Plan
Guide 2024
Take advantage of all your
Medicare Advantage plan has to
offer
The Episcopal Church Medical Trust
UnitedHealthcare® Group Medicare Advantage (PPO)
Group Number: 16241, 16242
Effective: January 1, 2024 through December 31, 2024
Table of Contents
Introduction .......................................................................................................................3
Plan information
Benefit highlights plan 1..........................................................................................6
Benefit highlights plan 2........................................................................................10
Plan details .............................................................................................................13
Summary of benefits plan 1 ..................................................................................24
Summary of benefits plan 2 ..................................................................................36
Drug list
Drug list...................................................................................................................52
Additional drug coverage ......................................................................................73
What©s next
Here©s what you can expect next ..........................................................................80
Statements of understanding................................................................................81
Y0066_GRPTOC_2024_C UHEX23MP0008321_000
UnitedHealthcare
®
Group Medicare Advantage (PPO) plan
Dear ECMT Medicare-Eligible,
The Episcopal Church Medical Trust (Medical Trust) has chosen a
UnitedHealthcare Group Medicare Advantage (PPO) plan that offers
both medical and prescription drug coverage for you and your eligible
dependents.
This plan delivers the benefits of Original Medicare (Parts A and B)
and prescription drug coverage (Part D) in a single plan, not only
providing you with an improved benefits experience, but also lowering
your cost.
As a UnitedHealthcare Group Medicare Advantage plan member,
you’ll have a team committed to understanding your needs as a retiree
and helping you get the right care.
Let us help you:
• Learn about this new plan and the many benefits it offers, such
as UnitedHealthcare Hearing, UnitedHealthcare Global Travel and
Renew Active®
• Get tools and resources to help you be in more control of your health
• Find ways to save money on healthcare so you can focus more on
what matters to you
• Get access to care when you need it
To speak with someone about plan choices and benefits, contact
UnitedHealthcare at 1-866-519-5401, TTY 711, 8 a.m.–8 p.m.
local time, Monday–Friday
H2001_SPRJ80335_091523_M UHEX24NP0112768_000 SPRJ80335
Take advantage of
healthy extras with
UnitedHealthcare
Health & Wellness
Experience
HouseCalls
Fitness Program
Call toll-free 1-866-519-5401, TTY 711,
8 a.m.–8 p.m. local time, Monday–Friday
retiree.uhc.com/ECMT
In this book, you will find:
• A description of this plan and its two options:
– GMA Premium (PPO) 16242—annual medical out of pocket maximum* of $1,500 (per member)
– GMA Comprehensive (PPO) 16241—annual medical out of pocket maximum* of $2,000 (per member)
• Information on benefits, programs and services — and how much they cost
• What you can expect after your enrollment
Introducing the Plan
Questions? We’re here to help.
Please note, Customer Service hours of operation will be 7 days a week October 15 – December 7.
3
Introduction
How to enroll
Please review your options and choose a medical plan that best meets your healthcare needs.
To enroll:
1
Read your UnitedHealthcare Plan Guide. The guide will include details on the GMA
Premium (PPO) and GMA Comprehensive (PPO) plan options.
2
Complete the enrollment form to make your benefits elections. You can find the form
in the retirement information sent to you from the Church Pension Group. You can also
access the enrollment form at cpg.org/gmaenrollmentform
3
Please sign the enrollment form and return it to us in the enclosed self-addressed
envelope. To prevent a delay in processing, please return it to us 60 days prior to your
effective date.
Need help enrolling?
Please contact The Medical Trust at 1-800-480-9967, 8:30 a.m.–8 p.m. ET, Monday–Friday.
To secure your Medical Trust dental coverage for 2024, you must enroll in a Delta Dental
plan during Annual Enrollment. Cigna Dental will no longer be offered.
Learn more
You can find plan information online at retiree.uhc.com/ECMT. You will need your Group
Number, found on the front cover of this book, to access your plan materials.
To learn about the other benefits, including dental, available to you as a retiree of the
Medical Trust, visit cpg.org/otherbenefits.
*An out-of-pocket maximum places a limit on how much money you pay out of pocket for your medical expenses in a
calendar year. This does not include prescription drug costs or plan premiums.
4
UHEX23MP0008323_000
Plan
Information
Plan
information
Benefit Highlights
The Episcopal Church Medical Trust 16241
Effective January 1, 2024 to December 31, 2024
This is a short summary of your plan benefits and costs. See your Summary of Benefits for more
information. Or review the Evidence of Coverage for a complete description of benefits, limitations,
exclusions and restrictions. Benefit limits and restrictions are combined in- and out-of-network.
Plan costs
In-network and out-of-network
Annual medical deductible
No deductible
Annual medical out-of-pocket maximum
(the most you pay in a plan year for
covered medical care)
Your plan has an annual combined in-network and
out-of-network out-of-pocket maximum of $2,000 for
this plan year.
Medical benefits
Medical benefits covered by the plan and Original Medicare
In-network and out-of-network
Doctor’s office visit
Primary care provider (PCP) $5 copay
Specialist $10 copay
Virtual visits $5 copay
Preventive services
Medicare-covered
$0 copay
Inpatient hospital care
$0 copay per stay
Skilled nursing facility (SNF)
$0 copay per day up to 100 days
Outpatient surgery
$0 copay
Outpatient rehabilitation
Physical, occupational, or speech/
language therapy
$0 copay
Outpatient mental health
Group therapy $10 copay
Individual therapy
$10 copay
Virtual visits $10 copay
Diagnostic radiology services
such as
MRIs, CT scans
$0 copay
Lab services
$0 copay
6
Benefit highlights plan 1
Medical benefits
Medical benefits covered by the plan and Original Medicare
In-network and out-of-network
Outpatient X-rays
$0 copay
Therapeutic radiology services such as
radiation treatment for cancer
$0 copay
Ambulance
$25 copay
Emergency care
$100 copay (worldwide)
Urgently needed services
$10 copay (worldwide)
Additional benefits and programs not covered by Original Medicare
In-network and out-of-network
Routine physical
$0 copay; 1 per plan year*
Acupuncture – routine^
$10 copay, and 12 visits per plan year*
Chiropractic – routine^
$10 copay for each visit per plan year*
Foot care – routine^
$10 copay, 6 visits per plan year*
Hearing – routine exam^
$0 copay, 1 exam per plan year*
Hearing aids ^
UnitedHealthcare Hearing
Plan pays a $3,000 allowance for hearing aids
(combined for both ears) every 3 years. Hearing aids
purchased outside of UnitedHealthcare Hearing’s
nationwide network are not covered.
Fitness program
Renew Active®
by UnitedHealthcare
$0 copay for a standard gym membership at
participating locations
Post-Discharge meal delivery
$0 copay for 84 home-delivered meals immediately
following one inpatient hospitalization or SNF stay
when referred by a UnitedHealthcare Engagement
Specialist
24/7 Nurse Support
Receive access to nurse consultations and additional
clinical resources at no additional cost.
Non-medical personal care
CareLinx
$0 copay for 8 hours of non-medical personal care
services each month.
Post-discharge routine transportation
ModivCare
$0 copay for unlimited rides up to 30 days following
an inpatient hospital or SNF stay when referred by a
UnitedHealthcare Engagement Specialist
Global travel assistance
UnitedHealthcare Global
$0 copay for 24-hour travel and medical assistance
services
*Benefits are combined in and out-of-network
^Covered services that do not count toward your maximum out-of-pocket amount.
7
Plan information
Prescription drugs
Your cost
Initial coverage stage
Network pharmacy
(31-day retail supply)
Mail service pharmacy
(90-day supply)
Tier 1: Preferred Generic
$10 copay $25 copay
Tier 2: Preferred Brand
1
$30 copay $70 copay
Tier 3: Non-Preferred Drug
1
$50 copay $120 copay
Tier 4: Specialty Tier
1
$50 copay $120 copay
Coverage gap stage
After your total drug costs reach $5,030, the plan continues
to pay its share of the cost of your drugs and you pay your
share of the cost
Catastrophic coverage stage
During this payment stage, the plan pays the full cost for
your covered drugs. You pay nothing.
1
You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by
our plan. Most adult Part D vaccines are covered at no cost to you.
Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug Coverage list for
more information.
Retiree plan prospects must meet the eligibility requirements to enroll for group coverage. This information is not a
complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may
apply. Benefits, premium and/or copayments/coinsurance may change each plan year.
The Drug List (Formulary), pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.
Y0066_GRMABH_2024_M UHEX24PP0108636_000
8
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9
Benefit Highlights
The Episcopal Church Medical Trust 16242
Effective January 1, 2024 to December 31, 2024
This is a short summary of your plan benefits and costs. See your Summary of Benefits for more
information. Or review the Evidence of Coverage for a complete description of benefits, limitations,
exclusions and restrictions. Benefit limits and restrictions are combined in- and out-of-network.
Plan costs
In-network and out-of-network
Annual medical deductible
No deductible
Annual medical out-of-pocket maximum
(the most you pay in a plan year for
covered medical care)
Your plan has an annual combined in-network and
out-of-network out-of-pocket maximum of $1,500 for
this plan year.
Medical benefits
Medical benefits covered by the plan and Original Medicare
In-network and out-of-network
Doctor’s office visit
Primary care provider (PCP) $5 copay
Specialist $10 copay
Virtual visits $5 copay
Preventive services
Medicare-covered
$0 copay
Inpatient hospital care
$0 copay per stay
Skilled nursing facility (SNF)
$0 copay per day up to 100 days
Outpatient surgery
$0 copay
Outpatient rehabilitation
Physical, occupational, or speech/
language therapy
$0 copay
Outpatient mental health
Group therapy $10 copay
Individual therapy
$10 copay
Virtual visits $10 copay
Diagnostic radiology services
such as
MRIs, CT scans
$0 copay
Lab services
$0 copay
10
Benefit highlights plan 2
Medical benefits
Medical benefits covered by the plan and Original Medicare
In-network and out-of-network
Outpatient X-rays
$0 copay
Therapeutic radiology services such as
radiation treatment for cancer
$0 copay
Ambulance
$25 copay
Emergency care
$50 copay (worldwide)
Urgently needed services
$10 copay (worldwide)
Additional benefits and programs not covered by Original Medicare
In-network and out-of-network
Routine physical
$0 copay; 1 per plan year*
Acupuncture – routine^
$10 copay, and 12 visits per plan year*
Chiropractic – routine^
$10 copay for each visit per plan year*
Foot care – routine^
$10 copay, 6 visits per plan year*
Hearing – routine exam^
$0 copay, 1 exam per plan year*
Hearing aids ^
UnitedHealthcare Hearing
Plan pays a $4,000 allowance for hearing aids
(combined for both ears) every 3 years. Hearing aids
purchased outside of UnitedHealthcare Hearing’s
nationwide network are not covered.
Fitness program
Renew Active®
by UnitedHealthcare
$0 copay for a standard gym membership at
participating locations
Post-Discharge meal delivery
$0 copay for 84 home-delivered meals immediately
following one inpatient hospitalization or SNF stay
when referred by a UnitedHealthcare Engagement
Specialist
24/7 Nurse Support
Receive access to nurse consultations and additional
clinical resources at no additional cost.
Non-medical personal care
CareLinx
$0 copay for 8 hours of non-medical personal care
services each month.
Post-discharge routine transportation
ModivCare
$0 copay for unlimited rides up to 30 days following
an inpatient hospital or SNF stay when referred by a
UnitedHealthcare Engagement Specialist
Global travel assistance
UnitedHealthcare Global
$0 copay for 24-hour travel and medical assistance
services
*Benefits are combined in and out-of-network
^Covered services that do not count toward your maximum out-of-pocket amount.
11
Plan information
Prescription drugs
Your cost
Initial coverage stage
Network pharmacy
(31-day retail supply)
Mail service pharmacy
(90-day supply)
Tier 1: Preferred Generic
$5 copay $12 copay
Tier 2: Preferred Brand
1
$25 copay $60 copay
Tier 3: Non-Preferred Drug
1
$40 copay $100 copay
Tier 4: Specialty Tier
1
$40 copay $100 copay
Coverage gap stage
After your total drug costs reach $5,030, the plan continues
to pay its share of the cost of your drugs and you pay your
share of the cost
Catastrophic coverage stage
During this payment stage, the plan pays the full cost for
your covered drugs. You pay nothing.
1
You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by
our plan. Most adult Part D vaccines are covered at no cost to you.
Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug Coverage list for
more information.
Retiree plan prospects must meet the eligibility requirements to enroll for group coverage. This information is not a
complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may
apply. Benefits, premium and/or copayments/coinsurance may change each plan year.
The Drug List (Formulary), pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.
Y0066_GRMABH_2024_M UHEX24PP0108644_000
12
Medicare Part A
Hospital
+
Medicare Part B
Doctor and Outpatient
+
Medicare Part D
Prescription Drugs
+
Extra Programs
Beyond Original Medicare
The Episcopal Church Medical Trust (Medical Trust) has
chosen a UnitedHealthcare® Group Medicare Advantage
plan, which includes medical and prescription drug
coverage. The word “Group” means this plan is designed
specifically for the Medical Trust. Only eligible retirees and
their dependents can enroll in this plan.
It is a Preferred Provider Organization (PPO) plan that allows
you to see any provider (in-network or out-of-network) at the
same cost share, as long as they accept the plan and have
not opted out of or been excluded from Medicare.
“Medicare Advantage” is also known as Medicare Part
C. The UnitedHealthcare® Group Medicare Advantage
(PPO) plan has all the benefits of Medicare Part A (hospital
coverage), Medicare Part B (doctor and outpatient care), and
includes Medicare Part D (drug coverage), plus additional
benefits including hearing aids, travel and fitness.
Make sure you know what parts of
Medicare you have
You must be entitled to Medicare Part A and
enrolled in Medicare Part B to enroll in this plan.
• If you’re not sure if you are enrolled in
Medicare Part B, check with Social
Security. Visit ssa.gov/locator or call
1-800-772-1213, TTY 1-800-325-0778,
8 a.m.–7 p.m., Monday–Friday, or call your
local office
• You must continue paying your Medicare
Part B premium to be eligible for coverage
under this group-sponsored plan
• If you stop paying your Medicare Part B
premium, you may be disenrolled from
this plan
Plan Details
H2001_SPRJ80336_091523_M
Medicare Advantage
Coverage:
UnitedHealthcare® Group
Medicare Advantage (PPO)
13
Plan details
Plan information
How your Group Medicare Advantage plan works
Medicare has rules about what types of coverage you can add or combine with a group-sponsored
Medicare Advantage plan.
One plan at a time
• You may be enrolled in only one Medicare Advantage plan and one Medicare Part D
prescription drug plan at a time
• The plan you enroll in last is the plan that the Centers for Medicare & Medicaid Services
(CMS) considers to be your final decision
• If you or any eligible family member enrolls in another Medicare Advantage plan or
a stand-alone Medicare Part D prescription drug plan after your enrollment in the
UnitedHealthcare GMA Premium (PPO) or GMA Comprehensive (PPO) plan, you will
be disenrolled from these plans. This means that you and your family may not have
hospital/medical or drug coverage through the Medical Trust.
Remember: If you drop or are disenrolled from your group-sponsored retiree
coverage, you may not be able to re-enroll. Limitations and restrictions vary by former
employer or plan sponsor.
UHEX24NP0112769_000 SPRJ80336
Call toll-free 1-866-519-5401, TTY 711,
8 a.m.–8 p.m. local time, Monday–Friday
retiree.uhc.com/ECMT
Questions? We’re here to help.
Please note, Customer Service hours of operation will be 7 days a week October 15 – December 7.
14
View Your Plan Information Online
How your medical coverage works
The UnitedHealthcare Group Medicare Advantage (PPO) — is a Preferred
Provider Organization (PPO) plan
You have access to our national coverage. You can see any provider (in-network or out-of-network) at
the same cost share as long as they accept the plan and have not opted out of or been excluded or
precluded from the Medicare Program.
In-network Out-of-network
Can I continue to see my
doctor/specialist?
Yes
Yes, as long as they participate
in Medicare and accept the plan
1
What is my copay or
coinsurance?
Copays and coinsurance
vary by service
2
Copays and coinsurance
vary by service
2
Do I need to choose a primary
care provider (PCP)?
No, but recommended No, but recommended
Do I need a referral to
see a specialist?
No No
Can I go to any hospital? Yes
Yes, as long as they participate
in Medicare and accept the plan
1
Are emergency and urgently
needed services covered?
Yes Yes
Do I have to pay the
full cost for all doctor or
hospital services?
You will pay your standard
copay or coinsurance for the
services you get
2
You will pay your standard
copay or coinsurance for the
services you get
2
Is there a limit on how much
I can spend on medical
services each year?
Yes
2
Yes
2
Are there any situations when
a doctor will balance bill me?
Under this plan, you are not responsible for any balance billing
when seeing healthcare providers who have not opted out of or
been excluded or precluded from the Medicare Program.
1
This means that the provider or hospital agrees to treat you and be paid according to UnitedHealthcare’s payment
schedule. With this plan, we pay the same as Medicare and follow Medicare’s rules. Emergencies would be covered
even if out-of-network.
2
Refer to the Summary of Benefits or Benefit Highlights in this guide for more information.
Once you receive your UnitedHealthcare member ID card, you can create your secure online
account at: retiree.uhc.com/ECMT
You’ll be able to view plan documents, find a provider, locate a pharmacy and access lifestyle and
learning articles, recipes, educational videos and more.
15
Plan information
How your prescription drug coverage works
Your Medicare Part D prescription drug coverage includes thousands of brand name and generic
prescription drugs. Check your plan’s drug list to see if your drugs are covered. The plan’s drug list
can be found at retiree.uhc.com/ECMT.
Here are answers to common questions:
What pharmacies can I use?
You can choose from thousands of national chain, regional and independent local retail pharmacies.
What is a drug-cost tier?
Drugs are divided into different cost levels, or tiers. In general, the lower the tier, the less you pay.
Can I have more than one prescription drug plan?
No. You can only have one Medicare plan that includes prescription drug coverage at a time. If
you enroll in another Medicare Part D prescription drug plan OR a Medicare Advantage plan that
includes prescription drug coverage, you will be disenrolled from this plan.
Is there an option to have prescriptions delivered to my home?
Yes, prescriptions can be delivered to your home from Optum® Home Delivery Pharmacy, a
UnitedHealth Group company.
Call toll-free 1-866-519-5401, TTY 711,
8 a.m.–8 p.m. local time, Monday–Friday
retiree.uhc.com/ECMT
Questions? We’re here to help.
Please note, Customer Service hours of operation will be 7 days a week October 15 – December 7.
16
Additional information about your prescription drugs
You may save on the medications you take regularly
If you prefer the convenience of mail order, you could save time and money by receiving your
maintenance medications from Optum® Home Delivery Pharmacy. You’ll get automatic refill
reminders and access to licensed pharmacists if you have questions.
Get a 3-month
1
supply at retail pharmacies
In addition to Optum® Home Delivery Pharmacy, most retail pharmacies offer 3-month
supplies for some prescription drugs.
Ask your doctor about trial supplies
A trial supply allows you to fill a prescription for less than 30 days. This way, you can pay a
reduced copay or coinsurance and make sure the medication works for you before getting a
full month’s supply.
Explore lower-cost options
Each covered drug in your drug list is assigned to a drug-cost tier. Generally, the lower the
tier, the less you pay. If you’re taking a higher-tier drug, you may want to ask your doctor if
there’s a lower-tier drug you could take instead.
Have an annual medication review
Take some time during your Annual Wellness Visit to make sure you are only taking the
drugs you need.
Filling your prescriptions is convenient
UnitedHealthcare has thousands of national chain, regional and independent local retail
pharmacies in our network.
2
The UnitedHealthcare Savings Promise
UnitedHealthcare is committed to keeping your prescription drug costs down. As a
UnitedHealthcare member, you have our Savings Promise that you’ll get the lowest price
available. That low price may be your plan copay, the pharmacy’s retail price or our
contracted price with the pharmacy.
1
Your former employer or plan sponsor may provide coverage beyond 3 months. Please refer to the Benefit Highlights
or Summary of Benefits for more information.
2
Network size varies by market.
17
Plan information
What is IRMAA?
The Income-Related Monthly Adjustment Amount (IRMAA) is an amount Social Security
determines you may need to pay in addition to your monthly plan premium if your
modified adjusted gross income on your IRS tax return from two years ago is above a
certain limit. This extra amount is paid directly to Social Security, not to your plan.
Social Security will contact you if you have to pay IRMAA.
Call Social Security to see if you qualify for Extra Help
If you have a limited income, you may be able to get Extra Help to pay for your
prescription drug costs. If you qualify, Extra Help could pay up to 75% or more of
your drug costs. Many people qualify and don’t know it. There’s no penalty for applying,
and you can re-apply every year.
Call toll-free 1-800-772-1213, TTY 1-800-325-0778, 8 a.m.–7 p.m., Monday–Friday, or
call your local office.
What is a Medicare Part D Late Enrollment Penalty (LEP)?
An LEP is a late fee Medicare charges if you had 63 days or more without
prescription drug coverage. This can happen if:
• You didn’t enroll in a Medicare Prescription Drug plan when you were
first eligible.
• You didn’t have a plan that met Medicare’s minimum standards.
The LEP is an amount added to your monthly Medicare premium and billed to you
separately by UnitedHealthcare.
When you become a member, your former employer or plan sponsor will be asked
to confirm that you have had continuous Medicare Part D coverage. If your former
employer or plan sponsor asks for information about your prescription drug
coverage history, please respond as quickly as possible to avoid an
unnecessary penalty.
Once you become a member, more information will be available in your Evidence
of Coverage (EOC). Your Quick Start Guide will include details on how to access
your EOC.
Call toll-free 1-866-519-5401, TTY 711,
8 a.m.–8 p.m. local time, Monday–Friday
retiree.uhc.com/ECMT
Questions? We’re here to help.
Please note, Customer Service hours of operation will be 7 days a week October 15 – December 7.
18
Your care begins with your doctor
• If your healthcare provider accepts Medicare, they likely participate in this plan.
• With this plan, you have the flexibility to see doctors inside or outside the UnitedHealthcare
network. See below for why you should use a network doctor.
• Even though it’s not required, it’s important to have a primary care provider.
• Unlike most PPO plans, with this plan, you pay the same share of cost in and out of the network
as long as they participate in Medicare and have not been excluded or precluded from the
Medicare Program.
• With your UnitedHealthcare Group Medicare Advantage plan, you’re connected to programs,
resources, tools and people that can help you live a healthier life.
• If your doctor has questions, they can contact UnitedHealthcare directly at 1-866-519-5401.
Finding a doctor is easy
If you need help finding a doctor or specialist, just give us a call. We can even help schedule that
first appointment. When you call your doctor, tell them you have a Medicare Advantage PPO plan.
Why use a UnitedHealthcare network doctor?
A network doctor or health care provider is contracted with us to provide services to our
members. We work closely with our network of doctors to give them access to resources and tools
that can help them work with you to make better health care decisions. You pay your copay or
coinsurance according to your plan benefits. Your provider will bill us for the rest.
An out-of-network provider does not have a contract with us. With the UnitedHealthcare Group
Medicare Advantage (PPO) plan, you can see any out-of-network provider as long as they accept
the plan and have not opted out of or been excluded or precluded from the Medicare Program. You
pay your copay or coinsurance according to your plan benefits. We will pay for the rest of the cost of
your covered service(s), including any charges up to the limit set by Medicare. If your provider won’t
accept the plan, we will contact them on your behalf.
If a provider refuses to directly bill us, they may ask that you pay the full allowable amount upfront.
In that case, you can pay the doctor and then submit a claim to us. You’ll be reimbursed for the cost
of the claim minus your cost share.
Getting the health care coverage you may need
19
Plan information
Take advantage of UnitedHealthcare’s additional support
and programs
Annual Physical and Wellness Visit
1
An Annual Wellness Visit with your doctor and many preventive services at $0 copay is
one of the best ways to start your year off and stay on top of your health. Take control by
scheduling your annual physical and wellness visit early in the year to give you the most
time to take action. You and your doctor can work as a team to create a preventive care
plan, review medications and talk about any health concerns. You may also be eligible to
earn rewards* for completing and reporting eligible health-related activities.
In-Home Preventive Care Visit from UnitedHealthcare® HouseCalls
With UnitedHealthcare® HouseCalls
2
, you get a yearly in-home visit from one of our
licensed health care practitioners at no cost to you. A HouseCalls visit is designed to
support, but not take the place of, your regular doctor’s care.
The visit takes up to an hour and is tailored to your needs. It includes select health
screenings and a chance to:
• Review medications
• Receive health education, prevention tips, care and resource assistance, if needed
• Get advice and ask questions on how to manage health conditions
• Receive referrals to other health services and more
At the end of the visit, our health care practitioner will leave you with a personalized
checklist and send a summary of the visit to your regular doctor.
24/7 Nurse Support
Speak to a registered nurse 24/7 over the phone about your medical concerns at no
additional cost to you.
Chronic Conditions Programs
UnitedHealthcare offers special programs to help members who are living with a chronic
disease like diabetes or heart disease or complex health needs. You get personal
attention and your doctors get up-to-date information to help them make decisions.
20
Virtual Visits
See a doctor or a behavioral health specialist using your computer, tablet or smartphone.
With Virtual Visits, you’re able to live video chat — anytime, day or night. You will first
need to register and then schedule an appointment. On your tablet or smartphone,
you can download the Amwell®, Doctor On Demand™ or Teladoc
TM
Health (medical
visits only) apps.
Virtual Doctor Visits
You can ask questions, get a diagnosis or even get medication prescribed and have it
sent to your pharmacy. All you need is a strong internet connection. Virtual doctor visits
may be good for minor health concerns like:
• Allergies, bronchitis, cold/cough
• Fever, seasonal flu, sore throat
• Migraines/headaches, sinus problems, stomachache
• Bladder/urinary tract infections, rashes
Virtual Behavioral Health Visits
May be best for:
• Initial evaluation
• Behavioral Health medication management
• Addiction
• Depression
• Trauma and loss
• Stress or anxiety
In-Home Care
What would make your day easier? Maybe it’s having some extra help in your home with
things like making meals, bathing, medication reminders or even transportation around
your community. CareLinx provides a network of pre-screened, professional caregivers
you can trust, which can give you greater peace of mind with non-medical personal care
support services at no additional cost.
Global Travel Assistance
UnitedHealthcare Global Assistance is a service that provides travel and medical
assistance 24 hours a day while you’re traveling outside your country or over 100 miles
from your home. It’s available to you at no additional cost.
Register for a UHC Global account at: worldwatch.uhcglobal.com
21
Plan information
Hearing Aids
With UnitedHealthcare Hearing, you have access to friendly, expert advice from our
national
3
network of 7,000+
4
hearing providers and a wide variety of prescription hearing
aid models to choose from, as well as a selection of audiologist-selected non-prescription
hearing aids at UHCHearing.com and virtual appointment options. UnitedHealthcare
Hearing helps give you the flexibility and confidence to choose the hearing care that’s
right for you -- so you get the care you need to hear better and live life to the fullest.
Get to Post-Hospitalization Health-Related Appointments
Our transportation program gives you a lift to and from medically related visits such as
doctors’ appointments, pharmacy trips and more after you have been discharged from
the hospital or skilled nursing facility. The program offers unlimited rides up to 30 days
following hospital or skilled nursing facility discharges when referred by a UnitedHealthcare
Engagement Specialist.
Post-Discharge Meals
Our post-discharge meal delivery program provides 84 prepared meals delivered to your
home after you have been discharged from the hospital or skilled nursing facility, at no
additional cost. A referral from a UnitedHealthcare Engagement Specialist is required.
UnitedHealthcare Fitness Program
Renew Active® is the gold standard in Medicare fitness programs for body and mind,
available at no additional cost. You’ll receive a free gym membership with access to the
largest Medicare fitness network of gyms and fitness locations. This includes access to
on-demand digital workout videos and live streaming classes, social activities and access
to an online Fitbit® Community for Renew Active (no Fitbit device is needed) and an
online program offering content about brain health from AARP® Staying Sharp®.
And so much more to help you live a healthier life
After you become a member, we will connect you to many programs and tools that may
help you on your wellness journey. You will get information soon after your coverage
becomes effective.
22
Tools and resources to help put you in control
Go online for valuable plan information
As a UnitedHealthcare member, you will have access to a safe, secure member site
where you’ll be able to:
• Look up your latest claim information
• Review benefit information and plan materials
• Print a temporary ID card and request a new one
• Search for network doctors
• Search for pharmacies
• Look up drugs and how much they cost under your plan
• Learn more about health and wellness topics and explore all Renew has to offer
based on your interests and goals
• Sign up to get your Explanation of Benefits online
Live Healthier with Renew
Explore Renew by UnitedHealthcare®,
5
our member-only health and wellness experience.
Renew helps inspire you to take charge of your health and wellness every day by
providing a wide variety of useful resources and activities, including:
• Brain games, healthy recipes, fitness activities, learning courses and more — all at
no additional cost
Let’s Move by UnitedHealthcare®
Let’s Move helps keep your mind, body and social life active. With simple resources,
tools, events and personalized support, Let’s Move helps you explore ways to eat well,
get fit, beat the blues and stay connected — all at no cost to you.
1
A copay or coinsurance may apply if you receive services that are not part of the Annual Physical/Wellness Visit.
2
HouseCalls may not be available in all areas.
3
Please refer to your Summary of Benefits for details regarding your benefit coverage.
4
Network size varies by market.
5
Renew by UnitedHealthcare is not available in all plans.
*Reward offerings may vary by plan and are not available in all plans. Reward program Terms of Service apply.
© 2023 United HealthCare Services, Inc. All Rights Reserved.
23
Plan information
Summary of
Benefits 2024
GMA Comprehensive (PPO)
Group Name
(Plan Sponsor): The Episcopal Church Medical Trust
Group Number: 16241
H2001-847-000
Look inside to learn more about the plan and the health and drug services
it covers.
Call Customer Service or go online for more information about the plan.
Toll-free
1-866-519-5401,
TTY
711
8 a.m.-8 p.m. local time, Monday-Friday
retiree.uhc.com/ECMT
Y0066_SB_H2001_847_000_2024_M
24
Summary of benefits plan 1
Summary of Benefits
January 1, 2024 - December 31, 2024
This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for
a complete list of covered services, limitations and exclusions. You can call Customer Service if
you want a copy of the EOC or need help. When you enroll in the plan, you will get more
information on how to view your plan details online.
GMA Comprehensive (PPO)
Medical premium and limits
In-network and out-of-network
Monthly plan premium
Contact your group plan benefit administrator to
determine your actual premium amount, if applicable.
Maximum out-of-pocket amount
(does not include prescription drugs)
Your plan has an annual combined in-network and
out-of-network out-of-pocket maximum of $2,000 for
this plan year.
If you reach the limit on out-of-pocket costs, you keep
getting covered hospital and medical services and
we will pay the full cost for the rest of the plan year.
Please note that you will still need to pay your
monthly premiums, if applicable, and cost-sharing for
your Part D prescription drugs.
25
Plan information
Medical benefits
In-network and out-of-network
Inpatient hospital care
1
$0 copay per stay
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient
hospital
1
Cost sharing for
additional plan
covered services
will apply.
Ambulatory
surgical center
(ASC)
$0 copay
Outpatient
surgery
$0 copay
Outpatient
hospital services,
including
observation
$0 copay
Doctor visits
Primary care
provider
$5 copay
Virtual doctor
visits
$5 copay
Specialists
1
$10 copay
Preventive
services
Routine physical $0 copay; 1 per plan year*
Medicare-covered
$0 copay
· Abdominal aortic aneurysm
screening
· Alcohol misuse counseling
· Annual wellness visit
· Bone mass measurement
· Breast cancer screening
(mammogram)
· Cardiovascular disease
(behavioral therapy)
· Cardiovascular screening
· Cervical and vaginal cancer
screening
· Colorectal cancer screenings
(colonoscopy, fecal occult blood
test, flexible sigmoidoscopy)
· Depression screening
· Diabetes screenings and
monitoring
· Diabetes – Self-Management
training
· Dialysis training
· Glaucoma screening
· Hepatitis C screening
· HIV screening
· Kidney disease education
· Lung cancer with low dose
computed tomography (LDCT)
screening
· Medical nutrition therapy
services
26
Medical benefits
In-network and out-of-network
· Medicare Diabetes Prevention
Program (MDPP)
· Obesity screenings and
counseling
· Prostate cancer screenings
(PSA)
· Sexually transmitted infections
screenings and counseling
· Tobacco use cessation
counseling (counseling for
people with no sign of tobacco-
related disease)
· Vaccines, including those for the
flu, Hepatitis B, pneumonia, or
COVID-19
· “Welcome to Medicare”
preventive visit (one-time)
Any additional preventive services approved by Medicare during the
contract year will be covered.
This plan covers preventive care screenings and annual physical exams at
100%.
Emergency care
$100 copay (worldwide)
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital cost sharing instead of
the emergency care copay. See the “Inpatient
Hospital Care” section of this booklet for other costs.
Urgently needed services
$10 copay (worldwide)
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital cost sharing instead of
the urgently needed services copay. See the
“Inpatient Hospital Care” section of this booklet for
other costs.
Diagnostic tests,
lab and radiology
services, and X-
rays
Diagnostic
radiology services
(e.g. MRI, CT
scan)
1
$0 copay
Lab services
1
$0 copay
Diagnostic tests
and procedures
1
$0 copay
Therapeutic
radiology
1
$0 copay
Outpatient X-rays
1
$0 copay
27
Plan information
Medical benefits
In-network and out-of-network
Hearing services
Exam to diagnose
and treat hearing
and balance
issues
1
$10 copay
Routine hearing
exam^
$0 copay, 1 exam per plan year*
Hearing Aids^
UnitedHealthcare
Hearing
Through UnitedHealthcare Hearing, the plan pays a
$3,000 allowance for hearing aids (combined for both
ears) every 3 years. Hearing aid coverage under this
plan is only available through UnitedHealthcare
Hearing.
Vision services
Exam to diagnose
and treat diseases
and conditions of
the eye
1
$10 copay
Eyewear after
cataract surgery
$0 copay
Mental
Health
Inpatient visit
1
$0 copay per stay
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient group
therapy visit
1
$10 copay
Outpatient
individual therapy
visit
1
$10 copay
Virtual behavioral
visits
$10 copay
Skilled nursing facility (SNF)
1
$0 copay per day: days 1-100
Our plan covers up to 100 days in a SNF per benefit
period.
Outpatient Rehabilitation (physical,
occupational, or speech/language
therapy)
1
$0 copay
Ambulance
2
$25 copay
28
Medical benefits
In-network and out-of-network
Post-discharge routine transportation
ModivCare
$0 copay for up to 30 days upon referral from a
UnitedHealthcare Engagement Specialist,
immediately following inpatient hospital discharges or
skilled nursing facility stays. Benefit is offered through
ModivCare to plan approved, medically related
appointments (locations). Restrictions apply.
Call or go online to schedule your trip after you've
received your referral from a UnitedHealthcare
Engagement Specialist. 1-833-219-1182, TTY
1-844-488-9724, or visit modivcare.com/BookNow
Medicare Part B
Drugs
Part B drugs may
be subject to Step
Therapy. See your
Evidence of
Coverage for
details.
Chemotherapy
drugs
1
20% coinsurance
Other Part B
drugs
1
20% coinsurance
29
Plan information
Prescription drugs
If the actual cost for 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.
Your plan sponsor has chosen to make supplemental drug coverage available to you. This
coverage is in addition to your Part D prescription drug benefit. The drug copays in this section are
for drugs that are covered by both your Part D prescription drug benefit and your supplemental
drug coverage. You can view the Certificate of Coverage at retiree.uhc.com/ECMT or call Customer
Service to have a hard copy sent to you.
Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug
Coverage list for more information.
If you reside in a long-term care facility, you will pay the same for a 31-day supply as a 31-day
supply at a retail pharmacy.
Stage 1: Annual
prescription (Part
D) deductible
Since you have no deductible, this payment stage doesn’t apply.
Stage 2:
Initial coverage
(After you pay
your deductible,
if applicable)
Retail Cost-Sharing Mail Order Cost-Sharing
31-day supply 90-day supply
Tier 1:
Preferred Generic
$10 copay $25 copay
Tier 2:
Preferred Brand
1
$30 copay $70 copay
Tier 3:
Non-preferred
Drug
1
$50 copay $120 copay
Tier 4:
Specialty Tier
1
$50 copay $120 copay
Stage 3:
Coverage
Gap Stage
After your total drug costs reach $5,030, the plan continues to pay its share
of the cost of your drugs and you pay your share of the cost.
Stage 4:
Catastrophic
coverage
During this payment stage,the plan pays the full cost for your covered
drugs. You pay nothing.
1
You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by
our plan. Most adult Part D vaccines are covered at no cost to you.
30
Additional benefits
In-network and out-of-network
Acupuncture
services
Medicare-covered
acupuncture
(for chronic low
back pain)
$10 copay
Routine
acupuncture
services^
$10 copay, up to 12 visits per plan year*
Chiropractic
services
Medicare-covered
chiropractic care
(manual
manipulation of
the spine to
correct
subluxation)
1
$10 copay
Routine
chiropractic
services^
$10 copay, for each visit per plan year*
Diabetes
management
Diabetes
monitoring
supplies
1
$0 copay
We only cover Accu-Chek® and OneTouch® brands.
Covered glucose monitors include: OneTouch Verio
Flex®, OneTouch Verio Reflect®, OneTouch® Verio,
OneTouch® Ultra 2, Accu-Chek® Guide Me, and
Accu-Chek® Guide.
Test strips: OneTouch Verio®, OneTouch Ultra®,
Accu-Chek® Guide, Accu-Chek® Aviva Plus, and
Accu-Chek® SmartView.
Other brands are not covered by your plan.
Medicare covered
Continuous
Glucose Monitors
(CGMs) and
supplies
1
$0 copay
Diabetes self-
management
training
$0 copay
31
Plan information
Additional benefits
In-network and out-of-network
Therapeutic
shoes or inserts
1
20% coinsurance
Durable Medical
Equipment
(DME) and
Related Supplies
Durable Medical
Equipment (e.g.,
wheelchairs,
oxygen)
1
20% coinsurance
Prosthetics (e.g.,
braces, artificial
limbs)
1
20% coinsurance
Fitness program
Renew Active® by UnitedHealthcare
$0 copay for Renew Active® by UnitedHealthcare, the
gold standard in Medicare fitness programs for body
and mind. It includes a free gym membership at a
fitness location you select from our nationwide
network, online classes, content about brain health
and fun social activities. Visit UHCRenewActive.com
to learn more today.
Once you become a member you will need a
confirmation code. Log in to your plan website, go to
Health & Wellness and select Renew Active or call the
number on your UnitedHealthcare member ID card to
obtain your code.
Foot care
(podiatry
services)
Foot exams and
treatment
1
$10 copay
Routine foot care^ $10 copay, 6 visits per plan year*
Global travel assistance
UnitedHealthcare Global
$0 copay for UnitedHealthcare Global Assistance, a
service that provides travel and medical assistance to
Medicare members while they're away from home. It
includes 24-hour a day access while you're traveling
outside your country or over 100 miles away from
your home.
You'll receive a separate ID card for UnitedHealthcare
Global Assistance that includes contact information
for the Emergency Response Center (ERC).
1-410-453-6330 or email [email protected].
Register for an Intelligence Center account at
worldwatch.uhcglobal.com.
32
Additional benefits
In-network and out-of-network
Home health care
1
$0 copay
Hospice
You pay nothing for hospice care from any Medicare-
approved hospice. You may have to pay part of the
costs for drugs and respite care. Hospice is covered
by Original Medicare, outside of our plan.
Non-medical personal care
CareLinx
$0 copay for 8 hours every month of non-medical
personal care like companionship, meal prep,
medication reminders and more with a CareLinx
professional caregiver. Unused hours do not roll over.
Some restrictions and limitations apply. Call or go
online to get non-medical personal care services.
1-833-253-5403 or carelinx.com/uhcgroup.
Post-Discharge meal delivery benefit
$0 copay for 84 home-delivered meals immediately
following one inpatient hospitalization or SNF stay
when referred by a UnitedHealthcare Engagement
Specialist. This benefit can be used once per year.
Restrictions apply. Call Customer Service to request a
referral.
24/7 Nurse Support
Receive access to nurse consultations and additional
clinical resources at no additional cost.
Opioid treatment program services
1
$0 copay
Outpatient
substance abuse
Outpatient group
therapy visit
1
$10 copay
Outpatient
individual therapy
visit
1
$10 copay
Renal Dialysis
1
$20 copay
1
Some of the network benefits listed may require your provider to obtain prior authorization. You never need approval
in advance for plan covered services from out-of-network providers. Please refer to the Evidence of Coverage for a
complete list of services that may require prior authorization.
2
Authorization is required for non-emergency Medicare-covered ambulance ground and air transportation. Emergency
ambulance does not require authorization.
*Benefits are combined in and out-of-network
^Covered services that do not count toward your maximum out-of-pocket amount.
33
Plan information
About this plan
GMA Comprehensive (PPO) is a Medicare Advantage
PPO plan with a Medicare contract.
To join this plan, you must be entitled to Medicare Part A,
be
enrolled in Medicare Part B, live in our
service area as listed below, be a United States citizen or lawfully present in the United States, and
meet the eligibility requirements of your former employer, union group or trust administrator (plan
sponsor).
Our service area includes the 50 United States, the District of Columbia and all US territories.
About providers and network pharmacies
GMA Comprehensive (PPO) has a network of doctors, hospitals, pharmacies and other providers.
You can see any provider (network or out-of-network) at the same cost share, as long as they
accept the plan and have not opted out of or been excluded or precluded from the Medicare
Program.
If you use pharmacies that are not in our network, the plan may not pay for those drugs,
or you may pay more than you pay at a network pharmacy.
You can go to
retiree.uhc.com/ECMT
to search for a network provider
or
pharmacy using the
online directories. You can also view the plan Drug List (Formulary) to see what drugs are covered
and if there are any restrictions.
34
Required Information
GMA Comprehensive (PPO) is insured through UnitedHealthcare Insurance Company or one of its affiliated
companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s
contract renewal with Medicare.
Plans may offer supplemental benefits in addition to Part C and Part D benefits.
If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You"
handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.
UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability in health
programs and activities.
UnitedHealthcare provides free services to help you communicate with us such as documents in other languages,
Braille, large print, audio, or you can ask for an interpreter. For more information, please call Customer Service at the
number on your member ID card or the front of your plan booklet.
UnitedHealthcare ofrece servicios gratuitos para ayudarle a que se comunique con nosotros. Por ejemplo,
documentos en otros idiomas, braille, en letra grande o en audio. O bien, usted puede pedir un intérprete. Para
obtener más información, llame a Servicio al Cliente al número que se encuentra en su tarjeta de ID de miembro o en
la portada de la guía de su plan.
This information is available for free in other languages. Please call our Customer Service number located on the first
page of this book.
Benefits, features and/or devices vary by plan/area. Limitations and exclusions may apply.
You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. If you have
not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to
OptumRx before it can be filled. New prescriptions from OptumRx should arrive within five business days from the date
the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx
anytime at 1-888-279-1828, TTY 711. OptumRx is an affiliate of UnitedHealthcare Insurance Company.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when
necessary.
You must continue to pay your Medicare Part B premium.
Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in
emergency situations. Please call our customer service number or see your Evidence of Coverage for more
information, including the cost-sharing that applies to out-of-network services.
24/7 Nurse Support should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the
nearest emergency room. The information provided through this service is for informational purposes only. The nurses
cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health
information is kept confidential in accordance with the law. Access to this service is subject to terms of use.
Participation in the Renew Active® program is voluntary. Consult your doctor prior to beginning an exercise program or
making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership and other
offerings. Fitness membership, equipment, classes, personalized fitness plans, caregiver access and events may vary
by location. Certain services, classes, events and online fitness offerings are provided by affiliates of UnitedHealthcare
Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these third-party services
are subject to your acceptance of their respective terms and policies. AARP® Staying Sharp is the registered trademark
of AARP. UnitedHealthcare is not responsible for the services or information provided by third parties. The information
provided through these services is for informational purposes only and is not a substitute for the advice of a doctor.
The Renew Active program varies by plan/area. Access to gym and fitness location network may vary by location and
plan.
UHEX24PP0108642_000
35
Plan information
Summary of
Benefits 2024
GMA Premium (PPO)
Group Name
(Plan Sponsor): The Episcopal Church Medical Trust
Group Number: 16242
H2001-847-000
Look inside to learn more about the plan and the health and drug services
it covers.
Call Customer Service or go online for more information about the plan.
Toll-free
1-866-519-5401,
TTY
711
8 a.m.-8 p.m. local time, Monday-Friday
retiree.uhc.com/ECMT
Y0066_SB_H2001_847_000_2024_M
36
Summary of benefits plan 2
Summary of Benefits
January 1, 2024 - December 31, 2024
This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for
a complete list of covered services, limitations and exclusions. You can call Customer Service if
you want a copy of the EOC or need help. When you enroll in the plan, you will get more
information on how to view your plan details online.
GMA Premium (PPO)
Medical premium and limits
In-network and out-of-network
Monthly plan premium
Contact your group plan benefit administrator to
determine your actual premium amount, if applicable.
Maximum out-of-pocket amount
(does not include prescription drugs)
Your plan has an annual combined in-network and
out-of-network out-of-pocket maximum of $1,500 for
this plan year.
If you reach the limit on out-of-pocket costs, you keep
getting covered hospital and medical services and
we will pay the full cost for the rest of the plan year.
Please note that you will still need to pay your
monthly premiums, if applicable, and cost-sharing for
your Part D prescription drugs.
37
Plan information
Medical benefits
In-network and out-of-network
Inpatient hospital care
1
$0 copay per stay
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient
hospital
1
Cost sharing for
additional plan
covered services
will apply.
Ambulatory
surgical center
(ASC)
$0 copay
Outpatient
surgery
$0 copay
Outpatient
hospital services,
including
observation
$0 copay
Doctor visits
Primary care
provider
$5 copay
Virtual doctor
visits
$5 copay
Specialists
1
$10 copay
Preventive
services
Routine physical $0 copay; 1 per plan year*
Medicare-covered
$0 copay
· Abdominal aortic aneurysm
screening
· Alcohol misuse counseling
· Annual wellness visit
· Bone mass measurement
· Breast cancer screening
(mammogram)
· Cardiovascular disease
(behavioral therapy)
· Cardiovascular screening
· Cervical and vaginal cancer
screening
· Colorectal cancer screenings
(colonoscopy, fecal occult blood
test, flexible sigmoidoscopy)
· Depression screening
· Diabetes screenings and
monitoring
· Diabetes – Self-Management
training
· Dialysis training
· Glaucoma screening
· Hepatitis C screening
· HIV screening
· Kidney disease education
· Lung cancer with low dose
computed tomography (LDCT)
screening
· Medical nutrition therapy
services
38
Medical benefits
In-network and out-of-network
· Medicare Diabetes Prevention
Program (MDPP)
· Obesity screenings and
counseling
· Prostate cancer screenings
(PSA)
· Sexually transmitted infections
screenings and counseling
· Tobacco use cessation
counseling (counseling for
people with no sign of tobacco-
related disease)
· Vaccines, including those for the
flu, Hepatitis B, pneumonia, or
COVID-19
· “Welcome to Medicare”
preventive visit (one-time)
Any additional preventive services approved by Medicare during the
contract year will be covered.
This plan covers preventive care screenings and annual physical exams at
100%.
Emergency care
$50 copay (worldwide)
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital cost sharing instead of
the emergency care copay. See the “Inpatient
Hospital Care” section of this booklet for other costs.
Urgently needed services
$10 copay (worldwide)
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital cost sharing instead of
the urgently needed services copay. See the
“Inpatient Hospital Care” section of this booklet for
other costs.
Diagnostic tests,
lab and radiology
services, and X-
rays
Diagnostic
radiology services
(e.g. MRI, CT
scan)
1
$0 copay
Lab services
1
$0 copay
Diagnostic tests
and procedures
1
$0 copay
Therapeutic
radiology
1
$0 copay
Outpatient X-rays
1
$0 copay
39
Plan information
Medical benefits
In-network and out-of-network
Hearing services
Exam to diagnose
and treat hearing
and balance
issues
1
$10 copay
Routine hearing
exam^
$0 copay, 1 exam per plan year*
Hearing Aids^
UnitedHealthcare
Hearing
Through UnitedHealthcare Hearing, the plan pays a
$4,000 allowance for hearing aids (combined for both
ears) every 3 years. Hearing aid coverage under this
plan is only available through UnitedHealthcare
Hearing.
Vision services
Exam to diagnose
and treat diseases
and conditions of
the eye
1
$10 copay
Eyewear after
cataract surgery
$0 copay
Mental
Health
Inpatient visit
1
$0 copay per stay
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient group
therapy visit
1
$10 copay
Outpatient
individual therapy
visit
1
$10 copay
Virtual behavioral
visits
$10 copay
Skilled nursing facility (SNF)
1
$0 copay per day: days 1-100
Our plan covers up to 100 days in a SNF per benefit
period.
Outpatient Rehabilitation (physical,
occupational, or speech/language
therapy)
1
$0 copay
Ambulance
2
$25 copay
40
Medical benefits
In-network and out-of-network
Post-discharge routine transportation
ModivCare
$0 copay for up to 30 days upon referral from a
UnitedHealthcare Engagement Specialist,
immediately following inpatient hospital discharges or
skilled nursing facility stays. Benefit is offered through
ModivCare to plan approved, medically related
appointments (locations). Restrictions apply.
Call or go online to schedule your trip after you've
received your referral from a UnitedHealthcare
Engagement Specialist. 1-833-219-1182, TTY
1-844-488-9724, or visit modivcare.com/BookNow
Medicare Part B
Drugs
Part B drugs may
be subject to Step
Therapy. See your
Evidence of
Coverage for
details.
Chemotherapy
drugs
1
10% coinsurance
Other Part B
drugs
1
10% coinsurance
41
Plan information
Prescription drugs
If the actual cost for 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.
Your plan sponsor has chosen to make supplemental drug coverage available to you. This
coverage is in addition to your Part D prescription drug benefit. The drug copays in this section are
for drugs that are covered by both your Part D prescription drug benefit and your supplemental
drug coverage. You can view the Certificate of Coverage at retiree.uhc.com/ECMT or call Customer
Service to have a hard copy sent to you.
Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug
Coverage list for more information.
If you reside in a long-term care facility, you will pay the same for a 31-day supply as a 31-day
supply at a retail pharmacy.
Stage 1: Annual
prescription (Part
D) deductible
Since you have no deductible, this payment stage doesn’t apply.
Stage 2:
Initial coverage
(After you pay
your deductible,
if applicable)
Retail Cost-Sharing Mail Order Cost-Sharing
31-day supply 90-day supply
Tier 1:
Preferred Generic
$5 copay $12 copay
Tier 2:
Preferred Brand
1
$25 copay $60 copay
Tier 3:
Non-preferred
Drug
1
$40 copay $100 copay
Tier 4:
Specialty Tier
1
$40 copay $100 copay
Stage 3:
Coverage
Gap Stage
After your total drug costs reach $5,030, the plan continues to pay its share
of the cost of your drugs and you pay your share of the cost.
Stage 4:
Catastrophic
coverage
During this payment stage,the plan pays the full cost for your covered
drugs. You pay nothing.
1
You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by
our plan. Most adult Part D vaccines are covered at no cost to you.
42
Additional benefits
In-network and out-of-network
Acupuncture
services
Medicare-covered
acupuncture
(for chronic low
back pain)
$10 copay
Routine
acupuncture
services^
$10 copay, up to 12 visits per plan year*
Chiropractic
services
Medicare-covered
chiropractic care
(manual
manipulation of
the spine to
correct
subluxation)
1
$10 copay
Routine
chiropractic
services^
$10 copay, for each visit per plan year*
Diabetes
management
Diabetes
monitoring
supplies
1
$0 copay
We only cover Accu-Chek® and OneTouch® brands.
Covered glucose monitors include: OneTouch Verio
Flex®, OneTouch Verio Reflect®, OneTouch® Verio,
OneTouch® Ultra 2, Accu-Chek® Guide Me, and
Accu-Chek® Guide.
Test strips: OneTouch Verio®, OneTouch Ultra®,
Accu-Chek® Guide, Accu-Chek® Aviva Plus, and
Accu-Chek® SmartView.
Other brands are not covered by your plan.
Medicare covered
Continuous
Glucose Monitors
(CGMs) and
supplies
1
$0 copay
Diabetes self-
management
training
$0 copay
43
Plan information
Additional benefits
In-network and out-of-network
Therapeutic
shoes or inserts
1
10% coinsurance
Durable Medical
Equipment
(DME) and
Related Supplies
Durable Medical
Equipment (e.g.,
wheelchairs,
oxygen)
1
10% coinsurance
Prosthetics (e.g.,
braces, artificial
limbs)
1
10% coinsurance
Fitness program
Renew Active® by UnitedHealthcare
$0 copay for Renew Active® by UnitedHealthcare, the
gold standard in Medicare fitness programs for body
and mind. It includes a free gym membership at a
fitness location you select from our nationwide
network, online classes, content about brain health
and fun social activities. Visit UHCRenewActive.com
to learn more today.
Once you become a member you will need a
confirmation code. Log in to your plan website, go to
Health & Wellness and select Renew Active or call the
number on your UnitedHealthcare member ID card to
obtain your code.
Foot care
(podiatry
services)
Foot exams and
treatment
1
$10 copay
Routine foot care^ $10 copay, 6 visits per plan year*
Global travel assistance
UnitedHealthcare Global
$0 copay for UnitedHealthcare Global Assistance, a
service that provides travel and medical assistance to
Medicare members while they're away from home. It
includes 24-hour a day access while you're traveling
outside your country or over 100 miles away from
your home.
You'll receive a separate ID card for UnitedHealthcare
Global Assistance that includes contact information
for the Emergency Response Center (ERC).
1-410-453-6330 or email [email protected].
Register for an Intelligence Center account at
worldwatch.uhcglobal.com.
44
Additional benefits
In-network and out-of-network
Home health care
1
$0 copay
Hospice
You pay nothing for hospice care from any Medicare-
approved hospice. You may have to pay part of the
costs for drugs and respite care. Hospice is covered
by Original Medicare, outside of our plan.
Non-medical personal care
CareLinx
$0 copay for 8 hours every month of non-medical
personal care like companionship, meal prep,
medication reminders and more with a CareLinx
professional caregiver. Unused hours do not roll over.
Some restrictions and limitations apply. Call or go
online to get non-medical personal care services.
1-833-253-5403 or carelinx.com/uhcgroup.
Post-Discharge meal delivery benefit
$0 copay for 84 home-delivered meals immediately
following one inpatient hospitalization or SNF stay
when referred by a UnitedHealthcare Engagement
Specialist. This benefit can be used once per year.
Restrictions apply. Call Customer Service to request a
referral.
24/7 Nurse Support
Receive access to nurse consultations and additional
clinical resources at no additional cost.
Opioid treatment program services
1
$0 copay
Outpatient
substance abuse
Outpatient group
therapy visit
1
$10 copay
Outpatient
individual therapy
visit
1
$10 copay
Renal Dialysis
1
$20 copay
1
Some of the network benefits listed may require your provider to obtain prior authorization. You never need approval
in advance for plan covered services from out-of-network providers. Please refer to the Evidence of Coverage for a
complete list of services that may require prior authorization.
2
Authorization is required for non-emergency Medicare-covered ambulance ground and air transportation. Emergency
ambulance does not require authorization.
*Benefits are combined in and out-of-network
^Covered services that do not count toward your maximum out-of-pocket amount.
45
Plan information
About this plan
GMA Premium (PPO) is a Medicare Advantage
PPO plan with a Medicare contract.
To join this plan, you must be entitled to Medicare Part A,
be
enrolled in Medicare Part B, live in our
service area as listed below, be a United States citizen or lawfully present in the United States, and
meet the eligibility requirements of your former employer, union group or trust administrator (plan
sponsor).
Our service area includes the 50 United States, the District of Columbia and all US territories.
About providers and network pharmacies
GMA Premium (PPO) has a network of doctors, hospitals, pharmacies and other providers. You can
see any provider (network or out-of-network) at the same cost share, as long as they accept the
plan and have not opted out of or been excluded or precluded from the Medicare Program.
If you
use pharmacies that are not in our network, the plan may not pay for those drugs, or you may pay
more than you pay at a network pharmacy.
You can go to
retiree.uhc.com/ECMT
to search for a network provider
or
pharmacy using the
online directories. You can also view the plan Drug List (Formulary) to see what drugs are covered
and if there are any restrictions.
46
Required Information
GMA Premium (PPO) is insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract
renewal with Medicare.
Plans may offer supplemental benefits in addition to Part C and Part D benefits.
If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You"
handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.
UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability in health
programs and activities.
UnitedHealthcare provides free services to help you communicate with us such as documents in other languages,
Braille, large print, audio, or you can ask for an interpreter. For more information, please call Customer Service at the
number on your member ID card or the front of your plan booklet.
UnitedHealthcare ofrece servicios gratuitos para ayudarle a que se comunique con nosotros. Por ejemplo,
documentos en otros idiomas, braille, en letra grande o en audio. O bien, usted puede pedir un intérprete. Para
obtener más información, llame a Servicio al Cliente al número que se encuentra en su tarjeta de ID de miembro o en
la portada de la guía de su plan.
This information is available for free in other languages. Please call our Customer Service number located on the first
page of this book.
Benefits, features and/or devices vary by plan/area. Limitations and exclusions may apply.
You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. If you have
not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to
OptumRx before it can be filled. New prescriptions from OptumRx should arrive within five business days from the date
the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx
anytime at 1-888-279-1828, TTY 711. OptumRx is an affiliate of UnitedHealthcare Insurance Company.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when
necessary.
You must continue to pay your Medicare Part B premium.
Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in
emergency situations. Please call our customer service number or see your Evidence of Coverage for more
information, including the cost-sharing that applies to out-of-network services.
24/7 Nurse Support should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the
nearest emergency room. The information provided through this service is for informational purposes only. The nurses
cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health
information is kept confidential in accordance with the law. Access to this service is subject to terms of use.
Participation in the Renew Active® program is voluntary. Consult your doctor prior to beginning an exercise program or
making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership and other
offerings. Fitness membership, equipment, classes, personalized fitness plans, caregiver access and events may vary
by location. Certain services, classes, events and online fitness offerings are provided by affiliates of UnitedHealthcare
Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these third-party services
are subject to your acceptance of their respective terms and policies. AARP® Staying Sharp is the registered trademark
of AARP. UnitedHealthcare is not responsible for the services or information provided by third parties. The information
provided through these services is for informational purposes only and is not a substitute for the advice of a doctor.
The Renew Active program varies by plan/area. Access to gym and fitness location network may vary by location and
plan.
UHEX24PP0108650_000
47
Plan information
Civil Rights Notice
The company complies with applicable federal civil rights laws and does not treat
members differently because of sex, age, race, color, disability, or national origin.
If you think you were treated unfairly because of your sex, age, race, color, disability, or national
origin, you can send a complaint to our Civil Rights Coordinator.
• Mail: Civil Rights Coordinator
UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UT 84130
You must send the complaint within 60 days of when you found out about it. A decision will be
sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look
at it again. If you need help with your complaint, please call the toll-free phone number listed on
the front of the booklet or your membership identication card (TTY 711).
You can also le a complaint with the U.S. Dept. of Health and Human Services.
• Online: https://www.hhs.gov/civil-rights/ling-a-complaint/index.html
• Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
• Mail: U.S. Department of Health and Human Services
200 Independence Ave SW
HHH Building, Room 509F
Washington, D.C. 20201
We provide free services to help you communicate with us.
Such as, letters in other languages or large print. Or you can
ask for an interpreter. To ask for help, please call the toll-free
phone number listed on the front of the booklet or your
membership identication card (TTY 711), Monday through
Friday, 8 a.m. to 8 p.m. ET.
UHEX24MP0115026_000
48
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or
drug plan. To get an interpreter, please call us using the toll-free number listed on the front of the
booklet. Someone who speaks your language can help you. This is a free service.
Spanish: Contamos con servicios gratuitos de intérprete para responder cualquier pregunta que
pudiera tener sobre nuestro plan de salud o de medicamentos. Para obtener los servicios de un
intérprete, llámenos al número de teléfono gratuito que figura en la portada del folleto. Una persona
que habla su idioma podrá ayudarle. Es un servicio gratuito.
Chinese Mandarin: 我们提供免费口译服务，解答您对我们的健康或药物计划的任何疑问。如需寻
找一名口译员，请使用宣传册前面列出的免费电话号码联系我们。一名与您讲相同语言的人可以为
您提供帮助。这是一项免费服务。
Chinese Cantonese: 我們提供免費的口譯服務，可回答您可能對我們的健康或藥物計劃的任何問
題。如需口譯員，請撥打本手冊正面的免付費電話號碼聯絡我們。會說您的語言的人可協助您。這
是免費服務。
Tagalog: Mayroon kaming libreng serbisyo ng interpreter para sagutin anumang tanong na maaaring
mayroon ka tungkol sa kalusugan o plano ng gamot. Para makakuha ng interpreter, pakitawagan kami
gamit ang libreng numerong nakalista sa harapan ng booklet. Sinumang nagsasalita ng wika mo ay
puwedeng makatulong sa iyo. Ang serbisyong ito ay libre.
French: Nous disposons de services d’interprétation gratuits pour répondre à toutes les questions
que vous pourriez vous poser sur notre régime d’assurance maladie ou d’assurance-médicaments.
Pour recevoir l’aide d’un interprète, veuillez nous appeler en composant le numéro gratuit figurant sur
votre carte d’identification de membre. Quelqu’un parlant votre langue peut vous aider. Ce service est
gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch viên miễn phí để trả lời các câu hỏi mà bạn có về chương
trình sức khoẻ hay thuốc của chúng tôi. Để gặp thông dịch viên, vui lòng gọi cho chúng tôi theo số điện
thoại được liệt kê ở mặt trước của quyển sách nhỏ (booklet). Người nói cùng ngôn ngữ với bạn có thể giúp
bạn. Đây là dịch vụ miễn phí.
German: Wir verfügen über kostenlose Dolmetscherdienste, um alle Fragen zu beantworten, die Sie
über unseren Gesundheits- oder Medikamentenplan haben mögen. Um einen Dolmetscher zu
erhalten, rufen Sie uns bitte unter der kostenfreien Nummer an, die auf der Vorderseite der Broschüre
aufgeführt ist. Jemand, der Ihre Sprache spricht, kann Ihnen helfen. Dies ist eine kostenlose
Dienstleistung.
Korean: 건강 또는 의약품 플랜에 관한 질문에 답변해드리기 위해 무료 통역 서비스를 제공합니다.
통역 서비스를 이용하려면, 책자 앞면에 있는 수신자 부담 전화번호로 전화해 주십시오. 한국어를
사용하는 통역사가 도움을 드릴 수 있습니다. 이 서비스는 무료입니다.
49
Plan information
.
Russian: Если у Вас возникнут какие-либо вопросы о нашем плане медицинского страхования или
плане по приобретению препаратов, мы предоставим Вам бесплатные услуги устного перевода. Для
того чтобы воспользоваться услугами устного перевода, пожалуйста, свяжитесь с нами по
бесплатному номеру телефона, указанному на лицевой стороне брошюры. Сотрудник, который
говорит на Вашем языке, сможет Вам помочь. Данная услуга предоставляется бесплатно.
ﻰﻠﻋ لوﺻﺣﻠﻟ . ﺎﻧﺑ ﺔﺻﺎﺧﻟا ﺔﯾودﻷا ﺔطﺧ وأ ﺔﯾﺣﺻﻟا ﺔطﺧﻟا لوﺣ كﯾدﻟ نوﻛﺗ دﻗ ﺔﻠﺋﺳأ يأ ﻰﻠﻋ درﻠﻟ ﺔﯾروﻓ ﺔﻣﺟرﺗ تﺎﻣدﺧ ﺎﻧﯾدﻟ :Arabic
هذھ .كﺗﻐﻟ ثدﺣﺗﯾ ﺎﻣ صﺧﺷ كدﻋﺎﺳﯾﺳ . بﯾﺗﻛﻟا نﻣ ﻲﻣﺎﻣﻷا ءزﺟﻟا ﻰﻠﻋ دوﺟوﻣﻟا ﻲﻧﺎﺟﻣﻟا فﺗﺎﮭﻟا مﻗر مادﺧﺗﺳﺎﺑ ﺎﻧﺑ لﺻﺗا كﻠﺿﻓ نﻣ ،مﺟرﺗﻣ
ﺔﯾﻧﺎﺟﻣ ﺔﻣدﺧ
Hindi:
, -
Italian: Mettiamo a disposizione un servizio di interpretariato gratuito per rispondere a eventuali
domande sul nostro piano sanitario o farmaceutico. Per avvalersi di un interprete, si prega di chiamare
il numero verde riportato nella parte anteriore dell’opuscolo. Una persona che parla italiano potrà
fornire l’assistenza richiesta. Il servizio è gratuito.
Portuguese: Dispomos de serviços de intérprete gratuitos para esclarecer quaisquer dúvidas que
tenha sobre o nosso plano de saúde ou medicação. Para obter um intérprete, contacte-nos através do
número gratuito indicado na parte da frente da brochura. Alguém que fala a sua língua pode ajudá-
lo(a). Este é um serviço gratuito.
French Creole: Nou gen sèvis entèprèt gratis pou reponn tout kesyon ou gendwa genyen konsènan
plan sante oswa medikaman nou an. Pou jwenn yon entèprèt, tanpri rele nou apati nimewo gratis pou
apèl ki sou lis devan livrè an. Yon moun ki pale lang ou ka ede ou. Sa se yon sèvis gratis.
Polish: Oferujemy bezpłatne usługi tłumaczeniowe, aby odpowiedzieć na wszelkie pytania dotyczące
naszego planu ubezpieczenia zdrowotnego lub planu refundacji leków. Aby skorzystać z pomocy
tłumacza, proszę zadzwonić pod bezpłatny numer telefonu podany na pierwszej stronie broszury.
Osoba posługująca się Pana/Pani językiem Panu/Pani pomoże. Usługa ta jest bezpłatna.
Japanese: 当社の医療または処方薬プランに関する質問にお答えするために、無料の通訳サービ
スをご利用いただけます。 通訳が必要な場合には、本冊子の表面に記載されているフリーダイヤ
ル番号を使用して、当社までお問い合わせください。 お客様の言語を話す通訳者がお手伝いいた
します。 これは無料のサービスです。
50
UHEX23MP0008329_000
Drug List
Drug list
Drug List
This is a partial alphabetical list of prescription drugs covered by the plan as of September 1, 2023.
This list can change throughout the year. Call us or go online for the most complete, up-to-date
information. Our phone number and website are listed on the back cover of this book.
· Brand name drugs are in bold type. Generic drugs are in plain type.
· Covered drugs are placed in tiers. Each tier has a different cost:
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-preferred Drug
Tier 4: Specialty Tier
· Each tier has a copay or coinsurance amount.
· See the Summary of Benefits in this book to find out what you’ll pay for these drugs.
· Some drugs have coverage requirements, such as prior authorization or step therapy. If your
drug has any coverage rules or limits, there will be code(s) in the list. The codes and what
they mean are shown below.
PA
Prior authorization
The plan needs more information from your doctor to make sure the drug
is being used correctly for a medical condition covered by Medicare. If you
don’t get prior approval, it may not be covered.
QL
Quantity limits
The plan only covers a certain amount of this drug for 1 copay or over a
certain number of days. Limits help make sure the drug is used safely. If
your doctor prescribes more than the limit, you or your doctor can ask the
plan to cover the additional quantity.
ST
Step therapy
You may need to try lower-cost drugs that treat the same condition before
the plan will cover your drug. If you have tried other drugs or your doctor
thinks they are not right for you, you or your doctor can ask the plan for
coverage.
B/D
Medicare Part B
or Part D
Depending on how this drug is used, it may be covered by Medicare Part B
or Part D. Your doctor may need to give the plan more information about
how this drug will be used to make sure it’s covered correctly.
HRM
High-risk
medication
This drug is known as a high-risk medication (HRM) for patients 65 years
and older. This drug may cause side effects if taken on a regular basis. We
suggest you talk with your doctor to see if an alternative drug is available to
treat your condition.
52
Drug list
LA
Limited access
The FDA only lets certain facilities or doctors give out this drug. It may
require extra handling, doctor coordination or patient education.
MME
Morphine
milligram
equivalent
Additional quantity limits may apply across all drugs in the opioid class
used for the treatment of pain. This additional limit is called a cumulative
morphine milligram equivalent (MME) and is designed to monitor safe
dosing levels of opioids for individuals who may be taking more than 1
opioid drug for pain management. If your doctor prescribes more than this
amount or thinks the limit is not right for your situation, you or your doctor
can ask the plan to cover the additional quantity.
7D
7-day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-
day supply for members with no recent history of opioid use. This limit is
intended to minimize long-term opioid use. For members who are new to
the plan and have a recent history of using opioids, the limit may be
overridden by the pharmacy when appropriate.
DL
Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1-month
supply per prescription.
A
Abacavir Sulfate-Lamivudine (Oral Tablet),T1 -
QL
Abilify Maintena (Intramuscular Prefilled
Syringe),T4
Abilify Maintena (Intramuscular Suspension
Reconstituted ER),T4
Abiraterone Acetate (250MG Oral Tablet),T1 - PA
Acamprosate Calcium (Oral Tablet Delayed
Release),T1
Acetaminophen-Codeine (300-15MG Oral Tablet,
300-30MG Oral Tablet, 300-60MG Oral
Tablet),T1 - 7D; MME; DL; QL
Acetazolamide (Oral Tablet),T1
Acetazolamide ER (Oral Capsule Extended
Release 12 Hour),T1
Actimmune (Subcutaneous Solution),T4
Acyclovir (Oral Capsule),T1
Acyclovir (Oral Tablet),T1
Adacel (Intramuscular Suspension),T2 - QL
Adbry (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Advair Diskus (Inhalation Aerosol Powder
Breath Activated),T1 - QL
Advair HFA (Inhalation Aerosol),T2 - QL
Aimovig (Subcutaneous Solution Auto-
Injector),T3 - PA; QL
Albendazole (Oral Tablet),T1 - QL
Albuterol Sulfate HFA (108 (90 Base)MCG/ACT
Inhalation Aerosol Solution) (Generic Proair),
Albuterol Sulfate HFA (108 (90 Base)MCG/ACT
Inhalation Aerosol Solution) (Generic
Proventil),T1
Alcohol Prep Pads,T2
Alecensa (Oral Capsule),T4 - PA
Alendronate Sodium (10MG Oral Tablet, 35MG
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
53
Drug list
Oral Tablet, 70MG Oral Tablet),T1
Alfuzosin HCl ER (Oral Tablet Extended Release
24 Hour),T1
Allopurinol (100MG Oral Tablet, 300MG Oral
Tablet),T1
Alphagan P (Ophthalmic Solution),T3
Alprazolam (Oral Tablet Immediate Release),T1 -
QL
Alrex (Ophthalmic Suspension),T3
Alvesco (Inhalation Aerosol Solution),T3 - ST;
QL
Amantadine HCl (Oral Capsule),T1
Amantadine HCl (Oral Solution),T1
Amantadine HCl (Oral Tablet),T1
Ambrisentan (Oral Tablet),T1 - PA; QL
Amiloride HCl (Oral Tablet),T1
Amiodarone HCl (Oral Tablet),T1
Amitriptyline HCl (Oral Tablet),T1 - HRM
Amlodipine Besylate (Oral Tablet),T1
Amlodipine-Benazepril (Oral Capsule),T1 - QL
Ammonium Lactate (External Cream),T1
Ammonium Lactate (External Lotion),T1
Amoxicillin (Oral Capsule),T1
Amoxicillin (Oral Tablet Immediate Release),T1
Amphetamine-Dextroamphetamine (Oral
Tablet),T1 - QL
Amphetamine-Dextroamphetamine ER (Oral
Capsule Extended Release 24 Hour),T1 - QL
Anastrozole (Oral Tablet),T1
Anoro Ellipta (Inhalation Aerosol Powder
Breath Activated),T2 - QL
Apriso (Oral Capsule Extended Release 24
Hour),T2 - QL
Aranesp (Albumin Free) (100MCG/0.5ML
Injection Solution Prefilled Syringe, 150MCG/
0.3ML Injection Solution Prefilled Syringe,
200MCG/0.4ML Injection Solution Prefilled
Syringe, 300MCG/0.6ML Injection Solution
Prefilled Syringe, 500MCG/ML Injection
Solution Prefilled Syringe, 60MCG/0.3ML
Injection Solution Prefilled Syringe),T4 - PA
Aranesp (Albumin Free) (100MCG/ML
Injection Solution, 200MCG/ML Injection
Solution),T4 - PA
Aranesp (Albumin Free) (10MCG/0.4ML
Injection Solution Prefilled Syringe, 25MCG/
0.42ML Injection Solution Prefilled Syringe,
40MCG/0.4ML Injection Solution Prefilled
Syringe),T3 - PA
Aranesp (Albumin Free) (25MCG/ML Injection
Solution, 40MCG/ML Injection Solution,
60MCG/ML Injection Solution),T3 - PA
Aripiprazole (Oral Tablet),T1 - QL
Aristada (Intramuscular Prefilled Syringe),T4
Aristada Initio (Intramuscular Prefilled
Syringe),T4
Arnuity Ellipta (Inhalation Aerosol Powder
Breath Activated),T2 - QL
Asmanex (120 Metered Doses) (Inhalation
Aerosol Powder Breath Activated),T3 - ST; QL
Asmanex (30 Metered Doses) (Inhalation
Aerosol Powder Breath Activated),T3 - ST; QL
Asmanex (60 Metered Doses) (Inhalation
Aerosol Powder Breath Activated),T3 - ST; QL
Asmanex HFA (Inhalation Aerosol),T3 - ST; QL
Aspirin-Dipyridamole ER (Oral Capsule Extended
Release 12 Hour),T1 - QL
Astagraf XL (Oral Capsule Extended Release
24 Hour),T3 - B/D,PA
Atazanavir Sulfate (Oral Capsule),T1 - QL
Atenolol (Oral Tablet),T1
Atomoxetine HCl (Oral Capsule),T1
Atorvastatin Calcium (Oral Tablet),T1 - QL
Atovaquone-Proguanil HCl (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
54
Atrovent HFA (Inhalation Aerosol Solution),T3
Austedo (Oral Tablet),T4 - PA; QL
Avonex Pen (Intramuscular Auto-Injector
Kit),T4
Avonex Prefilled (Intramuscular Prefilled
Syringe Kit),T4
Azasite (Ophthalmic Solution),T3
Azathioprine (50MG Oral Tablet),T1 - B/D,PA
Azelastine HCl (0.1% Nasal Solution),T1
Azelastine HCl (Ophthalmic Solution),T1
Azelastine-Fluticasone (Nasal Suspension),T1
Azithromycin (Oral Packet),T1
Azithromycin (Oral Tablet),T1
B
BRIVIACT (Oral Solution),T4 - PA
BRIVIACT (Oral Tablet),T4 - PA
Baclofen (Oral Tablet),T1
Bafiertam (Oral Capsule Delayed Release),T4 -
ST; QL
Balsalazide Disodium (Oral Capsule),T1
Baqsimi One Pack (Nasal Powder),T2
Basaglar KwikPen (Subcutaneous Solution
Pen-Injector),T3 - ST
Belsomra (Oral Tablet),T2 - QL
Benazepril HCl (Oral Tablet),T1 - QL
Benazepril-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Benztropine Mesylate (Oral Tablet),T1 - HRM
Bepreve (Ophthalmic Solution),T3
Berinert (Intravenous Kit),T4 - PA
Besivance (Ophthalmic Suspension),T3
Betaseron (Subcutaneous Kit),T4
Bethanechol Chloride (Oral Tablet),T1
Betimol (Ophthalmic Solution),T3
Bevespi Aerosphere (Inhalation Aerosol),T3 -
ST
Bexarotene (Oral Capsule),T1 - PA
Bicalutamide (Oral Tablet),T1
Bijuva (Oral Capsule),T3 - HRM
Biktarvy (50MG-200MG-25MG Oral Tablet),T4
- QL
Bisoprolol Fumarate (Oral Tablet),T1
Bisoprolol-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Breo Ellipta (Inhalation Aerosol Powder Breath
Activated),T2 - QL
Breztri Aerosphere (Inhalation Aerosol),T2 -
QL
Brilinta (Oral Tablet),T2 - QL
Brimonidine Tartrate (Ophthalmic Solution),T1
Brukinsa (Oral Capsule),T4 - PA; QL
Budesonide (Inhalation Suspension),T1 - B/D,PA
Budesonide (Oral Capsule Delayed Release
Particles),T1
Buprenorphine (Transdermal Patch Weekly),T1 -
7D; DL; QL
Buprenorphine HCl (Tablet Sublingual),T1 - QL
Buprenorphine HCl-Naloxone HCl (Sublingual
Film),T1 - QL
Bupropion HCl (Oral Tablet Immediate
Release),T1
Bupropion HCl ER (XL) (450MG Oral Tablet
Extended Release 24 Hour),T3
Bupropion HCl SR (150MG Oral Tablet
Extended Release 12 Hour Smoking-
Deterrent),T1
Bupropion HCl SR (Oral Tablet Extended
Release 12 Hour),T1
Bupropion HCl XL (150MG Oral Tablet Extended
Release 24 Hour, 300MG Oral Tablet Extended
Release 24 Hour),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
55
Drug list
Buspirone HCl (Oral Tablet),T1
Bydureon BCise (Subcutaneous Auto-
Injector),T3 - PA; QL
Byetta 10MCG Pen (Subcutaneous Solution
Pen-Injector),T3 - PA; QL
Byetta 5MCG Pen (Subcutaneous Solution
Pen-Injector),T3 - PA; QL
C
Cabergoline (Oral Tablet),T1
Calcitriol (Oral Capsule),T1 - B/D,PA
Calcium Acetate (667MG Oral Tablet),T1
Calcium Acetate (Phosphate Binder) (Oral
Capsule),T1
Carbamazepine (Oral Tablet Immediate
Release),T1
Carbidopa (Oral Tablet),T1
Carbidopa-Levodopa (Oral Tablet Immediate
Release),T1
Carbidopa-Levodopa ER (Oral Tablet Extended
Release),T1
Carbidopa-Levodopa ODT (Oral Tablet
Dispersible),T1
Carbidopa-Levodopa-Entacapone (Oral
Tablet),T1
Carvedilol (Oral Tablet),T1
Cefdinir (Oral Capsule),T1
Cefuroxime Axetil (Oral Tablet),T1
Celecoxib (Oral Capsule),T1 - QL
Celontin (Oral Capsule),T3
Cephalexin (Oral Capsule),T1
Cephalexin (Oral Tablet),T1
Chemet (Oral Capsule),T4
Chlorhexidine Gluconate (Mouth Solution),T1
Chlorthalidone (Oral Tablet),T1
Chlorzoxazone (500MG Oral Tablet, 750MG Oral
Tablet),T1 - HRM
Cholestyramine (Oral Packet),T1
Cholestyramine Light (Oral Packet),T1
Cibinqo (Oral Tablet),T4 - PA; QL
Cilostazol (Oral Tablet),T1
Cimetidine (Oral Tablet),T1
Cimetidine HCl (300MG/5ML Oral Solution),T1
Cimzia (Subcutaneous Kit),T4 - PA; QL
Cimzia Prefilled (2 X 200MG/ML
Subcutaneous Prefilled Syringe Kit),T4 - PA;
QL
Ciprofloxacin HCl (250MG Oral Tablet
Immediate Release, 500MG Oral Tablet
Immediate Release, 750MG Oral Tablet
Immediate Release),T1
Ciprofloxacin-Dexamethasone (Otic
Suspension),T1
Citalopram Hydrobromide (Oral Tablet),T1
Clarithromycin (Oral Tablet Immediate
Release),T1
Clenpiq (10MG-3.5GM-12GM/160ML Oral
Solution),T2
Climara Pro (Transdermal Patch Weekly),T3 -
HRM
Clobex (External Lotion),T4 - QL
Clobex (External Shampoo),T4
Clobex Spray (External Liquid),T3 - QL
Clonazepam (Oral Tablet),T1 - QL
Clonazepam ODT (Oral Tablet Dispersible),T1 -
QL
Clonidine (Transdermal Patch Weekly),T1
Clonidine HCl (Oral Tablet Immediate
Release),T1
Clopidogrel Bisulfate (75MG Oral Tablet),T1
Clozapine (Oral Tablet),T1
Clozapine ODT (Oral Tablet Dispersible),T1
Colchicine (0.6MG Oral Capsule) (Brand
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
56
Equivalent Mitigare),T2
Colchicine (0.6MG Oral Tablet) (Generic
Colcrys),T1
Colesevelam HCl (Oral Tablet),T1
Combigan (Ophthalmic Solution),T2
Combivent Respimat (Inhalation Aerosol
Solution),T2 - QL
Copaxone (Subcutaneous Solution Prefilled
Syringe),T4
Corlanor (Oral Solution),T3 - PA; QL
Corlanor (Oral Tablet),T3 - PA; QL
Cosentyx (300MG Dose) (Subcutaneous
Solution Prefilled Syringe),T4 - PA; QL
Cosentyx (75MG/0.5ML Subcutaneous
Solution Prefilled Syringe),T4 - PA; QL
Cosentyx Sensoready (300MG)
(Subcutaneous Solution Auto-Injector),T4 -
PA; QL
Cosopt PF (Ophthalmic Solution),T3
Creon (Oral Capsule Delayed Release
Particles),T2
Cromolyn Sodium (Inhalation Nebulization
Solution),T1 - B/D,PA
Cyclobenzaprine HCl (10MG Oral Tablet, 5MG
Oral Tablet),T1 - HRM
Cyclophosphamide (Oral Capsule),T1 - B/D,PA
D
DARAPRIM (Oral Tablet),T4
Dabigatran Etexilate Mesylate (Oral Capsule),T1
- QL
Dalfampridine ER (Oral Tablet Extended Release
12 Hour),T1 - QL
Daliresp (Oral Tablet),T3 - PA
Dapsone (Oral Tablet),T1
DayVigo (Oral Tablet),T2 - QL
Deferasirox (Oral Tablet Soluble) (Generic
Exjade),T1 - PA
Deferiprone (500MG Oral Tablet),T1 - PA
Depen Titratabs (Oral Tablet),T4
Descovy (200MG-25MG Oral Tablet),T4 - QL
Desmopressin Acetate (Oral Tablet),T1
Desvenlafaxine Succinate ER (Oral Tablet
Extended Release 24 Hour) (Generic Pristiq),T1
Dexamethasone (Oral Tablet),T1
Diazepam (10MG Oral Tablet, 2MG Oral Tablet,
5MG Oral Tablet),T1 - QL
Diazepam (5MG/5ML Oral Solution),T1
Diazepam Intensol (Oral Concentrate),T1 - QL
Diclofenac Potassium (50MG Oral Tablet),T1
Diclofenac Sodium (1% External Gel),T1
Diclofenac Sodium (Oral Tablet Delayed
Release),T1
Diclofenac Sodium ER (Oral Tablet Extended
Release 24 Hour),T1
Dicyclomine HCl (Oral Capsule),T1 - HRM
Dicyclomine HCl (Oral Tablet),T1 - HRM
Dificid (Oral Suspension Reconstituted),T4
Dificid (Oral Tablet),T4
Digoxin (125MCG Oral Tablet, 250MCG Oral
Tablet),T1 - HRM
Dihydroergotamine Mesylate (Nasal Solution),T1
- PA; QL
Diltiazem HCl (Oral Tablet Immediate
Release),T1
Diltiazem HCl ER (Oral Capsule Extended
Release 12 Hour),T1
Diltiazem HCl ER Beads (360MG Oral Capsule
Extended Release 24 Hour, 420MG Oral
Capsule Extended Release 24 Hour),T1
Diltiazem HCl ER Coated Beads (120MG Oral
Capsule Extended Release 24 Hour, 180MG
Oral Capsule Extended Release 24 Hour,
240MG Oral Capsule Extended Release 24
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
57
Drug list
Hour, 300MG Oral Capsule Extended Release
24 Hour),T1
Dimethyl Fumarate (240MG Oral Capsule
Delayed Release),T1 - QL
Dipentum (Oral Capsule),T4
Diphenoxylate-Atropine (Oral Tablet),T1 - HRM
Divalproex Sodium (Oral Capsule Delayed
Release Sprinkle),T1
Divalproex Sodium (Oral Tablet Delayed
Release),T1
Divalproex Sodium ER (Oral Tablet Extended
Release 24 Hour),T1
Donepezil HCl (Oral Tablet),T1 - QL
Donepezil HCl ODT (Oral Tablet Dispersible),T1 -
QL
Doptelet (Oral Tablet),T4 - PA; QL
Dorzolamide HCl (Ophthalmic Solution),T1
Dorzolamide HCl-Timolol Maleate
(22.3MG-6.8MG/ML Ophthalmic Solution),T1
Dovato (Oral Tablet),T4 - QL
Doxazosin Mesylate (Oral Tablet),T1
Doxycycline Hyclate (Oral Capsule),T1
Doxycycline Hyclate (Oral Tablet Immediate
Release),T1
Dronabinol (Oral Capsule),T1 - PA
Duavee (Oral Tablet),T3 - HRM
Dulera (Inhalation Aerosol),T3 - QL
Duloxetine HCl (20MG Oral Capsule Delayed
Release Particles, 30MG Oral Capsule Delayed
Release Particles, 60MG Oral Capsule Delayed
Release Particles),T1 - QL
Dupixent (Subcutaneous Solution Pen-
Injector),T4 - PA
Dupixent (Subcutaneous Solution Prefilled
Syringe),T4 - PA
Dutasteride (Oral Capsule),T1
Dymista (Nasal Suspension),T3
E
Edarbi (Oral Tablet),T3 - QL
Edarbyclor (Oral Tablet),T3 - QL
Efavirenz-Emtricitabine-Tenofovir (Oral
Tablet),T1 - QL
Eliquis (2.5MG Oral Tablet, 5MG Oral
Tablet),T2 - QL
Elmiron (Oral Capsule),T3
Emgality (120MG/ML Subcutaneous Solution
Prefilled Syringe),T3 - PA; QL
Emgality (300MG Dose) (100MG/ML
Subcutaneous Solution Prefilled Syringe),T3 -
PA; QL
Emgality (Subcutaneous Solution Auto-
Injector),T3 - PA; QL
Emtricitabine-Tenofovir Disoproxil Fumarate
(Oral Tablet),T1 - QL
Enalapril Maleate (Oral Tablet),T1 - QL
Enalapril-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Enbrel (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Enbrel (Subcutaneous Solution),T4 - PA; QL
Enbrel Mini (Subcutaneous Solution
Cartridge),T4 - PA; QL
Enbrel SureClick (Subcutaneous Solution
Auto-Injector),T4 - PA; QL
Entacapone (Oral Tablet),T1
Entecavir (Oral Tablet),T1
Entresto (Oral Tablet),T2 - QL
Envarsus XR (Oral Tablet Extended Release
24 Hour),T3 - B/D,PA
Epclusa (Oral Packet),T4 - PA; QL
Epclusa (Oral Tablet),T4 - PA; QL
EpiPen 2-Pak (Injection Solution Auto-
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
58
Injector),T3 - QL
EpiPen Jr 2-Pak (Injection Solution Auto-
Injector),T3 - QL
Epiduo (External Gel),T3
Epiduo Forte (External Gel),T3 - ST
Epinephrine (0.15MG/0.3ML Injection Solution
Auto-Injector, 0.3MG/0.3ML Injection Solution
Auto-Injector),T1 - QL
Eplerenone (Oral Tablet),T1
Ergoloid Mesylates (Oral Tablet),T1 - HRM
Ergotamine-Caffeine (Oral Tablet),T1
Erivedge (Oral Capsule),T4 - PA
Erleada (60MG Oral Tablet),T4 - PA
Ertapenem Sodium (Injection Solution
Reconstituted),T1
Erythromycin (Ophthalmic Ointment),T1
Esbriet (Oral Capsule),T4 - PA; QL
Esbriet (Oral Tablet),T4 - PA; QL
Escitalopram Oxalate (Oral Tablet),T1
Esomeprazole Magnesium (40MG Oral Capsule
Delayed Release) (Generic Nexium),T1 - QL
Estradiol (Oral Tablet),T1 - HRM
Estradiol (Transdermal Patch Twice Weekly),T1 -
HRM; QL
Estradiol (Transdermal Patch Weekly),T1 - HRM;
QL
Estradiol (Vaginal Cream),T1
Eszopiclone (Oral Tablet),T1 - HRM; QL
Ethambutol HCl (400MG Oral Tablet),T1
Ethosuximide (Oral Capsule),T1
Ethosuximide (Oral Solution),T1
Etravirine (200MG Oral Tablet),T1 - QL
Eucrisa (External Ointment),T3 - PA; QL
Extavia (Subcutaneous Kit),T4
Ezetimibe (Oral Tablet),T1
Ezetimibe-Simvastatin (Oral Tablet),T1 - QL
F
Famotidine (20MG Oral Tablet, 40MG Oral
Tablet),T1
Farxiga (Oral Tablet),T2 - QL
Fasenra (Subcutaneous Solution Prefilled
Syringe),T4 - PA
Fasenra Pen (Subcutaneous Solution Auto-
Injector),T4 - PA
Febuxostat (Oral Tablet),T1 - ST
Fenofibrate (145MG Oral Tablet, 160MG Oral
Tablet, 48MG Oral Tablet, 54MG Oral Tablet),T1
Finacea (External Foam),T3 - QL
Finacea (External Gel),T3 - QL
Finasteride (5MG Oral Tablet) (Generic
Proscar),T1
Flarex (Ophthalmic Suspension),T3
FloLipid (Oral Suspension),T3 - QL
Flovent Diskus (Inhalation Aerosol Powder
Breath Activated),T2
Flovent HFA (Inhalation Aerosol),T2 - QL
Fluconazole (Oral Tablet),T1
Fluoxetine HCl (10MG Oral Capsule Immediate
Release, 20MG Oral Capsule Immediate
Release, 40MG Oral Capsule Immediate
Release),T1
Fluphenazine HCl (Oral Tablet),T1
Fluticasone Propionate (Nasal Suspension),T1
Forteo (Subcutaneous Solution Pen-
Injector),T4 - PA
Furosemide (Oral Tablet),T1
Fuzeon (Subcutaneous Solution
Reconstituted),T4 - QL
G
Gabapentin (600MG Oral Tablet, 800MG Oral
Tablet),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
59
Drug list
Gabapentin (Oral Capsule),T1
Gammagard (2.5GM/25ML Injection
Solution),T4 - PA
Gammagard S/D Less IgA (Intravenous
Solution Reconstituted),T4 - PA
Gemfibrozil (Oral Tablet),T1
Gemtesa (Oral Tablet),T3
Genotropin (12MG Subcutaneous
Cartridge),T4 - PA
Genotropin (5MG Subcutaneous Cartridge),T3
- PA
Genotropin MiniQuick (0.2MG Subcutaneous
Prefilled Syringe),T3 - PA
Genotropin MiniQuick (0.4MG Subcutaneous
Prefilled Syringe, 0.6MG Subcutaneous
Prefilled Syringe, 0.8MG Subcutaneous
Prefilled Syringe, 1.2MG Subcutaneous
Prefilled Syringe, 1.4MG Subcutaneous
Prefilled Syringe, 1.6MG Subcutaneous
Prefilled Syringe, 1.8MG Subcutaneous
Prefilled Syringe, 1MG Subcutaneous Prefilled
Syringe, 2MG Subcutaneous Prefilled
Syringe),T4 - PA
Gentamicin Sulfate (40MG/ML Injection
Solution),T1
Genvoya (Oral Tablet),T4 - QL
Glatiramer Acetate (Subcutaneous Solution
Prefilled Syringe),T1
Glatopa (Subcutaneous Solution Prefilled
Syringe),T1
Glucagon (Injection Kit) (Lilly),T1
Glycopyrrolate (1MG Oral Tablet, 2MG Oral
Tablet),T1 - PA
Glyxambi (Oral Tablet),T2 - QL
Gvoke HypoPen 2-Pack (Subcutaneous
Solution Auto-Injector),T2
Gvoke Kit (Subcutaneous Solution),T2
Gvoke PFS (Subcutaneous Solution Prefilled
Syringe),T2
H
Haegarda (Subcutaneous Solution
Reconstituted),T4 - PA
Haloperidol (Oral Tablet),T1
Harvoni (90-400MG Oral Tablet),T4 - PA; QL
Harvoni (Oral Packet),T4 - PA; QL
Humalog (Injection Solution),T2
Humalog (Subcutaneous Solution
Cartridge),T2
Humalog Junior KwikPen (Subcutaneous
Solution Pen-Injector),T2
Humalog KwikPen (Subcutaneous Solution
Pen-Injector),T2
Humalog Mix 50/50 (Subcutaneous
Suspension),T2
Humalog Mix 50/50 KwikPen (Subcutaneous
Suspension Pen-Injector),T2
Humalog Mix 75/25 (Subcutaneous
Suspension),T2
Humalog Mix 75/25 KwikPen (Subcutaneous
Suspension Pen-Injector),T2
Humira (Subcutaneous Prefilled Syringe
Kit),T4 - PA; QL
Humira Pediatric Crohns Start (Subcutaneous
Prefilled Syringe Kit),T4 - PA; QL
Humira Pen (Subcutaneous Pen-Injector
Kit),T4 - PA; QL
Humira Pen Crohns Disease Starter
(Subcutaneous Pen-Injector Kit),T4 - PA
Humira Pen Psoriasis Starter (40MG/0.8ML
Subcutaneous Pen-Injector Kit),T4 - PA
Humira Pen Psoriasis Starter (80MG/0.8ML
and 40MG/0.4ML Subcutaneous Pen-Injector
Kit),T4 - PA; QL
Humira Pen-Pediatric UC Start (Subcutaneous
Pen-Injector Kit),T4 - PA
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
60
Humulin 70/30 (Subcutaneous
Suspension),T2
Humulin 70/30 KwikPen (Subcutaneous
Suspension Pen-Injector),T2
Humulin N (Subcutaneous Suspension),T2
Humulin N KwikPen (Subcutaneous
Suspension Pen-Injector),T2
Humulin R (Injection Solution),T2
Humulin R U-500 (Concentrated)
(Subcutaneous Solution),T2
Humulin R U-500 KwikPen (Subcutaneous
Solution Pen-Injector),T2
Hydralazine HCl (Oral Tablet),T1
Hydrochlorothiazide (Oral Capsule),T1
Hydrochlorothiazide (Oral Tablet),T1
Hydrocodone-Acetaminophen (10-325MG Oral
Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral
Tablet),T1 - 7D; MME; DL; QL
Hydromorphone HCl (Oral Tablet Immediate
Release),T1 - 7D; MME; DL; QL
Hydroxychloroquine Sulfate (200MG Oral
Tablet),T1 - QL
Hydroxyurea (Oral Capsule),T1
Hydroxyzine HCl (Oral Syrup),T1 - HRM
Hydroxyzine HCl (Oral Tablet),T1 - HRM
I
Ibandronate Sodium (Oral Tablet),T1
Ibuprofen (400MG Oral Tablet, 600MG Oral
Tablet, 800MG Oral Tablet),T1
Icatibant Acetate (Subcutaneous Solution
Prefilled Syringe),T1 - PA; QL
Ilevro (Ophthalmic Suspension),T2
Imatinib Mesylate (Oral Tablet),T1 - PA
Imbruvica (Oral Capsule),T4 - PA; QL
Imbruvica (Oral Tablet),T4 - PA; QL
Imiquimod (5% External Cream),T1 - QL
Imiquimod Pump (3.75% External Cream),T1 -
PA
Imvexxy Maintenance Pack (Vaginal Insert),T2
- PA
Incruse Ellipta (Inhalation Aerosol Powder
Breath Activated),T3 - ST; QL
Ingrezza (Oral Capsule Therapy Pack),T4 - PA;
QL
Ingrezza (Oral Capsule),T4 - PA; QL
Insulin Lispro (1 Unit Dial) (Subcutaneous
Solution Pen-Injector) (Brand Equivalent
Humalog),T2
Insulin Lispro (Injection Solution) (Brand
Equivalent Humalog),T2
Insulin Lispro Junior KwikPen (Subcutaneous
Solution Pen-Injector) (Brand Equivalent
Humalog),T2
Insulin Lispro Prot & Lispro (Subcutaneous
Suspension Pen-Injector) (Brand Equivalent
Humalog),T2
Insulin Syringes, Needles,T2
Invega Hafyera (Intramuscular Suspension
Prefilled Syringe),T4
Invega Sustenna (117MG/0.75ML
Intramuscular Suspension Prefilled Syringe,
156MG/ML Intramuscular Suspension
Prefilled Syringe, 234MG/1.5ML
Intramuscular Suspension Prefilled Syringe,
78MG/0.5ML Intramuscular Suspension
Prefilled Syringe),T4
Invega Sustenna (39MG/0.25ML
Intramuscular Suspension Prefilled
Syringe),T3
Invega Trinza (Intramuscular Suspension
Prefilled Syringe),T4
Inveltys (Ophthalmic Suspension),T3
Invokamet (Oral Tablet Immediate Release),T3
- ST; QL
Invokamet XR (Oral Tablet Extended Release
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
61
Drug list
24 Hour),T3 - ST; QL
Invokana (Oral Tablet),T3 - ST; QL
Ipratropium Bromide (Inhalation Solution),T1 - B/
D,PA
Ipratropium Bromide (Nasal Solution),T1
Ipratropium-Albuterol (Inhalation Solution),T1 -
B/D,PA
Irbesartan (Oral Tablet),T1 - QL
Irbesartan-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Isentress (Oral Tablet),T4 - QL
Isoniazid (Oral Tablet),T1
Isosorbide Dinitrate (Oral Tablet Immediate
Release),T1
Isosorbide Dinitrate-Hydralazine (Oral Tablet),T1
Isosorbide Mononitrate (Oral Tablet Immediate
Release),T1
Isosorbide Mononitrate ER (Oral Tablet
Extended Release 24 Hour),T1
Isturisa (Oral Tablet),T4 - PA
Ivermectin (Oral Tablet),T1 - PA
J
Janumet (Oral Tablet Immediate Release),T2 -
QL
Janumet XR (Oral Tablet Extended Release 24
Hour),T2 - QL
Januvia (Oral Tablet),T2 - QL
Jardiance (Oral Tablet),T2 - QL
Jentadueto (Oral Tablet Immediate
Release),T2 - QL
Jentadueto XR (Oral Tablet Extended Release
24 Hour),T2 - QL
Jublia (External Solution),T3
Juluca (Oral Tablet),T4 - QL
K
Ketoconazole (External Cream),T1 - QL
Ketorolac Tromethamine (Ophthalmic
Solution),T1
Kevzara (Subcutaneous Solution Auto-
Injector),T4 - PA; QL
Kevzara (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Klisyri (External Ointment),T4 - PA; QL
Klor-Con 10 (Oral Tablet Extended Release),T1
Klor-Con 8 (Oral Tablet Extended Release),T1
Klor-Con M10 (Oral Tablet Extended Release),T1
Klor-Con M20 (Oral Tablet Extended Release),T1
Korlym (Oral Tablet),T4 - PA
L
Lacosamide (Oral Tablet),T1 - QL
Lactulose (10GM/15ML Oral Solution),T1
Lactulose (Oral Packet),T1
Lamivudine (100MG Oral Tablet),T1
Lamivudine (150MG Oral Tablet, 300MG Oral
Tablet),T1 - QL
Lamotrigine (Oral Tablet Immediate Release),T1
Lantus (Subcutaneous Solution),T2
Lantus SoloStar (Subcutaneous Solution Pen-
Injector),T2
Latanoprost (Ophthalmic Solution),T1
Ledipasvir-Sofosbuvir (Oral Tablet),T4 - PA;
QL
Leflunomide (Oral Tablet),T1
Letrozole (Oral Tablet),T1
Leucovorin Calcium (Oral Tablet),T1
Leukeran (Oral Tablet),T4
Levemir (Subcutaneous Solution),T2
Levetiracetam (Oral Tablet Immediate
Release),T1
Levobunolol HCl (Ophthalmic Solution),T1
Levocarnitine (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
62
Levocetirizine Dihydrochloride (Oral Tablet),T1
Levofloxacin (Oral Tablet),T1
Levothyroxine Sodium (Oral Tablet),T1
Lialda (Oral Tablet Delayed Release),T3 - ST;
QL
Licart (External Patch 24 Hour),T3 - PA; QL
Lidocaine (5% External Ointment),T1 - QL
Lidocaine (5% External Patch),T1 - PA; QL
Lidocaine HCl (4% External Solution),T1
Lidocaine-Prilocaine (External Cream),T1
Linzess (Oral Capsule),T2 - QL
Liothyronine Sodium (Oral Tablet),T1
Lisinopril (Oral Tablet),T1 - QL
Lisinopril-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Lithium Carbonate (Oral Capsule),T1
Lithium Carbonate ER (Oral Tablet Extended
Release),T1
Livalo (Oral Tablet),T2 - QL
Lokelma (Oral Packet),T3 - QL
Loperamide HCl (Oral Capsule),T1
Lorazepam (Oral Tablet),T1 - QL
Lorazepam Intensol (Oral Concentrate),T1 - QL
Losartan Potassium (Oral Tablet),T1 - QL
Losartan Potassium-HCTZ (Oral Tablet),T1 - QL
Lotemax (Ophthalmic Gel),T3
Lotemax (Ophthalmic Ointment),T3
Lotemax (Ophthalmic Suspension),T3
Lotemax SM (Ophthalmic Gel),T3
Lovastatin (Oral Tablet),T1 - QL
Lumigan (Ophthalmic Solution),T2
Lupron Depot (1-Month) (Intramuscular
Kit),T3 - PA; QL
Lupron Depot (3-Month) (Intramuscular
Kit),T3 - PA; QL
Lupron Depot (4-Month) (Intramuscular
Kit),T3 - PA; QL
Lupron Depot (6-Month) (Intramuscular
Kit),T3 - PA; QL
Lurasidone HCl (Oral Tablet),T1 - QL
Luzu (External Cream),T3 - QL
Lysodren (Oral Tablet),T4
Lyumjev (Injection Solution),T2
Lyumjev KwikPen (Subcutaneous Solution
Pen-Injector),T2
M
Malathion (External Lotion),T1
Maraviroc (Oral Tablet),T1 - QL
Mavyret (Oral Packet),T4 - PA; QL
Mavyret (Oral Tablet),T4 - PA; QL
Mayzent (Oral Tablet),T4 - QL
Meclizine HCl (12.5MG Oral Tablet, 25MG Oral
Tablet),T1 - HRM
Medroxyprogesterone Acetate (Intramuscular
Suspension),T1
Medroxyprogesterone Acetate (Oral Tablet),T1
Meloxicam (Oral Tablet),T1
Memantine HCl (10MG Oral Tablet, 5MG Oral
Tablet),T1 - PA; QL
Memantine HCl ER (Oral Capsule Extended
Release 24 Hour),T1 - PA; QL
Mercaptopurine (Oral Tablet),T1
Meropenem (Intravenous Solution
Reconstituted),T1
Mesalamine (1.2GM Oral Tablet Delayed
Release) (Generic Lialda),T1 - QL
Mesnex (Oral Tablet),T3
Methadone HCl (Oral Solution),T1 - 7D; MME;
DL; QL
Methadone HCl (Oral Tablet),T1 - 7D; MME; DL;
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
63
Drug list
QL
Methamphetamine HCl (Oral Tablet),T1 - PA; QL
Methimazole (Oral Tablet),T1
Methotrexate Sodium (Oral Tablet),T1
Methscopolamine Bromide (Oral Tablet),T1 -
HRM
Methylphenidate HCl (Oral Tablet Immediate
Release) (Generic Ritalin),T1 - QL
Methylprednisolone (Oral Tablet),T1
Metoclopramide HCl (Oral Tablet),T1
Metoprolol Succinate ER (Oral Tablet Extended
Release 24 Hour),T1
Metoprolol Tartrate (100MG Oral Tablet, 25MG
Oral Tablet, 50MG Oral Tablet),T1
Metrogel (External Gel),T3
Metronidazole (External Cream),T1
Metronidazole (External Gel),T1
Metronidazole (External Lotion),T1
Metronidazole (Oral Tablet),T1
Midodrine HCl (Oral Tablet),T1
Minocycline HCl (Oral Capsule),T1
Minocycline HCl (Oral Tablet Immediate
Release),T1
Minoxidil (Oral Tablet),T1
Mirtazapine (Oral Tablet),T1
Mirtazapine ODT (Oral Tablet Dispersible),T1
Mirvaso (External Gel),T3
Misoprostol (Oral Tablet),T1
Mitigare (Oral Capsule),T2
Modafinil (Oral Tablet),T1 - PA; QL
Mometasone Furoate (Nasal Suspension),T1
Montelukast Sodium (Oral Packet),T1 - QL
Montelukast Sodium (Oral Tablet),T1 - QL
Morphine Sulfate ER (Oral Capsule Extended
Release 24 Hour) (Generic Kadian),T1 - 7D;
MME; DL; QL
Morphine Sulfate ER (Oral Tablet Extended
Release) (Generic MS Contin),T1 - 7D; MME; DL;
QL
Morphine Sulfate ER Beads (Oral Capsule
Extended Release 24 Hour) (Generic Avinza),T1 -
7D; MME; DL; QL
Motegrity (Oral Tablet),T3 - QL
Mounjaro (Subcutaneous Solution Pen-
Injector),T2 - PA; QL
Movantik (Oral Tablet),T2 - QL
MoviPrep (Oral Solution Reconstituted),T3
Multaq (Oral Tablet),T2
Myrbetriq (Oral Suspension Reconstituted
ER),T2
Myrbetriq (Oral Tablet Extended Release 24
Hour),T2
N
Naftin (External Gel),T3
Naloxone HCl (0.4MG/ML Injection Solution),T1
Naloxone HCl (Injection Solution Cartridge),T1
Naloxone HCl (Injection Solution Prefilled
Syringe),T1
Naltrexone HCl (Oral Tablet),T1
Namzaric (Oral Capsule ER 24 Hour Therapy
Pack),T2 - PA; QL
Namzaric (Oral Capsule Extended Release 24
Hour),T2 - PA; QL
Naproxen (250MG Oral Tablet Immediate
Release, 375MG Oral Tablet Immediate Release,
500MG Oral Tablet Immediate Release),T1
Narcan (Nasal Liquid),T2
Nayzilam (Nasal Solution),T3 - PA; QL
Neomycin Sulfate (Oral Tablet),T1
Neomycin-Polymyxin-HC (Otic Suspension),T1
Neulasta (Subcutaneous Solution Prefilled
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
64
Syringe),T4 - PA
Neupogen (Injection Solution Prefilled
Syringe),T4 - ST
Neupogen (Injection Solution),T4 - ST
Nevanac (Ophthalmic Suspension),T3
Nexium (10MG Oral Packet, 2.5MG Oral
Packet, 20MG Oral Packet, 40MG Oral Packet,
5MG Oral Packet),T2
Nexium (20MG Oral Capsule Delayed Release,
40MG Oral Capsule Delayed Release),T2 - QL
Nexletol (Oral Tablet),T3 - PA; QL
Nexlizet (Oral Tablet),T3 - PA; QL
Nifedipine ER Osmotic Release (Oral Tablet
Extended Release 24 Hour),T1
Nimodipine (Oral Capsule),T1
Nitrofurantoin Macrocrystal (100MG Oral
Capsule, 50MG Oral Capsule) (Generic
Macrodantin),T1 - HRM
Nitrofurantoin Monohydrate (Generic
Macrobid),T1 - HRM
Nitroglycerin (Tablet Sublingual),T1
Nivestym (Injection Solution Prefilled
Syringe),T4 - ST
Nivestym (Injection Solution),T4 - ST
Nizatidine (Oral Capsule),T1
Norethindrone Acetate (5MG Oral Tablet),T1
Nortriptyline HCl (Oral Capsule),T1 - HRM
NovoLog (Injection Solution),T2
NovoLog FlexPen (Subcutaneous Solution
Pen-Injector),T2
NovoLog Mix 70/30 (Subcutaneous
Suspension),T2
NovoLog Mix 70/30 FlexPen (Subcutaneous
Suspension Pen-Injector),T2
NovoLog PenFill (Subcutaneous Solution
Cartridge),T2
Novolin 70/30 (Subcutaneous Suspension),T2
Novolin 70/30 FlexPen (Subcutaneous
Suspension Pen-Injector),T2
Novolin N (Subcutaneous Suspension),T2
Novolin N FlexPen (Subcutaneous Suspension
Pen-Injector),T2
Novolin R (Injection Solution),T2
Novolin R FlexPen (Injection Solution Pen-
Injector),T2
Nubeqa (Oral Tablet),T4 - PA
Nucala (Subcutaneous Solution Auto-
Injector),T4 - PA; QL
Nucala (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Nucala (Subcutaneous Solution
Reconstituted),T4 - PA; QL
Nurtec ODT (Oral Tablet Dispersible),T4 - PA;
QL
Nutropin AQ NuSpin 10 (Subcutaneous
Solution Pen-Injector),T4 - PA
Nutropin AQ NuSpin 20 (Subcutaneous
Solution Pen-Injector),T4 - PA
Nutropin AQ NuSpin 5 (Subcutaneous
Solution Pen-Injector),T4 - PA
Nuzyra (Intravenous Solution
Reconstituted),T4 - PA
Nuzyra (Oral Tablet),T4 - PA; QL
Nystatin (External Cream),T1
Nystatin (External Ointment),T1
Nystatin (External Powder),T1 - QL
Nyvepria (Subcutaneous Solution Prefilled
Syringe),T4 - PA
O
Odomzo (Oral Capsule),T4 - PA
Ofev (Oral Capsule),T4 - PA; QL
Ofloxacin (Ophthalmic Solution),T1
Ofloxacin (Otic Solution),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
65
Drug list
Olanzapine (Oral Tablet),T1 - QL
Olopatadine HCl (0.1% Ophthalmic Solution),T1
Omega-3-Acid Ethyl Esters (Oral Capsule)
(Generic Lovaza),T1
Omeprazole (10MG Oral Capsule Delayed
Release),T1 - QL
Omeprazole (20MG Oral Capsule Delayed
Release, 40MG Oral Capsule Delayed
Release),T1
Ondansetron HCl (4MG Oral Tablet, 8MG Oral
Tablet),T1 - B/D,PA; QL
Ondansetron ODT (Oral Tablet Dispersible),T1 -
B/D,PA; QL
Opsumit (Oral Tablet),T4 - PA
Orenitram (0.125MG Oral Tablet Extended
Release),T3 - PA
Orenitram (0.25MG Oral Tablet Extended
Release, 1MG Oral Tablet Extended Release,
2.5MG Oral Tablet Extended Release, 5MG
Oral Tablet Extended Release),T4 - PA
Orgovyx (Oral Tablet),T4 - PA; QL
Orilissa (Oral Tablet),T4 - PA; QL
Oseltamivir Phosphate (Oral Capsule),T1
Osphena (Oral Tablet),T2 - PA; QL
Otezla (Oral Tablet Therapy Pack),T4 - PA; QL
Otezla (Oral Tablet),T4 - PA; QL
Oxcarbazepine (Oral Tablet),T1
Oxybutynin Chloride ER (Oral Tablet Extended
Release 24 Hour),T1
Oxycodone HCl (Oral Capsule),T1 - 7D; MME;
DL; QL
Oxycodone HCl (Oral Tablet Immediate
Release),T1 - 7D; MME; DL; QL
Oxycodone-Acetaminophen (10-325MG Oral
Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral
Tablet, 7.5-325MG Oral Tablet),T1 - 7D; MME;
DL; QL
Ozempic (1MG/DOSE) (4MG/3ML
Subcutaneous Solution Pen-Injector),T2 - PA;
QL
Ozempic (2MG/DOSE) (8MG/3ML
Subcutaneous Solution Pen-Injector),T2 - PA;
QL
P
Pantoprazole Sodium (Oral Tablet Delayed
Release),T1 - QL
Pegasys (Subcutaneous Solution),T4 - PA
Penicillamine (Oral Tablet),T1
Penicillin V Potassium (Oral Tablet),T1
Pentasa (Oral Capsule Extended Release),T3 -
QL
Perforomist (Inhalation Nebulization
Solution),T3 - B/D,PA; QL
Permethrin (External Cream),T1
Perseris (Subcutaneous Prefilled Syringe),T4
Phenelzine Sulfate (Oral Tablet),T1
Phenytoin Sodium Extended (Oral Capsule),T1
Phoslyra (667MG/5ML Oral Solution),T2
Pilocarpine HCl (Oral Tablet),T1
Pimecrolimus (External Cream),T1 - ST; QL
Pirfenidone (267MG Oral Tablet, 801MG Oral
Tablet),T1 - PA; QL
Plegridy (Subcutaneous Solution Pen-
Injector),T4 - QL
Plegridy (Subcutaneous Solution Prefilled
Syringe),T4 - QL
Pomalyst (2MG Oral Capsule, 3MG Oral
Capsule, 4MG Oral Capsule),T4 - PA
Potassium Chloride ER (Oral Capsule Extended
Release),T1
Potassium Chloride ER (Oral Tablet Extended
Release),T1
Potassium Citrate ER (Oral Tablet Extended
Release),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
66
Pradaxa (Oral Capsule),T3 - ST; QL
Praluent (Subcutaneous Solution Auto-
Injector),T2 - PA; QL
Pramipexole Dihydrochloride (Oral Tablet
Immediate Release),T1
Pravastatin Sodium (Oral Tablet),T1 - QL
Prazosin HCl (Oral Capsule),T1
Prednisolone Acetate (Ophthalmic
Suspension),T1
Prednisone (5MG/5ML Oral Solution),T1
Prednisone (Oral Tablet),T1
Premarin (Oral Tablet),T3 - HRM; QL
Premarin (Vaginal Cream),T2
Premphase (Oral Tablet),T3 - HRM; QL
Prempro (Oral Tablet),T3 - HRM; QL
Prenatal (27-1MG Oral Tablet),T1
Prezcobix (Oral Tablet),T4 - QL
Primidone (250MG Oral Tablet, 50MG Oral
Tablet),T1
Privigen (20GM/200ML Intravenous
Solution),T4 - PA
ProAir RespiClick (Inhalation Aerosol Powder
Breath Activated),T2
Procrit (10000UNIT/ML Injection Solution,
2000UNIT/ML Injection Solution, 3000UNIT/
ML Injection Solution, 4000UNIT/ML Injection
Solution),T3 - PA
Procrit (20000UNIT/ML Injection Solution,
40000UNIT/ML Injection Solution),T4 - PA
Procto-Med HC (External Cream),T1
Proctosol HC (External Cream),T1
Progesterone (Oral Capsule),T1
Prograf (0.5MG Oral Capsule, 1MG Oral
Capsule),T3 - B/D,PA
Prograf (5MG Oral Capsule),T4 - B/D,PA
Prograf (Oral Packet),T3 - B/D,PA
Prolastin-C (Intravenous Solution
Reconstituted),T4 - PA
Prolensa (Ophthalmic Solution),T3
Prolia (Subcutaneous Solution Prefilled
Syringe),T3 - QL
Propranolol HCl (Oral Tablet),T1
Propranolol HCl ER (Oral Capsule Extended
Release 24 Hour),T1
Propylthiouracil (Oral Tablet),T1
Pulmicort Flexhaler (Inhalation Aerosol
Powder Breath Activated),T3 - ST
Pulmozyme (Inhalation Solution),T4 - B/D,PA;
QL
Pyridostigmine Bromide (60MG Oral Tablet
Immediate Release),T1
Pyridostigmine Bromide (Oral Solution),T1
Pyridostigmine Bromide ER (Oral Tablet
Extended Release),T1
Q
QVAR RediHaler (Inhalation Aerosol Breath
Activated),T3 - ST; QL
Quetiapine Fumarate (100MG Oral Tablet
Immediate Release, 200MG Oral Tablet
Immediate Release, 25MG Oral Tablet
Immediate Release, 300MG Oral Tablet
Immediate Release, 400MG Oral Tablet
Immediate Release, 50MG Oral Tablet
Immediate Release),T1 - QL
Quetiapine Fumarate ER (Oral Tablet Extended
Release 24 Hour),T1 - QL
Quinapril HCl (Oral Tablet),T1 - QL
Quinapril-Hydrochlorothiazide (Oral Tablet),T1 -
QL
R
Raloxifene HCl (Oral Tablet),T1
Ramipril (Oral Capsule),T1 - QL
Ranolazine ER (Oral Tablet Extended Release 12
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
67
Drug list
Hour),T1
Rasagiline Mesylate (Oral Tablet),T1
Rasuvo (Subcutaneous Solution Auto-
Injector),T3 - PA
Rayaldee (Oral Capsule Extended Release),T4
- QL
Rebif (Subcutaneous Solution Prefilled
Syringe),T4 - ST
Rebif Rebidose (Subcutaneous Solution Auto-
Injector),T4 - ST
Regranex (External Gel),T4 - PA
Repatha (Subcutaneous Solution Prefilled
Syringe),T2 - PA; QL
Repatha Pushtronex System (Subcutaneous
Solution Cartridge),T2 - PA; QL
Repatha SureClick (Subcutaneous Solution
Auto-Injector),T2 - PA; QL
Restasis MultiDose (Ophthalmic Emulsion),T2
- QL
Restasis Single-Use Vials (Ophthalmic
Emulsion),T2 - QL
Retacrit (Injection Solution),T3 - PA
Rexulti (Oral Tablet),T4 - QL
Reyvow (Oral Tablet),T3 - PA; QL
Rhopressa (Ophthalmic Solution),T2 - ST
Ribavirin (Oral Tablet),T1
Rifabutin (Oral Capsule),T1
Rifampin (300MG Oral Capsule),T1
Riluzole (Oral Tablet),T1
Rinvoq (Oral Tablet Extended Release 24
Hour),T4 - PA; QL
Risperdal Consta (12.5MG Intramuscular
Suspension Reconstituted ER, 25MG
Intramuscular Suspension Reconstituted
ER),T3
Risperdal Consta (37.5MG Intramuscular
Suspension Reconstituted ER, 50MG
Intramuscular Suspension Reconstituted
ER),T4
Risperidone (Oral Tablet),T1
Ritonavir (Oral Tablet),T1 - QL
Rivastigmine (Transdermal Patch 24 Hour),T1 -
ST; QL
Rivastigmine Tartrate (Oral Capsule),T1
Rizatriptan Benzoate (Oral Tablet),T1 - QL
Rizatriptan Benzoate ODT (Oral Tablet
Dispersible),T1 - QL
Rocklatan (Ophthalmic Solution),T2 - ST
Roflumilast (500MCG Oral Tablet),T1 - PA
Ropinirole HCl (Oral Tablet Immediate
Release),T1
Rosuvastatin Calcium (Oral Tablet),T1 - QL
Rukobia (Oral Tablet Extended Release 12
Hour),T4 - QL
Rybelsus (Oral Tablet),T2 - PA; QL
Rytary (Oral Capsule Extended Release),T3 -
ST
S
SPS (Oral Suspension),T1
Sancuso (Transdermal Patch),T4 - QL
Santyl (External Ointment),T3
Saphris (Tablet Sublingual),T3
Savella (Oral Tablet),T2
Selegiline HCl (Oral Capsule),T1
Selegiline HCl (Oral Tablet),T1
Serevent Diskus (Inhalation Aerosol Powder
Breath Activated),T2 - QL
Sertraline HCl (Oral Tablet),T1
Sevelamer Carbonate (Oral Packet),T1
Sevelamer Carbonate (Oral Tablet) (Generic
Renvela),T1
Sevelamer HCl (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
68
Shingrix (Intramuscular Suspension
Reconstituted),T2 - PA; QL
Sildenafil Citrate (20MG Oral Tablet) (Generic
Revatio),T1 - PA
Siliq (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Silver Sulfadiazine (External Cream),T1
Simbrinza (Ophthalmic Suspension),T2
Simponi (Subcutaneous Solution Auto-
Injector),T4 - PA; QL
Simponi (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Simvastatin (Oral Tablet),T1 - QL
Skyrizi (360MG/2.4ML Subcutaneous Solution
Cartridge),T4 - PA; QL
Skyrizi (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Skyrizi Pen (Subcutaneous Solution Auto-
Injector),T4 - PA; QL
Sodium Oxybate (Oral Solution),T4 - PA; QL
Sodium Polystyrene Sulfonate (Oral Powder),T1
Sodium Sulfate-Potassium Sulfate-Magnesium
Sulfate (Oral Solution),T1
Sofosbuvir-Velpatasvir (Oral Tablet),T4 - PA;
QL
Solifenacin Succinate (Oral Tablet),T1 - QL
Soliqua (Subcutaneous Solution Pen-
Injector),T2 - PA; QL
Sotalol HCl (Oral Tablet),T1
Sotalol HCl AF (Oral Tablet),T1
Spiriva HandiHaler (Inhalation Capsule),T2 -
QL
Spiriva Respimat (Inhalation Aerosol
Solution),T2 - QL
Spironolactone (Oral Tablet),T1
Sprycel (Oral Tablet),T4 - PA
Stelara (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Stelara (Subcutaneous Solution),T4 - PA; QL
Stiolto Respimat (Inhalation Aerosol
Solution),T2
Striverdi Respimat (Inhalation Aerosol
Solution),T3 - ST
Suboxone (Sublingual Film),T3 - QL
Sucralfate (Oral Suspension),T1
Sucralfate (Oral Tablet),T1
Sulfadiazine (Oral Tablet),T1
Sulfamethoxazole-Trimethoprim (800MG-160MG
Oral Tablet),T1
Sulfasalazine (Oral Tablet Delayed Release),T1
Sulfasalazine (Oral Tablet Immediate
Release),T1
Sumatriptan Succinate (100MG Oral Tablet,
25MG Oral Tablet, 50MG Oral Tablet),T1 - QL
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Auto-Injector),T1 - QL
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution),T1 - QL
Sunosi (Oral Tablet),T3 - PA; QL
Sutab (Oral Tablet),T2
Symbicort (Inhalation Aerosol),T2 - QL
Symjepi (Injection Solution Prefilled
Syringe),T3 - QL
Symtuza (Oral Tablet),T4 - QL
Synjardy (Oral Tablet Immediate Release),T2 -
QL
Synjardy XR (Oral Tablet Extended Release 24
Hour),T2 - QL
Synribo (Subcutaneous Solution
Reconstituted),T4 - PA
Synthroid (Oral Tablet),T2
T
TOBI Podhaler (Inhalation Capsule),T4 - PA;
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
69
Drug list
QL
Tabrecta (Oral Tablet),T4 - PA; QL
Tadalafil (PAH) (20MG Oral Tablet) (Generic
Adcirca),T1 - PA
Taltz (Subcutaneous Solution Auto-
Injector),T4 - PA; QL
Taltz (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Tamoxifen Citrate (Oral Tablet),T1
Tamsulosin HCl (Oral Capsule),T1
Tecfidera (Oral Capsule Delayed Release),T4 -
QL
Temazepam (15MG Oral Capsule, 30MG Oral
Capsule),T1 - HRM; QL
Tenofovir Disoproxil Fumarate (Oral Tablet),T1 -
QL
Terazosin HCl (Oral Capsule),T1
Terbinafine HCl (Oral Tablet),T1 - QL
Teriparatide (Recombinant) (Subcutaneous
Solution Pen-Injector),T4 - PA
Testosterone (20.25MG/1.25GM 1.62%
Transdermal Gel, 25MG/2.5GM 1% Transdermal
Gel, 40.5MG/2.5GM 1.62% Transdermal Gel,
50MG/5GM 1% Transdermal Gel), Testosterone
Pump (1% Transdermal Gel, 1.62% Transdermal
Gel),T1
Testosterone Cypionate (Intramuscular
Solution),T1
Tetrabenazine (Oral Tablet),T1 - PA
Theophylline (Oral Solution),T1
Theophylline ER (Oral Tablet Extended Release
12 Hour),T1
Theophylline ER (Oral Tablet Extended Release
24 Hour),T1
Timolol Maleate (Once-Daily) (Ophthalmic
Solution) (Generic Istalol),T1
Timolol Maleate (Ophthalmic Solution) (Generic
Timoptic),T1
Timolol Maleate (Oral Tablet),T1
Timolol Maleate Ophthalmic Gel Forming
(Ophthalmic Solution) (Generic Timoptic-XE),T1
Timoptic Ocudose (Ophthalmic Solution),T3
Tivicay (25MG Oral Tablet),T3 - QL
Tivicay (50MG Oral Tablet),T4 - QL
Tizanidine HCl (Oral Tablet),T1
TobraDex ST (Ophthalmic Suspension),T3
Tobramycin (300MG/5ML Inhalation
Nebulization Solution),T1 - B/D,PA; QL
Tobramycin-Dexamethasone (Ophthalmic
Suspension),T1
Topiramate (Oral Capsule Sprinkle Immediate
Release),T1
Topiramate (Oral Tablet),T1
Toremifene Citrate (Oral Tablet),T1
Torsemide (Oral Tablet),T1
Toujeo Max SoloStar (Subcutaneous Solution
Pen-Injector),T2
Toujeo SoloStar (Subcutaneous Solution Pen-
Injector),T2
Tracleer (Oral Tablet Soluble),T4 - PA; QL
Tracleer (Oral Tablet),T4 - PA; QL
Tradjenta (Oral Tablet),T2 - QL
Tramadol HCl (50MG Oral Tablet Immediate
Release),T1 - 7D; MME; DL; QL
Tramadol-Acetaminophen (Oral Tablet),T1 - 7D;
MME; DL; QL
Tranexamic Acid (Oral Tablet),T1
Tranylcypromine Sulfate (Oral Tablet),T1
Travoprost (BAK Free) (Ophthalmic Solution),T1
Trazodone HCl (100MG Oral Tablet, 150MG Oral
Tablet, 50MG Oral Tablet),T1
Trelegy Ellipta (Inhalation Aerosol Powder
Breath Activated),T2 - QL
Tremfya (Subcutaneous Solution Pen-
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
70
Injector),T4 - PA; QL
Tremfya (Subcutaneous Solution Prefilled
Syringe),T4 - PA; QL
Tresiba (Subcutaneous Solution),T2
Tresiba FlexTouch (Subcutaneous Solution
Pen-Injector),T2
Tretinoin (External Cream),T1 - PA
Tretinoin (Oral Capsule),T1
Triamcinolone Acetonide (0.1% External
Ointment, 0.5% External Ointment),T1
Triamcinolone Acetonide (External Cream),T1
Triamterene-HCTZ (Oral Capsule),T1
Triamterene-HCTZ (Oral Tablet),T1
Trientine HCl (Oral Capsule),T1 - PA; QL
Trihexyphenidyl HCl (Oral Solution),T1 - HRM
Trihexyphenidyl HCl (Oral Tablet),T1 - HRM
Trijardy XR (Oral Tablet Extended Release 24
Hour),T2 - QL
Trintellix (Oral Tablet),T3
Trulance (Oral Tablet),T3
Trulicity (Subcutaneous Solution Pen-
Injector),T2 - PA; QL
Tymlos (Subcutaneous Solution Pen-
Injector),T4 - PA
Tyrvaya (Nasal Solution),T3 - QL
U
Ubrelvy (Oral Tablet),T4 - PA; QL
Udenyca (Subcutaneous Solution Prefilled
Syringe),T4 - PA
Ursodiol (300MG Oral Capsule),T1
Ursodiol (Oral Tablet),T1
V
Valacyclovir HCl (Oral Tablet),T1 - QL
Valganciclovir HCl (Oral Tablet),T1 - QL
Valsartan (Oral Tablet),T1 - QL
Valsartan-Hydrochlorothiazide (Oral Tablet),T1 -
QL
Varenicline Tartrate (Oral Tablet),T1
Vascepa (Oral Capsule),T1
Velphoro (Oral Tablet Chewable),T4
Veltassa (Oral Packet),T3 - QL
Venlafaxine HCl ER (Oral Capsule Extended
Release 24 Hour),T1
Ventolin HFA (Inhalation Aerosol Solution),T2
Verapamil HCl (Oral Tablet Immediate
Release),T1
Verapamil HCl ER (100MG Oral Capsule
Extended Release 24 Hour, 200MG Oral
Capsule Extended Release 24 Hour, 300MG
Oral Capsule Extended Release 24 Hour,
360MG Oral Capsule Extended Release 24
Hour),T1
Verapamil HCl ER (Oral Tablet Extended
Release),T1
Verquvo (Oral Tablet),T2 - PA; QL
Versacloz (Oral Suspension),T4
Viberzi (Oral Tablet),T4 - PA; QL
Victoza (Subcutaneous Solution Pen-
Injector),T2 - PA; QL
Viibryd (Oral Tablet),T3
Vitrakvi (Oral Capsule),T4 - PA; QL
Vitrakvi (Oral Solution),T4 - PA; QL
Vosevi (Oral Tablet),T4 - PA; QL
Vumerity (Oral Capsule Delayed Release)
(Maintenance Dose Bottle),T4 - ST; QL
Vyvanse (Oral Capsule),T3
Vyvanse (Oral Tablet Chewable),T3
Vyzulta (Ophthalmic Solution),T3
W
Warfarin Sodium (Oral Tablet),T1
Wixela Inhub (Inhalation Aerosol Powder Breath
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
71
Drug list
Activated) (Generic Advair),T1 - QL
X
Xarelto (Oral Suspension Reconstituted),T2 -
QL
Xarelto (Oral Tablet),T2 - QL
Xcopri (100MG Oral Tablet, 150MG Oral
Tablet, 200MG Oral Tablet, 50MG Oral
Tablet),T4 - PA; QL
Xcopri (14 x 12.5MG & 14 x 25MG Oral Tablet
Therapy Pack),T3 - PA; QL
Xcopri (14 x 150MG & 14 x 200MG Oral Tablet
Therapy Pack, 14 x 50MG & 14 x 100MG Oral
Tablet Therapy Pack),T4 - PA; QL
Xcopri (250MG Daily Dose) (100MG & 150MG
Oral Tablet Therapy Pack),T4 - PA; QL
Xcopri (350MG Daily Dose) (150MG & 200MG
Oral Tablet Therapy Pack),T4 - PA; QL
Xeljanz (Oral Solution),T4 - PA; QL
Xeljanz (Oral Tablet Immediate Release),T4 -
PA; QL
Xeljanz XR (Oral Tablet Extended Release 24
Hour),T4 - PA; QL
Xenleta (Oral Tablet),T3 - PA; QL
Xigduo XR (Oral Tablet Extended Release 24
Hour),T2 - QL
Xiidra (Ophthalmic Solution),T3 - QL
Xofluza (40MG Dose) (Oral Tablet Therapy
Pack),T2 - QL
Xofluza (80MG Dose) (Oral Tablet Therapy
Pack),T2 - QL
Xolair (Subcutaneous Solution Prefilled
Syringe),T4 - PA
Xolair (Subcutaneous Solution
Reconstituted),T4 - PA
Xtampza ER (Oral Capsule ER 12 Hour Abuse-
Deterrent),T3 - 7D; MME; DL; QL
Xtandi (Oral Capsule),T4 - PA
Xtandi (Oral Tablet),T4 - PA
Xultophy (Subcutaneous Solution Pen-
Injector),T3 - PA; QL
Xyrem (Oral Solution),T4 - PA; QL
Y
Yupelri (Inhalation Solution),T4 - B/D,PA; QL
Z
Zafirlukast (Oral Tablet),T1
Zaleplon (Oral Capsule),T1 - HRM; QL
Zarxio (Injection Solution Prefilled Syringe),T4
Zelapar ODT (Oral Tablet Dispersible),T4
Zenpep (Oral Capsule Delayed Release
Particles),T2
Zeposia (Oral Capsule),T4 - PA; QL
Zioptan (Ophthalmic Solution),T3
Zirgan (Ophthalmic Gel),T3
Zolinza (Oral Capsule),T4 - PA
Zolpidem Tartrate (Oral Tablet Immediate
Release),T1 - HRM; QL
Zonisamide (Oral Capsule),T1
Zubsolv (Tablet Sublingual),T3 - QL
Zylet (Ophthalmic Suspension),T3
This is a partial alphabetical list. This is not a complete list of the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
Y0066_070423_095600_M
UHEX24PD0113741_000
72
Additional Drug Coverage
Bonus drug list
Your employer group or plan sponsor offers a bonus drug list. The prescription drugs on this list
are covered in addition to the drugs on the plan’s Drug List (Formulary).
The drug tier for each prescription drug is shown on the list.
Although you pay the same copay or coinsurance for these drugs as shown in the Summary of
Benefits and Evidence of Coverage, the amount you pay for these additional prescription drugs
does not apply to your Medicare Part D out-of-pocket costs. Payments for these additional
prescription drugs (made by you or the plan) are treated differently from payments made for other
prescription drugs.
Coverage for the prescription drugs on the bonus drug list is in addition to your Part D drug
coverage. Unlike your Part D drug coverage, you are unable to file a Medicare appeal or grievance
for drugs on the bonus drug list. If you have questions, please call Customer Service using the
information on the cover of this book.
If you get Extra Help from Medicare to pay for your prescription drugs, it will not apply to the drugs
on this bonus drug list.
This is not a complete list of the prescription drugs available to you or the restrictions and
limitations that may apply through the bonus drug list. If your drug has any coverage rules or limits,
there will be code(s) in the “Coverage rules or limits on use” column of the chart. The codes and
what they mean are shown below. If you have questions about drug coverage, please call Customer
Service using the information on the cover of this book.
QL - Quantity limits
The plan only covers a certain amount of this drug for one copay or over a certain number of days.
These limits may be in place to ensure safe and effective use of the drug.
MME - Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of
pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is
designed to monitor safe dosing levels of opioids for individuals who may be taking more than one
opioid drug for pain management. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you or your doctor can ask the plan to cover the additional
quantity.
7D - 7-day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members
with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For
members who are new to the plan and have a recent history of using opioids, the limit may be
overridden by the pharmacy when appropriate.
73
Additional drug coverage
Additional drug coverage
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a one-month supply per prescription.
Drug name
Drug
tier
Coverage rules or limits on use
Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions
Inflammation
Salsalate 1
Urinary Tract Pain
Phenazopyridine 1
Anorexiants - drugs to promote weight loss
Phentermine 1
QL (maximum of 1 capsule/tablet
per day)
Anticoagulants - drugs to prevent clotting
Heparin Lock Flush 1
Dermatological agents - drugs to treat skin conditions
Dry, Itchy Skin
Sulfacetamide Sodium Liquid Wash 10% 1
Sulfacetamide Sodium w/Sulfur Cream 10-5% 1
Itching or Pain
Pramoxine/Hydrocortisone Cream 1-2.5% 1
Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions
Hemorrhoids
Hydrocortisone Acetate Suppository 25 mg 1
Lidocaine/Hydrocortisone Perianal Cream
3%-0.5%
1
Irritable Bowel or Ulcers
Hyoscyamine Sulfate 1
Levbid 3
Genitourinary agents - drugs to treat bladder, genital and kidney conditions
Bold type = Brand name drug Plain type = Generic drug
74
Drug name
Drug
tier
Coverage rules or limits on use
Erectile Dysfunction
Edex 3
QL (maximum of 6 cartridges per
month)
Sildenafil (25 mg, 50 mg, 100 mg) 1
QL (maximum of 6 tablets per
month)
Tadalafil 1
QL (maximum of 6 tablets per
month)
Vardenafil 1
QL (maximum of 6 tablets per
month)
Sexual Desire Disorder
Addyi 3
QL (maximum of 1 tablet per day)
Vyleesi 3
QL (maximum of 8 injections per 30
days)
Urinary Tract Infection
Uro-MP 118 mg 3
Urinary Tract Spasm and Pain
Belladonna Alkaloids & Opium Suppositories 1
MME, 7D, DL
Hormonal agents - hormone replacement/modifying drugs
Thyroid Supplement
Armour Thyroid 3
NP Thyroid 1
Nutritional supplements - drugs to treat vitamin & mineral deficiencies
Potassium Supplement
K-Phos Tab 3
Potassium Bicarbonate Effervescent Tab 25
mEq
1
Vitamins and Minerals
Cyanocobalamin Injection (Vitamin B12) 1000
mcg
1
Bold type = Brand name drug Plain type = Generic drug
75
Additional drug coverage
Drug name
Drug
tier
Coverage rules or limits on use
Folic Acid 1 mg (Rx only) 1
Folic Acid-Vitamin B6-Vitamin B12 Tablet
2.5-25-1 mg
1
Phytonadione Tab 1
Reno Cap 1
Vitamin D 50,000 unit (Rx only) 1
Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions
Cough and Cold
Benzonatate (100 mg, 200 mg) 1
Brompheniramine/Pseudoephedrine/
Dextromethorphan Syrup
1
Guaifenesin/Codeine Syrup 1
DL
Hydrocodone Polst/Chlorpheniramine ER Susp
(generic for Tussionex)
1
DL
Hydrocodone/Homatropine 1
DL
Promethazine/Codeine Syrup 1
DL
Promethazine/Dextromethorphan Syrup 1
Bold type = Brand name drug Plain type = Generic drug
BDL: U
76
This information is not a complete description of benefits. Contact the plan for more information. Limitations,
copayments, and restrictions may apply.
Benefits and/or copayments/coinsurance may change each plan/benefit year.
The Drug List may change at any time. You will receive notice when necessary.
This information is available for free in other languages. Please call our Customer Service number on the cover.
Y0066_230426_150900_C
UHEX24MP0113559_000
77
Additional drug coverage
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78
UHEX23MP0008341_000
What’s Next?
What©s next
Start using your plan on your effective date. Remember to use your UnitedHealthcare
member ID card.
UnitedHealthcare will process your enrollment
Quick Start Guide
and UnitedHealthcare
member ID card
UnitedHealthcare will mail you a Quick Start Guide 7–10 days after your
enrollment is approved by Medicare. Please note, your member ID card
will be attached to the front cover of your guide.
Member site access
After you receive your member ID card, you can register online at the
member site listed below to get access to plan information.
Health assessment
In the first 90 days after your plan’s effective date, we’ll give you a call.
Medicare requires us to call and ask you to complete a short health survey.
You can also go to the member site below and take the survey online.
We’re here for you
When you call, be sure to let the Customer Service Advocate know that you’re calling about a
group-sponsored plan. In addition, it will be helpful to have:
Your group number found on the front of this book
Names and addresses for your doctors, clinics and the name and address of
your pharmacy
If you’re calling about drug coverage, please have a list of your current prescriptions
and dosages ready
H2001_SPRJ80337_091523_M UHEX24NP0112770_000 SPRJ80337
Here’s What You Can Expect Next
Please note, Customer Service hours of operation will be 7 days a week October 15 – December 7.
Questions? We’re here to help.
Call toll-free 1-866-519-5401, TTY 711,
8 a.m.–8 p.m. local time, Monday–Friday
retiree.uhc.com/ECMT
80
Here©s what you can expect next
By enrolling in this plan, I agree to the following:
This is a Medicare Advantage Plan contracted with the federal government. This is not a
Medicare Supplement Plan.
I need to keep my Medicare Part A and/or Part B, and continue to pay my Medicare Part B
and, if applicable, Part A premiums, if they are not paid for by Medicaid or a third party. To be
eligible for this plan, I must live in the plan’s service area and be a United States citizen or be
lawfully present in the U.S.
The service area includes the 50 United States, the District of Columbia and all U.S.
territories.
I may not be covered while out of the country, except for limited coverage near the U.S.
border. However, under this plan, when I am outside of the U.S. I am covered for emergency
or urgently needed care.
I can only have one Medicare Advantage or Prescription Drug Plan at a time.
• Enrolling in this plan will automatically disenroll me from any other Medicare health plan.
• If I enroll in a different Medicare Advantage Plan or Medicare Part D Prescription Drug
Plan, I will be automatically disenrolled from this plan.
• If I disenroll from this plan, I will be automatically transferred to Original Medicare.
• Enrollment in this plan is for the entire plan year. I may leave this plan only at certain times
of the year or under special conditions.
My information will be released to Medicare and other plans, only as necessary, for
treatment, payment and health care operations.
Medicare may also release my information for research and other purposes that follow all
app
licable federal statutes and regulations.
For members of the Group Medicare Advantage Plan.
I understand that when my coverage begins, I must get all of my medical and prescription
drug benefits from the plan. Benefits and services provided by the plan and contained in the
Evidence of Coverage (EOC) document will be covered. Neither Medicare nor the plan will
pay for benefits or services that are not covered.
I give consent for all entities under UnitedHealthcare, its affiliates, and any outside
vendor used by UnitedHealthcare to call the phone number(s) I have provided using an
autodialer and/or prerecorded voice.
Y0066_SOU_2024_C UHEX24NP0114400_000
Statements of understanding
81
Statements of understanding
What©s next
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NOTES
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Important Plan Information
UHEX24PP0108639_001
Y0066_GRPCov_2024_C
Call toll-free 1-866-519-5401, TTY 711
8 a.m.-8 p.m. local time, Monday-Friday
retiree.uhc.com/ECMT
