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2016
Enrollment
Guide
You could get more benefits than
Original Medicare.
Hospital
Stays
Doctor
Visits
Additional
Benefits
UnitedHealthcare Dual Complete® ONE (HMO SNP)
H3113-005
Service area: New Jersey- Atlantic, Bergen, Burlington, Essex, Hudson, Mercer,
Monmouth, Morris, Ocean, Union counties
Prescription
Drug Coverage
Table of Contents
Introduction............................................................................................................................. 3
Plan
INFORMATION
Benefit Highlights.................................................................................................................. 8
How Your Plan Works........................................................................................................10
Benefits and Services Beyond Original Medicare...................................................... 11
Summary of Benefits..........................................................................................................13
Plan Ratings......................................................................................................................... 31
Required Information......................................................................................................... 32
Drug
LIST
Drug List................................................................................................................................36
Ready to
ENROLL
Enrollment Instructions......................................................................................................86
Scope of Sales Appointment Confirmation Form.......................................................87
Enrollment Request Form.................................................................................................89
Enrollment Checklist........................................................................................................113
Enrollment Receipt.......................................................................................................... 115
What's Next........................................................................................................................ 123
It’s more than a health plan.
IT’S A HEALTHY RELATIONSHIP.
From preventive care to treating a chronic condition, there are many ways you may use your Medicare plan.
We will work with you to help you live a healthier life and we strive to give you the best health care experience
possible.
Here are some reasons why this plan may be right for your needs.
Doctor coverage
Access your personal plan
information online, anytime
Worldwide ER coverage
Care coordination
Out-of-pocket maximums
HouseCallsSM
We are committed to providing the personal service that can help you get the most from your benefits. Your
local licensed sales representative is ready to answer all your questions.
Have any questions? We can help. Call:
Toll-Free 1-888-834-3721, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week. Se habla español.
Learn more online at www.UHCCommunityPlan.com
CSNJ16HM3717096_000
3
Medicare
EDUCATION
Original Medicare
Provided by the government
What is Medicare?
Medicare is a federal health insurance program for people
age 65 and older and others with disabilities.
Part A covers
hospital stays
Original Medicare is provided by the government and
covers some of the costs of hospital stays (Part A) and
doctor visits (Part B), but it does not cover everything —
you don’t get coverage for prescription drugs or for routine
vision, dental or hearing care.
Part B covers doctor
and outpatient visits
What if you need more coverage beyond Original Medicare?
Add one or both of the following
to Original Medicare:
OR
Medicare Supplement Insurance*
Add additional coverage by choosing
a Medicare Advantage plan:
Medicare Advantage (Part C)*
Covers some of the costs not
covered by Parts A and B
Part C combines
Parts A and B
Often provides
additional benefits
Medicare Part D*
Most plans cover
prescription drugs
Part D covers
prescription drugs
*Offered by private companies
When can you enroll?
It’s important to know your enrollment period so you always have health care coverage. You can
enroll or change Medicare Advantage or Part D plans at least once a year, typically during your
Initial Enrollment Period or the Open Enrollment Period. Medicare supplement plans have different
rules about enrolling, please contact the Medicare Helpline for more information on enrolling.
Initial Enrollment Period: For Medicare Advantage or Part D plans, this is the three months before and three months
after the month you turn 65 or become Medicare eligible. For Medicare supplement plans, you must submit your
application no later than six months after the date your Medicare Part B coverage takes effect.
Special Election Period: Depending on certain circumstances, you may be able to enroll in a Medicare plan outside
of the Initial Enrollment Period or Open Enrollment time frames.
Open Enrollment Period: October 15 – December 7
Medicare Advantage Disenrollment Period: January 1 – February 14. If you disenroll from a Medicare Advantage
plan during this time, you will return to Original Medicare and have a Special Election Period to enroll in a Medicare
Part D plan.
4
Medicare
EDUCATION
What are the drug payment stages?
If your plan includes prescription drug coverage, the amount you pay each time to fill a
prescription depends on which payment stage you’re in. How do you know which stage you’re in?
It depends on how much money you and your plan have paid for prescription drugs so far in the
plan year.
If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible
amount. You then move to the initial coverage stage.
The chart below shows the different payment stages you may go through in the plan year.
Initial
Coverage
In this drug payment stage:
• You pay a co-pay or
co-insurance (percentage
of a drug’s total cost). The
plan pays the rest
• You stay in this stage
until your total drug
costs reach $3,310
Coverage Gap
(Donut Hole)
Catastrophic
Coverage
After your total drug costs reach $3,310:
After your total out-of-pocket
costs reach $4,850:
• You pay:
• You pay a small co-pay or
co-insurance amount
– 45% of the cost of brand
name drugs
– 58% of the cost of generic drugs
• You stay in this stage for the
rest of the plan year
• You stay in this stage until
your total out‑of‑pocket costs
reach $4,850
Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for
prescription drugs starting on January 1, 2016.
Out-of-Pocket Costs: The amount you pay (or others pay on your behalf) for prescription drugs
starting on January 1, 2016. This does not include premiums.
Do you qualify for Extra Help?
If you have a limited income, you may be able to get Extra Help with your Medicare prescription drug
plan premiums, deductibles and co-pays. Many people qualify and don’t even know it.
To find out if you qualify, call the Social Security Administration at
1-800-772-1213, TTY 1-800-325-0778, 7 a.m. – 7 p.m., Monday – Friday
5
Medicare
EDUCATION
Are you eligible for this plan?
You are eligible for a Dual Special Needs Plan (DSNP) if you’re enrolled in Original Medicare Parts A
and B and receive state Medicaid benefits. Your state Medicaid benefits vary based on your level of
Medicaid eligibility.
• DSNP enrollment is not limited to a specific
• Based on your needs you may also qualify for
time; you can enroll year-round
Low Income Subsidy (LIS) assistance
What are the levels of eligibility in most states?
• Qualified Medicare Beneficiary Only (QMB Only)
• Qualified Medicare Beneficiary Plus (QMB Plus)
• Specified Low-Income Medicare Beneficiary
Only (SLMB Only)
• Specified Low-Income Medicare Beneficiary Plus
(SLMB Plus)
• Qualified Individual (QI)
• Qualified Disabled and Working Individual
(QDWI)
• Full Benefit Dual Eligible (FBDE)
What are the income requirements for each eligibility level?
QMB Only
QMB Plus
SLMB Only
SLMB Plus
QI
QDWI
FBDE
Federal Poverty Income Level
Social Security Income Level
At or lower than
Resources not more than two times
At or lower than
Between 100% and 120%
Below 200%
Based on Medical Need status, institutionalized income levels, home/community based waivers
What benefits does each eligibility level cover?
Eligibility Level
QMB Only
QMB Plus
SLMB Only
SLMB Plus
QI
QDWI
FBDE
Part A
Premium
Yes
Yes
No
No
No
Yes
No
Part B
Premium
Yes
Yes
Yes
Yes
Yes
No
Varies by state
Part D
Premium1
No2
No2
No2
No2
No2
No
No
Medicare Deductibles,
Co-pays, Co-insurance
Yes
Yes
No
Varies by state
No
No
Varies by state
Full Medicaid
Benefits
No
Yes
No
Yes
No
No
Yes
Low Income Subsidy may be available to help with Part D premium cost.
QMBs, SLMBs and QIs are automatically enrolled in the low income subsidy program to cover Part D premium
costs and will not have Part D premium expenses.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in
the plan depends on the plan’s contract renewal with Medicare.
Y0066_150728_100336 Accepted UHEX16MP3715078_000
1
2
6
UHEX16MP3700082_001
Benefit highlights
As a UnitedHealthcare Dual Complete® ONE (HMO SNP) member, you have no out-of-pocket expenses.
You will not be responsible for any copayments or coinsurance for drugs or other covered services
provided by plan providers.
This is a short description of your 2016 Plan benefits. For complete information, please refer to your
Summary of Benefits or Evidence of Coverage. Limitations, exclusions and restrictions may apply.
Plan Costs
Monthly Plan Premiums
$0
Medical Benefits
Doctor’s office visit
Primary Care Provider: $0 copay
Specialist: $0 copay (no referral needed)
Preventive services
$0 copay
Inpatient hospital care
$0 copay
Skilled nursing facility (SNF)
$0 copay
Outpatient surgery
$0 copay
Diabetes monitoring supplies
$0 copay for covered brands
Home health care
$0 copay
Diagnostic radiology services
(such as MRIs, CT scans)
Diagnostic tests and procedures
(non-radiological)
$0 copay
Lab services
$0 copay
Outpatient X-rays
$0 copay
Ambulance
$0 copay
Emergency care
$0 copay
Urgently needed services
$0 copay
$0 copay
Benefits and Services beyond Original Medicare
Health Products Catalog
Routine transportation
Personal Emergency Response System
(PERS)
NurseLineSM
Covered $500 per year ($125 quarterly credit)
$0 copay for 48 one-way trips per calendar year, includes
Basic Life Support
$0 copay for emergency response services through an
electronic monitoring system 24 hours a day, seven days
a week.
Speak with a registered nurse (RN) 24 hours a day,
7 days a week
H3113_150812_003144 Acccepted
8
Prescription Drugs
Generic (including brand drugs treated as
generic)
$0 copay
All other drugs
$0 copay
Benefits and Services covered by Medicaid
Acupuncture
You pay a $0 copayment
Chiropractic Services
Dental Services – preventive and routine
Durable Medical Equipment (DME)
Family Planning Services and Supplies
Federally Qualified Health Centers (FQHC)
Hearing services – hearing exams and
hearing aids
Medical Day Care
Managed Long Term Services and Supports
(MLTSS)
Nurse Midwife Services
Nursing Facility (long term/custodial care)
Personal Care Assistant
Podiatry – routine
Private Duty Nursing
Vision Care Services
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid
Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.
H3113_150812_003144 Acccepted
UHNJ16HM3699672_001
9
Plan INFORMATION
Your cost of a 30-day supply
from network retail pharmacy
How your
HMO PLAN WORKS
Your plan is a Health Maintenance Organization (HMO) plan. That means you must receive care
through a network of local doctors and hospitals. Your primary care provider (PCP) oversees your
care and can suggest a specialist, if needed.
In-Network
Out-of-Network
Will the doctor or hospital
accept my plan?
Yes
No
Do I need to choose a primary
care provider (PCP)?
Yes
N/A
Do I need a referral to see
a specialist?
No
N/A
Are emergency or urgently
needed services covered?
Yes
Yes
Do I have to pay the full cost
for all covered doctor or
hospital services?
Plan co-pay or
co‑insurance applies.
In most cases, yes, you must
pay the full cost for services.
Is there a limit on my total
out-of-pocket spending for
the year?
Yes
N/A
You’re part of a health care team.
A team dedicated to increasing access to care, reducing costs and improving your
health. Your primary care doctor is the leader, making sure everyone works together to
improve your well-being. If you want help choosing a primary care provider (PCP), call
Customer Service or your licensed sales representative. The website and Customer
Service phone number are listed on the first page of this booklet.
Plan co-pays and co-insurance apply. As a member, you will receive a Provider Directory listing
all network providers and facilities within your plan. You can also find a complete listing on
our website or you can request a Provider Directory from Customer Service. Please refer to the
Summary of Benefits and Benefit Highlights for more complete plan information.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated
companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal
with Medicare.
Y0066_150612_074721 Accepted UHEX16HM3689579_000
10
Get all the benefits of Original Medicare – and more.
With this plan, you get additional benefits and services designed to help you live a healthier life —
most at little or no additional cost. More benefits mean more value. It also means more peace of
mind for you, knowing you have access to a full range of services dedicated to your health and
wellness.
This is a short description of some of the 2016 plan benefits. For more information, please refer to
your Summary of Benefits. Limitations, exclusions and restrictions may apply.
A health and wellness program that comes to you
SM
With the HouseCalls program, you get an in-home clinical visit from one of our
licensed health care practitioners for no additional cost. A HouseCalls visit is
designed to support but not take the place of your regular doctor’s care.
What to expect from a HouseCalls visit:
• A knowledgeable health care practitioner will review your health history and
medications, perform a health screening, identify health risks and provide
health education
• You can talk about health concerns and ask questions
• You’ll get an Ask Your Doctor worksheet which you can bring to your next
doctor visit
We may call to talk to you about eligibility for the HouseCalls program or you can call
1-866-686-2504 TTY 711, Monday – Saturday 8:00AM – 8:00PM CST, to schedule your
in-home visit.
Health products benefit program
Get credits to use for ordering over-the-counter health products from the FirstLine
Medical catalog. You may order products one per quarter and the items will be
delivered directly to you for no additional cost. Our product assortment offers a
variety of health and wellness items such as:
• Cough medicine, pain relievers, vitamins and supplements
• Thermometers, blood pressure monitors and more
For a full list of items visit the website at www.healthproductsbenefit.com.
11
Plan INFORMATION
Benefits and services beyond
ORIGINAL MEDICARE
Benefits and services beyond
ORIGINAL MEDICARE (CONTINUED)
Transportation
Get rides to and from plan-approved locations, like your doctor’s office. See your
Summary of Benefits for the specific number of one-way or round trips included with
this plan.
NurseLineSM
Whether you have questions about a medication or have a health concern in the
middle of the night, with NurseLineSM a nurse is only a phone call away. A registered
nurse can answer questions like:
• Should I go to the emergency room or urgent care?
• How do I find a doctor or specialist?
Learn more about these extra benefits and services
For more information, call the number on the first page of this booklet.
companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare.
Y0066_150612_074537_ Accepted
UHNJ16HM3714324_000
12
BENEFITS
New Jersey
Atlantic, Bergen, Burlington, Essex, Hudson, Mercer, Monmouth, Morris,
Ocean, Union counties
H3113_150729_150314 Accepted
13
Plan INFORMATION
2016 Summary of
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
UnitedHealthcare Dual Complete® ONE (HMO SNP)).
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what UnitedHealthcare Dual
Complete® ONE (HMO SNP) covers and what you pay.
•
If you want to compare our plan with other Medicare health plans, ask the other
plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on
http://www.medicare.gov.
•
If you want to know more about the coverage and costs of Original Medicare, look in
your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a
copy by calling 1-800-MEDICARE (1-800-633- 4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
Sections in this booklet
•
Things to Know About UnitedHealthcare Dual Complete® ONE (HMO SNP)
•
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
•
Covered Medical and Hospital Benefits
•
Prescription Drug 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 1-800-514-4911.
Es posible que este documento esté disponible en otro idioma. Para información adicional llame
al 1-800-514-4911.
14
Hours of Operation
You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. local time.
UnitedHealthcare Dual Complete® ONE (HMO SNP) Phone Numbers
and Website
•
If you are a member of this plan, call toll-free 1-800-514-4911.
•
If you are not a member of this plan, call toll-free 1-888-834-3721.
•
Our website: http://www.UHCCommunityPlan.com
Who can join?
To join UnitedHealthcare Dual Complete® ONE (HMO SNP), you must be entitled to Medicare
Part A, be enrolled in Medicare Part B and Medicaid and live in our service area.
Our service area includes the following counties in New Jersey: Atlantic, Bergen, Burlington,
Essex, Hudson, Mercer, Monmouth, Morris, Ocean, and Union.
Which doctors, hospitals, and pharmacies can I use?
UnitedHealthcare Dual Complete® ONE (HMO SNP) has a network of doctors, hospitals,
pharmacies, and other providers. If you use the providers that are not in our network, the plan
may not pay for these services.
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
(www.UHCMedicareSolutions.com).
Or, call us and we will send you a copy of the provider and pharmacy directories.
15
Plan INFORMATION
THINGS TO KNOW ABOUT
UNITEDHEALTHCARE DUAL
COMPLETE® ONE (HMO SNP)
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.
•
Our plan members also get more than what is covered by Original Medicare. Some of the
extra benefits are outlined in this booklet.
We cover Part D drugs. 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 any restrictions on
our website http://www.UHCMedicareSolutions.com.
Or, call us and we will send you a copy of the formulary.
How will I determine my drug costs?
The amount you pay for drugs depends on the drug you are taking and what stage of the benefit
you have reached. Later in this document we discuss the benefit stages that occur after you meet
your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.
16
SUMMARY OF BENEFITS
MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY
FOR COVERED SERVICES
How much is
the monthly
premium?
$0 per month.
How much is
the deductible?
This plan does not have a deductible.
Is there any limit
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.
on how much I
will pay for my
In this plan, you may pay nothing for Medicare-covered services,
covered services?
depending on your level of Medicaid eligibility.
Your yearly limit(s) in this plan:
$6,700 for services you receive from in-network providers.
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.
Refer to the “Medicare & You” handbook for Medicare-covered services.
For Medicaid-covered services, refer to the Medicaid Coverage section in
this document.
Please note that you will still need to pay your monthly premiums and
cost-sharing for your Part D prescription drugs.
Is there a
limit on how
much the plan
will pay?
Our plan has a coverage limit every year for certain in-network benefits.
Contact us for the services that apply.
17
Plan INFORMATION
January 1, 2016 – December 31, 2016
COVERED MEDICAL AND HOSPITAL BENEFITS
OUTPATIENT CARE AND SERVICES
Acupuncture
Not covered
However, please see “Summary of Medicaid-Covered Benefits” after this
section for Medicaid-covered Acupuncture benefits.
Ambulance
•
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the
bones of your spine move out of position):
•
Dental Services
You pay nothing
You pay nothing
Limited dental services (this does not include services in connection with
care, treatment, filling, removal, or replacement of teeth):
•
$0 copay
Please see “Summary of Medicaid-Covered Benefits” after this section for
Medicaid-covered Dental benefits.
Diabetes Supplies Diabetes monitoring supplies:
and Services
• You pay nothing
Diabetes self-management training:
•
You pay nothing
Therapeutic shoes or inserts:
•
You pay nothing
The plan covers the following brands of blood glucose monitors and test
strips: OneTouch Ultra® 2 System, OneTouch Ultra Mini®, OneTouch
Verio® Sync, OneTouch Verio® IQ, ACCU-CHEK® Nano SmartView,
ACCU-CHEK® Aviva Plus.
Diagnostic
Tests, Lab
and Radiology
Services,
and X-Rays
(Costs for these
services may be
different if received
in an outpatient
surgery setting)
Diagnostic radiology services (such as MRIs, CT scans):
•
You pay nothing
Diagnostic tests and procedures:
•
You pay nothing
Lab services:
•
You pay nothing
Outpatient x-rays:
•
You pay nothing
Therapeutic radiology services (such as radiation treatment for cancer):
•
You pay nothing
18
Primary care physician visit:
•
You pay nothing
Plan INFORMATION
Doctor’s Office
Visits
Specialist visit:
•
You pay nothing
Durable Medical
Equipment
(wheelchairs,
oxygen, etc.)
•
You pay nothing
Emergency Care
•
You pay nothing
Foot Care
(podiatry
services)
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:
•
•
You pay nothing
$0 copay
Medicaid-covered Hearing benefits.
Home
Health Care
•
Mental
Health Care
Inpatient visit:
You pay nothing
Medicaid-covered Home Health Care benefits.
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.
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.
•
You pay nothing
Outpatient group therapy visit:
•
You pay nothing
Outpatient individual therapy visit:
•
You pay nothing
Medicaid-covered Mental Health Care benefits.
19
Outpatient
Rehabilitation
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per
day for up to 36 sessions up to 36 weeks):
•
You pay nothing
Occupational therapy visit:
•
You pay nothing
Physical therapy and speech and language therapy visit:
•
Outpatient
Substance Abuse
You pay nothing
Group therapy visit:
•
You pay nothing
Individual therapy visit:
•
You pay nothing
Medicaid-covered Substance Abuse benefits.
Outpatient
Surgery
Ambulatory surgical center:
•
You pay nothing
Outpatient hospital:
•
You pay nothing
Over-the-Counter
Items
Please visit our website to see our list of covered over-the-counter items.
Prosthetic
Devices
(braces, artificial
limbs, etc.)
Prosthetic devices:
•
You pay nothing
Related medical supplies:
•
You pay nothing
Renal Dialysis
•
You pay nothing
Transportation
•
You pay nothing
Urgently Needed
Services
•
You pay nothing
Vision Services
Exam to diagnose and treat diseases and conditions of the eye (including
yearly glaucoma screening):
•
$0 copay
Eyeglasses or contact lenses after cataract surgery:
•
$0 copay
Medicaid-covered Vision Care Services benefits.
20
Preventive Care
•
You pay nothing
•
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
•
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.
Annual physical exam
•
Hospice
You pay nothing
You pay nothing for hospice care from a Medicare-certified hospice. You may
have to pay part of the costs for drugs and respite care. Hospice is covered
outside of our plan. Please contact us for more details.
Medicaid-covered Hospice benefits.
21
Plan INFORMATION
Our plan covers many preventive services, including:
INPATIENT CARE
Inpatient Hospital
Care
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.
•
You pay nothing
Inpatient Mental
Health Care
For inpatient mental health care, see the “Mental Health Care” section of
this booklet.
Skilled Nursing
Facility (SNF)
Our plan covers up to 100 days in a SNF.
•
You pay nothing
Medicaid-covered Nursing Facility – Long Term Care benefits.
22
PRESCRIPTION DRUG BENEFITS
For Part B drugs such as chemotherapy drugs:
•
You pay nothing
Other Part B drugs:
•
You pay nothing
As a member of UnitedHealthcare Dual Complete® ONE (HMO SNP), you
have no cost sharing for covered, prescribed drugs.
Initial Coverage
Depending on your income and institutional status, you pay the following:
For generic drugs (including brand drugs treated as generic), either:
•
$0 copay; or
•
$1.20 copay; or
•
$2.95 copay.
For all other drugs, either:
•
$0 copay; or
•
$3.60 copay; or
•
$7.40 copay.
You may get your drugs at network retail pharmacies and mail order
pharmacies.
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 at the same
cost as an in-network pharmacy.
Catastrophic
Coverage
•
You pay nothing
23
Plan INFORMATION
How much
do I pay?
SUMMARY OF
MEDICAID-COVERED BENEFITS
People who qualify for Medicare and Medicaid are known as dual eligibles. If you are a dual
eligible, you are eligible for benefits under both the federal Medicare program and Medicaid.
The following chart describes Medicaid benefits that are available to you under Medicaid and
our Plan.
As a member of this plan you have no cost-shares for covered medical services or Part D
prescription drugs.
Many of the services that are covered by Medicaid are also covered by Medicare through your
Medicare Advantage SNP. These services are not listed below. Only the services that may continue
when Medicare coverage ends, or which are not covered by Medicare, are shown.
The benefits described below are covered by Medicaid. The benefits described in the Covered
Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For
each benefit listed below, you can see what Medicaid covers and what our plan covers.
Benefit Category
Medicaid
UnitedHealthcare
Dual Complete® ONE
(HMO SNP)
Acupuncture
Covered – $0 copay
Clinical Trials
Covered for services rendered beyond
Medicare Part B limits. Covered for
Medicaid approved services.
Dental Services
Includes diagnostic, preventive,
restorative, endodontic, periodontal,
prosthetic, and oral and maxillofacial
surgical services, including routine
dental exams, cleanings, dental
X-rays, fillings, dentures and fixed
prosthodontics.
Diagnostic and Therapeutic
Radiology and Laboratory
Services
Medicare Part B limits.
24
Durable Medical Equipment
Family Planning Services
and Supplies
Medicare Part B limits. Out-of-Network
services are covered through Medicaid
Fee-for-Service.
Hearing services
Hearing aids and exams to fit hearing
aids covered.
Home Health
Medicare Parts A and B limits. Includes
nursing services and home health aide
services.
Hospice
Covered in the community as well as
in institutional settings. Room and
board services are included only when
services are delivered in institutional
(non-private residence) setting.
Hospice care for children under 21
years of age shall cover both palliative
and curative care.
25
Plan INFORMATION
Covered for services rendered
beyond Medicare Part B limits.
Includes hearing aids.
Managed Long Term Services and
Supports (MLTSS)
Managed Long Term Services and
Supports (MLTSS) is a program that
provides Home and Community Based
services for members that require the
level of care typically provided in a
Nursing Facility, and allows them to
receive necessary care in a residential
or community setting. MLTSS services
include (but are not limited to): assisted
living services; cognitive, speech,
occupational, and physical therapy;
chore services; home-delivered meals;
residential modifications (such as the
installation of ramps or grab bars);
vehicle modifications; social adult day
care; and non-medical transportation.
Covered - $0 copay
Covered - $0 copay
MLTSS is available to members who
meet certain clinical and financial
requirements.
For more information on MLTSS, call
Customer Service (phone numbers
are printed on the back cover of this
booklet).
Medical Day Care
Provides preventive, diagnostic,
therapeutic and rehabilitative services
under medical and nursing supervision
in an ambulatory care setting to meet
the needs of individuals with physical
and/or cognitive impairments in order to
support their community living.
26
Mental Health Care
Nurse Midwife Service
Nursing Facility – Long
Term Care (also known
as “custodial” care)
Covered benefit for room and board
and services rendered in a nursing
facility for long-term care following
exhaustion of Medicare days.
Outpatient Mental Health
Includes Mental Health (MH)/Substance
Abuse (SA) services in hospital-based
and community-based settings, as well
as MH/SA screenings, referrals, and
prescription drugs. Other services are
covered directly through Medicaid
Fee-for-Service.
Outpatient Rehabilitation
Medicare Part B benefit limits. Includes
physical therapy, occupational therapy,
speech pathology, and cognitive
rehabilitation.
27
Plan INFORMATION
After Medicare coverage is exhausted,
inpatient mental health services are
covered via Medicaid Fee-for-Service
other than State- or County-operated
psychiatric facilities. The Medicaid
Psychiatric Hospital Inpatient benefit
applies to individuals under age 21
or over age 65. Inpatient hospital
services and nursing facility services
are covered for individuals 65 years of
age or over in an institution for mental
diseases. Inpatient psychiatric services
in approved beds in a general hospital
are covered for patients of any age.
Outpatient Substance Abuse
Methadone maintenance costs and
administration are covered. Other
services are covered via Medicaid
Fee-for-Service.
Personal Care Assistant
Covers health related tasks performed
by a qualified individual in a beneficiary’s
home, under the supervision of a
registered professional nurse, as certified
by a physician in accordance with a
beneficiary’s written plan of care.
Private Duty Nursing
When authorized, available for members
up to 21 years of age. This benefit
is also available to Managed Long
Term Services and Supports (MLTSS)
members of any age.
Transportation (routine)
Covered by Medicaid fee-for-service
for routine/non-emergent ground
transportation to medically necessary
services, including non-emergency basic
life support (BLS).
Vision Care Services
Covers medically necessary eye care
services for detection and treatment of
disease or injury to the eye, including
a comprehensive eye exam once per
year. Optometric services and optical
appliances are covered, including 1 pair
of lenses/frames or contact lenses every
24 months, artificial eyes, low vision
devices, vision training devices, and
intraocular lenses.
*For more information on plan benefits, please see the Evidence of Coverage. Authorization rules
may apply.
companies, a Medicare Advantage organization with a Medicare contract and a contract with
the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with
Medicare. This plan is available to anyone who has both Medical Assistance from the State and
Medicare.
28
Multi-language Interpreter Services
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,
1-800-514-4911 Alguien que hable español le podrá ayudar. Este es un
por favor llame al 1-866-674-0491.
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 1-800-514-4911
1-866-674-0491。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 1-866-674-0491。我們講中文的人員將樂意為您提供幫助。
1-800-514-4911
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 1-800-514-4911
1-866-674-0491. 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 1-800-514-4911
1-866-674-0491. 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 1-800-514-4911
1-866-674-0491 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 1-800-514-4911
1-866-674-0491.
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 1-800-514-4911
1-866-674-0491 번으로
문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로
운영됩니다.
29
Plan INFORMATION
English: We have free interpreter services to answer any questions you may have about our
health or drug plan. To get an interpreter, just call us at 1-800-514-4911
1-866-674-0491. Someone who speaks
English/Language can help you. This is a free service.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного
плана,
можете
нашими
бесплатными
услугами
Чтобы
Russian:выЕсли
у васвоспользоваться
возникнут вопросы
относительно
страхового
илипереводчиков.
медикаментного
воспользоваться
переводчика,
позвоните
нам поуслугами
телефонупереводчиков.
1-866-674-0491.
Вам
1-800-514-4911
плана, вы можетеуслугами
нашими
Чтобы
окажет
помощь сотрудник,
который говорит
по-pусски.
услуга1-866-674-0491.
бесплатная.
услугами переводчика,
позвоните
нам Данная
по телефону
1-800-514-4911 Вам
окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
Arabic: ‫ ﻟﻠﺣﺻول ﻋﻠﻰ‬.‫إﻧﻧﺎ ﻧﻘدم ﺧدﻣﺎت اﻟﻣﺗرﺟم اﻟﻔوري اﻟﻣﺟﺎﻧﯾﺔ ﻟﻺﺟﺎﺑﺔ ﻋن أي أﺳﺋﻠﺔ ﺗﺗﻌﻠق ﺑﺎﻟﺻﺣﺔ أو ﺟدول اﻷدوﯾﺔ ﻟدﯾﻧﺎ‬
‫اﻻﺗﺻﺎل ﺑﻧﺎ ﻋﻠﻰ‬
‫ﻋﻠﯾك ﺳوى‬
‫ﻟﯾس‬
،‫ﻓوري‬
‫ﻣﺗرﺟم‬
1-866-674-0491
‫اﻟﻣﺟﺎﻧﯾﺔﯾﺗﺣدث‬
‫ﺷﺧص ﻣﺎ‬
‫اﻟﻣﺗرﺟمﺳﯾﻘوم‬
. ‫ﺧدﻣﺎت ھذه‬
.‫ﺑﻣﺳﺎﻋدﺗك‬
1-800-514-4911
Arabic:
‫ﻟﻠﺣﺻول‬
‫اﻷدوﯾﺔ‬
‫ﺟدول‬
‫ﺑﺎﻟﺻﺣﺔ أو‬
‫اﻟﻌرﺑﯾﺔأي أﺳﺋﻠﺔ ﺗﺗﻌﻠق‬
‫ﻋن‬
‫ﻟﻺﺟﺎﺑﺔ‬
‫إﻧﻧﺎ ﻧﻘدم‬
Russian:‫ﻋﻠﻰ‬
Если
у вас.‫ﻟدﯾﻧﺎ‬
возникнут
вопросы
относительно
страхового
или‫اﻟﻔوري‬
медикаментного
‫ﻣﺟﺎﻧﯾﺔ‬
.
‫ﺧدﻣﺔﺑﻧﺎ ﻋﻠﻰ‬
‫اﻻﺗﺻﺎل‬
‫ﺳوى‬
‫ﻋﻠﯾك‬
‫ﻟﯾس‬
،‫ﻓوري‬
‫ﻣﺗرﺟم‬
1-866-674-0491
‫اﻟﻌرﺑﯾﺔ‬
‫ﯾﺗﺣدث‬
‫ﻣﺎ‬
‫ﺷﺧص‬
‫ﺳﯾﻘوم‬
.
‫ھذه‬
.
‫ﺑﻣﺳﺎﻋدﺗك‬
1-800-514-4911
плана,
вы можете
нашими
услугами
переводчиков.
Чтобы
1194-415-008-1
‫ﺧدﻣﺔ‬.
услугами переводчика, позвоните нам по телефону 1-866-674-0491.
1-800-514-4911 Вам
Italian:
È
disponibile
un
servizio
di
interpretariato
gratuito
per
rispondere
a eventuali
окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
domande
sul nostro piano
sanitario
e farmaceutico.gratuito
Per un per
interprete,
contattare
il numero
Italian:
È disponibile
un servizio
di interpretariato
rispondere
a eventuali
Hindi:
हमारे स्वास्Un
थ्यnostro
या दवा
की योजना
केparla
बारे Italianovi
में आपके fornirà
किसी भी
प्रश्न केnecessaria.
जवाब देने के लिए हमारे
1-866-674-0491.
incaricato
che
l'assistenza
1-800-514-4911
domande
nostro.‫ﻟدﯾﻧﺎ‬
piano
sanitario
farmaceutico.
un‫ﻟﻺﺟﺎﺑﺔ‬
interprete,
il numero
Arabic: ‫ﻋﻠﻰ‬sul‫ﻟﻠﺣﺻول‬
‫اﻷدوﯾﺔ‬
‫أو ﺟدول‬e‫ﺑﺎﻟﺻﺣﺔ‬
‫ أﺳﺋﻠﺔ ﺗﺗﻌﻠق‬Per
‫ﻋن أي‬
‫اﻟﻣﺟﺎﻧﯾﺔ‬contattare
‫اﻟﻣﺗرﺟم اﻟﻔوري‬
‫إﻧﻧﺎ ﻧﻘدم ﺧدﻣﺎت‬
È1-800-514-4911
un ‫ﺑﻧﺎ‬
servizio
gratuito.
पास
मुफ
्त दुभ
ाषिया
सेnostro
व‫ﻟﯾس‬
ाएँ उपलब्
ध
हैं. 1-800-514-4911
एक parla
दुभाषिया
प्‫اﻟﻌرﺑﯾﺔ‬
राप्तfornirà
करने
के
लिए, ‫ﺳﯾﻘوم‬
बसnecessaria.
हमे
ं 1-800-514-4911
1-866-674-0491.
Un
incaricato
che
Italianovi
‫ﻋﻠﻰ‬
‫اﻻﺗﺻﺎل‬
‫ﺳوى‬
‫ﻋﻠﯾك‬
،‫ﻓوري‬
‫ﻣﺗرﺟم‬
1-866-674-0491
‫ ﯾﺗﺣدث‬l'assistenza
‫ﺷﺧص ﻣﺎ‬
. ‫ھذه‬
.‫ﺑﻣﺳﺎﻋدﺗك‬
पर
फोन
करे
.
ं
कोई
व्
य
क्
त
ि
जो
हिन्
द
ी
बोलता
है
आपकी
मदद
कर
सकता
है
.
यह
एक
मु
फ्त सेवा है.
È un servizio
‫ﺧدﻣﺔ‬. gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer
questão
queDispomos
tenha acerca
do nossodeplano
de saúde gratuitos
ou de medicação.
Para obter
um intérprete,
Portugués:
deservizio
serviços
interpretação
para
responder
a qualquer
Italian:
È disponibile
un
di interpretariato
gratuito per
rispondere
a eventuali
1-800-514-4911
contacte-nos
através do número
1-866-674-0491.
encontrar alguém
queobter
fale oum
idioma
questão
que
nosso
plano
de saúdeIrá
ou
intérprete,
domande
sul tenha
nostroacerca
piano do
sanitario
e farmaceutico.
Perdeunmedicação.
interprete,Para
contattare
il numero
Português
para
o
ajudar.
Este
serviço
é
gratuito.
1-800-514-4911
contacte-nos
através
do número
1-866-674-0491.
Irá encontrar
que fale
o idioma
1-866-674-0491.
Un nostro
incaricato
che parla Italianovi
forniràalguém
l'assistenza
necessaria.
1-800-514-4911
para
o ajudar. Este serviço é gratuito.
ÈPortuguês
un servizio
gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen
konsènan
plan medikal
wa dwòg
an. Pou
jwenn
yon
entèprèt,
jis rele ou
noutanan
French Creole:
Nou genyen
sèvisnou
entèprèt
gratis
pou
reponn
tout responder
kesyon
genyen
Portugués:
Dispomos
de serviços
de interpretação
gratuitos
para
a qualquer
1-800-514-4911
1-866-674-0491.
Yon moun
ki pale
Kreyòl
kapab
ede yon
w. Sa a se yonjissèvis
ki gratis.
konsènan
plan
medikal
wado
dwòg
nou
an. Pou
jwenn
nan
questão
que
tenha
acerca
nosso
plano
de saúde
ou deentèprèt,
medicação. rele
Paranou
obter
um intérprete,
1-800-514-4911
1-866-674-0491.
Yondo
moun
ki pale
Kreyòl kapab ede
Sa a se alguém
yon sèvis
ki gratis.
1-800-514-4911
contacte-nos
através
número
1-866-674-0491.
Irá w.
encontrar
que
fale o idioma
Polish:
Umożliwiamy
bezpłatne
skorzystanie
z
usług
tłumacza
ustnego,
który
pomoże w
Português para o ajudar. Este serviço é gratuito.
uzyskaniu
odpowiedzi bezpłatne
na temat planu
zdrowotnego
dawkowania
leków.
skorzystać
Polish:
Umożliwiamy
skorzystanie
z usługlub
tłumacza
ustnego,
któryAby
pomoże
w z
pomocy
tłumacza
znającego
język
polski,
należy
zadzwonić
pod
numer
1-866-674-0491.
Ta z
1-800-514-4911
uzyskaniu
odpowiedzi
na temat
planu
zdrowotnego
dawkowania
leków.
skorzystać
French
Creole:
Nou genyen
sèvis
entèprèt
gratis poulub
reponn
tout kesyon
ouAby
ta genyen
usługa
bezpłatna.
pomocyjest
tłumacza
znającego
języknou
polski,
zadzwonić
pod numer
1-866-674-0491.
Ta
konsènan
plan
medikal
wa dwòg
an. należy
Pou jwenn
yon entèprèt,
jis rele
nou nan
1-800-514-4911
1-800-514-4911
usługa
jest bezpłatna.
1-866-674-0491.
Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Hindi: हमारे �वा��य या दवा क� योजना के बारे म� आपके �कसी भी ��न के जवाब दे ने के
Polish:
Umożliwiamy
skorzystanie
usług
tłumacza
ustnego,
któryकेpomoże
wने क
�लए
पास
म�
दभ
वयोजना
ाएँ उपल�ध
ह� . म�एक
दभ
�ा�त
करने
केजवाब
�लए, दे
बस
हम�
Hindi:हमारे
हमारे
�वा��य
या
दवा क�से
के zबारे
आपक
�कसी
भी ��न
े
ु त bezpłatne
ु ा�षया
ु े ा�षया
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z
1-866-674-0491
. कोई
�यि�त
जो �ह�द�
है आपक�
मदद ककर
सकता
.
1-800-514-4911
�लए
हमारे पास पर
म�
दभ
ा�षया
सेवाएँ
उपल�ध
ह� . एकबोलता
दभ
�ा�त करने
े �लए,
बस हैहम�
ु तफोन
ु कर�
ु ा�षया
pomocy tłumacza znającego
język polski, należy zadzwonić
pod numer 1-800-514-4911
1-866-674-0491. Ta
यह
एकjest
म�
त सेपर
वा हैफोन
. कर� . कोई �यि�त जो �ह�द� बोलता है आपक� मदद कर सकता है .
1-866-674-0491
1-800-514-4911
ु bezpłatna.
usługa
यह एक म�
ु त सेवा है .
Japanese:ᙜ♫ࡢ೺ᗣ೺ᗣಖ㝤࡜⸆ရฎ᪉⸆ࣉࣛࣥ࡟㛵ࡍࡿࡈ㉁ၥ࡟࠾⟅࠼ࡍࡿࡓࡵ
Hindi: हमारे �वा��य या दवा क� योजना के बारे म� आपके �कसी भी ��न के जवाब दे ने के
࡟ࠊ↓ᩱࡢ㏻ヂࢧ࣮ࣅࢫࡀ࠶ࡾࡲࡍࡈࡊ࠸ࡲࡍࠋ㏻ヂࢆࡈ⏝࿨࡟࡞ࡿ࡟ࡣࠊ
�लए
हमारे पास म�
ु त दभ
ु ा�षया सेवाएँ उपल�ध ह�. एक दभ
ु ा�षया �ा�त करने के �लए, बस हम�
1-866-674-0491
࡟࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ᥼࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ
1-800-514-4911
1-866-674-0491
1-800-514-4911 पर फोन कर� . कोई �यि�त जो �ह�द� बोलता है आपक� मदद कर सकता है .
ࡢࢧ࣮ࣅࢫ࡛ࡍࠋ
1-866-674-0491
1-800-514-4911 ࡟࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ᥼࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ
यह एक मु�त सेवा है .
1-866-674-0491
1-800-514-4911 ࡟࠾㟁ヰࡃࡔࡉ࠸ࠋ᪥ᮏㄒࢆヰࡍே⪅ࡀᨭ᥼࠸ࡓࡋࡲࡍࠋࡇࢀࡣ↓ᩱ
UHNJ16HM3699674_001
30
UnitedHealthcare - H3113
2015 Medicare Star Ratings*
1. An Overall Star Rating that combines all of our plan’s scores.
2. Summary Star Rating that focuses on our medical or our prescription drug services.
Some of the areas Medicare reviews for the ratings include:
·
How our members rate our plan’s services and care;
·
How well our doctors detect illnesses and keep members healthy;
·
How well our plan helps our members use recommended and safe prescription medications
For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare:
Not enough data available*
We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:
Health Plan Services:
Drug Plan Services:
Not enough data available
3.5 stars
The number of stars shows how well our plan performs.
excellent
above average
average
below average
poor
*Some contracts do not have enough data to rate performance.
Learn more about our plan and how we are different from other plans at www.medicare.gov.
You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-834-3721 (toll-free) or 711
(TTY).
Current members please call 800-514-4911 (toll-free) or 711 (TTY).
*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year
to the next.
UHEX15HM3630278_001
Y0066_H3113_B_PR2015 CMS Accepted
31
Plan INFORMATION
The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality
and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use
these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings
are:
2016 Required
INFORMATION
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid
Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is
available to anyone who has both Medical Assistance from the State and Medicare.
Members may enroll in the plan only during specific times of the year. Contact the plan for more
information. You must have both Medicare Parts A and B to enroll in the plan.
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/co-insurance may change on January 1 of each year.
Premium and/or co- payments/co-insurance may change on January 1 of each year. You must continue
to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.
Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive.
Please contact the plan for further details.
Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices
are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their
dispensing policy or by the plan based on Quantity Limit requirements; if a prescription is in excess of a
limit, co-pay amounts may be higher. Other pharmacies are available in our network. Members may use
any pharmacy in the network, but may not receive Pharmacy Saver pricing. Pharmacies participating in
the Pharmacy Saver program may not be available in all areas.
You are not required to use OptumRx to obtain a 90 - day supply of your maintenance medications. If
you have not used OptumRx home delivery, you must approve the first prescription order sent directly
from your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive
within ten business days from the date the completed order is received, and refill orders should arrive
in about seven business days. Contact OptumRx anytime at 1-877-266-4832. OptumRx is an affiliate of
UnitedHealthcare Insurance Company.
For PPO and HMO-POS members, with the exception of emergency or out-of-area renal dialysis, it may
cost more to get care from out-of-network providers. HMO members must use plan providers except
in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from
out-of-network providers neither Medicare nor UnitedHealthcare® Medicare Advantage plans will be
responsible for the costs.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may
change from one year to the next.
This information is available for free in other languages. Please call our customer service number located
on the first page of this book.
Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al número que
se encuentra en la primera página de esta guía.
Y0066_140728_115139_Accepted
32
UHEX16DU3720524_000
2016 Required
INFORMATION (CONTINUED)
NurseLineSM
This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the
nearest emergency room. The information provided through this service is for informational purposes
only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your
doctor's care. Your health information is kept confidential in accordance with the law. The service is not an
insurance program and may be discontinued at any time.
SilverSneakers®
Consult a health care professional before beginning any exercise program. Availability of the SilverSneakers
program varies by plan/market. Refer to your Evidence of Coverage for more details. SilverSneakers® is a
registered trademark of Healthways, Inc. © 2014 Healthways, Inc.
Y0066_140728_115139_Accepted
33
UHEX16DU3720524_000
Plan INFORMATION
Your Plan may contain one or more of the following:
NOTES
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_______________________________________________________________________________________ _______________________________________________________________________________________
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_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
UHEX16MP3700083_001
0
2016
DRUG LIST
This is an alphabetical list of Brand name and Generic drugs covered by the plan.
· Brand name drugs appear in bold type
· Generic drugs appear in plain type
Your plan has one tier named “Covered Drugs”. All covered drugs are in this tier.
· For a full description of the tier “Covered Drugs”, see the Summary of Benefits in this book
Some drugs may need Prior Authorization, Step Therapy or other requirements. To find out if your
drug has added coverage needs, please contact us or view the complete drug list on our website. Our
contact information is on the first page of this book.
This list was last updated August 1, 2015.
#
8-Mop (Capsule), T1
A
A-Hydrocort (Injection), T1
Abacavir (Tablet), T1
Abacavir Sulfate/Lamivudine/
Zidovudine (Tablet), T1
Abelcet (Injection), T1
Abilify Discmelt (Tablet
Dispersible), T1
Abilify Maintena (Injection),
T1
Abraxane (Injection), T1
Abstral (Tablet Sublingual),
T1
Acamprosate Calcium DR
(Tablet Delayed-Release), T1
Acarbose (Tablet), T1
Acebutolol HCl (Capsule), T1
Acetaminophen/Codeine
(120mg-12mg/5ml Oral
Solution, 300mg-15mg
Tablet, 300mg-30mg Tablet,
300mg-60mg Tablet), T1
Acetazolamide (Tablet
Immediate-Release), T1
Acetazolamide ER (Capsule
Extended-Release 12 Hour),
T1
Acetazolamide Sodium
(Injection), T1
Acetic Acid (Otic Solution), T1
Acetylcysteine (Inhalation
Solution), T1
Acitretin (Capsule), T1
ActHIB (Injection), T1
Actemra (162mg/0.9ml
Injection, 200mg/10ml
Injection), T1
Actimmune (Injection), T1
Actonel (150mg Tablet), T1
Acyclovir (200mg Capsule,
200mg/5ml Suspension),
T1
Acyclovir (400mg Tablet,
800mg Tablet), T1
Acyclovir (5% Ointment), T1
Acyclovir Sodium (Injection),
T1
Adacel (Injection), T1
Adagen (Injection), T1
Adapalene (0.1% Cream,
0.1% Gel), T1
T1 = Tier 1 Covered Drugs
H3113_150616_121143_FINAL Accepted
Adcirca (Tablet), T1
Adefovir Dipivoxil (Tablet), T1
Adempas (Tablet), T1
Adrucil (Injection), T1
Advair Diskus (Aerosol
Powder), T1
Advair HFA (Aerosol), T1
Afeditab CR (Tablet
T1
Afinitor (Tablet), T1
Afinitor Disperz (Tablet
Soluble), T1
Aggrenox (Capsule
Extended-Release 12
Hour), T1
Ala Cort (Cream), T1
Albenza (Tablet), T1
Albuterol Sulfate (0.083%
Nebulized Solution, 0.5%
Nebulized Solution,
0.63mg/3ml Nebulized
Solution, 1.25mg/3ml
Nebulized Solution), T1
0
Bold type = Brand name drug
Amikacin Sulfate (Injection),
T1
Amiloride HCl (Tablet), T1
Amiloride/
Hydrochlorothiazide
(Tablet), T1
Aminophylline (Injection), T1
Aminosyn 7%/Electrolytes
(Injection), T1
Aminosyn 8.5%/
Electrolytes (Injection), T1
Aminosyn II (Injection), T1
Aminosyn II 8.5%/
Electrolytes (Injection), T1
Aminosyn M (Injection), T1
Aminosyn-HBC (Injection),
T1
Aminosyn-PF (Injection), T1
Aminosyn-RF (Injection), T1
Amiodarone HCl (200mg
Tablet), T1
Amiodarone HCl (50mg/ml
Injection), T1
Amitiza (Capsule), T1
Amitriptyline HCl (Tablet), T1
Amlodipine Besylate (Tablet),
T1
Amlodipine Besylate/
Atorvastatin Calcium
(Tablet), T1
Benazepril HCl (Capsule),
T1
Valsartan (Tablet), T1
Amlodipine/Valsartan/
Hydrochlorothiazide
(Tablet), T1
Ammonium Chloride
(Injection), T1
Ammonium Lactate (12%
Cream, 12% Lotion), T1
Amoxapine (Tablet), T1
Amoxicillin (125mg Tablet
Chewable, 250mg Tablet
Chewable, 125mg/5ml
Suspension, 200mg/5ml
Suspension, 250mg
Capsule, 500mg Capsule,
500mg Tablet, 875mg
Tablet), T1
Amoxicillin/Clavulanate
Potassium (200mg-28.5mg
Tablet Chewable,
400mg-57mg Tablet
Chewable, 200mg-28.5mg/
5ml Suspension,
250mg-62.5mg/5ml
Suspension, 400mg-57mg/
5ml Suspension,
600mg-42.9mg/5ml
Suspension, 250mg-125mg
Tablet Immediate-Release,
500mg-125mg Tablet
Immediate-Release,
875mg-125mg Tablet
Immediate-Release)
(Generic Augmentin), T1
Amoxicillin/Clavulanate
Potassium ER (Tablet
T1
Amphetamine/
Dextroamphetamine
(Capsule Extended-Release
24 Hour), T1
Amphetamine/
Dextroamphetamine (Tablet
Amphotericin B (Injection), T1
Ampicillin (125mg/5ml
Suspension, 250mg
Capsule, 500mg Capsule),
T1
Plain type = Generic drug
37
Drug LIST
Albuterol Sulfate (2mg Tablet
Immediate-Release, 4mg
Tablet Immediate-Release),
T1
Alclometasone Dipropionate
(0.05% Cream, 0.05%
Ointment), T1
Alcohol Prep Pads, T1
Aldurazyme (Injection), T1
Alendronate Sodium (10mg
Tablet, 35mg Tablet, 40mg
Tablet), T1
Alendronate Sodium (70mg/
75ml Oral Solution), T1
Alfuzosin HCl ER (Tablet
T1
Alimta (Injection), T1
Alinia (100mg/5ml
Suspension, 500mg
Tablet), T1
Allopurinol (Tablet), T1
Alocril (Ophthalmic
Solution), T1
Alomide (Ophthalmic
Solution), T1
Alora (Patch Twice Weekly),
T1
Alosetron HCl (Tablet), T1
Aloxi (Injection), T1
Alphagan P (0.1%
Ophthalmic Solution), T1
Alprazolam (Tablet
Altabax (Ointment), T1
AmBisome (Injection), T1
Amantadine HCl (100mg
Capsule, 100mg Tablet,
50mg/5ml Syrup), T1
Amethia (Tablet), T1
Amethyst (Tablet), T1
Amifostine (Injection), T1
0
Ampicillin Sodium (10gm
Injection, 125mg Injection,
1gm Injection), T1
Ampicillin-Sulbactam
(10gm-5gm Injection,
1gm-0.5gm Injection,
2gm-1gm Injection), T1
Ampyra (Tablet ExtendedRelease 12 Hour), T1
Anadrol-50 (Tablet), T1
Anagrelide HCl (Capsule), T1
Anastrozole (Tablet), T1
Ancobon (Capsule), T1
Androderm (Patch 24
Hour), T1
Androgel (1.62% Packet),
T1
Androgel Pump (1.62%
Gel), T1
Anoro Ellipta (Aerosol
Powder), T1
Anzemet (100mg Tablet,
50mg Tablet), T1
Apokyn (Injection), T1
Apraclonidine (Ophthalmic
Solution), T1
Apri (Tablet), T1
Aptiom (200mg Tablet), T1
Aptiom (400mg Tablet,
600mg Tablet, 800mg
Tablet), T1
Aptivus (100mg/ml Oral
Solution, 250mg Capsule),
T1
Aralast NP (Injection), T1
Aranelle (Tablet), T1
Aranesp Albumin Free
(100mcg/0.5ml Injection,
100mcg/ml Injection,
150mcg/0.3ml Injection,
60mcg/ml Injection), T1
Aranesp Albumin Free
(10mcg/0.4ml Injection,
25mcg/ml Injection,
Arcalyst (Injection), T1
Argatroban (Injection), T1
Aripiprazole (10mg Tablet,
15mg Tablet, 2mg Tablet,
5mg Tablet), T1
Aripiprazole (20mg Tablet,
30mg Tablet), T1
Arranon (Injection), T1
Arzerra (Injection), T1
Ashlyna (Tablet), T1
Atenolol (Tablet), T1
Atenolol/Chlorthalidone
(Tablet), T1
Atgam (Injection), T1
Atorvastatin Calcium (Tablet),
T1
Atovaquone (Suspension), T1
Atovaquone/Proguanil HCl
(Tablet) (Generic Malarone),
T1
Atripla (Tablet), T1
Atropine Sulfate (Injection),
T1
Atrovent HFA (Aerosol
Solution), T1
Aubagio (Tablet), T1
Aubra (Tablet), T1
Augmented Betamethasone
Dipropionate (0.05%
Cream), T1
Augmented Betamethasone
Dipropionate (0.05% Gel,
0.05% Lotion, 0.05%
Ointment), T1
Avandamet (Tablet), T1
Avandia (Tablet), T1
Avastin (Injection), T1
Avelox (400mg/250ml-0.8%
Injection), T1
Aviane (Tablet), T1
Avita (0.025% Cream,
0.025% Gel), T1
Avonex (Injection), T1
Avonex Pen (Injection), T1
Azacitidine (Injection), T1
Azactam in Iso-Osmotic
Dextrose (Injection), T1
Azasite (Ophthalmic
Solution), T1
Azathioprine (Tablet), T1
Azelastine HCl (0.05%
Azelastine HCl (0.1% Nasal
Solution), T1
Azelastine HCl (0.15% Nasal
Solution), T1
Azilect (Tablet), T1
Azithromycin (100mg/5ml
Oral Suspension, 200mg/
5ml Oral Suspension,
250mg Tablet, 500mg
Tablet, 600mg Tablet), T1
Azithromycin (500mg
Injection), T1
Azopt (Suspension), T1
Azor (Tablet), T1
Aztreonam (Injection), T1
0
Betamethasone Dipropionate
(0.05% Cream, 0.05%
Lotion, 0.05% Ointment), T1
Betamethasone Valerate
(0.1% Cream, 0.1% Lotion,
0.1% Ointment), T1
Betaseron (Injection), T1
Betaxolol HCl (0.5%
Betaxolol HCl (10mg Tablet,
20mg Tablet), T1
Bethanechol Chloride
(Tablet), T1
Bethkis (Nebulized
Solution), T1
Betimol (Ophthalmic
Solution), T1
Bexsero (Injection), T1
BiCNU (Injection), T1
BiDil (Tablet), T1
Bicalutamide (Tablet), T1
Bicillin C-R (Injection), T1
Bicillin L-A (Injection), T1
Biltricide (Tablet), T1
Binosto (Tablet
Effervescent), T1
Bisoprolol Fumarate (Tablet),
T1
Bisoprolol Fumarate/
Hydrochlorothiazide
(Tablet), T1
Bleomycin Sulfate (Injection),
T1
Blephamide (Suspension),
T1
Blephamide S.O.P.
(Ointment), T1
Boniva (3mg/3ml Injection),
T1
Boostrix (Injection), T1
Bosulif (Tablet), T1
Botox (Injection), T1
Breo Ellipta (Aerosol
Powder), T1
Briellyn (Tablet), T1
Brilinta (Tablet), T1
Brimonidine Tartrate
(0.15% Ophthalmic
Solution), T1
Brimonidine Tartrate (0.2%
Brintellix (Tablet), T1
Bromocriptine Mesylate
(2.5mg Tablet, 5mg
Capsule), T1
Brovana (Nebulized
Solution), T1
Budesonide (0.25mg/2ml
Suspension, 0.5mg/2ml
Suspension), T1
Budesonide (3mg Capsule
T1
Bumetanide (0.25mg/ml
Injection), T1
Bumetanide (0.5mg Tablet,
1mg Tablet, 2mg Tablet), T1
Buprenorphine HCl (0.3mg/
ml Injection), T1
Buprenorphine HCl (2mg
Tablet Sublingual, 8mg
Tablet Sublingual), T1
Buprenorphine HCl/Naloxone
HCl (Tablet Sublingual), T1
Buproban (Tablet ExtendedRelease 12 Hour), T1
Bupropion HCl (Tablet
Bupropion HCl SR (Tablet
T1
Bupropion HCl XL (Tablet
T1
Buspirone HCl (Tablet), T1
Busulfex (Injection), T1
Butorphanol Tartrate (10mg/
ml Nasal Solution), T1
39
Drug LIST
B
BACiiM (Injection), T1
BCG Vaccine (Injection), T1
BIVIGAM (Injection), T1
Bacitracin (50000unit
Injection), T1
Bacitracin (500unit/gm
Ointment), T1
Bacitracin/Polymyxin B
(Ointment), T1
Baclofen (Tablet), T1
Bactocill in Dextrose (1gm/
50ml Injection), T1
Bactocill in Dextrose (2gm/
50ml Injection), T1
Bactroban Nasal
(Ointment), T1
Balsalazide Disodium
(Capsule), T1
Balziva (Tablet), T1
Banzel (200mg Tablet,
400mg Tablet, 40mg/ml
Suspension), T1
Baraclude (0.05mg/ml Oral
Solution, 0.5mg Tablet,
1mg Tablet), T1
Beleodaq (Injection), T1
Belsomra (Tablet), T1
Benazepril HCl (Tablet), T1
Benazepril HCl/
Hydrochlorothiazide
(Tablet), T1
Benicar (Tablet), T1
Benicar HCT (Tablet), T1
Benlysta (Injection), T1
Benztropine Mesylate (0.5mg
Tablet), T1
Benztropine Mesylate (1mg/
ml Injection), T1
Bepreve (Ophthalmic
Solution), T1
Berinert (Injection), T1
Besivance (Suspension), T1
0
Butorphanol Tartrate (1mg/ml
Injection, 2mg/ml Injection),
T1
Bydureon (Injection), T1
Byetta (Injection), T1
Bystolic (Tablet), T1
C
Cabergoline (Tablet), T1
Calcipotriene (0.005% Cream,
0.005% External Solution),
T1
Calcitonin-Salmon (Nasal
Solution), T1
Calcitriol (0.25mcg Capsule,
0.5mcg Capsule, 1mcg/ml
Oral Solution), T1
Calcitriol (1mcg/ml Injection),
T1
Calcitriol (3mcg/gm
Ointment), T1
Calcium Acetate (Capsule),
T1
Camila (Tablet), T1
Canasa (Suppository), T1
Cancidas (Injection), T1
Candesartan Cilexetil (Tablet),
T1
Candesartan Cilexetil/
Hydrochlorothiazide
(Tablet), T1
Capastat Sulfate (Injection),
T1
Caprelsa (Tablet), T1
Captopril (Tablet), T1
Captopril/Hydrochlorothiazide
(Tablet), T1
Carac (Cream), T1
Carafate (1gm/10ml
Suspension), T1
Carbaglu (Tablet), T1
Carbamazepine (100mg
Tablet Chewable, 100mg/
5ml Suspension, 200mg
T1
Carbamazepine ER (100mg
Capsule Extended-Release
12 Hour, 200mg Capsule
Extended-Release 12 Hour,
300mg Capsule ExtendedRelease 12 Hour, 200mg
Tablet Extended-Release 12
Hour, 400mg Tablet
T1
Carbidopa (Tablet), T1
Carbidopa/Levodopa (Tablet
Carbidopa/Levodopa ER
(Tablet Extended-Release),
T1
Carbidopa/Levodopa ODT
(Tablet Dispersible), T1
Carbidopa/Levodopa/
Entacapone (Tablet), T1
Carboplatin (Injection), T1
Cardene IV (Injection), T1
Carimune Nanofiltered
(Injection), T1
Carteolol HCl (Ophthalmic
Solution), T1
Cartia XT (Capsule ExtendedRelease 24 Hour), T1
Carvedilol (Tablet ImmediateRelease), T1
Cayston (Inhalation
Solution), T1
Cefaclor (250mg Capsule
Capsule ImmediateRelease), T1
Cefadroxil (250mg/5ml
Suspension, 500mg
Capsule), T1
Cefazolin Sodium (10gm
Injection, 1gm Injection,
500mg Injection, 1gm/50ml
Injection), T1
Cefdinir (125mg/5ml
Suspension, 300mg
Capsule), T1
Cefditoren Pivoxil (Tablet),
T1
Cefepime (1gm Injection,
2gm Injection), T1
Cefepime (1gm/50ml
Injection, 2gm/50ml
Injection), T1
Cefixime (Suspension), T1
Cefotaxime Sodium
(Injection), T1
Cefotetan (Injection), T1
Cefoxitin Sodium (10gm
2gm Injection), T1
Cefoxitin Sodium (1gm-4%
Injection, 2gm-2.2%
Injection), T1
Cefpodoxime Proxetil (100mg
Tablet, 200mg Tablet,
100mg/5ml Suspension,
50mg/5ml Suspension), T1
Cefprozil (125mg/5ml
Suspension, 250mg Tablet,
500mg Tablet), T1
Ceftazidime (Injection), T1
Ceftazidime/Dextrose
(Injection), T1
0
Chlorpromazine HCl (100mg
Tablet, 25mg/ml Injection),
T1
Chlorthalidone (Tablet), T1
Cholestyramine Light
(Packet), T1
Chorionic Gonadotropin
(Injection), T1
Ciclopirox (0.77% Gel, 0.77%
Suspension, 1% Shampoo),
T1
Ciclopirox Nail Lacquer
(External Solution), T1
Ciclopirox Olamine (Cream),
T1
Cilostazol (Tablet), T1
Ciloxan (0.3% Ointment), T1
Cimetidine (Tablet), T1
Cimetidine HCl (Oral
Solution), T1
Cimzia (Injection), T1
Cinryze (Injection), T1
Cipro HC (Suspension), T1
Ciprodex (Otic Suspension),
T1
Ciprofloxacin (250mg/5ml
Injection), T1
Ciprofloxacin ER (Tablet
T1
Ciprofloxacin HCl (0.3%
Ophthalmic Solution,
100mg Tablet ImmediateRelease, 250mg Tablet
750mg Tablet ImmediateRelease), T1
Ciprofloxacin I.V. in D5W
(Injection), T1
Cisplatin (Injection), T1
Citalopram HBr (10mg Tablet,
20mg Tablet, 40mg Tablet),
T1
Citalopram HBr (10mg/5ml
Oral Solution), T1
Cladribine (Injection), T1
Claravis (Capsule), T1
Clarithromycin (125mg/5ml
500mg Tablet), T1
Clarithromycin ER (Tablet
T1
Climara Pro (Patch Weekly),
T1
Clindamycin HCl (Capsule
Clindamycin Palmitate HCl
(Oral Solution), T1
Clindamycin Phosphate (1%
External Solution, 1% Gel,
1% Lotion, 1% Swab), T1
Clindamycin Phosphate (2%
Cream), T1
Clindamycin Phosphate AddVantage (Injection), T1
Clindamycin Phosphate in
D5W (Injection), T1
Clindamycin/Benzoyl
Peroxide (1%-5% Gel)
(Generic BenzaClin), T1
Clinisol SF 15% (Injection), T1
Clobetasol Propionate (0.05%
External Solution, 0.05%
Gel, 0.05% Ointment), T1
Clobetasol Propionate (0.05%
Shampoo), T1
Clobetasol Propionate E
(Cream), T1
Clolar (Injection), T1
Clomipramine HCl (Capsule),
T1
41
Drug LIST
Ceftriaxone Sodium (10gm
2gm Injection, 250mg
Injection, 500mg Injection),
T1
Cefuroxime Axetil (Tablet), T1
Cefuroxime Sodium
(Injection), T1
Celecoxib (Capsule), T1
Cellcept (200mg/ml
Suspension, 250mg
Capsule, 500mg Tablet),
T1
Cellcept Intravenous
(Injection), T1
Celontin (Capsule), T1
Cephalexin (125mg/5ml
Suspension, 250mg
750mg Capsule), T1
Cerezyme (Injection), T1
Cervarix (Injection), T1
Cesamet (Capsule), T1
Cetirizine HCl (Syrup), T1
Chantix (Tablet), T1
Chantix Continuing Month
Pak (Tablet), T1
Chantix Starting Month Pak
(Tablet), T1
Chemet (Capsule), T1
Chenodal (Tablet), T1
Chloramphenicol Sodium
Succinate (Injection), T1
Chlordiazepoxide HCl
(Capsule), T1
Chlorhexidine Gluconate Oral
Rinse (Solution), T1
Chloroquine Phosphate
(Tablet), T1
Chlorothiazide (Tablet), T1
Chlorothiazide Sodium
(Injection), T1
0
Clonazepam (Tablet
Clonazepam ODT (Tablet
Dispersible), T1
Clonidine HCl (0.1mg Tablet
Immediate-Release, 0.2mg
0.3mg Tablet ImmediateRelease), T1
Clonidine HCl (0.1mg/24hr
Patch Weekly, 0.2mg/24hr
Patch Weekly, 0.3mg/24hr
Patch Weekly), T1
Clonidine HCl ER (Tablet
T1
Clopidogrel (75mg Tablet),
T1
Clorazepate Dipotassium
(Tablet), T1
Clorpres (Tablet), T1
Clotrimazole (1% Cream, 1%
External Solution, 10mg
Troche), T1
Clotrimazole/Betamethasone
Dipropionate (1%-0.05%
Cream), T1
Clotrimazole/Betamethasone
Dipropionate (1%-0.05%
Lotion), T1
Clozapine (Tablet ImmediateRelease), T1
Clozapine ODT (100mg
Tablet Dispersible,
12.5mg Tablet
Dispersible, 150mg Tablet
Dispersible), T1
Clozapine ODT (200mg
Tablet Dispersible), T1
Coartem (Tablet), T1
Codeine Sulfate (Tablet), T1
Colchicine (0.6mg Tablet)
(Generic Colcrys), T1
Colcrys (Tablet), T1
Colestipol HCl (1gm Tablet,
5gm Granules), T1
Colistimethate Sodium
(Injection), T1
Colocort (Enema), T1
Coly-Mycin S (Suspension),
T1
Combigan (Ophthalmic
Solution), T1
Combivent Respimat
(Aerosol Solution), T1
Combivir (Tablet), T1
Cometriq (Kit), T1
Complera (Tablet), T1
Compro (Suppository), T1
Comvax (Injection), T1
Constulose (Oral Solution), T1
Copaxone (Injection), T1
Cordran Tape (Tape), T1
Cormax Scalp Application
(External Solution), T1
Cortisone Acetate (Tablet), T1
Cortisporin (0.5%-0.5%
Cream, 1%-0.5%
Ointment), T1
Cortisporin-TC
(Suspension), T1
Cosmegen (Injection), T1
Coumadin (Tablet), T1
Creon (Capsule DelayedRelease), T1
Crestor (Tablet), T1
Crinone (Gel), T1
Crixivan (Capsule), T1
Cromolyn Sodium (100mg/
5ml Concentrate), T1
Cromolyn Sodium (20mg/2ml
Nebulized Solution), T1
Cromolyn Sodium (4%
Cryselle-28 (Tablet), T1
Cubicin (Injection), T1
Cuprimine (Capsule), T1
Cuvposa (Oral Solution), T1
Cyclafem (Tablet), T1
Cyclobenzaprine HCl (7.5mg
Tablet), T1
Cyclophosphamide
(Capsule), T1
Cycloset (Tablet), T1
Cyclosporine (100mg
Capsule, 25mg Capsule), T1
Cyclosporine (50mg/ml
Injection), T1
Cyclosporine Modified
(100mg Capsule, 25mg
100mg/ml Oral Solution), T1
Cyproheptadine HCl (4mg
Tablet), T1
Cystadane (Powder), T1
Cystagon (Capsule), T1
Cystaran (Ophthalmic
Solution), T1
Cytarabine Aqueous
(Injection), T1
D
DARAPRIM (Tablet), T1
Dacarbazine (Injection), T1
Dacogen (Injection), T1
Daliresp (Tablet), T1
Dalvance (Injection), T1
Danazol (Capsule), T1
Dantrolene Sodium (Capsule),
T1
Dapsone (Tablet), T1
Daptacel (Injection), T1
DaunoXome (Injection), T1
Daunorubicin HCl (Injection),
T1
Deblitane (Tablet), T1
Decitabine (Injection), T1
Delyla (Tablet), T1
Demeclocycline HCl (Tablet),
T1
0
Dexmethylphenidate HCl ER
24 Hour), T1
Dexrazoxane (Injection), T1
Dextroamphetamine Sulfate
(10mg Tablet ImmediateRelease, 5mg Tablet
Dextroamphetamine Sulfate
ER (Capsule ExtendedRelease 24 Hour), T1
Dextrose 10% Flex
Container (Injection), T1
Dextrose 10%/NaCl 0.2%
(Injection), T1
(Injection), T1
Dextrose 2.5%/Sodium
Chloride 0.45% (Injection),
T1
Dextrose 5% (Injection), T1
(Injection), T1
(Injection), T1
(Injection), T1
(Injection), T1
(Injection), T1
Dextrose 5%/Potassium
Chloride 0.15% (Injection),
T1
Diastat AcuDial (Gel), T1
Diastat Pediatric (Gel), T1
Diazepam (10mg Gel,
2.5mg Gel, 20mg Gel), T1
Diazepam (10mg Tablet
Diazepam (1mg/ml Oral
Solution), T1
Diazepam Intensol (5mg/ml
Concentrate), T1
Diclofenac Potassium (Tablet
Diclofenac Sodium (0.1%
Diclofenac Sodium (3% Gel),
T1
Diclofenac Sodium DR
Diclofenac Sodium ER (Tablet
T1
Dicloxacillin Sodium
(Capsule), T1
Dicyclomine HCl (10mg
Capsule, 10mg/5ml Oral
Solution, 20mg Tablet), T1
Didanosine (Capsule DelayedRelease), T1
Dificid (Tablet), T1
Diflunisal (Tablet), T1
Digitek (0.125mg Tablet), T1
Digitek (0.25mg Tablet), T1
Digoxin (0.05mg/ml Oral
Solution), T1
Digoxin (0.25mg/ml
Injection), T1
Digoxin (125mcg Tablet), T1
Digoxin (250mcg Tablet), T1
Dihydroergotamine Mesylate
(1mg/ml Injection), T1
Dilantin (Capsule), T1
Dilantin INFATABS (Tablet
Chewable), T1
Dilt-XR (Capsule ExtendedRelease 24 Hour), T1
Diltiazem CD (240mg
24 Hour) (Generic Cardizem
CD), T1
43
Drug LIST
Demser (Capsule), T1
Denavir (Cream), T1
Depen Titratabs (Tablet), T1
Depo-Estradiol (Injection), T1
Depo-Medrol (20mg/ml
Injection), T1
Depo-Provera (Injection), T1
Desipramine HCl (Tablet), T1
Desmopressin Acetate
(0.01% Nasal Solution), T1
(0.01% Nasal Solution,
0.1mg Tablet, 0.2mg
Tablet), T1
(4mcg/ml Injection), T1
Desogestrel/Ethinyl Estradiol
(Tablet), T1
Desonide (0.05% Ointment),
T1
Desoximetasone (0.05%
Cream, 0.25% Cream), T1
Dexamethasone (0.5mg
Tablet, 0.75mg Tablet,
1.5mg Tablet, 1mg Tablet,
6mg Tablet, 0.5mg/5ml
Elixir), T1
Dexamethasone Intensol
(1mg/ml Concentrate), T1
Dexamethasone Sodium
Phosphate (0.1%
Dexamethasone Sodium
Phosphate (10mg/ml
Injection), T1
Dexedrine (10mg Tablet, 5mg
Tablet), T1
Dexilant (Capsule DelayedRelease), T1
Dexmethylphenidate HCl
(Tablet Immediate-Release)
(Generic Ritalin), T1
0
Diltiazem HCl (100mg
Injection), T1
Diltiazem HCl (120mg Tablet,
90mg Tablet), T1
Diltiazem HCl ER (Capsule
Extended-Release), T1
Dipentum (Capsule), T1
Diphenhydramine HCl
(50mg/ml Injection), T1
Diphenoxylate/Atropine
(2.5mg-0.025mg Tablet,
2.5mg-0.025mg/5ml
Liquid), T1
Diphtheria/Tetanus Toxoids
Adsorbed Pediatric
(Injection), T1
Disulfiram (Tablet), T1
Diuril (Suspension), T1
Divalproex Sodium (Capsule
Sprinkle), T1
Divalproex Sodium DR (Tablet
Delayed-Release), T1
Divalproex Sodium ER (Tablet
T1
Docefrez (Injection), T1
Docetaxel (80mg/4ml
Injection), T1
Docetaxel (80mg/8ml
Injection), T1
Donepezil HCl (10mg Tablet
Dispersible), T1
Donepezil HCl (10mg Tablet
Doribax (Injection), T1
Dorzolamide HCl (Ophthalmic
Solution), T1
Dorzolamide HCl/Timolol
Maleate (Ophthalmic
Solution), T1
Doxazosin Mesylate (Tablet),
T1
Doxepin HCl (100mg
150mg Capsule, 25mg
75mg Capsule, 10mg/ml
Concentrate), T1
Doxercalciferol (0.5mcg
Capsule, 1mcg Capsule,
2.5mcg Capsule), T1
Doxercalciferol (4mcg/2ml
Injection), T1
Doxil (Injection), T1
Doxorubicin HCl (Injection),
T1
Doxy 100 (Injection), T1
Doxycycline (150mg Capsule,
75mg Capsule), T1
Doxycycline (25mg/5ml
Suspension), T1
Doxycycline Hyclate (100mg
Capsule Immediate-Release,
50mg Capsule ImmediateRelease), T1
Doxycycline Hyclate (100mg
Injection, 100mg Tablet
T1
Doxycycline Monohydrate
75mg Tablet), T1
Dronabinol (10mg Capsule),
T1
Dronabinol (2.5mg Capsule,
5mg Capsule), T1
Drospirenone/Ethinyl
Estradiol (Tablet), T1
Droxia (Capsule), T1
Dulera (Aerosol), T1
Duloxetine HCl (20mg
Capsule Delayed-Release,
30mg Capsule DelayedRelease, 60mg Capsule
Duramorph (Injection), T1
Durezol (Emulsion), T1
Dymista (Suspension), T1
E
E.E.S. 400 (Tablet), T1
E.E.S. Granules
(Suspension), T1
Econazole Nitrate (Cream), T1
Edarbi (Tablet), T1
Edarbyclor (Tablet), T1
Edecrin (Tablet), T1
Edurant (Tablet), T1
Effient (Tablet), T1
Egrifta (Injection), T1
Elaprase (Injection), T1
Elelyso (Injection), T1
Elestrin (Gel), T1
Elidel (Cream), T1
Eliphos (Tablet), T1
Eliquis (Tablet), T1
Elitek (Injection), T1
Ellence (Injection), T1
Elmiron (Capsule), T1
Eloxatin (Injection), T1
Emcyt (Capsule), T1
Emend (Capsule), T1
Emoquette (Tablet), T1
Emsam (Patch 24 Hour), T1
Emtriva (10mg/ml Oral
Solution, 200mg Capsule),
T1
Enalapril Maleate (Tablet), T1
Enalapril Maleate/
Hydrochlorothiazide
(Tablet), T1
Enbrel (Injection), T1
0
Ery-Tab (Tablet DelayedRelease), T1
EryPed 200 (Suspension),
T1
EryPed 400 (Suspension),
T1
Erythrocin Lactobionate
(Injection), T1
Erythromycin (2% External
Solution), T1
Erythromycin (2% Gel), T1
Erythromycin (5mg/gm
Ophthalmic Ointment), T1
Erythromycin Base (Tablet),
T1
Erythromycin Ethylsuccinate
(Tablet), T1
Erythromycin/Benzoyl
Peroxide (Gel), T1
Esbriet (Capsule), T1
Escitalopram Oxalate (10mg
Tablet), T1
Escitalopram Oxalate (5mg/
Esomeprazole Magnesium
(Capsule Delayed-Release)
(Generic Nexium), T1
Esomeprazole Sodium
(Injection), T1
Estrace (0.1mg/gm Cream),
T1
Estradiol (0.5mg Tablet, 1mg
Tablet, 2mg Tablet) (Generic
Estrace), T1
Estradiol Valerate (Injection),
T1
Estring (Ring), T1
Ethambutol HCl (Tablet), T1
Ethosuximide (250mg
Solution), T1
Etidronate Disodium (Tablet),
T1
Etodolac (200mg Capsule,
300mg Capsule, 400mg
Etodolac ER (Tablet
T1
Etopophos (Injection), T1
Etoposide (Injection), T1
Eurax (10% Cream, 10%
Lotion), T1
Evotaz (Tablet), T1
Exelderm (1% Cream, 1%
External Solution), T1
Exelon (13.3mg/24hr Patch
24 Hour, 4.6mg/24hr
Patch 24 Hour, 9.5mg/
24hr Patch 24 Hour), T1
Exemestane (Tablet), T1
Exjade (Tablet Soluble), T1
F
FML (Ointment), T1
FML Forte (Suspension), T1
Fabrazyme (Injection), T1
Falmina (Tablet), T1
Famciclovir (Tablet), T1
Famotidine (20mg Tablet,
40mg Tablet), T1
Famotidine (20mg/2ml
Injection, 40mg/5ml
Suspension), T1
Famotidine Premixed
(Injection), T1
Fanapt (10mg Tablet, 12mg
Tablet), T1
Fanapt (1mg Tablet, 2mg
Fanapt Titration Pack
(Tablet), T1
Fareston (Tablet), T1
Farydak (Capsule), T1
45
Drug LIST
Enbrel Sureclick (Injection),
T1
Endocet (Tablet), T1
Engerix-B (Injection), T1
Enoxaparin Sodium (100mg/
ml Injection, 120mg/0.8ml
Injection, 150mg/ml
Injection), T1
Enoxaparin Sodium (300mg/
3ml Injection, 30mg/0.3ml
Injection, 40mg/0.4ml
Injection), T1
Enpresse-28 (Tablet), T1
Entacapone (Tablet), T1
Entecavir (Tablet), T1
Entocort EC (Capsule
Extended-Release 24
Hour), T1
Enulose (Oral Solution), T1
Epaned (Oral Solution), T1
EpiPen (Injection), T1
Epinastine HCl (Ophthalmic
Solution), T1
Epirubicin HCl (Injection), T1
Epitol (Tablet), T1
Epivir (10mg/ml Oral
Solution), T1
Epivir HBV (5mg/ml Oral
Solution), T1
Eplerenone (Tablet), T1
Eprosartan Mesylate (Tablet),
T1
Epzicom (Tablet), T1
Equetro (Capsule ExtendedRelease 12 Hour), T1
Eraxis (Injection), T1
Erbitux (Injection), T1
Erivedge (Capsule), T1
Errin (Tablet), T1
Erwinaze (Injection), T1
Ery (2% Pad), T1
0
Faslodex (Injection), T1
Fazaclo (100mg Tablet
Dispersible), T1
Felbamate (400mg Tablet,
600mg Tablet), T1
Felbamate (600mg/5ml
Suspension), T1
Felbatol (600mg/5ml
Suspension), T1
Felodipine ER (Tablet
T1
Femring (Ring), T1
Fenofibrate (145mg Tablet,
48mg Tablet) (Generic
Tricor), (160mg Tablet,
54mg Tablet) (Generic
Lofibra), T1
Fenofibrate Micronized
Capsule, 67mg Capsule)
(Generic Lofibra), T1
Fenofibric Acid DR (Capsule
Delayed-Release) (Generic
Trilipix), T1
Fentanyl (100mcg/hr Patch
72 Hour, 12mcg/hr Patch
72 Hour), T1
Ferriprox (Tablet), T1
Fetzima (Capsule ExtendedRelease 24 Hour), T1
Fetzima Titration Pack
(Capsule ExtendedRelease 24 Hour Therapy
Pack), T1
Finasteride (5mg Tablet)
(Generic Proscar), T1
Firazyr (Injection), T1
Firmagon (120mg
Injection), T1
Firmagon (80mg Injection),
T1
Flarex (Suspension), T1
Flebogamma DIF (Injection),
T1
Flecainide Acetate (Tablet),
T1
Flector (Patch), T1
Flovent Diskus (Aerosol
Powder), T1
Flovent HFA (Aerosol), T1
Fluconazole (100mg Tablet,
150mg Tablet, 200mg
Tablet, 50mg Tablet, 10mg/
ml Suspension, 40mg/ml
Suspension), T1
Fluconazole in Dextrose
(Injection), T1
Flucytosine (Capsule), T1
Fludarabine Phosphate
(Injection), T1
Fludrocortisone Acetate
(Tablet), T1
Flunisolide (Nasal Solution),
T1
Fluocinolone Acetonide
(0.01% Cream, 0.025%
Cream, 0.01% External
Solution, 0.025% Ointment),
T1
Fluocinolone Acetonide
(0.01% Oil), T1
Fluocinolone Acetonide Body
(Oil), T1
Fluocinonide (0.05% External
Solution, 0.05% Gel, 0.05%
Ointment), T1
Fluocinonide (0.1% Cream),
T1
Fluocinonide-E (Cream), T1
Fluorometholone
(Suspension), T1
Fluorouracil (2% External
Solution, 5% External
Solution, 5% Cream), T1
Fluorouracil (2.5gm/50ml
Injection), T1
Fluoxetine DR (Capsule
Fluoxetine HCl (10mg
20mg Capsule ImmediateRelease, 40mg Capsule
Immediate-Release, 20mg/
Fluphenazine Decanoate
(Injection), T1
Fluphenazine HCl (10mg
Tablet, 1mg Tablet, 2.5mg
Fluphenazine HCl (2.5mg/
5ml Elixir, 5mg/ml
Concentrate), T1
Fluphenazine HCl (2.5mg/ml
Injection), T1
Flurbiprofen (Tablet), T1
Flurbiprofen Sodium
(Ophthalmic Solution), T1
Flutamide (Capsule), T1
Fluticasone Propionate
(0.005% Ointment, 0.05%
Cream), T1
Fluticasone Propionate
(50mcg/ACT Suspension),
T1
Fluvastatin (Capsule
Fluvoxamine Maleate (Tablet),
T1
Folotyn (Injection), T1
Fomepizole (Injection), T1
Fondaparinux Sodium
(10mg/0.8ml Injection,
5mg/0.4ml Injection,
7.5mg/0.6ml Injection), T1
0
G
Gabapentin (100mg Capsule,
800mg Tablet), T1
Gabapentin (250mg/5ml Oral
Solution), T1
Gabitril (12mg Tablet, 16mg
Tablet), T1
Gablofen (10000mcg/20ml
Injection, 50mcg/ml
Injection), T1
Gablofen (40000mcg/20ml
Injection), T1
Galantamine HBr (12mg
Tablet, 16mg Capsule
24 Hour, 4mg/ml Oral
Solution), T1
Gamastan S/D (Injection),
T1
Gammagard Liquid
(Injection), T1
Gammaked (Injection), T1
Gammaplex (Injection), T1
Gamunex-C (Injection), T1
Ganciclovir (Injection), T1
Gardasil (Injection), T1
Gardasil 9 (Injection), T1
Gatifloxacin (Ophthalmic
Solution), T1
Gattex (Injection), T1
Gauze (Non-medicated 2X2),
T1
GaviLyte-C (Oral Solution), T1
GaviLyte-G (Oral Solution), T1
GaviLyte-N/Flavor Pack (Oral
Solution), T1
Gemcitabine HCl (Injection),
T1
Gemfibrozil (Tablet), T1
Gemzar (Injection), T1
Generlac (Oral Solution), T1
Gengraf (100mg Capsule,
Oral Solution), T1
Genotropin (12mg Injection,
5mg Injection), T1
Genotropin Miniquick
(0.2mg Injection), T1
Genotropin Miniquick
(0.4mg Injection, 0.6mg
Injection, 0.8mg Injection,
1.2mg Injection, 1.4mg
Injection, 1.6mg Injection,
1.8mg Injection, 1mg
T1
Gentak (Ointment), T1
Gentamicin Sulfate (0.1%
Cream, 0.1% Ointment,
0.3% Ophthalmic Ointment,
0.3% Ophthalmic Solution),
T1
Gentamicin Sulfate (10mg/ml
Injection, 40mg/ml
Injection), T1
Gentamicin Sulfate/0.9%
Sodium Chloride (Injection),
T1
Geodon (20mg Injection),
T1
Gianvi (Tablet), T1
Giazo (Tablet), T1
Gildagia (Tablet), T1
Gildess 1.5/30 (Tablet), T1
Gildess 24 Fe (Tablet), T1
Gilenya (Capsule), T1
Gilotrif (Tablet), T1
Glassia (Injection), T1
Glatopa (Injection), T1
Gleevec (Tablet), T1
Glimepiride (Tablet), T1
Glipizide (Tablet ImmediateRelease), T1
Glipizide ER (Tablet
T1
Glipizide/Metformin HCl
(Tablet), T1
Glucagen Hypokit
(Injection), T1
Glucagon Emergency Kit
(Injection), T1
47
Drug LIST
Fondaparinux Sodium
(2.5mg/0.5ml Injection), T1
Fortaz (1gm Injection, 2gm
6gm Injection), T1
Forteo (Injection), T1
Foscarnet Sodium (Injection),
T1
Fosinopril Sodium (Tablet), T1
Fosinopril Sodium/
Hydrochlorothiazide
(Tablet), T1
Fosphenytoin Sodium
(Injection), T1
Fosrenol (1000mg Packet,
750mg Packet, 1000mg
Tablet Chewable, 500mg
Tablet Chewable), T1
FreAmine HBC 6.9%
(Injection), T1
Furosemide (10mg/ml
Injection), T1
Furosemide (10mg/ml Oral
Solution, 8mg/ml Oral
Solution), T1
Furosemide (20mg Tablet,
T1
Fusilev (Injection), T1
Fuzeon (Injection), T1
Fycompa (Tablet), T1
0
Glycopyrrolate (4mg/20ml
Injection), T1
Glyset (Tablet), T1
Granisetron HCl (0.1mg/ml
Injection, 1mg/ml Injection),
T1
Granisetron HCl (1mg Tablet),
T1
Granix (Injection), T1
Griseofulvin Microsize
(125mg/5ml Suspension,
500mg Tablet), T1
Griseofulvin Ultramicrosize
(Tablet), T1
Guanidine HCl (Tablet), T1
H
Halaven (Injection), T1
Halobetasol Propionate
(0.05% Cream, 0.05%
Ointment), T1
Haloperidol (0.5mg Tablet,
5mg Tablet, 2mg/ml
Concentrate), T1
Haloperidol Decanoate
(Injection), T1
Haloperidol Lactate
(Injection), T1
Harvoni (Tablet), T1
Havrix (Injection), T1
Hectorol (1mcg Capsule,
2.5mcg Capsule), T1
Heparin Sodium (Injection),
T1
Heparin Sodium/D5W
(Injection), T1
HepatAmine (Injection), T1
Hepsera (Tablet), T1
Herceptin (Injection), T1
Hetlioz (Capsule), T1
Hexalen (Capsule), T1
Humalog Kwikpen
(Injection), T1
Humalog Mix 50/50
Kwikpen (Injection), T1
Humalog Mix 50/50 Vial
(Injection), T1
Humalog Mix 75/25
Kwikpen (Injection), T1
Humalog Mix 75/25 Vial
(Injection), T1
Humalog Vial (Injection), T1
Humatrope (Injection), T1
Humatrope Combo Pack
(Injection), T1
Humira (Injection), T1
Humira Pen-Crohns
Diseasestarter (Injection),
T1
Humulin 70/30 Kwikpen
(Injection), T1
Humulin 70/30 Vial
(Injection), T1
Humulin N Kwikpen
(Injection), T1
Humulin N Vial (Injection),
T1
Humulin R U-500 Vial
(Concentrated) (Injection),
T1
Humulin R Vial (Injection),
T1
Hycamtin (Injection), T1
Hydralazine HCl (100mg
Hydralazine HCl (20mg/ml
Injection), T1
Hydrochlorothiazide (12.5mg
Capsule, 12.5mg Tablet,
T1
Hydrocodone Bitartrate/
Acetaminophen
(7.5mg-325mg/15ml Oral
Solution), T1
Hydrocodone/
Acetaminophen
(10mg-325mg Tablet,
2.5mg-325mg Tablet,
5mg-325mg Tablet,
7.5mg-325mg Tablet), T1
Hydrocodone/Ibuprofen
(7.5mg-200mg Tablet), T1
Hydrocortisone (1% Cream,
2.5% Cream, 1% Ointment,
2.5% Ointment, 10mg
Tablet, 2.5% Lotion), T1
Hydrocortisone (100mg/
60ml Enema), T1
Hydrocortisone Butyrate
(0.1% Ointment), T1
Hydrocortisone Valerate
(0.2% Cream, 0.2%
Ointment), T1
Hydrocortisone/Acetic Acid
(Otic Solution), T1
Hydromorphone HCl (1mg/ml
Liquid), T1
Hydromorphone HCl (2mg
Hydromorphone HCl
(500mg/50ml Injection), T1
Hydromorphone HCl ER
(12mg Tablet ExtendedRelease 24 Hour AbuseDeterrent, 16mg Tablet
Extended-Release 24 Hour
Abuse-Deterrent), T1
0
(32mg Tablet ExtendedRelease 24 Hour AbuseDeterrent), T1
(8mg Tablet ExtendedRelease 24 Hour AbuseDeterrent), T1
Hydroxychloroquine Sulfate
(Tablet), T1
Hydroxyurea (Capsule), T1
Hydroxyzine HCl (10mg/5ml
Oral Solution, 25mg/ml
Injection, 50mg/ml
Injection), T1
Hydroxyzine Pamoate
(Capsule), T1
Irbesartan/
Hydrochlorothiazide
(Tablet), T1
Irinotecan (Injection), T1
Isentress (100mg Packet,
100mg Tablet Chewable,
400mg Tablet), T1
Isentress (25mg Tablet
Chewable), T1
Isolyte-P/Dextrose 5%
(Injection), T1
Isolyte-S (Injection), T1
Isoniazid (100mg Tablet,
300mg Tablet, 50mg/5ml
Syrup), T1
Isoniazid (100mg/ml
Injection), T1
Isosorbide Dinitrate (Tablet
Isosorbide Dinitrate ER
T1
Isosorbide Mononitrate
(Tablet Immediate-Release),
T1
Isosorbide Mononitrate ER
(Tablet Extended-Release
24 Hour), T1
Isotonic Gentamicin
(Injection), T1
Istodax (Injection), T1
Itraconazole (Capsule), T1
Ivermectin (Tablet), T1
Ixempra Kit (Injection), T1
Ixiaro (Injection), T1
J
Jadenu (Tablet), T1
Jakafi (Tablet), T1
Jantoven (Tablet), T1
Janumet (Tablet), T1
Janumet XR (Tablet
Extended-Release 24
Hour), T1
49
Drug LIST
I
IPOL Inactivated IPV
(Injection), T1
Ibandronate Sodium (150mg
Tablet), T1
Ibandronate Sodium (3mg/
3ml Injection), T1
Ibrance (Capsule), T1
Ibuprofen (100mg/5ml
600mg Tablet, 800mg
Tablet), T1
Iclusig (15mg Tablet), T1
Iclusig (45mg Tablet), T1
Idamycin PFS (Injection), T1
Idarubicin HCl (Injection), T1
Ifosfamide (Injection), T1
Ilaris (Injection), T1
Ilevro (Suspension), T1
Ilotycin (Ointment), T1
Imbruvica (Capsule), T1
Imipenem/Cilastatin
(Injection), T1
Imipramine HCl (Tablet), T1
Imipramine Pamoate
(Capsule), T1
Imiquimod (Cream), T1
Imovax Rabies (H.D.C.V.)
(Injection), T1
Increlex (Injection), T1
Indapamide (Tablet), T1
Infanrix (Injection), T1
Inlyta (Tablet), T1
Insulin Syringes, Needles, T1
Intelence (100mg Tablet,
200mg Tablet), T1
Intelence (25mg Tablet), T1
Intralipid (Injection), T1
Intron A (Injection), T1
Intron A w/Diluent
(Injection), T1
Introvale (Tablet), T1
Invanz (Injection), T1
Invega (Tablet ExtendedRelease 24 Hour), T1
Invega Sustenna (117mg/
0.75ml Injection, 156mg/
ml Injection, 234mg/1.5ml
Injection), T1
Invega Sustenna (39mg/
0.25ml Injection), T1
Invirase (200mg Capsule,
500mg Tablet), T1
Invokamet (Tablet), T1
Invokana (Tablet), T1
Ionosol-B/Dextrose 5%
(Injection), T1
Ionosol-MB/Dextrose 5%
(Injection), T1
Ipratropium Bromide (0.02%
Inhalation Solution), T1
Ipratropium Bromide (0.03%
Nasal Solution, 0.06% Nasal
Solution), T1
Ipratropium Bromide/
Albuterol Sulfate (Inhalation
Solution), T1
Irbesartan (Tablet), T1
0
Januvia (Tablet), T1
Jardiance (Tablet), T1
Jentadueto (Tablet), T1
Jevtana (Injection), T1
Jinteli (Tablet), T1
Jolivette (Tablet), T1
Junel 1.5/30 (Tablet), T1
Junel 1/20 (Tablet), T1
Junel Fe 1.5/30 (Tablet), T1
Junel Fe 1/20 (Tablet), T1
Junel Fe 24 (Tablet), T1
Juxtapid (Capsule), T1
K
K-Tab (10meq Tablet
Extended-Release, 8meq
Tablet Extended-Release),
T1
KCl 0.075%/D5W/NaCl
0.45% (Injection), T1
KCl 0.15%/D5W/LR
(Injection), T1
KCl 0.15%/D5W/NaCl 0.2%
(Injection), T1
KCl 0.15%/D5W/NaCl
0.225% (Injection), T1
KCl 0.15%/D5W/NaCl 0.9%
(Injection), T1
KCl 0.3%/D5W/NaCl 0.45%
(Injection), T1
KCl 0.3%/D5W/NaCl 0.9%
(Injection), T1
Kadcyla (Injection), T1
Kaletra (100mg-25mg
Tablet), T1
Kaletra (200mg-50mg
Tablet, 400mg-100mg/5ml
Oral Solution), T1
Kalydeco (150mg Tablet),
T1
Kalydeco (50mg Packet,
75mg Packet), T1
Kariva (Tablet), T1
Kazano (Tablet), T1
Kelnor 1/35 (Tablet), T1
Kenalog-10 (Injection), T1
Kenalog-40 (Injection), T1
Kepivance (Injection), T1
Ketoconazole (2% Cream, 2%
Shampoo, 200mg Tablet),
T1
Ketoprofen (Capsule
Ketorolac Tromethamine
(0.4% Ophthalmic Solution,
0.5% Ophthalmic Solution),
T1
Ketorolac Tromethamine
(15mg/ml Injection, 30mg/
ml Injection), T1
Keytruda (Injection), T1
Kineret (Injection), T1
Kionex (Powder), T1
Klor-Con 10 (Tablet
Klor-Con 8 (Tablet
Klor-Con M15 (Tablet
Klor-Con M20 (Tablet
Kombiglyze XR (Tablet
Extended-Release 24
Hour), T1
Korlym (Tablet), T1
Kuvan (100mg Tablet
Soluble, 500mg Packet),
T1
Kynamro (Injection), T1
L
LARIN 1.5/30 (Tablet), T1
LARIN 1/20 (Tablet), T1
LARIN Fe 1.5/30 (Tablet), T1
LARIN Fe 1/20 (Tablet), T1
Labetalol HCl (100mg Tablet,
200mg Tablet, 300mg
Tablet), T1
Labetalol HCl (5mg/ml
Injection), T1
Lacrisert (Insert), T1
Lactated Ringers Dextrose
5% Viaflex (Injection), T1
Lactated Ringers Irrigation
(Irrigation Solution), T1
Lactated Ringers Viaflex
(Injection), T1
Lactulose (Oral Solution), T1
Lamisil (125mg Packet,
187.5mg Packet), T1
Lamivudine (100mg Tablet),
T1
Lamivudine (10mg/ml Oral
Solution, 150mg Tablet,
300mg Tablet), T1
Lamivudine/Zidovudine
(Tablet), T1
Lamotrigine (100mg Tablet
Lamotrigine (25mg Tablet
Chewable), T1
Lanoxin (125mcg Tablet,
62.5mcg Tablet), T1
Lanoxin (187.5mcg Tablet,
250mcg Tablet), T1
Lantus SoloStar (Injection),
T1
Lantus Vial (Injection), T1
Lastacaft (Ophthalmic
Solution), T1
Latanoprost (Ophthalmic
Solution), T1
Latuda (Tablet), T1
Leena (Tablet), T1
Leflunomide (Tablet), T1
Lenvima (Capsule Therapy
Pack), T1
0
Levofloxacin (0.5%
Ophthalmic Solution, 25mg/
ml Oral Solution), T1
Levofloxacin (250mg Tablet,
500mg Tablet, 750mg
Tablet), T1
Levofloxacin (25mg/ml
Injection), T1
Levofloxacin in D5W
(Injection), T1
Levoleucovorin Calcium
(Injection), T1
Levonest (Tablet), T1
Levonorgestrel and Ethinyl
Levonorgestrel/Ethinyl
Levora 0.15/30-28 (Tablet),
T1
Levorphanol Tartrate (Tablet),
T1
Levothyroxine Sodium
(100mcg Injection), T1
Levothyroxine Sodium
(100mcg Tablet, 112mcg
Tablet, 125mcg Tablet,
137mcg Tablet, 150mcg
200mcg Tablet, 25mcg
50mcg Tablet, 75mcg
Tablet, 88mcg Tablet), T1
Levoxyl (Tablet), T1
Lexiva (50mg/ml
Suspension), T1
Lexiva (700mg Tablet), T1
Lialda (Tablet DelayedRelease), T1
Lidocaine (5% Ointment), T1
Lidocaine (5% Patch), T1
Lidocaine HCl (0.5% Injection,
2% Injection), T1
Lidocaine HCl (4% External
Solution), T1
Lidocaine HCl (Gel), T1
Lidocaine Viscous (Solution),
T1
Lidocaine/Prilocaine
(2.5%-2.5% Cream), T1
Lincocin (Injection), T1
Lindane (1% Lotion, 1%
Shampoo), T1
Linezolid (2mg/ml Injection),
T1
Linezolid (600mg Tablet),
T1
Linzess (Capsule), T1
Lioresal Intrathecal
(0.05mg/ml Injection,
10mg/20ml Injection), T1
Lioresal Intrathecal (10mg/
5ml Injection), T1
Liothyronine Sodium (10mcg/
ml Injection), T1
Liothyronine Sodium (25mcg
Tablet, 50mcg Tablet, 5mcg
Tablet), T1
Lisinopril (Tablet), T1
Lisinopril/Hydrochlorothiazide
(Tablet), T1
Lithium (Oral Solution), T1
Lithium Carbonate (150mg
T1
Lithium Carbonate ER (Tablet
Lithostat (Tablet), T1
Lomustine (Capsule), T1
Loperamide HCl (Capsule),
T1
Lorazepam (Tablet
Lorazepam Intensol (2mg/ml
Concentrate), T1
51
Drug LIST
Lessina (Tablet), T1
Letairis (Tablet), T1
Letrozole (Tablet), T1
Leucovorin Calcium (100mg
T1
Leucovorin Calcium (10mg
Leukeran (Tablet), T1
Leukine (Injection), T1
Leuprolide Acetate (Injection),
T1
Levalbuterol (Nebulized
Solution), T1
Levemir FlexTouch
(Injection), T1
Levemir Vial (Injection), T1
Levetiracetam (1000mg
Levetiracetam (1000mg/
100ml Injection, 1500mg/
100ml Injection, 500mg/
100ml Injection), T1
Levetiracetam (500mg/5ml
Injection), T1
Levetiracetam ER (Tablet
T1
Levobunolol HCl (Ophthalmic
Solution), T1
Levocarnitine (1gm/10ml Oral
Solution, 330mg Tablet), T1
Levocarnitine (200mg/ml
Injection), T1
Levocetirizine Dihydrochloride
(5mg Tablet), T1
0
Lorcet (Tablet), T1
Lorcet HD (Tablet), T1
Lorcet Plus (Tablet), T1
Lortab (10mg-325mg Tablet,
5mg-325mg Tablet,
Loryna (Tablet), T1
Losartan Potassium (Tablet),
T1
Losartan Potassium/
Hydrochlorothiazide
(Tablet), T1
Lotemax (0.5% Gel, 0.5%
Ointment, 0.5%
Suspension), T1
Lotronex (Tablet), T1
Lovastatin (Tablet ImmediateRelease), T1
Loxapine Succinate (10mg
Loxapine Succinate (25mg
Lumigan (0.01%
Lumizyme (Injection), T1
Lupaneta Pack (Kit), T1
Lupron Depot (Injection), T1
Lupron Depot-PED
(Injection), T1
Lutera (Tablet), T1
Lynparza (Capsule), T1
Lyrica (100mg Capsule,
25mg Capsule, 300mg
Oral Solution), T1
Lysodren (Tablet), T1
Lyza (Tablet), T1
M
M-M-R II w/Diluent 10 Dose
(Injection), T1
Magnesium Sulfate (1gm/
2ml-50% Injection), T1
Magnesium Sulfate (5gm/
10ml-50% Injection), T1
Malathion (Lotion), T1
Maprotiline HCl (Tablet), T1
Marlissa (Tablet), T1
Marplan (Tablet), T1
Matulane (Capsule), T1
Matzim LA (180mg Tablet
240mg Tablet ExtendedRelease 24 Hour, 300mg
Hour), T1
Matzim LA (360mg Tablet
420mg Tablet ExtendedRelease 24 Hour), T1
Meclizine HCl (12.5mg
Tablet), T1
Medroxyprogesterone
Acetate (10mg Tablet,
2.5mg Tablet, 5mg Tablet),
T1
Medroxyprogesterone
Acetate (150mg/ml
Injection), T1
Mefloquine HCl (Tablet), T1
Megace ES (Suspension),
T1
Megestrol Acetate (20mg
ml Suspension), T1
Mekinist (Tablet), T1
Meloxicam (15mg Tablet,
7.5mg Tablet), T1
Meloxicam (7.5mg/5ml
Suspension), T1
Melphalan HCl (Injection), T1
Menactra (Injection), T1
Menest (Tablet), T1
Menomune-A/C/Y/W-135
(Injection), T1
Mentax (Cream), T1
Menveo (Injection), T1
Mepron (Suspension), T1
Mercaptopurine (Tablet), T1
Meropenem (Injection), T1
Mesalamine (Kit), T1
Mesna (Injection), T1
Mesnex (400mg Tablet), T1
Mestinon (60mg/5ml
Syrup), T1
Mestinon Timespan (Tablet
Metadate ER (Tablet
Metaproterenol Sulfate (10mg
5ml Syrup), T1
Metformin HCl (Tablet
Metformin HCl ER (1000mg
Hour) (Generic Fortamet),
(500mg Tablet ExtendedRelease 24 Hour, 700mg
Hour) (Generic Glucophage
XR), T1
Methadone HCl (10mg
5ml Oral Solution, 5mg/5ml
Oral Solution), T1
Methadone HCl (10mg/ml
Injection), T1
Methazolamide (Tablet), T1
Methenamine Hippurate
(Tablet), T1
Methimazole (Tablet), T1
Methotrexate (Tablet), T1
Methotrexate Sodium
(Injection), T1
Methoxsalen (Capsule), T1
0
Metoprolol Tartrate (100mg
Metoprolol Tartrate (1mg/ml
Injection), T1
Metoprolol/
Hydrochlorothiazide
(Tablet), T1
Metronidazole (0.75% Cream,
0.75% Gel, 1% Gel, 0.75%
Lotion), T1
Metronidazole (250mg Tablet
375mg Capsule ImmediateRelease), T1
Metronidazole Vaginal (Gel),
T1
Metronidazole in NaCl 0.79%
(Injection), T1
Mexiletine HCl (Capsule), T1
Miacalcin (200unit/ml
Injection), T1
Miconazole 3 (Suppository),
T1
Microgestin 1.5/30 (Tablet),
T1
Microgestin 1/20 (Tablet), T1
Microgestin Fe (Tablet), T1
Microgestin Fe 1.5/30
(Tablet), T1
Midodrine HCl (Tablet), T1
Migergot (Suppository), T1
Millipred (5mg Tablet), T1
Minitran (Patch 24 Hour), T1
Minocycline HCl (100mg
Minocycline HCl (100mg
Minoxidil (Tablet), T1
Mirtazapine (Tablet
Mirtazapine ODT (Tablet
Dispersible), T1
Mirvaso (Gel), T1
Misoprostol (Tablet), T1
Mitomycin (Injection), T1
Mitoxantrone HCl (Injection),
T1
Modafinil (Tablet), T1
Moexipril HCl (Tablet), T1
Moexipril/Hydrochlorothiazide
(Tablet), T1
Mometasone Furoate (0.1%
Cream, 0.1% External
Solution, 0.1% Ointment), T1
Mononessa (Tablet), T1
Montelukast Sodium (10mg
Tablet), T1
Montelukast Sodium (4mg
Packet, 4mg Tablet
Chewable), T1
Morphine Sulfate (10mg/5ml
Oral Solution, 20mg/5ml
Oral Solution, 20mg/ml Oral
Solution), T1
Morphine Sulfate (10mg/ml
Injection, 2mg/ml
Injection, 4mg/ml
Injection, 8mg/ml
Injection), T1
Morphine Sulfate (15mg
53
Drug LIST
Methscopolamine Bromide
(Tablet), T1
Methyclothiazide (Tablet), T1
Methyldopa (Tablet), T1
Methyldopate HCl (Injection),
T1
Methylergonovine Maleate
(Tablet), T1
Methylphenidate HCl (10mg
Immediate-Release (Generic
Ritalin), (10mg/5ml Oral
Solution, 5mg/5ml Oral
Solution), T1
Methylphenidate HCl ER
(10mg Tablet ExtendedRelease, 20mg Tablet
Methylprednisolone (Tablet),
T1
Methylprednisolone Acetate
(Injection), T1
Methylprednisolone Dose
Pack (Tablet), T1
Methylprednisolone Sodium
Succinate (Injection), T1
Metipranolol (Ophthalmic
Solution), T1
Metoclopramide HCl (10mg
Metoclopramide HCl (5mg/
Metoclopramide HCl (5mg/ml
Injection), T1
Metolazone (Tablet), T1
Metoprolol Succinate ER
24 Hour), T1
0
Morphine Sulfate ER (Tablet
Extended-Release) (Generic
MS Contin), T1
Moxeza (Ophthalmic
Solution), T1
Moxifloxacin HCl (Tablet), T1
Mozobil (Injection), T1
Multaq (Tablet), T1
Mupirocin (2% Cream), T1
Mupirocin (2% Ointment), T1
Mustargen (Injection), T1
Myalept (Injection), T1
Mycamine (Injection), T1
Mycophenolate Mofetil
(200mg/ml Suspension), T1
Mycophenolate Mofetil
Tablet), T1
Mycophenolic Acid DR
Myozyme (Injection), T1
Myrbetriq (Tablet ExtendedRelease 24 Hour), T1
N
Nabumetone (Tablet), T1
Nadolol (Tablet), T1
Nadolol/Bendroflumethiazide
(40mg-5mg Tablet), T1
Nadolol/Bendroflumethiazide
(80mg-5mg Tablet), T1
Nafcillin Sodium (Injection),
T1
Naftifine HCl (Cream), T1
Naftin (1% Cream, 2%
Cream, 1% Gel, 2% Gel),
T1
Naglazyme (Injection), T1
Nalbuphine HCl (Injection), T1
Nallpen/Dextrose
(Injection), T1
Naloxone HCl (Injection), T1
Naltrexone HCl (Tablet), T1
Namenda (10mg Tablet
Tablet ImmediateRelease), T1
Namenda (10mg/5ml Oral
Solution), T1
Namenda Titration Pak
(Tablet), T1
Namenda XR (Capsule
Extended-Release 24
Hour), T1
Namenda XR Titration Pack
(Capsule ExtendedRelease 24 Hour), T1
Naphazoline HCl (Ophthalmic
Solution), T1
Naproxen (125mg/5ml
Suspension, 250mg Tablet
Naproxen DR (Tablet
Delayed-Release) (Generic
EC-Naprosyn), T1
Naproxen Sodium (Tablet
Naratriptan HCl (Tablet), T1
Nasonex (Suspension), T1
Natacyn (Suspension), T1
Nateglinide (Tablet), T1
Natpara (Injection), T1
Nebupent (Inhalation
Solution), T1
Necon 0.5/35-28 (Tablet), T1
Necon 1/35 (Tablet), T1
Necon 1/50-28 (Tablet), T1
Necon 10/11-28 (Tablet), T1
Necon 7/7/7 (Tablet), T1
Nefazodone HCl (Tablet), T1
Neomycin Sulfate (Tablet), T1
Neomycin/Bacitracin/
Polymyxin (Ointment), T1
Neomycin/Polymyxin B
Sulfates (Irrigation Solution),
T1
Neomycin/Polymyxin/
Bacitracin/Hydrocortisone
(Ointment), T1
Neomycin/Polymyxin/
Dexamethasone (0.1%
Ointment, 0.1%
Suspension), T1
Neomycin/Polymyxin/
Gramicidin (Ophthalmic
Solution), T1
Neomycin/Polymyxin/
Hydrocortisone (1%
Ophthalmic Suspension), T1
Neomycin/Polymyxin/
Hydrocortisone (1% Otic
Solution, 1% Otic
Suspension), T1
Nephramine (Injection), T1
Nesina (Tablet), T1
Neulasta (Injection), T1
Neumega (Injection), T1
Neupogen (Injection), T1
Nevanac (Suspension), T1
Nevirapine (200mg Tablet
Nevirapine (50mg/5ml
Suspension), T1
Nevirapine ER (Tablet
T1
Nexavar (Tablet), T1
Nexium (10mg Packet,
2.5mg Packet, 20mg
Packet, 40mg Packet,
5mg Packet), T1
Niacin ER (Tablet ExtendedRelease), T1
Niacor (Tablet), T1
Nicardipine HCl (2.5mg/ml
Injection), T1
0
Norethindrone Acetate/
Ethinyl Estradiol/Ferrous
Fumarate (Tablet), T1
Norlyroc (Tablet), T1
Normosol-M in D5W
(Injection), T1
Normosol-R (Injection), T1
Normosol-R in D5W
(Injection), T1
Northera (Capsule), T1
Nortrel 0.5/35 (28) (Tablet),
T1
Nortrel 1/35 (Tablet), T1
Nortrel 7/7/7 (Tablet), T1
Nortriptyline HCl (10mg
50mg Capsule, 75mg
Solution), T1
Norvir (100mg Capsule,
Oral Solution), T1
Novarel (Injection), T1
Noxafil (100mg Tablet
Noxafil (40mg/ml
Suspension), T1
Nucynta ER (Tablet
Extended-Release 12
Hour), T1
Nuedexta (Capsule), T1
Nulojix (Injection), T1
NutreStore (Packet), T1
Nutrilipid (Injection), T1
Nutropin AQ (Injection), T1
NuvaRing (Ring), T1
Nyamyc (Powder), T1
Nystatin (Cream, Ointment,
Powder, Suspension,
Tablet), T1
Nystop (Powder), T1
O
ONMEL (Tablet), T1
Ocella (Tablet), T1
Octagam (Injection), T1
Octreotide Acetate
(1000mcg/ml Injection,
Octreotide Acetate (100mcg/
ml Injection, 200mcg/ml
Injection, 50mcg/ml
Injection), T1
Ofev (Capsule), T1
Ofloxacin (0.3% Ophthalmic
Solution, 0.3% Otic Solution,
400mg Tablet), T1
Ogestrel (Tablet), T1
Olanzapine (10mg Injection),
T1
Olanzapine (10mg Tablet
2.5mg Tablet ImmediateRelease, 20mg Tablet
7.5mg Tablet ImmediateRelease), T1
Olanzapine ODT (Tablet
Dispersible), T1
Olysio (Capsule), T1
Omega-3-Acid Ethyl Esters
(Capsule) (Generic Lovaza),
T1
Omeprazole (10mg Capsule
Delayed-Release, 40mg
Capsule Delayed-Release),
T1
Omeprazole (20mg Capsule
Omnitrope (Injection), T1
Oncaspar (Injection), T1
Ondansetron HCl (24mg
Tablet), T1
55
Drug LIST
Nicardipine HCl (20mg
Nicotrol Inhaler, T1
Nifedical XL (Tablet ExtendedRelease 24 Hour), T1
Nifedipine ER (Tablet
T1
Nikki (Tablet), T1
Nilandron (Tablet), T1
Nimodipine (Capsule), T1
Nipent (Injection), T1
Nitro-Bid (Ointment), T1
Nitrofurantoin (Suspension),
T1
Nitrofurantoin Macrocrystals
(Capsule) (Generic
Macrodantin), T1
Nitrofurantoin Monohydrate
100mg Capsule (Generic
Macrobid), T1
Nitroglycerin (0.2mg/hr Patch
24 Hour, 0.4mg/hr Patch 24
Hour, 0.6mg/hr Patch 24
Hour), T1
Nitroglycerin (5mg/ml
Injection), T1
Nitroglycerin Lingual
(Translingual Solution), T1
Nitroglycerin Transdermal
(Patch 24 Hour), T1
Nitrostat (Tablet
Sublingual), T1
Nora-BE (Tablet), T1
Norditropin FlexPro
(Injection), T1
Norditropin NordiFlex Pen
(Injection), T1
Norethindrone & Ethinyl
Estradiol Ferrous Fumarate
(Tablet Chewable), T1
Norethindrone (Tablet), T1
Norethindrone Acetate
(Tablet), T1
0
Ondansetron HCl (4mg/2ml
Injection), T1
Ondansetron HCl (4mg/5ml
Oral Solution), T1
Ondansetron ODT (Tablet
Dispersible), T1
Onfi (10mg Tablet), T1
Onfi (2.5mg/ml
Suspension), T1
Onfi (20mg Tablet), T1
Onglyza (Tablet), T1
Opana ER (Crush Resistant)
12 Hour Abuse-Deterrent),
T1
Opdivo (Injection), T1
Opsumit (Tablet), T1
Orap (Tablet), T1
Orencia (125mg/ml
Injection, 250mg
Injection), T1
Orenitram (0.125mg Tablet
Extended-Release, 1mg
T1
Orfadin (Capsule), T1
Orphenadrine Citrate
(Injection), T1
Orsythia (Tablet), T1
Oseni (Tablet), T1
Otezla (Tablet Therapy
Pack, 30mg Tablet), T1
Oxacillin Sodium (10gm
Injection), T1
Oxacillin Sodium (2gm
Injection), T1
Oxaliplatin (Injection), T1
Oxandrolone (10mg Tablet),
T1
Oxandrolone (2.5mg Tablet),
T1
Oxaprozin (Tablet), T1
Oxcarbazepine (150mg
600mg Tablet), T1
Oxcarbazepine (300mg/5ml
Suspension), T1
Oxistat (1% Cream, 1%
Lotion), T1
Oxsoralen Ultra (Capsule),
T1
Oxybutynin Chloride (5mg
5mg/5ml Syrup), T1
Oxybutynin Chloride ER
24 Hour), T1
Oxycodone HCl (100mg/5ml
Concentrate, 5mg/5ml Oral
Solution), T1
Oxycodone HCl (10mg Tablet
T1
Oxycodone/Acetaminophen
(10mg-325mg Tablet,
2.5mg-325mg Tablet,
5mg-325mg Tablet,
Oxycodone/Aspirin (Tablet),
T1
Oxycodone/Ibuprofen
(Tablet), T1
P
PEG-3350/Electrolytes (Oral
Solution) (Generic
GoLYTELY), T1
PRUDOXIN (Cream), T1
Pacerone (200mg Tablet), T1
Paclitaxel (Injection), T1
Pamidronate Disodium
(Injection), T1
Panretin (Gel), T1
Pantoprazole Sodium (Tablet
Paricalcitol (1mcg Capsule,
2mcg Capsule), T1
Paricalcitol (2mcg/ml
Injection, 5mcg/ml
Injection), T1
Paricalcitol (4mcg Capsule),
T1
Paromomycin Sulfate
(Capsule), T1
Paroxetine HCl (Tablet
Paser (Packet), T1
Pataday (Ophthalmic
Solution), T1
Patanol (Ophthalmic
Solution), T1
Paxil (10mg/5ml
Suspension), T1
Pedvax HIB (Injection), T1
PegIntron (Injection), T1
PegIntron Redipen
(Injection), T1
Peganone (Tablet), T1
Pegasys (Injection), T1
Pegasys ProClick
(Injection), T1
Penicillin G Potassium
(Injection), T1
Penicillin G Procaine
(Injection), T1
Penicillin G Sodium
(Injection), T1
Penicillin V Potassium
(125mg/5ml Oral Solution,
250mg/5ml Oral Solution,
250mg Tablet, 500mg
Tablet), T1
Pentam 300 (Injection), T1
0
Pilocarpine HCl (1%
Ophthalmic Solution, 2%
Ophthalmic Solution, 4%
Pilocarpine HCl (5mg Tablet,
7.5mg Tablet), T1
Pimtrea (Tablet), T1
Pindolol (Tablet), T1
Pioglitazone HCl (Tablet), T1
Pioglitazone HCl/Glimepiride
(Tablet), T1
Pioglitazone HCl/Metformin
HCl (Tablet), T1
Piperacillin Sodium/
Tazobactam Sodium
(Injection), T1
Pirmella 1/35 (Tablet), T1
Piroxicam (Capsule), T1
Plasma-Lyte A (Injection),
T1
Plasma-Lyte-148 (Injection),
T1
Plasma-Lyte-56/D5W
(Injection), T1
Podofilox (External Solution),
T1
Polyethylene Glycol 3350
Powder (Generic Miralax),
T1
Polymyxin B Sulfate
(Injection), T1
Polymyxin B Sulfate/
Trimethoprim Sulfate
Pomalyst (Capsule), T1
Portia-28 (Tablet), T1
Potassium Chloride
(10meq/100ml Injection,
20meq/100ml Injection,
40meq/100ml Injection),
T1
Potassium Chloride (2meq/ml
Injection), T1
Potassium Chloride 0.15% /
NaCl 0.45% Viaflex
(Injection), T1
Potassium Chloride 0.15%
D5W/NaCl 0.33%
(Injection), T1
D5W/NaCl 0.45%
(Injection), T1
Potassium Chloride 0.15%/
NaCl 0.9% (Injection), T1
D5W/NaCl 0.45%
(Injection), T1
NaCl 0.9% (Injection), T1
D5W (Injection), T1
Potassium Chloride ER
(10meq Capsule ExtendedRelease, 8meq Capsule
Extended-Release, 8meq
T1
Potassium Chloride ER
Microencapsulated (10meq
Tablet Extended-Release,
20meq Tablet ExtendedRelease), T1
Potassium Citrate ER (Tablet
Potiga (Tablet), T1
Pradaxa (Capsule), T1
Pramipexole Dihydrochloride
(Tablet Immediate-Release),
T1
PrandiMet (Tablet), T1
Pravastatin Sodium (Tablet),
T1
Prazosin HCl (Capsule), T1
Pred Mild (Suspension), T1
Pred-G (Suspension), T1
Pred-G S.O.P. (Ointment),
T1
57
Drug LIST
Pentasa (Capsule ExtendedRelease), T1
Pentoxifylline ER (Tablet
Perforomist (Nebulized
Solution), T1
Perindopril Erbumine (Tablet),
T1
Periogard (Solution), T1
Perjeta (Injection), T1
Permethrin (Cream), T1
Perphenazine (Tablet), T1
Phenadoz (12.5mg
Suppository), T1
Phenelzine Sulfate (Tablet),
T1
Phenergan (12.5mg
Suppository), T1
Phenobarbital (100mg Tablet,
15mg Tablet, 16.2mg
32.4mg Tablet, 60mg
Tablet, 64.8mg Tablet,
97.2mg Tablet, 20mg/5ml
Elixir), T1
Phenytek (Capsule), T1
Phenytoin (125mg/5ml
Chewable), T1
Phenytoin Sodium (Injection),
T1
Phenytoin Sodium Extended
(Capsule), T1
PhosLo (Capsule), T1
Phoslyra (Oral Solution), T1
Phospholine Iodide
Physiolyte (Irrigation
Solution), T1
Physiosol Irrigation
Picato (Gel), T1
0
Prednicarbate (0.1%
Cream), T1
Prednicarbate (0.1%
Ointment), T1
Prednisolone Acetate
(Suspension), T1
Prednisolone Sodium
Phosphate (1% Ophthalmic
Solution), T1
Prednisolone Sodium
Phosphate (15mg/5ml Oral
Solution), T1
Prednisone (10mg Tablet,
1mg Tablet, 2.5mg Tablet,
5mg Tablet), T1
Prednisone (5mg/5ml Oral
Solution), T1
Prednisone Intensol (5mg/ml
Concentrate), T1
Pregnyl w/Diluent Benzyl
Alcohol/NaCl (Injection),
T1
Premarin (Vaginal Cream),
T1
Premasol (Injection), T1
Prevalite (Powder), T1
Previfem (Tablet), T1
Prezcobix (Tablet), T1
Prezista (100mg/ml
Suspension, 150mg
800mg Tablet), T1
Prezista (75mg Tablet), T1
Priftin (Tablet), T1
Primaquine Phosphate
(Tablet), T1
Primidone (Tablet), T1
Primsol (Oral Solution), T1
Pristiq (Tablet ExtendedRelease 24 Hour), T1
Privigen (Injection), T1
ProAir HFA (Aerosol
Solution), T1
ProAir RespiClick (Aerosol
Powder), T1
ProQuad (Injection), T1
Probenecid (Tablet), T1
Probenecid/Colchicine
(Tablet), T1
Procainamide HCl (Injection),
T1
Procalamine (Injection), T1
Prochlorperazine
(Suppository), T1
Prochlorperazine Edisylate
(Injection), T1
Prochlorperazine Maleate
(Tablet), T1
Procrit (10000unit/ml
Injection, 2000unit/ml
Injection), T1
Procrit (20000unit/ml
Injection), T1
Procto-Pak (Cream), T1
Proctosol HC (Cream), T1
Proctozone-HC (Cream), T1
Procysbi (Capsule DelayedRelease), T1
Progesterone (Capsule), T1
Proglycem (Suspension), T1
Prograf (5mg/ml Injection),
T1
Prolastin-C (Injection), T1
Prolensa (Ophthalmic
Solution), T1
Proleukin (Injection), T1
Prolia (Injection), T1
Promacta (Tablet), T1
Promethazine HCl (12.5mg
Suppository, 12.5mg
Tablet), T1
Propafenone HCl (Tablet), T1
Propafenone HCl ER
12 Hour), T1
Proparacaine HCl
Propranolol HCl (10mg Tablet
20mg/5ml Oral Solution,
40mg/5ml Oral Solution), T1
Propranolol HCl (1mg/ml
Injection), T1
Propranolol HCl ER (Capsule
T1
Propranolol/
Hydrochlorothiazide
(Tablet), T1
Propylthiouracil (Tablet), T1
Prosol (Injection), T1
Protriptyline HCl (Tablet), T1
Pulmicort (1mg/2ml
Suspension), T1
Pulmozyme (Inhalation
Solution), T1
Purixan (Suspension), T1
Pyrazinamide (Tablet), T1
Pyridostigmine Bromide
(Tablet), T1
Q
Quadracel (Injection), T1
Quasense (Tablet), T1
Quetiapine Fumarate (Tablet
Quinapril HCl (Tablet), T1
Quinapril/Hydrochlorothiazide
(Tablet), T1
Quinidine Gluconate
(Injection), T1
0
Quinidine Gluconate CR
T1
Quinidine Sulfate (Tablet), T1
Quinine Sulfate (Capsule), T1
Risperidone (0.25mg Tablet,
0.5mg Tablet, 1mg Tablet,
4mg Tablet), T1
Risperidone (1mg/ml Oral
Solution), T1
Risperidone ODT (Tablet
Dispersible), T1
Rituxan (Injection), T1
Rivastigmine Tartrate
(Capsule ImmediateRelease), T1
Rizatriptan Benzoate (Tablet
Rizatriptan Benzoate ODT
(Tablet Dispersible), T1
Ropinirole HCl (Tablet
RotaTeq (Oral Solution), T1
Rotarix (Suspension), T1
Roxicet (Oral Solution), T1
Rozerem (Tablet), T1
Ruconest (Injection), T1
S
SFRowasa (Enema), T1
SSD (Cream), T1
Sabril (500mg Packet,
500mg Tablet), T1
Saizen (Injection), T1
Samsca (Tablet), T1
Sancuso (Patch), T1
Sandimmune (100mg
Capsule), T1
Sandimmune (100mg/ml
Oral Solution), T1
Sandostatin LAR Depot
(Injection), T1
Santyl (Ointment), T1
Saphris (Tablet Sublingual),
T1
Savella (Tablet), T1
Savella Titration Pack, T1
59
Drug LIST
R
RAVICTI (Liquid), T1
Rabavert (Injection), T1
Raloxifene HCl (Tablet), T1
Ramipril (Capsule), T1
Ranexa (Tablet ExtendedRelease 12 Hour), T1
Ranitidine HCl (150mg
150mg/6ml Injection,
15mg/ml Syrup), T1
Ranitidine HCl (150mg
Rapaflo (Capsule), T1
Rapamune (1mg Tablet,
2mg Tablet, 1mg/ml Oral
Solution), T1
Rebif (Injection), T1
Rebif Rebidose (Injection),
T1
Rebif Rebidose Titration
Pack (Injection), T1
Rebif Titration Pack
(Injection), T1
Reclipsen (Tablet), T1
Recombivax HB (Injection),
T1
Regranex (Gel), T1
Relenza Diskhaler (Aerosol
Powder), T1
Relistor (Injection), T1
Remicade (Injection), T1
Remodulin (Injection), T1
Renagel (Tablet), T1
Renvela (0.8gm Packet,
2.4gm Packet, 800mg
Tablet), T1
Repaglinide (Tablet), T1
Rescriptor (Tablet), T1
Restasis (Emulsion), T1
Retrovir IV Infusion
(Injection), T1
Revatio (10mg/12.5ml
Injection), T1
Revatio (20mg Tablet), T1
Revlimid (Capsule), T1
Reyataz (150mg Capsule,
Capsule, 50mg Packet),
T1
Ribasphere (200mg Capsule),
T1
Ribasphere (200mg Tablet,
400mg Tablet), T1
Ribasphere (600mg Tablet),
T1
Ribavirin (200mg Capsule),
T1
Ribavirin (200mg Tablet), T1
Ridaura (Capsule), T1
Rifabutin (Capsule), T1
Rifampin (150mg Capsule,
300mg Capsule), T1
Rifampin (600mg Injection),
T1
Rifater (Tablet), T1
Rilutek (Tablet), T1
Riluzole (Tablet), T1
Rimantadine HCl (Tablet), T1
Ringers Injection
(Injection), T1
Ringers Irrigation (Irrigation
Solution), T1
Riomet (Oral Solution), T1
Risedronate Sodium (Tablet),
T1
Risperdal Consta (12.5mg
T1
Risperdal Consta (37.5mg
T1
0
Selegiline HCl (5mg Capsule,
5mg Tablet), T1
Selenium Sulfide (Lotion), T1
Selzentry (Tablet), T1
Sensipar (30mg Tablet), T1
Sensipar (60mg Tablet,
90mg Tablet), T1
Serevent Diskus (Aerosol
Powder), T1
Seroquel XR (Tablet
Extended-Release 24
Hour), T1
Serostim (Injection), T1
Sertraline HCl (100mg Tablet,
T1
Sertraline HCl (20mg/ml
Concentrate), T1
Sharobel (Tablet), T1
Signifor (Injection), T1
Sildenafil (10mg/12.5ml
Injection), T1
Sildenafil (20mg Tablet)
(Generic Revatio), T1
Silver Sulfadiazine (Cream),
T1
Simbrinza (Suspension), T1
Simponi (Injection), T1
Simponi Aria (Injection), T1
Simulect (Injection), T1
Simvastatin (Tablet), T1
Sirolimus (0.5mg Tablet), T1
Sirolimus (1mg Tablet, 2mg
Tablet), T1
Sirturo (Tablet), T1
Sodium Chloride (0.9%
Injection), T1
Sodium Chloride (2.5meq/
ml Injection, 3% Injection,
5% Injection), T1
Sodium Chloride 0.45%
Viaflex (Injection), T1
Sodium Chloride 0.9%
Sodium Fluoride (Tablet), T1
Sodium Lactate (Injection),
T1
Sodium Phenylbutyrate
(Powder), T1
Sodium Polystyrene Sulfonate
(Suspension), T1
Sodium Sulfacetamide
Solaraze (Gel), T1
Soltamox (Oral Solution), T1
Solu-Cortef (Injection), T1
Solu-Medrol (2gm
Injection), T1
Somatuline Depot
(Injection), T1
Somavert (Injection), T1
Soriatane (Capsule), T1
Sotalol HCl (AF) (Tablet), T1
Sotalol HCl (Tablet), T1
Sovaldi (Tablet), T1
Spiriva HandiHaler
(Capsule), T1
Spiriva Respimat (Aerosol
Solution), T1
Spironolactone (Tablet), T1
Spironolactone/
Hydrochlorothiazide
(Tablet), T1
Sporanox (10mg/ml Oral
Solution), T1
Sprintec 28 (Tablet), T1
Sprycel (Tablet), T1
Sronyx (Tablet), T1
Stavudine (15mg Capsule,
20mg Capsule, 30mg
Stelara (Injection), T1
Sterile Water Irrigation
Stiolto Respimat (Aerosol
Solution), T1
Stivarga (Tablet), T1
Strattera (Capsule), T1
Streptomycin Sulfate
(Injection), T1
Stribild (Tablet), T1
Suboxone (Film), T1
Sucraid (Oral Solution), T1
Sucralfate (Tablet), T1
Sulfacetamide Sodium
(Ointment), T1
Sulfacetamide Sodium/
Prednisolone Sodium
Phosphate (Ophthalmic
Solution), T1
Sulfadiazine (Tablet), T1
Sulfamethoxazole/
Trimethoprim
(200mg-40mg/5ml
Suspension, 400mg-80mg
Tablet), T1
Sulfamethoxazole/
Trimethoprim
(400mg-80mg/5ml
Injection), T1
Sulfamethoxazole/
Trimethoprim DS (Tablet),
T1
Sulfamylon (85mg/gm
Cream), T1
Sulfasalazine (Tablet), T1
Sulfazine EC (Tablet DelayedRelease), T1
Sulindac (Tablet), T1
Sumatriptan (Nasal
Solution), T1
Sumatriptan Succinate
(100mg Tablet, 25mg
Sumatriptan Succinate (6mg/
0.5ml Injection), T1
Sumavel DosePro
(Injection), T1
0
T
TOBI (Nebulized Solution),
T1
TOBI Podhaler (Capsule),
T1
TPN Electrolytes (Injection),
T1
TYPHIM Vi (Injection), T1
Tabloid (Tablet), T1
Tacrolimus (0.03% Ointment,
0.1% Ointment), T1
Tacrolimus (0.5mg Capsule,
1mg Capsule, 5mg
Capsule), T1
Tafinlar (Capsule), T1
Tamiflu (30mg Capsule,
45mg Capsule, 75mg
Capsule, 6mg/ml
Suspension), T1
Tamoxifen Citrate (Tablet), T1
Tamsulosin HCl (Capsule), T1
Tarceva (Tablet), T1
Targretin (1% Gel, 75mg
Capsule), T1
Tarina Fe 1/20 (Tablet), T1
Tasigna (Capsule), T1
Tasmar (Tablet), T1
Taxotere (Injection), T1
Tazicef (Injection), T1
Tazorac (0.05% Cream,
0.1% Cream), T1
Taztia XT (Capsule ExtendedRelease 24 Hour), T1
Tecfidera (Capsule DelayedRelease), T1
Tecfidera Starter Pack, T1
Tegretol-XR (100mg Tablet
Extended-Release 12
Hour), T1
Telmisartan (Tablet), T1
Telmisartan/Amlodipine
(Tablet), T1
Telmisartan/
Hydrochlorothiazide
(Tablet), T1
Tenivac (Injection), T1
Terazosin HCl (Capsule), T1
Terbinafine HCl (Tablet), T1
Terbutaline Sulfate (1mg/ml
Injection), T1
Terconazole (0.4% Cream,
0.8% Cream, 80mg
Suppository), T1
Testosterone Cypionate
(Injection), T1
Testosterone Enanthate
(Injection), T1
Tetanus/Diphtheria
Toxoids-Adsorbed Adult
(Injection), T1
Tetracycline HCl (Capsule),
T1
Thalomid (Capsule), T1
Theophylline (Oral Solution),
T1
Theophylline CR (Tablet
T1
Theophylline ER (300mg
Hour, 450mg Tablet
400mg Tablet ExtendedRelease 24 Hour, 600mg
Hour), T1
Thioridazine HCl (Tablet), T1
Thiothixene (Capsule), T1
Thymoglobulin (Injection),
T1
Thyrolar (Tablet), T1
Tiagabine HCl (2mg Tablet),
T1
Tiagabine HCl (4mg Tablet),
T1
Tikosyn (Capsule), T1
Timolol Maleate (0.25%
Ophthalmic Solution, 0.5%
Timolol Maleate (10mg
Tablet), T1
Timolol Maleate Ophthalmic
Gel Forming (Gel Form
Solution), T1
Tinidazole (Tablet), T1
Tivicay (Tablet), T1
Tizanidine HCl (2mg Tablet,
4mg Tablet), T1
Tobradex (0.3%-0.1%
Ophthalmic Ointment), T1
61
Drug LIST
Suprax (100mg Tablet
Chewable, 100mg/5ml
Suspension), T1
Suprax (400mg Capsule,
500mg/5ml Suspension),
T1
Suprep Bowel Prep (Oral
Solution), T1
Surmontil (Capsule), T1
Sustiva (200mg Capsule,
600mg Tablet), T1
Sustiva (50mg Capsule), T1
Sutent (Capsule), T1
Sylatron (Injection), T1
Sylvant (Injection), T1
Symbicort (Aerosol), T1
SymlinPen 120 (Injection),
T1
SymlinPen 60 (Injection), T1
Synagis (Injection), T1
Synarel (Nasal Solution), T1
Synercid (Injection), T1
Synribo (Injection), T1
Synthroid (Tablet), T1
Syprine (Capsule), T1
0
Tobradex ST (0.3%-0.05%
Ophthalmic Suspension),
T1
Tobramycin (Nebulized
Solution), T1
Tobramycin Sulfate (0.3%
Tobramycin Sulfate (10mg/ml
Injection, 80mg/2ml
Injection), T1
Tobramycin Sulfate/Sodium
Chloride (Injection), T1
Tobramycin/Dexamethasone
(Ophthalmic Suspension),
T1
Tobrex (0.3% Ophthalmic
Ointment), T1
Tolcapone (Tablet), T1
Topiramate (100mg Tablet
Capsule Sprinkle ImmediateRelease, 25mg Capsule
Sprinkle ImmediateRelease), T1
Toposar (Injection), T1
Topotecan HCl (Injection), T1
Torisel (Injection), T1
Torsemide (Tablet), T1
Tracleer (Tablet), T1
Tradjenta (Tablet), T1
Tramadol HCl (Tablet
Tramadol HCl ER (100mg
Hour) (Generic Ultram ER),
200mg Tablet ExtendedRelease 24 Hour (Generic
Ultram ER), T1
Tramadol HCl ER (300mg
Hour) (Generic Ryzolt), T1
Tramadol HCl/
Acetaminophen (Tablet), T1
Trandolapril (Tablet), T1
Tranexamic Acid (100mg/ml
Injection, 650mg Tablet), T1
Transderm-Scop (Patch 72
Hour), T1
Tranylcypromine Sulfate
(Tablet), T1
Travasol (Injection), T1
Travatan Z (Ophthalmic
Solution), T1
Travoprost (Ophthalmic
Solution), T1
Trazodone HCl (Tablet), T1
Treanda (Injection), T1
Trecator (Tablet), T1
Trelstar Mixject (Injection),
T1
Tretinoin (0.01% Gel, 0.025%
Gel, 0.025% Cream, 0.05%
Cream, 0.1% Cream), T1
Tretinoin (10mg Capsule), T1
Tretinoin Microsphere (Gel),
T1
Trexall (Tablet), T1
Trezix (320.5mg-30mg-16mg
Capsule), T1
Tri-Legest Fe (Tablet), T1
Tri-Previfem (Tablet), T1
Tri-Sprintec (Tablet), T1
TriLyte (Oral Solution), T1
Triamcinolone Acetonide
(0.025% Cream, 0.1%
Cream, 0.5% Cream,
0.025% Ointment, 0.1%
Ointment, 0.5% Ointment),
T1
(0.025% Lotion, 0.1%
Lotion), T1
(55mcg/ACT Aerosol)
(Generic Nasacort AQ), T1
Triamcinolone in Orabase
(Paste), T1
Triamterene/
Hydrochlorothiazide
(37.5mg-25mg Capsule,
50mg-25mg Capsule,
37.5mg-25mg Tablet,
75mg-50mg Tablet), T1
Tribenzor (Tablet), T1
Triderm (Cream), T1
Trifluoperazine HCl (Tablet),
T1
Trifluridine (Ophthalmic
Solution), T1
Trihexyphenidyl HCl (0.4mg/
ml Elixir), T1
Trimethoprim (Tablet), T1
Trinessa (Tablet), T1
Trisenox (Injection), T1
Triumeq (Tablet), T1
Trivora-28 (Tablet), T1
Trizivir (Tablet), T1
Trophamine (Injection), T1
Trulicity (Injection), T1
Trumenba (Injection), T1
Truvada (Tablet), T1
Twinrix (Injection), T1
Tybost (Tablet), T1
Tygacil (Injection), T1
Tykerb (Tablet), T1
Tysabri (Injection), T1
Tyvaso (Inhalation
Solution), T1
Tyzeka (Tablet), T1
Tyzine Pediatric Nasal Drops
(Nasal Solution), T1
0
U
Uceris (9mg Tablet
Extended-Release 24
Hour), T1
Uloric (Tablet), T1
Unithroid (Tablet), T1
Ursodiol (250mg Tablet,
500mg Tablet, 300mg
Capsule), T1
Uvadex (Injection), T1
Vfend (200mg Tablet, 50mg
Tablet, 40mg/ml
Suspension), T1
Vibramycin (50mg/5ml
Syrup), T1
Victoza (Injection), T1
Vidaza (Injection), T1
Videx Pediatric (Oral
Solution), T1
Vigamox (Ophthalmic
Solution), T1
Viibryd (Kit, 10mg Tablet,
20mg Tablet, 40mg
Tablet), T1
Vimpat (100mg Tablet,
150mg Tablet, 200mg
10mg/ml Oral Solution),
T1
Vimpat (200mg/20ml
Injection), T1
Vinblastine Sulfate (Injection),
T1
Vincasar PFS (Injection), T1
Vincristine Sulfate (Injection),
T1
Vinorelbine Tartrate
(Injection), T1
Viracept (Tablet), T1
Viramune (50mg/5ml
Suspension), T1
Viramune XR (100mg Tablet
Extended-Release 24
Hour), T1
Viramune XR (400mg Tablet
Extended-Release 24
Hour), T1
Virazole (Inhalation
Solution), T1
Viread (150mg Tablet,
200mg Tablet, 250mg
40mg/gm Powder), T1
Vitekta (Tablet), T1
63
Drug LIST
V
VAQTA (Injection), T1
VP-PNV-DHA (Capsule), T1
VPRIV (Injection), T1
Vagifem (Tablet), T1
Valacyclovir HCl (Tablet), T1
Valchlor (Gel), T1
Valcyte (450mg Tablet,
50mg/ml Oral Solution),
T1
Valganciclovir (Tablet), T1
Valproate Sodium (100mg/ml
Injection), T1
Valproic Acid (250mg
Capsule, 250mg/5ml
Syrup), T1
Valsartan (Tablet), T1
Valsartan/
Hydrochlorothiazide
(Tablet), T1
Vancocin HCl (Capsule), T1
Vancomycin HCl (1000mg
500mg Injection), T1
Vancomycin HCl (125mg
Capsule, 250mg Capsule),
T1
Vandazole (Gel), T1
Varivax (Injection), T1
Varizig (Injection), T1
Vascepa (Capsule), T1
Vectibix (Injection), T1
Velcade (Injection), T1
Velivet (Tablet), T1
Velphoro (Tablet
Chewable), T1
Venlafaxine HCl (Tablet
Venlafaxine HCl ER (150mg
24 Hour, 37.5mg Capsule
75mg Capsule ExtendedRelease 24 Hour), T1
Ventavis (Inhalation
Solution), T1
Verapamil HCl (120mg Tablet
Verapamil HCl (2.5mg/ml
Injection), T1
Verapamil HCl ER (100mg
300mg Capsule ExtendedRelease 24 Hour), T1
Verapamil HCl ER (120mg
180mg Tablet ExtendedRelease, 240mg Tablet
Verapamil HCl SR (Capsule
Extended-Release 24
Hour), T1
Versacloz (Suspension), T1
Vesicare (Tablet), T1
Vestura (Tablet), T1
Vexol (Suspension), T1
0
Vivitrol (Injection), T1
Voltaren (Gel), T1
Voriconazole (200mg
Injection), T1
Voriconazole (200mg Tablet,
Suspension), T1
Votrient (Tablet), T1
Vyfemla (Tablet), T1
Vytorin (Tablet), T1
Vyvanse (Capsule), T1
W
WYMZYA Fe (Tablet
Chewable), T1
Warfarin Sodium (Tablet), T1
Welchol (3.75gm Packet,
625mg Tablet), T1
X
Xalkori (Capsule), T1
Xarelto (Tablet), T1
Xarelto Starter Pack (Tablet
Therapy Pack), T1
Xeljanz (Tablet), T1
Xenazine (Tablet), T1
Xgeva (Injection), T1
Xifaxan (Tablet), T1
Xolair (Injection), T1
Xtandi (Capsule), T1
Xulane (Patch Weekly), T1
Xyrem (Oral Solution), T1
Y
YF-Vax (Injection), T1
Yervoy (Injection), T1
Z
Zafirlukast (Tablet), T1
Zaleplon (Capsule), T1
Zaltrap (Injection), T1
Zanosar (Injection), T1
Zavesca (Capsule), T1
Zazole (0.4% Cream), T1
Zazole (0.8% Cream), T1
Zelapar (Tablet
Dispersible), T1
Zelboraf (Tablet), T1
Zemaira (Injection), T1
Zemplar (2mcg/ml
Injection, 5mcg/ml
Injection), T1
Zenchent (Tablet), T1
Zenchent Fe (Tablet
Chewable), T1
Zenpep (Capsule DelayedRelease), T1
Zerbaxa (Injection), T1
Zetia (Tablet), T1
Ziagen (20mg/ml Oral
Solution), T1
Zidovudine (100mg Capsule,
300mg Tablet, 50mg/5ml
Syrup), T1
Zinecard (Injection), T1
Ziprasidone HCl (Capsule),
T1
Zirgan (Gel), T1
Zmax (Suspension), T1
Zoledronic Acid (4mg/5ml
Injection), T1
Zoledronic Acid (5mg/100ml
Injection), T1
Zolinza (Capsule), T1
Zolpidem Tartrate (Tablet
Zomacton (Injection), T1
Zometa (Injection), T1
Zonisamide (Capsule), T1
Zorbtive (Injection), T1
Zortress (Tablet), T1
Zostavax (Injection), T1
Zovia 1/35E (Tablet), T1
Zovia 1/50E (Tablet), T1
Zovirax (5% Cream), T1
Zovirax (5% Ointment), T1
Zyclara (Cream), T1
Zyclara Pump (Cream), T1
Zydelig (Tablet), T1
Zyflo (Tablet), T1
Zyflo CR (Tablet ExtendedRelease 12 Hour), T1
Zykadia (Capsule), T1
Zyprexa Relprevv
(Injection), T1
Zytiga (Tablet), T1
Zyvox (100mg/5ml
Suspension, 2mg/ml
Injection), T1
Zyvox (600mg Tablet), T1
Over-the-counter Medicaid drug list
This plan also covers selected over-the-counter (OTC) drugs not normally covered under our
Medicare Part D benefit.
The alphabetical OTC drugs listed below are covered only with a written prescription from your
doctor. If your prescription is for a brand name drug, the generic version of the drug will be provided
when available unless otherwise prescribed or directed by your physician.
#
12 Hour Decongestant
12 Hour)
12 Hour Nasal Spray (Nasal
Solution)
3 Day Vaginal (Cream)
65
All Day Allergy D (Tablet
Extended-Release 12 Hour)
All Day Allergy D-12 (Tablet
All Day Allergy-D (Tablet
All Day Pain Relief (Tablet)
All Day Relief (Tablet)
All-Nite Multi-Symptom Cold/
Flu Relief (Liquid)
Aller-Chlor (2mg/5ml Syrup,
4mg Tablet)
Aller-Ease (Tablet)
Allergy & Congestion Relief
12 Hour)
Allergy (10mg Tablet
Dispersible, 10mg Tablet,
25mg Capsule)
Allergy Eye Drops
(Ophthalmic Solution)
Allergy Multi-Symptom
(Tablet)
Allergy Relief (10mg Tablet
Dispersible, 10mg Tablet,
25mg Tablet)
Allergy Relief Child (Syrup)
Allergy Relief D-24 (Tablet
Allergy Relief/Nasal
Decongestant (Tablet
Allergy Tablets (Tablet)
Allergy-Time (Tablet)
Drug LIST
A
Ace Aerosol Cloud Enhancer
Acephen (Suppository)
Acetaminophen (Suppository)
Acid Gone (Suspension)
Acid Reducer (Tablet)
Acidophilus/Citrus Pectin
(Tablet)
Acidophilus/L-Sporogenes
Extra Strength (Tablet)
Acne Medication (Lotion)
Acne Medication 5 (Lotion)
Adult Mask Large
Advil (200mg Capsule,
200mg Tablet)
Advil Junior Strength (100mg
Tablet, 100mg Tablet
Chewable)
AeroGear Asthma Action (Kit)
Aerochamber MV
Aerochamber Mini Aerosol
Chamber (Device)
Aerochamber Plus Flow Vu
Aerochamber Plus Flow-Vu
Aerochamber Plus Flow-Vu/
Large Mask
Mask
Medium Mask
Small Mask
Aerochamber Plus/Small
Mask
Aerochamber Z-Stat Plus
Valved Holding Chamber w/
Flow Vu
Aerochamber Z-Stat Plus/
Flowsignal
Large Mask
Medium Mask
Small Mask
Aerochamber/Flowsignal
Aerotrach Plus
Aimsco Lubricated
Airzone Peak Flow Meter
(Device)
Akwa Tears (Ointment)
Alavert (Tablet Dispersible)
Alavert Allergy/Sinus (Tablet
Alaway (Ophthalmic Solution)
Alaway Childrens Allergy Eye
Itch Relief (Ophthalmic
Solution)
Alevazol (Ointment)
All Day Allergy (Tablet)
All Day Allergy Childrens
(Tablet Chewable)
Allerhist-1 (Tablet)
Almacone Double Strength
(Suspension)
Aloe Vesta Protective
(Ointment)
Alpha Lipoic Acid (100mg
Capsule)
Alpha Lipoic Acid (300mg
Capsule)
Aluminum Hydroxide
(Suspension)
Ameriphor (Ointment)
Amlactin (Lotion)
Amlactin Ultra (Cream)
Animal Shapes (Tablet
Chewable)
Animal Shapes + Iron (Tablet
Chewable)
Antacid (Suspension)
Antacid Anti-Gas Maximum
Strength (Suspension)
Antacid Fast Relief
(Suspension)
Antacid Maximum Strength
(Suspension)
Antacid Plus Anti-Gas Fast
Acting (Suspension)
Anti-Diarrheal (Tablet)
Anti-Fungal Powder (Powder)
Anti-Itch (Cream)
Anti-Nausea (Oral Solution)
Antifungal (Cream)
Aprodine (Tablet)
AquADEKs (Liquid)
AquADEKs (Tablet Chewable,
Capsule)
Aqua-E (Liquid)
Aquasol A Parenteral
(Injection)
Aquasol E (Oral Solution)
Aqueous Vitamin D Infants
(Liquid)
Aqueous Vitamin E (Oral
Solution)
Arginine (Tablet)
Artificial Tears (Ointment,
15%-83% Ointment, 1.4%
Ophthalmic Solution)
Aspir-81 (Tablet DelayedRelease)
Aspir-Low (Tablet DelayedRelease)
Aspirin (325mg Tablet,
325mg Tablet DelayedRelease, 81mg Tablet
Delayed-Release, 81mg
Tablet Chewable)
Aspirin Adult Low Strength
(Tablet Chewable)
Aspirin Childrens (Tablet
Chewable)
Aspirin EC (Tablet DelayedRelease)
Aspirin EC Lo-Dose (Tablet
Delayed-Release)
Aspirin EC Low Dose (Tablet
Delayed-Release)
Aspirin Enteric Coated Adult
Low Strength (Tablet
Delayed-Release)
Aspirin Low Dose (81mg
Tablet Delayed-Release)
Aspirin Low Strength (Tablet
Chewable)
Assess Full Range Peak Flow
Meter (Device)
Asthma Check Meter-Zone
System (Device)
AsthmaMentor (Device)
AsthmaPACK for Children
(Kit)
Athletes Foot AF Cream
(Cream)
B
B-Complex Plus Vitamin C
(Tablet)
BBO Creamy Wash Complete
Pack (Kit)
Bacitracin (OTC Only)
(500unit/gm Ointment)
Bacitracin Zinc (OTC Only)
(Ointment)
Bacitracin/Neomycin/
Polymyxin (OTC Only)
(Ointment)
Bacteriostatic Water for
Injection/Benzyl Alcohol
(Injection)
Banophen (12.5mg/5ml
Liquid, 2%-0.1% Cream,
25mg Capsule, 50mg
Capsule, 25mg Tablet)
Baza Antifungal (Cream)
Baza Protect (Cream)
Benzoin Compound Tincture
(Tincture)
Benzonatate (Capsule)
Benzoyl Peroxide (OTC Only)
(10% Gel, 5% Gel, 2.5% Gel)
Benzoyl Peroxide Cleanser
(OTC Only) (Lotion)
Benzoyl Peroxide Wash (OTC
Only) (Liquid)
Beta Care Betatar Gel
(Shampoo)
Beta HC (Lotion)
Betadine Surgical Scrub
(External Solution)
Bion Tears (Ophthalmic
Solution)
Biotin (Capsule)
Bisac-Evac (Suppository)
Bisacodyl (Suppository)
Bisacodyl EC (Tablet DelayedRelease)
Biscolax (Suppository)
Bismatrol (Suspension)
Bismatrol Maximum Strength
(Suspension)
BreatheRite Valved MDI
Chamber/Collapsible
(Device)
BreatheRite Valved MDI
Chamber/Rigid (Device)
Bromfed DM (Syrup)
Bromphen/Pseudoephedrine
HCl/Dextromethorphan HBr
(Syrup)
Brotapp (Liquid)
Brotapp DM (Liquid)
Brovex PEB (Liquid)
Brovex PSB (Liquid)
67
Childrens Chewable
Vitamins/Iron (Tablet
Chewable)
Childrens Cold & Allergy
(Elixir)
Childrens Ibuprofen (OTC
Only) (40mg/ml
Suspension)
Childrens Loratadine (5mg/
Syrup)
Childrens Mucus Relief
Cough (Liquid)
Childrens Mucus Relief
Expectorant (Liquid)
Childrens Pain Relief Plus
Multi-Symptom Cold
(Suspension)
Chlorpheniramine Maleate
(OTC Only) (12mg Tablet
Tablet)
Chromium Chloride (Injection)
Citrus Calcium+D (Tablet)
Citrus Calcium/Vitamin D
(Tablet)
Claritin (OTC Only) (10mg
Capsule, 10mg Tablet, 5mg
Tablet Chewable, 5mg/5ml
Syrup)
Claritin Reditabs (Tablet
Dispersible)
Claritin-D 12 Hour (Tablet
Claritin-D 24 Hour (Tablet
Clearlax (Powder)
Clemastine Fumarate (OTC
Only) (Tablet)
Clotrimazole (OTC Only)
(Cream)
Co Q-10 (Capsule)
Co Q-10 Plus (Capsule)
Co-Enzyme Q-10 (Capsule)
Drug LIST
C
Calcet Petites (Tablet)
Calci-Chew (Tablet Chewable)
Calci-Mix (Capsule)
Calciferol (Oral Solution)
Calcionate (Syrup)
Calcitrate (Tablet)
Calcium 600+D (Tablet)
Calcium Carbonate (1250mg
1250mg/5ml Suspension)
Calcium Carbonate (648mg
Tablet)
Calcium Citrate+D (Tablet)
Calcium High Potency +
Vitamin D (Tablet)
Calcium Lactate (Tablet)
Calcium Oyster Shell (Tablet)
Calcium Plus Vitamin D3
(Capsule)
Calcium+D3 (Tablet)
Calcium/Vitamin D (Tablet)
Calcium/Vitamin D/Minerals
(Tablet Chewable)
Calphron (Tablet)
Caltrate 600+D Plus Minerals
(Tablet Chewable)
Calvite P&D (Tablet)
Capcof (Syrup)
Capmist DM (Tablet)
Capron DM (Liquid)
Carrington Antifungal (Cream)
Castor Oil
Centamin (Liquid)
Centavite A-Z Complete
Multivitamin/Minerals
(Tablet)
Centrum (Liquid)
Centrum Adults (Tablet)
Centrum Silver (Tablet)
Centrum Ultra Womens
(Tablet)
Cerovite Advanced Formula
(Tablet, Liquid)
Cerovite Jr (Tablet Chewable)
Certavite/Antioxidants (Tablet,
Liquid)
Cetirizine HCl (OTC Only)
(10mg Tablet Chewable,
5mg Tablet Chewable,
10mg Tablet, 5mg Tablet)
Cetirizine HCl/
Pseudoephedrine HCl ER
(OTC Only) (Tablet
Cheratussin AC (Syrup)
Cheratussin DAC (Oral
Solution)
Chest Congestion Relief
(Tablet)
Chewable Vite Childrens
(Tablet Chewable)
Chewable Vite with Iron/
Childrens (Tablet Chewable)
Childrens Advil (Suspension)
Childrens Aspirin (Tablet
Chewable)
Childrens Aspirin Low
Strength (Tablet Chewable)
Childrens Chewable Vitamins
(Tablet Chewable)
Codituss DM (Syrup)
Cold Head Congestion
Daytime (Tablet)
Nighttime (Tablet)
Severe Daytime (Tablet)
Cold Multi-Symptom Daytime
(Tablet)
Cold Multi-Symptom
Nighttime (Tablet)
Cold Multi-Symptom Severe
Daytime (Tablet)
Cold/Allergy Childrens (Elixir)
Cold/Cough Childrens (Elixir)
Cold/Cough DM Childrens
(Elixir)
Cold/Cough/Sore Throat
Childrens (Liquid)
Complete (Tablet)
Complete Allergy (25mg
Complete Allergy Medicine
(Capsule)
Complete Lice Treatment Kit
(Kit)
Conex Cold/Allergy (1mg/
5ml-30mg/5ml Oral
Solution, 2mg-60mg Tablet)
Copper Trace Metal
(Injection)
Coricidin HBP Nighttime
Multi-Symptom Cold (Liquid)
Cough & Sore Throat Day
Time (Liquid)
Cough DM (Liquid ExtendedRelease)
Cough Syrup (Syrup)
Coughtab (Tablet)
Critic-Aid Clear AF (Ointment)
Cromolyn Sodium (OTC Only)
(Aerosol Solution)
Cyanocobalamin (Injection)
Cyto-Q Max (Liquid)
D
D 5000 (Tablet)
D-Vi-Sol (Liquid)
D-Vita (Liquid)
D3 High Potency (Capsule)
D3 Super Strength (Capsule)
D3-50 (Capsule)
DHS Sal (Shampoo)
DHS Tar (Shampoo)
DHS Tar Gel (Shampoo)
DHS Zinc (Shampoo)
DOK (100mg Capsule,
Tablet)
DOK PLUS (Tablet)
Daily Multiple Vitamins
(Tablet)
Daily Vite (Tablet)
Daily-Vite/Iron/Beta-Carotene
(Tablet)
Dallergy (Liquid)
Day Time Cold/Flu Relief
(Liquid)
Day Time Cough (Liquid)
Day Time Multi-Symptom
Cold/Flu Relief (Capsule)
Dayhist Allergy 12 Hour Relief
(Tablet)
Decongestant 12hour
Maximum Strength (Tablet
Deep Sea Nasal Spray (Nasal
Solution)
Delsym (Liquid ExtendedRelease)
Delsym Cough + Chest
Congestion DM (Liquid)
Delsym Cough + Chest
Congestion DM Childrens
(Liquid)
Delsym Cough + Cold
Daytime (Liquid)
Delsym Cough + Cold
Nighttime (Liquid)
Delsym Cough + Cold
Nighttime Childrens (Liquid)
Delsym Night Time Cough/
Cold (Liquid)
Delsym Night Time Cough/
Cold Childrens (Liquid)
Delsym Night Time MultiSymptom (Liquid)
Dermacerin (Cream)
Dermamed (Ointment)
Dermaphor (Ointment)
Desenex Shake Powder
(Powder)
Dexferrum (Injection)
Dextromethorphan Polistirex
(Liquid Extended-Release)
Dextromethorphan/
Guaifenesin (Oral Solution)
Diabetic Siltussin DAS-Na
(Liquid)
Diabetic Siltussin-DM (Liquid)
Diabetic Siltussin-DM
Maximum Strength (Liquid)
Diabetic Tussin (Liquid)
Diabetic Tussin DM (Liquid)
Diabetic Tussin Maximum
Strength (Liquid)
Dialyvite 800 (Tablet)
Dialyvite Vitamin D3 Max
(Tablet)
Dimaphen Childrens (Elixir)
Dimaphen DM Cold/Cough
Childrens (Elixir)
Dimenhydrinate (OTC Only)
(Tablet)
Dimetapp Cold & Allergy
(Elixir)
Dimetapp DM Cold & Cough
(Liquid)
Dimetapp Long Acting Cough
Plus Cold (Syrup)
Dimetapp Multi-Symptom
Cold & Flu (Liquid)
E
E-Z Spacer (Device)
ED A-Hist (Liquid)
ED A-Hist DM (Liquid)
ED A-Hist PSE (Tablet)
ED Bron GP (Liquid)
ED Chlorped (Liquid)
ED Chlorped D (Liquid)
ED Chlorped Jr (Syrup)
ED Chlortan (Tablet)
Ear Drops (Otic Solution)
Ear Wax Removal Drops (Otic
Solution)
Ear Wax Removal Kit (Otic
Solution)
Ear Wax Removal System
Easivent
Ecpirin (Tablet DelayedRelease)
Endacof-DM (Liquid)
Enema Ready-To-Use
(Enema)
Enemeez Mini (Enema)
Enemeez Plus (Enema)
Enfamil Enfalyte (Oral
Solution)
Enfamil Expecta
Enteric Coated Aspirin (Tablet
Delayed-Release)
Ergocalciferol (Oral Solution)
Exefen-IR (Tablet)
Extra Action Cough (Syrup)
Eye Drops Allergy Relief
Ezfe Forte (Capsule)
F
Fallback Solo (Tablet)
Famotidine (OTC Only) (10mg
Tablet)
Fantasy Lubricated
Fantasy Lubricated/
Spermicide
Fast Acting Antacid Plus AntiGas Maximum Strength
(Suspension)
Fer-In-Sol (Oral Solution)
Fer-Iron (Oral Solution)
Feraheme (Injection)
Ferate (Tablet)
Ferosul (Elixir)
Ferrex 150 (Capsule)
Ferrlecit (Injection)
Ferrous Drops (Oral Solution)
69
Ferrous Gluconate (Tablet)
Ferrous Sulfate (140mg
220mg/5ml Liquid)
Ferrous Sulfate (15mg/ml
Oral Solution, 220mg/5ml
Elixir, 325mg Tablet)
Fever Reducer Childrens
(Suppository)
Feverall Adults (Suppository)
Feverall Childrens
(Suppository)
Feverall Infants (Suppository)
Feverall Junior Strength
(Suppository)
Fexofenadine HCl (Tablet)
Fiber Laxative (Tablet)
Fiber Tabs (Tablet)
Fiber Therapy (Powder)
Fiber-Lax (Tablet)
Fish Oil (1000mg-300mg
1000mg-300mg Capsule,
1200mg-360mg Capsule,
1200mg Capsule,
120mg-180mg-1000mg-34
0mg-1unit Capsule,
144mg-180mg-1200mg
Capsule,
144mg-216mg-1200mg
Capsule, 1000mg-300mg
Capsule, 1000mg Capsule)
Fleet Bisacodyl (Enema)
Fleet Enema (Enema)
Fleet Enema Six Pack
(Enema)
Fleet Laxative (Tablet
Delayed-Release)
Fleet Oil (Enema)
Fleet Pediatric (Enema)
Folic Acid (5mg/ml Injection)
Folic Acid (OTC Only)
(800mcg Tablet)
Drug LIST
Dimetapp Nighttime Cold
&congestion (Liquid)
Diocto (50mg/5ml Liquid,
60mg/15ml Syrup)
Diphenhist (OTC Only)
(12.5mg/5ml Liquid, 25mg
Diphenhydramine HCl (OTC
Only) (25mg Capsule, 50mg
Diphenhydramine HCl/Zinc
Acetate (OTC Only) (Cream)
Doc-Q-Lace (Capsule)
Doc-Q-Lax (Tablet)
Docu (Liquid)
Docusate Calcium (Capsule)
Docusate Sodium & Senna
Stimulant Laxative/Stool
Softener (Tablet)
Docusate Sodium (Capsule)
Docusil (Capsule)
Docusol Mini (Enema)
Double Antibiotic (Ointment)
Driminate (Tablet)
Drisdol (RX Only) (50000unit
Capsule, 8000unit/ml Oral
Solution)
Dristan Cold (Tablet)
Ducodyl (Tablet DelayedRelease)
Duofer (Tablet)
Folic Acid (RX Only) (1mg
Tablet)
Folitab 500 (Tablet ExtendedRelease)
Formula EM (Oral Solution)
Fosfree (Tablet)
Freshkote (Ophthalmic
Solution)
Fungoid Tincture (External
Solution)
Fungoid-D (Cream)
G
GNP 12 Hour Nasal Spray
(Nasal Solution)
GNP Acid Reducer (Tablet)
GNP Adult Aspirin Low
Strength (81mg Tablet
Delayed-Release)
GNP All Day Allergy (Tablet)
GNP All Day Allergy-D (Tablet
GNP All Day Pain Relief
(Tablet)
GNP Allergy & Congestion
Relief (Tablet ExtendedRelease 24 Hour)
GNP Allergy (25mg Capsule,
25mg Tablet, 4mg Tablet)
GNP Allergy Multi-Symptom
(Tablet)
GNP Allergy Plus Severe
Sinus Headache Maximum
Strength (Tablet)
GNP Allergy Relief (10mg
Tablet Dispersible, 180mg
Tablet)
GNP Allergy Relief for Kids
(Tablet Dispersible)
GNP Antacid Anti-Gas
(Suspension)
GNP Antacid Maximum
GNP Anti-Diarrheal (Tablet)
GNP Anti-Itch (Cream)
GNP Artificial Tears
GNP Aspirin (Tablet DelayedRelease)
GNP Aspirin Low Dose
(Tablet Delayed-Release)
GNP Bacitracin Zinc (OTC
Only) (Ointment)
GNP Bisa-Lax (Tablet
Delayed-Release)
GNP Calcium 500+D3
(Tablet)
GNP Calcium 500/D (Tablet)
GNP Calcium 600+D (Tablet)
GNP Calcium Citrate+D3
(Tablet)
GNP Calcium Plus 600+D
(Tablet)
GNP Calcuim/Vitamin D/
Minerals (Tablet Chewable)
GNP Capsaicin (Cream)
GNP Castor Oil
GNP Century (Tablet)
GNP Century Adults 50+
Senior (Tablet)
GNP Century Ultimate Mens
Complete (Tablet)
GNP Century Ultimate Mens
Senior Formula (Tablet)
GNP Century Ultimate
Womens Complete (Tablet)
GNP Century Ultimate
Womens Senior Formula
(Tablet)
GNP Childrens Chewables/
Extra C (Tablet Chewable)
GNP Childrens Chewables/
Iron (Tablet Chewable)
GNP Childrens Pain Relief
Plus Cold (Suspension)
GNP Childrens Plus Cough &
Sore Throat (Liquid)
GNP Childrens Plus MultiSymptom Cold (Suspension)
GNP Clearlax (Powder)
GNP Clotrimazole 3 (OTC
Only) (Cream)
GNP Cold & Allergy Childrens
(Elixir)
GNP Cold & Allergy Maximum
Strength (Tablet)
GNP Cold & Cough Childrens
(Elixir)
GNP Cold Head Congestion
Night Time (Tablet)
GNP Cold Head Congestion
GNP Cold Multi-Symptom
Daytime (Tablet)
GNP Cold Multi-Symptom
Nighttime (Tablet)
GNP Cold Relief Head
Congestion Severe Daytime
(Tablet)
GNP Cold Relief MultiSymptom Daytime (Tablet)
GNP Cold Relief MultiSymptom Severe Daytime
(Tablet)
GNP Cold Severe
Congestion/Daytime (Tablet)
GNP Cough DM ER (Liquid
Extended-Release)
GNP Cough Relief (Liquid)
GNP Daily Prenatal (OTC
Only) (Tablet)
GNP Day Time Cold & Flu
(Capsule)
GNP Day Time Cold/Flu
(Capsule)
GNP Day Time Cold/Flu
Relief (Liquid)
GNP Day Time Sinus
(Capsule)
GNP Dayhist Allergy (Tablet)
GNP Infants Gas Relief
(Suspension)
GNP Iron (200mg Tablet,
45mg Tablet ExtendedRelease)
GNP Itchy Eye (Ophthalmic
Solution)
GNP K-Pec (Suspension)
GNP Laxative (10mg
Suppository, 5mg Tablet
Delayed-Release)
GNP Lice Solution Kit (Kit)
GNP Lice Treatment (Liquid)
GNP Little Ones Childrens
(Tablet Chewable)
GNP Loperamide HCl (OTC
Only) (Suspension)
GNP Loratadine (10mg
Tablet, 5mg/5ml Syrup)
GNP Loratadine Childrens
(Syrup)
GNP Loratadine-D 12 Hour
12 Hour)
GNP Loratadine-D 24 Hour
24 Hour)
GNP Lubricant Eye Drops
GNP Lubricating Plus Eye
Drops (Ophthalmic Solution)
GNP Magnesium Citrate (Oral
Solution)
GNP Masanti Maximum
GNP Masanti Regular
GNP Miconazole 1 (Kit)
GNP Miconazole 3 (Kit)
GNP Miconazorb AF
(Powder)
GNP Milk of Magnesia
(Suspension)
GNP Mucus Relief (Tablet)
71
GNP Mucus Relief Cold &
Sinus (Tablet)
GNP Mucus Relief Cold Flu &
Sore Throat (Tablet)
GNP Mucus Relief Cough
Childrens (Liquid)
GNP Mucus Relief DM
(Tablet)
GNP Mucus Relief Severe
Congestion & Cold (Tablet)
GNP Mucus-ER (Tablet
GNP Multi-Symptom Cold
Nighttime (Liquid)
GNP Nasal Decongestant
(Tablet)
GNP Nasal Decongestant
Pemaximum Strength
(Tablet)
GNP Nasal Spray (Nasal
Solution)
GNP Nasal Spray Extra
Moisturizing (Nasal Solution)
GNP Natural Fiber (Powder)
GNP Niacin TR (OTC Only)
(Tablet Extended-Release)
GNP Nicotine Mini Lozenge
(Lozenge)
GNP Nicotine Polacrilex (2mg
Gum, 4mg Gum, 2mg
Lozenge, 4mg Lozenge)
GNP Nicotine Polacrilex Mini
(Lozenge)
GNP Night Time Cold & Flu
(Capsule)
Multi-Symptom (Liquid)
Multisymptom (Capsule)
GNP Night Time Cold/Flu
Relief (Liquid)
GNP Night Time Cough
(Liquid)
Drug LIST
GNP Docusate Calcium
(Capsule)
GNP Ear Drops (Otic Solution)
GNP Ear Systems (Otic
Solution)
GNP Enema (Enema)
GNP Essential One Daily
(Tablet)
GNP Eye Itch Relief
GNP Fiber Therapy (Tablet)
GNP Fiber-Caps (Tablet)
GNP Fish Oil (1200mg
175mg-260mg-435mg
Capsule)
GNP Flu Relief Therapy Seere
Cold Daytime (Liquid)
GNP Flu Relief Therapy
Severe Cold Nighttime
(Liquid)
GNP Foaming Antacid
(80mg-20mg Tablet
Chewable, 95mg/
15ml-358mg/15ml
Suspension)
GNP Gas Relief (Tablet
Chewable)
GNP Gas Relief Extra
GNP Gas Relief Maximum
GNP Hemorrhoidal
(14%-71.9%-0.25%-3%
Ointment, 85.5%-0.25%-3%
Suppository)
GNP Hydrocortisone (OTC
Only) (0.5% Cream)
GNP Ibuprofen (OTC Only)
(200mg Tablet)
GNP Ibuprofen Junior
Strength (OTC Only)
(100mg Tablet Chewable)
GNP Night Time Sinus
(Capsule)
GNP Nighttime Sleep Aid
(Tablet)
GNP No Drip Nasal Spray
(Nasal Solution)
GNP Nose Drops Extra
Strength (Nasal Solution)
GNP Omeprazole (OTC Only)
(20 mg Tablet DelayedRelease)
GNP One Daily Maximum
(Tablet)
GNP One Daily Plus Iron
(Tablet)
GNP Pediatric Electrolyte
(Oral Solution)
GNP Povidone-Iodine
(External Solution)
GNP Prenatal (OTC Only)
(Tablet)
GNP Pseudoephedrine HCl
12 Hour (Tablet ExtendedRelease 12 Hour)
GNP Pseudoephedrine HCl
ER (Tablet ExtendedRelease 12 Hour)
GNP Senna Plus (Tablet)
GNP Sinus Congestion & Pain
Daytime (Tablet)
GNP Sinus Congestion/Pain
Nighttime (Tablet)
GNP Sinus Relief Congestion
& Pain Daytime/Nighttime
GNP Sinus Relief Congestion
& Pain Nighttime (Tablet)
GNP Slow Release Iron
(Tablet Extended-Release)
GNP Stomach Relief
(Suspension)
GNP Stomach Relief
Maximum Strength
(Suspension)
GNP Stool Softener (100mg
Capsule, 50mg/5ml Liquid,
60mg/15ml Syrup)
GNP Stool Softener/Stimulant
Laxative (Tablet)
GNP Suphedrin (Liquid)
GNP Tab Tussin (Tablet)
GNP Tab Tussin DM (Tablet)
GNP Terbinafine HCl (OTC
Only) (Cream)
GNP Tioconazole 1
(Ointment)
GNP Tolnaftate (Cream)
GNP Triacting Night Time
Cold & Cough Childrens
(Liquid)
GNP Triple Antibiotic
(Ointment)
GNP Triple Antibiotic Plus
(Ointment)
GNP Tussin (Syrup)
GNP Tussin CF Cough &
Cold (Syrup)
GNP Tussin CF Max MultiSymptom Cold (Liquid)
GNP Tussin Cough Long
Acting (Syrup)
GNP Tussin DM (Liquid)
GNP Tussin DM Cough
(Liquid)
GNP Tussin DM Max (Liquid)
GNP Tussin DM Max Cough
& Chest Congestion (Liquid)
GNP Tussin Night Time
(Liquid)
GNP Ultra Lubricant Eye
Drops (Ophthalmic Solution)
Gas Relief (20mg/0.3ml
Chewable)
Gas Relief Maximum Strength
(Tablet Chewable)
Gas-X Extra Strength (Tablet
Chewable)
Gavilax (Powder)
Gaviscon (Suspension)
GenTeal Mild to Moderate
Genteal Mild (Ophthalmic
Solution)
Genteal PM (Ointment)
Genteal Severe (Gel)
Geravim (Liquid)
Geriaton (Liquid)
Glucose (Tablet Chewable)
Glutose 15 (Gel)
Glycerin (Liquid)
Glycolax (Powder)
Goodsense All Day Allergy
(Tablet)
Guaiatussin AC (Syrup)
Guaifenesin (100mg/5ml Oral
Solution, 200mg Tablet)
Guaifenesin AC (Syrup)
Guaifenesin DAC (Oral
Solution)
Guaifenesin ER (Tablet
Guaifenesin-DM (Syrup)
Guaifenesin/Codeine (Oral
Solution)
H
HM Advanced Antacid
Maximum Strength
(Suspension)
HM All Day Allergy (Tablet)
HM Allergy & Congestion
12 Hour)
HM Allergy (Tablet)
HM Allergy Complete-D
12 Hour)
HM Day Time (Capsule)
HM Double Antibiotic
(Ointment)
HM Earwax Removal Aid (Otic
Solution)
HM Earwax Removal Kit (Otic
Solution)
HM Enema (Enema)
HM Enema Mineral Oil
(Enema)
HM Eye Itch Relief
HM Famotidine (OTC Only)
(10mg Tablet)
HM Fexofenadine HCl
(Tablet)
HM Fiber (0.52gm Capsule,
28.3% Powder, 30.9%
Powder, 48.57% Powder,
58.6% Powder, 500mg
Tablet)
HM Fish Oil (Capsule
Delayed-Release)
HM Gas Relief (Tablet
Chewable)
HM Gas Relief Infants Drops
(Suspension)
HM Glucose (Tablet
Chewable)
HM Ibuprofen (OTC Only)
Tablet)
HM Ibuprofen IB (OTC Only)
(200mg Tablet)
HM Ibuprofen Infants (OTC
Only) (50mg/1.25ml
Suspension)
HM Laxative (Tablet DelayedRelease)
HM Lice Killing Maximum
Strength (Shampoo)
HM Lice Treatment (Lotion)
HM Loperamide HCl (OTC
Only) (Suspension)
73
HM Loratadine Childrens
(Syrup)
HM Lubricating Plus
HM Magnesium Citrate (Oral
Solution)
HM Milk of Magnesia
(Suspension)
HM Motion Sickness Relief
(Tablet)
HM Mucus ER (Tablet
HM Naproxen Sodium (OTC
Only) (220mg Tablet
Immediate-Release)
HM Nasal Decongestant
(Tablet)
HM Nasal Decongestant 12
Hour (Tablet ExtendedRelease 12 Hour)
HM Nasal Decongestant PE
(Tablet)
HM Nasal Spray (Nasal
Solution)
HM Niacin (Tablet ExtendedRelease)
HM Nicotine Polacrilex (2mg
Gum, 4mg Gum, 2mg
HM Nicotine Transdermal
System (Patch 24 Hour)
HM Nicotine Transdermal
System Step 3 (Patch 24
Hour)
HM Night Time Cold & Flu
(Liquid)
HM Night Time Multi
Symptom Cold & Flu
(Capsule)
HM Nose Drops Extra
Strength (Nasal Solution)
HM Omeprazole (OTC Only)
(20 mg Tablet DelayedRelease)
Drug LIST
HM Allergy Relief &
Nasaldecongestant (Tablet
HM Allergy Relief (10mg
Tablet, 4mg Tablet)
HM Allgery Multi Symptom
(Capsule)
HM Antacid Anti-Gas Extra
HM Antacid/Antigas
(Suspension)
HM Anti-Diarrheal (Tablet)
HM Anti-Nausea (Oral
Solution)
HM Artificial Tears
HM Aspirin (325mg Tablet,
81mg Tablet Chewable)
HM Aspirin EC (Tablet
Delayed-Release)
HM Aspirin EC Low Dose
HM Bacitracin (OTC Only)
(Ointment)
HM Calcium/Vitamin D
(Tablet)
HM Castor Oil
HM Chest Congestion Relief
(Tablet)
HM Chest Congestion Relief
DM (Tablet)
HM Clearlax (Powder)
HM Cold & Allergy Childrens
(Elixir)
HM Cold & Cough Childrens
(Elixir)
HM Cold & Sinus Relief
(Tablet)
HM Complete (Tablet)
HM Complete 50+ (Tablet)
HM Cough DM (Liquid
Extended-Release)
HM Cough Relief (Liquid)
HM One Daily/Iron (Tablet)
HM Pediatric Electrolyte
(Solution)
HM Povidone-Iodine (External
Solution)
HM Saline Nasal Spray (Nasal
Solution)
HM Senna (Tablet)
HM Senna-S (Tablet)
HM Sinus Nasal Spray (Nasal
Solution)
HM Stomach Relief
(Suspension)
HM Stomach Relief Maximum
HM Stool Softener (Capsule)
HM Stool Softener/Laxative
(Tablet)
HM Triple Antibiotic
(Ointment)
HM Tussin Adult (Liquid)
HM Tussin Adult Cough &
Chest Congestion DM
(Liquid)
HM Tussin Adult MultiSymptom Cold (Liquid)
HM Vitamin B Complex/
Vitamin C (Tablet)
Healthy Eyes (Tablet)
Healthylax (Packet)
Heartburn Relief (Tablet)
Hem-Prep (Suppository)
Hemorrhoid (Suppository)
Hemorrhoidal
(14%-71.9%-0.25%-3%
Ointment,
14%-74.9%-0.25%
Ointment, 85.5%-0.25%-3%
Suppository)
Hemorrhoidal Suppositories
(Suppository)
Hydro Skin Maximum
Strength (Lotion)
Hydrocodone Bitartrate/
Homatropine Methylbromide
(1.5mg-5mg Tablet, 1.5mg/
5ml-5mg/5ml Syrup)
Hydrocodone Polistirex/
Chlorpheniramine Polistirex
(Liquid Extended-Release)
Hydrocortisone (OTC Only)
(0.5% Cream, 1% Cream,
0.5% Ointment)
Hydrocortisone/Aloe (OTC
Only) (Cream)
Hydromet (Syrup)
Hydroxocobalamin (Injection)
I
I-Caps (Capsule)
I-Vite (Tablet)
Ibu-Drops (OTC Only)
(Suspension)
Ibu-Drops Infants (OTC Only)
(Suspension)
Ibuprofen (OTC Only) (200mg
Ibuprofen Junior Strength
(OTC Only) (100mg Tablet
Chewable)
Iferex 150 (Capsule)
In-Check Inspiratory
Flowmeter/Nasal with Mask
(Device)
In-Check Inspiratory
Flowmeter/Oral (Device)
Infants Gas Relief
(Suspension)
Infants Ibuprofen (OTC Only)
(50mg/1.25ml Suspension)
Infants Simethicone
(Suspension)
Infed (Injection)
Infuvite (Injection)
Infuvite Adult (Injection)
Infuvite Pediatric (Injection)
InspiraChamber/Anti-Static
Valved/Mouthpiece (Device)
Inspirachamber/
Soothermask/Inspiramask/
Medium (Device)
Inspirachamber/
Soothermask/Inspiramask/
Small (Device)
Intense Cough Reliever Extra
Strength (Liquid)
Ionil-T (Shampoo)
Iophen C-NR (Liquid)
Iophen DM-NR (Liquid)
Iophen-NR (Liquid)
Iron (Tablet)
Iron Chews Pediatric (Tablet
Chewable)
Isopto Tears (Ophthalmic
Solution)
Itch Relief Extra Strength
(Cream)
J
J-TAN D PD (Liquid)
Jock Itch Spray (Aerosol
Powder)
K
Kao-Tin (240mg Capsule,
262mg/15ml Suspension)
Ketotifen Fumarate
Kidkare Cough/Cold (Liquid)
Kimono Lubricated
Kimono Micro Thin
Kimono Micro Thin Plus
Spermicide Lubricated
Kimono Sensation Lubricated
Kimono Sensation Plus
Spermicide Lubricated
Konsyl (28.3% Powder,
30.9% Powder, 520mg
Capsule)
Konsyl (60.3% Packet, 60.3%
Powder, 71.67% Powder)
Konsyl Fiber (Tablet)
Konsyl-D (Powder)
M
M-Clear WC (Oral Solution)
M-End PE (Liquid)
M-End WC (Liquid)
M.V.I. 12 without Vitamin K
(Injection)
M.V.I. Adult (Injection)
M.V.I. Pediatric (Injection)
MYTAB GAS (Tablet
Chewable)
MYTAB GAS Maximum
Maalox Advanced
(Suspension)
Maalox Advanced Maximum
Mag-Delay (Tablet ExtendedRelease)
Mag-G (Tablet)
Mag-Tab SR (Tablet
Extended-Release)
Magnebind 300 (Tablet)
Magnesium Citrate (Oral
Solution)
Magnesium Oxide (241.3mg
Tablet)
Magonate (1000mg/5ml
Liquid)
Magonate (500mg Tablet)
Major-Prep Hemorrhoidal
(Ointment)
75
Manganese Trace Metal
(Injection)
Mapap Sinus Maximum
Strength Congestion and
Pain (Tablet)
Maximum D3 (Capsule)
Maxx Lubricated
Meclizine HCl (OTC Only)
(Tablet Chewable)
Medi-Cortisone (Cream)
Mephyton (Tablet)
Meribin (Capsule)
Metamucil (Powder)
Metamucil Multihealth Fiber
(Powder)
Metamucil Original Texture
(Powder)
Metamucil Smooth Texture
(Powder)
Metamucil Smooth Texture
Sugar Free (Powder)
Mi-Acid (Suspension)
Mi-Acid Gas Relief (Tablet
Chewable)
Mi-Acid Maximum Strength
(Suspension)
Miconazole (Cream)
Miconazole 1 (Kit)
Miconazole 3 Combo Pack
(Kit)
Miconazole 7 (100mg
Suppository, 2% Cream)
Miconazole Nitrate (100mg
Suppository, 2% Cream)
Miconazorb AF (Powder)
Micro Guard (Powder)
Microchamber
Microlife Digital Peak Flow
Meter (Device)
Microspacer
Milantex (Suspension)
Milantex Extra Strength
(Suspension)
Drug LIST
L
L-Arginine (Powder)
L-Citrulline (Powder)
L-Glutamine (Powder)
Lactrase (Capsule)
Lamisil AF Defense (Aerosol
Powder)
Lamisil AT (Cream)
Lamisil AT Spray (External
Solution)
Lamisil Advanced (Gel)
Laxative (10mg Suppository,
5mg Tablet DelayedRelease)
Levonorgestrel (OTC Only)
(Tablet)
Lice Killing Maximum
Strength (Shampoo)
Lice Solution Kit (Kit)
Lice Treatment Creme Rinse
(Liquid)
Lidocaine (OTC Only)
(Cream)
Lidocream (Cream)
Liq-10 (Syrup)
Liquituss GG (Liquid)
Liteaire (Device)
LoHist-D (Liquid)
LoHist-DM (Syrup)
LoHist-PEB (Liquid)
Long Acting Nasal Spray
(Nasal Solution)
Loperamide HCl (OTC Only)
(1mg/5ml Liquid, 1mg/
7.5ml Suspension)
Loratadine (Tablet)
Loratadine Childrens (5mg/
Syrup)
Loratadine Hives Relief (Oral
Solution)
Loratadine-D 12 Hour (Tablet
Loratadine-D 24 Hour (Tablet
Lortuss EX (Liquid)
Lotrimin AF (Powder)
Lotrimin Ultra (Cream)
Lubricant Eye Drops Dry Eye
Therapy (Ophthalmic
Solution)
Lubricating Plus Eye Drops
Milk of Magnesia
(Suspension)
Milk of Magnesia Concentrate
(Suspension)
Minerin (Cream)
Mini Wright AFS Peak
Flowmeter Low Range
(Device)
Mini Wright Peak Flow Meter
(Device)
Miniprin Low Dose (Tablet
Delayed-Release)
Mintox (Suspension)
Mintox Maximum Strength
(Suspension)
Miralax (Packet, Powder)
Moisturizing Cream (Cream)
Motion Sickness (Tablet)
Motion-Time (Tablet
Chewable)
Mucinex (Tablet ExtendedRelease 12 Hour)
Mucinex Allergy (Tablet)
Mucinex Chest Congestion
Childrens (Liquid)
Mucinex Childrens Cold
Cough & Sore Throat
(Liquid)
Mucinex Childrens MultiSymptom Cold & Fever
(Liquid)
Mucinex Childrens MultiSymptom Cold (Liquid)
Mucinex Cold for Kids
(Liquid)
Mucinex Congestion & Cough
Childrens (Liquid)
Mucinex Cough Childrens
(Liquid)
Mucinex D (Tablet ExtendedRelease 12 Hour)
Mucinex DM (Tablet
Mucinex DM Maximum
Strength (Tablet ExtendedRelease 12 Hour)
Mucinex Fast-Max Cold &
Sinus (Tablet)
Mucinex Fast-Max Cold Flu&
Sore Throat (Liquid)
Mucinex Fast-Max Cold Flu&
Sore Throat (Tablet)
Mucinex Fast-Max DM Max
(Liquid)
Mucinex Fast-Max Night Time
Cold & Flu (Tablet, Liquid)
Mucinex Fast-Max Severe
Cold
(325mg-10mg-200mg-5mg
Tablet)
Cold (Liquid)
Congestion & Cold (Tablet)
Congestion & Cough
(Liquid)
Mucinex Maximum Strength
12 Hour)
Mucinex Multi-Symptom Cold
Night Time Childrens
(Liquid)
Mucinex Nasal Spray Full
Force (Nasal Solution)
Mucinex Nasal Spray
Moisture Smart (Nasal
Solution)
Mucinex Sinus-Max Full Force
(Nasal Solution)
Mucinex Sinus-Max Pressure
& Pain (Tablet)
Mucinex Sinus-Max Severe
Congestion Relief (Tablet)
Mucinex Stuffy Nose & Cold
Childrens (Liquid)
Mucinex for Kids (Packet)
Mucosa (Tablet)
Mucosa DM (Tablet)
Mucus Relief (Tablet)
Mucus Relief Childrens
(Liquid)
Mucus Relief Cold/Sinus
Maximum Strength (Liquid)
Mucus Relief Cough
Childrens (Liquid)
Mucus Relief DM (Tablet)
Mucus Relief Severe
Congestion/Cough (Liquid)
Mucus-DM (Tablet ExtendedRelease 12 Hour)
Mucus-DM Max (Tablet
Mucus-ER (Tablet ExtendedRelease 12 Hour)
Multi-Delyn (Liquid)
Multi-Delyn/Iron (Liquid)
Multi-Symptom Allergy
(Capsule)
Multi-Vitamins (Tablet)
Multilex (Tablet)
Multilex T&M (Tablet)
Muro 128 (5% Ointment, 5%
My Way (OTC Only) (Tablet)
MyKidz Iron 10 (Suspension)
Mykidz Iron (Suspension)
N
NRS Nasal Relief (Nasal
Solution)
Nail Scrub (Liquid)
Naproxen Sodium (OTC Only)
(220mg Tablet ImmediateRelease)
Nasal Decongestant (1%
Nasal Solution, 30mg
Tablet)
Nasal Decongestant (30mg/
5ml Liquid, 30mg/5ml
Syrup)
Nicorette (2mg Gum, 4mg
Gum, 2mg Lozenge, 4mg
Lozenge)
Nicorette Mini (Lozenge)
Nicorette Starter Kit (Gum)
Nicotine (Patch 24 Hour)
Nicotine Polacrilex (2mg
Gum, 4mg Gum, 2mg
Nicotine Transdermal System
(Patch 24 Hour)
Night Time Multi-Symptom
Cold/Flu Relief (Capsule)
Nighttime Sinus Congestion &
Pain (Tablet)
Nighttime Sleep Aid (Tablet)
Nite Time Cough (Liquid)
Nite Time Multi-Symptom
Cold/Flu Relief (Liquid)
Nite-Time Cold/Flu (Capsule)
Nite-Time Multi-Symptom
Cold/Flu Relief (Liquid)
Nohist-DM (Liquid)
Nohist-LQ (Liquid)
Novaferrum 125 (Liquid)
Novaferrum 50 (Capsule)
Novaferrum Pediatric Drops
(Liquid)
Nutraplus (10% Cream, 10%
Lotion)
O
ORA-Blend SF (Suspension)
ORA-Sweet SF (Syrup)
Ocean Nasal Spray (Nasal
Solution)
Ocean for Kids (Nasal
Solution)
Ocuvite Adult 50+ (Capsule)
Omega-3 Fish Oil (Capsule)
Omeprazole (OTC Only)
(20mg Tablet DelayedRelease)
Once Daily (Tablet)
77
Once Daily/Iron (Tablet)
One Daily (Tablet)
One Daily Mens (Tablet)
Opcicon One-Step (Tablet)
Operand Scrub (External
Solution)
Opti-Clear (Ophthalmic
Solution)
Optichamber Diamond
Optichamber Diamond/
Largeface Mask (Device)
Optichamber Diamond/
Medium Face Mask
Optichamber Diamond/Small
Face Mask
Ora-Blend (Suspension)
Ora-Plus (Liquid)
Oralyte (Oral Solution)
Oralyte Freezer Pops (Oral
Solution)
Organ-I NR (Tablet)
Oysco 500+D (Tablet
Chewable)
Oyster Shell Calcium (Tablet)
Oyster Shell Calcium+Vitamin
D (Tablet)
Oyster Shell Calcium/Vitamin
D (Tablet)
P
PRO-RED AC (Syrup)
Pain Relief Cold Severe
Congestion (Tablet)
Pain Relief Sinus PE Daytime
(Tablet)
Panoxyl Wash (Liquid)
Panoxyl-4 Creamy Wash
(Liquid)
Peak Air Peak Flow Meter
Adult/Pediatric (Device)
Pedi-Boro Soak Paks (Packet)
Pedia Relief Cough/Cold
(Liquid)
Pedia-Lax (Liquid)
Drug LIST
Nasal Decongestant PE
(Tablet)
Nasal Decongestant PE
Maximum Strength (Tablet)
Nasal Decongestant Spray
(Nasal Solution)
Nasal Spray 12 Hour (Nasal
Solution)
Nasal Spray Anti-Drip (Nasal
Solution)
Nasal Spray X-Moist (Nasal
Solution)
Natural Coenzyme Q10
(Capsule)
Natural Fiber Laxative
(Powder)
Natural Fiber Therapy
(Powder)
Nephro-Vite (Tablet)
Nessi Spacer/Large Mask
(Device)
Nessi Spacer/Mouthpiece
(Device)
Nessi Spacer/Small/Med
Mask (Device)
Next Choice One Dose (OTC
Only) (Tablet)
Niacin ER (OTC Only)
(Capsule Extended-Release)
Niacin Flush Free Formula
(OTC Only) (Capsule)
Niacin SR (OTC Only)
(Capsule Extended-Release)
Niacin TR (OTC Only)
(250mg Capsule ExtendedRelease, 500mg Capsule
750mg Tablet ExtendedRelease)
Nicoderm CQ (Patch 24
Hour)
Nicorelief (Gum)
Pedialyte (Oral Solution)
Pedialyte Advanced Care
(Solution)
Pedialyte Freezer Pops (Oral
Solution)
Pediatric Cough/Cold (Liquid)
Pediatric Electrolyte (Oral
Solution)
Pediatric Electrolyte Freezer
Pops (Oral Solution)
Pediatric Electrolyte/Zinc
(Oral Solution)
Pediatric Medium Mask
Pediatric Small Mask
Peleverus (Ointment, 0.25%
Liquid)
Peleverus Clear (Ointment)
Peleverus Gold (Ointment)
Peptic Relief (Suspension)
Periguard (Ointment)
Permethrin (OTC Only)
(Lotion)
Personal Best Full Range
(Device)
Personal Best Low Range
(Device)
Petrolatum (Ointment)
Pharbechlor (Tablet)
Pharbedryl (Capsule)
Phenylhistine DH (Liquid)
Phos-NaK Powder
Concentrate (Packet)
Piko 1 Electronic (Device)
Pink Bismuth Maximum
Plan B One-Step (OTC Only)
(Tablet)
Pocket Chamber (Device)
Pocket Peak Flow Meter
(Device)
Poly Vitamin (Tablet
Chewable)
Poly-Iron 150 (Capsule)
Polyvitamin (Oral Solution)
Polyvitamin/Iron (Oral
Solution, Tablet Chewable)
Povidone-Iodine (10%
External Solution, 10%
Ointment)
Premium Condoms
Lubricated
Prenatal (OTC Only) (Tablet)
Preparation H (Ointment)
Preservision Areds 2
(Capsule)
Prilosec OTC (Tablet DelayedRelease)
Primeaire Dual-Valved
Holding Chamber (Device)
Pro-Clear AC (Syrup)
Profe (Capsule)
Profe Forte (Capsule)
Promethazine VC/Codeine
(Syrup)
Promethazine-DM (Syrup)
Promethazine/Codeine
(Syrup)
Promethazine/
Dextromethorphan (Syrup)
Provil (Tablet)
Pseudoephedrine HCl
(Tablet)
Pseudoephedrine HCl ER
12 Hour)
Puralube (Ointment)
Pure & Gentle Lubricant
Q
Q-Dryl (Capsule)
Q-Gel Mega (Capsule)
Q-Tapp (Elixir)
Q-Tapp DM (Elixir)
Q-Tussin (Syrup)
Q-Tussin DM (Syrup)
QC 3 Day Vaginal Cream
(Cream)
QC AZO (Tablet)
QC Acid Controller (Tablet)
QC All Day Allergy (Tablet)
QC Allergy Relief (Tablet
Dispersible)
QC Allergy Relief MultiSymptom Daytime (Tablet)
QC Antacid (Suspension)
QC Antacid/Anti-Gas
(Suspension)
QC Antacid/Anti-Gas
Maximum Strength
(Suspension)
QC Anti-Diarrheal (Tablet)
QC Aspirin (325mg Tablet,
325mg Tablet DelayedRelease)
QC Aspirin Low Dose (Tablet
Delayed-Release)
QC Athletes Foot (Cream)
QC Bacitracin (OTC Only)
(Ointment)
QC Castor Oil
QC Childrens Aspirin (Tablet
Chewable)
QC Childrens Chewable
Vitamins/Extra C (Tablet
Chewable)
QC Childrens Chewable
Vitamins/Iron (Tablet
Chewable)
QC Chlor-Pheniramine
(Tablet)
QC Cold Relief Plus MultiSymptom Childrens
(Suspension)
QC Complete Allergy
Medicine (Tablet)
QC Cough Relief (Liquid)
QC Cough/Sore Throat
Nighttime (Liquid)
QC Nighttime Cold/Flu Relief
(Liquid)
QC Nighttime Cough (Liquid)
QC No Drip Nasal Relief
(Nasal Solution)
QC Pink Bismuth
(Suspension)
QC Prenatal (OTC Only)
(Tablet)
QC Senna (Tablet)
QC Senna-S (Tablet)
QC Sinus Pain Relief (Tablet)
QC Stool Softener (Capsule)
QC Stool Softener Plus
Laxative (Tablet)
QC Suphedrine (Tablet)
QC Suphedrine Maximum
Strength (Tablet ExtendedRelease 12 Hour)
QC Suphedrine PE (Tablet)
QC Therin-M (Tablet)
QC Tolnaftate (Cream)
QC Tussin CF (Liquid)
QC Womens Daily
Multivitamin (Tablet)
R
Reeses Pinworm Medicine
(Suspension)
Refresh Celluvisc (Ophthalmic
Solution)
Refresh P.M. (Ointment)
Refresh Plus (Ophthalmic
Solution)
Reguloid (0.52gm Capsule,
28.3% Powder, 48.57%
Powder, 58.6% Powder)
Relcof C (Oral Solution)
Remedy Antifungal (2%
Cream, 2% Powder)
Remedy Nutrashield (Cream)
Remedy Skin Repair (Cream)
Rena-Vite (Tablet)
Rescon DM (Syrup)
79
Rescon-GG (Liquid)
Respaire-30 (Capsule)
Rhinaris (Gel)
Risabal-pH (Cream)
Risacal-D (Tablet)
Riteflo (Device)
Robafen (Syrup)
Robafen CF Cough & Cold
(Syrup)
Robafen DM (Syrup)
Robafen DM Cough Clear
(Syrup)
Robitussin Childrens Cough &
Cold CF (Liquid)
Robitussin Childrens Cough
Long-Acting (Syrup)
Robitussin Childrens Cough/
Cold Long-Acting (Liquid)
Robitussin Cold+flu Daytime
(Capsule)
Robitussin Cold+flu Nighttime
(Capsule)
Robitussin Lingering
Coldlong-Acting Cough
(Liquid)
Robitussin Mucus+chest
Congestion (Liquid)
Robitussin Peak Cold Cough
+ Chest Congestion DM
(Liquid)
Robitussin Peak Cold Cough
+ Chest Congestion DM
Max Strength (Liquid)
Robitussin Peak Cold DM
(Syrup)
Robitussin Peak Cold MultiSymptom Cold (Liquid)
Robitussin Peak Cold MultiSymptom Cold Maximum
Strength (Liquid)
Robitussin Peak Cold Nasal
Relief (Tablet)
Drug LIST
QC Daily Multivitamins/Iron
(Tablet)
QC Docusate Calcium
(Capsule)
QC Ear Wax Removal Drops
(Otic Solution)
QC Enema (Enema)
QC Ferrous Sulfate (Tablet)
QC Fiber Laxative (Capsule)
QC Gas Relief (Tablet
Chewable)
QC Gas Relief Extra Strength
(Tablet Chewable)
QC Gentle Laxative (10mg
Suppository, 5mg Tablet
Delayed-Release)
QC Hemorrhoidal
(Suppository)
QC Ibuprofen (OTC Only)
(200mg Tablet)
QC Ibuprofen IB (OTC Only)
(200mg Tablet)
QC Loratadine Allergy Relief
(Tablet)
QC Loratadine-D (Tablet
QC Magnesium Citrate (Oral
Solution)
QC Maximum Daily
Multivitamin/Multimineral
(Tablet)
QC Medifin Mucus Relief
Childrens (Liquid)
QC Milk of Magnesia
(Suspension)
QC Multi-Vite (Tablet)
QC Multi-Vite 50 & Over
(Tablet)
QC Naproxen Sodium (OTC
Only) (220mg Tablet
Immediate-Release)
QC Natural Vegetable
(Powder)
Robitussin Peak Cold
Nighttime Multi-Symptom
Cold (Liquid)
Robitussin Peak Cold
Nighttime Nasal Relief
(Tablet)
Rulox (Suspension)
Rydex (Liquid)
Rynex DM (Liquid)
Rynex PE (Elixir)
Rynex PSE (Liquid)
S
SB Allergy (Tablet)
SB Antacid Anti-Gas
(Suspension)
SB Anti-Itch Maximum
Strength (Cream)
SB Aspirin (81mg Tablet
Delayed-Release)
SB Bismuth (Suspension)
SB Cold & Cough HBP
(Tablet)
SB Cold Head Congestion
SB Cold Multi-Symptom
SB Cough Control CF (Liquid)
SB Cough Control DM
(Liquid)
SB Cough Control DM Max
(Liquid)
SB Cough Relief (Liquid)
SB Coughtab (Tablet)
SB Flu Maximum Strength
HBP (Tablet)
SB Ibuprofen (OTC Only)
(200mg Tablet)
SB Lice Killing Maximum
Strength (Shampoo)
SB Loratadine (Tablet)
SB Naproxen Sodium (OTC
Only) (220mg Tablet
Immediate-Release)
SB Sinus & Allergy Maximum
Strength (Tablet)
SB Sinus Congestion & Pain
Daytime (Tablet)
Daytime/Nighttime
SM 12 Hour Sinus
Decongestant (Tablet
SM 12-Hour No Drip (Nasal
Solution)
SM 3-Day Vaginal (Cream)
SM Acid Reducer (Tablet)
SM All Day Allergy (Tablet)
SM All Day Allergy-D (Tablet
SM All Day Pain Relief
(220mg Tablet ImmediateRelease)
SM Allergy 4 Hour (Tablet)
SM Allergy Multi-Symptom
(Tablet)
SM Allergy Relief (1.34mg
Capsule)
SM Allergy Relief Loratadine
(Tablet)
SM Antacid Advanced
Maximum Strength
(Suspension)
SM Antacid Anti-Gas
(Suspension)
SM Antacid Maximum
SM Anti-Diarrheal (1mg/5ml
Liquid, 2mg Tablet)
SM Anti-Itch Extra Strength
(Cream)
SM Antifungal Miconazole
(Cream)
SM Antifungal Tolnaftate
(Cream)
SM Artificial Tears
SM Aspirin Adult Low
Strength (81mg Tablet
Delayed-Release)
SM Aspirin Enteric Coated
SM Aspirin Low Dose (Tablet
Delayed-Release)
SM Athletes Foot (Cream)
SM Calcium Citrate w/Vitamin
D3 (Tablet)
SM Castor Oil
SM Childrens Aspirin (Tablet
Chewable)
SM Childrens Loratadine
(Syrup)
SM Childrens Pain Relief Plus
Multi-Symptom Cold
(Suspension)
SM Clearlax (Powder)
SM Clotrimazole Vaginal
(OTC Only) (Cream)
SM Cold & Allergy Childrens
(Elixir)
SM Cold & Cough DM
Childrens (Elixir)
SM Cold Head Congestion
Severe Day Time (Tablet)
SM Complete Advanced
Formula (Tablet)
SM Complete Senior Formula
(Tablet)
SM Cough Relief (Syrup)
SM Day Time Cold & Flu
Relief (Liquid)
SM Day Time PE Cold &
Flurelief (Capsule)
SM Docusate Calcium
(Capsule)
SM Loratadine Allergy Relief
(Tablet Dispersible)
SM Loratadine-D 12 Hour
12 Hour)
SM Lubricant Eye Drops
SM Miconazole 7 (OTC Only)
(100mg Suppository, 2%
Cream)
SM Milk of Magnesia
(Suspension)
SM Mucus ER (Tablet
SM Mucus Relief Cough
Childrens (Liquid)
SM Naproxen Sodium (OTC
Only) (220mg Capsule
Immediate-Release)
SM Nasal Decongestant
Maximum Strength (Tablet)
SM Nasal Decongestant PE
(Tablet)
SM Nasal Spray Moisturizing
(Nasal Solution)
SM Nasal Spray Saline (Nasal
Solution)
SM Nasal Spray Sinus (Nasal
Solution)
SM Natural Laxative Plus
Stool Softener (Tablet)
SM Nicotine (14mg/24hr
Patch 24 Hour, 21mg/24hr
Patch 24 Hour, 7mg/24hr
Patch 24 Hour, 2mg
Lozenge, 4mg Gum)
SM Nicotine Polacrilex (2mg
Gum, 4mg Gum, 4mg
Lozenge)
SM Nite Time Cold & Flu
(Liquid)
81
SM Nite Time Cold & Flu
Relief
(325mg-15mg-6.25mg
Capsule, 500mg/
15ml-15mg/15ml-6.25mg/
15ml Liquid)
SM Nite Time Cough (Liquid)
SM Nose Drops Nasal
Decongestant Extra Strength
(Nasal Solution)
SM Omega-3 Fish Oil
(Capsule)
SM Omeprazole (OTC Only)
(20mg Tablet DelayedRelease)
SM Oral Saline Laxative (Oral
Solution)
SM Pediatric Electrolyte (Oral
Solution)
SM Stomach Relief
(Suspension)
SM Stomach Relief Maximum
SM Stool Softener (Capsule)
SM Stool Softener Plus
Laxative (Tablet)
SM Tioconazole-1 (Ointment)
SM Triple Antibiotic
(Ointment)
SM Tussin (Syrup)
SM Tussin CF (Liquid)
SM Tussin DM (Syrup)
SM Tussin DM Cough/Chest
Congestion (Syrup)
SM Tussin DM Max Cough/
Chest Congestion (Liquid)
SM Womans Laxative (Tablet
Delayed-Release)
Sal-Plant (Gel)
Salactic Film (External
Solution)
Saline Mist (Nasal Solution)
Saline Nasal Spray (Nasal
Solution)
Drug LIST
SM Double Antibiotic
(Ointment)
SM Enema (Enema)
SM Eye Itch Relief
SM Fexofenadine HCl (Tablet)
SM Fiber (Powder)
SM Fiber Laxative (0.52gm
625mg Tablet)
SM Flu Relief Therapy Severe
Cold Nighttime (Liquid)
SM Foaming Antacid (Tablet
Chewable)
SM Gas Relief (Tablet
Chewable)
SM Gas Relief Drops Infants
(Suspension)
SM Gas Relief Infants Drops
(Suspension)
SM Gentle Laxative (Tablet
Delayed-Release)
SM Glucose (Tablet
Chewable)
SM Hemorrhoidal (Ointment)
SM Hydrocortisone (OTC
Only) (Cream)
SM Ibuprofen (OTC Only)
(200mg Tablet)
SM Ibuprofen IB (OTC Only)
(200mg Tablet)
SM Infants Ibuprofen (OTC
Only) (50mg/1.25ml
Suspension)
SM Iron (Tablet)
SM Laxative (Suppository)
SM Lice Killing Maximum
Strength (Shampoo)
SM Lice Treatment (Lotion)
SM Loperamide HCl (OTC
Only) (Suspension)
SM Lorata-Dine D (Tablet
SM Loratadine (Syrup)
Sea Soft Nasal Mist (Nasal
Solution)
Sea-Omega 30 (Capsule)
Sea-Omega 50 (Capsule)
Senexon (8.6mg Tablet,
8.8mg/5ml Liquid)
Senexon-S (Tablet)
Senna (8.6mg Tablet, 8.8mg/
5ml Syrup)
Senna Lax (Tablet)
Senna Plus (Tablet)
Senna Prompt (Capsule)
Senna-S (Tablet)
Senna-Tabs (Tablet)
Senna-Time (Tablet)
Sennalax-S (Tablet)
Senno (Tablet)
Sennosides/Docusate
Sodium (Tablet)
Sensi-Care Protective Barrier
(Ointment)
Sentry (Tablet)
Sentry Senior (Tablet)
Sesame Oil
Sidestream Pediatric
Facemask/Tucker the Turtle
Silace (150mg/15ml Liquid,
60mg/15ml Syrup)
Siladryl Allergy (Liquid)
Silicone Mask for Breatherite
Chamber/Infant
Silicone Mask for Breatherite
Chamber/Pediatric
Siltussin SA (Syrup)
Siltussin-DM (Syrup)
Simethicone (40mg/0.6ml
Chewable)
Sinus Congestion & Pain
Daytime (Tablet)
Sinus Nasal Spray (Nasal
Solution)
Slo-Niacin (OTC Only)
(250mg Tablet ExtendedRelease)
Slo-Niacin (OTC Only)
(500mg Tablet ExtendedRelease, 750mg Tablet
Extended-Release)
Slow-Mag (Tablet DelayedRelease)
Sodium Bicarbonate (Tablet)
Sodium Chloride (OTC Only)
(5% Ointment, 5%
Soothe & Cool Free Moisture
Barrier (Ointment)
Soothe & Cool INZO
Antifungal Cream (Cream)
Soothe & Cool Protect
Moisture Barrier (Ointment)
Sterile Water for Injection
(Injection)
Stimulant Laxative (Tablet
Delayed-Release)
Stomach Relief (Suspension)
Stomach Relief Maximum
Stool Softener (Capsule)
Stool Softener Extra Strength
(Capsule)
Stool Softener Laxative DC
(Capsule)
Stress Formula (Tablet)
Stress Formula w/Iron (Tablet)
Stress Formula/Zinc (OTC
Only) (Tablet)
Stuart One (Capsule)
Sudogest (Tablet)
Sudogest 12 Hour (Tablet
Sudogest PE (Tablet)
Sudogest Sinus & Allergy
(Tablet)
Superplex-T (Tablet)
Systane (Ophthalmic Solution)
Systane Balance Restorative
Formula (Ophthalmic
Solution)
Systane Gel (Gel)
Systane Nighttime (Ointment)
Systane Overnight Therapy
Lubricant Eye (Gel)
Systane Ultra (Ophthalmic
Solution)
T
TAB-A-VITE (Tablet)
TAB-A-VITE Womens (Tablet)
TAB-A-VITE w/Beta Carotene
(Tablet)
TAB-A-VITE/Iron (Tablet)
TGT Glucose (Tablet
Chewable)
Take Action (Tablet)
Tears Naturale (Ophthalmic
Solution)
Tears Naturale Forte
Tears Naturale II (Ophthalmic
Solution)
Tears Pure (Ophthalmic
Solution)
Terbinafine HCl (OTC Only)
(Cream)
Tessalon Perles (Capsule)
Thera (Tablet)
Thera M Plus (Tablet)
Thera-M (Tablet)
Thera/Beta-Carotene (Tablet)
Therems (Tablet)
Therems-H (Tablet)
Therems-M (Tablet)
Thiamine HCl (Injection)
Tinactin (Aerosol)
Tioconazole-1 (Ointment)
Tolnaftate (1% Cream, 1%
External Solution, 1%
Powder)
Truzone Peak Flow Meter
(Device)
Tusnel (Liquid)
Tusnel Diabetic (Liquid)
Tusnel Pediatric (Liquid)
Tussi-Pres PE Pediatric
(Liquid)
Tussigon (Tablet)
Tussin (Syrup)
Tussin CF (Liquid)
Tussin CF Cough & Cold
(Liquid)
Tussin CF Max MultiSymptom (Liquid)
Tussin Chest Congestion
(Syrup)
Tussin Cough (Syrup)
Tussin DM (10mg-100mg/
5ml Liquid, 10mg/
5ml-100mg/5ml Syrup)
Tussin DM Max (Liquid)
Tussin Mucus + Chest
Congestion (Syrup)
Tussionex Pennkinetic
Extended-Release (Liquid
Extended-Release)
Vita-Bee/C (Tablet)
Vitamin B Complex-C
(Capsule)
Vitamin C (Tablet)
Vitamin D (RX Only) (1000unit
Capsule, 2000unit Capsule,
400unit/ml Liquid,
50000unit Capsule)
Vitamin D3 (OTC Only)
(10000unit Capsule,
50000unit Capsule,
5000unit Capsule, 1000unit
Tablet, 5000unit Tablet,
400unit/ml Liquid)
Vitamin D3 Super Strength
(OTC Only) (Tablet)
Vitamin K1 (10mg/ml
Injection)
Vitamin K1 (1mg/0.5ml
Injection)
Vortex Holding Chamber/
Mask/Childs (Device)
Vortex Holding Chamber/
Mask/Toddler (Device)
Vortex Valved Holding
Chamber (Device)
U
Unicomplex-M (Tablet)
Urea (10% Cream, 10%
Lotion)
Ureacin-10 (Lotion)
W
Watchhaler (Device)
Womans Laxative (Tablet
Delayed-Release)
V
Vagistat-1 (Ointment)
Vagistat-3 (Kit)
Valved Holding Chamber
(Device)
Vanahist PD (Liquid)
Venofer (Injection)
Vicks Dayquil Mucus Control
DM (Liquid)
Virtussin A/C (Oral Solution)
Virtussin DAC (Oral Solution)
83
Z
Zaditor (Ophthalmic Solution)
Zeasorb-AF (Powder)
Ziks Arthritis Pain Relief
(Cream)
Zinc Sulfate (OTC Only)
(220mg Capsule)
Zinc Trace Metal (Injection)
Zonatuss (Capsule)
Zoo Friends (Tablet
Chewable)
Zoo Friends Complete (Tablet
Chewable)
Drug LIST
Travel Sickness (25mg Tablet
Chewable, 50mg Tablet)
Tri-Vita (Oral Solution)
Tri-Vitamin (Oral Solution)
Triacting Nightime Cold&
Cough Childrens (Liquid)
Triaminic Cold & Allergy
(Syrup)
Triaminic Cold & Cough Day
Time Childrens (Syrup)
Triaminic Cough &
Congestion Childrens
(Syrup)
Triaminic Cough & Sore
Throat (Suspension)
Triaminic Multi-Symptom
Fever (Syrup)
Triaminic Night Time Cold &
Cough (Syrup)
Triple Antibiotic (Ointment)
Trixaicin (Cream)
Trixaicin HP (Cream)
Trustex Lubricated
Trustex Lubricated Extra
Large
Trustex Lubricated Extra
Strength
Trustex Lubricated/Ribbed/
Studded
Trustex Lubricated/
Spermicide
Trustex Lubricated/
Spermicide Extra Large
Trustex Lubricated/
Spermicide Extra Strength
Trustex Non-Lubricated
Trustex with Nonoxynol-9/
Ribbed/Studded
Trustex/Ria Lubricated
Trustex/Ria Lubricated
Spermicide
Trustex/Ria Lubricated/
Spermicide
Trustex/Ria Non-Lubricated
Zoo Friends Gummies (Tablet
Chewable)
Zoo Friends Plus Extra C
(Tablet Chewable)
Zoo Friends Plus Iron (Tablet
Chewable)
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid
Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is
available to anyone who has both Medical Assistance from the State and Medicare.
UHNJ16MP3700480_000
Ready to
ENROLL
UHEX16MP3700084_001
Enrollment
INSTRUCTIONS
We want to make your health care experience as easy as possible right from the start. Below we’ve
described the forms you need to fill out to enroll in your plan. Questions? Ask your licensed sales
representative or call the number on the first page of this booklet.
Sales Appointment
Confirmation Form
(use only with a
licensed sales
representative)
If you are meeting with a licensed sales representative, you will need to fill out
this form completely before your appointment can begin. On this form, you’ll select
which products and services you’d like to discuss during your appointment.
Enrollment
request form
We need certain information to complete your enrollment. This form gathers
that information. Two copies of the form are included. Fill out only one form for
each applicant.
For Dual Special Needs Plans, you have to provide your Social Security number
so we can verify your Medicaid eligibility.
Please sign your application, then return the completed enrollment form.
By mail: UnitedHealthcare
Attn: Enrollment Department
3315 Central AVE
Hot Springs, AR, 71913
By fax: 1-501-262-7070
Enrollment
checklist (use
only with a licensed
sales representative)
This checklist helps ensure that your licensed sales representative explains
the plan clearly to you and that you fully understand the plan you’ve chosen.
Enrollment
receipt (use only
with a licensed
sales representative)
Your licensed sales representative will help you fill out this receipt. You can
use the completed receipt as your temporary proof of coverage until you receive
your permanent membership materials.
If you received this kit through the mail, not from a licensed sales representative,
you will not receive an enrollment receipt.
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan’s contract renewal with Medicare.
Y0066_150608_140046 Accepted
CSAL16HM3709721_000
86
TEAR HERE
Scope of Sales Appointment Confirmation Form
Page 1 of 2
The Centers for Medicare and Medicaid Services requires Licensed Sales Representatives 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 Licensed Sales Representative 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
Licensed Sales Representative to discuss.
(Refer to page 2 for product type descriptions)
Stand-alone Medicare Prescription Drug Plans (Part D)
Hospital Indemnity Products
Medicare Advantage Plans (Part C) and Cost Plans
Medicare Supplement
(Medigap) Products
Dental/Vision/Hearing Products
By signing this form, you agree to a meeting with a Licensed Sales Representative 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
Signature Date
If you are the authorized representative, please sign above and print clearly and legibly below:
Name (First_Last)
Relationship to Beneficiary
To be completed by Licensed Sales Representative (please print clearly and legibly)
Licensed Sales Representative Name
(First_Last)
Licensed Sales
Representative Phone
Licensed Sales
Representative ID
Beneficiary Name (First_Last)
Beneficiary Phone (Optional)
Date Appointment
will be Completed
Initial Method of Contact
Plan(s) the Licensed Sales Representative will represent
during the meeting
Licensed Sales Representative Signature
Scope of appointment (SOA) is subject to CMS Record Retention Requirements
Licensed Sales Representative, if the form was not signed by the beneficiary at time of appointment, provide
explanation why SOA was not documented prior to meeting: Please check all that apply
Unplanned Attendee
Walk-in
New SOA required (consumer requested other Health Product information)
Other (please explain):
Y0066_140611_154714 Approved
87
Ready to ENROLL
TEAR HERE
Beneficiary Address (Optional)
Page 2 of 2
Fax to: 1-866-994-9659
Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to
Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-For-Service Plans, and Medicare
Medical Savings Account Plans.
Medicare Advantage Plans (Part C) and Cost Plans
Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all
Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug
coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except
in emergencies).
Medicare HMO Point-of-Service (HMO-POS) Plans — A Medicare Advantage Plan that provides all Original
Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. HMOPOS plans may allow you to get some services out of network for a higher copayment or coinsurance.
Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides
all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug
coverage. PPOs have network doctors, providers and hospitals but you can also use out-of-network
providers, usually at a higher cost.
Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any
Medicare-approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and
agrees to treat you — not all providers will. If you join a PFFS Plan that has a network, you can see any of the
network providers who have agreed to always treat plan members. You will usually pay more to see out-ofnetwork providers.
Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed
for people with special health care needs. Examples of the specific groups served include people who have
both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic
medical conditions.
Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan
with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your
medical expenses until your deductible is met.
Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you
get services outside of the plan’s network, your Medicare-covered services will be paid for under Original
Medicare but you will be responsible for Medicare coinsurance and deductibles.
Other Related Products
Dental/Vision/Hearing Products — Plans offering additional benefits for consumers who are looking to
cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare.
Hospital Indemnity Products — Plans offering additional benefits; payable to consumers based upon
their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are not affiliated or
connected to Medicare.
Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the out-of-pocket
costs not paid by Original Medicare (Parts A and B) such as deductibles and co-insurance amounts for
Medicare approved services.
companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal
with Medicare.
UHEX16MP3693102_000
88
2016 Enrollment Request Form
Page 1 of 6
Please contact the Plan if you need information in another language or format (Braille).
TEAR HERE
□ UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-005 - UDO
This plan is designed for people with both Medicare and Medicaid. We may need to contact you to ask for
proof. If we can't get proof before the enrollment deadline, you won’t be able to join the plan.
This is a Health Maintenance Organization (HMO) plan. It has a network of doctors, specialists, hospitals and
other providers you must use.
Information about you.
Please type or print in black or blue ink.
o Mr.
Last Name
o Mrs.
o Ms.
First Name
Middle Initial
Birth Date M M / D D / Y Y Y Y
Sex ¨ Male ¨ Female
Main Phone Number (
Other Phone Number (
)
-
Social Security Number
(Required for people who are enrolling in D-SNP plans):
_
)
-
_
Permanent Street Address (P.O. BOX IS NOT ALLOWED)
City
County
State
ZIP
TEAR HERE
Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.)
City
State
ZIP
Email Address
Copy 1
Enrollee name
89
This page intentionally left blank.
90
Page 2 of 6
Information about your Medicare
Please use the information from your red, white and blue Medicare card. Remember, you need to have both
Medicare Part A and Part B to join this plan.
You can simply fill in the blanks so they
match your card.
TEAR HERE
Or, you can attach a copy of the card or your
letter from Social Security or the Railroad
Retirement Board.
How do you want to pay?
You can pay your monthly plan premium if one applies, (including any late enrollment penalty you may owe)
by mail or from your bank account through Electronic Funds Transfer (EFT). You can also choose to pay your
premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each
month.
This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late
enrollment penalty (LEP), we’ll add it to your premium.
If you don’t choose an option, we’ll send a bill each month to your mailing address.
¨ I want to pay by mail.
We’ll send a bill to your mailing address each month.
¨ I want to pay directly from my bank account.
Please attach a blank check from the account you’d like to use. Write “VOID” across the front.
Please DO NOT send a deposit slip or money order.
· Please read the statement below.
My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare
Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my
checking account on or about the fifth of each month. If I choose to stop paying directly from my account,
I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of
payment.
TEAR HERE
·
Account Type □ Checking □ Savings
Account Holder Name: _________________________________________________________________
Bank Routing Number
Copy 1
Bank Account Number
·
Sign here:
¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check.
We’ll set it up. It may take a few months before payment starts, so the first payment may include more than
one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the
Enrollee name
91
92
Page 3 of 6
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.
A few notes about your costs.
TEAR HERE
If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA)
Social Security (SS) will send you a letter and ask you how you want to pay it:
·
·
·
You can pay it from your SS check
Medicare can bill you
The Railroad Retirement Board (RRB) can bill you
Please DO NOT pay the plan the Part D-IRMAA at this time.
Need help with your prescription drug costs?
If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify,
Medicare could pay for 75% or more of your costs, including your monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty.
Many people are eligible for these savings and don’t even know it. If you qualify for extra help with your
Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare
pays only part of your premium, we will bill you for the amount that Medicare doesn’t cover.
For more information about this extra help, contact your local Social Security office, or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at
www.socialsecurity.gov/prescriptionhelp.
A few questions to help us manage your plan.
¨ Yes ¨ No
1. Do you want plan information in another language or format?
Please check what you’d like:
¨ Spanish
¨ Chinese
¨ Other
TEAR HERE
If you don’t see the language or format you want, please call us at 1-888-834-3721, (TTY 711) during 8 a.m. to
8 p.m. local time, 7 days a week. Or visit www.UHCCommunityPlan.com for online help.
¨ Yes ¨ No
2. Do you have end stage renal disease?
If you have had a successful kidney transplant and/or you don’t need regular dialysis anymore, 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.
¨ Yes ¨ No
If “yes,” are you currently a member of a health care company?
Name of Company
Member ID
¨ Yes ¨ No
3. Do you have Medicaid?
If yes, please give us your Medicaid number:
Enrollee name
93
_
Copy 1
_
94
Page 4 of 6
¨ Yes ¨ No
4. Do you live in a nursing home or a long-term care facility?
If yes, please give us:
Name
City
Address
TEAR HERE
Phone Number (
)
--
State
Date you moved there
ZIP
M M/D D/Y Y Y Y
¨ Yes ¨ No
5. Do you have health insurance with an employer or union right now?
If yes, you could lose that plan if you join this plan. Please talk to your employer or union. Ask how joining
our plan could affect your current plan. You may also want to check your employer or union’s website, or
read any information sent to you. If there isn’t any information on whom to contact, your benefits
administrator or the office that answers questions about your coverage can help.
¨ Yes ¨ No
6. Do you or your spouse work?
Do you or your spouse have other health insurance that will cover medical services?
(Examples: Other employer group coverage, LTD coverage, Workman’s Compensation,
Auto Liability, or Veterans benefits)
If yes, please complete the following:
¨ Yes ¨ No
Name of Health Insurance Company
Subscriber Name
Group ID
Member ID
Effective Dates (if applicable)
M M/D D/Y Y Y Y - M M/D D/Y Y
¨ Yes ¨ No
7. Do you have other insurance that will cover your prescription drugs?
TEAR HERE
Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs.
If yes, what is it?
Name of other insurance
Member ID number
Group ID number
Date plan started
M M/D D/Y Y Y Y
8. Please give us the name of your primary care provider (PCP), clinic or health center.
You can find a list on the plan website or in the provider directory.
Provider/PCP ID number:
Phone number: (
)
-
(Please enter the number exactly as it appears on the
website or in the directory. It will be 10 to 12 digits.
Don't include dashes.)
Are you now seeing or have you recently seen this doctor?
Enrollee name
95
¨ Yes ¨ No
Copy 1
Provider or PCP full name
96
Page 5 of 6
Please read and sign.
TEAR HERE
TEAR HERE
By completing this form, I agree to the following:
· This is a Medicare Advantage plan. It has a contract with the federal government. This is not a Medicare
Supplement plan.
· I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless
Medicaid or someone else pays for it.
· I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another
Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan.
· If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan.
· I may have to pay a late enrollment penalty (LEP). This would only happen if I didn’t sign up for and keep
creditable prescription drug coverage when I first qualified for Medicare. “Creditable” means the
coverage is as good as a Medicare prescription drug plan. If I need to pay a LEP, the plan will tell me.
· I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do
so during the Open Enrollment Period for Medicare Advantage AND Medicare prescription drug
coverage between October 15 and December 7. There may be special situations that would allow me to
leave the plan at other times.
· This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in
the new area. Medicare may not cover me when I’m out of the country. However, I have some limited
coverage near the U.S. border.
· I will get an Evidence of Coverage (EOC). (The EOC is also known as a member contract or subscriber
agreement.) The EOC will list services the plan covers, as well as the plan’s terms and conditions. The
plan will cover services it approves, as well as services listed in the EOC. If a service isn’t listed in the EOC
or approved by the plan, Medicare and the plan won’t pay for it. If I disagree with how the plan covers my
care, I have the right to make an appeal.
· I understand that I must get my health care coverage from doctors or providers that are in my plan’s
network. I can go to any doctor or hospital in an emergency or urgently needed services or out-of-area
dialysis services.
· If I currently have Medicare Supplement Insurance (Medigap), I will cancel it in writing. I, not my agent,
must cancel. I will cancel after my new plan tells me I’ve been accepted into the plan.
· My plan will give my information to Medicare and other plans when needed for treatment, payment and
health care operations. This may include my prescription drug information. Medicare uses the information
to understand how my care was handled or billed. Other plans may need my information when they help
pay for my care. Medicare may also give my information for research and other purposes. All federal laws
and rules protecting my privacy will be followed.
· If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay
that person for this help.
· The information on this form is correct, to the best of my knowledge. I understand that if I put information
on this form that I know is not true, I will lose the plan.
When I sign below, it means that I have read and understand the information on this form.
Signature of applicant / member / authorized representative:
Enrollee name
97
Today’s date:
M M / D D / Y Y Y Y
Copy 1
If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show
written proof of this right if Medicare asks for it.
98
Page 6 of 6
If you are the authorized representative, please sign above and complete the information below.
First Name
Last Name
Address
State
TEAR HERE
City
Phone Number (
)
ZIP Code
Relationship to Applicant
--
For licensed sales representative/agency use only.
New Member
Plan Change
Employer Group Name
Branch ID
Employer Group ID
Where did this application originate?
□ Retail/Mall Program
□ Member Meeting
□ Local Event Outreach
□ Community Meeting
How was this application submitted?
Appointment
Other
□ Local B2B Outreach
□ Other
Mail In
Licensed Sales Representative/Writing ID
Initial Receipt Date
M M/D D/Y Y Y Y
Licensed Sales Representative/Agent Name
Proposed Effective Date
M M/D D/Y Y Y Y
Licensed Sales Representative Phone Number (
)
--
TEAR HERE
Agent must complete
AEP
OEPI
ICEP (MA enrollees)
SEP (SEP Reason)
SEP (Chronic)
IEP (MA-PD enrollees)
SEP (Full Dual Eligible)
IEP (MA-PD enrollees eligible for 2nd IEP)
SEP (Partial Dual Eligible)
SEP Eligibility Date M M / D D / Y Y Y Y
Licensed Sales Representative Signature (required)
Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al
número 1-888-834-3721, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana
本資訊也有其他語言的免費版本。請撥打 1-888-834-3721 聯絡我們的客戶服務部, 聽語障專線711, 每
週7天, 當地時間上午8 時至晚上8 時
Y0066_150729_133227 Approved
CSNJ16HM3724996_002
99
Copy 1
This information is available for free in other languages. Please call our customer service number at
1-888-834-3721, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
100
2016 Enrollment Request Form
Page 1 of 6
Please contact the Plan if you need information in another language or format (Braille).
TEAR HERE
□ UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-005 - UDO
This plan is designed for people with both Medicare and Medicaid. We may need to contact you to ask for
proof. If we can't get proof before the enrollment deadline, you won’t be able to join the plan.
This is a Health Maintenance Organization (HMO) plan. It has a network of doctors, specialists, hospitals and
other providers you must use.
Information about you.
Please type or print in black or blue ink.
o Mr.
Last Name
o Mrs.
o Ms.
First Name
Middle Initial
Birth Date M M / D D / Y Y Y Y
Sex ¨ Male ¨ Female
Main Phone Number (
Other Phone Number (
)
-
Social Security Number
(Required for people who are enrolling in D-SNP plans):
_
)
-
_
Permanent Street Address (P.O. BOX IS NOT ALLOWED)
City
County
State
ZIP
TEAR HERE
Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.)
City
State
ZIP
Email Address
Copy 2
Enrollee name
101
102
Page 2 of 6
Information about your Medicare
Please use the information from your red, white and blue Medicare card. Remember, you need to have both
Medicare Part A and Part B to join this plan.
You can simply fill in the blanks so they
match your card.
TEAR HERE
Or, you can attach a copy of the card or your
letter from Social Security or the Railroad
Retirement Board.
How do you want to pay?
You can pay your monthly plan premium if one applies, (including any late enrollment penalty you may owe)
by mail or from your bank account through Electronic Funds Transfer (EFT). You can also choose to pay your
premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each
month.
This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late
enrollment penalty (LEP), we’ll add it to your premium.
If you don’t choose an option, we’ll send a bill each month to your mailing address.
¨ I want to pay by mail.
We’ll send a bill to your mailing address each month.
¨ I want to pay directly from my bank account.
Please attach a blank check from the account you’d like to use. Write “VOID” across the front.
Please DO NOT send a deposit slip or money order.
· Please read the statement below.
My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare
Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my
checking account on or about the fifth of each month. If I choose to stop paying directly from my account,
I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of
payment.
TEAR HERE
·
Account Type □ Checking □ Savings
Account Holder Name: _________________________________________________________________
Bank Routing Number
Copy 2
Bank Account Number
·
Sign here:
¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check.
We’ll set it up. It may take a few months before payment starts, so the first payment may include more than
one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the
Enrollee name
103
104
Page 3 of 6
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.
A few notes about your costs.
TEAR HERE
If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA)
Social Security (SS) will send you a letter and ask you how you want to pay it:
·
·
·
You can pay it from your SS check
Medicare can bill you
The Railroad Retirement Board (RRB) can bill you
Please DO NOT pay the plan the Part D-IRMAA at this time.
Need help with your prescription drug costs?
If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify,
Medicare could pay for 75% or more of your costs, including your monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty.
Many people are eligible for these savings and don’t even know it. If you qualify for extra help with your
Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare
pays only part of your premium, we will bill you for the amount that Medicare doesn’t cover.
For more information about this extra help, contact your local Social Security office, or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at
www.socialsecurity.gov/prescriptionhelp.
A few questions to help us manage your plan.
¨ Yes ¨ No
1. Do you want plan information in another language or format?
Please check what you’d like:
¨ Spanish
¨ Chinese
¨ Other
TEAR HERE
If you don’t see the language or format you want, please call us at 1-888-834-3721, (TTY 711) during 8 a.m. to
8 p.m. local time, 7 days a week. Or visit www.UHCCommunityPlan.com for online help.
¨ Yes ¨ No
2. Do you have end stage renal disease?
If you have had a successful kidney transplant and/or you don’t need regular dialysis anymore, 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.
¨ Yes ¨ No
If “yes,” are you currently a member of a health care company?
Name of Company
Member ID
¨ Yes ¨ No
3. Do you have Medicaid?
If yes, please give us your Medicaid number:
Enrollee name
105
_
Copy 2
_
106
Page 4 of 6
¨ Yes ¨ No
4. Do you live in a nursing home or a long-term care facility?
If yes, please give us:
Name
City
Address
TEAR HERE
Phone Number (
)
--
State
Date you moved there
ZIP
M M/D D/Y Y Y Y
¨ Yes ¨ No
5. Do you have health insurance with an employer or union right now?
If yes, you could lose that plan if you join this plan. Please talk to your employer or union. Ask how joining
our plan could affect your current plan. You may also want to check your employer or union’s website, or
read any information sent to you. If there isn’t any information on whom to contact, your benefits
administrator or the office that answers questions about your coverage can help.
¨ Yes ¨ No
6. Do you or your spouse work?
Do you or your spouse have other health insurance that will cover medical services?
(Examples: Other employer group coverage, LTD coverage, Workman’s Compensation,
Auto Liability, or Veterans benefits)
If yes, please complete the following:
¨ Yes ¨ No
Name of Health Insurance Company
Subscriber Name
Group ID
Member ID
Effective Dates (if applicable)
M M/D D/Y Y Y Y - M M/D D/Y Y
¨ Yes ¨ No
7. Do you have other insurance that will cover your prescription drugs?
TEAR HERE
Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs.
If yes, what is it?
Name of other insurance
Member ID number
Group ID number
Date plan started
M M/D D/Y Y Y Y
8. Please give us the name of your primary care provider (PCP), clinic or health center.
You can find a list on the plan website or in the provider directory.
Provider/PCP ID number:
Phone number: (
)
-
(Please enter the number exactly as it appears on the
website or in the directory. It will be 10 to 12 digits.
Don't include dashes.)
Are you now seeing or have you recently seen this doctor?
Enrollee name
107
¨ Yes ¨ No
Copy 2
Provider or PCP full name
108
Page 5 of 6
Please read and sign.
TEAR HERE
TEAR HERE
By completing this form, I agree to the following:
· This is a Medicare Advantage plan. It has a contract with the federal government. This is not a Medicare
Supplement plan.
· I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless
Medicaid or someone else pays for it.
· I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another
Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan.
· If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan.
· I may have to pay a late enrollment penalty (LEP). This would only happen if I didn’t sign up for and keep
creditable prescription drug coverage when I first qualified for Medicare. “Creditable” means the
coverage is as good as a Medicare prescription drug plan. If I need to pay a LEP, the plan will tell me.
· I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do
so during the Open Enrollment Period for Medicare Advantage AND Medicare prescription drug
coverage between October 15 and December 7. There may be special situations that would allow me to
leave the plan at other times.
· This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in
the new area. Medicare may not cover me when I’m out of the country. However, I have some limited
coverage near the U.S. border.
· I will get an Evidence of Coverage (EOC). (The EOC is also known as a member contract or subscriber
agreement.) The EOC will list services the plan covers, as well as the plan’s terms and conditions. The
plan will cover services it approves, as well as services listed in the EOC. If a service isn’t listed in the EOC
or approved by the plan, Medicare and the plan won’t pay for it. If I disagree with how the plan covers my
care, I have the right to make an appeal.
· I understand that I must get my health care coverage from doctors or providers that are in my plan’s
network. I can go to any doctor or hospital in an emergency or urgently needed services or out-of-area
dialysis services.
· If I currently have Medicare Supplement Insurance (Medigap), I will cancel it in writing. I, not my agent,
must cancel. I will cancel after my new plan tells me I’ve been accepted into the plan.
· My plan will give my information to Medicare and other plans when needed for treatment, payment and
health care operations. This may include my prescription drug information. Medicare uses the information
to understand how my care was handled or billed. Other plans may need my information when they help
pay for my care. Medicare may also give my information for research and other purposes. All federal laws
and rules protecting my privacy will be followed.
· If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay
that person for this help.
· The information on this form is correct, to the best of my knowledge. I understand that if I put information
on this form that I know is not true, I will lose the plan.
When I sign below, it means that I have read and understand the information on this form.
Signature of applicant / member / authorized representative:
Enrollee name
109
Today’s date:
M M / D D / Y Y Y Y
Copy 2
If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show
written proof of this right if Medicare asks for it.
110
Page 6 of 6
If you are the authorized representative, please sign above and complete the information below.
First Name
Last Name
Address
State
TEAR HERE
City
Phone Number (
)
ZIP Code
Relationship to Applicant
--
For licensed sales representative/agency use only.
New Member
Plan Change
Employer Group Name
Branch ID
Employer Group ID
Where did this application originate?
□ Retail/Mall Program
□ Member Meeting
□ Local Event Outreach
□ Community Meeting
How was this application submitted?
Appointment
Other
□ Local B2B Outreach
□ Other
Mail In
Licensed Sales Representative/Writing ID
Initial Receipt Date
M M/D D/Y Y Y Y
Licensed Sales Representative/Agent Name
Proposed Effective Date
M M/D D/Y Y Y Y
Licensed Sales Representative Phone Number (
)
--
TEAR HERE
Agent must complete
AEP
OEPI
ICEP (MA enrollees)
SEP (SEP Reason)
SEP (Chronic)
IEP (MA-PD enrollees)
SEP (Full Dual Eligible)
IEP (MA-PD enrollees eligible for 2nd IEP)
SEP (Partial Dual Eligible)
SEP Eligibility Date M M / D D / Y Y Y Y
Licensed Sales Representative Signature (required)
Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al
número 1-888-834-3721, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana
本資訊也有其他語言的免費版本。請撥打 1-888-834-3721 聯絡我們的客戶服務部, 聽語障專線711, 每
週7天, 當地時間上午8 時至晚上8 時
Y0066_150729_133227 Approved
CSNJ16HM3724996_002
111
Copy 2
This information is available for free in other languages. Please call our customer service number at
1-888-834-3721, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
112
2016 Enrollment
CHECKLIST
Your Licensed Sales Representative has given you a lot of information about the plan you have chosen.
TEAR HERE
For each topic, please fill out information on this sheet and check each box to confirm you
understand what you and your Licensed Sales Representative have reviewed. If you have any
questions, please ask.
PLAN INFORMATION Here are some details about your plan and coverage.
My new plan is (circle one):
Medicare supplement insurance (Medigap) policy
Medicare Advantage plan
Medicare Part D plan
The name of my new plan is: .
My plan coverage begins (effective date): M M / D D / Y Y Y Y
My plan type is (circle):
HMO
HMO-POS
My plan type: Requires referrals
LPPO
RPPO
PFFS
Does not require referrals
I have purchased a rider(s) as part of my plan: Yes
No
N/A
I must have Medicare Part A and Part B to enroll in this plan.
My plan is available only in the plan’s service area, which is:
.
If I move outside of the service area, I will ask my Licensed Sales Representative or Customer Service to
help me choose a new plan.
My plan will now provide all my Medicare health coverage and prescription drug coverage.
TEAR HERE
I can cancel this plan before it goes into effect by calling Customer Service at
If my plan coverage starts and I want to leave the plan, I will generally need to wait until the Open
Enrollment Period, unless I qualify for a Special Election Period.
Y0066_150708_012328A Accepted
113
.
Ready to ENROLL
I should not have a Medicare Advantage plan and a Medicare supplement insurance (Medigap)
policy at the same time. If I have a Medicare supplement policy right now, once I receive confirmation
of my enrollment in my new Medicare Advantage plan, I will write to that insurance company,
, to cancel my Medicare supplement policy.
I cannot have a Medicare Advantage plan and a stand-alone Medicare Part D plan at the same
time. (There is one exception: Medicare Advantage Private Fee-for-Service plans that do not include
prescription drug coverage.)
PREMIUM INFORMATION What you need to know about paying a monthly premium.
I need to continue to pay my Medicare Part B premium unless the state or another third party pays this
premium for me.
My plan: Does not have a premium (monthly payment). Has a $
monthly premium (this would include the cost of any riders if applicable).
I must pay this monthly premium to stay in this plan.
NETWORK INFORMATION Understanding your network is important.
My current Primary Care Provider (PCP) is:
.
My specialists are:
.
My Licensed Sales Representative has confirmed that my PCP and my other providers are part of my
plan’s network, and has explained whether or not my plan requires provider referrals.
He/She has explained how provider referrals work. I need to get my care and services from network
providers. The only exceptions are emergencies, urgent care or out‑of-area dialysis services. I may have to
pay the full cost for any care I get outside of the network.
PRESCRIPTION DRUG COVERAGE Know what is covered by your prescription drug plan.
My prescription drug plan will cover only those drugs included on my plan’s list of covered drugs. My
Licensed Sales Representative helped me confirm whether my current medications are on my plan’s
drug list, and showed me how to look up any medications I am prescribed in the future.
My current medications are:
I understand how my prescription drug plan works, including:
• T
he cost difference between network
pharmacies and out-of-network pharmacies
• Tier levels
• Prior authorizations
• Quantity limits
• Step therapy
• Coverage gap drug stages and how they
impact my costs
• Late Enrollment Penalty
Remember that plans can change each year.
We’ll send you an Annual Notice of Changes prior to the Open Enrollment Period. It will tell you about
any changes to your plan for the next year. If your needs change throughout the year or you have
questions about your plan, please call your Licensed Sales Representative or Customer Service. A
few examples of when to call are: getting a new prescription, changing your doctor, or moving.
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan
depends on the plan's contract renewal with Medicare.
UHEX16HM3710668_000
114
TEAR HERE
2016 Enrollment Receipt
To be completed if enrolling with a licensed Sales Representative.
Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and
you have received your permanent membership materials. You will receive a copy of your original
Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your
local licensed Sales Representative.
This copy is for your records only. Please do not resubmit enrollment.
Applicant 1:
Applicant 2 (if applicable):
Name ____________________________________
Name ____________________________________
Application Date
MM / D D / Y Y Y Y
Application Date
MM / D D / Y Y Y Y
Proposed Effective Date M M / D D / Y Y Y Y
Plan Name ________________________________
Plan Name _____________________________
Plan Type _________________________________
Plan Type _________________________________
Health Plan/PBP No. _______________________
Health Plan/PBP No. _____________________
Enrollment Tracking No. (if applicable) _________
If you have any questions, please contact your local Licensed Sales Representative:
RxBIN: 610097
Licensed Sales Representative Name _______________________________
Rx PCN: 8500
Licensed Sales Representative Phone No. ____________________________
RxGRP:
MPDACUNJ
Licensed Sales Representative ID __________________________________
Questions? We’re always here to help.
Simply call the Customer Service number listed on the first page of this booklet.
Important Reminder - Once you have received confirmation of enrollment in your new Medicare
Advantage plan, if you are currently enrolled in a Medicare Supplement plan you must contact the plan
in writing with your intention to cancel your policy.
TEAR HERE
Copy 1
Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
Enrollment in the plan depends on the plan’s contract renewal with Medicare.
Y0066_150629_142455 Accepted
CSNJ16DU3707322_000
115
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116
TEAR HERE
2016 Enrollment Receipt
To be completed if enrolling with a licensed Sales Representative.
Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and
you have received your permanent membership materials. You will receive a copy of your original
Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your
local licensed Sales Representative.
This copy is for your records only. Please do not resubmit enrollment.
Applicant 1:
Applicant 2 (if applicable):
Name ____________________________________
Name ____________________________________
Application Date
MM / D D / Y Y Y Y
Application Date
MM / D D / Y Y Y Y
Plan Name ________________________________
Plan Name _____________________________
Plan Type _________________________________
Plan Type _________________________________
Health Plan/PBP No. _______________________
Health Plan/PBP No. _____________________
If you have any questions, please contact your local Licensed Sales Representative:
RxBIN: 610097
Licensed Sales Representative Name _______________________________
Rx PCN: 8500
Licensed Sales Representative Phone No. ____________________________
RxGRP:
MPDACUNJ
Licensed Sales Representative ID __________________________________
Questions? We’re always here to help.
Simply call the Customer Service number listed on the first page of this booklet.
Important Reminder - Once you have received confirmation of enrollment in your new Medicare
Advantage plan, if you are currently enrolled in a Medicare Supplement plan you must contact the plan
in writing with your intention to cancel your policy.
TEAR HERE
Copy 2
Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
Enrollment in the plan depends on the plan’s contract renewal with Medicare.
Y0066_150629_142455 Accepted
CSNJ16DU3707322_000
117
This page left intentionally blank.
118
NOTES
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TEAR HERE
What’s next?
Thank you for choosing
UnitedHeathcare.
Here’s what you can expect soon.
Verification Letter
We got your application and are reviewing it.
Welcome Letter and Member ID Card
Great news – your application has been approved.
Getting Started Guide and Plan Details
Learn how you can make the most of your plan.
Welcome Call
We’ll call you to welcome you and answer your questions.
Get ready to work together for better health.
Our commitment.
We’ll reach out to you throughout the year to
help make sure you are taking advantage of
all the programs your plan has to offer.
+
Your commitment.
Taking action is your first step to managing
your health. We’ll give you resources and
support you in taking those steps.
Schedule your Annual Wellness Visit.
Preventive care is vital to staying healthy. Call to schedule your visit after your plan coverage begins.
Take advantage of a HouseCalls visit.
Learn more about this in-home visit with a health care practitioner at www.uhchousecalls.com.
Complete your Health Survey.
Once your coverage begins, answering a few short questions will help us connect you to programs
and services.
TEAR HERE
Questions? Give us a call.
Helpful information:
Toll-Free 1-800-514-4911, TTY 711
8 a.m- 8 p.m. local time, 7 days a week
Y0066_150701_144908_FINAL_13 Accepted
UHEX16DU3700230_000
123
MAPD
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/co-insurance may change on January 1 of each year. The provider
network may change at any time. You will receive notice when necessary.
companies, a Medicare Advantage organization with a Medicare contract and a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s
contract renewal with Medicare.
Y0066_150619_112614A_FINAL_5 Accepted
This is an advertisement.
CSNJ16HM3701820_003

English - UHCCommunityPlan.com

Transcription

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