2016 enrollment guide - osborn & associates€¦ · itÕs more than a drug plan. itÕs a...

Connecting you to the coverage you may need. Convenient local pharmacies

Thousands of brand name and generic drugs

Prescription drugs as low as $1

EnrollmentGuide

2016

AARP® MedicareRx Preferred (PDP)AARP® MedicareRx Saver Plus (PDP)

S5820-017S5921-363

Service area: Missouri

Region: 18

Table of ContentsIntroduction............................................................................................................................. 3

Plan INFORMATION

Benefit Highlights.................................................................................................................. 8Summary of Benefits..........................................................................................................10Plan Ratings......................................................................................................................... 24Required Information......................................................................................................... 26

Drug LIST

Drug List................................................................................................................................28

Ready to ENROLL

Enrollment Instructions......................................................................................................42Scope of Sales Appointment Confirmation Form.......................................................43Enrollment Request Form.................................................................................................45Enrollment Checklist.......................................................................................................... 69Enrollment Receipt.............................................................................................................71What's Next...........................................................................................................................75

It’s more than a drug plan.IT’S A HEALTHY RELATIONSHIP.

As a member of our Medicare Part D plan, you get a relationship with a company dedicated to providing youwith service and support to help you get the most from your benefits.

PDMO16PD3716859_000

Here are some reasons why this plan may be right for your needs.

Prescription home delivery

Members-only savingswith the Preferred Retail Pharmacy Network

Coverage on 1,000s of generic and brand name drugs

Access your personal plan information online, anytime

A choice of plans

Have any questions? We can help. Call:

Toll-Free

Learn more online at

3

1-888-867-5564, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week. Se habla español.

www.AARPMedicareRx.com

Medicare is a federal health insurance program for people age 65 and older and others with disabilities.

Original Medicare is provided by the government and covers some of the costs of hospital stays (Part A) and doctor visits (Part B), but it does not cover everything — you don’t get coverage for prescription drugs or for routine vision, dental or hearing care.

What is Medicare?

MedicareEDUCATION

What if you need more coverage beyond Original Medicare?

Add one or both of the following to Original Medicare:

Add additional coverage by choosing a Medicare Advantage plan:OR

When can you enroll?

Initial Enrollment Period: For Medicare Advantage or Part D plans, this is the three months before and three months after the month you turn 65 or become Medicare eligible. For Medicare supplement plans, you must submit your application no later than six months after the date your Medicare Part B coverage takes effect.Special Election Period: Depending on certain circumstances, you may be able to enroll in a Medicare plan outside of the Initial Enrollment Period or Open Enrollment time frames.Open Enrollment Period: October 15 – December 7Medicare Advantage Disenrollment Period: January 1 – February 14. If you disenroll from a Medicare Advantage plan during this time, you will return to Original Medicare and have a Special Election Period to enroll in a Medicare Part D plan.

It’s important to know your enrollment period so you always have health care coverage. You can enroll or change Medicare Advantage or Part D plans at least once a year, typically during your Initial Enrollment Period or the Open Enrollment Period. Medicare supplement plans have different rules about enrolling, please contact the Medicare Helpline for more information on enrolling.

Medicare Supplement Insurance*

Medicare Part D*

Covers some of the costs not covered by Parts A and B

Part D covers prescription drugs

Medicare Advantage (Part C)*

Part C combines Parts A and B

Often provides additional benefits

Most plans cover prescription drugs

*Offered by private companies

Original MedicareProvided by the government

Part A covers hospital stays

Part B covers doctor and outpatient visits

4

If your plan includes prescription drug coverage, the amount you pay each time to fill a prescription depends on which payment stage you’re in. How do you know which stage you’re in? It depends on how much money you and your plan have paid for prescription drugs so far in the plan year.

If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible amount. You then move to the initial coverage stage.

The chart below shows the different payment stages you may go through in the plan year.

Coverage Gap(Donut Hole)

Initial Coverage

In this drug payment stage:

• You pay a co-pay or co-insurance (percentage of a drug’s total cost). The plan pays the rest

• You stay in this stage until your total drug costs reach $3,310

After your total drug costs reach $3,310:

• You pay:

– 45% of the cost of brand name drugs

– 58% of the cost of generic drugs

• You stay in this stage until your total out‑of‑pocket costs reach $4,850

After your total out‑of‑pocket costs reach $4,850:

• You pay a small co-pay or co-insurance amount

• You stay in this stage for the rest of the plan year

CatastrophicCoverage

Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for prescription drugs starting on January 1, 2016.

Out‑of‑Pocket Costs: The amount you pay (or others pay on your behalf) for prescription drugs starting on January 1, 2016. This does not include premiums.

Do you qualify for Extra Help?If you have a limited income, you may be able to get Extra Help with your Medicare prescription drug plan premiums, deductibles and co-pays. Many people qualify and don’t even know it.

To find out if you qualify, call the Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778, 7 a.m. – 7 p.m., Monday – Friday

MedicareEDUCATION

What are the drug payment stages?

5

MedicareEDUCATION

Are you eligible for this plan?

Are there special eligibility requirements for this plan?

No, as long as you are enrolled in Original Medicare Parts A or B (or both) and continue to pay your Part B premium, you are eligible to enroll in this plan.

You are enrolled in Original Medicare Parts A or B (or both)

Live in the plan’s service areaAND

You are eligible for a Medicare Part D plan if:

Medicare Made Clear™An educational platform developed by UnitedHealthcare to help the public better understand Medicare. Find out more at MedicareMadeClear.com.

Medicare HelplineFor questions about Medicare and detailed information about plans and policies available in your area, visit Medicare.gov or call Medicare at 1-800-633-4227, TTY 1-877-486-2048, 24 hours a day, 7 days a week.

Helpful resources.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.Y0066_150728_100336 Accepted PDEX16PD3715065_001

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UHEX16MP3700082_001

Benefit highlightsThis is a short description of 2016 plan benefits. For complete information, please refer to your Summary ofBenefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply.

Plan CostsPlan Feature AARP® MedicareRx Saver Plus

(PDP)AARP® MedicareRx Preferred(PDP)

Monthly premium $43.00 $59.00Annual prescription deductible $360 $0Initial coverage stage Preferred retail

cost sharing (in-network 30-daysupply)

Standard retailcost sharing (in-network 30-daysupply)

Preferred retailcost sharing (in-network 30-daysupply)

Standard retailcost sharing (in-network 30-daysupply)

Tier 1: Preferred Generic Drugs $1 copay $3 copay $4 copay $8 copayTier 2: Generic Drugs $2 copay $6 copay $8 copay $16 copayTier 3: Preferred Brand Drugs $23 copay $38 copay $35 copay $45 copayTier 4: Non-Preferred Brand Drugs 30% of the cost 40% of the cost 40% of the cost 50% of the costTier 5: Specialty Tier Drugs 25% of the cost 25% of the cost 33% of the cost 33% of the costCoverage gap stage After your total drug costs reach $3,310, you will pay no more than

58% of the total cost for generic drugs or 45% of the total cost forbrand name drugs, for any drug tier during the coverage gap

Catastrophic coverage stage After your total out-of-pocket costs reach $4,850, you will pay thegreater of $2.95 copay for generic (including brand drugs treated asgeneric), $7.40 copay for all other drugs, or 5% of the cost

Formulary (drug list) Includes most generic drugscovered by Medicare Part D andmany commonly used brandname drugs

Includes nearly all generic drugscovered by Medicare Part D andmany commonly used brandname drugs

Includes $0 for a 90-day supply of Tier 1 and Tier 2 medications (typically generic drugs) through ourPreferred Mail Service PharmacyPlans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, aMedicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal withMedicare.Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.This information is not a complete description of benefits. Contact the plan for more information. You mustcontinue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another thirdparty. Limitations, copayments, and restrictions may apply.

Y0066_PDPBH_16_FINAL_S5921363_S5820017 Accepted PDMO16PD3718649_000

8

Our benefits are designed to help you live a healthier life. Sometimes your health relies on the prescription drugs you take. Make the most of your prescription coverage by following these simple steps.

Review your drugs with your doctor.Each drug the plan covers is in a tier level, which determines your cost for the drug. Generally, the lower the tier, the less you have to pay. Talk with your doctor or pharmacist to see if there are lower-cost alternatives to your drug.

• There may be a generic version of your drug that may work just as well. You will find generic drugs at every tier level, so be sure to check the drug list to see which tier your specific generic drug is in.

• There may be a different drug that falls in a lower co-payment tier than the drug you’re currently taking. Ask your doctor if there are any lower-tier drugs that could work for you and help save you money.

Keep filling prescriptions where you already shop.Preferred Retail Pharmacy Network.With the Preferred Retail Pharmacy Network, you could save 25% or more on your prescriptions.1 Participating pharmacies are conveniently located in many local grocery, drug and discount stores. It’s easy to switch your prescriptions to a preferred retail pharmacy — and you can switch at any time throughout the year. Below we’ve listed some, but not all, of the retail pharmacies in our network. To see a complete list of preferred retail pharmacies in your area, visit: AARPMedicareRx.com.

Get home delivery for your prescriptions.You could save with OptumRx® Mail Service Pharmacy.You could pay less for prescriptions when you sign up for home delivery from OptumRx, our preferred mail service pharmacy. OptumRx will send a 90-day supply of the medications you take regularly right to your door with no cost for standard shipping. Register online at www.OptumRx.com to order new prescriptions, request refills and more. You’ll also get support, including access to a pharmacist, and medication or refill reminders.

Ways you could save onPRESCRIPTION DRUGS

1 Savings of 25% or more apply to Tier 1 and Tier 2 co-pays on the AARP MedicareRx Preferred (PDP) and AARP MedicareRx Saver Plus (PDP) plans at a preferred retail pharmacy compared with the co-pays of standard pharmacies within the network.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.Y0066_150716_124913 Accepted PDEX16MP3689937_000

9

Plan INFO

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2016 Summary of

BENEFITSAARP® MedicareRx Preferred (PDP)

Y0066_SB_S5820_017_2016 CMS Accepted

10

Summary of BenefitsJanuary 1, 2016 - December 31, 2016

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

You have choices about how to get your Medicare prescription drug benefits

• One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan,like AARPMedicareRx Preferred (PDP).

• Another choice is to get your prescription drug coverage through a Medicare Advantage Plan(like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drugcoverage. You get all of your Part A and Part B coverage, and prescription drug coverage (PartD), through these plans.

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what AARPMedicareRx Preferred(PDP) covers and what you pay.

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

• If you want to know more about the coverage and costs of Original Medicare, look in yourcurrent "Medicare & You" handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.

Sections in this booklet

• Things to Know About AARPMedicareRx Preferred (PDP)• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services• Prescription Drug Benefits

This document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call us at1-888-867-5575.Es posible que este documento esté disponible en otro idioma. Para información adicional llameal 1-888-867-5575.

Things to Know About AARP MedicareRx Preferred (PDP)

Hours of Operation

You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time.

AARP MedicareRx Preferred (PDP) Phone Numbers and Website

• If you are a member of this plan, call toll-free 1-888-867-5575.• If you are not a member of this plan, call toll-free 1-888-867-5564.• Our website: www.AARPMedicareRx.com

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Plan INFO

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Who can join?

To join AARP MedicareRx Preferred (PDP), you must be entitled to Medicare Part A, and/or beenrolled in Medicare Part B, and live in our service area.

Our service area includes the following: Missouri.

Which drugs are covered?

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictionson our website (www.AARPMedicareRx.com).Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?

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

Which pharmacies can I use?

We have a network of pharmacies and you must generally use these pharmacies to fill yourprescriptions for covered Part D drugs.

Some of our network pharmacies have preferred cost-sharing. You may pay less if you use thesepharmacies.

You can see our plan’s pharmacy directory at our website (www.AARPMedicareRx.com).Or, call us and we will send you a copy of the pharmacy directory.

12


Monthly Premium, Deductible, and Limits on How Much You Pay for Covered ServicesHow much is $59 per month.the monthlypremium?

How much is This plan does not have a deductible.the deductible?

Prescription Drug BenefitsInitial Coverage You pay the following until your total yearly drug costs reach $3,310.

Total yearly drug costs are the total drug costs paid by both you and ourPart D plan.

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

Standard Retail Cost-Sharing

Tier One-month supply Three-month sup-ply

Tier 1 (Preferred Generic) $8 copay $24 copay

Tier 2 (Generic) $16 copay $48 copay

Tier 3 (Preferred Brand) $45 copay $135 copay

Tier 4 (Non-Preferred 50% of the cost 50% of the costBrand)

Tier 5 (Specialty Tier) 33% of the cost 33% of the cost

Preferred Retail Cost-Sharing







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Plan INFO

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Standard Mail Order Cost-Sharing

Tier Three-month supply

Tier 1 (Preferred Generic) $24 copay

Tier 2 (Generic) $48 copay

Tier 3 (Preferred Brand) $135 copay

Tier 4 (Non-Preferred 50% of the costBrand)

Tier 5 (Specialty Tier) 33% of the cost

Preferred Mail Order Cost-Sharing


Tier 1 (Preferred Generic) $0

Tier 2 (Generic) $0




If you reside in a long-term care facility, you pay the same as at a retailpharmacy.

You may get drugs from an out-of-network pharmacy, but may pay morethan you pay at an in-network pharmacy.

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

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

Catastrophic After your yearly out-of-pocket drug costs (including drugs purchasedthrough your retail pharmacy and through mail order) reach $4,850, youCoveragepay the greater of:• 5% of the cost, or• $2.95 copay for generic (including brand drugs treated as generic) anda $7.40 copayment for all other drugs.

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Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health ordrug plan. To get an interpreter, just call us at 1-888-867-5564. Someone who speaksEnglish/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta quepueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favorllame al 1-888-867-5564. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电1-888-867-5564。我们的中文工作人员很乐意帮助您。这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-888-867-5564。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mgakatanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ngtagasaling-wika, tawagan lamang kami sa 1-888-867-5564. Maaari kayong tulungan ng isangnakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questionsrelatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au serviced'interprétation, il vous suffit de nous appeler au 1-888-867-5564. Un interlocuteur parlant Françaispourra vous aider. Ce service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sứckhỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-867-5564 sẽ cónhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits-und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-867-5564. Man wird Ihnen dortauf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역서비스를제공하고있습니다.통역서비스를이용하려면전화 1-888-867-5564번으로문의해주십시오.한국어를하는담당자가도와드릴것입니다.이서비스는무료로운영됩니다.

Russian: Если у вас возникнут вопросы относительно страхового или медикаментногоплана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобывоспользоваться услугами переводчика, позвоните нам по телефону 1-888-867-5564. Вамокажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

4655-768-888-1

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Plan INFO

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Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sulnostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-867-5564. Unnostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugues: Dispomos de serviços de interpretação gratuitos para responder a qualquer questãoque tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete,contacte-nos através do número 1-888-867-5564. Irá encontrar alguém que fale o idioma Portuguêspara o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènanplan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-867-5564. Yonmoun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże wuzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać zpomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-867-5564. Tausługa jest bezpłatna.

Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पासमुफ्त दुभाषिया सेवाएँ उपलब्ध हंै. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-888-867-5564 पर फोनकरंे. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、1-888-867-5564にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

PDMO16PD3709106_000

16

2016 Summary of

BENEFITSAARP® MedicareRx Saver Plus (PDP)

Y0066_SB_S5921_363_2016 CMS Accepted

17

Plan INFO

RM

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

You have choices about how to get your Medicare prescription drug benefits

• One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan,like AARPMedicareRx Saver Plus (PDP).

• Another choice is to get your prescription drug coverage through a Medicare Advantage Plan(like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drugcoverage. You get all of your Part A and Part B coverage, and prescription drug coverage (PartD), through these plans.

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what AARPMedicareRx Saver Plus(PDP) covers and what you pay.

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

• If you want to know more about the coverage and costs of Original Medicare, look in yourcurrent "Medicare & You" handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.

Sections in this booklet

• Things to Know About AARPMedicareRx Saver Plus (PDP)• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services• Prescription Drug Benefits

This document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call us at1-866-460-8854.Es posible que este documento esté disponible en otro idioma. Para información adicional llameal 1-866-460-8854.

Things to Know About AARP MedicareRx Saver Plus (PDP)

Hours of Operation

You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time.

AARP MedicareRx Saver Plus (PDP) Phone Numbers and Website

• If you are a member of this plan, call toll-free 1-866-460-8854.• If you are not a member of this plan, call toll-free 1-888-867-5564.• Our website: www.AARPMedicareRx.com

18

Who can join?

To join AARP MedicareRx Saver Plus (PDP), you must be entitled to Medicare Part A, and/or beenrolled in Medicare Part B, and live in our service area.

Our service area includes the following: Missouri.

Which drugs are covered?

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictionson our website (www.AARPMedicareRx.com).Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?

Our plan groups each medication into one of five "tiers." You will need to use your formulary tolocate what tier your drug is on to determine how much it will cost you. The amount you paydepends on the drug’s tier and what stage of the benefit you have reached. Later in thisdocument we discuss the benefit stages that occur after you meet your deductible: InitialCoverage, Coverage Gap, and Catastrophic Coverage.

Which pharmacies can I use?

We have a network of pharmacies and you must generally use these pharmacies to fill yourprescriptions for covered Part D drugs.

Some of our network pharmacies have preferred cost-sharing. You may pay less if you use thesepharmacies.

You can see our plan’s pharmacy directory at our website (www.AARPMedicareRx.com).Or, call us and we will send you a copy of the pharmacy directory.

19

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Monthly Premium, Deductible, and Limits on How Much You Pay for Covered ServicesHow much is $43 per month.the monthlypremium?

How much is $360 per year for Part D prescription drugs.the deductible?

Prescription Drug BenefitsInitial Coverage After you pay your yearly deductible, you pay the following until your

total yearly drug costs reach $3,310. Total yearly drug costs are the totaldrug costs paid by both you and our Part D plan.

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

Standard Retail Cost-Sharing







Preferred Retail Cost-Sharing







20

Standard Mail Order Cost-Sharing


Tier 1 (Preferred Generic) $9 copay

Tier 2 (Generic) $18 copay




Preferred Mail Order Cost-Sharing


Tier 1 (Preferred Generic) $0

Tier 2 (Generic) $0




If you reside in a long-term care facility, you pay the same as at a retailpharmacy.

You may get drugs from an out-of-network pharmacy, but may pay morethan you pay at an in-network pharmacy.

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

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

Catastrophic After your yearly out-of-pocket drug costs (including drugs purchasedthrough your retail pharmacy and through mail order) reach $4,850, youCoveragepay the greater of:• 5% of the cost, or• $2.95 copay for generic (including brand drugs treated as generic) anda $7.40 copayment for all other drugs.

21

Plan INFO

RM

ATION

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health ordrug plan. To get an interpreter, just call us at 1-888-867-5564. Someone who speaksEnglish/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta quepueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favorllame al 1-888-867-5564. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电1-888-867-5564。我们的中文工作人员很乐意帮助您。这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-888-867-5564。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mgakatanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ngtagasaling-wika, tawagan lamang kami sa 1-888-867-5564. Maaari kayong tulungan ng isangnakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questionsrelatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au serviced'interprétation, il vous suffit de nous appeler au 1-888-867-5564. Un interlocuteur parlant Françaispourra vous aider. Ce service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sứckhỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-867-5564 sẽ cónhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits-und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-867-5564. Man wird Ihnen dortauf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역서비스를제공하고있습니다.통역서비스를이용하려면전화 1-888-867-5564번으로문의해주십시오.한국어를하는담당자가도와드릴것입니다.이서비스는무료로운영됩니다.

Russian: Если у вас возникнут вопросы относительно страхового или медикаментногоплана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобывоспользоваться услугами переводчика, позвоните нам по телефону 1-888-867-5564. Вамокажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

4655-768-888-1

22

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sulnostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-867-5564. Unnostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugues: Dispomos de serviços de interpretação gratuitos para responder a qualquer questãoque tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete,contacte-nos através do número 1-888-867-5564. Irá encontrar alguém que fale o idioma Portuguêspara o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènanplan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-867-5564. Yonmoun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże wuzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać zpomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-867-5564. Tausługa jest bezpłatna.

Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पासमुफ्त दुभाषिया सेवाएँ उपलब्ध हंै. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-888-867-5564 पर फोनकरंे. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、1-888-867-5564にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

PDMO16PD3709180_000

23

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ATION

UnitedHealthcare - S5820

2015 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality

and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use

these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings

are:

1. An Overall Star Rating that combines all of our plan’s scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for the ratings include:

• How our members rate our plan’s services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications

For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare:

4 stars

We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:

Health Plan Services: Not offered

Drug Plan Services:4 stars

The number of stars shows how well our plan performs.

excellent

above average

average

below average

poor

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-867-5564 (toll-free) or 711

(TTY).

Current members please call 888-867-5575 (toll-free) or 711 (TTY).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year

to the next.

Y0066_S5820_A_PR2015 CMS Accepted

24

UnitedHealthcare - S5921

2015 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality

and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use

these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings

are:

1. An Overall Star Rating that combines all of our plan’s scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for the ratings include:

• How our members rate our plan’s services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications

For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare:

2.5 stars

We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:

Health Plan Services: Not offered

Drug Plan Services:2.5 stars

The number of stars shows how well our plan performs.

excellent

above average

average

below average

poor

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-867-5564 (toll-free) or 711

(TTY).

Current members please call 888-867-5575 (toll-free) or 711 (TTY).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year

to the next.

Y0066_S5921_A_PR2015 CMS Accepted UHEX15HM3635276_00225

Plan INFO

RM

ATION

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. AARP MedicareComplete and AARP MedicareRx Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. You do not need to be an AARP member to enroll. AARP and its affiliates are not insurers. AARP encourages you to consider your needs when selecting products and does not make specific product recommendations for individuals.

Members may enroll in the plan only during specific times of the year. Contact the plan for more information. You must have both Medicare Parts A and B to enroll in the plan.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply.

Benefits, formulary, pharmacy network premium and/or co-payments/co-insurance may change on January 1 of each year.

The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

Premium and/or co- payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Member may use any pharmacy in the network but may not receive preferred retail pharmacy pricing. Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas. Co-pays apply after deductible.

You are not required to use OptumRx to obtain a 90- day supply of your maintenance medications. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877-266-4832. OptumRx is an affiliate of UnitedHealthcare Insurance Company.

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

This information is available for free in other languages. Please call our customer service number located on the first page of this book.

Esta información está disponible sin costo en otros idiomas. Llame a Servicio al Cliente al número que se encuentra en la primera página de esta guía.

Y0066_150720_123853 Accepted PDEX16MP3720498_000

2016 RequiredINFORMATION

26

UHEX16MP3700083_001

Y0066_150616_1350421_FINAL Accepted

Sp = AARP MedicareRx Saver Plus Pr = AARP MedicareRx Preferred

2016DRUG LIST

This is an alphabetical partial list of Brand name and Generic drugs covered by the plan.

· Brand name drugs appear in bold type

· Generic drugs appear in plain type

Each drug is in one of five tiers, which is listed in the chart below.

· Each tier has a co-pay or co-insurance amount

· For a full description of the tiers, see the Summary of Benefits in this book

Some drugs may need Prior Authorization, Step Therapy or other requirements. To find out if

your drug has added coverageneeds, please contact us or view a complete drug list on our website.

Our contact information is on the first page of this book.

The drugs listed may be available in the AARP® MedicareRx Saver Plus (PDP) or AARP®

MedicareRx Preferred (PDP) Prescription Drug Plans. The chart below shows which plans cover

the drug.

This list was last updated August 1, 2015.

Drug Name Tier Sp Pr

A

Acamprosate Calcium DR

(Tablet Delayed-Release)4 X X

Acetaminophen/Codeine

(Tablet)2 X X

Acetazolamide (Tablet) 3 X X

Acetazolamide ER (Capsule

Extended-Release 12 Hour)4 X X

Acyclovir (Tablet) 2 X X

Adacel (Injection) 3 X X

Adcirca (Tablet) 5 X X

Advair Diskus (Aerosol

Powder)3 X X

Advair HFA (Aerosol) 3 X X

Aggrenox (Capsule Extended-

Release 12 Hour)4 X X

Albenza (Tablet) 5 X X

Alcohol Prep Pads 3 X X

Alendronate Sodium (Tablet) 1 X X

Alfuzosin HCl ER (Tablet



Allopurinol (Tablet) 1 X X

Alprazolam (Tablet Immediate-

Release)2 X X

Amantadine HCl (100mg

Capsule, 50mg/5ml Syrup,

100mg Tablet)

2 X

Amantadine HCl (100mg

Capsule, 50mg/5ml Syrup,

100mg Tablet)

3 X

Amiodarone HCl (200mg Tablet) 2 X X

Amitiza (Capsule) 3 X X

Amitriptyline HCl (Tablet) 3 X X

Amlodipine Besylate (Tablet) 1 X X

Ammonium Lactate (12%

Cream, 12% Lotion)3 X X

Amoxicillin (250mg Capsule,

500mg Capsule, 500mg Tablet,

875mg Tablet)

2 X X

Amoxicillin/Clavulanate

Potassium (Tablet Immediate-

Release) (Generic Augmentin)

2 X X

Bold type = Brand name drug Plain type = Generic drug


Amphetamine/

Dextroamphetamine (Tablet

Immediate-Release)

3 X X

Amphetamine/

Dextroamphetamine ER

(Capsule Extended-Release 24

Hour)

4 X X

Anagrelide HCl (Capsule) 2 X X

Anastrozole (Tablet) 2 X X

Androderm (Patch 24 Hour) 3 X X

Androgel (1.62% Packet,

1.62% Pump)3 X X

Anoro Ellipta (Aerosol

Powder)3 X

Argatroban (Injection) 5 X X

Atenolol (Tablet) 1 X X

Atenolol/Chlorthalidone (Tablet) 1 X X

Atorvastatin Calcium (Tablet) 1 X X

Atovaquone/Proguanil HCl

(Tablet) (Generic Malarone)2 X

Atovaquone/Proguanil HCl

(Tablet) (Generic Malarone)3 X

Atripla (Tablet) 5 X X

Atrovent HFA (Aerosol

Solution)4 X X

Aubagio (Tablet) 5 X X

Avastin (Injection) 5 X X

Avonex (Injection) 5 X

Azathioprine (Tablet) 2 X X

Azelastine HCl (0.05%

Ophthalmic Solution)2 X

Azelastine HCl (0.05%

Ophthalmic Solution)3 X

Azelastine HCl (0.1% Nasal

Solution)2 X


Solution)3 X


Solution)2 X


Solution)3 X


Azilect (Tablet) 3 X X

Azithromycin (Oral Suspension,

Tablet Immediate-Release)2 X X

Azopt (Suspension) 3 X

B

Baclofen (Tablet) 2 X X

Balsalazide Disodium (Capsule) 4 X X

Belsomra (Tablet) 3 X X

Benazepril HCl (Tablet) 1 X X

Benazepril HCl/

Hydrochlorothiazide (Tablet)1 X X

Benicar (Tablet) 3 X X

Benicar HCT (Tablet) 3 X X

Benlysta (Injection) 5 X X

Benztropine Mesylate (Tablet) 2 X

Benztropine Mesylate (Tablet) 3 X

Betaseron (Injection) 5 X

Bethanechol Chloride (Tablet) 2 X X

Bicalutamide (Tablet) 2 X X

Bisoprolol Fumarate (Tablet) 3 X

Bisoprolol Fumarate/

Hydrochlorothiazide (Tablet)3 X

Brimonidine Tartrate (0.15%

Ophthalmic Solution)3 X X

Brimonidine Tartrate (0.2%

Ophthalmic Solution)3 X X

Brintellix (Tablet) 4 X X

Budesonide (3mg Capsule


Bumetanide (Tablet) 2 X X

Buprenorphine HCl (Tablet

Sublingual)4 X X

Bupropion HCl (Tablet

Immediate-Release), Bupropion

HCl SR (Tablet Extended-

Release 12 Hour), Bupropion

HCl XL (Tablet Extended-

Release 24 Hour)

2 X X

Buspirone HCl (Tablet) 2 X X

Butrans (Patch Weekly) 3 X

Bydureon (Injection) 3 X X

29

Drug LIST



Byetta (Injection) 3 X

Byetta (Injection) 4 X

Bystolic (Tablet) 3 X X

C

Cabergoline (Tablet) 2 X

Cabergoline (Tablet) 3 X

Calcitriol (Capsule) 2 X X

Calcium Acetate (Capsule) 2 X

Calcium Acetate (Capsule) 3 X

Captopril (Tablet) 2 X X

Captopril/Hydrochlorothiazide

(Tablet)2 X X

Carafate (Suspension) 4 X X

Carbaglu (Tablet) 5 X X

Carbamazepine (Oral

Suspension, Tablet Immediate-

Release, Tablet Chewable),

Carbamazepine ER (Capsule

Extended-Release 12 Hour,

Tablet Extended-Release 12

Hour)

2 X

Carbamazepine (Oral

Suspension, Tablet Immediate-

Release, Tablet Chewable),

Carbamazepine ER (Capsule


Tablet Extended-Release 12

Hour)

3 X

Carbidopa (25mg Tablet) 4 X

Carbidopa/Levodopa (Tablet

Immediate-Release), Carbidopa/

Levodopa ER (Tablet Extended-

Release), Carbidopa/Levodopa

ODT (Tablet Dispersible)

2 X X

Carboplatin (Injection) 4 X X

Carvedilol (Tablet) 1 X X

Cayston (Inhalation Solution) 5 X X

Cefdinir (Capsule, Oral

Suspension)3 X X

Cefuroxime Axetil (Tablet) 2 X X

Celecoxib (Capsule) 4 X


Cephalexin (Capsule, Oral

Suspension)2 X X

Chantix (Tablet) 4 X X

Chlorhexidine Gluconate Oral

Rinse (Solution)2 X X

Chlorthalidone (Tablet) 2 X X

Cilostazol (Tablet) 2 X X

Cimetidine (Oral Solution,

Tablet)2 X

Cinryze (Injection) 5 X X

Ciprodex (Otic Suspension) 3 X

Ciprofloxacin HCl (Tablet

Immediate-Release)2 X X

Citalopram Hydrobromide

(Tablet)1 X X

Clindamycin HCl (Capsule

Immediate-Release, Oral

Solution)

2 X X

Clonazepam (Tablet Immediate-

Release)2 X X

Clonazepam ODT (Tablet

Dispersible)4 X X

Clonidine HCl (Tablet


Clopidogrel (75mg Tablet) 2 X X

Clozapine (Tablet Immediate-

Release)3 X X

Clozapine ODT (Tablet

Dispersible)3 X X

Colchicine (0.6mg Tablet)

(Generic Colcrys)3 X X

Combigan (Ophthalmic

Solution)3 X X

Combivent Respimat (Aerosol

Solution)3 X X

Copaxone (Injection) 5 X X

Creon (Capsule Delayed-

Release)3 X X

Crestor (Tablet) 3 X X

Cromolyn Sodium (Ophthalmic

Solution)2 X X



Cyclophosphamide (Capsule) 4 X X

Cyproheptadine HCl (4mg

Tablet)4 X X

D

Daliresp (Tablet) 4 X X

Dapsone (Tablet) 3 X X

Desmopressin Acetate (Tablet) 2 X

Desmopressin Acetate (Tablet) 3 X

Dextroamphetamine Sulfate

(Tablet Immediate-Release)4 X

Dextroamphetamine Sulfate

(Tablet Immediate-Release),

Dextroamphetamine Sulfate ER

(Capsule Extended-Release)

4 X

Dextrose 5%/NaCl (Injection) 4 X X

Diazepam (1mg/ml Oral

Solution)2 X X

Diazepam (Tablet Immediate-

Release), Diazepam Intensol

(5mg/ml Concentrate)

2 X X

Diclofenac Potassium (Tablet) 2 X X

Diclofenac Sodium DR (Tablet

Delayed-Release), Diclofenac

Sodium ER (Tablet Extended-

Release 24 Hour)

2 X X

Dicyclomine HCl (10mg

Capsule, 20mg Tablet)2 X X

Digoxin (125mcg Tablet) 2 X X

Digoxin (250mcg Tablet) 2 X X

Dihydroergotamine Mesylate

(Injection)4 X X

Diltiazem HCl (Tablet

Immediate-Release)2 X

Diltiazem HCl (Tablet Immediate-

Release), Diltiazem HCl ER

(120mg Capsule Extended-

Release, 240mg Capsule

Extended-Release, 300mg

Capsule Extended-Release)

(Generic Cardizem CD)

2 X


Diltiazem HCl ER (240mg

Capsule Extended-Release,

300mg Capsule Extended-

Release) (Generic Cardizem

CD), (360mg Capsule Extended-

Release) (Generic Tiazac)

3 X

Diphenoxylate/Atropine (Tablet) 4 X X

Disulfiram (Tablet) 2 X

Disulfiram (Tablet) 3 X

Divalproex Sodium (Capsule

Sprinkle), Divalproex Sodium DR

(Tablet Delayed-Release),

Divalproex Sodium ER (Tablet

Extended-Release 24 Hour)

2 X X

Donepezil HCl (10mg Tablet

Immediate-Release, 5mg Tablet

Immediate-Release), Donepezil

HCl ODT (Tablet Dispersible)

2 X X

Donepezil HCl (23mg Tablet


Dorzolamide HCl/Timolol

Maleate (Ophthalmic Solution)2 X X

Doxazosin Mesylate (Tablet) 2 X X

Doxepin HCl (Capsule, 10mg/ml

Concentrate)2 X

Doxepin HCl (Capsule, 10mg/ml

Concentrate)3 X

Doxycycline Hyclate (Capsule


Dronabinol (Capsule) 4 X X

Duloxetine HCl (Capsule

Delayed-Release)2 X X

Durezol (Emulsion) 3 X X

Dymista (Suspension) 4 X

E

Edarbi (Tablet) 4 X X

Edarbyclor (Tablet) 4 X X

Eliquis (Tablet) 3 X X

Elmiron (Capsule) 4 X X

Enalapril Maleate (Tablet) 2 X X

Enalapril Maleate/


31

Drug LIST



Enalapril Maleate/


Enbrel (Injection) 5 X X

Entacapone (Tablet) 4 X X

Entecavir (Tablet) 5 X X

EpiPen (Injection) 3 X X

Eplerenone (Tablet) 3 X X

Epzicom (Tablet) 5 X X

Equetro (Capsule Extended-


Erythromycin (Ophthalmic

Ointment)2 X X

Erythromycin Base (Tablet) 4 X X

Escitalopram Oxalate (Tablet) 2 X X

Estradiol (Tablet) (Generic

Estrace)3 X X

Ethambutol HCl (Tablet) 2 X

Ethambutol HCl (Tablet) 3 X

Ethosuximide (250mg Capsule,

250mg/5ml Oral Solution)2 X

Ethosuximide (250mg Capsule,

250mg/5ml Oral Solution)3 X

Etoposide (Injection) 2 X

Etoposide (Injection) 3 X

Exjade (Tablet Soluble) 5 X X

F

Famotidine (Tablet) 2 X X

Fareston (Tablet) 5 X X

Farxiga (Tablet) 3 X

Fenofibrate (145mg Tablet,

48mg Tablet) (Generic Tricor),

(160mg Tablet, 54mg Tablet)

(Generic Lofibra)

2 X X

Fentanyl (100mcg/hr Patch 72

Hour, 12mcg/hr Patch 72 Hour,

25mcg/hr Patch 72 Hour,

50mcg/hr Patch 72 Hour,

75mcg/hr Patch 72 Hour)

3 X X

Finasteride (5mg Tablet)

(Generic Proscar)2 X X

Firazyr (Injection) 5 X X


Flecainide Acetate (Tablet) 2 X X

Flovent Diskus (Aerosol

Powder)3 X

Flovent HFA (Aerosol) 3 X

Fluconazole (Tablet) 2 X X

Fluocinolone Acetonide (Otic

Oil)4 X X

Fluphenazine HCl (Tablet) 2 X X

Fluticasone Propionate

(Suspension)2 X X

Furosemide (Tablet) 1 X X

Fuzeon (Injection) 5 X X

G

Gabapentin (Capsule, Tablet) 2 X X

Gammagard Liquid (Injection) 4 X X

Gemfibrozil (Tablet) 2 X X

Gentamicin Sulfate (0.1%

Cream, 0.1% Ointment, 0.3%

Ophthalmic Ointment, 0.3%

Ophthalmic Solution)

2 X X

Gilenya (Capsule) 5 X X

Gleevec (Tablet) 5 X X

Glimepiride (Tablet) 1 X X

Glipizide (Tablet Immediate-

Release), Glipizide ER (Tablet


1 X X

Glipizide/Metformin HCl (Tablet) 1 X X

Glucagen Hypokit (Injection) 4 X X

Glucagon Emergency Kit

(Injection)3 X X

H

Haloperidol (Tablet) 2 X X

Harvoni (Tablet) 5 X X

Humalog Kwikpen (100unit/

ml Injection), Humalog Mix

50/50 Kwikpen, Humalog Mix

75/25 Kwikpen, Humalog Mix

50/50 Vial, Humalog Mix

75/25 Vial, Humalog Vial

(Injection)

3 X X

Humira (Injection) 5 X X



Humulin 70/30 Kwikpen,

Humulin N Kwikpen, Humulin

70/30 Vial, Humulin N Vial,

Humulin R Vial (Injection),

Humulin R U-500 Vial

(Concentrated Injection)

3 X X

Hydralazine HCl (Tablet) 2 X X

Hydrochlorothiazide (12.5mg

Capsule, 12.5mg Tablet, 25mg

Tablet, 50mg Tablet)

1 X X

Hydrocodone/Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

3 X X

Hydromorphone HCl (Tablet


Hydroxychloroquine Sulfate

(Tablet)2 X X

Hydroxyurea (Capsule) 2 X X

Hydroxyzine HCl (10mg/5ml

Oral Solution)3 X X

I

Ibandronate Sodium (Tablet) 3 X

Ibuprofen (100mg/5ml

Suspension, 400mg Tablet,

600mg Tablet, 800mg Tablet)

2 X X

Ilevro (Suspension) 3 X X

Imiquimod (Cream) 4 X X

Insulin Syringes, Needles 3 X X

Intelence (100mg Tablet,

200mg Tablet)5 X X

Invanz (Injection) 4 X X

Invokamet (Tablet) 3 X

Invokana (Tablet) 3 X

Ipratropium Bromide (0.02%

Inhalation Solution)2 X X

Ipratropium Bromide (0.03%

Nasal Solution, 0.06% Nasal

Solution)

2 X X

Ipratropium Bromide/Albuterol

Sulfate (Inhalation Solution)2 X X


Irbesartan (Tablet) 2 X X

Irbesartan/Hydrochlorothiazide

(Tablet)2 X

Isentress (Tablet) 5 X X

Isoniazid (Tablet) 3 X X

Isosorbide Dinitrate (Tablet

Immediate-Release), Isosorbide

Dinitrate ER (Tablet Extended-

Release)

2 X X

Isosorbide Mononitrate (Tablet

Immediate-Release), Isosorbide

Mononitrate ER (Tablet


2 X X

Ivermectin (Tablet) 3 X X

J

Janumet (Tablet Immediate-

Release), Janumet XR (Tablet


3 X

Januvia (Tablet) 3 X

Jardiance (Tablet) 3 X

K

Kalydeco (Packet) 5 X X

Ketoconazole (Cream,

Shampoo, Tablet)2 X X

Ketorolac Tromethamine

(Ophthalmic Solution)3 X X

Kionex (Powder) 3 X X

Klor-Con 8 (Tablet Extended-

Release), Klor-Con 10 (Tablet

Extended-Release)

3 X X

Klor-Con M20 (Tablet Extended-

Release)2 X X

Kombiglyze XR (Tablet

Extended-Release 24 Hour)3 X

Korlym (Tablet) 5 X X

L

Labetalol HCl (Tablet) 2 X X

Lactulose (Oral Solution) 2 X X

Lamivudine (Tablet) 3 X X

Lamotrigine (Tablet Immediate-

Release)2 X X

33

Drug LIST



Lantus Solostar (Injection),

Lantus Vial (Injection)3 X X

Lastacaft (Ophthalmic

Solution)3 X X

Latanoprost (Ophthalmic

Solution)2 X X

Latuda (Tablet) 5 X X

Leflunomide (Tablet) 2 X X

Letrozole (Tablet) 2 X X

Leucovorin Calcium (Tablet) 3 X X

Leukeran (Tablet) 3 X X

Levemir FlexTouch (Injection),

Levemir Vial (Injection)3 X X

Levetiracetam (Tablet


Levetiracetam (Tablet


Levocarnitine (Tablet) 3 X X

Levocetirizine Dihydrochloride

(Tablet)3 X X

Levofloxacin (Tablet) 3 X X

Levothyroxine Sodium (Tablet) 1 X X

Lialda (Tablet Delayed-

Release)3 X X

Lidocaine (Gel, Ointment, 2%

Viscous Solution)3 X X

Lidocaine/Prilocaine (Cream) 3 X X

Lindane (1% Lotion, 1%

Shampoo)4 X X

Linzess (Capsule) 3 X X

Liothyronine Sodium (Tablet) 2 X X

Lisinopril (Tablet) 1 X X

Lisinopril/Hydrochlorothiazide

(Tablet)1 X X

Lithium Carbonate (Capsule

Immediate-Release, Tablet

Immediate-Release), Lithium

Carbonate ER (Tablet Extended-

Release)

2 X X

Loperamide HCl (Capsule) 2 X X


Lorazepam (Tablet Immediate-

Release), Lorazepam Intensol

(2mg/ml Concentrate)

2 X X

Losartan Potassium (Tablet) 1 X X

Losartan Potassium/

Hydrochlorothiazide (Tablet)1 X X

Lotemax (0.5% Gel, 0.5%

Ointment, 0.5% Suspension)4 X X

Lovastatin (Tablet) 2 X X

Lumigan (Ophthalmic

Solution)3 X X

Lupron Depot (Injection),

Lupron Depot-PED (Injection)5 X X

Lyrica (Capsule) 3 X X

Lysodren (Tablet) 5 X X

M

Medroxyprogesterone Acetate

(Tablet)2 X X

Meloxicam (Tablet) 1 X X

Mercaptopurine (Tablet) 3 X X

Meropenem (Injection) 4 X X

Metformin HCl (Tablet

Immediate-Release), Metformin

HCl ER (500mg Tablet


750mg Tablet Extended-

Release 24 Hour) (Generic

Glucophage XR)

1 X X

Methadone HCl (10mg/5ml Oral

Solution, 5mg/5ml Oral Solution,


3 X X

Methimazole (Tablet) 2 X X

Methotrexate (Tablet) 2 X X

Methscopolamine Bromide

(Tablet)4 X X

Methyldopa (Tablet) 3 X X

Methylphenidate HCl (Tablet

Immediate-Release) (Generic

Ritalin)

3 X X

Methylprednisolone Dose Pack

(Tablet)2 X X

Metoclopramide HCl (Tablet) 2 X X



Metolazone (Tablet) 3 X X

Metoprolol Succinate ER (Tablet


Metoprolol Succinate ER (Tablet


Metoprolol Tartrate (Tablet


Metronidazole (Tablet


Midodrine HCl (Tablet) 3 X X

Migergot (Suppository) 3 X X

Minocycline HCl (Capsule


Minoxidil (Tablet) 2 X X

Mirtazapine (Tablet Immediate-

Release), Mirtazapine ODT

(Tablet Dispersible)

2 X X

Modafinil (Tablet) 4 X X

Montelukast Sodium (4mg

Packet, 10mg Tablet, 4mg

Tablet Chewable, 5mg Tablet

Chewable)

2 X X

Morphine Sulfate ER (Tablet

Extended-Release) (Generic MS

Contin)

3 X X

Multaq (Tablet) 3 X X

Mupirocin (Ointment) 2 X X

Myrbetriq (Tablet Extended-


N

Naltrexone HCl (Tablet) 3 X X

Namenda (Oral Solution),

Namenda XR (Capsule


3 X X

Namenda (Tablet Immediate-

Release)4 X X

Naproxen (Tablet Immediate-

Release)2 X X

Nasonex (Suspension) 4 X X

Neomycin/Polymyxin/

Hydrocortisone (Otic Solution,

Otic Suspension)

3 X X


Nevanac (Suspension) 3 X X

Niacin ER (Tablet Extended-

Release)3 X X

Nicotrol Inhaler 4 X X

Nitrofurantoin Macrocrystals

(50mg Capsule) (Generic

Macrodantin)

3 X X

Nitrofurantoin Monohydrate

(100mg Capsule) (Generic

Macrobid)

3 X X

Nitrostat (Tablet Sublingual) 3 X X

Norethindrone Acetate (Tablet) 2 X X

Nortriptyline HCl (Capsule, Oral

Solution)2 X X

Norvir (100mg Capsule,

80mg/ml Oral Solution,

100mg Tablet)

4 X X

Nuedexta (Capsule) 4 X X

Nutropin AQ (Injection) 5 X X

Nystatin (Cream, Ointment, Oral

Suspension, Topical Powder)2 X X

Nystop (Powder) 2 X X

O

Olanzapine (Tablet Immediate-

Release)2 X X

Omega-3-Acid Ethyl Esters

(Capsule) (Generic Lovaza)4 X X

Omeprazole (10mg Capsule

Delayed-Release, 40mg Capsule

Delayed-Release)

2 X X

Omeprazole (20mg Capsule


Ondansetron (Tablet Immediate-

Release), Ondansetron ODT

(Tablet Dispersible)

2 X X

Onglyza (Tablet) 3 X X

Opana ER (Crush Resistant)

(Tablet Extended-Release 12

Hour Abuse-Deterrent)

3 X

Opsumit (Tablet) 5 X X

Orenitram (0.125mg Tablet

Extended-Release)4 X X

35

Drug LIST




Extended-Release, 1mg Tablet

Extended-Release)

5 X X



Oxcarbazepine (Tablet) 3 X X

Oxybutynin Chloride (5mg/5ml

Syrup, 5mg Tablet)2 X X

Oxybutynin Chloride ER (Tablet


Oxybutynin Chloride ER (Tablet


Oxycodone HCl (Tablet


Oxycodone/Acetaminophen

(10mg-325mg Tablet,

2.5mg-325mg Tablet,

5mg-325mg Tablet,

7.5mg-325mg Tablet)

3 X X

P

Pantoprazole Sodium (Tablet


Pataday (Ophthalmic Solution) 3 X X

Pegasys (Injection) 5 X X

Penicillin V Potassium (Tablet) 2 X X

Perforomist (Nebulized

Solution)4 X X

Periogard (Solution) 2 X X

Permethrin (Cream) 3 X X

Phenytoin Sodium Extended

(Capsule)2 X X

Pilocarpine HCl (Tablet) 3 X X

Pioglitazone HCl (Tablet) 1 X X

Pioglitazone HCl/Glimepiride

(Tablet)3 X

Pioglitazone HCl/Metformin HCl

(Tablet)3 X

Polyethylene Glycol 3350

(Powder) (Generic Miralax)2 X X

Pomalyst (Capsule) 5 X X


Potassium Chloride ER (10meq

Capsule Extended-Release,

8meq Capsule Extended-

Release, 8meq Tablet Extended-

Release)

3 X X

Potassium Chloride ER

Microencapsulated (10meq

Tablet Extended-Release,

20meq Tablet Extended-

Release)

2 X X

Potassium Citrate ER (Tablet


Potiga (Tablet) 4 X X

Pradaxa (Capsule) 3 X X

Pramipexole Dihydrochloride


Pramipexole Dihydrochloride


Pravastatin Sodium (Tablet) 1 X X

Prazosin HCl (Capsule) 2 X X

Prednisolone Acetate

(Suspension)3 X X

Prednisone (5mg/5ml Oral

Solution, Tablet), Prednisone

Intensol (5mg/ml Concentrate)

2 X X

Premarin (Vaginal Cream) 3 X X

Prezista (100mg/ml

Suspension, 150mg Tablet,


5 X X

Pristiq (Tablet Extended-


ProAir HFA (Aerosol Solution),

ProAir RespiClick (Aerosol

Powder)

3 X X

Procrit (10000unit/ml

Injection, 2000unit/ml



Injection)

4 X X

Procrit (20000unit/ml


Injection)

5 X X



Proctosol HC (Cream) 2 X X

Proctozone-HC (Cream) 2 X X

Progesterone (Capsule) 2 X

Prolensa (Ophthalmic

Solution)4 X X

Promethazine HCl (12.5mg

Tablet)4 X X

Propranolol HCl (Tablet

Immediate-Release), Propranolol

HCl ER (Capsule Extended-

Release 24 Hour)

2 X X

Propylthiouracil (Tablet) 2 X X

Pulmicort Flexhaler (Aerosol

Powder)3 X

Pyridostigmine Bromide (Tablet) 2 X X

Q

Quetiapine Fumarate (Tablet


Quinapril HCl (Tablet) 3 X

Quinapril/Hydrochlorothiazide

(Tablet)3 X

R

Raloxifene HCl (Tablet) 2 X

Raloxifene HCl (Tablet) 3 X

Ramipril (Capsule) 2 X X

Ranexa (Tablet Extended-


Ranitidine HCl (Tablet) 2 X X

Rapaflo (Capsule) 3 X X

Rebif (Injection) 5 X X

Renagel (Tablet) 3 X X

Renvela (800mg Tablet) 3 X X

Restasis (Emulsion) 3 X X

Revlimid (Capsule) 5 X X

Reyataz (150mg Capsule,

200mg Capsule, 300mg

Capsule, 50mg Packet)

5 X X

Ribavirin (200mg Capsule) 3 X X

Ribavirin (200mg Tablet) 4 X X

Rifabutin (Capsule) 4 X X

Rifampin (Capsule) 2 X


Rifampin (Capsule) 3 X

Riluzole (Tablet) 3 X X

Rimantadine HCl (Tablet) 2 X

Rimantadine HCl (Tablet) 3 X

Risperidone (Tablet) 2 X X

Rituxan (Injection) 5 X X

Rivastigmine Tartrate (Capsule


Rivastigmine Tartrate (Capsule


Rizatriptan Benzoate (Tablet

Immediate-Release), Rizatriptan

Benzoate ODT (Tablet

Dispersible)

2 X

Rizatriptan Benzoate (Tablet

Immediate-Release), Rizatriptan

Benzoate ODT (Tablet

Dispersible)

3 X

Ropinirole HCl (Tablet


Rozerem (Tablet) 4 X X

S

Santyl (Ointment) 4 X X

Saphris (Tablet Sublingual) 4 X X

Savella (Tablet) 3 X X

Selegiline HCl (Capsule, Tablet) 3 X X

Selzentry (Tablet) 5 X X

Sensipar (30mg Tablet) 3 X X

Sensipar (60mg Tablet, 90mg

Tablet)5 X X

Serevent Diskus (Aerosol

Powder)3 X X

Seroquel XR (Tablet


Sertraline HCl (Tablet) 1 X X

Sildenafil (Tablet) 3 X X

Silver Sulfadiazine (Cream) 3 X X

Simvastatin (Tablet) 1 X X

Sodium Fluoride (Tablet) 2 X X

Sodium Polystyrene Sulfonate

(Suspension)3 X X

37

Drug LIST



Sotalol HCl (Tablet), Sotalol HCl

AF (Tablet)2 X X

Sovaldi (Tablet) 5 X X

Spiriva Handihaler (18mcg

Capsule), Spiriva Respimat

(2.5mcg/ACT Aerosol

Solution)

3 X X

Spironolactone (Tablet) 2 X X

Strattera (Capsule) 4 X X

Suboxone (Film) 4 X X

Sucralfate (Tablet) 2 X X

Sulfamethoxazole/Trimethoprim

(Tablet), Sulfamethoxazole/

Trimethoprim DS (Tablet)

2 X X

Sulfasalazine (Tablet Immediate-

Release)2 X X

Sulfazine EC (Tablet Delayed-

Release)2 X X

Sumatriptan Succinate (Tablet) 2 X

Sumatriptan Succinate (Tablet) 3 X

Suprax (100mg/5ml

Suspension, 200mg/5ml

Suspension, Tablet Chewable)

3 X X

Suprax (400mg Capsule,

500mg/5ml Suspension)3 X X

Symbicort (Aerosol) 3 X X

Synthroid (Tablet) 3 X X

T

Tamiflu (30mg Capsule, 45mg

Capsule, 75mg Capsule, 6mg/

ml Suspension)

4 X X

Tamoxifen Citrate (Tablet) 2 X X

Tamsulosin HCl (Capsule) 2 X X

Tarceva (Tablet) 5 X X

Targretin (75mg Capsule, 1%

Gel)5 X X

Tasigna (Capsule) 5 X X

Tecfidera (Capsule Delayed-

Release)5 X X

Telmisartan (Tablet) 3 X


Telmisartan/Hydrochlorothiazide

(Tablet)3 X

Terazosin HCl (Capsule) 2 X X

Terbinafine HCl (Tablet) 2 X X

Testosterone Cypionate

(Injection)4 X X

Theophylline (80mg/15ml Oral

Solution), Theophylline CR

(100mg Tablet Extended-

Release, 200mg Tablet

Extended-Release), Theophylline

ER (300mg Tablet Extended-

Release 12 Hour, 450mg Tablet


400mg Tablet Extended-

Release 24 Hour, 600mg Tablet


2 X X

Thymoglobulin (Injection) 5 X X

Timolol Maleate (Ophthalmic

Solution)2 X X

Tivicay (Tablet) 5 X X

Tizanidine HCl (Tablet) 2 X X

Tobramycin Sulfate (Ophthalmic

Solution)2 X X

Tobramycin/Dexamethasone

(Ophthalmic Suspension)3 X X

Topiramate (Tablet Immediate-

Release)2 X X

Topotecan HCl (Injection) 5 X X

Torsemide (Tablet) 2 X X

Tracleer (Tablet) 5 X X

Tradjenta (Tablet) 3 X

Tramadol HCl (Tablet


Tramadol HCl/Acetaminophen

(Tablet)2 X X

Tranexamic Acid (100mg/ml

Injection, 650mg Tablet)3 X X

Transderm-Scop (Patch 72

Hour)4 X X

Travatan Z (Ophthalmic

Solution)3 X X

UHEX16PD3701617_000


Trazodone HCl (Tablet) 1 X

Trazodone HCl (Tablet) 2 X

Tretinoin (Capsule) 5 X X

Triamcinolone Acetonide

(Cream, Ointment)3 X X

Triamcinolone in Orabase

(Paste)3 X X

Triamterene/

Hydrochlorothiazide (Capsule,

Tablet)

2 X X

Tribenzor (Tablet) 3 X

Trihexyphenidyl HCl (Elixir) 3 X X

Trulicity (Injection) 3 X

Truvada (Tablet) 5 X X

U

Uloric (Tablet) 3 X X

Ursodiol (Capsule, Tablet) 4 X X

V

Valacyclovir HCl (Tablet) 2 X

Valacyclovir HCl (Tablet) 3 X

Valganciclovir (Tablet) 4 X X

Valsartan (Tablet) 2 X X

Valsartan/Hydrochlorothiazide

(Tablet)2 X X

Verapamil HCl (Tablet

Immediate-Release), Verapamil

HCl ER (Tablet Extended-

Release)

2 X X


Versacloz (Suspension) 5 X X

Vesicare (Tablet) 3 X X

Victoza (Injection) 3 X

Viread (Powder, Tablet) 5 X X

Voltaren (Gel) 3 X X

Vytorin (Tablet) 4 X X

Vyvanse (Capsule) 4 X

W

Warfarin Sodium (Tablet) 1 X X

Welchol (3.75gm Packet,

625mg Tablet)3 X X

X

Xarelto (Tablet) 3 X X

Xolair (Injection) 5 X X

Z

Zafirlukast (Tablet) 2 X

Zafirlukast (Tablet) 3 X

Zenpep (Capsule Delayed-

Release)3 X X

Zetia (Tablet) 3 X X

Zirgan (Gel) 4 X X

Zolpidem Tartrate (Tablet


Zolpidem Tartrate (Tablet


Zonisamide (Capsule) 2 X X

Zostavax (Injection) 4 X X

Zytiga (Tablet) 5 X X

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated

companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s

contract renewal with Medicare.

UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual

property. These fees are used for the general purposes of AARP. AARP and its affiliates are not

insurers. You do not need to be an AARP member to enroll. AARP encourages you to consider

your needs when selecting products and does not make specific product recommendations for

individuals.

39

Drug LIST

This page is intentionally left blank

UHEX16MP3700084_001

Ready to ENROLL

EnrollmentINSTRUCTIONS

We want to make your health care experience as easy as possible right from the start. Below we’ve described the forms you need to fill out to enroll in your plan. Questions? Ask your licensed sales representative or call the number on the first page of this booklet.

PDEX16PD3704971_000Y0066_150608_140046 Accepted

Sales Appointment

Confirmation Form

(use only with a

licensed sales

representative)

If you are meeting with a licensed sales representative, you will need to fill out

this form completely before your appointment can begin. On this form, you’ll select

which products and services you’d like to discuss during your appointment.

Enrollment

request form

We need certain information to complete your enrollment. This form gathers

that information. Two copies of the form are included. Fill out only one form for

each applicant.

This form lists more than one plan. Make sure to select the plan you want to

enroll in.

Please sign your application, then return the completed enrollment form.

By mail: AARP MedicareRx Plans

Attn: Enrollment Department

3315 Central AVE

Hot Springs, AR, 71913

By fax: 1-866-994-9659

Enrollment

checklist (use

only with a licensed

sales representative)

This checklist helps ensure that your licensed sales representative explains

the plan clearly to you and that you fully understand the plan you’ve chosen.

Enrollment

receipt (use only

with a licensed

sales representative)

Your licensed sales representative will help you fill out this receipt. You can

use the completed receipt as your temporary proof of coverage until you receive

your permanent membership materials.

If you received this kit through the mail, not from a licensed sales representative,

you will not receive an enrollment receipt.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare

Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the

plan depends on the plan’s contract renewal with Medicare.

42

Y0066_140611_154714 Approved

Scope of Sales Appointment Confirmation FormThe Centers for Medicare and Medicaid Services requires Licensed Sales Representatives to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the Licensed Sales Representative and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please initial below beside the type of product(s) you want the Licensed Sales Representative to discuss.(Refer to page 2 for product type descriptions)

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

Beneficiary or Authorized Representative Signature and Signature Date: Signature Signature Date

If you are the authorized representative, please sign above and print clearly and legibly below:Name (First_Last) Relationship to Beneficiary

To be completed by Licensed Sales Representative (please print clearly and legibly) Licensed Sales Representative Name (First_Last)

Licensed Sales Representative Phone

Licensed Sales Representative ID

Beneficiary Name (First_Last) Beneficiary Phone (Optional) Date Appointment will be Completed

Beneficiary Address (Optional)

Initial Method of Contact Plan(s) the Licensed Sales Representative will represent during the meeting

Licensed Sales Representative Signature

Scope of appointment (SOA) is subject to CMS Record Retention Requirements

Licensed Sales Representative, if the form was not signed by the beneficiary prior to the appointment, provide explanation why SOA was not documented prior to meeting: Please check all that apply

Unplanned Attendee New SOA required (consumer requested other Health Product information)

Walk-in Other (please explain):

Page 1 of 2

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C) and Cost PlansDental/Vision/Hearing Products

Hospital Indemnity Products

Medicare Supplement (Medigap) Products

TEAR

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ETE

AR H

ERE

43

Ready to EN

RO

LL

Fax to: 1-866-994-9659

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-For-Service Plans, and Medicare Medical Savings Account Plans.

Medicare Advantage Plans (Part C) and Cost PlansMedicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare HMO Point-of-Service (HMO-POS) Plans — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. HMO-POS plans may allow you to get some services out of network for a higher copayment or coinsurance.

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

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you — not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Other Related ProductsDental/Vision/Hearing Products — Plans offering additional benefits for consumers who are looking to cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare.

Hospital Indemnity Products — Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are not affiliated or connected to Medicare.

Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and co-insurance amounts for Medicare approved services.

PDEX16PD3693103_001

Page 2 of 2

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

44

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Page 1 of 6

2016 Enrollment Request FormPlease contact the Plan if you need this information in another language or format (Braille).

Please check the plan you want:

o AARP® MedicareRx Saver Plus (PDP) K o AARP® MedicareRx Preferred (PDP) A

This is a Part D plan. It’s designed to help pay the cost of prescription drugs. Note: If you have a Medicare

Advantage plan:

· You may already have drug coverage

· You will lose that plan automatically when you sign up for a Part D plan. This means you would lose

your medical coverage. This will affect both your doctor and hospital coverage as well as your

prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if

you have questions, contact your Medicare Advantage Plan. If you have an MA-only PFFS plan, you

may still enroll in a PDP and will not lose your MA-only PFFS plan.

If you currently have health coverage from an employer or union, joining this plan could affect your

employer or union health benefits. You could lose your employer or union coverage if you join this plan.

Read the communication your employer or union sends you. If you have questions, visit their website, or

contact the office listed in their communications. If there isn’t information on whom to contact, your

benefits administrator or the office that answers questions about your coverage can help.

Information about you.

Please type or print in black or blue ink.

o Mr.

o Mrs.

o Ms.

Last Name First Name Middle Initial

Birth Date M M / D D / Y Y Y Y Sex ¨ Male ¨ Female

Main phone number ( ) — Other phone number ( ) —

Permanent street address (P.O. BOX IS NOT ALLOWED) Apt

City County State ZIP

Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.)


Email Address

Enrollee name

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Go green and save paper.

o Check here to get your plan information delivered online. Please note: not everything is online yet, so you’ll

still get some materials in the mail. We’ll let you know when a document is ready to view by sending you an

email. To view your documents, just log in and register at www.AARPMedicareRx.com. Want to go back to

getting paper documents? You can change your delivery preferences at any time by logging in to your

plan’s website.

By registering for an online account, I understand I may receive emails about my plan and transactions

such as claims and payment information, as well as news related to my specific conditions and therapies.

Information about your Medicare

Please use the information from your red, white and blue Medicare card. Remember, you need to have

Medicare Part A or Part B (or both) to join this plan.

You can simply fill in the blanks so they

match your card.

Or, you can attach a copy of the card or your

letter from Social Security or the Railroad

Retirement Board.

How do you want to pay?

You can pay your monthly premium (including any late enrollment penalty you may owe) by mail or from your

bank account through Electronic Funds Transfer (EFT). You can also choose to pay your premium by

automatic deduction from your Social Security or Railroad Retirement Board benefit check each month.

This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late

enrollment penalty (LEP), we’ll add it to your premium.

If you don’t choose an option, we’ll send a bill each month to your mailing address.

¨ I want to pay by mail.

We’ll send a bill to your mailing address each month.

¨ I want to pay directly from my bank account.

· Please attach a blank check from the account you’d like to use. Write “VOID” across the front.

Please DO NOT send a deposit slip or money order.

· Please read the statement below.

My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare

Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my

checking account on or about the fifth of each month. If I choose to stop paying directly from my account,

I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of

payment.

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Account Type □ Checking □ Savings

Account Holder Name: _________________________________________________________________

Bank Routing Number

Bank Account Number

· Sign here:

¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check.

We’ll set it up. It may take a few months before payment starts, so the first payment may include more than

one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first

deduction from your Social Security or RRB benefit check will include all premiums due from your

enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your

request for automatic deduction, we will send you a paper bill for your monthly premiums.

A few notes about your costs.

If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA)

Social Security (SS) will send you a letter and ask you how you want to pay it:

· You can pay it from your SS check

· Medicare can bill you

· The Railroad Retirement Board (RRB) can bill you

Please DO NOT pay the plan the Part D-IRMAA at this time.

Need help with your prescription drug costs?

If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify,

Medicare could pay for 75% or more of your costs, including monthly prescription drug premiums, annual

deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty. Many

people are eligible for these savings and don’t even know it. If you qualify for extra help with your Medicare

prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only part

of your premium, we will bill you for the amount that Medicare doesn’t cover.

For more information about this extra help, contact your local Social Security office, or call Social Security at

1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at

www.socialsecurity.gov/prescriptionhelp.

A few questions to help us manage your plan.

1. Do you want plan information in another language or format? ¨ Yes ¨ No

Please check what you’d like: ¨ Spanish ¨ Chinese ¨ Other

If you don’t see the language or format you want, please call us at 1-888-867-5564, (TTY 711) during 8 a.m. to

8 p.m. local time, 7 days a week. Or visit www.AARPMedicareRx.com for online help.

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2. Do you live in a nursing home or a long-term care facility? ¨ Yes ¨ No

If yes, please give us:

Name

Address City State ZIP

Phone Number ( ) -- Date you moved there M M / D D / Y Y Y Y

3. Do you have other insurance that will cover your prescription drugs? ¨ Yes ¨ No

Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs.

If yes, what is it?

Name of other insurance

Member ID number Group ID number Date plan started

M M / D D / Y Y Y Y

Please read and sign

By completing this form, I agree to the following:

· This is a Medicare Prescription Drug plan. It has a contract with the federal government. This Prescription

Drug coverage is in addition to Original Medicare. This is not a Medicare Supplement plan.

· I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless

Medicaid or someone else pays for it.

· I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another

Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan.

· If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan.

· I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do

so between October 15 and December 7. This is the Open Enrollment Period for Medicare Advantage

and Medicare prescription drug coverage. I understand that there may be special situations at other times

during the year in which I can leave the plan.

· This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in

the new area. Medicare may not cover me when I’m out of the country. However, I have some limited

coverage near the U.S. border. I understand that if I leave this plan and don’t have or get other Medicare

prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have

to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the

future.

· I will get a Welcome Guide with an Evidence of Coverage (EOC). (The EOC is also known as a member

contract or subscriber agreement.) The EOC will list services the plan covers, as well as the plan’s termsand conditions. The plan will cover services it approves, as well as services listed in the EOC. If a service

isn’t listed in the EOC or approved by the plan, Medicare and the plan won’t pay for it. If I disagree withhow the plan covers my care, I have the right to make an appeal.

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· I understand I must use network pharmacies except in an emergency. I have the right to make an appeal if

I disagree with how the plan covers or pays for services.

· My plan will give my information, including my prescription drug event data, to Medicare and other plans

when needed for treatment, payment and health care operations. Medicare uses the information to

understand how my care was handled or billed. Other plans may need my information when they help pay

for my care. Medicare may also give my information for research and other purposes. All federal laws and

rules protecting my privacy will be followed.

· I understand that my state may offer help and advice with Medicare supplement insurance or other

Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid

program, and the Medicare Savings Program.

· If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay that

person for this help.

· The information on this form is correct, to the best of my knowledge. I understand that if I put information

on this form that I know is not true, I will lose the plan.

When I sign below, it means that I have read and understand the information on this form.

If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show

written proof of this right if Medicare asks for it.

Signature of applicant / member / authorized representative:

Today’s date: M M / D D / Y Y Y Y

If you are the authorized representative, please sign above and complete the information below.

Last Name First Name

Address

City State ZIP Code

Phone Number ( ) -- Relationship to Applicant

For licensed sales representative/agent use only.

New Member

Plan Change

Employer Group Name

Employer Group ID Branch ID

Enrollee name

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Where did this application originate?

□ Retail/Mall Program

□ Member Meeting

□ Local Event Outreach

□ Community Meeting

□ Local B2B Outreach

□ Other

How was this application submitted? Appointment Other Mail In

Licensed Sales Representative/Writing ID Initial Receipt Date

M M / D D / Y Y Y Y

Licensed Sales Representative/Agent Name Proposed Effective Date

M M / D D / Y Y Y Y

Licensed Sales Representative Phone Number ( ) --

Agent must complete

IEPSEP (Dual Eligible)

AEP

SEP (Institutional)SEP (SEP Reason)

IEP 2SEP - GEP Part BSEP Eligibility Date M M / D D / Y Y Y Y

Licensed Sales Representative Signature (required)

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a

Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with

Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual

property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You

do not need to be an AARP member to enroll. AARP encourages you to consider your needs when selecting

products and does not make specific product recommendations for individuals.

This information is available for free in other languages. Please call our customer service number at

1-888-867-5564, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al

número 1-888-867-5564, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.

本資訊也有其他語言的免費版本。請撥打1-888-867-5564, 聯絡我們的客戶服務部, 聽語障專線711, 每週

7 天, 當地時間上午 8 時至晚上 8 時

Y0066_150729_133540a Approved UHEX16PD3712128_002

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2016 Enrollment Request FormPlease contact the Plan if you need this information in another language or format (Braille).

Please check the plan you want:

o AARP® MedicareRx Saver Plus (PDP) K o AARP® MedicareRx Preferred (PDP) A

This is a Part D plan. It’s designed to help pay the cost of prescription drugs. Note: If you have a Medicare

Advantage plan:

· You may already have drug coverage

· You will lose that plan automatically when you sign up for a Part D plan. This means you would lose

your medical coverage. This will affect both your doctor and hospital coverage as well as your

prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if

you have questions, contact your Medicare Advantage Plan. If you have an MA-only PFFS plan, you

may still enroll in a PDP and will not lose your MA-only PFFS plan.

If you currently have health coverage from an employer or union, joining this plan could affect your

employer or union health benefits. You could lose your employer or union coverage if you join this plan.

Read the communication your employer or union sends you. If you have questions, visit their website, or

contact the office listed in their communications. If there isn’t information on whom to contact, your

benefits administrator or the office that answers questions about your coverage can help.


Please type or print in black or blue ink.

o Mr.

o Mrs.

o Ms.

Last Name First Name Middle Initial

Birth Date M M / D D / Y Y Y Y Sex ¨ Male ¨ Female

Main phone number ( ) — Other phone number ( ) —

Permanent street address (P.O. BOX IS NOT ALLOWED) Apt


Mailing address (Only if it’s different from your permanent street address. You can give a P.O. box.)


Email Address

Enrollee name

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Page 2 of 6


Go green and save paper.

o Check here to get your plan information delivered online. Please note: not everything is online yet, so you’ll

still get some materials in the mail. We’ll let you know when a document is ready to view by sending you an

email. To view your documents, just log in and register at www.AARPMedicareRx.com. Want to go back to

getting paper documents? You can change your delivery preferences at any time by logging in to your

plan’s website.

By registering for an online account, I understand I may receive emails about my plan and transactions

such as claims and payment information, as well as news related to my specific conditions and therapies.

Information about your Medicare

Please use the information from your red, white and blue Medicare card. Remember, you need to have

Medicare Part A or Part B (or both) to join this plan.

You can simply fill in the blanks so they

match your card.

Or, you can attach a copy of the card or your

letter from Social Security or the Railroad

Retirement Board.

How do you want to pay?

You can pay your monthly premium (including any late enrollment penalty you may owe) by mail or from your

bank account through Electronic Funds Transfer (EFT). You can also choose to pay your premium by

automatic deduction from your Social Security or Railroad Retirement Board benefit check each month.

This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you have a late

enrollment penalty (LEP), we’ll add it to your premium.

If you don’t choose an option, we’ll send a bill each month to your mailing address.

¨ I want to pay by mail.

We’ll send a bill to your mailing address each month.

¨ I want to pay directly from my bank account.

· Please attach a blank check from the account you’d like to use. Write “VOID” across the front.

Please DO NOT send a deposit slip or money order.

· Please read the statement below.

My bank may pay my plan premium to UnitedHealthcare Insurance Company (UnitedHealthcare

Insurance Company of New York for New York residents) (UHIC). My bank will pay the funds from my

checking account on or about the fifth of each month. If I choose to stop paying directly from my account,

I will tell both UHIC and my bank. I will give them a reasonable amount of time to change my method of

payment.

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Account Type □ Checking □ Savings

Account Holder Name: _________________________________________________________________

Bank Routing Number

Bank Account Number

· Sign here:

¨ I want to pay from my Social Security or Railroad Retirement Board (RRB) check.

We’ll set it up. It may take a few months before payment starts, so the first payment may include more than

one premium. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first

deduction from your Social Security or RRB benefit check will include all premiums due from your

enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your

request for automatic deduction, we will send you a paper bill for your monthly premiums.

A few notes about your costs.

If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA)

Social Security (SS) will send you a letter and ask you how you want to pay it:

· You can pay it from your SS check

· Medicare can bill you

· The Railroad Retirement Board (RRB) can bill you

Please DO NOT pay the plan the Part D-IRMAA at this time.

Need help with your prescription drug costs?

If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If you qualify,

Medicare could pay for 75% or more of your costs, including monthly prescription drug premiums, annual

deductibles, and co-insurance. Additionally, you won’t have a coverage gap or late enrollment penalty. Many

people are eligible for these savings and don’t even know it. If you qualify for extra help with your Medicare

prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only part

of your premium, we will bill you for the amount that Medicare doesn’t cover.

For more information about this extra help, contact your local Social Security office, or call Social Security at

1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at

www.socialsecurity.gov/prescriptionhelp.

A few questions to help us manage your plan.

1. Do you want plan information in another language or format? ¨ Yes ¨ No

Please check what you’d like: ¨ Spanish ¨ Chinese ¨ Other

If you don’t see the language or format you want, please call us at 1-888-867-5564, (TTY 711) during 8 a.m. to

8 p.m. local time, 7 days a week. Or visit www.AARPMedicareRx.com for online help.

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2. Do you live in a nursing home or a long-term care facility? ¨ Yes ¨ No

If yes, please give us:

Name

Address City State ZIP

Phone Number ( ) -- Date you moved there M M / D D / Y Y Y Y

3. Do you have other insurance that will cover your prescription drugs? ¨ Yes ¨ No

Examples: Other private insurance, TRICARE, Federal employee coverage, VA benefits, or state programs.

If yes, what is it?

Name of other insurance

Member ID number Group ID number Date plan started

M M / D D / Y Y Y Y

Please read and sign

By completing this form, I agree to the following:

· This is a Medicare Prescription Drug plan. It has a contract with the federal government. This Prescription

Drug coverage is in addition to Original Medicare. This is not a Medicare Supplement plan.

· I need to keep my Medicare Parts A and B. I must keep paying my Part B premium if I have one, unless

Medicaid or someone else pays for it.

· I can only be in one Medicare health plan or Prescription Drug plan at a time. If I’m a member of another

Medicare health plan or Prescription Drug plan and I join this plan, I will lose the other plan.

· If I have prescription drug coverage now or if I get it from somewhere else later, I will tell the plan.

· I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll need to do

so between October 15 and December 7. This is the Open Enrollment Period for Medicare Advantage

and Medicare prescription drug coverage. I understand that there may be special situations at other times

during the year in which I can leave the plan.

· This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a plan in

the new area. Medicare may not cover me when I’m out of the country. However, I have some limited

coverage near the U.S. border. I understand that if I leave this plan and don’t have or get other Medicare

prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have

to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the

future.

· I will get a Welcome Guide with an Evidence of Coverage (EOC). (The EOC is also known as a member

contract or subscriber agreement.) The EOC will list services the plan covers, as well as the plan’s termsand conditions. The plan will cover services it approves, as well as services listed in the EOC. If a service

isn’t listed in the EOC or approved by the plan, Medicare and the plan won’t pay for it. If I disagree withhow the plan covers my care, I have the right to make an appeal.

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· I understand I must use network pharmacies except in an emergency. I have the right to make an appeal if

I disagree with how the plan covers or pays for services.

· My plan will give my information, including my prescription drug event data, to Medicare and other plans

when needed for treatment, payment and health care operations. Medicare uses the information to

understand how my care was handled or billed. Other plans may need my information when they help pay

for my care. Medicare may also give my information for research and other purposes. All federal laws and

rules protecting my privacy will be followed.

· I understand that my state may offer help and advice with Medicare supplement insurance or other

Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid

program, and the Medicare Savings Program.

· If I get help from a sales agent, broker or someone who has a contract with the plan, the plan may pay that

person for this help.

· The information on this form is correct, to the best of my knowledge. I understand that if I put information

on this form that I know is not true, I will lose the plan.

When I sign below, it means that I have read and understand the information on this form.

If I sign as an authorized representative, it means that I have the legal right under state law to sign. I can show

written proof of this right if Medicare asks for it.

Signature of applicant / member / authorized representative:

Today’s date: M M / D D / Y Y Y Y

If you are the authorized representative, please sign above and complete the information below.

Last Name First Name

Address

City State ZIP Code

Phone Number ( ) -- Relationship to Applicant

For licensed sales representative/agent use only.

New Member

Plan Change

Employer Group Name

Employer Group ID Branch ID

Enrollee name

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Where did this application originate?

□ Retail/Mall Program

□ Member Meeting

□ Local Event Outreach

□ Community Meeting

□ Local B2B Outreach

□ Other

How was this application submitted? Appointment Other Mail In

Licensed Sales Representative/Writing ID Initial Receipt Date

M M / D D / Y Y Y Y

Licensed Sales Representative/Agent Name Proposed Effective Date

M M / D D / Y Y Y Y

Licensed Sales Representative Phone Number ( ) --

Agent must complete

IEPSEP (Dual Eligible)

AEP

SEP (Institutional)SEP (SEP Reason)

IEP 2SEP - GEP Part BSEP Eligibility Date M M / D D / Y Y Y Y

Licensed Sales Representative Signature (required)

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a

Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with

Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual

property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You

do not need to be an AARP member to enroll. AARP encourages you to consider your needs when selecting

products and does not make specific product recommendations for individuals.

This information is available for free in other languages. Please call our customer service number at

1-888-867-5564, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al

número 1-888-867-5564, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.

本資訊也有其他語言的免費版本。請撥打1-888-867-5564, 聯絡我們的客戶服務部, 聽語障專線711, 每週

7 天, 當地時間上午 8 時至晚上 8 時

Y0066_150729_133540a Approved UHEX16PD3712128_002

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PLAN INFORMATION Here are some details about your plan and coverage.

My new plan is (circle one):Medicare supplement insurance (Medigap) policy Medicare Advantage plan Medicare Part D plan

The name of my new plan is: . My plan coverage begins (effective date): M M / D D / Y Y Y Y

I must have Medicare Part A and Part B (or both) to enroll in this plan.

My plan is available only in the plan’s service area, which is: . If I move outside of the service area, I will ask my Licensed Sales Representative or Customer Service to help me choose a new plan.

My plan will now provide all my Medicare prescription drug coverage.

I cannot have a stand-alone Medicare Part D plan and a Medicare Advantage plan at the same time. (There is one exception: Medicare Advantage Private Fee-for-Service plans that do not include prescription drug coverage.)

I can cancel this plan before it goes into effect by calling Customer Service at .If my plan coverage starts and I want to leave the plan, I will generally need to wait until the Open Enrollment Period, unless I qualify for a Special Election Period.

PREMIUM INFORMATION What you need to know about paying a monthly premium.

I need to continue to pay my Medicare Part B premium unless the state or another third party pays this premium for me.

My plan: Does not have a premium (monthly payment). Has a $ monthly premium (this would include the cost of any riders if applicable). I must pay this monthly premium to stay in this plan.

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2016 EnrollmentCHECKLIST

Your Licensed Sales Representative has given you a lot of information about the plan you have chosen.

For each topic, please fill out information on this sheet and check each box to confirm you understand what you and your Licensed Sales Representative have reviewed. If you have any questions, please ask.

Y0066_150708_012328A Accepted

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Ready to EN

RO

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Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan's contract renewal with Medicare.PDEX16MP3710696_000

PRESCRIPTION DRUG COVERAGE Know what is covered by your prescription drug plan.

My prescription drug plan will cover only those drugs included on my plan’s list of covered drugs. My Licensed Sales Representative helped me confirm whether my current medications are on my plan’s drug list, and showed me how to look up any medications I am prescribed in the future.

My current medications are:

I understand how my prescription drug plan works, including: • The cost difference between network

pharmacies and out-of-network pharmacies • Tier levels • Prior authorizations• Quantity limits

• Step therapy • Coverage gap drug stages and how they

impact my costs• Late Enrollment Penalty

We’ll send you an Annual Notice of Changes prior to the Open Enrollment Period. It will tell you about any changes to your plan for the next year. If your needs change throughout the year or you have questions about your plan, please call your Licensed Sales Representative or Customer Service. A few examples of when to call are: getting a new prescription, changing your doctor, or moving.

Remember that plans can change each year.

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2016 Enrollment Receipt

To be completed if enrolling with a licensed Sales Representative.

Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and

you have received your permanent membership materials. You will receive a copy of your original

Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your

local licensed Sales Representative.

This copy is for your records only. Please do not resubmit enrollment.

Applicant 1:

Name ____________________________________

Application Date M M / D D / Y Y Y Y

Proposed Effective Date M M / D D / Y Y Y Y

Plan Name ________________________________

Plan Type _________________________________

Enrollment Tracking No. (if applicable) _________

Applicant 2 (if applicable):

Name ____________________________________



Plan Name _____________________________

Plan Type _________________________________


If you have any questions, please contact your local Licensed Sales Representative:

Licensed Sales Representative Name _______________________________

Licensed Sales Representative Phone No. ____________________________

Licensed Sales Representative ID __________________________________

RxBIN: 610097

Rx PCN: 9999

RxGRP: PDPIND

Questions? We’re always here to help.

Simply call the Customer Service number listed on the first page of this booklet.

Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a

Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.

Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Y0066_150629_142455 Accepted PDEX16PD3707402_000

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2016 Enrollment Receipt

To be completed if enrolling with a licensed Sales Representative.

Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and

you have received your permanent membership materials. You will receive a copy of your original

Enrollment Request Form in the mail within two weeks. If you do not receive a copy please contact your

local licensed Sales Representative.

This copy is for your records only. Please do not resubmit enrollment.

Applicant 1:

Name ____________________________________



Plan Name ________________________________

Plan Type _________________________________


Applicant 2 (if applicable):

Name ____________________________________



Plan Name _____________________________

Plan Type _________________________________


If you have any questions, please contact your local Licensed Sales Representative:

Licensed Sales Representative Name _______________________________

Licensed Sales Representative Phone No. ____________________________

Licensed Sales Representative ID __________________________________

RxBIN: 610097

Rx PCN: 9999

RxGRP: PDPIND

Questions? We’re always here to help.

Simply call the Customer Service number listed on the first page of this booklet.

Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a

Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.

Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Y0066_150629_142455 Accepted PDEX16PD3707402_000

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Here’s what you can expect soon.

What’s next?Thank you for choosing UnitedHealthcare.

1 Member may use any pharmacy in the network but may not receive preferred retail pharmacy pricing. Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas. You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New precriptions from OptumRx should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877-266-4832. OptumRx is an affiliate of UnitedHealthcare Insurance Company. AARP MedicareRx Plan’s pharmacy network offers limited access to pharmacies with preferred cost sharing in rural IA, MN, MT, NE, ND, SD and WY. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, please call the customer service number located on the first page of this booklet or consult the online pharmacy directory at AARPMedicareRx.com.This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Premium and/or co- payments/co-insurance may change on January 1 of each year.The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.Y0066_PDP07012015_000 Accepted PDEX16DU3719663_000

Helpful information:Questions? Give us a call.Toll-Free 1-866-883-0659, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week

Verification Letter We got your application and are reviewing it.

Welcome Letter and Member ID Card Great news — your application has been approved.

Welcome Guide and Plan Details Learn how you can make the most of your plan.

Welcome Call We’ll call you to check in and answer any questions you may have.

Get ready to get the most out of your plan. Take advantage of members-only savings at preferred retail pharmacies.

Get extra savings by filling your prescriptions through our Preferred Retail Pharmacy Network.1

Review your drugs with your doctor. Bring the drug list shown in the formulary with you to your doctor’s appointments. Ask about generics and lower-cost options listed on your formulary and if they might work for you.

Learn about and sign up for home delivery. Once your coverage begins, sign up to start getting more savings by having your prescriptions conveniently mailed to your home.

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Y0066_150619_112614A_FINAL_6 AcceptedThis is an advertisement.

PDMO16PD3707500_003

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliatedcompanies, a Medicare Advantage organization with a Medicare contract and aMedicare-approved Part D sponsor. Enrollment in the plan depends on the plan’scontract renewal with Medicare.

PDP

2016 enrollment guide - osborn & associates€¦ · itÕs more than a drug plan. itÕs a...

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