Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015 Enrollment Guide
AARP® MedicareRx Preferred (PDP)
AARP® MedicareRx Saver Plus (PDP)
Service area: California
Region: 32
Connecting you to the
coverage you may need.
Thousands of brand name and generic drugs
Prescription drugs as low as $1
Convenient local pharmacies
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Table of Contents
Medicare education
Find out how Medicare plans work and when you are eligible to enroll in
a Medicare plan.
Introduction......................................................................................................................... 3
More plan information
Read all about your plan benefits, including services and support for
your overall health and well-being.
Benefit Highlights.............................................................................................................. 8
Summary of Benefits...................................................................................................... 11
Plan Ratings..................................................................................................................... 27
Required Information...................................................................................................... 29
Drug list
Look here to find what drugs are covered. The list in the book is the full
list of the covered drugs.
Drug List............................................................................................................................ 32
Welcome aboard
We want to make enrolling easy. This section includes instructions
and forms you’ll need to become a member of this plan.
Enrollment Instructions.................................................................................................. 48
Enrollment Request Form..............................................................................................49
Enrollment Checklist.......................................................................................................73
Enrollment Receipt..........................................................................................................77
What to Expect After You Enroll...................................................................................78
What to expect after you enroll
Learn what happens next, including what you can do right now
and how we’ll keep in touch with you after you become a member.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
It’s more than a drug plan.
IT’S A HEALTHY RELATIONSHIP.
When you’re a member of our Medicare Part D plan, you get more
than a set of drug coverage benefits. You get a relationship with a
company dedicated to providing you with the service and support
you may need to get the most from your benefits.
We’re committed to providing the benefits you may need along with
programs designed to help you control your health care coverage
costs. This plan may help you:
Get connected
Local pharmacies from our nationwide network
Extensive drug lists
Pharmacists who can help you manage and understand
your prescriptions
Find ways to save
Preferred retail network savings
Coverage on 1,000s of brand name and generic drugs
Part D helps make drugs more affordable since Original Medicare
doesn’t cover prescription drugs
Service and support that can help you take control
A choice of plans, so you can pick the plan with the right coverage
for you
Convenient 24/7 online access
Questions? One call does it all.
Toll Free 866-883-0659, TTY 711
8 a.m. – 8 p.m. local time, 7 days a week
Se habla español.
AARPMedicareRxInfo.com
Go online anytime.
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Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Medicare
EDUCATION
What is Medicare?
Medicare is a federal health insurance program for people age 65 and older and others with disabilities.
You’re eligible for Original Medicare (Parts A and B) if:
You’re at least 65 years old, or you’re under 65 and qualify on the basis of a disability or other special situation.
AND
You’re a U.S. citizen or a legal resident who has lived in the U.S. for at least five consecutive years.
Original Medicare is provided by the government and covers some of the costs of hospital
stays (Part A) and doctor visits (Part B), but it does not cover everything — you don’t get
coverage for prescription drugs or for vision, dental or hearing care.
What if you need more coverage beyond
Original Medicare?
If you need more coverage, there are additional types of Medicare plans you can enroll in:
You can enroll in a Medicare supplement insurance plan to help pay for some or all of the costs
and benefits not covered by Original Medicare Parts A and B. Medicare supplement plans can be
purchased alone or can be combined with a Part D plan.
You can enroll in a stand-alone Medicare prescription drug (Part D) plan to help pay for the costs
of prescription drugs. Part D plans can be purchased alone or can be combined with a Medicare
supplement insurance plan, or a Private-Fee-For-Service plan without prescription drugs.
Or you can enroll in an all-in-one Medicare Advantage (Part C) plan.
Unlike Medicare supplement and Part D plans, Part C plans give you all the coverage of Original
Medicare and often include prescription drug coverage, plus extra benefits like routine vision and
hearing coverage — all in one plan.
Do you qualify for Extra Help?
If you have a limited income, you may qualify for Extra Help with your Medicare prescription
drug plan premiums, deductibles and co-pays. Many people qualify and don’t even know it.
To find out if you qualify, call the Social Security Administration at
1-800-772-1213, TTY 1-800-325-0778,
7 a.m. – 7 p.m., Monday – Friday
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Medicare
EDUCATION (CONTINUED)
What are the drug payment stages?
If your plan includes prescription drug coverage, the amount you pay each time to fill a prescription depends on
which payment stage you’re in. How do you know which stage you’re in? It depends on how much money you and
your plan have paid for prescription drugs so far in the plan year. The chart below shows the different payment
stages you may go through in the plan year.
Annual deductible
If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible amount. You
then move to the initial coverage stage.
In this drug payment stage:
After your total drug costs reach $2,960:
• You pay a co-pay or
co-insurance (percentage of
a drug’s total cost). The plan
pays the rest
You pay:
– 65% of the cost of generic drugs
You pay a small co-pay or
co-insurance amount.
• You stay in this stage until
your total drug costs
reach $2,960
You stay in this stage until your
out-of-pocket costs reach $4,700.
You stay in this stage for
the rest of the plan year.
– 45% of the cost of brand name drugs
After your total
out-of-pocket costs
reach $4,700:
Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for prescription drugs
starting on January 1, 2015.
Out-of-Pocket Costs: The amount you pay (or others pay on your behalf) for prescription drugs starting on
January 1, 2015. This does not include premiums.
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Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Medicare
EDUCATION (CONTINUED)
When can you enroll in a Medicare plan?
Sept.
Oct.
Nov.
Open Enrollment
October 15 – December 7
Dec.
Jan.
Feb.
March
Medicare Advantage
Disenrollment Period
April
May
June
July
Aug.
Special Election Period
Annual Election Period: A set time frame when you can sign up for a new plan or elect to keep your existing
plan. Once you enroll, your coverage will begin on January 1.
Initial Enrollment Period: This is the three months before and three months after the month you turn 65 or
become Medicare eligible.
Special Election Period: In certain situations you may be able to enroll in a Medicare plan outside of the
Open or Initial Enrollment Period time frames. Call our customer service number on the first page of this
booklet to learn more.
Avoid the Part D late-enrollment penalty
If you go without Part D coverage for longer than 63 days in a row after your Initial Enrollment Period ends,
an additional fee will be added to your Part D premium per government requirements. To avoid incurring this
additional fee, make sure to sign up for either a Medicare Advantage plan that offers drug coverage or a standalone Part D plan during your Initial Enrollment Period. Please note that if you have employer coverage, you
may not need to enroll until that coverage ends. When your employer coverage ends, you could have a Special
Election Period to enroll in a Medicare plan and may not be subject to an additional Part D premium.
Are you eligible for this plan?
You are eligible if you are enrolled in Original Medicare and live in the plan’s service area AND you are currently
enrolled in a plan that does not offer drug coverage.
Do you need to meet special requirements to be eligible
for this plan?
No, as long as you are enrolled in Original Medicare and continue to pay your Part B premium, you are eligible to
enroll in this plan.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan’s contract renewal with Medicare.
Y0066_140806_090054_FINAL_21 Accepted
AAEX15PD3577986_000
6
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
More plan
INFORMATION
Read all about your plan benefits, including
services and support for your overall health
and well-being.
Y0066_140725_103934 Accepted
UHEX15MP3584413_000
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Benefit highlights
This is a short description of 2015 plan benefits. For complete information, please refer to your Summary of
Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply.
Plan Feature
AARP® MedicareRx Saver Plus
(PDP)
AARP® MedicareRx Preferred
(PDP)
Monthly premium
$28.00
$57.90
Annual prescription deductible
$320
$0
Initial coverage stage
Preferred retail
cost sharing (innetwork 30-day
supply)
Standard retail
cost sharing (innetwork 30-day
supply)
Preferred retail
cost sharing (innetwork 30-day
supply)
Standard retail
cost sharing (innetwork 30-day
supply)
Tier 1: Preferred Generic Drugs
$1 copay
$2 copay
$2 copay
$5 copay
Tier 2: Non-Preferred Generic
Drugs
$2 copay
$4 copay
$3 copay
$8 copay
Tier 3: Preferred Brand Drugs
$25 copay
$30 copay
$40 copay
$45 copay
Tier 4: Non-Preferred Brand
Drugs
$40 copay
$55 copay
$85 copay
$95 copay
Tier 5: Specialty Tier Drugs
25% of the
cost
25% of the
cost
33% of the
cost
33% of the
cost
Coverage gap stage
After your total drug costs reach $2,960, you will pay no more than
65% of the total cost for generic drugs or 45% of the total cost for
brand name drugs, for any drug tier during the coverage gap
Catastrophic coverage stage
After your total out-of-pocket costs reach $4,700, you will pay the
greater of $2.65 copay for generic (including brand drugs treated as
generic), $6.60 copay for all other drugs, or 5% of the cost
Formulary (drug list)
Includes most generic drugs
covered by Medicare Part D and
many commonly used brand
name drugs
Includes nearly all generic drugs
covered by Medicare Part D and
many commonly used brand
name drugs
Includes $0 for a 90-day supply of Tier 1 medications (typically generic drugs) through our Preferred Mail
Service Pharmacy
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare.
Formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of
each year.
The benefit information provided is a brief summary, not a complete description of benefits. For more
information, contact the plan. You must continue to pay your Medicare Part B premium, if not otherwise paid
for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply.
Y0066_PDPBH_FINAL_S5921376_S5820031 Accepted
8
PDCA15PD3575760_000
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Our benefits are designed to help you live a healthier life. Sometimes your health relies on the prescription drugs
you take. Make the most of your prescription coverage by following these simple steps.
Ways to save on your prescription drugs.
As a member of our plan you’re part of a relationship built around your care. You’re on a team that’s dedicated
to looking for ways to reduce costs and improve your health. So you can worry less and live more.
Review your drugs with your doctor.
Each drug that the plan covers is in a tier level, which determines your cost for the drug. Generally, the lower
the tier, the less you have to pay. Talk with your doctor or pharmacist to see if there are lower-cost alternatives
to your drug.
••There may be a generic version of your drug that may work just as well. You will find generic drugs at every
tier level, so be sure to check the drug list to see which tier your specific generic drug is in
••There may be a brand name drug that falls in a lower co-payment tier than the drug you’re currently taking.
Ask your doctor if there are any lower-tier drugs that could work for you and save you money
Spend less on your prescription drugs.
Preferred Retail Pharmacy Network.
With the Preferred Retail Pharmacy Network, you could save 20% or more on your prescriptions.1 Participating
pharmacies are conveniently located in many local grocery, drug and discount stores. It’s easy to switch your
prescriptions to a preferred retail pharmacy — and you can switch at any time throughout the year. To get
started and see a complete list of preferred retail pharmacies in your area, visit: AARPMedicareRxInfo.com.
OptumRx® Mail Service Pharmacy.
Our Preferred Mail Service Pharmacy, OptumRx, is designed to make filling your prescriptions more affordable
and convenient. Learn more at OptumRx.com.
Savings of 20% or more apply to Tier 1 and Tier 2 co-pays on the AARP MedicareRx Preferred (PDP) and
AARP MedicareRx Saver Plus (PDP) plans at a preferred retail pharmacy compared with the co-pays of
standard pharmacies within the network.
1
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
Enrollment in the plan depends on the plan’s contract renewal with Medicare.
9
Y0066_140723_165426 Accepted PDEX15MP3578438_000
MORE PLAN INFORMATION
Make the most
OF YOUR PLAN
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
NOTES
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Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015 Summary of
BENEFITS
AARP® MedicareRx Saver Plus (PDP)
Y0066_SB_S5921_376_2015 CMS Accepted
11
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Section 1 - Introduction to Summary of Benefits
You have choices about how to get your Medicare prescription drug benefits
•
•
One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan, like
AARP MedicareRx Saver Plus (PDP).
Another choice is to get your prescription drug coverage through a Medicare Advantage Plan (like
an HMO or PPO) or another Medicare health plan that of
f
ers Medicare prescription drug coverage.
You get all of
your Part A and Part B coverage, and prescription drug coverage (Part D), through
these plans.
Tips for comparing your Medicare choices
This Summary of
Benef
its booklet gives you a summary of
what AARP MedicareRx Saver Plus (PDP)
covers and what you pay.
•
•
If
you want to compare our plan with other Medicare health plans, ask the other plans f
or their
Summary of
Benef
its booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.
If
you want to know more about the coverage and costs of
Original Medicare, look in your current
“Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
Sections in this booklet
•
•
•
Things to Know About AARP MedicareRx Saver Plus (PDP)
Monthly Premium, Deductible, and Limits on How Much You Pay f
or Covered Services
Prescription Drug Benef
its
This document is available in other f
ormats such as Braille and large print.
This document may be available in a non-English language. For additional inf
ormation, call us at
1-888-867-5575.
Es posible que este documento esté disponible en otro idioma. Para inf
ormación adicional llame al
1-888-867-5575.
Things to Know About AARP MedicareRx Saver Plus (PDP)
Hours of Operation
You can call us 7 days a week f
rom 8:00 a.m. to 8:00 p.m. Local time.
AARP MedicareRx Saver Plus (PDP) Phone Numbers and Website
•
•
•
If
you are a member of
this plan, call toll-f
ree 1-888-867-5575.
If
you are not a member of
this plan, call toll-f
ree 1-888-867-5564.
Our website: www.AARPMedicareRx.com
Who can join?
To join AARP MedicareRx Saver Plus (PDP), you must be entitled to Medicare Part A, and/or be
enrolled in Medicare Part B, and live in our service area.
12
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MORE PLAN INFORMATION
Our service area includes the f
ollowing: Calif
ornia.
Which drugs are covered?
You can see the complete plan f
ormulary (list of
Part D prescription drugs) and any restrictions on our
website (www.AARPMedicareRx.com). Or, call us and we will send you a copy of
the f
ormulary.
How will I determine my drug costs?
Our plan groups each medication into one of
f
ive "tiers." You will need to use your f
ormulary to locate
what tier your drug is on to determine how much it will cost you. The amount you pay depends on the
drug’s tier and what stage of
the benef
it you have reached. Later in this document we discuss the benef
it
stages that occur af
ter you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic
Coverage.
Which pharmacies can I use?
We have a network of
pharmacies and you must generally use these pharmacies to f
ill your prescriptions
f
or covered Part D drugs.
Some of
our network pharmacies have pref
erred cost-sharing. You may pay less if
you use these
pharmacies.
You can see our plan’s pharmacy directory at our website (www.AARPMedicareRx.com). Or, call us and
we will send you a copy of
the pharmacy directory.
13
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Section 2 - Summary of Benefits
If
you have any questions about this plan’s benef
its or costs, please contact UnitedHealthcare f
or details.
AARP® MedicareRx Saver Plus (PDP)
Monthly Premium, Deductible, and Limits On How Much You Pay For Covered Services
$28 per month.
How much is
the monthly
premium?
$320 per year f
or Part D prescription drugs.
How much is
the deductible?
Prescription Drug Benefits
Initial Coverage
Af
ter you pay your yearly deductible, you pay the f
ollowing until your total
yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs
paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order
pharmacies.
Pref
erred Retail Cost-Sharing
Tier
One-month supply
Three-month supply
Tier 1 (Pref
erred Generic)
$1 copay
$3 copay
Tier 2 (Non-Pref
erred
$2 copay
$6 copay
Generic)
Tier 3 (Pref
erred Brand)
$25 copay
$75 copay
Tier 4 (Non-Pref
erred
$40 copay
$120 copay
Brand)
Tier 5 (Specialty Tier)
25% of
the cost
25% of
the cost
Standard Retail Cost-Sharing
Tier
One-month supply
Three-month supply
Tier 1 (Pref
erred Generic)
$2 copay
$6 copay
Tier 2 (Non-Pref
erred
$4 copay
$12 copay
Generic)
Tier 3 (Pref
erred Brand)
$30 copay
$90 copay
Tier 4 (Non-Pref
erred
$55 copay
$165 copay
Brand)
Tier 5 (Specialty Tier)
25% of
the cost
25% of
the cost
14
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Tier
Three-month supply
MORE PLAN INFORMATION
Pref
erred Mail Order Cost-Sharing
Tier 1 (Pref
erred Generic)
$0
Tier 2 (Non-Pref
erred
$2 copay
Generic)
Tier 3 (Pref
erred Brand)
$60 copay
Tier 4 (Non-Pref
erred
$105 copay
Brand)
Tier 5 (Specialty Tier)
25% of
the cost
Standard Mail Order Cost-Sharing
Tier
Three-month supply
Tier 1 (Pref
erred Generic)
$6 copay
Tier 2 (Non-Pref
erred
$12 copay
Generic)
Tier 3 (Pref
erred Brand)
$90 copay
Tier 4 (Non-Pref
erred
$165 copay
Brand)
Tier 5 (Specialty Tier)
25% of
the cost
If
you reside in a long-term care f
acility, you pay the same as at a retail
pharmacy.
You may get drugs f
rom an out-of
-network pharmacy, but may pay more than
you pay at an in-network pharmacy.
Coverage Gap
Most Medicare drug plans have a coverage gap (also called the "donut hole").
This means that there’s a temporary change in what you will pay f
or your
drugs. The coverage gap begins af
ter the total yearly drug cost (including what
our plan has paid and what you have paid) reaches $2,960.
Af
ter you enter the coverage gap, you pay 45% of
the plan’s cost f
or covered
brand name drugs and 65% of
the plan’s cost f
or covered generic drugs until
your costs total $4,700, which is the end of
the coverage gap. Not everyone
will enter the coverage gap.
15
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Catastrophic
Coverage
Af
ter your yearly out-of
-pocket drug costs (including drugs purchased through
your retail pharmacy and through mail order) reach $4,700, you pay the
greater of
:
• 5% of
the cost, or
• $2.65 copay f
or generic (including brand drugs treated as generic) and a
$6.60 copayment f
or all other drugs.
16
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English: We have free interpreter services to answer any questions you may have about our health
or drug plan. To get an interpreter, just call us at 1-888-867-5564. Someone who speaks
English/Language can help you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que
pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor
llame al 1-888-867-5564. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。
如果您需要此翻译服务，请致电1-888-867-5564。我们的中文工作人员很乐意帮助您。这是一项
免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服
務。如需翻譯服務，請致電 1-888-867-5564。我們講中文的人員將樂意為您提供幫助。這是一
項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang
mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha
ng tagasaling-wika, tawagan lamang kami sa 1-888-867-5564. Maaari kayong tulungan ng isang
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos
questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service
d'interprétation, il vous suffit de nous appeler au 1-888-867-5564. Un interlocuteur parlant
Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức
khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-867-5564 sẽ có
nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-867-5564.
Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제
공하고 있습니다. 통역 서비스를 이용하려면 전화 1-888-867-5564번으로 문의해 주십시오.
한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного
плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы
воспользоваться услугами переводчика, позвоните нам по телефону 1-888-867-5564. Вам
окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
1-888-867-5564
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul
nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-867-5564. Un
nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
17
MORE PLAN INFORMATION
Multi-language Interpreter Services
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Portugues: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão
que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete,
contacte-nos através do número 1-888-867-5564. Irá encontrar alguém que fale o idioma
Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan
plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-867-5564. Yon
moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z
pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-867-5564. Ta
usługa jest bezpłatna.
Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास
मुफ्त दुभाषिया सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-888-867-5564 पर फोन
करें. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために、無
料の通訳サービスがありますございます。通訳をご用命になるには、1-888-867-5564にお電話
ください。日本語を話す人 者 が支援いたします。これは無料のサービスです。
PDCA15PD3576870_001
18
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015 Summary of
BENEFITS
AARP® MedicareRx Preferred (PDP)
Y0066_SB_S5820_031_2015 CMS Accepted
19
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Section 1 - Introduction to Summary of Benefits
You have choices about how to get your Medicare prescription drug benefits
•
•
One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan, like
AARP MedicareRx Pref
erred (PDP).
Another choice is to get your prescription drug coverage through a Medicare Advantage Plan (like
an HMO or PPO) or another Medicare health plan that of
f
ers Medicare prescription drug coverage.
You get all of
your Part A and Part B coverage, and prescription drug coverage (Part D), through
these plans.
Tips for comparing your Medicare choices
This Summary of
Benef
its booklet gives you a summary of
what AARP MedicareRx Pref
erred (PDP)
covers and what you pay.
•
•
If
you want to compare our plan with other Medicare health plans, ask the other plans f
or their
Summary of
Benef
its booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.
If
you want to know more about the coverage and costs of
Original Medicare, look in your current
“Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
Sections in this booklet
•
•
•
Things to Know About AARP MedicareRx Pref
erred (PDP)
Monthly Premium, Deductible, and Limits on How Much You Pay f
or Covered Services
Prescription Drug Benef
its
This document is available in other f
ormats such as Braille and large print.
This document may be available in a non-English language. For additional inf
ormation, call us at
1-888-867-5575.
Es posible que este documento esté disponible en otro idioma. Para inf
ormación adicional llame al
1-888-867-5575.
Things to Know About AARP MedicareRx Preferred (PDP)
Hours of Operation
You can call us 7 days a week f
rom 8:00 a.m. to 8:00 p.m. Local time.
AARP MedicareRx Preferred (PDP) Phone Numbers and Website
•
•
•
If
you are a member of
this plan, call toll-f
ree 1-888-867-5575.
If
you are not a member of
this plan, call toll-f
ree 1-888-867-5564.
Our website: www.AARPMedicareRx.com
Who can join?
To join AARP MedicareRx Pref
erred (PDP), you must be entitled to Medicare Part A, and/or be
enrolled in Medicare Part B, and live in our service area.
20
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
MORE PLAN INFORMATION
Our service area includes the f
ollowing: Calif
ornia.
Which drugs are covered?
You can see the complete plan f
ormulary (list of
Part D prescription drugs) and any restrictions on our
website (www.AARPMedicareRx.com). Or, call us and we will send you a copy of
the f
ormulary.
How will I determine my drug costs?
Our plan groups each medication into one of
f
ive "tiers." You will need to use your f
ormulary to locate
what tier your drug is on to determine how much it will cost you. The amount you pay depends on the
drug’s tier and what stage of
the benef
it you have reached. Later in this document we discuss the benef
it
stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.
Which pharmacies can I use?
We have a network of
pharmacies and you must generally use these pharmacies to f
ill your prescriptions
f
or covered Part D drugs.
Some of
our network pharmacies have pref
erred cost-sharing. You may pay less if
you use these
pharmacies.
You can see our plan’s pharmacy directory at our website (www.AARPMedicareRx.com). Or, call us and
we will send you a copy of
the pharmacy directory.
21
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Section 2 - Summary of Benefits
If
you have any questions about this plan’s benef
its or costs, please contact UnitedHealthcare f
or details.
AARP® MedicareRx Pref
erred (PDP)
Monthly Premium, Deductible, and Limits On How Much You Pay For Covered Services
$57.90 per month.
How much is
the monthly
premium?
This plan does not have a deductible.
How much is
the deductible?
Prescription Drug Benefits
Initial Coverage
You pay the f
ollowing until your total yearly drug costs reach $2,960. Total
yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order
pharmacies.
Pref
erred Retail Cost-Sharing
Tier
One-month supply
Three-month supply
Tier 1 (Pref
erred Generic)
$2 copay
$6 copay
Tier 2 (Non-Pref
erred
$3 copay
$9 copay
Generic)
Tier 3 (Pref
erred Brand)
$40 copay
$120 copay
Tier 4 (Non-Pref
erred
$85 copay
$255 copay
Brand)
Tier 5 (Specialty Tier)
33% of
the cost
33% of
the cost
Standard Retail Cost-Sharing
Tier
One-month supply
Three-month supply
Tier 1 (Pref
erred Generic)
$5 copay
$15 copay
Tier 2 (Non-Pref
erred
$8 copay
$24 copay
Generic)
Tier 3 (Pref
erred Brand)
$45 copay
$135 copay
Tier 4 (Non-Pref
erred
$95 copay
$285 copay
Brand)
Tier 5 (Specialty Tier)
33% of
the cost
33% of
the cost
22
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Tier
Three-month supply
MORE PLAN INFORMATION
Pref
erred Mail Order Cost-Sharing
Tier 1 (Pref
erred Generic)
$0
Tier 2 (Non-Pref
erred
$3 copay
Generic)
Tier 3 (Pref
erred Brand)
$115 copay
Tier 4 (Non-Pref
erred
$250 copay
Brand)
Tier 5 (Specialty Tier)
33% of
the cost
Standard Mail Order Cost-Sharing
Tier
Three-month supply
Tier 1 (Pref
erred Generic)
$15 copay
Tier 2 (Non-Pref
erred
$24 copay
Generic)
Tier 3 (Pref
erred Brand)
$135 copay
Tier 4 (Non-Pref
erred
$285 copay
Brand)
Tier 5 (Specialty Tier)
33% of
the cost
If
you reside in a long-term care f
acility, you pay the same as at a retail
pharmacy.
You may get drugs f
rom an out-of
-network pharmacy, but may pay more than
you pay at an in-network pharmacy.
Coverage Gap
Most Medicare drug plans have a coverage gap (also called the "donut hole").
This means that there’s a temporary change in what you will pay f
or your
drugs. The coverage gap begins af
ter the total yearly drug cost (including what
our plan has paid and what you have paid) reaches $2,960.
Af
ter you enter the coverage gap, you pay 45% of
the plan’s cost f
or covered
brand name drugs and 65% of
the plan’s cost f
or covered generic drugs until
your costs total $4,700, which is the end of
the coverage gap. Not everyone
will enter the coverage gap.
23
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Catastrophic
Coverage
Af
ter your yearly out-of
-pocket drug costs (including drugs purchased through
your retail pharmacy and through mail order) reach $4,700, you pay the
greater of
:
• 5% of
the cost, or
• $2.65 copay f
or generic (including brand drugs treated as generic) and a
$6.60 copayment f
or all other drugs.
24
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
English: We have free interpreter services to answer any questions you may have about our health
or drug plan. To get an interpreter, just call us at 1-888-867-5564. Someone who speaks
English/Language can help you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que
pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor
llame al 1-888-867-5564. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。
如果您需要此翻译服务，请致电1-888-867-5564。我们的中文工作人员很乐意帮助您。这是一项
免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服
務。如需翻譯服務，請致電 1-888-867-5564。我們講中文的人員將樂意為您提供幫助。這是一
項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang
mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha
ng tagasaling-wika, tawagan lamang kami sa 1-888-867-5564. Maaari kayong tulungan ng isang
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos
questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service
d'interprétation, il vous suffit de nous appeler au 1-888-867-5564. Un interlocuteur parlant
Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức
khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-867-5564 sẽ có
nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-867-5564.
Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제
공하고 있습니다. 통역 서비스를 이용하려면 전화 1-888-867-5564번으로 문의해 주십시오.
한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного
плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы
воспользоваться услугами переводчика, позвоните нам по телефону 1-888-867-5564. Вам
окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
1-888-867-5564
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul
nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-867-5564. Un
nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
25
MORE PLAN INFORMATION
Multi-language Interpreter Services
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Portugues: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão
que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete,
contacte-nos através do número 1-888-867-5564. Irá encontrar alguém que fale o idioma
Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan
plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-867-5564. Yon
moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z
pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-867-5564. Ta
usługa jest bezpłatna.
Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास
मुफ्त दुभाषिया सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-888-867-5564 पर फोन
करें. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために、無
料の通訳サービスがありますございます。通訳をご用命になるには、1-888-867-5564にお電話
ください。日本語を話す人 者 が支援いたします。これは無料のサービスです。
PDCA15PD3576904_001
26
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
UnitedHealthcare - S5921
The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and
performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star
Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are:
1. An Overall Star Rating that combines all of our plan’s scores.
2. Summary Star Rating that focuses on our medical or our prescription drug services.
Some of the areas Medicare reviews for the ratings include:
•
•
•
How our members rate our plan’s services and care;
How well our doctors detect illnesses and keep members healthy;
How well our plan helps our members use recommended and safe prescription medications
For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare:
2.5 stars
We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:
Health Plan Services: Not offered
Drug Plan Services:
2.5 stars
The number of stars shows how well our plan performs.
excellent
above average
average
below average
poor
Learn more about our plan and how we are different from other plans at www.medicare.gov.
You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-867-5564 (toll-free) or 711 (TTY/
TDD).
Current members please call 888-867-5575 (toll-free) or 711 (TTY/TDD).
*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the
next.
This information is available for free in other languages. Please contact our customer service number at
888-867-5575, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al
número 888-867-5575, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.
īdžĉŞĈŵǕƝ
ƃŌƺŇī。NJƤŒ 888-867-5575 ŮŠĐĐƃơĵČǘǧ, żƝƛćǙ 711, ǎ İ
7 Ĩ, ŵįŁƒĉǺ 8 ŁDzřĉ 8 Ł。
Y0066_S5921_A_PR2015 CMS Accepted
27
MORE PLAN INFORMATION
2015 Medicare Plan Ratings*
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
UnitedHealthcare - S5820
2015 Medicare Plan Ratings*
The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and
performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star
Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are:
1. An Overall Star Rating that combines all of our plan’s scores.
2. Summary Star Rating that focuses on our medical or our prescription drug services.
Some of the areas Medicare reviews for the ratings include:
•
•
•
How our members rate our plan’s services and care;
How well our doctors detect illnesses and keep members healthy;
How well our plan helps our members use recommended and safe prescription medications
For 2015, UnitedHealthcare received the following Overall Star Rating from Medicare:
4 stars
We received the following Summary Star Rating for UnitedHealthcare’s health/drug plan services:
Health Plan Services: Not offered
Drug Plan Services:
4 stars
The number of stars shows how well our plan performs.
excellent
above average
average
below average
poor
Learn more about our plan and how we are different from other plans at www.medicare.gov.
You may also contact us 8 a.m. - 8 p.m. local time, 7 days a week at 888-867-5564 (toll-free) or 711 (TTY/
TDD).
Current members please call 888-867-5575 (toll-free) or 711 (TTY/TDD).
*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the
next.
This information is available for free in other languages. Please contact our customer service number at
888-867-5575, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al
número 888-867-5575, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.
īdžĉŞĈŵǕƝ
ƃŌƺŇī。NJƤŒ 888-867-5575 ŮŠĐĐƃơĵČǘǧ, żƝƛćǙ 711, ǎ İ
7 Ĩ, ŵįŁƒĉǺ 8 ŁDzřĉ 8 Ł。
Y0066_S5820_A_PR2015 CMS Accepted
UHEX15HM3635276_001
28
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan’s contract renewal with Medicare. AARP MedicareComplete and AARP MedicareRx
Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the
use of its intellectual property. These fees are used for the general purposes of AARP. You do not need to be
an AARP member to enroll. AARP and its affiliates are not insurers. AARP encourages you to consider your
needs when selecting products and does not make specific product recommendations for individuals.
Members may enroll in the plan only during specific times of the year. Contact the plan for more information.
You must have both Medicare Parts A and B to enroll in the plan.
The benefit information provided is a brief summary, not a complete description of benefits. For more
information contact the plan. Limitations, copayments, and restrictions may apply. You must continue to pay
your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.
Formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each
year.
Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive.
Please contact the plan for further details. You may be able to get Extra Help to pay for your prescription drug
premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY
users should call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social Security Office at 1-800-772-1213
between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your Medicaid
Office.
Member may use any pharmacy in the network but may not receive preferred retail pharmacy pricing.
Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas. Co-pays apply after
deductible.
You are not required to use OptumRx to obtain a 90-day supply of your maintenance medications, but you
may pay more out-of-pocket compared to using OptumRx, your plan’s Preferred Mail Service Pharmacy.
Prescription orders sent directly to OptumRx from your doctor must have your approval before OptumRx
can send your medications. This includes new prescriptions and prescription refills. OptumRx will contact
you, by phone, to get your approval. At that time you may also tell OptumRx to automatically fill any future
prescriptions they receive directly from your doctor(s) for up to one year. If OptumRx is unable to reach you
for approval your prescription will not be sent to you. Refunds may be available for prescriptions you did not
approve and did not want. You may request a refund or cancel your approval by calling OptumRx at 1-877-8895802, (TTY 711), 24 hours, 7 days a week. New prescriptions should arrive within ten business days from the
date the completed order is received by the Mail Service Pharmacy. Completed refill orders should arrive in
about seven business days. OptumRx will contact you if there will be an extended delay in the delivery of your
medications.
OptumRx is an affiliate of UnitedHealthcare Insurance Company.
For PPO and HMO-POS members, with the exception of emergency or out-of-area renal dialysis, it may cost
more to get care from out-of-network providers. HMO members must use plan providers except in emergency
or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network
providers neither Medicare nor UnitedHealthcare® Medicare Advantage plans will be responsible for the costs.
Y0066_140728_115139 Accepted
29
PDEX15PD3574707_000
MORE PLAN INFORMATION
2015 Required
Information
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015 Required
Information (continued)
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change
from one year to the next.
This information is available for free in other languages. Please call our customer service number located on the
first page of this book.
Esta informacion esta disponible sin costo en otros idiomas. Contacte por favor nuestro número de servicio de
atención al cliente situado en la cobertura de este libro.
Y0066_140728_115139 Accepted
30
PDEX15PD3574707_000
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug
LIST
This list is the first place to check to see if your
drug is covered. If you don’t see your drug
listed, it may still be covered. Simply call the
Customer Service number listed on the first
page of this booklet and we’ll help you find out.
Y0066_140725_103934 Accepted
UHEX15MP3580915_000
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015
DRUG LIST
This is an alphabetical partial list of drugs covered by the plan.
• Brand name drugs appear in bold type
• Generic drugs in plain type
- Generic drugs are approved by the Food and Drug Administration (FDA) as having the same
ingredients as brand name drugs
- They usually don't have well-known names and cost less than brand name drugs
Each drug is in one of five tiers, which are listed in the chart below.
• Each tier has a different co-pay or co-insurance amount
• For a full description of the tiers, see the Summary of Benefits in this book
Some drugs may need Prior Authorization, Step Therapy or other requirements. To find out if your
drug has coverage rules or quantity limits on the amount you can get, please contact us. You can view a
complete drug list on our website. Our contact information is listed on the Introduction page of this
book.
The drugs listed may be available in the AARP® MedicareRx Saver Plus (PDP) or AARP® MedicareRx
Preferred (PDP) Prescription Drug Plans. The chart below shows which plans cover the drug.
This list is effective as of August 1, 2014 and may change at any time.
Drug Name
Tier
Sp Pr
Drug Name
Actemra (162mg/0.9ml Injection,
200mg/10ml Injection)
Acthar HP
Acyclovir (Capsule, Suspension, Tablet)
Acyclovir (Ointment)
Acyclovir Sodium (500mg Injection)
Adcirca
Advair Diskus
Advair HFA
Aggrenox
Albuterol Sulfate (Nebulization Solution)
Alcohol Preps (Pad)
Alendronate Sodium (Oral Solution)
Alendronate Sodium (Tablet)
A
Abilify (Injection)
Abilify (Oral Solution, Tablet)
Abilify Discmelt
Abilify Maintena (300mg Injection)
Abstral
Acamprosate Calcium DR
Acarbose
Acetaminophen/Codeine
Acetazolamide (Tablet)
Acetazolamide ER
Acetazolamide Sodium (Injection)
Acetic Acid (Otic Solution)
4
X
X
5
X
X
5
X
X
5
X
X
5
X
X
4
X
X
3
X
X
2
X
X
2
X
X
4
X
X
4
X
X
2
X
X
Tier
Sp Pr
5
X
X
5
X
X
2
X
X
4
X
4
X
X
5
X
X
3
X
3
X
4
X
X
2
X
X
3
X
X
4
X
X
2
X
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
Y0066_140709_110950 Accepted
00015003, 9, 00015002, 9
32
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Sp Pr
2
X
X
2
X
X
3
X
X
2
X
X
3
X
X
2
X
X
2
X
X
2
X
X
4
X
X
3
X
X
3
X
X
1
X
X
2
X
X
2
X
X
4
X
X
4
X
X
3
X
X
2
X
X
3
X
X
3
X
X
3
X
X
3
3
X
X
X
3
X
5
4
X
X
X
Tier
Arcapta Neohaler
Argatroban (100mg/ml Injection, 125mg/
125ml-0.9% Injection)
Asmanex
Atelvia
Atenolol (Tablet)
Atenolol/Chlorthalidone (100mg-25mg
Tablet)
Atenolol/Chlorthalidone (50mg-25mg Tablet)
Atorvastatin Calcium
Atovaquone
Atovaquone/Proguanil HCl (250mg-100mg
Tablet)
Atripla
Atrovent HFA
Aubagio
Avastin (100mg/4ml Injection)
Avonex
Azathioprine (Tablet)
Azelastine HCl (137mcg/Spray Nasal
Solution)
Azelastine HCl (Ophthalmic Solution)
Azilect
Azithromycin (500mg Injection)
Azithromycin (Suspension Reconstituted,
Tablet)
Azopt
X
3
3
Drug Name
X
Sp Pr
4
X
X
5
X
X
4
X
X
4
X
1
X
X
1
X
X
1
X
X
2
X
X
5
X
X
3
X
X
5
X
X
4
X
X
5
X
X
5
X
X
5
X
X
2
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
X
X
3
X
B
Baclofen (Tablet)
Balsalazide Disodium
Baraclude
Benazepril HCl (Tablet)
Benazepril HCl/Hydrochlorothiazide
Benicar
Benicar HCT
Benztropine Mesylate (Injection)
Benztropine Mesylate (Tablet)
X
X
2
X
X
4
X
X
5
X
X
1
X
X
1
X
X
3
X
X
3
X
X
4
X
X
2
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
33
DRUG LIST
Alfuzosin HCl ER
Allopurinol (Tablet)
Alphagan P (0.1% Ophthalmic Solution)
Alprazolam (Immediate-Release Tablet)
Amantadine HCl (Capsule, Syrup, Tablet)
Amiloride HCl
Amiloride/Hydrochlorothiazide
Amiodarone HCl (200mg Tablet)
Amiodarone HCl (50mg/ml Injection)
Amitiza
Amitriptyline HCl (Tablet)
Amlodipine Besylate (Tablet)
Amoxicillin
Amoxicillin/Potassium Clavulanate
Amoxicillin/Potassium Clavulanate ER
Amphetamine/Dextroamphetamine (Capsule
Extended Release 24 Hour)
Amphetamine/Dextroamphetamine (Tablet)
Anastrozole (Tablet)
Androderm
Androgel (50mg/5gm Gel)
Androgel Pump (1.62% Gel)
Anoro Ellipta
Antara
Apidra
Apidra SoloStar
Apriso
Aranesp Albumin Free (100mcg/0.5ml
Injection, 100mcg/ml Injection, 150mcg/
0.3ml Injection, 200mcg/0.4ml Injection,
200mcg/ml Injection, 300mcg/0.6ml
Injection, 300mcg/ml Injection, 500mcg/
ml Injection)
Aranesp Albumin Free (25mcg/0.42ml
Injection, 25mcg/ml Injection, 40mcg/
0.4ml Injection, 40mcg/ml Injection,
60mcg/0.3ml Injection, 60mcg/ml
Injection)
Tier
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Benztropine Mesylate (Tablet)
Besivance
Betaseron
Bethanechol Chloride (Tablet)
Bicalutamide
BiDil
Biltricide
Binosto
Bisoprolol Fumarate
Boostrix
Breo Ellipta
Brilinta
Brilinta
Brimonidine Tartrate (0.15%
Ophthalmic Solution)
Brimonidine Tartrate (0.2% Ophthalmic
Solution)
Budesonide (0.25mg/2ml Suspension,
0.5mg/2ml Suspension)
Budesonide (Capsule Extended Release 24
Hour)
Bumetanide (Injection)
Bumetanide (Tablet)
Bupropion HCl (Tablet)
Bupropion HCl SR
Bupropion HCl XL
Buspirone HCl (Tablet)
Butalbital/Acetaminophen
Butalbital/Acetaminophen/Caffeine
Butalbital/Acetaminophen/Caffeine/Codeine
Butalbital/Aspirin/Caffeine
Butrans
Byetta
Bystolic
Sp Pr
3
X
3
X
5
X
2
X
X
2
X
X
3
Drug Name
Carafate (Suspension)
Carbaglu
Carbamazepine (Suspension, Tablet, Tablet
Chewable)
Carbamazepine ER
Carbidopa (Tablet)
Carbidopa/Levodopa
Carbidopa/Levodopa ER
Carbidopa/Levodopa ODT
Carbidopa/Levodopa ODT
Carboplatin (150mg/15ml Injection)
Carisoprodol (350mg Tablet)
Carvedilol (Immediate-Release Tablet)
Cefdinir
Cefuroxime Axetil (Tablet)
Cefuroxime Sodium (1.5gm Injection, 7.5gm
Injection, 750mg Injection)
Celebrex
Cephalexin (Capsule, Suspension
Reconstituted)
Chantix (0.5mg Tablet, 1mg Tablet)
Chantix Starting Month Pak
Chlorhexidine Gluconate Oral Rinse
Chlorthalidone (25mg Tablet, 50mg Tablet)
Cilostazol
Cimzia
Cinryze
Ciprofloxacin (400mg/40ml Injection)
Ciprofloxacin ER
Ciprofloxacin HCl (Ophthalmic Solution,
Tablet)
Ciprofloxacin I.V. in D5W (200mg/100ml-5%
Injection)
Citalopram Hydrobromide (Oral Solution)
Citalopram Hydrobromide (Tablet)
Clindamycin HCl (Capsule)
Clindamycin Palmitate HCl
Clindamycin Phosphate (150mg/ml
Injection)
X
3
X
X
4
X
X
3
X
3
X
X
3
X
X
3
X
4
X
3
X
X
3
X
X
4
X
X
5
X
X
4
X
X
2
X
X
2
X
X
2
X
X
2
X
X
2
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
3
X
X
3
X
X
C
Cabergoline
Calcitriol (Capsule, Oral Solution)
Calcitriol (Injection)
Captopril (Tablet)
Captopril/Hydrochlorothiazide
3
X
X
2
X
X
4
X
X
2
X
X
2
X
X
34
Tier
Sp Pr
4
X
X
5
X
X
3
X
X
3
X
X
4
X
2
X
X
2
X
X
2
X
3
X
4
X
X
3
X
X
1
X
X
3
X
X
2
X
X
4
X
X
4
X
2
X
X
4
X
X
4
X
X
2
X
X
2
X
X
2
X
X
5
X
X
5
X
X
4
X
X
3
X
X
2
X
X
4
X
X
3
X
X
1
X
X
2
X
X
2
X
X
4
X
X
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
3
X
X
4
X
X
3
X
X
4
X
X
3
X
X
2
X
X
4
X
X
3
X
X
2
X
X
4
X
X
2
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
5
X
X
4
Drug Name
Desmopressin Acetate (Nasal Solution,
Tablet)
Dexilant
Dextroamphetamine Sulfate (Tablet)
Dextroamphetamine Sulfate ER
Dextrose 10% Flex Container
Dextrose 10%/NaCl 0.2%
Dextrose 10%/NaCl 0.45%
Dextrose 2.5%/NaCl 0.45%
Dextrose 5%
Dextrose 5%/NaCl 0.2%
Dextrose 5%/NaCl 0.225%
Dextrose 5%/NaCl 0.33%
Dextrose 5%/NaCl 0.45%
Dextrose 5%/NaCl 0.9%
Dextrose 5%/Potassium Chloride 0.15%
Diazepam (Gel)
Diazepam (Oral Solution)
Diazepam (Tablet)
Diazepam Intensol (Oral Solution)
Diclofenac Potassium
Diclofenac Sodium (Gel)
Diclofenac Sodium (Ophthalmic Solution)
Diclofenac Sodium DR
Diclofenac Sodium ER
Dicyclomine HCl (Oral Dosage Forms)
Digoxin (125mcg Tablet)
Digoxin (250mcg Tablet)
Digoxin (Injection)
Digoxin (Oral Solution)
Dihydroergotamine Mesylate (Injection)
Dilantin (Capsule)
Dilantin (Suspension)
Dilantin Infatabs
Diltiazem CD (120mg Capsule Extended
Release 24 Hour, 240mg Capsule Extended
Release 24 Hour)
X
3
X
X
3
X
X
3
X
X
3
X
X
5
X
X
3
X
X
2
X
X
4
X
X
3
X
X
D
Daliresp
Danazol (Capsule)
Dapsone (Tablet)
Desmopressin Acetate (Injection)
4
X
X
4
X
X
3
X
X
4
X
X
Tier
Sp Pr
3
X
X
4
X
X
4
X
X
4
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
2
X
X
2
X
X
2
X
X
2
X
X
5
X
X
2
X
X
2
X
X
2
X
X
2
X
X
2
X
X
2
X
X
4
X
X
4
X
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
35
X
DRUG LIST
Clindamycin Phosphate (Cream, External
Solution, Gel, Lotion, Swab)
Clindamycin Phosphate in D5W
Clobetasol Propionate (External Solution, Gel,
Lotion, Ointment, Shampoo)
Clobetasol Propionate (Foam)
Clobetasol Propionate E
Clonazepam (Tablet)
Clonazepam ODT
Clonidine HCl (Patch Weekly)
Clonidine HCl (Tablet)
Clopidogrel (300mg Tablet)
Clopidogrel (75mg Tablet)
Clotrimazole/Betamethasone Dipropionate
Clozapine
Codeine Sulfate (Tablet)
Colcrys
Combigan
Combivent Respimat
Copaxone
Coumadin (Injection)
Coumadin (Tablet)
Creon
Crestor
Crixivan
Cromolyn Sodium (Concentrate)
Cromolyn Sodium (Nebulization Solution)
Cromolyn Sodium (Ophthalmic Solution)
Cyclobenzaprine HCl (10mg Tablet, 5mg
Tablet)
Cyclophosphamide (Tablet)
Sp Pr
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Diltiazem HCl (100mg Injection, 50mg/10ml
Injection)
Diltiazem HCl (Tablet)
Diltiazem HCl ER (300mg Capsule Extended
Release 24 Hour)
Diltiazem HCl ER (Capsule Extended Release
12 Hour, 180mg Capsule Extended Release
24 Hour, 300mg Capsule Extended Release
24 Hour, 360mg Capsule Extended Release
24 Hour, 420mg Capsule Extended Release
24 Hour)
Diphenoxylate/Atropine
Divalproex Sodium
Divalproex Sodium DR
Divalproex Sodium ER
Donepezil HCl (10mg Tablet, 5mg Tablet,
Tablet Dispersible)
Donepezil HCl (23mg Tablet)
Dorzolamide HCl
Dorzolamide HCl/Timolol Maleate
Doxazosin Mesylate
Doxycycline (Capsule)
Doxycycline (Suspension Reconstituted)
Doxycycline Hyclate (Capsule)
Doxycycline Hyclate (Tablet)
Doxycycline Hyclate DR
Doxycycline Monohydrate (150mg Tablet,
50mg Tablet, 75mg Tablet)
Dronabinol (10mg Capsule)
Dronabinol (2.5mg Capsule, 5mg Capsule)
Dulera
Duloxetine HCl (Capsule Delayed Release
Particles)
Durezol
Dymista
Sp Pr
4
X
X
2
X
X
3
X
3
Drug Name
Elmiron
Enalapril Maleate (Tablet)
Enalapril Maleate (Tablet)
Enalapril Maleate/Hydrochlorothiazide
Enalapril Maleate/Hydrochlorothiazide
Enbrel
Entacapone
EpiPen
Eplerenone
Epzicom
Erythromycin (External Solution, Gel,
Ointment)
Erythromycin Base
Erythromycin Ethylsuccinate (Tablet)
Escitalopram Oxalate
Estrace (Cream)
Estradiol (Generic Estrace)
Estradiol (Patch Weekly)
Estradiol Tablet (Generic Estrace)
Estradiol Valerate (Injection)
Ethambutol HCl (Tablet)
Ethosuximide (Capsule, Oral Solution)
Etoposide (500mg/25ml Injection)
Evista
Exalgo
Exelon (Patch 24 Hour)
Exjade
Extavia
X
4
X
X
2
X
X
2
X
X
2
X
X
2
X
X
4
X
2
X
X
2
X
X
2
X
X
4
X
X
3
X
X
3
X
X
4
X
X
4
X
X
4
X
X
5
X
X
4
X
X
4
X
X
3
X
X
3
X
X
3
F
Famotidine (20mg Tablet, 40mg Tablet)
Famotidine (20mg Tablet, 40mg Tablet)
Famotidine (20mg/2ml Injection)
Famotidine Premixed
Faslodex
Fenofibrate (130mg Capsule, 43mg Capsule,
Tablet)
Fenofibrate Micronized
Fenofibric Acid DR (Generic Trilipix)
Fentanyl (Patch)
Fentanyl Citrate Oral Transmucosal
X
E
Edarbi
Edarbyclor
Effient
Effient
Eliquis
4
X
X
4
X
X
3
X
4
X
3
X
X
36
Tier
Sp Pr
4
X
2
X
3
2
X
X
X
3
X
5
X
X
4
X
X
3
X
X
3
X
X
5
X
X
2
X
X
2
X
X
2
X
X
2
X
X
4
2
X
X
2
X
3
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
5
X
X
5
X
X
2
X
3
X
4
X
4
X
5
X
X
2
X
X
2
X
X
3
X
3
X
X
5
X
X
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Sp Pr
3
X
X
2
X
X
5
X
X
3
X
3
X
2
X
X
X
2
X
X
3
X
X
3
X
X
4
X
X
4
X
X
X
X
2
X
X
4
X
X
3
X
X
4
X
X
2
X
X
3
X
X
2
X
X
3
X
X
3
X
X
5
Gabapentin (Capsule, Tablet)
Gabapentin (Oral Solution)
Gammagard Liquid
Gauze Pads
GaviLyte-C
GaviLyte-G
GaviLyte-N/Flavor Pack
Gelnique (10% Gel)
Gelnique (3% Gel)
Gemfibrozil (Tablet)
Gentamicin Sulfate (Cream, Ointment,
Ophthalmic Solution)
Gentamicin Sulfate (Injection)
Gentamicin Sulfate/NaCl (0.9mg/ml-0.9%
Injection, 1.4mg/ml-0.9% Injection, 1.6mg/
ml-0.9% Injection, 1mg/ml-0.9% Injection)
Gilenya
Gleevec
Glimepiride
Glipizide (Immediate-Release Tablet)
Glipizide ER
Glipizide/Metformin HCl
Glipizide/Metformin HCl
Glucagen HypoKit
Glucagon Emergency Kit
Glyburide
Glyburide Micronized
Glyburide/Metformin HCl
Guanidine HCl
X
4
X
X
4
X
X
4
X
X
2
X
X
5
X
X
Tier
Sp Pr
G
X
4
4
Drug Name
H
Haloperidol (Concentrate, Tablet)
Haloperidol Decanoate (Injection)
Haloperidol Lactate (Injection)
Humalog (Vial)
Humalog KwikPen (25unit/ml-75unit/ml
Injection, 50unit/ml-50unit/ml Injection)
2
X
X
3
X
X
5
X
X
3
X
X
2
X
X
2
X
X
2
X
X
3
X
3
X
2
X
X
2
X
X
4
X
X
4
X
X
5
X
X
5
X
X
1
X
X
1
X
X
2
X
X
2
3
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
X
X
4
X
X
4
X
X
3
X
3
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
37
X
DRUG LIST
Finacea
Finasteride (5mg Tablet)
Firazyr
Flovent Diskus
Flovent HFA
Fluconazole (Suspension Reconstituted,
Tablet)
Fluconazole in Dextrose (56mg/ml-400mg/
200ml Injection)
Fludrocortisone Acetate (Tablet)
Flunisolide
Fluocinolone Acetonide (Cream, Ointment)
Fluocinolone Acetonide (External Solution)
Fluocinolone Acetonide (Oil)
Fluocinolone Acetonide Body Oil
Fluoxetine DR (90mg Capsule)
Fluoxetine HCl (Capsule, Oral Solution, 10mg
Tablet, 20mg Tablet)
Fluphenazine Decanoate (Injection)
Fluphenazine HCl (Concentrate, Elixir)
Fluphenazine HCl (Injection)
Fluphenazine HCl (Tablet)
Fluticasone Propionate (Cream, Lotion,
Ointment)
Fluticasone Propionate (Suspension)
Foradil Aerolizer
Forfivo XL
Fragmin (10000unit/ml Injection,
12500unit/0.5ml Injection, 15000unit/
0.6ml Injection, 18000unt/0.72ml
Injection, 25000unit/ml Injection,
7500unit/0.3ml Injection)
Fragmin (2500unit/0.2ml Injection,
5000unit/0.2ml Injection)
Furosemide (Injection)
Furosemide (Oral Solution, Tablet)
Fuzeon
Tier
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Humira
Humira Starter Kit
Humulin (Vial)
Humulin Pen
Hydralazine HCl (Injection)
Hydralazine HCl (Tablet)
Hydrochlorothiazide (Capsule, Tablet)
Hydrocodone/Acetaminophen (Oral Solution,
300mg-10mg Tablet, 300mg-5mg Tablet,
300mg-7.5mg Tablet, 325mg-10mg Tablet,
325mg-5mg Tablet, 325mg-7.5mg Tablet)
Hydroxychloroquine Sulfate (Tablet)
Hydroxyurea (Capsule)
Hydroxyzine HCl (Injection)
Hydroxyzine HCl (Oral Solution)
Hydroxyzine HCl (Oral Solution, Tablet)
Hydroxyzine HCl (Tablet)
Hydroxyzine Pamoate (Capsule)
Hydroxyzine Pamoate (Capsule)
Sp Pr
5
X
X
5
X
X
3
X
3
X
4
X
X
2
X
X
2
X
X
3
X
X
X
2
X
X
4
X
X
2
2
Jantoven
Jentadueto
Jinteli
X
X
X
4
X
3
X
2
X
X
3
X
X
4
X
X
3
X
X
5
X
X
4
X
X
4
X
X
2
X
X
2
X
X
2
X
X
2
X
X
2
X
X
5
X
X
2
X
X
2
X
X
X
2
X
X
4
X
X
2
X
X
3
X
X
X
4
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
2
X
X
5
X
X
3
X
X
3
X
X
3
X
X
3
X
X
2
X
X
3
X
5
X
X
5
X
X
4
X
X
2
X
X
4
X
X
2
X
X
3
X
X
3
X
X
3
X
X
2
X
X
4
X
X
3
X
X
3
X
X
L
Labetalol HCl (Injection)
Labetalol HCl (Tablet)
Lactated Ringers Dextrose 5% Viaflex
Lactulose
Lamivudine (100mg Tablet)
Lamivudine (150mg Tablet, 300mg Tablet)
Lamotrigine (Tablet Chewable)
Lamotrigine (Tablet)
Lansoprazole (Capsule Delayed Release)
Lantus
Lantus SoloStar
X
3
X
3
Kazano
KCl 0.075%/D5W/NaCl 0.45%
KCl 0.15%/D5W/LR
KCl 0.15%/D5W/NaCl 0.2%
KCl 0.15%/D5W/NaCl 0.225%
KCl 0.15%/D5W/NaCl 0.9%
KCl 0.3%/D5W/NaCl 0.45%
KCl 0.3%/D5W/NaCl 0.9%
Ketoconazole (Cream, Shampoo, Tablet)
Kineret
Kionex (Powder)
Klor-Con 10
Klor-Con 8
Klor-Con M15
Klor-Con M20
Kombiglyze XR
Korlym
Kuvan (Tablet Soluble)
I
Ibandronate Sodium (Injection)
Ibandronate Sodium (Tablet)
Ibuprofen (Suspension, 400mg Tablet,
600mg Tablet, 800mg Tablet)
Ilevro
Imiquimod (Cream)
Insulin Syringes, Needles
Intelence (100mg Tablet, 200mg Tablet)
Intelence (25mg Tablet)
Invanz
Ipratropium Bromide (Inhalation Solution)
Ipratropium Bromide (Nasal Solution)
Ipratropium Bromide/Albuterol Sulfate
Irbesartan
Irbesartan/Hydrochlorothiazide
Isentress (25mg Tablet Chewable)
Isentress (Tablet, 100mg Tablet
Chewable)
Isosorbide Dinitrate
Isosorbide Dinitrate ER
2
K
X
3
Sp Pr
J
X
3
Tier
Isosorbide Mononitrate
Isosorbide Mononitrate ER
Isotonic Gentamicin (0.8mg/ml-0.9%
Injection, 1.2mg/ml-0.9% Injection)
X
2
4
Drug Name
38
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Sp Pr
3
X
X
2
X
X
4
X
X
2
X
X
5
X
X
2
X
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
Drug Name
Lindane
Linzess
Liothyronine Sodium (Injection)
Liothyronine Sodium (Tablet)
Lisinopril (Tablet)
Lisinopril/Hydrochlorothiazide
Lithium Carbonate (Capsule, Tablet)
Lithium Carbonate ER
Lithium Citrate
Lo Loestrin Fe
Lo Minastrin Fe
Lorazepam (Tablet)
Lorazepam Intensol (Oral Solution)
Losartan Potassium
Losartan Potassium/Hydrochlorothiazide
Lovastatin
Lumigan (0.01% Ophthalmic Solution)
Lupron Depot
Lupron Depot-PED (11.25mg Injection,
15mg Injection)
Lyrica
Lysodren
X
3
X
3
X
X
4
X
X
3
X
X
4
X
X
4
X
X
3
X
X
4
X
X
5
X
X
2
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
Tier
Sp Pr
4
X
X
3
X
X
4
X
X
2
X
X
1
X
X
1
X
X
2
X
X
2
X
X
3
X
X
4
X
4
X
X
2
X
X
2
X
X
1
X
X
1
X
X
2
X
X
3
X
X
5
X
X
5
X
X
3
X
X
5
X
X
2
X
X
4
X
X
2
X
X
5
X
X
4
X
X
1
X
X
3
X
X
4
X
X
4
X
X
4
X
X
1
X
X
2
X
X
M
Meclizine HCl (Tablet)
Medroxyprogesterone Acetate (Injection)
Medroxyprogesterone Acetate (Tablet)
Megace ES
Meloxicam (Suspension)
Meloxicam (Tablet)
Mercaptopurine (Tablet)
Meropenem (500mg Injection)
Mestinon (Syrup)
Mestinon Timespan
Metformin HCl (Tablet)
Metformin HCl ER 500mg, 750mg Tablet
Extended Release 24 Hour (Generic
Glucophage XR)
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
39
DRUG LIST
Lastacaft
Latanoprost
Latuda
Leflunomide (Tablet)
Letairis
Letrozole (Tablet)
Leucovorin Calcium (100mg Injection,
350mg Injection)
Leucovorin Calcium (Tablet)
Leukeran
Levemir
Levemir FlexPen
Levetiracetam (500mg/5ml Injection)
Levetiracetam (Oral Solution, Tablet)
Levetiracetam (Oral Solution, Tablet)
Levetiracetam ER
Levocarnitine (Injection)
Levocarnitine (Oral Solution, Tablet)
Levocetirizine Dihydrochloride (Tablet)
Levofloxacin (Injection)
Levofloxacin (Ophthalmic Solution, Oral
Solution, Tablet)
Levofloxacin in D5W (5%-500mg/100ml
Injection)
Levothyroxine Sodium (100mcg
Injection)
Levothyroxine Sodium (Tablet)
Levoxyl
Lialda
Lidocaine (Ointment)
Lidocaine (Patch)
Lidocaine 2% Viscous Solution
Lidocaine HCl (0.5% Injection, 1% Injection)
Lidocaine HCl (External Solution)
Lidocaine HCl (Gel)
Lidocaine/Prilocaine (Cream)
Lidoderm
Tier
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Methadone HCl (Injection)
Methadone HCl (Oral Solution, Tablet)
Methimazole (Tablet)
Methocarbamol (Tablet)
Methotrexate (Tablet)
Methotrexate Sodium (1gm Injection, 1gm/
40ml Injection)
Methscopolamine Bromide (Tablet)
Methylphenidate HCl (Oral Solution, Tablet)
Methylphenidate HCl ER (10mg Tablet
Extended Release, 20mg Tablet Extended
Release)
Methylprednisolone (Tablet)
Methylprednisolone Acetate (Injection)
Methylprednisolone Dose Pack
Methylprednisolone Sodium Succinate
(125mg Injection, 40mg Injection)
Metoclopramide HCl (Injection)
Metoclopramide HCl (Oral Solution, Tablet)
Metolazone
Metoprolol Succinate ER
Metoprolol Tartrate (Injection)
Metoprolol Tartrate (Tablet)
Metronidazole (Capsule, Cream, Gel, Lotion,
Tablet)
Metronidazole in NaCl 0.79%
Metronidazole Vaginal
Midodrine HCl
Migergot
Minocycline HCl (Capsule)
Minocycline HCl (Tablet)
Minocycline HCl ER
Minoxidil (Tablet)
Mirtazapine
Mirtazapine ODT (30mg Tablet Dispersible,
45mg Tablet Dispersible)
Misoprostol (Tablet)
Modafinil
Montelukast Sodium (Packet, Tablet, Tablet
Chewable)
Tier
Sp Pr
4
X
X
3
X
X
2
X
X
3
X
X
2
X
X
4
X
X
4
X
X
3
X
X
3
X
X
2
X
X
4
X
X
2
X
X
4
X
X
4
X
X
2
X
X
3
X
X
3
X
X
4
X
X
1
X
X
3
X
X
4
X
X
3
X
X
3
X
X
3
X
X
2
X
X
4
X
4
X
2
X
X
2
X
X
2
X
X
2
X
X
4
X
X
2
X
X
Drug Name
Morphine Sulfate (10mg/5ml Oral Solution,
20mg/5ml Oral Solution)
Morphine Sulfate (20mg/ml Oral
Solution, Tablet)
Morphine Sulfate (2mg/ml Injection,
4mg/ml Injection)
Morphine Sulfate ER (Generic Avinza,
Generic MS Contin)
Morphine Sulfate ER (Generic MS Contin)
Morphine Sulfate ER 100mg Capsule
Extended Release 24 Hour (Generic Kadian)
Morphine Sulfate ER 10mg Capsule Extended
Release 24 Hour, 20mg Capsule Extended
Release 24 Hour, 30mg Capsule Extended
Release 24 Hour, 50mg Capsule Extended
Release 24 Hour, 60mg Capsule Extended
Release 24 Hour, 80mg Capsule Extended
Release 24 Hour (Generic Kadian)
Multaq
Mupirocin (Cream, Ointment)
Mupirocin (Ointment)
Mycobutin
Myrbetriq
N
Naloxone HCl (1mg/ml Injection)
Naltrexone HCl (Tablet)
Namenda (Oral Solution)
Namenda XR
Namenda XR Titration Pack
Naproxen (Suspension, Tablet)
Naproxen DR
Naproxen Sodium (275mg Tablet, 550mg
Tablet)
Nateglinide
Nesina
Nevanac
Nexium
Niacin ER (Tablet Extended Release)
Nicotrol Inhaler
Nifedical XL
Nifedipine ER
40
Tier
Sp Pr
3
X
X
3
X
X
4
X
X
3
X
3
X
5
X
X
4
X
X
3
X
X
2
X
2
X
4
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
2
X
X
2
X
X
2
X
X
3
X
X
4
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
X
2
X
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Nitrofurantoin (Suspension)
Nitrofurantoin Macrocrystals (50mg Capsule)
Nitrofurantoin Monohydrate
Nitrostat
Nizatidine
Nortriptyline HCl (Capsule, Oral Solution)
Norvir
Novolin (Vial)
Novolog (Vial)
Novolog FlexPen (30unit/ml-70unit/ml
Injection)
Novolog PenFill
Nucynta ER
Nuedexta
Nystatin (Cream, Ointment, 100000unit/gm
Powder, Suspension, Tablet)
Nystatin/Triamcinolone
Sp Pr
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
X
X
4
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
2
X
X
3
X
X
3
X
X
4
X
X
2
X
X
4
X
X
2
X
Orencia
Oseni
Oxybutynin Chloride
Oxybutynin Chloride ER
Oxycodone HCl (Capsule, Concentrate,
Tablet)
Oxycodone HCl (Oral Solution)
Oxycodone/Acetaminophen
Oxycodone/Aspirin
Oxycodone/Ibuprofen
Oxycontin
Oxytrol
3
2
Pacerone (200mg Tablet)
Pantoprazole Sodium (Injection)
Pantoprazole Sodium (Tablet Delayed
Release)
Pantoprazole Sodium (Tablet Delayed
Release)
Paroxetine HCl
Paroxetine HCl ER
Pataday
Patanase
Patanol
Pegasys
Pegasys ProClick (135mcg/0.5ml
Injection)
Penicillin G Potassium (5mu Injection)
Penicillin G Potassium in Iso-Osmotic
Dextrose (40000unit/ml Injection,
60000unit/ml Injection)
Penicillin G Procaine
Penicillin G Sodium
Penicillin V Potassium
Pentasa
Perforomist
Perindopril Erbumine
X
X
3
X
4
X
X
4
X
X
2
X
X
2
X
X
3
X
3
X
5
X
Sp Pr
5
X
4
X
X
2
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
X
3
X
3
X
P
O
Ofloxacin
Olanzapine (Injection)
Olanzapine (Tablet)
Olanzapine ODT
Omeprazole (10mg Capsule Delayed Release,
20mg Capsule Delayed Release)
Omeprazole (10mg Capsule Delayed Release,
20mg Capsule Delayed Release)
Omeprazole (40mg Capsule Delayed
Release)
Omeprazole (40mg Capsule Delayed
Release)
Ondansetron HCl (4mg/2ml Injection)
Ondansetron HCl (Oral Solution)
Ondansetron HCl (Tablet)
Ondansetron ODT
Onglyza
Opana ER (Crush Resistant)
Opsumit
Tier
X
2
4
2
41
X
X
X
3
X
2
X
X
4
X
X
3
X
X
3
X
3
X
X
5
X
X
5
X
X
4
X
X
4
X
X
4
X
X
4
X
X
2
X
X
4
X
4
X
X
2
X
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
X
DRUG LIST
3
Drug Name
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Permethrin (Cream)
Phenelzine Sulfate (Tablet)
Phenytoin (Suspension)
Phenytoin (Tablet Chewable)
Phenytoin Sodium (Injection)
Phenytoin Sodium Extended (Capsule)
Phoslyra
Pilocarpine HCl (Tablet)
Pioglitazone HCl
Pioglitazone HCl/Glimepiride
Pioglitazone HCl/Metformin HCl
Polyethylene Glycol 3350 (Powder)
Pomalyst
Potassium Chloride (10meq/100ml Injection,
2meq/ml Injection, 40meq/100ml Injection)
Potassium Chloride (20meq/100ml
Injection)
Potassium Chloride 0.15% D5W/NaCl
0.45%
Potassium Chloride 0.15%/D5W/NaCl
0.33%
Potassium Chloride 0.15%/NaCl 0.45%
Viaflex
Potassium Chloride 0.15%/NaCl 0.9%
Potassium Chloride 0.22%/D5W/NaCl
0.45%
Potassium Chloride 0.3%/D5W
Potassium Chloride 0.3%/NaCl 0.9%
Potassium Chloride ER (10meq Tablet
Extended Release, 20meq Tablet Extended
Release)
Potassium Chloride ER (Capsule Extended
Release)
Potassium Citrate (1080mg Tablet Extended
Release)
Potassium Citrate (540mg Tablet
Extended Release)
Potiga
Pradaxa
Pramipexole Dihydrochloride (ImmediateRelease Tablet)
Tier
Sp Pr
3
X
X
3
X
X
2
X
X
3
X
X
4
X
X
2
X
X
3
X
X
3
X
X
3
X
X
4
X
4
X
2
X
X
5
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
4
X
X
2
X
X
3
X
X
3
X
X
3
X
X
5
X
X
3
X
X
3
X
X
Drug Name
Tier
Pravastatin Sodium
Prazosin HCl
Prednisone (Oral Solution, Tablet)
Prednisone Intensol (Oral Solution)
Premarin (Tablet)
Premarin (Vaginal Cream)
Premphase
Prempro
Prenatabs OBN
Primidone (Tablet)
Pristiq
Proair HFA
Prochlorperazine (25mg Suppository)
Prochlorperazine Edisylate (Injection)
Prochlorperazine Maleate (Tablet)
Procrit (10000unit/ml Injection,
2000unit/ml Injection, 3000unit/ml
Injection, 4000unit/ml Injection)
Procrit (20000unit/ml Injection,
40000unit/ml Injection)
Procto-Pak
Proglycem
Prolensa
Promethazine HCl (Injection, Suppository,
Syrup, Tablet)
Promethazine VC Plain
Propranolol HCl (Injection)
Propranolol HCl (Oral Solution, Tablet)
Propranolol HCl ER
Propylthiouracil (Tablet)
Pulmicort (1mg/2ml Suspension)
Pulmicort Flexhaler
Sp Pr
1
X
X
2
X
X
2
X
X
2
X
X
4
X
X
3
X
X
4
X
X
4
X
X
2
X
X
2
X
X
4
X
X
3
X
X
3
X
X
4
X
X
2
X
X
4
X
X
5
X
X
2
X
X
5
X
X
4
X
X
4
X
X
4
X
X
4
X
X
2
X
X
2
X
X
2
X
X
5
X
X
3
X
X
2
X
X
Q
Quetiapine Fumarate
Quinapril HCl
Quinapril/Hydrochlorothiazide
QVAR
42
4
X
4
X
3
X
X
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Sp Pr
Drug Name
Raloxifene Hydrochloride
Ramipril
Ranexa
Ranitidine HCl (150mg Tablet, 300mg
Tablet)
Ranitidine HCl (150mg Tablet, 300mg
Tablet)
Ranitidine HCl (Capsule, 150mg/6ml
Injection)
Rapaflo
Rebif
Rebif Titration Pack
Renvela
Repaglinide
Restasis
Revlimid
Ribavirin (Capsule, Tablet)
Rifampin (Capsule)
Rifampin (Injection)
Riluzole
Rimantadine HCl
Risperidone (Oral Solution)
Risperidone (Tablet)
Risperidone ODT
Rituxan
Rizatriptan Benzoate
Rizatriptan Benzoate ODT
Ropinirole HCl (Immediate-Release)
Rozerem
3
X
3
X
X
3
X
2
X
3
X
X
4
X
3
X
X
5
X
5
X
5
X
X
4
X
X
3
X
X
5
X
X
3
X
X
3
X
X
4
X
X
3
X
X
3
X
X
4
X
X
2
X
X
4
X
X
5
X
X
3
X
X
3
X
X
2
X
X
4
X
S
Sancuso
Santyl
Saphris (10mg Tablet Sublingual)
Saphris (5mg Tablet Sublingual)
Savella
5
X
X
4
X
X
5
X
X
4
X
X
3
X
Sp Pr
3
3
X
X
5
X
X
3
X
X
5
X
X
3
43
X
4
X
3
X
X
4
X
X
1
X
X
3
X
X
3
X
X
5
X
X
5
X
X
1
X
X
2
X
X
2
X
X
2
X
X
3
X
X
2
X
X
5
X
X
5
X
X
4
X
X
5
X
X
3
X
X
4
X
X
2
X
X
4
X
X
2
X
X
2
X
X
2
X
X
2
X
X
4
X
X
3
X
X
Plain type = Generic drug
Pr = AARP MedicareRx Preferred
Bold type = Brand name drug
Sp = AARP MedicareRx Saver Plus
X
DRUG LIST
Savella Titration Pack
Selegiline HCl (Capsule, Tablet)
Selzentry
Sensipar (30mg Tablet)
Sensipar (60mg Tablet, 90mg Tablet)
Serevent Diskus
Serevent Diskus
Seroquel XR
Sertraline HCl (Concentrate)
Sertraline HCl (Tablet)
Silver Sulfadiazine (Cream)
Simbrinza
Simponi (50mg/0.5ml Injection)
Simponi Aria
Simvastatin (Tablet)
Sodium Fluoride (1mg Tablet)
Sotalol HCl (160mg Tablet, 240mg Tablet,
80mg Tablet)
Sotalol HCl (AF) (120mg Tablet)
Spiriva Handihaler
Spironolactone (Tablet)
Sprycel
Stelara
Strattera
Stribild
Stromectol
Suboxone
Sucralfate (Tablet)
Sulfamethoxazole/Trimethoprim (Injection)
Sulfamethoxazole/Trimethoprim
(Suspension, Tablet)
Sulfamethoxazole/Trimethoprim DS
Sulfasalazine (Tablet)
Sulfazine EC
Sumatriptan Succinate (6mg/0.5ml
Injection)
Sumatriptan Succinate (Tablet)
R
Tier
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Suprax (100mg/5ml Suspension
Reconstituted, 200mg/5ml Suspension
Reconstituted, Tablet, Tablet Chewable)
Suprax (Capsule, 500mg/5ml
Suspension Reconstituted)
Suprep Bowel Prep
Symbicort
SymlinPen 120
SymlinPen 60
Synthroid
3
Sp Pr
X
Drug Name
Topiramate (Capsule Sprinkle, Tablet)
Topotecan HCl (4mg Injection)
Torsemide (20mg/2ml Injection)
Torsemide (Tablet)
Toviaz
Tracleer
Tradjenta
Tramadol HCl (Immediate-Release Tablet)
Tramadol HCl ER 100mg, 200mg Tablet
Extended Release 24 Hour (Generic Ultram
ER)
Tramadol HCl ER 300mg Tablet Extended
Release 24 Hour (Generic Ryzolt)
Tramadol HCl/Acetaminophen
Trandolapril
Tranexamic Acid (Injection, Tablet)
Tranylcypromine Sulfate
Travatan Z
Trazodone HCl (Tablet)
Tretinoin (Capsule)
Tretinoin (Cream, Gel)
Triamcinolone Acetonide (Cream, Lotion,
Ointment)
Triamcinolone Acetonide (Inhaler)
Triamcinolone in Orabase
Triamterene/Hydrochlorothiazide
Tribenzor
Trihexyphenidyl HCl
Trihexyphenidyl HCl
TriLyte
Truvada
X
3
X
X
4
X
X
3
X
X
5
X
X
4
X
X
3
X
X
3
X
X
2
X
X
2
X
X
5
X
X
5
X
X
5
X
X
5
X
X
5
X
X
4
X
X
T
Tamiflu
Tamoxifen Citrate (Tablet)
Tamsulosin HCl
Tarceva
Targretin
Tasigna
Tecfidera
Tecfidera Starter Pack
Telmisartan
Telmisartan/Amlodipine
Temazepam
Terazosin HCl
Testosterone Cypionate (Injection)
Testosterone Enanthate (Injection)
Theophylline (Oral Solution)
Theophylline CR (100mg Tablet Extended
Release 12 Hour, 200mg Tablet Extended
Release 12 Hour)
Theophylline ER (300mg Tablet Extended
Release 12 Hour, 450mg Tablet Extended
Release 12 Hour, Tablet Extended Release 24
Hour)
Thymoglobulin
Timolol Maleate (Gel Forming Solution)
Timolol Maleate (Ophthalmic Solution)
Timolol Maleate (Tablet)
Tizanidine HCl (Tablet)
Tobradex (Ointment)
Tobradex ST (0.05%-0.3% Suspension)
4
X
4
X
X
2
X
X
4
X
X
4
X
X
2
X
X
2
2
X
X
Tier
X
X
Sp Pr
2
X
X
5
X
X
4
X
X
2
X
X
3
X
X
5
X
X
3
X
X
2
X
X
4
X
4
X
2
X
2
X
X
3
X
X
4
X
X
3
X
X
2
X
X
5
X
X
4
X
X
3
X
X
4
X
X
3
X
X
2
X
X
3
2
X
X
4
X
2
X
X
5
X
X
3
X
X
3
X
X
4
X
X
3
X
X
5
X
X
U
5
X
X
3
X
X
2
X
X
3
X
X
2
X
X
3
X
X
4
X
X
Uloric
Ursodiol (Capsule)
Ursodiol (Tablet)
V
Valacyclovir HCl (Tablet)
Valcyte
Valsartan/Hydrochlorothiazide
Vascepa
44
3
4
X
X
X
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Drug Name
Tier
Velphoro
Venlafaxine HCl
Venlafaxine HCl ER (Capsule Extended
Release 24 Hour)
Verapamil HCl (Injection)
Verapamil HCl (Tablet)
Verapamil HCl ER (Capsule Extended Release
24 Hour)
Verapamil HCl ER (Tablet Extended Release)
Verapamil HCl SR (360mg Capsule
Extended Release 24 Hour)
Vesicare
Victoza
Vigamox
Virazole
Voltaren
Vytorin
Vyvanse
Sp Pr
4
X
X
3
X
X
2
X
X
4
X
X
2
X
X
3
2
Drug Name
3
Xarelto
Xeljanz
Xolair
Xyrem
X
3
X
X
3
X
5
X
X
3
X
X
4
X
X
4
X
W
Warfarin Sodium
Welchol
2
X
X
3
X
X
X
X
5
X
X
5
X
X
3
X
X
3
X
X
3
X
X
3
X
X
4
X
X
4
X
X
2
X
3
X
2
X
X
4
X
X
3
X
X
3
X
X
5
X
X
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare.
UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property.
These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You do
not need to be an AARP member to enroll. AARP encourages you to consider your needs when
selecting products and does not make specific product recommendations for individuals.
UHEX15PD3580676_001
45
DRUG LIST
Zafirlukast
Zenpep
Zetia
Zetonna
Zirgan
Zolpidem Tartrate (Immediate-Release
Tablet)
Zolpidem Tartrate (Immediate-Release
Tablet)
Zonisamide
Zostavax
Zyclara
Zyclara Pump (2.5% Cream)
Zytiga
X
X
3
Z
X
3
Sp Pr
X
X
X
Tier
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
NOTES
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Welcome
ABOARD
We’re excited to welcome you to our plan.
And we want to make it easy for you to join.
Important information about your enrollment
is in this section.
Y0066_140725_103934 Accepted
UHEX15MP3580917_000
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Enrollment
INSTRUCTIONS
Our goal is to make your health care experience as easy as possible right from the start. Below we’ve described
the forms you need to fill out to enroll in your plan.
Enrollment
request form
We need certain information to complete your enrollment. This form
gathers that information. Two copies of the form are included. Use only one for
each applicant.
This form lists more than one plan. Make sure to select the plan you want to
enroll in.
Please sign your application, then mail or fax the completed enrollment form to:
UnitedHealthcare Medicare Enrollment
Attn: Xerox/ACS
P.O. Box 29675
Hot Springs, AR 71903
Enrollment
checklist (use
only with a licensed
sales agent)
Fax: 1-866-994-9659
This checklist helps ensure that your sales agent explains the plan clearly
to you and that you fully understand the plan you’ve chosen. Once you have
filled out the checklist with your sales agent, read the “Enrollee Statement” and
sign the form. There are two copies of this form. One is for your records and the
other is for your agent.
If you received this kit through the mail, not from a sales agent, you will not receive
an enrollment checklist.
Enrollment
receipt (use only
with a licensed
sales agent)
Your sales agent will help you fill out this receipt. You can use the completed
receipt as your temporary proof of coverage until you receive your permanent
membership materials.
If you received this kit through the mail, not from a sales agent, you will not receive
an enrollment receipt.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan’s contract renewal with Medicare.
Y0066_140730_234134 Accepted
UHEX15PD3586426_000
48
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
TEAR HERE
AARP® MedicareRx Plans
Medicare Prescription Drug Plan
Individual Enrollment Request Form
1 of 6
Please contact AARP® MedicareRx plan if you need information in another language or format
(Braille).
1. To Enroll in one of the AARP MedicareRx Plans, Please Provide the Following Information:
Please check which plan you want to enroll in:
 AARP® MedicareRx Saver Plus (PDP) K
 AARP® MedicareRx Preferred (PDP) A
2. Applicant Information (please type or print in black or blue ink).
 Mr.
Last Name
First Name
 Mrs.
 Ms.
Birth Date
Sex Male
Female
M M / D
D
/ Y Y Y Y
Primary Phone Number
(
)
Alternate Phone Number
-
(
)
-
Permanent Residence Street Address (P.O. Box not allowed)
City
Middle Initial
State
Zip Code
Apt
County
TEAR HERE
Mailing Address (only if different from your Permanent Residence Address; P.O. Box is allowed for
mailing address only)
City
State
Zip Code
E-mail Address. Please email me plan information and updates.
COPY 1
Enrollee Name ___________________________________________________________________________________
49
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3. Please Provide Your Medicare Insurance Information.
Please 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 it appears on Medicare card)
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY
JANE DOE
MEDICARE CLAIM NUMBER
000-00-0000-A
IS ENTITLED TO
TEAR HERE
HOSPITAL
MEDICAL
SEX
FEMALE
EFFECTIVE DATE
(PART A)
(PART B)
07-01-1986
07-01-1986
Medicare Claim Number
Letter(s)
__ __ __-__ __ __-__ __ __ __
__ __
Sex  Male  Female
Part A (Hospital) effective date ____ ____ ___________
SIGN
HERE
M M/ D D / Y Y Y Y
Part B (Medical) effective date ____ ____ ___________
M M/D D / Y Y Y Y
You must have Medicare Part A and Part B (or both) to join a Medicare Prescription Drug plan.
4. Please Answer The Following Questions:
Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal
employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to AARP® MedicareRx plan?  Yes  No
If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage
ID # for this coverage
Group # for this coverage
Effective Date
M M / D
D / Y Y Y Y
Are you a resident in a long-term care facility, such as a nursing home?  Yes  No
If “yes,” please provide the following information:
Name of institution
Address of institution
TEAR HERE
City
State
Phone number of institution
(
)
-
Zip Code
Date of admission to the institution
M M / D D / Y Y Y Y
COPY 1
Enrollee Name ___________________________________________________________________________________
51
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3 of 6
TEAR HERE
5. Your Plan Premium Payment Options.
You can pay your monthly plan premium (including any late-enrollment penalty you may owe) by mail (we
will provide you a monthly statement), automatically deducted from your Social Security or Railroad
Retirement Board benefit check or automatically deducted from your checking or savings account through
automatic debit, also known as Electronic Funds Transfer (EFT). If you are assessed a Part D-Income
Related Monthly Adjustment Amount (IRMAA), you will be notified by the Social Security Administration.
You will be responsible for paying this extra amount in addition to your plan premium. You will either have
the Part D-IRMAA amount withheld from your Social Security or Railroad Retirement Board benefits
check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to AARP®
MedicareRx.
If you do not select a payment option, you will receive a monthly statement.
Please Select a Premium Payment Option (choose only one):
 Monthly Statement
 Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a
blank check with VOID written on the front or provide the following:
Account Type
 Checking  Savings
Account Holder Name
Bank Routing Number
__ __ __ __ __ __ __ __ __
Bank Account Number
__ __ __ __ __ __ __ __ __ __
TEAR HERE
 Automatic deduction from your monthly Social Security/Railroad Retirement Board
benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social
Security or RRB approves the deduction. In most cases, if Social Security/the Railroad Retirement Board
accepts your request for automatic deduction, the first deduction from your Social Security/Railroad
Retirement Board benefit check will include all premiums due from your enrollment effective date up to
the point withholding begins. If Social Security/the Railroad Retirement Board does not approve your
request for automatic deduction, we will send you a monthly statement for your monthly premiums)
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you
qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug
premiums, annual deductibles and coinsurance. Additionally, those who qualify won’t have a 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 office or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at
www.socialsecurity.gov/prescriptionhelp.
Enrollee Name ___________________________________________________________________________________
53
COPY 1
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, we will send you a monthly
statement for the amount Medicare doesn’t cover.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
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4 of 6
TEAR HERE
6. Alternative Formats (check only one):
Please check one of the boxes below if you would prefer that we send you information in a
language other than English or in another format if available:
Spanish  Large Print
Please contact the Plan at 1-866-883-0659, TTY 711, if you need information in another format or
language than those listed above. Our office hours are 8 a.m. to 8 p.m. local time, 7 days a week, or
visit us online at www.AARPMedicareRx.com.
Please Read This Important Information.
If I am a member of a Medicare Advantage plan (like an HMO or PPO), I may already have
prescription drug coverage from my Medicare Advantage plan that will meet my needs. By enrolling in
one of the AARP® MedicareRx plans, my membership in my Medicare Advantage plan may end.
This will affect my doctor and hospital coverage as well as my prescription drug coverage. I will read the
information that my Medicare Advantage plan sends me. If I have questions, I will contact my Medicare
Advantage plan.
If I have coverage from an employer or union right now, I could lose my employer or union health
coverage if I join this plan. I will read the communications my employer or union sends me and if I have
questions, I will visit their website or call my benefits administrator or the office who answers questions
about my employer or union coverage.
7. Read and Sign Below.
TEAR HERE
By completing this enrollment request form, I agree to the following:
This is a Medicare Prescription Drug plan and has a contract with the Federal government. This
Prescription Drug coverage is in addition to my coverage under Medicare. I need to keep my Medicare
Part A or B coverage, and I must continue to pay my Medicare Part B premium. One thing I need to know
is that I can only be in one Prescription Drug plan at a time. My enrollment in this plan will automatically
end my enrollment in another Prescription Drug plan. If I have prescription drug coverage, or if I get
prescription drug coverage from somewhere other than this plan, I will inform the plan. I may have to pay a
late enrollment penalty for Medicare's prescription drug coverage. This would only apply if I did not sign
up for and maintain creditable prescription drug coverage when I first became eligible for Medicare. If I
have a late enrollment penalty from Medicare, I will receive a letter making me aware of the penalty and
what the next steps are.
Enrollment in this plan is generally for the entire calendar year. I can leave or change this plan only during
the Annual Election Period between October 15th and December 7th of each year, or under special
circumstances.
I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or
creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty
in addition to my premium for Medicare prescription drug coverage in the future.
Enrollee Name ___________________________________________________________________________________
55
COPY 1
This plan covers a specific service area. If I plan to move out of the area, I will call the plan to disenroll
and find a new plan in my new area. I may not be covered under Medicare while out of the country, with
the exception of limited coverage near the U.S. border.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
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5 of 6
Upon enrollment, I will receive a Welcome Guide that includes an Evidence of Coverage document. The
Evidence of Coverage will have more information about services covered by the plan, as well as the terms
and conditions. If a service is not listed in the Evidence of Coverage, it will not be paid for by Medicare or
the plan without authorization. I understand I must use network pharmacies except in an emergency
when I cannot reasonably use the plan’s network pharmacies. I have the right to appeal plan decisions
about payment or services if I do not agree.
TEAR HERE
My information, including my prescription drug event data, will be released to Medicare and other plans,
only as necessary, for treatment, payment and healthcare operations. Medicare may also release my
information for research and other purposes which follow all applicable Federal statutes and regulations.
I understand that if I receive assistance from a sales agent, broker, or other individual employed by or
contracted with the plan, they may receive compensation based on my enrollment in this plan. 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 application means that I have read and understand the information on this application. If
signed by an authorized individual (as described above), this signature certifies that: 1) this person is
authorized under State law to complete this enrollment and 2) documentation of this authority is available
upon request by Medicare. Counseling services may be available in my state to provide advice concerning
Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical
assistance through the state Medicaid program, and the Medicare Savings Program.
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 form, I will be disenrolled from the plan.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and
may change from one year to the next. Star ratings for all plans can be found on Medicare.gov.
Signature of applicant/authorized representative
Today’s Date
M M / D D / Y Y Y Y
8. If You Are the Authorized Representative, You Must Sign Above and Provide the Following
Information.
TEAR HERE
Last Name __________________________________
First Name ____________________________
Address _____________________________________________________________________________________
City ____________________________________
Phone Number (
)
-
State ____________
Zip Code ________________
Relationship to Applicant
COPY 1
Enrollee Name ___________________________________________________________________________________
57
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6 of 6
9. For Broker or Licensed Sales Agent Use Only
Licensed Sales Agent Signature [Signature on file]
Today’s Date
M M / D D / Y Y Y Y
Licensed Sales Agent Name
Steve Shorr
TEAR HERE
Licensed Sales Agent ID
2044245
Licensed Sales Agent Organization
Effective Date of Coverage
 AEP
 IEP
 SEP (type) ___________________
M M / D D / Y Y Y Y
Sales initiative:
 Retail/Mall Program
 Community Meeting
 Member Meeting
 Local B2B Outreach
 Local Event Outreach
 Other________________
For proper commission processing, please print clearly and include the correct Agent ID number. Agents
must be licensed, appointed and certified to receive commission. Incomplete agent information will
cause delays in commission.
10. For AARP® MedicareRx Plans Use Only
Plan ID
TEAR HERE
Employer ID
Branch ID
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual
property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.
You do not need to be an AARP member to enroll. AARP encourages you to consider your needs when
selecting products and does not make specific product recommendations for individuals.
Esta información está disponible sin costo en otros idiomas.Comuníquese con nuestro Servicio al Cliente al
número 1-866-883-0659, TTY 711, de 8 a.m. to 8 p.m. local time, 7 days a week.
本資訊也有其他語言的免費版本。請撥打 1-866-883-0659, 聯絡我們的客戶服務部, 聽語障專線 711,
每週 7 天, 當地時間上午 8 時至晚上 8 時
Y0066_140707_100255A PDP Approved
UHEX15PD3582654_001
59
COPY 1
This information is available for free in other languages. Please call our customer service number at
1-866-883-0659, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
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Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
TEAR HERE
AARP® MedicareRx Plans
Medicare Prescription Drug Plan
Individual Enrollment Request Form
1 of 6
Please contact AARP® MedicareRx plan if you need information in another language or format
(Braille).
1. To Enroll in one of the AARP MedicareRx Plans, Please Provide the Following Information:
Please check which plan you want to enroll in:
 AARP® MedicareRx Saver Plus (PDP) K
 AARP® MedicareRx Preferred (PDP) A
2. Applicant Information (please type or print in black or blue ink).
 Mr.
Last Name
First Name
 Mrs.
 Ms.
Birth Date
Sex Male
Female
M M / D
D
/ Y Y Y Y
Primary Phone Number
(
)
Alternate Phone Number
-
(
)
-
Permanent Residence Street Address (P.O. Box not allowed)
City
Middle Initial
State
Zip Code
Apt
County
TEAR HERE
Mailing Address (only if different from your Permanent Residence Address; P.O. Box is allowed for
mailing address only)
City
State
Zip Code
E-mail Address. Please email me plan information and updates.
COPY 2
Enrollee Name ___________________________________________________________________________________
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3. Please Provide Your Medicare Insurance Information.
Please 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 it appears on Medicare card)
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY
JANE DOE
MEDICARE CLAIM NUMBER
000-00-0000-A
IS ENTITLED TO
TEAR HERE
HOSPITAL
MEDICAL
SEX
FEMALE
EFFECTIVE DATE
(PART A)
(PART B)
07-01-1986
07-01-1986
Medicare Claim Number
Letter(s)
__ __ __-__ __ __-__ __ __ __
__ __
Sex  Male  Female
Part A (Hospital) effective date ____ ____ ___________
SIGN
HERE
M M/ D D / Y Y Y Y
Part B (Medical) effective date ____ ____ ___________
M M/D D / Y Y Y Y
You must have Medicare Part A and Part B (or both) to join a Medicare Prescription Drug plan.
4. Please Answer The Following Questions:
Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal
employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to AARP® MedicareRx plan?  Yes  No
If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage
ID # for this coverage
Group # for this coverage
Effective Date
M M / D
D / Y Y Y Y
Are you a resident in a long-term care facility, such as a nursing home?  Yes  No
If “yes,” please provide the following information:
Name of institution
Address of institution
TEAR HERE
City
State
Phone number of institution
(
)
-
Zip Code
Date of admission to the institution
M M / D D / Y Y Y Y
COPY 2
Enrollee Name ___________________________________________________________________________________
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TEAR HERE
5. Your Plan Premium Payment Options.
You can pay your monthly plan premium (including any late-enrollment penalty you may owe) by mail (we
will provide you a monthly statement), automatically deducted from your Social Security or Railroad
Retirement Board benefit check or automatically deducted from your checking or savings account through
automatic debit, also known as Electronic Funds Transfer (EFT). If you are assessed a Part D-Income
Related Monthly Adjustment Amount (IRMAA), you will be notified by the Social Security Administration.
You will be responsible for paying this extra amount in addition to your plan premium. You will either have
the Part D-IRMAA amount withheld from your Social Security or Railroad Retirement Board benefits
check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to AARP®
MedicareRx.
If you do not select a payment option, you will receive a monthly statement.
Please Select a Premium Payment Option (choose only one):
 Monthly Statement
 Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a
blank check with VOID written on the front or provide the following:
Account Type
 Checking  Savings
Account Holder Name
Bank Routing Number
__ __ __ __ __ __ __ __ __
Bank Account Number
__ __ __ __ __ __ __ __ __ __
TEAR HERE
 Automatic deduction from your monthly Social Security/Railroad Retirement Board
benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social
Security or RRB approves the deduction. In most cases, if Social Security/the Railroad Retirement Board
accepts your request for automatic deduction, the first deduction from your Social Security/Railroad
Retirement Board benefit check will include all premiums due from your enrollment effective date up to
the point withholding begins. If Social Security/the Railroad Retirement Board does not approve your
request for automatic deduction, we will send you a monthly statement for your monthly premiums)
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you
qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug
premiums, annual deductibles and coinsurance. Additionally, those who qualify won’t have a 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 office or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at
www.socialsecurity.gov/prescriptionhelp.
Enrollee Name ___________________________________________________________________________________
65
COPY 2
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, we will send you a monthly
statement for the amount Medicare doesn’t cover.
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TEAR HERE
6. Alternative Formats (check only one):
Please check one of the boxes below if you would prefer that we send you information in a
language other than English or in another format if available:
Spanish  Large Print
Please contact the Plan at 1-866-883-0659, TTY 711, if you need information in another format or
language than those listed above. Our office hours are 8 a.m. to 8 p.m. local time, 7 days a week, or
visit us online at www.AARPMedicareRx.com.
Please Read This Important Information.
If I am a member of a Medicare Advantage plan (like an HMO or PPO), I may already have
prescription drug coverage from my Medicare Advantage plan that will meet my needs. By enrolling in
one of the AARP® MedicareRx plans, my membership in my Medicare Advantage plan may end.
This will affect my doctor and hospital coverage as well as my prescription drug coverage. I will read the
information that my Medicare Advantage plan sends me. If I have questions, I will contact my Medicare
Advantage plan.
If I have coverage from an employer or union right now, I could lose my employer or union health
coverage if I join this plan. I will read the communications my employer or union sends me and if I have
questions, I will visit their website or call my benefits administrator or the office who answers questions
about my employer or union coverage.
7. Read and Sign Below.
TEAR HERE
By completing this enrollment request form, I agree to the following:
This is a Medicare Prescription Drug plan and has a contract with the Federal government. This
Prescription Drug coverage is in addition to my coverage under Medicare. I need to keep my Medicare
Part A or B coverage, and I must continue to pay my Medicare Part B premium. One thing I need to know
is that I can only be in one Prescription Drug plan at a time. My enrollment in this plan will automatically
end my enrollment in another Prescription Drug plan. If I have prescription drug coverage, or if I get
prescription drug coverage from somewhere other than this plan, I will inform the plan. I may have to pay a
late enrollment penalty for Medicare's prescription drug coverage. This would only apply if I did not sign
up for and maintain creditable prescription drug coverage when I first became eligible for Medicare. If I
have a late enrollment penalty from Medicare, I will receive a letter making me aware of the penalty and
what the next steps are.
Enrollment in this plan is generally for the entire calendar year. I can leave or change this plan only during
the Annual Election Period between October 15th and December 7th of each year, or under special
circumstances.
I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or
creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty
in addition to my premium for Medicare prescription drug coverage in the future.
Enrollee Name ___________________________________________________________________________________
67
COPY 2
This plan covers a specific service area. If I plan to move out of the area, I will call the plan to disenroll
and find a new plan in my new area. I may not be covered under Medicare while out of the country, with
the exception of limited coverage near the U.S. border.
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Upon enrollment, I will receive a Welcome Guide that includes an Evidence of Coverage document. The
Evidence of Coverage will have more information about services covered by the plan, as well as the terms
and conditions. If a service is not listed in the Evidence of Coverage, it will not be paid for by Medicare or
the plan without authorization. I understand I must use network pharmacies except in an emergency
when I cannot reasonably use the plan’s network pharmacies. I have the right to appeal plan decisions
about payment or services if I do not agree.
TEAR HERE
My information, including my prescription drug event data, will be released to Medicare and other plans,
only as necessary, for treatment, payment and healthcare operations. Medicare may also release my
information for research and other purposes which follow all applicable Federal statutes and regulations.
I understand that if I receive assistance from a sales agent, broker, or other individual employed by or
contracted with the plan, they may receive compensation based on my enrollment in this plan. 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 application means that I have read and understand the information on this application. If
signed by an authorized individual (as described above), this signature certifies that: 1) this person is
authorized under State law to complete this enrollment and 2) documentation of this authority is available
upon request by Medicare. Counseling services may be available in my state to provide advice concerning
Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical
assistance through the state Medicaid program, and the Medicare Savings Program.
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 form, I will be disenrolled from the plan.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and
may change from one year to the next. Star ratings for all plans can be found on Medicare.gov.
Signature of applicant/authorized representative
Today’s Date
M M / D D / Y Y Y Y
8. If You Are the Authorized Representative, You Must Sign Above and Provide the Following
Information.
TEAR HERE
Last Name __________________________________
First Name ____________________________
Address _____________________________________________________________________________________
City ____________________________________
Phone Number (
)
-
State ____________
Zip Code ________________
Relationship to Applicant
COPY 2
Enrollee Name ___________________________________________________________________________________
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9. For Broker or Licensed Sales Agent Use Only
Licensed Sales Agent Signature [Signature on file]
Today’s Date
M M / D D / Y Y Y Y
Licensed Sales Agent Name
Steve Shorr
TEAR HERE
Licensed Sales Agent ID
2044245
Licensed Sales Agent Organization
Effective Date of Coverage
 AEP
 IEP
 SEP (type) ___________________
M M / D D / Y Y Y Y
Sales initiative:
 Retail/Mall Program
 Community Meeting
 Member Meeting
 Local B2B Outreach
 Local Event Outreach
 Other________________
For proper commission processing, please print clearly and include the correct Agent ID number. Agents
must be licensed, appointed and certified to receive commission. Incomplete agent information will
cause delays in commission.
10. For AARP® MedicareRx Plans Use Only
Plan ID
TEAR HERE
Employer ID
Branch ID
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual
property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.
You do not need to be an AARP member to enroll. AARP encourages you to consider your needs when
selecting products and does not make specific product recommendations for individuals.
Esta información está disponible sin costo en otros idiomas.Comuníquese con nuestro Servicio al Cliente al
número 1-866-883-0659, TTY 711, de 8 a.m. to 8 p.m. local time, 7 days a week.
本資訊也有其他語言的免費版本。請撥打 1-866-883-0659, 聯絡我們的客戶服務部, 聽語障專線 711,
每週 7 天, 當地時間上午 8 時至晚上 8 時
Y0066_140707_100255A PDP Approved
UHEX15PD3582654_001
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COPY 2
This information is available for free in other languages. Please call our customer service number at
1-866-883-0659, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
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2015 Enrollment
checklist
TEAR HERE
If you enroll with a Sales Agent, please review the following items.
Your agent has presented a lot of information to you about Medicare and the plan you’re enrolling in today.
Review the items in this checklist with your agent. If you have any questions, be sure to ask. We recommend
removing the checklist once it’s complete and putting it somewhere handy so you can refer to it later if you have
any questions.
As each topic is discussed, make sure you understand it and check the box before moving on.
My Sales Agent is a licensed representative of this plan and does not represent Medicare or any part of
the federal or state government. When my enrollment is complete, the Sales Agent may be paid a fee.
The name of my new plan is:
My plan coverage begins (effective date):
.
.
My plan will now provide all my Medicare prescription drug coverage.
I cannot have a stand-alone Medicare Part D plan and any type of Medicare Advantage (MA) plan
at the same time. (There is one exception: MA Private Fee-for-Service plans that do not include
prescription drug coverage.)
My plan may have (circle all that apply): Co-pays
Co-insurance
Prior authorization for some benefits
Annual deductible
Certain limitations
I need to continue to pay my Medicare Part B premium unless the state pays this premium for me.
My plan: does not have a premium (monthly payment).
has a $
monthly premium. I must pay this monthly premium to stay in this plan.
Once Medicare approves my enrollment, the plan will send me a member ID card. I will use that card
instead of my Original Medicare card when I visit the pharmacy.
My prescription drug plan will cover only those drugs included on my plan’s list of covered drugs
(also called a drug list). My Sales Agent helped me confirm whether my current medications are on
my plan’s drug list and showed me how to look up any medications I am prescribed in the future.
Generic medications do not always have the lowest co-pay. I understand that a generic medication
can be available at ANY tier level.
Medicare has rules about prescription drug coverage. I might receive a letter from the plan requesting
information about my past prescription drug coverage. If I have not had creditable drug coverage as
required by Medicare, I may have to pay a late-enrollment penalty each month to the plan for as long
as I have prescription drug coverage. This penalty is required by Medicare.
My plan will send me a letter to make sure I understand the type of plan I am enrolled in.
Enrollee Name:______________________________________________________________________________
Y0066_140806_071954 Accepted
73
PDEX15MP3577573_000
COPY 1
TEAR HERE
I understand how my prescription drug plan works, including:
••Step therapy
••The cost difference between network
••Coverage gap drug stages and how they
pharmacies and out-of-network pharmacies
impact my costs
••Tier levels
••Quantity limits
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I will receive a Welcome call to help me get started and answer any questions I may have.
My Sales Agent explained the enrollment cancellation process to me.
TEAR HERE
If my enrollment request form is incomplete for any reason, the plan will call or write to me and ask
for the missing information. This may delay the date my coverage begins.
Enrollee Statement
By signing this enrollment request form, I confirm that my Sales Agent has explained my plan benefits and
reviewed the information in the enrollment guide, including multi-language interpreter services, Star Ratings,
disclaimers and important contact information. I have been able to ask questions. I understand that by completing
this enrollment request form, I am applying to enroll in (join) this plan. I know that if I have more questions, I may
call my Sales Agent or Customer Service. The plan will send me a copy of my completed enrollment request form
within 10 days after I enroll in this plan.
Enrollee Signature____________________________________ Phone Number________________________
Medicare Number_____________________________________ Plan Selected_________________________
Power of Attorney Name_______________________________ Phone Number ________________________
TEAR HERE
Sales Agent Signature______________________________________ Agent ID________________________
Sales Agent Phone Number_________________________________
Sales Agent and Applicant must both retain a signed copy.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan's contract renewal with Medicare.
Y0066_140806_071954 Accepted
74
PDEX15MP3577573_000
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1 of 2
2015 Enrollment
checklist
TEAR HERE
If you enroll with a Sales Agent, please review the following items.
Your agent has presented a lot of information to you about Medicare and the plan you’re enrolling in today.
Review the items in this checklist with your agent. If you have any questions, be sure to ask. We recommend
removing the checklist once it’s complete and putting it somewhere handy so you can refer to it later if you have
any questions.
As each topic is discussed, make sure you understand it and check the box before moving on.
My Sales Agent is a licensed representative of this plan and does not represent Medicare or any part of
the federal or state government. When my enrollment is complete, the Sales Agent may be paid a fee.
The name of my new plan is:
My plan coverage begins (effective date):
.
.
My plan will now provide all my Medicare prescription drug coverage.
I cannot have a stand-alone Medicare Part D plan and any type of Medicare Advantage (MA) plan
at the same time. (There is one exception: MA Private Fee-for-Service plans that do not include
prescription drug coverage.)
My plan may have (circle all that apply): Co-pays
Co-insurance
Prior authorization for some benefits
Annual deductible
Certain limitations
I need to continue to pay my Medicare Part B premium unless the state pays this premium for me.
My plan: does not have a premium (monthly payment).
has a $
monthly premium. I must pay this monthly premium to stay in this plan.
Once Medicare approves my enrollment, the plan will send me a member ID card. I will use that card
instead of my Original Medicare card when I visit the pharmacy.
My prescription drug plan will cover only those drugs included on my plan’s list of covered drugs
(also called a drug list). My Sales Agent helped me confirm whether my current medications are on
my plan’s drug list and showed me how to look up any medications I am prescribed in the future.
Generic medications do not always have the lowest co-pay. I understand that a generic medication
can be available at ANY tier level.
Medicare has rules about prescription drug coverage. I might receive a letter from the plan requesting
information about my past prescription drug coverage. If I have not had creditable drug coverage as
required by Medicare, I may have to pay a late-enrollment penalty each month to the plan for as long
as I have prescription drug coverage. This penalty is required by Medicare.
My plan will send me a letter to make sure I understand the type of plan I am enrolled in.
Enrollee Name:______________________________________________________________________________
Y0066_140806_071954 Accepted
75
PDEX15MP3577573_000
COPY 2
TEAR HERE
I understand how my prescription drug plan works, including:
••Step therapy
••The cost difference between network
••Coverage gap drug stages and how they
pharmacies and out-of-network pharmacies
impact my costs
••Tier levels
••Quantity limits
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I will receive a Welcome call to help me get started and answer any questions I may have.
My Sales Agent explained the enrollment cancellation process to me.
TEAR HERE
If my enrollment request form is incomplete for any reason, the plan will call or write to me and ask
for the missing information. This may delay the date my coverage begins.
Enrollee Statement
By signing this enrollment request form, I confirm that my Sales Agent has explained my plan benefits and
reviewed the information in the enrollment guide, including multi-language interpreter services, Star Ratings,
disclaimers and important contact information. I have been able to ask questions. I understand that by completing
this enrollment request form, I am applying to enroll in (join) this plan. I know that if I have more questions, I may
call my Sales Agent or Customer Service. The plan will send me a copy of my completed enrollment request form
within 10 days after I enroll in this plan.
Enrollee Signature____________________________________ Phone Number________________________
Medicare Number_____________________________________ Plan Selected_________________________
Power of Attorney Name_______________________________ Phone Number ________________________
TEAR HERE
Sales Agent Signature______________________________________ Agent ID________________________
Sales Agent Phone Number_________________________________
Sales Agent and Applicant must both retain a signed copy.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan's contract renewal with Medicare.
Y0066_140806_071954 Accepted
76
PDEX15MP3577573_000
TEAR HERE
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
2015 Enrollment Receipt
To be completed if enrolling with a licensed Sales Agent.
Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment, and you
have received your permanent membership materials. You will receive a copy of your original Enrollment Form
in the mail within two weeks. If you do not receive a copy please contact your local licensed Sales Agent. This
copy is for your records only. Please do not resubmit.
Applicant 1:
Applicant 2 (if applicable):
Name _____________________________________
Name _____________________________________
Application Date M M / D D / Y Y Y Y
Application Date M M / D D / Y Y Y Y
Proposed Effective Date M M / D D / Y Y Y Y
Proposed Effective Date M M / D D / Y Y Y Y
Plan Name _________________________________
Plan Name _________________________________
iEnroll Tracking No. (if applicable) ______________
iEnroll Tracking No. (if applicable) ______________
If you have any questions, please contact your local Sales Agent:
RxBIN: 610097
Licensed Sales Agent Name
Rx PCN: 9999
_____________________________________
Licensed Sales Agent Phone No.
Licensed Sales Agent ID
__________________________________
RxGRP: PDPIND
_________________________________________
Plans are insured through UnitedHealthcare® Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
Enrollment in the plan depends on the plan’s contract renewal with Medicare.
Y0066_140610_124348 Accepted
PDEX15PD3574237_000
77
WELCOME ABOARD
TEAR HERE
If you have questions about your enrollment, we can help.
Please call the Customer Service number located on the first page of this booklet.
Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
What to expect
AFTER YOU ENROLL
We’re excited to have you as
a member.
Here’s what you can do
right now:
To help you use your plan benefits, we’ll provide
ongoing support throughout the year. We’ll reach out
to you by phone, mail and email with tips, reminders
and information about any updates to your plan.
Each communication is designed to give you the right
information at the right time.
atch the New Member
W
Orientation videos at
myAARPMedicare.com to learn
more about your plan
When you receive a mailing from us, look for the image
below. One step will be highlighted, showing where you
are in the member experience. The goal is to make sure
you stay informed.
Questions? We’re always here to help.
Simply call the Customer Service number listed on the first page of this booklet.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the
plan depends on the plan’s contract renewal with Medicare.
Y0066_140804_190543 Accepted
78
PDEX15PD3574404_000
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NOTES
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NOTES
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NOTES
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NOTES
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NOTES
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Steve Shorr Insurance - Authorized Agent - 310.519.1335 http://medicare.healthreformquotes.com/part-d-rx-prescriptions/aarp/
Plans are insured through UnitedHealthcare Insurance Company or one of
its af
f
iliated companies, a
Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
Enrollment in the plan depends on the plan’s contract renewal with Medicare.
Y0066_140717_165817_FINAL_4 Approved
This is an advertisement.
PDCA15PD3576186_002