Entire Enrollment Kit

COVER - APPROVED VERSION

convenientplanOnE

2011 Enrollment KitRx DrugsDoctorsHospitals

$0 monthly plan premium

AARP® MedicareComplete Choice® Plan 2 (Regional PPO)

Florida

R5287-001

Y0004Y0066_100707_142434 CMS Approved 08202010

Additional Plan Information

Pharmacy Options

Enrollment Materials

- Outbound Education & Verification Call Checklist (See back of Enrollment Materials Divider)

- Scope of Appointment Form

Enrollment Form

Roadmap After Enrollment

What You’ll Find in this Booklet

Cover Letter.........................................................................1

Medicare Advantage Explained............................................3

Benefits at a Glance.............................................................4

Passport Brochure...............................................................6

Ready to Enroll.................................................................... 8

Summary of Benefits............................................................9

.....................................31

- Appeals & Grievances............................................33

- Plan Ratings.......................................................... 35

- Disclaimers............................................................37

..........................................39

- Drug List................................................................41

Health Care to Fit Your Needs… now that is peace of mind At UnitedHealthcare we realize more than ever the importance of affordable health care coverage. We are dedicated to helping you make the right choices by providing quality, cost-effective health care solutions. As one of the largest and most recognized health carriers in the United States, you can be confident we will be here when you need us.

INSIDE THIS BOOKLET:

• Understand the basics of Medicare Advantage

• Learn how our plans can benefit you

• View plan details and how they compare to your Original Medicare

• Start your application process

• Continue on your path to good health

Thank you for your interest in this plan. The world of Medicare can be confusing, but we’re here to help. Together we’ll find a plan that’s right for you.

Sincerely,

Thomas S. PaulChief Executive Officer, UnitedHealthcare Medicare Solutions

We’re Here For You

We Make Health Care Simple… and provide the answers you need

Cover Letter - Version 3 with revisions from 6/10/10

Talk with your local sales agent. Health care is personal. Your agent will answer your questions and help you enroll.

Go online: <WebsiteAddress>.

If you don’t have a local sales agent, call SecureHorizons toll-free: x-xxx-xxx-xxxx, <8 a.m. – 8 p.m. local time, 7 days a week>. TTY users, call 711.

Medicare members use our Medicare

Advantage Programs

ONEFIVE

out of

1-800-547-5514, 8 a.m.– 8 p.m. local time, 7 days a week.

www.AARPMedicarePlans.com.

• Look up your medications

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If you don’t have a local sales agent, call SecureHorizons toll-free:

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You may contact 1-800-MEDICARE (1-800-633-4227) and TTY users should call 1-877-486-2028,24 hours a day, 7 days a week or visit www.medicare.gov for more information about Medicarebenefits and services including general information regarding health and Part D benefit.

The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an affiliate ofUnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicarecontract. AARP MedicareComplete plans carry the AARP name, and UnitedHealthcare pays aroyalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the generalpurpose of AARP and its members. AARP is not the insurer. You do not need to be an AARPmember to enroll.

AARP does not recommend health related products, services, insurance or programs. You arestrongly encouraged to evaluate your needs.

This document is available in alternative formats. You must have both Medicare Part A and B, andmust reside in the service area of the plan. You must continue to pay your Medicare Part Bpremium if not otherwise paid for under Medicaid or by another third party. Your ability to enrollmay be limited certain times of the year. For more information contact Customer Service at1-800-547-5514 7 days a week, between 8:00 a.m. and 8:00 p.m. local time. TTY users can call711 or write us at P.O. Box 29675, Hot Springs, AR 71903-9675, or go towww.AARPMedicarePlans.com. You must use plan providers except in emergency or urgent caresituations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providersneither Medicare nor AARP MedicareComplete RX plans will be responsible for the costs. For PPOand HMO-POS members, with the exception of emergency or urgent care or out-of-area renaldialysis, it may cost more to get care from out-of-network providers. For PPO members,reimbursement is provided for all covered benefits regardless of whether they are received innetwork. Out of network services may cost more than in network services. You may be able to getExtra Help to pay for your prescription drug premiums and costs. To see if you qualify for ExtraHelp, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours aday/ 7 days a week; Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Mondaythrough Friday. TTY users should call 1-800-325-0778; or your State Medicaid Office. The MedicarePrescription Drug benefit is only available to members of the Medicare Advantage with PrescriptionDrug (MA-PD) plans. By enrolling in an MA-PD you will automatically be disenrolled from anyexisting Medicare Prescription Drug coverage. To receive the highest level of benefit you must usecontracted network pharmacies to access your prescription drug benefit except in the case ofemergency. The pharmacy network includes retail, mail order, long-term care, home infusion andI/T/U (Indian Health Service, Tribes, or Urban Indian) pharmacy services. You may obtain yourprescriptions from pharmacies outside the contracted network at a reduced benefit. Quantitylimitations and restrictions may apply. For more information about mail order, names andaddresses of network pharmacies or for more information call 1-800-547-5514, or TTY 711,Monday through Friday, 8:00 a.m. to 8:00 p.m. local times. Or write us at P.O. Box 29675, HotSprings, AR 71903-9675, or go to www.AARPMedicarePlans.com. The AARP® MedicareComplete®benefit packages, plan premiums, copayments/coinsurance may vary by county, and service areasare all subject to change annually at the Medicare Advantage contract renewal time with theCenters for Medicare & Medicaid Services (January 1). Availability of coverage beyond the end ofthe current year is not guaranteed.

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Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage Organization with a Medicare contract.

MA EXPLAINED APPROVED LAYOUT - Legal Edits

Medicare Advantage ExplainedMedicare is health insurance for people 65 and older and others with certain disabilities. You have choices about how you get your Medicare coverage. You can choose Original Medicare (Parts A and B) or a Medicare Advantage plan.

Many people with Original Medicare find there are expenses that are not covered. To help pay for some of these additional costs, many people choose to enroll in a Medicare Advantage plan.

• Part A helps with hospital costs• Part B helps with doctor services

and outpatient care

Original Medicare consists of Medicare Parts A and B

• Medicare Advantage plans cover at least the same services as Parts A and B

Medicare Advantage (Part C) Combines Your Coverage into ONE Plan

Original Medicare (Parts A and B)

Operated by the Federal government. Medicare pays fees for your care

directly to the doctors and hospitals you visit

DPART

Optional Plan You Can Add

= +APART BPART

Original Medicare

CPART

DPART

Operated by private companies approved by Medicare.

Individuals must have both Parts A and B to enroll. You pay a low or no additional monthly plan

premium beyond the Medicare Part B premium

= + +Medicare Advantage plans may be a lower-cost alternative to Original Medicare. Medicare

Advantage can offer extra preventive benefits and prescription drugs all in ONE convenient plan.

Prescription Drug Coverage

Other Services May Be Included

• Part D (optional add-on) stand-alone prescription drug plans can be added to help with the cost of prescription drugs

• Most preventive care services are not covered – expect to pay additional costs for these services

• Original Medicare has unpredictable out-of-pocket expenses

• Prescription drug coverage (Part D) is included in many Medicare Advantage plans

• Preventive care services like dental, vision, hearing and foot care may be included at no extra charge

• Medicare Advantage plans have predictable out-of-pocket expenses

OVEX11MP3244608_000

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Benefits at a GlanceThis plan is a Preferred Provider Organization (PPO). PPO plans provide care through a network of doctors and hospitals, and give you the option to receive care out-of-network for covered services, generally at a higher cost to you. With a PPO you do not need a referral to see specialists. PPO plans may be a good fit for someone looking for predictable cost shares and benefits above Original Medicare.

To verify your provider is in the plan’s network or for additional plan informationvisit us online at www.AARPMedicarePlans.com

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Benefit In-Network Out-of-NetworkMonthly plan premium $0Deductible None

Medical CoverageAnnual physical $0 copay $40 copayPreventive services (Medicare-covered) $0 copay 30% coinsuranceImmunizations (pneumonia and flu) $0 copay $0 copayPrimary Care Physician (PCP) office visit $10 copay $40 copaySpecialist office visit $30 copay (No Referral Needed) $40 copayInpatient hospitalization $290 copay per day: days 1-5.

$0 thereafter.$375 copay per day: days 1-27. $0 thereafter.

Outpatient surgery and hospital services 20% coinsurance 30% coinsuranceUrgently needed care $30 copay $40 copayEmergency care $50 copay $50 copayAmbulance services $200 copay $200 copayHome health care $0 copay 30% coinsuranceSkilled nursing facility (SNF) care $50 copay per day: days 1-20. $175 copay per day: days 1-58.Lab services:

HIV & cardiovascular screenings $0 copay $0 - $20 copayAll other lab services $20 copay $20 copay

Diagnostic testing:EKG & AAA screenings 0% - 20% coinsurance 30% coinsuranceAll other diagnostic tests 20% coinsurance 30% coinsurance

X-rays $16 copay $21 copayAnnual out-of-pocket maximum $4750 $10000 combined

Prescription DrugsPrescription drug deductible $0Initial coverage stage 31-day retail supply 90-day mail order supplyn Tier 1: $6 $12n Tier 2: $45 $125n Tier 3: $85 $245n Tier 4: 33% 33%Coverage gap stage (after prescriptioncosts paid reach $2840)

No Coverage

Catastrophic coverage stage (after youhave paid $4550 out-of-pocket)

The greater of $2.50 for generic, $6.30 for brand-name, or 5%

5

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,a Medicare Advantage Organization with a Medicare contract.

To verify your provider is in the plan’s network or for additional plan informationvisit us online at www.AARPMedicarePlans.com

Also included in this plan In-Network Out-of-NetworkFoot care $30 copay for 6 visits per year* $40 copay for 6 visits per year*Vision services $0 copay for Medicare-covered

glaucoma screening$30 copay for routine exams; 1per year*

$40 copay for Medicare-coveredglaucoma screening$40 copay for routine exams; 1per year*

Dental services $0 copay for oral exams; 1 every 6 months*$0 copay for routine cleanings; 1 every 6 months*$0 copay for X-rays; 1 everyyear as ordered by your dentist*

$40 copay for oral exams; 1every 6 months*$40 copay for routine cleanings; 1 every 6 months*$40 copay for X-rays; 1 everyyear as ordered by your dentist*

Hearing services $30 copay for annual hearingtest*

$40 copay for annual hearingtest*

SilverSneakers® Fitness Program Fitness center membership andclasses at over 10,000participating nationwidelocations. Access to treadmills,weights, and fitness classes and a heated pool at selectlocations. Please visitwww.silversneakers.com formore information

Self-directed, pedometer-basedphysical activity and walkingprogramAvailable for members living 15miles or more from aSilverSneakers fitness center

UnitedHealth Passport® Program Included in this plan. See the Passport brochure in this bookletfor more information.

NurselineSM Speak with a registered nurse (RN) 24 hours a day

* Benefit combined in and out-of-networkThe benefit information provided here in is a brief summary, not a comprehensive description of benefits. For more information contact the plan or review the Summary of Benefits provided within this booklet for more benefit information.

To verify your provider is in the plan’s network or for additional plan information visit us online at www.AARPMedicarePlans.com2

Master Template

The 2011 UnitedHealth Passport® ProgramThe UnitedHealth Passport® Program is Included in Your Plan.

You pay no additional charge (beyond your monthly health plan premium) for health care coverage while you travel within the UnitedHealth Passport® service area. Simply pay the same copay or coinsurance as you would at home to receive non‑emergency care benefit coverage when traveling within the service area, including preventive care, specialist care and hospitalizations. Emergency care is covered worldwide.

The gray states on the map to the right show the states in which there are UnitedHealth Passport® service areas. If you are a plan member who resides within one of the counties in this list, you are eligible to participate in the UnitedHealth Passport Program. If you travel to any of the counties on this list, you will be able to use the Passport benefit to access routine and preventive care as needed.

Alabama Autauga, Baldwin, Bibb, Blount, Chilton, Elmore, Jefferson, Lowndes, Macon, Mobile, Montgomery, Russell, Shelby, St. Clair, Walker

Arizona Cochise, Graham, Maricopa, Pima, Pinal, Santa Cruz, Yavapai

Arkansas Benton, Carroll, Crawford, Sebastian, Washington

Connecticut1 All Counties in the State of Connecticut

Florida All Counties in the State of Florida

Georgia Chatham, Cherokee, Clayton, Cobb, Columbia, DeKalb, Forsyth, Fulton, Harris, Muscogee, Rich‑mond

Hawaii All Counties in the State of Hawaii

Idaho Ada, Canyon

Illinois Bureau, Carroll, Cook, Henderson, Henry, Jersey, Jo Daviess, Kane, Knox, Madison, Marshall, Mercer, Monroe, Peoria, Putnam, Rock Island, Stark, St. Clair, Tazewell, Warren, Whiteside, Will, Woodford

Indiana Adams, Allen, Boone, Fulton, Hamilton, Hancock, Hendricks, Huntington, Johnson, Kosciusko, Madi‑son, Marion, Noble, Posey, St. Joseph, Vanderburgh, Warrick, Wells, Whitley

Iowa Appanoose, Benton, Black Hawk, Boone, Bremer, Buchanan, Butler, Cedar, Chickasaw, Clarke, Clayton, Clinton, Crawford, Dallas, Davis, Delaware, Des Moines, Dubuque, Fayette, Floyd, Greene, Grundy, Guthrie, Hamilton, Hardin, Henry, Iowa, Jackson, Jasper, Jefferson, Johnson, Jones, Keokuk, Lee, Linn, Louisa, Lucas, Madison, Mahaska, Marion, Marshall, Monroe, Muscatine, Page, Polk, Pottawattamie, Poweshiek, Scott, Shelby, Story, Tama, Van Buren, Wapello, Warren, Washington, Wayne

Kansas Johnson, Sedgwick

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Kentucky Boone, Campbell, Kenton

Maine Cumberland, Kennebec, Sagadahoc, York

Massachusetts All Counties in the State of Massachusetts

Michigan Allegan, Kent, Ottawa

Missouri Barry, Cass, Christian, Cole, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Jackson, Jefferson, Laclede, Lafayette, Lawrence, Lincoln, McDonald, Polk, St. Charles, St. Louis, St. Louis City, Stone, Texas, Warren, Washington, Webster, Wright

Nebraska Burt, Cass, Douglas, Otoe, Sarpy, Washington

New Mexico Dona Ana, Grant, Hidalgo, Luna, Sierra

New York1 All Counties in the State of New York

North Carolina Alamance, Caswell, Catawba, Chatham, Cumberland, Davidson, Davie, Durham, Forsyth, Guilford, Haywood, Henderson, Iredell, Mecklenburg, Orange, Person, Randolph, Rockingham, Rowan, Stokes, Surry, Wake, Wilkes, Yadkin

Ohio Butler, Clark, Clermont, Cuyahoga, Delaware, Franklin, Greene, Hamilton, Madison, Mahoning, Montgomery, Preble, Stark, Summit, Trumbull, Warren

Oregon2 Clackamas, Lane, Marion, Multnomah, Washington, Yamhill

Pennsylvania Erie, Lancaster, Lehigh, Northampton, York

Rhode Island All Counties in the State of Rhode Island

South Carolina Beaufort, Charleston, Greenville, York

Tennessee Anderson, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Davidson, DeKalb, Fayette, Grainger, Greene, Hamblen, Hamilton, Hancock, Hawkins, Hickman, Jefferson, Johnson, Knox, Loudon, McMinn, Meigs, Monroe, Morgan, Roane, Rutherford, Scott, Sevier, Shelby, Sullivan, Tipton, Unicoi, Union, Washington

Texas Austin, Brazoria, El Paso, Fort Bend, Hardin, Harris, Jefferson, Liberty, Montgomery

Utah Box Elder, Cache, Davis, Morgan, Salt Lake, Summit, Tooele, Utah, Wasatch, Weber

Vermont All Counties in the State of Vermont

Virginia Bland, Botetourt, Bristol City, Buchanan, Chester‑field, Craig, Dickenson, Floyd, Franklin, Goochland, Grayson, Lee, Hanover, Henrico, Montgomery, Newport News City, Norfolk City, Norton City, Ports‑mouth City, Radford City, Richmond City, Roanoke, Roanoke City, Russell, Salem City, Scott, Smyth, Tazewell, Washington, Wise, Wythe

Washington Skagit, Spokane, Whatcom

Wisconsin Brown, Calumet, Dodge, Fond Du Lac, Green Lake, Kewaunee, La Crosse, Manitowoc, Milwaukee, Monroe, Oconto, Outagamie, Ozaukee, Racine, Shawano, Sheboygan, Trempeleau, Vernon, Washington, Waukesha, Waupaca, Waushara, Winnebago

1 Members of HMO plans H3307 in New York as well as Point of Service plans H0752 in Connecticut and H3107 in New Jersey may access Passport services in the state of Florida only.2 The H3805 HMO plans in the Oregon counties of Clackamas, Lane, Marion, Multnomah and Washington do not participate in UnitedHealth Passport. Therefore, members of these plans are not eligible to participate in the program.

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract. 7

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract.

After Medicare approves your enrollment you will receive your Welcome Letter, New Member Kit and your Member ID card.

Ready to Enroll?Things to Do Before You Enroll:

I’m a Member…What’s Next?Enjoy Peace of Mind with One Convenient Plan

Review the benefit information in this booklet.

You may choose to contact your doctor to confirm if he or she is in the network or you may ask your sales agent to check for you. For a complete list of plan providers, visit our Web site.

Check the Drug List in this booklet to see if your medications are included. Visit our Web site for a detailed listing of prescription medications. (for MAPD plans)

Have your Original Medicare ID card ready or other proof that states you are eligible for Medicare. This information will help you fill out the Enrollment Form.

Customer service phone number is located on the back of your card.

Please secure your Original Medicare card in a safe place.

CHOICEan informed

makE

This is a sample card; your card may look different.

www.myaaRPmedicare.com Register online to view your personal information, plan details, coverage summaries, payment history, options and claims.

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Summary of BenefitsJanuary 1, 2011 — December 31, 2011

AARP® MedicareComplete Choice® Plan 2 (Regional PPO)R5287-001

Florida

AAFL11RP3240860_000Y0066_100816EA01_SB_PPO CMS Approved 09082010

Section I - Introduction to Summary of BenefitsThank you for your interest in AARP MedicareComplete Choice Plan 2 (Regional PPO). Our plan is offeredby UNITEDHEALTHCARE INSURANCE COMPANY/SecureHorizons by UnitedHealthcare, a MedicareAdvantage Preferred Provider Organization (PPO). This Summary of Benefits tells you some features ofour plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a completelist of our benefits, please call AARP MedicareComplete Choice Plan 2 (Regional PPO) and ask for the"Evidence of Coverage".

You Have Choices in Your Health CareAs a Medicare beneficiary, you can choose from different Medicare options. One option is the Original(fee-for-service) Medicare Plan. Another option is a Medicare health plan, like AARP MedicareCompleteChoice Plan 2 (Regional PPO). You may have other options too. You make the choice. No matter what youdecide, you are still in the Medicare Program.

You may be able to join or leave a plan only at certain times. Please call AARP MedicareComplete ChoicePlan 2 (Regional PPO) at the number listed at the end of this introduction or 1-800-MEDICARE(1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call thisnumber 24 hours a day, 7 days a week.

How Can I Compare My Options?You can compare AARP MedicareComplete Choice Plan 2 (Regional PPO) and the Original Medicare Planusing this Summary of Benefits. The charts in this booklet list some important health benefits. For eachbenefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits,which may change from year to year.

Where is AARP MedicareComplete Choice Plan 2 (Regional PPO) Available?The service area for this plan includes: Florida. You must live in this area to join the plan.

Who is Eligible to Join AARP MedicareComplete Choice Plan 2 (Regional PPO)You can join AARP MedicareComplete Choice Plan 2 (Regional PPO) if you are entitled to Medicare PartA and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage RenalDisease are generally not eligible to enroll in AARP MedicareComplete Choice Plan 2 (Regional PPO) unlessthey are members of our organization and have been since their dialysis began.

Can I Choose My Doctors?AARP MedicareComplete Choice Plan 2 (Regional PPO) has formed a network of doctors, specialists, andhospitals. You can use any doctor who is part of our network. You may also go to doctors outside of ournetwork. The health providers in our network can change at any time.

You can ask for a current Provider Directory or for an up-to-date list visit us at www.AARPMedicarePlans.com

Our customer service number is listed at the end of this introduction.

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What Happens if I go to a Doctor Who's Not in Your Network?You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for theservices you receive outside the network, and you may have to follow special rules prior to getting servicesin and/or out of network. For more information, please call the customer service number at the end ofthis introduction.

Where can I Get My Prescriptions if I Join This Plan?AARP MedicareComplete Choice Plan 2 (Regional PPO) has formed a network of pharmacies. You mustuse a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use anout-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time.You can ask for a pharmacy directory or visit us at www.AARPMedicarePlans.com Our customer servicenumber is listed at the end of this introduction.

AARP MedicareComplete Choice Plan 2 (Regional PPO) has a list of preferred pharmacies. At thesepharmacies, you may get your drugs at a lower co-pay or co-insurance. You may go to a non-preferredpharmacy, but you may have to pay more for your prescription drugs.

Does My Plan Cover Medicare Part B or Part D Drugs?AARP MedicareComplete Choice Plan 2 (Regional PPO) does cover both Medicare Part B prescription drugsand Medicare Part D prescription drugs.

What is a Prescription Drug Formulary?AARP MedicareComplete Choice Plan 2 (Regional PPO) uses a formulary. A formulary is a list of drugscovered by your plan to meet patient needs. We may periodically add, remove, or make changes to coveragelimitations on certain drugs or change how much you pay for a drug. If we make any formulary changethat limits our members' ability to fill their prescriptions, we will notify the affected enrollees before thechange is made. We will send a formulary to you and you can see our complete formulary on our Web siteat www.AARPMedicarePlans.com

If you are currently taking a drug that is not on our formulary or subject to additional requirements orlimits, you may be able to get a temporary supply of the drug. You can contact us to request an exceptionor switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you canget a temporary supply of the drug or for more details about our drug transition policy.

How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra HelpWith Other Medicare Costs?You may be able to get extra help to pay for your prescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify for getting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources' in thepublication Medicare & You.

* The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday throughFriday. TTY/TDD users should call 1-800-325-0778 or

* Your State Medicaid Office.

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What Are My Protections in This Plan?All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plansdecide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, youwill not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of AARP MedicareComplete Choice Plan 2 (Regional PPO), you have the right to request anorganization determination, which includes the right to file an appeal if we deny coverage for an item orservice, and the right to file a grievance. You have the right to request an organization determination ifyou want us to provide or pay for an item or service that you believe should be covered. If we deny coveragefor your requested item or service, you have the right to appeal and ask us to review our decision. Youmay ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decisioncould seriously put your life or health at risk, or affect your ability to regain maximum function. If yourdoctor makes or supports the expedited request, we must expedite our decision. Finally, you have theright to file a grievance with us if you have any type of problem with us or one of our network providersthat does not involve coverage for an item or service. If your problem involves quality of care, you alsohave the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Pleaserefer to the Evidence of Coverage (EOC) for the QIO contact information.

As a member of AARP MedicareComplete Choice Plan 2 (Regional PPO), you have the right to request acoverage determination, which includes the right to request an exception, the right to file an appeal if wedeny coverage for a prescription drug, and the right to file a grievance. You have the right to request acoverage determination if you want us to cover a Part D drug that you believe should be covered. Anexception is a type of coverage determination. You may ask us for an exception if you believe you need adrug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lowerout-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantityof a drug. If you think you need an exception, you should contact us before you try to fill your prescriptionat a pharmacy. Your doctor must provide a statement to support your exception request. If we denycoverage for your prescription drug(s), you have the right to appeal and ask us to review our decision.Finally, you have the right to file a grievance if you have any type of problem with us or one of our networkpharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care,you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

What is a Medication Therapy Management (MTM) Program?A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited toparticipate in a program designed for your specific health and pharmacy needs. You may decide not toparticipate but it is recommended that you take full advantage of this covered service if you are selected.Contact AARP MedicareComplete Choice Plan 2 (Regional PPO) for more details.

What Types of Drugs May be Covered Under Medicare Part B?Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but arenot limited to, the following types of drugs. Contact AARP MedicareComplete Choice Plan 2 (RegionalPPO) for more details.

Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (whocould be the patient) under doctor supervision.Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

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Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanentkidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.Injectable Drugs: Most injectable drugs administered incident to a physician's service.Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplantwas paid for by Medicare, or paid by a private insurance that paid as a primary payer to your MedicarePart A coverage, in a Medicare-certified facility.Some Oral Cancer Drugs: If the same drug is available in injectable form.Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.Inhalation and Infusion Drugs provided through DME.

Where Can I Find Information on Plan Ratings?The Medicare program rates how well plans perform in different categories (for example, detecting andpreventing illness, ratings from patients and customer service). If you have access to the web, you mayuse the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or"Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plansin your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customerservice number is listed below.

Please call SecureHorizons by UnitedHealthcare for more information aboutAARP MedicareComplete Choice Plan 2 (Regional PPO).

Visit us at www.AARPMedicarePlans.com or, call us:

Customer Service Hours:

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m - 8:00 p.m Eastern

Current members should call toll-free 1-800-643-4845 for questions related to theMedicare Advantage Program and Medicare Part D Prescription Drug program.

TTY/TDD: 711

Prospective members should call toll-free 1-800-547-5514 for questions related to theMedicare Advantage and Medicare Part D Prescription Drug Program.

TTY/TDD: 711

For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 daysa week. Or, visit www.medicare.gov on the web.

This document may be available in a different format or language. For additional information, callcustomer service at the phone number listed above.Este documento puede estar disponible en diferentes formatos e idiomas. Por favor, llame al númerode Servicio al Cliente dado anteriormente si necesita obtener más información.本資訊可以不同形式或語言提供。如需更多資訊，請撥打上文所列的電話號碼，與客戶服

務部聯絡。If you have special needs, this document may be available in other formats.

13

Section II - Summary Of BenefitsIf you have any questions about this plan's benefits or costs, please contact SecureHorizons by UnitedHealthcarefor details.

AARP MedicareComplete ChoicePlan 2 (Regional PPO)

Original MedicareBenefit

Important Information

General$0 monthly plan premium in additionto your monthly Medicare Part Bpremium.

In 2010 the monthly Part B Premiumwas $96.40 and may change for 2011and the yearly Part B deductibleamount was $155 and may change for2011.

1 Premium and OtherImportantInformation

Most people will pay the standardmonthly Part B premium in addition toIf a doctor or supplier does not accept

assignment, their costs are oftenhigher, which means you pay more.

their MA plan premium. However,some people will pay higher Part B andPart D premiums because of theirMost people will pay the standard

monthly Part B premium. However, yearly income (over $85,000 forsingles, $170,000 for marriedsome people will pay a higher premiumcouples). For more information aboutbecause of their yearly income (overPart B and Part D premiums based on$85,000 for singles, $170,000 forincome, call Medicare atmarried couples). For more information1-800-MEDICARE (1-800-633-4227).about Part B premiums based onTTY users should call 1-877-486-2048.income, call Medicare atYou may also call Social Security at1-800-MEDICARE (1-800-633-4227).1-800-772-1213. TTY users should call1-800-325-0778.

TTY users should call 1-877-486-2048.You may also call Social Security at1-800-772-1213. TTY users should call1-800-325-0778.

This plan covers all Medicare-coveredpreventive services with zero costsharing.

In-Network$4,750 out-of-pocket limit.

This limit includes onlyMedicare-covered services.

In and Out-of-Network$10,000 out-of-pocket limit.

In-Network:


Out-Of-Network:


14



Important Information (continued)

In-NetworkNo referral required for networkdoctors, specialists, and hospitals.

You may go to any doctor, specialistor hospital that accepts Medicare.

2 Doctor and HospitalChoice(For moreinformation, seeEmergency Care -#15 and UrgentlyNeeded Care - #16.)

In and Out-of-NetworkYou can go to doctors, specialists, andhospitals in or out of the network. Itwill cost more to get out of networkbenefits.

Out of Service AreaPlan covers you when you travel in theU.S.

Inpatient Care

In-NetworkNo limit to the number of days coveredby the plan each benefit period.

In 2010 the amounts for each benefitperiod were:

3 Inpatient HospitalCare(includes SubstanceAbuse andRehabilitationServices)

Days 1 - 60: $1100 deductibleFor Medicare-covered hospital stays:Days 61 - 90: $275 per day

Days 91 - 150: $550 per lifetimereserve day These amounts willchange for 2011. Call1-800-MEDICARE (1-800-633-4227)for information about lifetime reservedays.

Days 1 - 5: $290 copay per dayDays 6 - 90: $0 copay per day

$0 copay for each additional hospitalday.

Out-of-NetworkFor hospital stays:

Lifetime reserve days can only be usedonce.

Days 1 - 27: $375 copay per dayA "benefit period" starts the day yougo into a hospital or skilled nursing

Days 28 and beyond: $0 copay perday

facility. It ends when you go for 60days in a row without hospital orskilled nursing care. If you go into thehospital after one benefit period hasended, a new benefit period begins.You must pay the inpatient hospitaldeductible for each benefit period.There is no limit to the number ofbenefit periods you can have.

In-NetworkYou get up to 190 days in a PsychiatricHospital in a lifetime.

Same deductible and copay asinpatient hospital care (see "InpatientHospital Care" above).

4 Inpatient MentalHealth Care

For Medicare-covered hospital stays:

15



Inpatient Care (continued)

190 day lifetime limit in a PsychiatricHospital.


Out-of-NetworkFor hospital stays:


In-NetworkPlan covers up to 100 days eachbenefit period

In 2010 the amounts for each benefitperiod after at least a 3-day coveredhospital stay were:

5 Skilled NursingFacility (SNF)(in aMedicare-certifiedskilled nursingfacility)

No prior hospital stay is required.

For Medicare-covered SNF stays:

Days 1 - 20: $0 per dayDays 21 - 100: $137.50 per dayThese amounts will change for 2011.

Days 1 - 20: $50 copay per day100 days for each benefit period.Days 21 - 58: $100 copay per day

A "benefit period" starts the day yougo into a hospital or SNF. It ends when

Days 59 - 100: $0 copay per day

Out-of-NetworkFor each SNF stay:you go for 60 days in a row without

hospital or skilled nursing care. If youDays 1 - 58: $175 copay per SNF daygo into the hospital after one benefit

period has ended, a new benefit period Days 59 - 100: $0 copay per SNF day

begins. You must pay the inpatienthospital deductible for each benefitperiod. There is no limit to the numberof benefit periods you can have.

In-Network$0 copay for each Medicare-coveredhome health visit.

$0 copay.6 Home Health Care(includes medicallynecessaryintermittent skillednursing care, homehealth aide services,and rehabilitationservices, etc.)

Out-of-Network30% for home health visits.

GeneralYou must get care from aMedicare-certified hospice.

You pay part of the cost for outpatientdrugs and inpatient respite care.

You must get care from aMedicare-certified hospice.

7 Hospice

Outpatient Care

16



Outpatient Care (continued)

In-Network$10 copay for each primary caredoctor visit for Medicare-coveredbenefits.

20% coinsurance8 Doctor Office Visits

$30 copay for each in-area, networkurgent care Medicare-covered visit.

$30 copay for each specialist visit forMedicare-covered benefits.

Out-of-Network$40 copay for each primary caredoctor visit.

$40 copay for each specialist visit.

In-Network50% of the cost for eachMedicare-covered visit.

Routine care not covered

20% coinsurance for manualmanipulation of the spine to correct

9 ChiropracticServices

subluxation (a displacement or Medicare-covered chiropractic visitsare for manual manipulation of themisalignment of a joint or body part)spine to correct subluxation (aif you get it from a chiropractor or

other qualified providers. displacement or misalignment of ajoint or body part) if you get it from achiropractor or other qualifiedproviders.

Out-of-Network50% of the cost for chiropracticbenefits.

In-Network$30 copay for each Medicare-coveredvisit.

Routine care not covered.

20% coinsurance for medicallynecessary foot care, including care for

10 Podiatry Services

medical conditions affecting the lowerlimbs.

$30 copay for up to 6 routine visit(s)every year

Medicare-covered podiatry benefitsare for medically-necessary foot care.

Out-of-Network$40 copay for podiatry benefits.

17




In-Network$40 copay for each Medicare-coveredindividual therapy visit.

45% coinsurance for most outpatientmental health services.

11 Outpatient MentalHealth Care

$30 copay for each Medicare-coveredgroup therapy visit.

Out-of-Network$35 to $45 copay for Mental Healthbenefits.

$35 to $45 copay for Mental Healthbenefits with a psychiatrist.

In-Network$40 copay for Medicare-coveredindividual visits.

20% coinsurance12 OutpatientSubstance AbuseCare

$30 copay for Medicare-covered groupvisits.

Out-of-Network$35 to $45 copay for outpatientsubstance abuse benefits.

In-Network20% of the cost for eachMedicare-covered ambulatory surgicalcenter visit.

20% coinsurance for the doctor

Specified copayment for outpatienthospital facility charges. Copay cannotexceed than Part A inpatient hospitaldeductible.

13 OutpatientServices/Surgery

20% of the cost for eachMedicare-covered outpatient hospitalfacility visit.

20% coinsurance for ambulatorysurgical center facility charges

Out-of-Network30% of the cost for ambulatory surgicalcenter benefits.

30% of the cost for outpatient hospitalfacility benefits.

In-Network$200 copay for Medicare-coveredambulance benefits.

20% coinsurance14 AmbulanceServices(medically necessaryambulance services) Out-of-Network

$200 copay for ambulance benefits.

18




General$50 copay for Medicare-coveredemergency room visits.

20% coinsurance for the doctor

Specified copayment for outpatienthospital emergency room (ER) facilitycharge.

15 Emergency Care(You may go to anyemergency room ifyou reasonablybelieve you needemergency care.)

Worldwide coverage.

If you are admitted to the hospitalwithin 24-hour(s) for the same

ER Copay cannot exceed Part Ainpatient hospital deductible.

condition, you pay $0 for theemergency room visit

You don't have to pay the emergencyroom copay if you are admitted to thehospital for the same condition within3 days of the emergency room visit.

NOT covered outside the U.S. exceptunder limited circumstances.

General$40 copay for Medicare-coveredurgently needed care visits.

20% coinsurance, or a set copay

NOT covered outside the U.S. exceptunder limited circumstances.

16 Urgently NeededCare(This is NOTemergency care, andin most cases, is outof the service area.)

In-Network$30 copay for Medicare-coveredOccupational Therapy visits.

20% coinsurance17 OutpatientRehabilitationServices(OccupationalTherapy, PhysicalTherapy, Speech andLanguage Therapy,Respiratory TherapyServices, Social/PsychologicalServices, and more)

$30 copay for Medicare-coveredPhysical and/or Speech and LanguageTherapy visits.

$30 copay for Medicare-coveredCardiac Rehab services.

Out-of-Network$40 copay for Occupational Therapybenefits.

$40 copay for Physical and/or Speechand Language Therapy visits.

$40 copay for Cardiac Rehab services.

Outpatient Medical Services and Supplies

19



Outpatient Medical Services and Supplies (continued)

In-Network20% of the cost for Medicare-covereditems.

20% coinsurance18 Durable MedicalEquipment(includeswheelchairs, oxygen,etc.)

Out-of-Network30% of the cost for durable medicalequipment.

In-Network20% of the cost for Medicare-covereditems.

20% coinsurance19 Prosthetic Devices(includes braces,artificial limbs andeyes, etc.) Out-of-Network

30% of the cost for prosthetic devices.

In-Network$0 copay for Diabetes self-monitoringtraining.

20% coinsurance

Nutrition therapy is for people whohave diabetes or kidney disease (but

20 DiabetesSelf-MonitoringTraining, NutritionTherapy, andSupplies(includes coveragefor glucose monitors,test strips, lancets,screening tests,self-managementtraining, retinalexam/glaucoma test,and foot exam/therapeutic softshoes)

$0 copay for Nutrition Therapy forDiabetes.

$0 copay for Diabetes supplies.

Out-of-Network30% of the cost for Diabetesself-monitoring training.

30% of the cost for Nutrition Therapyfor Diabetes.

30% of the cost for Diabetes supplies.

aren't on dialysis or haven't had akidney transplant) when referred by adoctor. These services can be given bya registered dietitian or include anutritional assessment and counselingto help you manage your diabetes orkidney disease.

In-Network$0 to $20 copay or 0% of the cost forMedicare-covered lab services.

20% coinsurance for diagnostic testsand x-rays

$0 copay for Medicare-covered labservices

21 Diagnostic Tests,X-Rays, LabServices, andRadiology Services 0% to 20% of the cost for

Medicare-covered diagnosticprocedures and tests.

Lab Services: Medicare coversmedically necessary diagnostic labservices that are ordered by your $16 copay for Medicare-covered

X-rays.treating doctor when they are providedby a Clinical Laboratory Improvement 20% of the cost for Medicare-covered

diagnostic radiology services (notincluding x-rays).

Amendments (CLIA) certifiedlaboratory that participates inMedicare. Diagnostic lab services are

20



Outpatient Medical Services and Supplies (continued)

20% of the cost for Medicare-coveredtherapeutic radiology services.

done to help your doctor diagnose orrule out a suspected illness orcondition. Medicare does not cover Out-of-Network

30% of the cost for diagnosticradiology services.

most routine screening tests, likechecking your cholesterol.

30% of the cost for therapeuticradiology services.

$20 copay or 30% of the cost fordiagnostic procedures, tests, and labservices.

$21 copay for outpatient x-rays.

Preventive Services

In-Network$0 copay for Medicare-covered bonemass measurement.

No coinsurance, copayment ordeductible.

Covered once every 24 months (moreoften if medically necessary) if youmeet certain medical conditions.

22 Bone MassMeasurement(for people withMedicare who are atrisk)

Out-of-Network30% of the cost for Medicare-coveredbone mass measurement.

In-Network$0 copay for Medicare-coveredcolorectal screenings.

No coinsurance, copayment ordeductible for screening colonoscopyor screening flexible sigmoidoscopy.

23 ColorectalScreening Exams(for people withMedicare age 50 andolder)

$0 copay up to 1 additionalscreening(s) every year.

Covered when you are high risk orwhen you are age 50 and older.

Out-of-Network30% of the cost for colorectalscreenings.

In-Network$0 copay for Flu and Pneumoniavaccines.

$0 copay for Flu, and Pneumonia andHepatitis B vaccines.

You may only need the Pneumoniavaccine once in your lifetime. Call yourdoctor for more information.

24 Immunizations(Flu vaccine,Hepatitis B vaccine -for people withMedicare who are atrisk, Pneumoniavaccine)

No referral needed for Flu andpneumonia vaccines.

$0 copay for Hepatitis B vaccine.

Out-of-Network$0 copay for immunizations.

21



Preventive Services (continued)

In-Network$0 copay for Medicare-coveredscreening mammograms.

No coinsurance, copayment ordeductible.

No referral needed.

25 Mammograms(Annual Screening)(for women withMedicare age 40 andolder)

Out-of-Network30% of the cost for screeningmammograms.

Covered once a year for all womenwith Medicare age 40 and older. Onebaseline mammogram covered forwomen with Medicare between age 35and 39.

In-Network$0 copay for Medicare-covered papsmears and pelvic exams

No coinsurance, copayment, ordeductible for Pap smears.

No coinsurance, copayment, ordeductible for Pelvic and clinical breastexams.

26 Pap Smears andPelvic Exams(for women withMedicare) $0 copay up to 1 additional pap

smear(s) and pelvic exam(s) every year

Covered once every 2 years. Coveredonce a year for women with Medicareat high risk.

Out-of-Network30% of the cost for pap smears andpelvic exams.

In-Network$0 copay for Medicare-coveredprostate cancer screening.

20% coinsurance for the digital rectalexam.

$0 for the PSA test; 20% coinsurancefor other related services.

27 Prostate CancerScreening Exams(for men withMedicare age 50 andolder)

Out-of-Network30% of the cost for prostate cancerscreening.

Covered once a year for all men withMedicare over age 50.

In-Network20% of the cost for renal dialysis

20% coinsurance for renal dialysis

20% coinsurance for Nutrition Therapyfor End-Stage Renal Disease

28 End-Stage RenalDisease

$0 copay for Nutrition Therapy forEnd-Stage Renal Disease.Nutrition therapy is for people who

have diabetes or kidney disease (but Out-of-Network30% of the cost for Nutrition Therapyfor End-Stage Renal Disease.

aren't on dialysis or haven't had akidney transplant) when referred by adoctor. These services can be given by 20% of the cost for renal dialysis.a registered dietitian or include anutritional assessment and counselingto help you manage your diabetes orkidney disease.

22




Drugs covered under Medicare PartB General20% of the cost for Part B-coveredchemotherapy drugs and other PartB-covered drugs.

Most drugs are not covered underOriginal Medicare. You can addprescription drug coverage to OriginalMedicare by joining a MedicarePrescription Drug Plan, or you can get

29 Prescription Drugs

all your Medicare coverage, including 30% of the cost for Part B drugsout-of-network.prescription drug coverage, by joining

a Medicare Advantage Plan or aDrugs covered under Medicare PartD GeneralThis plan uses a formulary. The planwill send you the formulary. You can

Medicare Cost Plan that offersprescription drug coverage.

also see the formulary atwww.AARPMedicarePlans.com on theweb.

Different out-of-pocket costs mayapply for people who

have limited incomes,live in long term care facilities, orhave access to Indian/Tribal/Urban(Indian Health Service).

The plan offers national in-networkprescription coverage (i.e., this wouldinclude 50 states and DC). This meansthat you will pay the same cost-sharingamount for your prescription drugs ifyou get them at an in-networkpharmacy outside of the plan's servicearea (for instance when you travel).

Total yearly drug costs are the totaldrug costs paid by both you and theplan.

The plan may require you to first tryone drug to treat your condition beforeit will cover another drug for thatcondition.

Some drugs have quantity limits.

Your provider must get priorauthorization from AARPMedicareComplete Choice Plan 2(Regional PPO) for certain drugs.

23




You must go to certain pharmacies fora very limited number of drugs, due tospecial handling, provider coordination,or patient education requirements thatcannot be met by most pharmacies inyour network. These drugs are listedon the plan's website, formulary,printed materials, as well as on theMedicare Prescription Drug Plan Finderon Medicare.gov.

If the actual cost of a drug is less thanthe normal cost-sharing amount forthat drug, you will pay the actual cost,not the higher cost-sharing amount.

If you request a formulary exceptionfor a drug and AARPMedicareComplete Choice Plan 2(Regional PPO) approves theexception, you will pay Tier 3:Non-Preferred Generic andNon-Preferred Brand Drugs costsharing for that drug.

$0 deductible.In-Network

You pay the following until total yearlydrug costs reach $2,840:

Initial Coverage

Tier 1: Preferred Generic DrugsRetail Pharmacy

$6 copay for a one-month (31-day)supply of drugs in this tier$18 copay for a three-month (90-day)supply of drugs in this tier

Tier 2: Generic and Preferred BrandDrugs

$45 copay for a one-month (31-day)supply of drugs in this tier$135 copay for a three-month(90-day) supply of drugs in this tier

Tier 3: Non-Preferred Generic andNon-Preferred Brand Drugs

24




$85 copay for a one-month (31-day)supply of drugs in this tier$255 copay for a three-month(90-day) supply of drugs in this tier

Tier 4: Specialty Tier Drugs

33% coinsurance for a one-month(31-day) supply of drugs in this tier33% coinsurance for a three-month(90-day) supply of drugs in this tier

Tier 1: Preferred Generic DrugsLong Term CarePharmacy

$6 copay for a one-month (31-day)supply of drugs in this tier






33% coinsurance for a one-month(31-day) supply of drugs in this tier

Tier 1: Preferred Generic DrugsMail Order

$12 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy.$18 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy.


$125 copay for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.$135 copay for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.

25





$245 copay for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.$255 copay for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.


33% coinsurance for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.33% coinsurance for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.

After your total yearly drug costs reach$2,840, you receive a discount on

Coverage Gap

brand name drugs and pay 93% of theplan's costs for all generic drugs, untilyour yearly out-of-pocket drug costsreach $4,550.

After your yearly out-of-pocket drugcosts reach $ 4,550, you pay thegreater of:

Catastrophic Coverage

A $ 2.50 copay for generic (includingbrand drugs treated as generic) anda $ 6.30 copay for all other drugs, or5% coinsurance.

Plan drugs may be covered in specialcircumstances, for instance, illness

Out-of-Network

while traveling outside of the plan'sservice area where there is no networkpharmacy. You may have to pay morethan your normal cost-sharing amountif you get your drugs at anout-of-network pharmacy. In addition,you will likely have to pay the

26




pharmacy's full charge for the drug andsubmit documentation to receivereimbursement from AARPMedicareComplete Choice Plan 2(Regional PPO).

You will be reimbursed up to the fullcost of the drug minus the following

Out-of-Network InitialCoverage

for drugs purchased out-of-networkuntil total yearly drug costs reach$2,840:

Tier 1: Preferred Generic Drugs







33% coinsurance for a one-month(31-day) supply of drugs in this tier

You will not be reimbursed for thedifference between the Out-of-NetworkPharmacy charge and the plan'sIn-Network allowable amount.

You will be reimbursed up to 7% of theplan allowable cost for generic drugs

Out-of-NetworkCoverage Gap

purchased out-of-network until totalyearly out-of-pocket drug costs reach$4,550.

You will be reimbursed up to thediscounted price for brand name drugspurchased out-of-network until totalyearly out-of-pocket drug costs reach$4,550.

27





After your yearly out-of-pocket drugcosts reach $ 4,550, you will be

Out-of-NetworkCatastrophic Coverage

reimbursed for drugs purchasedout-of-network up to the full cost ofthe drug minus your cost share, whichis the greater of:

A $ 2.50 copay for generic (includingbrand drugs treated as generic) anda $ 6.30 copay for all other drugs, or5% coinsurance.


In-Network$30 copay for Medicare-covered dentalbenefits.

Preventive dental services (such ascleaning) not covered.

30 Dental Services

$0 copay for up to 1 oral exam(s)every six months$0 copay for up to 1 cleaning(s)every six months$0 copay for up to 1 dental x-ray(s)

Out-of-Network$40 copay for preventive dentalbenefits.

$40 copay for comprehensive dentalbenefits.

In-NetworkHearing aids not covered.

Routine hearing exams and hearingaids not covered.

31 Hearing Services

20% coinsurance for diagnostic hearingexams.

$30 copay for Medicare-covereddiagnostic hearing exams$30 copay for up to 1 routine hearingtest(s) every year

Out-of-Network$40 copay for hearing exams.

28




In-Network20% coinsurance for diagnosis andtreatment of diseases and conditionsof the eye.

32 Vision Services$0 copay for one pair of eyeglassesor contact lenses after cataractsurgery.

Routine eye exams and glasses notcovered.

$0 to $30 copay for exams todiagnose and treat diseases andconditions of the eye.

Medicare pays for one pair ofeyeglasses or contact lenses aftercataract surgery.

$30 copay for up to 1 routine eyeexam(s) every year

Out-of-Network$40 copay for eye exams.Annual glaucoma screenings covered

for people at risk. 30% of the cost for eye wear.

In-NetworkWhen you get Medicare Part B, you canget a one-time physical within the first

When you join Medicare Part B, thenyou are eligible as follows.

During the first 12 months of your newPart B coverage, you can get either a

33 Welcome toMedicare; andAnnual WellnessVisit 12 months of your new Part B

coverage. The coverage does notinclude lab tests.

Welcome to Medicare exam or anAnnual Wellness visit.

$0 copay for the requiredMedicare-covered initial preventive

After your first 12 months, you can getone Annual Wellness visit every 12months. physical exam and annual wellness

visits.There is no coinsurance, copaymentor deductible for either the Welcometo Medicare exam or the AnnualWellness visit.

The Welcome to Medicare exam doesnot include lab tests.

In-NetworkThe plan covers the following health/wellness education benefits:

Smoking Cessation: Covered if orderedby your doctor. Includes twocounseling attempts within a 12-month

34 Health/WellnessEducation

period if you are diagnosed with a Written health education materials,including Newsletterssmoking-related illness or are taking

medicine that may be affected by Health Club Membership/FitnessClassestobacco. Each counseling attempt

includes up to four face-to-face visits. Nursing HotlineYou pay coinsurance, and Part Bdeductible applies.

$0 copay for each Medicare-coveredsmoking cessation counseling session.

$0 copay for the HIV screening, butyou generally pay 20% of the

$0 copay for each Medicare-coveredHIV screening.

29




HIV screening is covered for peoplewith Medicare who are pregnant and

Medicare-approved amount for thedoctor's visit. HIV screening is covered

people at increased risk for thefor people with Medicare who areinfection, including anyone who askspregnant and people at increased riskfor the test. Medicare covers this testfor the infection, including anyone whoonce every 12 months or up to threetimes during a pregnancy.

asks for the test. Medicare covers thistest once every 12 months or up tothree times during a pregnancy. Out-of-Network

$0 copay for Health and Wellnessservices.

In-NetworkThis plan does not cover routinetransportation.

Not covered.Transportation(Routine)

In-NetworkThis plan does not cover Acupuncture.

Not covered.Acupuncture

30

Additional Information

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Member Appeals and Grievances ProcessMembers of our Medicare Advantage health plans have the right to request an organization determination including the right to file an appeal and the right to file a grievance. Medicare Advantage health plan organizations must identify, track, resolve and report all activity related to an appeal or grievance.

Medicare Advantage Member Appeals

What is an Appeal?An appeal is a type of request you make when you want us to reconsider a decision concerning coverage of a service or the amount your health plan pays or will pay for a service. The initial decision concerning medical care or services is called an “organization determination.”

When can an Appeal be filed?You may file an appeal within 60 calendar days of the date of the initial organization determination. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe.

Who can file an Appeal?You may file an appeal or someone else may file an appeal on your behalf. You must appoint the individual to act as your representative to file the appeal for you. To learn how to name a representative, contact Customer Service.

How can an Appeal be filed?An appeal must be filed in writing directly to us. You may call Customer Service for additional information. To learn how to file an appeal, contact Customer Service.

Fast ReviewsYou have the right to request and receive fast decisions affecting your medical treatment in “time-sensitive” situations. A situation is time-sensitive if waiting for a decision to be made within the standard timeframe could seriously harm your health or your ability to function. If your doctor provides a written or oral statement supporting your need of a fast review we will automatically give you a fast review. A decision will be issued as quickly as possible but no later than 72 hours after receiving the request.

Medicare Advantage Member Grievances

What is a Grievance?A grievance is a complaint that doesn’t involve coverage for an item or service by your health plan or a contracting medical provider. If your grievance involves quality of care, you have the right to file a grievance with the Quality Improvement Organization (QIO) of your state. Refer to Section I of the Summary of Benefits for the name of the QIO in your state.

When can a Grievance be filed?You may file a grievance within 60 calendar days of the date of the event causing the grievance. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe. There is no time limit for complaints concerning quality of care.

Who can file a Grievance?You may file a grievance or someone else may file a grievance on your behalf. You must appoint the individual to act as your representative to file the grievance for you. To learn how to name a representative, contact Customer Service.

133

Master Template


How can a Grievance be filed?A grievance for Quality of Care may be filed verbally by contacting Customer Service. All other grievances must be submitted in writing.

Fast GrievancesYou have the right to file a fast grievance. We will respond to fast grievances within 24 hours of receipt. You may file a fast grievance if you disagree with our decision to deny your request for a fast review. You may also file a fast grievance if we notify you that we are extending our timeframe to make an organization determination or reconsideration decision, or if we downgrade your expedited appeal request to standard due to not meeting expedited criteria.

For Members with Medicare Part D Drug Coverage through our Plan

Coverage DeterminationsWe will make an initial decision as to whether or not we will provide the Part D drug you are requesting or pay for the Part D drug you already received. This initial decision is called a “coverage determination.”

ExceptionsYou or your doctor may ask us to make an exception to our Part D coverage determination. You may request an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. Generally, we will only approve your request for an exception if the alternative Part D drug is included in your plan’s formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor or other prescriber must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor or other prescriber should be sent to us with the exception request. If we approve your exception request for a Part D non-formulary drug, you can’t request an exception to the copayment or coinsurance amount we require you to pay for the drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy.

Part D Drug AppealsIf you are getting Medicare prescription Part D drug coverage through our plan you have the right to file an appeal. This includes the right to appeal our decision regarding your exception request. Follow the process outlined above to file an appeal. An appeal concerning coverage determinations must be filed in writing directly to us.

Part D Drug GrievancesIf you are getting Medicare prescription Part D drug coverage through our plan, you have the right to file a grievance. Follow the process outlined above to file a grievance concerning your Part D prescription drug coverage.

34

SecureHorizons by UnitedHealthcare - R5287

Medicare Health Plan Ratings

The Medicare Program rates how well Medicare Advantage performs in different categories (for example, detecting and preventing illness, rating from patients, patient safety and customer service). The information provided below is a summary rating of our plan’s overall performance. This information is available to help you make the best choice. If you would like to get additional information on our plan’s performance please contact us at 1-800-547-5514 (toll-free) or 711 (TTY/TDD) for prospective members, 1-800-643-4845 (toll-free) or 711 (TTY/TDD) for current members or you may visit www.medicare.gov.

Below is a summary of how our plan rated in quality and performance.

The number of stars show how well our plans perform.

means excellent means very good means good means fair means poor

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Summary Rating ofHealth Plan Quality

3 Stars

This summary rating gives an overall score on the health plan’s quality and performance on 33 different topics in 5 categories:

• Staying healthy: screenings, tests, and vaccines. Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy.

• Managing chronic (long-term) conditions. Includes how often members with different conditions got certain tests and treatments that help them manage their condition.

• Ratings of health plan responsiveness and care. Includes ratings of member satisfactions with the plan.

• Health Plan member complaints, appeals, and choosing to leave the health plan. Includes how often members have made complaints against the plan and how often members choose to leave the plan.

• Health plan telephone customer service. Includes how well the plan handles member calls.

35


Summary Rating of Prescription Drug

Plan Quality3.5 Stars

This summary rating gives an overall score on the drug plan’s quality and performance on 19 different topics in 4 categories:

• Drug plan customer service: Includes how well the drug plan handles calls and makes decisions about member appeals.

• Drug plan member complaints, members who choose to leave, and Medicare audit findings: Includes how often members complain about the drug plan and how often members choose to leave the drug plan.

• Member experience with drug plan: Includes member satisfaction information.

• Drug pricing and patient safety: Includes how well the drug plan prices pre-scriptions and provides accurate pricing information on the Medicare website. Includes information on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their condition.

This information is gathered from several different sources, including results from Medicare’s regular monitoring activities, reviews of billing and other information that plans submit to Medicare, and Medicare’s member surveys.


Medicare Prescription Drug Plan Ratings

The Medicare Program rates how well Medicare Prescription Drug Plans perform in different categories (for example, customer service, drug pricing, patient safety). The information provided below is a summary rating of our plan’s overall performance. This information is available to help you make the best choice. If you would like to get additional information on our plan’s performance please contact us at 1-800-547-5514 (toll-free) or 711 (TTY/TDD) for prospective members, 1-800-643-4845 (toll-free) or 711 (TTY/TDD) for current members, or you may visit www.medicare.gov.

Below is a summary of how our plan rated in quality and performance.

The number of stars show how well our plans perform.

means excellent means very good means good means fair means poor

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2011 DisclaimersYour Plan may contain one or more of the following:

NurseLineSM OptumHealthSM is a health and well-being company that provides information and support as part of your health plan. NurseLineSM nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor’s care. NurseLineSM services are not an insurance program and may be discontinued at any time.

SilverSneakers® SilverSneakers® is a registered trademark of Healthways, Inc. Healthways, Inc., is an independent company. The SilverSneakers® program is made available as part of this Plan’s benefits to those insured through this Plan. Neither AARP nor UnitedHealthcare endorse or are responsible for the services or information provided by this program. Consult a health care professional before beginning any exercise program.

Silver & Fit Silver & Fit is provided by American Specialty Health Networks, Inc. and Healthyroads, Inc., subsidiaries of American Specialty Health Incorporated.

Evercare™ Hospice Evercare™ Hospice and Palliative Care is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, sex, religion, color, age, national origin, disability, sexual orientation or other protected factor. Evercare™ Hospice and Palliative Care is offered by Evercare Hospice, Inc.

General Information Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January1, 2012.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the Plan.

This document is available in alternate formats or languages. For more information please contact the Plan at 1-800-547-5514, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.

Este documento está disponible en diferentes formatos o idiomas. Para obtener más información, por favor comuníquese con el Plan llamando al 1-800-547-5514, TTY: 711, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana.

本文件可以其他形式或語言提供。如需更多資訊，請與本計劃聯絡，電話號碼是 1-800-547-5514，TTY: 711，每週七天，上午八時至晚上八時。


37

Our Plans Are Accepted by More Than 60,000 Network Pharmacies

Wherever you go, there is a pharmacy near you that accepts our plans’ prescription drug coverage. In fact, more than 60,000 of the nation’s pharmacies are part of our network. And thousands of brand name and generic prescription drugs are covered. Whatever your prescription needs, we are here to help you meet them.

Other pharmacies are available in our network.

Please review our 2011 Drug List on the following pages.OVEX11NA3240730_000Y0066_100709_094119 File & Use 07192010

Covering the Country Our Prescription Drug Coverage Goes Where You Go

Ingredients for life.

When you join one of our plans, you can take advantage of a mail service benefit from Prescription Solutions, the plans’ Preferred Mail Service Pharmacy. This means you won’t have to wait in line at a pharmacy to get your maintenance medications.* They can be delivered right to your mailbox. Prescription Solutions® Mail Service makes it fast, easy and safe. After you select your health plan, review your Welcome Kit for details.

*Maintenance medications are typically those drugs you take on a regular basis for a chronic or long-term condition.

Plans are insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage Organization with a Medicare contract and a Medicare-approved Part D sponsor.

You are not required to use the plan’s Preferred Mail Service Pharmacy to obtain a 90-day supply of your maintenance medications. You can also use a network retail extended day supply pharmacy or a network non-preferred mail service pharmacy, but you may pay more out-of-pocket compared to using the Preferred Mail Service Pharmacy. You should pay the same out of pocket at a network retail extended day supply pharmacy and a network non-preferred mail service pharmacy. Please call Customer Service, at the number located on the back of your member ID card for up-to-date information on which pharmacies are in the network.

Your prescriptions should arrive in about seven days from the date the completed order is received by Prescription Solutions. If Prescription Solutions needs to contact you or your prescribing physician to clarify information on your order or to request prescriptions from your physician, delivery may take longer. If you prefer rush delivery, medications can be shipped overnight for an additional charge.

Prescription Solutions will contact you if they anticipate there will be an extended delay in the delivery of your medications. If you need your medications immediately, Prescription Solutions can coordinate a refill with a local retail pharmacy. Standard delivery is no charge to U.S. addresses, including U.S. territories.

Prescription Solutions is an affiliate of UnitedHealthcare Insurance Company and UnitedHealthcare Insurance Company of New York.

Save Money With Home Delivery

Brand name drugs are bolded • Generic drugs are listed in light fontThis is not a comprehensive list of drugs covered by your Plan. This list is subject to change.

#8-Mop, T4

AAbelcet, T4Abilify, T3Abilify Discmelt

(10 mg Dispersible Tablet), T3Abilify Discmelt

(15 mg Dispersible Tablet), T4Abraxane, T4Acarbose, T1Accolate, T3Acebutolol HCl, T1Acetadote, T3Acetaminophen/Caffeine/

Dihydrocodeine Bitartrate, T2Acetaminophen/Codeine, T1Acetasol HC, T2Acetazolamide

(12-Hour Capsule), T2Acetazolamide (Tablet), T1Acetazolamide Sodium, T2Acetic Acid, T1Acetic Acid/Hydrocortisone, T2Acetylcysteine, T1Actemra, T4Acthib, T2Acticin, T1Actimmune, T4Actiq, T4Activella, T3Actonel, T2Actoplus Met, T2Actos, T2Acular, T2Acular LS, T2

Acyclovir (Capsule, Tablet), T1Acyclovir (Oral Suspension), T2Acyclovir Sodium, T2Adacel, T2Adagen, T4Adcirca, T4Adderall XR, T3Adriamycin, T2Advair Diskus, T2Advair HFA, T2Aerobid-M, T3Afeditab CR, T1Afinitor, T4Aggrenox, T2A-Hydrocort, T2AK-Con, T1Akne-Mycin, T3AK-Tob, T1Ala Scalp, T3Ala-Cort, T1Alamast, T3Albenza, T2Albuterol Sulfate

(Nebulizer Solution), T1Albuterol Sulfate (Syrup, Tablet), T1Albuterol Sulfate ER, T1Alcaine, T3Alclometasone Dipropionate, T1Alcohol 5%/Dextrose 5%, T2Alcohol Preps, T1Aldara, T3Aldurazyme, T4Alendronate Sodium, T1Alferon N, T3Alimta, T4Alinia, T3

Alkeran, T4Allopurinol, T1Allopurinol Sodium, T2Alocril, T3Alomide, T3Alora, T3Aloxi, T4Alphagan P, T2Alrex, T2Altabax, T3Alvesco, T3Amantadine HCl, T1Ambisome, T4Amcinonide, T1A-Methapred, T2Amevive, T4Amifostine, T4Amikacin Sulfate, T2Amiloride HCl, T1Amiloride/Hydrochlorothiazide, T1Aminophylline (Injection), T2Aminophylline (Tablet), T1Aminosyn, T3Aminosyn 7%/Electrolytes, T3Aminosyn 8.5%/Electrolytes, T2Aminosyn II

(10% Injection, 7% Injection, 8.5% Injection), T3

Aminosyn II 8.5%/Electrolytes, T2Aminosyn II M/Dextrose, T3Aminosyn II/Dextrose, T3Aminosyn M, T3Aminosyn-HBC, T3Aminosyn-HF, T2Aminosyn-PF, T3

2011 Drug ListH

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Amiodarone HCl (Injection), T2Amiodarone HCl (Tablet), T1Amitiza, T2Amitriptyline HCl, T1Amlodipine Besylate, T1Amlodipine Besylate/

Benazepril HCl, T1Ammonium Chloride, T3Ammonium Lactate, T1Amnesteem, T2Amoxapine, T1Amoxicillin, T1Amoxicillin/

Potassium Clavulanate, T1Amoxicillin/Potassium Clavulanate

ER, T2Amphetamine/Dextroamphetamine

(24-Hour Capsule), T2Amphetamine/Dextroamphetamine

(Tablet), T1Amphotec (50mg Injection), T3Amphotericin B, T2Ampicillin, T1Ampicillin Sodium

(10 gm Injection, 1 gm Injection), T2

Ampicillin Sodium (125mg Injection), T2

Ampicillin-Sulbactam, T2Ampyra, T4Anadrol-50, T4Anagrelide HCl, T1Anastrozole, T2Ancobon, T4Androderm, T2Androgel, T2Androxy, T2Anestacon, T1Antabuse, T2Antara, T2

Antizol, T4Anzemet (100 mg Tablet), T4Anzemet (50 mg Tablet), T3Apidra, T2Apokyn, T4Apraclonidine, T2Apri, T1Apriso, T2Aptivus, T4Aralast NP, T4Aranelle, T1Aranesp Albumin Free

(100 mcg/0.5 ml Injection, 100 mcg/1 ml Injection, 150 mcg/0.3 ml Injection, 200 mcg/ 0.4 ml Injection, 200 mcg/1 ml Injection, 300 mcg/0.6 ml Injection, 300 mcg/1 ml Injection, 500 mcg/1 ml Injection, 60 mcg/0.3 ml Injection, 60 mcg/1 ml Injection), T4

Aranesp Albumin Free (25 mcg/0.42 ml Injection, 25 mcg/1 ml Injection, 40 mcg/0.4 ml Injection, 40 mcg/1 ml Injection), T3

Arcalyst, T4Aredia (30 mg Injection), T3Aredia (90 mg Injection), T4Aricept

(5 mg Tablet, 10 mg Tablet), T2Aricept ODT

(5 mg Dispersible Tablet, 10 mg Dispersible Tablet), T2

Arimidex, T3Arixtra

(10 mg/0.8 ml Injection, 5.0 mg/0.4 ml Injection, 7.5 mg/0.6 ml Injection), T4

Arixtra (2.5 mg/0.5 ml Injection), T3

Aromasin, T3

Arranon, T4Arthrotec, T3Arzerra, T4Asacol, T2Ascomp/Codeine, T1Asmanex, T3Astelin, T2Astepro, T2Astramorph, T2Atamet, T1Atenolol, T1Atenolol/Chlorthalidone, T1Atgam, T4Atripla, T4Atropine Sulfate, T1Atrovent HFA, T3Attenuvax, T2Augmented Betamethasone

Dipropionate (Cream, Gel, Ointment), T1

Augmented Betamethasone Dipropionate (Lotion), T2

Avandamet, T3Avandaryl, T3Avandia, T3Avastin, T4Avelox (Injection), T3Avelox (Tablet), T2Avelox ABC Pack, T2Aviane, T1Avinza, T2Avita (Cream), T1Avita (Gel), T2Avodart, T2Avonex, T4Azactam, T2Azactam in Dextrose, T3Azactam in Iso-Osmotic

Dextrose, T3

42


Azasan, T3Azasite, T2Azathioprine, T1Azathioprine Sodium, T1Azelastine HCl (Nasal Spray), T2Azelastine HCl

(Ophthalmic Solution), T2Azilect, T2Azithromycin (Injection), T2Azithromycin

(Oral Suspension, Tablet), T1Azopt, T2Azor, T2

BBACiiM, T2Bacitracin (Injection), T2Bacitracin (Ophthalmic Ointment), T1Bacitracin/Neomycin/Polymyxin, T1Bacitracin/Polymyxin B, T1Baclofen, T1Bactocill in Dextrose, T4Bactroban (Cream), T3Balacet 325, T2Balsalazide Disodium, T2Balziva, T1Banzel, T3Baraclude (Oral Solution), T3Baraclude (Tablet), T4Benazepril HCl, T1Benazepril HCl/

Hydrochlorothiazide, T1Benicar, T2Benicar HCT, T2Benztropine Mesylate (Injection), T2Benztropine Mesylate (Tablet), T1Betamethasone Dipropionate, T1Betamethasone Valerate, T1Betaseron, T4Beta-Val, T1

Betaxolol HCl, T1Bethanechol Chloride, T1Betimol, T3Betoptic-S, T3Bicalutamide, T2Bicillin C-R, T3Bicillin L-A, T3BiCNU, T3BiDil, T2Biltricide, T2Bisoprolol Fumarate, T1Bisoprolol Fumarate/

Hydrochlorothiazide, T1Bleomycin Sulfate, T2Blephamide, T2Blephamide S.O.P., T2Boniva (Injection), T3Boniva (Tablet), T2Boostrix, T2Borofair, T1Botox, T4Brevicon, T3Brimonidine Tartrate, T1Bromocriptine Mesylate, T2Budeprion SR, T1Budeprion XL, T1Budesonide

(Nebulizer Suspension), T2Bumetanide (Injection), T2Bumetanide (Tablet), T1Buphenyl, T4Buprenorphine HCl, T2Buproban, T1Bupropion HCl, T1Bupropion HCl SR, T1Buspirone HCl, T1Busulfex, T4Butalbital/Acetaminophen/

Caffeine/Codeine, T1

Butorphanol Tartrate (Injection), T2Butorphanol Tartrate

(Nasal Spray), T2Byetta, T2Bystolic, T2

CCabergoline, T2Calcipotriene, T2Calcitonin-Salmon (Nasal Spray), T2Calcitriol (1 mcg/ml Injection), T2Calcitriol (2 mcg/ml Injection), T2Calcitriol (Capsule, Oral Solution), T1Calcium Acetate, T2Camila, T1Campath, T4Campral, T3Camptosar, T4Canasa, T2Cancidas, T4Capastat Sulfate, T4Capex, T3Captopril, T1Captopril/Hydrochlorothiazide, T1Carac, T3Carafate (Oral Suspension), T3Carbamazepine

(Chewable Tablet, Tablet), T1Carbamazepine

(Oral Suspension), T2Carbamazepine ER, T2Carbatrol, T2Carbidopa/Levodopa, T1Carbidopa/Levodopa CR, T1Carbidopa/Levodopa ODT, T2Carbinoxamine Maleate, T1Carboplatin, T2Carimune Nanofiltered, T4Carisoprodol, T1Carisoprodol/Aspirin, T1

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Carisoprodol/Aspirin/Codeine, T2Carteolol HCl, T1Cartia XT, T1Carvedilol, T1Casodex, T3Catapres-TTS, T3Cedax, T3CeeNU, T3Cefaclor, T1Cefaclor ER, T1Cefadroxil (Capsule,

Oral Suspension), T1Cefadroxil (Tablet), T2Cefazolin Sodium, T2Cefazolin Sodium/Dextrose, T1Cefdinir (Capsule), T1Cefdinir (Oral Suspension), T2Cefepime, T2Cefotaxime Sodium, T2Cefotetan, T3Cefoxitin Sodium, T2Cefoxitin Sodium/Dextrose, T3Cefpodoxime Proxetil, T2Cefprozil, T1Ceftazidime, T2Ceftriaxone Sodium, T2Ceftriaxone/Dextrose, T2Cefuroxime Axetil

(Oral Suspension), T2Cefuroxime Axetil (Tablet), T1Cefuroxime Sodium, T2Cefuroxime/Dextrose, T1Celebrex, T2Cellcept (Capsule), T3Cellcept

(Oral Suspension, Tablet), T4Cellcept Intravenous, T3Celontin, T3Cenestin, T3

Cephalexin, T1Cerebyx, T3Ceredase, T4Cerezyme, T4Cerubidine, T3Cervarix, T3Cesamet, T4Cesia, T1Cetirizine HCl, T1Cetraxal, T3Chantix, T3Chemet, T3Chloramphenicol Sodium

Succinate, T2Chlordiazepoxide/Amitriptyline, T1Chlorhexidine Gluconate Oral

Rinse, T1Chloroquine Phosphate, T1Chlorothiazide, T1Chlorothiazide Sodium, T2Chlorpromazine HCl, T1Chlorpropamide, T1Chlorthalidone, T1Chlorzoxazone, T1Cholestyramine, T1Chorionic Gonadotropin, T2Ciclopirox (Gel,Shampoo), T2Ciclopirox (Suspension), T1Ciclopirox Nail Lacquer, T2Ciclopirox Olamine, T1Cilostazol, T1Ciloxan, T3Cimetidine, T1Cimetidine HCl (Injection), T2Cimetidine HCl (Oral Solution), T1Cimzia, T4Cipro (Oral Suspension), T3Cipro HC, T3Cipro IV, T3

Ciprodex, T2Ciprofloxacin, T1Ciprofloxacin ER, T2Ciprofloxacin HCl, T1Cisplatin, T2Citalopram Hydrobromide

(Oral Solution), T2Citalopram Hydrobromide

(Tablet), T1Cladribine, T4Claforan

(1 gm Injection, 2 gm Injection), T3

Claravis, T2Clarithromycin

(Oral Suspension), T2Clarithromycin (Tablet), T1Clarithromycin ER, T1Clemastine Fumarate, T1Cleocin (75 mg Capsule), T3Cleocin Galaxy, T3Cleocin Pediatric Granules, T3Cleocin Phosphate, T3Climara Pro, T3Clindagel, T3Clindamycin HCl, T1Clindamycin Phosphate

(Cream, Gel, Lotion, Swab, Topical Solution), T1

Clindamycin Phosphate (Foam), T2Clindamycin Phosphate

Add-Vantage, T2Clindamycin/Benzoyl Peroxide, T2Clindesse, T3Clinimix E/Dextrose, T3Clinimix/Dextrose

(2.75%/D5W Injection, 4.25%/D5W Injection, 5%/D15W Injection, 5%/D20W Injection, 5%/D25W Injection), T3

Clinimix/Dextrose

44


(4.25%/D10W Injection, 4.25%/D20W Injection, 4.25%/D25W Injection), T1

Clinisol SF 15%, T2Clobetasol Propionate (Foam), T2Clobetasol Propionate

(Gel, Ointment, Topical Solution), T1Clobetasol Propionate E, T1Clobex, T3Cloderm, T3Clolar, T4Clomipramine HCl, T1Clonidine HCl (Tablet), T1Clonidine HCl (Weekly Patch), T2Clorpres, T3Clotrimazole, T1Clotrimazole/Betamethasone

Dipropionate, T1Clozapine, T2Codeine Sulfate, T1Cogentin, T3Co-Gesic, T1Cognex, T3Colcrys, T3Colestipol HCl (Granules), T2Colestipol HCl (Tablet), T1Colistimethate Sodium, T4Colocort, T2Coly-Mycin M, T4Coly-Mycin S, T3Combigan, T2Combipatch, T3Combivent, T2Combivir, T4Compro, T1Comtan, T2Comvax, T2Constulose, T1Copaxone, T4

Copegus, T4Cordran, T3Cordran SP, T3Cordran Tape, T3Cortef, T3Cortisone Acetate, T1Cortisporin, T3Cortisporin-TC, T3Cortomycin, T1Cosmegen, T3Coumadin (Injection), T3Coumadin (Tablet), T2Creon, T2Crestor, T2Crixivan, T2Cromolyn Sodium

(Nebulizer Solution), T2Cromolyn Sodium

(Ophthalmic Solution), T1Cryselle, T1Cubicin, T4Cuprimine, T3Cutivate (Lotion), T3Cyclessa, T3Cyclobenzaprine HCl, T1Cyclophosphamide, T2Cyclosporine, T2Cyclosporine Modified, T2Cyklokapron, T2Cymbalta, T2Cyproheptadine HCl, T1Cystadane, T4Cystagon, T3Cytarabine, T2Cytarabine Aqueous, T1

DD.H.E. 45, T4Dacarbazine, T2Danazol, T2

Dantrolene Sodium, T2Dapsone, T2Daptacel, T2Daraprim, T2Daunorubicin HCl, T1DDAVP (Injection), T4Decavac, T2Demeclocycline HCl, T2Demser, T4Denavir, T3Depade, T2Depo-Estradiol, T3Depo-Medrol

(20 mg/ml Injection), T3Depo-Provera

(400 mg/ml Injection), T3Derma-Smoother/FS, T3Dermotic, T2Desipramine HCl, T1Desmopressin Acetate, T2Desogen, T3Desonate, T3Desonide, T1Desowen/Cetaphil, T3Desoximetasone, T2Dexamethasone, T1Dexamethasone Intensol, T1Dexamethasone Sodium Phosphate

(Injection), T2Dexamethasone Sodium Phosphate

(Ophthalmic Solution), T1Dexasporin, T1Dexchlorpheniramine Maleate, T1Dexilant, T3Dexmethylphenidate HCl, T1Dexrazoxane, T4Dextroamphetamine Sulfate, T1Dextroamphetamine Sulfate ER, T2Dextrose 10%, T2

45

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Dextrose 10%/NaCl 0.2%, T2Dextrose 10%/NaCl 0.45%, T2Dextrose 2.5%/NaCl 0.45%, T2Dextrose 5%, T2Dextrose 5%/

Electrolyte #48, T3Dextrose 5%/KCl 0.075%, T2Dextrose 5%/NaCl 0.2%, T2Dextrose 5%/NaCl 0.225%, T2Dextrose 5%/NaCl 0.33%, T2Dextrose 5%/NaCl 0.45%, T2Dextrose 5%/NaCl 0.9%, T2Dibenzyline, T3Diclofenac Potassium, T1Diclofenac Sodium, T1Diclofenac Sodium EC, T1Diclofenac Sodium XR, T1Dicloxacillin Sodium, T1Dicyclomine HCl

(Capsule, Oral Solution, Tablet), T1Dicyclomine HCl (Injection), T2Didanosine, T2Diflorasone Diacetate, T1Diflucan in NaCl, T3Diflunisal, T1Digoxin (Injection), T2Digoxin (Oral Solution, Tablet), T1Dihydroergotamine Mesylate, T2Dilantin, T2Dilantin Infatabs, T2Dilatrate SR, T3Dilaudid

(1 mg/ml Injection, 2 mg/ml Injection, 4 mg/ml Injection), T3

Dilt-CD, T1Diltiazem CD, T1Diltiazem HCl

(24-Hour Capsule, Tablet), T1Diltiazem HCl (Injection), T2

Diltiazem HCl ER (12-Hour Capsule, 24-Hour Capsule), T1

Diltiazem HCl ER (24-Hour Tablet), T2

Dilt-XR, T1Diltzac, T1Diovan, T2Diovan HCT, T2Diphenhydramine HCl

(Capsule, Elixir), T1Diphenhydramine HCl

(Injection), T2Diphenoxylate/Atropine, T1Diphtheria/Tetanus Toxoid

Pediatric, T2Dipyridamole, T1Disopyramide Phosphate, T1Diuril, T3Divalproex Sodium

(Delayed Release Tablet), T1Divalproex Sodium

(Sprinkle Capsule), T2Divalproex Sodium ER, T2Divigel, T3Doribax, T3Doryx, T3Dorzolamide HCl, T1Dorzolamide HCl/

Timolol Maleate, T2Dovonex (Cream), T3Doxazosin Mesylate, T1Doxepin HCl, T1Doxil, T4Doxorubicin HCl, T2Doxycycline Hyclate

(100 mg Tablet, Extended Release Capsule, Injection), T2

Doxycycline Hyclate (20mg Tablet, Capsule), T1

Doxycycline Monohydrate, T2

Dronabinol (10 mg Capsule), T4Dronabinol (2.5 mg Capsule), T2Dronabinol (5 mg Capsule), T4Droxia, T3Duetact, T2Duramorph, T2Durezol, T3Dyrenium, T3

EE.E.S. 400, T1E.E.S. Granules, T2Econazole Nitrate, T1ED K+10, T1Edecrin, T3Effient, T2Elaprase, T4Elestat, T3Elidel, T3Eligard, T3Eliphos, T3Elitek, T4Elixophyllin, T2Ellence, T4Elmiron, T3Eloxatin, T4Elspar, T3Emcyt, T3Emend, T2Emsam, T3Emtriva, T3Enablex, T2Enalapril Maleate, T1Enalapril Maleate/

Hydrochlorothiazide, T1Enbrel, T4Endocet, T1Endodan, T1Engerix-B, T2Enjuvia, T2

46


Enpresse, T1Entocort EC, T3Enulose, T1Epinephrine HCl, T2Epipen, T2Epirubicin HCl, T2Epitol, T1Epivir, T2Epivir HBV, T2Eplerenone, T2Epogen

(10,000 units/ml Injection, 2,000 units/ml Injection, 3,000 units/ml Injection, 4,000 units/ ml Injection), T3

Epogen (20,000 units/ml Injection), T4

Epogen (40,000 units/ml Injection), T4

Epzicom, T4Equetro, T3Eraxis, T4Erbitux, T4Ergoloid Mesylates, T2Ergotamine Tartrate/Caffeine, T1Errin, T1Ertaczo, T3Ery, T1Eryped, T2Ery-Tab, T2Erythrocin Lactobionate, T3Erythrocin Stearate, T3Erythromycin, T1Erythromycin Base, T1Erythromycin/Benzoyl Peroxide, T1Erythromycin/Sulfisoxazole, T1Estrace (Cream), T3Estraderm, T2Estradiol, T1Estradiol Valerate, T2

Estradiol/ Norethindrone Acetate, T1

Estring, T3Estrogel, T3Estropipate, T1Estrostep Fe, T3Ethambutol HCl, T2Ethosuximide, T2Ethyol, T4Etidronate Disodium, T2Etodolac, T1Etodolac ER, T1Etopophos, T4Etoposide, T2Eurax, T3Evista, T2Exelderm, T3Exelon, T3Exforge, T2Exforge HCT, T2Exjade, T4Extavia, T4

FFabrazyme, T4Factive, T3Famciclovir, T2Famotidine

(Injection, Oral Suspension), T2Famotidine (Tablet), T1Fanapt, T3Fanapt Titration Pack, T3Fareston, T3Faslodex, T4Fazaclo, T2Felbatol, T3Felodipine ER, T1Femara, T2Femhrt, T3Femring, T3

Femtrace, T3Fenofibrate, T1Fenofibrate Micronized, T1Fenoprofen Calcium, T1Fentanyl (Patch), T2Fentanyl Citrate (Injection), T2Fentanyl Citrate Oral

Transmucosal, T4Fentora, T4Fexofenadine HCl, T1Finacea, T2Finasteride (5 mg Tablet), T1Firmagon (120 mg Injection), T4Firmagon (80 mg Injection), T3Flagyl ER, T3Flarex, T2Flavoxate HCl, T2Flebogamma, T4Flecainide Acetate, T1Flovent Diskus, T2Flovent HFA, T2Fluconazole, T1Fluconazole in Dextrose, T2Fludara, T4Fludarabine Phosphate, T4 Fludrocortisone Acetate, T1Flunisolide, T1Fluocinolone Acetonide, T1Fluocinonide, T1Fluocinonide-E, T1Fluorometholone, T1Fluorouracil

(Cream, Topical Solution), T2Fluorouracil (Injection), T1Fluoxetine DR, T2Fluoxetine HCl, T1Fluphenazine Decanoate, T2Fluphenazine HCl

(Concentrate, Elixir, Tablet), T1

47

Master Template


Fluphenazine HCl (Injection), T2Flurbiprofen, T1Flurbiprofen Sodium, T1Flutamide, T2Fluticasone Propionate, T1Fluvoxamine Maleate, T1FML, T2FML Forte, T2Fomepizole, T4Foradil Aerolizer, T2Fortaz, T3Forteo, T3Fortical, T2Fosamax (Oral Solution), T3Foscarnet Sodium, T2Fosinopril Sodium, T1Fosinopril Sodium/

Hydrochlorothiazide, T1Fosphenytoin Sodium, T2Fosrenol, T3Fragmin

(10,000 units/1ml Injection, 25,000 units/1 ml Injection, 7,500 units/0.3 ml Injection), T4

Fragmin (2,500 units/0.2 ml Injection, 5,000 units/0.2 ml Injection), T3

Freamine HBC, T3Freamine III (3% Injection), T3Freamine III (8.5% Injection), T3Furadantin, T3Furosemide (Injection), T2Furosemide

(Oral Solution, Tablet), T1Fusilev, T4Fuzeon, T4

GGabapentin, T1

Gabitril (12 mg Tablet, 16 mg Tablet, 2 mg Tablet), T3

Gabitril (4 mg Tablet), T3Galantamine Hydrobromide

(24-Hour Capsule), T2Galantamine Hydrobromide

(Oral Solution, Tablet), T2Gamastan S/D, T2Gammagard Liquid, T4Gamunex, T4Ganciclovir, T4Gardasil, T2Gauze Pads, T2Gavilyte-C, T1Gavilyte-G, T1Gavilyte-N/Flavor Pack, T1Gelnique, T3Gemfibrozil, T1Gemzar, T4Generlac, T1Gengraf (Capsule), T2Gengraf (Oral Solution), T4Genotropin, T4Genotropin Miniquick

(0.2 mg Injection), T3Genotropin Miniquick

(0.4 mg Injection, 0.6 mg Injection, 0.8 mg Injection, 1.2 mg Injection, 1.4 mg Injection, 1.6 mg Injection, 1.8 mg Injection, 1 mg Injection, 2 mg Injection), T4

Gentak, T1Gentamicin Sulfate

(Cream, Ointment, Ophthalmic Solution), T1

Gentamicin Sulfate (Injection), T2

Gentamicin Sulfate/NaCl (100 mg Injection, 60 mg Injection, 80 mg Injection), T2

Gentamicin Sulfate/NaCl (70 mg Injection, 90 mg Injection), T2

Gentasol, T1Geodon (Capsule), T2Geodon (Injection), T3Gleevec, T4Glimepiride, T1Glipizide, T1Glipizide ER, T1Glipizide/Metformin HCl, T1Glucagen Hypokit, T3Glucagon Emergency Kit, T2Glyburide, T1Glyburide Micronized, T1Glyburide/Metformin HCl, T1Glycopyrrolate, T2Glycron

(1.5 mg Tablet, 3 mg Tablet, 6 mg Tablet), T1

Glyset, T3Granisetron HCl (Injection), T2Granisetron HCl (Tablet), T2Granisol, T2Grifulvin V, T2Griseofulvin Microsize, T2Gris-Peg, T3Guanabenz Acetate, T1Guanfacine HCl, T1Guanidine HCl, T3Gynazole-1, T3Gynodiol, T3

HHalflytely Bowel Prep, T2Halobetasol Propionate, T1

48


Halog, T3Haloperidol, T1Haloperidol Decanoate, T2Haloperidol Lactate, T2Havrix, T2Hectorol, T2Heparin Sodium

(1,000 units/ml Injection, 10,000 units/ml Injection, 5,000 units/ml Injection), T2

Heparin Sodium (2,000 units/ml Injection, 2,500 units/ ml Injection), T2

Heparin Sodium DCU, T2Heparin Sodium/D5W, T2Heparin Sodium/NaCl, T2Heparin Sodium/NaCl 0.9%

Premix, T2Hepatamine, T2Hepatasol, T3Hepsera, T4Herceptin, T4Hexalen, T4Humalog, T2Humatrope, T4Humira, T4Humulin, T2Hycamtin, T4Hydralazine HCl (Injection), T2Hydralazine HCl (Tablet), T1Hydrochlorothiazide, T1Hydrocodone/Acetaminophen

(10 mg-325 mg Tablet, 10 mg-500 mg Tablet, 10 mg-650 mg Tablet, 10 mg-660 mg Tablet, 2.5 mg-500 mg Tablet, 5 mg-325 mg Tablet, 5 mg-500 mg Tablet, 7.5 mg-750 mg Tablet, 7.5 mg-325 mg Tablet, 7.5 mg-500 mg Tablet,

7.5 mg-650 mg Tablet, Oral Solution), T1

Hydrocodone/ Acetaminophen (10 mg-750 mg Tablet), T2

Hydrocodone/Ibuprofen, T1Hydrocortisone

(Cream, Lotion, Ointment, Tablet), T1

Hydrocortisone (Enema), T2Hydrocortisone Butyrate, T1Hydrocortisone Valerate, T1Hydromorphone HCl (Injection), T2Hydromorphone HCl (Tablet), T1Hydroxychloroquine Sulfate, T1Hydroxyurea, T1Hydroxyzine HCl (Injection), T2Hydroxyzine HCl (Syrup, Tablet), T1Hydroxyzine Pamoate, T1

IIbuprofen, T1Idamycin PFS, T4Idarubicin HCl, T4Ifosfamide, T2Ifosfamide/Mesna, T4Imipramine HCl, T1Imipramine Pamoate, T2Imiquimod, T2Imovax Rabies (H.D.C.V.), T2Increlex, T4Indapamide, T1Indomethacin, T1Indomethacin ER, T2Infanrix, T2Infergen, T4Infumorph, T3Innopran XL, T3Insulin Syringes, Needles, T2Intelence, T4Intralipid (20% Injection), T2

Intralipid (30% Injection), T3Intron-A

(10 mu Injection, 10 mu Pen Injection, 5 mu Pen Injection, 18 mu Injection), T4

Intron-A (3 mu Pen Injection), T3Invanz, T3Invega, T3Invega Sustenna

(117 mg/0.75 ml Injection, 156 mg/1 ml Injection, 234 mg/1.5 ml Injection), T4

Invega Sustenna (39 mg/0.25 ml Injection, 78 mg/0.5 ml Injection), T3

Invirase, T4Ionosol-B/Dextrose 5%, T3Ionosol-MB/Dextrose 5%, T3Ionosol-T/Dextrose 5%, T3Iopidine

(1% Ophthalmic Solution), T3Ipol Inactivated IPV, T2Ipratropium Bromide

(Nasal Spray), T1Ipratropium Bromide

(Nebulizer Solution), T1Ipratropium Bromide/Albuterol

Sulfate (Nebulizer Solution), T1Iressa, T4Irinotecan, T2Isentress, T4Isochron, T1Isolyte-H/Dextrose 5%, T3Isolyte-M/Dextrose 5%, T2Isolyte-P/Dextrose 5%, T3Isolyte-S, T3Isolyte-S/Dextrose 5%, T3Isonarif, T2Isoniazid (Injection), T2Isoniazid (Syrup, Tablet), T1Isordil Titradose (40 mg Tablet), T3

49

Master Template


Isosorbide Dinitrate, T1Isosorbide Dinitrate ER, T1Isosorbide Mononitrate, T1Isosorbide Mononitrate ER, T1Isotonic Gentamicin, T2Isovate, T1Isradipine, T1Istalol, T3Istodax, T4Itraconazole, T2Ixempra Kit, T4Ixiaro, T2

JJantoven, T1Janumet, T2Januvia, T2Je-Vax, T2Jolivette, T1Junel, T1Junel Fe, T1

KKadian

(100 mg 24-Hour Capsule, 10 mg 24-Hour Capsule, 20 mg 24-Hour Capsule, 30 mg 24-Hour Capsule, 50 mg 24-Hour Capsule, 60 mg 24-Hour Capsule, 80 mg 24-Hour Capsule), T2

Kadian (200 mg 24-Hour Capsule), T4

Kaletra (100-25 mg Tablet), T3Kaletra

(200-50 mg Tablet, Oral Solution), T4

Kanamycin Sulfate, T2Kaon-Cl-10, T1Kariva, T1

KCl (0.4 meq/1 ml Injection, 10 meq/100 ml Injection, 2 meq/1 ml Injection, 30 meq/100 ml Injection), T2

KCl (10 meq/50 ml Injection), T2KCl 0.15%/NaCl, T2KCl 0.3%/NaCl 0.9%, T2KCl ER, T1KCl/D10W/NaCl, T2KCl/D5W, T2KCl/D5W/LR, T2KCl/D5W/NaCl, T2Keflex (750 mg Capsule), T3Kelnor, T1Kenalog, T3Kepivance, T4Keppra (Injection), T4Keppra (Oral Solution, Tablet), T3Ketek, T3Ketoconazole, T1Ketoprofen, T1Ketoprofen ER, T2Ketorolac Tromethamine

(Injection), T2Ketorolac Tromethamine

(Ophthalmic Solution), T2Ketorolac Tromethamine (Tablet), T1Kineret, T4Kionex, T2Klor-Con 10, T1Klor-Con 8, T1Klor-Con M10, T1Klor-Con M15, T2Klor-Con M20, T1Kristalose, T3Kuric, T1Kuvan, T4Kytril (Tablet), T4

LLabetalol HCl (Injection), T2Labetalol HCl (Tablet), T1Laclotion, T1Lacrisert, T3Lactated Ringer’s, T2Lactated Ringer’s Irrigation, T2Lactulose, T1Lamictal, T3Lamictal ODT, T3Lamictal Starter Kit, T3Lamisil (Pack), T3Lamotrigine, T2Lanoxin

(0.1 mg/ml Injection), T3Lanoxin (Tablet), T2Lansoprazole, T2Lantus, T2Leena, T1Leflunomide, T1Lessina, T1Letairis, T4Leucovorin Calcium (Injection), T2Leucovorin Calcium (Tablet), T1Leukeran, T2Leukine, T4Leuprolide Acetate, T2Levalbuterol

(Nebulizer Solution), T2Levaquin

(Injection, Oral Solution), T3Levaquin (Tablet), T2Levemir, T2Levetiracetam (Injection), T4Levetiracetam

(Oral Solution, Tablet), T2Levobunolol HCl, T1Levocarnitine, T2Levora, T1

50


Levorphanol Tartrate, T2Levothroid, T2Levothyroxine Sodium, T1Levoxyl, T1Lexapro, T2Lexiva (Oral Suspension), T3Lexiva (Tablet), T4Lidocaine, T1Lidocaine HCl

(Gel, Topical Solution), T1Lidocaine HCl (Injection), T2Lidocaine Viscous, T1Lidocaine/Prilocaine, T1Lidoderm, T2Lincocin, T3Lindane, T2Liothyronine Sodium (Injection), T2Liothyronine Sodium (Tablet), T1Lipitor, T2Liposyn II, T3Liposyn III

(10% Injection, 20% Injection), T3Liposyn III (30% Injection), T1Lisinopril, T1Lisinopril/Hydrochlorothiazide, T1Lithium Carbonate, T1Lithium Carbonate ER, T1Lithium Citrate, T1Lithobid, T2Lithostat, T3Lo/Ovral, T3Locoid, T3Locoid Lipocream, T3Lodosyn, T3Loestrin, T3Loestrin Fe, T3Lokara, T1Loperamide HCl, T1Losartan Potassium, T1

Losartan Potassium/ Hydrochlorothiazide, T1

Loseasonique, T3Lotemax, T2Lotrel

(10 mg-40 mg Capsule, 5 mg-40 mg Capsule), T3

Lotronex, T4Lovastatin, T1Lovaza, T3Lovenox

(100 mg/1 ml Injection, 120 mg/0.8 ml Injection, 150 mg/1 ml Injection, 300 mg/3 ml Injection, 60 mg/0.6 ml Injection, 80 mg/0.8 ml Injection), T4

Lovenox (30 mg/0.3 ml Injection, 40 mg/ 0.4 ml Injection), T3

Low-Ogestrel, T1Loxapine Succinate, T1Lumigan, T2Lunesta, T2Lupron Depot

(11.25 mg Injection, 3.75 mg Injection), T3

Lupron Depot (22.5 mg Injection, 30 mg Injection, 7.5 mg Injection), T4

Lupron Depot-PED, T4Lutera, T1Luxiq, T3Lyrica, T2Lysodren, T4

MMacrodantin, T3Magnesium Sulfate, T1Magnesium Sulfate in D5W, T2Malarone, T3Malathion, T2

Maprotiline HCl, T1Margesic-H, T1Marinol (10 mg Capsule), T4Marinol (2.5 mg Capsule), T3Marinol (5 mg Capsule), T4Marplan, T3Matulane, T4Maxair Autohaler, T3Maxalt, T2Maxalt-MLT, T2Maxipime (2 gm Injection), T3Mebendazole, T1Meclizine HCl, T1Meclofenamate Sodium, T1Medroxyprogesterone Acetate

(Injection), T2Medroxyprogesterone Acetate

(Tablet), T1Mefloquine HCl, T1Megace ES, T3Megestrol Acetate, T1Meloxicam (Oral Suspension), T2Meloxicam (Tablet), T1Melphalan HCl, T4Menactra, T2Menest, T2Menomune-A/C/Y/W-135, T2Mentax, T3Meperidine HCl (Injection), T1Meperidine HCl

(Oral Solution, Tablet), T1Meprobamate, T2Mepron, T4Mercaptopurine, T1Merrem, T3Meruvax II, T2Mesalamine, T2Mesna, T2Mesnex (Tablet), T4Mestinon (Syrup), T3

51

Master Template


Mestinon Timespan, T3Metaproterenol Sulfate, T1Metaxalone, T2Metformin HCl, T1Metformin HCl ER, T1Methadone HCl

(Concentrate, Oral Solution, Tablet), T1

Methadone HCl (Injection), T3Methadose, T1Methamphetamine HCl, T2Methazolamide, T1Methenamine Hippurate, T2Methergine, T2Methimazole, T1Methocarbamol, T1Methotrexate, T1Methotrexate Sodium, T2Methscopolamine Bromide, T2Methyclothiazide, T1Methyldopa, T1Methyldopa/Hydrochlorothiazide, T1Methyldopate HCl, T1Methylin (Tablet), T1Methylin ER, T1Methylphenidate HCl, T1Methylphenidate HCl SR, T1Methylprednisolone, T1Methylprednisolone Acetate, T2Methylprednisolone

Sodium Succinate, T2Metipranolol, T1Metoclopramide HCl (Injection), T2Metoclopramide HCl

(Oral Solution, Tablet), T1Metolazone, T1Metoprolol Succinate ER, T1Metoprolol Tartrate (Injection), T2Metoprolol Tartrate (Tablet), T1

Metoprolol/Hydrochlorothiazide, T1Metrogel, T3Metronidazole (Capsule, Lotion), T2Metronidazole

(Cream, Gel, Tablet), T1Metronidazole in NaCl 0.79%, T1Metronidazole Vaginal, T1Mexiletine HCl, T1Miacalcin (Injection), T3Micardis, T3Micardis HCT, T3Miconazole 3, T1Microgestin, T1Microgestin Fe, T1Midodrine HCl, T2Migergot, T2Millipred (Tablet), T3Minitran, T1Minocycline HCl (Capsule), T1Minocycline HCl (Tablet), T2Minocycline HCl ER, T2Minoxidil (Tablet), T1Mirapex, T2Mirtazapine, T1Mirtazapine ODT, T1Misoprostol, T1Mitomycin, T2Mitoxantrone HCl, T2M-M-R II, T2Moexipril HCl, T1Moexipril/Hydrochlorothiazide, T1Mometasone Furoate, T1Monodox (75 mg Capsule), T3MonoNessa, T1Morphine Sulfate (Injection), T2Morphine Sulfate

(Oral Solution, Tablet), T1Morphine Sulfate ER, T1Moviprep, T3

Mozobil, T4MS Contin

(200 mg 12-Hour Tablet), T4Multaq, T3Mupirocin, T1Mustargen, T4Mycamine, T4Mycobutin, T3Mycophenolate Mofetil, T2Mydral, T1Myfortic, T3Myobloc, T3Myozyme, T4Mytelase, T3

NNabumetone, T1NaCl, T2NaCl 0.45% Viaflex, T2NaCl 0.9%, T1Nadolol, T1Nadolol/Bendroflumethiazide, T1Nafcillin Sodium, T2Naftin, T3Naglazyme, T4Nalbuphine HCl, T2Nallpen/Dextrose, T3Naloxone HCl, T1Naltrexone HCl, T2Namenda, T2Namenda Titration Pak, T2Naphazoline HCl, T1Naproxen, T1Naproxen DR, T1Nardil, T2Nasonex, T2Natacyn, T2Nateglinide, T2Navane (20 mg Capsule), T3Nebupent, T3

52


Necon, T1Nefazodone HCl, T1Neo-Fradin, T3Neomycin Sulfate, T1Neomycin/

Polymyxin B Sulfates, T2Neomycin/Polymyxin/

Bacitracin/Hydrocortisone, T1Neomycin/Polymyxin/

Dexamethasone, T1Neomycin/Polymyxin/

Gramicidin, T1Neomycin/Polymyxin/

Hydrocortisone, T1Neomycin/Polymyxin/

Hydrocortisone, T1Nephramine, T3Neulasta, T4Neumega, T2Neupogen, T4Neurontin (Oral Solution), T3Nevanac, T3Nexavar, T4Nexium, T2Nexium I.V., T3Next Choice, T1Niacor, T1Niaspan, T2Nicardipine HCl (Capsule), T1Nicardipine HCl (Injection), T2Nicotrol Inhaler, T3Nicotrol NS, T3Nifediac CC, T1Nifedical XL, T1Nifedipine, T1Nifedipine ER, T1Nilandron, T3Nimodipine, T4Nipent, T4Nisoldipine, T1

Nitro-Bid, T3Nitro-Dur

(0.3 mg/hr 24-Hour Patch, 0.8 mg/hr 24-Hour Patch), T3

Nitrofurantoin Macrocrystalline, T1Nitrofurantoin Monohydrate, T1Nitroglycerin

(24-Hour Patch, Injection), T1Nitrolingual Pumpspray, T3Nitrostat, T2Nizatidine (Capsule), T1Nizatidine (Oral Solution), T2Nora-BE, T1Norditropin, T4Norethindrone Acetate, T1Noritate, T3Normosol-M in D5W, T2Normosol-R, T3Normosol-R in D5W, T2Noroxin, T3Nortrel, T1Nortriptyline HCl (Capsule), T1Nortriptyline HCl (Oral Solution), T2Norvir (Capsule, Tablet), T3Norvir (Oral Solution), T4Novamine, T2Novantrone, T4Novarel, T2Novolin, T2Novolog, T2Noxafil, T4Nulytely/Flavor Packs, T2Nutropin, T4Nutropin AQ, T4NuvaRing, T2Nyamyc, T1Nystatin, T1Nystatin/Triamcinolone, T1Nystop, T1

OOcella, T1Octagam, T4Octreotide Acetate

(1,000 mcg/ml Injection), T4Octreotide Acetate

(100 mcg/ml Injection, 200 mcg/ml Injection, 500 mcg/ml Injection), T4

Octreotide Acetate (50 mcg/ml Injection), T3

Ofloxacin (Ophthalmic Solution, Otic Solution), T1

Ofloxacin (Tablet), T2Ogestrel, T1Olux-E, T3Omeprazole, T1Omnitrope, T4Oncaspar, T4Ondansetron HCl (Injection), T2Ondansetron HCl (Oral Solution), T2Ondansetron HCl (Tablet), T1Ondansetron ODT, T1Onglyza, T2Onsolis, T4Ontak, T4Opana, T2Opana ER, T2Optipranolol, T3Orap, T2Orencia, T4Orfadin, T4Orphenadrine Citrate, T2Orphenadrine Citrate ER, T1Orphenadrine/Aspirin/Caffeine, T2Ortho Evra, T3Ortho Micronor, T3Ortho Tri-Cyclen Lo, T3Ortho-Cept, T3

53

Master Template


Orthoclone OKT3, T4Ortho-Cyclen, T3Ortho-Est, T1Ortho-Novum 7/7/7, T3Osmoprep, T3Ovcon, T3Oxacillin Sodium, T3Oxaliplatin, T4Oxandrin (10 mg Tablet), T4Oxandrin (2.5 mg Tablet), T3Oxandrolone (10 mg Tablet), T4Oxandrolone (2.5 mg Tablet), T2Oxaprozin, T1Oxcarbazepine, T2Oxistat, T3Oxsoralen, T3Oxsoralen Ultra, T4Oxybutynin Chloride, T1Oxybutynin Chloride ER, T1Oxycodone HCl, T1Oxycodone/Acetaminophen, T1Oxycodone/Aspirin, T1Oxycodone/Ibuprofen, T2Oxycontin, T2Oxytrol, T2

PPacerone

(100 mg Tablet, 400 mg Tablet), T3

Pacerone (200 mg Tablet), T1Paclitaxel, T2Pamelor, T4Pamidronate Disodium

(30 mg/10 ml Injection, 90 mg/10 ml Injection), T2

Pamidronate Disodium (6 mg/1 ml Injection), T3

Pandel, T3Panretin, T4Pantoprazole Sodium, T2

Parcaine, T1Parcopa, T3Paromomycin Sulfate, T1Paroxetine HCl

(Oral Suspension), T2Paroxetine HCl (Tablet), T1Paroxetine HCl ER, T2Paser, T3Pataday, T2Patanase, T2Patanol, T2PCE, T3Pediarix, T2Pedi-Dri, T1Pedvax HIB, T2Peganone, T3Pegasys, T4Peg-Intron, T4Penicillin G Potassium, T2Penicillin G Potassium in

Iso-Osmotic Dextrose, T2Penicillin G Procaine, T3Penicillin G Sodium, T2Penicillin V Potassium, T1Pentam 300, T3Pentasa, T3Pentazocine/Acetaminophen, T1Pentazocine/Naloxone HCl, T2Pentopak, T1Pentostatin, T4Pentoxifylline ER, T1Perindopril Erbumine, T1Periogard, T1Permethrin, T1Perphenazine, T1Perphenazine/Amitriptyline, T1Pexeva, T3Pfizerpen-G, T3Phenadoz, T1

Phenytek, T2Phenytoin, T1Phenytoin Sodium, T2Phenytoin Sodium Extended

(100 mg Capsule), T1Phenytoin Sodium Extended

(200 mg Capsule, 300 mg Capsule), T2

Phoslo, T2Phospholine Iodide, T2Photofrin, T4Physiolyte, T1Physiosol Irrigation, T3Pilocarpine HCl, T2Pilopine HS, T2Pindolol, T1Piperacillin Sodium, T3Piperacillin Sodium/

Tazobactam Sodium, T2Piroxicam, T1Plasma-Lyte, T3Plasma-Lyte/D5W, T3Plasma-Lyte-R, T2Plavix, T2Podofilox, T2Polycin B, T1Poly-Dex, T1Polyethylene Glycol 3350, T1Polymyxin B Sulfate, T2Poly-Pred, T3Portia, T1Potassium Citrate

Extended-Release, T1Pramipexole Dihydrochloride, T2Prandimet, T3Prandin, T3Pravastatin Sodium, T1Prazosin HCl, T1Pred Mild, T2Pred-G, T2

54


Pred-G S.O.P., T2Prednicarbate, T1Prednisolone, T1Prednisolone Acetate, T1Prednisolone Sodium Phosphate, T1Prednisone, T1Prednisone Intensol, T1Prefest, T3Pregnyl w/Diluent Benzyl Alcohol/

NaCl, T2Premarin (Cream, Tablet), T2Premarin (Injection), T3Premasol (10% Injection), T3Premasol (6% Injection), T2Premphase, T2Prempro, T2Prenatal Vitamins, T1Prevalite, T1Previfem, T1Prezista


Prezista (75 mg Tablet), T3Priftin, T3Primaquine Phosphate, T3Primaxin, T3Primidone, T1Primsol, T3Pristiq, T3Privigen, T4Proair HFA, T2Probenecid, T1Probenecid/Colchicine, T1Procainamide HCl, T1Procalamine, T3Prochieve, T3Prochlorperazine, T1Prochlorperazine Edisylate, T2Prochlorperazine Maleate, T1

Procrit (10,000 units/ml Injection, 2,000 units/ml Injection, 3,000 units/ml Injection, 4,000 units/ml Injection), T3

Procrit (20,000 units/ml Injection), T4

Procrit (40,000 units/ml Injection), T4

Proctocream-HC, T1Procto-Pak, T1Proctosol HC, T1Proctozone-HC, T1Proglycem, T3Prograf

(0.5 mg Capsule, 1 mg Capsule), T3

Prograf (5 mg Capsule), T4Prograf (Injection), T3Prolastin, T4Proleukin, T4Promacta, T4Promethazine HCl (Injection), T2Promethazine HCl

(Suppository, Syrup, Tablet), T1Promethazine VC, T1Promethegan, T1Prometrium, T3Propafenone HCl, T1Proparacaine HCl, T1Propoxyphene HCl, T1Propoxyphene/Acetaminophen, T1Propoxyphene-N/Acetaminophen, T1Propranolol HCl, T1Propranolol HCl ER, T1Propranolol/Hydrochlorothiazide, T1Propylthiouracil, T1ProQuad, T2Prosol, T3Protonix (Injection), T3

Protopic, T3Protriptyline HCl, T2Provigil, T3Pulmicort

(Nebulizer Suspension), T3Pulmicort Flexhaler, T2Pulmozyme, T4Pyrazinamide, T1Pyridostigmine Bromide, T1

QQualaquin, T3Quasense, T1Quinapril HCl, T1Quinapril/Hydrochlorothiazide, T1Quinidine Gluconate, T3Quinidine Gluconate CR, T1Quinidine Sulfate, T1Quinidine Sulfate ER, T1Quixin, T3QVAR, T2

RRabavert, T2Ramipril, T1Ranexa, T2Ranitidine HCl (Capsule, Tablet), T1Ranitidine HCl (Injection, Syrup), T2Rapaflo, T3Rapamune (Oral Solution), T3Rapamune (Tablet), T4Razadyne (Oral Solution), T3Rebetol, T4Rebif, T4Rebif Titration Pack, T4Reclipsen, T1Recombivax HB, T2Regonol, T1Regranex, T4Relenza Diskhaler, T3Relion, T3

55

Master Template


Relistor, T3Remicade, T4Remodulin, T4Renagel, T2Renamin, T3Renvela, T2Rescriptor, T3Reserpine, T1Restasis, T2Retin-A Micro, T3Retrovir IV Infusion, T3Revatio, T4Revlimid, T4Reyataz, T4Ribapak, T4Ribasphere

(200 mg Tablet, Capsule), T2Ribasphere


Ribavirin (200 mg Tablet, Capsule), T2

Ribavirin (400 mg Tablet, 600 mg Tablet), T4

Ridaura, T3Rifampin (Capsule), T1Rifampin (Injection), T4Rifater, T3Rilutek, T4Rimantadine HCl, T1Ringer’s Injection, T2Ringer’s Irrigation, T1Riomet, T3Risperdal Consta

(12.5 mg Injection, 25 mg Injection), T3

Risperdal Consta (37.5 mg Injection, 50 mg Injection), T4

Risperdal M-Tab, T3

Risperidone (Oral Solution), T2Risperidone (Tablet), T1Risperidone ODT, T2Rituxan, T4Rivastigmine Tartrate, T2Robaxin (Injection), T3Rocephin, T3Romycin, T1Ropinirole HCl, T1RotaTeq, T2Rowasa, T3Roxicet (Oral Solution), T3Roxicet (Tablet), T1Rozerem, T3Rythmol SR, T3

SSabril, T4Saizen, T4Samsca, T4Sanctura XR, T3Sancuso, T4Sandimmune

(Capsule, Oral Solution), T3Sandostatin

(1,000 mcg/ml Injection), T4Sandostatin

(100 mcg/ml Injection, 200 mcg/ml Injection, 500 mcg/ml Injection, 50 mcg/ml Injection), T4

Sandostatin LAR Depot, T4Santyl, T3Saphris, T3Savella, T2Savella Titration Pack, T2Seasonale, T3Seasonique, T3Selegiline HCl, T1Selenium Sulfide, T1Selfemra, T2

Selzentry, T4Sensipar (30 mg Tablet), T2Sensipar

(60 mg Tablet, 90 mg Tablet), T4Serevent Diskus, T2Seromycin, T3Seroquel, T3Seroquel XR, T2Serostim, T4Sertraline HCl (Concentrate), T2Sertraline HCl (Tablet), T1Silver Sulfadiazine, T1Simponi, T4Simulect, T4Simvastatin, T1Singulair, T2Sodium Bicarbonate, T1Sodium Fluoride, T1Sodium Lactate, T2Sodium Polystyrene Sulfonate, T2Solaraze, T3Solia, T1Solu-Cortef, T3Solu-Medrol, T3Somatuline Depot, T4Somavert, T4Soriatane, T4Sorine, T1Sotalol HCl (Injection), T2Sotalol HCl (Tablet), T1Sotret

(10 mg Capsule, 20 mg Capsule, 40 mg Capsule), T2

Spectracef, T3Spiriva Handihaler, T2Spironolactone, T1Spironolactone/

Hydrochlorothiazide, T1Sporanox (Capsule), T4

56


Sporanox (Oral Solution), T3Sprintec, T1Sprycel, T4Sronyx, T1SSD, T1Stagesic, T1Stalevo, T2Stavudine, T2Stavzor, T3Stelara, T4Sterile Water Irrigation, T1Stimate, T3Strattera, T3Streptomycin Sulfate, T3Stromectol, T2Suboxone, T3Sucraid, T4Sucralfate, T1Sulfacetamide Sodium (Lotion), T2Sulfacetamide Sodium

(Ophthalmic Solution), T1Sulfacetamide Sodium/

Prednisolone Sodium Phosphate, T1Sulfadiazine, T2Sulfamethoxazole/

Trimethoprim (Injection), T2Sulfamethoxazole/Trimethoprim

(Oral Suspension, Tablet), T1Sulfamylon, T3Sulfasalazine, T1Sulfatrim, T1Sulfazine EC, T1Sulindac, T1Sumatriptan Succinate

(Injection), T2Sumatriptan Succinate (Tablet), T1Sumavel Dosepro, T4Suprax, T3Surmontil, T3Sustiva, T3

Sutent, T4Symbicort, T2Symbyax, T3Symlin, T3Synagis, T4Synalgos-DC, T3Synarel, T4Synercid, T4Synthroid, T2Syprine, T3

TTabloid, T3Tacrolimus

(0.5 mg Capsule, 1 mg Capsule), T2Tacrolimus (5 mg Capsule), T4Tamiflu, T2Tamoxifen Citrate, T1Tamsulosin HCl, T1Tarceva, T4Targretin (Capsule), T4Targretin (Gel), T4Tasigna, T4Tasmar, T4Taxotere, T4Tazicef, T2Tazorac, T3Taztia XT, T1Tegretol, T2Tegretol-XR, T2Tekturna, T2Tekturna HCT, T2Terazosin HCl, T1Terbinafine HCl, T1Terbutaline Sulfate (Injection), T2Terbutaline Sulfate (Tablet), T1Terconazole, T1Testosterone Cypionate, T2Testosterone Enanthate, T2Tetanus Toxoid Adsorbed, T2

Tetanus/Diphtheria Toxoids- Adsorbed Adult, T2

Tetracycline HCl, T1Tev-Tropin, T4Thalomid, T4Theo-24, T2Theochron, T1Theophylline ER, T1Thermazene, T1Thiola, T3Thioridazine HCl, T1Thiotepa, T3Thiothixene, T1Thymoglobulin, T4Thyrolar, T2Ticlopidine HCl, T1Tikosyn, T3Timentin, T3Timolol Maleate, T1Tindamax, T2Tis-U-Sol, T1Tizanidine HCl, T1Tobi, T4Tobradex

(Ophthalmic Ointment), T2Tobradex

(Ophthalmic Suspension), T3Tobramycin Sulfate (Injection), T2Tobramycin Sulfate

(Ophthalmic Solution), T1Tobramycin Sulfate/NaCl, T1Tobramycin/Dexamethasone, T1Tobrasol, T1Tobrex

(Ophthalmic Ointment), T2Tobrex

(Ophthalmic Solution), T3Tolazamide, T1Tolbutamide, T1Tolmetin Sodium (Capsule), T1

57

Master Template


Tolmetin Sodium (Tablet), T2Topiramate, T1Toposar, T2Toprol XL, T3Torisel, T4Torsemide (Injection), T2Torsemide (Tablet), T1TPN Electrolytes FTV, T2Tracleer, T4Tramadol HCl, T1Tramadol HCl ER

(100 mg Tablet, 200 mg Tablet), T2Tramadol HCl/Acetaminophen, T1Trandolapril, T1Trandolapril/Verapamil HCl, T2Transderm-Scop, T3Tranylcypromine Sulfate, T2Travasol, T3Travatan, T2Travatan Z, T2Trazodone HCl, T1Treanda, T4Trecator, T3Trelstar Depot, T4Trelstar LA, T4Tretinoin (Capsule), T4Tretinoin (Cream), T1Tretinoin (Gel), T2Tretin-X, T3Trexall, T3Triamcinolone Acetonide, T1Triamcinolone Acetonide in

Absorbase, T1Triamcinolone in Orabase, T1Triamterene/

Hydrochlorothiazide, T1Tricor, T2Triderm, T1Trifluoperazine HCl, T1

Trifluridine, T2Trihexyphenidyl HCl, T1TriHiBit, T2Tri-Legest Fe, T1Trilipix, T2Trilyte, T3Trimethobenzamide HCl

(Capsule), T1Trimethobenzamide HCl

(Injection), T2Trimethoprim, T1Trimethoprim Sulfate/

Polymyxin B Sulfate, T1TriNessa, T1Tripedia, T2Tri-Previfem, T1Trisenox, T3Tri-Sprintec, T1Trivora, T1Trizivir, T4Trophamine (10% Injection), T3Tropicamide, T1Truvada, T4Twinject, T3Twinrix, T2Twynsta, T3Tygacil, T3Tykerb, T4Typhim Vi, T2Tysabri, T4Tyzeka, T4Tyzine, T2

UU-Cort, T1Ulesfia, T3Uloric, T2Unasyn (3 gm Injection), T3Unithroid, T1Uroxatral, T2

Ursodiol (Capsule), T2Ursodiol (Tablet), T1Uvadex, T3

VVagifem, T3Valacyclovir HCl, T2Valcyte, T4Valproate Sodium, T2Valproic Acid, T1Valtrex, T2Vancocin HCl, T4Vancomycin HCl, T2Vancomycin HCl Iso-Osmotic

Dextrose, T3Vandazole, T1Vanos, T3Vaqta, T2Varivax, T2Vectibix, T4Vectical, T3Velcade, T4Velivet, T1Venlafaxine HCl, T1Venlafaxine HCl ER

(24-Hour Capsule), T2Venlafaxine HCl ER

(24-Hour Tablet), T3Ventavis, T4Verapamil HCl (Injection), T2Verapamil HCl (Tablet), T1Verapamil HCl ER, T1Vesicare, T2Vexol, T3Vfend, T4Vibativ, T4Vibramycin

(Oral Suspension, Syrup), T3Vidaza, T4Videx Pediatric, T3

58

Vigamox, T2Vimpat (Injection), T3Vimpat

(Oral Solution, Tablet), T3Vinblastine Sulfate, T1Vincasar PFS, T2Vincristine Sulfate, T2Vinorelbine Tartrate, T2Viracept (Powder), T3Viracept (Tablet), T4Viramune (Oral Suspension), T3Viramune (Tablet), T2Virazole, T4Viread, T3Visicol, T3Vistide, T4Vivaglobin, T4Vivelle-Dot, T2Vivitrol, T4Vivotif Berna, T2Voltaren (Gel), T2Votrient, T4Vpriv, T4Vytorin, T3Vyvanse, T3

WWarfarin Sodium, T1Welchol (Pack), T2Welchol (Tablet), T2

XXalatan, T3Xenazine, T4Xibrom, T3Xifaxan, T3Xolair, T4Xolegel, T3Xyrem, T2

YYasmin, T3Yaz, T3YF-Vax, T2

ZZaleplon, T1Zanosar, T3Zantac

(50 mg/50 ml Injection), T3Zavesca, T4Zazole, T1Zelapar, T3Zemaira, T4Zemplar, T2Zenpep, T3Zerlor, T2Zetia, T2Ziagen, T3Ziana, T3Zidovudine, T2Zinacef

(1.5 gm Injection, 750 mg Injection), T3

Zinacef (7.5 gm Injection), T3Zinacef in Iso-Osmotic

Dextrose, T3Zinacef in Iso-Osmotic

Diluent, T3Zinecard, T4Zmax, T3Zofran (Injection), T4Zofran (Oral Solution, Tablet), T4Zofran ODT, T4Zolinza, T4Zolpidem Tartrate (10 mg Tablet), T1Zolpidem Tartrate (5 mg Tablet), T1Zometa, T4Zonisamide, T1Zorbtive, T4Zostavax, T3Zosyn

(2-0.25 gm/50 ml lnjection, 3-0.375 gm/50 ml Injection), T3

Zovia, T1Zovirax (Cream, Ointment), T3Zyflo CR, T3Zylet, T2Zymar, T2Zyprexa, T2Zyprexa Zydis, T2Zyvox (Injection), T4Zyvox

(Oral Suspension, Tablet), T4


OVEX11MP3245293_000

59

Enrollment Materials

Master Template

Y000

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0061

8_12

2454

CM

S Ap

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ed 0

8032

010


OEV - Version1_R1

For all Plans:

Do you understand you have applied for a Medicare Advantage Plan? £ yes £ no

Do you understand to enroll you must have Medicare Part A and Part B? £ yes £ no

Did the sales agent fully explain your premium, benefits, copays, and coinsurances? £ yes £ no

Did the sales agent confirm that your doctor is in-network? £ yes £ no

Did the sales agent show you the Summary of Benefits (SB) inside this booklet? £ yes £ no

Did the sales agent give you their contact information? (name, phone or business card) £ yes £ no

Did the sales agent give you a receipt from the Enrollment Form? £ yes £ no

Only for PFFS plans:

Did the sales agent ask if you receive both Medicare and Medicaid benefits? And that PFFS plans may not always be a good option for people with Medicare and Medicaid? £ yes £ no

Did the sales agent fully explain the meaning of “deeming”? £ yes £ no

Only for Dual SNP plans:

Did the sales agent tell you that your Enrollment Form will not be processed until your Medicaid status is confirmed? £ yes £ no

Only for Chronic plans:

Did the sales agent tell you that your Enrollment Form will not be processed until your chronic illness has been confirmed and it may take up to 21 days? £ yes £ no

Only for HMO, HMO-POS, and PPO plans:

Do you understand you must use contracted health care providers to get the in-network benefits, copays and coinsurances? £ yes £ no

Do you understand if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? £ yes £ no

Only for Medicare Advantage plans including Prescription Drug coverage:

Did the sales agent explain the plan’s Drug List and Drug Tiers, inside this booklet? £ yes £ no

Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole? £ yes £ no

Do you understand you must use a UnitedHealthcare contracted pharmacy? £ yes £ no

Outbound Education & Verification Call Checklist

Your sales agent will review the following questions with you to verify the Medicare Advantage Plan was fully explained.

If you have enrolled, within the next 15 days a friendly representative from DSS Research, our vendor, will call you to verify the Medicare Advantage Plan was fully explained. The agent will not be on the call with you. This call is required by Medicare and will not affect your ability to enroll in the plan. The representative will ask for your Date of Birth to confirm your identity.

þ

62

1 of 2

Y0004Y0035Y0066_100720_114616 CMS Approved 08272010

Scope of Sales Appointment Confirmation FormTo be completed by person with Medicare or Authorized Representative.

Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.)

Stand-alone Medicare Prescription Drug Plans (Part D)

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

Medicare Advantage (Part C), Medicare Advantage

Prescription Drug Plans, and other Medicare Plans

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the Plan’s network except in an emergency.

Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms and conditions.

Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

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

Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of the Plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services).

2 of 2 SHEX11MP3241167_000

By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing Plan options with you is not employed by the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan, and they may be compensated based on your enrollment in a Plan.

Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan.

Beneficiary Signature ___________________________________________________________________

If you are the authorized representative, you must sign above and provide the following information:

PLEASE PRINTName (First_Last) _______________________________________________________________________

Address _______________________________________________________________________________

Phone number _________________________________________________________________________

Relationship to Beneficiary _______________________________________________________________

PLEASE PRINTTo be completed by Agent

Agent Name (First_Last) Agent Phone

Agent ID # Date of Appointment

Beneficiary Name (First_Last) Beneficiary Phone

Beneficiary Address

Agent’s Signature

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.

To be completed by Agent, if Scope of Appointment was obtained at time of appointment:Reason SOA was not completed prior to Appointment – please check all that apply

Unplanned Attendee

Walk-In

New SOA required (consumer requested other Health Product information)

Other

If Other, please explain ___________________________________________________________________

______________________________________________________________________________________

To submit Scope of Appointment documents: Send Email To: [email protected]; no subject line or body of email required.

Include one PDF per email. Do not attach any other documents. OR

Send Fax To: 877.825.1914

1 of 2

Y0004Y0035Y0066_100720_114616 CMS Approved 08272010

Scope of Sales Appointment Confirmation FormTo be completed by person with Medicare or Authorized Representative.

Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.)

Stand-alone Medicare Prescription Drug Plans (Part D)

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

Medicare Advantage (Part C), Medicare Advantage

Prescription Drug Plans, and other Medicare Plans

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the Plan’s network except in an emergency.

Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms and conditions.

Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

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

Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of the Plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services).

2 of 2 SHEX11MP3241167_000

By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing Plan options with you is not employed by the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan, and they may be compensated based on your enrollment in a Plan.

Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan.

Beneficiary Signature ___________________________________________________________________

If you are the authorized representative, you must sign above and provide the following information:

PLEASE PRINTName (First_Last) _______________________________________________________________________

Address _______________________________________________________________________________

Phone number _________________________________________________________________________

Relationship to Beneficiary _______________________________________________________________

PLEASE PRINTTo be completed by Agent

Agent Name (First_Last) Agent Phone

Agent ID # Date of Appointment

Beneficiary Name (First_Last) Beneficiary Phone

Beneficiary Address

Agent’s Signature

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.

To be completed by Agent, if Scope of Appointment was obtained at time of appointment:Reason SOA was not completed prior to Appointment – please check all that apply

Unplanned Attendee

Walk-In

New SOA required (consumer requested other Health Product information)

Other

If Other, please explain ___________________________________________________________________

______________________________________________________________________________________

To submit Scope of Appointment documents: Send Email To: [email protected]; no subject line or body of email required.

Include one PDF per email. Do not attach any other documents. OR

Send Fax To: 877.825.1914

2011 Individual Enrollment Form

When You Are Ready to Enroll

Contact your local sales agent to help you choose the best plan for you and complete this Individual Enrollment Form, or

Call a SecureHorizons® sales agent to have them help you enroll over the phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week. TTY users: call 711.

Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form, sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR 71903-9973

I understand the person who is discussing plan options with me is a sales agent, broker or other person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid based on my enrollment in a plan.

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

Turn the Page to Enroll

Y0066_100723_233355 CMS Approved 09142010

Enrollment Form

1

1 of 6 AAEX11MP3241235_000

2011 Individual Enrollment FormPlease contact SecureHorizons® if you need information in another language or format (Audio Tape).

For Sales Representative/Agency Use Only

New Member Plan Change Employer Group ID Number Branch ID

How was this application taken? Appointment Mail-In Other

1. Applicant Information (Please type or print in black or blue ink.)Last Name First Name Middle Initial

Birth Date / / Gender Male Female Mr. Mrs. Ms.

Home Telephone Number ( )

Alternate Phone Number (optional) ( )

Permanent Residence Street Address (not a P.O. Box)

City State ZIP Code County

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

City State ZIP Code

E-mail Address (optional)

Please e-mail me plan information and updates.

2. Medicare Insurance InformationPlease take out your red, white and blue Medicare card to complete this section — OR — Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (exactly as appears on Medicare Card)

– – – Medicare Claim Number Letter(s)

Part A (Hospital) effective date / /

Part B (Medical) effective date / /

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

Enrollment Form

1&

&&

1-800-MEDICARE (1-800-633-4227)NAME OF BENEFICIARY

JANE DOEMEDICARE CLAIM NUMBER SEX

000-00-0000-A FEMALEIS ENTITLED TO EFFECTIVE DATE

HOSPITAL (PART A) 07-01-1986 MEDICAL (PART B) 07-01-1986SIGNHERE Jane Doe

2 of 6 AAEX11MP3241235_000

If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my (If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover. If you would like to set up EFT, please enclose a blank check with VOID written on the front.)

Monthly Social Security benefit check

Electronic Funds Transfer (EFT) from your bank account each month. Enclose a VOIDED check or provide the following

Account Holder Name Bank Routing Number

Bank Account Number Account Type Checking Savings

Coupon Book

Enrollment Form

1&

&&

4a. Benefit Plan Selections — Choose Only One

3. Your Payment Options (If applicable)If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security Administration office, or call the Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, it is recommended you choose the coupon book or EFT option.

Point of Service (HMO-POS) plans with a medical and Part D drug benefit AARP® MedicareComplete® Plus (HMO-POS) AP AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1

HMO-POS plans with medical benefits only AARP® MedicareComplete® Plus Essential (HMO-POS) APE

Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR AARP® MedicareComplete Choice® Plan 1 (PPO) AC1 AARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2

PPO plans with medical benefits only AARP® MedicareComplete Choice® Essential (PPO) ACE AARP® MedicareComplete Choice® Essential (Regional PPO) ACP

AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Plan 3 (HMO) A3

AARP® MedicareComplete® Value (HMO) AV AARP® MedicareComplete® Premier (HMO) APR AARP® MedicareComplete® Mosaic (HMO) AM

HMO plans with medical benefits only AARP® MedicareComplete Essential® (HMO) AE

Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit

3 of 6 AAEX11MP3241235_000

Enrollment Form

1&

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4b. Complete the following if the plan chosen includes routine dental coverage

Name of dental provider Provider ID# (please refer to Provider Directory) Are you currently a patient of this dentist? Yes No

4c. OPTIONAL Supplemental Benefit PlansThese plans are not available in all service areas. Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums.If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below).

Fitness Rider Deluxe RiderIf available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans below.

High Option Dental Rider Optional Dental Rider Dental 260 RiderDental Facility # (please refer to the Provider Directory)

Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans.

5. Primary Care Physician (PCP), Clinic or Health Center SelectionRefer to your Provider Directory or the plan Web site to select a PCP. Provider ID# PCP name Are you now seeing or have you recently seen this doctor? Yes No

6. Please Read and Answer These Important QuestionsDo you have End-Stage Renal Disease (ESRD)? Yes NoIf you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant, please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney transplant. (Use Form 2728 if available.) If “yes”, are you currently a member of a health care company? Yes NoIf “yes”, name of company Member ID#

Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes NoIf “yes”, name of institution Address of institution City, State, ZIP Code Telephone number of institution ( ) Your date of admission to the institution / /Are you enrolled in your state Medicaid program? Yes NoIf “yes”, please provide your Medicaid ID number

Do you or your spouse work? Yes No

Do you or your spouse have any health insurance other than Medicare, such as private insurance, Workers’ Compensation or Veterans Administration (VA) benefits? Yes NoIf you have other health insurance, what kind do you have? What is the name of the health insurance? Group # ID#

Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes NoPlan name of other coverage Member ID# for this coverage Group ID# Effective Date (optional)

4 of 6 AAEX11MP3241235_000

7. Alternative Formats (Check only one)

If available, I prefer to receive materials in the following format Spanish Chinese Large Print (English Only)

Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.

Enrollment Form

1&

&&

Statements of Understanding

By Completing This Enrollment Form, I Agree to the Following

1. AARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.

2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move. I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment under the Plan.

4. By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this Enrollment Form, I may be disenrolled from the Plan.

Statements of Understanding (continued)


5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may visit www.medicare.gov or 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.

6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid Program and the Medicare Savings Program.

5 of 6 AAEX11MP3241235_000

&&

&Enrollm

ent Form 1

Additional Statements of Understanding for Each Specific Plan

AARP® MedicareComplete® from SecureHorizons (HMO) I understand that beginning on the date AARP® MedicareComplete® from SecureHorizons plan coverage begins, I must receive all covered benefits from plan contracted providers and pharmacies, except for emergency or urgently needed services or out-of-area renal dialysis. I understand that authorized services and other services contained in my Evidence of Coverage document will be covered as disclosed. If I do not receive prior authorization as required for covered services, I understand that neither Medicare nor AARP® MedicareComplete® will pay for services.

AARP® MedicareComplete Choice® (PPO) I understand that beginning on the date AARP® MedicareComplete Choice® plan coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, the Plan provides refunds for all covered benefits, even if I get services out-of-network.

AARP® MedicareComplete® Plus (HMO-POS) I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available both in and out-of-network, and I understand I must use in-network providers to enjoy the lowest cost sharing. Some non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally, some out-of-network services may be limited by county or state and require prior authorization.

Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud. Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or criminal liability.

6 of 6 AAEX11MP3241235_000

&&

&

8. Please Read This Important InformationI understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form, Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.

You must sign and date this Individual Enrollment Form in order for it to be processed.

If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive health care related information on his/her behalf and that documentation of this authority is available upon request by the Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes.

Signature of applicant/member/authorized representative Date / /

If you are the authorized representative of the applicant, you must provide the following information and sign above.Name Relationship to applicant

Address Telephone Number ( )

City State ZIP Code Alternate Phone Number (optional) ( )

9. For Sales Representative/Agency Use Only

Selling Staff Member/Agent ID Initial Receipt Date

Selling Staff Member/Agent Name Proposed Effective Date

Agent Telephone Number

Signature (if assisted in enrollment)

10. Election Period

AEP ICEP IEP IEP2 (MAPD Plans Only) OEPI SEP (SEP Reason Code )

Enrollment Form

1

Important Enrollment Information

I-Enroll Tracking Number

Effective Date

Medicare ID

Plan Name

Sales Agent ID

Sales Agent Name

Sales Agent Phone Number

Health Plan/PBP Number

This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT.

Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail within two weeks.

If you do not have a local sales agent, please call 1-800-547-5514, 8 a.m. - 8 p.m. local time, 7 days a week. TTY users call 711.

Visit our web site at www.AARPMedicarePlans.com

&&

&

Talk to your local sales agent for answers or to enroll.

Y0066_100723_233355 CMS Approved 09142010 AAEX11MP3241235_000

The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll.

AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged to evaluate your needs.

AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers, representatives or advisors.

Visit our Web site at: www.AARPMedicarePlans.com

2011 Individual Enrollment Form

When You Are Ready to Enroll

Contact your local sales agent to help you choose the best plan for you and complete this Individual Enrollment Form, or

Call a SecureHorizons® sales agent to have them help you enroll over the phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week. TTY users: call 711.

Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form, sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR 71903-9973

I understand the person who is discussing plan options with me is a sales agent, broker or other person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid based on my enrollment in a plan.

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

Turn the Page to Enroll

Y0066_100723_233355 CMS Approved 09142010

Enrollment Form

2

1 of 6 AAEX11MP3241235_000

2011 Individual Enrollment FormPlease contact SecureHorizons® if you need information in another language or format (Audio Tape).

For Sales Representative/Agency Use Only

New Member Plan Change Employer Group ID Number Branch ID

How was this application taken? Appointment Mail-In Other

1. Applicant Information (Please type or print in black or blue ink.)Last Name First Name Middle Initial

Birth Date / / Gender Male Female Mr. Mrs. Ms.

Home Telephone Number ( )

Alternate Phone Number (optional) ( )

Permanent Residence Street Address (not a P.O. Box)

City State ZIP Code County

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

City State ZIP Code

E-mail Address (optional)

Please e-mail me plan information and updates.

2. Medicare Insurance InformationPlease take out your red, white and blue Medicare card to complete this section — OR — Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (exactly as appears on Medicare Card)

– – – Medicare Claim Number Letter(s)

Part A (Hospital) effective date / /

Part B (Medical) effective date / /

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

Enrollment Form

2&

&&

1-800-MEDICARE (1-800-633-4227)NAME OF BENEFICIARY

JANE DOEMEDICARE CLAIM NUMBER SEX

000-00-0000-A FEMALEIS ENTITLED TO EFFECTIVE DATE

HOSPITAL (PART A) 07-01-1986 MEDICAL (PART B) 07-01-1986SIGNHERE Jane Doe

2 of 6 AAEX11MP3241235_000

If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my (If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover. If you would like to set up EFT, please enclose a blank check with VOID written on the front.)

Monthly Social Security benefit check

Electronic Funds Transfer (EFT) from your bank account each month. Enclose a VOIDED check or provide the following

Account Holder Name Bank Routing Number

Bank Account Number Account Type Checking Savings

Coupon Book

Enrollment Form

2&

&&

4a. Benefit Plan Selections — Choose Only One

3. Your Payment Options (If applicable)If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security Administration office, or call the Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, it is recommended you choose the coupon book or EFT option.

Point of Service (HMO-POS) plans with a medical and Part D drug benefit AARP® MedicareComplete® Plus (HMO-POS) AP AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1

HMO-POS plans with medical benefits only AARP® MedicareComplete® Plus Essential (HMO-POS) APE

Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR AARP® MedicareComplete Choice® Plan 1 (PPO) AC1 AARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2

PPO plans with medical benefits only AARP® MedicareComplete Choice® Essential (PPO) ACE AARP® MedicareComplete Choice® Essential (Regional PPO) ACP

AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Plan 3 (HMO) A3

AARP® MedicareComplete® Value (HMO) AV AARP® MedicareComplete® Premier (HMO) APR AARP® MedicareComplete® Mosaic (HMO) AM

HMO plans with medical benefits only AARP® MedicareComplete Essential® (HMO) AE

Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit

3 of 6 AAEX11MP3241235_000

Enrollment Form

2&

&&

4b. Complete the following if the plan chosen includes routine dental coverage

Name of dental provider Provider ID# (please refer to Provider Directory) Are you currently a patient of this dentist? Yes No

4c. OPTIONAL Supplemental Benefit PlansThese plans are not available in all service areas. Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums.If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below).

Fitness Rider Deluxe RiderIf available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans below.

High Option Dental Rider Optional Dental Rider Dental 260 RiderDental Facility # (please refer to the Provider Directory)

Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans.

5. Primary Care Physician (PCP), Clinic or Health Center SelectionRefer to your Provider Directory or the plan Web site to select a PCP. Provider ID# PCP name Are you now seeing or have you recently seen this doctor? Yes No

6. Please Read and Answer These Important QuestionsDo you have End-Stage Renal Disease (ESRD)? Yes NoIf you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant, please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney transplant. (Use Form 2728 if available.) If “yes”, are you currently a member of a health care company? Yes NoIf “yes”, name of company Member ID#

Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes NoIf “yes”, name of institution Address of institution City, State, ZIP Code Telephone number of institution ( ) Your date of admission to the institution / /Are you enrolled in your state Medicaid program? Yes NoIf “yes”, please provide your Medicaid ID number

Do you or your spouse work? Yes No

Do you or your spouse have any health insurance other than Medicare, such as private insurance, Workers’ Compensation or Veterans Administration (VA) benefits? Yes NoIf you have other health insurance, what kind do you have? What is the name of the health insurance? Group # ID#

Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes NoPlan name of other coverage Member ID# for this coverage Group ID# Effective Date (optional)

4 of 6 AAEX11MP3241235_000

7. Alternative Formats (Check only one)

If available, I prefer to receive materials in the following format Spanish Chinese Large Print (English Only)

Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.

Enrollment Form

2&

&&

Statements of Understanding


1. AARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.

2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move. I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment under the Plan.

4. By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this Enrollment Form, I may be disenrolled from the Plan.

Statements of Understanding (continued)


5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may visit www.medicare.gov or 1-800-MEDICARE (1-800-633-4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.

6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid Program and the Medicare Savings Program.

5 of 6 AAEX11MP3241235_000

&&

&Enrollm

ent Form 2

Additional Statements of Understanding for Each Specific Plan

AARP® MedicareComplete® from SecureHorizons (HMO) I understand that beginning on the date AARP® MedicareComplete® from SecureHorizons plan coverage begins, I must receive all covered benefits from plan contracted providers and pharmacies, except for emergency or urgently needed services or out-of-area renal dialysis. I understand that authorized services and other services contained in my Evidence of Coverage document will be covered as disclosed. If I do not receive prior authorization as required for covered services, I understand that neither Medicare nor AARP® MedicareComplete® will pay for services.

AARP® MedicareComplete Choice® (PPO) I understand that beginning on the date AARP® MedicareComplete Choice® plan coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, the Plan provides refunds for all covered benefits, even if I get services out-of-network.

AARP® MedicareComplete® Plus (HMO-POS) I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available both in and out-of-network, and I understand I must use in-network providers to enjoy the lowest cost sharing. Some non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally, some out-of-network services may be limited by county or state and require prior authorization.

Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud. Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or criminal liability.

6 of 6 AAEX11MP3241235_000

&&

&

8. Please Read This Important InformationI understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form, Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.

You must sign and date this Individual Enrollment Form in order for it to be processed.

If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive health care related information on his/her behalf and that documentation of this authority is available upon request by the Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes.

Signature of applicant/member/authorized representative Date / /

If you are the authorized representative of the applicant, you must provide the following information and sign above.Name Relationship to applicant

Address Telephone Number ( )

City State ZIP Code Alternate Phone Number (optional) ( )

9. For Sales Representative/Agency Use Only

Selling Staff Member/Agent ID Initial Receipt Date

Selling Staff Member/Agent Name Proposed Effective Date

Agent Telephone Number

Signature (if assisted in enrollment)

10. Election Period

AEP ICEP IEP IEP2 (MAPD Plans Only) OEPI SEP (SEP Reason Code )

Enrollment Form

2

Important Enrollment Information

I-Enroll Tracking Number

Effective Date

Medicare ID

Plan Name

Sales Agent ID

Sales Agent Name

Sales Agent Phone Number

Health Plan/PBP Number

This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT.

Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail within two weeks.

If you do not have a local sales agent, please call 1-800-547-5514, 8 a.m. - 8 p.m. local time, 7 days a week. TTY users call 711.

Visit our web site at www.AARPMedicarePlans.com

&&

&

Talk to your local sales agent for answers or to enroll.

Y0066_100723_233355 CMS Approved 09142010 AAEX11MP3241235_000

The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its members. AARP is not the insurer. You do not need to be an AARP member to enroll.

AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged to evaluate your needs.

AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers, representatives or advisors.

Visit our Web site at: www.AARPMedicarePlans.com

Roadmap After Enrollment Continue On Your Path to…

Steps How You Get It Description

1 Receipt of Enrollment Form

Confirms you submitted an Enrollment Form.

2 Copy of Completed Enrollment Form

We will mail you a copy of your completed Enrollment Form for your personal records only.

3Acknowledgement of Receipt of Application Letter

We received your completed Enrollment Form. (Please note: Medicare must approve your Enrollment Form)

4 Notice to Confirm Enrollment

Notice that Medicare has approved yourEnrollment Form. Your enrollment is complete.

5 Outbound Education & Verification Call

Verifies the Medicare Advantage plan was fully explained by your sales agent.

6 Premium AssistanceYou may receive a letter on how to get extra help with your Medicare premiums and other health care costs, if you qualify.

7 Member ID CardBring this new Member ID card when you visit your doctor, hospital or pharmacy.

8 Welcome KitIncludes important information about yourbenefits, such as: Evidence of Coverage and Provider Directory.

9 Health Risk Assessment Call

Agent

Mailed

Mailed

Mailed

Mailed

Mailed

Mailed

PhoneYou will receive this call to inform us about your health history. This information will not affect your ability to enroll in this plan. Your answers will help us develop a health program to fit your needs.

Phone

Y000

4Y00

35Y0

066_

1007

07_1

1021

8 Fi

le &

Use

071

9201

0


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AAFL11RP3242425_000Y0004Y0066_100707_142434 CMS Approved 08202010

Entire Enrollment Kit

Documents

Transcript of Entire Enrollment Kit