of the cost for each Medicare-covered visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

16

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Outpatient Care (continued)

10 Podiatry Services

Routine care not covered.

In-Network $35 copay for each Medicare-covered 20% coinsurance for medically necessary foot care, including care for visit. medical conditions affecting the lower $35 copay for up to 6 routine visit(s) limbs. every year Medicare-covered podiatry benefits are for medically-necessary foot care.

11 Outpatient Mental
Health Care

45% coinsurance for most outpatient In-Network mental health services. $40 copay for each Medicare-covered individual therapy visit. $30 copay for each Medicare-covered group therapy visit.

12 Outpatient

Substance Abuse Care

20% coinsurance

In-Network $40 copay for Medicare-covered individual visits. $30 copay for Medicare-covered group visits.

13 Outpatient

Services/Surgery

20% coinsurance for the doctor

In-Network 20% of the cost for each Specified copayment for outpatient hospital facility charges. Copay cannot Medicare-covered ambulatory surgical exceed than Part A inpatient hospital center visit. deductible. 20% of the cost for each Medicare-covered outpatient hospital 20% coinsurance for ambulatory facility visit. surgical center facility charges 20% coinsurance In-Network $200 copay for Medicare-covered ambulance benefits.

14 Ambulance

Services (medically necessary ambulance services) (You may go to any emergency room if you reasonably believe you need emergency care.)

15 Emergency Care

20% coinsurance for the doctor

General $50 copay for Medicare-covered Specified copayment for outpatient hospital emergency room (ER) facility emergency room visits. charge. Worldwide coverage. ER Copay cannot exceed Part A inpatient hospital deductible. If you are admitted to the hospital within 24-hour(s) for the same

17

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Outpatient Care (continued) You don't have to pay the emergency condition, you pay $0 for the room copay if you are admitted to the emergency room visit hospital for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances.

16 Urgently Needed

General 20% coinsurance, or a set copay Care NOT covered outside the U.S. except $40 copay for Medicare-covered (This is NOT urgently needed care visits. under limited circumstances. emergency care, and in most cases, is out of the service area.) Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory Therapy Services, Social/ Psychological Services, and more) 20% coinsurance In-Network $35 copay for Medicare-covered Occupational Therapy visits. $35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. $35 copay for Medicare-covered Cardiac Rehab services.

17 Outpatient

Outpatient Medical Services and Supplies

18 Durable Medical

Equipment (includes wheelchairs, oxygen, etc.) (includes braces, artificial limbs and eyes, etc.)

20% coinsurance

In-Network 20% of the cost for Medicare-covered items.

19 Prosthetic Devices 20% coinsurance

In-Network 20% of the cost for Medicare-covered items.

18

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Outpatient Medical Services and Supplies (continued)

20 Diabetes

Self-Monitoring Training, Nutrition Therapy, and Supplies (includes coverage for glucose monitors, test strips, lancets, screening tests, self-management training, retinal exam/glaucoma test, and foot exam/ therapeutic soft shoes) X-Rays, Lab Services, and Radiology Services

20% coinsurance

Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a $0 copay for Nutrition Therapy for kidney transplant) when referred by a Diabetes. doctor. These services can be given by $0 copay for Diabetes supplies. a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

In-Network $0 copay for Diabetes self-monitoring training.

21 Diagnostic Tests,

20% coinsurance for diagnostic tests In-Network and x-rays $0 to $10 copay for Medicare-covered lab services. $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol. 0% to 20% of the cost for Medicare-covered diagnostic procedures and tests.

$16 copay for Medicare-covered X-rays. 20% of the cost for Medicare-covered diagnostic radiology services (not including x-rays). 20% of the cost for Medicare-covered therapeutic radiology services.

Preventive Services

22 Bone Mass

In-Network Measurement $0 copay for Medicare-covered bone (for people with Covered once every 24 months (more mass measurement. Medicare who are at often if medically necessary) if you risk) meet certain medical conditions.

No coinsurance, copayment or deductible.

19

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued)

23 Colorectal

No coinsurance, copayment or Screening Exams deductible for screening colonoscopy (for people with or screening flexible sigmoidoscopy. Medicare age 50 and Covered when you are high risk or older) when you are age 50 and older. (Flu vaccine, Hepatitis B vaccine for people with Medicare who are at risk, Pneumonia vaccine)

In-Network $0 copay for Medicare-covered colorectal screenings. $0 copay up to 1 additional screening(s) every year.

24 Immunizations

$0 copay for Flu, and Pneumonia and In-Network Hepatitis B vaccines. $0 copay for Flu and Pneumonia vaccines. You may only need the Pneumonia vaccine once in your lifetime. Call your No referral needed for Flu and doctor for more information. pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

25 Mammograms

In-Network No coinsurance, copayment or (Annual Screening) deductible. $0 copay for Medicare-covered (for women with screening mammograms. No referral needed. Medicare age 40 and Covered once a year for all women older) with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39. Pelvic Exams (for women with Medicare) No coinsurance, copayment, or deductible for Pap smears. In-Network $0 copay for Medicare-covered pap smears and pelvic exams

26 Pap Smears and

No coinsurance, copayment, or deductible for Pelvic and clinical breast $0 copay up to 1 additional pap exams. smear(s) and pelvic exam(s) every year Covered once every 2 years. Covered once a year for women with Medicare at high risk.

27 Prostate Cancer

Screening Exams (for men with Medicare age 50 and for other related services. older) Covered once a year for all men with Medicare over age 50.

20% coinsurance for the digital rectal In-Network exam. $0 copay for Medicare-covered $0 for the PSA test; 20% coinsurance prostate cancer screening.

20

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued)

28 End-Stage Renal
Disease

20% coinsurance for renal dialysis

In-Network 20% coinsurance for Nutrition Therapy 20% of the cost for renal dialysis for End-Stage Renal Disease $0 copay for Nutrition Therapy for End-Stage Renal Disease. Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

29 Prescription Drugs Most drugs are not covered under

Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

Drugs covered under Medicare Part B General 20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. Drugs covered under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.AARPMedicarePlans.com on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service). The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

21

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued) Total yearly drug costs are the total drug costs paid by both you and the plan. The plan 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. Your provider must get prior authorization from AARP MedicareComplete Plus (HMO-POS) 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, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and AARP MedicareComplete Plus (HMO-POS) approves the exception, you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug. In-Network Initial Coverage Retail Pharmacy $0 deductible. You pay the following until total yearly drug costs reach $2,840: Tier 1: Preferred Generic Drugs

22

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) $5 copay for a one-month (31-day) supply of drugs in this tier $15 copay for a three-month (90-day) supply of drugs in this tier Tier 2: Generic and Preferred Brand Drugs $45 copay for a one-month (31-day) supply of drugs in this tier $135 copay for a three-month (90-day) supply of drugs in this tier Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs $85 copay for a one-month (31-day) supply of drugs in this tier $255 copay for a three-month (90-day) supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a one-month (31-day) supply of drugs in this tier 33% coinsurance for a three-month (90-day) supply of drugs in this tier

Preventive Services (continued)

Long Term Care Pharmacy

Tier 1: Preferred Generic Drugs $5 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Generic and Preferred Brand Drugs $45 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs $85 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a one-month (31-day) supply of drugs in this tier

Mail Order

Tier 1: Preferred Generic Drugs $10 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

23

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) $15 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 2: Generic and Preferred Brand Drugs $125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs $245 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $255 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 4: Specialty Tier Drugs 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Preventive Services (continued)

Coverage Gap

After your total yearly drug costs reach $2,840, you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs, until your yearly out-of-pocket drug costs reach $4,550. After your yearly out-of-pocket drug costs reach $ 4,550, you pay the greater of:

Catastrophic Coverage

24

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or 5% coinsurance.

Preventive Services (continued)

Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from AARP MedicareComplete Plus (HMO-POS). You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,840: Tier 1: Preferred Generic Drugs $5 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Generic and Preferred Brand Drugs $45 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs $85 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Specialty Tier Drugs 33% coinsurance for a one-month (31-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of-Network

Out-of-Network Initial Coverage

25

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued) Pharmacy charge and the plan's In-Network allowable amount. Out-of-Network Coverage Gap You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share, which is the greater of: A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or 5% coinsurance. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

30 Dental Services

Preventive dental services (such as cleaning) not covered.

In-Network In general, preventive dental benefits (such as cleaning) not covered. $35 copay for Medicare-covered dental benefits.

31 Hearing Services

Routine hearing exams and hearing aids not covered.

In-Network $35 copay for Medicare-covered diagnostic hearing exams

26

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) $0 to $35 copay for up to 1 routine hearing test(s) every year $0 copay per hearing aid $300 plan coverage limit for hearing aids every two years.

Preventive Services (continued) 20% coinsurance for diagnostic hearing exams.

32 Vision Services

In-Network 20% coinsurance for diagnosis and treatment of diseases and conditions $0 copay for one pair of eyeglasses or contact lenses after cataract of the eye. surgery. Routine eye exams and glasses not $0 to $35 copay for exams to diagnose and treat diseases and covered. conditions of the eye. Medicare pays for one pair of $35 copay for up to 1 routine eye eyeglasses or contact lenses after exam(s) every year $30 copay for contacts cataract surgery. $0 copay for up to 1 pair(s) of lenses Annual glaucoma screenings covered every two years for people at risk. $30 copay for up to 1 frame(s) every two years $105 plan coverage limit for contact lenses every two years. $70 plan coverage limit for eye glass frames every two years.

33 Welcome to

Medicare; and Annual Wellness Visit

When you join Medicare Part B, then you are eligible as follows.

In-Network $0 copay for the required During the first 12 months of your new Medicare-covered initial preventive physical exam and annual wellness Part B coverage, you can get either a visits. Welcome to Medicare exam or an Annual Wellness visit. After your first 12 months, you can get one Annual Wellness visit every 12 months. There is no coinsurance, copayment or deductible for either the Welcome to Medicare exam or the Annual Wellness visit. The Welcome to Medicare exam does not include lab tests.

27

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued)

34 Health/Wellness
Education

Smoking Cessation: Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor's visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

In-Network The plan covers the following health/ wellness education benefits: Written health education materials, including Newsletters Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session. $0 copay for each Medicare-covered HIV screening. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

Transportation (Routine) Acupuncture Point of Service

Not covered.

In-Network This plan does not cover routine transportation. In-Network This plan does not cover Acupuncture. Out-of-Network Point of Service coverage is available for the following benefits: - Inpatient Hospital Acute Inpatient Hospital Psychiatric Skilled Nursing Facility (SNF) Comprehensive Outpatient Rehabilitation Facility (CORF) Partial Hospitalization Home Health Services Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services

Not covered. You may go to any doctor, specialist or hospital that accepts Medicare.

28

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech/ Language Pathology Services Outpatient Diag Procs/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Outpatient Substance Abuse Cardiac Rehabilitation Services Ambulance Services DME Prosthetics/Medical Supplies Diabetes Monitoring Supplies Blood Health Education/Wellness Immunizations Routine Physical Exams Pap Smears and Pelvic Exams Prostate Screening Colorectal Screening Bone Mass Measurement Mammography Screening Diabetes Monitoring Nutrition Therapy for Diabetes and Renal Disease Comprehensive Dental Eye Exams Eye Wear Hearing Exams $325 copay per hospital day. For Inpatient Psychiatric Hospital stays: Days 1 - 90: $325 copay per day For each SNF stay: Days 1 - 40: $175 copay per SNF day Days 41 - 100: $0 copay per SNF day $15 copay for Primary Care Physician Services Other Health Care Professional Routine Physical Exams

Preventive Services (continued)

29

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS)

Preventive Services (continued) $40 copay for Comprehensive Outpatient Rehabilitation Facility (CORF) Occupational Therapy Services Physician Specialist Services Podiatry Services Physical Therapy and Speech/ Language Pathology Services Cardiac Rehabilitation Services Comprehensive Dental Eye Exams Hearing Exams 30% of the cost for Home Health Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services DME Prosthetics/Medical Supplies Diabetes Monitoring Supplies Pap Smears and Pelvic Exams Prostate Screening Colorectal Screening Bone Mass Measurement Mammography Screening Diabetes Monitoring Nutrition Therapy for Diabetes and Renal Disease Eye Wear $10 copay or 30% of the cost for Outpatient Diag Procs/Tests/Lab Services $21 copay for Outpatient X-Rays $75 copay for Partial Hospitalization $200 copay for Ambulance Services $35 to $45 copay for Mental Health Specialty Services Psychiatric Services

30

Benefit

Original Medicare

AARP MedicareComplete Plus (HMO-POS) Outpatient Substance Abuse $0 copay for Blood Health Education/Wellness Immunizations 50% of the cost for Chiropractic Services

Preventive Services (continued)

Optional Supplemental Package #1 Premium and Other Important Information General Package: 1 - Dental Platinum Rider: $32 monthly premium, in addition to your $0 monthly plan premium and the monthly Medicare Part B premium, for the following optional benefits: Preventive Dental Comprehensive Dental Dental Services General Plan offers additional comprehensive dental benefits. In-Network $0 copay for up to 1 cleaning(s) every six months $0 copay for up to 1 fluoride treatment(s) every six months $0 copay for up to 1 oral exam(s) every six months $0 copay for up to 1 dental x-ray(s) $1,000 plan coverage limit for dental benefits every year. Optional Supplemental Package #2 Premium and Other Important Information General Package: 2 - Fitness Rider: $13 monthly premium, in addition to your $0 monthly plan premium and the monthly Medicare Part B premium, for the following optional benefits: Health Education/Wellness

31

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Additional Information

This Page Intentionally Left Blank

Member Appeals and Grievances Process
Members of our Medicare Advantage health plans have the right to request an organization determination including the right to file an appeal and the right to file a grievance. Medicare Advantage health plan organizations must identify, track, resolve and report all activity related to an appeal or grievance.

Medicare Advantage Member Appeals
What is an Appeal?
An appeal is a type of request you make when you want us to reconsider a decision concerning coverage of a service or the amount your health plan pays or will pay for a service. The initial decision concerning medical care or services is called an “organization determination.”

When can an Appeal be filed?

You may file an appeal within 60 calendar days of the date of the initial organization determination. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe.

Who can file an Appeal?

You may file an appeal or someone else may file an appeal on your behalf. You must appoint the individual to act as your representative to file the appeal for you. To learn how to name a representative, contact Customer Service.

How can an Appeal be filed?

An appeal must be filed in writing directly to us. You may call Customer Service for additional information. To learn how to file an appeal, contact Customer Service.

Fast Reviews

Y0004Y0066_100618_124951 CMS Approved 07022010

You have the right to request and receive fast decisions affecting your medical treatment in “time-sensitive” situations. A situation is time-sensitive if waiting for a decision to be made within the standard timeframe could seriously harm your health or your ability to function. If your doctor provides a written or oral statement supporting your need of a fast review we will automatically give you a fast review. A decision will be issued as quickly as possible but no later than 72 hours after receiving the request.

Medicare Advantage Member Grievances
What is a Grievance?
A grievance is a complaint that doesn’t involve coverage for an item or service by your health plan or a contracting medical provider. If your grievance involves quality of care, you have the right to file a grievance with the Quality Improvement Organization (QIO) of your state. Refer to Section I of the Summary of Benefits for the name of the QIO in your state.

When can a Grievance be filed?

You may file a grievance within 60 calendar days of the date of the event causing the grievance. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe. There is no time limit for complaints concerning quality of care.

Who can file a Grievance?

You may file a grievance or someone else may file a grievance on your behalf. You must appoint the individual to act as your representative to file the grievance for you. To learn how to name a representative, contact Customer Service. 1 35

How can a Grievance be filed?

A grievance for Quality of Care may be filed verbally by contacting Customer Service. All other grievances must be submitted in writing.

Fast Grievances

You have the right to file a fast grievance. We will respond to fast grievances within 24 hours of receipt. You may file a fast grievance if you disagree with our decision to deny your request for a fast review. You may also file a fast grievance if we notify you that we are extending our timeframe to make an organization determination or reconsideration decision, or if we downgrade your expedited appeal request to standard due to not meeting expedited criteria.

For Members with Medicare Part D Drug Coverage through our Plan
Coverage Determinations
We will make an initial decision as to whether or not we will provide the Part D drug you are requesting or pay for the Part D drug you already received. This initial decision is called a “coverage determination.”

Exceptions

You or your doctor may ask us to make an exception to our Part D coverage determination. You may request an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. Generally, we will only approve your request for an exception if the alternative Part D drug is included in your plan’s formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor or other prescriber must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor or other prescriber should be sent to us with the exception request. If we approve your exception request for a Part D non-formulary drug, you can’t request an exception to the copayment or coinsurance amount we require you to pay for the drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy.

Part D Drug Appeals

If you are getting Medicare prescription Part D drug coverage through our plan you have the right to file an appeal. This includes the right to appeal our decision regarding your exception request. Follow the process outlined above to file an appeal. An appeal concerning coverage determinations must be filed in writing directly to us.

Part D Drug Grievances

If you are getting Medicare prescription Part D drug coverage through our plan, you have the right to file a grievance. Follow the process outlined above to file a grievance concerning your Part D prescription drug coverage.

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

36

SecureHorizons by UnitedHealthcare - H2182

Medicare Health Plan Ratings
The Medicare Program rates how well Medicare Advantage performs in different categories (for example, detecting and preventing illness, rating from patients, patient safety and customer service). The information provided below is a summary rating of our plan’s overall performance. This information is available to help you make the best choice. If you would like to get additional information on our plan’s performance please contact us at 1-800-547-5514 (toll-free) or 711 (TTY/TDD) for prospective members, 1-800-643-4845 (toll-free) or 711 (TTY/TDD) for current members or you may visit www.medicare.gov. Below is a summary of how our plan rated in quality and performance. The number of stars show how well our plans perform.

 means excellent  means very good  means good  means fair  means poor
SecureHorizons by UnitedHealthcare - H2182 Summary Rating of Health Plan Quality Y0066_100827_H2182_001_Plan Rating File & Use 09072010

Plan too new to be measured
This summary rating gives an overall score on the health plan’s quality and performance on 33 different topics in 5 categories: • Staying healthy: screenings, tests, and vaccines. Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy. • Managing chronic (long-term) conditions. Includes how often members with different conditions got certain tests and treatments that help them manage their condition. • Ratings of health plan responsiveness and care. Includes ratings of member satisfactions with the plan. • Health Plan member complaints, appeals, and choosing to leave the health plan. Includes how often members have made complaints against the plan and how often members choose to leave the plan. • Health plan telephone customer service. Includes how well the plan handles member calls.

37

SecureHorizons by UnitedHealthcare - H2182

Medicare Prescription Drug Plan Ratings
The Medicare Program rates how well Medicare Prescription Drug Plans perform in different categories (for example, customer service, drug pricing, patient safety). The information provided below is a summary rating of our plan’s overall performance. This information is available to help you make the best choice. If you would like to get additional information on our plan’s performance please contact us at 1-800-547-5514 (toll-free) or 711 (TTY/TDD) for prospective members, 1-800-643-4845 (toll-free) or 711 (TTY/TDD) for current members, or you may visitt www.medicare.gov. Below is a summary of how our plan rated in quality and performance. The number of stars show how well our plans perform.

 means excellent  means very good  means good  means fair  means poor
SecureHorizons by UnitedHealthcare - H2182 Summary Rating of Prescription Drug Plan Quality

Not enough data to calculate summary score
This summary rating gives an overall score on the drug plan’s quality and performance on 19 different topics in 4 categories: • Drug plan customer service: Includes how well the drug plan handles calls and makes decisions about member appeals. • Drug plan member complaints, members who choose to leave, and Medicare audit findings: Includes how often members complain about the drug plan and how often members choose to leave the drug plan. • Member experience with drug plan: Includes member satisfaction information. • Drug pricing and patient safety: Includes how well the drug plan prices prescriptions and provides accurate pricing information on the Medicare website. Includes information on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their condition. This information is gathered from several different sources, including results from Medicare’s regular monitoring activities, reviews of billing and other information that plans submit to Medicare, and Medicare’s member surveys.

38

Dental Platinum Rider
If you’re looking for extra dental protection and coverage, our SecureHorizons® optional supplemental dental rider may be right for you. The Platinum Rider is available for an additional monthly premium of $32.

What Dental Benefits Do I Receive?
With the Platinum Rider, you get: • 100% coverage for preventive and diagnostic services such as oral exams, X-rays and routine cleanings. Partial coverage for basic services such as fillings and for major services such as crowns, dentures, root canals and oral surgery. There is a $100 member deductible and a $1,000 calendar year maximum. Deductible does not apply to preventive and diagnostic services.

How Do I Enroll?
You must be enrolled in a SecureHorizons® health plan in order to purchase a rider. Purchasing a rider is optional. Please contact Customer Service at the number listed on the back of your Member ID Card to enroll in a rider.

When is the Enrollment Effective Date?
If your completed enrollment request is received by the last day of the month, your benefits will be effective the first day of the following month. For example, if you call Customer Service and enroll on March 31, your benefits will begin on April 1. If you are an existing plan member, you may enroll any time during the year. Please note that you can’t be enrolled in more than one dental rider at a time during the calendar year, including the Deluxe Rider.

Can I See Any Dentist?
Choose your dentist from a large national network of providers. You may change network dentists at any time however you will need to complete any dental service currently in progress. Please see your Provider Directory for a listing of participating dentists. When you receive your Covered Dental Services from an Out-of-Network Dentist, the plan pays according to a Maximum Allowable Fee Schedule*. You pay all fees in excess of this amount. Y0066_100812_073716 File & Use 09052010 Please refer to your Evidence of Coverage to learn more about the full range of covered services, including a dental procedural and fee chart.

*Allowable Fee Schedules vary according to geographic area and is a set amount that may not be equal to the Dentist’s full fee. For further details, please contact Customer Service.

39

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related products, service insurance or programs. You are strongly encouraged to evaluate your needs. AAEX11MP3244438_000

40

SilverSneakers Fitness Rider
®

The SilverSneakers® Fitness Rider can help you take charge of your health and maintain an active lifestyle. This award-winning program is available for an additional $13 monthly premium.

Take advantage of the following SilverSneakers® services:
• A basic fitness center membership at over 10,000 participating locations. • Access to cardio equipment, resistance machines, free weights and a heated pool at certain locations. • SilverSneakers classes for Medicare-eligible beneficiaries who want to improve their strength, flexibility, balance and endurance (available at select locations). • Access to any participating fitness center while traveling throughout the United States. To find participating locations in your area, please visit www.SilverSneakers.com. The SilverSneakers® Fitness Program is a winner of the 2004 Healthcare and Aging Network Award of the American Society on Aging.

How Do I Enroll?
You must be enrolled in a SecureHorizons® health plan in order to purchase a rider. Purchasing a rider is optional. Please contact Customer Service at the number listed on the back of your Member ID Card to enroll in a rider.

When is the Enrollment Effective Date?
If your completed enrollment request is received by the last day of the month, your benefits will be effective the first day of the following month. For example, if you call Customer Service and enroll on March 31, your benefits will begin on April 1.

Y0066_100811_124823 File & Use 09012010

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The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. SilverSneakers® is a registered trademark of Healthways, Inc. Healthways, Inc., is an independent company. Consult a health care professional before beginning any exercise program. The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related products, service insurance or programs. You are strongly encouraged to evaluate your needs. AAEX11MP3244453_000

42

2011 Disclaimers
Your Plan may contain one or more of the following:
OptumHealthSM is a health and well-being company that provides information and support as part of your health plan. NurseLineSM nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor’s care. NurseLineSM services are not an insurance program and may be discontinued at any time. SilverSneakers® is a registered trademark of Healthways, Inc. Healthways, Inc., is an independent company. The SilverSneakers® program is made available as part of this Plan’s benefits to those insured through this Plan. Neither AARP nor UnitedHealthcare endorse or are responsible for the services or information provided by this program. Consult a health care professional before beginning any exercise program. Silver & Fit is provided by American Specialty Health Networks, Inc. and Healthyroads, Inc., subsidiaries of American Specialty Health Incorporated. Evercare™ Hospice and Palliative Care is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, sex, religion, color, age, national origin, disability, sexual orientation or other protected factor. Evercare™ Hospice and Palliative Care is offered by Evercare Hospice, Inc.

NurseLineSM

SilverSneakers®

Silver & Fit

Evercare™ Hospice

General Information

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January1, 2012. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the Plan.

Y0066_100722_182504 File & Use 08022010

This document is available in alternate formats or languages. For more information please contact the Plan at 1-800-547-5514, TTY: 711, 8 a.m. to 8 p.m., 7 days a week. Este documento está disponible en diferentes formatos o idiomas. Para obtener más información, por favor comuníquese con el Plan llamando al 1-800-547-5514, TTY: 711, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. 本文件可以其他形式或語言提供。如需更多資訊,請與本計劃聯絡,電話號碼是 1-800-547-5514,TTY: 711,每週七天,上午八時至晚上八時。 Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage Organization with a Medicare contract.

43

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Covering the Country
Our Prescription Drug Coverage Goes Where You Go

Our Plans Are Accepted by More Than 60,000 Network Pharmacies
Wherever you go, there is a pharmacy near you that accepts our plans’ prescription drug coverage. In fact, more than 60,000 of the nation’s pharmacies are part of our network. And thousands of brand name and generic prescription drugs are covered. Whatever your prescription needs, we are here to help you meet them.

Ingredients for life.

Other pharmacies are available in our network. Please review our 2011 Drug List on the following pages. OVEX11NA3240730_000 Y0066_100709_094119 File & Use 07192010

Save Money With Home Delivery

When you join one of our plans, you can take advantage of a mail service benefit from Prescription Solutions, the plans’ Preferred Mail Service Pharmacy. This means you won’t have to wait in line at a pharmacy to get your maintenance medications.* They can be delivered right to your mailbox. Prescription Solutions® Mail Service makes it fast, easy and safe. After you select your health plan, review your Welcome Kit for details.
*Maintenance medications are typically those drugs you take on a regular basis for a chronic or long-term condition. Plans are insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage Organization with a Medicare contract and a Medicare-approved Part D sponsor. You are not required to use the plan’s Preferred Mail Service Pharmacy to obtain a 90-day supply of your maintenance medications. You can also use a network retail extended day supply pharmacy or a network non-preferred mail service pharmacy, but you may pay more out-of-pocket compared to using the Preferred Mail Service Pharmacy. You should pay the same out of pocket at a network retail extended day supply pharmacy and a network non-preferred mail service pharmacy. Please call Customer Service, at the number located on the back of your member ID card for up-to-date information on which pharmacies are in the network. Your prescriptions should arrive in about seven days from the date the completed order is received by Prescription Solutions. If Prescription Solutions needs to contact you or your prescribing physician to clarify information on your order or to request prescriptions from your physician, delivery may take longer. If you prefer rush delivery, medications can be shipped overnight for an additional charge. Prescription Solutions will contact you if they anticipate there will be an extended delay in the delivery of your medications. If you need your medications immediately, Prescription Solutions can coordinate a refill with a local retail pharmacy. Standard delivery is no charge to U.S. addresses, including U.S. territories. Prescription Solutions is an affiliate of UnitedHealthcare Insurance Company and UnitedHealthcare Insurance Company of New York.

2011 Drug List
#
8-Mop, T4

A
Abelcet, T4 Abilify, T3 Abilify Discmelt (10 mg Dispersible Tablet), T3 Abilify Discmelt (15 mg Dispersible Tablet), T4 Abraxane, T4 Acarbose, T1 Accolate, T3 Acebutolol HCl, T1 Acetadote, T3 Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate, T2 Acetaminophen/Codeine, T1 Acetasol HC, T2 Acetazolamide (12-Hour Capsule), T2 Acetazolamide (Tablet), T1 Acetazolamide Sodium, T2 Acetic Acid, T1 Acetic Acid/Hydrocortisone, T2 Acetylcysteine, T1 Actemra, T4 Acthib, T2 Acticin, T1 Actimmune, T4 Actiq, T4 Activella, T3 Actonel, T2 Actoplus Met, T2 Actos, T2 Acular, T2 Acular LS, T2

H0755Y0066_100715_165108 CMS Approved 08252010

Acyclovir (Capsule, Tablet), T1 Acyclovir (Oral Suspension), T2 Acyclovir Sodium, T2 Adacel, T2 Adagen, T4 Adcirca, T4 Adderall XR, T3 Adriamycin, T2 Advair Diskus, T2 Advair HFA, T2 Aerobid-M, T3 Afeditab CR, T1 Afinitor, T4 Aggrenox, T2 A-Hydrocort, T2 AK-Con, T1 Akne-Mycin, T3 AK-Tob, T1 Ala Scalp, T3 Ala-Cort, T1 Alamast, T3 Albenza, T2 Albuterol Sulfate (Nebulizer Solution), T1 Albuterol Sulfate (Syrup, Tablet), T1 Albuterol Sulfate ER, T1 Alcaine, T3 Alclometasone Dipropionate, T1 Alcohol 5%/Dextrose 5%, T2 Alcohol Preps, T1 Aldara, T3 Aldurazyme, T4 Alendronate Sodium, T1 Alferon N, T3 Alimta, T4 Alinia, T3

Alkeran, T4 Allopurinol, T1 Allopurinol Sodium, T2 Alocril, T3 Alomide, T3 Alora, T3 Aloxi, T4 Alphagan P, T2 Alrex, T2 Altabax, T3 Alvesco, T3 Amantadine HCl, T1 Ambisome, T4 Amcinonide, T1 A-Methapred, T2 Amevive, T4 Amifostine, T4 Amikacin Sulfate, T2 Amiloride HCl, T1 Amiloride/Hydrochlorothiazide, T1 Aminophylline (Injection), T2 Aminophylline (Tablet), T1 Aminosyn, T3 Aminosyn 7%/Electrolytes, T3 Aminosyn 8.5%/Electrolytes, T2 Aminosyn II (10% Injection, 7% Injection, 8.5% Injection), T3 Aminosyn II 8.5%/Electrolytes, T2 Aminosyn II M/Dextrose, T3 Aminosyn II/Dextrose, T3 Aminosyn M, T3 Aminosyn-HBC, T3 Aminosyn-HF, T2 Aminosyn-PF, T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

47

Amiodarone HCl (Injection), T2 Amiodarone HCl (Tablet), T1 Amitiza, T2 Amitriptyline HCl, T1 Amlodipine Besylate, T1 Amlodipine Besylate/ Benazepril HCl, T1 Ammonium Chloride, T3 Ammonium Lactate, T1 Amnesteem, T2 Amoxapine, T1 Amoxicillin, T1 Amoxicillin/ Potassium Clavulanate, T1 Amoxicillin/Potassium Clavulanate ER, T2 Amphetamine/Dextroamphetamine (24-Hour Capsule), T2 Amphetamine/Dextroamphetamine (Tablet), T1 Amphotec (50mg Injection), T3 Amphotericin B, T2 Ampicillin, T1 Ampicillin Sodium (10 gm Injection, 1 gm Injection), T2 Ampicillin Sodium (125mg Injection), T2 Ampicillin-Sulbactam, T2 Ampyra, T4 Anadrol-50, T4 Anagrelide HCl, T1 Anastrozole, T2 Ancobon, T4 Androderm, T2 Androgel, T2 Androxy, T2 Anestacon, T1 Antabuse, T2 Antara, T2

Antizol, T4 Anzemet (100 mg Tablet), T4 Anzemet (50 mg Tablet), T3 Apidra, T2 Apokyn, T4 Apraclonidine, T2 Apri, T1 Apriso, T2 Aptivus, T4 Aralast NP, T4 Aranelle, T1 Aranesp Albumin Free (100 mcg/0.5 ml Injection, 100 mcg/1 ml Injection, 150 mcg/0.3 ml Injection, 200 mcg/ 0.4 ml Injection, 200 mcg/1 ml Injection, 300 mcg/0.6 ml Injection, 300 mcg/1 ml Injection, 500 mcg/1 ml Injection, 60 mcg/0.3 ml Injection, 60 mcg/1 ml Injection), T4 Aranesp Albumin Free (25 mcg/0.42 ml Injection, 25 mcg/1 ml Injection, 40 mcg/0.4 ml Injection, 40 mcg/1 ml Injection), T3 Arcalyst, T4 Aredia (30 mg Injection), T3 Aredia (90 mg Injection), T4 Aricept (5 mg Tablet, 10 mg Tablet), T2 Aricept ODT (5 mg Dispersible Tablet, 10 mg Dispersible Tablet), T2 Arimidex, T3 Arixtra (10 mg/0.8 ml Injection, 5.0 mg/0.4 ml Injection, 7.5 mg/0.6 ml Injection), T4 Arixtra (2.5 mg/0.5 ml Injection), T3 Aromasin, T3

Arranon, T4 Arthrotec, T3 Arzerra, T4 Asacol, T2 Ascomp/Codeine, T1 Asmanex, T3 Astelin, T2 Astepro, T2 Astramorph, T2 Atamet, T1 Atenolol, T1 Atenolol/Chlorthalidone, T1 Atgam, T4 Atripla, T4 Atropine Sulfate, T1 Atrovent HFA, T3 Attenuvax, T2 Augmented Betamethasone Dipropionate (Cream, Gel, Ointment), T1 Augmented Betamethasone Dipropionate (Lotion), T2 Avandamet, T3 Avandaryl, T3 Avandia, T3 Avastin, T4 Avelox (Injection), T3 Avelox (Tablet), T2 Avelox ABC Pack, T2 Aviane, T1 Avinza, T2 Avita (Cream), T1 Avita (Gel), T2 Avodart, T2 Avonex, T4 Azactam, T2 Azactam in Dextrose, T3 Azactam in Iso-Osmotic Dextrose, T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

48

Azasan, T3 Azasite, T2 Azathioprine, T1 Azathioprine Sodium, T1 Azelastine HCl (Nasal Spray), T2 Azelastine HCl (Ophthalmic Solution), T2 Azilect, T2 Azithromycin (Injection), T2 Azithromycin (Oral Suspension, Tablet), T1 Azopt, T2 Azor, T2

B
BACiiM, T2 Bacitracin (Injection), T2 Bacitracin (Ophthalmic Ointment), T1 Bacitracin/Neomycin/Polymyxin, T1 Bacitracin/Polymyxin B, T1 Baclofen, T1 Bactocill in Dextrose, T4 Bactroban (Cream), T3 Balacet 325, T2 Balsalazide Disodium, T2 Balziva, T1 Banzel, T3 Baraclude (Oral Solution), T3 Baraclude (Tablet), T4 Benazepril HCl, T1 Benazepril HCl/ Hydrochlorothiazide, T1 Benicar, T2 Benicar HCT, T2 Benztropine Mesylate (Injection), T2 Benztropine Mesylate (Tablet), T1 Betamethasone Dipropionate, T1 Betamethasone Valerate, T1 Betaseron, T4 Beta-Val, T1

Betaxolol HCl, T1 Bethanechol Chloride, T1 Betimol, T3 Betoptic-S, T3 Bicalutamide, T2 Bicillin C-R, T3 Bicillin L-A, T3 BiCNU, T3 BiDil, T2 Biltricide, T2 Bisoprolol Fumarate, T1 Bisoprolol Fumarate/ Hydrochlorothiazide, T1 Bleomycin Sulfate, T2 Blephamide, T2 Blephamide S.O.P., T2 Boniva (Injection), T3 Boniva (Tablet), T2 Boostrix, T2 Borofair, T1 Botox, T4 Brevicon, T3 Brimonidine Tartrate, T1 Bromocriptine Mesylate, T2 Budeprion SR, T1 Budeprion XL, T1 Budesonide (Nebulizer Suspension), T2 Bumetanide (Injection), T2 Bumetanide (Tablet), T1 Buphenyl, T4 Buprenorphine HCl, T2 Buproban, T1 Bupropion HCl, T1 Bupropion HCl SR, T1 Buspirone HCl, T1 Busulfex, T4 Butalbital/Acetaminophen/ Caffeine/Codeine, T1

Butorphanol Tartrate (Injection), T2 Butorphanol Tartrate (Nasal Spray), T2 Byetta, T2 Bystolic, T2

C
Cabergoline, T2 Calcipotriene, T2 Calcitonin-Salmon (Nasal Spray), T2 Calcitriol (1 mcg/ml Injection), T2 Calcitriol (2 mcg/ml Injection), T2 Calcitriol (Capsule, Oral Solution), T1 Calcium Acetate, T2 Camila, T1 Campath, T4 Campral, T3 Camptosar, T4 Canasa, T2 Cancidas, T4 Capastat Sulfate, T4 Capex, T3 Captopril, T1 Captopril/Hydrochlorothiazide, T1 Carac, T3 Carafate (Oral Suspension), T3 Carbamazepine (Chewable Tablet, Tablet), T1 Carbamazepine (Oral Suspension), T2 Carbamazepine ER, T2 Carbatrol, T2 Carbidopa/Levodopa, T1 Carbidopa/Levodopa CR, T1 Carbidopa/Levodopa ODT, T2 Carbinoxamine Maleate, T1 Carboplatin, T2 Carimune Nanofiltered, T4 Carisoprodol, T1 Carisoprodol/Aspirin, T1

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

49

Carisoprodol/Aspirin/Codeine, T2 Carteolol HCl, T1 Cartia XT, T1 Carvedilol, T1 Casodex, T3 Catapres-TTS, T3 Cedax, T3 CeeNU, T3 Cefaclor, T1 Cefaclor ER, T1 Cefadroxil (Capsule, Oral Suspension), T1 Cefadroxil (Tablet), T2 Cefazolin Sodium, T2 Cefazolin Sodium/Dextrose, T1 Cefdinir (Capsule), T1 Cefdinir (Oral Suspension), T2 Cefepime, T2 Cefotaxime Sodium, T2 Cefotetan, T3 Cefoxitin Sodium, T2 Cefoxitin Sodium/Dextrose, T3 Cefpodoxime Proxetil, T2 Cefprozil, T1 Ceftazidime, T2 Ceftriaxone Sodium, T2 Ceftriaxone/Dextrose, T2 Cefuroxime Axetil (Oral Suspension), T2 Cefuroxime Axetil (Tablet), T1 Cefuroxime Sodium, T2 Cefuroxime/Dextrose, T1 Celebrex, T2 Cellcept (Capsule), T3 Cellcept (Oral Suspension, Tablet), T4 Cellcept Intravenous, T3 Celontin, T3 Cenestin, T3

Cephalexin, T1 Cerebyx, T3 Ceredase, T4 Cerezyme, T4 Cerubidine, T3 Cervarix, T3 Cesamet, T4 Cesia, T1 Cetirizine HCl, T1 Cetraxal, T3 Chantix, T3 Chemet, T3 Chloramphenicol Sodium Succinate, T2 Chlordiazepoxide/Amitriptyline, T1 Chlorhexidine Gluconate Oral Rinse, T1 Chloroquine Phosphate, T1 Chlorothiazide, T1 Chlorothiazide Sodium, T2 Chlorpromazine HCl, T1 Chlorpropamide, T1 Chlorthalidone, T1 Chlorzoxazone, T1 Cholestyramine, T1 Chorionic Gonadotropin, T2 Ciclopirox (Gel,Shampoo), T2 Ciclopirox (Suspension), T1 Ciclopirox Nail Lacquer, T2 Ciclopirox Olamine, T1 Cilostazol, T1 Ciloxan, T3 Cimetidine, T1 Cimetidine HCl (Injection), T2 Cimetidine HCl (Oral Solution), T1 Cimzia, T4 Cipro (Oral Suspension), T3 Cipro HC, T3 Cipro IV, T3

Ciprodex, T2 Ciprofloxacin, T1 Ciprofloxacin ER, T2 Ciprofloxacin HCl, T1 Cisplatin, T2 Citalopram Hydrobromide (Oral Solution), T2 Citalopram Hydrobromide (Tablet), T1 Cladribine, T4 Claforan (1 gm Injection, 2 gm Injection), T3 Claravis, T2 Clarithromycin (Oral Suspension), T2 Clarithromycin (Tablet), T1 Clarithromycin ER, T1 Clemastine Fumarate, T1 Cleocin (75 mg Capsule), T3 Cleocin Galaxy, T3 Cleocin Pediatric Granules, T3 Cleocin Phosphate, T3 Climara Pro, T3 Clindagel, T3 Clindamycin HCl, T1 Clindamycin Phosphate (Cream, Gel, Lotion, Swab, Topical Solution), T1 Clindamycin Phosphate (Foam), T2 Clindamycin Phosphate Add-Vantage, T2 Clindamycin/Benzoyl Peroxide, T2 Clindesse, T3 Clinimix E/Dextrose, T3 Clinimix/Dextrose (2.75%/D5W Injection, 4.25%/ D5W Injection, 5%/D15W Injection, 5%/D20W Injection, 5%/D25W Injection), T3 Clinimix/Dextrose

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

50

(4.25%/D10W Injection, 4.25%/ D20W Injection, 4.25%/D25W Injection), T1 Clinisol SF 15%, T2 Clobetasol Propionate (Foam), T2 Clobetasol Propionate (Gel, Ointment, Topical Solution), T1 Clobetasol Propionate E, T1 Clobex, T3 Cloderm, T3 Clolar, T4 Clomipramine HCl, T1 Clonidine HCl (Tablet), T1 Clonidine HCl (Weekly Patch), T2 Clorpres, T3 Clotrimazole, T1 Clotrimazole/Betamethasone Dipropionate, T1 Clozapine, T2 Codeine Sulfate, T1 Cogentin, T3 Co-Gesic, T1 Cognex, T3 Colcrys, T3 Colestipol HCl (Granules), T2 Colestipol HCl (Tablet), T1 Colistimethate Sodium, T4 Colocort, T2 Coly-Mycin M, T4 Coly-Mycin S, T3 Combigan, T2 Combipatch, T3 Combivent, T2 Combivir, T4 Compro, T1 Comtan, T2 Comvax, T2 Constulose, T1 Copaxone, T4

Copegus, T4 Cordran, T3 Cordran SP, T3 Cordran Tape, T3 Cortef, T3 Cortisone Acetate, T1 Cortisporin, T3 Cortisporin-TC, T3 Cortomycin, T1 Cosmegen, T3 Coumadin (Injection), T3 Coumadin (Tablet), T2 Creon, T2 Crestor, T2 Crixivan, T2 Cromolyn Sodium (Nebulizer Solution), T2 Cromolyn Sodium (Ophthalmic Solution), T1 Cryselle, T1 Cubicin, T4 Cuprimine, T3 Cutivate (Lotion), T3 Cyclessa, T3 Cyclobenzaprine HCl, T1 Cyclophosphamide, T2 Cyclosporine, T2 Cyclosporine Modified, T2 Cyklokapron, T2 Cymbalta, T2 Cyproheptadine HCl, T1 Cystadane, T4 Cystagon, T3 Cytarabine, T2 Cytarabine Aqueous, T1

D
D.H.E. 45, T4 Dacarbazine, T2 Danazol, T2

Dantrolene Sodium, T2 Dapsone, T2 Daptacel, T2 Daraprim, T2 Daunorubicin HCl, T1 DDAVP (Injection), T4 Decavac, T2 Demeclocycline HCl, T2 Demser, T4 Denavir, T3 Depade, T2 Depo-Estradiol, T3 Depo-Medrol (20 mg/ml Injection), T3 Depo-Provera (400 mg/ml Injection), T3 Derma-Smoother/FS, T3 Dermotic, T2 Desipramine HCl, T1 Desmopressin Acetate, T2 Desogen, T3 Desonate, T3 Desonide, T1 Desowen/Cetaphil, T3 Desoximetasone, T2 Dexamethasone, T1 Dexamethasone Intensol, T1 Dexamethasone Sodium Phosphate (Injection), T2 Dexamethasone Sodium Phosphate (Ophthalmic Solution), T1 Dexasporin, T1 Dexchlorpheniramine Maleate, T1 Dexilant, T3 Dexmethylphenidate HCl, T1 Dexrazoxane, T4 Dextroamphetamine Sulfate, T1 Dextroamphetamine Sulfate ER, T2 Dextrose 10%, T2

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

51

Dextrose 10%/NaCl 0.2%, T2 Dextrose 10%/NaCl 0.45%, T2 Dextrose 2.5%/NaCl 0.45%, T2 Dextrose 5%, T2 Dextrose 5%/ Electrolyte #48, T3 Dextrose 5%/KCl 0.075%, T2 Dextrose 5%/NaCl 0.2%, T2 Dextrose 5%/NaCl 0.225%, T2 Dextrose 5%/NaCl 0.33%, T2 Dextrose 5%/NaCl 0.45%, T2 Dextrose 5%/NaCl 0.9%, T2 Dibenzyline, T3 Diclofenac Potassium, T1 Diclofenac Sodium, T1 Diclofenac Sodium EC, T1 Diclofenac Sodium XR, T1 Dicloxacillin Sodium, T1 Dicyclomine HCl (Capsule, Oral Solution, Tablet), T1 Dicyclomine HCl (Injection), T2 Didanosine, T2 Diflorasone Diacetate, T1 Diflucan in NaCl, T3 Diflunisal, T1 Digoxin (Injection), T2 Digoxin (Oral Solution, Tablet), T1 Dihydroergotamine Mesylate, T2 Dilantin, T2 Dilantin Infatabs, T2 Dilatrate SR, T3 Dilaudid (1 mg/ml Injection, 2 mg/ml Injection, 4 mg/ml Injection), T3 Dilt-CD, T1 Diltiazem CD, T1 Diltiazem HCl (24-Hour Capsule, Tablet), T1 Diltiazem HCl (Injection), T2

Diltiazem HCl ER (12-Hour Capsule, 24-Hour Capsule), T1 Diltiazem HCl ER (24-Hour Tablet), T2 Dilt-XR, T1 Diltzac, T1 Diovan, T2 Diovan HCT, T2 Diphenhydramine HCl (Capsule, Elixir), T1 Diphenhydramine HCl (Injection), T2 Diphenoxylate/Atropine, T1 Diphtheria/Tetanus Toxoid Pediatric, T2 Dipyridamole, T1 Disopyramide Phosphate, T1 Diuril, T3 Divalproex Sodium (Delayed Release Tablet), T1 Divalproex Sodium (Sprinkle Capsule), T2 Divalproex Sodium ER, T2 Divigel, T3 Doribax, T3 Doryx, T3 Dorzolamide HCl, T1 Dorzolamide HCl/ Timolol Maleate, T2 Dovonex (Cream), T3 Doxazosin Mesylate, T1 Doxepin HCl, T1 Doxil, T4 Doxorubicin HCl, T2 Doxycycline Hyclate (100 mg Tablet, Extended Release Capsule, Injection), T2 Doxycycline Hyclate (20mg Tablet, Capsule), T1 Doxycycline Monohydrate, T2

Dronabinol (10 mg Capsule), T4 Dronabinol (2.5 mg Capsule), T2 Dronabinol (5 mg Capsule), T4 Droxia, T3 Duetact, T2 Duramorph, T2 Durezol, T3 Dyrenium, T3

E
E.E.S. 400, T1 E.E.S. Granules, T2 Econazole Nitrate, T1 ED K+10, T1 Edecrin, T3 Effient, T2 Elaprase, T4 Elestat, T3 Elidel, T3 Eligard, T3 Eliphos, T3 Elitek, T4 Elixophyllin, T2 Ellence, T4 Elmiron, T3 Eloxatin, T4 Elspar, T3 Emcyt, T3 Emend, T2 Emsam, T3 Emtriva, T3 Enablex, T2 Enalapril Maleate, T1 Enalapril Maleate/ Hydrochlorothiazide, T1 Enbrel, T4 Endocet, T1 Endodan, T1 Engerix-B, T2 Enjuvia, T2

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

52

Enpresse, T1 Entocort EC, T3 Enulose, T1 Epinephrine HCl, T2 Epipen, T2 Epirubicin HCl, T2 Epitol, T1 Epivir, T2 Epivir HBV, T2 Eplerenone, T2 Epogen (10,000 units/ml Injection, 2,000 units/ml Injection, 3,000 units/ml Injection, 4,000 units/ ml Injection), T3 Epogen (20,000 units/ml Injection), T4 Epogen (40,000 units/ml Injection), T4 Epzicom, T4 Equetro, T3 Eraxis, T4 Erbitux, T4 Ergoloid Mesylates, T2 Ergotamine Tartrate/Caffeine, T1 Errin, T1 Ertaczo, T3 Ery, T1 Eryped, T2 Ery-Tab, T2 Erythrocin Lactobionate, T3 Erythrocin Stearate, T3 Erythromycin, T1 Erythromycin Base, T1 Erythromycin/Benzoyl Peroxide, T1 Erythromycin/Sulfisoxazole, T1 Estrace (Cream), T3 Estraderm, T2 Estradiol, T1 Estradiol Valerate, T2

Estradiol/ Norethindrone Acetate, T1 Estring, T3 Estrogel, T3 Estropipate, T1 Estrostep Fe, T3 Ethambutol HCl, T2 Ethosuximide, T2 Ethyol, T4 Etidronate Disodium, T2 Etodolac, T1 Etodolac ER, T1 Etopophos, T4 Etoposide, T2 Eurax, T3 Evista, T2 Exelderm, T3 Exelon, T3 Exforge, T2 Exforge HCT, T2 Exjade, T4 Extavia, T4

F
Fabrazyme, T4 Factive, T3 Famciclovir, T2 Famotidine (Injection, Oral Suspension), T2 Famotidine (Tablet), T1 Fanapt, T3 Fanapt Titration Pack, T3 Fareston, T3 Faslodex, T4 Fazaclo, T2 Felbatol, T3 Felodipine ER, T1 Femara, T2 Femhrt, T3 Femring, T3

Femtrace, T3 Fenofibrate, T1 Fenofibrate Micronized, T1 Fenoprofen Calcium, T1 Fentanyl (Patch), T2 Fentanyl Citrate (Injection), T2 Fentanyl Citrate Oral Transmucosal, T4 Fentora, T4 Fexofenadine HCl, T1 Finacea, T2 Finasteride (5 mg Tablet), T1 Firmagon (120 mg Injection), T4 Firmagon (80 mg Injection), T3 Flagyl ER, T3 Flarex, T2 Flavoxate HCl, T2 Flebogamma, T4 Flecainide Acetate, T1 Flovent Diskus, T2 Flovent HFA, T2 Fluconazole, T1 Fluconazole in Dextrose, T2 Fludara, T4 Fludarabine Phosphate, T4 Fludrocortisone Acetate, T1 Flunisolide, T1 Fluocinolone Acetonide, T1 Fluocinonide, T1 Fluocinonide-E, T1 Fluorometholone, T1 Fluorouracil (Cream, Topical Solution), T2 Fluorouracil (Injection), T1 Fluoxetine DR, T2 Fluoxetine HCl, T1 Fluphenazine Decanoate, T2 Fluphenazine HCl (Concentrate, Elixir, Tablet), T1

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

53

Fluphenazine HCl (Injection), T2 Flurbiprofen, T1 Flurbiprofen Sodium, T1 Flutamide, T2 Fluticasone Propionate, T1 Fluvoxamine Maleate, T1 FML, T2 FML Forte, T2 Fomepizole, T4 Foradil Aerolizer, T2 Fortaz, T3 Forteo, T3 Fortical, T2 Fosamax (Oral Solution), T3 Foscarnet Sodium, T2 Fosinopril Sodium, T1 Fosinopril Sodium/ Hydrochlorothiazide, T1 Fosphenytoin Sodium, T2 Fosrenol, T3 Fragmin (10,000 units/1ml Injection, 25,000 units/1 ml Injection, 7,500 units/0.3 ml Injection), T4 Fragmin (2,500 units/0.2 ml Injection, 5,000 units/0.2 ml Injection), T3 Freamine HBC, T3 Freamine III (3% Injection), T3 Freamine III (8.5% Injection), T3 Furadantin, T3 Furosemide (Injection), T2 Furosemide (Oral Solution, Tablet), T1 Fusilev, T4 Fuzeon, T4

G
Gabapentin, T1

Gabitril (12 mg Tablet, 16 mg Tablet, 2 mg Tablet), T3 Gabitril (4 mg Tablet), T3 Galantamine Hydrobromide (24-Hour Capsule), T2 Galantamine Hydrobromide (Oral Solution, Tablet), T2 Gamastan S/D, T2 Gammagard Liquid, T4 Gamunex, T4 Ganciclovir, T4 Gardasil, T2 Gauze Pads, T2 Gavilyte-C, T1 Gavilyte-G, T1 Gavilyte-N/Flavor Pack, T1 Gelnique, T3 Gemfibrozil, T1 Gemzar, T4 Generlac, T1 Gengraf (Capsule), T2 Gengraf (Oral Solution), T4 Genotropin, T4 Genotropin Miniquick (0.2 mg Injection), T3 Genotropin Miniquick (0.4 mg Injection, 0.6 mg Injection, 0.8 mg Injection, 1.2 mg Injection, 1.4 mg Injection, 1.6 mg Injection, 1.8 mg Injection, 1 mg Injection, 2 mg Injection), T4 Gentak, T1 Gentamicin Sulfate (Cream, Ointment, Ophthalmic Solution), T1 Gentamicin Sulfate (Injection), T2

Gentamicin Sulfate/NaCl (100 mg Injection, 60 mg Injection, 80 mg Injection), T2 Gentamicin Sulfate/NaCl (70 mg Injection, 90 mg Injection), T2 Gentasol, T1 Geodon (Capsule), T2 Geodon (Injection), T3 Gleevec, T4 Glimepiride, T1 Glipizide, T1 Glipizide ER, T1 Glipizide/Metformin HCl, T1 Glucagen Hypokit, T3 Glucagon Emergency Kit, T2 Glyburide, T1 Glyburide Micronized, T1 Glyburide/Metformin HCl, T1 Glycopyrrolate, T2 Glycron (1.5 mg Tablet, 3 mg Tablet, 6 mg Tablet), T1 Glyset, T3 Granisetron HCl (Injection), T2 Granisetron HCl (Tablet), T2 Granisol, T2 Grifulvin V, T2 Griseofulvin Microsize, T2 Gris-Peg, T3 Guanabenz Acetate, T1 Guanfacine HCl, T1 Guanidine HCl, T3 Gynazole-1, T3 Gynodiol, T3

H
Halflytely Bowel Prep, T2 Halobetasol Propionate, T1

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

54

Halog, T3 Haloperidol, T1 Haloperidol Decanoate, T2 Haloperidol Lactate, T2 Havrix, T2 Hectorol, T2 Heparin Sodium (1,000 units/ml Injection, 10,000 units/ml Injection, 5,000 units/ml Injection), T2 Heparin Sodium (2,000 units/ml Injection, 2,500 units/ ml Injection), T2 Heparin Sodium DCU, T2 Heparin Sodium/D5W, T2 Heparin Sodium/NaCl, T2 Heparin Sodium/NaCl 0.9% Premix, T2 Hepatamine, T2 Hepatasol, T3 Hepsera, T4 Herceptin, T4 Hexalen, T4 Humalog, T2 Humatrope, T4 Humira, T4 Humulin, T2 Hycamtin, T4 Hydralazine HCl (Injection), T2 Hydralazine HCl (Tablet), T1 Hydrochlorothiazide, T1 Hydrocodone/Acetaminophen (10 mg-325 mg Tablet, 10 mg-500 mg Tablet, 10 mg-650 mg Tablet, 10 mg-660 mg Tablet, 2.5 mg-500 mg Tablet, 5 mg-325 mg Tablet, 5 mg-500 mg Tablet, 7.5 mg-750 mg Tablet, 7.5 mg-325 mg Tablet, 7.5 mg-500 mg Tablet,

7.5 mg-650 mg Tablet, Oral Solution), T1 Hydrocodone/ Acetaminophen (10 mg-750 mg Tablet), T2 Hydrocodone/Ibuprofen, T1 Hydrocortisone (Cream, Lotion, Ointment, Tablet), T1 Hydrocortisone (Enema), T2 Hydrocortisone Butyrate, T1 Hydrocortisone Valerate, T1 Hydromorphone HCl (Injection), T2 Hydromorphone HCl (Tablet), T1 Hydroxychloroquine Sulfate, T1 Hydroxyurea, T1 Hydroxyzine HCl (Injection), T2 Hydroxyzine HCl (Syrup, Tablet), T1 Hydroxyzine Pamoate, T1

I
Ibuprofen, T1 Idamycin PFS, T4 Idarubicin HCl, T4 Ifosfamide, T2 Ifosfamide/Mesna, T4 Imipramine HCl, T1 Imipramine Pamoate, T2 Imiquimod, T2 Imovax Rabies (H.D.C.V.), T2 Increlex, T4 Indapamide, T1 Indomethacin, T1 Indomethacin ER, T2 Infanrix, T2 Infergen, T4 Infumorph, T3 Innopran XL, T3 Insulin Syringes, Needles, T2 Intelence, T4 Intralipid (20% Injection), T2

Intralipid (30% Injection), T3 Intron-A (10 mu Injection, 10 mu Pen Injection, 5 mu Pen Injection, 18 mu Injection), T4 Intron-A (3 mu Pen Injection), T3 Invanz, T3 Invega, T3 Invega Sustenna (117 mg/0.75 ml Injection, 156 mg/1 ml Injection, 234 mg/1.5 ml Injection), T4 Invega Sustenna (39 mg/0.25 ml Injection, 78 mg/0.5 ml Injection), T3 Invirase, T4 Ionosol-B/Dextrose 5%, T3 Ionosol-MB/Dextrose 5%, T3 Ionosol-T/Dextrose 5%, T3 Iopidine (1% Ophthalmic Solution), T3 Ipol Inactivated IPV, T2 Ipratropium Bromide (Nasal Spray), T1 Ipratropium Bromide (Nebulizer Solution), T1 Ipratropium Bromide/Albuterol Sulfate (Nebulizer Solution), T1 Iressa, T4 Irinotecan, T2 Isentress, T4 Isochron, T1 Isolyte-H/Dextrose 5%, T3 Isolyte-M/Dextrose 5%, T2 Isolyte-P/Dextrose 5%, T3 Isolyte-S, T3 Isolyte-S/Dextrose 5%, T3 Isonarif, T2 Isoniazid (Injection), T2 Isoniazid (Syrup, Tablet), T1 Isordil Titradose (40 mg Tablet), T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

55

Isosorbide Dinitrate, T1 Isosorbide Dinitrate ER, T1 Isosorbide Mononitrate, T1 Isosorbide Mononitrate ER, T1 Isotonic Gentamicin, T2 Isovate, T1 Isradipine, T1 Istalol, T3 Istodax, T4 Itraconazole, T2 Ixempra Kit, T4 Ixiaro, T2

J
Jantoven, T1 Janumet, T2 Januvia, T2 Je-Vax, T2 Jolivette, T1 Junel, T1 Junel Fe, T1

K
Kadian (100 mg 24-Hour Capsule, 10 mg 24-Hour Capsule, 20 mg 24-Hour Capsule, 30 mg 24-Hour Capsule, 50 mg 24-Hour Capsule, 60 mg 24-Hour Capsule, 80 mg 24-Hour Capsule), T2 Kadian (200 mg 24-Hour Capsule), T4 Kaletra (100-25 mg Tablet), T3 Kaletra (200-50 mg Tablet, Oral Solution), T4 Kanamycin Sulfate, T2 Kaon-Cl-10, T1 Kariva, T1

KCl (0.4 meq/1 ml Injection, 10 meq/100 ml Injection, 2 meq/1 ml Injection, 30 meq/100 ml Injection), T2 KCl (10 meq/50 ml Injection), T2 KCl 0.15%/NaCl, T2 KCl 0.3%/NaCl 0.9%, T2 KCl ER, T1 KCl/D10W/NaCl, T2 KCl/D5W, T2 KCl/D5W/LR, T2 KCl/D5W/NaCl, T2 Keflex (750 mg Capsule), T3 Kelnor, T1 Kenalog, T3 Kepivance, T4 Keppra (Injection), T4 Keppra (Oral Solution, Tablet), T3 Ketek, T3 Ketoconazole, T1 Ketoprofen, T1 Ketoprofen ER, T2 Ketorolac Tromethamine (Injection), T2 Ketorolac Tromethamine (Ophthalmic Solution), T2 Ketorolac Tromethamine (Tablet), T1 Kineret, T4 Kionex, T2 Klor-Con 10, T1 Klor-Con 8, T1 Klor-Con M10, T1 Klor-Con M15, T2 Klor-Con M20, T1 Kristalose, T3 Kuric, T1 Kuvan, T4 Kytril (Tablet), T4

L
Labetalol HCl (Injection), T2 Labetalol HCl (Tablet), T1 Laclotion, T1 Lacrisert, T3 Lactated Ringer’s, T2 Lactated Ringer’s Irrigation, T2 Lactulose, T1 Lamictal, T3 Lamictal ODT, T3 Lamictal Starter Kit, T3 Lamisil (Pack), T3 Lamotrigine, T2 Lanoxin (0.1 mg/ml Injection), T3 Lanoxin (Tablet), T2 Lansoprazole, T2 Lantus, T2 Leena, T1 Leflunomide, T1 Lessina, T1 Letairis, T4 Leucovorin Calcium (Injection), T2 Leucovorin Calcium (Tablet), T1 Leukeran, T2 Leukine, T4 Leuprolide Acetate, T2 Levalbuterol (Nebulizer Solution), T2 Levaquin (Injection, Oral Solution), T3 Levaquin (Tablet), T2 Levemir, T2 Levetiracetam (Injection), T4 Levetiracetam (Oral Solution, Tablet), T2 Levobunolol HCl, T1 Levocarnitine, T2 Levora, T1

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

56

Levorphanol Tartrate, T2 Levothroid, T2 Levothyroxine Sodium, T1 Levoxyl, T1 Lexapro, T2 Lexiva (Oral Suspension), T3 Lexiva (Tablet), T4 Lidocaine, T1 Lidocaine HCl (Gel, Topical Solution), T1 Lidocaine HCl (Injection), T2 Lidocaine Viscous, T1 Lidocaine/Prilocaine, T1 Lidoderm, T2 Lincocin, T3 Lindane, T2 Liothyronine Sodium (Injection), T2 Liothyronine Sodium (Tablet), T1 Lipitor, T2 Liposyn II, T3 Liposyn III (10% Injection, 20% Injection), T3 Liposyn III (30% Injection), T1 Lisinopril, T1 Lisinopril/Hydrochlorothiazide, T1 Lithium Carbonate, T1 Lithium Carbonate ER, T1 Lithium Citrate, T1 Lithobid, T2 Lithostat, T3 Lo/Ovral, T3 Locoid, T3 Locoid Lipocream, T3 Lodosyn, T3 Loestrin, T3 Loestrin Fe, T3 Lokara, T1 Loperamide HCl, T1 Losartan Potassium, T1

Losartan Potassium/ Hydrochlorothiazide, T1 Loseasonique, T3 Lotemax, T2 Lotrel (10 mg-40 mg Capsule, 5 mg-40 mg Capsule), T3 Lotronex, T4 Lovastatin, T1 Lovaza, T3 Lovenox (100 mg/1 ml Injection, 120 mg/0.8 ml Injection, 150 mg/1 ml Injection, 300 mg/3 ml Injection, 60 mg/0.6 ml Injection, 80 mg/0.8 ml Injection), T4 Lovenox (30 mg/0.3 ml Injection, 40 mg/ 0.4 ml Injection), T3 Low-Ogestrel, T1 Loxapine Succinate, T1 Lumigan, T2 Lunesta, T2 Lupron Depot (11.25 mg Injection, 3.75 mg Injection), T3 Lupron Depot (22.5 mg Injection, 30 mg Injection, 7.5 mg Injection), T4 Lupron Depot-PED, T4 Lutera, T1 Luxiq, T3 Lyrica, T2 Lysodren, T4

M
Macrodantin, T3 Magnesium Sulfate, T1 Magnesium Sulfate in D5W, T2 Malarone, T3 Malathion, T2

Maprotiline HCl, T1 Margesic-H, T1 Marinol (10 mg Capsule), T4 Marinol (2.5 mg Capsule), T3 Marinol (5 mg Capsule), T4 Marplan, T3 Matulane, T4 Maxair Autohaler, T3 Maxalt, T2 Maxalt-MLT, T2 Maxipime (2 gm Injection), T3 Mebendazole, T1 Meclizine HCl, T1 Meclofenamate Sodium, T1 Medroxyprogesterone Acetate (Injection), T2 Medroxyprogesterone Acetate (Tablet), T1 Mefloquine HCl, T1 Megace ES, T3 Megestrol Acetate, T1 Meloxicam (Oral Suspension), T2 Meloxicam (Tablet), T1 Melphalan HCl, T4 Menactra, T2 Menest, T2 Menomune-A/C/Y/W-135, T2 Mentax, T3 Meperidine HCl (Injection), T1 Meperidine HCl (Oral Solution, Tablet), T1 Meprobamate, T2 Mepron, T4 Mercaptopurine, T1 Merrem, T3 Meruvax II, T2 Mesalamine, T2 Mesna, T2 Mesnex (Tablet), T4 Mestinon (Syrup), T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

57

Mestinon Timespan, T3 Metaproterenol Sulfate, T1 Metaxalone, T2 Metformin HCl, T1 Metformin HCl ER, T1 Methadone HCl (Concentrate, Oral Solution, Tablet), T1 Methadone HCl (Injection), T3 Methadose, T1 Methamphetamine HCl, T2 Methazolamide, T1 Methenamine Hippurate, T2 Methergine, T2 Methimazole, T1 Methocarbamol, T1 Methotrexate, T1 Methotrexate Sodium, T2 Methscopolamine Bromide, T2 Methyclothiazide, T1 Methyldopa, T1 Methyldopa/Hydrochlorothiazide, T1 Methyldopate HCl, T1 Methylin (Tablet), T1 Methylin ER, T1 Methylphenidate HCl, T1 Methylphenidate HCl SR, T1 Methylprednisolone, T1 Methylprednisolone Acetate, T2 Methylprednisolone Sodium Succinate, T2 Metipranolol, T1 Metoclopramide HCl (Injection), T2 Metoclopramide HCl (Oral Solution, Tablet), T1 Metolazone, T1 Metoprolol Succinate ER, T1 Metoprolol Tartrate (Injection), T2 Metoprolol Tartrate (Tablet), T1

Metoprolol/Hydrochlorothiazide, T1 Metrogel, T3 Metronidazole (Capsule, Lotion), T2 Metronidazole (Cream, Gel, Tablet), T1 Metronidazole in NaCl 0.79%, T1 Metronidazole Vaginal, T1 Mexiletine HCl, T1 Miacalcin (Injection), T3 Micardis, T3 Micardis HCT, T3 Miconazole 3, T1 Microgestin, T1 Microgestin Fe, T1 Midodrine HCl, T2 Migergot, T2 Millipred (Tablet), T3 Minitran, T1 Minocycline HCl (Capsule), T1 Minocycline HCl (Tablet), T2 Minocycline HCl ER, T2 Minoxidil (Tablet), T1 Mirapex, T2 Mirtazapine, T1 Mirtazapine ODT, T1 Misoprostol, T1 Mitomycin, T2 Mitoxantrone HCl, T2 M-M-R II, T2 Moexipril HCl, T1 Moexipril/Hydrochlorothiazide, T1 Mometasone Furoate, T1 Monodox (75 mg Capsule), T3 MonoNessa, T1 Morphine Sulfate (Injection), T2 Morphine Sulfate (Oral Solution, Tablet), T1 Morphine Sulfate ER, T1 Moviprep, T3

Mozobil, T4 MS Contin (200 mg 12-Hour Tablet), T4 Multaq, T3 Mupirocin, T1 Mustargen, T4 Mycamine, T4 Mycobutin, T3 Mycophenolate Mofetil, T2 Mydral, T1 Myfortic, T3 Myobloc, T3 Myozyme, T4 Mytelase, T3

N
Nabumetone, T1 NaCl, T2 NaCl 0.45% Viaflex, T2 NaCl 0.9%, T1 Nadolol, T1 Nadolol/Bendroflumethiazide, T1 Nafcillin Sodium, T2 Naftin, T3 Naglazyme, T4 Nalbuphine HCl, T2 Nallpen/Dextrose, T3 Naloxone HCl, T1 Naltrexone HCl, T2 Namenda, T2 Namenda Titration Pak, T2 Naphazoline HCl, T1 Naproxen, T1 Naproxen DR, T1 Nardil, T2 Nasonex, T2 Natacyn, T2 Nateglinide, T2 Navane (20 mg Capsule), T3 Nebupent, T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

58

Necon, T1 Nefazodone HCl, T1 Neo-Fradin, T3 Neomycin Sulfate, T1 Neomycin/ Polymyxin B Sulfates, T2 Neomycin/Polymyxin/ Bacitracin/Hydrocortisone, T1 Neomycin/Polymyxin/ Dexamethasone, T1 Neomycin/Polymyxin/ Gramicidin, T1 Neomycin/Polymyxin/ Hydrocortisone, T1 Neomycin/Polymyxin/ Hydrocortisone, T1 Nephramine, T3 Neulasta, T4 Neumega, T2 Neupogen, T4 Neurontin (Oral Solution), T3 Nevanac, T3 Nexavar, T4 Nexium, T2 Nexium I.V., T3 Next Choice, T1 Niacor, T1 Niaspan, T2 Nicardipine HCl (Capsule), T1 Nicardipine HCl (Injection), T2 Nicotrol Inhaler, T3 Nicotrol NS, T3 Nifediac CC, T1 Nifedical XL, T1 Nifedipine, T1 Nifedipine ER, T1 Nilandron, T3 Nimodipine, T4 Nipent, T4 Nisoldipine, T1

Nitro-Bid, T3 Nitro-Dur (0.3 mg/hr 24-Hour Patch, 0.8 mg/hr 24-Hour Patch), T3 Nitrofurantoin Macrocrystalline, T1 Nitrofurantoin Monohydrate, T1 Nitroglycerin (24-Hour Patch, Injection), T1 Nitrolingual Pumpspray, T3 Nitrostat, T2 Nizatidine (Capsule), T1 Nizatidine (Oral Solution), T2 Nora-BE, T1 Norditropin, T4 Norethindrone Acetate, T1 Noritate, T3 Normosol-M in D5W, T2 Normosol-R, T3 Normosol-R in D5W, T2 Noroxin, T3 Nortrel, T1 Nortriptyline HCl (Capsule), T1 Nortriptyline HCl (Oral Solution), T2 Norvir (Capsule, Tablet), T3 Norvir (Oral Solution), T4 Novamine, T2 Novantrone, T4 Novarel, T2 Novolin, T2 Novolog, T2 Noxafil, T4 Nulytely/Flavor Packs, T2 Nutropin, T4 Nutropin AQ, T4 NuvaRing, T2 Nyamyc, T1 Nystatin, T1 Nystatin/Triamcinolone, T1 Nystop, T1

O
Ocella, T1 Octagam, T4 Octreotide Acetate (1,000 mcg/ml Injection), T4 Octreotide Acetate (100 mcg/ml Injection, 200 mcg/ml Injection, 500 mcg/ml Injection), T4 Octreotide Acetate (50 mcg/ml Injection), T3 Ofloxacin (Ophthalmic Solution, Otic Solution), T1 Ofloxacin (Tablet), T2 Ogestrel, T1 Olux-E, T3 Omeprazole, T1 Omnitrope, T4 Oncaspar, T4 Ondansetron HCl (Injection), T2 Ondansetron HCl (Oral Solution), T2 Ondansetron HCl (Tablet), T1 Ondansetron ODT, T1 Onglyza, T2 Onsolis, T4 Ontak, T4 Opana, T2 Opana ER, T2 Optipranolol, T3 Orap, T2 Orencia, T4 Orfadin, T4 Orphenadrine Citrate, T2 Orphenadrine Citrate ER, T1 Orphenadrine/Aspirin/Caffeine, T2 Ortho Evra, T3 Ortho Micronor, T3 Ortho Tri-Cyclen Lo, T3 Ortho-Cept, T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

59

Orthoclone OKT3, T4 Ortho-Cyclen, T3 Ortho-Est, T1 Ortho-Novum 7/7/7, T3 Osmoprep, T3 Ovcon, T3 Oxacillin Sodium, T3 Oxaliplatin, T4 Oxandrin (10 mg Tablet), T4 Oxandrin (2.5 mg Tablet), T3 Oxandrolone (10 mg Tablet), T4 Oxandrolone (2.5 mg Tablet), T2 Oxaprozin, T1 Oxcarbazepine, T2 Oxistat, T3 Oxsoralen, T3 Oxsoralen Ultra, T4 Oxybutynin Chloride, T1 Oxybutynin Chloride ER, T1 Oxycodone HCl, T1 Oxycodone/Acetaminophen, T1 Oxycodone/Aspirin, T1 Oxycodone/Ibuprofen, T2 Oxycontin, T2 Oxytrol, T2

P
Pacerone (100 mg Tablet, 400 mg Tablet), T3 Pacerone (200 mg Tablet), T1 Paclitaxel, T2 Pamelor, T4 Pamidronate Disodium (30 mg/10 ml Injection, 90 mg/10 ml Injection), T2 Pamidronate Disodium (6 mg/1 ml Injection), T3 Pandel, T3 Panretin, T4 Pantoprazole Sodium, T2

Parcaine, T1 Parcopa, T3 Paromomycin Sulfate, T1 Paroxetine HCl (Oral Suspension), T2 Paroxetine HCl (Tablet), T1 Paroxetine HCl ER, T2 Paser, T3 Pataday, T2 Patanase, T2 Patanol, T2 PCE, T3 Pediarix, T2 Pedi-Dri, T1 Pedvax HIB, T2 Peganone, T3 Pegasys, T4 Peg-Intron, T4 Penicillin G Potassium, T2 Penicillin G Potassium in Iso-Osmotic Dextrose, T2 Penicillin G Procaine, T3 Penicillin G Sodium, T2 Penicillin V Potassium, T1 Pentam 300, T3 Pentasa, T3 Pentazocine/Acetaminophen, T1 Pentazocine/Naloxone HCl, T2 Pentopak, T1 Pentostatin, T4 Pentoxifylline ER, T1 Perindopril Erbumine, T1 Periogard, T1 Permethrin, T1 Perphenazine, T1 Perphenazine/Amitriptyline, T1 Pexeva, T3 Pfizerpen-G, T3 Phenadoz, T1

Phenytek, T2 Phenytoin, T1 Phenytoin Sodium, T2 Phenytoin Sodium Extended (100 mg Capsule), T1 Phenytoin Sodium Extended (200 mg Capsule, 300 mg Capsule), T2 Phoslo, T2 Phospholine Iodide, T2 Photofrin, T4 Physiolyte, T1 Physiosol Irrigation, T3 Pilocarpine HCl, T2 Pilopine HS, T2 Pindolol, T1 Piperacillin Sodium, T3 Piperacillin Sodium/ Tazobactam Sodium, T2 Piroxicam, T1 Plasma-Lyte, T3 Plasma-Lyte/D5W, T3 Plasma-Lyte-R, T2 Plavix, T2 Podofilox, T2 Polycin B, T1 Poly-Dex, T1 Polyethylene Glycol 3350, T1 Polymyxin B Sulfate, T2 Poly-Pred, T3 Portia, T1 Potassium Citrate Extended-Release, T1 Pramipexole Dihydrochloride, T2 Prandimet, T3 Prandin, T3 Pravastatin Sodium, T1 Prazosin HCl, T1 Pred Mild, T2 Pred-G, T2

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

60

Pred-G S.O.P., T2 Prednicarbate, T1 Prednisolone, T1 Prednisolone Acetate, T1 Prednisolone Sodium Phosphate, T1 Prednisone, T1 Prednisone Intensol, T1 Prefest, T3 Pregnyl w/Diluent Benzyl Alcohol/ NaCl, T2 Premarin (Cream, Tablet), T2 Premarin (Injection), T3 Premasol (10% Injection), T3 Premasol (6% Injection), T2 Premphase, T2 Prempro, T2 Prenatal Vitamins, T1 Prevalite, T1 Previfem, T1 Prezista (400 mg Tablet, 600 mg Tablet), T4 Prezista (75 mg Tablet), T3 Priftin, T3 Primaquine Phosphate, T3 Primaxin, T3 Primidone, T1 Primsol, T3 Pristiq, T3 Privigen, T4 Proair HFA, T2 Probenecid, T1 Probenecid/Colchicine, T1 Procainamide HCl, T1 Procalamine, T3 Prochieve, T3 Prochlorperazine, T1 Prochlorperazine Edisylate, T2 Prochlorperazine Maleate, T1

Procrit (10,000 units/ml Injection, 2,000 units/ml Injection, 3,000 units/ml Injection, 4,000 units/ml Injection), T3 Procrit (20,000 units/ml Injection), T4 Procrit (40,000 units/ml Injection), T4 Proctocream-HC, T1 Procto-Pak, T1 Proctosol HC, T1 Proctozone-HC, T1 Proglycem, T3 Prograf (0.5 mg Capsule, 1 mg Capsule), T3 Prograf (5 mg Capsule), T4 Prograf (Injection), T3 Prolastin, T4 Proleukin, T4 Promacta, T4 Promethazine HCl (Injection), T2 Promethazine HCl (Suppository, Syrup, Tablet), T1 Promethazine VC, T1 Promethegan, T1 Prometrium, T3 Propafenone HCl, T1 Proparacaine HCl, T1 Propoxyphene HCl, T1 Propoxyphene/Acetaminophen, T1 Propoxyphene-N/Acetaminophen, T1 Propranolol HCl, T1 Propranolol HCl ER, T1 Propranolol/Hydrochlorothiazide, T1 Propylthiouracil, T1 ProQuad, T2 Prosol, T3 Protonix (Injection), T3

Protopic, T3 Protriptyline HCl, T2 Provigil, T3 Pulmicort (Nebulizer Suspension), T3 Pulmicort Flexhaler, T2 Pulmozyme, T4 Pyrazinamide, T1 Pyridostigmine Bromide, T1

Q
Qualaquin, T3 Quasense, T1 Quinapril HCl, T1 Quinapril/Hydrochlorothiazide, T1 Quinidine Gluconate, T3 Quinidine Gluconate CR, T1 Quinidine Sulfate, T1 Quinidine Sulfate ER, T1 Quixin, T3 QVAR, T2

R
Rabavert, T2 Ramipril, T1 Ranexa, T2 Ranitidine HCl (Capsule, Tablet), T1 Ranitidine HCl (Injection, Syrup), T2 Rapaflo, T3 Rapamune (Oral Solution), T3 Rapamune (Tablet), T4 Razadyne (Oral Solution), T3 Rebetol, T4 Rebif, T4 Rebif Titration Pack, T4 Reclipsen, T1 Recombivax HB, T2 Regonol, T1 Regranex, T4 Relenza Diskhaler, T3 Relion, T3

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

61

Relistor, T3 Remicade, T4 Remodulin, T4 Renagel, T2 Renamin, T3 Renvela, T2 Rescriptor, T3 Reserpine, T1 Restasis, T2 Retin-A Micro, T3 Retrovir IV Infusion, T3 Revatio, T4 Revlimid, T4 Reyataz, T4 Ribapak, T4 Ribasphere (200 mg Tablet, Capsule), T2 Ribasphere (400 mg Tablet, 600 mg Tablet), T4 Ribavirin (200 mg Tablet, Capsule), T2 Ribavirin (400 mg Tablet, 600 mg Tablet), T4 Ridaura, T3 Rifampin (Capsule), T1 Rifampin (Injection), T4 Rifater, T3 Rilutek, T4 Rimantadine HCl, T1 Ringer’s Injection, T2 Ringer’s Irrigation, T1 Riomet, T3 Risperdal Consta (12.5 mg Injection, 25 mg Injection), T3 Risperdal Consta (37.5 mg Injection, 50 mg Injection), T4 Risperdal M-Tab, T3

Risperidone (Oral Solution), T2 Risperidone (Tablet), T1 Risperidone ODT, T2 Rituxan, T4 Rivastigmine Tartrate, T2 Robaxin (Injection), T3 Rocephin, T3 Romycin, T1 Ropinirole HCl, T1 RotaTeq, T2 Rowasa, T3 Roxicet (Oral Solution), T3 Roxicet (Tablet), T1 Rozerem, T3 Rythmol SR, T3

S
Sabril, T4 Saizen, T4 Samsca, T4 Sanctura XR, T3 Sancuso, T4 Sandimmune (Capsule, Oral Solution), T3 Sandostatin (1,000 mcg/ml Injection), T4 Sandostatin (100 mcg/ml Injection, 200 mcg/ml Injection, 500 mcg/ml Injection, 50 mcg/ml Injection), T4 Sandostatin LAR Depot, T4 Santyl, T3 Saphris, T3 Savella, T2 Savella Titration Pack, T2 Seasonale, T3 Seasonique, T3 Selegiline HCl, T1 Selenium Sulfide, T1 Selfemra, T2

Selzentry, T4 Sensipar (30 mg Tablet), T2 Sensipar (60 mg Tablet, 90 mg Tablet), T4 Serevent Diskus, T2 Seromycin, T3 Seroquel, T3 Seroquel XR, T2 Serostim, T4 Sertraline HCl (Concentrate), T2 Sertraline HCl (Tablet), T1 Silver Sulfadiazine, T1 Simponi, T4 Simulect, T4 Simvastatin, T1 Singulair, T2 Sodium Bicarbonate, T1 Sodium Fluoride, T1 Sodium Lactate, T2 Sodium Polystyrene Sulfonate, T2 Solaraze, T3 Solia, T1 Solu-Cortef, T3 Solu-Medrol, T3 Somatuline Depot, T4 Somavert, T4 Soriatane, T4 Sorine, T1 Sotalol HCl (Injection), T2 Sotalol HCl (Tablet), T1 Sotret (10 mg Capsule, 20 mg Capsule, 40 mg Capsule), T2 Spectracef, T3 Spiriva Handihaler, T2 Spironolactone, T1 Spironolactone/ Hydrochlorothiazide, T1 Sporanox (Capsule), T4

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

62

Sporanox (Oral Solution), T3 Sprintec, T1 Sprycel, T4 Sronyx, T1 SSD, T1 Stagesic, T1 Stalevo, T2 Stavudine, T2 Stavzor, T3 Stelara, T4 Sterile Water Irrigation, T1 Stimate, T3 Strattera, T3 Streptomycin Sulfate, T3 Stromectol, T2 Suboxone, T3 Sucraid, T4 Sucralfate, T1 Sulfacetamide Sodium (Lotion), T2 Sulfacetamide Sodium (Ophthalmic Solution), T1 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate, T1 Sulfadiazine, T2 Sulfamethoxazole/ Trimethoprim (Injection), T2 Sulfamethoxazole/Trimethoprim (Oral Suspension, Tablet), T1 Sulfamylon, T3 Sulfasalazine, T1 Sulfatrim, T1 Sulfazine EC, T1 Sulindac, T1 Sumatriptan Succinate (Injection), T2 Sumatriptan Succinate (Tablet), T1 Sumavel Dosepro, T4 Suprax, T3 Surmontil, T3 Sustiva, T3

Sutent, T4 Symbicort, T2 Symbyax, T3 Symlin, T3 Synagis, T4 Synalgos-DC, T3 Synarel, T4 Synercid, T4 Synthroid, T2 Syprine, T3

T
Tabloid, T3 Tacrolimus (0.5 mg Capsule, 1 mg Capsule), T2 Tacrolimus (5 mg Capsule), T4 Tamiflu, T2 Tamoxifen Citrate, T1 Tamsulosin HCl, T1 Tarceva, T4 Targretin (Capsule), T4 Targretin (Gel), T4 Tasigna, T4 Tasmar, T4 Taxotere, T4 Tazicef, T2 Tazorac, T3 Taztia XT, T1 Tegretol, T2 Tegretol-XR, T2 Tekturna, T2 Tekturna HCT, T2 Terazosin HCl, T1 Terbinafine HCl, T1 Terbutaline Sulfate (Injection), T2 Terbutaline Sulfate (Tablet), T1 Terconazole, T1 Testosterone Cypionate, T2 Testosterone Enanthate, T2 Tetanus Toxoid Adsorbed, T2

Tetanus/Diphtheria ToxoidsAdsorbed Adult, T2 Tetracycline HCl, T1 Tev-Tropin, T4 Thalomid, T4 Theo-24, T2 Theochron, T1 Theophylline ER, T1 Thermazene, T1 Thiola, T3 Thioridazine HCl, T1 Thiotepa, T3 Thiothixene, T1 Thymoglobulin, T4 Thyrolar, T2 Ticlopidine HCl, T1 Tikosyn, T3 Timentin, T3 Timolol Maleate, T1 Tindamax, T2 Tis-U-Sol, T1 Tizanidine HCl, T1 Tobi, T4 Tobradex (Ophthalmic Ointment), T2 Tobradex (Ophthalmic Suspension), T3 Tobramycin Sulfate (Injection), T2 Tobramycin Sulfate (Ophthalmic Solution), T1 Tobramycin Sulfate/NaCl, T1 Tobramycin/Dexamethasone, T1 Tobrasol, T1 Tobrex (Ophthalmic Ointment), T2 Tobrex (Ophthalmic Solution), T3 Tolazamide, T1 Tolbutamide, T1 Tolmetin Sodium (Capsule), T1

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

63

Tolmetin Sodium (Tablet), T2 Topiramate, T1 Toposar, T2 Toprol XL, T3 Torisel, T4 Torsemide (Injection), T2 Torsemide (Tablet), T1 TPN Electrolytes FTV, T2 Tracleer, T4 Tramadol HCl, T1 Tramadol HCl ER (100 mg Tablet, 200 mg Tablet), T2 Tramadol HCl/Acetaminophen, T1 Trandolapril, T1 Trandolapril/Verapamil HCl, T2 Transderm-Scop, T3 Tranylcypromine Sulfate, T2 Travasol, T3 Travatan, T2 Travatan Z, T2 Trazodone HCl, T1 Treanda, T4 Trecator, T3 Trelstar Depot, T4 Trelstar LA, T4 Tretinoin (Capsule), T4 Tretinoin (Cream), T1 Tretinoin (Gel), T2 Tretin-X, T3 Trexall, T3 Triamcinolone Acetonide, T1 Triamcinolone Acetonide in Absorbase, T1 Triamcinolone in Orabase, T1 Triamterene/ Hydrochlorothiazide, T1 Tricor, T2 Triderm, T1 Trifluoperazine HCl, T1

Trifluridine, T2 Trihexyphenidyl HCl, T1 TriHiBit, T2 Tri-Legest Fe, T1 Trilipix, T2 Trilyte, T3 Trimethobenzamide HCl (Capsule), T1 Trimethobenzamide HCl (Injection), T2 Trimethoprim, T1 Trimethoprim Sulfate/ Polymyxin B Sulfate, T1 TriNessa, T1 Tripedia, T2 Tri-Previfem, T1 Trisenox, T3 Tri-Sprintec, T1 Trivora, T1 Trizivir, T4 Trophamine (10% Injection), T3 Tropicamide, T1 Truvada, T4 Twinject, T3 Twinrix, T2 Twynsta, T3 Tygacil, T3 Tykerb, T4 Typhim Vi, T2 Tysabri, T4 Tyzeka, T4 Tyzine, T2

Ursodiol (Capsule), T2 Ursodiol (Tablet), T1 Uvadex, T3

V
Vagifem, T3 Valacyclovir HCl, T2 Valcyte, T4 Valproate Sodium, T2 Valproic Acid, T1 Valtrex, T2 Vancocin HCl, T4 Vancomycin HCl, T2 Vancomycin HCl Iso-Osmotic Dextrose, T3 Vandazole, T1 Vanos, T3 Vaqta, T2 Varivax, T2 Vectibix, T4 Vectical, T3 Velcade, T4 Velivet, T1 Venlafaxine HCl, T1 Venlafaxine HCl ER (24-Hour Capsule), T2 Venlafaxine HCl ER (24-Hour Tablet), T3 Ventavis, T4 Verapamil HCl (Injection), T2 Verapamil HCl (Tablet), T1 Verapamil HCl ER, T1 Vesicare, T2 Vexol, T3 Vfend, T4 Vibativ, T4 Vibramycin (Oral Suspension, Syrup), T3 Vidaza, T4 Videx Pediatric, T3

U
U-Cort, T1 Ulesfia, T3 Uloric, T2 Unasyn (3 gm Injection), T3 Unithroid, T1 Uroxatral, T2

Brand name drugs are bolded • Generic drugs are listed in light font This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

64

Vigamox, T2 Vimpat (Injection), T3 Vimpat (Oral Solution, Tablet), T3 Vinblastine Sulfate, T1 Vincasar PFS, T2 Vincristine Sulfate, T2 Vinorelbine Tartrate, T2 Viracept (Powder), T3 Viracept (Tablet), T4 Viramune (Oral Suspension), T3 Viramune (Tablet), T2 Virazole, T4 Viread, T3 Visicol, T3 Vistide, T4 Vivaglobin, T4 Vivelle-Dot, T2 Vivitrol, T4 Vivotif Berna, T2 Voltaren (Gel), T2 Votrient, T4 Vpriv, T4 Vytorin, T3 Vyvanse, T3

X
Xalatan, T3 Xenazine, T4 Xibrom, T3 Xifaxan, T3 Xolair, T4 Xolegel, T3 Xyrem, T2

Y
Yasmin, T3 Yaz, T3 YF-Vax, T2

Z
Zaleplon, T1 Zanosar, T3 Zantac (50 mg/50 ml Injection), T3 Zavesca, T4 Zazole, T1 Zelapar, T3 Zemaira, T4 Zemplar, T2 Zenpep, T3 Zerlor, T2 Zetia, T2 Ziagen, T3 Ziana, T3 Zidovudine, T2 Zinacef (1.5 gm Injection, 750 mg Injection), T3

W
Warfarin Sodium, T1 Welchol (Pack), T2 Welchol (Tablet), T2

Zinacef (7.5 gm Injection), T3 Zinacef in Iso-Osmotic Dextrose, T3 Zinacef in Iso-Osmotic Diluent, T3 Zinecard, T4 Zmax, T3 Zofran (Injection), T4 Zofran (Oral Solution, Tablet), T4 Zofran ODT, T4 Zolinza, T4 Zolpidem Tartrate (10 mg Tablet), T1 Zolpidem Tartrate (5 mg Tablet), T1 Zometa, T4 Zonisamide, T1 Zorbtive, T4 Zostavax, T3 Zosyn (2-0.25 gm/50 ml lnjection, 3-0.375 gm/50 ml Injection), T3 Zovia, T1 Zovirax (Cream, Ointment), T3 Zyflo CR, T3 Zylet, T2 Zymar, T2 Zyprexa, T2 Zyprexa Zydis, T2 Zyvox (Injection), T4 Zyvox (Oral Suspension, Tablet), T4

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage Organization with a Medicare contract. OVEX11MP3245293_000

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Enrollment Materials

Outbound Education & Verification Call Checklist

þ

If you have enrolled, within the next 15 days a friendly representative from DSS Research, our vendor, will call you to verify the Medicare Advantage Plan was fully explained. The agent will not be on the call with you. This call is required by Medicare and will not affect your ability to enroll in the plan. The representative will ask for your Date of Birth to confirm your identity.

Your sales agent will review the following questions with you to verify the Medicare Advantage Plan was fully explained. For all Plans:
Do you understand you have applied for a Medicare Advantage Plan? Do you understand to enroll you must have Medicare Part A and Part B? Did the sales agent fully explain your premium, benefits, copays, and coinsurances? Did the sales agent confirm that your doctor is in-network? Did the sales agent show you the Summary of Benefits (SB) inside this booklet? Did the sales agent give you their contact information? (name, phone or business card) Did the sales agent give you a receipt from the Enrollment Form? £ yes £ no £ yes £ no £ yes £ no £ yes £ no £ yes £ no £ yes £ no £ yes £ no

Only for PFFS plans:
Did the sales agent ask if you receive both Medicare and Medicaid benefits? And that PFFS plans may not always be a good option for people with Medicare and Medicaid? Did the sales agent fully explain the meaning of “deeming”? £ yes £ no £ yes £ no

Only for Dual SNP plans:
£ yes £ no Y0004Y0066_100618_122454 CMS Approved 08032010 Did the sales agent tell you that your Enrollment Form will not be processed until your Medicaid status is confirmed?

Only for Chronic plans:
Did the sales agent tell you that your Enrollment Form will not be processed until your chronic illness has been confirmed and it may take up to 21 days? £ yes £ no

Only for HMO, HMO-POS, and PPO plans:
Do you understand you must use contracted health care providers to get the in-network benefits, copays and coinsurances? Do you understand if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? £ yes £ no £ yes £ no

Only for Medicare Advantage plans including Prescription Drug coverage:
Did the sales agent explain the plan’s Drug List and Drug Tiers, inside this booklet? Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole? Do you understand you must use a UnitedHealthcare contracted pharmacy? £ yes £ no £ yes £ no £ yes £ no

68

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

Scope of Sales Appointment Confirmation Form
To be completed by person with Medicare or Authorized Representative. Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.)

 Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Feefor-Service Plans, and Medicare Medical Savings Account Plans.

 Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the Plan’s network except in an emergency. Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms and conditions. Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The Plan deposits money from Medicare in the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of the Plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services). Y0004Y0035Y0066_100720_114616 CMS Approved 08272010 1 of 2

Medicare Advantage (Part C), Medicare Advantage

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By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing Plan options with you is not employed by the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan, and they may be compensated based on your enrollment in a Plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan. Beneficiary Signature ___________________________________________________________________ If you are the authorized representative, you must sign above and provide the following information: PLEASE PRINT Name (First_Last) _______________________________________________________________________ Address _______________________________________________________________________________ Phone number _________________________________________________________________________ Relationship to Beneficiary _______________________________________________________________ PLEASE PRINT To be completed by Agent Agent Name (First_Last) Agent ID # Beneficiary Name (First_Last) Beneficiary Address Agent’s Signature To be completed by Agent, if Scope of Appointment was obtained at time of appointment: Reason SOA was not completed prior to Appointment – please check all that apply Agent Phone Date of Appointment Beneficiary Phone

   

Unplanned Attendee Walk-In New SOA required (consumer requested other Health Product information) Other

If Other, please explain ___________________________________________________________________ ______________________________________________________________________________________ To submit Scope of Appointment documents: Send Email To: [email protected]; no subject line or body of email required. Include one PDF per email. Do not attach any other documents. OR Send Fax To: 877.825.1914 Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. 2 of 2 SHEX11MP3241167_000

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Scope of Sales Appointment Confirmation Form
To be completed by person with Medicare or Authorized Representative. Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.)

 Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Feefor-Service Plans, and Medicare Medical Savings Account Plans.

 Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the Plan’s network except in an emergency. Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms and conditions. Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The Plan deposits money from Medicare in the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of the Plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services). Y0004Y0035Y0066_100720_114616 CMS Approved 08272010 1 of 2

Medicare Advantage (Part C), Medicare Advantage

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By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing Plan options with you is not employed by the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan, and they may be compensated based on your enrollment in a Plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan. Beneficiary Signature ___________________________________________________________________ If you are the authorized representative, you must sign above and provide the following information: PLEASE PRINT Name (First_Last) _______________________________________________________________________ Address _______________________________________________________________________________ Phone number _________________________________________________________________________ Relationship to Beneficiary _______________________________________________________________ PLEASE PRINT To be completed by Agent Agent Name (First_Last) Agent ID # Beneficiary Name (First_Last) Beneficiary Address Agent’s Signature To be completed by Agent, if Scope of Appointment was obtained at time of appointment: Reason SOA was not completed prior to Appointment – please check all that apply Agent Phone Date of Appointment Beneficiary Phone

   

Unplanned Attendee Walk-In New SOA required (consumer requested other Health Product information) Other

If Other, please explain ___________________________________________________________________ ______________________________________________________________________________________ To submit Scope of Appointment documents: Send Email To: [email protected]; no subject line or body of email required. Include one PDF per email. Do not attach any other documents. OR Send Fax To: 877.825.1914 Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. 2 of 2 SHEX11MP3241167_000

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Enrollment Form 1

2011 Individual Enrollment Form
When You Are Ready to Enroll
Contact your local sales agent to help you choose the best plan for you and complete this Individual Enrollment Form, or Call a SecureHorizons® sales agent to have them help you enroll over the phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week. TTY users: call 711.
Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form, sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR 71903-9973

I understand the person who is discussing plan options with me is a sales agent, broker or other person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid based on my enrollment in a plan. If you currently have health coverage from an employer or union, joining one of our plans could affect your employer or union health benefits. You could lose your employer or union health coverage if you join our plan. Read the communications your employer or union sends you. If you have questions, visit their Web site, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Turn the Page to Enroll

Y0066_100723_233355 CMS Approved 09142010

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2011 Individual Enrollment Form
Please contact SecureHorizons® if you need information in another language or format (Audio Tape).

Enrollment Form 1

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For Sales Representative/Agency Use Only New Member Plan Change Employer Group ID Number Appointment Mail-In Other Middle Initial Female Mr. Mrs. Ms. Branch ID

How was this application taken?

1. Applicant Information (Please type or print in black or blue ink.) Last Name First Name Birth Date / / Gender Male

Home Telephone Number ( ) Permanent Residence Street Address (not a P.O. Box) City State

Alternate Phone Number (optional) ( )

ZIP Code

County

Mailing Address (only if different from your Permanent Residence Street Address) City State ZIP Code

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E-mail Address (optional) Please e-mail me plan information and updates. 2. Medicare Insurance Information Please take out your red, white and blue Medicare card to complete this section — OR — Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. Name (exactly as appears on Medicare Card)
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY

JANE DOE

– Medicare Claim Number





Letter(s)

MEDICARE CLAIM NUMBER

000-00-0000-A HOSPITAL MEDICAL

SEX

FEMALE 07-01-1986 07-01-1986

IS ENTITLED TO

SIGN HERE

Jane Doe

(PART A) (PART B)

EFFECTIVE DATE

Part A (Hospital) effective date Part B (Medical) effective date

/ /

/ /

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

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AAEX11MP3241235_000

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3. Your Payment Options (If applicable) If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security Administration office, or call the Social Security Administration 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. 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 a portion of this premium, it is recommended you choose the coupon book or EFT option. If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my (If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover. If you would like to set up EFT, please enclose a blank check with VOID written on the front.) Monthly Social Security benefit check Electronic Funds Transfer (EFT) from your bank account each month. Enclose a VOIDED check or provide the following Account Holder Name Bank Account Number Bank Routing Number Account Type Checking Savings

Enrollment Form 1

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Coupon Book 4a. Benefit Plan Selections — Choose Only One Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Value (HMO) AV AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Premier (HMO) APR AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Mosaic (HMO) AM AARP® MedicareComplete® Plan 3 (HMO) A3 HMO plans with medical benefits only AARP® MedicareComplete Essential® (HMO) AE Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR AARP® MedicareComplete Choice® Plan 1 (PPO) AC1 AARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2 PPO plans with medical benefits only AARP® MedicareComplete Choice® Essential (PPO) ACE AARP® MedicareComplete Choice® Essential (Regional PPO) ACP Point of Service (HMO-POS) plans with a medical and Part D drug benefit AARP® MedicareComplete® Plus (HMO-POS) AP AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1 HMO-POS plans with medical benefits only AARP® MedicareComplete® Plus Essential (HMO-POS) APE 2 of 6 AAEX11MP3241235_000

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4b. Complete the following if the plan chosen includes routine dental coverage Name of dental provider Are you currently a patient of this dentist? Yes Provider ID# (please refer to Provider Directory) No

Enrollment Form 1

4c. OPTIONAL Supplemental Benefit Plans These plans are not available in all service areas. Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums. If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below). Fitness Rider Deluxe Rider If available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans below. High Option Dental Rider Optional Dental Rider Dental 260 Rider Dental Facility # (please refer to the Provider Directory) Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans. 5. Primary Care Physician (PCP), Clinic or Health Center Selection Refer to your Provider Directory or the plan Web site to select a PCP. Provider ID# PCP name Are you now seeing or have you recently seen this doctor? Yes No 6. Please Read and Answer These Important Questions Do you have End-Stage Renal Disease (ESRD)? Yes No If you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant, please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney transplant. (Use Form 2728 if available.) If “yes”, are you currently a member of a health care company? Yes No If “yes”, name of company Member ID# Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes No If “yes”, name of institution Address of institution City, State, ZIP Code Telephone number of institution ( ) Your date of admission to the institution / / Are you enrolled in your state Medicaid program? Yes No If “yes”, please provide your Medicaid ID number Do you or your spouse work? Yes No Do you or your spouse have any health insurance other than Medicare, such as private insurance, Yes No Workers’ Compensation or Veterans Administration (VA) benefits? If you have other health insurance, what kind do you have? What is the name of the health insurance? Group # ID# Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes No Plan name of other coverage Member ID# for this coverage Group ID# Effective Date (optional) 3 of 6 AAEX11MP3241235_000

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7. Alternative Formats (Check only one) If available, I prefer to receive materials in the following format Spanish Chinese Large Print (English Only)

Enrollment Form 1

Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.

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Statements of Understanding By Completing This Enrollment Form, I Agree to the Following 1. AARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week. 2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move. I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. 3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment under the Plan. 4. By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this Enrollment Form, I may be disenrolled from the Plan.

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AAEX11MP3241235_000

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Statements of Understanding (continued) By Completing This Enrollment Form, I Agree to the Following 5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may visit www.medicare.gov or 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week. 6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid Program and the Medicare Savings Program.

Enrollment Form 1

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Additional Statements of Understanding for Each Specific Plan AARP® MedicareComplete® from SecureHorizons (HMO) I understand that beginning on the date AARP® MedicareComplete® from SecureHorizons plan coverage begins, I must receive all covered benefits from plan contracted providers and pharmacies, except for emergency or urgently needed services or out-of-area renal dialysis. I understand that authorized services and other services contained in my Evidence of Coverage document will be covered as disclosed. If I do not receive prior authorization as required for covered services, I understand that neither Medicare nor AARP® MedicareComplete® will pay for services. AARP® MedicareComplete Choice® (PPO) I understand that beginning on the date AARP® MedicareComplete Choice® plan coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, the Plan provides refunds for all covered benefits, even if I get services out-of-network. AARP® MedicareComplete® Plus (HMO-POS) I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available both in and out-of-network, and I understand I must use in-network providers to enjoy the lowest cost sharing. Some non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally, some out-of-network services may be limited by county or state and require prior authorization. Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud. Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or criminal liability.

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AAEX11MP3241235_000

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8. Please Read This Important Information I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form, Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.

Enrollment Form 1

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You must sign and date this Individual Enrollment Form in order for it to be processed. If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive health care related information on his/her behalf and that documentation of this authority is available upon request by the Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes. Signature of applicant/member/authorized representative Date / /

If you are the authorized representative of the applicant, you must provide the following information and sign above. Name Relationship to applicant Address City State ZIP Code Telephone Number ( ) Alternate Phone Number (optional) ( )

9. For Sales Representative/Agency Use Only Selling Staff Member/Agent ID Initial Receipt Date Proposed Effective Date

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Selling Staff Member/Agent Name Agent Telephone Number Signature (if assisted in enrollment) 10. Election Period AEP ICEP IEP IEP2 (MAPD Plans Only)

OEPI

SEP (SEP Reason Code

)

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AAEX11MP3241235_000

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Important Enrollment Information

I-Enroll Tracking Number Effective Date Medicare ID Plan Name Sales Agent ID Sales Agent Name Sales Agent Phone Number

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Health Plan/PBP Number This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT. Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail within two weeks.

Talk to your local sales agent for answers or to enroll.

If you do not have a local sales agent, please call 1-800-547-5514, 8 a.m. - 8 p.m. local time, 7 days a week. TTY users call 711.

Visit our web site at www.AARPMedicarePlans.com

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Visit our Web site at: www.AARPMedicarePlans.com

The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged to evaluate your needs. AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers, representatives or advisors.

Y0066_100723_233355 CMS Approved 09142010

AAEX11MP3241235_000

Enrollment Form 2

2011 Individual Enrollment Form
When You Are Ready to Enroll
Contact your local sales agent to help you choose the best plan for you and complete this Individual Enrollment Form, or Call a SecureHorizons® sales agent to have them help you enroll over the phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week. TTY users: call 711.
Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form, sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR 71903-9973

I understand the person who is discussing plan options with me is a sales agent, broker or other person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid based on my enrollment in a plan. If you currently have health coverage from an employer or union, joining one of our plans could affect your employer or union health benefits. You could lose your employer or union health coverage if you join our plan. Read the communications your employer or union sends you. If you have questions, visit their Web site, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Turn the Page to Enroll

Y0066_100723_233355 CMS Approved 09142010

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2011 Individual Enrollment Form
Please contact SecureHorizons® if you need information in another language or format (Audio Tape).

Enrollment Form 2

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For Sales Representative/Agency Use Only New Member Plan Change Employer Group ID Number Appointment Mail-In Other Middle Initial Female Mr. Mrs. Ms. Branch ID

How was this application taken?

1. Applicant Information (Please type or print in black or blue ink.) Last Name First Name Birth Date / / Gender Male

Home Telephone Number ( ) Permanent Residence Street Address (not a P.O. Box) City State

Alternate Phone Number (optional) ( )

ZIP Code

County

Mailing Address (only if different from your Permanent Residence Street Address) City State ZIP Code

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E-mail Address (optional) Please e-mail me plan information and updates. 2. Medicare Insurance Information Please take out your red, white and blue Medicare card to complete this section — OR — Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. Name (exactly as appears on Medicare Card)
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY

JANE DOE

– Medicare Claim Number





Letter(s)

MEDICARE CLAIM NUMBER

000-00-0000-A HOSPITAL MEDICAL

SEX

FEMALE 07-01-1986 07-01-1986

IS ENTITLED TO

SIGN HERE

Jane Doe

(PART A) (PART B)

EFFECTIVE DATE

Part A (Hospital) effective date Part B (Medical) effective date

/ /

/ /

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

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AAEX11MP3241235_000

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3. Your Payment Options (If applicable) If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security Administration office, or call the Social Security Administration 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. 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 a portion of this premium, it is recommended you choose the coupon book or EFT option. If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my (If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover. If you would like to set up EFT, please enclose a blank check with VOID written on the front.) Monthly Social Security benefit check Electronic Funds Transfer (EFT) from your bank account each month. Enclose a VOIDED check or provide the following Account Holder Name Bank Account Number Bank Routing Number Account Type Checking Savings

Enrollment Form 2

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Coupon Book 4a. Benefit Plan Selections — Choose Only One Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Value (HMO) AV AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Premier (HMO) APR AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Mosaic (HMO) AM AARP® MedicareComplete® Plan 3 (HMO) A3 HMO plans with medical benefits only AARP® MedicareComplete Essential® (HMO) AE Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR AARP® MedicareComplete Choice® Plan 1 (PPO) AC1 AARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2 PPO plans with medical benefits only AARP® MedicareComplete Choice® Essential (PPO) ACE AARP® MedicareComplete Choice® Essential (Regional PPO) ACP Point of Service (HMO-POS) plans with a medical and Part D drug benefit AARP® MedicareComplete® Plus (HMO-POS) AP AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1 HMO-POS plans with medical benefits only AARP® MedicareComplete® Plus Essential (HMO-POS) APE 2 of 6 AAEX11MP3241235_000

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4b. Complete the following if the plan chosen includes routine dental coverage Name of dental provider Are you currently a patient of this dentist? Yes Provider ID# (please refer to Provider Directory) No

Enrollment Form 2

4c. OPTIONAL Supplemental Benefit Plans These plans are not available in all service areas. Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums. If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below). Fitness Rider Deluxe Rider If available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans below. High Option Dental Rider Optional Dental Rider Dental 260 Rider Dental Facility # (please refer to the Provider Directory) Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans. 5. Primary Care Physician (PCP), Clinic or Health Center Selection Refer to your Provider Directory or the plan Web site to select a PCP. Provider ID# PCP name Are you now seeing or have you recently seen this doctor? Yes No 6. Please Read and Answer These Important Questions Do you have End-Stage Renal Disease (ESRD)? Yes No If you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant, please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney transplant. (Use Form 2728 if available.) If “yes”, are you currently a member of a health care company? Yes No If “yes”, name of company Member ID# Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes No If “yes”, name of institution Address of institution City, State, ZIP Code Telephone number of institution ( ) Your date of admission to the institution / / Are you enrolled in your state Medicaid program? Yes No If “yes”, please provide your Medicaid ID number Do you or your spouse work? Yes No Do you or your spouse have any health insurance other than Medicare, such as private insurance, Yes No Workers’ Compensation or Veterans Administration (VA) benefits? If you have other health insurance, what kind do you have? What is the name of the health insurance? Group # ID# Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes No Plan name of other coverage Member ID# for this coverage Group ID# Effective Date (optional) 3 of 6 AAEX11MP3241235_000

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7. Alternative Formats (Check only one) If available, I prefer to receive materials in the following format Spanish Chinese Large Print (English Only)

Enrollment Form 2

Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.

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Statements of Understanding By Completing This Enrollment Form, I Agree to the Following 1. AARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week. 2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move. I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. 3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment under the Plan. 4. By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this Enrollment Form, I may be disenrolled from the Plan.

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Statements of Understanding (continued) By Completing This Enrollment Form, I Agree to the Following 5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may visit www.medicare.gov or 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week. 6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid Program and the Medicare Savings Program.

Enrollment Form 2

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Additional Statements of Understanding for Each Specific Plan AARP® MedicareComplete® from SecureHorizons (HMO) I understand that beginning on the date AARP® MedicareComplete® from SecureHorizons plan coverage begins, I must receive all covered benefits from plan contracted providers and pharmacies, except for emergency or urgently needed services or out-of-area renal dialysis. I understand that authorized services and other services contained in my Evidence of Coverage document will be covered as disclosed. If I do not receive prior authorization as required for covered services, I understand that neither Medicare nor AARP® MedicareComplete® will pay for services. AARP® MedicareComplete Choice® (PPO) I understand that beginning on the date AARP® MedicareComplete Choice® plan coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, the Plan provides refunds for all covered benefits, even if I get services out-of-network. AARP® MedicareComplete® Plus (HMO-POS) I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available both in and out-of-network, and I understand I must use in-network providers to enjoy the lowest cost sharing. Some non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally, some out-of-network services may be limited by county or state and require prior authorization. Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud. Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or criminal liability.

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8. Please Read This Important Information I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form, Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.

Enrollment Form 2

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You must sign and date this Individual Enrollment Form in order for it to be processed. If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive health care related information on his/her behalf and that documentation of this authority is available upon request by the Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes. Signature of applicant/member/authorized representative Date / /

If you are the authorized representative of the applicant, you must provide the following information and sign above. Name Relationship to applicant Address City State ZIP Code Telephone Number ( ) Alternate Phone Number (optional) ( )

9. For Sales Representative/Agency Use Only Selling Staff Member/Agent ID Initial Receipt Date Proposed Effective Date

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Selling Staff Member/Agent Name Agent Telephone Number Signature (if assisted in enrollment) 10. Election Period AEP ICEP IEP IEP2 (MAPD Plans Only)

OEPI

SEP (SEP Reason Code

)

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Important Enrollment Information

I-Enroll Tracking Number Effective Date Medicare ID Plan Name Sales Agent ID Sales Agent Name Sales Agent Phone Number

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Health Plan/PBP Number This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT. Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail within two weeks.

Talk to your local sales agent for answers or to enroll.

If you do not have a local sales agent, please call 1-800-547-5514, 8 a.m. - 8 p.m. local time, 7 days a week. TTY users call 711.

Visit our web site at www.AARPMedicarePlans.com

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Visit our Web site at: www.AARPMedicarePlans.com

The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged to evaluate your needs. AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers, representatives or advisors.

Y0066_100723_233355 CMS Approved 09142010

AAEX11MP3241235_000

Roadmap After Enrollment
Steps How You Get It
Agent

Good Continue On Your Path to… Health
Description
Confirms you submitted an Enrollment Form. Mailed We will mail you a copy of your completed Enrollment Form for your personal records only. We received your completed Enrollment Form. (Please note: Medicare must approve your Enrollment Form) Notice that Medicare has approved your Enrollment Form. Your enrollment is complete. Verifies the Medicare Advantage plan was fully explained by your sales agent. You may receive a letter on how to get extra help with your Medicare premiums and other health care costs, if you qualify. Bring this new Member ID card when you visit your doctor, hospital or pharmacy. Includes important information about your benefits, such as: Evidence of Coverage and Provider Directory. You will receive this call to inform us about your health history. This information will not affect your ability to enroll in this plan. Your answers will help us develop a health program to fit your needs.

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Y0004Y0035Y0066_100707_110218 File & Use 07192010

Receipt of Enrollment Form Copy of Completed Enrollment Form Acknowledgement of Receipt of Application Letter Notice to Confirm Enrollment Outbound Education & Verification Call

Mailed

Mailed

Phone

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Mailed Premium Assistance Mailed Member ID Card Mailed Welcome Kit

Health Risk Assessment Call

Phone

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

This is an advertisement.
Y0004Y0066_100707_142434 CMS Approved 08202010 AAGA11PO3242216_000

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