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UnitedHealthcare SignatureValueTM Offered by UnitedHealthcare of California HMO Pharmacy Schedule of Benefits Prescription Units or up to a 90-day supply) This Schedule of Benefits provides specific details about it may be Medically Necessary for you to receive a your prescription drug benefit, as well as the exclusions certain medication without trying an alternative drug first. and limitations. Together, this document and the In these instances, your Participating Physicians will Supplement to the Combined Evidence of Coverage and need to provide evidence to UnitedHealthcare in the Disclosure Form as well as the medical Combined form of documents, lab results, records or clinical trials Evidence of Coverage and Disclosure Form determine that establish the use of the requested medications as the exact terms and conditions of your prescription drug Medically Necessary. Participating Physicians may call or fax Preauthorization requests to UnitedHealthcare. Applicable Copayments will be charged for prescriptions What do I pay when I fill a prescription? that require Preauthorization if approved. You will pay only a Copayment when filling a For a list of the selected medications that require prescription at a UnitedHealthcare Participating UnitedHealthcare’s Preauthorization, please contact Pharmacy. You will pay a Copayment every time a UnitedHealthcare’s Customer Service department. prescription is filled. Your Copayments are as shown in the grid above. There are selected brand-name medications where you When prescribed by your Participating Physician as will pay a generic Copayment of just $15. A copy of the Medically Necessary and filled at a Participating Selected Brands List is available upon request from Pharmacy, subject to all the other terms and conditions UnitedHealthcare’s Customer Service department and of this outpatient prescription drug benefit, the following may be found on UnitedHealthcare’s Web site at Disposable all-in-one prefilled insulin pens, insulin cartridges and needles for nondisposable pen devices are covered when Medically Necessary, in accordance Selected generic Formulary, brand-name Formulary and with UnitedHealthcare’s Preauthorization process. non-Formulary medications require a Member to go Federal Legend Drugs: Any medicinal substance through a Preauthorization process using criteria based which bears the legend: “Caution: Federal law upon Food and Drug Administration (FDA)-approved prohibits dispensing without a prescription.” indications or medical findings, and the current availability of the medication. UnitedHealthcare reviews Generic Drugs: Comparable generic drugs may be requests for these selected medications to ensure that substituted for brand-name drugs unless they are on they are Medically Necessary, being prescribed UnitedHealthcare’s Selected Brands List. A copy of according to treatment guidelines consistent with the Selected Brands List is available upon request standard professional practice and are not otherwise from UnitedHealthcare’s Customer Service department or may be found on UnitedHealthcare’s Web site at www.uhcwest.com. Because UnitedHealthcare offers a comprehensive Formulary, selected non-Formulary medications will not Miscellaneous Prescription Drug Coverage: For the be covered until one or more Formulary alternatives, or purposes of determining coverage, the following items non-Formulary preferred drugs have been tried. are considered prescription drug benefits and are UnitedHealthcare understands that situations arise when covered when Medically Necessary: glucagons, insulin, insulin syringes, blood glucose test strips, Questions? Call the Customer Service Department at 1-800-624-8822. lancets, inhaler extender devices, urine test strips and Combined Evidence of Coverage and Disclosure anaphylaxis prevention kits (including, but not limited to, EpiPen®, Ana-Kits® and Ana-Guard®). See the Drugs prescribed by a dentist or drugs when medical Combined Evidence of Coverage and prescribed for dental treatment are not covered. Disclosure Form for coverage of other injectable Drugs when prescribed to shorten the duration of medications in Section Five under “Your Medical Enhancement medications when prescribed for the Oral Contraceptives: Federal Legend oral following nonmedical conditions are not covered: contraceptives, prescription diaphragms and oral weight loss, hair growth, sexual performance, athletic medications for emergency contraception. performance, cosmetic purposes, anti-aging for State Restricted Drugs: Any medicinal substance cosmetic purposes, and mental performance. that may be dispensed by prescription only, according Examples of drugs that are excluded when prescribed for such conditions include, but are not limited to, Penlac®, Retin-A®, Renova®, Vaniqa®, Propecia®, Lustra®, Xenical® or Meridia®. This exclusion does not While the prescription drug benefit covers most exclude coverage for drugs when Preauthorized as medications, there are some that are not covered or Medically Necessary to treat morbid obesity or limited. These drugs are listed below. Some of the diagnosed medical conditions affecting memory, following excluded drugs may be covered under your including, but not limited to, Alzheimer’s dementia. medical benefit. Please refer to Section Five of your Infertility: All forms of prescription medication when medical Combined Evidence of Coverage and prescribed for the treatment of infertility are not Disclosure Form titled “Your Medical Benefits” for more covered. If your Employer has purchased coverage for information about medications covered by your medical infertility treatment, prescription medications for the treatment of infertility may be covered under that Administered Drugs: Drugs or medicines delivered or benefit. Please refer to Section Five of your medical administered to the Member by the prescriber or the Combined Evidence of Coverage and Disclosure Form prescriber’s staff are not covered. Injectable drugs are titled “Your Medical Benefits” for additional administered during a Physician’s office visit or self- Injectable Medications: Except as described under administered pursuant to training by an appropriate the section “Medications Covered by Your Benefit,” health care professional. Refer to Section Five of your injectable medications, including, but not limited to, medical Combined Evidence of Coverage and self-injectables, infusion therapy, allergy serum, Disclosure Form titled “Your Medical Benefits” for immunization agents and blood products, are not more information about medications covered under covered as an outpatient prescription drug benefit. However, these medications are covered under your Compounded Medication: Any medicinal substance medical benefit as described in and according to the that has at least one ingredient that is Federal Legend terms and conditions of your medical Combined or State Restricted in a therapeutic amount. Evidence of Coverage and Disclosure Form. Compounded medications are not covered unless Outpatient injectable medications administered in the Physician’s office (except insulin) are covered as a medical benefit when part of a medical office visit. Diagnostic Drugs: Drugs used for diagnostic Injectable medications may be subject to purposes are not covered. Refer to Section Five of UnitedHealthcare’s Preauthorization requirements. For your medical Combined Evidence of Coverage and additional information, refer to Section Five of your Disclosure Form for information about medications medical Combined Evidence of Coverage and covered for diagnostic tests, services and treatment. Disclosure Form under “Your Medical Benefits.” Dietary or nutritional products and food Inpatient Medications: Medications administered to a supplements, whether prescription or nonprescription, Member while an inpatient in a Hospital or while including vitamins (except prenatal), minerals and receiving Skilled Nursing Care as an inpatient in a fluoride supplements, health or beauty aids, herbal Skilled Nursing Facility are not covered under this supplements and/or alternative medicine, are not Pharmacy Schedule of Benefits. Please refer to covered. Phenylketonura (PKU) testing and treatment Section Five of your medical Combined Evidence of is covered under your medical benefit including those Coverage and Disclosure Form titled “Your Medical formulas and special food products that are a part of a Benefits” for information on coverage of prescription diet prescribed by a Participating Physician provided medications while hospitalized or in a Skilled Nursing that the diet is Medically Necessary. For additional Facility. Outpatient prescription drugs are covered for information, refer to Section Five of your medical Members receiving Custodial Care in a rest home, nursing home, sanitarium, or similar facility if they are treat the medical condition. (4) The drug has been obtained from a Participating Pharmacy in accordance recognized for treatment of a medical condition by one with all the terms and conditions of coverage set forth of the following: (a) The American Hospital Formulary in this Schedule of Benefits and in the Pharmacy Service Drug Information, (b) One of the following Supplement to the Combined Evidence of Coverage compendia, if recognized by the federal Centers for and Disclosure Form. When a Member is receiving Medicare and Medicaid Services as part of an Custodial Care in any facility, relatives, friends or anticancer chemotherapy regimen: (i) The Elsevier caregivers may purchase the medication prescribed by Gold Standard's Clinical Pharmacology; (ii) The a Participating Physician at a Participating Pharmacy National Comprehensive Cancer Network Drug and and pay the applicable Copayment on behalf of the Biologics Compendium; (iii) The Thompson Micromedex DRUGDEX, or (c) Two articles from Investigational or Experimental Drugs: Medication major peer reviewed medical journals that present prescribed for experimental or investigational data supporting the proposed Off-Label Drug Use or therapies are not covered, unless required by an uses as generally safe and effective. Nothing in this external, independent review panel pursuant to section shall prohibit UnitedHealthcare from use of a California Health and Safety Code Section 1370.4. Formulary, Copayment, technology assessment panel, Further information about Investigational and or similar mechanism as a means for appropriately Experimental procedures and external review by an controlling the utilization of a drug that is prescribed for independent panel can be found in the medical a use that is different from the use for which that drug Combined Evidence of Coverage and Disclosure Form has been approved for marketing by the FDA. Denial in Section Five, “Your Medical Benefits” and Section of a drug as investigational or experimental will allow Eight, “Overseeing Your Health Care” for appeal the Member to use the Independent Medical Review System as defined in the medical Combined Evidence of Coverage and Disclosure Form. Medications dispensed by a non-Participating Pharmacy are not covered except for prescriptions Over-the-Counter Drugs: Medications (except required as a result of an Emergency or Urgently insulin) available without a prescription (over-the- counter) or for which there is a nonprescription chemical and dosage equivalent available, even if Medications prescribed by non-Participating ordered by a Physician, are not covered. All Physicians are not covered except for prescriptions nonprescription (over-the-counter) contraceptive required as a result of an Emergency or Urgently jellies, ointments, foams or devices are not covered. Prior to Effective Date: Drugs or medicines New medications that have not been reviewed for purchased and received prior to the Member’s safety, efficacy and cost-effectiveness and effective date or subsequent to the Member’s approved by UnitedHealthcare are not covered unless Preauthorized by UnitedHealthcare as Medically Necessary. Replacement of lost, stolen or destroyed medications Non-Covered Medical Condition: Prescription medications for the treatment of a non-covered Saline and irrigation solutions are not covered. medical condition are not covered. This exclusion Saline and irrigation solutions are covered when does not exclude Medically Necessary medications Medically Necessary, depending on the purpose for directly related to non-Covered Services when which they are prescribed, as part of the home health complications exceed follow-up care, such as life- or Durable Medical Equipment benefit. Refer to your threatening complications of cosmetic surgery. medical Combined Evidence of Coverage and Disclosure Form Section Five for additional Off-Label Drug Use. Off Label Drug Use means that the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is Sexual Dysfunction Medication: All forms of different than that for which the FDA approved the medications when prescribed for the treatment of drug. UnitedHealthcare excludes coverage for Off sexual dysfunction, which includes, but is not limited Label Drug Use, including off label self-injectable to, erectile dysfunction, impotence, anorgasmy or drugs, except as described in the medical Combined hyporgasmy, are not covered. An example of such Evidence of Coverage and Disclosure Form and any applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: (1) The drug is approved by the FDA. (2) The drug is prescribed by a participating licensed health care professional. (3) The drug is Medically Necessary to Smoking cessation products, including, but not limited to, nicotine gum, nicotine patches and nicotine nasal spray, are not covered. However, smoking cessation products are covered when the Member is enrolled in a smoking cessation program approved by UnitedHealthcare. For information on UnitedHealthcare’s smoking cessation program, refer to the medical Combined Evidence of Coverage and Disclosure Form in Section Five, “Your Medical Benefits, in the section titled “Outpatient Benefits”, under “Health Education Services” or contact Customer Service or visit our Web site at www.uhcwest.com. Therapeutic devices or appliances, including, but not limited to, support garments and other nonmedical substances, insulin pumps and related supplies (these services are provided as Durable Medical Equipment) and hypodermic needles and syringes not related to diabetic needs or cartridges are not covered. Birth control devices and supplies or preparations that do not require a Participating Physician’s prescription by law are also not covered, even if prescribed by a Participating Physician. For further information on certain therapeutic devices and appliances that are covered under your medical benefit, refer to your medical Combined Evidence of Coverage and Disclosure Form in Section Five, titled “Your Medical Benefits” under “Outpatient Benefits” located, for example, in subsections titled “Diabetic Self Management”, “Durable Medical Equipment,” or “Home Health Care and Prosthetics and Corrective Appliances.” Workers’ Compensation: Medication for which the cost is recoverable under any workers’ compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient is not covered. Further information about workers’ compensation can be found in the medical Combined Evidence of Coverage and Disclosure Form in Section Six under “Payment Responsibility.” UnitedHealthcare reserves the right to expand the Preauthorization requirement for any drug product. Questions? Call the HMO Customer Service department at 1-800-624-8822 or TDHI 1-800-442-8833. 2011 United HealthCare Services, Inc.

Source: http://vcpfa.org/images/shared/2014%20Health%20Benefits/HMO%20Low%20Rx%20plan%20information.pdf