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HR Is “Kind-Of” Going Paperless Only Because Some Forms Still Need to be Printed, Completed, and Returned

October 14th Open Enrollment Meetings (OE) Updated Plan Documents are given out to employees at our OE meeting. The packet will also be available on our employee portal.

January 1, 2020 2020 Plan Year Begins! Plan Documents and related information (including forms) will be available through our employee portal including links to other providers for your convenience.

Avoid Lost / Misplaced Documents Save Time Looking for Information

Employee Portal = Information

Future Plan Documents Changes and Updates Employees who currently have city email address will automatically be sent information by email. And if you don’t have a city email, but are OK with getting notified (similar to when paycheck stubs are ready for review) just provide your personal email address to HR during Open Enrollment Meetings on October 14th.

employee.warsaw.in.gov

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City of Warsaw 2020 Open Enrollment Information Annual Benefit / Open Enrollment

Your Benefit Choices Are Up to You Between Monday, October 14th and Monday October 28th employees eligible for benefits will have the opportunity to choose benefits for plan year 2020. Annual Benefit Open Enrollment (OE) is the only time you can choose plans that work best for you and your family. And then, once enrolled, you won’t be able to change benefits until our next Annual Benefit OE unless a COBRA qualifying event in one’s life triggers a 30-day window for an employee to make a benefit election change outside of the annual OE period. Below you will see what is considered a COBRA “Qualifying Event” and what “Supporting Documentation” must be attached to a fully completed and signed by the employee enrollment form. Completed forms must be returned to Human Resources within 30-days of the qualifying event with supporting documentation. Qualifying Event Examples

Supporting Documentation Examples

Marriage Divorce Change in Spouse’s Employment Status/Loss of Health Coverage Birth Adoption/Guardianship Death Enrolled with Medicare/Medicaid or Loss of Medicare/Medicaid Change of Child Custody Requiring Health Coverage

Marriage Certificate Divorce Degree Document From Plan or Employer With Loss of Coverage Date Birth Certificate Court Order For Adoption/Guardianship Death Certificate Government Certification That Coverage Was Gained/Lost Court Documentation/Qualified Medical Child Support Order

As a reminder, notices and plan documents are available for view or download on our “employee” portal at: employee.warsaw.in.gov. And, as soon as we receive them from our providers for plan year 2020 – those will be added under the 2020 Benefits tab! If you have questions, or prefer hard copies of Plans (or change forms) please let me know. Sincerely, Jennifer Human Resources

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City pays for all or part of the premiums and/or employee contributes towards

INSURANCE PLANS

Medical Insurance … Pg. 4 Preventative Prescription Updates Preventive, Prescription, Prescription Exclusions My-UHC, Telemedicine, Other Information Advantage/Essential Drug List Can be Found On Employee Portal Prescription Step Therapy My-UHC; Telemedicine; Other Vision Insurance … Pg. 5 Dental Insurance … Pg. 6 Short-Term Disability … Pg. 7 Long-Term Disability … Pg. 7 Life Insurance … Pg. 7

Both the city and employee contribute towards these retirement funds.

PENSION/Retirement INPRS and 77-Fund

The city doesn’t pay for any premiums or make contributions (but will payroll deduct).

OTHER PLANS America Fidelity OneAmerica (457 savings)

Pg. 8

… …

Pg. 9 Pg. 9

WELLNESS / RALLY Tobacco Free Policy Tobacco Use Surcharge Rally Wellness Free Blood Draws

… … … …

Pg. 10

Pg. 12

Pg. 11 Pg. 12 Pg. 12

NOTICES /Instructions Notices

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Medical Plan UHC Plus / AIM Medical Trust - 2020 Summary Plan Documents Enclosed Monthly contributions (shown below) are divided in half, and taken the first and second payroll of every month. Voluntary deductions for elected benefits or programs will also be in accordance with this same schedule.

Plan D - PPO

Non-Tobacco User

Tobacco User Surcharge Applied

(EE) Employee Only (ES) Employee + Spouse (EC) Employee + Child(ren) (EF) Employee + Spouse + Child(ren) (EE) Employee Only (ES) Employee + Spouse (EC) Employee + Child(ren) (EF) Employee + Spouse + Child(ren)

Plan F – High Deductible Health Plan (HDHP)

Non-Tobacco User

Tobacco User Surcharge Applied

Monthly Medical Insurance Premium City Total Contribution Premium $37.56 $720.95 $758.51 $75.10 $1,441.93 $1,517.03 $71.34 $1,369.82 $1,441.16 $108.90 $2,090.76 $2,199.66 $62.56 $695.95 $758.51 $100.10 $1,416.93 $1,517.03 $96.34 $1,344.82 $1,441.16 $133.90 $2,065.76 $2,199.66

Employee Contribution

(EE) Employee Only (ES) Employee + Spouse (EC) Employee + Child(ren) (EF) Employee + Spouse + Child(ren) (EE) Employee Only (ES) Employee + Spouse (EC) Employee + Child(ren) (EF) Employee + Spouse + Child(ren)

Monthly Medical Insurance Premium City Total Contribution Premium $33.38 $640.78 $674.16 $66.76 $1,281.56 $1,348.32 $63.42 $1,217.50 $1,280.92 $96.80 $1,858.27 $1,955.07 $58.38 $615.78 $674.16 $91.76 $1,256.56 $1,348.32 $88.42 $1,192.50 $1,280.92 $121.80 $1,833.27 $1,955.07

Employee Contribution

The city will contribute money into a Health savings Account (HSA) for eligible employees who elect Plan F – HDHP. The quarterly city contributions are as follows: EE-$125.00, ES-$156.25, EC-$168.75, EF-$187.50. Employees must be employed by the first day of the month and at the beginning of the quarter. There are no “partial/or pro-rated contributions”. We partner with 1st Source Bank for HSA contributions. The employee is responsible for setting up their savings account if electing Plan F. Employees may also contribute to their HSA through payroll deduction, upon completion of deduction forms. Note: Our agreement with 1st Source states “no account fees” will be charged for employees. Please check statements carefully!

* As a reminder, notices and plan documents are available for view or download on our employee portal at: employee.warsaw.in.gov. And, as soon as we receive them from our providers for plan year 2020 – those will be added!

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Vision Plan Vision Through VSP / AIM Medical Trust Monthly contributions (shown below) are divided in half, and taken the first and second payroll of every month. Monthly Employee Contribution Employee Only (EE) $6.00 Employee/Spouse (ES) $12.00 Employee/Child(ren) (EC) $13.00 Employee/Family (EF) $21.00

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YOUR VSP VISION BENEFITS SUMMARY AIM MEDICAL TRUST (Plan 1) and VSP provide you with a choice of affordable vision plans. Choose the eye care essentials to give your eyes extra love. Benefit

PROVIDER NETWORK: VSP Choice EFFECTIVE DATE: 01/01/2020

Description

Copay

Frequency

Your Coverage with a VSP Provider WellVision Exam

Focuses on your eyes and overall wellness

PRESCRIPTION GLASSES

$10

Every calendar year

$20

See frame and lenses

Frame

$150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $80 Costco® frame allowance

Included in Prescription Glasses

Every other calendar year

Lenses

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children

Included in Prescription Glasses

Every calendar year

Lens Enhancements

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements

Contacts (instead of glasses)

$150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)

Diabetic Eyecare Plus Program

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$0 $95 - $105 $150 - $175

Every calendar year

Up to $60

Every calendar year

$20

As needed

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Extra Savings

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details. Exam ............................................................ up to $45 Frame ........................................................... up to $70 Single Vision Lenses .............................. up to $30

Lined Bifocal Lenses .............................. up to $50 Lined Trifocal Lenses ............................. up to $65

Progressive Lenses ................................. up to $50 Contacts .................................................... up to $105

Coverage with a retail chain may be different or not apply. Once your benefit is effective, visit vsp.com for details. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

*Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Ask your VSP network doctor for more details. ©2019 Vision Service Plan. All rights reserved. VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.


Dental Plan Self-Insured – Administered Through Group Administrators Enclosed New Plan Documents This Schedule of Benefits includes the benefits available; coverage amounts and maximum amounts that apply under the Plan. However, plan payment is not based solely on the Schedule of Benefits. For a complete understanding of whether a particular charge will be paid and at what level, all provisions outlined in this document can found in the Plan Document.

Amount of Monthly Employee Contributions to Plan Employee Only (EE) $10.50 Employee/Spouse (ES) $15.00 Employee/Child(ren) (EC) $12.00 Employee/Family (EF) $17.50

Pre-populated “Paper” Dental Enrollment Forms are enclosed. Please review, make any changes, signed to confirm benefits. These are also due on/by October 28 th. PLEASE place completed forms in a secure/sealed envelope made to my attention (Jennifer/HR)

WHO CAN BE ON OUR DENTAL PLAN? ELIGIBLE CLASSES OF DEPENDENTS - A family member of an Employee will become eligible for Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member satisfies the requirements for Dependent coverage. A "Dependent" is any one of the following persons: • A covered Employee’s Spouse and children from birth to the limiting age of 26 years (or up to age 27 in enrolled in fulltime school) who reside in the United States. When the child reaches the Plan's limiting age, coverage will end at the end of the calendar year following the dependent’s 26th birthday. • The term “Spouse” means the spouse of the employee under a legally valid existing marriage, unless court ordered separation exists. The Plan Administrator may require documentation proving a legal marital relationship. The term “Child” means: A. An Employee’s own natural children (if an employee is divorced or separated, and there is a court decree which establishes financial responsibility for medical and health expenses for his/her natural children, the plan will consider them “children” regardless of the residence); B. An Employee’s legally adopted child (or one for whom legal adoption proceedings have been initiated) living in the same house as the Employee; C. All step-children living in the same house with and Employee and his/her spouse who are principally dependent on the employee for maintenance and support, and living with the Employee in a regular parent-child relationship. Stepchildren will not be included as dependents when they are not living in the same house, regardless as to whether they are included as a dependent for Federal Income Tax purposes. The child must be: 1. Twenty-six (26) years of age or younger, or if enrolled full-time in school, less than twenty-seven (27); 2. Unmarried; 3. Principally dependent upon the employee for support and maintenance, and; 4. Not regularly employed by one or more employers on a full-time basis, exclusive of scheduled vacation periods. SCHEDULE OF BENEFITS: Verification of Eligibility: Please refer to the numbers on your ID cards. Call these numbers to verify eligibility for Plan benefits before the charge is Incurred. DENTAL BENEFITS: All benefits are subject to the exclusions and limitations described more fully herein including, but not limited to, the Plan Administrator’s determination that: a) care and treatment is Medically Necessary; and b) that charges are Reasonable and Customary; that services, supplies and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the “Defined Terms” section of your plan document. DENTAL PERCENTAGE PAYABLE (NO DEDUCTIBLE FOR ALL SERVICE TYPES): Class A Services - Preventive ……………………………………….. 100% Preventive Exams and Cleanings are limited to two per year, but no more than one every 6 months. Class B Services - Basic …………………………………………….. 50% Class C Services - Major ……………………………………………. 50% Class D Services - Orthodontia…………………………………… 50% MAXIMUM BENEFIT AMOUNT: For other than Class D - Orthodontia, Calendar Year maximum, per Covered Person ….. $1,000.00 For Class D - Orthodontia, Lifetime maximum, per Covered Person ……………………………. $1,000.00

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Short-Term Disability Insurance (STD) Self-Insured – Administered through Group Administrators Enclosed New Plan Documents Note: STD runs concurrent with our Family Medical Leave (FML) policy. Weekly Indemnity Benefits will begin only after exhaustion of banked or accrued benefit time. When time has been exhausted, the employee may be eligible to receive, upon completion of applications and medical documentation, Weekly Indemnity Benefits.

Benefit Description / Plan Limitations • • •

Maximum Weekly Benefit - 70% of base weekly earnings not to exceed $600 per week ($50 minimum per week) Maximum Payment Period - 12 weeks (within a 365-day period) Waiting Period for Benefits for Non-Work-Related Illnesses or Injury is 7 days*

* Benefits begin after the waiting period shown in the Schedule of Benefits, but in no event prior to the date of first treatment by a doctor.

Monthly Employee Contribution

Please Note: Benefits will be paid out in gross, meaning that the employee will be responsible for any taxes due as a result of the benefit.

Employees eligible for these benefits (i.e. full-time) are not required to contribute toward this benefit; the city pays 100% of the premium.

Long-Term Disability Insurance (LTD) Standard Insurance Enclosed New Plan Documents Monthly Employee Contribution

Please Note: Benefits will be paid out in gross, meaning that the employee will be responsible for any taxes due as a result of the benefit.

Employees eligible for these benefits (i.e. full-time) are not required to contribute toward this benefit; the city pays 100% of the premium.

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Group Life Insurance Standard Insurance Enclosed New Plan Documents Monthly Employee Contribution

Please Note: Benefits will be paid out in gross, meaning that the employee will be responsible for any taxes due as a result of the benefit.

Employees eligible for these benefits (i.e. full-time) are not required to contribute toward this benefit; the city pays 100% of the premium.

A “NEW” Beneficiary Form Is Enclosed Please review, make any changes, signed to confirm benefits. These are also due on/by October 28 th.

PLEASE place completed forms in a secure/sealed envelope made to my attention (Jennifer/HR)

INPRS INDIANA Public Retirement System - Our Pension Plan Jim Neddeff will be at the Fireman’s Building for two separate meetings (9:00 am and again at 11:00 am) on October 22nd to talk about our INPRS plan.

Indiana Public Retirement System One North Capitol, Indianapolis, IN 46204.

Toll-Free: (888) 286-3544.

https://www.in.gov/inprs/ Public Employee Information: https://www.in.gov/inprs/publicemployees.htm Educational Video(s): https://www.in.gov/inprs/educational_videos.htm Member Handbook: http://online.flipbuilder.com/kaxi/bisn/mobile/index.html#p=1 Police/Fire 77-Fund Information: https://www.in.gov/inprs/publicemployees.htm Pension 77-Fund members can also contact your Pension Secretary

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American Fidelity Elective VOLUNTARY Benefits (i.e. FLEX Spending, Cancer Policy, Accident Protection, Life Insurances, etc.) American Fidelity serves as our Section 125 service provider, which allows employees to pay their portion of health/ dental premiums “before taxes” or “pre-taxed”. This is why every employee who is offered health/dental insurance must meet with them even if they do not elect optional benefits. Representatives from American Fidelity will be visiting departments October 23 rd – 25th for Section 125 plan service, and to wave or change optional benefits (FLEX Spending, Cancer Plan, Additional Life Insurance Plans, Accident Plans, etc.). Our Account Contact Is: Aram Touloukian Executive Account Manager (800) 654-8489, extension 7896 aram.touloukian@americanfidelity.com

OneAmerica (457 Savings Plan) Elective VOLUNTARY Benefit www.oneamerica.com or 1-800-249-6269 Account Contact: Amy Haupert ahaupert@gwnsecurities.com (cell) 317-797-2739 NOTE: Amy said she would be here in November (around Thanksgiving) to speak with employees.

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Tobacco Free Policy PURPOSE - The City of Warsaw (city) is committed to providing a safe and healthy workplace and to promoting the health and well-being of its employees. Because the city recognizes the hazards caused by exposure to environmental tobacco smoke, as well as the lifethreatening diseases linked to the use of all forms of tobacco, it shall be the policy of the city, effective January 1, 2017, to provide a tobacco-free environment for all employees and visitors. SMOKING CHARACTERIZATION - For purposes of this Policy “smoking” means the act of lighting, smoking or carrying a lighted or smoldering cigar, cigarette, pipe of any kind or any other device, including but not limited to e-cigarettes, used to burn tobacco or other like substances, and includes the use of oral tobacco products or “spit” tobacco. OUTLINE 1. This Policy applies to the following: a. Any areas of buildings occupied by a city employee. b. A vehicle owned or leased by the city. c. A visitor, customer and vendor of the city. d. A contractor or consultant and their employees working on city property. e. A full-time or part-time employee, an intern, temporary or seasonal employee, or volunteer. f. For off-site conferences and meetings, employees should follow smoking rules at specific designations and/or as outlined in SOP’s where indicated. 2. The use of tobacco products or smoking will NOT be allowed in any city vehicle at any time. 3. The use of tobacco products or smoking will NOT be allowed within the enclosed facilities of the city at any time. For purposes of this Policy, “facility or facilities” means any building, structure, improved or unimproved land, or any part of any building, structure, or land which is owned, used or occupied by the city. 4. The decision to provide an outside designated smoking area will be at the discretion of a Department Head in consultation with the Mayor. If a designated smoking area is permitted, the designated smoking area must comply with the following: a. The area must be located at least twenty (20) feet from a facility’s entryways, windows, vents and doorways, and not in any location that allows smoke to circulate back into a building. b. All materials used for smoking in this area, including, but not limited to, cigarette butts and matches, will be extinguished and disposed of in an appropriate container. c. Department Heads will ensure periodic cleanup of the designated smoking area. If the area is not properly maintained (for example, if cigarette butts are found on the ground), the area can be eliminated at the discretion of the Mayor. 5. Department Heads will discuss the issue of taking breaks with his/her staff, both tobacco and non-tobacco users. Together, they will develop effective solutions that do not interfere with the productivity of the staff. 6. An employee may not smoke or use tobacco products when they are performing the duties of their city position. For example, an employee may not smoke or use tobacco while performing duties which may include but are not limited to: mowing, repairing streets or sidewalks, inspections, landscaping, or lifeguarding. ENFORCEMENT - The city believes that the spirit of thoughtfulness and cooperation which is characteristic at the city is adequate to resolve a dispute which might arise under this Policy. Where a dispute cannot be resolved, the rights of the non-tobacco user shall be given precedence. 1.

2.

To resolve a complaint about tobacco use, see below: a. A complaint about the application of this Policy to the city workplace should be brought to the attention of a Department Head or Human Resources. b. The complaint should be submitted in writing and identify specific objections. The city will investigate the complaint when appropriate, and resolve it in accordance with this Policy or other applicable city rules and policies. c. No employee shall be subject to any form of retaliation for raising a complaint under or asking a question about this Policy. An employee who knowingly violates this Policy, will subject to disciplinary action up to and including termination of employment.

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Wellness Initiative Tobacco Use Surcharge SURCHARGE EXPLANATION - The surcharge, by way of employees certifying their tobacco-user status, will be completed during open enrollment for benefits annually. Employees covered by the City of Warsaw’s Medical Plan who do not certify their status will be considered a Tobacco-User and will be surcharged as outlined below.

• Tobacco User. For purposes of this Policy, “smoking” means the act of lighting, smoking or carrying a lighted or smoldering cigar, cigarette, pipe of any kind or any other device, including but not limited to e-cigarettes, used to burn tobacco or other like substances, and includes the use of oral tobacco products or “spit” tobacco . (Religious or ceremonial use of tobacco is allowed, such as by Alaska natives or Native Americans).

• Tobacco/Non-Tobacco User Definition. For the purpose of this Program, a Non-Tobacco user is defined as any employee who does not use tobacco products, and a Tobacco user is defined as any employee who uses tobacco products. The Wellness Initiative Program was introduced during Open Enrollment in 2016 and applied to all employees who were tobacco users and who were covered on any of the City of Warsaw’s Medical Plans. SURCHARGE DESIGN - The Surcharge gradually increased over several plan years, and continues for 2020. Tobacco users will be surcharged a monthly amount of $25.00. A Tobacco-User is defined as any employee who uses tobacco products “more than one-time(s) per month” regardless of the method of use. A Tobacco Non-Use Affidavit is completed “online” when enrolling for Medical Benefits through the TRUST’s portal. NOTE: If your Tobacco use or status changes in the year, the employee is required to complete a new affidavit and return it to HR to either (1) eliminate the surcharge, or (2) add the surcharge

Ready To Quit? Please see Advantage and Essential Drugs section on covered Tobacco Cessation Medications and the criteria for a member to qualify for the no-cost medications. Outside of the health plan, members can access Quit Now at https://www.smokefree.gov/expert.aspx - this is a free, phone based service with educational materials, coaches, and referrals to local resources to help quit tobacco use (1-800-QUIT NOW) 1-800-784-8669) and https://smokefree.gov/tools-tips/text-programs offers smoke-free Text Messaging Programs and phone apps.

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Free Blood-Draw Opportunity Notices and Powerpoint presented at OE meeting is available at employee portal: employee.warsaw.in.gov

Wellness Initiative / Rally Notices and Powerpoint presented at OE meeting is available at employee portal: employee.warsaw.in.gov

Notices / OE Meeting Powerpoint Notices and Powerpoint presented at OE meeting is available at employee portal: employee.warsaw.in.gov

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Preventive care guidelines for children and adults.


Keeping a focus on regular preventive care can help you — and your family — stay healthier. Preventive care can help you avoid potentially serious health conditions and/or obtain early diagnosis and treatment. Generally, the sooner your doctor can identify and treat a medical condition, the better the outcome. Under the Affordable Care Act (ACA),1 you can get certain preventive health care services, covered at 100 percent, without any cost to you. Just obtain your preventive care from a health plan network provider. Diagnostic (non-preventive) services are also covered, but you may have to pay a copayment, coinsurance or deductible. Check your plan documents to make sure.

Preventive care guidelines for children.2

Recommended preventive care services for children will vary based on age and may include some of the following: • Age-appropriate well-child examination. • Anemia screening. • Cholesterol screening for children 24 months and older. • Metabolic screening panel for newborns. • Age-appropriate immunizations. For more information, visit cdc.gov/vaccines. • Vision screening by primary care physician. • Oral health risk assessment, by primary care physician. • Fluoride application. • Hearing screening by primary care physician. • Autism and Developmental screening for children under age 3. • Counseling on the harmful effects of smoking and illicit use of drugs (children and adolescents). • Counseling for children on promoting improvements in weight. • Screening certain children at high risk for sexually transmitted diseases, lead, depression and tuberculosis. Not all children require all of the services identified above.³ Your doctor should give you information about your child’s growth, development and general health, and answer any questions you may have.

Help protect and maintain your child’s health with regular preventive care visits with a network doctor.


Preventive care screening guidelines and counseling services for adults.2 A preventive health visit can help you see how healthy you are now and help identify any health issues before they become more serious. You and your doctor can then work together to choose the care that may be right for you. Recommended preventive care services may include the following: • Wellness Examinations.

• Gestational Diabetes Mellitus Screening — during pregnancy.

• Well-Woman Visits — including routine prenatal visits.

• Healthy Diet Behavioral Counseling — for persons with cardiovascular disease risk factors, in a primary care setting.

• Abdominal Aortic Aneurysm Screening — for age 65–75 years who have ever smoked. • Alcohol Screening and Brief Counseling — screening during wellness examinations. Brief counseling interventions for certain patients. • Bacteriuria Screening — during pregnancy. • Blood Pressure Screening — at each wellness examination. Certain patients may also require ambulatory blood pressure measurements outside of a clinical setting. Check with your doctor. • Breastfeeding Primary Care Interventions, Counseling, Support and Supplies — during pregnancy and after birth. Includes personal use electric breast pump. • Cervical Cancer Screening (Pap Smear) — women age 21–65 years old.

• Hepatitis B Virus Infection Screening — for persons at high risk. • Hepatitis C Virus Infection Screening — one-time screening for adults born between 1945–1965, or, persons at high risk. • Human Immunodeficiency Virus (HIV) Screening — for all adults. • Human Papillomavirus DNA Testing — for women age 30–65. • Immunizations — FDA approved and have explicit ACIP recommendations for routine use. For more information, visit cdc.gov/vaccines. • Intimate Partner Violence, Interpersonal and Domestic Violence, Counseling and Screening — during wellness examination. • Latent Tuberculosis Infection Screening — for persons at increased risk.

• Chemoprevention of Breast Cancer, Counseling — for women • Lung Cancer Screening with Low-Dose CT Scan — for at high risk of breast cancer, but low risk for adverse effects. age 55–80 years with at least a 30 pack-year history (with prior authorization). • Chlamydia and Gonorrhea Infection Screening — for sexually active women age 24 and younger, and older women at • Mammography Screening. increased risk. • Obesity Screening and Counseling — at each • Cholesterol Screening — for age 40–75 years. wellness examination. Certain patients may need medical nutrition therapy. • Colorectal Cancer Screening — for age 50–75 years. Ask your physician about screening methods and intervals • Osteoporosis Screening — women age 65 and older, and for screening. younger women at increased risk. • Contraceptive Methods (Including Sterilizations) — FDA• Rh Incompatibility Screening — during pregnancy. approved methods of contraception for women, including • Sexually Transmitted Infections, Behavioral Counseling to patient education and counseling. Prevent — behavioral counseling for adults who are sexually • Depression Screening — for all adults, in a primary care setting. active or otherwise at increased risk, in a primary care setting. • Diabetes Screening — for age 40–70 who are overweight • Skin Cancer, Behavioral Counseling to Prevent — at each or obese or for those of any age that have a history of wellness examination, for young adults up to age 24 years. gestational diabetes. • Syphilis Screening — for adults at increased risk. • Falls Prevention Counseling — during wellness examination, • Tobacco Cessation, Screening, Behavioral for community-dwelling older adults. Counseling — screening, and behavioral counseling for adults • Genetic Counseling and Evaluation for BRCA Testing, and who smoke, in a primary care setting (refer to pharmacy BRCA Lab Testing — lab testing requires prior authorization. vendor for pharmacotherapy for tobacco cessation).

1


For more information about preventive guidelines for your age and gender, visit uhc.com/preventivecare.

2

Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age and other health factors. UnitedHealthcare also covers other routine services that may require a copay, coinsurance or deductible. Always refer to your plan documents for specific benefit coverage and limitations or call the toll-free member phone number on your health plan ID card. These guidelines are based, in part, on the requirements of the Patient Protection and Affordable Care Act, and recommendations of the U.S. Preventive Services Task Force (USPSTF), the Health Resources & Services Administration (HRSA) of the U.S. Department of Health and Human Services, and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). Individuals with symptoms or at high risk for disease may need additional services or more frequent interventions that may not be covered as a preventive benefit. These guidelines do not necessarily reflect the vaccines, screenings or tests that will be covered by your benefit plan. These clinical guidelines are provided for informational purposes only, and do not constitute medical advice. Preventive care benefits may not apply to certain services listed above. Always refer to your plan documents for specific benefit coverage and limitations or call the toll-free member phone number on your health plan ID card. 3

Development, psychosocial and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits. These guidelines represent a consensus by the American Academy of Pediatrics (AAP) and Bright Futures. The recommendations in this statement do not indicate an exclusive course of treatment or standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Discuss with your doctor how these guidelines may be right for your child, and always consult your doctor before making any decisions about medical care. These clinical guidelines are provided for informational purposes only, and do not constitute medical advice. Preventive care benefits may not apply to certain services listed above. Always refer to your plan documents for your specific coverage. Source: Centers for Disease Control and Prevention, Recommended immunization schedules for children and adolescents aged 18 years or younger - United States, 2019, at: https://www.cdc.gov/vaccines/schedules/ index.html. Additional information about the vaccines in this schedule, extent of available data, including a full list of footnotes and contraindications for vaccination is also available at cdc.gov/vaccines or from the CDC-INFO Contact Center at 1-800-CDC-INFO (1-800-232-4636) in English and Spanish, 8 a.m.–8 p.m. Eastern Time, Monday–Friday, excluding holidays. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. 9471577.0 7/19 ©2019 United HealthCare Services, Inc. 19-13072-A




Pharmacy |  Preventive Vaccines

Preventive vaccine coverage under the pharmacy benefit. Preventive Vaccination List Category

Name

Influenza

Afluria®, Afluria PF®, Afluria Quad®, Afluria Quad PF®, Fluad®, Fluarix Quad®, Flublok Quad®, Flulaval Quad®, Fluzone HD®, Fluclvx Quad®, Flumist Quad®

Haemophilus Influenza B (HiB)

ActHIB®, Hiberix®, PedvaxHIB®

Hepatitis A1

Havrix®, Twinrix®, VAQTA®

Hepatitis B

Havrix®, Twinrix®, VAQTA®

Human Papilloma Virus (HPV)

Engerix-B®, HEPLISAV-B®, Recombivax HB®

Measles, Mumps, Rubella (MMR)

Gardasil9®

Meningococcal (MenB; MenB-4C; MenB-FHbp; Hib-MenCY; MPSV4; MCV4; MenACWY-CRM)

MMR II®

Pneumococcal conjugate

Bexsero®, Menactra®, Menveo®, Trumenba®

Pneumococcal polysaccharide (PPSV23)

Prevnar 13® (PCV13)

Polio (IPV)

Pneumovax 23®

Tetanus and diphtheria (Td)

Ipol®

Tetanus, diphtheria toxoids and acellular pertussis (Tdap)

Adacel®, Boostrix®

Varicella (VAR) (‘chicken pox’)

Varivax®

Zoster / Shingles (HZV/ZVL, RZV)

Shingrix®, Zostavax®

Contact your UnitedHealthcare representative for additional information. 1

Hepatitis A vaccinations are not covered under the pharmacy or medical benefit at Wagreens locations. UnitedHealthcare and the dimensional U logo are trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. ©2019 United HealthCare Services, Inc. 1334118-190712


Nondiscrimination notice and access to communication services UnitedHealthcareÂŽ and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online:

UHC_Civil_Rights@uhc.com

Mail:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents. You can also fi e a complaint with the U.S. Dept. of Health and Human Services. Online:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone:

Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail:

U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.


Prescription drugs moving to a higher tier

The following medications are moving to a higher tier. Medications may move from a lower tier to a higher tier when they are more costly and have available lower-cost options. Therapeutic Use

Medication Name

Tier Placement

Lower-Cost Options

FML Eye Inflammation

FML Forte

prednisolone (generic Pred Forte)

2u3

Pred Mild

Prescription drugs excluded from benefit coverage

We evaluate prescription drugs based on their total value, including how a drug works and how much it costs. When several drugs work in the same way, we may choose to exclude the higher-cost option. Effective Jan. 1, 2020, the drugs listed below may be excluded from coverage or you may need to get a prior authorization. Sign into your online account to check which drugs your planUcovers and if there are anyInc. actions you need to take. Š2019 nited HealthCare Services, 100-19486 A dvantage 3-Tier PDL Update Summary

Therapeutic Use

Medication Name

8/19

Alternative Treatment Option(s)

Altreno

OTC Differin gel, tretinoin cream (generic Retin-A)

Minolira

minocycline immediate-release capsules (generic Minocin)

Seysara

doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Monodox), minocycline immediate-release capsules (generic Minocin)

ADHD

Dexedrine (Brand Only)

dextroamphetamine extended-release (generic Dexedrine)

Allergies

dexchlorpheniramine maleate (generic Ryclora)

OTC chlorpheniramine (generic Chlor-Trimeton)

Acne

Ryclora Anemia

Epogen Procrit

Angina

Ranexa (Brand Only)

Asthma

Albuterol HFA [Ventolin HFA authorized generic (Prasco)] Inhaler Pulmicort inhalation suspension (Brand Only)

Retacrit ranolazine (generic Ranexa) Ventolin HFA budesonide inhalation suspension (generic Pulmicort)

Blood Clots

Lovenox (Brand Only)

enoxaparin (generic Lovenox)

Constipation

lactulose (generic Kristalose)

lactulose oral solution

Lonhala Magnair

Incruse Ellipta, Spiriva Handihaler/Resipmat, Yupelri

Tudorza Pressair

Incruse Ellipta, Spiriva Handihaler/Resipmat

Cough and Cold

Hydrocodone/Guaifenesin 2.5 mg/200 mg/5 mL Solution

guaifenesin/codeine solution (Cheratussin AC)

Diabetes

Levemir

Basaglar, Tresiba

Glaucoma

Xalatan (Brand Only)

latanoprost (generic Xalatan)

High Blood Pressure

Norvasc (Brand Only)

amlodipine (generic Norvasc)

COPD


Therapeutic Use

Medication Name

Alternative Treatment Option(s)

Hormone Replacement

Minivelle (Brand Only)

estradiol patch (generic Minivelle), Vivelle-Dot

Prometrium (Brand Only)

progesterone (generic Prometrium)

Infections

Tolsura

itraconazole capsule (generic Sporanox)

Ilumya

Cimzia, Cosentyx, Humira, Skyrizi, Stelara, Tremfya

Plaquenil (Brand Only)

hydroxychloroquine (generic Plaquenil)

Inflammatory Conditions

Siliq

Cimzia, Cosentyx, Humira, Skyrizi, Stelara, Tremfya

Taltz Iron Overload

Exjade (Brand Only)

desferasirox (generic Exjade)

Mental Health

Abilify MyCite

aripiprazole (generic Abilify)

Neuropathic Pain

ZTLido

lidocaine patch (generic Lidoderm)

Fulphila

Neulasta

Nivestym

Zarxio

Udenyca

Neulasta

Neutropenia

©2019 U nited HealthCare Services, Inc. Parkinson's Disease Osmolex ER 100-19486 A dvantage 3-Tier PDL Update Summary

Pulmonary Hypertension Rosacea

Seizures

8/19

Letairis (Brand Only)

ambrisentan (generic Letairis)

Oracea

doxycycline hyclate 50 mg, 100 mg (generic Morgidox, Vibramycin), doxycycline hyclate 20 mg (generic Periostat), doxycycline monohydrate 50 mg and 100 mg (generic Monodox)

Klonopin (Brand Only)

clonazepam (generic Klonopin)

Sympazan Bryhali Cordran 0.025% cream

Skin Conditions

amantadine immediate-release

diflorasone diacetate 0.05% ointment (generic Psorcon) Halobetasol 0.05% (Lexette) foam Lexette

clobazam (generic Onfi), clonazepam (generic Klonopin), lamotrigine (generic Lamictal), topiramate (generic Topamax) fluocinonide 0.05% gel/solution (generic Lidex), desoximetasone 0.05% gel (generic Topicort) hydrocortisone valerate 0.2% cream (generic Westcort cream), prednicarbate 0.1% cream (generic Dermatop cream), fluticasone propionate cream 0.05% (generic Cutivate cream) clobetasol 0.05% ointment (generic Temovate), halobetasol 0.05% ointment (generic Ultravate) betamethasone 0.05% augmented gel (generic Diprolene), clobetasol propionate 0.05% gel/solution (generic Temovate)

Ultravate 0.05% lotion

1

Testosterone Replacement

Xyosted

testosterone injection, Testim

Thyroid Replacement

Cytomel (Brand Only)

liothyronine (generic Cytomel)

Coverage is determined by the consumer’s prescription drug benefit plan. lease consult plan documents regarding benefit overage and cost-share. Infertility coverage is determined by the consumer’s prescription drug benefit plan. or those who qualify, all infertility medications are required to be either fully excluded or fully covered. Prior authorization (sometimes referred to as precertifi ation) may be required for Oxford plans.


Advantage 3-Tier PDL Clinical Programs Update Summary

Updates to your prescription benefits Effective Jan. 1, 2020 Some prescription drugs may have programs or limits that apply. Below are the changes that will be effective Jan. 1, 2020. SL

Supply Limits

Supply Limits establish the maximum quantity of a drug that is covered per copay or in a specified ime frame. The drugs below will now be part of the Supply Limits program. Therapeutic Use

Medication Name

New Supply Limit

Revised Supply Limit

Retacrit - 2,000 units/1 ml vials Retacrit - 3,000 units/1 ml vials Anemia

12 mL (12 vials) per month

Retacrit - 4,000 units/1 ml vials Retacrit - 10,000 units/1 ml vials

8 mL (8 vials) per month

Retacrit - 40,000 units/1 ml vials

4 mL (4 vials) per month

Bosulif 400 mg tablets

31 tablets per month

Imbruvica 70 mg capsules

31 capsules per month

Imbruvica 140 mg capsules Cancer

31 capsules per month

Imbruvica 140 mg tablets; 280 mg tablets; 420 mg tablets; 560 mg tablets

31 tablets per month

Rubraca 250 mg tablets

124 tablets per month

Sprycel 80 mg tablets

31 tablets per month

Tasigna 50 mg capsules

124 capsules per month

Cystic Fibrosis

Kalydeco 25 mg oral granules

62 packets per month

Diabetes

Ozempic 2 mg/1.5 ml (0.5 mg injection) pen

1 pen per month

Electrolyte Imbalance

Samsca 15 mg tablets

90 tablets per year

Samsca 30 mg tablets

60 tablets per year

Severe Allergic Reactions

Symjepi 0.15 mg prefi led syringe Symjepi 0.3 mg prefi led syringe

2 pens per copay

Inflammatory Conditions

Actemra ACTpen 162 mg/0.9 mL autoinjector

4 autoinjectors per month

Skin Conditions

Triderm (triamcinolone) 0.5% cream

15 grams per copay

Š2019 United HealthCare Services, Inc. 100-19486 Advantage 3-Tier PDL Update Summary

8/19


N

Prior Authorization – Notification

Prior Authorization – Notifi ation requires additional clinical information to verify members benefit overage. Therapeutic Use

Medication Name

Electrolyte Imbalance

Samsca Tablet

Coverage is determined by the consumer’s prescription drug benefit plan. lease consult plan documents regarding benefit overage and cost-share. Prior authorization (sometimes referred to as precertifi ation) may be required for Oxford plans.

1

2

Referred to as First Start in New Jersey.

For additional information: Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, fin lower-cost options and more.

©2019 U nited HealthCare Services, Inc. 100-19486 A dvantage 3-Tier PDL Update Summary

8/19

Call the toll-free phone number on your ID card to speak with a Customer Service representative.


Nondiscrimination notice and access to communication services UnitedHealthcareÂŽ and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online:

UHC_Civil_Rights@uhc.com

Mail:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents. You can also fi e a complaint with the U.S. Dept. of Health and Human Services. Online:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone:

Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail:

U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.


Aim Medical Trust Prescription Program Standard Drug Exclusions Effective 1/1/20 Drug Name

Drug Type

Disease State

ABILIFY

Brand

ANTIPSYCHOTICS

ABSORICA

Brand

MISC SKIN CONDITION

ACANYA

Brand

MISC SKIN CONDITION

ACTICLATE

Brand

ANTIBIOTICS

ADAPALENE/BENZOYL PEROXIDE

Generic

MISC SKIN CONDITION

ADZENYS XR-ODT

Brand

ADHD

AFREZZA

Brand

DIABETES

AKTIPAK

Brand

MISC SKIN CONDITION

AMLODIPINE/OLMESARTAN MEDOXOMI

Generic

CARDIOVASCULAR

ANDROGEL

Brand

MALE AND FEMALE HORMONE REPLACEMENT

ANDROGEL PUMP

Brand

MALE AND FEMALE HORMONE REPLACEMENT

ANUSOL-HC

Brand

RECTAL PREPARATIONS

APIDRA

Brand

DIABETES

APIDRA SOLOSTAR

Brand

DIABETES

APLENZIN

Brand

DEPRESSION

AZELASTINE HCL

Generic

ALLERGIES

AZOR

Brand

CARDIOVASCULAR

BECONASE AQ

Brand

ALLERGIES

BENICAR

Brand

CARDIOVASCULAR

BENICAR HCT

Brand

CARDIOVASCULAR

BENZONATATE

Generic

COUGH AND COLD

BUNAVAIL

Brand

NARCOTIC ANALGESICS

BUPRENORPHINE HCL/NALOXONE HCL

Generic

NARCOTIC ANALGESICS

BUTRANS

Brand

NARCOTIC ANALGESICS

CAMBIA

Brand

MIGRAINE/PAIN RELIEF

CAPECITABINE

Generic

ONCOLOGY

CELEBREX

Brand

NON-NARCOTIC ANALGESICS

CELLCEPT

Brand

TRANSPLANT

CLINDAGEL

Brand

MISC SKIN CONDITION

CLINDAMYCIN PHOSPHATE/TRETINOI

Generic

MISC SKIN CONDITION

CLINDAMYCIN/BENZOYL PEROXIDE

Generic

MISC SKIN CONDITION

CLOBETASOL PROPIONATE

Generic

MISC SKIN CONDITION

CLONIDINE HCL ER

Generic

ADHD

COLCHICINE

Brand

GOUT

COPAXONE

Brand

MULTIPLE SCLEROSIS

CRESTOR

Brand

CHOLESTEROL LOWERING AGENTS

CYMBALTA

Brand

DEPRESSION

DARIFENACIN HYDROBROMIDE ER

Generic

OVERACTIVE BLADDER / INCONTINENCE

DAYTRANA

Brand

ADHD

DENAVIR

Brand

ANTIVIRALS

DEXMETHYLPHENIDATE HCL ER

Generic

ADHD

DEXMETHYLPHENIDATE HYDROCHLORI

Generic

ADHD

DICLOFENAC SODIUM

Generic

MISC SKIN CONDITION

DIOVAN

Brand

CARDIOVASCULAR

DIOVAN HCT

Brand

CARDIOVASCULAR

DOXYCYCLINE HYCLATE

Generic

ANTIBIOTICS

DOXYCYCLINE HYCLATE DR

Generic

ANTIBIOTICS

DYMISTA

Brand

ALLERGIES

ECOZA

Brand

TOPICAL ANTI-FUNGAL

EFFIENT

Brand

BLOOD CLOT/STROKE PREVENTION

ELETONE

Brand

MISC SKIN CONDITION 1


Drug Name

Drug Type

Disease State

EPINASTINE HCL

Generic

OPTHALAMIC AGENTS

EPINEPHRINE

Brand

SEVERE ALLERGIC REACTION

EPIPEN 2-PAK

Brand

SEVERE ALLERGIC REACTION

EPIPEN-JR 2-PAK

Brand

SEVERE ALLERGIC REACTION

FENOFIBRATE

Generic

CHOLESTEROL LOWERING AGENTS

FENOFIBRATE MICRONIZED

Generic

CHOLESTEROL LOWERING AGENTS

FENOFIBRIC ACID DR

Generic

CHOLESTEROL LOWERING AGENTS

FENORTHO

Generic

NON-NARCOTIC ANALGESICS

FLUOXETINE HYDROCHLORIDE

Generic

PREMENSTRUAL DYSPHORIC DISORDER

GRALISE

Brand

NEUROLOGIC

HPR PLUS

Brand

MISC SKIN CONDITION

HPR PLUS HYDROGEL KIT

Brand

MISC SKIN CONDITION

HYDROCODONE BITARTRATE/ACETAMI

Generic

NARCOTIC ANALGESICS

HYLATOPIC PLUS

Brand

MISC SKIN CONDITION

ILEVRO

Brand

OPTHALAMIC AGENTS

KAITLIB FE

Generic

CONTRACEPTION

LANTUS

Brand

DIABETES

LANTUS SOLOSTAR

Brand

DIABETES

LEXAPRO

Brand

DEPRESSION

LIPITOR

Brand

CHOLESTEROL LOWERING AGENTS

LORZONE

Brand

MUSCLE RELAXANTS

LOTEMAX

Brand

OPTHALAMIC AGENTS

MAXALT

Brand

MIGRAINE/PAIN RELIEF

MELODETTA 24 FE

Generic

CONTRACEPTION

METRONIDAZOLE

Generic

MISC SKIN CONDITION

MIBELAS 24 FE

Generic

CONTRACEPTION

MIGRANAL

Brand

MIGRAINE/PAIN RELIEF

MINOCYCLINE HCL

Generic

ANTIBIOTICS

MOMETASONE FUROATE

Generic

ALLERGIES

MYRBETRIQ

Brand

OVERACTIVE BLADDER / INCONTINENCE

NASONEX

Brand

ALLERGIES

NEORAL

Brand

TRANSPLANT

NEUPOGEN

Brand

BLOOD CELL STIMULATORS

NITROGLYCERIN LINGUAL

Generic

CARDIOVASCULAR

NOVOLIN 70/30 RELION

Brand

DIABETES

NOVOLIN N

Brand

DIABETES

NOVOLIN R RELION

Brand

DIABETES

NOVOLOG

Brand

DIABETES

NOVOLOG FLEXPEN

Brand

DIABETES

NOVOLOG PENFILL

Brand

DIABETES

NUVIGIL

Brand

ADHD

NYSTATIN/TRIAMCINOLONE

Generic

TOPICAL ANTI-FUNGAL

OKEBO

Generic

ANTIBIOTICS

OLMESARTAN MEDOXOMIL/AMLODIPIN

Generic

CARDIOVASCULAR

OLOPATADINE HYDROCHLORIDE

Generic

OPTHALAMIC AGENTS

ONEXTON

Brand

MISC SKIN CONDITION

ORTHO TRI-CYCLEN LO

Brand

CONTRACEPTION

OTOVEL

Brand

EAR CONDITION

OTREXUP

Brand

INFLAMMATORY CONDITIONS

OXYCONTIN

Brand

NARCOTIC ANALGESICS

PAROXETINE

Generic

MISC WOMEN'S HEALTH

PAZEO

Brand

OPTHALAMIC AGENTS

PENNSAID

Brand

MISC SKIN CONDITION

PENTASA

Brand

INFLAMMATORY CONDITIONS

PRAMIPEXOLE DIHYDROCHLORIDE ER

Generic

PARKINSON'S DISEASE

PRILOSEC

Brand

ULCER/ACID REFLUX/GERD 2


Drug Name

Drug Type

Disease State

PROLENSA

Brand

OPTHALAMIC AGENTS

PROTONIX

Brand

ULCER/ACID REFLUX/GERD

QNASL

Brand

ALLERGIES

QUILLIVANT XR

Brand

ADHD

RAYOS

Brand

ANTI-INFLAMMATORY (STEROIDS)

RELPAX

Brand

MIGRAINE/PAIN RELIEF

RESTASIS MULTIDOSE

Brand

OPTHALAMIC AGENTS

RETIN-A MICRO

Brand

MISC SKIN CONDITION

RETIN-A MICRO PUMP

Brand

MISC SKIN CONDITION

RISEDRONATE SODIUM DR

Generic

OSTEOPOROSIS

SAIZEN CLICK.EASY

Brand

GROWTH HORMONE DEFICIENCY

SAIZENPREP RECONSTITUTIONKIT

Brand

GROWTH HORMONE DEFICIENCY

SILENOR

Brand

INSOMNIA

SODIUM SULFACETAMIDE/SULFUR

Generic

MISC SKIN CONDITION

STAXYN

Brand

ERECTILE DYSFUNCTION

SUBOXONE

Brand

NARCOTIC ANALGESICS

SULFACLEANSE 8/4

Generic

MISC SKIN CONDITION

SUMAVEL DOSEPRO

Brand

MIGRAINE/PAIN RELIEF

TAMIFLU

Brand

ANTIVIRALS

TESTOSTERONE

Generic

MALE AND FEMALE HORMONE REPLACEMENT

TESTOSTERONE PUMP

Generic

MALE AND FEMALE HORMONE REPLACEMENT

TESTOSTERONE TOPICAL SOLUTION

Generic

MALE AND FEMALE HORMONE REPLACEMENT

TIROSINT

Brand

THYROID REPLACEMENT

TOLTERODINE TARTRATE

Generic

OVERACTIVE BLADDER / INCONTINENCE

TRETINOIN

Generic

MISC SKIN CONDITION

TRETINOIN MICROSPHERE

Generic

MISC SKIN CONDITION

TRICOR

Brand

CHOLESTEROL LOWERING AGENTS

TROKENDI XR

Brand

SEIZURE DISORDERS

TROSPIUM CHLORIDE

Generic

OVERACTIVE BLADDER / INCONTINENCE

VAGIFEM

Brand

MALE AND FEMALE HORMONE REPLACEMENT

VELTIN

Brand

MISC SKIN CONDITION

VESICARE

Brand

OVERACTIVE BLADDER / INCONTINENCE

VIAGRA

Brand

ERECTILE DYSFUNCTION

WELLBUTRIN XL

Brand

DEPRESSION

XIGDUO XR

Brand

DIABETES

ZIPSOR

Brand

NON-NARCOTIC ANALGESICS

ZOLPIDEM TARTRATE ER

Generic

INSOMNIA

ZORVOLEX

Brand

NON-NARCOTIC ANALGESICS

ZOVIRAX

Brand

ANTIVIRALS

ZYCLARA PUMP

Brand

MISC SKIN CONDITION

3


For our members

Preventive Care Medications

Advantage and Essential Prescription Drug List (PDL) $0 Cost-share Medications & Products

1,2,3

U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements4 The Affordable Care Act (ACA) makes certain preventive medications and supplements available to you at no cost – both prescription and over-the-counter (OTC). The following preventive medications are covered at 100% with $0 copay when: • Prescribed by a health care professional • Age and/or condition appropriate • Filled at a network pharmacy OTC

Medication/Supplement

Population

Reason

Aspirin – 81 mg

Women who are at risk for preeclampsia during pregnancy

Prevent preeclampsia during pregnancy

Aspirin – 81, 162 & 325 mg

Men age 45-79 Women age 55-79

Prevent cardiovascular disease

Folic acid 400 & 800 mcg

Women who are or may become pregnant

Prevent birth defects

Vitamin D – 400 & 1,000 units

Age 65 and over

Fall risk prevention

Bisacodyl EC Magnesium Citrate

Rx

PEG 3350 (generic Miralax) Recommended age 50-75 Only the OTC product is covered at $0 cost-share. The prescription version of this product may be covered with a copay or coinsurance depending on your plan.

Bowel preparation for colonoscopy needed for colon cancer screening

Medication/Supplement

Population

Reason

Recommended age 50-75

Bowel preparation for colonoscopy needed for colon cancer screening

Children age 0 -16 years

Prevent dental cavities if water source is deficient in fluoride

Generic Colyte 240/22.74 g sold as: PEG-3350/electrolytes Gavilyte-C Generic Golytely 236/22.7 g sold as: PEG-3350/electrolytes Gavilyte-G Generic Nulytely sold as: PEG-3350/NaCl/NaBicarbonate/KCl Gavilyte-N Trilyte Fluoride tablets, solution (not toothpaste, rinses)

1. Please note this list is subject to change. 2. Always refer to your benefit plan materials to determine your coverage for medications and cost-share. Some medications listed on the PDL may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern. 3. All branded medications are trademarks or registered trademarks of their respective owners. 4. The listed age limits are based on U.S. Preventive Services Task Force Recommendations; coverage for additional populations may also apply as required.

Continued }


Over-the-Counter Birth Control (contraceptives) for Women Birth Control Contraceptives (over-the-counter) Contraceptive films Contraceptive foams Contraceptive gels Contraceptive sponges Emergency birth control (contraceptives) (generic for Plan B, generic for Plan B One-Step)

The following forms of birth control (contraceptives) are available over-the-counter (OTC) and will be covered at $0 cost-share when prescribed by a health care professional and filled at a network pharmacy. Male forms of birth control (contraception) are not currently considered Preventive Care Medications under the Affordable Care Act.

Female condoms

Prescription Hormonal Birth Control (contraceptives) Brand Hormonal Birth Control (contraceptives) NuvaRing Generic Hormonal Birth Control (contraceptives) Altavera, Chateal, Kurvelo, Levonorgestrel/Ethinyl Estradiol 0.15/0.03 mg, Levora-28, Lillow, Marlissa, Portia-28 (generic Nordette) Alyacen 1/35, Cyclafem 1/35, Dasetta 1/35, Nortrel 1/35, Pirmella 1/35 (generic Ortho-Novum 1/35) Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (generic Ortho-Novum 7/7/7) Apri, Cyred, Desogestrel/Ethinyl Estradiol 0.15/0.03 mg, Emoquette, Enskyce, Isibloom, Juleber, Reclipsen (generic Desogen, Ortho-Cept) Aranelle, Leena (generic Tri-Norinyl) Aubra, Aviane, Delyla, Falmina, Larissia, Lessina, Levonorgestrel/Ethinyl Estradiol 0.1/0.02 mg, Lutera, Orsythia, Sronyx, Vienva (generic Alesse) Blisovi FE, Junel FE, Larin FE, Microgestin FE, Norethindrone/Ethinyl Estradiol/FE 1/0.02 mg, Tarina FE (generic Loestrin FE) Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norethindrone 35 mcg, Norlyda, Norlyroc, Sharobel (generic Micronor, Nor-Q-D) Caziant, Velivet (generic Cyclessa) Cryselle-28, Elinest, Low-Ogestrel (generic Lo/Ovral) Enpresse-28, Levonest, Levonorgestrel/Ethinyl Estradiol 6-5-10, Myzilra, Trivora-28 (generic Triphasil) Estarylla, Femynor, Mono-Linyah, MonoNessa, Norgestimate/Ethinyl Estradiol 0.25/0.035 mg, Previfem, Sprintec (generic Ortho-Cyclen) Ethynodiol Diacetate/Ethinyl Estradiol 1/0.05 mg, (generic Demulen 1/50) Introvale, Jolessa, Levonorgestrel/Ethinyl Estradiol 0.15/0.03 mg, Quasense, Setlakin (generic Seasonale) Kelnor 1/35, Zovia-1/35E (generic Demulen 1/35) Medroxyprogesterone Acetate 150 mg/mL (generic Depo-Provera) Necon 0.5/35, Nortrel 0.5/35, Wera 0.5/35 (generic Brevicon, Modicon) Necon 1/50 (generic Norinyl 1/50) Norgestimate/Ethinyl Estradiol 0.18-0.215-0.25/0.035 mg, Tri-Estarylla, Tri-Femynor, Tri-Linyah, Trinessa, Tri-Previfem, Tri-Sprintec (generic Ortho Tri-Cyclen) Xulane (generic Ortho-Evra) KEY Birth Control Pill (oral contraceptive) Birth Control Ring (contraceptive vaginal ring) Birth Control Shot (injectable contraceptive) Birth Control Patch (contraceptive transdermal patch)

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Prescription Cervical Caps and Diaphragms for Birth Control (contraceptives) Brand Cervical Caps Femcap Brand Diaphragms Caya Omniflex Wide-Seal

Prescription Emergency Birth Control (contraceptives) Brand Emergency Birth Control (contraceptives) ella Plan B One-Step Generic Emergency Birth Control (contraceptives) Aftera, EContra EZ, Fallback Solo, Levonorgestrel 1.5 mg, My Way, Next Choice One Dose, Opcicon One-Step, Option 2, React, Take Action (generic Plan B One-Step)

Tobacco Cessation Medications4 If you need help to quit smoking or using tobacco products, these preventive medications are available to you at $0 cost-share. To qualify, you need to: • Be age 18 or older.6 • Ask your doctor to obtain Notification/Prior Authorization if required.5,7,8,9 Your doctor will need to let us know you are also getting counseling to help you stop using tobacco products. • Get a prescription for these products from your doctor, even if the products are sold over-the-counter (OTC). • Fill the prescription at a network pharmacy. Up to two 90-day treatment courses are covered at no cost each year. Prior Authorization5,7,8,9 is required for each 90-day drug supply.

Over-the-counter Medications Requires Prior Authorization5,7,9

• Nicotine Replacement Gum • Nicotine Replacement Lozenge • Nicotine Replacement Patch • Bupropion sustained-release (generic Zyban) Tablet5,8,9

Prescriptions Requires Prior Authorization5,8,9

• Nicotrol Inhaler • Nicotrol Nasal Spray • Chantix Tablet

These three prescription medications are covered with Prior Authorization after members have tried: 1) One over-the-counter nicotine product and 2) Bupropion sustained-release (generic Zyban) separately

5. If your pharmacy benefit plan is administered in New Jersey, these products are not subject to prior authorization, step therapy or quantity limit requirements for the first 180 days of therapy per plan year. 6. For pharmacy benefits plans administered in the state of Oregon, these tobacco cessation medications are covered for members age 15 and older. 7. Prior Authorization is not required for over-the-counter nicotine products if your pharmacy benefit plan is administered in Oregon. 8. Prior Authorization is not required for bupropion if your pharmacy benefit plan is administered in Indiana, Louisiana, Massachusetts, New Mexico or Oregon. 9. If your pharmacy benefit plan is administered in Kentucky, you are eligible for a total of 180 days of medication dispensed as 30-day fills over a period of 365 days before prior authorization or step therapy requirements will be applied to additional quit attempts.

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Breast Cancer Preventive Medications4 For members who are at increased risk for breast cancer but have not had breast cancer, these preventive medications are available at $0 cost-share. To qualify, you must: • Be age 35 or older10 • At increased risk for the first occurrence of breast cancer – after risk assessment and counseling • Obtain Prior Authorization These medications are typically covered at the customary cost-share amount for your plan for the treatment of breast cancer, to prevent breast cancer recurrence and for other indications. They are available at $0 cost-share to prevent the first occurrence of breast cancer if a prior authorization is obtained. If you qualify, you can receive these drugs at $0 cost-share for up to five years, minus any time you have been taking them for prevention. Breast Cancer Medications (prescription) raloxifene tamoxifen 10. For pharmacy benefit plans administered in the District of Columbia, there is no age restriction.

Statin Preventive Medications4 The U.S. Preventive Service Task Force recommends that adults without a history of cardiovascular disease (CVD) — symptomatic coronary artery disease or stroke — use a low-to-moderate-dose statin for the prevention of CVD events in individuals who meet the following criteria: • Are age 40-75, and • Have one or more cardiovascular risk factors (high cholesterol, diabetes, hypertension, or smoking), and • A calculated 10-year risk of a cardiovascular event of 10% or greater. Statins available at $0 cost-share lovastatin (generic Mevacor) – All strengths atorvastatin (generic Lipitor) 10 & 20 mg11 Prior Authorization required to confirm risk of CVD simvastatin (generic Zocor) 5, 10, 20 & 40 mg11 Prior Authorization required to confirm risk of CVD 11. These medications are typically covered at the customary cost-share amount for your plan. However, they are available at $0 cost-share to prevent cardiovascular disease if a prior authorization is obtained. If you qualify based on criteria above, you can receive these drugs at $0 cost-share.

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Health Care Reform Pharmacy Benefit Preventive Care Medications Coverage

Frequently Asked Questions Under the health reform law, health plans must cover U.S. Preventive Services Task Force A & B Recommendation medications and FDA-approved prescription and overthe-counter (OTC) contraceptives for women at 100 percent without charging a copayment, coinsurance or deductible when: • Prescribed by a health care professional • Age and/or condition appropriate • Filled at a network pharmacy To comply with these regulations which continue to be clarified further by the U.S. Dept. of Labor, Health & Human Services and the Treasury, UnitedHealthcare offers this list of $0 cost-share Preventive Care Medications.

If I need to take preparation medications before a preventive colonoscopy, how can I get these for no cost?

If you are scheduled for a preventive colonoscopy, ask your doctor for a prescription for one of the no cost preparation medications. You can fill this prescription at a retail network pharmacy at no cost to you.

What if my doctor prescribes a preparation medication for my preventive colonoscopy that is not on this list?

Which Preventive Care Medications are available at no cost?

Refer to the list in this document, sign in to myuhc.com, or call the number on the back of your health plan ID card for a list of medications covered at $0 cost-share.

You can ask your doctor for a prescription for one of the medications on this list that your doctor feels would work for you. For some medical reasons, your doctor may decide you need a medication that is not on this list to prepare for your preventive colonoscopy. If so, you can request the medication you need by calling the number on your health plan ID card, and asking how to obtain coverage at no cost. Medical reasons may include side effects, and whether you can use the product as required.

Please note, in order to obtain coverage at no cost for Preventive Care Medications and products (including over-the-counter) you will need a prescription from your doctor.

If you need a prescription medication to prepare for a colonoscopy that is not preventive, these medications may still be covered with a copayment or coinsurance.

What if my doctor says I need birth control that is not on this Preventive Care Medication List?

If I’m at risk for cardiovascular disease, how can I get statin medications at no cost to me?

Our Preventive Care Medications list covers all methods of FDA-approved birth control available through your pharmacy benefit. However, your doctor may decide you need birth control (contraception) that is not on this list for medical reasons. If so, you can request the type you need by calling the number on your health plan ID card, and asking how to obtain coverage. Medical reasons may include side effects, whether the birth control is permanent or can be reversed, and whether you can use the product as required. Your medical benefit will also cover other forms of birth control such as IUDs, implants and surgical sterilization (having your tubes tied).

What if my plan has a religious or moral exemption for covering contraceptives?

Some plans may not have coverage for contraceptives if your employer elects a religious or moral exemption. However, you will still have coverage without cost-share of the U.S. Preventive Services Task Force A & B Recommendation medications listed on the Preventive Care Medications list, such as aspirin and vitamin D, tobacco cessation and breast cancer preventive medications.

If you are a member age 40-75, and at risk for cardiovascular disease, your doctor may offer to prescribe statin medications. Select statins are covered at no cost-share for individuals who have certain risk factors for cardiovascular disease. Depending on the medication, your doctor may need to submit a prior authorization request to get medications approved for you at $0 cost-share if you meet coverage criteria. For members who don’t meet this $0 cost-share criteria or don’t request prior authorization, those statins will continue to be covered at the customary cost-share amount for your plan.

How can I get preventive medications to help me stop using tobacco for no cost? If you are age 186 or older and want to quit using tobacco products, talk to your doctor about medications that can help. If your doctor decides this therapy is right for you, they may prescribe an over-the-counter or prescription medication. Your doctor can submit a Prior Authorization request to get these approved for you at $0 cost-share if you are also getting counseling to help you stop using tobacco products. Your doctor can provide this counseling or help you to find a provider.

Continued }


Frequently Asked Questions continued If I’m at risk for breast cancer, how can I get preventive medications for no cost? If you are a member age 35 or older, talk to your doctor about your risk of getting breast cancer if you have not had it.

If your doctor decides these drugs are appropriate for you, your doctor may offer to prescribe risk-reducing medications, such as raloxifene or tamoxifen. Your doctor can submit a Prior Authorization request to get these approved for you at $0 cost-share if you meet coverage criteria.12

How can I get aspirin to prevent preeclampsia during pregnancy for no cost? Low-dose or baby aspirin (81 mg) is available at no cost to pregnant women at risk for preeclampsia. If you are pregnant and at risk for preeclampsia, ask your doctor about whether low-dose aspirin can help. If so, your doctor can give you a prescription for low-dose aspirin to be filled at a retail network pharmacy at no cost to you.

Will this drug list change?

Drug lists can and do change, so it’s always good to check. You can find updated information by: • Signing in to myuhc.com, and going to Pharmacy Information • Calling the number on your health plan ID card

What if I have a high-deductible or consumer-driven health (CDH) plan?

The same no-cost options on the list applicable to your plan will be available to you if you are in one of these plans. If you fill a prescription for covered products not on your plan’s no-cost drug list, you will need to pay the full cost, until your pharmacy plan deductible is reached.

Are the no-cost Preventive Care Medications available at both retail and mail pharmacies? Preventive Care Medications are available at both network retail pharmacies and the mail order pharmacy for plans with a mail order benefit.

What if the health care reform law requirements for Preventive Care Medication coverage change?

If the law requiring plans to provide Preventive Care Medications at no cost changes, information on how your costs may be impacted will be available to you by: • Signing in to myuhc.com, and going to Pharmacy Information • Calling the number on your health plan ID card

What if my doctor prescribes a similar preventive medication that is not on this list?

The health reform law allows plans to use reasonable medical management to decide which product/medications are provided at $0 cost-share. If you choose a no-cost product from the list applicable to your plan, your cost at the pharmacy will be $0. If you choose a covered product/medication that is not on the list, a copay or coinsurance may be required. And this cost will apply to your deductible if you have one. You can ask your doctor for a prescription for one of the medications on this list that your doctor feels would work for you. For some medical reasons, your doctor may decide you need a medication that is not on this list.13 If so, you can request the medication you need by calling the number on your health plan ID card, and asking how to obtain coverage at no cost. Medical reasons may include side effects, and whether you can use the medication/product as required.

Still have questions? Sign in to myuhc.com and go to Pharmacy Information or call the number on your health plan ID card.

12. These medications are typically covered at the customary cost-share amount for your plan. However, they are available at $0 cost-share when used for breast cancer prevention if a prior authorization is obtained. If you qualify based on criteria above, you can receive these drugs at $0 cost-share. 13. When informed by a member’s health care provider, UnitedHealthcare will accommodate a coverage exception request for any member when one of the $0 cost medications listed on the Preventive Care Medications list may be medically inappropriate as determined by the health care provider for that member and UnitedHealthcare will waive the otherwise applicable cost-sharing for a medication not represented on the Preventive Care Medications list. M51372-LL Revised 03/18 Effective 1/1/2018 © 2018 United HealthCare Services, Inc.


Pharmacy Step Therapy

Step Therapy Most medical conditions have multiple medication options. Although the options treat the same condition effectively, their prices can vary. Step therapy helps you get the treatment you need and may save you money.

Here’s how it works:

You get a prescription.

$

$$

Try a Step 1 drug first.

Before a Step 2 drug is covered.

Step therapy requires you to try Step 1 drugs before Step 2 drugs can be covered. Step 1 drugs usually cost less and can be used to treat the same conditions as Step 2 drugs. If you already tried a Step 1 drug and it didn’t meet your needs, or your doctor wants you to keep taking your Step 2 drug(s), your doctor will need to ask for a prior authorization (PA). A prior authorization is an approval your doctor gets from us before you can get coverage for the drug. If the PA is approved, you may continue to fill your prescription(s) as usual. If the PA is not approved, you will have to pay the full cost of the drug(s). The amount you pay for the drug(s) will not count toward any deductible or out-of-pocket maximum you may have. In some situations, coverage for your original medication may be extended if you need extra time to review your options with your doctor. We encourage you to discuss your treatment and medication options with your doctor.

To learn more, visit myuhc.com® or call the toll-free member phone number on the back of your health plan ID card.

UnitedHealthcare and the dimensional U logo are trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. UHC FI/ASO – all states except NJ FI business – Member   Facebook.com/UnitedHealthcare    Twitter.com/UHC    Instagram.com/UnitedHealthcare  100-9848 8/18 ©2018 United HealthCare Services, Inc. All rights reserved. 76973-082018

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UnitedHealthcare Resources

Chris, UnitedHealthcare Advocate

More than a health plan — a personalized experience. Whatever your health plan questions and care needs are, you can count on any of our experts  —  including someone like Chris — to help with answers and guidance. Feel the support of a team that’s dedicated to helping you: • Understand your benefits and claims. • Talk through your bill or payment. • Avoid overpaying, find the right care and cost options.

Let’s connect.

• Get answers to your pharmacy questions.

We’re available 7 a.m.–10 p.m. CT, Monday–Friday.

• Maximize your health savings. • Take advantage of all your plan’s health and well-being benefits.

3 easy ways to get personalized answers and information. Call the member number on your health plan ID card 7 a.m.–10 p.m. CT, Monday–Friday.

Log in to myuhc.com® and click on Call or Chat.

Tap into the UnitedHealthcare® app for assistance when you’re on the go.

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through the program is for informational purposes only and provided as part of your health plan. Wellness nurses, coaches and other representatives cannot diagnose problems or recommend treatment and are not a substitute for your doctor’s care. Your health information is kept confidential in accordance with the law. The program is not an insurance program and may be discontinued at any time. Additionally, if there is any difference between this information and your coverage documents (Summary Plan Description, Schedule of Benefits, and any attached Riders and/or Amendments), your coverage documents govern. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company.   Facebook.com/UnitedHealthcare    Twitter.com/UHC    Instagram.com/UnitedHealthcare  8842269.0 7/19 ©2019 United HealthCare Services, Inc. 19-11745-B ACIS Only 100-16919

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Tools  |  UnitedHealthcare app

Get on-the-go access to your health plan. The UnitedHealthcare® app puts your plan at your fingertips.

The app has you covered. When you’re out and about, you can do everything from managing your plan to getting convenient care. Just download the app to: • Find nearby care options in your network. • Estimate costs. • Video chat with a doctor 24/7. • View and share your health plan ID card. • See your claim details and view progress toward your deductible.

The UnitedHealthcare app is available for download for iPhone® or Android™.

Apple, App Store, iPhone, Touch ID and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. Android is a trademark of Google LLC. Google Play and the Google Play logo are registered trademarks of Google Inc. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Virtual Visits are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times or in all locations. *Data rates may apply.   Facebook.com/UnitedHealthcare 

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  Instagram.com/UnitedHealthcare 

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Get the app and log on with Touch ID®.


Tools Virtual Visits

With Virtual Visits, it’s easy to video chat with a doctor 24/7 — whenever, wherever. Whether you’re at work, home, traveling, you name it — a Virtual Visit lets you talk with a doctor by video 24/7. If needed, a Virtual Visit doctor can treat and prescribe* medication for everyday illnesses like the flu, sinus infections, a cough and more. And, with a UnitedHealthcare plan, your cost is $50 or less.** To get started sign in at myuhc.com/virtualvisits or download the UnitedHealthcare® app. In addition to all of the great things you can do on myuhc.com® or the UnitedHealthcare app, you can now talk to a doctor as well. There are no additional accounts to set up or apps to download.

Quality care when and where you need it. Use a Virtual Visit for everyday medical conditions: • Allergies

• Rashes

• Bronchitis

• Sore throats

• Eye infections

• Stomachaches

• Flu

• And more

Virtual Visits may save you time and money. An estimated 25% of ER visits could be treated with a Virtual Visit — bringing a potential $1,700 cost down to just $50.***

• Headaches/migraines

* Certain prescriptions may not be available, and other restrictions may apply. **The Designated Virtual Visit Provider’s reduced rate for a virtual visit is subject to change at any time. *** UnitedHealthcare data: based on analysis of 2016 UnitedHealthcare ER claim volumes, where ER visits are low acuity and could be treated in a Virtual Visit, primary care physician or urgent/convenient care setting. The UnitedHealthcare® app is available for download for iPhone® or AndroidTM. iPhone is a registered trademark of Apple, Inc. Android is a trademark of Google LLC. Virtual visits are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times or in all locations. Insurance coverage provided by or through UnitedHealthcare Insurance Company and its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company.   Facebook.com/UnitedHealthcare    Twitter.com/UHC    Instagram.com/UnitedHealthcare  9541190.0  8/19 ©2019 United HealthCare Services, Inc. 19-13232-A

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Health & Wellness Back Pain Management

Get 3 visits for lower back pain at no cost to you — with a network physical therapist or chiropractor.* With your first 3 visits to a network physical therapist or chiropractor at $0 out-of-pocket cost, now’s a great time to take care of that new low back pain. Schedule an appointment today and get back to doing what you love.

The benefits of back care. Reduce pain.

Pay $0.

Early treatment may provide pain relief and help prevent chronic pain down the road.

Your first 3 back care visits are covered at $0 out-ofpocket with a network physical therapist or chiropractor.*

Visit myuhc.com® or call the number on your health plan ID card to get connected with a network provider.

*Members must have physical therapy or chiropractic benefits, with remaining visits in the plan year (i.e. these benefits do not extend the member’s physical therapy or chiropractic benefit maximum). A copay will not apply to services provided during the first 3 visits for new low back pain with a network physical therapist or chiropractor, as long as the plan limit has not been reached. In deductible plans there may be out of pocket costs for services like x-rays or durable medical equipment, but there may not be out of pocket costs for services like spinal manipulation, exercise instruction and other therapies. After the first 3 visits with a network physical therapist or chiropractor for new low back pain, any subsequent visits with any network or out of network physical therapist or chiropractor will be subject to deductibles, copays and coinsurance. Check your plan benefits for additional detail or call the number on your health plan ID card. For help in determining whether to see a chiropractor or physical therapist call the number on your health plan ID card. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.   Facebook.com/UnitedHealthcare    Twitter.com/UHC    Instagram.com/UnitedHealthcare  8862743.0 4/19 ©2019 United HealthCare Services, Inc. 18-10816-C

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