Annual Notice of Changes/ Evidence of Coverage 2016

Annual Notice of Changes/ Evidence of Coverage 2016 Indiana University Health Plans Medicare Select Plus HMO 950 N. Meridian St., Suite 200 Indianapolis, IN 46204-1202 800.455.9776 TTY users call Relay Indiana at 800.743.3333. Oct. 1 to Feb. 14 8 am to 8 pm seven days a week. Feb. 15 to Sept. 30 8 am to 8 pm Monday through Friday. iuhealthplansmedicare.org For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. 2015 IUHealth 8/15 IUH#20054 H7220_IUHMA1607 CMS File & Use 8.26.2015

For Your Reference You can locate specific Indiana University Health Plans documents in this book by the numbered divider pages: Section No. 1 Evidence of Coverage Indiana University Health Plans Medicare Select Plus HMO 2 Abridged Formulary Included with this book, you will also receive a cover letter and Provider/Pharmacy Directory. For Your Reference

Indiana University Health Plans Medicare Select Plus (HMO) offered by Indiana University Health Plans Annual Notice of Changes for 2016 You are currently enrolled as a member of Indiana University Health Plans Medicare Select Plus (HMO). Next year, there will be some changes to the plan s costs and benefits. This booklet tells about the changes. You have from October 15 until December 7 to make changes to your Medicare coverage for next year. Additional Resources Our Customer Solutions Center has free language interpreter services available for non- English speakers (phone numbers are in the back of this booklet). Please contact our Customer Solutions Center at 800.455.9776 for additional information. TTY users should call Relay Indiana at 800.743.3333. Hours are Oct. 1 to Feb. 14, 8 am to 8pm, seven days a week. Feb. 15 to Sept. 30, 8 am to 8 pm Monday through Friday. You may receive assistance through alternate technology after 8pm, on weekends and holidays. This information is available in alternate formats. Please call our Customer Solutions Center at the number listed at the back of this booklet if you need plan information in another format. About Indiana University Health Plans Medicare Select Plus (HMO) Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. When this booklet says we, us, or our, it means Indiana University Health Plans. When it says plan or our plan, it means Indiana University Health Plans Medicare Select Plus (HMO). H7220_IUHMA1607 CMS File & Use 8/26/2015 Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Approved 03/2014)

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 1 Think about Your Medicare Coverage for Next Year Each fall, Medicare allows you to change your Medicare health and drug coverage during the Annual Enrollment Period. It s important to review your coverage now to make sure it will meet your needs next year. Important things to do: Check the changes to our benefits and costs to see if they affect you. Do the changes affect the services you use? It is important to review benefit and cost changes to make sure they will work for you next year. Look in Section 1.1 and Section 1.4 for information about benefit and cost changes for our plan. Check the changes to our prescription drug coverage to see if they affect you. Will your drugs be covered? Are they in a different tier? Can you continue to use the same pharmacies? It is important to review the changes to make sure our drug coverage will work for you next year. Look in Section 1.5 for information about changes to our drug coverage. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 1.2 and 1.3 for information about our Provider/Pharmacy Directory. Think about your overall health care costs. How much will you spend out-of-pocket for the services and prescription drugs you use regularly? How much will you spend on your premium? How do the total costs compare to other Medicare coverage options? Think about whether you are happy with our plan. If you decide to stay with Indiana University Health Plans Medicare Select Plus (HMO): If you want to stay with us next year, it s easy - you don t need to do anything. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch plans between October 15 and December 7. If you enroll in a new plan, your new coverage will begin on January 1, 2016. Look in Section 2.2 to learn more about your choices.

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 2 Summary of Important Costs for 2016 The table below compares the 2015 costs and 2016 costs for Indiana University Health Plans Medicare Select Plus in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the enclosed Evidence of Coverage to see if other benefit or cost changes affect you. Cost 2015 (this year) 2016 (next year) Maximum Out-of-Pocket Amount This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Evidence of Coverage, Chapter 1, Section 2.2 for details) $4,750 $4,850 Doctor Office Visits Primary care visits: $15 copay per visit Specialist visits: $45 copay per visit Primary care visits: $10 copay per visit Specialist visits: $40 copay per visit Inpatient Hospital Care Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. Days 1-7: $235 copay per day, per admission 90 days plus 60 Medicare covered lifetime reserve days Days 1-7: $260 copay per day, per admission 90 days plus 60 Medicare covered lifetime reserve days

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 3 Annual Notice of Changes for 2016 Table of Contents Think about Your Medicare Coverage for Next Year... 1 Summary of Important Costs for 2016... 2 SECTION 1 Changes to Benefits and Costs for Next Year... 4 Section 1.1 Changes to Your Maximum Out-of-Pocket Amount... 4 Section 1.2 Changes to the Provider Network... 4 Section 1.3 Changes to the Pharmacy Network... 5 Section 1.4 Changes to Benefits and Costs for Medical Services... 5 Section 1.5 Changes to Part D Prescription Drug Coverage... 6 SECTION 2 Deciding Which Plan to Choose... 9 Section 2.1 If you want to stay in Indiana University Health Plans Medicare Select Plus (HMO)... 9 Section 2.2 If you want to change plans... 9 SECTION 3 Deadline for Changing Plans... 10 SECTION 4 Programs That Offer Free Counseling about Medicare... 10 SECTION 5 Programs That Help Pay for Prescription Drugs... 11 SECTION 6 Questions?... 12 Section 6.1 Getting Help from Indiana University Health Plans Medicare Select Plus (HMO)... 12 Section 6.2 Getting Help from Medicare... 12

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 4 SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires all health plans to limit how much you pay out-of-pocket during the year. This limit is called the maximum out-of-pocket amount. Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year. Cost 2015 (this year) 2016 (next year) Maximum Out-of-Pocket Amount Your costs for covered medical services (such as copays) count toward your maximum out-of-pocket amount. Your plan premium and your prescription drugs costs do not count toward your maximum out-ofpocket amount. $4,750 $4,850 Once you have paid $4,850 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year. Section 1.2 Changes to the Provider Network There are changes to our network of providers for next year. We included a copy of our Provider/Pharmacy Directory in the envelope with this booklet. An updated Provider/Pharmacy Directory is located on our website at www.iuhealthplansmedicare.org. You may also call Customer Solutions Center for updated provider information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2016 Provider/Pharmacy Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network. It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections summarized below: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. When possible we will provide you with at least 30 days notice that your provider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your health care needs.

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 5 If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted. If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care. Section 1.3 Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. There are changes to our network of pharmacies for next year. We included a copy of our Provider/Pharmacy Directory in the envelope with this booklet. An updated Provider/Pharmacy Directory is located on our website at www.iuhealthplansmedicare.org. You may also call Customer Solutions Center for updated provider/pharmacy information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2016 Provider/Pharmacy Directory to see which pharmacies are in our network. Section 1.4 Changes to Benefits and Costs for Medical Services We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2016 Evidence of Coverage. Cost 2015 (this year) 2016 (next year) Doctor Office Visits Primary Care Physician: $15 copay per visit Specialist: $45 copay per visit Primary Care Physician: $10 copay per visit Specialist: $40 copay per visit Routine Hearing Exams Not Covered $75 copay

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 6 Cost 2015 (this year) 2016 (next year) Hearing Aids Not Covered $699 or $999 copay for select TruHearing Chime Products (See Evidence of Coverage, Chapter 4 for more information) Inpatient Hospital Care Days 1-7: $235 copay per day, per admission 90 days plus 60 Medicare covered lifetime reserve days Days 1-7: $260 copay per day, per admission 90 days plus 60 Medicare covered lifetime reserve days Inpatient Mental Health Care Days 1-6: $235 copay per day, per admission Days 1-6: $260 copay per day, per admission Skilled Nursing Facility (SNF) Care Days 21-100: $150 copay per day Days 21-100: $160 copay per day Outpatient Diagnostic Services $125 copay $135 copay Outpatient Surgery $265 copay $285 copay Dental Services Any preventative dental services we cover (such as cleanings, routine dental exams, and dental x-rays) that are performed by out-of-network providers. See Chapter 4 for covered preventative dental services. 0% coinsurance, after $10 deductible 50% coinsurance, after $10 deductible Section 1.5 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our list of covered drugs is called a Formulary or Drug List. A copy of our Drug List is in this envelope. The Drug List we included in this envelope includes many but not all of the drugs that we will cover next year. If you don t see your drug on this list, it might still be covered.

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 7 You can get the complete Drug List by calling Customer Solutions Center (see the back cover) or visit our website, www.iuhealthplansmedicare.org. We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage, you can: Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. We encourage current members to ask for an exception before next year. o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Customer Solutions Center. Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Customer Solutions Center to ask for a list of covered drugs that treat the same medical condition. In some situations, we are required to cover a one-time, temporary supply of a non-formulary prescription drug in the first 90 days of coverage of the plan year or coverage. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. Changes to Prescription Drug Costs Note: If you are in a program that helps pay for your drugs ( Extra Help ), the information about costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug costs. If you get Extra Help and didn t receive this insert with this packet, please call Customer Solutions Center and ask for the LIS Rider. Phone numbers for Customer Solutions Center are in Section 6.1 of this booklet. There are four drug payment stages. How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.) The information below shows the changes for next year to the first two stages the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the enclosed Evidence of Coverage.)

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 8 Changes to the Deductible Stage Stage 2015 (this year) 2016 (next year) Stage 1: Yearly Deductible Stage Because we have no deductible, this payment stage does not apply to you. Because we have no deductible, this payment stage does not apply to you. Changes to Your Cost-sharing in the Initial Coverage Stage To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-ofpocket costs you may pay for covered drugs in your Evidence of Coverage. Stage 2015 (this year) 2016 (next year) Stage 2: Initial Coverage Stage During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. The costs in this row are for a onemonth (30-day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a long-term supply; or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage. We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List. Your cost for a 30-day supply filled at a network pharmacy with standard cost-sharing: Tier 1 (Preferred Generic drugs): You pay $6 per prescriptions Tier 2 (Generic drugs): You pay $15 per prescription Tier 3 (Preferred Brand Name & Generic drugs): You pay $45 per prescription Tier 4 (Non-Preferred Brand Name & Generic drugs): You pay $95 per prescription Tier 5 (Specialty drugs): You pay 33% of the total cost. Once your total drug costs have reached Your cost for a 30-day supply filled at a network pharmacy with standard cost-sharing: Tier 1 (Preferred Generic drugs): You pay $6 per prescriptions Tier 2 (Generic Drugs): You pay $15 per prescription Tier 3 (Preferred Brand & Generic drugs): You pay $45 per prescription Tier 4 (Non-Preferred Brand Name & Generic drugs): You pay $95 per prescription Tier 5: Specialty Drugs: You pay 33% of the total cost. Once your total drug costs have reached

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 9 $2,960, you will move to the next stage (the Coverage Gap Stage). Once you have paid $4,700 out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage). $3,310, you will move to the next stage (the Coverage Gap Stage). Once you have paid $4,850 out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage). Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages the Coverage Gap Stage and the Catastrophic Coverage Stage are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage. SECTION 2 Deciding Which Plan to Choose Section 2.1 If you want to stay in Indiana University Health Plans Medicare Select Plus (HMO) To stay in our plan you don t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for 2016. Section 2.2 If you want to change plans We hope to keep you as a member next year but if you want to change for 2016 follow these steps: Step 1: Learn about and compare your choices You can join a different Medicare health plan, OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan and whether to buy a Medicare supplement (Medigap) policy. To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2016, call your State Health Insurance Assistance Program (see Section 4), or call Medicare (see Section 6.2).

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 10 You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to http://www.medicare.gov and click Find health & drug plans. Here, you can find information about costs, coverage, and quality ratings for Medicare plans. As a reminder, Indiana University Health Plans offers other Medicare Advantage plans with and without prescription drug coverage. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts. Step 2: Change your coverage To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Indiana University Health Plans Medicare Select Plus (HMO). To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Indiana University Health Plans Medicare Select Plus (HMO). To change to Original Medicare without a prescription drug plan, you must either: o Send us a written request to disenroll. Contact Customer Solutions Center if you need more information on how to do this (phone numbers are in Section 6.1 of this booklet). o or Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048. SECTION 3 Deadline for Changing Plans If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2016. Are there other times of the year to make a change? In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs, and those who move out of the service area are allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage. If you enrolled in a Medicare Advantage plan for January 1, 2016, and don t like your plan choice, you can switch to Original Medicare between January 1 and February 14, 2016. For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage. SECTION 4 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Indiana the SHIP is called the State Health Insurance Assistance Program.

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 11 The State Health Insurance Assistance Program is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The State Health Insurance Assistance Program counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call the State Health Insurance Assistance Program at 1-800-452-4800. You can learn more about the State Health Insurance Assistance Program by visiting their website at www.medicare.in.gov. SECTION 5 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs. Below we list different kinds of help: Extra Help from Medicare. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don t even know it. To see if you qualify, call: o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778 (applications); or o Your State Medicaid Office (applications); Help from your state s pharmaceutical assistance program. Indiana has a program called Hoosier Rx that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section 4 of this booklet). Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. To be eligible for the program Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medical Part D plan name or policy number. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the Indiana State Department of Health, ADAP Coordinator, 2 N. Meridian St., Suite 6-C, Indianapolis, IN 46204, Phone: 1-866-588-4948.

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 12 SECTION 6 Questions? Section 6.1 Getting Help from Indiana University Health Plans Medicare Select Plus (HMO) We re here to help. Please call our Customer Solutions Center at (317) 963-9700, toll free 1-800- 455-9776. From October 1, 2015 through February 14, 2016, a representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Our Customer Solutions Center also has free language interpreter services available for non-english speakers. For TTY/TDD only, call Relay Indiana toll free at 1-800-743-3333. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to these numbers are free. Read your 2016 Evidence of Coverage (it has details about next year's benefits and costs) This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2016. For details, look in the 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus (HMO). The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is included in this envelope. Visit our Website You can also visit our website at www.iuhealthplansmedicare.org. As a reminder, our website has the most up-to-date information about our provider network (Provider/Pharmacy Directory) and our list of covered drugs (Formulary/Drug List). Section 6.2 Getting Help from Medicare To get information directly from Medicare: Call 1-800-MEDICARE (1-800-633-4227) You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Visit the Medicare Website You can visit the Medicare website (http://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the

Indiana University Health Plans Medicare Select Plus Annual Notice of Changes for 2016 13 Medicare website. (To view the information about plans, go to http://www.medicare.gov and click on Find health & drug plans ). Read Medicare & You 2016 You can read the Medicare & You 2016 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website (http://www.medicare.gov) or 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.

Evidence of Coverage January 1, 2016 December 31, 2016 Your Medicare Health Benefits and Services as a Member of Indiana University Health Plans Medicare Select Plus HMO The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. You must continue to pay your Medicare Part B premium Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana Univeristy Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. H7220_IUHMA1607 CMS File & Use 8/26/2015 SECTION I Evidence of Coverage - IU Health Plans Medicare Plans SELECT PLUS HMO

January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Indiana University Health Plans Medicare Select Plus (HMO). This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 December 31, 2016. It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, Indiana University Health Plans Medicare Select Plus (HMO), is offered by Indiana University Health Plans. (When this Evidence of Coverage says we, us, or our, it means Indiana University Health Plans. When it says plan or our plan, it means Indiana University Health Plans Medicare Select Plus (HMO)). Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. Our Customer Solutions Center has free language interpreter services available for non-english speakers (phone numbers are printed on the back cover of this booklet). This information is available in alternate formats. Please call our Customer Solutions Center at the number listed if you need plan information in another format. Benefits, formulary, pharmacy network, premium, deductible, and/or co-payments/coinsurance may change on January 1, 2017. H7220_IUHMA1607 CMS File & Use 8/26/2015 Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Approved 03/2014)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 1 Table of Contents 2016 Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member... 4 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources... 18 Tells you how to get in touch with our plan (Indiana University Health Plans Medicare Select Plus) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan s coverage for your medical services... 39 Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan s network and how to get care when you have an emergency. Chapter 4. Medical Benefits Chart (what is covered and what you pay)... 54 Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan s coverage for your Part D prescription drugs... 88 Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan s programs for drug safety and managing medications.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 2 Table of Contents Chapter 6. What you pay for your Part D prescription drugs... 111 Tells about the three (3) stages of drug coverage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage and how these stages affect what you pay for your drugs. Explains the five (5) cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each costsharing tier. Tells about the late enrollment penalty. Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs... 133 Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Chapter 8. Your rights and responsibilities... 141 Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)... 152 Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan... 208 Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices... 218 Includes notices about governing law and about non-discrimination. Chapter 12. Definitions of important words... 221 Explains key terms used in this booklet

CHAPTER 1 Getting started as a member

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 4 Chapter 1. Getting started as a member Chapter 1. Getting started as a member SECTION 1 Introduction... 5 Section 1.1 You are enrolled in Indiana University Health Plans Medicare Select Plus (HMO)... 5 Section 1.2 What is the Evidence of Coverage booklet about?... 5 Section 1.3 Legal information about the Evidence of Coverage... 5 SECTION 2 What makes you eligible to be a plan member?... 6 Section 2.1 Your eligibility requirements... 6 Section 2.2 What are Medicare Part A and Medicare Part B?... 6 Section 2.3 Here is the plan service area for Indiana University Health Plans Medicare Select Plus (HMO)... 6 SECTION 3 What other materials will you get from us?... 7 Section 3.1 Your plan membership card Use it to get all covered care and prescription drugs... 7 Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers in the plan s network... 8 Section 3.3 The plan s List of Covered Drugs (Formulary)... 9 Section 3.4 The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs... 9 SECTION 4 Your monthly premium for Indiana University Health Plans Medicare Select Plus (HMO)... 10 Section 4.1 How much is your plan premium?... 10 Section 4.2 There are several ways you can pay your plan premium... 12 Section 4.3 Can we change your monthly plan premium during the year?... 13 SECTION 5 Please keep your plan membership record up to date... 13 Section 5.1 How to help make sure that we have accurate information about you... 13 SECTION 6 We protect the privacy of your personal health information... 14 Section 6.1 We make sure that your health information is protected... 14 SECTION 7 How other insurance works with our plan... 15 Section 7.1 Which plan pays first when you have other insurance?... 15

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 5 Chapter 1. Getting started as a member SECTION 1 Section 1.1 Introduction You are enrolled in Indiana University Health Plans Medicare Select Plus (HMO) You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Indiana University Health Plans Medicare Select Plus (HMO). There are different types of Medicare health plans. Indiana University Health Plans Select Plus (HMO) is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. The word coverage and covered services refers to the medical care and services and the prescription drugs available to you as a member of Indiana University Health Plans Medicare Select Plus (HMO). It s important for you to learn what the plan s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan s Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 1.3 Legal information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how Indiana University Health Plans Medicare Select Plus covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for months in which you are enrolled in Indiana University Health Plans Medicare Select Plus (HMO) between January 1, 2016 and December 31, 2016. Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Indiana University Health Plans Medicare Select Plus

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 6 Chapter 1. Getting started as a member (HMO) after December 31, 2016. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2016. Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve Indiana University Health Plans Medicare Select Plus (HMO) each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. SECTION 2 Section 2.1 What makes you eligible to be a plan member? Your eligibility requirements You are eligible for membership in our plan as long as: You have both Medicare Part A and Medicare Part B (section 2.2 tells you about Medicare Part A and Medicare Part B) -- and -- you live in our geographic service area (section 2.3 below describes our service area) -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies). Medicare Part B is for most other medical services (such as physician s services and other outpatient services) and certain items (such as durable medical equipment and supplies). Section 2.3 Here is the plan service area for Indiana University Health Plans Medicare Select Plus (HMO) Although Medicare is a Federal program, Indiana University Health Plans Medicare Select Plus (HMO) is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 7 Chapter 1. Getting started as a member Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clay, Clinton, Crawford, Daviess, Decatur, DeKalb, Delaware, Dubois, Elkhart, Fayette, Fountain, Fulton, Gibson, Greene, Hamilton, Hancock, Hendricks, Henry, Howard, Huntington, Jackson, Jay, Jennings, Johnson, Knox, LaGrange, LaPorte, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Noble, Orange, Owen, Parke, Perry, Pike, Posey, Pulaski, Putnam, Randolph, Rush, Scott, Shelby, Spencer, Starke, Steuben, St. Joseph, Sullivan, Tippecanoe, Tipton, Union, Vanderburgh, Vermillion, Vigo, Wabash, Warren, Warrick, Wells, Whitley and White. If you plan to move out of the service area, please contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. SECTION 3 Section 3.1 What other materials will you get from us? Your plan membership card Use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Here s a sample membership card to show you what yours will look like: As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your Indiana University Health Plans Medicare Select Plus (HMO) membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Customer Solutions Center right away and we will send you a new card. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 8 Chapter 1. Getting started as a member Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers in the plan s network The Provider/Pharmacy Directory lists our network providers and network pharmacies. What are network providers? Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Indiana University Health Plans Select Plus (HMO) authorizes use of out-of-network providers. See Chapter 3 (Using the plan s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. If you don t have your copy of the Provider/Pharmacy Directory, you can request a copy from Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You may ask Customer Solutions Center for more information about our network providers, including their qualifications. You can also see the Provider/Pharmacy Directory at www.iuhealthplansmedicare.org, or download it from this website. Both Customer Solutions Center and the website can give you the most up-to-date information about changes in our network providers. What are network pharmacies? Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. Why do you need to know about network pharmacies? You can use the Provider/Pharmacy Directory to find the network pharmacy you want to use. There are changes to our network of pharmacies for next year. We included a copy of our Provider/Pharmacy Directory in the envelope with this booklet. An updated Pharmacy Directory is located on our website at www.iuhealthplansmedicare.org. You may also call Customer Solutions Center for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2016 Provider/Pharmacy Directory to see which pharmacies are in our network.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 9 Chapter 1. Getting started as a member If you don t have the Provider/Pharmacy Directory, you can get a copy from Customer Solutions Center (phone numbers are printed on the back cover of this booklet). At any time, you can call Customer Solutions Center to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at www.iuhealthplansmedicare.org. Section 3.3 The plan s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D prescription drugs are covered under the Part D benefit included in Indiana University Health Plans Medicare Select Plus (HMO). The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the Indiana University Health Plans Medicare Select Plus (HMO) Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will send you a copy of the Drug List. The Drug List we send to you includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact the Customer Solutions Center to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan s website, www.iuhealthplansmedicare.org. or call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 3.4 The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the Part D EOB ). The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage. A Part D Explanation of Benefits summary is also available upon request. To get a copy, please contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 10 Chapter 1. Getting started as a member SECTION 4 Section 4.1 Your monthly premium for Indiana University Health Plans Medicare Select Plus (HMO) How much is your plan premium? As a member of our plan, you pay a monthly plan premium. For 2016, the monthly premium for Indiana University Health Plans Medicare Select Plus is $42. In addition, you must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). In some situations, your plan premium could be less There are programs to help people with limited resources pay for their drugs. These include Extra Help and State Pharmaceutical Assistance Programs. The Extra Help program helps people with limited resources pay for their drugs. Chapter 2, Section 7 tells more about these programs. If you qualify, enrolling in the program might lower your monthly plan premium. If you are already enrolled and getting help from one of these programs, the information about premiums in this Evidence of Coverage may not apply to you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you don t have this insert, please call our Customer Solutions Center and ask for the LIS Rider. (Phone numbers for our Customer Solutions Center are printed on the back cover of this booklet.) In some situations, your plan premium could be more In some situations, your plan premium could be more than the amount listed above in Section 4.1. These situations are described below. Most people pay a standard monthly Part D premium. Some people pay an extra amount because of their yearly income. If your income is $85,000 or above for an individual (or married individuals filing separately) or $170,000 or above for married couples, you must pay an extra amount. The Social Security Administration, not your Medicare plan will send you a letter telling you what the extra amount will be. For more information about Part D premiums based on income go to Chapter 6, section 10 of this booklet. You can also visit http://www.medicare.gov on the web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day and 7 days a week. TTY/TDD users should call 1-877-486-2048. You may also call the Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778. Some members are required to pay a late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn t have creditable prescription drug coverage. ( Creditable means the drug coverage is expected to pay, on average, at least as much as

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 11 Chapter 1. Getting started as a member Medicare s standard prescription drug coverage.) For these members, the late enrollment penalty is added to the plan s monthly premium. Their premium amount will be the monthly plan premium plus the amount of their late enrollment penalty. o If you are required to pay the late enrollment penalty, the amount of your penalty depends on how long you waited before you enrolled in drug coverage or how many months you were without drug coverage after you became eligible. Chapter 6, Section 9 explains the late enrollment penalty. o If you have a late enrollment penalty and do not pay it, you could be disenrolled from the plan. Many members are required to pay other Medicare premiums In addition to paying the monthly plan premium, many members are required to pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. For that reason, some plan members (those who aren t eligible for premium-free Part A) pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part B. You must continue paying your Medicare premiums to remain a member of the plan. Some people pay an extra amount for Part D because of their yearly income. This is known as Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater than $85,000 for an individual (or married individuals filing separately) or greater than $170,000 for married couples, you must pay an extra amount directly to the government (not the Medicare plan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage. If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. For more information about Part D premiums based on income, go to Chapter 6, Section 11 of this booklet. You can also visit http://www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Your copy of Medicare & You 2016 gives information about the Medicare premiums in the section called 2016 Medicare Costs. This explains how the Medicare Part B and Part D premiums differ for people with different incomes. Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy of Medicare & You 2016 from the Medicare website (http://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 12 Chapter 1. Getting started as a member Section 4.2 There are several ways you can pay your plan premium There are four ways you can pay your plan premium. If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. While we are processing your request for a new payment method, you are responsible for making sure that your plan premium is paid on time. Option 1: You can pay by check You may decide to pay your monthly premium directly to our plan with a check or money order. You will receive a statement on or about the 20 th of each month for your premium, and it will be due on the first of the next month. You have the option of mailing the check in or delivering it in person to 950 N Meridian Street, Suite 200, Indianapolis, IN 46204. Option 2: You may have your monthly premium automatically withdrawn from your bank account Instead of paying by check, you can have your monthly plan premium automatically withdrawn from your bank account. This can be done on the 3 rd of each month. Indiana University Health Plans will provide a form for the authorization to implement this process. Option 3: You can have the plan premium taken out of your monthly Social Security check You can have the plan premium taken out of your monthly Social Security check. Contact our Customer Solutions Center for more information on how to pay your plan premium this way. We will be happy to help you set this up. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) Option 4: Credit/Debit card You may make a credit/debit card payment by phone. You can call monthly to make a Visa card, Discover card, MasterCard credit/debit payment. What to do if you are having trouble paying plan premium Your plan premium is due in our office by the 1 st day of the month. If we have not received your premium payment by the 1 st day of the month, we will send you a notice telling you that your plan membership will end if we do not receive your premium within 90 days. If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage. If you are having trouble paying your premium on time, please contact Customer Solutions Center to see if we can direct you to programs that will help with your plan premium. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 13 Chapter 1. Getting started as a member If we end your membership because you did not pay your premium, you will have health coverage under Original Medicare. If we end your membership with the plan because you did not pay your plan premium, then you may not be able to receive Part D coverage until the following year if you enroll in a new plan during the annual enrollment period. During the annual enrollment period, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go without creditable drug coverage for more than 63 days, you may have to pay a late enrollment penalty for as long as you have Part D coverage.) At the time we end your membership, you may still owe us for premiums you have not paid. We have the right to pursue collection of the premiums you owe. In the future, if you want to enroll again in our plan (or another plan that we offer), you will need to pay the amount you owe before you can enroll. If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. Chapter 9, Section 10 of this booklet tells how to make a complaint. If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your premiums within our grace period, you can ask Medicare to reconsider this decision 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. Section 4.3 Can we change your monthly plan premium during the year? No. We are not allowed to change the amount we charge for the plan s monthly premium during the year. If the monthly plan premium changes for next year we will tell you in September and the change will take effect on January 1 of the following year. However, in some cases the part of the premium that you have to pay can change during the year. This happens if you become eligible for the Extra Help program or if you lose your eligibility for the Extra Help program during the year. If a member qualifies for Extra Help with their prescription drug costs, the Extra Help program will pay part of the member s monthly plan premium. A member who loses their eligibility during the year will need to start paying their full monthly premium. You can find out more about the Extra Help program in Chapter 2, Section 7. SECTION 5 Section 5.1 Please keep your plan membership record up to date How to help make sure that we have accurate information about you Your membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage including your Primary Care Provider.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 14 Chapter 1. Getting started as a member The doctors, hospitals, pharmacists, and other providers in the plan s network need to have correct information about you. These network providers use your membership record to know what services and drugs are covered and the cost-sharing amounts for you. Because of this, it is very important that you help us keep your information up to date. Let us know about these changes: Changes to your name, your address, or your phone number Changes in any other health insurance coverage you have (such as from your employer, your spouse s employer, workers compensation, or Medicaid) If you have any liability claims, such as claims from an automobile accident If you have been admitted to a nursing home If you receive care in an out-of-area or out-of-network hospital or emergency room If your designated responsible party (such as a caregiver) changes If you are participating in a clinical research study If any of this information changes, please let us know by calling Customer Solutions Center (phone numbers are printed on the back cover of this booklet). It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. Read over the information we send you about any other insurance coverage you have Medicare requires that we collect information from you about any other medical or drug insurance coverage that you have. That s because we must coordinate any other coverage you have with your benefits under our plan. (For more information about how our coverage works when you have other insurance, see Section 7 in this chapter.) Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about. Please read over this information carefully. If it is correct, you don t need to do anything. If the information is incorrect, or if you have other coverage that is not listed, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). SECTION 6 Section 6.1 We protect the privacy of your personal health information We make sure that your health information is protected Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 15 Chapter 1. Getting started as a member For more information about how we protect your personal health information, please go to Chapter 8, Section 1.4 of this booklet. SECTION 7 Section 7.1 How other insurance works with our plan Which plan pays first when you have other insurance? When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that pays first is called the primary payer and pays up to the limits of its coverage. The one that pays second, called the secondary payer, only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. These rules apply for employer or union group health plan coverage: If you have retiree coverage, Medicare pays first. If your group health plan coverage is based on your or a family member s current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-stage Renal Disease (ESRD): o If you re under 65 and disabled and you or your family member is still working, your group health plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan that has more than 100 employees. o If you re over 65 and you or your spouse is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees. If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: No-fault insurance (including automobile insurance) Liability (including automobile insurance) Black lung benefits Workers compensation Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You may need to give

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 16 Chapter 1. Getting started as a member your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.

CHAPTER 2 Important phone numbers and resources

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 18 Chapter 2. Important phone numbers and resources Chapter 2. Important phone numbers and resources SECTION 1 SECTION 2 SECTION 3 SECTION 4 Indiana University Health Plans Medicare Select Plus (HMO) contacts (how to contact us, including how to reach Customer Solutions Center at the plan)... 19 Medicare (how to get help and information directly from the Federal Medicare program)... 28 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare)... 30 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare)... 30 SECTION 5 Social Security... 31 SECTION 6 SECTION 7 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources)... 32 Information about programs to help people pay for their prescription drugs... 33 SECTION 8 How to contact the Railroad Retirement Board... 36 SECTION 9 Do you have group insurance or other health insurance from an employer?... 36

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 19 Chapter 2. Important phone numbers and resources SECTION 1 Indiana University Health Plans Medicare Select Plus (HMO) contacts (how to contact us, including how to reach Customer Solutions Center at the plan) How to contact our plan s Customer Solutions Center For assistance with claims, billing, or member card questions, please call or write to Indiana University Health Plans Medicare Select Plus Customer Solutions Center. We will be happy to help you. Method CALL Customer Solutions Center Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 20 Chapter 2. Important phone numbers and resources Method WRITE WEBSITE Customer Solutions Center Contact Information Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 www.iuhealthplansmedicare.org How to contact us when you are asking for a coverage decision about your medical care A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. For more information on asking for coverage decisions about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). You may call us if you have questions about our coverage decision process. Method CALL Coverage Decisions For Medical Care Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 21 Chapter 2. Important phone numbers and resources Method TTY Coverage Decisions For Medical Care Contact Information 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 WRITE WEBSITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 www.iuhealthplansmedicare.org How to contact us when you are making an appeal about your medical care An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 22 Chapter 2. Important phone numbers and resources Method CALL Appeals For Medical Care Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 WRITE WEBSITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 www.iuhealthplansmedicare.org How to contact us when you are making a complaint about your medical care You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan s coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 23 Chapter 2. Important phone numbers and resources your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). Method CALL Complaints About Medical Care Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 WRITE MEDICARE WEBSITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 You can submit a complaint about Indiana University Health Plans Medicare Select Plus (HMO) directly to Medicare. To submit an online complaint to Medicare go to: www.medicare.gov/medicarecomplaintform/home.aspx.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 24 Chapter 2. Important phone numbers and resources How to contact us when you are asking for a coverage decision about your Part D prescription drugs A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints). Method Coverage Decisions for Part D Prescription Drugs Contact Information CALL 1-866-823-1016 (Calls to this number are free.) Pharmacy services representatives are available to take your calls Monday through Friday from 8:00 a.m. to 8:00 p.m. A secure voicemail box will be checked routinely to handle expedited requests received outside of our normal business hours. TTY 1-800-743-3333 (Relay Indiana) This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. A pharmacy services representative will be available to speak to you 8:00 a.m. to 8:00 p.m. Monday through Friday. A secure voicemail box will be checked routinely to handle expedited requests received outside of our normal business hours. FAX 1-855-397-8762 You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. WRITE WEBSITE Indiana University Health Plans- Pharmacy Services 950 N. Meridian Street, Suite 600 Indianapolis, IN 46204 www.iuhealthplansmedicare.org

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 25 Chapter 2. Important phone numbers and resources How to contact us when you are making an appeal about your Part D prescription drugs An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). Method CALL Appeals for Part D Prescription Drugs Contact Information 1-866-823-1016 (Calls to this number are free.) Pharmacy services representatives are available to take your calls Monday through Friday from 8:00 a.m. to 8:00 p.m. A secure voicemail box will be checked routinely to handle expedited requests received outside of our normal business hours. TTY 1-800-743-3333 (Relay Indiana) FAX 1-855-397-8762 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. A pharmacy services representative will be available to speak to you 8:00 a.m. to 8:00 p.m. Monday through Friday. A secure voicemail box will be checked routinely to handle expedited requests received outside of our normal business hours. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. WRITE WEBSITE Indiana University Health Plans Pharmacy Services 950 N. Meridian Street, Suite 600 Indianapolis, IN 46204 www.iuhealthplansmedicare.org How to contact us when you are making a complaint about your Part D prescription drugs You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan s coverage or payment, you should look at the

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 26 Chapter 2. Important phone numbers and resources section above about making an appeal.) For more information on making a complaint about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). Method CALL Complaints about Part D prescription drugs Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 WRITE MEDICARE WEBSITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 You can submit a complaint about Indiana University Health Plans Medicare Select Plus directly to Medicare. To submit an online complaint to Medicare go to: www.medicare.gov/medicarecomplaintform/home.aspx.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 27 Chapter 2. Important phone numbers and resources Where to send a request asking us to pay for our share of the cost for medical care or a drug you have received For more information on situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs). Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more information. Method CALL Payment Requests Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 28 Chapter 2. Important phone numbers and resources Method WRITE WEBSITE Payment Requests Contact Information Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 www.iuhealthplansmedicare.org SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called CMS ). This agency contracts with Medicare Advantage organizations including us. Method Medicare Contact Information CALL 1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week. TTY 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 29 Chapter 2. Important phone numbers and resources Method WEBSITE Medicare Contact Information http://www.medicare.gov This is the official government website for Medicare. It gives you upto-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools: Medicare Eligibility Tool: Provides Medicare eligibility status information. Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans. You can also use the website to tell Medicare about any complaints you have about Indiana University Health Plans Medicare Select Plus: Tell Medicare about your complaint: You can submit a complaint about Indiana University Health Plans Medicare Select Plus directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/medicarecomplaintform/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you don t have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) Minimum essential coverage (MEC): Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at http://www.irs.gov/uac/questions-and-answers-on-the- Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 30 Chapter 2. Important phone numbers and resources SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Indiana, the SHIP is called State Health Insurance Assistance Program of Indiana. The State Health Insurance Assistance Program is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The State Health Insurance Assistance Program counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills. The State Health Insurance Assistance Program counselors can also help you understand your Medicare plan choices and answer questions about switching plans. Method State Health Insurance Assistance Program CALL 1-800-452-4800 TTY 1-866-846-0139 WRITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking 714 W 53 rd Street Anderson, IN 46013 WEBSITE www.medicare.in.gov SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) There is a designated Quality Improvement Organization for serving Medicare beneficiaries in each state. For Indiana, the Quality Improvement Organization is called KEPRO. KEPRO has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. KEPRO is an independent organization. It is not connected with our plan.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 31 Chapter 2. Important phone numbers and resources You should contact KEPRO in any of these situations: You have a complaint about the quality of care you have received. You think coverage for your hospital stay is ending too soon. You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon. Method CALL KEPRO 855-408-8557 toll free TTY 844-834-7130 WRITE 5201 W. Kennedy Blvd., Suite 900 Tampa, FL 33609 WEBSITE www.keproqio.com SECTION 5 Social Security Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office. Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for a reconsideration. If you move or change your mailing address, it is important that you contact Social Security to let them know.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 32 Chapter 2. Important phone numbers and resources Method Social Security Contact Information CALL 1-800-772-1213 Calls to this number are free. Available 7:00 am to 7:00 pm, Monday through Friday. You can use Social Security s automated telephone services to get recorded information and conduct some business 24 hours a day. TTY 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available 7:00 am to 7:00 pm, Monday through Friday. WEBSITE http://www.ssa.gov SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources) Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid. In addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These Medicare Savings Programs help people with limited income and resources save money each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).) Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums. To find out more about Medicaid and its programs, contact Family and Social Services Administration of Indiana (Indiana s Medicaid Program). Method CALL Family and Social Services Administration of Indiana 317-233-4454 or 1-888-673-0002 toll free

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 33 Chapter 2. Important phone numbers and resources Method TTY Family and Social Services Administration of Indiana 1-800-743-3333 (Relay Indiana) WRITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Family and Social Service Administration of Indiana 402 W. Washington Street, P.O. Box 7083 Indianapolis, IN 46204 WEBSITE www.in.gov/fssa/ SECTION 7 Information about programs to help people pay for their prescription drugs Medicare s Extra Help Program Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan s monthly premium, yearly deductible, and prescription copayments. This Extra Help also counts toward your out-ofpocket costs. People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don t need to apply. Medicare mails a letter to people who automatically qualify for Extra Help. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week. The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778 (applications); or Your State Medicaid Office (applications) (See Section 6 of this chapter for contact information). If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. You may call our Customer Solutions Center to discuss your situation with a representative and we will help you determine what information you have that we can use

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 34 Chapter 2. Important phone numbers and resources as proof of qualification. You can also mail copies of the information you have to the address provided in the introduction. Our Customer Solutions Center will then forward the information along to Medicare. When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Customer Solutions Center if you have questions (phone numbers are printed on the back cover of this booklet). Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not receiving Extra Help. A 50% discount on the negotiated price (excluding the dispensing fee) is available for those brand name drugs from manufacturers. The plan pays an additional 5% and you pay the remaining 45% for your brand drugs. If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Part D Explanation of Benefits (Part D EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. The amount paid by the plan (5%) does not count toward your out-of-pocket costs. You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 42% of the price for generic drugs and you pay the remaining 58% of the price. For generic drugs, the amount paid by the plan (42%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug. If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet). What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)? If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Help ), you still get the 50% discount on covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coverage gap. The 50% discount and the 5% paid by the plan are both applied to the price of the drug before any SPAP or other coverage.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 35 Chapter 2. Important phone numbers and resources What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance. Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan name or policy number. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the Indiana State Department of Health, ADAP Coordinator, 2 N. Meridian Street, Suite 6-C, Indianapolis, IN 46204, Phone: 1-866-588-4948. What if you get Extra Help from Medicare to help pay your prescription drug costs? Can you get the discounts? No. If you get Extra Help, you already get coverage for your prescription drug costs during the coverage gap. What if you don t get a discount, and you think you should have? If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB) notice. If the discount doesn t appear on your Part D Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or 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. State Pharmaceutical Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug coverage to its members. In Indiana, the State Pharmaceutical Assistance Program is Hoosier Rx.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 36 Chapter 2. Important phone numbers and resources Method Hoosier Rx CALL 1-866-267-4679 WRITE Hoosier Rx P.O. Box 6224 Indianapolis, IN 46202-6224 WEBSITE www.in.gov/hoosierrx SECTION 8 How to contact the Railroad Retirement Board The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation s railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board, contact the agency. If you receive your Medicare through the Railroad Retirement Board, it is important that you let them know if you move or change your mailing address Method Railroad Retirement Board CALL 1-877-772-5772 Calls to this number are free. TTY 1-312-751-4701 Available 9:00 am to 3:30 pm, Monday through Friday If you have a touch-tone telephone, recorded information and automated services are available 24 hours a day, including weekends and holidays. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. WEBSITE http://www.rrb.gov SECTION 9 Do you have group insurance or other health insurance from an employer? If you (or your spouse) get benefits from your (or your spouse s) employer or retiree group as part of this plan, you may call the employer/union benefits administrator or Customer Solutions Center if you have any questions. You can ask about your (or your spouse s) employer or retiree health benefits, premiums, or the enrollment period. (Phone numbers for Customer Solutions

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 37 Chapter 2. Important phone numbers and resources Center are printed on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan. If you have other prescription drug coverage through your (or your spouse s) employer or retiree group, please contact that group s benefits administrator. The benefits administrator can help you determine how your current prescription drug coverage will work with our plan.

CHAPTER 3 Using the plan s coverage for your medical services

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 39 Chapter 3. Using the plan s coverage for your medical services Chapter 3. Using the plan s coverage for your medical services SECTION 1 Things to know about getting your medical care covered as a member of our plan... 41 Section 1.1 What are network providers and covered services?... 41 Section 1.2 Basic rules for getting your medical care covered by the plan... 41 SECTION 2 Use providers in the plan s network to get your medical care... 42 Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your medical care... 42 Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP?... 43 Section 2.3 How to get care from specialists and other network providers... 44 Section 2.4 How to get care from out-of-network providers... 45 SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster... 45 Section 3.1 Getting care if you have a medical emergency... 45 Section 3.2 Getting care when you have an urgent need for services... 46 Section 3.3 Getting care during a disaster... 47 SECTION 4 What if you are billed directly for the full cost of your covered services?... 47 Section 4.1 You can ask us to pay our share of the cost of covered services... 47 Section 4.2 If services are not covered by our plan, you must pay the full cost... 47 SECTION 5 How are your medical services covered when you are in a clinical research study?... 48 Section 5.1 What is a clinical research study?... 48 Section 5.2 When you participate in a clinical research study, who pays for what?... 49 SECTION 6 Rules for getting care covered in a religious non-medical health care institution... 50 Section 6.1 What is a religious non-medical health care institution?... 50 Section 6.2 What care from a religious non-medical health care institution is covered by our plan?... 50

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 40 Chapter 3. Using the plan s coverage for your medical services SECTION 7 Rules for ownership of durable medical equipment... 51 Section 7.1 Will you own the durable medical equipment after making a certain number of payments under our plan?... 51

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 41 Chapter 3. Using the plan s coverage for your medical services SECTION 1 Things to know about getting your medical care covered as a member of our plan This chapter explains what you need to know about using the plan to get your medical care covered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, services, and other medical care that are covered by the plan. For the details on what medical care is covered by our plan and how much you pay when you get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is covered and what you pay). Section 1.1 What are network providers and covered services? Here are some definitions that can help you understand how you get the care and services that are covered for you as a member of our plan: Providers are doctors and other health care professionals licensed by the state to provide medical services and care. The term providers also includes hospitals and other health care facilities. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services. Covered services include all the medical care, health care services, supplies, and equipment that are covered by our plan. Your covered services for medical care are listed in the benefits chart in Chapter 4. Section 1.2 Basic rules for getting your medical care covered by the plan As a Medicare health plan, Indiana University Health Plans Medicare Select Plus (HMO) must cover all services covered by Original Medicare and must follow Original Medicare s coverage rules. Indiana University Health Plans Medicare Select Plus (HMO) will generally cover your medical care as long as: The care you receive is included in the plan s Medical Benefits Chart (this chart is in Chapter 4 of this booklet). The care you receive is considered medically necessary. Medically necessary means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 42 Chapter 3. Using the plan s coverage for your medical services You have a network primary care provider (a PCP) who is providing and overseeing your care. As a member of our plan, you must choose a network PCP (for more information about this, see Section 2.1 in this chapter). o In most situations, your network PCP must give you approval in advance before you can use other providers in the plan s network, such as specialists, hospitals, skilled nursing facilities, or home health care agencies. This is called giving you a referral. For more information about this, see Section 2.3 of this chapter. o Referrals from your PCP are not required for emergency care or urgently needed services. There are also some other kinds of care you can get without having approval in advance from your PCP (for more information about this, see Section 2.2 of this chapter). You must receive your care from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care you receive from an out-ofnetwork provider (a provider who is not part of our plan s network) will not be covered. Here are three exceptions: o The plan covers emergency care or urgently needed services that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed services means, see Section 3 in this chapter. o If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-ofnetwork provider. You must obtain authorization from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-ofnetwork doctor, see Section 2.4 in this chapter. o The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan s service area. SECTION 2 Section 2.1 Use providers in the plan s network to get your medical care You must choose a Primary Care Provider (PCP) to provide and oversee your medical care What is a PCP and what does the PCP do for you? What is a PCP? Primary Care Provider (PCP) is a health care professional you select to coordinate your healthcare. Your PCP is responsible for providing or authorizing covered services while you are a plan member. What types of providers may act as a PCP? Family Practice, General Practice or Internal Medicine

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 43 Chapter 3. Using the plan s coverage for your medical services Explain the role of a PCP in your plan. You will usually see your PCP first for most of your routine health care needs. There are only a few types of covered services you can get on your own, without contacting your PCP first as we explain below. What is the role of the PCP in coordinating covered services? Coordinating your services includes checking or consulting with other plan providers about your care and how it is going. If you need certain types of covered services or supplies, you must get approval in advance from your PCP. In some cases, your PCP will need to get authorization (prior approval) from us. Since your PCP will provide and coordinate your medical care you should have all of your past medical records sent to you PCP s office. How do you choose your PCP? When enrolling in Indiana University Health Plans Select Plus (HMO) you will need to select a PCP (Primary Care Physician) from the Indiana University Medicare Provider/Pharmacy Directory and write your selection on your enrollment application. Changing your PCP You may change your PCP for any reason, at any time. Also, it s possible that your PCP might leave our plan s network of providers and you would have to find a new PCP. When possible we will provide you with at least 30 days notice that your PCP is leaving our plan so that you have time to select a new provider. To change your PCP, call our Customer Solutions Center. This change will take effect immediately upon receipt of the request Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP? You can get the services listed below without getting approval in advance from your PCP. Routine women s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. Flu shots: Hepatitis B vaccinations and pneumonia vaccinations as long as you get them from a network provider. Emergency services from network providers or from out-of-network providers. Urgently needed services from network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan s service area.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 44 Chapter 3. Using the plan s coverage for your medical services Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan s service area. (If possible, please call Customer Solutions Center before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away. Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) Section 2.3 How to get care from specialists and other network providers A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples: Oncologists care for patients with cancer. Cardiologists care for patients with heart conditions. Orthopedists care for patients with certain bone, joint, or muscle conditions. What is the role (if any) of the PCP in referring members to specialists and other providers? The PCP can direct the member to specialist and other providers for care. PCP referrals are limited to network specialists, hospitals or facilities. PCP referrals to out-of-network providers must receive prior authorization. What if a specialist or another network provider leaves our plan? We may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections summarized below: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. When possible we will provide you with at least 30 days notice that your provider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your health care needs. If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted. If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 45 Chapter 3. Using the plan s coverage for your medical services If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care. Section 2.4 How to get care from out-of-network providers It is important to know which providers are included in our network because, with limited exceptions, care you receive from out-of-network providers will not be covered. Here are three exceptions: The plan covers emergency care or urgently needed services that you get from an out-ofnetwork provider. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider. The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan s service area. SECTION 3 Section 3.1 How to get covered services when you have an emergency or urgent need for care or during a disaster Getting care if you have a medical emergency What is a medical emergency and what should you do if you have one? A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP. What is covered if you have a medical emergency? You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. For more information, see the Medical Benefits Chart in Chapter 4 of this booklet.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 46 Chapter 3. Using the plan s coverage for your medical services If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over. After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If your emergency care is provided by out-of-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow. What if it wasn t a medical emergency? Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care thinking that your health is in serious danger and the doctor may say that it wasn t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor has said that it was not an emergency, we will cover additional care only if you get the additional care in one of these two ways: You go to a network provider to get the additional care. or The additional care you get is considered urgently needed services and you follow the rules for getting this urgently needed services (for more information about this, see Section 3.2 below). Section 3.2 Getting care when you have an urgent need for services What are urgently needed services? Urgently needed services are non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition that you have. What if you are in the plan s service area when you have an urgent need for care? You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 47 Chapter 3. Using the plan s coverage for your medical services What if you are outside the plan s service area when you have an urgent need for care? When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed services that you get from any provider. Our plan does not cover urgently need care or any other non-emergency care if you receive the care outside of the United States. Section 3.3 Getting care during a disaster If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan. Please visit the following website: www.iuhealthplansmedicare.org for information on how to obtain needed care during a disaster. Generally, during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5 for more information. SECTION 4 Section 4.1 What if you are billed directly for the full cost of your covered services? You can ask us to pay our share of the cost of covered services If you have paid more than your share for covered services, or if you have received a bill for the full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do. Section 4.2 If services are not covered by our plan, you must pay the full cost Indiana University Health Plans Medicare Select Plus (HMO) covers all medical services that are medically necessary, are listed in the plan s Medical Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren t covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and were not authorized. If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. You also

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 48 Chapter 3. Using the plan s coverage for your medical services have the right to ask for this in writing. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made. You may also call Customer Solutions Center to get more information (phone numbers are printed on the back cover of this booklet). For covered services that have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type of covered service. You can call Customer Solutions Center when you want to know how much of your benefit limit you have already used. SECTION 5 Section 5.1 How are your medical services covered when you are in a clinical research study? What is a clinical research study? A clinical research study (also called a clinical trial ) is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe. Not all clinical research studies are open to members of our plan. Medicare first needs to approve the research study. If you participate in a study that Medicare has not approved, you will be responsible for paying all costs for your participation in the study. Once Medicare approves the study, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study. If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan. If you want to participate in a Medicare-approved clinical research study, you do not need to get approval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need to be part of our plan s network of providers.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 49 Chapter 3. Using the plan s coverage for your medical services Although you do not need to get our plan s permission to be in a clinical research study, you do need to tell us before you start participating in a clinical research study. Here is why you need to tell us: 1. We can let you know whether the clinical research study is Medicare-approved. 2. We can tell you what services you will get from clinical research study providers instead of from our plan. If you plan on participating in a clinical research study, contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 5.2 When you participate in a clinical research study, who pays for what? Once you join a Medicare-approved clinical research study, you are covered for routine items and services you receive as part of the study, including: Room and board for a hospital stay that Medicare would pay for even if you weren t in a study. An operation or other medical procedure if it is part of the research study. Treatment of side effects and complications of the new care. Original Medicare pays most of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost for these services, our plan will also pay for part of the costs. We will pay the difference between the cost-sharing in Original Medicare and your cost-sharing as a member of our plan. This means you will pay the same amount for the services you receive as part of the study as you would if you received these services from our plan. Here s an example of how the cost-sharing works: Let s say that you have a lab test that costs $100 as part of the research study. Let s also say that your share of the costs for this test is $20 under Original Medicare, but the test would be $10 under our plan s benefits. In this case, Original Medicare would pay $80 for the test and we would pay another $10. This means that you would pay $10, which is the same amount you would pay under our plan s benefits. In order for us to pay for our share of the costs, you will need to submit a request for payment. With your request, you will need to send us a copy of your Medicare Summary Notices or other documentation that shows what services you received as part of the study and how much you owe. Please see Chapter 7 for more information about submitting requests for payment. When you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 50 Chapter 3. Using the plan s coverage for your medical services Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would cover the item or service even if you were not in a study. Items and services the study gives you or any participant for free. Items or services provided only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly CT scans done as part of the study if your medical condition would normally require only one CT scan. Do you want to know more? You can get more information about joining a clinical research study by reading the publication Medicare and Clinical Research Studies on the Medicare website (http://www.medicare.gov). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 6 Section 6.1 Rules for getting care covered in a religious nonmedical health care institution What is a religious non-medical health care institution? A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a hospital or a skilled nursing facility is against a member s religious beliefs, we will instead provide coverage for care in a religious non-medical health care institution. You may choose to pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient services (non-medical health care services). Medicare will only pay for non-medical health care services provided by religious non-medical health care institutions. Section 6.2 What care from a religious non-medical health care institution is covered by our plan? To get care from a religious non-medical health care institution, you must sign a legal document that says you are conscientiously opposed to getting medical treatment that is non-excepted. Non-excepted medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state, or local law. Excepted medical treatment is medical care or treatment that you get that is not voluntary or is required under federal, state, or local law. To be covered by our plan, the care you get from a religious non-medical health care institution must meet the following conditions: The facility providing the care must be certified by Medicare.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 51 Chapter 3. Using the plan s coverage for your medical services Our plan s coverage of services you receive is limited to non-religious aspects of care. If you get services from this institution that are provided to you in your home, our plan will cover these services only if your condition would ordinarily meet the conditions for coverage of services given by home health agencies that are not religious non-medical health care institutions. If you get services from this institution that are provided to you in a facility, the following conditions apply: o You must have a medical condition that would allow you to receive covered services for inpatient hospital care or skilled nursing facility care. o and you must get approval in advance from our plan before you are admitted to the facility or your stay will not be covered. Medicare Inpatient Hospital coverage limits apply. Refer to Benefits Chart in Chapter 4 SECTION 7 Section 7.1 Rules for ownership of durable medical equipment Will you own the durable medical equipment after making a certain number of payments under our plan? Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a provider for use in the home. Certain items, such as prosthetics, are always owned by the member. In this section, we discuss other types of durable medical equipment that must be rented. In Original Medicare, people who rent certain types of durable medical equipment own the equipment after paying co-payments for the item for 13 months. As a member of Indiana University Health Plans Medicare Select Plus (HMO), under certain limited circumstances we will transfer ownership of the durable medical equipment item to you. Call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) to find out about the requirements you must meet and the documentation you need to provide. What happens to payments you have made for durable medical equipment if you switch to Original Medicare? If you switch to Original Medicare after being a member of our plan: If you did not acquire ownership of the durable medical equipment item while in our plan, you will have to make 13 new consecutive payments for the item while in Original Medicare in order to acquire ownership of the item. Your previous payments while in our plan do not count toward these 13 consecutive payments. If you made payments for the durable medical equipment item under Original Medicare before you joined our plan, these previous Original Medicare payments also do not count toward the 13 consecutive payments. You will have to make 13 consecutive payments for the item under

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 52 Chapter 3. Using the plan s coverage for your medical services Original Medicare in order to acquire ownership. There are no exceptions to this case when you return to Original Medicare.

CHAPTER 4 Medical Benefits Chart (what is covered and what you pay)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 54 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Chapter 4. Medical Benefits Chart (what is covered and what you pay) SECTION 1 Understanding your out-of-pocket costs for covered services... 55 Section 1.1 Types of out-of-pocket costs you may pay for your covered services... 55 Section 1.2 What is the most you will pay for Medicare Part A and Part B covered medical services?... 55 Section 1.3 Our plan does not allow providers to balance bill you... 56 SECTION 2 Use the Medical Benefits Chart to find out what is covered for you and how much you will pay... 55 Section 2.1 Your medical benefits and costs as a member of the plan... 57 SECTION 3 What services are not covered by the plan?... 83 Section 3.1 Services we do not cover (exclusions)... 83

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 55 Chapter 4. Medical Benefits Chart (what is covered and what you pay) SECTION 1 Understanding your out-of-pocket costs for covered services This chapter focuses on your covered services and what you pay for your medical benefits. It includes a Medical Benefits Chart that lists your covered services and shows how much you will pay for each covered service as a member of Indiana University Health Plans Medicare Select Plus (HMO). Later in this chapter, you can find information about medical services that are not covered. Section 1.1 Types of out-of-pocket costs you may pay for your covered services To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. A copayment is the fixed amount you pay each time you receive certain medical services. You pay a copayment at the time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more about your copayments.) Coinsurance is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more about your coinsurance.) Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs for Medicare. (These Medicare Savings Programs include the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of these programs, you may still have to pay a copayment for the service, depending on the rules in your state. Section 1.2 What is the most you will pay for Medicare Part A and Part B covered medical services? Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have to pay out-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B (see the Medical Benefits Chart in Section 2, below). This limit is called the maximum out-of-pocket amount for medical services. As a member of Indiana University Health Plans Medicare Select Plus (HMO), the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 2016 is $4,850. The amounts you pay for copayments, and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. The amounts you pay for your plan premiums and for your Part D prescription drugs do not count toward your maximum out-of-pocket amount. (In addition, amounts you pay for some services do not count toward your maximum out-of-pocket

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 56 Chapter 4. Medical Benefits Chart (what is covered and what you pay) amount. These services are marked with an asterisk in the Medical Benefits Chart.) If you reach the maximum out-of-pocket amount of $4,850, you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay your plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). Section 1.3 Our plan does not allow providers to balance bill you As a member of Indiana University Health Plans Medicare Select Plus (HMO), an important protection for you is that after you meet any deductibles, you only have to pay your cost-sharing amount when you get services covered by our plan. We do not allow providers to add additional separate charges, called balance billing. This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don t pay certain provider charges. Here is how this protection works. If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then you pay only that amount for any covered services from a network provider. If your cost-sharing is a coinsurance (a percentage of the total charges), then you never pay more than that percentage. However, your cost depends on which type of provider you see: o If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by the plan s reimbursement rate (as determined in the contract between the provider and the plan). o If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. (Remember, the plan covers services from out-of-network providers only in certain situations, such as when you get a referral.) o If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. (Remember, the plan covers services from out-of-network providers only in certain situations, such as when you get a referral.) If you believe a provider has balance billed you, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 57 Chapter 4. Medical Benefits Chart (what is covered and what you pay) SECTION 2 Section 2.1 Use the Medical Benefits Chart to find out what is covered for you and how much you will pay Your medical benefits and costs as a member of the plan The Medical Benefits Chart on the following pages lists the services Indiana University Health Plans Select Plus (HMO) covers and what you pay out-of-pocket for each service. The services listed in the Medical Benefits Chart are covered only when the following coverage requirements are met: Your Medicare covered services must be provided according to the coverage guidelines established by Medicare. Your services (including medical care, services, supplies, and equipment) must be medically necessary. Medically necessary means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. You receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. Chapter 3 provides more information about requirements for using network providers and the situations when we will cover services from an out-of-network provider. You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP must give you approval in advance before you can see other providers in the plan s network. This is called giving you a referral. Chapter 3 provides more information about getting a referral and the situations when you do not need a referral. Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called prior authorization ) from us. Other important things to know about our coverage: Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2016 Handbook. View it online at http://www.medicare.gov or ask for 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.) For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition.

Apple icon. You Apple icon. Abdominal Apple icon. Annual 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 58 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Sometimes, Medicare adds coverage under Original Medicare for new services during the year. If Medicare adds coverage for any services during 2016, either Medicare or our plan will cover those services. will see this apple next to the preventive services in the benefits chart. Medical Benefits Chart Services that are covered for you Aortic Aneurysm Screening A one-time screening ultrasound for people at risk. The plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. Ambulance Services Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person s health or if authorized by the plan. Non-emergency transportation by ambulance is appropriate if it is documented that the member s condition is such that other means of transportation could endanger the person s health and that transportation by ambulance is medically required. Wellness Visit If you ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Note: Your first annual wellness visit can t take place within 12 months of your Welcome to Medicare preventive visit. However, you don t need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you ve had Part B for 12 months. What you must pay when you get these services There is no coinsurance, copayment, or deductible for beneficiaries eligible for this preventive screening. Member cost-sharing applies to your $4,850 out-of-pocket maximum $225 copay (per one way trip) for Medicare covered ambulance benefits There is no coinsurance, copayment, or deductible for this benefit.

Apple icon. Bone Apple icon. Breast Apple icon. Cardiovascular 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 59 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Mass Measurement For qualified individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician s interpretation of the results. What you must pay when you get these services There is no coinsurance, copayment, or deductible for Medicare covered bone mass measurement Cancer Screening (mammograms) Covered services include: One baseline mammogram between the ages of 35 and 39 One screening mammogram every 12 months for women age 40 and older Clinical breast exams once every 24 months Cardiac Rehabilitation Services Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor s referral. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. There is no coinsurance, copayment, or deductible for Medicare covered screening mammograms Once screening becomes diagnostic, outpatient copay applies There is no coinsurance, copayment, or deductible for Medicare covered Cardiac Rehabilitation Services Disease Risk Reduction Visit (Therapy for Cardiovascular Disease) We cover one visit per year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you re eating well. There is no coinsurance, copayment, or deductible for Medicare covered intensive behavioral therapy cardiovascular disease preventive benefit.

Apple icon. Cardiovascular Apple icon. Cervical Apple icon. Colorectal 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 60 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Disease Testing Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months). and Vaginal Cancer Screening Covered services include: For all women: Pap tests and pelvic exams are covered once every 24 months If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age: one Pap test every 12 months What you must pay when you get these services There is no coinsurance, copayment, or deductible for cardiovascular disease testing that is covered once every 5 years. There is no coinsurance, copayment, or deductible for Medicare covered preventive Pap and pelvic exams. Chiropractic Services Covered services include: We cover only manual manipulation of the spine to correct subluxation Cancer Screening For people 50 and older, the following are covered: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months Fecal occult blood test, every 12 months For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy Member cost-sharing applies to your $4,850 outof-pocket maximum $20 copay for each Medicare covered visit There is no coinsurance, copayment, or deductible for a Medicare covered colorectal cancer screening exam. Once screening becomes diagnostic, outpatient surgery copay may apply

Apple icon. Depression Apple icon. Diabetes 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 61 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Dental Services In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover one (1) oral exam every six months, one (1) set of bite wing x-rays every six (6) months and one cleaning every six (6) months. What you must pay when you get these services Preventive dental services and non-medicare covered services do not count towards your $4,850 outof-pocket maximum. $10 deductible every calendar year. Screening We cover one screening for depression per year. The screening must be done in a primary care setting that can provide followup treatment and referrals. There is no coinsurance, copayment, or deductible for an annual depression screening visit. Screening We cover this screening (includes fasting glucose tests) if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. There is no coinsurance, copayment, or deductible for Medicare covered diabetes screening test.

Apple icon. Diabetes 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 62 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Self-Management Training, Diabetic Services and Supplies For all people who have diabetes (insulin and non-insulin users). Covered services include: Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. For people with diabetes who have severe diabetic foot disease: One pair per calendar year of therapeutic custommolded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting. Diabetes self-management training is covered under certain conditions. What you must pay when you get these services There is no coinsurance, copayment, or deductible for Medicare covered preventive diabetes selfmanagement training. $0 copy for all diabetes supplies (supplies are diabetes glucose monitor, test strips and lancets). Durable Medical Equipment and Related Supplies (For a definition of durable medical equipment, see Chapter 12 of this booklet.) Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. We cover all medically necessary durable medical equipment covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. Member cost-sharing applies to your $4,850 outof-pocket maximum Authorization rules may apply. 20% of the cost for Medicare covered equipment

Apple icon. Health 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 63 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Emergency Care Emergency care refers to services that are: Furnished by a provider qualified to furnish emergency services, and Needed to evaluate or stabilize an emergency medical condition. A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories and Wellness Education Programs Programs designed to enrich the health and lifestyles of members include weight management, fitness, and stress management. What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum $65 copay for Medicare covered visits NOT covered outside the United States or its territories. If you are admitted as an in-patient to the hospital you pay $0 for the Emergency room visit If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must return to a network hospital for your care to continue to be covered OR you must have your inpatient care at the out-ofnetwork hospital authorized by the plan and your cost is the same cost sharing you would pay at a network hospital Annual Fitness reimbursement up to $200.00 for qualified gym membership, fitness classes and programs. Reimbursement based on receipts from member.

Apple icon. HIV 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 64 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Hearing Services Diagnostic hearing and balance evaluations performed by your PCP or provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist or other qualified provider. Additional Covered Hearing Services Benefits are for in-network providers only. Routine Hearing Exam We cover one (1) routine (non-diagnostic) hearing exam every 12 months. What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum $25 copay for Medicare covered diagnostic hearing exams Routine Exams and Hearing Aids do not count towards your $4,850 outof-pocket maximum. $75 copay for routine hearing exams Hearing Aids Copayments for hearing aids apply only to the TruHearing Chime products. Limited to two (2) hearing aids every 12 months. $699 for Chime 500 per aid. $999 for Chime 900 per aid. Screening For people who ask for an HIV screening test or who are at increased risk for HIV infection, we cover: One screening exam every 12 months For women who are pregnant, we cover: Up to three screening exams during a pregnancy There is no coinsurance, copayment, or deductible for Medicare covered preventive HIV screening.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 65 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Home health agency care Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort. Covered services include, but are not limited to: Part-time or intermittent skilled nursing and home health aide services (To be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week) Physical therapy, occupational therapy, and speech therapy Medical and social services Medical equipment and supplies Hospice care You may receive care from any Medicare-certified hospice program. You are eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you re terminally ill and have 6 months or less to live if your illness runs its normal course. Your hospice doctor can be a network provider or an out-ofnetwork provider. Covered services include: Drugs for symptom control and pain relief Short-term respite care Home care For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for. For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need nonemergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan s network: What you must pay when you get these services Member cost-sharing applies to your $4,850 out-of-pocket maximum $0 copay for Medicare covered Home Health visits 20% of cost for Medicare covered medical equipment and supplies When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not Indiana University Health Plans Medicare Select Plus (HMO).

Apple icon. Immunizations 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 66 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services If you obtain the covered services from a network provider, you only pay the plan cost-sharing amount for in-network services If you obtain the covered services from an out-of-network provider, you pay the cost-sharing under Fee-for-Service Medicare (Original Medicare) For services that are covered by Indiana University Health Plans Medicare Select Plus, but are not covered by Medicare Part A or B: Indiana University Health Plans Medicare Select Plus will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services. For drugs that may be covered by the plan s Part D benefit: Drugs are never covered by both hospice and our plan at the same time. For more information, please see Chapter 5, Section 9.4 (What if you re in Medicare-certified hospice). Note: If you need non-hospice care (care that is not related to your terminal prognosis), you should contact us to arrange the services. Getting your non-hospice care through our network providers will lower your share of the costs for the services. Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn t elected the hospice benefit at $0 copay. Covered Medicare Part B services include: Pneumonia vaccine Flu shots, once a year in the fall or winter Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B Other vaccines if you are at risk and they meet Medicare Part B coverage rules We also cover some vaccines under our Part D prescription drug benefit. There is no coinsurance, copayment, or deductible for the pneumonia, influenza, and Hepatitis B vaccines.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 67 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Inpatient Hospital Care Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. Covered services include but are not limited to: Semi-private room (or a private room if medically necessary) Meals including special diets Regular nursing services Costs of special care units (such as intensive care or coronary care units) Drugs and medications Lab tests X-rays and other radiology services Necessary surgical and medical supplies Use of appliances, such as wheelchairs Operating and recovery room costs Physical, occupational, and speech language therapy Inpatient substance abuse services What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum Authorization rules may apply Plan covers 90 days each benefit period Days 1-7: $260 copay per day, per admission Days 8-90: $0 copay per day, per admission 60 Medicare covered lifetime reserve days

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 68 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. If Indiana University Health Plans Medicare Select Plus provides transplant services at a distant location (outside of the service area) and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. Physician services Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff. You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the 2 at http://www.medicare.gov/publications/pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. What you must pay when you get these services If you get authorized inpatient care at an out-ofnetwork hospital after your emergency condition is stabilized, your cost is the same cost-sharing you would pay at a network hospital.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 69 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Inpatient Mental Health Care Covered services include mental health care services that require a hospital stay. There is a 190 day lifetime limit for inpatient services in a psychiatric hospital. The 190 day limit does not apply to mental health services provided in a psychiatric unit of a general hospital What you must pay when you get these services Member cost-sharing applies to your $4,850 out-of-pocket maximum Authorization rules may apply For Medicare covered hospital stays Indiana University Health Plans Medicare Select Plus (HMO) covers 90 days each benefit period You get up to 190 days in a Psychiatric Hospital in a lifetime Days 1-6: $260 copay per day, per admission Days 7-90 $0 copay per day, per admission

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 70 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Inpatient Services Covered During Non-Covered Inpatient Care If you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF). Covered services include, but are not limited to: Physician services Diagnostic tests (like lab tests) X-ray, radium, and isotope therapy including technician materials and services Surgical dressings Splints, casts and other devices used to reduce fractures and dislocations Prosthetics and orthotics devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices Leg, arm, back, and neck braces; trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient s physical condition Physical therapy, speech therapy, and occupational therapy What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum You pay 100% for hospital or SNF days that are not or no longer covered. After your SNF day limits are reached Indiana University Health Plans Medicare Select Plus will still pay for covered physicians services and other medical services outlined in this benefit chart. All applicable copays apply

Apple icon. Medical 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 71 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Nutrition Therapy This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when referred by your doctor. We cover 3 hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and 2 hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician s referral. A physician must prescribe these services and renew their referral yearly if your treatment is needed into the next calendar year. What you must pay when you get these services There is no coinsurance, copayment, or deductible for beneficiaries eligible for Medicare covered medical nutrition therapy services.

Apple icon. Obesity 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 72 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Medicare Part B Prescription Drugs These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include: Drugs that usually aren t self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan Clotting factors you give yourself by injection if you have hemophilia Immunosuppressive Drugs, if you were enrolled in Medicare Part A at the time of the organ transplant Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to postmenopausal osteoporosis, and cannot self-administer the drug Antigens Certain oral anti-cancer drugs and anti-nausea drugs Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen, Procrit, Epoetin Alfa, Aranesp, or Darbepoetin Alfa) Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases Chapter 5 explains the Part D prescription drug benefit, including rules you must follow to have prescriptions covered. What you pay for your Part D prescription drugs through our plan is explained in Chapter 6. Screening and Therapy to Promote Sustained Weight Loss If you have a body mass index of 30 or more, we cover intensive counseling to help you lose weight. This counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more. What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum Authorization rules may apply 20% of the cost for Part B covered chemotherapy drugs and other Part B covered drugs There is no coinsurance, copayment, or deductible for preventive obesity screening and therapy.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 73 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Outpatient Diagnostic Tests and Therapeutic Services and Supplies Covered services include, but are not limited to: X-rays Radiation (radium and isotope) therapy including technician materials and supplies Surgical supplies, such as dressings Splints, casts and other devices used to reduce fractures and dislocations Laboratory tests Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. Other outpatient diagnostic tests What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum Authorization rules may apply $10 copay for Medicare covered lab services $10 copay for Medicare covered diagnostic procedures and tests $25 copay for Medicare covered X-rays $25 copay for Medicare covered therapeutic radiology services $135 copay for Medicare covered diagnostic radiology services (not including x-rays)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 74 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Outpatient Hospital Services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to: Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery Laboratory and diagnostic tests billed by the hospital Mental health care, including care in a partialhospitalization program, if a doctor certifies that inpatient treatment would be required without it X-rays and other radiology services billed by the hospital Medical supplies such as splints and casts Certain screenings and preventive services Certain drugs and biologicals that you can t give yourself Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an outpatient, you should ask the hospital staff. You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at http://www.medicare.gov/publications/pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum All applicable copays apply

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 75 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Outpatient Mental Health Care Covered services include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws. What you must pay when you get these services Member cost-sharing applies to your $4,850 out-of-pocket maximum $25 copay for each Medicare covered individual therapy visit $25 copay for each Medicare covered group therapy visit $40 copay for each Medicare covered individual session with a psychiatrist $40 copay for each Medicare covered group session with a psychiatrist Outpatient Rehabilitation Services Covered services include: physical therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). Member cost-sharing applies to your $4,850 outof-pocket maximum $15 copay for Medicare covered Occupational therapy visits $15 copay for Medicare covered Physical and/or Speech and Language therapy visits

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 76 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Outpatient Substance Abuse Services Medicare Part B covers outpatient alcohol or drug abuse treatment under certain circumstances, from Medicare approved providers. Medicare Part B covers diagnosis, establishment of a treatment plan, and follow-up care from a physician for alcohol or drug abuse Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers Note: If you are having surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. What you must pay when you get these services Member cost-sharing applies to your $4,850 out-of-pocket maximum $25 copay for Medicare covered individual visits $25 copay for Medicare covered group visits Member cost-sharing applies to your $4,850 out-of-pocket maximum $285 copay for each Medicare covered surgical center visit $0-$285 copay for each Medicare covered hospital facility visit Authorization rules may apply. Partial Hospitalization Services Partial hospitalization is a structured program of active psychiatric treatment provided in a hospital outpatient setting or by a community mental health center, that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. Member cost-sharing applies to your $4,850 outof-pocket maximum Authorization rules may apply $40 copay for Medicare covered partial hospitalization

Apple icon. Prostate 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 77 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Physician/Practitioner Services, Including Doctor s Office Visits Covered services include: Medically-necessary medical care or surgery services furnished in a physician s office, certified ambulatory surgical center, hospital outpatient department, or any other location Consultation, diagnosis, and treatment by a specialist Basic hearing and balance exams performed by your PCP, if your doctor orders it to see if you need medical treatment Certain telehealth services including consultation, diagnosis, and treatment by a physician or practitioner for patients in certain rural areas or other locations approved by Medicare Second opinion by another network provider prior to surgery Non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician) What you must pay when you get these services Member cost-sharing applies to your $4,850 outof-pocket maximum $10 copay for Primary care doctor visits for Medicare covered benefits $40 copay for each specialist visit for Medicare covered benefits Podiatry Services Covered services include: Diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). Routine foot care for members with certain medical conditions affecting the lower limbs Member cost-sharing applies to your $4,850 outof-pocket maximum $15 copay for each Medicare covered visit Cancer Screening Exams For men age 50 and older, covered services include the following - once every 12 months: Digital rectal exam Prostate Specific Antigen (PSA) test There is no coinsurance, copayment, or deductible for an annual PSA test.

Apple icon. Screening 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 78 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Prosthetic Devices and Related Supplies Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery see Vision Care later in this section for more detail. What you must pay when you get these services Member cost-sharing applies to your $4850 outof-pocket maximum 20% of the cost for Medicare covered prosthetic devices and related supplies Pulmonary Rehabilitation Services Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and referral for pulmonary rehabilitation from the doctor treating the chronic respiratory disease. $0 copay for Medicare covered Pulmonary Rehab services and Counseling to Reduce Alcohol Misuse We cover one alcohol misuse screening for adults with Medicare (including pregnant women) who misuse alcohol, but aren t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face-to-face counseling sessions per year (if you re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare covered screening and counseling to reduce alcohol misuse preventive benefit.

Apple icon. Screening 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 79 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you for Sexually Transmitted Infections (STIs) and Counseling to Prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor s office. What you must pay when you get these services There is no coinsurance, copayment, or deductible for the Medicare covered screening for STI s and counseling to prevent STI s preventive benefit. Services to Treat Kidney Disease and Conditions Covered services include: Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime. Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3) Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) Home dialysis equipment and supplies Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, Medicare Part B prescription drugs. $0 copay for Renal Dialysis

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 80 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Skilled Nursing Facility (SNF) care (For a definition of skilled nursing facility care, see Chapter 12 of this booklet. Skilled nursing facilities are sometimes called SNFs. ) Covered services include but are not limited to: Semiprivate room (or a private room if medically necessary) Meals, including special diets Skilled nursing services Physical therapy, occupational therapy, and speech therapy Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. Medical and surgical supplies ordinarily provided by SNFs Laboratory tests ordinarily provided by SNFs X-rays and other radiology services ordinarily provided by SNFs Use of appliances such as wheelchairs ordinarily provided by SNFs Physician/Practitioner services Generally, you will get your SNF care from network facilities. However, under certain conditions listed below, you may be able to pay in-network cost-sharing for a facility that isn t a network provider, if the facility accepts our plan s amounts for payment. A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care). A SNF where your spouse is living at the time you leave the hospital. What you must pay when you get these services Member cost-sharing applies to your $4,850 out-of-pocket maximum Authorization rules may apply Plan covers up to 100 days each benefit period No prior hospital stay is required For Medicare covered SNF stays: Days:1-20: $0 copay per day Days 21-100: $160 copay per day

Apple icon. Smoking 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 81 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you and Tobacco Use Cessation (Counseling to Stop Smoking or Tobacco Use) If you use tobacco, but do not have signs or symptoms of tobacco-related disease: We cover two counseling quit attempts within a 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face-to-face visits. If you use tobacco and have been diagnosed with a tobaccorelated disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable cost-sharing. Each counseling attempt includes up to four face-to-face visits. What you must pay when you get these services There is no coinsurance, copayment, or deductible for Medicare covered smoking and tobacco use cessation preventive benefits Urgently Needed Services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories Member cost-sharing applies to your $4,850 outof-pocket maximum $50 copay for Medicare covered urgently needed care NOT covered outside the United States or its territories

Apple icon. Vision 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 82 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you Care Covered services include: Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn t cover routine eye exams (eye refractions) for eyeglasses/contacts. For people who are at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes, and African-Americans who are age 50 and older: glaucoma screening once per year. One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) Additional Covered Vision Care Benefits are for in-network providers only. There are limited out-of-network benefits and your cost-sharing will be different. Routine Vision Exam We cover one (1) routine (non-diagnostic) vision exam every 12 months. Plastic Lenses and Frames We cover one (1) pair of lenses every 24 months. Copays vary on what type of plastic lenses you need. We cover one (1) set of frames every 24 months. Member will receive a credit of up to $120 for frames. Any balance exceeding $120, member will pay 80% of remaining balance. Contacts We cover contact lenses and contact materials every 24 months in lieu of lenses and frames. Member will receive a credit of up to $120 for contacts. Any balance exceeding $120, member will pay up to 100% of remaining balance. What you must pay when you get these services $0 copay for exams to diagnose and treat diseases and conditions of the eye. Routine Exams, Lenses, Frames, and Contacts do not count towards your $4,850 out-of-pocket maximum. $0 copay for up to one routine eye exam As low as a $20 copay for one (1) pair of standard plastic lenses. $20 copay for one (1) set of frames under the credit amount. $0 copay for contact lenses and contact materials under the credit amount.

Apple icon. Welcome 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 83 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services that are covered for you to Medicare Preventive Visit The plan covers the one-time Welcome to Medicare preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: We cover the Welcome to Medicare preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor s office know you would like to schedule your Welcome to Medicare preventive visit. What you must pay when you get these services There is no coinsurance, copayment, or deductible for your Welcome to Medicare preventive visit. SECTION 3 Section 3.1 What services are not covered by the plan? Services we do not cover (exclusions) This section tells you what services are excluded from Medicare coverage and therefore, are not covered by this plan. If a service is excluded, it means that this plan doesn t cover the service. The chart below lists services and items that either are not covered under any condition or are covered only under specific conditions. If you get services that are excluded (not covered), you must pay for them yourself. We won t pay for the excluded medical services listed in the chart below except under the specific conditions listed. The only exception: we will pay if a service in the chart below is found upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3 in this booklet.) All exclusions or limitations on services are described in the Benefits Chart or in the chart below. Even if you receive the excluded services at an emergency facility, the excluded services are still not covered and our plan will not pay for them.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 84 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services not covered by Medicare Services considered not reasonable and necessary, according to the standards of Original Medicare Experimental medical and surgical procedures, equipment and medications. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Private room in a hospital. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television. Full-time nursing care in your home. *Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Homemaker services include basic household assistance, including light housekeeping or light meal preparation. Fees charged for care by your immediate relatives or members of your household. Not covered under any condition Covered only under specific conditions May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan. (See Chapter 3, Section 5 for more information on clinical research studies.) Covered only when medically necessary. * Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 85 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services not covered by Medicare Cosmetic surgery or procedures Not covered under any condition Covered only under specific conditions Covered in cases of an accidental injury or for improvement of the functioning of a malformed body member. Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Routine dental care, such as cleanings, fillings or dentures. Non-routine dental care. Routine chiropractic care Routine foot care Orthopedic shoes Supportive devices for the feet Routine hearing exams, hearing aids, or exams to fit hearing aids. Some routine/preventative dental care is covered. See Section 2.1 for more information. Dental care required to treat illness or injury may be covered as inpatient or outpatient care. Manual manipulation of the spine to correct a subluxation is covered. Some limited coverage provided according to Medicare guidelines, e.g., if you have diabetes. If shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease. Orthopedic or therapeutic shoes for people with diabetic foot disease. Routine hearing exams and hearing aids are covered. See Section 2.1 for

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 86 Chapter 4. Medical Benefits Chart (what is covered and what you pay) Services not covered by Medicare Routine eye examinations, eyeglasses, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. Reversal of sterilization procedures and or nonprescription contraceptive supplies. Acupuncture Naturopath services (uses natural or alternative treatments). Not covered under any condition Covered only under specific conditions more information. Eye exam and one pair of eyeglasses (or contact lenses) are covered for people after cataract surgery.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 87 Chapter 4. Medical Benefits Chart (what is covered and what you pay) CHAPTER 5 Using the plan s coverage for your Part D prescription drugs

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 88 Chapter 5. Using the plan s coverage for your Part D prescription drugs Chapter 5. Using the plan s coverage for your Part D prescription drugs SECTION 1 Introduction... 91 Section 1.1 This chapter describes your coverage for Part D drugs... 91 Section 1.2 Basic rules for the plan s Part D drug coverage... 91 SECTION 2 Fill your prescription at a network pharmacy or through the plan s mail-order service... 92 Section 2.1 To have your prescription covered, use a network pharmacy... 92 Section 2.2 Finding network pharmacies... 92 Section 2.3 Using the plan s mail-order services... 93 Section 2.4 How can you get a long-term supply of drugs?... 94 Section 2.5 When can you use a pharmacy that is not in the plan s network?... 95 SECTION 3 Your drugs need to be on the plan s Drug List... 95 Section 3.1 The Drug List tells which Part D drugs are covered... 95 Section 3.2 There are five (5) cost-sharing tiers for drugs on the Drug List... 96 Section 3.3 How can you find out if a specific drug is on the Drug List?... 97 SECTION 4 There are restrictions on coverage for some drugs... 97 Section 4.1 Why do some drugs have restrictions?... 97 Section 4.2 What kinds of restrictions?... 98 Section 4.3 Do any of these restrictions apply to your drugs?... 99 SECTION 5 Section 5.1 Section 5.2 Section 5.3 What if one of your drugs is not covered in the way you d like it to be covered?... 99 There are things you can do if your drug is not covered in the way you d like it to be covered... 99 What can you do if your drug is not on the Drug List or if the drug is restricted in some way?... 100 What can you do if your drug is in a cost-sharing tier you think is too high?... 102 SECTION 6 What if your coverage changes for one of your drugs?... 103 Section 6.1 The Drug List can change during the year... 103 Section 6.2 What happens if coverage changes for a drug you are taking?... 103

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 89 Chapter 5. Using the plan s coverage for your Part D prescription drugs SECTION 7 What types of drugs are not covered by the plan?... 104 Section 7.1 Types of drugs we do not cover... 104 SECTION 8 Show your plan membership card when you fill a prescription... 105 Section 8.1 Show your membership card... 105 Section 8.2 What if you don t have your membership card with you?... 106 SECTION 9 Part D drug coverage in special situations... 106 Section 9.1 What if you re in a hospital or a skilled nursing facility for a stay that is covered by the plan?... 106 Section 9.2 What if you re a resident in a long-term care (LTC) facility?... 106 Section 9.3 What if you re also getting drug coverage from an employer or retiree group plan?... 107 Section 9.4 What if you re in Medicare-certified hospice?... 107 SECTION 10 Programs on drug safety and managing medications... 108 Section 10.1 Programs to help members use drugs safely... 108 Section 10.2 Medication Therapy Management (MTM) program to help members manage their medications... 108

question mark. Did 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 90 Chapter 5. Using the plan s coverage for your Part D prescription drugs you know there are programs to help people pay for their drugs? There are programs to help people with limited resources pay for their drugs. These include Extra Help and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7. Are you currently getting help to pay for your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you don t have this insert, please call Customer Solutions Center and ask for the LIS Rider. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 91 Chapter 5. Using the plan s coverage for your Part D prescription drugs SECTION 1 Section 1.1 Introduction This chapter describes your coverage for Part D drugs This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs). In addition to your coverage for Part D drugs, Indiana University Health Plans Select Plus (HMO) also covers some drugs under the plan s medical benefits. Through its coverage of Medicare A benefits, our plan generally covers drugs you are given during covered stays in the hospital or in a skilled nursing facility. Through its coverage of Medicare Part B benefits, our plan covers drugs including certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a dialysis facility. Chapter 4 (Medical Benefits Chart, what is covered and what you pay) tells about the benefits and costs for drugs during a covered hospital or skilled nursing facility stay, as well as your benefits and costs for Part B drugs. Your drugs may be covered by Original Medicare if you are in Medicare hospice. Our plan only covers Medicare Parts A, B, and D services and drugs that are unrelated to your terminal prognosis and related conditions and therefore not covered under the Medicare hospice benefit. For more information, please see Section 9.4 (What if you re in Medicare-certified hospice). For information on hospice coverage, see the hospice section of Chapter 4 (Medical Benefits Chart, what is covered and what you pay). The following sections discuss coverage of your drugs under the plan s Part D benefit rules. Section 9, Part D drug coverage in special situations includes more information on your Part D coverage and Original Medicare. Section 1.2 Basic rules for the plan s Part D drug coverage The plan will generally cover your drugs as long as you follow these basic rules: You must have a provider (a doctor, dentist or other prescriber) write your prescription. Your prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time for your prescriber to submit the necessary paperwork to be processed. You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a network pharmacy or through the plan s mail-order service.) Your drug must be on the plan s List of Covered Drugs (Formulary) (we call it the Drug List for short). (See Section 3, Your drugs need to be on the plan s Drug List. )

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 92 Chapter 5. Using the plan s coverage for your Part D prescription drugs Your drug must be used for a medically accepted indication. A medically accepted indication is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medically accepted indication.) SECTION 2 Section 2.1 Fill your prescription at a network pharmacy or through the plan s mail-order service To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered only if they are filled at the plan s network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term covered drugs means all of the Part D prescription drugs that are covered on the plan s Drug List. Section 2.2 Finding network pharmacies How do you find a network pharmacy in your area? To find a network pharmacy, you can look in your Provider/Pharmacy Directory, visit our website at www.iuhealthplansmedicare.org, or call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy. What if the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan s network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or use the Provider/Pharmacy Directory. You can also find information on our website at www.iuhealthplansmedicare.org. What if you need a specialized pharmacy? Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 93 Chapter 5. Using the plan s coverage for your Part D prescription drugs Pharmacies that supply drugs for home infusion therapy. Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a long-term care facility (such as a nursing home) has its own pharmacy. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies, which is typically the pharmacy that the LTC facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility, please contact Customer Solutions Center. Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network. Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.) To locate a specialized pharmacy, look in your Provider/Pharmacy Directory or call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 2.3 Using the plan s mail-order services For certain kinds of drugs, you can use the plan s network mail-order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan s mail-order service are marked as mail-order drugs in our Drug List Our plan s mail-order service allows you to order up to a 90-day supply of the drug. To get information about filling your prescriptions by mail please call our Customer Solutions Center. Usually a mail-order pharmacy order will get to you in no more than 14 days. If you need to start your medications right away, but the mail-order is delayed, ask your doctor for a one month (30) day supply (prescription) to be filled at your local pharmacy. New prescriptions the pharmacy receives directly from your doctor s office. The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either: You used mail order services with this plan in the past, or You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions now or at any time by providing consent on your first new home delivery prescription, sent in by your physician. If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 94 Chapter 5. Using the plan s coverage for your Part D prescription drugs If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact us by calling the Customer Service phone number on the back of your ID card. If you never have never used our mail order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping. To opt out of automatic deliveries of new prescriptions received directly from your health care provider s office, please contact us by calling the Customer Service phone number on the back of your ID card. Refills on mail order prescriptions. For refills, please contact your pharmacy 21 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time. So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. You can do this by calling the Customer Service phone number on the back of your ID card. Section 2.4 How can you get a long-term supply of drugs? When you get a long-term supply of drugs, your cost-sharing may be lower. The plan offers two ways to get a long-term supply (also called an extended supply ) of maintenance drugs on our plan s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) You may order this supply through mail order (see Section 2.3) or you may go to a retail pharmacy. 1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider/Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can also call Customer Solutions Center for more information (phone numbers are printed on the back cover of this booklet). 2. For certain kinds of drugs, you can use the plan s network mail-order services. The drugs available through our plan s mail-order service are marked as mail-order drugs in our Drug List. Our plan s mail-order service allows you to order up to a 90-day supply of the drug. See Section 2.3 for more information about using our mail-order services.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 95 Chapter 5. Using the plan s coverage for your Part D prescription drugs Section 2.5 When can you use a pharmacy that is not in the plan s network? Your prescription may be covered in certain situations Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-ofnetwork pharmacy: Getting prescriptions related to a medical emergency or urgently needed care. Note: We cannot pay for any prescriptions that are filled by pharmacies outside the United States or its territories, even for a medical emergency. Getting coverage when you travel or are away from the plans service area. If you are traveling within the United States or its territories, but outside the plan s service area, and you become ill, lose or run out of your prescription drugs, call Customer Solutions to find out if there is a network pharmacy in the area where you are traveling. You are unable to get a prescription drug in a timely manner within our service area because there are not network pharmacies within a reasonable driving distance that provide 24-hour emergency service. In these situations, please check first with Customer Solutions Center to see if there is a network pharmacy nearby. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy. How do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you back.) SECTION 3 Section 3.1 Your drugs need to be on the plan s Drug List The Drug List tells which Part D drugs are covered The plan has a List of Covered Drugs (Formulary). In this Evidence of Coverage, we call it the Drug List for short.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 96 Chapter 5. Using the plan s coverage for your Part D prescription drugs The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan s Drug List. The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs). We will generally cover a drug on the plan s Drug List as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A medically accepted indication is a use of the drug that is either: approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) -- or -- supported by certain reference books. (These reference books are the American Hospital Formulary Service Drug Information; the DRUGDEX Information System; and the USPDI or its successor; and, for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology or their successors.) The Drug List includes both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs. What is not on the Drug List? The plan does not cover all prescription drugs. In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, see Section 7.1 in this chapter). In other cases, we have decided not to include a particular drug on the Drug List. Section 3.2 There are five (5) cost-sharing tiers for drugs on the Drug List Every drug on the plan s Drug List is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug: Cost-Sharing Tier 1 includes Preferred Generic drugs and is the lowest cost sharing tier Cost-Sharing Tier 2 includes Generic drugs Cost-Sharing Tier 3 includes Preferred Brand Name and Generic drugs

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 97 Chapter 5. Using the plan s coverage for your Part D prescription drugs Cost-Sharing Tier 4 includes Non-Preferred Brand Name and Generic drugs which will have a higher cost-share. You may want to check with your provider to see if there is an equivalent drug on Tier 1, Tier 2 or Tier 3. Cost-Sharing Tier 5 includes Specialty drugs and is the highest cost-sharing tier To find out which cost-sharing tier your drug is in, look it up in the plan s Drug List. The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for your Part D prescription drugs). Section 3.3 How can you find out if a specific drug is on the Drug List? You have three ways to find out: 1. Check the most recent Drug List we sent you in the mail. (Please note: The Drug List we send includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact the Customer Solutions Center to find out if we cover it. 2. Visit the plan s website (www.iuhealthplansmedicare.org). The Drug List on the website is always the most current. 3. Call Customer Solutions Center to find out if a particular drug is on the plan s Drug List or to ask for a copy of the list. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) SECTION 4 Section 4.1 There are restrictions on coverage for some drugs Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a highercost drug, the plan s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare s rules and regulations for drug coverage and cost-sharing.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 98 Chapter 5. Using the plan s coverage for your Part D prescription drugs If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.) Please note that sometimes a drug may appear more than once in our drug list. This is because different restrictions or cost-sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid). Section 4.2 What kinds of restrictions? Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs. Restricting brand name drugs when a generic version is available Generally, a Generic drug works the same as a Brand Name drug and usually costs less. In most cases, when a Generic version of a Brand Name drug is available, our network pharmacies will provide you the Generic version. We usually will not cover the Brand Name drug when a Generic version is available. However, if your provider has told us the medical reason that neither the Generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the Brand Name drug. (Your share of the cost may be greater for the Brand Name drug than for the Generic drug.) Getting plan approval in advance For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. Trying a different drug first This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called step therapy. Quantity limits For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 99 Chapter 5. Using the plan s coverage for your Part D prescription drugs safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Section 4.3 Do any of these restrictions apply to your drugs? The plan s Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or check our website, www.iuhealthplansmedicare.org. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact Customer Solutions Center to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.) SECTION 5 Section 5.1 What if one of your drugs is not covered in the way you d like it to be covered? There are things you can do if your drug is not covered in the way you d like it to be covered We hope that your drug coverage will work well for you. But it s possible that there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking that is not on our formulary or is on our formulary with restrictions. For example: The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered. The drug is covered, but there are extra rules or restrictions on coverage for that drug. As explained in Section 4, some of the drugs covered by the plan have extra rules to restrict their use. For example, you might be required to try a different drug first, to see if it will work, before the drug you want to take will be covered for you. Or there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. In some cases, you may want us to waive the restriction for you. The drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than you think it should be. The plan puts each covered drug into one of five (5) different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. There are things you can do if your drug is not covered in the way that you d like it to be covered. Your options depend on what type of problem you have:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 100 Chapter 5. Using the plan s coverage for your Part D prescription drugs If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do. If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do. Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? If your drug is not on the Drug List or is restricted, here are things you can do: You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered. You can change to another drug. You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. You may be able to get a temporary supply Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do. To be eligible for a temporary supply, you must meet the two requirements below: 1. The change to your drug coverage must be one of the following types of changes: The drug you have been taking is no longer on the plan s Drug List. or -- the drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions). 2. You must be in one of the situations described below: For those members who are new or who were in the plan last year and aren t in a long-term care (LTC ) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 101 Chapter 5. Using the plan s coverage for your Part D prescription drugs For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 93- day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 93-day supply of medication. (Please note that the longterm care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) For those members who have been in the plan for more than 90 day and reside in a long-term care (LTC) facility and need a supply right away: We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply. Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who: Enter a long-term care (LTC) facility from the hospital and get a discharge list of drugs from the hospital, with a very short term planning taken into account (often under 8 hours). Are discharged from a hospital to a home. End their skilled nursing facility under a Medicare Part A stay (where payments include all pharmacy charges) and need to use your Part D Indiana University Health Plans Medicare Select Plus (HMO) Drug List. End a long term care facility stay and return to their homes. To ask for a temporary supply, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options. You can change to another drug Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Customer Solutions Center to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 102 Chapter 5. Using the plan s coverage for your Part D prescription drugs You can ask for an exception You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? If your drug is in a cost-sharing tier you think is too high, here are things you can do: You can change to another drug If your drug is in a cost-sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call Customer Solutions Center to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) You can ask for an exception For drugs in Tier 4, you and your provider can ask the plan to make an exception in the costsharing tier for the drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 explains what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Drugs in our Tier 5 (Specialty drugs) are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs in this tier.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 103 Chapter 5. Using the plan s coverage for your Part D prescription drugs SECTION 6 Section 6.1 What if your coverage changes for one of your drugs? The Drug List can change during the year Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make changes to the Drug List. For example, the plan might: Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective. Move a drug to a higher or lower cost-sharing tier. Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter). Replace a brand name drug with a generic drug. In almost all cases, we must get approval from Medicare for changes we make to the plan s Drug List. Section 6.2 What happens if coverage changes for a drug you are taking? How will you find out if your drug s coverage has been changed? If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, a drug is suddenly recalled because it s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your provider will also know about this change, and can work with you to find another drug for your condition. Do changes to your drug coverage affect you right away? If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan: If we move your drug into a higher cost-sharing tier. If we put a new restriction on your use of the drug.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 104 Chapter 5. Using the plan s coverage for your Part D prescription drugs If we remove your drug from the Drug List, but not because of a sudden recall or because a new generic drug has replaced it. If any of these changes happens for a drug you are taking, then the change won t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will affect you. In some cases, you will be affected by the coverage change before January 1: If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days notice or give you a 60-day refill of your brand name drug at a network pharmacy. o During this 60-day period, you should be working with your provider to switch to the generic or to a different drug that we cover. o Or you and your provider can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). Again, if a drug is suddenly recalled because it s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. o Your provider will also know about this change, and can work with you to find another drug for your condition. SECTION 7 Section 7.1 What types of drugs are not covered by the plan? Types of drugs we do not cover This section tells you what kinds of prescription drugs are excluded. This means Medicare does not pay for these drugs. If you get drugs that are excluded, you must pay for them yourself. We won t pay for the drugs that are listed in this section. The only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specific situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 9, Section 6.5 in this booklet.) Here are three general rules about drugs that Medicare drug plans will not cover under Part D: Our plan s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 105 Chapter 5. Using the plan s coverage for your Part D prescription drugs Our plan cannot cover a drug purchased outside the United States or its territories. Our plan usually cannot cover off-label use. Off-label use is any use of the drug other than those indicated on a drug s label as approved by the Food and Drug Administration. o Generally, coverage for off-label use is allowed only when the use is supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology, or their successors. If the use is not supported by any of these reference books, then our plan cannot cover its off-label use. Also, by law, these categories of drugs are not covered by Medicare drug plans: Non-prescription drugs (also called over-the-counter drugs) Drugs when used to promote fertility Drugs when used for the relief of cough or cold symptoms Drugs when used for cosmetic purposes or to promote hair growth Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject Drugs when used for treatment of anorexia, weight loss, or weight gain Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale If you receive Extra Help paying for your drugs, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.) SECTION 8 Section 8.1 Show your plan membership card when you fill a prescription Show your membership card To fill your prescription, show your plan membership card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill the plan for our share of your covered prescription drug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 106 Chapter 5. Using the plan s coverage for your Part D prescription drugs Section 8.2 What if you don t have your membership card with you? If you don t have your plan membership card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information. If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2.1 for information about how to ask the plan for reimbursement.) SECTION 9 Section 9.1 Part D drug coverage in special situations What if you re in a hospital or a skilled nursing facility for a stay that is covered by the plan? If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this section that tell about the rules for getting drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a Special Enrollment Period. During this time period, you can switch plans or change your coverage. (Chapter 10, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.) Section 9.2 What if you re a resident in a long-term care (LTC) facility? Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility s pharmacy as long as it is part of our network. Check your Provider/Pharmacy Directory to find out if your long-term care facility s pharmacy is part of our network. If it isn t, or if you need more information, please contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet). What if you re a resident in a long-term care (LTC) facility and become a new member of the plan? If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary supply of your drug during the first 90 days of your membership. The total supply will be for a maximum of a 93-day supply, or less if your prescription is written for fewer days.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 107 Chapter 5. Using the plan s coverage for your Part D prescription drugs (Please note that the long-term care (LTC) pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been a member of the plan for more than 90 days and need a drug that is not on our Drug List or if the plan has any restriction on the drug s coverage, we will cover one 31-day supply, or less if your prescription is written for fewer days. During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. Section 9.3 What if you re also getting drug coverage from an employer or retiree group plan? Do you currently have other prescription drug coverage through your (or your spouse s) employer or retiree group? If so, please contact that group s benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan. In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first. Special note about creditable coverage : Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next calendar year is creditable and the choices you have for drug coverage. If the coverage from the group plan is creditable, it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage. Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from your employer or retiree plan s benefits administrator or the employer or union. Section 9.4 What if you re in Medicare-certified hospice? Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti-nausea, laxative, pain medication or antianxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 108 Chapter 5. Using the plan s coverage for your Part D prescription drugs that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription. In the event you either revoke your hospice election or are discharged from hospice our plan should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that tell about the rules for getting drug coverage under Part D Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. SECTION 10 Section 10.1 Programs on drug safety and managing medications Programs to help members use drugs safely We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs. We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as: Possible medication errors Drugs that may not be necessary because you are taking another drug to treat the same medical condition Drugs that may not be safe or appropriate because of your age or gender Certain combinations of drugs that could harm you if taken at the same time Prescriptions written for drugs that have ingredients you are allergic to Possible errors in the amount (dosage) of a drug you are taking. If we see a possible problem in your use of medications, we will work with your provider to correct the problem. Section 10.2 Medication Therapy Management (MTM) program to help members manage their medications We have a program that can help our members with complex health needs. For example, some members have several medical conditions, take different drugs at the same time, and have high drug costs.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 109 Chapter 5. Using the plan s coverage for your Part D prescription drugs This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. This program can help make sure that our members get the most benefit from the drugs they take. Our program is called a Medication Therapy Management (MTM) program. Some members who take medications for different medical conditions may be able to get services through a MTM program. A pharmacist or other health professional will give you a comprehensive review of all your medications. You can talk about how best to take your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You ll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You ll also get a personal medication list that will include all the medications you re taking and why you take them. It s a good idea to have your medication review before your yearly Wellness visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, keep your medication list with you (for example, with your ID) in case you go to the hospital or emergency room. If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Customer Solutions Center (phone numbers are printed on the back cover of this booklet).

CHAPTER 6 What you pay for your Part D prescription drugs

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 111 Chapter 6. What you pay for your Part D prescription drugs Chapter 6. What you pay for your Part D prescription drugs SECTION 1 Introduction... 113 Section 1.1 Use this chapter together with other materials that explain your drug coverage... 113 Section 1.2 Types of out-of-pocket costs you may pay for covered drugs... 114 SECTION 2 Section 2.1 What you pay for a drug depends on which drug payment stage you are in when you get the drug... 114 What are the drug payment stages for Indiana University Health Plans Select Plus (HMO) members?... 114 SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in... 116 Section 3.1 We send you a monthly report called the Part D Explanation of Benefits (the Part D EOB )... 116 Section 3.2 Help us keep our information about your drug payments up to date... 116 SECTION 4 There is no Deductible for Indiana Health Plans Medicare Select Plus (HMO)... 117 Section 4.1 You do not pay a deductible for your Part D drugs... 117 SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share... 117 Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription... 117 Section 5.2 A table that shows your costs for a one-month supply of a drug... 118 Section 5.3 If your doctor prescribes less than a full month s supply, you may not have to pay the cost of the entire month s supply... 120 Section 5.4 A table that shows your costs for a long-term up to a 90-day supply of a drug... 120 Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for the year reach $3,310... 121 SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 58% of the costs of generic drugs... 122 Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $4,850.... 122 Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs. 123

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 112 Chapter 6. What you pay for your Part D prescription drugs SECTION 7 Section 7.1 SECTION 8 Section 8.1 Section 8.2 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs... 125 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year... 125 What you pay for vaccinations covered by Part D depends on how and where you get them... 125 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine... 125 You may want to call us at Customer Solutions Center before you get a vaccination... 127 SECTION 9 Do you have to pay the Part D late enrollment penalty?... 127 Section 9.1 What is the Part D late enrollment penalty?... 127 Section 9.2 How much is the Part D late enrollment penalty?... 128 Section 9.3 In some situations, you can enroll late and not have to pay the penalty... 129 Section 9.4 What can you do if you disagree about your late enrollment penalty?... 129 SECTION 10 Do you have to pay an extra Part D amount because of your income?... 130 Section 10.1 Who pays an extra Part D amount because of income?... 130 Section 10.2 How much is the extra Part D amount?... 130 Section 10.3 What can you do if you disagree about paying an extra Part D amount?... 131 Section 10.4 What happens if you do not pay the extra Part D amount?... 131

question mark. Did 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 113 Chapter 6. What you pay for your Part D prescription drugs you know there are programs to help people pay for their drugs? There are programs to help people with limited resources pay for their drugs. These include Extra Help and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7. Are you currently getting help to pay for your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you don t have this insert, please call Customer Solutions Center and ask for the LIS Rider. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) SECTION 1 Section 1.1 Introduction Use this chapter together with other materials that explain your drug coverage This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use drug in this chapter to mean a Part D prescription drug. As explained in Chapter 5, not all drugs are Part D drugs some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics: The plan s List of Covered Drugs (Formulary). To keep things simple, we call this the Drug List. o This Drug List tells which drugs are covered for you. o It also tells which of the five (5) cost-sharing tiers the drug is in and whether there are any restrictions on your coverage for the drug. o If you need a copy of the Drug List, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can also find the Drug List on our website at www.iuhealthplansmedicare.org The Drug List on the website is always the most current. Chapter 5 of this booklet gives the details about your prescription drug coverage, including rules you need to follow when you get your covered drugs. Chapter 5 also tells which types of prescription drugs are not covered by our plan.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 114 Chapter 6. What you pay for your Part D prescription drugs The plan s Provider/Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 5 for the details). The Provider/ Pharmacy Directory has a list of pharmacies in the plan s network. It also tells you which pharmacies in our network can give you a long-term supply of a drug (such as filling a prescription for a 90-day supply). Section 1.2 Types of out-of-pocket costs you may pay for covered drugs To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is called cost-sharing and there are three ways you may be asked to pay. The deductible is the amount you must pay for drugs before our plan begins to pay its share. Copayment means that you pay a fixed amount each time you fill a prescription. Coinsurance means that you pay a percent of the total cost of the drug each time you fill a prescription. SECTION 2 Section 2.1 What you pay for a drug depends on which drug payment stage you are in when you get the drug What are the drug payment stages for Indiana University Health Plans Select Plus (HMO) members? As shown in the table below, there are drug payment stages for your prescription drug coverage under Indiana University Health Plans Medicare Select Plus (HMO). How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Keep in mind you are always responsible for the plan s monthly premium regardless of the drug payment stage.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 115 Chapter 6. What you pay for your Part D prescription drugs Stage 1 Yearly Deductible Stage Stage 2 Initial Coverage Stage Stage 3 Coverage Gap Stage Stage 4 Catastrophic Coverage Stage Because there is no deductible for the plan, this payment stage does not apply to you. You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date total drug costs (your payments plus any Part D plan s payments) total $3,310. (Details are in Section 5 of this chapter.) During this stage, you pay 45% of the price for brand name drugs (plus a portion of the dispensing fee) and 58% of the price for generic drugs. You stay in this stage until your year-to-date out-ofpocket costs (your payments) reach a total of $4,850. This amount and rules for counting costs toward this amount have been set by Medicare. (Details are in Section 6 of this chapter.) During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2016). (Details are in Section 7 of this chapter.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 116 Chapter 6. What you pay for your Part D prescription drugs SECTION 3 Section 3.1 We send you reports that explain payments for your drugs and which payment stage you are in We send you a monthly report called the Part D Explanation of Benefits (the Part D EOB ) Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of: We keep track of how much you have paid. This is called your out-of-pocket cost. We keep track of your total drug costs. This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan. Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes called the Part D EOB ) when you have had one or more prescriptions filled through the plan during the previous month. It includes: Information for that month. This report gives the payment details about the prescriptions you have filled during the previous month. It shows the total drug costs, what the plan paid, and what you and others on your behalf paid. Totals for the year since January 1. This is called year-to-date information. It shows you the total drug costs and total payments for your drugs since the year began. Section 3.2 Help us keep our information about your drug payments up to date To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date: Show your membership card when you get a prescription filled. To make sure we know about the prescriptions you are filling and what you are paying, show your plan membership card every time you get a prescription filled. Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 7, Section 2 of this booklet.) Here are some types of

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 117 Chapter 6. What you pay for your Part D prescription drugs situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs: o When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan s benefit. o When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program. o Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances. Send us information about the payments others have made for you. Payments made by certain other individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs. Check the written report we send you. When you receive an Part D Explanation of Benefits (a Part D EOB ) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questions, please call us at Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Be sure to keep these reports. They are an important record of your drug expenses. SECTION 4 Section 4.1 There is no Deductible for Indiana Health Plans Medicare Select Plus (HMO) You do not pay a deductible for your Part D drugs There is no deductible for Indiana University Health Plans Medicare Select Plus (HMO). You begin in the Initial Coverage Stage when you fill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage. SECTION 5 Section 5.1 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share What you pay for a drug depends on the drug and where you fill your prescription During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 118 Chapter 6. What you pay for your Part D prescription drugs The plan has five (5) cost-sharing tiers Every drug on the plan s Drug List is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug: Cost-Sharing Tier 1 includes Preferred Generic drugs and is the lowest cost-sharing tier Cost-Sharing Tier 2 includes Generic drugs Cost-Sharing Tier 3 includes Preferred Brand Name and Generic drugs Cost-Sharing Tier 4 includes Non-Preferred Brand Name and Generic drugs which will have a higher cost-share. You may want to check with your provider to see if there is an equivalent drug on Tier 1, Tier 2 or Tier 3. Cost-Sharing Tier 5 includes Specialty drugs and is the highest cost-sharing tier To find out which cost-sharing tier your drug is in, look it up in the plan s Drug List. Your pharmacy choices How much you pay for a drug depends on whether you get the drug from: A retail pharmacy that is in our plan s network A pharmacy that is not in the plan s network The plan s mail-order pharmacy For more information about these pharmacy choices and filling your prescriptions, see Chapter 5 in this booklet and the plan s Provider/Pharmacy Directory. Section 5.2 A table that shows your costs for a one-month supply of a drug During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance. Copayment means that you pay a fixed amount each time you fill a prescription. Coinsurance means that you pay a percent of the total cost of the drug each time you fill a prescription. As shown in the table below, the amount of the copayment or coinsurance depends on which cost-sharing tier your drug is in. Please note: If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 119 Chapter 6. What you pay for your Part D prescription drugs We cover prescriptions filled at out-of-network pharmacies in only limited situations. Please see Chapter 5, Section 2.5 for information about when we will cover a prescription filled at an out-of-network pharmacy. Your share of the cost when you get a one-month supply of a covered Part D prescription drug: Standard retail costsharing (innetwork) (up to a 30- day supply) Mail-order costsharing (up to a 90- day supply) Long-term care (LTC) costsharing (up to a 31- day supply) Out-ofnetwork costsharing (Coverage is limited to certain situations; see Chapter 5 for details.) (up to a 30- day supply) Cost-Sharing Tier 1 (Preferred Generic) Cost-Sharing Tier 2 (Generic) Cost-Sharing Tier 3 (Preferred- Brand Name and Generic) Cost-Sharing Tier 4 (Non-Preferred Brand Name and Generic) $ 6 $ 18 $ 6 $ 6 $ 15 $ 44 $ 15 $ 15 $ 45 $ 126 $ 45 $ 45 $95 $266 $95 $95 Cost-Sharing Tier 5 (Specialty) 33% 33% (maximum 30 day supply) 33% 33%

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 120 Chapter 6. What you pay for your Part D prescription drugs Section 5.3 If your doctor prescribes less than a full month s supply, you may not have to pay the cost of the entire month s supply Typically, the amount you pay for a prescription drug covers a full month s supply of a covered drug. However your doctor can prescribe less than a month s supply of drugs. There may be times when you want to ask your doctor about prescribing less than a month s supply of a drug (for example, when you are trying a medication for the first time that is known to have serious side effects). If your doctor prescribes less than a full month s supply, you will not have to pay for the full month s supply for certain drugs. The amount you pay when you get less than a full month s supply will depend on whether you are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollar amount). If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. You pay the same percentage regardless of whether the prescription is for a full month s supply or for fewer days. However, because the entire drug cost will be lower if you get less than a full month s supply, the amount you pay will be less. If you are responsible for a copayment for the drug, your copay will be based on the number of days of the drug that you receive. We will calculate the amount you pay per day for your drug (the daily cost-sharing rate ) and multiply it by the number of days of the drug you receive. o Here s an example: Let s say the copay for your drug for a full month s supply (a 30-day supply) is $30. This means that the amount you pay per day for your drug is $1. If you receive a 7 days supply of the drug, your payment will be $1 per day multiplied by 7 days, for a total payment of $7. Daily cost-sharing allows you to make sure a drug works for you before you have to pay for an entire month s supply. You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full month s supply of a drug or drugs, if this will help you better plan refill date for different prescriptions so that you can take fewer trips to the pharmacy. The amount you pay will depend upon the days supply you receive. Section 5.4 A table that shows your costs for a long-term up to a 90-day supply of a drug For some drugs, you can get a long-term supply (also called an extended supply ) when you fill your prescription. A long-term supply is 90-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 5, Section 2.4.) The table below shows what you pay when you get a long-term up to a 90-day supply of a drug.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 121 Chapter 6. What you pay for your Part D prescription drugs Please note: If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower. Your share of the cost when you get a long-term supply of a covered Part D prescription drug: Standard retail cost-sharing (innetwork) (up to a 90-day supply) Mail-order costsharing (up to a 90-day supply) Cost-Sharing Tier 1 (Preferred Generic) Cost-Sharing Tier 2 (Generic) Cost-Sharing Tier 3 (Preferred Brand Name and Generic) Cost-Sharing Tier 4 (Non-Preferred Brand Name and Generic) $18 $18 $44 $44 $126 $126 $266 $266 Cost-Sharing Tier 5 (Specialty) A long term supply is not available for drugs in tier 5 A long term supply is not available for drugs in tier 5 Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for the year reach $3,310 You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches the $3,310 limit for the Initial Coverage Stage. Your total drug cost is based on adding together what you have paid and what any Part D plan has paid: What you have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 122 Chapter 6. What you pay for your Part D prescription drugs o The total you paid as your share of the cost for your drugs during the Initial Coverage Stage. What the plan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2016, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.) The Part D Explanation of Benefits (Part D EOB) that we send to you will help you keep track of how much you and the plan, as well as any third parties, have spent on your behalf during the year. Many people do not reach the $3,310 limit in a year. We will let you know if you reach this $3,310 amount. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage. SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 58% of the costs of generic drugs Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $4,850. When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 45% of the negotiated price and a portion of the dispensing fee for brand name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. You also receive some coverage for generic drugs. You pay no more than 58% of the cost for generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (42%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than 58% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2016, that amount is $4,850. Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $4,850, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 123 Chapter 6. What you pay for your Part D prescription drugs Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs Here are Medicare s rules that we must follow when we keep track of your out-of-pocket costs for your drugs. These payments are included in your out-of-pocket costs When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 5 of this booklet): The amount you pay for drugs when you are in any of the following drug payment stages: o The Initial Coverage Stage. o The Coverage Gap Stage. Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan. It matters who pays: If you make these payments yourself, they are included in your out-of-pocket costs. These payments are also included if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare s Extra Help Program are also included. Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included. Moving on to the Catastrophic Coverage Stage: When you (or those paying on your behalf) have spent a total of $4,850 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 124 Chapter 6. What you pay for your Part D prescription drugs These payments are not included in your out-of-pocket costs When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs: The amount you pay for your monthly premium. Drugs you buy outside the United States or its territories. Drugs that are not covered by our plan. Drugs you get at an out-of-network pharmacy that do not meet the plan s requirements for out-of-network coverage. Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare. Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan. Payments made by the plan for your brand or generic drugs while in the Coverage Gap. Payments for your drugs that are made by group health plans including employer health plans. Payments for your drugs that are made by certain insurance plans and governmentfunded health programs such as TRICARE and the Veteran s Administration. Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Worker s Compensation). Reminder: If any other organization such as the ones listed above pays part or all of your outof-pocket costs for drugs, you are required to tell our plan. Call Customer Solutions Center to let us know (phone numbers are printed on the back cover of this booklet). How can you keep track of your out-of-pocket total? We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to you includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $4,850 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 125 Chapter 6. What you pay for your Part D prescription drugs SECTION 7 Section 7.1 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,850 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. During this stage, the plan will pay most of the cost for your drugs. Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is the larger amount: o either coinsurance of 5% of the cost of the drug o or $2.95 for a Generic drug or a drug that is treated like a Generic and $7.40 for all other drugs. Our plan pays the rest of the cost. SECTION 8 Section 8.1 What you pay for vaccinations covered by Part D depends on how and where you get them Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine Our plan provides coverage of a number of Part D vaccines. We also cover vaccines that are considered medical benefits. You can find out about coverage of these vaccines by going to the Medical Benefits Chart in Chapter 4, Section 2.1. There are two parts to our coverage of Part D vaccinations: The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication. The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the administration of the vaccine.) What do you pay for a Part D vaccination? What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 126 Chapter 6. What you pay for your Part D prescription drugs o Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is covered and what you pay). o Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan s List of Covered Drugs (Formulary). 2. Where you get the vaccine medication. 3. Who gives you the vaccine? What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example: Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine. You can ask our plan to pay you back for our share of the cost. Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the cost. To show how this works, here are three common ways you might get a Part D vaccine. Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Coverage Gap Stage of your benefit. Situation 1: Situation 2: You buy the Part D vaccine at the pharmacy and you get your vaccine at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) You will have to pay the pharmacy the amount of your copayment for the vaccine and the cost of giving you the vaccine. Our plan will pay the remainder of the costs. You get the Part D vaccination at your doctor s office. When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 7 of this booklet (Asking us to pay our share of a bill you have received for covered medical services or drugs). You will be reimbursed the amount you paid less your normal copayment for the vaccine (including administration) less any difference between the amount the doctor charges and what we normally pay. (If you get Extra Help, we will reimburse you for this difference.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 127 Chapter 6. What you pay for your Part D prescription drugs Situation 3: Section 8.2 You buy the Part D vaccine at your pharmacy, and then take it to your doctor s office where they give you the vaccine. You will have to pay the pharmacy the amount of your copayment for the vaccine itself. When your doctor gives you the vaccine, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7 of this booklet. You will be reimbursed the amount charged by the doctor for administering the vaccine less any difference between the amount the doctor charges and what we normally pay. (If you get Extra Help, we will reimburse you for this difference.) You may want to call us at Customer Solutions Center before you get a vaccination The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at Customer Solutions Center whenever you are planning to get a vaccination. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) We can tell you about how your vaccination is covered by our plan and explain your share of the cost. We can tell you how to keep your own cost down by using providers and pharmacies in our network. If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost. SECTION 9 Section 9.1 Do you have to pay the Part D late enrollment penalty? What is the Part D late enrollment penalty? Note: If you receive Extra Help from Medicare to pay for your prescription drugs, you will not pay a late enrollment penalty. The late enrollment penalty is an amount that is added to you Part D premium. You may owe a late enrollment penalty if at any time after your initial enrollment period is over, there is a period of 63 days or more in a row when you did not have Part D or other creditable prescription drug coverage. Creditable prescription drug coverage is coverage that meets Medicare s minimum standards since it is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage. The amount of the penalty depends on how long you waited to enroll in a creditable prescription drug coverage plan any time after the end of your initial enrollment

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 128 Chapter 6. What you pay for your Part D prescription drugs period or how many full calendar months you went without creditable prescription drug coverage. You will have to pay this penalty for as long as you have Part D coverage. The late enrollment penalty is added to your monthly premium. When Indiana University Health Plans has received the completed information and evaluated what your monthly penalty will be, you will be notified of your penalty amount and the total monthly premium due. Your late enrollment penalty is considered part of your plan premium. If you do not pay your late enrollment penalty, you could lose your prescription drug benefits for failure to pay your plan premium. Section 9.2 How much is the Part D late enrollment penalty? Medicare determines the amount of the penalty. Here is how it works: First count the number of full months that you delayed enrolling in a Medicare drug plan, after you were eligible to enroll. Or count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn t have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%. Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2016, this average premium amount is $34.10. This amount may change for 2016. To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would be 14% times $34.10, which equals 4.774. This rounds to $4.80. This amount would be added to the monthly premium for someone with a late enrollment penalty. There are three important things to note about this monthly late enrollment penalty: First, the penalty may change each year, because the average monthly premium can change each year. If the national average premium (as determined by Medicare) increases, your penalty will increase. Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits. Third, if you are under 65 and currently receiving Medicare benefits, the late enrollment penalty will reset when you turn 65. After age 65, your late enrollment penalty will be based only on the months that you don t have coverage after your initial enrollment period for aging into Medicare.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 129 Chapter 6. What you pay for your Part D prescription drugs Section 9.3 In some situations, you can enroll late and not have to pay the penalty Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were first eligible, sometimes you do not have to pay the late enrollment penalty. You will not have to pay a penalty for late enrollment if you are in any of these situations: If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage. Medicare calls this creditable drug coverage. Please note: o Creditable coverage could include drug coverage from a former employer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later. Please note: If you receive a certificate of creditable coverage when your health coverage ends, it may not mean your prescription drug coverage was creditable. The notice must state that you had creditable prescription drug coverage that expected to pay as much as Medicare s standard prescription drug plan pays. o The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites. o For additional information about creditable coverage, please look in your Medicare & You 2016 Handbook or call Medicare at 1-800-MEDICARE (1-800- 633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. If you were without creditable coverage, but you were without it for less than 63 days in a row. If you are receiving Extra Help from Medicare. Section 9.4 What can you do if you disagree about your late enrollment penalty? If you disagree about your late enrollment penalty, you or your representative can ask for a review of the decision about your late enrollment penalty. Generally, you must request this review within 60 days from the date on the letter you receive stating you have to pay a late enrollment penalty. Call Customer Solutions Center to find out more about how to do this (phone numbers are printed on the back cover of this booklet).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 130 Chapter 6. What you pay for your Part D prescription drugs Important: Do not stop paying your late enrollment penalty while you re waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan premiums. SECTION 10 Section 10.1 Do you have to pay an extra Part D amount because of your income? Who pays an extra Part D amount because of income? Most people pay a standard monthly Part D premium. However, some people pay an extra amount because of their yearly income. If your income is $85,000 or above for an individual (or married individuals filing separately) or $170,000 or above for married couples, you must pay an extra amount directly to the government for your Medicare Part D coverage. If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your monthly benefit isn t enough to cover the extra amount owed. If your benefit check isn t enough to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthly plan premium. Section 10.2 How much is the extra Part D amount? If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium. The chart below shows the extra amount based on your income.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 131 Chapter 6. What you pay for your Part D prescription drugs If you filed an individual tax return and your income in 2015 was: If you were married but filed a separate tax return and your income in 2015 was: If you filed a joint tax return and your income in 2015 was: This is the monthly cost of your extra Part D amount (to be paid in addition to your plan premium) Equal to or less than $85,000 Greater than $85,000 and less than or equal to $107,000 Equal to or less than $85,000 Equal to or less than $170,000 Greater than $170,000 and less than or equal to $214,000 $0 $12.30 Greater than $107,000 and less than or equal to $160,000 Greater than $160,000 and less than or equal to $214,000 Greater than $214,000 Greater than $214,000 and less than or equal to $320,000 Greater than $320,000 and less than or equal to $428,000 Greater than $428,000 $31.80 Greater than $85,000 and less than or equal to $129,000 Greater than $129,000 $51.30 $70.80 Section 10.3 What can you do if you disagree about paying an extra Part D amount? If you disagree about paying an extra amount because of your income, you can ask Social Security to review the decision. To find out more about how to do this, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Section 10.4 What happens if you do not pay the extra Part D amount? The extra amount is paid directly to the government (not your Medicare plan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage.

CHAPTER 7 Asking us to pay our share of a bill you have received for covered medical services or drugs

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 133 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs SECTION 1 Section 1.1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs... 134 If you pay our plan s share of the cost of your covered services or drugs, or if you receive a bill, you can ask us for payment... 134 SECTION 2 How to ask us to pay you back or to pay a bill you have received... 136 Section 2.1 How and where to send us your request for payment... 136 SECTION 3 Section 3.1 Section 3.2 SECTION 4 Section 4.1 We will consider your request for payment and say yes or no... 137 We check to see whether we should cover the service or drug and how much we owe... 137 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal... 137 Other situations in which you should save your receipts and send copies to us... 138 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs... 138

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 134 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs SECTION 1 Section 1.1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs If you pay our plan s share of the cost of your covered services or drugs, or if you receive a bill, you can ask us for payment Sometimes when you get medical care or a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called reimbursing you). It is your right to be paid back by our plan whenever you ve paid more than your share of the cost for medical services or drugs that are covered by our plan. There may also be times when you get a bill from a provider for the full cost of medical care you have received. In many cases, you should send this bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly. Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received: 1. When you ve received emergency or urgently needed medical care from a provider who is not in our plan s network You can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgently needed services from a provider who is not part of our network, you are only responsible for paying your share of the cost, not for the entire cost. You should ask the provider to bill the plan for our share of the cost. If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made. At times you may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made. o If the provider is owed anything, we will pay the provider directly. o If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 135 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs 2. When a network provider sends you a bill you think you should not pay Network providers should always bill the plan directly, and ask you only for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share. You only have to pay your cost-sharing amount when you get services covered by our plan. We do not allow providers to add additional separate charges, called balance billing. This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don t pay certain provider charges. For more information about balance billing, go to Chapter 4, Section 1.3. Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem. If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under the plan. 3. If you are retroactively enrolled in our plan. Sometimes a person s enrollment in the plan is retroactive. (Retroactive means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement. Please call Customer Solutions Center for additional information about how to ask us to pay you back and deadlines for making your request. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) 4. When you use an out-of-network pharmacy to get a prescription filled If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 5, Section 2.5 to learn more.) Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 136 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs 5. When you pay the full cost for a prescription because you don t have your plan membership card with you If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 6. When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find that the drug is not covered for some reason. For example, the drug may not be on the plan s List of Covered Drugs (Formulary); or it could have a requirement or restriction that you didn t know about or don t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 9 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal. SECTION 2 Section 2.1 How to ask us to pay you back or to pay a bill you have received How and where to send us your request for payment Send us your request for payment, along with your bill and documentation of any payment you have made. It s a good idea to make a copy of your bill and receipts for your records. To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. You don t have to use the form, but it will help us process the information faster. Either download a copy of the form from our website, www.iuhealthplansmedicare.org, or call Customer Solutions Center and ask for the form. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 137 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs Mail your request for payment together with any bills or receipts to us at this address: Indiana University Health Plans 950 North Meridian Street, Suite 200 Indianapolis, Indiana 46204 Contact Customer Solutions Center if you have any questions (phone numbers are printed on the back cover of this booklet). If you don t know what you should have paid, or you receive bills and you don t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. SECTION 3 Section 3.1 We will consider your request for payment and say yes or no We check to see whether we should cover the service or drug and how much we owe When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision. If we decide that the medical care or drug is covered and you followed all the rules for getting the care or drug, we will pay for our share of the cost. If you have already paid for the service or drug, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the provider. (Chapter 3 explains the rules you need to follow for getting your medical services covered. Chapter 5 explains the rules you need to follow for getting your Part D prescription drugs covered.) If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision. Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal If you think we have made a mistake in turning down your request for payment or you don t agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 138 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs a formal process with detailed procedures and important deadlines. If making an appeal is new to you, you will find it helpful to start by reading Section 4 of Chapter 9. Section 4 is an introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such as appeal. Then after you have read Section 4, you can go to the section in Chapter 9 that tells what to do for your situation: Go to Chapter 9, Section 5.3 if you want to make an appeal about getting paid back for a medical service. Go to Chapter 9, Section 6.5 if you want to make an appeal about getting paid back for a drug. SECTION 4 Section 4.1 Other situations in which you should save your receipts and send copies to us In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs There are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage Stage more quickly. Here are two situations when you should send us copies of receipts to let us know about payments you have made for your drugs: 1. When you buy the drug for a price that is lower than our price Sometimes when you are in Coverage Gap Stage you can buy your drug at a network pharmacy for a price that is lower than our price. For example, a pharmacy might offer a special price on the drug. Or you may have a discount card that is outside our benefit that offers a lower price. Unless special conditions apply, you must use a network pharmacy in these situations and your drug must be on our Drug List. Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. Please note: If you are in the Coverage Gap Stage, we may not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-ofpocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 139 Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs 2. When you get a drug through a patient assistance program offered by a drug manufacturer Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside the plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a copayment to the patient assistance program. Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. Please note: Because you are getting your drug through the patient assistance program and not through the plan s benefits, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our decision.

CHAPTER 8 Your rights and responsibilities

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 141 Chapter 8. Your rights and responsibilities Chapter 8. Your rights and responsibilities SECTION 1 Our plan must honor your rights as a member of the plan... 142 Section 1.1 We must provide information in a way that works for you... 142 Section 1.2 We must treat you with fairness and respect at all times... 142 Section 1.3 We must ensure that you get timely access to your covered services and drugs... 142 Section 1.4 We must protect the privacy of your personal health information... 143 Section 1.5 We must give you information about the plan, its network of providers, and your covered services... 144 Section 1.6 We must support your right to make decisions about your care... 145 Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made... 147 Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected?... 147 Section 1.9 How to get more information about your rights... 148 SECTION 2 You have some responsibilities as a member of the plan... 148 Section 2.1 What are your responsibilities?... 148

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 142 Chapter 8. Your rights and responsibilities SECTION 1 Section 1.1 Our plan must honor your rights as a member of the plan We must provide information in a way that works for you To get information from us in a way that works for you, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Our plan has people and free language interpreter services available to answer questions from non-english speaking members. We can also give you information in alternate formats if you need it. If you are eligible for Medicare because of a disability, we are required to give you information about the plan s benefits that is accessible and appropriate for you. To get information from us in a way that works for you, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). If you have any trouble getting information from our plan because of problems related to language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048. Section 1.2 We must treat you with fairness and respect at all times Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services Office for Civil Rights 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. If you have a disability and need help with access to care, please call us at Customer Solutions Center (phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Customer Solutions Center can help. Section 1.3 We must ensure that you get timely access to your covered services and drugs As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan s network to provide and arrange for your covered services (Chapter 3 explains more about this). Call Customer Solutions Center to learn which doctors are accepting new patients (phone numbers are printed on the back cover of this booklet). You also have the right to go to a

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 143 Chapter 8. Your rights and responsibilities women s health specialist (such as a gynecologist) without a referral. We do not require you to get referrals to go to network providers. As a plan member, you have the right to get appointments and covered services from the plan s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9, Section 10 of this booklet tells what you can do. (If we have denied coverage for your medical care or drugs and you don t agree with our decision, Chapter 9, Section 4 tells what you can do.) Section 1.4 We must protect the privacy of your personal health information Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. Your personal health information includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a Notice of Privacy Practice, that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information? We make sure that unauthorized people don t see or change your records. In most situations, if we give your health information to anyone who isn t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you. There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. o For example, we are required to release health information to government agencies that are checking on quality of care. o Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 144 Chapter 8. Your rights and responsibilities You can see the information in your records and know how it has been shared with others You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 1.5 We must give you information about the plan, its network of providers, and your covered services As a member of Indiana University Health Plans Medicare Select Plus (HMO), you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.) If you want any of the following kinds of information, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet): Information about our plan. This includes, for example, information about the plan s financial condition. It also includes information about the number of appeals made by members and the plan s performance ratings, including how it has been rated by plan members and how it compares to other Medicare health plans. Information about our network providers including our network pharmacies. o For example, you have the right to get information from us about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network. o For a list of the providers in the plan s network, see the Provider/Pharmacy Directory. o For a list of the pharmacies in the plan s network, see the Provider/Pharmacy Directory. o For more detailed information about our providers or pharmacies, you can call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or visit our website at www.iuhealthplansmedicare.org.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 145 Chapter 8. Your rights and responsibilities Information about your coverage and the rules you must follow when using your coverage. o In Chapters 3 and 4 of this booklet, we explain what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services. o To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of this booklet plus the plan s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs. o If you have questions about the rules or restrictions, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Information about why something is not covered and what you can do about it. o If a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service or drug from an out-of-network provider or pharmacy. o If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 of this booklet. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 9 also tells about how to make a complaint about quality of care, waiting times, and other concerns.) o If you want to ask our plan to pay our share of a bill you have received for medical care or a Part D prescription drug, see Chapter 7 of this booklet. Section 1.6 We must support your right to make decisions about your care You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 146 Chapter 8. Your rights and responsibilities To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely. To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments. The right to say no. You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result. To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of this booklet tells how to ask the plan for a coverage decision. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can: Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself. Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called advance directives. There are different types of advance directives and different names for them. Documents called living will and power of attorney for health care are examples of advance directives. If you want to use an advance directive to give your instructions, here is what to do: Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Solutions Center to ask for the forms (phone numbers are printed on the back cover of this booklet). Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 147 Chapter 8. Your rights and responsibilities Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the Indiana State Board of Health, 2 N. Meridian Street, Indianapolis, IN 46204 and/or phone (317) 233-1325. Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made If you have any problems or concerns about your covered services or care, Chapter 9 of this booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do ask for a coverage decision, make an appeal, or make a complaint we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected? If it is about discrimination, call the Office for Civil Rights If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 148 Chapter 8. Your rights and responsibilities call the Department of Health and Human Services Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. Is it about something else? If you believe you have been treated unfairly or your rights have not been respected, and it s not about discrimination, you can get help dealing with the problem you are having: You can call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Section 1.9 How to get more information about your rights There are several places where you can get more information about your rights: You can call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. You can contact Medicare. o You can visit the Medicare website to read or download the publication Your Medicare Rights & Protections. (The publication is available at: http://www.medicare.gov/pubs/pdf/11534.pdf.) o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 2 Section 2.1 You have some responsibilities as a member of the plan What are your responsibilities? Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). We re here to help.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 149 Chapter 8. Your rights and responsibilities Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services. o Chapters 3 and 4 give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay. o Chapters 5 and 6 give the details about your coverage for Part D prescription drugs. If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Customer Solutions Center to let us know (phone numbers are printed on the back cover of this booklet). o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called coordination of benefits because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We ll help you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 7.) Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care or Part D prescription drugs. Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. o Make sure your doctors know all of the drugs you are taking, including over-thecounter drugs, vitamins, and supplements. o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don t understand the answer you are given, ask again. Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor s office, hospitals, and other offices. Pay what you owe. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B. For that reason, some plan members must pay a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 150 Chapter 8. Your rights and responsibilities o For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 tells what you must pay for your medical services. Chapter 6 tells what you must pay for your Part D prescription drugs. o If you get any medical services or drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost. If you disagree with our decision to deny coverage for a service or drug, you can make an appeal. Please see Chapter 9 of this booklet for information about how to make an appeal. o If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage. o If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly to the government to remain a member of the plan. Tell us if you move. If you are going to move, it s important to tell us right away. Call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). o If you move outside of our plan service area, you cannot remain a member of our plan. (Chapter 1 tells about our service area.) We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area. o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you. o If you move, it is also important to tell Social Security (or the Railroad Retirement Board). You can find phone numbers and contact information for these organizations in Chapter 2. Call Customer Solutions Center for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Customer Solutions Center are printed on the back cover of this booklet. o For more information on how to reach us, including our mailing address, please see Chapter 2.

CHAPTER 9 What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 152 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) BACKGROUND 155 SECTION 1 Introduction... 155 Section 1.1 What to do if you have a problem or concern... 155 Section 1.2 What about the legal terms?... 155 SECTION 2 You can get help from government organizations that are not connected with us... 156 Section 2.1 Where to get more information and personalized assistance... 156 SECTION 3 To deal with your problem, which process should you use?... 156 Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints?... 156 COVERAGE DECISIONS AND APPEALS... 157 SECTION 4 A guide to the basics of coverage decisions and appeals... 157 Section 4.1 Asking for coverage decisions and making appeals: the big picture... 157 Section 4.2 How to get help when you are asking for a coverage decision or making an appeal... 158 Section 4.3 Which section of this chapter gives the details for your situation?... 159 SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal... 160 Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care... 160 Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want)... 161 Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan)... 164 Section 5.4 Step-by-step: How a Level 2 Appeal is done... 168 Section 5.5 What if you are asking us to pay you for our share of a bill you have received for medical care?... 169

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 153 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal... 171 Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug... 171 Section 6.2 What is an exception?... 173 Section 6.3 Important things to know about asking for exceptions... 174 Section 6.4 Step-by-step: How to ask for a coverage decision, including an exception 175 Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan)... 178 Section 6.6 Step-by-step: How to make a Level 2 Appeal... 180 SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon... 182 Section 7.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights... 183 Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date... 184 Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date... 187 Section 7.4 What if you miss the deadline for making your Level 1 Appeal?... 188 SECTION 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon... 191 Section 8.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services... 191 Section 8.2 We will tell you in advance when your coverage will be ending... 192 Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time... 192 Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time... 195 Section 8.5 What if you miss the deadline for making your Level 1 Appeal?... 196 SECTION 9 Taking your appeal to Level 3 and beyond... 199 Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals... 199 Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals... 200

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 154 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) MAKING COMPLAINTS... 202 SECTION 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns... 202 Section 10.1 What kinds of problems are handled by the complaint process?... 202 Section 10.2 The formal name for making a complaint is filing a grievance... 204 Section 10.3 Step-by-step: Making a complaint... 205 Section 10.4 You can also make complaints about quality of care to the Quality Improvement Organization... 206 Section 10.5 You can also tell Medicare about your complaint... 206

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 155 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) BACKGROUND SECTION 1 Section 1.1 Introduction What to do if you have a problem or concern This chapter explains two types of processes for handling problems and concerns: For some types of problems, you need to use the process for coverage decisions and appeals. For other types of problems, you need to use the process for making complaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use. Section 1.2 What about the legal terms? There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of certain legal terms. For example, this chapter generally says making a complaint rather than filing a grievance, coverage decision rather than organization determination, or coverage determination, and Independent Review Organization instead of Independent Review Entity. It also uses abbreviations as little as possible. However, it can be helpful and sometimes quite important for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 156 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 2 Section 2.1 You can get help from government organizations that are not connected with us Where to get more information and personalized assistance Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You will find phone numbers in Chapter 2, Section 3 of this booklet. You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare: You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can visit the Medicare website (http://www.medicare.gov). SECTION 3 Section 3.1 To deal with your problem, which process should you use? Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The guide that follows will help.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 157 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) To figure out which part of this chapter will help with your specific problem or concern, START HERE Is your problem or concern about your benefits or coverage? (This includes problems about whether particular medical care or prescription drugs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drugs.) Yes. My problem is about benefits or coverage. Go on to the next section of this chapter, Section 4, A guide to the basics of coverage decisions and appeals. No. My problem is not about benefits or coverage. Skip ahead to Section 10 at the end of this chapter: How to make a complaint about quality of care, waiting times, customer service or other concerns. COVERAGE DECISIONS AND APPEALS SECTION 4 Section 4.1 A guide to the basics of coverage decisions and appeals Asking for coverage decisions and making appeals: the big picture The process for coverage decisions and appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 158 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or fast coverage decision or fast appeal of a coverage decision. If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal. Section 4.2 How to get help when you are asking for a coverage decision or making an appeal Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision: You can call us at Customer Solutions Center (phone numbers are printed on the back cover of this booklet). To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter). Your doctor can make a request for you. o For medical care, your doctor can request a coverage decision or a Level 1 Appeal on your behalf. If your appeal is denied at Level 1, it will be automatically

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 159 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) forwarded to Level 2. To request any appeal after Level 2, your doctor must be appointed as your representative. o For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative. You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your representative to ask for a coverage decision or make an appeal. o There may be someone who is already legally authorized to act as your representative under State law. o If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) and ask for the Appointment of Representative form. (The form is also available on Medicare s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at www.iuhealthplanmedicare.org. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. Section 4.3 Which section of this chapter gives the details for your situation? There are four different types of situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: Section 5 of this chapter: Your medical care: How to ask for a coverage decision or make an appeal Section 6 of this chapter: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Section 7 of this chapter: How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon Section 8 of this chapter: How to ask us to keep covering certain medical services if you think your coverage is ending too soon (Applies to these services only: home

question mark. Have 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 160 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services) If you re not sure which section you should be using, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can also get help or information from government organizations such as your SHIP (Chapter 2, Section 3, of this booklet has the phone numbers for this program). SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal you read Section 4 of this chapter (A guide to the basics of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care This section is about your benefits for medical care and services. These benefits are described in Chapter 4 of this booklet: Medical Benefits Chart (what is covered and what you pay). To keep things simple, we generally refer to medical care coverage or medical care in the rest of this section, instead of repeating medical care or treatment or services every time. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here s what to read in those situations:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 161 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o Chapter 9, Section 7: How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon. o Chapter 9, Section 8: How to ask us to keep covering certain medical services if you think your coverage is ending too soon. This section is about three services only: home health care, skilled nursing facility care, and CORF services. For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. Which of these situations are you in? If you are in this situation: Do you want to find out whether we will cover the medical care or services you want? Have we already told you that we will not cover or pay for a medical service in the way that you want it to be covered or paid for? Do you want to ask us to pay you back for medical care or services you have already received and paid for? This is what you can do: You can ask us to make a coverage decision for you. Go to the next section of this chapter, Section 5.2. You can make an appeal. (This means you are asking us to reconsider.) Skip ahead to Section 5.3 of this chapter. You can send us the bill. Skip ahead to Section 5.5 of this chapter. Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) Legal Terms When a coverage decision involves your medical care, it is called an organization determination. Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a fast coverage decision. Legal Terms

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 162 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Legal Terms A fast coverage decision is called an expedited determination. How to request coverage for the medical care you want Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. For the details on how to contact us, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are asking for a coverage decision about your medical care. Generally we use the standard deadlines for giving you our decision When we give you our decision, we will use the standard deadlines unless we have agreed to use the fast deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request. However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) If your health requires it, ask us to give you a fast coverage decision A fast coverage decision means we will answer within 72 hours. o However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. o If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) We will call you as soon as we make the decision. To get a fast coverage decision, you must meet two requirements:

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 163 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.) o You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your doctor s support, we will decide whether your health requires that we give you a fast coverage decision. o If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. o The letter will also tell how you can file a fast complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) Step 2: We consider your request for medical care coverage and give you our answer. Deadlines for a fast coverage decision Generally, for a fast coverage decision, we will give you our answer within 72 hours. o As explained above, we can take up to 14 more calendar days under certain circumstances. If we decide to take extra days to make the coverage decision, we will tell you in writing. o If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) o If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal. If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 164 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) decision, we will authorize or provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no. Deadlines for a standard coverage decision Generally, for a standard coverage decision, we will give you our answer within 14 calendar days of receiving your request. o We can take up to 14 more calendar days ( an extended time period ) under certain circumstances. If we decide to take extra days to make the coverage decision, we will tell you in writing. o If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) o If we do not give you our answer within 14 calendar days (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal. If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 calendar days after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal. If we say no, you have the right to ask us to reconsider and perhaps change this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process (see Section 5.3 below). Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 165 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Legal Terms An appeal to the plan about a medical care coverage decision is called a plan reconsideration. Step 1: You contact us and make your appeal. If your health requires a quick response, you must ask for a fast appeal. What to do To start an appeal you, your doctor, or your representative, must contact us. For details on how to reach us for any purpose related to your appeal, go to Chapter 2, Section 1 and look for section called, How to contact us when you are making an appeal about your medical care. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request to us or by calling our Customer Solutions Center. o If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) and ask for the Appointment of Representative form. It is also available on our website at http://www.iuhealthplansmedicare.org or Medicare s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. While we can accept an appeal request without the form, we cannot begin or complete our review until we receive it. If we do not receive the form within 44 calendar days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision. If you are asking for a fast appeal, make your fast appeal in writing or call us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your medical care). You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal. You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 166 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor may give us additional information to support your appeal. Legal Terms A fast appeal is also called an expedited reconsideration. If your health requires it, ask for a fast appeal (you can make a request by calling us) If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a fast appeal. The requirements and procedures for getting a fast appeal are the same as those for getting a fast coverage decision. To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. (These instructions are given earlier in this section.) If your doctor tells us that your health requires a fast appeal, we will give you a fast appeal. Step 2: We consider your appeal and we give you our answer. When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request. We will gather more information if we need it. We may contact you or your doctor to get more information. Deadlines for a fast appeal When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing. o If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell you about this organization and explain what happens at Level 2 of the appeals process.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 167 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal. If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Deadlines for a standard appeal If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to. o However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. o If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) o If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process. If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 calendar days after we receive your appeal. If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process. To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the Independent Review Organization. When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 168 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 5.4 Step-by-step: How a Level 2 Appeal is done If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews our decision for your first appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the Independent Review Organization is the Independent Review Entity. It is sometimes called the IRE. Step 1: The Independent Review Organization reviews your appeal. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work. We will send the information about your appeal to this organization. This information is called your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Organization additional information to support your appeal. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a fast appeal at Level 1, you will also have a fast appeal at Level 2 If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal. However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. If you had a standard appeal at Level 1, you will also have a standard appeal at Level 2 If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal. However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 169 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 2: The Independent Review Organization gives you their answer. The Independent Review Organization will tell you its decision in writing and explain the reasons for it. If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization. If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called upholding the decision. It is also called turning down your appeal. ) o If the Independent Review Organization upholds the decision you have the right to a Level 3 appeal. However, to make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. The written notice you get from the Independent Review Organization will tell you how to find out the dollar amount to continue the appeals process. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further. There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal. The Level 3 Appeal is handled by an administrative law judge. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 5.5 What if you are asking us to pay you for our share of a bill you have received for medical care? If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement or to pay a bill you have received from a provider. It also tells how to send us the paperwork that asks us for payment.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 170 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Asking for reimbursement is asking for a coverage decision from us If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 4.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service (see Chapter 4: Medical Benefits Chart (what is covered and what you pay)). We will also check to see if you followed all the rules for using your coverage for medical care (these rules are given in Chapter 3 of this booklet: Using the plan s coverage for your medical services). We will say yes or no to your request If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven t paid for the services, we will send the payment directly to the provider. When we send the payment, it s the same as saying yes to your request for a coverage decision.) If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why in detail. (When we turn down your request for payment, it s the same as saying no to your request for a coverage decision.) What if you ask for payment and we say that we will not pay? If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals that we describe in part 5.3 of this section. Go to this part for step-by-step instructions. When you are following these instructions, please note: If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.) If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days.

question mark. Have 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 171 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal you read Section 4 of this chapter (A guide to the basics of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan s List of Covered Drugs (Formulary). To be covered, the drug must be used for a medically accepted indication. (A medically accepted indication is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.) This section is about your Part D drugs only. To keep things simple, we generally say drug in the rest of this section, instead of repeating covered outpatient prescription drug or Part D drug every time. For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan s coverage for your Part D prescription drugs) and Chapter 6 (What you pay for your Part D prescription drugs). Part D coverage decisions and appeals As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Legal Terms An initial coverage decision about your Part D drugs is called a coverage determination. Here are examples of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, including: o Asking us to cover a Part D drug that is not on the plan s List of Covered Drugs (Formulary) o Asking us to waive a restriction on the plan s coverage for a drug (such as limits on the amount of the drug you can get)

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 172 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o Asking to pay a lower cost-sharing amount for a covered non-preferred drug You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan s List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.) o Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision. You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment. If you disagree with a coverage decision we have made, you can appeal our decision. This section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart below to help you determine which part has information for your situation: Which of these situations are you in? Do you need a drug that isn t on our Drug List or need us to waive a rule or restriction on a drug we cover? Do you want us to cover a drug on our Drug List and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need? Do you want to ask us to pay you back for a drug you have already received and paid for? Have we already told you that we will not cover or pay for a drug in the way that you want it to be covered or paid for? You can ask us to make an exception. (This is a type of coverage decision.) Start with Section 6.2 of this chapter. You can ask us for a coverage decision. Skip ahead to Section 6.4 of this chapter. You can ask us to pay you back. (This is a type of coverage decision.) Skip ahead to Section 6.4 of this chapter. You can make an appeal. (This means you are asking us to reconsider.) Skip ahead to Section 6.5 of this chapter.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 173 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 6.2 What is an exception? If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make: 1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (We call it the Drug List for short.) Legal Terms Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a formulary exception. If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Tier 4 (Non- Preferred Brand Name and Generic) You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 5 and look for Section 4). Legal Terms Asking for removal of a restriction on coverage for a drug is sometimes called asking for a formulary exception. The extra rules and restrictions on coverage for certain drugs include: o Being required to use the generic version of a drug instead of the brand name drug. o Getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called prior authorization. ) o Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called step therapy. ) o Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 174 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List is in one of five (5) cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. Legal Terms Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a tiering exception. If your drug is in Tier 4 (Non-Preferred Brand Name and Generic) you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3 (Preferred Brand Name and Generic). This would lower your share of the cost for the drug. You cannot ask us to change the cost sharing tier for any drug in Tier 5 (Specialty). Section 6.3 Important things to know about asking for exceptions Your doctor must tell us the medical reasons Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called alternative drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. We can say yes or no to your request If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. Section 6.5 tells how to make an appeal if we say no. The next section tells you how to ask for a coverage decision, including an exception.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 175 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 6.4 Step-by-step: How to ask for a coverage decision, including an exception Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a fast coverage decision. You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought. What to do Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our website. For the details, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called, Where to send a request that asks us to pay for our share of the cost for medical care or a drug you have received. You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf. If you want to ask us to pay you back for a drug, start by reading Chapter 7 of this booklet: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the supporting statement. ) Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. See Sections 6.2 and 6.3 for more information about exception requests. We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form available on our website.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 176 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Legal Terms A fast coverage decision is called an expedited coverage determination. If your health requires it, ask us to give you a fast coverage decision When we give you our decision, we will use the standard deadlines unless we have agreed to use the fast deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor s statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor s statement. To get a fast coverage decision, you must meet two requirements: o You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.) o You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own (without your doctor s or other prescriber s support), we will decide whether your health requires that we give you a fast coverage decision. o If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision. o The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a fast complaint, which means you would get our answer to your complaint within 24 hours of receiving the complaint. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, see Section 10 of this chapter.) Step 2: We consider your request and we give you our answer. Deadlines for a fast coverage decision If we are using the fast deadlines, we must give you our answer within 24 hours.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 177 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor s statement supporting your request. We will give you our answer sooner if your health requires us to. o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2. If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor s statement supporting your request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal. Deadlines for a standard coverage decision about a drug you have not yet received If we are using the standard deadlines, we must give you our answer within 72 hours. o Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor s statement supporting your request. We will give you our answer sooner if your health requires us to. o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2. If our answer is yes to part or all of what you requested o If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor s statement supporting your request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal. Deadlines for a standard coverage decision about payment for a drug you have already bought We must give you our answer within 14 calendar days after we receive your request. o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 178 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal. Step 3: If we say no to your coverage request, you decide if you want to make an appeal. If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider and possibly change the decision we made. Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) Legal Terms An appeal to the plan about a Part D drug coverage decision is called a plan redetermination. Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a fast appeal. What to do To start your appeal, you (or your representative or your doctor or other prescriber) must contact us. o For details on how to reach us by phone, fax, or mail, or on our website, for any purpose related to your appeal, go to Chapter 2, Section 1, and look for the section called, How to contact us when you are making an appeal about your Part D prescription drugs. If you are asking for a standard appeal, make your appeal by submitting a written request. You may also ask for an appeal by calling us at the phone number shown in Chapter 2, Section 1 (How to contact our plan when you are making an appeal about your Part D prescription drugs). If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your part D prescription drugs). We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 179 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal. You can ask for a copy of the information in your appeal and add more information. o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. Legal Terms A fast appeal is also called an expedited redetermination. If your health requires it, ask for a fast appeal If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal. The requirements for getting a fast appeal are the same as those for getting a fast coverage decision in Section 6.4 of this chapter. Step 2: We consider your appeal and we give you our answer. When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. Deadlines for a fast appeal If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. o If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process. If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 180 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision. Deadlines for a standard appeal If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for fast appeal. o If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process. If our answer is yes to part or all of what you requested o If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. o If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision. Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal. If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below). Section 6.6 Step-by-step: How to make a Level 2 Appeal If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the Independent Review Organization is the Independent Review Entity. It is sometimes called the IRE.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 181 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case. If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization. When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Organization additional information to support your appeal. Step 2: The Independent Review Organization does a review of your appeal and gives you an answer. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it. Deadlines for fast appeal at Level 2 If your health requires it, ask the Independent Review Organization for a fast appeal. If the review organization agrees to give you a fast appeal, the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request. If the Independent Review Organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization. Deadlines for standard appeal at Level 2 If you have a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days after it receives your appeal. If the Independent Review Organization says yes to part or all of what you requested

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 182 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization. o If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization. What if the review organization says no to your appeal? If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called upholding the decision. It is also called turning down your appeal. ) If the Independent Review Organization upholds the decision you have the right to a Level 3 appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process. Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further. There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal. The Level 3 Appeal is handled by an administrative law judge. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. For more information about our coverage for your hospital care, including any limitations on this coverage, see Chapter 4 of this booklet: Medical Benefits Chart (what is covered and what you pay).

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 183 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) During your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave. The day you leave the hospital is called your discharge date. When your discharge date has been decided, your doctor or the hospital staff will let you know. If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask. Section 7.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights During your covered hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital (for example, a caseworker or nurse) must give it to you within two days after you are admitted. If you do not get the notice, ask any hospital employee for it. If you need help, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. 1. Read this notice carefully and ask questions if you don t understand it. It tells you about your rights as a hospital patient, including: Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them. Your right to be involved in any decisions about your hospital stay, and know who will pay for it. Where to report any concerns you have about quality of your hospital care. Your right to appeal your discharge decision if you think you are being discharged from the hospital too soon. Legal Terms The written notice from Medicare tells you how you can request an immediate review. Requesting an immediate review is a formal, legal way to ask for a delay in your discharge date so that we will cover your hospital care for a longer time. (Section 7.2 below tells you how you can request an immediate review.) 2. You must sign the written notice to show that you received it and understand your rights.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 184 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) You or someone who is acting on your behalf must sign the notice. (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative.) Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it. If you sign the notice more than two days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged. To look at a copy of this notice in advance, you can call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see it online at http://www.cms.gov/medicare/medicare-general- Information/BNI/HospitalDischargeAppealNotices.html Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date If you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. Follow the process. Each step in the first two levels of the appeals process is explained below. Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. Ask for help if you need it. If you have questions or need help at any time, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 185 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 1: Contact the Quality Improvement Organization for your state and ask for a fast review of your hospital discharge. You must act quickly. What is the Quality Improvement Organization? This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. How can you contact this organization? Act quickly: The written notice you received (An Important Message from Medicare About Your Rights) tells you how to reach this organization. (Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4, of this booklet.) To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. (Your planned discharge date is the date that has been set for you to leave the hospital.) o If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization. o If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date. If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details about this other way to make your appeal, see Section 7.4. Ask for a fast review : You must ask the Quality Improvement Organization for a fast review of your discharge. Asking for a fast review means you are asking for the organization to use the fast deadlines for an appeal instead of using the standard deadlines. Legal Terms A fast review is also called an immediate review or an expedited review.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 186 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review? Health professionals at the Quality Improvement Organization (we will call them the reviewers for short) will ask you (or your representative) why you believe coverage for the services should continue. You don t have to prepare anything in writing, but you may do so if you wish. The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and we have given to them. By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. Legal Terms This written explanation is called the Detailed Notice of Discharge. You can get a sample of this notice by calling Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a sample notice online at http://www.cms.hhs.gov/bni/ Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes? If the review organization says yes to your appeal, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary. You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. (See Chapter 4 of this booklet). What happens if the answer is no? If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal. If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 187 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to Level 2 of the appeals process. Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to pay the full cost for your stay after your planned discharge date. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review. You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 calendar days of receipt of your request for a second review, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. If the review organization says yes: We must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 188 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no: It means they agree with the decision they made on your Level 1 Appeal and will not change it. This is called upholding the decision. The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3. There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 7.4 What if you miss the deadline for making your Level 1 Appeal? You can appeal to us instead As explained above in Section 7.2, you must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. ( Quickly means before you leave the hospital and no later than your planned discharge date.) If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a fast review. A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Legal Terms A fast review (or fast appeal ) is also called an expedited appeal.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 189 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 1: Contact us and ask for a fast review. For details on how to contact us, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are making an appeal about your medical care. Be sure to ask for a fast review. This means you are asking us to give you an answer using the fast deadlines rather than the standard deadlines. Step 2: We do a fast review of your planned discharge date, checking to see if it was medically appropriate. During this review, we take a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules. In this situation, we will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: We give you our decision within 72 hours after you ask for a fast review ( fast appeal ). If we say yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered inpatient hospital services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) If we say no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end. o If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. Step 4: If we say no to your fast appeal, your case will automatically be sent on to the next level of the appeals process. To make sure we were following all the rules when we said no to your fast appeal, we are required to send your appeal to the Independent Review Organization. When we do this, it means that you are automatically going on to Level 2 of the appeals process.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 190 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step-by-Step: Level 2 Alternate Appeal Process If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, an Independent Review Organization reviews the decision we made when we said no to your fast appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the Independent Review Organization is the Independent Review Entity. It is sometimes called the IRE. Step 1: We will automatically forward your case to the Independent Review Organization. We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 10 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a fast review of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge. If this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan s coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. If this organization says no to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate. o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 191 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further. There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 8 Section 8.1 How to ask us to keep covering certain medical services if you think your coverage is ending too soon This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services This section is about the following types of care only: Home health care services you are getting. Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn about requirements for being considered a skilled nursing facility, see Chapter 12, Definitions of important words.) Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. (For more information about this type of facility, see Chapter 12, Definitions of important words.) When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see Chapter 4 of this booklet: Medical Benefits Chart (what is covered and what you pay). When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying our share of the cost for your care.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 192 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal. Section 8.2 We will tell you in advance when your coverage will be ending 1. You receive a notice in writing. At least two days before our plan is going to stop covering your care, you will receive a notice. The written notice tells you the date when we will stop covering the care for you. The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time. Legal Terms In telling you what you can do, the written notice is telling how you can request a fast-track appeal. Requesting a fast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your care. (Section 7.3 below tells how you can request a fast-track appeal.) The written notice is called the Notice of Medicare Non-Coverage. To get a sample copy, call Customer Solutions Center (phone numbers are printed on the back cover of this booklet) or 1-800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.). Or see a copy online at http://www.cms.hhs.gov/bni/ 2. You must sign the written notice to show that you received it. You or someone who is acting on your behalf must sign the notice. (Section 4 tells how you can give written permission to someone else to act as your representative.) Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it s time to stop getting the care. Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. Follow the process. Each step in the first two levels of the appeals process is explained below.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 193 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Section 10 of this chapter tells you how to file a complaint.) Ask for help if you need it. If you have questions or need help at any time, please call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter). If you ask for a Level 1 Appeal on time, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan. Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization for your state and ask for a review. You must act quickly. What is the Quality Improvement Organization? This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it s time to stop covering certain kinds of medical care. How can you contact this organization? The written notice you received tells you how to reach this organization. (Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4, of this booklet.) What should you ask for? Ask this organization for a fast-track appeal (to do an independent review) of whether it is medically appropriate for us to end coverage for your medical services. Your deadline for contacting this organization. You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care. If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. For details about this other way to make your appeal, see Section 8.5.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 194 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review? Health professionals at the Quality Improvement Organization (we will call them the reviewers for short) will ask you (or your representative) why you believe coverage for the services should continue. You don t have to prepare anything in writing, but you may do so if you wish. The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them. By the end of the day the reviewers inform us of your appeal, and you will also get a written notice from us that explains in detail our reasons for ending our coverage for your services. Legal Terms This notice of explanation is called the Detailed Explanation of Non- Coverage. Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal? If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary. You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services (see Chapter 4 of this booklet). What happens if the reviewers say no to your appeal? If the reviewers say no to your appeal, then your coverage will end on the date we have told you. We will stop paying our share of the costs of this care on the date listed on the notice. If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 195 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. This first appeal you make is Level 1 of the appeals process. If reviewers say no to your Level 1 Appeal and you choose to continue getting care after your coverage for the care has ended then you can make another appeal. Making another appeal means you are going on to Level 2 of the appeals process. Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review. You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal? We must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary. You must continue to pay your share of the costs and there may be coverage limitations that apply.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 196 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) What happens if the review organization says no? It means they agree with the decision we made to your Level 1 Appeal and will not change it. The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further. There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 8.5 What if you miss the deadline for making your Level 1 Appeal? You can appeal to us instead As explained above in Section 8.3, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a fast review. A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Here are the steps for a Level 1 Alternate Appeal: Step 1: Contact us and ask for a fast review. Legal Terms A fast review (or fast appeal ) is also called an expedited appeal. For details on how to contact us, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are making an appeal about your medical care.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 197 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Be sure to ask for a fast review. This means you are asking us to give you an answer using the fast deadlines rather than the standard deadlines. Step 2: We do a fast review of the decision we made about when to end coverage for your services. During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan s coverage for services you were receiving. We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: We give you our decision within 72 hours after you ask for a fast review ( fast appeal ). If we say yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) If we say no to your fast appeal, then your coverage will end on the date we told you and we will not pay any share of the costs after this date. If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will have to pay the full cost of this care yourself. Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process. To make sure we were following all the rules when we said no to your fast appeal, we are required to send your appeal to the Independent Review Organization. When we do this, it means that you are automatically going on to Level 2 of the appeals process.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 198 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step-by-Step: Level 2 Alternate Appeal Process If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your fast appeal. This organization decides whether the decision we made should be changed. Legal Terms The formal name for the Independent Review Organization is the Independent Review Entity. It is sometimes called the IRE. Step 1: We will automatically forward your case to the Independent Review Organization. We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 10 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a fast review of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 199 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further. There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 9 Section 9.1 Taking your appeal to Level 3 and beyond Levels of Appeal 3, 4, and 5 for Medical Service Appeals This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 Appeal: A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an Administrative Law Judge. If the Administrative Law Judge says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 calendar days after receiving the judge s decision. o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute. If the Administrative Law Judge says no to your appeal, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 200 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) o If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Level 4 Appeal: The Appeals Council will review your appeal and give you an answer. The Appeals Council works for the Federal government. If the answer is yes, or if the Appeals Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you. o If we decide not to appeal the decision, we must authorize or provide you with the service within 60 calendar days after receiving the Appeals Council s decision. o If we decide to appeal the decision, we will let you know in writing. If the answer is no or if the Appeals Council denies the review request, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal: A judge at the Federal District Court will review your appeal. This is the last step of the administrative appeals process. Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 201 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Level 3 Appeal: A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an Administrative Law Judge. If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. If the answer is no, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Level 4 Appeal The Appeals Council will review your appeal and give you an answer. The Appeals Council works for the Federal government. If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Appeals Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. If the answer is no, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over. o If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Appeals Council says no to your appeal or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal A judge at the Federal District Court will review your appeal. This is the last step of the appeals process.

question mark. If 2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 202 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) MAKING COMPLAINTS SECTION 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter. Section 10.1 What kinds of problems are handled by the complaint process? This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 203 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If you have any of these kinds of problems, you can make a complaint Complaint Example Quality of your medical care Respecting your privacy Disrespect, poor customer service, or other negative behaviors Are you unhappy with the quality of the care you have received (including care in the hospital)? Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential? Has someone been rude or disrespectful to you? Are you unhappy with how our Customer Solutions Center has treated you? Do you feel you are being encouraged to leave the plan? Waiting times Are you having trouble getting an appointment, or waiting too long to get it? Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Customer Solutions Center or other staff at the plan? o Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room. Cleanliness Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor s office? Information you get from us Do you believe we have not given you a notice that we are required to give? Do you think written information we have given you is hard to understand?

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 204 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Complaint Timeliness (These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals) Example The process of asking for a coverage decision and making appeals is explained in sections 4-9 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples: If you have asked us to give you a fast coverage decision or a fast appeal, and we have said we will not, you can make a complaint. If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint. When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint. When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint. Section 10.2 The formal name for making a complaint is filing a grievance Legal Terms What this section calls a complaint is also called a grievance. Another term for making a complaint is filing a grievance. Another way to say using the process for complaints is using the process for filing a grievance.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 205 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 10.3 Step-by-step: Making a complaint Step 1: Contact us promptly either by phone or in writing. Usually, calling Customer Solutions Center is the first step. If there is anything else you need to do, Customer Solutions Center will let you know. If you have questions we are here to help. Please call our Customer Solutions Center at (317) 963-9700, toll-free 1-800-455-9776. (TTY/TDD only call Relay Indiana at 1-800-743-3333) and calls to these numbers are free. From October 15, 2015 through February 14, 2016, a representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2015, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website; (iuhealthplansmedicare.org). Customer Solutions also has free language interpreter services available for non-english speakers. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can fax your grievance to (317) 963-9801, or you can mail your written grievance to Indiana University Health Plans, 950 N. Meridian Street, Suite 200, Indianapolis, IN 46204. Whether you call or write, you should contact Customer Solutions Center right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If you are making a complaint because we denied your request for a fast coverage decision or a fast appeal, we will automatically give you a fast complaint. If you have a fast complaint, it means we will give you an answer within 24 hours. Step 2: We look into your complaint and give you our answer. Legal Terms What this section calls a fast complaint is also called an expedited grievance. If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 206 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If we do not agree with some or all of your complaint or don t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. Section 10.4 You can also make complaints about quality of care to the Quality Improvement Organization You can make your complaint about the quality of care you received to us by using the step-bystep process outlined above. When your complaint is about quality of care, you also have two extra options: You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us). o The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. o To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint to this organization, we will work with them to resolve your complaint. Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization. Section 10.5 You can also tell Medicare about your complaint You can submit a complaint about Indiana University Health Plans Medicare Select Plus directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/medicarecomplaintform/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

CHAPTER 10 Ending your membership in the plan

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 208 Chapter 10. Ending your membership in the plan Chapter 10. Ending your membership in the plan SECTION 1 Introduction... 209 Section 1.1 This chapter focuses on ending your membership in our plan... 209 SECTION 2 When can you end your membership in our plan?... 209 Section 2.1 You can end your membership during the Annual Enrollment Period... 209 Section 2.2 You can end your membership during the annual Medicare Advantage Disenrollment Period, but your choices are more limited... 211 Section 2.3 In certain situations, you can end your membership during a Special Enrollment Period... 211 Section 2.4 Where can you get more information about when you can end your membership?... 212 SECTION 3 How do you end your membership in our plan?... 213 Section 3.1 Usually, you end your membership by enrolling in another plan... 213 SECTION 4 Until your membership ends, you must keep getting your medical services and drugs through our plan... 214 Section 4.1 Until your membership ends, you are still a member of our plan... 214 SECTION 5 Indiana University Health Plans Medicare Select Plus (HMO) must end your membership in the plan in certain situations... 215 Section 5.1 When must we end your membership in the plan?... 215 Section 5.2 We cannot ask you to leave our plan for any reason related to your health 216 Section 5.3 You have the right to make a complaint if we end your membership in our plan... 216

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 209 Chapter 10. Ending your membership in the plan SECTION 1 Section 1.1 Introduction This chapter focuses on ending your membership in our plan Ending your membership in Indiana University Health Plans Medicare Select Plus (HMO) may be voluntary (your own choice) or involuntary (not your own choice): You might leave our plan because you have decided that you want to leave. o There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Section 2 tells you when you can end your membership in the plan. o The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation. There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership. If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. SECTION 2 When can you end your membership in our plan? You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the annual Medicare Advantage Disenrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year. Section 2.1 You can end your membership during the Annual Enrollment Period You can end your membership during the Annual Enrollment Period (also known as the Annual Coordinated Election Period ). This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year. When is the Annual Enrollment Period? This happens from October 15 to December 7. What type of plan can you switch to during the Annual Enrollment Period? During this time, you can review your health coverage and your prescription drug coverage. You can choose to keep your current coverage or make changes to your

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 210 Chapter 10. Ending your membership in the plan coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans: o Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.) o Original Medicare with a separate Medicare prescription drug plan. o or Original Medicare without a separate Medicare prescription drug plan. If you receive Extra Help from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ( Creditable coverage means the coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) See Chapter 6, Section 10 for more information about the late enrollment penalty. When will your membership end? Your membership will end when your new plan s coverage begins on January 1. When can you end your membership? You can end your membership in Indiana University Health Plans Medicare Select Plus (HMO) at any time. Most people with Medicare can end their membership only during certain times of the year. However, because you live in a nursing home or need a level of care that is usually provided in a nursing home, you can end your membership at any time. What type of plan can you switch to? If you decide to change to a new plan, you can choose any of the following types of plans: o Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.) o Original Medicare with a separate Medicare prescription drug plan. o or Original Medicare without a separate Medicare prescription drug plan. If you receive Extra Help from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ( Creditable coverage means the

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 211 Chapter 10. Ending your membership in the plan coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) See Chapter 6, Section 10 for more information about the late enrollment penalty. When will your membership end? Your membership will usually end on the first day of the month after your request to change your plan is received. Section 2.2 You can end your membership during the annual Medicare Advantage Disenrollment Period, but your choices are more limited You have the opportunity to make one change to your health coverage during the annual Medicare Advantage Disenrollment Period. When is the annual Medicare Advantage Disenrollment Period? This happens every year from January 1 to February 14. What type of plan can you switch to during the annual Medicare Advantage Disenrollment Period? During this time, you can cancel your Medicare Advantage Plan enrollment and switch to Original Medicare. If you choose to switch to Original Medicare during this period, you have until February 14 to join a separate Medicare prescription drug plan to add drug coverage. When will your membership end? Your membership will end on the first day of the month after we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request. Section 2.3 In certain situations, you can end your membership during a Special Enrollment Period In certain situations, members of Indiana University Health Plans Medicare Select Plus (HMO) may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period. Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website (http://www.medicare.gov): o Usually, when you have moved. o If you have Medicaid. o If you are eligible for Extra Help with paying for your Medicare prescriptions.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 212 Chapter 10. Ending your membership in the plan o If we violate our contract with you. o If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital. When are Special Enrollment Periods? The enrollment periods vary depending on your situation. What can you do? To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans: o Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.) o Original Medicare with a separate Medicare prescription drug plan. o or Original Medicare without a separate Medicare prescription drug plan. If you receive Extra Help from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ( Creditable coverage means the coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) See Chapter 6, Section 10 for more information about the late enrollment penalty. When will your membership end? Your membership will usually end on the first day of the month after your request to change your plan is received. Section 2.4 Where can you get more information about when you can end your membership? If you have any questions or would like more information on when you can end your membership: You can call Customer Solutions Center (phone numbers are printed on the back cover of this booklet). You can find the information in the Medicare & You 2016 Handbook. o Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 213 Chapter 10. Ending your membership in the plan o You can also download a copy from the Medicare website (http://www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below. You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTION 3 Section 3.1 How do you end your membership in our plan? Usually, you end your membership by enrolling in another plan Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 2 in this chapter for information about the enrollment periods). However, if you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan. There are two ways you can ask to be disenrolled: You can make a request in writing to us. Contact Customer Solutions Center if you need more information on how to do this (phone numbers are printed on the back cover of this booklet). --or--you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ( Creditable coverage means the coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) See Chapter 6, Section 10 for more information about the late enrollment penalty. The table below explains how you should end your membership in our plan. If you would like to switch from our plan to: This is what you should do: Another Medicare health plan. Enroll in the new Medicare health plan. You will automatically be disenrolled from Indiana University Health Plans Medicare Select Plus (HMO) when your new plan s coverage begins. Original Medicare with a separate Medicare prescription drug plan. Enroll in the new Medicare prescription drug plan.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 214 Chapter 10. Ending your membership in the plan If you would like to switch from our plan to: This is what you should do: You will automatically be disenrolled from Indiana University Health Plans Medicare Select Plus (HMO) when your new plan s coverage begins. Original Medicare without a separate Medicare prescription drug plan. o Note: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. See Chapter 6, Section 10 for more information about the late enrollment penalty. Send us a written request to disenroll. Contact Customer Solutions Center if you need more information on how to do this (phone numbers are printed on the back cover of this booklet). You can also contact Medicare, at 1-800- MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048. You will be disenrolled from Indiana University Health Plans Medicare Select Plus (HMO) when your coverage in Original Medicare begins. SECTION 4 Section 4.1 Until your membership ends, you must keep getting your medical services and drugs through our plan Until your membership ends, you are still a member of our plan If you leave Indiana University Health Plans Medicare Select Plus (HMO), it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your medical care and prescription drugs through our plan. If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins). You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 215 Chapter 10. Ending your membership in the plan SECTION 5 Section 5.1 Indiana University Health Plans Medicare Select Plus (HMO) must end your membership in the plan in certain situations When must we end your membership in the plan? Indiana University Health Plans Medicare Select Plus (HMO) must end your membership in the plan if any of the following happen: If you do not stay continuously enrolled in Medicare Part A and Part B. If you move out of our service area. If you are away from our service area for more than six months. o If you move or take a long trip, you need to call Customer Solutions Center to find out if the place you are moving or traveling to is in our plan s area. (Phone numbers for Customer Solutions Center are printed on the back cover of this booklet.) If you become incarcerated (go to prison). If you lie about or withhold information about other insurance you have that provides prescription drug coverage. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) o If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General. If you do not pay the plan premiums for 90 days. o We must notify you in writing that you have until the last day of the 90 day grace period to pay the plan premium before we end your membership to pay the plan premium before we end your membership. If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 216 Chapter 10. Ending your membership in the plan Where can you get more information? If you have questions or would like more information on when we can end your membership: You can call Customer Solutions Center for more information (phone numbers are printed on the back cover of this booklet). Section 5.2 We cannot ask you to leave our plan for any reason related to your health Indiana University Health Plans Medicare Select Plus is not allowed to ask you to leave our plan for any reason related to your health. What should you do if this happens? If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877- 486-2048. You may call 24 hours a day, 7 days a week. Section 5.3 You have the right to make a complaint if we end your membership in our plan If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can look in Chapter 9, Section 10 for information about how to make a complaint.

CHAPTER 11 Legal notices

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 218 Chapter 11. Legal notices Chapter 11. Legal notices SECTION 1 Notice about governing law... 219 SECTION 2 Notice about non-discrimination... 219 SECTION 3 Notice about Medicare Secondary Payer subrogation rights... 219

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 219 Chapter 11. Legal notices SECTION 1 Notice about governing law Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are required by law. This may affect your rights and responsibilities even if the laws are not included or explained in this document. The principal law that applies to this document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in. SECTION 2 Notice about non-discrimination We don t discriminate based on a person s race, disability, religion, sex, health, ethnicity, creed, age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason. SECTION 3 Notice about Medicare Secondary Payer subrogation rights We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Indiana University Health Plans Medicare Select Plus, as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any State laws.

CHAPTER 12 Definitions of important words

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 221 Chapter 12. Definitions of important words Chapter 12. Definitions of important words Allowed Amount - The total sum the plan considers reasonable and necessary for a covered service. At the HMO (in-network) coverage level, this is an amount agreed upon between the plan and the contracted provider. At the out-of-network coverage level, this is the amount approved by Medicare as a payment in full for covered services. The allowed amount includes any applicable co-payments, coinsurance owed by you plus what the plan reimburses the provider for covered services. Ambulatory Surgical Center An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours. Annual Enrollment Period A set time each fall when members can change their health or drugs plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7. Appeal An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don t pay for a drug, item, or service you think you should be able to receive. Chapter 9 explains appeals, including the process involved in making an appeal. Balance Billing When a provider (such as a doctor or hospital) bills a patient more than the plan s allowed cost-sharing amount. As a member of Indiana University Health Plans Medicare Select Plus, you only have to pay our plan s cost-sharing amounts when you get services covered by our plan. We do not allow providers to balance bill or otherwise charge you more than the amount of cost-sharing your plan says you must pay. Benefit Period The way Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods. Brand Name Drug A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 222 Chapter 12. Definitions of important words Catastrophic Coverage Stage The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,850 in covered drugs during the covered year. Centers for Medicare & Medicaid Services (CMS) The Federal agency that administers Medicare. Chapter 2 explains how to contact CMS. Coinsurance An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%). Complaint - The formal name for making a complaint is filing a grievance. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also Grievance, in this list of definitions. Comprehensive Outpatient Rehabilitation Facility (CORF) A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services. Copayment An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription drug. Cost-sharing Cost-sharing refers to amounts that a member has to pay when services or drugs are received. (This is in addition to the plan s monthly premium.) Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed copayment amount that a plan requires when a specific service or drug is received; or (3) any coinsurance amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received. A daily cost-sharing rate may apply when your doctor prescribes less than a full month s supply of certain drugs for you and you are required to pay a copayment. Cost-Sharing Tier Every drug on the list of covered drugs is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug. Coverage Determination A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn t covered under your plan, that isn t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called coverage decisions in this booklet. Chapter 9 explains how to ask us for a coverage decision. Covered Drugs The term we use to mean all of the prescription drugs covered by our plan.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 223 Chapter 12. Definitions of important words Covered Services The general term we use to mean all of the health care services and supplies that are covered by our plan. Creditable Prescription Drug Coverage Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later. Custodial Care Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care is personal care that can be provided by people who don t have professional skills or training, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn t pay for custodial care. Customer Solutions Center A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. See Chapter 2 for information about how to contact Customer Solutions Center. Daily cost-sharing rate A daily cost-sharing rate may apply when your doctor prescribes less than a full month s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a onemonth s supply in your plan is 30 days, then your daily cost-sharing rate is $1 per day. This means you pay $1 for each day s supply when you fill your prescription. Deductible The amount you must pay for health care or prescriptions before our plan begins to pay. Disenroll or Disenrollment The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice). Dispensing Fee A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist s time to prepare and package the prescription. Durable Medical Equipment Certain medical equipment that is ordered by your doctor for medical reasons. Examples are walkers, wheelchairs, or hospital beds. Emergency A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 224 Chapter 12. Definitions of important words Emergency Care Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition. Evidence of Coverage (EOC) and Disclosure Information This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan. Exception A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor s formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception). Extra Help A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Generic Drug A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a generic drug works the same as a brand name drug and usually costs less. Grievance - A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Home Health Aide A home health aide provides services that don t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy. Hospice - An enrollee who has 6 months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state. Hospital Inpatient Stay A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an outpatient. Income Related Monthly Adjustment Amount (IRMAA) If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium. For example, individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 225 Chapter 12. Definitions of important words income-related monthly adjustment amount. Less than 5 percent of people with Medicare are affected, so most people will not pay a higher premium. Initial Coverage Limit The maximum limit of coverage under the Initial Coverage Stage. Initial Coverage Stage This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $3,310. Initial Enrollment Period When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. Institutional Special Needs Plan (SNP) A Special Needs Plan that enrolls eligible individuals who continuously reside or are expected to continuously reside for 90 days or longer in a longterm care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); and/or an inpatient psychiatric facility. An institutional Special Needs Plan to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the specific LTC facility(ies). Institutional Equivalent Special Needs Plan (SNP) An institutional Special Needs Plan that enrolls eligible individuals living in the community but requiring an institutional level of care based on the State assessment. The assessment must be performed using the same respective State level of care assessment tool and administered by an entity other than the organization offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of specialized care. Late Enrollment Penalty An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive Extra Help from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty. List of Covered Drugs (Formulary or Drug List ) A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs. Low Income Subsidy (LIS) See Extra Help. Maximum Out-of-Pocket Amount The most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums, and prescription drugs do not count toward

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 226 Chapter 12. Definitions of important words the maximum out-of-pocket amount. See Chapter 4, Section 1.2 for information about your maximum out-of-pocket amount. Medicaid (or Medical Assistance) A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state. Medically Accepted Indication A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication. Medically Necessary Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Medicare The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare or a Medicare Advantage Plan. Medicare Advantage Disenrollment Period A set time each year when members in a Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare. The Medicare Advantage Disenrollment Period is from January 1 until February 14, 2016. Medicare Advantage (MA) Plan Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply). Medicare Cost Plan A Medicare Cost Plan is a plan operated by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section 1876(h) of the Act. Medicare Coverage Gap Discount Program A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving Extra Help. Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 227 Chapter 12. Definitions of important words Medicare-Covered Services Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B. Medicare Health Plan A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). Medicare Prescription Drug Coverage (Medicare Part D) Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B. Medigap (Medicare Supplement Insurance) Policy Medicare supplement insurance sold by private insurance companies to fill gaps in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.) Member (Member of our Plan, or Plan Member ) A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS). Network Pharmacy A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them network pharmacies because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Network Provider Provider is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them network providers when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as plan providers. Organization Determination The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage plan s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations are called coverage decisions in this booklet. Chapter 9 explains how to ask us for a coverage decision. Original Medicare ( Traditional Medicare or Fee-for-service Medicare) Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 228 Chapter 12. Definitions of important words Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States or its territories. Out-of-Network Pharmacy A pharmacy that doesn t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply. Out-of-Network Provider or Out-of-Network Facility A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-ofnetwork providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you. Using out-of-network providers or facilities is explained in this booklet in Chapter 3. Out-of-Pocket Costs See the definition for cost-sharing above. A member s cost-sharing requirement to pay for a portion of services or drugs received is also referred to as the member s out-of-pocket cost requirement. Part C see Medicare Advantage (MA) Plan. Part D The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.) Part D Drugs Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs. Preferred Network Pharmacy A network pharmacy that offers drugs to members of our plan that may have lower cost-sharing levels than at other network pharmacies. Preferred Provider Organization (PPO) Plan A Preferred Provider Organization plan is a Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers. Member cost-sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both network (preferred) and out-of-network (non-preferred) providers. Premium The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Primary Care Physician (PCP) Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 229 Chapter 12. Definitions of important words you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider. See Chapter 3, Section 2.1 for information about Primary Care Physicians. Prior Authorization Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network provider gets prior authorization from us. Covered drugs that need prior authorization are marked in the formulary. Prosthetics and Orthotics These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy. Quality Improvement Organization (QIO) A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state. Quantity Limits A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. Rehabilitation Services These services include physical therapy, speech and language therapy, and occupational therapy. Service Area A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan s service area. Skilled Nursing Facility (SNF) Care Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor. Special Enrollment Period A set time when members can change their health or drugs plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting Extra Help with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you. Special Needs Plan A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

2016 Evidence of Coverage for Indiana University Health Plans Medicare Select Plus 230 Chapter 12. Definitions of important words Step Therapy A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. Supplemental Security Income (SSI) A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits. Urgently Needed Services Urgently needed services are care provided to treat a nonemergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.

Indiana University Health Plans Medicare Select Plus Customer Solutions Center Method CALL Customer Solutions Center Contact Information (317) 963-9700 or toll-free 1-800-455-9776 (Calls to this number are free). From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. Customer Solutions Center also has free language interpreter services for non-english speakers. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. TTY 1-800-743-3333 (Relay Indiana) FAX (317) 963-9801 WRITE WEBSITE This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. From October 1, 2015 through February 14, 2016, a Customer Solutions representative will be available to speak to you 8:00 a.m. to 8:00 p.m. seven days a week. Beginning February 15, 2016, a representative will be available from 8:00 a.m. to 8:00 p.m. Monday through Friday. You may receive assistance through alternate technology after hours, on weekends, and holidays. You can also visit our website, www.iuhealthplansmedicare.org. Indiana University Health Plans 950 N. Meridian Street, Suite 200 Indianapolis, IN 46204 www.iuhealthplansmedicare.org

State Health Insurance Assistance Program (SHIP) State Health Insurance Assistance Program (SHIP) is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. Method CALL 1-800-452-4800 TTY 1-866-846-0139 State Health Insurance Assistance Program This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking WRITE WEBSITE 714 W 53 rd Street Anderson, IN 46013 www.medicare.in.gov

Multi-Language Insert Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-455-9776. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-455-9776. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 1-800-455-9776 Chinese Cantonese: 1-800-455-9776 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 1-800-455-9776. 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'assurancemédicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-455-9776. 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 1-800-455-9776 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 H7220_IUHMA1604 CMS File & Use 7/13/2015

erreichen Sie unter 1-800-455-9776. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean:. 1-800-455-9776... Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-455-9776. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: إننا نقدم خدمات المترجم الفوري المجانیة للا جابة عن أي أسي لة تتعلق بالصحة أو جدول الا دویة لدینا. للحصول على ی مترجم فوري كلیس سوى الاتصال بنا عل 9776-455-800-1. سیقوم شخص ما ع.بمساعدتك. ھذه خدمة مجانیة یتحدث العربیة Hindi: हम र व य य दव क य जन क ब र म आपक कस भ न क जव ब द न क लए हम र प स म त द भ षय स व ए उपलध ह. एक द भ षय त करन क लए, बस हम 1-800-455-9776 पर फ न कर. क ई य त ज हद ब लत ह आपक मदद कर सकत ह. यह एक म त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-455-9776. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-455-9776. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-455-9776. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język

polski, należy zadzwonić pod numer 1-800-455-9776. Ta usługa jest bezpłatna. Japanese: 1-800-455 9776

Abridged Formulary 2016 (Partial List of Covered Drugs) THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Indiana University Health Plans Medicare Choice HMO-POS Indiana University Health Plans Medicare Select Plus HMO 950 N. Meridian St., Suite 200 Indianapolis, IN 46204-1202 This abridged formulary was updated on 8.19.2015. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact us, IU Health Plans, Pharmacy Member Services, at 866.823.1016 or, for TTY users, 800.743.3333, Oct. 1 to Feb. 14 8 am to 8 pm seven days a week; Feb. 15 to Sept. 30 8 am to 8 pm Monday through Friday, or visit iuhealthplansmedicare.org. Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. 2015 IUHealth 9/15 IUH#20073 H7220_IUHMA16017 CMS File & Use 8.26.2015

Indiana University Health Plans 2016 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID:00016333, Version Number 6 This abridged formulary was updated on 09/01/2015. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact us, IU Health Plans, Pharmacy Member Services, at 866.823.1016 or, for TTY users, 1.800.743.3333, Monday through Friday from 8am to 8pm, or visit iuhealthplansmedicare.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means IU Health Plans. When it refers to plan or our plan, it means Indiana University Health Plans. This document includes a partial list of the drugs (formulary) for IU Health Plans which is current as of 09/01/2015. For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. What is the IU Health Plans Abridged Formulary? A formulary is a list of covered drugs selected by IU Health Plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. IU Health Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. i

This document is a partial formulary and includes only some of the drugs covered by IU Health Plans. For a complete listing of all prescription drugs covered by IU Health Plans, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose IU Health Plans, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/01/2015. To get updated information about the drugs covered by IU Health Plans, please contact us. Our contact information appears on the front and back cover pages. If IU Health Plans makes non-maintenance drug changes to this formulary that were approved by the Centers for Medicare & Medicaid Services (CMS), we will notify members by mailing errata sheets that list the prescription drug, change made and the effective date. This will enable members to have the most up-to-date information regarding the covered drugs on the plan s formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 2. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page index page number. The Index provides an alphabetical list of all of the drugs included in this document. Both ii

brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Indiana University Health Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: IU Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from IU Health Plans before you fill your prescriptions. If you don t get approval, IU Health Plans may not cover the drug. Quantity Limits: For certain drugs, IU Health Plans limits the amount of the drug that we will cover. For example, IU Health Plans provides 10 patches per prescription for fentanyl 50 mcg/hr patches. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, IU Health Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, IU Health Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Indiana University Health Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the plans formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so IU Health Plans may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. iii

If you learn that IU Health Plans does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by IU Health Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by IU Health Plans You can ask IU Health Plans to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the IU Health Plans Formulary? You can ask IU Health Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, IU Health Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, IU Health Plans will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in IU Health Plans you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of IU Health Plans. iv

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of IU Health Plans. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in IU Health Plans, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. In addition, all members who experience a level-of-care change are eligible for a transition supply. A level-of-care change is when a member changes from one treatment setting to another. For example, if a member is discharged from an inpatient facility to home on a non-formulary medication, the member will be eligible for a transition supply of that non-formulary medication. You can receive up to a 30-day supply of the medication (unless you have a prescription written for fewer days) after being discharged, to allow time for you and your physician to switch to a formulary alternative or request an exception. After your first 30-day supply, we will not pay for the drug, unless an exception was approved. Our transition policy applies only to those drugs that are Part D drugs. The transition policy cannot be used to cover non-part D drugs. For more information For more detailed information about your IU Health Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about IU Health Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. IU Health Plans Formulary The abridged formulary below provides coverage information about some of the drugs covered by IU Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 99. Remember: This is only a partial list of drugs covered by IU Health Plans. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., XARELTO ) and generic drugs are listed in lower-case italics (e.g., amoxicillin ). v

The information in the Requirements/Limits column tells you if Indiana University Health Plans has any special requirements for coverage of your drug. IU Health Plans Choice Drug Tier 30 Day Copay 90 Day Copay 1 Preferred Generic drugs* $4 $12 2 Generic drugs $8 $24 3 Preferred Brand and some Generic drugs $42 $118 4 Non-Preferred Brand and some Generic drugs $95 $266 5 Specialty drugs 33% 33% (maximum 30-day supply) * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. NOTE: Drugs are provided in a Long-term Care Facility for up to a 31-day supply. IU Health Plans Select Plus Drug Tier 30 Day Copay 90 Day Copay 1 Preferred Generic drugs $6 $18 2 Generic drugs $15 $44 3 Preferred Brand and some Generic drugs $45 $126 4 Non-Preferred Brand and some Generic drugs $95 $266 5 Specialty drugs 33% 33% (maximum 30-day supply) NOTE: Drugs are provided in a Long-term Care Facility for up to a 31-day supply. vi

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations *: Gap Coverage. We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. B/D: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 1

Drug Name Drug Tier Requirements/Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION 5 B/D; MO AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 5 B/D; MO amphotericin b injection recon soln 4 B/D; MO CANCIDAS INTRAVENOUS RECON SOLN 5 B/D; MO clotrimazole mucous membrane troche 2 MO CRESEMBA INTRAVENOUS RECON SOLN 5 CRESEMBA ORAL CAPSULE 5 MO ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml 4 MO fluconazole oral suspension for reconstitution 2 MO fluconazole oral tablet 2 MO flucytosine oral capsule 5 MO griseofulvin microsize oral suspension 2 MO griseofulvin microsize oral tablet 2 MO griseofulvin ultramicrosize oral tablet 2 MO itraconazole oral capsule 4 PA; MO; QL (120 per 30 days) ketoconazole oral tablet 2 MO MYCAMINE INTRAVENOUS RECON SOLN 5 MO NOXAFIL ORAL SUSPENSION 5 PA; MO NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral suspension 2 MO nystatin oral tablet 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 2 2 5 PA; MO; QL (93 per 30 days) ONMEL ORAL TABLET 4 PA; MO; QL (30 per 30 days) terbinafine hcl oral tablet 1 MO; * voriconazole intravenous solution 2 MO voriconazole oral suspension for reconstitution 5 MO

Drug Name Drug Tier Requirements/Limits voriconazole oral tablet 5 MO ANTIVIRALS abacavir oral tablet 2 MO abacavir-lamivudine-zidovudine oral tablet 5 MO acyclovir oral capsule 1 MO; * acyclovir oral suspension 200 mg/5 ml 2 MO acyclovir oral tablet 2 MO acyclovir sodium intravenous solution 2 B/D; MO adefovir oral tablet 5 PA; MO amantadine hcl oral capsule 2 MO amantadine hcl oral solution 2 MO amantadine hcl oral tablet 2 MO APTIVUS ORAL CAPSULE 5 MO APTIVUS ORAL SOLUTION 5 ATRIPLA ORAL TABLET 5 MO BARACLUDE ORAL SOLUTION 4 PA; MO cidofovir intravenous solution 5 B/D; MO COMPLERA ORAL TABLET 5 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 3 MO didanosine oral capsule,delayed release(dr/ec) 2 MO EDURANT ORAL TABLET 5 MO EMTRIVA ORAL CAPSULE 3 MO EMTRIVA ORAL SOLUTION 3 MO entecavir oral tablet 5 PA; MO EPIVIR HBV ORAL SOLUTION 4 PA; MO EPZICOM ORAL TABLET 5 MO EVOTAZ ORAL TABLET 5 MO famciclovir oral tablet 2 MO foscarnet intravenous solution 2 B/D; MO FUZEON SUBCUTANEOUS RECON SOLN 5 MO ganciclovir sodium intravenous recon soln 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 3

Drug Name Drug Tier Requirements/Limits HARVONI ORAL TABLET 5 PA; MO; QL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 5 MO INTELENCE ORAL TABLET 25 MG 4 INVIRASE ORAL CAPSULE 4 MO INVIRASE ORAL TABLET 5 MO ISENTRESS ORAL POWDER IN PACKET 3 MO ISENTRESS ORAL TABLET 5 MO ISENTRESS ORAL TABLET,CHEWABLE 3 MO KALETRA ORAL SOLUTION 5 MO KALETRA ORAL TABLET 100-25 MG 4 MO KALETRA ORAL TABLET 200-50 MG 5 MO lamivudine oral solution 2 MO lamivudine oral tablet 100 mg 2 PA; MO lamivudine oral tablet 150 mg, 300 mg 2 MO lamivudine-zidovudine oral tablet 5 MO LEXIVA ORAL SUSPENSION 4 MO LEXIVA ORAL TABLET 5 MO moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) 5 MO moderiba oral tablet 2 MO nevirapine oral suspension 2 MO nevirapine oral tablet 2 MO nevirapine oral tablet extended release 24 hr 2 MO NORVIR ORAL CAPSULE 4 MO NORVIR ORAL SOLUTION 4 MO NORVIR ORAL TABLET 4 MO PREZCOBIX ORAL TABLET 5 MO PREZISTA ORAL SUSPENSION 4 MO PREZISTA ORAL TABLET 150 MG, 75 MG 4 MO PREZISTA ORAL TABLET 600 MG, 800 MG 5 MO REBETOL ORAL SOLUTION 5 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 4

Drug Name Drug Tier Requirements/Limits RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET 4 MO RESCRIPTOR ORAL TABLET, DISPERSIBLE 4 MO RETROVIR INTRAVENOUS SOLUTION 4 MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 3 MO; QL (120 per 365 days) 5 MO REYATAZ ORAL POWDER IN PACKET 5 MO ribasphere oral capsule 2 MO ribasphere oral tablet 200 mg, 400 mg 2 MO ribasphere oral tablet 600 mg 5 MO ribavirin oral capsule 2 MO ribavirin oral tablet 200 mg 2 MO rimantadine oral tablet 2 MO SELZENTRY ORAL TABLET 5 MO SOVALDI ORAL TABLET 5 PA; MO; QL (30 per 30 days) stavudine oral capsule 2 MO stavudine oral recon soln 2 MO STRIBILD ORAL TABLET 5 MO SUSTIVA ORAL CAPSULE 4 MO SUSTIVA ORAL TABLET 5 MO SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 5 PA; MO; LA TAMIFLU ORAL CAPSULE 30 MG 3 MO; QL (84 per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG 3 MO; QL (42 per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY ORAL TABLET 5 MO TRIUMEQ ORAL TABLET 5 MO TRUVADA ORAL TABLET 5 MO TYBOST ORAL TABLET 3 MO 3 MO; QL (525 per 180 days) TYZEKA ORAL TABLET 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 5

Drug Name Drug Tier Requirements/Limits valacyclovir oral tablet 2 MO VALCYTE ORAL RECON SOLN 5 MO valganciclovir oral tablet 5 MO VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 4 MO VIRACEPT ORAL TABLET 5 MO VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 4 MO VIRAZOLE INHALATION RECON SOLN 5 MO VIREAD ORAL POWDER 5 MO VIREAD ORAL TABLET 5 MO VITEKTA ORAL TABLET 5 MO ZIAGEN ORAL SOLUTION 4 MO zidovudine oral capsule 2 MO zidovudine oral syrup 2 MO zidovudine oral tablet 2 MO CEPHALOSPORINS cefaclor oral capsule 2 MO cefaclor oral tablet extended release 12 hr 2 MO cefadroxil oral capsule 2 MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2 MO cefadroxil oral tablet 2 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml 2 MO cefazolin injection recon soln 1 gram, 500 mg 2 MO cefazolin injection recon soln 10 gram 2 cefdinir oral capsule 2 MO cefdinir oral suspension for reconstitution 2 MO cefditoren pivoxil oral tablet 200 mg 2 MO CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 4 MO cefepime injection recon soln 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 6

Drug Name Drug Tier Requirements/Limits cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotetan injection recon soln 2 cefotetan intravenous recon soln 2 cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln 1 gram 2 MO cefoxitin intravenous recon soln 10 gram, 2 gram 2 cefpodoxime oral suspension for reconstitution 2 MO cefpodoxime oral tablet 2 MO cefprozil oral suspension for reconstitution 2 MO cefprozil oral tablet 2 MO CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK ceftazidime injection recon soln 1 gram, 2 gram 2 MO ceftazidime injection recon soln 6 gram 2 ceftriaxone injection recon soln 10 gram 2 ceftriaxone injection recon soln 250 mg, 500 mg 2 MO ceftriaxone intravenous recon soln 2 MO cefuroxime axetil oral tablet 2 MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 2 2 2 4 2 MO cephalexin oral capsule 250 mg, 500 mg 1 MO; * cephalexin oral capsule 750 mg 2 MO cephalexin oral suspension for reconstitution 1 MO; * cephalexin oral tablet 1 MO; * FORTAZ INTRAVENOUS RECON SOLN 4 SUPRAX ORAL CAPSULE 4 MO SUPRAX ORAL TABLET,CHEWABLE 4 MO TEFLARO INTRAVENOUS RECON SOLN 400 MG 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 7

Drug Name Drug Tier Requirements/Limits TEFLARO INTRAVENOUS RECON SOLN 600 MG ZERBAXA INTRAVENOUS RECON SOLN 5 ERYTHROMYCINS / OTHER MACROLIDES 5 MO azithromycin intravenous recon soln 500 mg 2 MO azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral packet 2 MO azithromycin oral suspension for reconstitution 2 MO azithromycin oral tablet 2 MO clarithromycin oral suspension for reconstitution 2 MO clarithromycin oral tablet 2 MO clarithromycin oral tablet extended release 24 hr 2 MO DIFICID ORAL TABLET 5 ST; MO; QL (20 per 10 days) e.e.s. 400 oral tablet 2 MO E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG 2 4 MO 4 MO 4 MO 2 MO 4 MO erythrocin (as stearate) oral tablet 250 mg 2 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet 2 MO erythromycin oral tablet 2 MO PCE ORAL TABLET, PARTICLES/CRYSTALS 4 MO MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET 3 MO 4 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 8

Drug Name Drug Tier Requirements/Limits ALINIA ORAL SUSPENSION FOR RECONSTITUTION 4 MO ALINIA ORAL TABLET 4 MO amikacin injection solution 500 mg/2 ml 2 MO atovaquone oral suspension 5 MO atovaquone-proguanil oral tablet 2 MO AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML aztreonam injection recon soln 1 gram 2 MO baciim intramuscular recon soln 2 bacitracin intramuscular recon soln 2 MO BETHKIS INHALATION SOLUTION FOR NEBULIZATION BILTRICIDE ORAL TABLET 3 MO CAPASTAT INJECTION RECON SOLN 4 CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln chloroquine phosphate oral tablet 2 MO clindamycin hcl oral capsule 2 MO clindamycin in 5 % dextrose intravenous piggyback clindamycin pediatric oral recon soln 2 clindamycin phosphate intravenous solution 600 mg/4 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 9 4 5 5 B/D; MO; QL (224 per 56 days) 5 MO; LA; QL (84 per 56 days) 2 2 MO 2 MO COARTEM ORAL TABLET 3 MO colistin (colistimethate na) injection recon soln 2 MO CUBICIN INTRAVENOUS RECON SOLN 5 MO DALVANCE INTRAVENOUS SOLUTION 5 DAPSONE ORAL TABLET 3 MO DARAPRIM ORAL TABLET 4 MO

Drug Name Drug Tier Requirements/Limits DORIBAX INTRAVENOUS RECON SOLN 500 MG ethambutol oral tablet 2 MO FLAGYL ER ORAL TABLET EXTENDED RELEASE gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 10 4 4 MO 2 MO gentamicin injection solution 40 mg/ml 2 MO gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral tablet 2 MO imipenem-cilastatin intravenous recon soln 2 MO INVANZ INJECTION RECON SOLN 4 MO isoniazid injection solution 2 isoniazid oral solution 1 MO; * isoniazid oral tablet 1 MO; * ivermectin oral tablet 2 MO LINCOCIN INJECTION SOLUTION 4 MO linezolid intravenous parenteral solution 5 linezolid oral tablet 5 MO mefloquine oral tablet 2 MO meropenem intravenous recon soln 500 mg 2 MO metronidazole in nacl (iso-os) intravenous piggyback 2 2 2 MO metronidazole oral capsule 2 MO metronidazole oral tablet 2 MO NEBUPENT INHALATION RECON SOLN 4 B/D; MO neomycin oral tablet 2 MO paromomycin oral capsule 2 MO PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 MO

Drug Name Drug Tier Requirements/Limits PENTAM INJECTION RECON SOLN 4 MO polymyxin b sulfate injection recon soln 2 PRIFTIN ORAL TABLET 4 MO PRIMAQUINE ORAL TABLET 3 MO pyrazinamide oral tablet 2 MO quinine sulfate oral capsule 2 PA; MO rifabutin oral capsule 4 MO RIFAMATE ORAL CAPSULE 4 MO rifampin intravenous recon soln 2 MO rifampin oral capsule 2 MO RIFATER ORAL TABLET 4 MO SIRTURO ORAL TABLET 5 PA; MO; LA SIVEXTRO INTRAVENOUS RECON SOLN 5 QL (24 per 30 days) SIVEXTRO ORAL TABLET 5 MO; QL (6 per 30 days) STREPTOMYCIN INTRAMUSCULAR RECON SOLN SYNERCID INTRAVENOUS RECON SOLN 5 4 MO tinidazole oral tablet 2 MO TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.225 % nacl inhalation solution for nebulization tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml 5 MO; QL (224 per 56 days) 5 B/D; MO; QL (280 per 56 days) 2 MO tobramycin sulfate injection solution 2 MO TRECATOR ORAL TABLET 4 MO TYGACIL INTRAVENOUS RECON SOLN 5 MO XIFAXAN ORAL TABLET 200 MG 4 MO; QL (9 per 3 days) XIFAXAN ORAL TABLET 550 MG 5 PA; MO; QL (60 per 30 days) ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS 5 MO amoxicillin oral capsule 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 11

Drug Name Drug Tier Requirements/Limits amoxicillin oral suspension for reconstitution 1 MO; * amoxicillin oral tablet 1 MO; * amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO; * amoxicillin-pot clavulanate oral suspension for reconstitution 2 MO amoxicillin-pot clavulanate oral tablet 2 MO amoxicillin-pot clavulanate oral tablet extended release 12 hr 2 MO amoxicillin-pot clavulanate oral tablet,chewable 2 MO ampicillin oral capsule 2 MO ampicillin oral suspension for reconstitution 2 MO ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 15 gram 2 2 MO ampicillin-sulbactam injection recon soln 3 gram 2 MO ampicillin-sulbactam intravenous recon soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 4 MO BICILLIN L-A INTRAMUSCULAR SYRINGE 4 MO dicloxacillin oral capsule 2 MO nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin injection recon soln 1 gram 2 MO nafcillin injection recon soln 10 gram 5 MO oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml 2 2 2 5 MO oxacillin injection recon soln 10 gram 5 MO oxacillin intravenous recon soln 2 gram 2 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML 4 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 12

Drug Name Drug Tier Requirements/Limits penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml 2 MO 2 MO penicillin g sodium injection recon soln 5 MO penicillin v potassium oral recon soln 1 MO; * penicillin v potassium oral tablet 1 MO; * piperacillin-tazobactam intravenous recon soln 3.375 gram, 4.5 gram ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 13 4 4 MO 4 MO 2 MO; QL (14 per 30 days) 2 MO; QL (28 per 30 days) ciprofloxacin hcl oral tablet 1 MO; * ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 2 MO FACTIVE ORAL TABLET 4 MO; QL (7 per 30 days) levofloxacin in d5w intravenous piggyback 500 mg/100 ml 2 2 MO levofloxacin intravenous solution 2 MO levofloxacin oral solution 2 MO levofloxacin oral tablet 2 MO moxifloxacin oral tablet 2 MO ofloxacin oral tablet 400 mg 2

Drug Name Drug Tier Requirements/Limits SULFA'S / RELATED AGENTS sulfadiazine oral tablet 2 MO sulfamethoxazole-trimethoprim intravenous solution 2 MO sulfamethoxazole-trimethoprim oral suspension 1 MO; * sulfamethoxazole-trimethoprim oral tablet 1 MO; * TETRACYCLINES doxy-100 intravenous recon soln 2 MO doxycycline hyclate intravenous recon soln 4 doxycycline hyclate oral capsule 100 mg 4 MO doxycycline hyclate oral capsule 50 mg 3 MO doxycycline hyclate oral tablet 100 mg 4 MO doxycycline hyclate oral tablet 20 mg 2 MO doxycycline hyclate oral tablet 50 mg 2 doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg 2 MO 4 MO 4 MO doxycycline monohydrate oral tablet 75 mg 2 MO minocycline oral capsule 2 MO tetracycline oral capsule 2 MO VIBRAMYCIN ORAL SYRUP 4 MO URINARY TRACT AGENTS methenamine hippurate oral tablet 2 MO MONUROL ORAL PACKET 4 MO nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg 2 MO; QL (90 per 365 days) nitrofurantoin monohyd/m-cryst oral capsule 2 MO; QL (90 per 365 days) trimethoprim oral tablet 2 MO VANCOMYCIN You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 14

Drug Name Drug Tier Requirements/Limits vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg 2 MO vancomycin oral capsule 5 MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln 2 MO dexrazoxane hcl intravenous recon soln 250 mg 5 ELITEK INTRAVENOUS RECON SOLN 1.5 MG FUSILEV INTRAVENOUS RECON SOLN 5 MO KEPIVANCE INTRAVENOUS RECON SOLN 5 LA leucovorin calcium injection recon soln 100 mg, 350 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 15 5 2 MO leucovorin calcium oral tablet 2 MO LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION mesna intravenous solution 2 MO MESNEX ORAL TABLET 4 MO XGEVA SUBCUTANEOUS SOLUTION 5 PA; MO; QL (1.7 per 28 days) ZINECARD (AS HCL) INTRAVENOUS RECON SOLN 250 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 5 5 MO 5 MO adrucil intravenous solution 500 mg/10 ml 2 MO AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 5 PA; MO AFINITOR ORAL TABLET 10 MG 5 PA; MO; QL (30 per 30 days) AFINITOR ORAL TABLET 2.5 MG 5 PA; MO; QL (120 per 30 days) AFINITOR ORAL TABLET 5 MG, 7.5 MG 5 PA; MO; QL (60 per 30 days) ALIMTA INTRAVENOUS RECON SOLN 500 MG 5 MO anastrozole oral tablet 2 MO

Drug Name Drug Tier Requirements/Limits ARRANON INTRAVENOUS SOLUTION 5 ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML 5 B/D; MO AVASTIN INTRAVENOUS SOLUTION 5 MO azacitidine injection recon soln 5 MO azathioprine oral tablet 2 B/D; MO BELEODAQ INTRAVENOUS RECON SOLN 5 MO bicalutamide oral tablet 2 MO BICNU INTRAVENOUS RECON SOLN 4 MO bleomycin injection recon soln 30 unit 2 MO BOSULIF ORAL TABLET 100 MG 5 PA; MO; QL (180 per 30 days) BOSULIF ORAL TABLET 500 MG 5 PA; MO; QL (60 per 30 days) BUSULFEX INTRAVENOUS SOLUTION 5 CAPRELSA ORAL TABLET 100 MG 5 PA; MO; LA; QL (90 per 30 days) CAPRELSA ORAL TABLET 300 MG 5 PA; MO; LA; QL (30 per 30 days) carboplatin intravenous solution 2 MO CELLCEPT INTRAVENOUS RECON SOLN 4 B/D; MO cisplatin intravenous solution 2 MO cladribine intravenous solution 5 MO CLOLAR INTRAVENOUS SOLUTION 5 MO COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG [3]/DAY) 5 PA; MO; QL (112 per 28 days) 5 PA; MO; QL (252 per 28 days) CYCLOPHOSPHAMIDE ORAL CAPSULE 3 B/D; MO cyclosporine intravenous solution 2 B/D cyclosporine modified oral capsule 2 B/D; MO cyclosporine modified oral solution 2 B/D; MO cyclosporine oral capsule 2 B/D; MO cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) 2 MO cytarabine injection solution 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 16

Drug Name Drug Tier Requirements/Limits dacarbazine intravenous recon soln 200 mg 2 MO daunorubicin intravenous solution 2 decitabine intravenous recon soln 5 MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 17 5 5 MO doxorubicin intravenous solution 50 mg/25 ml 2 MO ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) 4 PA; MO; QL (1 per 84 days) 4 PA; MO; QL (1 per 112 days) 4 PA; MO; QL (1 per 168 days) 4 PA; MO; QL (1 per 28 days) EMCYT ORAL CAPSULE 4 PA; MO epirubicin intravenous solution 50 mg/25 ml 2 MO ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML 5 MO ERIVEDGE ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) ERWINAZE INTRAMUSCULAR RECON SOLN 5 MO ETOPOPHOS INTRAVENOUS RECON SOLN 4 MO etoposide intravenous solution 2 MO exemestane oral tablet 2 MO FARESTON ORAL TABLET 5 PA; MO FARYDAK ORAL CAPSULE 10 MG, 15 MG 5 PA; MO; QL (12 per 21 days) FARYDAK ORAL CAPSULE 20 MG 5 PA; MO; QL (6 per 21 days) FASLODEX INTRAMUSCULAR SYRINGE 5 MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 5 PA; MO; QL (2 per 365 days) 4 PA; MO; QL (12 per 28 days)

Drug Name Drug Tier Requirements/Limits fludarabine intravenous recon soln 2 MO fluorouracil intravenous solution 2.5 gram/50 ml 2 MO flutamide oral capsule 2 MO FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) 5 MO gemcitabine intravenous recon soln 1 gram 5 MO gengraf oral capsule 2 B/D; MO gengraf oral solution 2 B/D; MO GILOTRIF ORAL TABLET 20 MG, 30 MG 5 PA; MO; QL (60 per 30 days) GILOTRIF ORAL TABLET 40 MG 5 PA; MO; QL (30 per 30 days) GLEEVEC ORAL TABLET 100 MG 5 PA; MO; QL (240 per 30 days) GLEEVEC ORAL TABLET 400 MG 5 PA; MO; QL (60 per 30 days) GLEOSTINE ORAL CAPSULE 4 PA; MO HALAVEN INTRAVENOUS SOLUTION 5 MO HERCEPTIN INTRAVENOUS RECON SOLN 5 MO HEXALEN ORAL CAPSULE 5 MO hydroxyurea oral capsule 2 MO IBRANCE ORAL CAPSULE 100 MG, 75 MG 5 PA; MO; QL (42 per 28 days) IBRANCE ORAL CAPSULE 125 MG 5 PA; MO; QL (21 per 28 days) ICLUSIG ORAL TABLET 15 MG 5 PA; MO; QL (90 per 30 days) ICLUSIG ORAL TABLET 45 MG 5 PA; MO; QL (30 per 30 days) idarubicin intravenous solution 5 ifosfamide intravenous recon soln 1 gram 2 MO IMBRUVICA ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) INLYTA ORAL TABLET 1 MG 5 PA; MO; QL (600 per 30 days) INLYTA ORAL TABLET 5 MG 5 PA; MO; QL (120 per 30 days) irinotecan intravenous solution 100 mg/5 ml 3 MO ISTODAX INTRAVENOUS RECON SOLN 5 MO IXEMPRA INTRAVENOUS RECON SOLN 45 MG 5 MO JAKAFI ORAL TABLET 10 MG 5 PA; MO; QL (180 per 30 days) JAKAFI ORAL TABLET 15 MG, 20 MG 5 PA; MO; QL (120 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 18

Drug Name Drug Tier Requirements/Limits JAKAFI ORAL TABLET 25 MG 5 PA; MO; QL (60 per 30 days) JAKAFI ORAL TABLET 5 MG 5 PA; MO; QL (300 per 30 days) JEVTANA INTRAVENOUS SOLUTION 5 MO KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 MO KEYTRUDA INTRAVENOUS RECON SOLN 5 MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY), 24 MG (10 MG[2] -4 MG[1])/DAY LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) letrozole oral tablet 2 MO LEUKERAN ORAL TABLET 4 MO 5 PA; MO; QL (90 per 30 days) 5 PA; MO; QL (120 per 30 days) leuprolide subcutaneous kit 2 PA; MO; QL (6 per 28 days) LOMUSTINE ORAL CAPSULE 4 MO LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG 5 PA; MO; QL (1 per 84 days) 5 PA; MO; QL (1 per 112 days) 5 PA; MO; QL (1 per 168 days) 5 PA; MO; QL (1 per 28 days) 5 PA; MO; QL (1 per 28 days) LYNPARZA ORAL CAPSULE 5 PA; MO; QL (480 per 30 days) LYSODREN ORAL TABLET 5 MO MATULANE ORAL CAPSULE 5 MO megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 PA; MO megestrol oral tablet 2 PA; MO MEKINIST ORAL TABLET 0.5 MG 5 PA; MO; QL (120 per 30 days) MEKINIST ORAL TABLET 2 MG 5 PA; MO; QL (30 per 30 days) melphalan hcl intravenous recon soln 5 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 19

Drug Name Drug Tier Requirements/Limits mercaptopurine oral tablet 2 MO methotrexate sodium (pf) injection recon soln 2 B/D methotrexate sodium (pf) injection solution 2 B/D; MO methotrexate sodium oral tablet 2 B/D; MO mitomycin intravenous recon soln 20 mg 4 MO mitoxantrone intravenous concentrate 2 MO MUSTARGEN INJECTION RECON SOLN 4 MO mycophenolate mofetil oral capsule 2 B/D; MO mycophenolate mofetil oral suspension for reconstitution 5 B/D; MO mycophenolate mofetil oral tablet 2 B/D; MO mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 360 mg 4 B/D; MO 5 B/D; MO NEXAVAR ORAL TABLET 5 PA; MO; LA; QL (120 per 30 days) NILANDRON ORAL TABLET 5 PA; MO NULOJIX INTRAVENOUS RECON SOLN 5 PA; MO octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 500 mcg/ml octreotide acetate injection solution 200 mcg/ml, 50 mcg/ml 5 MO 2 MO ONCASPAR INJECTION SOLUTION 5 MO OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML 5 MO oxaliplatin intravenous solution 100 mg/20 ml 5 MO paclitaxel intravenous concentrate 2 MO PERJETA INTRAVENOUS SOLUTION 5 MO POMALYST ORAL CAPSULE 1 MG 5 PA; MO; QL (84 per 28 days) POMALYST ORAL CAPSULE 2 MG, 3 MG 5 PA; MO; QL (42 per 28 days) POMALYST ORAL CAPSULE 4 MG 5 PA; MO; QL (21 per 28 days) PROGRAF INTRAVENOUS SOLUTION 4 B/D; MO PURIXAN ORAL SUSPENSION 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 20

Drug Name Drug Tier Requirements/Limits RAPAMUNE ORAL SOLUTION 5 PA; MO REVLIMID ORAL CAPSULE 10 MG 5 PA; MO; LA; QL (63 per 28 days) REVLIMID ORAL CAPSULE 15 MG, 20 MG 5 PA; MO; LA; QL (42 per 28 days) REVLIMID ORAL CAPSULE 2.5 MG 5 PA; MO; LA; QL (210 per 28 days) REVLIMID ORAL CAPSULE 25 MG 5 PA; MO; LA; QL (21 per 28 days) REVLIMID ORAL CAPSULE 5 MG 5 PA; MO; LA; QL (105 per 28 days) RITUXAN INTRAVENOUS CONCENTRATE 5 PA; MO SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 5 PA; MO 5 PA; MO; QL (2 per 28 days) SIGNIFOR SUBCUTANEOUS SOLUTION 5 PA; MO; QL (60 per 30 days) SIMULECT INTRAVENOUS RECON SOLN 20 MG 4 B/D; MO sirolimus oral tablet 0.5 mg, 1 mg 2 PA; MO sirolimus oral tablet 2 mg 5 PA; MO SOLTAMOX ORAL SOLUTION 4 MO SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML 5 PA; MO; QL (0.5 per 28 days) 5 PA; MO; QL (0.4 per 28 days) 5 PA; MO; QL (0.6 per 28 days) SPRYCEL ORAL TABLET 100 MG, 140 MG 5 PA; MO; QL (60 per 30 days) SPRYCEL ORAL TABLET 20 MG 5 PA; MO; QL (270 per 30 days) SPRYCEL ORAL TABLET 50 MG 5 PA; MO; QL (120 per 30 days) SPRYCEL ORAL TABLET 70 MG, 80 MG 5 PA; MO; QL (90 per 30 days) STIVARGA ORAL TABLET 5 PA; MO; QL (84 per 28 days) SUTENT ORAL CAPSULE 12.5 MG 5 PA; MO; QL (210 per 30 days) SUTENT ORAL CAPSULE 25 MG 5 PA; MO; QL (120 per 30 days) SUTENT ORAL CAPSULE 37.5 MG 5 PA; MO; QL (90 per 30 days) SUTENT ORAL CAPSULE 50 MG 5 PA; MO; QL (60 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 21

Drug Name Drug Tier Requirements/Limits SYLVANT INTRAVENOUS RECON SOLN 100 MG 5 PA; MO SYNRIBO SUBCUTANEOUS RECON SOLN 5 MO TABLOID ORAL TABLET 4 PA; MO tacrolimus oral capsule 0.5 mg, 1 mg 2 B/D; MO tacrolimus oral capsule 5 mg 5 B/D; MO TAFINLAR ORAL CAPSULE 50 MG 5 PA; MO; QL (180 per 30 days) TAFINLAR ORAL CAPSULE 75 MG 5 PA; MO; QL (120 per 30 days) tamoxifen oral tablet 2 MO TARCEVA ORAL TABLET 100 MG 5 PA; MO; QL (150 per 30 days) TARCEVA ORAL TABLET 150 MG 5 PA; MO; QL (90 per 30 days) TARCEVA ORAL TABLET 25 MG 5 PA; MO TARGRETIN ORAL CAPSULE 5 PA; MO TARGRETIN TOPICAL GEL 5 MO TASIGNA ORAL CAPSULE 150 MG 5 PA; MO; QL (180 per 30 days) TASIGNA ORAL CAPSULE 200 MG 5 PA; MO; QL (120 per 30 days) THALOMID ORAL CAPSULE 100 MG, 50 MG 5 PA; MO THALOMID ORAL CAPSULE 150 MG 5 PA; MO; QL (90 per 30 days) THALOMID ORAL CAPSULE 200 MG 5 PA; MO; QL (60 per 30 days) toposar intravenous solution 2 MO topotecan intravenous recon soln 5 MO TORISEL INTRAVENOUS RECON SOLN 5 MO TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML 5 MO 5 MO tretinoin (chemotherapy) oral capsule 5 MO 5 PA; MO; QL (1 per 168 days) 5 PA; MO; QL (1 per 84 days) 5 PA; MO; QL (1 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 22

Drug Name Drug Tier Requirements/Limits TRISENOX INTRAVENOUS SOLUTION 5 MO TYKERB ORAL TABLET 5 PA; MO; LA; QL (180 per 30 days) VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML) 5 B/D; MO VELCADE INJECTION RECON SOLN 5 MO vinblastine intravenous solution 2 MO vincasar pfs intravenous solution 1 mg/ml 2 vincristine intravenous solution 1 mg/ml 2 MO vinorelbine intravenous solution 50 mg/5 ml 2 MO VOTRIENT ORAL TABLET 5 PA; MO; QL (120 per 30 days) XALKORI ORAL CAPSULE 200 MG 5 PA; MO; QL (90 per 30 days) XALKORI ORAL CAPSULE 250 MG 5 PA; MO; QL (60 per 30 days) XTANDI ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) 5 MO 5 MO ZANOSAR INTRAVENOUS RECON SOLN 4 MO ZELBORAF ORAL TABLET 5 PA; MO; QL (240 per 30 days) ZOLINZA ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) ZORTRESS ORAL TABLET 0.25 MG 4 PA; MO ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 PA; MO ZYDELIG ORAL TABLET 100 MG 5 PA; MO; QL (90 per 30 days) ZYDELIG ORAL TABLET 150 MG 5 PA; MO; QL (60 per 30 days) ZYKADIA ORAL CAPSULE 5 PA; MO; QL (150 per 30 days) ZYTIGA ORAL TABLET 5 PA; MO; QL (120 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG 4 PA; MO APTIOM ORAL TABLET 400 MG, 600 MG, 800 MG 5 PA; MO BANZEL ORAL SUSPENSION 4 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 23

Drug Name Drug Tier Requirements/Limits BANZEL ORAL TABLET 200 MG 4 PA; MO BANZEL ORAL TABLET 400 MG 5 PA; MO carbamazepine oral capsule, er multiphase 12 hr 2 MO carbamazepine oral suspension 100 mg/5 ml 2 MO carbamazepine oral tablet 1 MO; * carbamazepine oral tablet extended release 12 hr 2 MO carbamazepine oral tablet,chewable 2 MO CELONTIN ORAL CAPSULE 300 MG 4 MO clonazepam oral tablet 0.5 mg 2 MO; QL (1200 per 30 days) clonazepam oral tablet 1 mg 2 MO; QL (600 per 30 days) clonazepam oral tablet 2 mg 2 MO; QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg 2 ST; MO; QL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg 2 ST; MO; QL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg 2 ST; MO; QL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg 2 ST; MO; QL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg 2 ST; MO; QL (300 per 30 days) diazepam rectal kit 2 MO DILANTIN 30 MG ORAL CAPSULE 3 MO divalproex oral capsule, sprinkle 2 MO divalproex oral tablet extended release 24 hr 2 MO divalproex oral tablet,delayed release (dr/ec) 2 MO epitol oral tablet 2 MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 4 MO ethosuximide oral capsule 2 MO ethosuximide oral solution 2 MO felbamate oral suspension 2 MO felbamate oral tablet 2 MO fosphenytoin injection solution 100 mg pe/2 ml 2 MO FYCOMPA ORAL TABLET 4 PA; MO gabapentin oral capsule 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 24

Drug Name Drug Tier Requirements/Limits gabapentin oral solution 250 mg/5 ml 2 MO gabapentin oral tablet 600 mg, 800 mg 2 MO GABITRIL ORAL TABLET 12 MG, 16 MG 4 MO GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 MG lamotrigine oral tablet 2 MO lamotrigine oral tablet, chewable dispersible 2 MO lamotrigine oral tablet,disintegrating 2 ST; MO LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 1,000 MG/100 ML, 1,500 MG/100 ML LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 500 MG/100 ML 4 PA; MO; QL (156 per 365 days) 4 PA; MO; QL (30 per 30 days) 4 PA; MO; QL (90 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 25 4 4 MO levetiracetam intravenous solution 2 MO levetiracetam oral solution 100 mg/ml 2 MO levetiracetam oral tablet 2 MO levetiracetam oral tablet extended release 24 hr 2 MO LYRICA ORAL CAPSULE 100 MG 4 PA; MO; QL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG 4 PA; MO; QL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG, 225 MG 4 PA; MO; QL (90 per 30 days) LYRICA ORAL CAPSULE 25 MG 4 PA; MO; QL (720 per 30 days) LYRICA ORAL CAPSULE 300 MG 4 PA; MO; QL (60 per 30 days) LYRICA ORAL CAPSULE 50 MG 4 PA; MO; QL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG 4 PA; MO; QL (240 per 30 days) LYRICA ORAL SOLUTION 4 PA; MO; QL (900 per 30 days) ONFI ORAL SUSPENSION 4 PA; MO ONFI ORAL TABLET 10 MG, 20 MG 4 PA; MO oxcarbazepine oral suspension 2 MO oxcarbazepine oral tablet 2 MO

Drug Name Drug Tier Requirements/Limits PEGANONE ORAL TABLET 4 MO phenobarbital oral elixir 2 PA; MO phenobarbital oral tablet 100 mg 2 PA phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 2 PA; MO phenytoin oral suspension 125 mg/5 ml 2 MO phenytoin oral tablet,chewable 2 MO phenytoin sodium extended oral capsule 2 MO phenytoin sodium intravenous solution 2 MO POTIGA ORAL TABLET 200 MG 5 PA; MO POTIGA ORAL TABLET 300 MG, 400 MG, 50 MG 4 PA; MO primidone oral tablet 2 MO SABRIL ORAL POWDER IN PACKET 5 PA; MO; LA; QL (180 per 30 days) SABRIL ORAL TABLET 5 PA; MO; LA; QL (180 per 30 days) TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 3 MO tiagabine oral tablet 2 MO topiramate oral capsule, sprinkle 2 MO topiramate oral tablet 2 MO valproate sodium intravenous solution 2 MO valproic acid (as sodium salt) oral solution 250 mg/5 ml 2 MO valproic acid oral capsule 2 MO VIMPAT INTRAVENOUS SOLUTION 4 PA VIMPAT ORAL SOLUTION 4 PA; MO VIMPAT ORAL TABLET 4 PA; MO zonisamide oral capsule 2 MO ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA; QL (90 per 30 days) AZILECT ORAL TABLET 3 MO benztropine injection solution 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 26

Drug Name Drug Tier Requirements/Limits benztropine oral tablet 2 MO bromocriptine oral capsule 2 MO bromocriptine oral tablet 2 MO carbidopa oral tablet 5 MO carbidopa-levodopa oral tablet 2 MO carbidopa-levodopa oral tablet extended release 2 MO carbidopa-levodopa oral tablet,disintegrating 2 MO carbidopa-levodopa-entacapone oral tablet 2 MO entacapone oral tablet 2 MO NEUPRO TRANSDERMAL PATCH 24 HOUR 4 PA; MO; QL (30 per 30 days) pramipexole oral tablet 2 MO ropinirole oral tablet 2 MO selegiline hcl oral capsule 2 MO selegiline hcl oral tablet 2 MO trihexyphenidyl oral elixir 2 MO trihexyphenidyl oral tablet 2 MO ZELAPAR ORAL TABLET,DISINTEGRATING 5 MO MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection solution 3 MO dihydroergotamine nasal spray,non-aerosol 5 MO migergot rectal suppository 5 MO MIGRANAL NASAL SPRAY,NON-AEROSOL 5 MO naratriptan oral tablet 2 MO; QL (9 per 28 days) rizatriptan oral tablet 10 mg 2 MO; QL (12 per 28 days) rizatriptan oral tablet 5 mg 2 MO; QL (24 per 28 days) rizatriptan oral tablet,disintegrating 10 mg 2 MO; QL (12 per 28 days) rizatriptan oral tablet,disintegrating 5 mg 2 MO; QL (24 per 28 days) sumatriptan nasal spray,non-aerosol 2 MO; QL (6 per 28 days) sumatriptan succinate oral tablet 2 MO; QL (9 per 28 days) sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml 2 MO; QL (4 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 27

Drug Name Drug Tier Requirements/Limits sumatriptan succinate subcutaneous solution 2 MO; QL (4 per 28 days) zolmitriptan oral tablet 2 MO; QL (6 per 28 days) zolmitriptan oral tablet,disintegrating 2 MO; QL (6 per 28 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 5 PA; MO; LA; QL (60 per 30 days) AUBAGIO ORAL TABLET 5 PA; MO; QL (30 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML donepezil oral tablet 10 mg, 5 mg 2 MO donepezil oral tablet,disintegrating 2 MO EXELON TRANSDERMAL PATCH 24 HOUR 3 MO galantamine oral capsule,ext rel. pellets 24 hr 2 MO galantamine oral solution 2 MO galantamine oral tablet 2 MO 5 MO; QL (30 per 30 days) GILENYA ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) HORIZANT ORAL TABLET EXTENDED RELEASE NAMENDA ORAL SOLUTION 3 PA; MO NAMENDA ORAL TABLET 3 PA; MO NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 4 PA; MO; QL (60 per 30 days) 3 PA; MO; QL (49 per 28 days) NUEDEXTA ORAL CAPSULE 4 PA; MO; QL (60 per 30 days) rivastigmine tartrate oral capsule 2 MO TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 240 MG 5 PA; MO; QL (120 per 365 days) 5 PA; MO; QL (60 per 30 days) TYSABRI INTRAVENOUS SOLUTION 5 PA; MO; LA; QL (15 per 28 days) XENAZINE ORAL TABLET 12.5 MG 5 PA; MO; LA; QL (90 per 30 days) XENAZINE ORAL TABLET 25 MG 5 PA; MO; LA; QL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 28

Drug Name Drug Tier Requirements/Limits carisoprodol oral tablet 350 mg 2 PA; MO carisoprodol-asa-codeine oral tablet 4 PA; MO; QL (240 per 30 days) carisoprodol-aspirin oral tablet 2 PA; MO chlorzoxazone oral tablet 2 PA; MO cyclobenzaprine oral tablet 10 mg, 5 mg 2 PA; MO dantrolene oral capsule 2 MO GABLOFEN INTRATHECAL SOLUTION 10,000 MCG/20ML (500 MCG/ML) GABLOFEN INTRATHECAL SOLUTION 40,000 MCG/20ML (2,000 MCG/ML) GABLOFEN INTRATHECAL SYRINGE 50 MCG/ML (1 ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML LIORESAL INTRATHECAL SOLUTION 500 MCG/ML 4 B/D; MO 5 B/D; MO 4 B/D; MO 5 B/D; MO 4 B/D 4 B/D; MO MESTINON ORAL SYRUP 4 MO methocarbamol oral tablet 2 PA; MO orphenadrine citrate injection solution 2 PA; MO orphenadrine citrate oral tablet extended release 2 PA; MO pyridostigmine bromide oral tablet 2 MO tizanidine oral tablet 2 MO NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG 5 PA; MO; QL (120 per 30 days) ABSTRAL SUBLINGUAL TABLET 400 MCG 5 PA; MO; QL (116 per 30 days) ABSTRAL SUBLINGUAL TABLET 600 MCG 5 PA; MO; QL (77 per 30 days) ABSTRAL SUBLINGUAL TABLET 800 MCG 5 PA; MO; QL (58 per 30 days) acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg 2 QL (4500 per 30 days) 2 MO; QL (390 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 29

Drug Name Drug Tier Requirements/Limits acetaminophen-codeine oral tablet 300-60 mg 2 MO; QL (180 per 30 days) ascomp with codeine oral capsule 4 MO; QL (180 per 30 days) buprenorphine hcl injection syringe 4 QL (267 per 30 days) buprenorphine hcl sublingual tablet 2 PA; MO; QL (60 per 30 days) butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg 4 MO; QL (180 per 30 days) codeine sulfate oral tablet 2 MO; QL (180 per 30 days) duramorph (pf) injection solution 0.5 mg/ml 2 B/D; MO; QL (4000 per 30 days) duramorph (pf) injection solution 1 mg/ml 2 B/D; QL (2000 per 30 days) endocet oral tablet 10-325 mg, 7.5-325 mg 4 MO; QL (360 per 30 days) endocet oral tablet 5-325 mg 2 MO; QL (360 per 30 days) endodan oral tablet 2 MO; QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 400 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 600 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 800 MCG 5 PA; MO; QL (39 per 30 days) 5 PA; MO; QL (29 per 30 days) 5 PA; MO; QL (120 per 30 days) 5 PA; MO; QL (116 per 30 days) 5 PA; MO; QL (77 per 30 days) 5 PA; MO; QL (58 per 30 days) 2 MO; QL (10 per 30 days) 5 PA; MO; QL (120 per 30 days) 5 PA; MO; QL (116 per 30 days) 5 PA; MO; QL (77 per 30 days) 5 PA; MO; QL (58 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 30

Drug Name Drug Tier Requirements/Limits hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 4 MO; QL (3600 per 30 days) 4 MO; QL (390 per 30 days) 2 MO; QL (360 per 30 days) hydrocodone-ibuprofen oral tablet 7.5-200 mg 2 MO; QL (150 per 30 days) hydromorphone (pf) injection solution 10 mg/ml 4 MO; QL (120 per 30 days) hydromorphone oral tablet 2 mg, 4 mg 2 MO; QL (180 per 30 days) hydromorphone oral tablet 8 mg 4 MO; QL (180 per 30 days) ibuprofen-oxycodone oral tablet 4 MO; QL (120 per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 400 MCG/SPRAY 5 PA; MO; QL (30 per 30 days) 5 PA; MO; QL (28 per 30 days) levorphanol tartrate oral tablet 4 MO; QL (240 per 30 days) lorcet (hydrocodone) oral tablet 4 MO; QL (360 per 30 days) lorcet hd oral tablet 4 MO; QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg 4 MO; QL (360 per 30 days) lortab 10-325 oral tablet 4 MO; QL (360 per 30 days) lortab 5-325 oral tablet 4 MO; QL (360 per 30 days) lortab 7.5-325 oral tablet 4 MO; QL (360 per 30 days) methadone injection solution 2 QL (160 per 30 days) methadone oral solution 10 mg/5 ml 4 MO; QL (1000 per 30 days) methadone oral solution 5 mg/5 ml 2 MO; QL (2000 per 30 days) methadone oral tablet 10 mg 2 MO; QL (200 per 30 days) methadone oral tablet 5 mg 2 MO; QL (90 per 30 days) morphine concentrate oral solution 2 MO; QL (300 per 30 days) morphine intravenous syringe 2 mg/ml 2 QL (1000 per 30 days) morphine intravenous syringe 4 mg/ml 2 QL (500 per 30 days) morphine oral solution 2 MO; QL (900 per 30 days) morphine oral tablet 2 MO; QL (180 per 30 days) morphine oral tablet extended release 100 mg 2 MO; QL (60 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 31

Drug Name Drug Tier Requirements/Limits morphine oral tablet extended release 15 mg, 30 mg, 60 mg 2 MO; QL (90 per 30 days) morphine oral tablet extended release 200 mg 2 MO; QL (30 per 30 days) OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG 3 MO; QL (60 per 30 days) 3 MO; QL (50 per 30 days) oxycodone oral capsule 2 MO; QL (180 per 30 days) oxycodone oral concentrate 4 MO; QL (180 per 30 days) oxycodone oral solution 2 MO; QL (900 per 30 days) oxycodone oral tablet 10 mg, 5 mg 2 MO; QL (180 per 30 days) oxycodone oral tablet 15 mg, 20 mg 4 MO; QL (180 per 30 days) oxycodone oral tablet 30 mg 4 MO; QL (134 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 4 MO; QL (360 per 30 days) oxycodone-acetaminophen oral tablet 5-325 mg 2 MO; QL (360 per 30 days) oxycodone-aspirin oral tablet 4 MO; QL (360 per 30 days) oxymorphone oral tablet 4 MO; QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 40 mg 4 MO; QL (60 per 30 days) 4 MO; QL (50 per 30 days) ROXICET ORAL SOLUTION 4 MO; QL (1800 per 30 days) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 400 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 600 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 800 MCG/SPRAY 5 PA; MO; LA; QL (120 per 30 days) 5 PA; MO; LA; QL (116 per 30 days) 5 PA; MO; LA; QL (77 per 30 days) 5 PA; MO; LA; QL (58 per 30 days) vicodin es oral tablet 7.5-300 mg 4 MO; QL (390 per 30 days) vicodin hp oral tablet 10-300 mg 4 MO; QL (390 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 32

Drug Name Drug Tier Requirements/Limits vicodin oral tablet 5-300 mg 4 MO; QL (390 per 30 days) NON-NARCOTIC ANALGESICS butorphanol tartrate injection solution 1 mg/ml 2 MO; QL (720 per 30 days) butorphanol tartrate injection solution 2 mg/ml 2 MO; QL (360 per 30 days) butorphanol tartrate nasal spray,non-aerosol 4 MO; QL (7.5 per 30 days) celecoxib oral capsule 2 MO diclofenac potassium oral tablet 2 MO diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg diclofenac sodium oral tablet,delayed release (dr/ec) 50 mg, 75 mg 2 MO 4 MO 2 MO diflunisal oral tablet 4 MO etodolac oral capsule 4 MO etodolac oral tablet 4 MO fenoprofen oral tablet 2 MO flurbiprofen oral tablet 2 MO ibuprofen oral suspension 1 MO; * ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO; * ketoprofen oral capsule 2 MO meclofenamate oral capsule 4 MO meloxicam oral suspension 2 MO meloxicam oral tablet 1 MO; * nabumetone oral tablet 2 MO nalbuphine injection solution 4 MO naloxone injection syringe 1 mg/ml 2 MO naltrexone oral tablet 2 MO naproxen oral suspension 1 MO; * naproxen oral tablet 1 MO; * naproxen oral tablet,delayed release (dr/ec) 2 MO naproxen sodium oral tablet 275 mg, 550 mg 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 33

Drug Name Drug Tier Requirements/Limits piroxicam oral capsule 3 MO SUBOXONE SUBLINGUAL FILM 3 PA; MO; QL (60 per 30 days) sulindac oral tablet 2 MO tolmetin oral capsule 4 MO tolmetin oral tablet 600 mg 4 MO tramadol oral tablet 2 MO; QL (240 per 30 days) tramadol-acetaminophen oral tablet 2 MO; QL (40 per 5 days) VOLTAREN GEL TOPICAL GEL 1 % 4 MO; QL (1000 per 30 days) ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG 3 PA; MO; QL (180 per 30 days) ZUBSOLV SUBLINGUAL TABLET 5.7-1.4 MG 3 PA; MO; QL (90 per 30 days) ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG 3 PA; QL (60 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 5 PA; MO; QL (90 per 30 days) 5 PA; MO; QL (2 per 28 days) 5 PA; QL (1 per 28 days) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 2 MO; QL (90 per 30 days) alprazolam oral tablet 2 mg 2 MO; QL (150 per 30 days) alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg alprazolam oral tablet extended release 24 hr 2 mg alprazolam oral tablet extended release 24 hr 3 mg 2 MO; QL (30 per 30 days) 2 MO; QL (150 per 30 days) 2 MO; QL (90 per 30 days) amitriptyline oral tablet 2 PA; MO amitriptyline-chlordiazepoxide oral tablet 2 MO amoxapine oral tablet 2 MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 20 mg, 5 mg, 7.5 mg 2 PA; MO; QL (90 per 30 days) amphetamine salt combo oral tablet 15 mg, 30 mg 2 PA; MO; QL (60 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 34

Drug Name Drug Tier Requirements/Limits aripiprazole oral tablet 10 mg 3 PA; MO; QL (90 per 30 days) aripiprazole oral tablet 15 mg 3 PA; MO; QL (60 per 30 days) aripiprazole oral tablet 2 mg 3 PA; MO; QL (450 per 30 days) aripiprazole oral tablet 20 mg 3 PA; MO; QL (45 per 30 days) aripiprazole oral tablet 30 mg 3 PA; MO; QL (30 per 30 days) aripiprazole oral tablet 5 mg 3 PA; MO; QL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG 4 PA; MO; QL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG 4 PA; MO; QL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG 4 PA; MO; QL (120 per 30 days) bupropion hcl oral tablet 2 MO bupropion hcl oral tablet extended release 2 MO bupropion hcl oral tablet extended release 24 hr 2 MO buspirone oral tablet 10 mg, 15 mg, 5 mg 1 MO; * buspirone oral tablet 30 mg 4 MO buspirone oral tablet 7.5 mg 3 MO chlorpromazine injection solution 2 MO chlorpromazine oral tablet 2 MO citalopram oral solution 1 MO; *; QL (600 per 30 days) citalopram oral tablet 10 mg 1 MO; *; QL (120 per 30 days) citalopram oral tablet 20 mg 1 MO; *; QL (60 per 30 days) citalopram oral tablet 40 mg 1 MO; *; QL (30 per 30 days) clomipramine oral capsule 4 PA; MO clonidine hcl oral tablet extended release 12 hr 2 PA; MO; QL (120 per 30 days) clorazepate dipotassium oral tablet 15 mg 2 MO; QL (180 per 30 days) clorazepate dipotassium oral tablet 3.75 mg 2 MO; QL (720 per 30 days) clorazepate dipotassium oral tablet 7.5 mg 2 MO; QL (360 per 30 days) clozapine oral tablet 100 mg, 25 mg, 50 mg 2 MO clozapine oral tablet 200 mg 2 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG 2 ST 4 ST; QL (180 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 35

Drug Name Drug Tier Requirements/Limits CLOZAPINE ORAL TABLET,DISINTEGRATING 200 MG desipramine oral tablet 2 MO 4 ST; QL (150 per 30 days) dexmethylphenidate oral tablet 2 PA; MO; QL (60 per 30 days) dextroamphetamine oral capsule, extended release 10 mg, 15 mg dextroamphetamine oral capsule, extended release 5 mg 4 PA; MO; QL (120 per 30 days) 4 PA; MO; QL (30 per 30 days) dextroamphetamine oral tablet 2 PA; MO; QL (180 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg 2 PA; MO; QL (30 per 30 days) 2 PA; MO; QL (60 per 30 days) diazepam intensol oral concentrate 2 MO; QL (240 per 30 days) diazepam oral solution 5 mg/5 ml 2 MO; QL (1200 per 30 days) diazepam oral tablet 10 mg 2 MO; QL (120 per 30 days) diazepam oral tablet 2 mg 2 MO; QL (600 per 30 days) diazepam oral tablet 5 mg 2 MO; QL (240 per 30 days) doxepin oral capsule 2 PA; MO doxepin oral concentrate 2 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM TRANSDERMAL PATCH 24 HOUR 5 MO ergoloid oral tablet 2 MO 2 MO; QL (180 per 30 days) 2 MO; QL (120 per 30 days) 4 PA; MO; QL (90 per 30 days) 2 MO; QL (60 per 30 days) escitalopram oxalate oral solution 2 MO; QL (600 per 30 days) escitalopram oxalate oral tablet 10 mg 2 MO; QL (60 per 30 days) escitalopram oxalate oral tablet 20 mg 2 MO; QL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 36

Drug Name Drug Tier Requirements/Limits escitalopram oxalate oral tablet 5 mg 2 MO; QL (120 per 30 days) FANAPT ORAL TABLET 1 MG 4 PA; MO; QL (720 per 30 days) FANAPT ORAL TABLET 10 MG, 8 MG 4 PA; MO; QL (90 per 30 days) FANAPT ORAL TABLET 12 MG 4 PA; MO; QL (60 per 30 days) FANAPT ORAL TABLET 2 MG 4 PA; MO; QL (360 per 30 days) FANAPT ORAL TABLET 4 MG 4 PA; MO; QL (180 per 30 days) FANAPT ORAL TABLET 6 MG 4 PA; MO; QL (120 per 30 days) FANAPT ORAL TABLETS,DOSE PACK 4 PA; MO; QL (8 per 30 days) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 80 MG fluoxetine oral capsule 1 MO; * fluoxetine oral solution 1 MO; * fluoxetine oral tablet 10 mg, 20 mg 1 MO; * fluphenazine decanoate injection solution 2 MO fluphenazine hcl injection solution 2 MO fluphenazine hcl oral concentrate 1 MO; * fluphenazine hcl oral elixir 1 MO; * fluphenazine hcl oral tablet 1 MO; * fluvoxamine oral tablet 2 MO GEODON INTRAMUSCULAR RECON SOLN 4 MO guanidine oral tablet 2 MO haloperidol decanoate intramuscular solution 2 MO haloperidol lactate injection solution 2 MO haloperidol lactate oral concentrate 2 MO haloperidol oral tablet 1 MO; * 4 PA; MO; QL (28 per 28 days) 4 PA; MO; QL (30 per 30 days) 4 PA; MO; QL (180 per 30 days) 4 PA; MO; QL (90 per 30 days) 4 PA; MO; QL (60 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 37

Drug Name Drug Tier Requirements/Limits HETLIOZ ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) imipramine hcl oral tablet 2 PA; MO imipramine pamoate oral capsule 2 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG, 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 234 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG 5 PA; MO; QL (240 per 30 days) 5 PA; MO; QL (120 per 30 days) 5 PA; MO; QL (60 per 30 days) 5 PA; MO; QL (1.5 per 28 days) 5 PA; MO; QL (2 per 28 days) 4 PA; MO; QL (1.5 per 28 days) 4 ST; MO; QL (120 per 30 days) 4 ST; MO; QL (240 per 30 days) LATUDA ORAL TABLET 120 MG, 80 MG 4 MO; QL (60 per 30 days) LATUDA ORAL TABLET 20 MG 4 MO; QL (240 per 30 days) LATUDA ORAL TABLET 40 MG 4 MO; QL (120 per 30 days) LATUDA ORAL TABLET 60 MG 4 MO; QL (90 per 30 days) lithium carbonate oral capsule 1 MO; * lithium carbonate oral tablet 1 MO; * lithium carbonate oral tablet extended release 2 MO lithium citrate oral solution 8 meq/5 ml 2 MO lorazepam intensol oral concentrate 2 MO; QL (150 per 30 days) lorazepam oral tablet 0.5 mg 2 MO; QL (600 per 30 days) lorazepam oral tablet 1 mg 2 MO; QL (300 per 30 days) lorazepam oral tablet 2 mg 2 MO; QL (150 per 30 days) loxapine succinate oral capsule 2 MO maprotiline oral tablet 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 38

Drug Name Drug Tier Requirements/Limits MARPLAN ORAL TABLET 4 MO metadate er oral tablet extended release 4 PA; MO; QL (90 per 30 days) methamphetamine oral tablet 2 MO; QL (150 per 30 days) methylphenidate oral capsule, er biphasic 30-70 10 mg, 50 mg, 60 mg 2 PA; MO; QL (30 per 30 days) methylphenidate oral capsule,er biphasic 50-50 2 PA; MO; QL (30 per 30 days) methylphenidate oral solution 10 mg/5 ml 2 PA; MO; QL (900 per 30 days) methylphenidate oral solution 5 mg/5 ml 2 PA; MO; QL (1800 per 30 days) methylphenidate oral tablet 10 mg, 5 mg 2 PA; MO; QL (90 per 30 days) methylphenidate oral tablet 20 mg 2 PA; MO; QL (150 per 30 days) methylphenidate oral tablet extended release 4 PA; MO; QL (90 per 30 days) methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg mirtazapine oral tablet 2 MO mirtazapine oral tablet,disintegrating 2 MO 4 PA; MO; QL (30 per 30 days) 4 PA; MO; QL (60 per 30 days) modafinil oral tablet 3 PA; MO; QL (60 per 30 days) nefazodone oral tablet 2 MO nortriptyline oral capsule 1 MO; * nortriptyline oral solution 2 MO NUVIGIL ORAL TABLET 3 PA; MO; QL (30 per 30 days) olanzapine intramuscular recon soln 2 MO olanzapine oral tablet 10 mg, 15 mg 2 MO; QL (60 per 30 days) olanzapine oral tablet 2.5 mg 2 MO; QL (240 per 30 days) olanzapine oral tablet 20 mg 2 MO; QL (30 per 30 days) olanzapine oral tablet 5 mg 2 MO; QL (120 per 30 days) olanzapine oral tablet 7.5 mg 2 MO; QL (90 per 30 days) olanzapine oral tablet,disintegrating 10 mg, 15 mg 2 MO; QL (60 per 30 days) olanzapine oral tablet,disintegrating 20 mg 2 MO; QL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg 2 MO; QL (120 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 39

Drug Name Drug Tier Requirements/Limits olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg 2 MO; QL (60 per 30 days) olanzapine-fluoxetine oral capsule 3-25 mg 2 MO; QL (180 per 30 days) olanzapine-fluoxetine oral capsule 6-25 mg, 6-50 mg ORAP ORAL TABLET 4 MO 2 MO; QL (90 per 30 days) oxazepam oral capsule 2 MO; QL (120 per 30 days) paroxetine hcl oral tablet 1 MO; * paroxetine hcl oral tablet extended release 24 hr 2 MO PAXIL ORAL SUSPENSION 4 MO perphenazine oral tablet 2 MO perphenazine-amitriptyline oral tablet 2 MO phenelzine oral tablet 2 MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline oral tablet 2 MO 4 ST; MO; QL (120 per 30 days) 4 ST; MO; QL (480 per 30 days) 4 ST; MO; QL (240 per 30 days) quetiapine oral tablet 100 mg 2 PA; MO; QL (240 per 30 days) quetiapine oral tablet 200 mg 2 PA; MO; QL (120 per 30 days) quetiapine oral tablet 25 mg 2 PA; MO; QL (960 per 30 days) quetiapine oral tablet 300 mg, 400 mg 2 PA; MO; QL (90 per 30 days) quetiapine oral tablet 50 mg 2 PA; MO; QL (480 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution 2 MO 4 PA; MO; QL (8 per 28 days) 4 PA; MO; QL (4 per 28 days) 5 PA; MO; QL (4 per 28 days) 5 PA; MO; QL (2 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 40

Drug Name Drug Tier Requirements/Limits risperidone oral tablet 0.25 mg 2 MO; QL (1920 per 30 days) risperidone oral tablet 0.5 mg 2 MO; QL (960 per 30 days) risperidone oral tablet 1 mg 2 MO; QL (480 per 30 days) risperidone oral tablet 2 mg 2 MO; QL (240 per 30 days) risperidone oral tablet 3 mg 2 MO; QL (180 per 30 days) risperidone oral tablet 4 mg 2 MO; QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg 2 MO; QL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg 2 MO; QL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg 2 MO; QL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg 2 MO; QL (240 per 30 days) risperidone oral tablet,disintegrating 3 mg 2 MO; QL (180 per 30 days) risperidone oral tablet,disintegrating 4 mg 2 MO; QL (120 per 30 days) ROZEREM ORAL TABLET 4 MO; QL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate 2 MO sertraline oral tablet 2 MO 4 PA; MO; QL (60 per 30 days) 4 PA; MO; QL (240 per 30 days) 4 PA; MO; QL (120 per 30 days) 4 PA; MO; QL (180 per 30 days) 4 PA; MO; QL (120 per 30 days) 4 PA; MO; QL (90 per 30 days) 4 PA; MO; QL (60 per 30 days) 4 PA; MO; QL (480 per 30 days) SILENOR ORAL TABLET 4 MO; QL (30 per 30 days) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 40 MG, 60 MG, 80 MG 4 MO; QL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 41

Drug Name Drug Tier Requirements/Limits STRATTERA ORAL CAPSULE 18 MG 4 MO; QL (60 per 30 days) STRATTERA ORAL CAPSULE 25 MG 4 MO; QL (90 per 30 days) SURMONTIL ORAL CAPSULE 4 PA; MO thioridazine oral tablet 2 MO thiothixene oral capsule 2 MO tranylcypromine oral tablet 2 MO trazodone oral tablet 100 mg, 150 mg, 50 mg 1 MO; * trazodone oral tablet 300 mg 2 MO trifluoperazine oral tablet 2 MO venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 2 MO 2 MO; QL (90 per 30 days) 2 MO; QL (300 per 30 days) 2 MO; QL (150 per 30 days) VERSACLOZ ORAL SUSPENSION 5 PA; LA; QL (540 per 30 days) VIIBRYD ORAL TABLET 10 MG 4 PA; MO; QL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG 4 PA; MO; QL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG 4 PA; MO; QL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) 4 PA; MO; QL (30 per 30 days) XYREM ORAL SOLUTION 5 PA; MO; LA; QL (540 per 30 days) zaleplon oral capsule 2 ST; MO; QL (30 per 30 days) zenzedi oral tablet 10 mg, 5 mg 2 PA; MO; QL (180 per 30 days) ziprasidone hcl oral capsule 20 mg 2 MO; QL (300 per 30 days) ziprasidone hcl oral capsule 40 mg 2 MO; QL (150 per 30 days) ziprasidone hcl oral capsule 60 mg 2 MO; QL (120 per 30 days) ziprasidone hcl oral capsule 80 mg 2 MO; QL (90 per 30 days) zolpidem oral tablet 2 ST; MO; QL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG 5 PA; LA; QL (2 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 42

Drug Name Drug Tier Requirements/Limits CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution 2 B/D; MO amiodarone oral tablet 200 mg, 400 mg 2 MO disopyramide phosphate oral capsule 2 MO flecainide oral tablet 2 MO mexiletine oral capsule 2 MO MULTAQ ORAL TABLET 3 MO pacerone oral tablet 100 mg, 200 mg, 400 mg 2 MO procainamide injection solution 100 mg/ml 2 MO procainamide injection solution 500 mg/ml 2 propafenone oral capsule,extended release 12 hr 2 MO propafenone oral tablet 2 MO quinidine gluconate injection solution 2 MO quinidine gluconate oral tablet extended release 2 MO quinidine sulfate oral tablet 2 MO sorine oral tablet 120 mg, 160 mg, 80 mg 2 MO sorine oral tablet 240 mg 2 sotalol af oral tablet 120 mg 2 MO sotalol oral tablet 160 mg, 240 mg, 80 mg 2 MO TIKOSYN ORAL CAPSULE 3 MO ANTIHYPERTENSIVE THERAPY acebutolol oral capsule 2 MO afeditab cr oral tablet extended release 2 MO amiloride oral tablet 2 MO amiloride-hydrochlorothiazide oral tablet 2 MO amlodipine oral tablet 2 MO amlodipine-benazepril oral capsule 2 MO amlodipine-valsartan oral tablet 2 MO amlodipine-valsartan-hcthiazid oral tablet 2 MO atenolol oral tablet 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 43

Drug Name Drug Tier Requirements/Limits atenolol-chlorthalidone oral tablet 1 MO; * benazepril oral tablet 1 MO; * benazepril-hydrochlorothiazide oral tablet 1 MO; * betaxolol oral tablet 2 MO bisoprolol fumarate oral tablet 2 MO bisoprolol-hydrochlorothiazide oral tablet 1 MO; * bumetanide injection solution 2 MO bumetanide oral tablet 1 MO; * candesartan oral tablet 4 MO candesartan-hydrochlorothiazid oral tablet 4 MO captopril oral tablet 1 MO; * captopril-hydrochlorothiazide oral tablet 1 MO; * CARDENE IV IN SODIUM CHLORIDE INTRAVENOUS PIGGYBACK cartia xt oral capsule,extended release 24hr 2 MO carvedilol oral tablet 1 MO; * chlorothiazide oral tablet 2 MO chlorothiazide sodium intravenous recon soln 2 MO chlorthalidone oral tablet 25 mg, 50 mg 2 MO clonidine hcl oral tablet 1 MO; * clonidine transdermal patch weekly 2 MO DEMSER ORAL CAPSULE 5 PA; MO diltiazem hcl intravenous recon soln 2 diltiazem hcl intravenous solution 2 diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 44 4 2 MO diltiazem hcl oral capsule,extended release 12 hr 2 MO diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg 2 MO diltiazem hcl oral tablet 1 MO; * dilt-xr oral capsule,ext release degradable 2 MO DIURIL ORAL SUSPENSION 4 MO

Drug Name Drug Tier Requirements/Limits doxazosin oral tablet 1 MO; * enalapril maleate oral tablet 1 MO; * enalapril-hydrochlorothiazide oral tablet 1 MO; * eplerenone oral tablet 2 MO eprosartan oral tablet 4 MO felodipine oral tablet extended release 24 hr 2 MO fosinopril oral tablet 2 MO fosinopril-hydrochlorothiazide oral tablet 2 MO furosemide injection solution 2 MO furosemide injection syringe 2 MO furosemide oral solution 10 mg/ml, 40 mg/5 ml 2 MO furosemide oral tablet 1 MO; * hydralazine injection solution 2 MO hydralazine oral tablet 2 MO hydrochlorothiazide oral capsule 1 MO; * hydrochlorothiazide oral tablet 1 MO; * indapamide oral tablet 1 MO; * irbesartan oral tablet 1 MO; * irbesartan-hydrochlorothiazide oral tablet 1 MO; * isradipine oral capsule 2 MO labetalol intravenous solution 2 MO labetalol oral tablet 2 MO lisinopril oral tablet 1 MO; * lisinopril-hydrochlorothiazide oral tablet 1 MO; * losartan oral tablet 1 MO; * losartan-hydrochlorothiazide oral tablet 1 MO; * matzim la oral tablet extended release 24 hr 2 MO methyclothiazide oral tablet 2 MO metolazone oral tablet 2 MO metoprolol succinate oral tablet extended release 24 hr 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 45

Drug Name Drug Tier Requirements/Limits metoprolol ta-hydrochlorothiaz oral tablet 3 MO metoprolol tartrate intravenous solution 2 MO metoprolol tartrate oral tablet 1 MO; * minoxidil oral tablet 2 MO moexipril oral tablet 2 MO moexipril-hydrochlorothiazide oral tablet 2 MO nadolol oral tablet 1 MO; * nadolol-bendroflumethiazide oral tablet 2 MO nicardipine intravenous solution 2 MO nicardipine oral capsule 2 MO nifedical xl oral tablet extended release 24hr 2 MO nifedipine oral tablet extended release 24hr 2 MO nimodipine oral capsule 2 MO perindopril erbumine oral tablet 2 MO pindolol oral tablet 2 MO prazosin oral capsule 1 MO; * propranolol intravenous solution 2 propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 80 mg propranolol oral capsule,extended release 24 hr 60 mg 4 MO 3 MO propranolol oral solution 2 MO propranolol oral tablet 1 MO; * propranolol-hydrochlorothiazid oral tablet 2 MO quinapril oral tablet 1 MO; * quinapril-hydrochlorothiazide oral tablet 1 MO; * ramipril oral capsule 2 MO REMODULIN INJECTION SOLUTION 5 PA; MO; LA reserpine oral tablet 2 MO spironolactone oral tablet 1 MO; * spironolacton-hydrochlorothiaz oral tablet 2 MO taztia xt oral capsule, extended release 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 46

Drug Name Drug Tier Requirements/Limits TEKTURNA HCT ORAL TABLET 3 ST; MO TEKTURNA ORAL TABLET 3 ST; MO telmisartan oral tablet 2 MO telmisartan-amlodipine oral tablet 2 MO telmisartan-hydrochlorothiazid oral tablet 2 MO terazosin oral capsule 1 MO; * timolol maleate oral tablet 2 MO torsemide oral tablet 2 MO trandolapril oral tablet 2 MO triamterene-hydrochlorothiazid oral capsule 1 MO; * triamterene-hydrochlorothiazid oral tablet 1 MO; * valsartan oral tablet 2 MO valsartan-hydrochlorothiazide oral tablet 2 MO verapamil intravenous solution 2 MO verapamil oral capsule, 24 hr er pellet ct 2 MO verapamil oral capsule,ext rel. pellets 24 hr 2 MO verapamil oral tablet 1 MO; * verapamil oral tablet extended release 2 MO CARDIAC GLYCOSIDES digitek oral tablet 125 mcg 1 MO; * digitek oral tablet 250 mcg 2 MO digoxin injection solution 2 MO digoxin oral solution 50 mcg/ml 2 MO digoxin oral tablet 125 mcg 1 MO; * digoxin oral tablet 250 mcg 2 MO COAGULATION THERAPY AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS SOLUTION 4 MO ARGATROBAN INTRAVENOUS SOLUTION 5 MO BRILINTA ORAL TABLET 3 MO; QL (60 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 47 5

Drug Name Drug Tier Requirements/Limits cilostazol oral tablet 2 MO clopidogrel oral tablet 2 MO dipyridamole oral tablet 2 MO EFFIENT ORAL TABLET 3 MO; QL (30 per 30 days) ELIQUIS ORAL TABLET 2.5 MG 3 MO; QL (60 per 30 days) ELIQUIS ORAL TABLET 5 MG 3 MO; QL (74 per 30 days) enoxaparin subcutaneous solution 4 MO; QL (360 per 365 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml 5 MO; QL (120 per 365 days) enoxaparin subcutaneous syringe 120 mg/0.8 ml 5 MO; QL (96 per 365 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml 4 MO; QL (36 per 365 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml 4 MO; QL (48 per 365 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml 4 MO; QL (72 per 365 days) enoxaparin subcutaneous syringe 80 mg/0.8 ml 4 MO; QL (96 per 365 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml 5 MO; QL (48 per 365 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 4 MO; QL (30 per 365 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml 5 MO; QL (24 per 365 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 5 MO; QL (36 per 365 days) FRAGMIN SUBCUTANEOUS SOLUTION 5 MO; QL (60 per 365 days) FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML FRAGMIN SUBCUTANEOUS SYRINGE 15,000 ANTI-XA UNIT/0.6 ML FRAGMIN SUBCUTANEOUS SYRINGE 18,000 ANTI-XA UNIT/0.72 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA UNIT/0.3 ML 5 MO; QL (60 per 365 days) 5 MO; QL (30 per 365 days) 5 MO; QL (36 per 365 days) 5 MO; QL (43.2 per 365 days) 4 MO; QL (12 per 365 days) 5 MO; QL (18 per 365 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 48

Drug Name Drug Tier Requirements/Limits heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) 2 2 MO heparin (porcine) injection solution 2 MO jantoven oral tablet 2 MO pentoxifylline oral tablet extended release 2 MO PRADAXA ORAL CAPSULE 4 MO; QL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG 5 PA; MO; LA; QL (30 per 30 days) PROMACTA ORAL TABLET 50 MG, 75 MG 5 PA; MO; LA; QL (60 per 30 days) ticlopidine oral tablet 2 MO tranexamic acid intravenous solution 2 MO warfarin oral tablet 1 MO; * XARELTO ORAL TABLET 10 MG 3 MO; QL (70 per 365 days) XARELTO ORAL TABLET 15 MG 3 MO; QL (42 per 30 days) XARELTO ORAL TABLET 20 MG 3 MO; QL (30 per 30 days) XARELTO ORAL TABLETS,DOSE PACK 3 MO; QL (51 per 30 days) ZONTIVITY ORAL TABLET 4 PA; MO; QL (30 per 30 days) LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin oral tablet 1 MO; * cholestyramine light oral powder in packet 2 MO colestipol oral granules 2 MO colestipol oral tablet 2 MO fenofibrate micronized oral capsule 130 mg, 200 mg 4 MO; QL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 43 mg 3 MO; QL (30 per 30 days) fenofibrate micronized oral capsule 67 mg 2 MO; QL (30 per 30 days) fenofibrate nanocrystallized oral tablet 145 mg 4 MO; QL (30 per 30 days) fenofibrate nanocrystallized oral tablet 48 mg 2 MO; QL (30 per 30 days) fenofibrate oral tablet 160 mg, 54 mg 2 MO; QL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 49

Drug Name Drug Tier Requirements/Limits fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg fluvastatin oral capsule 4 MO gemfibrozil oral tablet 2 MO 4 MO; QL (30 per 30 days) 3 MO; QL (30 per 30 days) JUXTAPID ORAL CAPSULE 5 PA; MO; LA; QL (30 per 30 days) KYNAMRO SUBCUTANEOUS SYRINGE 5 PA; MO; LA; QL (4 per 28 days) LIPTRUZET ORAL TABLET 4 ST; MO lovastatin oral tablet 1 MO; * niacin oral tablet extended release 24 hr 2 MO omega-3 acid ethyl esters oral capsule 4 MO pravastatin oral tablet 1 MO; * prevalite oral powder 2 MO simvastatin oral tablet 1 MO; * VASCEPA ORAL CAPSULE 3 MO VYTORIN 10-10 ORAL TABLET 4 ST; MO VYTORIN 10-20 ORAL TABLET 4 ST; MO VYTORIN 10-40 ORAL TABLET 4 ST; MO VYTORIN 10-80 ORAL TABLET 4 ST; MO WELCHOL ORAL POWDER IN PACKET 3 MO WELCHOL ORAL TABLET 3 MO ZETIA ORAL TABLET 3 MO MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL TABLET 4 PA; MO; QL (60 per 30 days) RANEXA ORAL TABLET EXTENDED RELEASE 12 HR VECAMYL ORAL TABLET 5 PA NITRATES isosorbide dinitrate oral tablet 2 MO isosorbide dinitrate oral tablet extended release 2 MO 3 MO; QL (60 per 30 days) isosorbide mononitrate oral tablet 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 50

Drug Name Drug Tier Requirements/Limits isosorbide mononitrate oral tablet extended release 24 hr 1 MO; * nitro-bid transdermal ointment 2 MO NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 4 MO nitroglycerin intravenous solution 2 B/D nitroglycerin transdermal patch 24 hour 2 MO nitroglycerin translingual spray,non-aerosol 2 MO NITROSTAT SUBLINGUAL TABLET 3 MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 5 PA; MO calcipotriene topical cream 2 MO calcipotriene topical ointment 2 MO calcipotriene topical solution 2 MO calcitriol topical ointment 2 MO; QL (800 per 28 days) COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN INJECTOR selenium sulfide topical suspension 2 MO STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 90 MG/ML BURN THERAPY silver sulfadiazine topical cream 1 MO; * ssd topical cream 1 MO; * MISCELLANEOUS DERMATOLOGICALS 5 PA; MO; QL (2 per 28 days) 5 PA; MO; QL (2 per 28 days) 5 PA; MO; QL (0.5 per 28 days) 5 PA; MO; QL (1 per 28 days) 8-MOP ORAL CAPSULE 4 PA; MO ammonium lactate topical cream 2 MO ammonium lactate topical lotion 2 MO CONDYLOX TOPICAL GEL 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 51

Drug Name Drug Tier Requirements/Limits ELIDEL TOPICAL CREAM 4 PA; MO FLUOROURACIL TOPICAL CREAM 0.5 % 5 MO fluorouracil topical cream 5 % 2 MO fluorouracil topical solution 2 MO imiquimod topical cream in packet 2 MO methoxsalen rapid oral capsule 5 PA; MO PANRETIN TOPICAL GEL 5 PA; MO PICATO TOPICAL GEL 5 PA; MO podofilox topical solution 2 MO REGRANEX TOPICAL GEL 5 MO tacrolimus topical ointment 2 PA; MO UVADEX INJECTION SOLUTION 4 VALCHLOR TOPICAL GEL 5 PA; MO THERAPY FOR ACNE adapalene topical cream 4 PA; MO adapalene topical gel 0.1 % 4 PA; MO amnesteem oral capsule 4 MO avita topical cream 2 PA; MO claravis oral capsule 4 MO clindamycin phosphate topical gel 2 MO clindamycin phosphate topical lotion 2 MO clindamycin phosphate topical solution 2 MO clindamycin phosphate topical swab 2 MO ery pads topical swab 2 MO erythromycin with ethanol topical gel 2 MO erythromycin with ethanol topical solution 2 MO erythromycin-benzoyl peroxide topical gel 3 MO FABIOR TOPICAL FOAM 4 PA; MO metronidazole topical cream 2 MO metronidazole topical gel 0.75 % 2 MO metronidazole topical lotion 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 52

Drug Name Drug Tier Requirements/Limits myorisan oral capsule 4 MO TAZORAC TOPICAL CREAM 4 PA; MO TAZORAC TOPICAL GEL 4 PA; MO tretinoin topical cream 3 PA; MO tretinoin topical gel 3 PA; MO zenatane oral capsule 4 MO TOPICAL ANESTHETICS lidocaine (pf) injection solution 5 mg/ml (0.5 %) 2 MO lidocaine hcl injection solution 20 mg/ml (2 %) 2 MO lidocaine hcl mucous membrane gel 2 MO lidocaine hcl mucous membrane jelly in applicator 2 MO lidocaine hcl mucous membrane solution 2 % 1 * lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl urethral gel 2 2 MO lidocaine topical adhesive patch,medicated 2 PA; MO; QL (90 per 30 days) lidocaine topical ointment 2 MO lidocaine-prilocaine topical cream 2 MO TOPICAL ANTIBACTERIALS gentamicin topical cream 1 MO; * gentamicin topical ointment 1 MO; * mupirocin topical ointment 2 MO sulfacetamide sodium (acne) topical suspension 2 MO TOPICAL ANTIFUNGALS ciclopirox topical cream 3 MO ciclopirox topical gel 4 MO ciclopirox topical solution 2 MO ciclopirox topical suspension 2 MO clotrimazole topical cream 2 MO clotrimazole topical solution 2 MO clotrimazole-betamethasone topical cream 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 53

Drug Name Drug Tier Requirements/Limits clotrimazole-betamethasone topical lotion 4 MO econazole topical cream 3 MO ketoconazole topical cream 2 MO ketoconazole topical shampoo 2 MO nyamyc topical powder 2 MO nystatin topical cream 1 MO; * nystatin topical ointment 1 MO; * nystatin topical powder 2 MO nystatin-triamcinolone topical cream 4 MO nystatin-triamcinolone topical ointment 4 MO nystop topical powder 2 MO TOPICAL ANTIVIRALS acyclovir topical ointment 2 MO DENAVIR TOPICAL CREAM 4 MO TOPICAL CORTICOSTEROIDS alclometasone topical cream 3 MO alclometasone topical ointment 4 MO amcinonide topical cream 4 MO amcinonide topical lotion 2 MO amcinonide topical ointment 2 MO betamethasone dipropionate topical cream 4 MO betamethasone dipropionate topical lotion 2 MO betamethasone dipropionate topical ointment 4 MO betamethasone valerate topical cream 2 MO betamethasone valerate topical lotion 3 MO betamethasone valerate topical ointment 2 MO betamethasone, augmented topical cream 2 MO betamethasone, augmented topical gel 4 MO betamethasone, augmented topical lotion 4 MO betamethasone, augmented topical ointment 4 MO clobetasol topical gel 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 54

Drug Name Drug Tier Requirements/Limits clobetasol topical ointment 4 MO clobetasol topical solution 2 MO clobetasol-emollient topical cream 4 MO cormax topical solution 2 MO desonide topical cream 2 MO desonide topical lotion 4 MO desonide topical ointment 2 MO desoximetasone topical cream 4 MO desoximetasone topical gel 4 MO desoximetasone topical ointment 0.25 % 4 MO diflorasone topical cream 4 MO diflorasone topical ointment 4 MO fluocinolone topical cream 4 MO fluocinolone topical oil 4 MO fluocinolone topical ointment 4 MO fluocinolone topical solution 4 MO fluocinonide topical gel 4 MO fluocinonide topical ointment 4 MO fluocinonide topical solution 4 MO fluocinonide-e topical cream 3 MO fluticasone topical cream 2 MO fluticasone topical ointment 2 MO halobetasol propionate topical cream 2 MO halobetasol propionate topical ointment 4 MO hydrocortisone butyrate topical ointment 2 MO hydrocortisone butyrate topical solution 3 MO hydrocortisone topical cream 1 %, 2.5 % 1 MO; * hydrocortisone topical lotion 2.5 % 1 MO; * hydrocortisone topical ointment 1 %, 2.5 % 1 MO; * hydrocortisone valerate topical cream 4 MO hydrocortisone valerate topical ointment 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 55

Drug Name Drug Tier Requirements/Limits mometasone topical cream 2 MO mometasone topical ointment 2 MO mometasone topical solution 2 MO prednicarbate topical cream 2 MO prednicarbate topical ointment 2 MO triamcinolone acetonide topical cream 1 MO; * triamcinolone acetonide topical lotion 2 MO triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % 1 MO; * triderm topical cream 2 MO TOPICAL ENZYMES SANTYL TOPICAL OINTMENT 3 MO TOPICAL SCABICIDES / PEDICULICIDES lindane topical lotion 4 MO lindane topical shampoo 4 MO malathion topical lotion 2 MO permethrin topical cream 4 MO DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation solution 2 MO neomycin-polymyxin b gu irrigation solution 2 MO PHYSIOLYTE IRRIGATION SOLUTION 3 PHYSIOSOL IRRIGATION SOLUTION 3 ringers irrigation solution 2 MO MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 2 MO ADAGEN INTRAMUSCULAR SOLUTION 5 PA; MO; LA alendronate oral tablet 40 mg 1 MO; * anagrelide oral capsule 2 MO ARALAST NP INTRAVENOUS RECON SOLN 500 MG 5 PA; MO; LA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 56

Drug Name Drug Tier Requirements/Limits AURYXIA ORAL TABLET 3 MO CARBAGLU ORAL TABLET, DISPERSIBLE 5 PA; MO; LA cevimeline oral capsule 2 MO CHEMET ORAL CAPSULE 4 PA; MO CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION d10 % & 0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 10 % in water (d10w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 4 B/D 4 B/D 4 B/D 2 2 2 MO 2 MO 2 2 MO 2 MO 2 MO disulfiram oral tablet 2 MO etidronate disodium oral tablet 2 MO EXJADE ORAL TABLET, DISPERSIBLE 5 PA; MO; LA 2 2 2 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 57

Drug Name Drug Tier Requirements/Limits FERRIPROX ORAL TABLET 5 PA; MO FOSRENOL ORAL POWDER IN PACKET 5 FOSRENOL ORAL TABLET,CHEWABLE 5 MO GLASSIA INTRAVENOUS SOLUTION 5 PA; MO; LA INCRELEX SUBCUTANEOUS SOLUTION 5 PA; MO; LA kionex oral powder 2 MO levocarnitine (with sugar) oral solution 2 MO levocarnitine intravenous solution 2 MO levocarnitine oral tablet 2 MO LITHOSTAT ORAL TABLET 3 MO midodrine oral tablet 2 MO NORTHERA ORAL CAPSULE 100 MG 5 PA; MO; QL (540 per 30 days) NORTHERA ORAL CAPSULE 200 MG 5 PA; MO; QL (360 per 30 days) NORTHERA ORAL CAPSULE 300 MG 5 PA; MO; QL (180 per 30 days) ORFADIN ORAL CAPSULE 5 PA; LA pilocarpine hcl oral tablet 2 MO PROLASTIN-C INTRAVENOUS RECON SOLN 5 PA; MO; LA RAVICTI ORAL LIQUID 5 PA; MO; QL (525 per 30 days) RENVELA ORAL POWDER IN PACKET 3 MO RENVELA ORAL TABLET 3 MO riluzole oral tablet 3 MO; QL (60 per 30 days) sodium chloride 0.9 % intravenous parenteral solution 2 MO sodium chloride irrigation solution 2 MO sodium phenylbutyrate oral powder 5 PA; MO sodium polystyrene (sorb free) oral suspension 2 SYPRINE ORAL CAPSULE 5 PA; MO THIOLA ORAL TABLET 4 MO water for irrigation, sterile irrigation solution 2 MO ZEMAIRA INTRAVENOUS RECON SOLN 5 PA; MO; LA zoledronic acid-mannitol-water intravenous solution 2 ST; MO; QL (100 per 365 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 58

Drug Name Drug Tier Requirements/Limits SMOKING DETERRENTS buproban oral tablet extended release 2 MO CHANTIX CONTINUING MONTH BOX ORAL TABLET 4 MO; QL (336 per 365 days) CHANTIX ORAL TABLET 4 MO; QL (336 per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK NICOTROL INHALATION CARTRIDGE 4 MO NICOTROL NS NASAL SPRAY,NON- AEROSOL EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS 4 MO; QL (106 per 365 days) 4 MO azelastine nasal aerosol,spray 137 mcg 2 MO BACTROBAN NASAL OINTMENT 4 MO chlorhexidine gluconate mucous membrane mouthwash 1 MO; * ipratropium bromide nasal spray,non-aerosol 1 MO; * periogard mucous membrane mouthwash 2 MO triamcinolone acetonide dental paste 2 MO TYZINE NASAL DROPS 0.05 % 4 MO MISCELLANEOUS OTIC PREPARATIONS acetasol hc otic drops 2 MO acetic acid otic solution 2 MO fluocinolone acetonide oil otic drops 2 MO hydrocortisone-acetic acid otic drops 2 MO ofloxacin otic drops 2 MO OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC DROPS,SUSPENSION 4 MO CIPRODEX OTIC DROPS,SUSPENSION 4 MO COLY-MYCIN S OTIC DROPS,SUSPENSION 4 MO CORTISPORIN-TC OTIC DROPS,SUSPENSION 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 59

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc otic drops,suspension 1 MO; * neomycin-polymyxin-hc otic solution 1 MO; * ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. INJECTION GEL 5 PA; MO; QL (35 per 28 days) a-hydrocort injection recon soln 2 MO cortisone oral tablet 2 MO DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 4 MO dexamethasone intensol oral drops 2 MO dexamethasone oral elixir 2 MO dexamethasone oral tablet 1 MO; * dexamethasone sodium phosphate injection solution 2 MO fludrocortisone oral tablet 2 MO hydrocortisone oral tablet 2 MO methylprednisolone acetate injection suspension 2 MO methylprednisolone oral tablet 2 MO methylprednisolone oral tablets,dose pack 2 MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg prednisolone sodium phosphate oral solution 15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) 2 MO 2 MO prednisone intensol oral concentrate 2 MO prednisone oral solution 1 MO; * prednisone oral tablet 1 MO; * SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML SOLU-MEDROL (PF) INJECTION RECON SOLN SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 500 MG/4 ML 4 MO 4 MO 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 60

Drug Name Drug Tier Requirements/Limits SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM ANTITHYROID AGENTS 4 MO methimazole oral tablet 10 mg, 5 mg 2 MO propylthiouracil oral tablet 2 MO DIABETES THERAPY acarbose oral tablet 2 MO AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30) 4 PA; MO alcohol pads topical pads, medicated 2 MO APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 4 MO; QL (45 per 30 days) APIDRA SUBCUTANEOUS SOLUTION 4 MO; QL (50 per 30 days) BYDUREON SUBCUTANEOUS PEN INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 4 MO; QL (4 per 28 days) 4 MO; QL (4 per 28 days) 4 MO; QL (2.4 per 28 days) 4 MO; QL (1.2 per 28 days) FARXIGA ORAL TABLET 4 ST; MO; QL (30 per 30 days) GAUZE PADS 2X2 3 MO glimepiride oral tablet 1 mg 1 MO; *; QL (240 per 30 days) glimepiride oral tablet 2 mg 1 MO; *; QL (120 per 30 days) glimepiride oral tablet 4 mg 1 MO; *; QL (60 per 30 days) glipizide oral tablet 10 mg 1 MO; *; QL (120 per 30 days) glipizide oral tablet 5 mg 1 MO; *; QL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg 1 MO; *; QL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg 1 MO; *; QL (240 per 30 days) glipizide oral tablet extended release 24hr 5 mg 1 MO; *; QL (120 per 30 days) glipizide-metformin oral tablet 2.5-250 mg 2 MO; QL (240 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 61

Drug Name Drug Tier Requirements/Limits glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT INJECTION RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 2 MO; QL (120 per 30 days) 3 MO 4 MO GLYSET ORAL TABLET 4 MO GLYXAMBI ORAL TABLET 3 MO; QL (30 per 30 days) HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 3 MO; QL (45 per 30 days) 3 MO; QL (24 per 30 days) 3 MO; QL (45 per 30 days) 3 MO; QL (50 per 30 days) 3 MO; QL (45 per 30 days) 3 MO; QL (50 per 30 days) HUMALOG SUBCUTANEOUS CARTRIDGE 3 MO; QL (45 per 30 days) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 3 MO; QL (50 per 30 days) 3 QL (45 per 30 days) 3 MO; QL (45 per 30 days) 3 MO; QL (50 per 30 days) 3 MO; QL (45 per 30 days) HUMULIN N SUBCUTANEOUS SUSPENSION 3 MO; QL (50 per 30 days) HUMULIN R INJECTION SOLUTION 3 MO; QL (50 per 30 days) HUMULIN R U-500 "CONCENTRATED" SUBCUTANEOUS SOLUTION INSULIN PEN NEEDLE 3 MO 3 MO; QL (40 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 62

Drug Name Drug Tier Requirements/Limits INSULIN SYRINGE (DISP) U-100 0.3 ML, 1/2 ML, 1 ML INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG 3 MO 3 MO; QL (60 per 30 days) INVOKAMET ORAL TABLET 50-500 MG 3 MO; QL (120 per 30 days) INVOKANA ORAL TABLET 3 MO; QL (30 per 30 days) JANUMET ORAL TABLET 3 MO JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 3 MO JANUVIA ORAL TABLET 3 MO JARDIANCE ORAL TABLET 10 MG 3 MO; QL (60 per 30 days) JARDIANCE ORAL TABLET 25 MG 3 MO; QL (30 per 30 days) JENTADUETO ORAL TABLET 3 MO LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 3 MO; QL (45 per 30 days) LANTUS SUBCUTANEOUS SOLUTION 3 MO; QL (50 per 30 days) LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 3 MO; QL (45 per 30 days) LEVEMIR SUBCUTANEOUS SOLUTION 3 MO; QL (50 per 30 days) metformin oral tablet 1,000 mg 1 MO; *; QL (75 per 30 days) metformin oral tablet 500 mg 1 MO; *; QL (150 per 30 days) metformin oral tablet 850 mg 1 MO; *; QL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet 2 MO NEEDLES, INSULIN DISP.,SAFETY 3 MO NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 1 MO; *; QL (120 per 30 days) 1 MO; *; QL (60 per 30 days) 1 MO; *; QL (60 per 30 days) 3 MO; QL (50 per 30 days) NOVOLIN N SUBCUTANEOUS SUSPENSION 3 MO; QL (50 per 30 days) NOVOLIN R INJECTION SOLUTION 3 MO; QL (50 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 63

Drug Name Drug Tier Requirements/Limits NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 3 MO; QL (45 per 30 days) 3 MO; QL (45 per 30 days) 3 MO; QL (50 per 30 days) 3 MO; QL (45 per 30 days) NOVOLOG SUBCUTANEOUS SOLUTION 3 MO; QL (50 per 30 days) pioglitazone oral tablet 2 MO; QL (30 per 30 days) pioglitazone-glimepiride oral tablet 2 MO; QL (30 per 30 days) pioglitazone-metformin oral tablet 2 MO; QL (90 per 30 days) PROGLYCEM ORAL SUSPENSION 4 MO repaglinide oral tablet 2 MO RIOMET ORAL SOLUTION 4 MO; QL (765 per 30 days) SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 3 ST; MO; QL (10.8 per 28 days) 3 ST; MO; QL (12 per 28 days) tolazamide oral tablet 250 mg 2 MO; QL (120 per 30 days) tolazamide oral tablet 500 mg 2 MO; QL (60 per 30 days) tolbutamide oral tablet 2 MO; QL (180 per 30 days) TRADJENTA ORAL TABLET 3 MO TRULICITY SUBCUTANEOUS PEN INJECTOR VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 5-1,000 MG, 5-500 MG MISCELLANEOUS HORMONES 3 MO; QL (2 per 28 days) 3 MO; QL (9 per 30 days) 4 ST; MO; QL (30 per 30 days) 4 ST; MO; QL (60 per 30 days) ALDURAZYME INTRAVENOUS SOLUTION 5 PA; MO; LA ANADROL-50 ORAL TABLET 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 64

Drug Name Drug Tier Requirements/Limits ANDRODERM TRANSDERMAL PATCH 24 HOUR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) 4 PA; MO 3 PA; MO 3 PA; MO ANDROID ORAL CAPSULE 4 PA; MO cabergoline oral tablet 2 MO calcitonin (salmon) nasal spray,non-aerosol 2 MO calcitriol intravenous solution 1 mcg/ml 2 MO calcitriol oral capsule 2 MO calcitriol oral solution 2 MO CERDELGA ORAL CAPSULE 5 PA; MO; QL (60 per 30 days) CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chorionic gonadotropin, human intramuscular recon soln 5 PA; MO; LA 2 PA; MO danazol oral capsule 2 MO desmopressin injection solution 2 MO desmopressin nasal solution 2 MO desmopressin nasal spray,non-aerosol 2 MO desmopressin oral tablet 2 MO doxercalciferol intravenous solution 2 doxercalciferol oral capsule 0.5 mcg, 2.5 mcg 2 MO doxercalciferol oral capsule 1 mcg 5 MO ELAPRASE INTRAVENOUS SOLUTION 5 PA; MO; LA ELELYSO INTRAVENOUS RECON SOLN 5 PA; MO FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 PA; MO; LA fortical nasal spray,non-aerosol 2 MO KORLYM ORAL TABLET 5 PA; MO; QL (120 per 30 days) KUVAN ORAL POWDER IN PACKET 500 MG 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 65

Drug Name Drug Tier Requirements/Limits KUVAN ORAL TABLET,SOLUBLE 5 PA; MO; LA LUMIZYME INTRAVENOUS RECON SOLN 5 PA; MO MIACALCIN INJECTION SOLUTION 4 MO MYALEPT SUBCUTANEOUS RECON SOLN 5 PA; MO; LA; QL (60 per 30 days) MYOZYME INTRAVENOUS RECON SOLN 5 PA; MO; LA NAGLAZYME INTRAVENOUS SOLUTION 5 PA; MO; LA NATPARA SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA; QL (2 per 28 days) oxandrolone oral tablet 2 PA; MO pamidronate intravenous solution 2 MO PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION paricalcitol oral capsule 2 MO SAMSCA ORAL TABLET 15 MG 5 PA; MO; QL (30 per 30 days) SAMSCA ORAL TABLET 30 MG 5 PA; MO; QL (60 per 30 days) SENSIPAR ORAL TABLET 30 MG 3 MO SENSIPAR ORAL TABLET 60 MG, 90 MG 5 MO SOMAVERT SUBCUTANEOUS RECON SOLN 5 PA; MO; QL (30 per 30 days) STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR 4 4 PA; MO SYNAREL NASAL SPRAY,NON-AEROSOL 5 PA; MO TESTIM TRANSDERMAL GEL 4 PA; MO testosterone cypionate intramuscular oil 2 PA; MO testosterone enanthate intramuscular oil 2 PA; MO TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) TESTOSTERONE TRANSDERMAL GEL IN PACKET 4 PA; MO 4 PA; MO VPRIV INTRAVENOUS RECON SOLN 5 PA; MO ZAVESCA ORAL CAPSULE 5 PA; MO; LA ZEMPLAR INTRAVENOUS SOLUTION 4 MO zoledronic acid intravenous solution 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 66

Drug Name Drug Tier Requirements/Limits ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORMONES 5 MO levothyroxine oral tablet 1 MO; * liothyronine intravenous solution 2 MO liothyronine oral tablet 2 MO unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2 2 MO BENTYL INTRAMUSCULAR SOLUTION 4 MO dicyclomine oral capsule 2 MO dicyclomine oral solution 2 MO dicyclomine oral tablet 2 MO diphenoxylate-atropine oral liquid 2 MO diphenoxylate-atropine oral tablet 2 MO FULYZAQ ORAL TABLET,DELAYED RELEASE (DR/EC) glycopyrrolate injection solution 2 MO glycopyrrolate oral tablet 2 MO loperamide oral capsule 2 MO methscopolamine oral tablet 2 MO propantheline oral tablet 2 MO MISCELLANEOUS GASTROINTESTINAL AGENTS 4 PA; MO; QL (60 per 30 days) AKYNZEO ORAL CAPSULE 4 B/D; MO; QL (2 per 30 days) alosetron oral tablet 5 PA; MO ALOXI INTRAVENOUS SOLUTION 4 MO AMITIZA ORAL CAPSULE 3 MO; QL (60 per 30 days) ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 67

Drug Name Drug Tier Requirements/Limits ANZEMET ORAL TABLET 100 MG 4 B/D; ST; MO; QL (14 per 30 days) ANZEMET ORAL TABLET 50 MG 4 B/D; ST; MO; QL (7 per 30 days) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 3 MO 3 MO balsalazide oral capsule 2 MO budesonide oral capsule,delayed,extend.release 5 MO CANASA RECTAL SUPPOSITORY 5 MO CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 5 PA; MO; QL (6 per 28 days) CIMZIA SUBCUTANEOUS SYRINGE KIT 5 PA; MO; QL (6 per 28 days) compro rectal suppository 2 MO constulose oral solution 2 MO CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 3 MO cromolyn oral concentrate 2 MO CYSTADANE ORAL POWDER 5 MO DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 3 MO DIPENTUM ORAL CAPSULE 5 ST; MO dronabinol oral capsule 10 mg 5 B/D; MO dronabinol oral capsule 2.5 mg, 5 mg 2 B/D; MO EMEND ORAL CAPSULE 125 MG 4 B/D; MO; QL (2 per 30 days) EMEND ORAL CAPSULE 40 MG 4 B/D; MO; QL (1 per 30 days) EMEND ORAL CAPSULE 80 MG 4 B/D; MO; QL (4 per 30 days) EMEND ORAL CAPSULE,DOSE PACK 4 B/D; MO; QL (6 per 30 days) enulose oral solution 2 MO GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 PA; MO; QL (30 per 30 days) gavilyte-c oral recon soln 2 MO gavilyte-g oral recon soln 2 MO gavilyte-n oral recon soln 2 MO generlac oral solution 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 68

Drug Name Drug Tier Requirements/Limits granisetron (pf) intravenous solution 100 mcg/ml 2 MO granisetron hcl intravenous solution 1 mg/ml (1 ml) 2 MO granisetron hcl oral tablet 4 B/D; ST; MO; QL (30 per 30 days) hydrocortisone rectal enema 2 MO lactulose oral solution 10 gram/15 ml 2 MO LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 4 ST; MO LINZESS ORAL CAPSULE 3 MO; QL (30 per 30 days) meclizine oral tablet 12.5 mg, 25 mg 2 MO mesalamine with cleansing wipe rectal enema kit 2 MO metoclopramide hcl injection solution 2 MO metoclopramide hcl oral solution 1 MO; * metoclopramide hcl oral tablet 1 MO; * MOVANTIK ORAL TABLET 4 PA; MO; QL (30 per 30 days) ondansetron hcl (pf) injection solution 2 MO ondansetron hcl (pf) injection syringe 2 ondansetron hcl oral solution 2 B/D; MO; QL (900 per 30 days) ondansetron hcl oral tablet 24 mg 2 B/D; QL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg 2 B/D; MO; QL (90 per 30 days) ondansetron oral tablet,disintegrating 2 B/D; MO; QL (90 per 30 days) PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram PENTASA ORAL CAPSULE, EXTENDED RELEASE PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4 ST; MO 2 MO 4 MO 4 ST; MO polyethylene glycol 3350 oral powder 2 MO prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 2 MO prochlorperazine maleate oral tablet 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 69

Drug Name Drug Tier Requirements/Limits prochlorperazine rectal suppository 2 MO procto-pak rectal cream 2 MO proctosol hc rectal cream 2 MO proctozone-hc rectal cream 2 MO RELISTOR SUBCUTANEOUS SOLUTION 5 PA; MO RELISTOR SUBCUTANEOUS SYRINGE 4 PA; MO REMICADE INTRAVENOUS RECON SOLN 5 PA; MO SANCUSO TRANSDERMAL PATCH WEEKLY 4 ST; MO; QL (4 per 28 days) SUCRAID ORAL SOLUTION 5 PA; MO sulfasalazine oral tablet 2 MO sulfazine ec oral tablet,delayed release (dr/ec) 2 MO SUPREP BOWEL PREP KIT ORAL RECON SOLN TRANSDERM-SCOP TRANSDERMAL PATCH 72 HOUR 3 MO 4 MO trilyte with flavor packets oral recon soln 2 MO UCERIS ORAL TABLET, DELAYED & EXT.RELEASE 5 PA; MO UCERIS RECTAL FOAM 4 PA; MO ULTRESA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4 ST; MO ursodiol oral capsule 2 MO ursodiol oral tablet 2 MO VIOKACE ORAL TABLET 4 ST; MO ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68,000-109,000 UNIT, 25,000-85,000-136,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-136,000-218,000 UNIT ULCER THERAPY 4 ST; MO amoxicil-clarithromy-lansopraz oral combo pack 4 MO carafate oral suspension 2 MO cimetidine hcl oral solution 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 70

Drug Name Drug Tier Requirements/Limits cimetidine oral tablet 1 MO; * DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS famotidine (pf) intravenous solution 2 MO famotidine (pf)-nacl (iso-os) intravenous piggyback famotidine oral suspension 4 MO famotidine oral tablet 20 mg, 40 mg 1 MO; * 4 ST; MO; QL (30 per 30 days) lansoprazole oral capsule,delayed release(dr/ec) 2 MO; QL (30 per 30 days) misoprostol oral tablet 100 mcg 2 MO misoprostol oral tablet 200 mcg 3 MO nizatidine oral capsule 150 mg 2 MO nizatidine oral capsule 300 mg 4 MO nizatidine oral solution 2 MO omeprazole oral capsule,delayed release(dr/ec) 2 MO; QL (60 per 30 days) pantoprazole oral tablet,delayed release (dr/ec) 2 MO; QL (60 per 30 days) PROTONIX INTRAVENOUS RECON SOLN 4 MO; QL (30 per 30 days) ranitidine hcl injection solution 25 mg/ml 2 MO ranitidine hcl oral capsule 3 MO ranitidine hcl oral syrup 4 MO ranitidine hcl oral tablet 150 mg, 300 mg 1 MO; * sucralfate oral tablet 2 MO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE SUBCUTANEOUS SOLUTION 5 PA; MO; LA ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML 4 5 PA; MO 4 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 71

Drug Name Drug Tier Requirements/Limits ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML 4 PA; MO 5 PA; MO ARCALYST SUBCUTANEOUS RECON SOLN 5 PA; MO; LA AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT AVONEX INTRAMUSCULAR PEN INJECTOR KIT 5 MO; QL (4 per 28 days) 5 MO; QL (2 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 5 MO; QL (2 per 28 days) BETASERON SUBCUTANEOUS KIT 5 ST; MO; QL (14 per 28 days) EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 20,000 UNIT/ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 5 PA; QL (60 per 30 days) 4 PA; MO 5 PA; MO 3 PA; MO 5 PA; MO 5 PA; MO GRANIX SUBCUTANEOUS SYRINGE 5 PA; MO HUMATROPE INJECTION CARTRIDGE 5 PA; MO HUMATROPE INJECTION RECON SOLN 5 PA; MO ILARIS (PF) SUBCUTANEOUS RECON SOLN 5 PA; MO; LA; QL (2 per 28 days) INTRON A INJECTION RECON SOLN 5 PA; MO INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 72

Drug Name Drug Tier Requirements/Limits LEUKINE INJECTION RECON SOLN 5 PA; MO MOZOBIL SUBCUTANEOUS SOLUTION 5 PA; MO; QL (9.6 per 4 days) NEULASTA SUBCUTANEOUS SYRINGE 5 PA; MO NEUMEGA SUBCUTANEOUS RECON SOLN 5 MO NEUPOGEN INJECTION SOLUTION 5 PA; MO NEUPOGEN INJECTION SYRINGE 5 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR NUTROPIN AQ NUSPIN SUBCUTANEOUS CARTRIDGE 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO OMNITROPE SUBCUTANEOUS CARTRIDGE 5 PA; MO OMNITROPE SUBCUTANEOUS RECON SOLN PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 5 PA; MO 5 PA; MO; QL (4 per 28 days) PEGINTRON SUBCUTANEOUS KIT 5 PA; MO; QL (4 per 28 days) PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML 3 PA; MO 5 PA; MO PROLEUKIN INTRAVENOUS RECON SOLN 5 MO SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 5 PA; MO SAIZEN SUBCUTANEOUS RECON SOLN 5 PA; MO SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG 5 PA; MO; LA SYLATRON SUBCUTANEOUS KIT 5 PA; MO ZOMACTON SUBCUTANEOUS RECON SOLN 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 73

Drug Name Drug Tier Requirements/Limits ZORBTIVE SUBCUTANEOUS RECON SOLN 5 PA; MO; LA VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON SOLN ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 3 MO 3 MO ATGAM INTRAVENOUS INJECTABLE 5 B/D BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION BEXSERO (PF) INTRAMUSCULAR SYRINGE 3 BIVIGAM INTRAVENOUS SOLUTION 5 PA; MO BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 4 3 MO 3 MO BOTOX INJECTION RECON SOLN 100 UNIT 4 PA; MO; QL (4 per 84 days) BOTOX INJECTION RECON SOLN 200 UNIT 4 PA; MO; QL (2 per 84 days) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE COMVAX (PF) INTRAMUSCULAR SUSPENSION DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % 5 PA; MO 3 PA; MO 3 MO 3 MO 4 PA; MO; QL (9 per 84 days) 3 B/D; MO 3 B/D; MO 3 B/D 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 74

Drug Name Drug Tier Requirements/Limits fomepizole intravenous solution 2 MO GAMASTAN S/D INTRAMUSCULAR SOLUTION GAMMAGARD LIQUID INJECTION SOLUTION GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %) 3 PA; MO 5 PA; MO 5 PA; MO GAMMAPLEX INTRAVENOUS SOLUTION 5 PA; MO GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) GARDASIL (PF) INTRAMUSCULAR SUSPENSION GARDASIL (PF) INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 5 PA; MO 3 PA; MO 3 PA; MO 3 PA; MO 3 PA; MO GRASTEK SUBLINGUAL TABLET 4 PA; MO; QL (30 per 30 days) HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 3 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 75 3 3 MO 3 MO IPOL INJECTION SUSPENSION 3 MO IPOL INJECTION SYRINGE 3 MO IXIARO (PF) INTRAMUSCULAR SYRINGE 3 MO MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 3 MO 3 MO 3 MO

Drug Name Drug Tier Requirements/Limits M-M-R II (PF) SUBCUTANEOUS RECON SOLN 3 MO OCTAGAM INTRAVENOUS SOLUTION 5 PA; MO PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 3 MO PRIVIGEN INTRAVENOUS SOLUTION 5 PA; MO PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR SUSPENSION RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 76 3 3 3 MO RAGWITEK SUBLINGUAL TABLET 4 PA; MO; QL (30 per 30 days) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 3 B/D; MO 3 B/D; MO 3 B/D ROTATEQ VACCINE ORAL SUSPENSION 3 MO TENIVAC (PF) INTRAMUSCULAR SYRINGE 3 MO TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION THYMOGLOBULIN INTRAVENOUS RECON SOLN TRUMENBA INTRAMUSCULAR SYRINGE 3 TWINRIX (PF) INTRAMUSCULAR SUSPENSION TYPHIM VI INTRAMUSCULAR SOLUTION 3 3 3 MO 3 MO 5 B/D 3 MO TYPHIM VI INTRAMUSCULAR SYRINGE 3 MO VAQTA (PF) INTRAMUSCULAR SYRINGE 3

Drug Name Drug Tier Requirements/Limits VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION XEOMIN INTRAMUSCULAR RECON SOLN 50 UNIT YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY 3 MO 4 PA; MO; QL (8 per 84 days) 3 MO allopurinol oral tablet 2 MO colchicine-probenecid oral tablet 2 MO COLCRYS ORAL TABLET 3 MO probenecid oral tablet 2 MO 3 PA; MO; QL (1 per 365 days) ULORIC ORAL TABLET 3 ST; MO; QL (30 per 30 days) OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 MO; * FORTEO SUBCUTANEOUS PEN INJECTOR 5 ST; MO; QL (2.4 per 28 days) ibandronate intravenous solution 2 ST; MO; QL (3 per 90 days) ibandronate oral tablet 2 MO; QL (1 per 28 days) PROLIA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (1 per 168 days) raloxifene oral tablet 2 MO risedronate oral tablet 150 mg 2 ST; MO; QL (1 per 28 days) OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) 5 PA; MO; QL (40 per 28 days) ACTEMRA SUBCUTANEOUS SYRINGE 5 PA; MO; QL (3.6 per 28 days) BENLYSTA INTRAVENOUS RECON SOLN 120 MG 5 PA; MO DEPEN TITRATABS ORAL TABLET 5 PA; MO ENBREL SUBCUTANEOUS RECON SOLN 5 PA; MO; QL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 5 PA; MO; QL (8 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 77

Drug Name Drug Tier Requirements/Limits ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR HUMIRA CROHN'S DIS START PCK SUBCUTANEOUS PEN INJECTOR KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 5 PA; MO; QL (8 per 28 days) 5 PA; MO; QL (9.6 per 365 days) 5 PA; MO; QL (1 per 28 days) 5 PA; MO; QL (2 per 28 days) KINERET SUBCUTANEOUS SYRINGE 5 PA; MO; QL (18.76 per 28 days) leflunomide oral tablet 2 MO ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 5 PA; MO ORENCIA SUBCUTANEOUS SYRINGE 5 PA; MO; QL (4 per 28 days) OTEZLA ORAL TABLET 5 PA; MO; QL (60 per 30 days) OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.2 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 12.5 MG/0.25 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 15 MG/0.3 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 17.5 MG/0.35 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 20 MG/0.4 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 22.5 MG/0.45 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 25 MG/0.5 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 27.5 MG/0.55 ML 5 PA; MO; QL (110 per 365 days) 5 PA; MO; QL (54 per 365 days) 4 PA; MO; QL (1.6 per 28 days) 3 PA; MO; QL (0.8 per 28 days) 3 PA; MO; QL (1 per 28 days) 3 PA; MO; QL (1.2 per 28 days) 3 PA; MO; QL (1.4 per 28 days) 3 PA; MO; QL (1.6 per 28 days) 3 PA; MO; QL (1.8 per 28 days) 3 PA; MO; QL (2 per 28 days) 3 PA; MO; QL (2.2 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 78

Drug Name Drug Tier Requirements/Limits RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 30 MG/0.6 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 5 MO 3 PA; MO; QL (2.4 per 28 days) 3 PA; MO; QL (0.6 per 28 days) SAVELLA ORAL TABLET 4 PA; MO; QL (60 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK 4 PA; MO; QL (110 per 365 days) SIMPONI ARIA INTRAVENOUS SOLUTION 5 PA; MO SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML 5 PA; MO; QL (1 per 28 days) 5 PA; MO; QL (0.5 per 28 days) 5 PA; MO; QL (1 per 28 days) 5 PA; MO; QL (0.5 per 28 days) XELJANZ ORAL TABLET 5 PA; MO; QL (60 per 30 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila oral tablet 2 MO deblitane oral tablet 2 MO DEPO-ESTRADIOL INTRAMUSCULAR OIL 4 MO DEPO-PROVERA INTRAMUSCULAR SOLUTION DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE DIVIGEL TRANSDERMAL GEL IN PACKET 0.5 MG (0.1 %) 4 MO 4 MO; QL (0.65 per 84 days) 4 MO DUAVEE ORAL TABLET 3 PA; MO errin oral tablet 2 MO ESTRACE VAGINAL CREAM 4 MO estradiol oral tablet 2 MO estradiol transdermal patch semiweekly 2 MO; QL (8 per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 79

Drug Name Drug Tier Requirements/Limits estradiol transdermal patch weekly 0.025 mg/24 hr, 0.05 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.0375 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 4 MO; QL (4 per 28 days) 2 MO; QL (4 per 28 days) 2 MO estradiol-norethindrone acet oral tablet 4 MO ESTRING VAGINAL RING 4 MO estropipate oral tablet 2 MO FEMRING VAGINAL RING 4 MO jinteli oral tablet 3 MO jolivette oral tablet 2 MO lyza oral tablet 4 MO medroxyprogesterone intramuscular suspension 2 MO; QL (1 per 84 days) medroxyprogesterone oral tablet 2 MO MENEST ORAL TABLET 4 MO MENOSTAR TRANSDERMAL PATCH WEEKLY mimvey lo oral tablet 4 MO mimvey oral tablet 4 MO nora-be oral tablet 2 MO norethindrone (contraceptive) oral tablet 2 MO norethindrone acetate oral tablet 2 MO norethindrone ac-eth estradiol oral tablet 1-5 mgmcg norlyroc oral tablet 2 4 MO; QL (4 per 28 days) 2 MO PREMARIN INJECTION RECON SOLN 4 MO PREMARIN ORAL TABLET 3 MO PREMARIN VAGINAL CREAM 3 MO PREMPHASE ORAL TABLET 3 MO PREMPRO ORAL TABLET 3 MO progesterone micronized oral capsule 2 MO sharobel oral tablet 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 80

Drug Name Drug Tier Requirements/Limits VAGIFEM VAGINAL TABLET 4 MO MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY 4 MO clindamycin phosphate vaginal cream 2 MO LUPANETA PACK (1 MONTH) KIT. SYRINGE & TABLET LUPANETA PACK (3 MONTH) KIT. SYRINGE & TABLET metronidazole vaginal gel 2 MO miconazole-3 vaginal suppository 2 MO 5 PA; MO; QL (1 per 28 days) 5 PA; MO; QL (1 per 84 days) NUVARING VAGINAL RING 4 MO; QL (1 per 28 days) terconazole vaginal cream 2 MO terconazole vaginal suppository 4 MO tranexamic acid oral tablet 2 MO; QL (30 per 28 days) vandazole vaginal gel 2 MO xulane transdermal patch weekly 4 MO; QL (3 per 28 days) ORAL CONTRACEPTIVES / RELATED AGENTS amethia oral tablets,dose pack,3 month 4 MO amethyst oral tablet 4 MO apri oral tablet 2 MO aranelle (28) oral tablet 4 MO ashlyna oral tablets,dose pack,3 month 4 MO aubra oral tablet 2 MO aviane oral tablet 2 MO balziva (28) oral tablet 2 MO briellyn oral tablet 4 MO cryselle (28) oral tablet 2 MO cyclafem 1/35 (28) oral tablet 2 MO cyclafem 7/7/7 (28) oral tablet 2 MO delyla (28) oral tablet 2 desog-e.estradiol/e.estradiol oral tablet 2 drospirenone-ethinyl estradiol oral tablet 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 81

Drug Name Drug Tier Requirements/Limits emoquette oral tablet 2 MO enpresse oral tablet 2 MO falmina (28) oral tablet 2 MO gianvi (28) oral tablet 3 MO gildagia oral tablet 4 MO gildess 24 fe oral tablet 2 MO gildess oral tablet 1.5-30 mg-mcg 2 MO introvale oral tablets,dose pack,3 month 4 MO junel 1.5/30 (21) oral tablet 2 MO junel 1/20 (21) oral tablet 2 MO junel fe 1.5/30 (28) oral tablet 2 MO junel fe 1/20 (28) oral tablet 2 MO junel fe 24 oral tablet 2 MO kariva (28) oral tablet 2 MO kelnor 1/35 (28) oral tablet 2 MO l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet 2 larin 1/20 (21) oral tablet 4 MO larin fe oral tablet 2 MO leena 28 oral tablet 2 MO lessina oral tablet 2 MO levonest (28) oral tablet 4 MO levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg levonorgestrel-ethinyl estrad oral tablet 90-20 mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 82 4 2 MO 2 2 MO levora-28 oral tablet 2 MO lomedia 24 fe oral tablet 2 MO loryna (28) oral tablet 3 MO

Drug Name Drug Tier Requirements/Limits lutera (28) oral tablet 2 MO marlissa oral tablet 2 MO microgestin 1.5/30 (21) oral tablet 2 MO microgestin 1/20 (21) oral tablet 2 MO microgestin fe 1.5/30 (28) oral tablet 2 MO microgestin fe 1/20 (28) oral tablet 2 MO mononessa (28) oral tablet 2 MO necon 0.5/35 (28) oral tablet 2 MO necon 1/35 (28) oral tablet 2 MO necon 1/50 (28) oral tablet 2 MO necon 10/11 (28) oral tablet 4 MO necon 7/7/7 (28) oral tablet 2 MO nikki (28) oral tablet 2 MO noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 83 2 2 MO nortrel 0.5/35 (28) oral tablet 2 MO nortrel 1/35 (21) oral tablet 4 MO nortrel 1/35 (28) oral tablet 2 MO nortrel 7/7/7 (28) oral tablet 4 MO ocella oral tablet 2 MO ogestrel (28) oral tablet 4 MO orsythia oral tablet 2 MO pimtrea (28) oral tablet 4 MO pirmella oral tablet 1-35 mg-mcg 4 MO portia oral tablet 2 MO previfem oral tablet 2 MO quasense oral tablets,dose pack,3 month 2 MO reclipsen (28) oral tablet 2 MO sprintec (28) oral tablet 2 MO sronyx oral tablet 2 MO

Drug Name Drug Tier Requirements/Limits tarina fe oral tablet 2 MO tri-legest fe oral tablet 2 MO trinessa (28) oral tablet 2 MO tri-previfem (28) oral tablet 2 MO tri-sprintec (28) oral tablet 2 MO trivora (28) oral tablet 4 MO velivet triphasic regimen (28) oral tablet 2 MO vestura (28) oral tablet 3 MO vyfemla (28) oral tablet 4 MO wymzya fe oral tablet,chewable 2 MO zenchent (28) oral tablet 4 MO zenchent fe oral tablet,chewable 4 MO zovia 1/35e (28) oral tablet 2 MO zovia 1/50e (28) oral tablet 4 MO OXYTOCICS methylergonovine oral tablet 2 MO OPHTHALMOLOGY ANTIBIOTICS AZASITE OPHTHALMIC DROPS 4 MO bacitracin ophthalmic ointment 2 MO bacitracin-polymyxin b ophthalmic ointment 2 MO BESIVANCE OPHTHALMIC DROPS,SUSPENSION 4 MO CILOXAN OPHTHALMIC OINTMENT 4 MO ciprofloxacin hcl ophthalmic drops 2 MO erythromycin ophthalmic ointment 1 MO; * garamycin ophthalmic drops 2 gatifloxacin ophthalmic drops 4 MO gentak ophthalmic ointment 1 MO; * gentamicin ophthalmic drops 1 MO; * gentamicin ophthalmic ointment 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 84

Drug Name Drug Tier Requirements/Limits levofloxacin ophthalmic drops 2 MO MOXEZA OPHTHALMIC DROPS, VISCOUS 4 MO NATACYN OPHTHALMIC DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic ointment 4 MO 1 MO; * neomycin-polymyxin-gramicidin ophthalmic drops 1 MO; * ofloxacin ophthalmic drops 2 MO polymyxin b sulf-trimethoprim ophthalmic drops 1 MO; * tobramycin ophthalmic drops 1 MO; * TOBREX OPHTHALMIC OINTMENT 4 MO VIGAMOX OPHTHALMIC DROPS 4 MO ANTIVIRALS trifluridine ophthalmic drops 2 MO ZIRGAN OPHTHALMIC GEL 4 MO BETA-BLOCKERS betaxolol ophthalmic drops 2 MO BETIMOL OPHTHALMIC DROPS 0.5 % 4 MO BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 4 MO carteolol ophthalmic drops 2 MO levobunolol ophthalmic drops 0.5 % 1 MO; * metipranolol ophthalmic drops 2 MO timolol maleate ophthalmic drops 1 MO; * timolol maleate ophthalmic gel forming solution 1 MO; * CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC DROPS CYCLOPLEGIC MYDRIATICS 4 MO atropine ophthalmic drops 2 MO DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 85

Drug Name Drug Tier Requirements/Limits MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL OPHTHALMIC DROPS 4 MO ALOMIDE OPHTHALMIC DROPS 4 MO azelastine ophthalmic drops 2 MO BEPREVE OPHTHALMIC DROPS 4 MO cromolyn ophthalmic drops 2 MO CYSTARAN OPHTHALMIC DROPS 5 PA; MO EMADINE OPHTHALMIC DROPS 4 MO epinastine ophthalmic drops 2 MO RESTASIS OPHTHALMIC DROPPERETTE 3 MO; QL (60 per 30 days) NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC DROPPERETTE 4 MO bromfenac ophthalmic drops 4 MO diclofenac sodium ophthalmic drops 2 MO flurbiprofen sodium ophthalmic drops 2 MO ketorolac ophthalmic drops 2 MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release 2 MO acetazolamide oral tablet 2 MO acetazolamide sodium injection recon soln 2 MO methazolamide oral tablet 2 MO OTHER GLAUCOMA DRUGS bimatoprost ophthalmic drops 2 ST; MO COMBIGAN OPHTHALMIC DROPS 3 MO dorzolamide ophthalmic drops 2 MO dorzolamide-timolol ophthalmic drops 2 MO latanoprost ophthalmic drops 2 MO LUMIGAN OPHTHALMIC DROPS 0.01 % 3 MO SIMBRINZA OPHTHALMIC DROPS,SUSPENSION 3 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 86

Drug Name Drug Tier Requirements/Limits TRAVATAN Z OPHTHALMIC DROPS 4 ST; MO travoprost (benzalkonium) ophthalmic drops 2 ST; MO ZIOPTAN (PF) OPHTHALMIC DROPPERETTE 4 ST; MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic ointment 1 MO; * neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neomycin-polymyxin-hc ophthalmic drops,suspension 1 MO; * 1 MO; * 1 MO; * PRED-G OPHTHALMIC DROPS,SUSPENSION 4 MO PRED-G S.O.P. OPHTHALMIC OINTMENT 4 MO TOBRADEX OPHTHALMIC OINTMENT 4 MO tobramycin-dexamethasone ophthalmic drops,suspension 2 MO ZYLET OPHTHALMIC DROPS,SUSPENSION 4 MO STEROIDS ALREX OPHTHALMIC DROPS,SUSPENSION 4 MO dexamethasone sodium phosphate ophthalmic drops 2 MO DUREZOL OPHTHALMIC DROPS 3 MO fluorometholone ophthalmic drops,suspension 2 MO FML FORTE OPHTHALMIC DROPS,SUSPENSION 4 MO FML S.O.P. OPHTHALMIC OINTMENT 4 MO LOTEMAX OPHTHALMIC DROPS,GEL 4 MO LOTEMAX OPHTHALMIC DROPS,SUSPENSION 4 MO LOTEMAX OPHTHALMIC OINTMENT 4 MO MAXIDEX OPHTHALMIC DROPS,SUSPENSION PRED MILD OPHTHALMIC DROPS,SUSPENSION 4 MO 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 87

Drug Name Drug Tier Requirements/Limits prednisolone acetate ophthalmic drops,suspension 2 MO prednisolone sodium phosphate ophthalmic drops 2 MO VEXOL OPHTHALMIC DROPS,SUSPENSION 4 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 4 MO 4 MO sulfacetamide-prednisolone ophthalmic drops 2 MO SULFONAMIDES sulfacetamide sodium ophthalmic drops 1 MO; * sulfacetamide sodium ophthalmic ointment 2 MO SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % 3 MO apraclonidine ophthalmic drops 2 MO brimonidine ophthalmic drops 2 MO IOPIDINE OPHTHALMIC DROPPERETTE 4 MO VASOCONSTRICTOR DECONGESTANTS naphazoline ophthalmic drops 2 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS arbinoxa oral liquid 2 PA; MO arbinoxa oral tablet 2 PA; MO AUVI-Q INJECTION AUTO-INJECTOR 3 MO carbinoxamine maleate oral liquid 2 PA; MO carbinoxamine maleate oral tablet 2 PA; MO clemastine oral tablet 2.68 mg 2 PA; MO cyproheptadine oral syrup 2 PA; MO cyproheptadine oral tablet 2 PA; MO diphenhydramine hcl injection solution 50 mg/ml 2 MO diphenhydramine hcl oral elixir 2 PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 88

Drug Name Drug Tier Requirements/Limits epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000) 2 MO EPIPEN 2-PAK INJECTION AUTO-INJECTOR 3 MO EPIPEN JR 2-PAK INJECTION AUTO- INJECTOR 3 MO hydroxyzine hcl intramuscular solution 4 MO hydroxyzine hcl oral solution 10 mg/5 ml 4 PA; MO hydroxyzine hcl oral tablet 2 PA; MO hydroxyzine pamoate oral capsule 2 PA; MO levocetirizine oral solution 2 MO levocetirizine oral tablet 2 MO phenadoz rectal suppository 12.5 mg 2 MO phenergan rectal suppository 2 promethazine injection solution 2 MO promethazine oral syrup 2 PA; MO promethazine oral tablet 2 PA; MO promethazine rectal suppository 12.5 mg, 25 mg 2 MO promethazine rectal suppository 50 mg 2 promethazine vc oral syrup 2 PA; MO promethegan rectal suppository 25 mg, 50 mg 2 MO PULMONARY AGENTS acetylcysteine solution 2 B/D; MO ADCIRCA ORAL TABLET 5 PA; MO; QL (60 per 30 days) ADEMPAS ORAL TABLET 5 PA; MO; LA; QL (90 per 30 days) ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml 3 MO 3 MO 1 B/D; MO; * albuterol sulfate oral syrup 1 MO; * albuterol sulfate oral tablet 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 89

Drug Name Drug Tier Requirements/Limits albuterol sulfate oral tablet extended release 12 hr 4 mg albuterol sulfate oral tablet extended release 12 hr 8 mg aminophylline intravenous solution 250 mg/10 ml 2 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER 4 MO 2 MO 3 MO 4 MO 3 MO 3 MO 3 MO 4 MO BERINERT INTRAVENOUS KIT 5 PA; MO BREO ELLIPTA INHALATION BLISTER WITH DEVICE BROVANA INHALATION SOLUTION FOR NEBULIZATION budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 3 MO 4 B/D; MO 2 B/D; MO CINRYZE INTRAVENOUS RECON SOLN 5 PA; MO; QL (20 per 30 days) COMBIVENT RESPIMAT INHALATION MIST 3 MO cromolyn inhalation solution for nebulization 2 B/D; MO DALIRESP ORAL TABLET 4 PA; MO DULERA INHALATION HFA AEROSOL INHALER 3 MO ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 4 MO ESBRIET ORAL CAPSULE 5 PA; MO; QL (270 per 30 days) FIRAZYR SUBCUTANEOUS SYRINGE 5 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 90

Drug Name Drug Tier Requirements/Limits FLOVENT DISKUS INHALATION BLISTER WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL INHALER flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 3 MO 3 MO 2 MO fluticasone nasal spray,suspension 2 MO FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 3 MO 3 MO ipratropium bromide inhalation solution 1 B/D; MO; * ipratropium-albuterol inhalation solution for nebulization 1 B/D; MO; * KALYDECO ORAL GRANULES IN PACKET 5 PA; MO; QL (56 per 28 days) KALYDECO ORAL TABLET 5 PA; MO; QL (60 per 30 days) LETAIRIS ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml 2 B/D; ST; MO metaproterenol oral syrup 2 MO metaproterenol oral tablet 2 MO montelukast oral granules in packet 2 MO; QL (30 per 30 days) montelukast oral tablet 2 MO; QL (30 per 30 days) montelukast oral tablet,chewable 2 MO; QL (30 per 30 days) OFEV ORAL CAPSULE 5 PA; MO; QL (60 per 30 days) OPSUMIT ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 4 B/D; MO PULMOZYME INHALATION SOLUTION 5 PA; MO; QL (150 per 30 days) REVATIO ORAL SUSPENSION FOR RECONSTITUTION RUCONEST INTRAVENOUS RECON SOLN 5 PA; MO 5 PA; MO; QL (180 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 91

Drug Name Drug Tier Requirements/Limits SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 3 MO sildenafil oral tablet 2 PA; MO; QL (90 per 30 days) SPIRIVA RESPIMAT INHALATION MIST 3 MO SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 3 MO STRIVERDI RESPIMAT INHALATION MIST 4 MO terbutaline oral tablet 2 MO terbutaline subcutaneous solution 2 MO theophylline oral solution 2 theophylline oral tablet extended release 2 MO theophylline oral tablet extended release 12 hr 2 MO TRACLEER ORAL TABLET 5 PA; MO; LA; QL (60 per 30 days) TYVASO INHALATION SOLUTION FOR NEBULIZATION VENTAVIS INHALATION SOLUTION FOR NEBULIZATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 5 PA; MO 5 PA; MO VERAMYST NASAL SPRAY,SUSPENSION 3 MO 3 MO; QL (36 per 30 days) XOLAIR SUBCUTANEOUS RECON SOLN 5 PA; MO; LA; QL (6 per 28 days) XOPENEX HFA INHALATION HFA AEROSOL INHALER zafirlukast oral tablet 4 MO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate oral tablet 2 MO GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 4 ST; MO; QL (30 per 30 days) 4 MO GELNIQUE TRANSDERMAL GEL IN PACKET 4 MO MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 3 MO; QL (30 per 30 days) oxybutynin chloride oral syrup 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 92

Drug Name Drug Tier Requirements/Limits oxybutynin chloride oral tablet 1 MO; * oxybutynin chloride oral tablet extended release 24hr 2 MO tolterodine oral capsule,extended release 24hr 2 MO tolterodine oral tablet 2 MO trospium oral capsule,extended release 24hr 2 MO trospium oral tablet 2 MO VESICARE ORAL TABLET 3 MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin oral tablet extended release 24 hr 2 MO AVODART ORAL CAPSULE 3 MO finasteride oral tablet 5 mg 1 MO; * JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 3 MO tamsulosin oral capsule,extended release 24hr 2 MO CHOLINERGIC STIMULANTS bethanechol chloride oral tablet 2 MO MISCELLANEOUS UROLOGICALS AMMONIUM CHLORIDE INTRAVENOUS SOLUTION CYSTAGON ORAL CAPSULE 3 PA; MO; LA ELMIRON ORAL CAPSULE 3 MO potassium citrate oral tablet extended release 4 MO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule 2 MO dextrose-kcl-nacl intravenous solution 2 eliphos oral tablet 2 MO klor-con 10 oral tablet extended release 2 MO klor-con 8 oral tablet extended release 2 MO klor-con m15 oral tablet,er particles/crystals 2 MO klor-con m20 oral tablet,er particles/crystals 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 93 3

Drug Name Drug Tier Requirements/Limits k-tab oral tablet extended release 8 meq 2 lactated ringers intravenous parenteral solution 2 MO magnesium sulfate injection solution 2 MO magnesium sulfate injection syringe 2 NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION PHOSLYRA ORAL SOLUTION 4 MO potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml 4 2 2 MO 2 2 2 MO potassium chloride intravenous solution 4 MO potassium chloride oral capsule, extended release 2 MO potassium chloride oral liquid 20 meq/15 ml 4 MO potassium chloride oral liquid 40 meq/15 ml 3 MO potassium chloride oral tablet extended release 8 meq 2 2 MO potassium chloride oral tablet,er particles/crystals 2 MO potassium chloride-0.45 % nacl intravenous parenteral solution potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l 2 2 MO 2 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 94

Drug Name Drug Tier Requirements/Limits potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous parenteral solution 2 sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % intravenous parenteral solution sodium chloride 5 % intravenous parenteral solution sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 2 TPN ELECTROLYTES INTRAVENOUS SOLUTION MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 2 2 MO 2 MO 2 2 MO 3 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 95

Drug Name Drug Tier Requirements/Limits AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D; MO 4 B/D 4 B/D intralipid intravenous emulsion 20 % 2 B/D; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 96

Drug Name Drug Tier Requirements/Limits INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 4 B/D You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 97 4 4 4 4 4 B/D premasol 10 % intravenous parenteral solution 2 B/D; MO PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION 4 4 4 4 4 4 B/D 4 B/D 4 B/D; MO travasol 10 % intravenous parenteral solution 2 B/D; MO TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION VITAMINS / HEMATINICS prenatal vitamin oral tablet 2 4 B/D; MO 4 B/D

Drug Name Drug Tier Requirements/Limits sodium fluoride oral tablet 2 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. 98

Index 8 8-MOP... 51 A abacavir... 3 abacavir-lamivudinezidovudine... 3 ABELCET... 2 ABILIFY DISCMELT... 34 ABILIFY MAINTENA... 34 ABRAXANE... 15 ABSTRAL... 29 acamprosate... 56 acarbose... 61 acebutolol... 43 acetaminophen-codeine.. 29, 30 acetasol hc... 59 acetazolamide... 86 acetazolamide sodium... 86 acetic acid... 59 acetylcysteine... 89 acitretin... 51 ACTEMRA... 77 ACTHAR H.P.... 60 ACTHIB (PF)... 74 ACTIMMUNE... 71 ACUVAIL (PF)... 86 acyclovir... 3, 54 acyclovir sodium... 3 ADACEL(TDAP ADOLESN/ADULT)(PF) 74 ADAGEN... 56 adapalene... 52 ADCIRCA... 89 adefovir... 3 ADEMPAS... 89 adrucil... 15 ADVAIR DISKUS... 89 ADVAIR HFA... 89 afeditab cr... 43 AFINITOR... 15 AFINITOR DISPERZ... 15 AFREZZA... 61 AGGRENOX... 47 a-hydrocort... 60 AKYNZEO... 67 ALBENZA... 8 albuterol sulfate... 89, 90 alclometasone... 54 alcohol pads... 61 ALDURAZYME... 64 alendronate... 56, 77 alfuzosin... 93 ALIMTA... 15 ALINIA... 9 allopurinol... 77 ALOCRIL... 86 ALOMIDE... 86 alosetron... 67 ALOXI... 67 ALPHAGAN P... 88 alprazolam... 34 ALREX... 87 amantadine hcl... 3 AMBISOME... 2 amcinonide... 54 amethia... 81 amethyst... 81 amifostine crystalline... 15 amikacin... 9 amiloride... 43 amiloride-hydrochlorothiazide... 43 aminophylline... 90 AMINOSYN 7 % WITH ELECTROLYTES... 95 AMINOSYN 8.5 %- ELECTROLYTES... 95 AMINOSYN II 10 %... 95 AMINOSYN II 15 %... 95 AMINOSYN II 7 %... 95 AMINOSYN II 8.5 %... 95 AMINOSYN II 8.5 %- ELECTROLYTES... 95 AMINOSYN M 3.5 %... 95 AMINOSYN-HBC 7%... 95 AMINOSYN-PF 10 %... 95 AMINOSYN-PF 7 % (SULFITE-FREE)... 96 AMINOSYN-RF 5.2 %... 96 amiodarone... 43 AMITIZA... 67 amitriptyline... 34 amitriptyline-chlordiazepoxide... 34 amlodipine... 43 amlodipine-benazepril... 43 99 amlodipine-valsartan... 43 amlodipine-valsartan-hcthiazid... 43 AMMONIUM CHLORIDE. 93 ammonium lactate... 51 amnesteem... 52 amoxapine... 34 amoxicil-clarithromy-lansopraz... 70 amoxicillin... 11, 12 amoxicillin-pot clavulanate.. 12 amphetamine salt combo... 34 amphotericin b... 2 ampicillin... 12 ampicillin sodium... 12 ampicillin-sulbactam... 12 AMPYRA... 28 ANADROL-50... 64 anagrelide... 56 anastrozole... 15 ANDRODERM... 65 ANDROGEL... 65 ANDROID... 65 ANORO ELLIPTA... 90 ANZEMET... 67, 68 APIDRA... 61 APIDRA SOLOSTAR... 61 APOKYN... 26 apraclonidine... 88 apri... 81 APRISO... 68 APTIOM... 23 APTIVUS... 3 ARALAST NP... 56 aranelle (28)... 81 ARANESP (IN POLYSORBATE)... 71, 72 arbinoxa... 88 ARCALYST... 72 ARCAPTA NEOHALER... 90 ARGATROBAN... 47 ARGATROBAN IN 0.9 % SOD CHLOR... 47 aripiprazole... 35 ARNUITY ELLIPTA... 90 ARRANON... 16 ARZERRA... 16 ASACOL HD... 68

ascomp with codeine... 30 ashlyna... 81 ASMANEX HFA... 90 ASMANEX TWISTHALER 90 atenolol... 43 atenolol-chlorthalidone... 44 ATGAM... 74 atorvastatin... 49 atovaquone... 9 atovaquone-proguanil... 9 ATRIPLA... 3 atropine... 67, 85 ATROVENT HFA... 90 AUBAGIO... 28 aubra... 81 AURYXIA... 57 AUVI-Q... 88 AVASTIN... 16 AVELOX IN NACL (ISO- OSMOTIC)... 13 aviane... 81 avita... 52 AVODART... 93 AVONEX... 72 AVONEX (WITH ALBUMIN)... 72 azacitidine... 16 AZACTAM IN DEXTROSE (ISO-OSM)... 9 AZASITE... 84 azathioprine... 16 azelastine... 59, 86 AZILECT... 26 azithromycin... 8 aztreonam... 9 B baciim... 9 bacitracin... 9, 84 bacitracin-polymyxin b... 84 baclofen... 28 BACTROBAN NASAL... 59 balsalazide... 68 balziva (28)... 81 BANZEL... 23, 24 BARACLUDE... 3 BCG VACCINE, LIVE (PF) 74 BELEODAQ... 16 benazepril... 44 benazepril-hydrochlorothiazide... 44 BENLYSTA... 77 BENTYL... 67 benztropine... 26, 27 BEPREVE... 86 BERINERT... 90 BESIVANCE... 84 betamethasone dipropionate. 54 betamethasone valerate... 54 betamethasone, augmented... 54 BETASERON... 72 betaxolol... 44, 85 bethanechol chloride... 93 BETHKIS... 9 BETIMOL... 85 BETOPTIC S... 85 BEXSERO (PF)... 74 bicalutamide... 16 BICILLIN C-R... 12 BICILLIN L-A... 12 BICNU... 16 BILTRICIDE... 9 bimatoprost... 86 bisoprolol fumarate... 44 bisoprolol-hydrochlorothiazide... 44 BIVIGAM... 74 bleomycin... 16 BLEPHAMIDE... 88 BLEPHAMIDE S.O.P.... 88 BOOSTRIX TDAP... 74 BOSULIF... 16 BOTOX... 74 BREO ELLIPTA... 90 briellyn... 81 BRILINTA... 47 brimonidine... 88 BRINTELLIX... 35 bromfenac... 86 bromocriptine... 27 BROVANA... 90 budesonide... 68, 90 bumetanide... 44 buprenorphine hcl... 30 buproban... 59 bupropion hcl... 35 buspirone... 35 BUSULFEX... 16 butalbital-acetaminop-caf-cod... 30 butorphanol tartrate... 33 100 BYDUREON... 61 BYETTA... 61 C cabergoline... 65 calcipotriene... 51 calcitonin (salmon)... 65 calcitriol... 51, 65 calcium acetate... 93 camila... 79 CANASA... 68 CANCIDAS... 2 candesartan... 44 candesartan-hydrochlorothiazid... 44 CAPASTAT... 9 CAPRELSA... 16 captopril... 44 captopril-hydrochlorothiazide... 44 carafate... 70 CARBAGLU... 57 carbamazepine... 24 carbidopa... 27 carbidopa-levodopa... 27 carbidopa-levodopaentacapone... 27 carbinoxamine maleate... 88 carboplatin... 16 CARDENE IV IN SODIUM CHLORIDE... 44 CARIMUNE NF NANOFILTERED... 74 carisoprodol... 29 carisoprodol-asa-codeine... 29 carisoprodol-aspirin... 29 carteolol... 85 cartia xt... 44 carvedilol... 44 CAYSTON... 9 cefaclor... 6 cefadroxil... 6 cefazolin... 6 cefazolin in dextrose (iso-os).. 6 cefdinir... 6 cefditoren pivoxil... 6 cefepime... 6 CEFEPIME IN DEXTROSE 5 %... 6 cefotaxime... 7 cefotetan... 7

cefoxitin... 7 cefoxitin in dextrose, iso-osm 7 cefpodoxime... 7 cefprozil... 7 ceftazidime... 7 CEFTAZIDIME IN D5W... 7 ceftriaxone... 7 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib... 33 CELLCEPT INTRAVENOUS... 16 CELONTIN... 24 cephalexin... 7 CERDELGA... 65 CEREZYME... 65 CERVARIX VACCINE (PF)... 74 cevimeline... 57 CHANTIX... 59 CHANTIX CONTINUING MONTH BOX... 59 CHANTIX STARTING MONTH BOX... 59 CHEMET... 57 chloramphenicol sod succinate... 9 chlorhexidine gluconate... 59 chloroquine phosphate... 9 chlorothiazide... 44 chlorothiazide sodium... 44 chlorpromazine... 35 chlorthalidone... 44 chlorzoxazone... 29 cholestyramine light... 49 chorionic gonadotropin, human... 65 ciclopirox... 53 cidofovir... 3 cilostazol... 48 CILOXAN... 84 cimetidine... 71 cimetidine hcl... 70 CIMZIA... 68 CIMZIA POWDER FOR RECONST... 68 CINRYZE... 90 CIPRO HC... 59 CIPRODEX... 59 ciprofloxacin (mixture)... 13 ciprofloxacin hcl... 13, 84 ciprofloxacin in 5 % dextrose... 13 ciprofloxacin lactate... 13 cisplatin... 16 citalopram... 35 cladribine... 16 claravis... 52 clarithromycin... 8 clemastine... 88 CLEOCIN... 81 clindamycin hcl... 9 clindamycin in 5 % dextrose.. 9 clindamycin pediatric... 9 clindamycin phosphate... 9, 52, 81 CLINIMIX 5%/D15W SULFITE FREE... 96 CLINIMIX 5%/D25W SULFITE-FREE... 96 CLINIMIX 2.75%/D5W SULFIT FREE... 96 CLINIMIX 4.25%/D10W SULF FREE... 96 CLINIMIX 4.25%/D5W SULFIT FREE... 57 CLINIMIX 4.25%-D20W SULF-FREE... 96 CLINIMIX 4.25%-D25W SULF-FREE... 96 CLINIMIX 5%- D20W(SULFITE-FREE). 96 CLINIMIX E 2.75%/D10W SUL FREE... 57 CLINIMIX E 2.75%/D5W SULF FREE... 57 CLINIMIX E 4.25%/D10W SUL FREE... 96 CLINIMIX E 4.25%/D25W SUL FREE... 96 CLINIMIX E 4.25%/D5W SULF FREE... 96 CLINIMIX E 5%/D15W SULFIT FREE... 96 CLINIMIX E 5%/D20W SULFIT FREE... 96 CLINIMIX E 5%/D25W SULFIT FREE... 96 CLINISOL SF 15 %... 96 clobetasol... 54, 55 101 clobetasol-emollient... 55 CLOLAR... 16 clomipramine... 35 clonazepam... 24 clonidine... 44 clonidine hcl... 35, 44 clopidogrel... 48 clorazepate dipotassium... 35 clotrimazole... 2, 53 clotrimazole-betamethasone 53, 54 clozapine... 35 CLOZAPINE... 35, 36 COARTEM... 9 codeine sulfate... 30 colchicine-probenecid... 77 COLCRYS... 77 colestipol... 49 colistin (colistimethate na)... 9 COLY-MYCIN S... 59 COMBIGAN... 86 COMBIVENT RESPIMAT.. 90 COMETRIQ... 16 COMPLERA... 3 compro... 68 COMVAX (PF)... 74 CONDYLOX... 51 constulose... 68 COPAXONE... 28 CORLANOR... 50 cormax... 55 cortisone... 60 CORTISPORIN-TC... 59 COSENTYX PEN... 51 COSENTYX PEN (2 PENS) 51 CREON... 68 CRESEMBA... 2 CRIXIVAN... 3 cromolyn... 68, 86, 90 cryselle (28)... 81 CUBICIN... 9 cyclafem 1/35 (28)... 81 cyclafem 7/7/7 (28)... 81 cyclobenzaprine... 29 CYCLOPHOSPHAMIDE... 16 cyclosporine... 16 cyclosporine modified... 16 cyproheptadine... 88 CYSTADANE... 68 CYSTAGON... 93

CYSTARAN... 86 cytarabine... 16 cytarabine (pf)... 16 D d10 % & 0.45 % sodium chloride... 57 d2.5 %-0.45 % sodium chloride... 57 d5 % and 0.9 % sodium chloride... 57 d5 %-0.45 % sodium chloride... 57 dacarbazine... 17 DALIRESP... 90 DALVANCE... 9 danazol... 65 dantrolene... 29 DAPSONE... 9 DAPTACEL (DTAP PEDIATRIC) (PF)... 74 DARAPRIM... 9 daunorubicin... 17 deblitane... 79 decitabine... 17 delyla (28)... 81 DELZICOL... 68 DEMSER... 44 DENAVIR... 54 DEPEN TITRATABS... 77 DEPO-ESTRADIOL... 79 DEPO-MEDROL... 60 DEPO-PROVERA... 79 DEPO-SUBQ PROVERA 104... 79 desipramine... 36 desmopressin... 65 desog-e.estradiol/e.estradiol. 81 desonide... 55 desoximetasone... 55 dexamethasone... 60 dexamethasone intensol... 60 dexamethasone sodium phosphate... 60, 87 DEXILANT... 71 dexmethylphenidate... 36 dexrazoxane hcl... 15 dextroamphetamine... 36 dextroamphetamineamphetamine... 36 dextrose 10 % and 0.2 % nacl... 57 dextrose 10 % in water (d10w)... 57 dextrose 5 % in water (d5w). 57 dextrose 5 %-lactated ringers57 dextrose 5%-0.2 % sod chloride... 57 dextrose 5%-0.3 % sod.chloride... 57 dextrose with sodium chloride... 57 dextrose-kcl-nacl... 93 diazepam... 24, 36 diazepam intensol... 36 diclofenac potassium... 33 diclofenac sodium... 33, 86 dicloxacillin... 12 dicyclomine... 67 didanosine... 3 DIFICID... 8 diflorasone... 55 diflunisal... 33 digitek... 47 digoxin... 47 dihydroergotamine... 27 DILANTIN 30 MG... 24 diltiazem hcl... 44 dilt-xr... 44 DIPENTUM... 68 diphenhydramine hcl... 88 diphenoxylate-atropine... 67 dipyridamole... 48 disopyramide phosphate... 43 disulfiram... 57 DIURIL... 44 divalproex... 24 DIVIGEL... 79 DOCEFREZ... 17 docetaxel... 17 donepezil... 28 DORIBAX... 10 dorzolamide... 86 dorzolamide-timolol... 86 doxazosin... 45 doxepin... 36 doxercalciferol... 65 doxorubicin... 17 doxy-100... 14 doxycycline hyclate... 14 102 doxycycline monohydrate... 14 dronabinol... 68 drospirenone-ethinyl estradiol... 81 DUAVEE... 79 DULERA... 90 duloxetine... 36 duramorph (pf)... 30 DUREZOL... 87 DYSPORT... 74 E e.e.s. 400... 8 E.E.S. GRANULES... 8 econazole... 54 EDURANT... 3 EFFIENT... 48 EGRIFTA... 72 ELAPRASE... 65 ELELYSO... 65 ELIDEL... 52 ELIGARD... 17 eliphos... 93 ELIQUIS... 48 ELITEK... 15 ELIXOPHYLLIN... 90 ELMIRON... 93 EMADINE... 86 EMCYT... 17 EMEND... 68 emoquette... 82 EMSAM... 36 EMTRIVA... 3 enalapril maleate... 45 enalapril-hydrochlorothiazide... 45 ENBREL... 77 ENBREL SURECLICK... 78 endocet... 30 endodan... 30 ENGERIX-B (PF)... 74 ENGERIX-B PEDIATRIC (PF)... 74 enoxaparin... 48 enpresse... 82 entacapone... 27 entecavir... 3 enulose... 68 epinastine... 86 epinephrine... 89 EPIPEN 2-PAK... 89

EPIPEN JR 2-PAK... 89 epirubicin... 17 epitol... 24 EPIVIR HBV... 3 eplerenone... 45 EPOGEN... 72 eprosartan... 45 EPZICOM... 3 EQUETRO... 24 ERAXIS(WATER DILUENT)... 2 ERBITUX... 17 ergoloid... 36 ERIVEDGE... 17 errin... 79 ERWINAZE... 17 ery pads... 52 ERYPED 200... 8 ERYPED 400... 8 ery-tab... 8 ERY-TAB... 8 ERYTHROCIN... 8 erythrocin (as stearate)... 8 erythromycin... 8, 84 erythromycin ethylsuccinate.. 8 erythromycin with ethanol... 52 erythromycin-benzoyl peroxide... 52 ESBRIET... 90 escitalopram oxalate... 36, 37 ESTRACE... 79 estradiol... 79, 80 estradiol valerate... 80 estradiol-norethindrone acet. 80 ESTRING... 80 estropipate... 80 ethambutol... 10 ethosuximide... 24 etidronate disodium... 57 etodolac... 33 ETOPOPHOS... 17 etoposide... 17 EVOTAZ... 3 EXELON... 28 exemestane... 17 EXJADE... 57 F FABIOR... 52 FABRAZYME... 65 FACTIVE... 13 falmina (28)... 82 famciclovir... 3 famotidine... 71 famotidine (pf)... 71 famotidine (pf)-nacl (iso-os) 71 FANAPT... 37 FARESTON... 17 FARXIGA... 61 FARYDAK... 17 FASLODEX... 17 felbamate... 24 felodipine... 45 FEMRING... 80 fenofibrate... 49 fenofibrate micronized... 49 fenofibrate nanocrystallized. 49 fenofibric acid (choline)... 50 fenoprofen... 33 fentanyl... 30 fentanyl citrate... 30 FENTORA... 30 FERRIPROX... 58 FETZIMA... 37 finasteride... 93 FIRAZYR... 90 FIRMAGON KIT W DILUENT SYRINGE... 17 FLAGYL ER... 10 flavoxate... 92 FLEBOGAMMA DIF... 74 flecainide... 43 FLOVENT DISKUS... 91 FLOVENT HFA... 91 fluconazole... 2 fluconazole in dextrose(iso-o) 2 flucytosine... 2 fludarabine... 18 fludrocortisone... 60 flunisolide... 91 fluocinolone... 55 fluocinolone acetonide oil... 59 fluocinonide... 55 fluocinonide-e... 55 fluorometholone... 87 fluorouracil... 18, 52 FLUOROURACIL... 52 fluoxetine... 37 fluphenazine decanoate... 37 fluphenazine hcl... 37 flurbiprofen... 33 103 flurbiprofen sodium... 86 flutamide... 18 fluticasone... 55, 91 fluvastatin... 50 fluvoxamine... 37 FML FORTE... 87 FML S.O.P.... 87 FOLOTYN... 18 fomepizole... 75 fondaparinux... 48 FORADIL AEROLIZER... 91 FORTAZ... 7 FORTEO... 77 fortical... 65 foscarnet... 3 fosinopril... 45 fosinopril-hydrochlorothiazide... 45 fosphenytoin... 24 FOSRENOL... 58 FRAGMIN... 48 FREAMINE HBC 6.9 %... 96 FULYZAQ... 67 furosemide... 45 FUSILEV... 15 FUZEON... 3 FYCOMPA... 24 G gabapentin... 24, 25 GABITRIL... 25 GABLOFEN... 29 galantamine... 28 GAMASTAN S/D... 75 GAMMAGARD LIQUID... 75 GAMMAKED... 75 GAMMAPLEX... 75 GAMUNEX-C... 75 ganciclovir sodium... 3 garamycin... 84 GARDASIL (PF)... 75 GARDASIL 9 (PF)... 75 gatifloxacin... 84 GATTEX ONE-VIAL... 68 GAUZE PAD... 61 gavilyte-c... 68 gavilyte-g... 68 gavilyte-n... 68 GELNIQUE... 92 gemcitabine... 18 gemfibrozil... 50

generlac... 68 gengraf... 18 GENOTROPIN... 72 GENOTROPIN MINIQUICK... 72 gentak... 84 gentamicin... 10, 53, 84 gentamicin in nacl (iso-osm) 10 gentamicin sulfate (pf)... 10 GEODON... 37 gianvi (28)... 82 gildagia... 82 gildess... 82 gildess 24 fe... 82 GILENYA... 28 GILOTRIF... 18 GLASSIA... 58 GLEEVEC... 18 GLEOSTINE... 18 glimepiride... 61 glipizide... 61 glipizide-metformin... 61, 62 GLUCAGEN HYPOKIT... 62 GLUCAGON EMERGENCY KIT (HUMAN)... 62 glycopyrrolate... 67 GLYSET... 62 GLYXAMBI... 62 GRALISE... 25 GRALISE 30-DAY STARTER PACK... 25 granisetron (pf)... 69 granisetron hcl... 69 GRANIX... 72 GRASTEK... 75 griseofulvin microsize... 2 griseofulvin ultramicrosize... 2 guanidine... 37 H HALAVEN... 18 halobetasol propionate... 55 haloperidol... 37 haloperidol decanoate... 37 haloperidol lactate... 37 HARVONI... 4 HAVRIX (PF)... 75 heparin (porcine)... 49 heparin (porcine) in 5 % dex 49 HEPATAMINE 8%... 96 HERCEPTIN... 18 HETLIOZ... 38 HEXALEN... 18 HORIZANT... 28 HUMALOG... 62 HUMALOG KWIKPEN... 62 HUMALOG MIX 50-50... 62 HUMALOG MIX 50-50 KWIKPEN... 62 HUMALOG MIX 75-25... 62 HUMALOG MIX 75-25 KWIKPEN... 62 HUMATROPE... 72 HUMIRA... 78 HUMIRA CROHN'S DIS START PCK... 78 HUMULIN 70/30... 62 HUMULIN 70/30 KWIKPEN... 62 HUMULIN N... 62 HUMULIN N KWIKPEN... 62 HUMULIN R... 62 HUMULIN R U-500... 62 hydralazine... 45 hydrochlorothiazide... 45 hydrocodone-acetaminophen 31 hydrocodone-ibuprofen... 31 hydrocortisone... 55, 60, 69 hydrocortisone butyrate... 55 hydrocortisone valerate... 55 hydrocortisone-acetic acid... 59 hydromorphone... 31 hydromorphone (pf)... 31 hydroxychloroquine... 10 hydroxyurea... 18 hydroxyzine hcl... 89 hydroxyzine pamoate... 89 I ibandronate... 77 IBRANCE... 18 ibuprofen... 33 ibuprofen-oxycodone... 31 ICLUSIG... 18 idarubicin... 18 ifosfamide... 18 ILARIS (PF)... 72 IMBRUVICA... 18 imipenem-cilastatin... 10 imipramine hcl... 38 imipramine pamoate... 38 imiquimod... 52 104 IMOVAX RABIES VACCINE (PF)... 75 INCRELEX... 58 INCRUSE ELLIPTA... 91 indapamide... 45 INFANRIX (DTAP) (PF)... 75 INLYTA... 18 INSULIN PEN NEEDLE... 62 INSULIN SYRINGE (DISP) U-100... 63 INTELENCE... 4 intralipid... 96 INTRALIPID... 97 INTRON A... 72 introvale... 82 INVANZ... 10 INVEGA... 38 INVEGA SUSTENNA... 38 INVIRASE... 4 INVOKAMET... 63 INVOKANA... 63 IONOSOL-B IN D5W... 97 IONOSOL-MB IN D5W... 97 IOPIDINE... 88 IPOL... 75 ipratropium bromide... 59, 91 ipratropium-albuterol... 91 irbesartan... 45 irbesartan-hydrochlorothiazide... 45 irinotecan... 18 ISENTRESS... 4 ISOLYTE-P IN 5 % DEXTROSE... 97 ISOLYTE-S... 97 isoniazid... 10 isosorbide dinitrate... 50 isosorbide mononitrate... 50, 51 isradipine... 45 ISTODAX... 18 itraconazole... 2 ivermectin... 10 IXEMPRA... 18 IXIARO (PF)... 75 J JAKAFI... 18, 19 JALYN... 93 jantoven... 49 JANUMET... 63 JANUMET XR... 63

JANUVIA... 63 JARDIANCE... 63 JENTADUETO... 63 JEVTANA... 19 jinteli... 80 jolivette... 80 junel 1.5/30 (21)... 82 junel 1/20 (21)... 82 junel fe 1.5/30 (28)... 82 junel fe 1/20 (28)... 82 junel fe 24... 82 JUXTAPID... 50 K KADCYLA... 19 KALETRA... 4 KALYDECO... 91 kariva (28)... 82 kelnor 1/35 (28)... 82 KEPIVANCE... 15 ketoconazole... 2, 54 ketoprofen... 33 ketorolac... 86 KEYTRUDA... 19 KHEDEZLA... 38 KINERET... 78 kionex... 58 klor-con 10... 93 klor-con 8... 93 klor-con m15... 93 klor-con m20... 93 KORLYM... 65 k-tab... 94 KUVAN... 65, 66 KYNAMRO... 50 L l norgest/e.estradiol-e.estrad. 82 labetalol... 45 lactated ringers... 56, 94 lactulose... 69 lamivudine... 4 lamivudine-zidovudine... 4 lamotrigine... 25 lansoprazole... 71 LANTUS... 63 LANTUS SOLOSTAR... 63 larin 1.5/30 (21)... 82 larin 1/20 (21)... 82 larin fe... 82 latanoprost... 86 LATUDA... 38 LAZANDA... 31 leena 28... 82 leflunomide... 78 LENVIMA... 19 lessina... 82 LETAIRIS... 91 letrozole... 19 leucovorin calcium... 15 LEUKERAN... 19 LEUKINE... 73 leuprolide... 19 levalbuterol hcl... 91 LEVEMIR... 63 LEVEMIR FLEXTOUCH... 63 levetiracetam... 25 LEVETIRACETAM IN NACL (ISO-OS)... 25 levobunolol... 85 levocarnitine... 58 levocarnitine (with sugar)... 58 levocetirizine... 89 levofloxacin... 13, 85 levofloxacin in d5w... 13 LEVOLEUCOVORIN CALCIUM... 15 levonest (28)... 82 levonorgestrel-ethinyl estrad 82 levora-28... 82 levorphanol tartrate... 31 levothyroxine... 67 LEXIVA... 4 LIALDA... 69 lidocaine... 53 lidocaine (pf)... 53 lidocaine hcl... 53 lidocaine-prilocaine... 53 LINCOCIN... 10 lindane... 56 linezolid... 10 LINZESS... 69 LIORESAL... 29 liothyronine... 67 LIPTRUZET... 50 lisinopril... 45 lisinopril-hydrochlorothiazide... 45 lithium carbonate... 38 lithium citrate... 38 LITHOSTAT... 58 lomedia 24 fe... 82 105 LOMUSTINE... 19 loperamide... 67 lorazepam... 38 lorazepam intensol... 38 lorcet (hydrocodone)... 31 lorcet hd... 31 lorcet plus... 31 lortab 10-325... 31 lortab 5-325... 31 lortab 7.5-325... 31 loryna (28)... 82 losartan... 45 losartan-hydrochlorothiazide 45 LOTEMAX... 87 lovastatin... 50 loxapine succinate... 38 LUMIGAN... 86 LUMIZYME... 66 LUPANETA PACK (1 MONTH)... 81 LUPANETA PACK (3 MONTH)... 81 LUPRON DEPOT... 19 LUPRON DEPOT (3 MONTH)... 19 LUPRON DEPOT (4 MONTH)... 19 LUPRON DEPOT (6 MONTH)... 19 LUPRON DEPOT-PED... 19 lutera (28)... 83 LYNPARZA... 19 LYRICA... 25 LYSODREN... 19 lyza... 80 M magnesium sulfate... 94 malathion... 56 maprotiline... 38 marlissa... 83 MARPLAN... 39 MATULANE... 19 matzim la... 45 MAXIDEX... 87 meclizine... 69 meclofenamate... 33 medroxyprogesterone... 80 mefloquine... 10 megestrol... 19 MEKINIST... 19

meloxicam... 33 melphalan hcl... 19 MENACTRA (PF)... 75 MENEST... 80 MENOMUNE - A/C/Y/W-135 (PF)... 75 MENOSTAR... 80 MENVEO A-C-Y-W-135-DIP (PF)... 75 mercaptopurine... 20 meropenem... 10 mesalamine with cleansing wipe... 69 mesna... 15 MESNEX... 15 MESTINON... 29 metadate er... 39 metaproterenol... 91 metformin... 63 methadone... 31 methamphetamine... 39 methazolamide... 86 methenamine hippurate... 14 methimazole... 61 methocarbamol... 29 methotrexate sodium... 20 methotrexate sodium (pf)... 20 methoxsalen rapid... 52 methscopolamine... 67 methyclothiazide... 45 methylergonovine... 84 methylphenidate... 39 methylprednisolone... 60 methylprednisolone acetate.. 60 methylprednisolone sodium succ... 60 metipranolol... 85 metoclopramide hcl... 69 metolazone... 45 metoprolol succinate... 45 metoprolol ta-hydrochlorothiaz... 46 metoprolol tartrate... 46 metronidazole... 10, 52, 81 metronidazole in nacl (iso-os)... 10 mexiletine... 43 MIACALCIN... 66 miconazole-3... 81 microgestin 1.5/30 (21)... 83 microgestin 1/20 (21)... 83 microgestin fe 1.5/30 (28)... 83 microgestin fe 1/20 (28)... 83 midodrine... 58 migergot... 27 MIGRANAL... 27 mimvey... 80 mimvey lo... 80 minocycline... 14 minoxidil... 46 mirtazapine... 39 misoprostol... 71 mitomycin... 20 mitoxantrone... 20 M-M-R II (PF)... 76 modafinil... 39 moderiba... 4 moderiba dose pack... 4 moexipril... 46 moexipril-hydrochlorothiazide... 46 mometasone... 56 mononessa (28)... 83 montelukast... 91 MONUROL... 14 morphine... 31, 32 morphine concentrate... 31 MOVANTIK... 69 MOXEZA... 85 moxifloxacin... 13 MOZOBIL... 73 MULTAQ... 43 mupirocin... 53 MUSTARGEN... 20 MYALEPT... 66 MYCAMINE... 2 mycophenolate mofetil... 20 mycophenolate sodium... 20 myorisan... 53 MYOZYME... 66 MYRBETRIQ... 92 N nabumetone... 33 nadolol... 46 nadolol-bendroflumethiazide 46 nafcillin... 12 nafcillin in dextrose iso-osm 12 NAGLAZYME... 66 nalbuphine... 33 naloxone... 33 106 naltrexone... 33 NAMENDA... 28 NAMENDA TITRATION PAK... 28 naphazoline... 88 naproxen... 33 naproxen sodium... 33 naratriptan... 27 NATACYN... 85 nateglinide... 63 NATPARA... 66 NEBUPENT... 10 necon 0.5/35 (28)... 83 necon 1/35 (28)... 83 necon 1/50 (28)... 83 necon 10/11 (28)... 83 necon 7/7/7 (28)... 83 NEEDLES, INSULIN DISP.,SAFETY... 63 nefazodone... 39 neomycin... 10 neomycin-bacitracin-poly-hc 87 neomycin-bacitracinpolymyxin... 85 neomycin-polymyxin b gu... 56 neomycin-polymyxin b- dexameth... 87 neomycin-polymyxingramicidin... 85 neomycin-polymyxin-hc. 60, 87 NEPHRAMINE 5.4 %... 97 NEULASTA... 73 NEUMEGA... 73 NEUPOGEN... 73 NEUPRO... 27 nevirapine... 4 NEXAVAR... 20 niacin... 50 nicardipine... 46 NICOTROL... 59 NICOTROL NS... 59 nifedical xl... 46 nifedipine... 46 nikki (28)... 83 NILANDRON... 20 nimodipine... 46 nitro-bid... 51 NITRO-DUR... 51 nitrofurantoin macrocrystal.. 14

nitrofurantoin monohyd/mcryst... 14 nitroglycerin... 51 NITROSTAT... 51 nizatidine... 71 nora-be... 80 NORDITROPIN FLEXPRO 73 NORDITROPIN NORDIFLEX... 73 noreth-ethinyl estradiol-iron. 83 norethindrone (contraceptive)... 80 norethindrone acetate... 80 norethindrone ac-eth estradiol... 80 norethindrone-e.estradiol-iron... 83 norlyroc... 80 NORMOSOL-M IN 5 % DEXTROSE... 97 NORMOSOL-R IN 5 % DEXTROSE... 94 NORMOSOL-R PH 7.4... 97 NORTHERA... 58 nortrel 0.5/35 (28)... 83 nortrel 1/35 (21)... 83 nortrel 1/35 (28)... 83 nortrel 7/7/7 (28)... 83 nortriptyline... 39 NORVIR... 4 NOVOLIN 70/30... 63 NOVOLIN N... 63 NOVOLIN R... 63 NOVOLOG... 64 NOVOLOG FLEXPEN... 64 NOVOLOG MIX 70-30... 64 NOVOLOG MIX 70-30 FLEXPEN... 64 NOVOLOG PENFILL... 64 NOXAFIL... 2 NUEDEXTA... 28 NULOJIX... 20 NUTROPIN AQ... 73 NUTROPIN AQ NUSPIN... 73 NUVARING... 81 NUVIGIL... 39 nyamyc... 54 nystatin... 2, 54 nystatin-triamcinolone... 54 nystop... 54 O ocella... 83 OCTAGAM... 76 octreotide acetate... 20 OFEV... 91 ofloxacin... 13, 59, 85 ogestrel (28)... 83 olanzapine... 39 olanzapine-fluoxetine... 40 omega-3 acid ethyl esters... 50 omeprazole... 71 OMNITROPE... 73 ONCASPAR... 20 ondansetron... 69 ondansetron hcl... 69 ondansetron hcl (pf)... 69 ONFI... 25 ONMEL... 2 OPANA ER... 32 OPDIVO... 20 OPSUMIT... 91 ORAP... 40 ORENCIA... 78 ORENCIA (WITH MALTOSE)... 78 ORFADIN... 58 orphenadrine citrate... 29 orsythia... 83 OTEZLA... 78 OTEZLA STARTER... 78 OTREXUP (PF)... 78 oxacillin... 12 oxacillin in dextrose(iso-osm)... 12 oxaliplatin... 20 oxandrolone... 66 oxazepam... 40 oxcarbazepine... 25 oxybutynin chloride... 92, 93 oxycodone... 32 oxycodone-acetaminophen... 32 oxycodone-aspirin... 32 oxymorphone... 32 P pacerone... 43 paclitaxel... 20 pamidronate... 66 PANCREAZE... 69 PANRETIN... 52 pantoprazole... 71 107 paricalcitol... 66 PARICALCITOL... 66 paromomycin... 10 paroxetine hcl... 40 PASER... 10 PAXIL... 40 PCE... 8 PEDVAX HIB (PF)... 76 peg 3350-electrolytes... 69 PEGANONE... 26 PEGINTRON... 73 PEGINTRON REDIPEN... 73 PENICILLIN G POT IN DEXTROSE... 12 penicillin g potassium... 13 penicillin g procaine... 13 penicillin g sodium... 13 penicillin v potassium... 13 PENTAM... 11 PENTASA... 69 pentoxifylline... 49 PERFOROMIST... 91 perindopril erbumine... 46 periogard... 59 PERJETA... 20 permethrin... 56 perphenazine... 40 perphenazine-amitriptyline... 40 PERTZYE... 69 phenadoz... 89 phenelzine... 40 phenergan... 89 phenobarbital... 26 phenytoin... 26 phenytoin sodium... 26 phenytoin sodium extended.. 26 PHOSLYRA... 94 PHOSPHOLINE IODIDE... 85 PHYSIOLYTE... 56 PHYSIOSOL IRRIGATION 56 PICATO... 52 pilocarpine hcl... 58, 85 pimtrea (28)... 83 pindolol... 46 pioglitazone... 64 pioglitazone-glimepiride... 64 pioglitazone-metformin... 64 piperacillin-tazobactam... 13 pirmella... 83 piroxicam... 34

PLASMA-LYTE 148... 97 PLASMA-LYTE A... 97 PLASMA-LYTE-56 IN 5 % DEXTROSE... 97 podofilox... 52 polyethylene glycol 3350... 69 polymyxin b sulfate... 11 polymyxin b sulf-trimethoprim... 85 POMALYST... 20 portia... 83 potassium chlorid-d5-0.45%nacl... 94 potassium chloride... 94 potassium chloride in 0.9%nacl... 94 potassium chloride in 5 % dex... 94 potassium chloride in lr-d5... 94 potassium chloride-0.45 % nacl... 94 potassium chloride-d5-0.2%nacl... 94 potassium chloride-d5-0.3%nacl... 94 potassium chloride-d5-0.9%nacl... 94, 95 potassium citrate... 93 POTIGA... 26 PRADAXA... 49 pramipexole... 27 pravastatin... 50 prazosin... 46 PRED MILD... 87 PRED-G... 87 PRED-G S.O.P.... 87 prednicarbate... 56 prednisolone acetate... 88 prednisolone sodium phosphate... 60, 88 prednisone... 60 prednisone intensol... 60 PREMARIN... 80 premasol 10 %... 97 PREMASOL 6 %... 97 PREMPHASE... 80 PREMPRO... 80 prenatal vitamin oral tablet... 97 prevalite... 50 previfem... 83 PREZCOBIX... 4 PREZISTA... 4 PRIFTIN... 11 PRIMAQUINE... 11 primidone... 26 PRISTIQ... 40 PRIVIGEN... 76 probenecid... 77 procainamide... 43 PROCALAMINE 3%... 97 prochlorperazine... 70 prochlorperazine edisylate... 69 prochlorperazine maleate... 69 PROCRIT... 73 procto-pak... 70 proctosol hc... 70 proctozone-hc... 70 progesterone micronized... 80 PROGLYCEM... 64 PROGRAF... 20 PROLASTIN-C... 58 PROLEUKIN... 73 PROLIA... 77 PROMACTA... 49 promethazine... 89 promethazine vc... 89 promethegan... 89 propafenone... 43 propantheline... 67 propranolol... 46 propranolol-hydrochlorothiazid... 46 propylthiouracil... 61 PROQUAD (PF)... 76 PROSOL 20 %... 97 PROTONIX... 71 protriptyline... 40 PULMOZYME... 91 PURIXAN... 20 pyrazinamide... 11 pyridostigmine bromide... 29 Q QUADRACEL (PF)... 76 quasense... 83 quetiapine... 40 quinapril... 46 quinapril-hydrochlorothiazide... 46 quinidine gluconate... 43 quinidine sulfate... 43 108 quinine sulfate... 11 R RABAVERT (PF)... 76 RAGWITEK... 76 raloxifene... 77 ramipril... 46 RANEXA... 50 ranitidine hcl... 71 RAPAMUNE... 21 RASUVO (PF)... 78, 79 RAVICTI... 58 REBETOL... 4 reclipsen (28)... 83 RECOMBIVAX HB (PF)... 76 REGRANEX... 52 RELENZA DISKHALER... 5 RELISTOR... 70 REMICADE... 70 REMODULIN... 46 RENVELA... 58 repaglinide... 64 RESCRIPTOR... 5 reserpine... 46 RESTASIS... 86 RETROVIR... 5 REVATIO... 91 REVLIMID... 21 REYATAZ... 5 ribasphere... 5 ribavirin... 5 RIDAURA... 79 rifabutin... 11 RIFAMATE... 11 rifampin... 11 RIFATER... 11 riluzole... 58 rimantadine... 5 ringers... 56, 95 RIOMET... 64 risedronate... 77 RISPERDAL CONSTA... 40 risperidone... 40, 41 RITUXAN... 21 rivastigmine tartrate... 28 rizatriptan... 27 ropinirole... 27 ROTARIX... 76 ROTATEQ VACCINE... 76 ROXICET... 32 ROZEREM... 41

RUCONEST... 91 S SABRIL... 26 SAIZEN... 73 SAIZEN CLICK.EASY... 73 SAMSCA... 66 SANCUSO... 70 SANDOSTATIN LAR DEPOT... 21 SANTYL... 56 SAPHRIS (BLACK CHERRY)... 41 SAVELLA... 79 selegiline hcl... 27 selenium sulfide... 51 SELZENTRY... 5 SENSIPAR... 66 SEREVENT DISKUS... 92 SEROQUEL XR... 41 SEROSTIM... 73 sertraline... 41 sharobel... 80 SIGNIFOR... 21 SIGNIFOR LAR... 21 sildenafil... 92 SILENOR... 41 silver sulfadiazine... 51 SIMBRINZA... 86 SIMPONI... 79 SIMPONI ARIA... 79 SIMULECT... 21 simvastatin... 50 sirolimus... 21 SIRTURO... 11 SIVEXTRO... 11 sodium chloride... 58, 95 sodium chloride 0.45 %... 95 sodium chloride 0.9 %... 58 sodium chloride 3 %... 95 sodium chloride 5 %... 95 sodium fluoride... 98 sodium lactate... 95 sodium phenylbutyrate... 58 sodium polystyrene (sorb free)... 58 SOLTAMOX... 21 SOLU-CORTEF (PF)... 60 SOLU-MEDROL... 61 SOLU-MEDROL (PF)... 60 SOMATULINE DEPOT... 21 SOMAVERT... 66 sorine... 43 sotalol... 43 sotalol af... 43 SOVALDI... 5 SPIRIVA RESPIMAT... 92 SPIRIVA WITH HANDIHALER... 92 spironolactone... 46 spironolacton-hydrochlorothiaz... 46 sprintec (28)... 83 SPRYCEL... 21 sronyx... 83 ssd... 51 stavudine... 5 STELARA... 51 STIVARGA... 21 STRATTERA... 41, 42 STREPTOMYCIN... 11 STRIANT... 66 STRIBILD... 5 STRIVERDI RESPIMAT... 92 SUBOXONE... 34 SUBSYS... 32 SUCRAID... 70 sucralfate... 71 sulfacetamide sodium... 88 sulfacetamide sodium (acne) 53 sulfacetamide-prednisolone.. 88 sulfadiazine... 14 sulfamethoxazole-trimethoprim... 14 sulfasalazine... 70 sulfazine ec... 70 sulindac... 34 sumatriptan... 27 sumatriptan succinate... 27, 28 SUPRAX... 7 SUPREP BOWEL PREP KIT... 70 SURMONTIL... 42 SUSTIVA... 5 SUTENT... 21 SYLATRON... 73 SYLVANT... 22 SYMLINPEN 120... 64 SYMLINPEN 60... 64 SYNAGIS... 5 SYNAREL... 66 109 SYNERCID... 11 SYNRIBO... 22 SYPRINE... 58 T TABLOID... 22 tacrolimus... 22, 52 TAFINLAR... 22 TAMIFLU... 5 tamoxifen... 22 tamsulosin... 93 TARCEVA... 22 TARGRETIN... 22 tarina fe... 84 TASIGNA... 22 TAZORAC... 53 taztia xt... 46 TECFIDERA... 28 TEFLARO... 7, 8 TEGRETOL XR... 26 TEKTURNA... 47 TEKTURNA HCT... 47 telmisartan... 47 telmisartan-amlodipine... 47 telmisartan-hydrochlorothiazid... 47 TENIVAC (PF)... 76 terazosin... 47 terbinafine hcl... 2 terbutaline... 92 terconazole... 81 TESTIM... 66 TESTOSTERONE... 66 testosterone cypionate... 66 testosterone enanthate... 66 TETANUS,DIPHTHERIA TOX PED(PF)... 76 TETANUS-DIPHTHERIA TOXOIDS-TD... 76 tetracycline... 14 THALOMID... 22 theophylline... 92 THIOLA... 58 thioridazine... 42 thiothixene... 42 THYMOGLOBULIN... 76 tiagabine... 26 ticlopidine... 49 TIKOSYN... 43 timolol maleate... 47, 85 tinidazole... 11

TIVICAY... 5 tizanidine... 29 TOBI PODHALER... 11 TOBRADEX... 87 tobramycin... 85 tobramycin in 0.225 % nacl.. 11 tobramycin in 0.9 % nacl... 11 tobramycin sulfate... 11 tobramycin-dexamethasone.. 87 TOBREX... 85 tolazamide... 64 tolbutamide... 64 tolmetin... 34 tolterodine... 93 topiramate... 26 toposar... 22 topotecan... 22 TORISEL... 22 torsemide... 47 TPN ELECTROLYTES... 95 TRACLEER... 92 TRADJENTA... 64 tramadol... 34 tramadol-acetaminophen... 34 trandolapril... 47 tranexamic acid... 49, 81 TRANSDERM-SCOP... 70 tranylcypromine... 42 travasol 10 %... 97 TRAVATAN Z... 87 travoprost (benzalkonium)... 87 trazodone... 42 TREANDA... 22 TRECATOR... 11 TRELSTAR... 22 tretinoin... 53 tretinoin (chemotherapy)... 22 triamcinolone acetonide. 56, 59 triamterene-hydrochlorothiazid... 47 triderm... 56 trifluoperazine... 42 trifluridine... 85 trihexyphenidyl... 27 tri-legest fe... 84 trilyte with flavor packets... 70 trimethoprim... 14 trinessa (28)... 84 tri-previfem (28)... 84 TRISENOX... 23 tri-sprintec (28)... 84 TRIUMEQ... 5 trivora (28)... 84 TROPHAMINE 10 %... 97 TROPHAMINE 6%... 97 trospium... 93 TRULICITY... 64 TRUMENBA... 76 TRUVADA... 5 TWINRIX (PF)... 76 TYBOST... 5 TYGACIL... 11 TYKERB... 23 TYPHIM VI... 76 TYSABRI... 28 TYVASO... 92 TYZEKA... 5 TYZINE... 59 U UCERIS... 70 ULORIC... 77 ULTRESA... 70 unithroid... 67 ursodiol... 70 UVADEX... 52 V VAGIFEM... 81 valacyclovir... 6 VALCHLOR... 52 VALCYTE... 6 valganciclovir... 6 valproate sodium... 26 valproic acid... 26 valproic acid (as sodium salt)... 26 valsartan... 47 valsartan-hydrochlorothiazide... 47 vancomycin... 15 vandazole... 81 VAQTA (PF)... 76 VARIVAX (PF)... 77 VASCEPA... 50 VECAMYL... 50 VECTIBIX... 23 VELCADE... 23 velivet triphasic regimen (28)... 84 venlafaxine... 42 VENTAVIS... 92 110 VENTOLIN HFA... 92 VERAMYST... 92 verapamil... 47 VERSACLOZ... 42 VESICARE... 93 vestura (28)... 84 VEXOL... 88 VIBRAMYCIN... 14 vicodin... 33 vicodin es... 32 vicodin hp... 32 VICTOZA 3-PAK... 64 VIDEX 2 GRAM PEDIATRIC... 6 VIGAMOX... 85 VIIBRYD... 42 VIMPAT... 26 vinblastine... 23 vincasar pfs... 23 vincristine... 23 vinorelbine... 23 VIOKACE... 70 VIRACEPT... 6 VIRAMUNE XR... 6 VIRAZOLE... 6 VIREAD... 6 VITEKTA... 6 VOLTAREN GEL... 34 voriconazole... 2, 3 VOTRIENT... 23 VPRIV... 66 vyfemla (28)... 84 VYTORIN 10-10... 50 VYTORIN 10-20... 50 VYTORIN 10-40... 50 VYTORIN 10-80... 50 W warfarin... 49 water for irrigation, sterile... 58 WELCHOL... 50 wymzya fe... 84 X XALKORI... 23 XARELTO... 49 XELJANZ... 79 XENAZINE... 28 XEOMIN... 77 XGEVA... 15 XIFAXAN... 11 XIGDUO XR... 64

XOLAIR... 92 XOPENEX HFA... 92 XTANDI... 23 xulane... 81 XYREM... 42 Y YERVOY... 23 YF-VAX (PF)... 77 Z zafirlukast... 92 zaleplon... 42 ZALTRAP... 23 ZANOSAR... 23 ZAVESCA... 66 ZELAPAR... 27 ZELBORAF... 23 ZEMAIRA... 58 ZEMPLAR... 66 zenatane... 53 zenchent (28)... 84 zenchent fe... 84 ZENPEP... 70 zenzedi... 42 ZERBAXA... 8 ZETIA... 50 ZIAGEN... 6 zidovudine... 6 ZINECARD (AS HCL)... 15 ZIOPTAN (PF)... 87 ziprasidone hcl... 42 ZIRGAN... 85 zoledronic acid... 66 zoledronic acid-mannitol-water... 58 ZOLINZA... 23 zolmitriptan... 28 zolpidem... 42 ZOMACTON... 73 ZOMETA... 67 zonisamide... 26 ZONTIVITY... 49 ZORBTIVE... 74 ZORTRESS... 23 ZOSTAVAX (PF)... 77 ZOSYN IN DEXTROSE (ISO- OSM)... 13 zovia 1/35e (28)... 84 zovia 1/50e (28)... 84 ZUBSOLV... 34 ZYDELIG... 23 ZYKADIA... 23 ZYLET... 87 ZYPREXA RELPREVV... 42 ZYTIGA... 23 ZYVOX... 11 111

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