2016 ENROLLMENT KIT · 2018-08-09 · Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot

HEALTHTEAM ADVANTAGE PLAN I (PPO)HEALTHTEAM ADVANTAGE PLAN II (PPO)

2016 ENROLLMENT KIT

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.H9808_16_01 Accepted

TABLE OF CONTENTSMulti-language Sheet ....................................................................... 2Benefit Highlights ............................................................................ 5Understanding Drug Payment Stages ............................................... 7Provider Network ............................................................................. 8

BENEFITS ....................................................................................9Summary of Benefits ........................................................................ 10

DRUG LIST (MAPD PLANS ONLY) ................................................29

MORE PLAN INFORMATION ......................................................51Healthcare Concierge ....................................................................... 52Silver&Fit® Fitness ............................................................................ 53Dental Rider ...................................................................................... 54Supplemental Combination Rider .................................................... 56

HOW TO ENROLL ........................................................................59Understanding Enrollment Periods .................................................. 60Scope of Sales ................................................................................... 61Enrollment Application Instructions ................................................. 65Enrollment Form .............................................................................. 67Attestation Form ............................................................................... 75Application Checklist ........................................................................ 77Receipt .............................................................................................. 97What’s Next ...................................................................................... 101

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MULTI LANGUAGE INSERTMulti-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, call Care N’ Care at 1-877-905-9216. Someone who speaks English/Language can help you. This is a free service.

SPANISH: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-877-905-9216. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

CHINESE MANDARIN: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电 1-877-905-9216。我们的中文工作人员很乐意帮助您。这是一项免费服务。

CHINESE CANTONESE: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-877-905-9216。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

TAGALOG: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-877-905-9216. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

FRENCH: Nous proposons des services gratuits d’interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d’assurance-médicaments. Pour accéder au service d’interprétation, il vous suffit de nous appeler au 1-877-905-9216. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.

VIETNAMESE: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-877-905-9216 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí.

GERMAN: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-877-905-9216. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

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KOREAN: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-905-9216 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

RUSSIAN: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-877-905-9216. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

ARABIC: إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدولاألدوية لدينا . للحصول على مترجم فوري، ليس عليك سوى االتصال بنا على 6129-509-778-1. سيقوم شخص ما يتحدث العربية بمساعدتك . هذه خدمة مجانيةHINDI1: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-877-905-9216 पर फोन करें. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

ITALIAN: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-877-905-9216. Un nostro incaricato che parla Italianovi fornirà l’assistenza necessaria. È un servizio gratuito.

PORTUGUÉS: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-877-905-9216. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

FRENCH CREOLE: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-877-905-9216. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

POLISH: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-877-905-9216. Ta usługa jest bezpłatna.

JAPANESE: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、1-877-905-9216 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

H6328_MR61130ML File & Use 09202013<Page #>

H9808_16_36 Accepted

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.

3

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2016

2016 BENEFIT HIGHLIGHTSHEALTHTEAM ADVANTAGE

HEALTH PLAN I (MAPD – PPO)

HEALTHTEAM ADVANTAGE HEALTH PLAN II (MAPD – PPO)

Monthly Plan Premium $0 $57IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Out-of-Pocket Maximum $3,400 $5,100 $3,100 $5,100DOCTOR OFFICE VISITSPrimary Care Physician (PCP) $15 copay $40 copay $10 copay $30 copaySpecialist $30 copay $50 copay $20 copay $50 copayINPATIENT CAREInpatient Hospital

CopayDays 1-7 Days 1-7 Day 1 Days 1-6

$275 per day $400 per day $225 per day $425 per day

CopayDays 8-90 Days 8-90 Days 2-5 Days 7-90$0 per day $0 per day $75 per day $0 per day

Days 6-90$0 per day

Skilled Nursing Facility (SNF) CareIN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

CopayDays 1-20 Days 1-20 Days 1-20 Days 1-20

$0 $40 $0 $40

CopayDays 21-100 Days 21-100 Days 21-100 Days 21-100$150 per day $160 per day $140 per day $160 per day

CopayDays 101+ Days 101+$0 per day $0 per day

OUTPATIENT SERVICESOutpatient Surgery

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORKAmbulatory Surgical Center $150 copay $200 copay $100 copay $175 copayOutpatient Hospital Facility $170 copay $250 copay $125 copay $225 copayHome Health Services $25 copay $45 copay $10 copay $40 copay

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicarecontract. Enrollment in HealthTeam Advantage depends on contract renewal. H9808_16_02

2016 5

HEALTHTEAM ADVANTAGE HEALTH PLAN I (MAPD – PPO)

HEALTHTEAM ADVANTAGE HEALTH PLAN II (MAPD – PPO)

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORKOutpatient Rehabilitation $15 copay $40 copay $10 copay $30 copayAmbulance Services $200 copay $100 copayEmergency Care $75 copay $75 copayDIAGNOSTIC TESTS & LABS

Office/Reference $0 copay $10 copay $0 copay $10 copayOutpatient Facility $5 copay $25 copay $5 copay $25 copay

X-RAYSOffice/Reference X-Rays $10 copay $10 copay $0 copay $10 copayOutpatient facility X-Rays $10 copay $25 copay $0 copay $25 copay

DIAGNOSTIC RADIOLOGY SERVICES$50 to $200

copay$75 to $250

copay$50 to $175

copay$75 to $200

copayDURABLE MEDICAL EQUIPMENT

20% of the cost 30% of the cost 20% of the cost 30% of the costPRESCRIPTION DRUGS1 Month (30 Days) Supply

Preferred Generic $4 $0Non-Preferred Generic $15 $12Preferred Brand $45 $40Non-Preferred Brand $85 $75Specialty Tier 33% of the cost 33% of the cost

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premium and/or co-payments may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

To learn more about HealthTeam Advantage’s Health Plans, call a Benefits Consultant at 1-877-905-9216 (TTY 711), 8 a.m. to 8 p.m. (EST), seven days a week.

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I N I T I A L G A P C ATA S T R O P H I CUp to $3,310

# of

peo

ple

in st

age

Up to $4,850 Through the end of the year

UNDERSTANDING DRUG PAYMENT STAGES

INITIAL COVERAGE STAGE During this stage you pay a flat fee (copay) or a percentage of a drug’s total cost (coinsurance) for each prescription you fill.The plan pays the rest until your total drug costs (paid by you and the plan) reach $3,310.

COVERAGE GAP STAGE During this stage you pay 45% of the total cost for brand name drugs and 58% of the total cost for generic drugs.Once your out-of-pocket costs reach $4,850, you move to catastrophic coverage.

CATASTROPHIC COVERAGE STAGE In this stage you pay only a small copay or coinsurance amount for each filled prescription.The plan and Medicare pay the rest until the end of the calendar year.


HealthTeamAdvantage, a product of Care N’ Care Insurance Company of North Carolina is a Medicare Advantage Organization with a Medicare con-tract.Enrollment in HealthTeam Advantage depends on contract renewal.

2016 7

THE HEALTHTEAM ADVANTAGE PROVIDER NETWORK

As a HealthTeam Advantage PPO health plan member, you can choose to receive care from any provider or hospital. In addition, because HealthTeam Advantage is a PPO plan, you do not need a referral to go to any doctor or hospital. We encourage you to select an in-network provider to act as your primary care provider (PCP) because you’ll have a dedicated doctor who will focus on your individual healthcare needs and coordinate your care with other in-network providers if needed. This allows you to keep your out-of-pocket costs lower and more predictable.

If you select an out-of-network provider, please make sure that the provider accepts Medicare; otherwise, you will be responsible for the full cost of services. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers. To view the most updated list of HealthTeam Advantage providers, go to www.healthteamadvantage.com.



2016 8

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.HH9808_16_06 Accepted

SUMMARY OF BENEFITS

HEALTHTEAM ADVANTAGE PLAN I (PPO)HEALTHTEAM ADVANTAGE PLAN II (PPO)

2016 9

Summary of Benefits January 1, 2016 – December 31, 2016

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service

Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such

as HealthTeam Advantage Plan I (PPO) or HealthTeam Advantage Plan II (PPO).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what HealthTeam Advantage Plan I (PPO) or HealthTeam Advantage Plan II (PPO) covers and what you pay.

If you want to compare our plan with other Medicare health plans, ask the other plansfor their Summary of Benefits booklets. Or, use the Medicare Plan Finder onhttp://www.medicare.gov.

If you want to know more about the coverage and costs of Original Medicare, look inyour current "Medicare & You" handbook. View it online at http://www.medicare.govor get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days aweek. TTY users should call 1-877-486-2048.

Sections in this booklet Things to Know About HealthTeam Advantage Health Plan I (PPO) and HealthTeam

Advantage Plan II (PPO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits)

This document is available in other formats such as Braille and large print.

This document may be available in a non-English language. For additional information, call us at 1-877-905-9216.

Este documento esta disponible en otros formatos como Braille y en letra grande.

Este documento puede ser disponible en un idioma que no sea Ingles. Para obtener mas informacion, llame al 1-877-905-9216.

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Things to Know About HealthTeam Advantage Plan I (PPO) and HealthTeam Advantage Plan II (PPO). Hours of Operation You can call us 7 days a week from 8:00 am to 8:00 pm eastern standard time. HealthTeam Advantage Plan I (PPO) and HealthTeam Advantage Plan II (PPO) Phone Numbers and Website

• If you are a member of this plan, call toll-free 1-800-222-CARE. • If you are not a member of this plan, call toll-free 1-877-905-9216. • Our website: http://www.healthteamadvantage.com

Who can join?

To join HealthTeam Advantage Plan I (PPO) and HealthTeam Advantage Plan II (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in North Carolina: Alamance, Guilford, Randolph and Rockingham.

Which doctors, hospitals, and pharmacies can I use?

HealthTeam Advantage Plan I (PPO) and HealthTeam Advantage Plan II (PPO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website (http://www.healthteamadvantage.com). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover?

Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less.

Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

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We cover Part D drugs for HealthTeam Advantage Plan I (PPO) and HealthTeam Advantage Plan II (PPO). In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

You can see the complete plan formulary (list of Part D prescription drugs) and anyrestrictions on our website, http://www.healthteamadvantage.com.

Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?

Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

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Summary of Benefits January 1, 2016 – December 31, 2016

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES

HealthTeam Advantage Plan I (PPO)

HealthTeam Advantage Plan II (PPO)

How much is the monthly premium?

How much is the deductible?

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

Is there a limit on how much the plan will pay?

$0 per month. In addition, you must keep paying your Medicare Part B premium.

This plan does not have a deductible.

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

Your yearly limit(s) in this plan: 3,400 for services you receive from in-

network providers. $5,100 for services you receive from

any provider. Your limit for servicesreceived from in-network providerswill count toward this limit.

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 year.

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

No. there are no limits on how much our plan will pay.

$57 per month. In addition, you must keep paying your Medicare Part B premium.

This plan does not have a deductible.

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

Your yearly limit(s) in this plan: $3,100 for services you receive from in-

network providers. $5,100 for services you receive from

any provider. Your limit for servicesreceived from in-network providers willcount toward this limit.

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 year.

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

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

Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

OUTPATIENT CARE AND SERVICES Acupuncture Not covered Not covered

Ambulance In-network: $200 copay Out-of-network: $200 copay

In-network: $100 copay Out-of-network: $100 copay

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Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the ones of your spine move out of position):


Manipulation of the spine to correct a subluxation (when 1 or more of the ones of your spine move out of position):


Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):


Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):


Diabetes Supplies and Services

Diabetes monitoring supplies:

In-network: You pay nothing Out-of-network: 20% of the cost

Diabetes self-management training:


Therapeutic shoes or inserts:


Diabetes monitoring supplies:


Diabetes self-management training:


Therapeutic shoes or inserts:


Diagnostic Tests, Lab and Radiology Services, and X-Rays (costs for these services may vary based on the place of service)1

Dianostic radiology services (such as MRIs, CT scans):

In-network: $50-$200 copay, depending on the service

Out-of-network: $75-$250 copay, depending on the service

Diagnostic tests and procedures:



Lab services:



Dianostic radiology services (such as MRIs, CT scans):



Diagnostic tests and procedures:



Lab services:



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Diagnostic Tests, Lab and Radiology Services, and X-Rays1 (cont’d)

Outpatient x-rays:

In-network: $10 copay Out-of-network: $10-$25 copay,

depending on the service

Therapeutic radiology services (such as radiation treatment for cancer):

In-network: 20% of the cost Out-of-network: 30% of the cost

Outpatient x-rays:

In-network: You pay nothing Out-of-network: $10-$25 copay,

depending on the service

Therapeutic radiology services (such as radiation treatment for cancer):


Doctor's Office Visits Primary care physician visit:


Specialist visit:


Primary care physician visit:


Specialist visit:


Durable Medical Equipment (wheelchairs oxygen, etc.)1



Emergency Care $75 copay

If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs.

$75 copay

If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs.

Foot Care (podiatry services)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:


Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:


Hearing Services Exam to diagnose and treat hearing and balance issues:


Exam to diagnose and treat hearing and balance issues:


Home Health Care1



Mental Health Care1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

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Mental Health Care1

(cont’d)

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

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

In-network: $350 copay per day for days

1 through 5

You pay nothing per day for days 6 through 90

Out-of-network: 35% of the cost per stay

Outpatient group therapy visit:


Outpatient individual therapy visit:


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

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

In-network: $300 copay per day for days

1 through 5


Out-of-network: 35% of the cost per stay

Outpatient group therapy visit:


Outpatient individual therapy visit:


Outpatient Rehabilitation1

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):


Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):


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Outpatient Rehabilitation1

(cont’d)

Occupational therapy visit:


Physical therapy and speech and language therapy visit:


Occupational therapy visit:


Physical therapy and speech and language therapy visit:


Outpatient Substance Abuse

Group therapy visit:


Individual therapy visit:


Group therapy visit:


Individual therapy visit:


Outpatient Surgery1 Ambulatory surgical center:


Outpatient hospital:


Ambulatory surgical center:


Outpatient hospital:


Over-the-Counter Items Not Covered Not Covered

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

Prosthetic devices:


Related medical supplies:


Prosthetic devices:


Related medical supplies:


Renal Dialysis In-network: $30 copay Out-of-network: $60 copay


Transportation Not Covered Not Covered

Urgently Needed Services

$30 copay $30 copay

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Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):


Out-of-network: $50 copay

Eyeglasses or contact lenses after cataract surgery:


Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):


Out-of-network: $40 copay

Routine eye exam (for up to 1 every year):


Contact lenses:

In-network: $0 copay Out-of-network: 50% of the cost

Eyeglasses (frames and lenses):


Eyeglass frames:


Eyeglass lenses:


Eyeglasses or contact lenses after cataract surgery:


Our plan pays up to $100 every year for eyewear from any provider.

Preventive Care In-network: You pay nothing Out-of-network: $30 copay

Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral

therapy) Cardiovascular screenings Cervical and vaginal cancer screening

In-network: You pay nothing Out-of-network: $30 copay

Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral

therapy) Cardiovascular screenings Cervical and vaginal cancer screening

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Preventive Care (cont’d)

Colorectal cancer screenings (colonoscopy, Fecal occult blood test, flexible sigmoidoscopy)

Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections

screening and counseling Tobacco use cessation counseling

(counseling for people with no sign of tobacco-related disease)

Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

"Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit

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

Colorectal cancer screenings (colonoscopy, Fecal occult blood test, flexible sigmoidoscopy)

Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening

and counseling Tobacco use cessation counseling

(counseling for people with no sign of tobacco-related disease)

Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

"Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit

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

Hospice

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details.

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details.

INPATIENT CARE

Inpatient Hospital Care1 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you have not received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay.

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

Our plan covers an unlimited number of days for an inpatient hospital stay.

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Inpatient Hospital Care1

(cont’d) Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

In-network: $275 copay per day for days 1 through 7


Out-of-network: $400 copay per day for days 1 through 7


In-network: $225 copay per day for days 1

$75 copay per day for days 2 through 5


Out-of-network: $425 copay per day for days 1 through 6


You pay nothing per day for days 91 and beyond

Inpatient Mental Health Care

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

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

Skilled Nursing Facility (SNF) 1

Our plan covers an unlimited number of days in a SNF.

In-network: You pay nothing per day for days 1-20

$150 copay per day for days 21-100


Out-of-network: $40 copay per day for days 1-20


Our plan covers an unlimited number of days in a SNF.

In-network: You pay nothing per day for days 1-20



Out-of-network: $40 copay per day for days 1-20 $160 copay per day for days 21-100

PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy

drugs:


Other Part B drugs:


For Part B drugs such as chemotherapy drugs:


Other Part B drugs:


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Initial Coverage You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

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

Standard Retail Cost-Sharing

Tier 1 (Preferred Generic) 1-month: $4 2-month: $8 3-month: $12 Tier 2: (Generic) 1-month: $15 2-month: $30 3-month: $45 Tier 3: (Preferred Brand) 1-month: $45 2-month: $90 3-month: $135 Tier 4: (Non-Preferred Brand) 1-month: $85 2-month: $170 3-month: $255 Tier 5: (Specialty Tier) 1-month: 33% of the cost 2-month: 33% of the cost 3-month: 33% of the cost

Standard Mail Order Cost-Sharing

Tier 1: (Preferred Generic) 1-month: $4 2-month: $8 3-month: $12 Tier 2: (Generic) 1-month: $15 copay 2-month: $30 copay 3-month: $45 copay Tier 3: (Preferred Brand) 1-month: $45 copay 2-month: $90 copay 3-month: $135 copay Tier 4: (Non-Preferred Brand) 1-month: $85 copay 2-month: $170 copay 3-month: $255 copay

You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

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

Standard Retail Cost-Sharing

Tier 1: (Preferred Generic) 1-month: $0 2-month: $0 3-month: $0 Tier 2: (Generic) 1-month: $12 2-month: $24 3-month: $36 Tier 3: (Preferred Brand) 1-month: $40 2-month: $80 3-month: $120 Tier 4: (Non-Preferred Brand) 1-month: $75 2-month: $150 3-month: $225 Tier 5: (Specialty Tier)

1-month: 33% of the cost 2-month: 33% of the cost 3-month: 33% of the cost

Standard Mail Order Cost-Sharing

Tier 1: (Preferred Generic) 1-month: $0 2-month: $0 3-month: $0

Tier 2: (Generic) 1-month: $12 copay 2-month: $24 copay 3-month: $36 copay Tier 3: (Preferred Brand) 1-month: $40 copay 2-month: $80 copay 3-month: $120 copay Tier 4: (Non-Preferred Brand) 1-month: $75 copay 2-month: $150 copay 3-month: $225 copay

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Initial Coverage (cont’d)

Tier 5: (Specialty Tier) 1-month: 33% of the cost 2-month: 33% of the cost 3-month: 33% of the cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy and pay the same as an in-network pharmacy, but you will get less of the drug.

Tier 5: (Specialty Tier) 1-month: 33% of the cost 2-month: 33% of the cost 3-month: 33% of the cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of- network pharmacy and pay the same as an in-network pharmacy, but you will get less of the drugs.

Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310.

After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310.

After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Coverage Gap

(cont’d) Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.

Standard Retail Cost-Sharing Tier 1 (Preferred Generic) Drugs covered: All 1-month Supply: $4 2-month Supply: $8 3-month Supply: $12

Standard Mail Order Cost-Sharing Tier 1 (Preferred Generic) Drugs covered: All 1-month Supply: $4 2-month Supply: $8 3-month Supply: $12

Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.

Standard Retail Cost-Sharing Tier 1 (Preferred Generic) Drugs covered: All 1-month Supply:$0 2-month Supply:$0 3-month Supply:$0

Standard Mail Order Cost-Sharing Tier 1 (Preferred Generic) Drugs covered: All 1-month Supply:$0 2-month Supply:$0 3-month Supply:$0

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Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of:

5% of the cost, or $2.95 copay for generic (including brand

drugs treated as generic) and a $7.40 copayment for all other drugs.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of:

5% of the cost, or $2.95 copay for generic (including brand

drugs treated as generic) and a $7.40 copayment for all other drugs.

Optional Benefits (you must pay an extra premium each month for these benefits)

Package 1: Dental Rider How much is the monthly premium?



Benefits include: • Preventive Dental • Comprehensive Dental

Additional $20 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium.

This package does not have a deductible.

No. There is no limit to how much our plan will pay for benefits in this package.

Benefits include: • Preventive Dental • Comprehensive Dental

Additional $20 per month. You must keep paying your Medicare Part B premium and your $57 monthly plan premium.

This package does not have a deductible.

No. There is no limit to how much our plan will pay for benefits in this package.

Package 2: Combination Rider (Dental, Hearing, Vision)

How much is the monthly premium?



Benefits include: • Preventive Dental • Comprehensive Dental • Eye Exams • Eyewear • Hearing Exams • Hearing Aids

Additional $35 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. This package does not have a deductible. Our plan has a coverage limit for certain benefits.

Benefits include: • Preventive Dental • Comprehensive Dental • Hearing Exams • Hearing Aids • Eye Exams • Eyewear

Additional $35 per month. You must keep paying your Medicare Part B premium and your $57 monthly plan premium. This package does not have a deductible. Our plan has a coverage limit for certain benefits.

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Multi-language Interpreter Services English:

We have free interpreter services to answer any questions you may have about our healthor drug plan. To get an interpreter, just call us at 1-877-905-9216. Someone who speaks English/Language can help you. This is a free service.

Spanish:

Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-877-905-9216. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin:

我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电 1-877-905-9215。我们的中文工作人员很乐意帮助您。这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-877-905-9216。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog:

Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-877-905-9216. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French:

Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-877-905-9216. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.

Vietnamese:

Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-877- 905-9216. sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí.

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German:

Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1- 877-905-9216. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean:

당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-905-9216 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Russian:

Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-877-905-9216. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

.

إننا نقدم خدمات المترجم الفوري المجانیة لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدویة لدینا. للحصول على مترجم فوري، لیس علیك سوى االتصال بنا على1-877-905-9216 . سیقوم شخص ما یتحدث العربیة بمساعدتك. ھذه خدمة مجانیة

Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी पर् ्न के जवाब देने के िलए हमारे पासमुफ्त दभुाषिया सेवाएँ उिपब्ध हैं. एक दभुाषिया पर्ाप्त करने के िलए, बस हमें 1-877-905-9216 परफोन करें. कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

Italian:

È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-877-905-9216. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués:

Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-877-905-9216. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

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French Creole:

Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-877-905-9216. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish:

Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-877-905-9216. Ta usługa jest bezpłatna.

Japanese:

当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、1-877-905-9216 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

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HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage or-ganization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.

DRUG LISTHEALTHTEAM ADVANTAGE PLAN I (PPO)HEALTHTEAM ADVANTAGE PLAN I I (PPO)

This Drug List was updated on 08/19/2015. This is not a complete list of drugs covered by our plan. For a complete listing and updates, or other questions, please contact HealthTeam Advantage at 1-877-905-9216 (TTY 711), between 8 a.m. - 8 p.m., (EST) seven days a week, or visit www.healthteamadvantage.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Prescription drugs listed on the HealthTeam Advantage formulary may have certain restrictions such as prior authorizations, quantity limits, or a step therapy requirement. If you have questions about these restrictions, please review the 2016 HealthTeam Advantage Formulary or contact HealthTeam Advantage at 1-877-905-9216 (TTY 711) between 8am and 8pm (EST), seven days per week.


Formulary ID 00016384, Version 6H9808_16_07 Accepted

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DRUG LIST This is an alphabetical list of drugs covered by the plan. Each drug is in one of five tiers, which is listed after the drug name. Each tier has a different copay based on the plan selected. Drugs on this list may also have restrictions such as prior authorizations, quantity limits or step therapy requirements. Please refer to the Evidence of Coverage or contact the plan for a full formulary for more information.

#

8-MOP CAP 10MG, Tier 4

A

ABACAV/LAMIV TAB /ZIDOVUD, Tier 5ABACAVIR TAB 300MG, Tier 4ABELCET INJ 5MG/ML, Tier 4ABILIFY DISC TAB 10MG, Tier 5ABILIFY MAIN INJ 300MG, Tier 4ABRAXANE INJ 100MG, Tier 5ABSTRAL SUB 100MCG, Tier 4ABSTRAL SUB 200MCG, Tier 5ABSTRAL SUB 300MCG, Tier 5ABSTRAL SUB 400MCG, Tier 5ABSTRAL SUB 600MCG, Tier 5ABSTRAL SUB 800MCG, Tier 5ACAMPRO CAL TAB 333MG, Tier 2ACANYA GEL 1.2-2.5%, Tier 4ACARBOSE TAB, Tier 1ACEBUTOLOL CAP, Tier 2ACETASOL HC SOL OTIC, Tier 1ACETAZOLAMID CAP 500MG ER, Tier 1ACETAZOLAMID INJ 500MG, Tier 1ACETAZOLAMID TAB, Tier 1ACETIC ACID SOL 2% OTIC, Tier 1ACETYLCYST SOL, Tier 1ACID REDUCER TAB 150MG, Tier 1ACID REDUCER TAB 20MG, Tier 1ACITRETIN CAP , Tier 5ACTEMRA INJ 162/0.9, Tier 5ACTEMRA INJ 80MG/4ML, Tier 5ACTHIB INJ, Tier 3ACTIMMUNE INJ 2MU/0.5, Tier 5ACYCLOVIR CAP 200MG, Tier 1ACYCLOVIR NA INJ 50MG/ML, Tier 2ACYCLOVIR OIN 5%, Tier 2

ACYCLOVIR SUS 200/5ML, Tier 2ACYCLOVIR TAB, Tier 1ADACEL INJ, Tier 3ADAGEN INJ 250/ML, Tier 5ADALAT CC TAB 90MG ER, Tier 4ADAPALENE CRE 0.1%, Tier 1ADAPALENE GEL 0.1%, Tier 1ADAPALENE GEL 0.3%, Tier 2ADCIRCA TAB 20MG, Tier 5ADEFOV DIPIV TAB 10MG, Tier 5ADEMPAS TAB 0.5MG, Tier 4ADRUCIL INJ 500/10ML, Tier 4ADVAIR DISKU AER, Tier 3ADVAIR HFA AER, Tier 3AFEDITAB TAB CR, Tier 2AFINITOR DIS TAB 2MG, Tier 5AFINITOR DIS TAB 3MG, Tier 5AFINITOR DIS TAB 5MG, Tier 5AFINITOR TAB, Tier 5AGGRENOX CAP 25-200MG, Tier 4A-HYDROCORT INJ 100MG, Tier 1AK-POLY-BAC OIN OP, Tier 1AKYNZEO CAP, Tier 4ALA CORT CRE 1%, Tier 1ALA SCALP LOT 2%, Tier 4ALBENZA TAB 200MG, Tier 3ALBUTEROL NEB 0.083%, Tier 1ALBUTEROL NEB 0.5%, Tier 1ALBUTEROL NEB 0.63MG/3, Tier 1ALBUTEROL NEB 1.25MG/3, Tier 1ALBUTEROL SYP 2MG/5ML, Tier 2ALBUTEROL TAB, Tier 2ALBUTEROL TAB ER, Tier 2ALCLOMETASON CRE 0.05%, Tier 1ALCLOMETASON OIN 0.05%, Tier 1ALCOHOL PREP PAD 70%, Tier 3ALDACTAZIDE TAB 50/50, Tier 4

ALDURAZYME INJ 2.9MG/5M, Tier 5ALENDRONATE TAB 10MG, Tier 1ALENDRONATE TAB 35MG, Tier 1ALENDRONATE TAB 40MG, Tier 1ALENDRONATE TAB 5MG, Tier 1ALENDRONATE TAB 70MG, Tier 1ALFUZOSIN TAB 10MG, Tier 1ALIMTA INJ 500MG, Tier 5ALINIA SUS 100/5ML, Tier 4ALINIA TAB 500MG, Tier 4ALL DAY ALLG SOL 5MG/5ML, Tier 1ALLOPURINOL TAB, Tier 1ALORA DIS , Tier 4ALOSETRON TAB, Tier 5ALOXI INJ 0.25MG/5, Tier 4ALPHAGAN P SOL, Tier 3ALPRAZOLAM CON 1 MG/ML, Tier 2ALPRAZOLAM TAB, Tier 2ALPRAZOLAM TAB 0.25 ODT, Tier 2ALPRAZOLAM TAB 0.5MG ER, Tier 2ALPRAZOLAM TAB 0.5MG ODT, Tier 2ALPRAZOLAM TAB 1MG ER, Tier 2ALPRAZOLAM TAB 1MG ODT, Tier 2ALPRAZOLAM TAB 3MG ER, Tier 2ALTABAX OIN 1%, Tier 4AMANTADINE CAP 100MG, Tier 1AMANTADINE SYP 50MG/5ML, Tier 1AMANTADINE TAB 100MG, Tier 1AMBISOME INJ 50MG, Tier 4AMCINONIDE CRE 0.1%, Tier 1AMCINONIDE LOT 0.1%, Tier 1AMCINONIDE OIN 0.1%, Tier 1AMETHIA TAB, Tier 1AMETHYST TAB 90-20MCG, Tier 1AMIFOSTINE INJ 500MG, Tier 5AMIKACIN INJ 500/2ML, Tier 3AMILOR/HCTZ TAB 5-50, Tier 2

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AMILORIDE TAB 5MG, Tier 1AMINOPHYLLIN INJ 25MG/ML, Tier 1AMINOSYN 7% INJ /LYTES, Tier 4AMINOSYN II INJ 10%, Tier 3AMINOSYN II INJ 7%, Tier 3AMINOSYN II INJ 8.5%, Tier 3AMINOSYN II INJ 8.5/LYTE, Tier 1AMINOSYN INJ 8.5/LYTE, Tier 1AMINOSYN M INJ 3.5%, Tier 3AMINOSYN-HBC INJ 7%, Tier 3AMINOSYN-PF INJ 10%, Tier 3AMINOSYN-PF INJ 7%, Tier 3AMINOSYN-RF INJ 5.2%, Tier 4AMIODARONE INJ 50MG/ML, Tier 1AMIODARONE TAB, Tier 1AMITIZA CAP, Tier 3AMITRIPTYLIN TAB, Tier 2AMLACTIN LOT 12%, Tier 1AMLOD/ATORVA TAB, Tier 3AMLOD/BENAZP CAP, Tier 2AMLOD/VALSAR TAB, Tier 3AMLOD/VALSAR TAB /HCTZ, Tier 3AMLODIPINE TAB 10MG, Tier 1AMLODIPINE TAB 2.5MG, Tier 1AMLODIPINE TAB 5MG, Tier 1AMMONIUM CHL INJ 5MEQ/ML, Tier 1AMMONIUM LAC CRE 12%, Tier 1AMNESTEEM CAP, Tier 1AMOX/K CLAV CHW, Tier 2AMOX/K CLAV SUS, Tier 2AMOX/K CLAV TAB, Tier 2AMOXAPINE TAB, Tier 2AMOXICILLIN CAP, Tier 1AMOXICILLIN CHW, Tier 1AMOXICILLIN SUS, Tier 1AMOXICILLIN TAB 500MG, Tier 1AMOXICILLIN TAB 875MG, Tier 1AMOX-POT CLA TAB ER, Tier 3AMPHETAMINE CAP ER, Tier 2AMPHETAMINE TAB, Tier 1AMPHOTERICIN INJ 50MG, Tier 4AMPICILLIN CAP 250MG, Tier 1AMPICILLIN CAP 500MG, Tier 2

AMPICILLIN INJ 10GM, Tier 2AMPICILLIN INJ 125MG, Tier 2AMPICILLIN INJ 250MG, Tier 2AMPICILLIN SUS , Tier 2AMP-SULBACTA INJ 1.5GM, Tier 3AMP-SULBACTA INJ 1.5GM, Tier 3AMP-SULBACTA INJ 15GM, Tier 3AMPYRA TAB 10MG, Tier 5AMRIX CAP 30MG, Tier 4ANADROL-50 TAB 50MG, Tier 4ANAGRELIDE CAP 0.5MG, Tier 1ANAGRELIDE CAP 1MG, Tier 1ANASTROZOLE TAB 1MG, Tier 1ANDRODERM DIS 2MG/24HR, Tier 3ANDRODERM DIS 4MG/24HR, Tier 3ANTI-ITCH CRE 1%, Tier 1APAP/CODEINE SOL 120-12/5, Tier 2APAP/CODEINE TAB, Tier 2APIDRA INJ SOLOSTAR, Tier 3APIDRA INJ U-100, Tier 3APOKYN INJ 10MG/ML, Tier 5APRACLONIDIN SOL 0.5% OP, Tier 3APRI TAB, Tier 1APRISO CAP 0.375GM, Tier 3APTIOM TAB 200MG, Tier 4APTIOM TAB 400MG, Tier 5APTIOM TAB 600MG, Tier 5APTIOM TAB 800MG, Tier 5APTIVUS CAP 250MG, Tier 5APTIVUS SOL, Tier 5ARALAST NP INJ 400MG, Tier 5ARANELLE TAB, Tier 1ARANESP INJ 100MCG, Tier 5ARANESP INJ 100MCG, Tier 5ARANESP INJ 150MCG, Tier 5ARANESP INJ 200MCG, Tier 5ARANESP INJ 200MCG, Tier 5ARANESP INJ 25MCG, Tier 3ARANESP INJ 25MCG, Tier 3ARANESP INJ 300MCG, Tier 5ARANESP INJ 300MCG, Tier 5ARANESP INJ 40MCG, Tier 3ARANESP INJ 40MCG, Tier 3ARANESP INJ 500MCG, Tier 5

ARANESP INJ 60MCG, Tier 3ARANESP INJ 60MCG, Tier 3ARCALYST INJ 220MG, Tier 5ARGATROBAN INJ 100MG/ML, Tier 4ARIPIPRAZOLE TAB, Tier 3ARNUITY ELPT INH, Tier 3ARRANON INJ 5MG/ML, Tier 4ARZERRA CON 1000/50, Tier 5ASACOL HD TAB 800MG, Tier 3ASCOMP/COD CAP 30MG, Tier 2ASTAGRAF XL CAP 0.5MG, Tier 4ASTAGRAF XL CAP 1MG, Tier 4ASTAGRAF XL CAP 5MG, Tier 5ATENOL/CHLOR TAB, Tier 1ATENOLOL TAB, Tier 1ATGAM INJ 250MG, Tier 5ATORVASTATIN TAB, Tier 1ATOVAQ/PROGU TAB, Tier 3ATOVAQUONE SUS 750/5ML, Tier 5ATRALIN GEL 0.05%, Tier 4ATRIPLA TAB, Tier 5ATROPINE SUL INJ 0.05MG/1, Tier 1ATROPINE SUL INJ 0.1MG/ML, Tier 1ATROPINE SUL SOL 1% OP, Tier 2ATROVENT HFA AER 17MCG, Tier 3AUG BETAMET CRE 0.05%, Tier 1AUG BETAMET LOT 0.05%, Tier 1AUG BETAMET OIN 0.05%, Tier 1AVASTIN INJ, Tier 5AVELOX INJ, Tier 4AVIANE TAB, Tier 1AVITA CRE 0.025%, Tier 1AVITA GEL 0.025%, Tier 1AVODART CAP 0.5MG, Tier 3AVONEX KIT 30MCG, Tier 5AVONEX PEN KIT 30MCG, Tier 5AVONEX PREFL KIT 30MCG, Tier 5AXERT TAB, Tier 4AXIRON SOL 30MG/ACT, Tier 4AZACITIDINE INJ 100MG, Tier 5AZACTAM/DEX INJ 1GM, Tier 4AZACTAM/DEX INJ 2GM, Tier 5AZASAN TAB, Tier 3AZATHIOPRINE TAB 50MG, Tier 1

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AZELASTINE DRO 0.05%, Tier 2AZELASTINE SPR 0.1%, Tier 1AZELASTINE SPR 0.15%, Tier 2AZELEX CRE 20%, Tier 4AZILECT TAB 0.5MG, Tier 3AZILECT TAB 1MG, Tier 3AZITHROMYCIN INJ 500MG, Tier 2AZITHROMYCIN POW 1GM PAK, Tier 2AZITHROMYCIN SUS 100/5ML, Tier 2AZITHROMYCIN SUS 200/5ML, Tier 2AZITHROMYCIN TAB 250MG, Tier 1AZITHROMYCIN TAB 500MG, Tier 1AZITHROMYCIN TAB 600MG, Tier 2AZOPT SUS 1% OP, Tier 3AZOR TAB, Tier 4AZTREONAM INJ 1GM, Tier 4

B

BACITRACIN OIN OP, Tier 2BACLOFEN TAB, Tier 1BACTOCILL INJ DEX, Tier 4BACTROBAN OIN NASAL 2%, Tier 4BALSALAZIDE CAP 750MG, Tier 1BALZIVA TAB, Tier 1BANZEL SUS 40MG/ML, Tier 4BANZEL TAB, Tier 4BARACLUDE SOL .05MG/ML, Tier 5BCG VACCINE INJ, Tier 4BECONASE AQ SUS 0.042%, Tier 4BELEODAQ INJ 500MG, Tier 5BENAZEP/HCTZ TAB, Tier 2BENAZEPRIL TAB, Tier 1BENICAR HCT TAB, Tier 4BENICAR TAB, Tier 4BENLYSTA INJ 120MG, Tier 5BENTYL INJ 10MG/ML, Tier 4BENZTROPINE INJ 1MG/ML, Tier 1BENZTROPINE TAB, Tier 1BETAMETH DIP CRE 0.05%, Tier 1BETAMETH DIP LOT 0.05%, Tier 1BETAMETH DIP OIN 0.05%, Tier 1BETAMETH VAL AER 0.12%, Tier 2BETAMETH VAL CRE 0.1%, Tier 1

BETAMETH VAL LOT 0.1%, Tier 1BETAMETH VAL OIN 0.1%, Tier 1BETASERON INJ 0.3MG, Tier 5BETAXOLOL SOL 0.5% OP, Tier 2BETAXOLOL TAB, Tier 1BETHANECHOL TAB, Tier 1BEXSERO INJ, Tier 3BEYAZ TAB, Tier 4BICALUTAMIDE TAB 50MG, Tier 1BICILLIN C-R INJ 1200000, Tier 3BICILLIN C-R INJ 900/300, Tier 3BICILLIN L-A INJ, Tier 3BICNU INJ 100MG, Tier 4BIDIL TAB, Tier 3BILTRICIDE TAB 600MG, Tier 4BIMATOPROST SOL 0.03%, Tier 2BISOPRL/HCTZ TAB, Tier 1BISOPROL FUM TAB, Tier 2BIVIGAM INJ 10%, Tier 5BLEOMYCIN INJ 15UNIT, Tier 1BLEPHAMIDE OIN S.O.P., Tier 3BLEPHAMIDE SUS OP, Tier 3BOOSTRIX INJ, Tier 3BOOSTRIX INJ, Tier 3BOSULIF TAB 100MG, Tier 5BOSULIF TAB 500MG, Tier 5BOTOX INJ 100UNIT, Tier 4BREO ELLIPTA INH, Tier 3BRIELLYN TAB, Tier 1BRILINTA TAB 90MG, Tier 3BRIMONIDINE SOL 0.15%, Tier 2BRIMONIDINE SOL 0.2% OP, Tier 1BRINTELLIX TAB, Tier 4BRISDELLE CAP 7.5MG, Tier 4BROMFENAC SOL 0.09% OP, Tier 2BROMOCRIPTIN CAP 5MG, Tier 1BROMOCRIPTIN TAB 2.5MG, Tier 1BUDESONIDE CAP 3MG/24HR, Tier 4BUDESONIDE SUS 0.25MG/2, Tier 3BUDESONIDE SUS 0.5MG/2, Tier 3BUDESONIDE SUS 32MCG, Tier 2BUMETANIDE INJ 0.25/ML, Tier 1BUMETANIDE TAB, Tier 1

BUPREN/NALOX SUB, Tier 3BUPRENORPHIN SUB, Tier 3BUPROBAN TAB 150MG, Tier 1BUPROPION TAB, Tier 1BUPROPION TAB SR, Tier 1BUPROPN HCL TAB XL, Tier 1BUSPIRONE TAB, Tier 1BUSULFEX INJ 6MG/ML, Tier 5BUT/APAP/CAF CAP CODEINE, Tier 2BUTORPHANOL INJ 1MG/ML, Tier 2BUTORPHANOL INJ 2MG/ML, Tier 2BUTORPHANOL SOL 10MG/ML, Tier 2BYDUREON INJ, Tier 4BYDUREON INJ, Tier 4BYSTOLIC TAB, Tier 3

C

CABERGOLINE TAB 0.5MG, Tier 1CALC ACETATE CAP 667MG, Tier 1CALC FOLINAT INJ 300/30ML, Tier 1CALCIPOTRIEN CRE 0.005%, Tier 2CALCIPOTRIEN OIN 0.005%, Tier 1CALCIPOTRIEN OIN BETAMETH, Tier 2CALCIPOTRIEN SOL 0.005%, Tier 1CALCITONIN SPR 200/ACT, Tier 3CALCITRIOL CAP, Tier 1CALCITRIOL INJ 1MCG/ML, Tier 1CALCITRIOL OIN 3MCG/GM, Tier 3CALCITRIOL SOL 1MCG/ML, Tier 1CAMILA TAB 0.35MG, Tier 1CANCIDAS INJ, Tier 5CANDESA/HCTZ TAB, Tier 2CANDESARTAN TAB, Tier 2CANTIL TAB 25MG, Tier 4CAPASTAT SUL INJ 1GM, Tier 4CAPEX SHA 0.01%, Tier 4CAPITAL/COD SUS 120-12/5, Tier 2CAPRELSA TAB 100MG, Tier 5CAPRELSA TAB 300MG, Tier 5CAPTOPR/HCTZ TAB, Tier 2CAPTOPRIL TAB, Tier 2CARAFATE SUS 1GM/10ML, Tier 3CARB/LEVO ER TAB, Tier 1

32

CARB/LEVO TAB, Tier 1CARB/LEVO TAB /ENTACAP, Tier 2CARB/LEVO TAB ODT, Tier 1CARBAGLU TAB 200MG, Tier 5CARBAMAZEPIN CAP ER, Tier 1CARBAMAZEPIN CHW 100MG, Tier 1CARBAMAZEPIN SUS 100/5ML, Tier 1CARBAMAZEPIN TAB 200MG, Tier 1CARBAMAZEPIN TAB ER, Tier 2CARBIDOPA TAB 25MG, Tier 3CARBINOXAMIN SOL 4MG/5ML, Tier 1CARBINOXAMIN TAB 4MG, Tier 1CARBOPLATIN INJ 600/60ML, Tier 3CARDIZEM CD CAP 360MG/24, Tier 4CARDIZEM LA TAB 120MG, Tier 4CARDURA XL TAB, Tier 4CARIMUNE NF INJ 6GM, Tier 5CARISOPR/ASA TAB 200-325, Tier 2CARISOPRODOL TAB 350MG, Tier 2CARISOPRODOL TAB ASA/COD, Tier 2CARTEOLOL SOL 1% OP, Tier 1CARTIA XT CAP HR, Tier 2CARVEDILOL TAB, Tier 1CAYSTON INH 75MG, Tier 5CEFACLOR CAP, Tier 2CEFACLOR ER TAB 500MG, Tier 3CEFADROXIL CAP 500MG, Tier 1CEFADROXIL SUS, Tier 2CEFADROXIL TAB 1GM, Tier 1CEFAZOL/DEX SOL 1GM, Tier 3CEFAZOLIN INJ 10GM, Tier 3CEFAZOLIN INJ 1GM, Tier 3CEFAZOLIN INJ 500MG, Tier 3CEFDINIR CAP 300MG, Tier 2CEFDINIR SUS, Tier 2CEFEPIME INJ, Tier 4CEFIXIME SUS, Tier 3CEFOTAXIME INJ 2GM, Tier 2CEFOTAXIME INJ 500MG, Tier 2CEFOTETAN INJ, Tier 4CEFOXITIN INJ, Tier 4CEFPODO PROX SUS, Tier 4CEFPODOXIME TAB, Tier 4

CEFPROZIL SUS, Tier 2CEFPROZIL TAB, Tier 2CEFTAZIDIME INJ 1GM, Tier 3CEFTAZIDIME INJ 2GM, Tier 3CEFTAZIDIME INJ 6GM, Tier 3CEFTAZIDIME/ SOL D5W, Tier 3CEFTIN SUS, Tier 4CEFTRIAX/DEX INJ, Tier 3CEFTRIAXONE INJ 10GM, Tier 3CEFTRIAXONE INJ 250MG, Tier 3CEFTRIAXONE INJ 2GM, Tier 3CEFUROXIME INJ 1.5GM, Tier 3CEFUROXIME INJ 7.5GM, Tier 3CEFUROXIME INJ 750MG, Tier 3CEFUROXIME TAB, Tier 2CELECOXIB CAP 100MG, Tier 3CELECOXIB CAP 200MG, Tier 3CELECOXIB CAP 400MG, Tier 3CELECOXIB CAP 50MG, Tier 2CELLCEPT IV INJ 500MG, Tier 4CELONTIN CAP 300MG, Tier 3CEPHALEXIN CAP 250MG, Tier 1CEPHALEXIN CAP 500MG, Tier 1CEPHALEXIN SUS, Tier 2CEPHALEXIN TAB, Tier 1CEREBYX INJ 100/2ML, Tier 4CEREZYME INJ 400UNIT, Tier 5CERVARIX INJ, Tier 3CESAMET CAP 1MG, Tier 4CEVIMELINE CAP 30MG, Tier 2CHANTIX PAK 0.5& 1MG, Tier 3CHANTIX PAK 1MG, Tier 3CHANTIX TAB 0.5MG, Tier 3CHANTIX TAB 1MG, Tier 3CHEMET CAP 100MG, Tier 4CHLORAMPHEN INJ 1GM, Tier 2CHLORDIAZEP CAP, Tier 2CHLORHEX GLU SOL 0.12%, Tier 1CHLOROQUINE TAB, Tier 1CHLOROTHIAZ INJ 500MG, Tier 3CHLOROTHIAZ TAB, Tier 2CHLORPROMAZ INJ 25MG/ML, Tier 3CHLORPROMAZ TAB, Tier 2

CHLORTHALID TAB, Tier 1CHLORZOXAZON TAB 500MG, Tier 1CHOLESTYRAM POW 4GM LITE, Tier 2CHOR GONADOT INJ 10000UNT, Tier 1CICLOPIROX CRE 0.77%, Tier 1CICLOPIROX GEL 0.77%, Tier 1CICLOPIROX SHA 1%, Tier 1CICLOPIROX SUS 0.77%, Tier 1CIDOFOVIR INJ 75MG/ML, Tier 4CILOSTAZOL TAB, Tier 1CIMETIDINE SOL 300/5ML, Tier 1CIMETIDINE TAB, Tier 1CIMZIA KIT, Tier 5CIMZIA PREFL KIT 200MG/ML, Tier 5CINRYZE SOL 500 UNIT, Tier 5CIPRO HC SUS OTIC, Tier 4CIPRO I.V. INJ 200MG, Tier 4CIPRODEX SUS 0.3-0.1%, Tier 4CIPROFLOXACN INJ, Tier 2CIPROFLOXACN SOL 0.3% OP, Tier 1CIPROFLOXACN SUS, Tier 4CIPROFLOXACN TAB 1000MG, Tier 2CIPROFLOXACN TAB 100MG, Tier 1CIPROFLOXACN TAB 250MG, Tier 1CIPROFLOXACN TAB 500MG, Tier 1CIPROFLOXACN TAB 500MG ER, Tier 2CIPROFLOXACN TAB 750MG, Tier 1CISPLATIN INJ 50/50ML, Tier 4CITALOPRAM SOL 10MG/5ML, Tier 2CITALOPRAM TAB, Tier 1CLADRIBINE INJ 1MG/ML, Tier 5CLAFORAN INJ 1GM, Tier 4CLARAVIS CAP, Tier 1CLARINEX SYP 0.5MG/ML, Tier 4CLARINEX-D TAB 2.5-120, Tier 4CLARITHROMYC SUS, Tier 2CLARITHROMYC TAB, Tier 2CLARITHROMYC TAB 500MG ER, Tier 2CLEMASTINE TAB 2.68MG, Tier 1CLEOCIN PHOS INJ 300MG, Tier 3CLEOCIN SUP 100MG, Tier 3CLIMARA PRO DIS WEEKLY, Tier 4CLINDACIN-P PAD 1%, Tier 1

33

CLINDAMAX GEL 1%, Tier 2CLINDAMY/BEN GEL 1-5%, Tier 1CLINDAMYCIN AER 1%, Tier 1CLINDAMYCIN CAP, Tier 1CLINDAMYCIN CRE 2% VAG, Tier 1CLINDAMYCIN GEL 1%, Tier 1CLINDAMYCIN INJ 150MG/ML, Tier 3CLINDAMYCIN INJ 300MG, Tier 3CLINDAMYCIN INJ 600MG, Tier 3CLINDAMYCIN INJ 900MG, Tier 3CLINDAMYCIN LOT 1%, Tier 1CLINDAMYCIN PAD 1%, Tier 1CLINDAMYCIN SOL 1%, Tier 1CLINDAMYCIN SOL 75MG/5ML, Tier 2CLINIMIX E INJ 2.75/D10, Tier 3CLINIMIX E INJ 2.75/D5W, Tier 3CLINIMIX E INJ 4.25/D10, Tier 4CLINIMIX E INJ 4.25/D25, Tier 3CLINIMIX E INJ 4.25/D5W, Tier 3CLINIMIX E INJ 5%/D15W, Tier 3CLINIMIX E INJ 5%/D20W, Tier 3CLINIMIX E INJ 5%/D25W, Tier 3CLINIMIX INJ 2.75/D5W, Tier 3CLINIMIX INJ 4.25/D10, Tier 3CLINIMIX INJ 4.25/D20, Tier 3CLINIMIX INJ 4.25/D25, Tier 3CLINIMIX INJ 4.25/D5W, Tier 3CLINIMIX INJ 5%/D15W, Tier 3CLINIMIX INJ 5%/D20W, Tier 3CLINIMIX INJ 5%/D25W, Tier 3CLINISOL SF INJ 15%, Tier 1CLOBETASOL AER 0.05%, Tier 1CLOBETASOL CRE 0.05%, Tier 1CLOBETASOL GEL 0.05%, Tier 1CLOBETASOL LOT 0.05%, Tier 2CLOBETASOL OIN 0.05%, Tier 1CLOBETASOL SHA 0.05%, Tier 1CLOBETASOL SOL 0.05%, Tier 1CLOBEX SPR 0.05%, Tier 4CLODERM CRE 0.1% PMP, Tier 4CLOLAR INJ 1MG/ML, Tier 4CLOMIPRAMINE CAP, Tier 3CLONAZEP ODT TAB 0.125MG, Tier 2

CLONAZEP ODT TAB 0.25MG, Tier 2CLONAZEP ODT TAB 0.5MG, Tier 2CLONAZEP ODT TAB 1MG, Tier 2CLONAZEP ODT TAB 2MG, Tier 2CLONAZEPAM TAB 0.5MG, Tier 2CLONAZEPAM TAB 1MG, Tier 2CLONAZEPAM TAB 2MG, Tier 2CLONIDINE DIS HR, Tier 2CLONIDINE TAB, Tier 1CLONIDINE TAB 0.1MG ER, Tier 2CLOPIDOGREL TAB 300MG, Tier 2CLOPIDOGREL TAB 75MG, Tier 2CLORAZ DIPOT TAB 15MG, Tier 2CLORAZ DIPOT TAB 3.75MG, Tier 2CLORAZ DIPOT TAB 7.5MG, Tier 2CLORPRES TAB, Tier 1CLOTRIMAZOLE CRE 1%, Tier 1CLOTRIMAZOLE SOL 1%, Tier 1CLOTRIMAZOLE TRO 10MG, Tier 1CLOZAPINE TAB, Tier 2CLOZAPINE TAB 100/ODT, Tier 4CLOZAPINE TAB 12.5/ODT, Tier 4CLOZAPINE TAB 150/ODT, Tier 4CLOZAPINE TAB 200/ODT, Tier 5CLOZAPINE TAB 25MG ODT, Tier 4COARTEM TAB 20-120MG, Tier 4CODEINE SULF TAB, Tier 2COLCHICINE CAP 0.6MG, Tier 2COLCHICINE TAB 0.6MG, Tier 2COLESTIPOL GRA 5GM, Tier 2COLESTIPOL TAB 1GM, Tier 2COLISTIMETH INJ 150MG, Tier 4COLOCORT ENE 100MG, Tier 1COMBIGAN SOL 0.2/0.5%, Tier 3COMBIPATCH DIS HR, Tier 4COMBIVENT AER RESPIMAT, Tier 3COMETRIQ KIT, Tier 5COMPLERA TAB, Tier 5COMPRO SUP 25MG, Tier 3COMVAX INJ, Tier 3CONDYLOX GEL 0.5%, Tier 4CONSTULOSE SOL 10GM/15, Tier 1COPAXONE INJ, Tier 5

CORDRAN 24X3 TAP 4MCG/CM, Tier 4COREG CR CAP , Tier 4CORMAX SCALP SOL 0.05%, Tier 1CORTISONE AC TAB 25MG, Tier 1CORTISPORIN CRE 0.5%, Tier 4CORTISPORIN OIN 1%, Tier 4COSMEGEN INJ 0.5MG, Tier 4CREON CAP, Tier 4CRESTOR TAB, Tier 3CRIXIVAN CAP 200MG, Tier 3CRIXIVAN CAP 400MG, Tier 3CROMOLYN SOD CON 100/5ML, Tier 1CROMOLYN SOD NEB 20MG/2ML, Tier 1CROMOLYN SOD SOL 4% OP, Tier 2CRYSELLE-28 TAB 28 TABS, Tier 1CUBICIN SOL 500MG, Tier 5CUVPOSA SOL 1MG/5ML, Tier 4CYCLAFEM TAB 1/35, Tier 1CYCLAFEM TAB 7/7/7, Tier 1CYCLOBENZAPR TAB, Tier 2CYCLOPHOSPH CAP, Tier 1CYCLOSET TAB 0.8MG, Tier 4CYCLOSPORINE CAP, Tier 1CYCLOSPORINE CAP MOD, Tier 1CYCLOSPORINE INJ 50MG/ML, Tier 1CYCLOSPORINE SOL MODIFIED, Tier 1CYPROHEPTAD SYP 2MG/5ML, Tier 1CYPROHEPTAD TAB 4MG, Tier 1CYSTADANE POW, Tier 5CYSTAGON CAP, Tier 3CYTARABINE INJ 100MG/ML, Tier 3CYTARABINE INJ 20MG/ML, Tier 2

D

D10W/NACL INJ 0.2%, Tier 1D10W/NACL INJ 0.45%, Tier 1D2.5W/NACL INJ 0.45%, Tier 1D5W/LR INJ, Tier 1D5W/NACL INJ 0.2%, Tier 1D5W/NACL INJ 0.225%, Tier 1D5W/NACL INJ 0.33%, Tier 1D5W/NACL INJ 0.45%, Tier 1D5W/NACL INJ 0.9%, Tier 1

34

DACARBAZINE INJ 200MG, Tier 3DALIRESP TAB 500MCG, Tier 4DANAZOL CAP, Tier 1DANTROLENE CAP, Tier 1DAPSONE TAB, Tier 2DAPTACEL INJ, Tier 3DARAPRIM TAB 25MG, Tier 3DAUNORUBICIN INJ 5MG/ML, Tier 2DAUNOXOME INJ 2MG/ML, Tier 5DAYTRANA DIS 15MG/9HR, Tier 4DDAVP SPR 0.01%, Tier 4DECITABINE INJ 50MG, Tier 2DEMECLOCYCL TAB, Tier 4DEMSER CAP 250MG, Tier 4DENAVIR CRE 1%, Tier 3DEPEN TITRA TAB 250MG, Tier 5DEPO-ESTRADI INJ 5MG/ML, Tier 4DEPO-MEDROL INJ 20MG/ML, Tier 4DEPO-PROVERA INJ 400/ML, Tier 3DEPO-SQ PROV INJ 104, Tier 4DESIPRAMINE TAB, Tier 2DESLORATADIN TAB 5MG, Tier 2DESLORATADIN TAB ODT, Tier 2DESMOPRESSIN INJ 4MCG/ML, Tier 1DESMOPRESSIN SOL 0.01%, Tier 1DESMOPRESSIN SPR 0.01%, Tier 1DESMOPRESSIN TAB, Tier 1DESONATE GEL 0.05%, Tier 4DESONIDE CRE 0.05%, Tier 1DESONIDE LOT 0.05%, Tier 1DESONIDE OIN 0.05%, Tier 1DESOXIMETAS CRE, Tier 2DESOXIMETAS GEL 0.05%, Tier 2DESOXIMETAS OIN 0.25%, Tier 2DEXAMETH PHO INJ 10MG/ML, Tier 1DEXAMETH PHO INJ 4MG/ML, Tier 1DEXAMETH PHO SOL 0.1% OP, Tier 1DEXAMETHASON CON 1MG/ML, Tier 1DEXAMETHASON SOL 0.5/5ML, Tier 1DEXAMETHASON TAB, Tier 1DEXILANT CAP DR, Tier 3DEXPAK PAK 13 DAY, Tier 4DEXRAZOXANE INJ 250MG, Tier 5

DEXTROAMPHET CAP ER, Tier 2DEXTROAMPHET TAB, Tier 2DEXTROSE INJ 10%, Tier 1DEXTROSE INJ 5%, Tier 1DIAZEPAM CON 5MG/ML, Tier 3DIAZEPAM GEL, Tier 3DIAZEPAM SOL 1MG/ML, Tier 3DIAZEPAM TAB 10MG, Tier 2DIAZEPAM TAB 2MG, Tier 2DIAZEPAM TAB 5MG, Tier 2DICLO/MISOPR TAB, Tier 3DICLOFEN POT TAB 50MG, Tier 2DICLOFENAC GEL 3%, Tier 2DICLOFENAC SOL 0.1% OP, Tier 1DICLOFENAC SOL 1.5%, Tier 3DICLOFENAC TAB 100MG ER, Tier 2DICLOFENAC TAB DR, Tier 1DICLOXACILL CAP, Tier 1DICYCLOMINE CAP 10MG, Tier 1DICYCLOMINE SOL 10MG/5ML, Tier 1DICYCLOMINE TAB 20MG, Tier 1DIDANOSINE CAP 125MG, Tier 3DIDANOSINE CAP 200MG, Tier 3DIDANOSINE CAP 250MG, Tier 3DIDANOSINE CAP 400MG, Tier 3DIFFERIN LOT 0.1%, Tier 4DIFICID TAB 200MG, Tier 5DIFLORASONE CRE 0.05%, Tier 1DIFLORASONE OIN 0.05%, Tier 1DIFLUNISAL TAB 500MG, Tier 1DIGITEK TAB, Tier 1DIGOXIN INJ 0.25MG/1, Tier 1DIGOXIN SOL 50MCG/ML, Tier 1DIGOXIN TAB, Tier 1DIHYDROERGOT INJ 1MG/ML, Tier 1DILANTIN CAP 30MG, Tier 3DILTIAZEM CAP ER, Tier 2DILTIAZEM INJ 100MG, Tier 1DILTIAZEM INJ 25MG/5ML, Tier 1DILTIAZEM TAB, Tier 1DILT-XR CAP, Tier 2DIP/TET PED INJ 25-5LFU, Tier 2DIPENTUM CAP 250MG, Tier 4

DIPHEN/ATROP LIQ 2.5/5, Tier 1DIPHEN/ATROP TAB 2.5MG, Tier 1DIPHENHYDRAM INJ 50MG/ML, Tier 1DIPYRIDAMOLE TAB, Tier 1DISOPYRAMIDE CAP, Tier 1DISULFIRAM TAB, Tier 1DIURIL SUS 250/5ML, Tier 4DIVALPROEX CAP 125MG, Tier 1DIVALPROEX TAB 250MG ER, Tier 1DIVALPROEX TAB 500MG ER, Tier 2DIVALPROEX TAB DR, Tier 1DIVIGEL GEL 0.25MG, Tier 4DOCEFREZ INJ 20MG, Tier 5DOCETAXEL INJ 20MG/ML, Tier 5DONEPEZIL TAB, Tier 1DONEPEZIL TAB HCL 23MG, Tier 2DONEPEZIL TAB ODT, Tier 1DORIBAX INJ 500MG, Tier 4DORZOL/TIMOL SOL 2-0.5%OP, Tier 1DORZOLAMIDE SOL 2% OP, Tier 1DOXAZOSIN TAB, Tier 1DOXEPIN HCL CAP, Tier 2DOXEPIN HCL CON 10MG/ML, Tier 2DOXERCALCIF CAP, Tier 2DOXERCALCIF INJ 4MCG/2ML, Tier 2DOXIL INJ 2MG/ML, Tier 5DOXORUBICIN INJ 2MG/ML, Tier 3DOXY 100 INJ 100MG, Tier 4DOXYCYC MONO CAP 100MG, Tier 1DOXYCYC MONO CAP 50MG, Tier 1DOXYCYC MONO TAB 100MG, Tier 1DOXYCYC MONO TAB 150MG, Tier 3DOXYCYC MONO TAB 50MG, Tier 3DOXYCYC MONO TAB 50MG, Tier 1DOXYCYC MONO TAB 75MG, Tier 3DOXYCYCL HYC CAP, Tier 2DOXYCYCL HYC INJ 100MG, Tier 4DOXYCYCL HYC TAB 100MG, Tier 2DOXYCYCL HYC TAB DR, Tier 4DOXYCYCLINE SUS 25MG/5ML, Tier 2DOXYCYCLINE TAB 20MG, Tier 3DRONABINOL CAP 10MG, Tier 5DRONABINOL CAP 2.5MG, Tier 1

35

DRONABINOL CAP 5MG, Tier 1DROSPIR/ETHI TAB 3-0.03MG, Tier 1DROXIA CAP, Tier 4DUAVEE TAB 0.45-20, Tier 4DULOXETINE CAP, Tier 2DURAMORPH INJ 0.5MG/ML, Tier 2DURAMORPH INJ 1MG/ML, Tier 2DUREZOL EMU 0.05%, Tier 3DYMISTA SPR 137-50, Tier 4

E

E.E.S. GRAN SUS 200/5ML, Tier 3ECONAZOLE CRE 1%, Tier 1EDECRIN TAB 25MG, Tier 4EDLUAR SUB, Tier 4EDURANT TAB 25MG, Tier 5ELAPRASE INJ 6MG/3ML, Tier 5ELIDEL CRE 1%, Tier 3ELIGARD INJ, Tier 4ELIPHOS TAB 667MG, Tier 1ELIQUIS TAB, Tier 3ELITEK INJ 1.5MG, Tier 5ELIXOPHYLLIN ELX 80/15ML, Tier 3ELLENCE INJ 2MG/ML, Tier 5ELMIRON CAP 100MG, Tier 4EMBEDA CAP 100-4MG, Tier 5EMBEDA CAP 20-0.8MG, Tier 4EMBEDA CAP 30-1.2MG, Tier 4EMBEDA CAP 50-2MG, Tier 4EMBEDA CAP 60-2.4MG, Tier 4EMBEDA CAP 80-3.2MG, Tier 4EMCYT CAP 140MG, Tier 3EMEND PAK 80 & 125, Tier 3EMOQUETTE TAB, Tier 1EMSAM DIS HR, Tier 5EMTRIVA CAP 200MG, Tier 4EMTRIVA SOL 10MG/ML, Tier 4ENALAPR/HCTZ TAB, Tier 1ENALAPRIL TAB, Tier 1ENBREL INJ, Tier 5ENBREL SRCLK INJ 50MG/ML, Tier 5ENDOCET TAB 10-325MG, Tier 2ENDOCET TAB 5-325MG, Tier 2

ENDOCET TAB 7.5-325, Tier 2ENGERIX-B INJ, Tier 3ENJUVIA TAB, Tier 4ENOXAPARIN INJ, Tier 1ENPRESSE-28 TAB, Tier 1ENTACAPONE TAB 200MG, Tier 2ENTECAVIR TAB, Tier 5ENULOSE SOL 10GM/15, Tier 1EPIDUO GEL 0.1-2.5%, Tier 4EPINASTINE DRO 0.05%, Tier 2EPINEPHRINE INJ 0.3MG, Tier 2EPIPEN 2-PAK INJ 0.3MG, Tier 3EPIRUBICIN INJ 50/25ML, Tier 3EPITOL TAB 200MG, Tier 1EPIVIR HBV SOL 5MG/ML, Tier 3EPIVIR SOL 10MG/ML, Tier 3EPLERENONE TAB, Tier 2EPOGEN INJ 10000/ML, Tier 4EPOGEN INJ 2000/ML, Tier 4EPOGEN INJ 20000/ML, Tier 4EPOGEN INJ 3000/ML, Tier 4EPOGEN INJ 4000/ML, Tier 4EPROSART MES TAB 600MG, Tier 2EPZICOM TAB 600-300, Tier 5EQUETRO CAP, Tier 4ERAXIS INJ 50MG, Tier 4ERBITUX INJ 100MG, Tier 5ERGOLOID MES TAB 1MG ORAL, Tier 2ERIVEDGE CAP 150MG, Tier 5ERRIN TAB 0.35MG, Tier 1ERWINAZE INJ 10000UNT, Tier 3ERY PAD 2%, Tier 1ERYPED SUS, Tier 3ERY-TAB TAB EC, Tier 3ERYTHROCIN INJ 500MG, Tier 4ERYTHROCIN TAB 250MG, Tier 2ERYTHROM ETH TAB 400MG, Tier 2ERYTHROMYCIN GEL /BENZOYL, Tier 1ERYTHROMYCIN GEL 2%, Tier 1ERYTHROMYCIN OIN 5MG/GM, Tier 1ERYTHROMYCIN SOL 2%, Tier 1ERYTHROMYCIN TAB BS, Tier 2ESBRIET CAP 267MG, Tier 5

ESCITALOPRAM SOL 5MG/5ML, Tier 2ESCITALOPRAM TAB, Tier 1ESOMEPRAZOLE INJ 20MG, Tier 2ESTAZOLAM TAB 1MG, Tier 2ESTAZOLAM TAB 2MG, Tier 2ESTRA/NORETH TAB, Tier 1ESTRACE VAG CRE 0.1MG/GM, Tier 4ESTRAD VAL INJ 200MG/5, Tier 2ESTRAD VAL INJ 20MG/ML, Tier 1ESTRADIOL DIS 0.025MG, Tier 2ESTRADIOL DIS 0.025MG, Tier 3ESTRADIOL DIS 0.0375MG, Tier 2ESTRADIOL DIS 0.0375MG, Tier 3ESTRADIOL DIS 0.05MG, Tier 2ESTRADIOL DIS 0.05MG, Tier 3ESTRADIOL DIS 0.06MG, Tier 3ESTRADIOL DIS 0.075MG, Tier 2ESTRADIOL DIS 0.075MG, Tier 3ESTRADIOL DIS 0.1MG, Tier 2ESTRADIOL DIS 0.1MG, Tier 3ESTRADIOL TAB, Tier 1ESTRING MIS 2MG, Tier 4ESTROPIPATE TAB, Tier 1ESZOPICLONE TAB 1MG, Tier 2ESZOPICLONE TAB 2MG, Tier 2ESZOPICLONE TAB 3MG, Tier 2ETHAMBUTOL TAB, Tier 3ETHOSUXIMIDE CAP 250MG, Tier 1ETHOSUXIMIDE SOL 250/5ML, Tier 1ETODOLAC CAP, Tier 2ETODOLAC ER TAB, Tier 3ETODOLAC TAB, Tier 2ETOPOPHOS INJ 100MG, Tier 4ETOPOSIDE INJ 20MG/ML, Tier 1EURAX CRE 10%, Tier 4EURAX LOT 10%, Tier 4EVAMIST SPR 1.53MG, Tier 4EVOTAZ TAB 300-150, Tier 5EXELDERM CRE 1%, Tier 4EXELDERM SOL 1%, Tier 4EXELON DIS, Tier 3EXEMESTANE TAB 25MG, Tier 2EXJADE TAB 125MG, Tier 3

36

EXJADE TAB 250MG, Tier 5EXJADE TAB 500MG, Tier 5EXTINA AER 2%, Tier 4

F

FABRAZYME INJ 35MG, Tier 5FAMCICLOVIR TAB, Tier 2FAMOTIDINE INJ 200/20ML, Tier 2FAMOTIDINE INJ 20MG/50M, Tier 2FAMOTIDINE SUS 40MG/5ML, Tier 2FAMOTIDINE TAB 40MG, Tier 1FANAPT PAK, Tier 4FANAPT TAB, Tier 4FARESTON TAB 60MG, Tier 3FARYDAK CAP, Tier 5FASLODEX INJ 250MG, Tier 5FELBAMATE SUS 600/5ML, Tier 1FELBAMATE TAB, Tier 1FELODIPINE TAB ER, Tier 2FEMRING MIS HR, Tier 4FENOFIBRATE CAP, Tier 2FENOFIBRATE TAB, Tier 2FENOFIBRIC CAP DR, Tier 2FENTANYL DIS, Tier 3FENTANYL DIS HR, Tier 3FENTANYL OT LOZ 1200MCG, Tier 5FENTANYL OT LOZ 1600MCG, Tier 5FENTANYL OT LOZ 200MCG, Tier 3FENTANYL OT LOZ 400MCG, Tier 5FENTANYL OT LOZ 600MCG, Tier 5FENTANYL OT LOZ 800MCG, Tier 5FENTORA TAB, Tier 5FERRIPROX TAB 500MG, Tier 4FETZIMA CAP, Tier 4FETZIMA CAP TITRATIO, Tier 4FINACEA GEL 15%, Tier 4FINASTERIDE TAB 5MG, Tier 1FIRAZYR INJ 30MG/3ML, Tier 5FIRMAGON INJ 120MG, Tier 4FIRMAGON INJ 80MG, Tier 4FLAGYL ER TAB 750MG, Tier 4FLAREX SUS 0.1% OP, Tier 4FLEBOGAMMA INJ DIF 10%, Tier 3

FLECAINIDE TAB, Tier 1FLOVENT DISK AER, Tier 3FLOVENT HFA AER, Tier 3FLUCONAZOLE SUS, Tier 2FLUCONAZOLE TAB, Tier 2FLUCONAZOLE/ INJ NACL 200, Tier 2FLUCYTOSINE CAP, Tier 5FLUDARABINE INJ 50MG/2ML, Tier 1FLUDROCORT TAB 0.1MG, Tier 1FLUNISOLIDE SPR 0.025%, Tier 1FLUOCIN ACET CRE, Tier 1FLUOCIN ACET OIL BODY, Tier 1FLUOCIN ACET OIL EAR0.01%, Tier 1FLUOCIN ACET OIN 0.025%, Tier 1FLUOCIN ACET SOL 0.01%, Tier 1FLUOCINONIDE CRE 0.05%, Tier 1FLUOCINONIDE CRE 0.1%, Tier 2FLUOCINONIDE GEL 0.05%, Tier 1FLUOCINONIDE OIN 0.05%, Tier 1FLUOCINONIDE SOL 0.05%, Tier 1FLUOROMETHOL SUS 0.1% OP, Tier 2FLUOROURACIL CRE 5%, Tier 3FLUOROURACIL DRO, Tier 2FLUOROURACIL INJ 500/10ML, Tier 3FLUOXETINE CAP, Tier 1FLUOXETINE CAP 90MG DR, Tier 3FLUOXETINE SOL 20MG/5ML, Tier 2FLUOXETINE TAB 10MG, Tier 2FLUOXETINE TAB 20MG, Tier 2FLUOXETINE TAB 60MG, Tier 3FLUPHENAZ DE INJ 25MG/ML, Tier 3FLUPHENAZINE CON 5MG/ML, Tier 2FLUPHENAZINE ELX 2.5/5ML, Tier 2FLUPHENAZINE INJ 2.5MG/ML, Tier 2FLUPHENAZINE TAB, Tier 2FLURAZEPAM CAP 15MG, Tier 2FLURAZEPAM CAP 30MG, Tier 2FLURBIPROFEN SOL 0.03% OP, Tier 1FLURBIPROFEN TAB, Tier 2FLUTAMIDE CAP 125MG, Tier 1FLUTICASONE CRE 0.05%, Tier 1FLUTICASONE LOT 0.05%, Tier 2FLUTICASONE OIN 0.005%, Tier 1

FLUTICASONE SPR 50MCG, Tier 1FLUVASTATIN CAP, Tier 2FLUVOXAMINE CAP ER, Tier 3FLUVOXAMINE TAB, Tier 2FONDAPARINUX SOL 10/0.8, Tier 5FONDAPARINUX SOL 2.5/0.5, Tier 1FONDAPARINUX SOL 5.0/0.4, Tier 5FONDAPARINUX SOL 7.5/0.6, Tier 5FORFIVO XL TAB 450MG, Tier 3FORTAMET TAB 500MG, Tier 4FORTAZ INJ 1GM, Tier 4FORTEO SOL 600/2.4, Tier 5FORTESTA GEL 10MG/ACT, Tier 4FOSCARNET INJ 24MG/ML, Tier 3FOSINOP/HCTZ TAB, Tier 2FOSINOPRIL TAB, Tier 1FOSPHENYTOIN INJ 500/10ML, Tier 2FOSRENOL POW, Tier 4FRAGMIN INJ 10000/ML, Tier 5FRAGMIN INJ 12500UNT, Tier 5FRAGMIN INJ 15000UNT, Tier 5FRAGMIN INJ 18000UNT, Tier 5FRAGMIN INJ 2500/0.2, Tier 4FRAGMIN INJ 5000/0.2, Tier 4FRAGMIN INJ 7500/0.3, Tier 5FRAGMIN INJ 95000UNT, Tier 5FREAMINE HBC INJ 6.9%, Tier 4FROVA TAB 2.5MG, Tier 4FULYZAQ TAB 125MG, Tier 4FUROSEMIDE INJ 10MG/ML, Tier 1FUROSEMIDE INJ 10MG/ML, Tier 1FUROSEMIDE SOL, Tier 1FUROSEMIDE TAB, Tier 1FUZEON INJ 90MG, Tier 5FYCOMPA TAB, Tier 4

G

GABAPENTIN CAP 100MG, Tier 1GABAPENTIN CAP 300MG, Tier 1GABAPENTIN CAP 400MG, Tier 1GABAPENTIN SOL 250/5ML, Tier 1GABAPENTIN TAB 600MG, Tier 1GABAPENTIN TAB 800MG, Tier 1

37

GABITRIL TAB 12MG, Tier 4GABITRIL TAB 16MG, Tier 4GALANTAMINE CAP ER, Tier 2GALANTAMINE SOL 4MG/ML, Tier 2GALANTAMINE TAB, Tier 2GAMMAGARD SD INJ 5GM HU, Tier 5GAMMAKED INJ 1GM/10ML, Tier 3GAMMAPLEX INJ 2.5GM, Tier 5GAMUNEX-C INJ 1GM/10ML, Tier 3GANCICLOVIR INJ 500MG, Tier 3GARDASIL 9 INJ, Tier 3GARDASIL 9 INJ, Tier 4GARDASIL INJ, Tier 3GARDASIL INJ, Tier 4GATIFLOXACIN SOL 0.5%, Tier 3GATTEX KIT 5MG, Tier 5GAUZE PADS & DRESSINGS - PADS 2 X 2, Tier 3GAVILYTE-C SOL, Tier 1GAVILYTE-G SOL, Tier 1GAVILYTE-N SOL FLAV PK, Tier 1GEMCITABINE INJ 1GM, Tier 5GEMFIBROZIL TAB 600MG, Tier 1GENERLAC SOL 10GM/15, Tier 1GENGRAF CAP, Tier 1GENGRAF SOL 100MG/ML, Tier 1GENOTROPIN INJ 0.2MG, Tier 4GENOTROPIN INJ 0.4MG, Tier 5GENOTROPIN INJ 0.6MG, Tier 5GENOTROPIN INJ 0.8MG, Tier 5GENOTROPIN INJ 1.2MG, Tier 5GENOTROPIN INJ 1.4MG, Tier 5GENOTROPIN INJ 1.6MG, Tier 5GENOTROPIN INJ 1.8MG, Tier 5GENOTROPIN INJ 12MG, Tier 5GENOTROPIN INJ 1MG, Tier 5GENOTROPIN INJ 2MG, Tier 5GENOTROPIN INJ 5MG, Tier 5GENTAK OIN 0.3% OP, Tier 1GENTAM/NACL INJ 0.9MG/ML, Tier 2GENTAM/NACL INJ 1.4MG/ML, Tier 2GENTAM/NACL INJ 100MG, Tier 2GENTAM/NACL INJ 60MG, Tier 2GENTAM/NACL INJ 80MG, Tier 2

GENTAM/NACL INJ 80MG, Tier 2GENTAMICIN CRE 0.1%, Tier 1GENTAMICIN INJ, Tier 2GENTAMICIN OIN 0.1%, Tier 1GENTAMICIN SOL 0.3% OP, Tier 1GEODON INJ 20MG, Tier 4GILOTRIF TAB, Tier 5GLASSIA INJ, Tier 5GLEEVEC TAB 100MG, Tier 5GLEEVEC TAB 400MG, Tier 5GLIMEPIRIDE TAB 1MG, Tier 1GLIMEPIRIDE TAB 2MG, Tier 1GLIMEPIRIDE TAB 4MG, Tier 1GLIP/METFORM TAB, Tier 1GLIPIZIDE ER TAB 10MG, Tier 1GLIPIZIDE ER TAB 2.5MG, Tier 1GLIPIZIDE ER TAB 5MG, Tier 1GLIPIZIDE TAB 10MG, Tier 1GLIPIZIDE TAB 5MG, Tier 1GLUCAGEN INJ HYPOKIT, Tier 3GLUCAGON KIT 1MG, Tier 3GLYCOPYRROL INJ 4MG/20ML, Tier 1GLYCOPYRROL TAB, Tier 1GLYSET TAB, Tier 4GOLYTELY SOL, Tier 4GRALISE STAR MIS 300/600, Tier 4GRALISE TAB, Tier 4GRANISETRON INJ 0.1MG/ML, Tier 1GRANISETRON INJ 1MG/ML, Tier 1GRANISETRON TAB 1MG, Tier 1GRISEOFULVIN SUS 125/5ML, Tier 4GRISEOFULVIN TAB ULTR, Tier 4GUANFACINE TAB, Tier 1GUANFACINE TAB ER, Tier 4GUANIDINE TAB 125MG, Tier 2

H

H.P. ACTHAR INJ 80UNIT, Tier 5HALAVEN INJ 1MG/2ML, Tier 5HALOBETASOL CRE 0.05%, Tier 1HALOBETASOL OIN 0.05%, Tier 1HALOG CRE 0.1%, Tier 4HALOG OIN 0.1%, Tier 4

HALOPER DEC INJ, Tier 2HALOPER LAC INJ 5MG/ML, Tier 2HALOPERIDOL CON 2MG/ML, Tier 2HALOPERIDOL TAB, Tier 2HARVONI TAB 90-400MG, Tier 5HAVRIX INJ 720UNIT, Tier 3HAVRIX INJ 720UNIT, Tier 3HC BUTYRATE OIN 0.1%, Tier 1HC BUTYRATE SOL 0.1%, Tier 1HC VALERATE CRE 0.2%, Tier 1HC VALERATE OIN 0.2%, Tier 1HC/ACET ACID SOL OTIC, Tier 1HEP SOD/D5W INJ 20000UNT, Tier 1HEP SOD/D5W INJ 25000UNT, Tier 1HEP SOD/D5W INJ 25000UNT, Tier 1HEPARIN SOD INJ 1000/ML, Tier 1HEPARIN SOD INJ 10000/ML, Tier 1HEPARIN SOD INJ 20000/ML, Tier 1HEPARIN SOD INJ 5000/ML, Tier 1HEPATAMINE SOL 8%, Tier 1HERCEPTIN INJ 440MG, Tier 5HETLIOZ CAP 20MG, Tier 5HEXALEN CAP 50MG, Tier 5HUMATROPE INJ 12MG, Tier 5HUMATROPE INJ 24MG, Tier 5HUMIRA INJ 10MG/0.2, Tier 4HUMIRA INJ 40MG/0.8, Tier 5HUMIRA KIT 20MG/0.4, Tier 5HUMIRA PEN INJ CROHNS, Tier 5HYDRALAZINE INJ 20MG/ML, Tier 1HYDRALAZINE TAB, Tier 1HYDROCHLOROT CAP 12.5MG, Tier 1HYDROCHLOROT TAB, Tier 1HYDROCO/APAP SOL 7.5-325, Tier 2HYDROCO/APAP TAB 10-300MG, Tier 2HYDROCO/APAP TAB 10-325MG, Tier 2HYDROCO/APAP TAB 2.5-325, Tier 2HYDROCO/APAP TAB 5-300MG, Tier 2HYDROCO/APAP TAB 5-325MG, Tier 2HYDROCO/APAP TAB 7.5-300, Tier 2HYDROCO/APAP TAB 7.5-325, Tier 2HYDROCOD/IBU TAB 7.5-200, Tier 2HYDROCORT CRE 2.5%, Tier 1

38

HYDROCORT ENE 100MG, Tier 1HYDROCORT LOT 2.5%, Tier 1HYDROCORT OIN 1%, Tier 1HYDROCORT OIN 2.5%, Tier 1HYDROCORT TAB, Tier 1HYDROMORPHON INJ 10MG/ML, Tier 2HYDROMORPHON LIQ 1MG/ML, Tier 2HYDROMORPHON TAB 2MG, Tier 2HYDROMORPHON TAB 4MG, Tier 2HYDROMORPHON TAB 8MG, Tier 2HYDROMORPHON TAB ER, Tier 3HYDROXYCHLOR TAB 200MG, Tier 2HYDROXYUREA CAP 500MG, Tier 1HYDROXYZ HCL INJ, Tier 4HYDROXYZ HCL SYP 10MG/5ML, Tier 4HYDROXYZ HCL TAB, Tier 2HYDROXYZ PAM CAP, Tier 2HYPERRAB S/D INJ 150/ML, Tier 4HYPERRAB S/D INJ 150/ML, Tier 4HYSINGLA ER TAB 100 MG, Tier 5HYSINGLA ER TAB 120 MG, Tier 5HYSINGLA ER TAB 20 MG, Tier 4HYSINGLA ER TAB 30 MG, Tier 4HYSINGLA ER TAB 40 MG, Tier 4HYSINGLA ER TAB 60 MG, Tier 4HYSINGLA ER TAB 80 MG, Tier 4

I

IBANDRONATE INJ 3MG/3ML, Tier 3IBANDRONATE TAB 150MG, Tier 3IBRANCE CAP, Tier 5IBUPROFEN SUS 100/5ML, Tier 1IBUPROFEN TAB 400MG, Tier 1IBUPROFEN TAB 600MG, Tier 1IBUPROFEN TAB 800MG, Tier 1ICLUSIG TAB, Tier 5IDAMYCIN PFS INJ 5MG/5ML, Tier 4IDARUBICIN INJ 5MG/5ML, Tier 5IFOSFAMIDE INJ 1GM/20ML, Tier 3ILARIS INJ 180MG, Tier 5ILEVRO DRO 0.3% OP, Tier 4IMBRUVICA CAP 140MG, Tier 5IMIPENEM/CIL INJ 250MG, Tier 3

IMIPENEM/CIL INJ 500MG, Tier 3IMIPRAM HCL TAB, Tier 2IMIPRAM PAM CAP, Tier 4IMIQUIMOD CRE 5%, Tier 2IMITREX INJ 4MG/0.5, Tier 4IMOVAX RABIE INJ 2.5/ML, Tier 4INCRELEX INJ 40MG/4ML, Tier 5INDAPAMIDE TAB, Tier 1INDOCIN SUS 25MG/5ML, Tier 3INDOMETHACIN CAP, Tier 1INDOMETHACIN CAP 75MG ER, Tier 3INFANRIX INJ, Tier 3INLYTA TAB 1MG, Tier 5INLYTA TAB 5MG, Tier 5INSULIN PEN NEEDLE, Tier 3INSULIN SYRINGE (DISP) U-100 0.3 ML, Tier 3INSULIN SYRINGE (DISP) U-100 1 ML, Tier 3INSULIN SYRINGE (DISP) U-100 1/2 ML, Tier 3INTELENCE TAB 100MG, Tier 5INTELENCE TAB 200MG, Tier 5INTELENCE TAB 25MG, Tier 4INTRALIPID INJ 20%, Tier 1INTRALIPID INJ 30%, Tier 4INTRON-A INJ 10MU, Tier 5INTRON-A INJ 18MU, Tier 5INTRON-A INJ 18MU, Tier 4INTRON-A INJ 50MU, Tier 4INTROVALE TAB, Tier 1INVANZ INJ 1GM, Tier 4INVEGA SUST INJ 117/0.75, Tier 5INVEGA SUST INJ 156MG/ML, Tier 5INVEGA SUST INJ 234/1.5, Tier 5INVEGA SUST INJ 39/0.25, Tier 4INVEGA SUST INJ 78/0.5ML, Tier 4INVEGA TAB, Tier 4INVIRASE CAP 200MG, Tier 4INVIRASE TAB 500MG, Tier 5INVOKAMET TAB, Tier 3INVOKANA TAB, Tier 3IONOSOL-B/ INJ D5W, Tier 3IONOSOL-MB INJ /D5W, Tier 3

IPOL INJ INACTIVE, Tier 3IPOL INJ INACTIVE, Tier 3IPRATROPIUM SOL 0.02%INH, Tier 1IPRATROPIUM SPR 0.03%, Tier 1IPRATROPIUM SPR 0.06%, Tier 1IPRATROPIUM/ SOL ALBUTER, Tier 1IRBESAR/HCTZ TAB, Tier 2IRBESARTAN TAB, Tier 2IRENKA CAP 40MG, Tier 4IRINOTECAN INJ 100/5ML, Tier 4ISENTRESS CHW 100MG, Tier 4ISENTRESS CHW 25MG, Tier 3ISENTRESS POW 100MG, Tier 4ISENTRESS TAB 400MG, Tier 5ISOLYTE-P INJ /D5W, Tier 3ISOLYTE-S INJ, Tier 3ISONIAZID INJ 100MG/ML, Tier 1ISONIAZID SYP 50MG/5ML, Tier 1ISONIAZID TAB, Tier 1ISORDIL TAB 40MG, Tier 4ISOSORB DIN TAB, Tier 2ISOSORB DIN TAB 40MG ER, Tier 2ISOSORB MONO TAB, Tier 2ISOSORB MONO TAB ER, Tier 1ISRADIPINE CAP, Tier 3ISTODAX INJ 10MG, Tier 5ITRACONAZOLE CAP 100MG, Tier 3IVERMECTIN TAB 3MG, Tier 3IXEMPRA KIT INJ 15MG, Tier 5IXIARO INJ, Tier 3

J

JAKAFI TAB, Tier 5JALYN CAP, Tier 3JANTOVEN TAB, Tier 1JANUMET TAB, Tier 3JANUMET XR TAB 100-1000, Tier 3JANUMET XR TAB 50-1000, Tier 3JANUMET XR TAB 50-500MG, Tier 3JANUVIA TAB, Tier 3JENTADUETO TAB, Tier 3JINTELI TAB 1MG-5MCG, Tier 1JOLIVETTE TAB 0.35MG, Tier 1

39

JUNEL 1.5/30 TAB, Tier 1JUNEL 1/20 TAB, Tier 1JUNEL FE TAB 1.5/30, Tier 1JUNEL FE TAB 1/20, Tier 1JUXTAPID CAP 10MG, Tier 5JUXTAPID CAP 20MG, Tier 5JUXTAPID CAP 5MG, Tier 5

K

KADCYLA INJ 160MG, Tier 5KADIAN CAP 200MG ER, Tier 3KADIAN CAP 40MG ER, Tier 4KALETRA SOL, Tier 5KALETRA TAB 100-25MG, Tier 4KALETRA TAB 200-50MG, Tier 5KALYDECO PAK, Tier 5KALYDECO TAB 150MG, Tier 5KARIVA TAB 28 DAY, Tier 1KAZANO 12.5- TAB, Tier 4KCL IN NACL INJ .15-0.45, Tier 1KCL/D5W INJ 0.15%, Tier 1KCL/D5W INJ 0.3%, Tier 1KCL/D5W/LR INJ 0.15%, Tier 1KCL/D5W/NACL INJ .075/.45, Tier 1KCL/D5W/NACL INJ .15/.33%, Tier 1KCL/D5W/NACL INJ .15/.45%, Tier 1KCL/D5W/NACL INJ .22/.45, Tier 1KCL/D5W/NACL INJ 0.15/0.2, Tier 1KCL/D5W/NACL INJ 0.15/0.2, Tier 1KCL/D5W/NACL INJ 0.15/0.9, Tier 1KCL/D5W/NACL INJ 0.3/0.45, Tier 1KCL/D5W/NACL INJ 0.3/0.9%, Tier 1KCL/NACL INJ 0.15-0.9, Tier 1KCL/NACL INJ 0.3-0.9, Tier 4KELNOR TAB 1/35, Tier 1KEPIVANCE INJ 6.25MG, Tier 4KETOCONAZOLE CRE 2%, Tier 1KETOCONAZOLE SHA 2%, Tier 1KETOCONAZOLE TAB 200MG, Tier 1KETOPROFEN CAP, Tier 1KETOPROFEN CAP 200MG ER, Tier 3KETOROLAC SOL 0.4%, Tier 1KETOROLAC SOL 0.5%, Tier 1

KEYTRUDA INJ 100MG/4M, Tier 5KINERET INJ, Tier 5KIONEX SUS 15GM/60, Tier 1KLOR-CON 8 TAB 8MEQ ER, Tier 1KLOR-CON TAB ER, Tier 1KORLYM TAB 300MG, Tier 5KUVAN POW 500MG, Tier 5KUVAN TAB 100MG, Tier 5KYNAMRO INJ 200MG/ML, Tier 4

L

LABETALOL INJ 5MG/ML, Tier 2LABETALOL TAB, Tier 2LACTATED RIN INJ, Tier 1LACTULOSE SOL 10GM/15, Tier 1LAMICTAL KIT START, Tier 4LAMICTAL ODT TAB, Tier 4LAMICTAL XR KIT, Tier 4LAMISIL GRA, Tier 4LAMIVUD/ZIDO TAB 150-300, Tier 4LAMIVUDINE SOL 10MG/ML, Tier 3LAMIVUDINE TAB 100MG, Tier 3LAMIVUDINE TAB 150MG, Tier 3LAMIVUDINE TAB 300MG, Tier 3LAMOTRIGINE CHW, Tier 1LAMOTRIGINE TAB, Tier 1LAMOTRIGINE TAB ER, Tier 2LANSOPR/AMOX MIS /CLARITH, Tier 2LANSOPRAZOLE CAP DR, Tier 2LANTUS INJ 100/ML, Tier 3LANTUS INJ SOLOSTAR, Tier 3LATANOPROST SOL 0.005%, Tier 1LATUDA TAB, Tier 3LAZANDA SPR, Tier 5LEFLUNOMIDE TAB, Tier 1LENVIMA CAP, Tier 5LESSINA TAB, Tier 1LETAIRIS TAB, Tier 5LETROZOLE TAB 2.5MG, Tier 1LEUCOVOR CA INJ 350MG, Tier 1LEUCOVOR CA TAB, Tier 1LEUKERAN TAB 2MG, Tier 3LEUKINE INJ 250MCG, Tier 5

LEUPROLIDE INJ 1MG/0.2, Tier 1LEVALBUTEROL NEB 0.31MG, Tier 2LEVALBUTEROL NEB 0.63MG, Tier 2LEVALBUTEROL NEB 1.25/0.5, Tier 2LEVEMIR INJ, Tier 3LEVEMIR INJ FLEXTOUC, Tier 3LEVETIRACETA INJ, Tier 4LEVETIRACETA SOL 100MG/ML, Tier 1LEVETIRACETA TAB, Tier 1LEVETIRACETA TAB ER, Tier 2LEVETIRACETM INJ 500/5ML, Tier 1LEVOBUNOLOL SOL 0.5% OP, Tier 1LEVOCARNITIN INJ 200MG/ML, Tier 1LEVOCARNITIN SOL 1GM/10ML, Tier 1LEVOCARNITIN TAB 330MG, Tier 1LEVOCETIRIZI SOL 2.5/5ML, Tier 1LEVOCETIRIZI TAB 5MG, Tier 1LEVOFLOX/D5W INJ 750/150, Tier 4LEVOFLOXACIN INJ 25MG/ML, Tier 4LEVOFLOXACIN SOL 0.5%, Tier 2LEVOFLOXACIN SOL 25MG/ML, Tier 3LEVOFLOXACIN TAB, Tier 1LEVOLEUCOVOR INJ 50MG, Tier 3LEVORA-28 TAB 0.15/30, Tier 1LEVORPHANOL TAB 2MG, Tier 3LEVOTHYROXIN TAB, Tier 1LEVOXYL TAB, Tier 1LEXIVA SUS 50MG/ML, Tier 3LEXIVA TAB 700MG, Tier 5LIDO/PRILOCN CRE 2.5-2.5%, Tier 2LIDOCAINE GEL 2% JELLY, Tier 1LIDOCAINE GEL 2% JELLY, Tier 1LIDOCAINE INJ 0.5%, Tier 1LIDOCAINE INJ 2%, Tier 1LIDOCAINE OIN 5%, Tier 1LIDOCAINE PAD 5%, Tier 3LIDOCAINE SOL 2% VISC, Tier 1LIDOCAINE SOL 4%, Tier 1LINEZOLID INJ 2MG/ML, Tier 5LINEZOLID TAB 600MG, Tier 5LINZESS CAP 145MCG, Tier 3LINZESS CAP 290MCG, Tier 3LIOTHYRONINE INJ 10MCG/ML, Tier 2

40

LIOTHYRONINE TAB, Tier 2LISINOP/HCTZ TAB, Tier 1LISINOPRIL TAB, Tier 1LITHIUM CARB CAP, Tier 1LITHIUM CARB TAB ER, Tier 2LITHIUM SOL 8MEQ/5ML, Tier 2LITHOSTAT TAB 250MG, Tier 2LIVALO TAB, Tier 3LO LOESTRIN TAB, Tier 4LOKARA LOT 0.05%, Tier 2LOMUSTINE CAP, Tier 2LOPERAMIDE CAP 2MG, Tier 1LORAZEPAM CON 2MG/ML, Tier 2LORAZEPAM TAB 0.5MG, Tier 2LORAZEPAM TAB 1MG, Tier 2LORAZEPAM TAB 2MG, Tier 2LORCET PLUS TAB 7.5-325, Tier 2LORYNA TAB 3-0.02MG, Tier 2LOSARTAN POT TAB, Tier 1LOSARTAN/HCT TAB, Tier 1LOSEASONIQUE TAB, Tier 4LOTEMAX GEL 0.5%, Tier 3LOTEMAX OIN 0.5%, Tier 3LOTEMAX SUS 0.5%, Tier 3LOVASTATIN TAB, Tier 1LOXAPINE CAP, Tier 2LUPR DEP-PED INJ 11.25MG, Tier 5LUPR DEP-PED INJ 15MG, Tier 5LUPR DEP-PED INJ 7.5MG, Tier 5LUPRON DEPOT INJ 11.25MG, Tier 5LUPRON DEPOT INJ 22.5MG, Tier 5LUPRON DEPOT INJ 3.75MG, Tier 5LUPRON DEPOT INJ 30MG, Tier 5LUPRON DEPOT INJ 45MG, Tier 5LUTERA TAB, Tier 1LYNPARZA CAP 50MG, Tier 5LYRICA CAP 100MG, Tier 3LYRICA CAP 150MG, Tier 3LYRICA CAP 200MG, Tier 3LYRICA CAP 225MG, Tier 3LYRICA CAP 25MG, Tier 3LYRICA CAP 300MG, Tier 3LYRICA CAP 50MG, Tier 3

LYRICA CAP 75MG, Tier 3LYRICA SOL 20MG/ML, Tier 3LYSODREN TAB 500MG, Tier 3LYZA TAB 0.35MG, Tier 2

M

MAGNESIUM SU INJ 50%, Tier 1MAGNESIUM SU INJ 50%, Tier 1MALATHION LOT 0.5%, Tier 1MAPROTILINE TAB, Tier 2MARLISSA TAB 0.15/30, Tier 1MARPLAN TAB 10MG, Tier 4MATULANE CAP 50MG, Tier 5MATZIM LA TAB, Tier 2MAXIDEX SUS 0.1% OP, Tier 4MECLIZINE TAB 12.5MG, Tier 1MEDROXYPR AC INJ 150MG/ML, Tier 1MEDROXYPR AC TAB, Tier 1MEFENAM ACID CAP 250MG, Tier 3MEFLOQUINE TAB 250MG, Tier 2MEGACE ES SUS 625/5ML, Tier 3MEGESTROL AC SUS 40MG/ML, Tier 1MEGESTROL AC TAB, Tier 1MEKINIST TAB, Tier 5MELOXICAM SUS 7.5/5ML, Tier 1MELOXICAM TAB, Tier 1MELPHALAN INJ 50MG, Tier 4MENACTRA INJ, Tier 4MENEST TAB, Tier 4MENOMUNE INJ A/C/Y/W, Tier 3MENOSTAR DIS 14MCG, Tier 4MENTAX CRE 1%, Tier 4MENVEO INJ, Tier 3MERCAPTOPUR TAB 50MG, Tier 1MEROPENEM INJ 500MG, Tier 4MESALAMINE ENE 4GM, Tier 1MESNA INJ 1GM, Tier 3MESNEX TAB 400MG, Tier 5MESTINON SYP 60MG/5ML, Tier 3MESTINON TAB TIMESPAN, Tier 3METADATE CD CAP 20MG, Tier 4METADATE CD CAP 30MG, Tier 4METADATE CD CAP 40MG, Tier 4

METADATE TAB 20MG ER, Tier 2METAXALONE TAB 800MG, Tier 2METFORMIN ER TAB 1000MG, Tier 2METFORMIN TAB 1000MG, Tier 1METFORMIN TAB 500MG, Tier 1METFORMIN TAB 500MG ER, Tier 1METFORMIN TAB 750MG ER, Tier 1METFORMIN TAB 850MG, Tier 1METHADONE INJ 10MG/ML, Tier 4METHADONE SOL 10MG/5ML, Tier 2METHADONE SOL 5MG/5ML, Tier 2METHADONE TAB 10MG, Tier 2METHADONE TAB 5MG, Tier 2METHENAM HIP TAB 1GM, Tier 3METHIMAZOLE TAB, Tier 1METHOCARBAM TAB, Tier 2METHOTREXATE INJ 1GM, Tier 1METHOTREXATE INJ 25MG/ML, Tier 1METHOTREXATE TAB 2.5MG, Tier 2METHOXSALEN CAP 10MG, Tier 2METHSCOPOLAM TAB, Tier 1METHYCLOTHIA TAB 5MG, Tier 1METHYLD/HCTZ TAB, Tier 1METHYLERGON TAB 0.2MG, Tier 1METHYLPHENID CAP 10MG, Tier 3METHYLPHENID CAP 20MG, Tier 3METHYLPHENID CAP 30MG, Tier 3METHYLPHENID CAP 40MG, Tier 3METHYLPHENID CAP 50MG, Tier 3METHYLPHENID CAP 60MG, Tier 3METHYLPHENID SOL, Tier 3METHYLPHENID TAB, Tier 2METHYLPHENID TAB 18MG ER, Tier 2METHYLPHENID TAB 20MG ER, Tier 2METHYLPHENID TAB 27MG ER, Tier 2METHYLPHENID TAB 36MG ER, Tier 2METHYLPHENID TAB 54MG ER, Tier 2METHYLPR ACE INJ, Tier 1METHYLPR SS INJ 125MG, Tier 1METHYLPR SS INJ 40MG, Tier 1METHYLPRED PAK 4MG, Tier 2METHYLPRED TAB, Tier 1METIPRANOLOL SOL 0.3% OPH, Tier 2

41

METOCLOPRAM INJ 5MG/ML, Tier 1METOCLOPRAM SOL 5MG/5ML, Tier 1METOCLOPRAM TAB, Tier 1METOCLOPRAM TAB 5MG ODT, Tier 3METOLAZONE TAB, Tier 1METOPRL/HCTZ TAB, Tier 2METOPROL TAR TAB, Tier 1METOPROLOL INJ 5MG/5ML, Tier 1METOPROLOL TAB ER, Tier 2METRO IV INJ 5MG/ML, Tier 2METRONIDAZOL CAP 375MG, Tier 2METRONIDAZOL CRE 0.75%, Tier 1METRONIDAZOL GEL 0.75%, Tier 2METRONIDAZOL GEL 0.75%VAG, Tier 1METRONIDAZOL GEL 1%, Tier 2METRONIDAZOL LOT 0.75%, Tier 1METRONIDAZOL TAB, Tier 2MEXILETINE CAP, Tier 1MIACALCIN INJ 200/ML, Tier 4MICONAZOLE 3 SUP 200MG, Tier 1MICROGESTIN TAB, Tier 1MICROGESTIN TAB FE, Tier 1MIDODRINE TAB, Tier 1MIGERGOT SUP 2/100, Tier 1MIGRANAL SPR 4MG/ML, Tier 4MILLIPRED SOL 10MG/5ML, Tier 4MILLIPRED TAB 5MG, Tier 4MINITRAN DIS HR, Tier 1MINOCYCLINE CAP 100MG, Tier 2MINOCYCLINE CAP 50MG, Tier 2MINOCYCLINE CAP 75MG, Tier 2MINOCYCLINE TAB 100MG, Tier 3MINOCYCLINE TAB 50MG, Tier 3MINOCYCLINE TAB 75MG, Tier 3MINOCYCLINE TAB ER, Tier 4MINOXIDIL TAB, Tier 2MIRCERA INJ 100MCG, Tier 4MIRCERA INJ 50MCG, Tier 4MIRCERA INJ 75MCG, Tier 4MIRTAZAPINE TAB, Tier 1MIRTAZAPINE TAB ODT, Tier 2MISOPROSTOL TAB, Tier 1MITOMYCIN INJ 20MG, Tier 3

MITOXANTRON INJ 2MG/ML, Tier 1M-M-R II INJ LIVE, Tier 3MOBIC SUS 7.5/5ML, Tier 4MODAFINIL TAB, Tier 3MOEXIPR/HCTZ TAB, Tier 2MOEXIPRIL TAB, Tier 2MOMETASONE CRE 0.1%, Tier 1MOMETASONE OIN 0.1%, Tier 1MOMETASONE SOL 0.1%, Tier 1MONONESSA TAB, Tier 1MONTELUKAST CHW, Tier 2MONTELUKAST GRA 4MG, Tier 2MONTELUKAST TAB 10MG, Tier 1MORPHINE SUL CAP 100MG ER, Tier 3MORPHINE SUL CAP BEADS ER, Tier 3MORPHINE SUL CAP ER, Tier 3MORPHINE SUL SOL 10MG/5ML, Tier 2MORPHINE SUL SOL 20MG/5ML, Tier 2MORPHINE SUL SOL 20MG/ML, Tier 2MORPHINE SUL TAB, Tier 2MORPHINE SUL TAB ER, Tier 2MOVIPREP SOL, Tier 4MOXEZA SOL 0.5%, Tier 3MOXIFLOXACIN TAB 400MG, Tier 3MOZOBIL INJ, Tier 5MULTAQ TAB 400MG, Tier 3MUPIROCIN CA CRE 2%, Tier 2MUPIROCIN OIN 2%, Tier 1MUSTARGEN INJ 10MG, Tier 5MYCAMINE INJ 100MG, Tier 5MYCAMINE INJ 50MG, Tier 4MYCOPHENOLAT CAP 250MG, Tier 1MYCOPHENOLAT SUS 200MG/ML, Tier 3MYCOPHENOLAT TAB 500MG, Tier 1MYCOPHENOLIC TAB DR, Tier 2MYOZYME INJ 50MG, Tier 5MYRBETRIQ TAB, Tier 3

N

NABUMETONE TAB, Tier 1NADOLOL TAB, Tier 2

NADOLOL/BEND TAB, Tier 1NAFCILLIN INJ 10GM, Tier 4NAFCILLIN INJ 2GM, Tier 4NAFTIFINE CRE HCL 1%, Tier 3NAFTIN CRE, Tier 4NAFTIN CRE 2%, Tier 4NAFTIN GEL 1%, Tier 4NAGLAZYME INJ 1MG/ML, Tier 5NALLPEN/DEX INJ 1GM/50ML, Tier 4NALOXONE INJ 1MG/ML, Tier 1NALTREXONE TAB 50MG, Tier 1NAMENDA TAB 5-10MG, Tier 3NAMENDA XR CAP, Tier 3NAMENDA XR CAP TITRATIO, Tier 3NAPHAZOLINE SOL 0.1% OP, Tier 1NAPROXEN DR TAB, Tier 1NAPROXEN SOD TAB 275MG, Tier 1NAPROXEN SOD TAB 550MG, Tier 1NAPROXEN SUS 125/5ML, Tier 1NAPROXEN TAB, Tier 1NARATRIPTAN TAB, Tier 1NASONEX SPR 50MCG/AC, Tier 4NATEGLINIDE TAB, Tier 1NATPARA INJ 25MCG, Tier 5NEBUPENT INH 300MG, Tier 4NECON TAB, Tier 1NEEDLES, INSULIN DISP., SAFETY, Tier 3NEFAZODONE TAB, Tier 3NEO/BAC/POLY OIN OP, Tier 2NEO/POLY GU SOL 40/ML IR, Tier 1NEO/POLY/BAC OIN /HC 1%OP, Tier 2NEO/POLY/DEX OIN 0.1% OP, Tier 1NEO/POLY/DEX SUS 0.1% OP, Tier 1NEO/POLY/GRA SOL OP, Tier 2NEO/POLY/HC SOL 1% OTIC, Tier 1NEO/POLY/HC SUS 1% OTIC, Tier 1NEO/POLY/HC SUS OP, Tier 2NEOMYCIN TAB 500MG, Tier 1NEPHRAMINE INJ 5.4%, Tier 3NEPTAZANE TAB, Tier 1NESINA TAB, Tier 4NEULASTA INJ 6MG/0.6M, Tier 5NEUMEGA INJ 5MG, Tier 5

42

NEUPOGEN INJ 300/0.5, Tier 5NEUPOGEN INJ 300MCG, Tier 5NEUPOGEN INJ 300MCG, Tier 4NEUPOGEN INJ 480/0.8, Tier 5NEUPRO DIS, Tier 4NEVANAC SUS 0.1%, Tier 4NEVIRAPINE SUS 50MG/5ML, Tier 3NEVIRAPINE TAB 200MG, Tier 3NEVIRAPINE TAB 400MG ER, Tier 3NEXAVAR TAB 200MG, Tier 5NIACIN ER TAB, Tier 2NIACOR TAB 500MG, Tier 1NICARDIPINE CAP, Tier 1NICOTROL INH, Tier 3NIFEDICAL XL TAB, Tier 2NIFEDIPINE TAB ER, Tier 2NILANDRON TAB 150MG, Tier 3NIMODIPINE CAP 30MG, Tier 1NISOLDIPINE TAB, Tier 3NISOLDIPINE TAB ER, Tier 3NITRO-BID OIN 2%, Tier 4NITROFUR MAC CAP 50MG, Tier 2NITROFUR MAC CAP 100MG, Tier 1NITROFURANTN SUS 25MG/5ML, Tier 2NITROGLYCER AER 400MCG, Tier 3NITROGLYCER DIS HR, Tier 2NITROMIST AER 400MCG, Tier 4NITROSTAT SUB 0.3MG, Tier 1NITROSTAT SUB 0.4MG, Tier 1NITROSTAT SUB 0.6MG, Tier 3NIZATIDINE CAP, Tier 1NIZATIDINE SOL 15MG/ML, Tier 2NORDITROPIN INJ 10/1.5ML, Tier 5NORDITROPIN INJ 15/1.5ML, Tier 5NORDITROPIN INJ 5/1.5ML, Tier 5NORETHIN ACE TAB 5MG, Tier 1NORETHINDRON TAB 0.35MG, Tier 2NORMOSOL -M INJ /D5W, Tier 1NORMOSOL -R INJ /D5W, Tier 1NORMOSOL-R INJ PH 7.4, Tier 3NORPACE CAP CR, Tier 4NORTHERA CAP 100MG, Tier 5NORTHERA CAP 200MG, Tier 5

NORTHERA CAP 300MG, Tier 5NORTREL TAB, Tier 1NORTRIPTYLIN CAP, Tier 1NORTRIPTYLIN SOL 10MG/5ML, Tier 2NORVIR CAP 100MG, Tier 4NORVIR SOL 80MG/ML, Tier 4NORVIR TAB 100MG, Tier 4NOVOLIN N INJ RELION, Tier 3NOVOLIN R INJ RELION, Tier 3NOVOLIN70/30 INJ RELION, Tier 3NOVOLOG INJ 100/ML, Tier 3NOVOLOG INJ PENFILL, Tier 3NOVOLOG INJ PENFILL, Tier 3NOVOLOG MIX INJ 70/30, Tier 3NOVOLOG MIX INJ FLEXPEN, Tier 3NOXAFIL SUS 40MG/ML, Tier 5NOXAFIL TAB 100MG, Tier 5NUCYNTA ER TAB 100MG, Tier 3NUCYNTA ER TAB 150MG, Tier 3NUCYNTA ER TAB 200MG, Tier 3NUCYNTA ER TAB 250MG, Tier 3NUCYNTA ER TAB 50MG, Tier 3NUCYNTA TAB 100MG, Tier 3NUCYNTA TAB 50MG, Tier 3NUCYNTA TAB 75MG, Tier 3NUEDEXTA CAP 20-10MG, Tier 3NULOJIX INJ 250MG, Tier 5NUTROPIN AQ INJ 20MG/2ML, Tier 5NUTROPIN AQ INJ NUSPIN 5, Tier 4NUVARING MIS, Tier 3NUVIGIL TAB, Tier 4NYAMYC POW 100000, Tier 1NYSTATIN CRE 100000, Tier 1NYSTATIN OIN 100000, Tier 1NYSTATIN POW 100000, Tier 1NYSTATIN SUS 100000, Tier 1NYSTATIN TAB 500000, Tier 2NYSTOP POW 100000, Tier 1

O

OCTREOTIDE INJ 1000MCG, Tier 5OCTREOTIDE INJ 100MCG, Tier 1OCTREOTIDE INJ 200MCG, Tier 1

OCTREOTIDE INJ 500MCG, Tier 5OCTREOTIDE INJ 50MCG/ML, Tier 1OFEV CAP 100MG, Tier 5OFLOXACIN DRO 0.3% OP, Tier 1OFLOXACIN DRO 0.3%OTIC, Tier 1OGESTREL TAB, Tier 1OLANZA/FLUOX CAP, Tier 4OLANZAPINE INJ 10MG, Tier 4OLANZAPINE TAB, Tier 1OLANZAPINE TAB 7.5MG, Tier 1OLANZAPINE TAB ODT, Tier 3OLOPATADINE SPR 0.6%, Tier 3OMEGA-3-ACID CAP 1GM, Tier 2OMEPRAZOLE CAP 10MG, Tier 2OMEPRAZOLE CAP 20.6MGDR, Tier 2OMEPRAZOLE CAP 40MG, Tier 2OMNARIS SPR, Tier 4OMNITROPE INJ 10/1.5ML, Tier 4OMNITROPE INJ 5.8MG, Tier 5OMNITROPE INJ 5/1.5ML, Tier 4ONCASPAR INJ 750/ML, Tier 5ONDANSETRON INJ 40/20ML, Tier 1ONDANSETRON INJ 4MG/2ML, Tier 1ONDANSETRON SOL 4MG/5ML, Tier 1ONDANSETRON TAB 24MG, Tier 1ONDANSETRON TAB 4MG, Tier 1ONDANSETRON TAB 8MG, Tier 1ONDANSETRON TAB ODT, Tier 1ONFI SUS 2.5MG/ML, Tier 4ONFI TAB 10MG, Tier 4ONFI TAB 20MG, Tier 4OPANA ER TAB, Tier 3OPDIVO INJ 40MG/4ML, Tier 5OPSUMIT TAB 10MG, Tier 5ORACEA CAP 40MG, Tier 3ORAP TAB, Tier 3ORENCIA INJ, Tier 5ORFADIN CAP, Tier 5ORPHENADRINE TAB 100MG ER, Tier 2ORSYTHIA TAB, Tier 1OSENI TAB, Tier 4OSMOPREP TAB 1.5GM, Tier 4OTREXUP INJ, Tier 4

43

OXACILLIN INJ 10GM, Tier 4OXACILLIN INJ 1GM, Tier 4OXALIPLATIN INJ 50MG, Tier 5OXANDROLONE TAB, Tier 1OXAPROZIN TAB 600MG, Tier 2OXAZEPAM CAP, Tier 2OXCARBAZEPIN SUS 300MG/5M, Tier 1OXCARBAZEPIN TAB, Tier 1OXISTAT CRE 1%, Tier 4OXISTAT LOT 1%, Tier 4OXTELLAR XR TAB, Tier 4OXYBUTYNIN SYP 5MG/5ML, Tier 1OXYBUTYNIN TAB 5MG, Tier 1OXYBUTYNIN TAB ER, Tier 2OXYCOD/APAP TAB 10-325MG, Tier 2OXYCOD/APAP TAB 5-325MG, Tier 2OXYCOD/APAP TAB 7.5-325, Tier 2OXYCOD/ASA TAB, Tier 2OXYCOD/IBU TAB 5-400MG, Tier 2OXYCODONE CAP 5MG, Tier 2OXYCODONE CON 100/5ML, Tier 2OXYCODONE TAB, Tier 2OXYCODONE TAB 10MG ER, Tier 3OXYCODONE TAB 20MG ER, Tier 3OXYCODONE TAB 40MG ER, Tier 4OXYCODONE TAB 80MG ER, Tier 4OXYMORPHONE TAB ER, Tier 3OXYMORPHONE TAB HCL, Tier 3

P

PACERONE TAB, Tier 1PACLITAXEL INJ 30MG/5ML, Tier 3PAMIDRONATE INJ 30/10ML, Tier 1PAMIDRONATE INJ 6MG/ML, Tier 1PAMIDRONATE INJ 90/10ML, Tier 1PANCREAZE CAP, Tier 3PANDEL CRE 0.1%, Tier 4PANRETIN GEL 0.1%, Tier 5PANTOPRAZOLE TAB, Tier 1PARICALCITOL CAP, Tier 3PARICALCITOL INJ 2MCG/ML, Tier 2PARICALCITOL INJ 5MCG/ML, Tier 3PAROMOMYCIN CAP 250MG, Tier 3

PAROXETINE ER TAB , Tier 2PAROXETINE TAB, Tier 1PASER GRA 4GM, Tier 4PATADAY SOL 0.2%, Tier 3PAXIL SUS 10MG/5ML, Tier 4PCE TAB EC, Tier 4PEDVAX HIB INJ, Tier 3PEGANONE TAB 250MG, Tier 3PEGASYS INJ, Tier 5PEGASYS INJ 180MCG/M, Tier 5PEGASYS INJ PROCLICK, Tier 5PEGASYS INJ PROCLICK, Tier 5PEG-INTRON KIT 120 RP, Tier 5PEG-INTRON KIT 120MCG, Tier 5PEG-INTRON KIT 150 RP, Tier 5PEG-INTRON KIT 150MCG, Tier 5PEG-INTRON KIT 50MCG, Tier 5PEG-INTRON KIT 50MCG RP, Tier 5PEG-INTRON KIT 80MCG, Tier 5PEG-INTRON KIT 80MCG RP, Tier 5PEN G PROC INJ 600000, Tier 4PEN G SOD INJ 5000000, Tier 3PENICILL GK/ INJ DEX 2MU, Tier 3PENICILL GK/ INJ DEX 3MU, Tier 3PENICILLN GK INJ 5MU, Tier 3PENICILLN VK SOL, Tier 2PENICILLN VK TAB, Tier 1PENNSAID SOL 2%, Tier 3PENTAM 300 INJ 300MG, Tier 4PENTOXIFYLLI TAB 400MG ER, Tier 1PERINDOPRIL TAB, Tier 2PERIOGARD SOL 0.12%, Tier 1PERJETA INJ 420/14ML, Tier 5PERMETHRIN CRE 5%, Tier 1PERPHEN/AMIT TAB, Tier 3PERPHENAZINE TAB 16MG, Tier 3PERPHENAZINE TAB 2MG, Tier 2PERPHENAZINE TAB 4MG, Tier 2PERPHENAZINE TAB 8MG, Tier 2PERTZYE CAP, Tier 4PERTZYE CAP, Tier 4PHENADOZ SUP 12.5MG, Tier 1PHENELZINE TAB 15MG, Tier 2

PHENOBARB ELX 20MG/5ML, Tier 1PHENOBARB TAB, Tier 1PHENYLBUTYRA POW SODIUM, Tier 2PHENYTOIN CHW 50MG, Tier 2PHENYTOIN EX CAP, Tier 1PHENYTOIN INJ 50MG/ML, Tier 1PHENYTOIN SUS 125/5ML, Tier 1PHOSPHOLINE SOL 0.125%OP, Tier 4PICATO GEL, Tier 5PILOCARPINE SOL OP, Tier 2PILOCARPINE TAB, Tier 1PINDOLOL TAB, Tier 2PIOGLIT/GLIM TAB, Tier 2PIOGLITA/MET TAB, Tier 2PIOGLITAZONE TAB 15MG, Tier 2PIOGLITAZONE TAB 30MG, Tier 2PIOGLITAZONE TAB 45MG, Tier 2PIPER/TAZOBA INJ 2-0.25GM, Tier 4PIPER/TAZOBA INJ 4-0.5GM, Tier 4PIROXICAM CAP, Tier 2PLASMA-LYTE INJ -148, Tier 3PLASMA-LYTE INJ 56/D5W, Tier 3PLASMA-LYTE INJ -A, Tier 3PODOFILOX SOL 0.5%, Tier 1POLYMYXIN B INJ 500000, Tier 2POLYMYXIN B/ SOL TRIMETHP, Tier 1POMALYST CAP, Tier 5PORTIA-28 TAB, Tier 1POT CHLORIDE CAP ER, Tier 1POT CHLORIDE INJ 10MEQ, Tier 1POT CHLORIDE INJ 10MEQ, Tier 1POT CHLORIDE INJ 20MEQ, Tier 1POT CHLORIDE INJ 2MEQ/ML, Tier 1POT CHLORIDE LIQ SF, Tier 2POT CHLORIDE TAB 10MEQ ER, Tier 1POT CHLORIDE TAB 8MEQ ER, Tier 1POT CITRATE TAB, Tier 1POT CITRATE TAB 540MG ER, Tier 1POT CL MICRO TAB 20MEQ ER, Tier 1POTIGA TAB, Tier 3PRADAXA CAP , Tier 4PRAMIPEXOLE TAB, Tier 1PRAMIPEXOLE TAB 0.75 ER, Tier 3

44

PRAMIPEXOLE TAB 1.5MG ER, Tier 3PRANDIMET TAB 1-500MG, Tier 4PRANDIMET TAB 2-500MG, Tier 3PRAVASTATIN TAB, Tier 1PRAZOSIN HCL CAP, Tier 2PRED SOD PHO SOL 1% OP, Tier 2PRED SOD PHO SOL 5MG/5ML, Tier 1PREDNICARBAT CRE 0.1%, Tier 1PREDNICARBAT OIN 0.1%, Tier 1PREDNISOLONE SOL 15MG/5ML, Tier 1PREDNISOLONE SOL 25MG/5ML, Tier 2PREDNISOLONE SUS 1% OP, Tier 2PREDNISOLONE TAB 10MG ODT, Tier 3PREDNISOLONE TAB 15MG ODT, Tier 4PREDNISOLONE TAB 30MG ODT, Tier 4PREDNISONE CON 5MG/ML, Tier 1PREDNISONE SOL 5MG/5ML, Tier 1PREDNISONE TAB, Tier 1PREFEST TAB, Tier 4PREMARIN INJ 25MG, Tier 3PREMARIN TAB, Tier 3PREMARIN VAG CRE 0.625MG, Tier 3PREMASOL SOL 10%, Tier 3PREMASOL SOL 6%, Tier 1PREMPHASE TAB, Tier 3PREMPRO TAB, Tier 3PRENATAL VITAMIN, Tier 1PREPOPIK PAK, Tier 4PREVALITE POW 4GM, Tier 2PREVIFEM TAB, Tier 1PREZCOBIX TAB 800-150, Tier 5PREZISTA SUS 100MG/ML, Tier 4PREZISTA TAB 150MG, Tier 4PREZISTA TAB 600MG, Tier 5PREZISTA TAB 75MG, Tier 4PREZISTA TAB 800MG, Tier 5PRIFTIN TAB 150MG, Tier 4PRIMAQUINE TAB 26.3MG, Tier 4PRIMIDONE TAB 250MG, Tier 1PRIMIDONE TAB 50MG, Tier 1PRIMSOL SOL 50MG/5ML, Tier 4PRISTIQ TAB, Tier 4

PROAIR HFA AER, Tier 3PROAIR RESPI AER, Tier 3PROBEN/COLCH TAB 500-0.5, Tier 1PROBENECID TAB 500MG, Tier 1PROCALAMINE INJ 3%, Tier 3PROCHLORPER INJ 10MG/2ML, Tier 2PROCHLORPER SUP 25MG, Tier 2PROCHLORPER TAB, Tier 1PROCRIT INJ 10000/ML, Tier 3PROCRIT INJ 2000/ML, Tier 3PROCRIT INJ 20000/ML, Tier 5PROCRIT INJ 3000/ML, Tier 3PROCRIT INJ 4000/ML, Tier 3PROCRIT INJ 40000/ML, Tier 5PROCTOZONE CRE -HC 2.5%, Tier 2PROGESTERONE CAP, Tier 2PROGLYCEM SUS 50MG/ML, Tier 3PROGRAF INJ 5MG/ML, Tier 4PROLASTIN-C INJ 1000MG, Tier 5PROLEUKIN INJ 22MU, Tier 5PROLIA SOL 60MG/ML, Tier 4PROMACTA TAB, Tier 5PROMETH VC SYP PLAIN, Tier 1PROMETHAZINE INJ, Tier 1PROMETHAZINE SUP, Tier 1PROMETHAZINE SYP 6.25/5ML, Tier 1PROMETHAZINE TAB, Tier 1PROMETHEGAN SUP 25MG, Tier 1PROMETHEGAN SUP 50MG, Tier 1PROPAFENONE CAP ER, Tier 2PROPAFENONE TAB , Tier 2PROPARACAINE SOL 0.5% OP, Tier 1PROPRAN/HCTZ TAB, Tier 1PROPRANOLOL CAP ER, Tier 1PROPRANOLOL INJ 1MG/ML, Tier 1PROPRANOLOL SOL, Tier 1PROPRANOLOL TAB, Tier 1PROPYLTHIOUR TAB 50MG, Tier 1PROQUAD INJ, Tier 3PROSOL INJ 20%, Tier 3PROTRIPTYLIN TAB, Tier 3PROVENTIL AER HFA, Tier 3PULMICORT INH 180MCG, Tier 3

PULMICORT INH 90MCG, Tier 3PULMICORT SUS 0.25MG/2, Tier 3PULMICORT SUS 0.5MG/2, Tier 3PULMICORT SUS 1MG/2ML, Tier 3PULMOZYME SOL 1MG/ML, Tier 5PURIXAN SUS 20MG/ML, Tier 4PYLERA CAP, Tier 4PYRAZINAMIDE TAB 500MG, Tier 2PYRIDOSTIGM TAB 60MG, Tier 1

Q

QNAPRIL/HCTZ TAB, Tier 2QUADRACEL INJ, Tier 3QUASENSE TAB, Tier 1QUDEXY XR CAP, Tier 4QUESTRAN POW 4GM, Tier 4QUETIAPINE TAB, Tier 2QUINAPRIL TAB, Tier 1QUINIDINE GL TAB 324MG CR, Tier 1QUINIDINE SU TAB, Tier 1QUININE SULF CAP 324MG, Tier 4QVAR AER 40MCG, Tier 3QVAR AER 80MCG, Tier 3

R

RABAVERT INJ, Tier 3RABEPRAZOLE TAB 20MG, Tier 2RALOXIFENE TAB 60MG, Tier 2RAMIPRIL CAP, Tier 1RANEXA TAB, Tier 3RANITIDINE CAP, Tier 2RANITIDINE INJ 50MG/2ML, Tier 2RANITIDINE SYP 75MG/5ML, Tier 1RANITIDINE TAB 300MG, Tier 1RAPAFLO CAP, Tier 4RAPAMUNE SOL 1MG/ML, Tier 5RAVICTI LIQ 1.1GM/ML, Tier 4REBETOL SOL 40MG/ML, Tier 5REBIF REBIDO INJ, Tier 5REBIF REBIDO SOL TITRATN, Tier 5RECLIPSEN TAB, Tier 1RECOMBIVA HB INJ, Tier 3REGRANEX GEL 0.01%, Tier 5

45

RELENZA MIS DISKHALE, Tier 4RELISTOR INJ, Tier 3RELPAX TAB, Tier 4REMICADE INJ 100MG, Tier 5REMODULIN INJ, Tier 5RENVELA PAK, Tier 3RENVELA TAB 800MG, Tier 3REPAGLINIDE TAB, Tier 2REPREXAIN TAB, Tier 4RESCRIPTOR TAB 100 MG, Tier 4RESCRIPTOR TAB 200MG, Tier 4RESTASIS EMU 0.05%, Tier 3RETROVIR INJ 10MG/ML, Tier 4REVLIMID CAP 10MG, Tier 5REVLIMID CAP 15MG, Tier 5REVLIMID CAP 2.5MG, Tier 5REVLIMID CAP 20MG, Tier 5REVLIMID CAP 25MG, Tier 5REVLIMID CAP 5MG, Tier 5REYATAZ CAP 150MG, Tier 5REYATAZ CAP 200MG, Tier 5REYATAZ CAP 300MG, Tier 5REYATAZ POW 50MG, Tier 5RHEUMATREX TAB 2.5MG, Tier 3RIBAPAK PAK 1000/DAY, Tier 5RIBAPAK PAK 800/DAY, Tier 5RIBASPHERE CAP 200MG, Tier 3RIBASPHERE TAB 200MG, Tier 3RIBASPHERE TAB 400MG, Tier 4RIBASPHERE TAB 600MG, Tier 5RIBATAB TAB 1200/DAY, Tier 5RIBAVIRIN CAP 200MG, Tier 3RIBAVIRIN TAB 200MG, Tier 3RIFABUTIN CAP 150MG, Tier 3RIFAMATE CAP, Tier 4RIFAMPIN CAP, Tier 2RIFAMPIN INJ 600 MG, Tier 2RIFATER TAB, Tier 4RILUZOLE TAB 50MG, Tier 4RIMANTADINE TAB 100MG, Tier 3RINGERS INJ, Tier 1RIOMET SOL, Tier 4RISEDRON SOD TAB 35MG DR, Tier 3

RISEDRONATE TAB, Tier 3RISPERDAL INJ 12.5MG, Tier 4RISPERDAL INJ 25MG, Tier 4RISPERDAL INJ 37.5MG, Tier 5RISPERDAL INJ 50MG, Tier 5RISPERIDONE SOL 1MG/ML, Tier 2RISPERIDONE TAB, Tier 1RISPERIDONE TAB ODT, Tier 2RITUXAN INJ 100MG, Tier 3RIVASTIGMINE CAP, Tier 2RIZATRIPTAN TAB, Tier 2RIZATRIPTAN TAB ODT, Tier 2ROPINIROLE TAB, Tier 1ROPINIROLE TAB ER, Tier 2ROTARIX SUS, Tier 3ROTATEQ SOL, Tier 3ROZEREM TAB 8MG, Tier 4

S

SABRIL POW 500MG, Tier 5SABRIL TAB 500MG, Tier 5SAFYRAL TAB, Tier 4SAIZEN INJ 5MG, Tier 5SAIZEN INJ 8.8MG, Tier 5SAIZEN INJ 8.8MG, Tier 5SAMSCA TAB, Tier 5SANCUSO DIS 3.1MG, Tier 3SANDIMMUNE CAP, Tier 3SANDIMMUNE SOL 100MG/ML, Tier 3SANDOSTATIN KIT LAR, Tier 5SANTYL OIN 250/GM, Tier 3SAPHRIS SUB, Tier 4SAPHRIS SUB 2.5MG, Tier 4SARAFEM TAB, Tier 4SAVELLA MIS TITR PAK, Tier 3SAVELLA TAB, Tier 3SELEGILINE CAP 5MG, Tier 1SELEGILINE TAB 5MG, Tier 2SELENIUM SUL LOT 2.5%, Tier 1SELZENTRY TAB 150MG, Tier 5SELZENTRY TAB 300MG, Tier 5SENSIPAR TAB 30MG, Tier 3SENSIPAR TAB 60MG, Tier 5

SENSIPAR TAB 90MG, Tier 5SEREVENT DIS AER 50MCG, Tier 3SEROQUEL XR TAB, Tier 3SEROSTIM INJ, Tier 5SERTRALINE CON 20MG/ML, Tier 1SERTRALINE TAB, Tier 1SFROWASA ENE 4GM, Tier 4SIGNIFOR INJ, Tier 4SILDENAFIL TAB 20MG, Tier 2SILENOR TAB 3MG, Tier 3SILENOR TAB 6MG, Tier 3SILVER SULFA CRE 1%, Tier 1SIMBRINZA SUS 1-0.2%, Tier 4SIMPONI ARIA SOL 50MG/4ML, Tier 5SIMPONI INJ 100MG/ML, Tier 5SIMPONI INJ 50/0.5ML, Tier 5SIMULECT INJ 20MG, Tier 4SIMVASTATIN TAB, Tier 1SIROLIMUS TAB 0.5MG, Tier 2SIROLIMUS TAB 1MG, Tier 4SIROLIMUS TAB 2MG, Tier 5SIRTURO TAB 100MG, Tier 5SKLICE LOT 0.5%, Tier 4SMOOTH LAX POW, Tier 1SMZ/TMP DS TAB 800-160, Tier 1SMZ-TMP INJ 400-80/5, Tier 2SMZ-TMP SUS 200-40/5, Tier 2SMZ-TMP TAB 400-80MG, Tier 1SOD CHLORIDE INJ 0.45%, Tier 1SOD CHLORIDE INJ 0.9%, Tier 1SOD CHLORIDE INJ 2.5/ML, Tier 1SOD CHLORIDE INJ 3%, Tier 1SOD CHLORIDE INJ 5%, Tier 1SOD FLUORIDE TAB 1MG F, Tier 1SOD POLY SUL SUS 30/120ML, Tier 1SODIUM CHLOR SOL 0.9% IRR, Tier 1SOLTAMOX SOL 10MG/5ML, Tier 4SOLU-CORTEF INJ 1000MG, Tier 3SOLU-MEDROL INJ 2GM, Tier 4SOLU-MEDROL INJ 500MG, Tier 4SOMA TAB 250MG, Tier 4SOMATULINE INJ, Tier 5SOMAVERT INJ 10MG, Tier 5

46

SOMAVERT INJ 15MG, Tier 5SOMAVERT INJ 20MG, Tier 5SOOLANTRA CRE 1%, Tier 4SORINE TAB, Tier 2SOTALOL HCL TAB, Tier 1SOVALDI TAB 400MG, Tier 5SPIRIVA CAP HANDIHLR, Tier 3SPIRIVA SPR RESPIMAT, Tier 3SPIRONO/HCTZ TAB 25/25, Tier 2SPIRONOLACT TAB, Tier 1SPORANOX SOL 10MG/ML, Tier 5SPRINTEC 28 TAB 28 DAY, Tier 1SPRIX SPR 15.75MG, Tier 4SPRYCEL TAB 100MG, Tier 5SPRYCEL TAB 140MG, Tier 5SPRYCEL TAB 20MG, Tier 5SPRYCEL TAB 50MG, Tier 5SPRYCEL TAB 70MG, Tier 5SPRYCEL TAB 80MG, Tier 5SRONYX TAB, Tier 1SSD CRE 1%, Tier 1STAVUDINE CAP 15MG, Tier 3STAVUDINE CAP 20MG, Tier 3STAVUDINE CAP 30MG, Tier 3STAVUDINE CAP 40MG, Tier 3STAVUDINE SOL 1MG/ML, Tier 3STELARA INJ 45MG/0.5, Tier 5STELARA INJ 90MG/ML, Tier 5STIMATE SOL 1.5MG/ML, Tier 4STIVARGA TAB 40MG, Tier 5STRATTERA CAP 100MG, Tier 3STRATTERA CAP 10MG, Tier 3STRATTERA CAP 18MG, Tier 3STRATTERA CAP 25MG, Tier 3STRATTERA CAP 40MG, Tier 3STRATTERA CAP 60MG, Tier 3STRATTERA CAP 80MG, Tier 3STREPTOMYCIN INJ 1GM, Tier 3STRIBILD TAB, Tier 5SUBOXONE MIS 12-3MG, Tier 4SUBOXONE MIS 2-0.5MG, Tier 4SUBOXONE MIS 4-1MG, Tier 4SUBOXONE MIS 8-2MG, Tier 4

SUBSYS SPR 100MCG, Tier 5SUBSYS SPR 200MCG, Tier 5SUBSYS SPR 400MCG, Tier 5SUBSYS SPR 600MCG, Tier 5SUBSYS SPR 800MCG, Tier 5SUCLEAR KIT, Tier 4SUCRALFATE TAB 1GM, Tier 1SULF/PRED NA SOL OP, Tier 1SULFACET SOD SOL 10% OP, Tier 1SULFACETAMID SUS 10%, Tier 1SULFADIAZINE TAB 500MG, Tier 2SULFAMYLON CRE 85MG/GM, Tier 4SULFASALAZIN TAB 500MG, Tier 1SULFAZINE EC TAB 500MG, Tier 1SULINDAC TAB, Tier 2SUMATRIPTAN INJ 6MG/0.5, Tier 2SUMATRIPTAN INJ 6MG/0.5, Tier 1SUMATRIPTAN SPR, Tier 2SUMATRIPTAN TAB, Tier 1SUPRAX CHW, Tier 3SUPRAX SUS 500/5ML, Tier 3SUPREP BOWEL SOL PREP, Tier 4SURMONTIL CAP, Tier 4SUSTIVA CAP 200MG, Tier 4SUSTIVA CAP 50MG, Tier 4SUSTIVA TAB 600MG, Tier 4SUTENT CAP 12.5MG, Tier 5SUTENT CAP 25MG, Tier 5SUTENT CAP 37.5MG, Tier 5SUTENT CAP 50MG, Tier 5SYLATRON KIT , Tier 5SYMBICORT AER, Tier 3SYMLINPEN 60 INJ 1000MCG, Tier 1SYMLNPEN 120 INJ 1000MCG, Tier 4SYNAGIS INJ 100MG/ML, Tier 5SYNALGOS-DC CAP, Tier 4SYNAREL SOL 2MG/ML, Tier 5SYNERCID INJ 500MG, Tier 5SYNRIBO INJ 3.5MG, Tier 5SYNTHROID TAB, Tier 3SYNTHROID TAB 100MCG, Tier 3SYPRINE CAP 250MG, Tier 3

T

TABLOID TAB 40MG, Tier 3TACLONEX SUS, Tier 3TACROLIMUS CAP 0.5MG, Tier 2TACROLIMUS CAP 1MG, Tier 2TACROLIMUS CAP 5MG, Tier 5TACROLIMUS OIN, Tier 3TAFINLAR CAP, Tier 5TAMIFLU CAP 30MG, Tier 3TAMIFLU CAP 45MG, Tier 3TAMIFLU CAP 75MG, Tier 3TAMIFLU SUS 6MG/ML, Tier 3TAMOXIFEN TAB, Tier 1TAMSULOSIN CAP 0.4MG, Tier 1TARCEVA TAB 100MG, Tier 5TARCEVA TAB 150MG, Tier 5TARCEVA TAB 25MG, Tier 5TARGRETIN CAP 75MG, Tier 5TARGRETIN GEL 1%, Tier 5TASIGNA CAP, Tier 5TAXOTERE INJ 20MG/ML, Tier 5TAZORAC CRE, Tier 4TAZORAC GEL , Tier 4TAZTIA XT CAP, Tier 2TECFIDERA CAP, Tier 5TECFIDERA MIS STARTER, Tier 5TEFLARO INJ, Tier 4TEGRETOL-XR TAB 100MG, Tier 3TEKTURNA TAB, Tier 3TELMIS/AMLOD TAB, Tier 2TELMISA/HCTZ TAB, Tier 3TELMISARTAN TAB, Tier 2TEMAZEPAM CAP 15MG, Tier 2TEMAZEPAM CAP 22.5MG, Tier 2TEMAZEPAM CAP 30MG, Tier 2TEMAZEPAM CAP 7.5MG, Tier 2TEMOVATE CRE 0.05%, Tier 4TENIVAC INJ 5-2LF, Tier 3TERAZOSIN CAP, Tier 1TERBINAFINE TAB 250MG, Tier 1TERBUTALINE INJ 1MG/ML, Tier 4TERBUTALINE TAB, Tier 3TERCONAZOLE CRE 0.4%, Tier 1

47

TERCONAZOLE SUP 80MG, Tier 1TESTIM GEL 1%(50MG), Tier 4TESTOST CYP INJ , Tier 1TESTOST ENAN INJ 200MG/ML, Tier 1TESTOSTERONE GEL 1%(25MG), Tier 3TET/DIP TOX INJ 2-2 LF, Tier 3TEVETEN HCT TAB, Tier 4THALOMID CAP, Tier 5THEOPHYLLINE TAB ER, Tier 1THIORIDAZINE TAB, Tier 2THIOTHIXENE CAP, Tier 1THYMOGLOBULN INJ 25MG, Tier 5TIAGABINE TAB, Tier 2TIKOSYN CAP, Tier 3TIMOLOL GEL SOL OP, Tier 2TIMOLOL MAL SOL OP, Tier 1TIMOLOL MAL TAB, Tier 1TINIDAZOLE TAB, Tier 3TIROSINT CAP, Tier 3TIVICAY TAB 50MG, Tier 5TIZANIDINE CAP, Tier 2TIZANIDINE TAB, Tier 1TOBI PODHALR CAP 28MG, Tier 5TOBRA/DEXAME SUS 0.3-0.1%, Tier 2TOBRA/NACL INJ 80/0.9, Tier 2TOBRADEX OIN 0.3-0.1%, Tier 3TOBRADEX ST SUS 0.3-0.05, Tier 3TOBRAMYCIN INJ 10MG/ML, Tier 2TOBRAMYCIN INJ 80MG/2ML, Tier 2TOBRAMYCIN NEB 300/5ML, Tier 2TOBRAMYCIN SOL 0.3% OP, Tier 1TOBREX OIN 0.3% OP, Tier 3TOLAZAMIDE TAB, Tier 1TOLBUTAMIDE TAB 500MG, Tier 1TOLMETIN SOD CAP 400MG, Tier 2TOLMETIN SOD TAB 600MG, Tier 2TOLTERODINE CAP ER, Tier 2TOLTERODINE TAB, Tier 2TOPICORT CRE 0.05%, Tier 4TOPICORT SPR 0.25%, Tier 4TOPIRAMATE CAP, Tier 1TOPIRAMATE CAP ER, Tier 3TOPIRAMATE TAB, Tier 1

TOPOSAR INJ 100/5ML, Tier 1TOPOTECAN INJ 4MG/4ML, Tier 5TORISEL SOL 25MG/ML, Tier 5TORSEMIDE TAB, Tier 2TPN ELECTROL INJ, Tier 1TRACLEER TAB, Tier 5TRADJENTA TAB 5MG, Tier 3TRAMADL/APAP TAB 37.5-325, Tier 1TRAMADOL HCL TAB 50MG, Tier 1TRAMADOL HCL TAB ER, Tier 2TRANDOLAPRIL TAB, Tier 2TRANEX ACID INJ 100MG/ML, Tier 1TRANEX ACID TAB 650MG, Tier 2TRANSDERM-SC DIS 1MG, Tier 4TRANYLCYPROM TAB 10MG, Tier 2TRAVASOL INJ 10%, Tier 3TRAVATAN Z DRO 0.004%, Tier 3TRAVOPROST DRO 0.004%, Tier 2TRAZODONE TAB 100MG, Tier 1TRAZODONE TAB 150MG, Tier 1TRAZODONE TAB 300MG, Tier 2TRAZODONE TAB 50MG, Tier 1TREANDA INJ 25MG, Tier 5TREANDA INJ 45/0.5ML, Tier 5TRECATOR TAB 250MG, Tier 4TRELSTAR INJ, Tier 5TRELSTAR MIX INJ 22.5MG, Tier 5TRETINOIN CAP 10MG, Tier 5TRETINOIN CRE, Tier 1TRETINOIN GEL 0.01%, Tier 1TRETINOIN GEL 0.025%, Tier 1TRETINOIN GEL 0.04%, Tier 4TRETINOIN GEL 0.1%, Tier 4TREXALL TAB, Tier 4TREXIMET TAB 85-500MG, Tier 4TRIAMCINOLON AER 55MCG/AC, Tier 1TRIAMCINOLON AER SPRAY, Tier 3TRIAMCINOLON CRE, Tier 1TRIAMCINOLON LOT, Tier 1TRIAMCINOLON OIN, Tier 1TRIAMCINOLON PST 0.1%, Tier 1TRIAMT/HCTZ CAP, Tier 1TRIAMT/HCTZ TAB, Tier 1

TRIAZOLAM TAB 0.125MG, Tier 2TRIAZOLAM TAB 0.25MG, Tier 2TRIBENZOR TAB, Tier 4TRIDERM CRE 0.1%, Tier 1TRIFLUOPERAZ TAB 10MG, Tier 1TRIFLUOPERAZ TAB 1MG, Tier 2TRIFLUOPERAZ TAB 2MG, Tier 1TRIFLUOPERAZ TAB 5MG, Tier 1TRIFLURIDINE SOL 1% OP, Tier 4TRIHEXYPHEN ELX 0.4MG/ML, Tier 1TRIHEXYPHEN TAB, Tier 1TRI-LEGEST TAB FE, Tier 1TRILYTE SOL, Tier 1TRIMETHOBENZ CAP 300MG, Tier 1TRIMETHOPRIM TAB 100MG, Tier 1TRINESSA TAB, Tier 1TRI-PREVIFEM TAB, Tier 1TRISENOX SOL 10MG/10M, Tier 3TRI-SPRINTEC TAB, Tier 1TRIUMEQ TAB, Tier 5TRIVORA-28 TAB, Tier 1TROKENDI XR CAP, Tier 4TROPHAMINE INJ 10%, Tier 3TROSPIUM CHL CAP 60MG ER, Tier 2TROSPIUM CL TAB 20MG, Tier 2TRUMENBA INJ, Tier 4TRUVADA TAB 200-300, Tier 5TWINRIX INJ, Tier 3TYBOST TAB 150MG, Tier 4TYGACIL INJ 50MG, Tier 4TYKERB TAB 250MG, Tier 5TYPHIM VI INJ, Tier 3TYPHIM VI INJ, Tier 3TYSABRI INJ 300/15ML, Tier 5TYZEKA TAB 600MG, Tier 5TYZINE PED DRO 0.05%, Tier 4

U

UCERIS TAB 9MG, Tier 5ULORIC TAB, Tier 3UNITHROID TAB 100MCG, Tier 2UNITHROID TAB 112MCG, Tier 2UNITHROID TAB 125MCG, Tier 2

48

UNITHROID TAB 150MCG, Tier 2UNITHROID TAB 175MCG, Tier 2UNITHROID TAB 200MCG, Tier 2UNITHROID TAB 25MCG, Tier 2UNITHROID TAB 300MCG, Tier 2UNITHROID TAB 50MCG, Tier 2UNITHROID TAB 75MCG, Tier 2UNITHROID TAB 88MCG, Tier 2URSODIOL CAP 300MG, Tier 1URSODIOL TAB , Tier 1UVADEX INJ 20MCG/ML, Tier 4

V

VAGIFEM TAB 10MCG, Tier 4VALACYCLOVIR TAB 1GM, Tier 2VALACYCLOVIR TAB 500MG, Tier 2VALCHLOR GEL 0.016%, Tier 5VALGANCICLOV TAB 450MG, Tier 5VALPROATE INJ 500/5ML, Tier 1VALPROIC ACD CAP 250MG, Tier 1VALPROIC ACD SYP 250/5ML, Tier 1VALSART/HCTZ TAB, Tier 2VALSARTAN TAB, Tier 2VANCOMYC/DEX INJ 500MG, Tier 3VANCOMYCIN CAP, Tier 4VANCOMYCIN INJ 1 GM, Tier 3VANCOMYCIN INJ 10GM, Tier 3VANDAZOLE GEL 0.75%, Tier 1VAQTA INJ 25/0.5ML, Tier 3VAQTA INJ 50UNT/ML, Tier 3VARIVAX INJ, Tier 3VARIZIG INJ 125UNIT, Tier 4VECTIBIX INJ 100MG, Tier 4VELCADE INJ 3.5MG, Tier 5VELIVET PAK, Tier 1VENLAFAXINE CAP ER, Tier 1VENLAFAXINE TAB, Tier 2VENLAFAXINE TAB 150MG ER, Tier 3VENLAFAXINE TAB 225MG ER, Tier 4VENLAFAXINE TAB 37.5 ER, Tier 3VENLAFAXINE TAB 75MG ER, Tier 3VENTAVIS SOL 20MCG/ML, Tier 5VENTOLIN HFA AER, Tier 4

VERAMYST SPR 27.5MCG, Tier 4VERAPAMIL CAP 100MG ER, Tier 2VERAPAMIL CAP 120MG ER, Tier 2VERAPAMIL CAP 180MG ER, Tier 2VERAPAMIL CAP 200MG ER, Tier 2VERAPAMIL CAP 240MG ER, Tier 2VERAPAMIL CAP 300MG ER, Tier 2VERAPAMIL CAP 360MG SR, Tier 3VERAPAMIL INJ 2.5MG/ML, Tier 1VERAPAMIL TAB, Tier 1VERAPAMIL TAB ER, Tier 2VERIPRED 20 SOL 20MG/5ML, Tier 4VERSACLOZ SUS 50MG/ML, Tier 4VESICARE TAB, Tier 3VESTURA TAB 3-0.02MG, Tier 2VEXOL SUS 1% OP, Tier 4VIBRAMYCIN SYP 50MG/5ML, Tier 4VICTOZA INJ 18MG/3ML, Tier 3VIDEX SOL 2GM, Tier 4VIGAMOX DRO 0.5%, Tier 3VIIBRYD KIT, Tier 4VIIBRYD TAB, Tier 4VIMPAT INJ 200MG/20, Tier 4VIMPAT SOL 10MG/ML, Tier 4VIMPAT TAB, Tier 4VINBLASTINE INJ 1MG/ML, Tier 3VINCASAR PFS INJ 1MG/ML, Tier 3VINCRISTINE INJ 1MG/ML, Tier 3VINORELBINE INJ 10MG/ML, Tier 3VIOKACE TAB, Tier 4VIOKACE TAB 20880, Tier 4VIRACEPT TAB 250MG, Tier 5VIRACEPT TAB 625MG, Tier 5VIRAMUNE XR TAB 100MG, Tier 4VIRAZOLE INH 6GM, Tier 5VIREAD POW 40MG/GM, Tier 5VIREAD TAB, Tier 5VITEKTA TAB, Tier 5VIVITROL INJ 380MG, Tier 5VOLTAREN GEL 1%, Tier 3VORICONAZOLE INJ 200MG, Tier 4VORICONAZOLE SUS 40MG/ML, Tier 5VORICONAZOLE TAB 200MG, Tier 5

VORICONAZOLE TAB 50MG, Tier 5VOTRIENT TAB 200MG, Tier 5VPRIV INJ 400UNIT, Tier 5VYFEMLA TAB 0.4-35, Tier 1VYVANSE CAP, Tier 4

W

WAL-DRAM II TAB 25MG, Tier 1WARFARIN TAB, Tier 1WELLBUTRIN TAB 100MG, Tier 4WELLBUTRIN TAB 75MG, Tier 4WELLBUTRIN TAB SR, Tier 4

X

XALKORI CAP, Tier 5XARELTO STAR TAB 15/20MG, Tier 3XARELTO TAB, Tier 3XELJANZ TAB 5MG, Tier 5XENAZINE TAB, Tier 5XGEVA INJ, Tier 5XIFAXAN TAB 200MG, Tier 4XIFAXAN TAB 550MG, Tier 5XOLAIR SOL 150MG, Tier 5XTANDI CAP 40MG, Tier 5XULANE DIS 150-35, Tier 2XYREM SOL 500MG/ML, Tier 5

Y

YERVOY INJ 50MG, Tier 5YF-VAX INJ, Tier 3

Z

ZAFIRLUKAST TAB, Tier 2ZALEPLON CAP 10MG, Tier 2ZALEPLON CAP 5MG, Tier 1ZALTRAP INJ 100/4ML, Tier 5ZANOSAR INJ 1GM, Tier 4ZAVESCA CAP 100MG, Tier 5ZAZOLE CRE, Tier 1ZELAPAR TAB 1.25MG, Tier 4ZELBORAF TAB 240MG, Tier 5ZEMAIRA INJ 1000MG, Tier 5

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ZEMPLAR INJ, Tier 3ZENPEP CAP, Tier 3ZENZEDI TAB 15MG, Tier 4ZENZEDI TAB 20MG, Tier 4ZENZEDI TAB 30MG, Tier 4ZERBAXA INJ 1-0.5 GM, Tier 4ZETIA TAB 10MG, Tier 3ZETONNA AER 37MCG, Tier 4ZIAGEN SOL 20MG/ML, Tier 4ZIANA GEL, Tier 4ZIDOVUDINE CAP 100MG, Tier 3ZIDOVUDINE SYP 50MG/5ML, Tier 3ZIDOVUDINE TAB 300MG, Tier 3ZIPRASIDONE CAP, Tier 2ZIRGAN GEL 0.15%, Tier 4ZMAX SUS 2GM, Tier 4ZOLEDRONIC INJ 4MG/5ML, Tier 2ZOLEDRONIC INJ 5/100ML, Tier 2ZOLINZA CAP 100MG, Tier 5ZOLMITRIPTAN TAB, Tier 2ZOLMITRIPTAN TAB ODT, Tier 2ZOLPIDEM ER TAB, Tier 2ZOLPIDEM TAB, Tier 2ZOMIG NASAL SPR 5MG, Tier 4ZONALON CRE 5%, Tier 3ZONISAMIDE CAP, Tier 2ZORBTIVE INJ 8.8MG, Tier 5ZORTRESS TAB 0.25MG, Tier 3ZORTRESS TAB 0.5MG, Tier 5ZORTRESS TAB 0.75MG, Tier 5ZOSTAVAX INJ, Tier 3ZOSYN SOL 2-0.25GM, Tier 4ZOSYN SOL 3-0.375G, Tier 4ZOVIA TAB, Tier 1ZOVIRAX CRE 5%, Tier 4ZYDELIG TAB, Tier 5ZYFLO CR TAB 600MG, Tier 4ZYFLO TAB 600MG, Tier 4ZYKADIA CAP 150MG, Tier 5ZYPREXA RELP INJ 210MG, Tier 4ZYTIGA TAB 250MG, Tier 5ZYVOX SOL 2MG/ML, Tier 5

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MORE PLAN INFORMATION

51

WE’RE HERE FOR YOUPersonal assistance from a HealthTeam Advantage Healthcare Concierge.

At HealthTeam Advantage, we work hard to provide our members excellent customer service. Whenever you have a question, we are always just a phone call or email away.

When you enroll in a HealthTeam Advantage PPO plan, you will have a personal Healthcare Concierge who will work closely with you each time you need assistance, as well as follow up with you when needed.

At HealthTeam Advantage, your Healthcare Concierge can help:

Explain health plan benefits. Your Healthcare Concierge will take the guesswork out of understanding your health plan coverage. Give us a call or send us an email and we will answer questions you may have about your health plan benefits, pending claims, or account status.

Coordinate healthcare services with an in-network doctor. HealthTeam Advantage’s strong network of primary care and specialty doctors knows what it takes to care for seniors. Your personal Healthcare Concierge is there for you to find a doctor that is within our network, which in some cases can help lower your copayment.

Verify health plan coverage with a participating provider. Navigating the healthcare system can sometimes be confusing. Your Healthcare Concierge can contact a healthcare provider on your behalf before your visit to confirm health plan coverage and coordinate the claims and billing process for you.

Find a healthcare facility near you. No matter where you go, your HealthTeam Advantage Healthcare Concierge is available to help you access the healthcare you need. Your Healthcare Concierge can locate doctors or healthcare providers based on your location as well as assist you with scheduling an appointment.

And much more!

H9808_16_08 AcceptedHealthTeam Advantage is a Medicare Advantage Organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.

2016 52

2016

S ILVER&FIT® Exercise & Healthy Aging Program - Something for Everyone!




Staying healthy and active is important to your overall health. When you join HealthTeam Advantage (PPO), you will receive a membership to Silver&Fit® Exercise and Healthy Aging Program at no cost. This program is a unique opportunity to help you stay active whether you are at home or on the road.

Fitness at a locationThe Silver&Fit® Exercise & Healthy Aging Program provides members access to a broad network of participating fitness facilities and instructor-led classes. Some facilities have classes designed for older adults.

Fitness at homePrefer to exercise at home? No problem! You can exercise in your home using the Home Fitness program. Choose up to 2 Home Fitness Kits each year. These kits may include DVDs, guides, and other items to help you get fit on your own terms.

Silver&Fit® gives members:• Access to a fitness club or exercise center• Group classes made for older adults, where offered• The option to work out at home using up to 2

Home Fitness Kits per year• Healthy aging materials (online or DVD)• A newsletter 4 times a year• The Silver&Fit Connected™ program, a fun and easy way to

track exercise at a facility or thorugh a wearable fitness device• Other web tools like a facility search, health articles, and more

To find out more about Silver&Fit®, please go to www.SilverandFit.com or call toll-free 1-877-427-4788, Monday-Friday, 8 a.m. - 8 p.m. Eastern Time.

2016 53

DENTAL HEALTHTaking care of your health includes caring for your teeth, too.

At HealthTeam Advantage, we believe your dental health can have a direct impact on your overall health and well-being, and may have an influence on the development of certain conditions, such as diabetes and heart disease.

HealthTeam Advantage’s Dental Rider helps meet most of your everyday dental needs. The rider covers services most often used, without the need for a referral or preauthorization. Members receive all of the services with only an additional $20 monthly premium.

Exams – choose two per year (either two A’s or one A and one B):ADA CODE DESCRIPTION LIMITATIONS COPAY

A D0120 Recall Exam Up to two per year $0

B D0150 Comprehensive Exam One per year; New Patients only; Limited to one every 3 years $0

Cleanings:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D1110 Routine Cleaning 2 per year $0

X-Rays – choose one per year (A or B): ADA CODE DESCRIPTION LIMITATIONS COPAY

A D0270/D0272/D0273/D0274 Bitewing X-rays One set per year $0

B D0210 Full Mouth X-rays One set per year; Allowed once every 3 years $0

Fillings:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D2140 Amalgam filling one surface

Up to 4 total fillings per year

$35

B D2150 Amalgam filling two surfaces $45

C D2160 Amalgam filling three surfaces $55

D D2330 Resin-based composite - one surface, anterior $50

E D2331 Resin-based composite - two surfaces, anterior $65

F D2332 Resin-based composite - three surfaces, anterior $80



2016 54

Scaling and Root Planing:ADA CODE DESCRIPTION LIMITATIONS COPAY

D4341 Scaling and root planing (per quadrant) Up to 2 quads per year $50 copay per

quadrant

Denture Adjustments:ADA CODE DESCRIPTION LIMITATIONS COPAY

D5410 or D5411 Denture Adjustment Total of 2 per year $0

Extractions:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D7140 Extraction, erupted toothUp to 2 per year

$40

B D7210 Extraction, surgical $75

Crowns:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D2751 Crown - porcelain fused to base metal

Total of 2 per year. Crowns have a 6 month waiting period for new enrollees.

$305

B D2752 Crown - porcelain fused to noble metal $320

C D2791 Crown - full cast base metal $307

D D2792 Crown - full cast noble metal $305

OUT-OF-NETWORK BENEFIT

Member reimbursed the in-network fee that providers are paid for covered services after applicable copay

* Out-of-Network dentists can bill you for charges above the amount covered by your HealthTeam Advantage Dental Rider. To ensure you do not receive additional charges, visit a dentist in the HealthTeam Advantage Provider Network. To talk to a benefits consultant, call 1-877-905-9216 (TTY 711), available to help you seven days a week, 8 a.m. to 8 p.m (EST).

You must continue to pay your Medicare Part B premium. You must also continue to pay your applicable monthly plan premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.

55

DENTAL - VISION - HEARING Supplemental Combination Rider provides peace of mind knowing you have the extra coverage.

Sometimes we need a little something extra to care for our vision, hearing and dental needs. HealthTeam Advantage offers a supplemental combination rider to fill the gap.

$35 ADDITIONAL MONTHLY PREMIUM

HERE ARE SOME OF THE BENEFITS:Preventive and Comprehensive Dental Services

» Up to 2 oral exams per year » Up to 2 routine cleanings per year

» 1 dental x-ray per year

Hearing Services » 1 routine hearing test per year » 1 hearing aid fitting (every 3 years) » $800 plan coverage limit for hearing aids (every 3 years)

Vision Services » 1 routine eye exam per year » $200* plan coverage limit every year for eyewear (frames and lenses OR contacts)

*excludes in-store provider specials

Exams – choose two per year (either two A’s or one A and one B):COVERED DENTAL BENEFITS

ADA CODE DESCRIPTION LIMITATIONS COPAY

A D0120 Recall Exam Up to two per year $0

B D0150 Comprehensive Exam One per year; New Patients only; Limited to one every 3 years $0

Cleanings:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D1110 Routine Cleaning 2 per year $0

X-Rays – choose one per year (A or B): ADA CODE DESCRIPTION LIMITATIONS COPAY

A D0270/D0272/D0273/D0274 Bitewing X-rays One set per year $0

B D0210 Full Mouth X-rays One set per year; Allowed once every 3 years $0

Fillings:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D2140 Amalgam filling one surface

Up to 4 total fillings per year

$35

B D2150 Amalgam filling two surfaces $45

C D2160 Amalgam filling three surfaces $55

D D2330 Resin-based composite - one surface, anterior $50

E D2331 Resin-based composite - two surfaces, anterior $65

F D2332 Resin-based composite - three surfaces, anterior $80



2016 56

Scaling and Root Planing:ADA CODE DESCRIPTION LIMITATIONS COPAY

D4341 Scaling and root planing (per quadrant) Up to 2 quads per year $50 copay per

quadrant

Denture Adjustments:ADA CODE DESCRIPTION LIMITATIONS COPAY

D5410 or D5411 Denture Adjustment Total of 2 per year $0

Extractions:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D7140 Extraction, erupted toothUp to 2 per year

$40

B D7210 Extraction, surgical $75

Crowns:ADA CODE DESCRIPTION LIMITATIONS COPAY

A D2751 Crown - porcelain fused to base metalTotal of 2 per year. Crowns have a 6 month waiting period for new enrollees.

$305

B D2752 Crown - porcelain fused to noble metal $320

C D2791 Crown - full cast base metal $307

D D2792 Crown - full cast noble metal $305

COVERED VISION BENEFITSDESCRIPTION LIMITATIONS COPAY

Routine eye exam 1 per year $0

Frames & lenses OR contacts (excludes in-store or in-office provider specials)

$200 coverage limit per year $0

COVERED HEARING BENEFITSDESCRIPTION LIMITATIONS COPAY

Routine hearing exam 1 per year $0

Hearing aid fitting evaluation Up to 1 every 3 years $0

Hearing aid $800 coverage limit every 3 years $0

OUT-OF-NETWORK BENEFIT

Member reimbursed the in network fee that providers are paid for covered services after applicable copay

** Member reimbursed in-network fee for covered services after applicable copay. Frequency limits apply. Out-of-network providers can bill you for charges above the amount covered by your HealthTeam Advantage Combination Rider. To ensure you do not receive additional charges, visit a provider in the HealthTeam Advantage Provider Network. To talk to a benefits consultant, call 1-877-905-9216, available to help seven days a week, 8 a.m. to 8 p.m. EST.

You must continue to pay your Medicare Part B premium. You must also continue to pay your applicable monthly plan premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, provider network, premium and/or copayments/coinsur-ance may change on January 1 of each year.

57

58

HOW TO ENROLL

59

Open Enrollment Period: October 15, 2015 through December 7, 2015This is the time where you may to choose to switch, drop or join a Medicare Advantage plan.

Special Election Period: Year-Round If you answer yes to any of the following questions, you may be eligible for a Special Election Period. If you think you qualify, talk to your local sales agent.

• Have you recently moved? • Are you currently receiving Extra Help with your

health care costs?• Do you no longer qualify for Extra Help with your

health care costs? • Have you recently left a PACE program (Program

of All-inclusive Care for the Elderly)?• Do you live in a long-term care facility?

• Have you recently retired and lost your employer or union coverage?

• Will you be moving into a long-term care facility?

• Have you recently moved out of a long-term care facility?

• Are you currently receiving Medicaid? • Have you recently stopped receiving Medicaid?

Disenrollment Period: January 1, 2016 through February 14, 2016For Medicare Advantage plans, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare, you have until February 14, 2016, to sign up for a prescription drug plan.

During this period, you cannot: • Switch from Original Medicare to a Medicare Advantage plan• Switch from one Medicare Advantage plan to another

1Unless you qualify for a special election period

SEPT

2015 2016

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG

E N R O L L

S P E C I A L E L E C T I O N P E R I O D ( Y E A R R O U N D )

OCT 15 – DEC 7 Y O U C A N N O T E N R O L L I N O U R P L A N A F T E R D E C 7 T H 1

1Unless you qualify for a special election period

UNDERSTANDING ENROLLMENT PERIODS


HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, is a Medicare Advantage Organization with a Medicare con-tract. Enrollment in HealthTeam Advantge depends on contract renewal.

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SCOPE OF SALES Appointment Confirmation Form The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative. Please initial below beside the type of product(s) you want the agent to discuss.

MEDICARE ADVANTAGE PLANS (PART C)

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: ___________________________________________________ Date: ________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ______________________________________________________________________

Your Relationship to the Beneficiary: ____________________________________________________________



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To be completed by Agent:

Plan(s) the agent represented during this meeting: _________________________________________________

Agent Name: ___________________________________________ Agent Phone: ________________________

Beneficiary Name: __________________________________ Beneficiary Phone: ________________________

Beneficiary Address: ________________________________________________________________________(optional)

Initial Method of Contact: ____________________________________________________________________(Indicate here if beneficiary was a walk-in.)

Date Appointment Completed: ________________________________________________________________*Scope of Appointment documentation is subject to CMS record retention requirements

Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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Enrollment Application Instructions – 2016 Plan YearPlease read before completing your enrollment request form.You are eligible to join HealthTeam Advantage Health Plan(s) PPO if:• You are entitled to Medicare Part A and are enrolled in Part B;• You do not have End Stage Renal Disease (ESRD);• You live in Alamance County, Rockingham County, Guilford County, or Randolph County.

Please make sure you complete all necessary information on the enrollment request formand send all of the information to HealthTeam Advantage.

1. Complete all sections of the application in full, including the plan you want to enroll in and yourpremium payment option. Missing or incomplete information may cause delay in the effective dateof your coverage.

2. If you are using a mailing address that is different from your permanent residential address,please provide the name of the person and his/her address to which mail should be sent.

3. When completing the Medicare insurance information, please write your name exactly as itappears on your Medicare card.

4. Please provide the name of your Primary Care Physician (PCP).5. If you would prefer to receive information in a language other than English or in another format,

please check the box indicated.6. Your application must be signed, dated, and received by HealthTeam Advantage by the last calendar

day of the month in order for your coverage to be effective the first day of the following month.7. Mail completed enrollment request form to HealthTeam Advantage at:

Enrollment Department HealthTeam Advantage1150 Revolution Mill Drive,Studio #6 Greensboro, NC 27405

Other Important Information• If you have questions about your enrollment request form, please call us at 1-877-905-9216 (TTY 711).

A benefit consultant is available to help you seven days a week, 8 a.m. to 8 p.m. (EST). A benefitconsultant will meet with you in-person to help you with your enrollment request form, if you prefer.

• HealthTeam Advantage determines when your enrollment request form is considered to be completebased on Medicare enrollment guidelines.

• Your enrollment with HealthTeam Advantage is subject to approval by the Centers for Medicare &Medicaid Services (CMS). If your enrollment is not accepted by CMS, we will notify you immediately.

• HealthTeam Advantage is not a Medicare Supplement. By enrolling in one of our plans, you willremain a part of the Medicare program. Depending on which plan you select, you will have eitherPart C (MA-Only), which replaces Medicare Part A and Part B, or you will have Part C and Part D(MA-PD), which replaces Part A, Part B, and Part D (drug coverage).

• You may also enroll directly online or by phone. Go to www.healthteamadvantage.com, or call1-877-905-9216, TTY users call 711.HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is aMedicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantagedepends on contract renewal. H9808_16_16 Accepted

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Individual Enrollment Request Form -‐2016

H9808_16_38 Accepted 1 of 4

Please contact HealthTeam Advantage if you need information in another language or format (Braille).

To Enroll in HealthTeam Advantage Health Plans, Please Provide the Following Information: Please check which plan you want to enroll in: MA-‐PD Plans: o HealthTeam Advantage Health Plan I PPO

$0 per month o HealthTeam Advantage Health Plan II PPO

$57 per month

Optional Supplemental Benefits Riders: o HealthTeam Advantage Dental Rider $20 per month o HealthTeam Advantage Combo Rider $35 per month

LAST name: FIRST Name: Middle Initial o Mr. o Mrs.

o Ms.

Birth Date: (__ __/__ __/__ __ __ __) (M M / D D / Y Y Y Y)

Sex: o M o F

Home Phone Number: ( )

Alternate Phone Number: ( )

Permanent Residence Street Address (P.O. Box is not allowed): City:

County: State: ZIP Code:

Mailing Address (only if different from your Permanent Residence Address): Street Address: City:


Emergency contact: Phone Number: Relationship to You:

E-‐mail Address:

Please Provide Your Medicare Insurance Information Please take out your Medicare card to complete this section. • Please fill in these blanks so they match your red, white and blue Medicare card -‐ OR -‐ • Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. You must have Medicare Part A and Part B to join a Medicare Advantage plan.

SAMPLE ONLY Name: __________________________ __ Medicare Claim Number Sex ___ __ __ __ -‐ __ __ -‐ __ __ __ __ ___ Is Entitled To Effective Date HOSPITAL (Part A) ______________ MEDICAL (Part B) ______________

Paying Your Plan Premium If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail or “Electronic Funds Transfer (EFT)” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-‐Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay HealthTeam Advantage the Part D-‐IRMAA.

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You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or “Electronic Funds Transfer (EFT)” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you are assessed a Part D-‐Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay HealthTeam Advantage Part D-‐IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-‐insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-‐800-‐772-‐1213. TTY users should call 1-‐800-‐325-‐0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option: o Get a bill monthly o Electronic funds transfer (EFT) from your bank account each month. Please enclose

a VOIDED check or provide the following: Account holder name: ______________________ Bank routing number: _ _ _ _ _ _ _ _ _ Bank account number: _ _ _ _ _ _ _ _ _ _ _ _

Account type: o Checking o Saving

o Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions: 1. Do you have End-‐Stage Renal Disease (ESRD)? If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

o Yes o No

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to HealthTeam Advantage Health Plan?

o Yes o No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage

ID # for this coverage Group # for this coverage

3. Are you a resident in a long-‐term care facility, such as a nursing home? If “yes,” please provide the following information:

o Yes o No

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Name of Institution:________________________________ Address & Phone Number of Institution (number and street):_____________________________________________ 4. Are you enrolled in your State Medicaid program? If yes, please provide your Medicaid number:

o Yes o No

5. Do you or your spouse work? o Yes o No Please choose the name of a Primary Care Physician (PCP): Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: o Spanish Please contact Customer Service at 1-‐877-‐905-‐9216, if you need information in another format or language than what is listed above. Our office hours are 8 a.m. to 8 p.m., seven days a week (EST), TTY users should call 711.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining HealthTeam Advantage Health Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join HealthTeam Advantage Health Plan. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below By completing this enrollment application, I agree to the following: HealthTeam Advantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances. HealthTeam Advantage serves a specific service area. If I move out of the area that HealthTeam Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of HealthTeam Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from HealthTeam Advantage when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

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I understand that beginning on the date HealthTeam Advantage PPO coverage begins, using services in-‐network can cost less than using services out-‐of-‐network, except for emergency or urgently needed services or out-‐of-‐area dialysis services. If medically necessary, HealthTeam Advantage provides refunds for all covered benefits, even if I get services out of network.” Services authorized by HealthTeam Advantage and other services contained in my HealthTeam Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR HEALTHTEAM ADVANTAGE WILL PAY FOR THE SERVICES. I understand that if, I am getting assistance from a sales agent, broker, or other individual employed by or contracted with HealthTeam Advantage he/she may be paid based on my enrollment in HealthTeam Advantage. Release of Information: By joining this Medicare health plan, I acknowledge that HealthTeam Advantage will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that HealthTeam Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information: Name:_______________________________________________________ Address: _____________________________________________________ Phone Number: (___) _______-‐______________ Relationship to Enrollee:____________________

Office Use Only: Name of staff member/agent/broker (if assisted in enrollment):____________________________________________ Plan ID#:__________________________________ Effective Date of Coverage: ___________________________ ICEP/IEP:________ AEP:_______ SEP (type): ______________ Not Eligible: _________

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Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare.

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) ________________________

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) ________________________

I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.

I get extra help paying for Medicare prescription drug coverage.

I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra help on (insert date) ________________________

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date) ________________________

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare). I lost my drug coverage on (insert date) ________________________

I am leaving employer or union coverage on (insert date) ________________________

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

If none of these statements apply to you or you’re not sure, please contact HealthTeam Advantage at1-877-905-9216 (TTY 711) to see if you are eligible to enroll. We are open 8 a.m. to 8 p.m., seven days a week.

Attestation of Eligibility for an Enrollment Period

Individual Enrollment Request Form - 2016

I left a PACE program on (insert date) ________________________



I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date) ________________________

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APPLICATION CHECKLIST BENEFICIARY: PLEASE INITIAL ALL APPLICABLE L INES

1. The agent reviewed the HealthTeam Advantage (PPO) Summary of Benefits for all HealthTeam Advantage plans.

2. I selected the HealthTeam Advantage plan that best fits my current Medicare needs.3. I understand that the plan I have chosen is NOT a Medicare supplement (Medigap) plan.4. The agent explained the assistance a HealthTeam Advantage Healthcare Concierge can provide.5. The agent explained why a payment option should be selected for HealthTeam Advantage Health Plan.6. The agent reviewed prescription drug (Rx) needs and identified the tiers and related co-pays

using the Drug List. The agent explained the Rx benchmark, 2016 coverage gap, new changes once the coverage gap is reached, step therapy (if required), late enrollment penalty, and prior authorization.

7. The agent explained I must continue to pay the Medicare Part B premium.8. If I have current group coverage (active or retiree), the name of the carrier, policy number, ID

number, customer service phone number(s), and effective date and term date are listed below:

Name of Other Coverage __________________________ Phone Number ________________

ID# ________________ Group # ________________9. If I have current group coverage (active or retiree), I provided the term date on the HealthTeam

Advantage 2016 Attestation form.10. The agent gave me the following materials:

A. HealthTeam Advantage 2016 Summary of BenefitsB. Multi Language Insert

C. Business Card

11. If my recent move provided the opportunity to enroll in HealthTeam Advantage, my previous address was:

Street __________________________City____________________ State __ Zip Code ________

OPTIONAL SUPPLEMENTAL COVERAGE:1. The agent reviewed the HealthTeam Advantage Dental Rider with me. If selected, the

agentexplained that this optional coverage requires an additional $20 monthly premium.2. The agent reviewed the HealthTeam Advantage Combination Rider with me. If selected,the

agent explained that this optional coverage requires an additional $35 monthly premium.

Beneficiary Signature: Plan:

Agent Name/ID: Date: AGENT: APPLICATION CHECKLIST MUST BE AT TACHED TO ORIGINAL APPLICATION



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SCOPE OF SALES Appointment Confirmation Form The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative. Please initial below beside the type of product(s) you want the agent to discuss.

MEDICARE ADVANTAGE PLANS (PART C)

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: ___________________________________________________ Date: ________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ______________________________________________________________________

Your Relationship to the Beneficiary: ____________________________________________________________



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To be completed by Agent:

Plan(s) the agent represented during this meeting: _________________________________________________

Agent Name: ___________________________________________ Agent Phone: ________________________

Beneficiary Name: __________________________________ Beneficiary Phone: ________________________

Beneficiary Address: ________________________________________________________________________(optional)

Initial Method of Contact: ____________________________________________________________________(Indicate here if beneficiary was a walk-in.)

Date Appointment Completed: ________________________________________________________________*Scope of Appointment documentation is subject to CMS record retention requirements

Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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Enrollment Application Instructions – 2016 Plan YearPlease read before completing your enrollment request form.You are eligible to join HealthTeam Advantage Health Plan(s) PPO if:• You are entitled to Medicare Part A and are enrolled in Part B;• You do not have End Stage Renal Disease (ESRD);• You live in Alamance County, Rockingham County, Guilford County, or Randolph County.

Please make sure you complete all necessary information on the enrollment request formand send all of the information to HealthTeam Advantage.

1. Complete all sections of the application in full, including the plan you want to enroll in and yourpremium payment option. Missing or incomplete information may cause delay in the effective dateof your coverage.

2. If you are using a mailing address that is different from your permanent residential address,please provide the name of the person and his/her address to which mail should be sent.

3. When completing the Medicare insurance information, please write your name exactly as itappears on your Medicare card.

4. Please provide the name of your Primary Care Physician (PCP).5. If you would prefer to receive information in a language other than English or in another format,

please check the box indicated.6. Your application must be signed, dated, and received by HealthTeam Advantage by the last calendar

day of the month in order for your coverage to be effective the first day of the following month.7. Mail completed enrollment request form to HealthTeam Advantage at:

Enrollment Department HealthTeam Advantage1150 Revolution Mill Drive,Studio #6 Greensboro, NC 27405

Other Important Information• If you have questions about your enrollment request form, please call us at 1-877-905-9216 (TTY 711).

A benefit consultant is available to help you seven days a week, 8 a.m. to 8 p.m. (EST). A benefitconsultant will meet with you in-person to help you with your enrollment request form, if you prefer.

• HealthTeam Advantage determines when your enrollment request form is considered to be completebased on Medicare enrollment guidelines.

• Your enrollment with HealthTeam Advantage is subject to approval by the Centers for Medicare &Medicaid Services (CMS). If your enrollment is not accepted by CMS, we will notify you immediately.

• HealthTeam Advantage is not a Medicare Supplement. By enrolling in one of our plans, you willremain a part of the Medicare program. Depending on which plan you select, you will have eitherPart C (MA-Only), which replaces Medicare Part A and Part B, or you will have Part C and Part D(MA-PD), which replaces Part A, Part B, and Part D (drug coverage).

• You may also enroll directly online or by phone. Go to www.healthteamadvantage.com, or call1-877-905-9216, TTY users call 711.HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is aMedicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantagedepends on contract renewal. H9808_16_16 Accepted

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Please contact HealthTeam Advantage if you need information in another language or format (Braille).

To Enroll in HealthTeam Advantage Health Plans, Please Provide the Following Information: Please check which plan you want to enroll in: MA-‐PD Plans: o HealthTeam Advantage Health Plan I PPO

$0 per month o HealthTeam Advantage Health Plan II PPO

$57 per month

Optional Supplemental Benefits Riders: o HealthTeam Advantage Dental Rider $20 per month o HealthTeam Advantage Combo Rider $35 per month

LAST name: FIRST Name: Middle Initial o Mr. o Mrs.

o Ms.

Birth Date: (__ __/__ __/__ __ __ __) (M M / D D / Y Y Y Y)

Sex: o M o F

Home Phone Number: ( )

Alternate Phone Number: ( )

Permanent Residence Street Address (P.O. Box is not allowed): City:


Mailing Address (only if different from your Permanent Residence Address): Street Address: City:


Emergency contact: Phone Number: Relationship to You:

E-‐mail Address:

Please Provide Your Medicare Insurance Information Please take out your Medicare card to complete this section. • Please fill in these blanks so they match your red, white and blue Medicare card -‐ OR -‐ • Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. You must have Medicare Part A and Part B to join a Medicare Advantage plan.

SAMPLE ONLY Name: __________________________ __ Medicare Claim Number Sex ___ __ __ __ -‐ __ __ -‐ __ __ __ __ ___ Is Entitled To Effective Date HOSPITAL (Part A) ______________ MEDICAL (Part B) ______________

Paying Your Plan Premium If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail or “Electronic Funds Transfer (EFT)” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-‐Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay HealthTeam Advantage the Part D-‐IRMAA.

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You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or “Electronic Funds Transfer (EFT)” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you are assessed a Part D-‐Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay HealthTeam Advantage Part D-‐IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-‐insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-‐800-‐772-‐1213. TTY users should call 1-‐800-‐325-‐0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option: o Get a bill monthly o Electronic funds transfer (EFT) from your bank account each month. Please enclose

a VOIDED check or provide the following: Account holder name: ______________________ Bank routing number: _ _ _ _ _ _ _ _ _ Bank account number: _ _ _ _ _ _ _ _ _ _ _ _

Account type: o Checking o Saving

o Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions: 1. Do you have End-‐Stage Renal Disease (ESRD)? If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

o Yes o No

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to HealthTeam Advantage Health Plan?

o Yes o No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage

ID # for this coverage Group # for this coverage

3. Are you a resident in a long-‐term care facility, such as a nursing home? If “yes,” please provide the following information:

o Yes o No

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Name of Institution:________________________________ Address & Phone Number of Institution (number and street):_____________________________________________ 4. Are you enrolled in your State Medicaid program? If yes, please provide your Medicaid number:

o Yes o No

5. Do you or your spouse work? o Yes o No Please choose the name of a Primary Care Physician (PCP): Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: o Spanish Please contact Customer Service at 1-‐877-‐905-‐9216, if you need information in another format or language than what is listed above. Our office hours are 8 a.m. to 8 p.m., seven days a week (EST), TTY users should call 711.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining HealthTeam Advantage Health Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join HealthTeam Advantage Health Plan. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below By completing this enrollment application, I agree to the following: HealthTeam Advantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances. HealthTeam Advantage serves a specific service area. If I move out of the area that HealthTeam Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of HealthTeam Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from HealthTeam Advantage when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

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I understand that beginning on the date HealthTeam Advantage PPO coverage begins, using services in-‐network can cost less than using services out-‐of-‐network, except for emergency or urgently needed services or out-‐of-‐area dialysis services. If medically necessary, HealthTeam Advantage provides refunds for all covered benefits, even if I get services out of network.” Services authorized by HealthTeam Advantage and other services contained in my HealthTeam Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR HEALTHTEAM ADVANTAGE WILL PAY FOR THE SERVICES. I understand that if, I am getting assistance from a sales agent, broker, or other individual employed by or contracted with HealthTeam Advantage he/she may be paid based on my enrollment in HealthTeam Advantage. Release of Information: By joining this Medicare health plan, I acknowledge that HealthTeam Advantage will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that HealthTeam Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information: Name:_______________________________________________________ Address: _____________________________________________________ Phone Number: (___) _______-‐______________ Relationship to Enrollee:____________________

Office Use Only: Name of staff member/agent/broker (if assisted in enrollment):____________________________________________ Plan ID#:__________________________________ Effective Date of Coverage: ___________________________ ICEP/IEP:________ AEP:_______ SEP (type): ______________ Not Eligible: _________

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Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare.

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) ________________________

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) ________________________

I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.

I get extra help paying for Medicare prescription drug coverage.

I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra help on (insert date) ________________________

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date) ________________________

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare). I lost my drug coverage on (insert date) ________________________

I am leaving employer or union coverage on (insert date) ________________________

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

If none of these statements apply to you or you’re not sure, please contact HealthTeam Advantage at1-877-905-9216 (TTY 711) to see if you are eligible to enroll. We are open 8 a.m. to 8 p.m., seven days a week.

Attestation of Eligibility for an Enrollment Period

Individual Enrollment Request Form - 2016

I left a PACE program on (insert date) ________________________



I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date) ________________________

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APPLICATION CHECKLIST BENEFICIARY: PLEASE INITIAL ALL APPLICABLE L INES

1. The agent reviewed the HealthTeam Advantage (PPO) Summary of Benefits for all HealthTeam Advantage plans.

2. I selected the HealthTeam Advantage plan that best fits my current Medicare needs.3. I understand that the plan I have chosen is NOT a Medicare supplement (Medigap) plan.4. The agent explained the assistance a HealthTeam Advantage Healthcare Concierge can provide.5. The agent explained why a payment option should be selected for HealthTeam Advantage Health Plan.6. The agent reviewed prescription drug (Rx) needs and identified the tiers and related co-pays

using the Drug List. The agent explained the Rx benchmark, 2016 coverage gap, new changes once the coverage gap is reached, step therapy (if required), late enrollment penalty, and prior authorization.

7. The agent explained I must continue to pay the Medicare Part B premium.8. If I have current group coverage (active or retiree), the name of the carrier, policy number, ID

number, customer service phone number(s), and effective date and term date are listed below:

Name of Other Coverage __________________________ Phone Number ________________

ID# ________________ Group # ________________9. If I have current group coverage (active or retiree), I provided the term date on the HealthTeam

Advantage 2016 Attestation form.10. The agent gave me the following materials:

A. HealthTeam Advantage 2016 Summary of BenefitsB. Multi Language Insert

C. Business Card

11. If my recent move provided the opportunity to enroll in HealthTeam Advantage, my previous address was:

Street __________________________City____________________ State __ Zip Code ________

OPTIONAL SUPPLEMENTAL COVERAGE:1. The agent reviewed the HealthTeam Advantage Dental Rider with me. If selected, the

agentexplained that this optional coverage requires an additional $20 monthly premium.2. The agent reviewed the HealthTeam Advantage Combination Rider with me. If selected,the

agent explained that this optional coverage requires an additional $35 monthly premium.

Beneficiary Signature: Plan:

Agent Name/ID: Date: AGENT: APPLICATION CHECKLIST MUST BE AT TACHED TO ORIGINAL APPLICATION



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RECEIPT

IMPORTANT ENROLLMENT INFORMATION

APPLICATION DATE: ________________________________________________

PROPOSED EFFECTIVE DATE: ________________________________________

MEDICARE ID: _____________________________________________________

PLAN NAME: ______________________________________________________

SALES AGENT NAME: _______________________________________________

SALES AGENT PHONE: ______________________________________________

SALES AGENT ID: __________________________________________________

THANK YOU FOR ENROLLING IN HEALTHTEAM ADVANTAGE! This receipt verifies that you completed an enrollment form with an agent who sells HealthTeam Advantage PPO Medicare Advantage health plans.

To speak with a benefits consultant, call 1-877-905-9216 (TTY 711), 8am - 8pm (EST) seven days a week, or visit HealthTeam Advantage at www.healthteamadvantage.com.


HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, is a Medicare Advantage organization with a Medicare con-tract. Enrollment in HealthTeam Advantge depends on contract renewal.

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RECEIPT

IMPORTANT ENROLLMENT INFORMATION

APPLICATION DATE: ________________________________________________

PROPOSED EFFECTIVE DATE: ________________________________________

MEDICARE ID: _____________________________________________________

PLAN NAME: ______________________________________________________

SALES AGENT NAME: _______________________________________________

SALES AGENT PHONE: ______________________________________________

SALES AGENT ID: __________________________________________________

THANK YOU FOR ENROLLING IN HEALTHTEAM ADVANTAGE! This receipt verifies that you completed an enrollment form with an agent who sells HealthTeam Advantage PPO Medicare Advantage health plans.

To speak with a benefits consultant, call 1-877-905-9216 (TTY 711), 8am - 8pm (EST) seven days a week, or visit HealthTeam Advantage at www.healthteamadvantage.com.


HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, is a Medicare Advantage organization with a Medicare con-tract. Enrollment in HealthTeam Advantge depends on contract renewal.

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WHAT’S NEXT

The following next steps will help you better understand what to expect on your way to becoming a HealthTeam Advantage PPO Member.

The Day You Enroll…

• Receipt of completed enrollment form – The agent will provide a receipt that confirms you submitted an enrollment form. If you enroll online, you will receive a confirmation number.

WITHIN 10 DAYS OF SUBMITTING ENROLLMENT FORM…

• Letter confirming receipt of your enrollment and enrollment approval from Medicare to the HealthTeam Advantage plan you selected.

WHEN YOU BECOME A HEALTHTEAM ADVANTAGE MEMBER…

• Welcome Kit – This kit includes your HealthTeam Advantage Evidence of Coverage, important Silver&Fit program information and other plan information.

• HealthTeam Advantage PPO member identification cards – you will receive two HealthTeam Advantage PPO member identification cards – one to keep with you at all times and one to keep in a safe place.

• Personal Healthcare Concierge at your service – If you would like assistance finding an in-network doctor,scheduling an appointment, have questions about your benefits, or need a replacement identification card,simply call your Healthcare Concierge at 1-800-222-CARE (2273) (TTY 711) from 8 a.m. to 8 p.m. EST, seven days a week or email [email protected].



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H E A L T H T E A M A D V A N T A G E H E A L T H P L A N

C O N T A C T I N F O R M A T I O N

WEB ADDRESSVisit HealthTeam Advantage at www.healthteamadvantage.com.

SALES INFORMATIONProspective members should calltoll-free 1-877-905-9216 for questions related to the Medicare Advantage program from 8AM to 8PM Eastern, seven days a week.

HEALTHCARE CONCIERGECurrent members should call toll-free1-800-222-CARE (2273) for questions related to the Medicare Advantage program from 8AM to 8PM Eastern, seven days a week.

TTY USERSTTY Users should call toll-free 711 for questions related to the Medicare Advantage Program from 8AM to 8PM Eastern, seven days a week.

PRESCRIPTION DRUG BENEFIT Current and prospective members should call toll-free 1-844-846-8003 for questions related to the Medicare Part D Prescription Drug program. TTY users should call 711.

MEDICARE INFORMATIONFor more information about Medicare, please call Medicare at 1-800-Medicare (1-800-633-4227). TTY users shouldcall 1-877-486-2048. You can call 24 hours a day, seven days a week. Or, visit www.medicare.gov on the web.

Documents

2016 ENROLLMENT KIT · 2018-08-09 · Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot