2011 Enrollment Kit

2011 Enrollment Kit
Hospitals Doctors Rx Drugs

ONE
convenient
$0 monthly plan premium plan
AARP® MedicareComplete ® Plus (HMO-POS)
H2182-001
Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton counties
Y0004Y0066_100707_142434 CMS Approved 08202010

What You’ll Find in this Booklet
Cover Letter.........................................................................1
Medicare Advantage Explained............................................3
Benefits at a Glance.............................................................4
Passport Brochure...............................................................6
Ready to Enroll.................................................................... 8
Summary of Benefits............................................................9
Additional Plan Information .....................................33
- Appeals & Grievances............................................35
- Plan Ratings.......................................................... 37
- Dental Platinum Rider............................................39
- Fitness Rider..........................................................41
- Disclaimers............................................................43
Pharmacy Options ..........................................45
- Drug List................................................................47
Enrollment Materials
- Outbound Education & Verification Call Checklist
(See back of Enrollment Materials Divider)
- Scope of Appointment Form
Enrollment Form
Roadmap After Enrollment
Health Care to Fit Your Needs…
now that is peace of mind
At UnitedHealthcare we realize more than ever the importance of affordable health care
coverage. We are dedicated to helping you make the right choices by providing quality, cost-
effective health care solutions. As one of the largest and most recognized health carriers in
the United States, you can be confident we will be here
when you need us.
ONE
We Make Health Care Simple… out of
and provide the answers you need
INSIDE THIS BOOKLET:
FIVE
Medicare members
use our Medicare
• Understand the basics of Advantage Programs
Medicare Advantage
• Learn how our plans can benefit you
• View plan details and how they • Start your application process
compare to your Original Medicare
• Continue on your path to good health
• Look up your medications
We’re Here For You

Y0035Y0066_100624_153203 CMS Approved 08032010
Talk with your local sales agent. Health care is personal. Your agent will
answer your questions and help you enroll.
If you don’t have a local sales agent, call SecureHorizons toll-free:

x-xxx-xxx-xxxx, <88a.m.
1-800-547-5514, a.m.–– 8 p.m. local time, 7 days a week>.
week.
TTY users, call 711.
Go online: www.AARPMedicarePlans.com.
<WebsiteAddress>.
Thank you for your interest in this plan. The world of Medicare can be confusing, but we’re here
to help. Together we’ll find a plan that’s right for you.
Sincerely,
Thomas S. Paul
Chief Executive Officer, UnitedHealthcare Medicare Solutions
1
You may contact 1-800-MEDICARE (1-800-633-4227) and TTY users should call 1-877-486-2028,
24 hours a day, 7 days a week or visit www.medicare.gov for more information about Medicare
benefits and services including general information regarding health and Part D benefit.
The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an affiliate of
UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare
contract. AARP MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a
royalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general
purpose of AARP and its members. AARP is not the insurer. You do not need to be an AARP
member to enroll.
AARP does not recommend health related products, services, insurance or programs. You are
strongly encouraged to evaluate your needs.
This document is available in alternative formats. You must have both Medicare Part A and B, and
must reside in the service area of the plan. You must continue to pay your Medicare Part B
premium if not otherwise paid for under Medicaid or by another third party. Your ability to enroll
may be limited certain times of the year. For more information contact Customer Service at
1-800-547-5514 7 days a week, between 8:00 a.m. and 8:00 p.m. local time. TTY users can call
711 or write us at P.O. Box 29675, Hot Springs, AR 71903-9675, or go to
www.AARPMedicarePlans.com. You 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 AARP MedicareComplete RX plans will be responsible for the costs. For PPO
and HMO-POS members, with the exception of emergency or urgent care or out-of-area renal
dialysis, it may cost more to get care from out-of-network providers. For PPO members,
reimbursement is provided for all covered benefits regardless of whether they are received in
network. Out of network services may cost more than in network services. 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; 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 State Medicaid Office. The Medicare
Prescription Drug benefit is only available to members of the Medicare Advantage with Prescription
Drug (MA-PD) plans. By enrolling in an MA-PD you will automatically be disenrolled from any
existing Medicare Prescription Drug coverage. To receive the highest level of benefit you must use
contracted network pharmacies to access your prescription drug benefit except in the case of
emergency. The pharmacy network includes retail, mail order, long-term care, home infusion and
I/T/U (Indian Health Service, Tribes, or Urban Indian) pharmacy services. You may obtain your
prescriptions from pharmacies outside the contracted network at a reduced benefit. Quantity
limitations and restrictions may apply. For more information about mail order, names and
addresses of network pharmacies or for more information call 1-800-547-5514, or TTY 711,
Monday through Friday, 8:00 a.m. to 8:00 p.m. local times. Or write us at P.O. Box 29675, Hot
Springs, AR 71903-9675, or go to www.AARPMedicarePlans.com. The AARP ® MedicareComplete®
benefit packages, plan premiums, copayments/coinsurance may vary by county, and service areas
are all subject to change annually at the Medicare Advantage contract renewal time with the
Centers for Medicare & Medicaid Services (January 1). Availability of coverage beyond the end of
the current year is not guaranteed.
2
Medicare Advantage Explained
Medicare is health insurance for people 65 and older and others with certain disabilities. You have choices
about how you get your Medicare coverage. You can choose Original Medicare (Parts A and B) or a Medicare
Advantage plan.
Many people with Original Medicare find there are expenses that are not covered. To help pay for some of
these additional costs, many people choose to enroll in a Medicare Advantage plan.
Original Medicare consists of Medicare Parts A and B
• Part A helps with hospital costs •P art D (optional add-on) stand-alone prescription drug plans
•P art B helps with doctor services can be added to help with the cost of prescription drugs
and outpatient care • Most preventive care services are not covered –
expect to pay additional costs for these services
• Original Medicare has unpredictable out-of-pocket expenses
Original Medicare
A
(Parts A and B)
= +
PAR T PAR T
B D
PAR T
Operated by the Federal government.
Medicare pays fees for your care
directly to the doctors and
hospitals you visit Original Medicare Optional Plan
You Can Add
Medicare Advantage (Part C) Combines Your Coverage into ONE Plan
• Medicare Advantage plans • Prescription drug coverage (Part D) is included in many

cover at least the same services Medicare Advantage plans
Y0004Y0066_100722_192352 File & Use 08092010
as Parts A and B • Preventive care services like dental, vision, hearing and
foot care may be included at no extra charge
• Medicare Advantage plans have predictable out-of-pocket
Operated by private companies expenses
C
approved by Medicare.
= + +
PA R T
D
PA R T
Individuals must have both
Parts A and B to enroll. You pay a
low or no additional monthly plan
premium beyond the Prescription Other Services
Medicare Part B premium Drug Coverage May Be Included
Medicare Advantage plans may be a lower-cost alternative to Original Medicare. Medicare

Advantage can offer extra preventive benefits and prescription drugs all in ONE convenient plan.
[CMSCODE]
Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,

a Medicare Advantage Organization with a Medicare contract.
OVEX11MP3244608_000
33
Benefits at a Glance
This plan is a Health Maintenance Organization (HMO) with a Point-of-Service (POS) option plan or HMO-POS.
HMO-POS plans provide care through a network of local doctors and hospitals, and the POS plans may provide
covered services out-of-network. HMO-POS plans may be a good fit for someone looking for predictable cost shares,
benefits above Original Medicare, and the freedom to receive out-of-network services.
Benefit In-Network Out-of-Network
Monthly plan premium $0
Deductible None
Medical Coverage
Annual physical $0 copay $15 copay
Preventive services (Medicare-covered) $0 copay 30% coinsurance
Immunizations (pneumonia and flu) $0 copay $0 copay
Primary Care Physician (PCP) office visit $10 copay $15 copay
Specialist office visit $35 copay (No Referral Needed) $40 copay
Inpatient hospitalization $295 copay per day: days 1-7. $325 copay per day for
$0 thereafter. unlimited days.
Outpatient surgery and hospital services 20% coinsurance 30% coinsurance
Urgently needed care $30 copay $40 copay
Emergency care $50 copay $50 copay
Ambulance services $200 copay $200 copay
Home health care $0 copay 30% coinsurance
Skilled nursing facility (SNF) care $100 copay per day: days 1-34. $175 copay per day: days 1-40.
Lab services:
HIV & cardiovascular screenings $0 copay $0 - $10 copay
All other lab services $10 copay $10 copay
Diagnostic testing:
EKG & AAA screenings 0% - 20% coinsurance 30% coinsurance
All other diagnostic tests 20% coinsurance 30% coinsurance
Y0004Y0066_100622_141023 CMS Approved 08032010

X-rays $16 copay $21 copay
Annual out-of-pocket maximum $3380 Unlimited
Prescription Drugs
Prescription drug deductible $0
Initial coverage stage 31-day retail supply 90-day mail order supply
n Tier 1: $5 $10
n Tier 2: $45 $125
n Tier 3: $85 $245
n Tier 4: 33% 33%
Coverage gap stage (after prescription No Coverage
costs paid reach $2840)
Catastrophic coverage stage (after you The greater of $2.50 for generic, $6.30 for brand-name, or 5%
have paid $4550 out-of-pocket)
To verify your provider is in the plan’s network or for additional plan information
4 visit us online at www.AARPMedicarePlans.com
Also included in this plan In-Network Out-of-Network
Foot care $35 copay for 6 visits per year* $40 copay for 6 visits per year*
Vision services $0 copay for Medicare-covered $40 copay for Medicare-covered
glaucoma screening glaucoma screening
$35 copay for routine exams; 1 $40 copay for routine exams; 1
per year* per year*
$30 copay for coverage up to No coverage for eyewear
$70 every 2 years for frames
(standard lenses included) or
$105 for contact lenses
Hearing services $0 copay for Epic Hearing $40 copay for annual hearing
Healthcare provider or $35 test*
copay for other network provider No coverage for hearing aids
for annual hearing test*
$300 hearing aids allowance
every 2 years
UnitedHealth Passport® Program Included in this plan. See the Passport brochure in this booklet
for more information.
NurselineSM Speak with a registered nurse (RN) 24 hours a day
Optional additional plan coverage
Dental Platinum Rider $32 additional monthly premium
See the “Additional Information” section for more information
Fitness Rider $13 additional monthly premium
See the “Additional Information” section for more information
* Benefit combined in and out-of-network
The benefit information provided here in is a brief summary, not a comprehensive description of benefits. For
more information contact the plan or review the Summary of Benefits provided within this booklet for more
benefit information.

visit us online at www.AARPMedicarePlans.com 5
The 2011 UnitedHealth Passport Program ®
The UnitedHealth Passport® Program is Included in Your Plan.

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

states in which there are UnitedHealth Passport®
service areas. If you are a plan member who resides
within one of the counties in this list, you are eligible
to participate in the UnitedHealth Passport Program. If you travel to any of the counties on this list, you will be
able to use the Passport benefit to access routine and preventive care as needed.
Alabama Illinois
Autauga, Baldwin, Bibb, Blount, Chilton, Elmore, Bureau, Carroll, Cook, Henderson, Henry, Jersey, Jo
Jefferson, Lowndes, Macon, Mobile, Montgomery, Daviess, Kane, Knox, Madison, Marshall, Mercer,
Russell, Shelby, St. Clair, Walker Monroe, Peoria, Putnam, Rock Island, Stark, St. Clair,
Arizona Tazewell, Warren, Whiteside, Will, Woodford
Cochise, Graham, Maricopa, Pima, Pinal, Santa Cruz, Indiana
Yavapai Adams, Allen, Boone, Fulton, Hamilton, Hancock,
Arkansas Hendricks, Huntington, Johnson, Kosciusko, Madi‑
Benton, Carroll, Crawford, Sebastian, Washington son, Marion, Noble, Posey, St. Joseph, Vanderburgh,
Warrick, Wells, Whitley
Connecticut1
All Counties in the State of Connecticut Iowa
Appanoose, Benton, Black Hawk, Boone, Bremer,
Florida
Y0066_100716_122643 File & Use 08032010

Buchanan, Butler, Cedar, Chickasaw, Clarke, Clayton,
All Counties in the State of Florida Clinton, Crawford, Dallas, Davis, Delaware, Des
Georgia Moines, Dubuque, Fayette, Floyd, Greene, Grundy,
Chatham, Cherokee, Clayton, Cobb, Columbia, Guthrie, Hamilton, Hardin, Henry, Iowa, Jackson,
DeKalb, Forsyth, Fulton, Harris, Muscogee, Rich‑ Jasper, Jefferson, Johnson, Jones, Keokuk, Lee, Linn,
mond Louisa, Lucas, Madison, Mahaska, Marion, Marshall,
Hawaii Monroe, Muscatine, Page, Polk, Pottawattamie,
All Counties in the State of Hawaii Poweshiek, Scott, Shelby, Story, Tama, Van Buren,
Wapello, Warren, Washington, Wayne
Idaho
Ada, Canyon Kansas
Johnson, Sedgwick
26 visit us online at www.AARPMedicarePlans.com
Kentucky Rhode Island
Boone, Campbell, Kenton All Counties in the State of Rhode Island
Maine South Carolina
Cumberland, Kennebec, Sagadahoc, York Beaufort, Charleston, Greenville, York
Massachusetts Tennessee
All Counties in the State of Massachusetts Anderson, Blount, Bradley, Campbell, Carter,
Michigan Claiborne, Cocke, Davidson, DeKalb, Fayette,
Allegan, Kent, Ottawa Grainger, Greene, Hamblen, Hamilton, Hancock,
Hawkins, Hickman, Jefferson, Johnson, Knox,
Missouri Loudon, McMinn, Meigs, Monroe, Morgan, Roane,
Barry, Cass, Christian, Cole, Crawford, Dade, Dallas, Rutherford, Scott, Sevier, Shelby, Sullivan, Tipton,
Douglas, Franklin, Gasconade, Greene, Jackson, Unicoi, Union, Washington
Jefferson, Laclede, Lafayette, Lawrence, Lincoln,
McDonald, Polk, St. Charles, St. Louis, St. Louis City, Texas
Stone, Texas, Warren, Washington, Webster, Wright Austin, Brazoria, El Paso, Fort Bend, Hardin, Harris,
Jefferson, Liberty, Montgomery
Nebraska
Burt, Cass, Douglas, Otoe, Sarpy, Washington Utah
Box Elder, Cache, Davis, Morgan, Salt Lake, Summit,
New Mexico Tooele, Utah, Wasatch, Weber
Dona Ana, Grant, Hidalgo, Luna, Sierra
Vermont
New York1 All Counties in the State of Vermont
All Counties in the State of New York
Virginia
North Carolina Bland, Botetourt, Bristol City, Buchanan, Chester‑
Alamance, Caswell, Catawba, Chatham, Cumberland, field, Craig, Dickenson, Floyd, Franklin, Goochland,
Davidson, Davie, Durham, Forsyth, Guilford, Haywood, Grayson, Lee, Hanover, Henrico, Montgomery,
Henderson, Iredell, Mecklenburg, Orange, Person, Newport News City, Norfolk City, Norton City, Ports‑
Randolph, Rockingham, Rowan, Stokes, Surry, Wake, mouth City, Radford City, Richmond City, Roanoke,
Wilkes, Yadkin Roanoke City, Russell, Salem City, Scott, Smyth,
Ohio Tazewell, Washington, Wise, Wythe
Butler, Clark, Clermont, Cuyahoga, Delaware, Franklin, Washington
Greene, Hamilton, Madison, Mahoning, Montgomery, Skagit, Spokane, Whatcom
Preble, Stark, Summit, Trumbull, Warren
Wisconsin
Oregon2 Brown, Calumet, Dodge, Fond Du Lac, Green Lake,
Clackamas, Lane, Marion, Multnomah, Washington, Kewaunee, La Crosse, Manitowoc, Milwaukee, Monroe,
Yamhill Oconto, Outagamie, Ozaukee, Racine, Shawano,
Pennsylvania Sheboygan, Trempeleau, Vernon, Washington,
Erie, Lancaster, Lehigh, Northampton, York Waukesha, Waupaca, Waushara, Winnebago
1
Members of HMO plans H3307 in New York as well as Point of Service plans H0752 in Connecticut and
H3107 in New Jersey may access Passport services in the state of Florida only.
2
The H3805 HMO plans in the Oregon counties of Clackamas, Lane, Marion, Multnomah and Washington do
not participate in UnitedHealth Passport. Therefore, members of these plans are not eligible to participate in
the program.

a Medicare Advantage organization with a Medicare contract. 37
Ready to Enroll?
Things to Do Before You Enroll: make
an informed
CHOICE
Review the benefit information in this booklet.
You may choose to contact your doctor to confirm if he or she is in the

network or you may ask your sales agent to check for you. For a complete
list of plan providers, visit our Web site.
heck the Drug List in this booklet to see if your medications are included.
C
Visit our Web site for a detailed listing of prescription medications. (for MAPD plans)
Have your Original Medicare ID card ready or other proof that states you are eligible for
Medicare. This information will help you fill out the Enrollment Form.
I’m a Member…What’s Next?

Enjoy Peace of Mind with One Convenient Plan
After Medicare approves your enrollment you will receive your Welcome Letter, New Member Kit and
your Member ID card.
This is a sample card; your card may look different.
Y0066_100720_090630 File & Use 08102010

Customer service phone number is located
on the back of your card.
Please secure your Original Medicare card

in a safe place.
www.myAARPMedicare.com
Register online to view your personal information, plan details, coverage summaries, payment history,
options and claims.

a Medicare Advantage organization with a Medicare contract.
8
Summary of Benefits
January 1, 2011 — December 31, 2011
AARP® MedicareComplete® Plus (HMO-POS)

H2182-001
Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth,

Fulton counties
AAGA11PO3240581_000
H0755Y0066_100816EA01_SB_MAMAPD CMS Approved 09082010
Section I - Introduction to Summary of Benefits
Thank you for your interest in AARP MedicareComplete Plus (HMO-POS). Our plan is offered by
UNITEDHEALTHCARE INSURANCE COMPANY/SecureHorizons by UnitedHealthcare, a Medicare Advantage
Health Maintenance Organization (HMO), with a point-of-service option (POS). This Summary of Benefits
tells you some features of our plan. It doesn't list every service that we cover or list every limitation or
exclusion. To get a complete list of our benefits, please call AARP MedicareComplete Plus (HMO-POS) and
ask for the "Evidence of Coverage".
You Have Choices in Your Health Care

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original
(fee-for-service) Medicare Plan. Another option is a Medicare health plan, like AARP MedicareComplete
Plus (HMO-POS). You may have other options too. You make the choice. No matter what you decide, you
are still in the Medicare Program.
You may join or leave a plan only at certain times. Please call AARP MedicareComplete Plus (HMO-POS)
at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more
information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days
a week.
How Can I Compare My Options?

You can compare AARP MedicareComplete Plus (HMO-POS) and the Original Medicare Plan using this
Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you
can see what our plan covers and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits,
which may change from year to year.
Where is AARP MedicareComplete Plus (HMO-POS) Available?

The service area for this plan includes: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton Counties,
GA. You must live in one of these areas to join the plan.
Who is Eligible to Join AARP MedicareComplete Plus (HMO-POS)

You can join AARP MedicareComplete Plus (HMO-POS) if you are entitled to Medicare Part A and enrolled
in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are
generally not eligible to enroll in AARP MedicareComplete Plus (HMO-POS) unless they are members of
our organization and have been since their dialysis began.
Can I Choose My Doctors?

AARP MedicareComplete Plus (HMO-POS) has formed a network of doctors, specialists, and hospitals.
You can use any doctor who is part of our network. In some cases, you may also go to doctors outside of
our network. The health providers in our network can change at any time.
You can ask for a current Provider Directory or for an up-to-date list visit us at www.AARPMedicarePlans.com
Our customer service number is listed at the end of this introduction.
10
What Happens if I go to a Doctor Who's Not in Your Network?
You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the
services you receive outside the network, and you may have to follow special rules prior to getting services
in and/or out of network. For more information, please call the customer service number at the end of
this introduction.
Where can I Get My Prescriptions if I Join This Plan?

AARP MedicareComplete Plus (HMO-POS) has formed a network of pharmacies. You must use a network
pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network
pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask
for a pharmacy directory or visit us at www.AARPMedicarePlans.com Our customer service number is
listed at the end of this introduction.
AARP MedicareComplete Plus (HMO-POS) has a list of preferred pharmacies. At these pharmacies, you
may get your drugs at a lower co-pay or co-insurance. You may go to a non-preferred pharmacy, but you
may have to pay more for your prescription drugs.
Does My Plan Cover Medicare Part B or Part D Drugs?

AARP MedicareComplete Plus (HMO-POS) does cover both Medicare Part B prescription drugs and Medicare
Part D prescription drugs.
What is a Prescription Drug Formulary?

AARP MedicareComplete Plus (HMO-POS) uses a formulary. A formulary is a list of drugs covered by your
plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations
on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our
members' ability to fill their prescriptions, we will notify the affected enrollees before the change is made.
We will send a formulary to you and you can see our complete formulary on our Web site at
www.AARPMedicarePlans.com
If you are currently taking a drug that is not on our formulary or subject to additional requirements or
limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception
or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can
get a temporary supply of the drug or for more details about our drug transition policy.
How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra Help
With Other Medicare Costs?
You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help
with other Medicare costs. To see if you qualify for getting extra help, call:
* 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7
days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources' in the
publication Medicare & You.
* The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through
Friday. TTY/TDD users should call 1-800-325-0778 or
* Your State Medicaid Office.
11
What Are My Protections in This Plan?
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans
decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you
will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90
days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request an organization
determination, which includes the right to file an appeal if we deny coverage for an item or service, and
the right to file a grievance. You have the right to request an organization determination if you want us to
provide or pay for an item or service that you believe should be covered. If we deny coverage for your
requested item or service, you have the right to appeal and ask us to review our decision. You may ask us
for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could
seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor
makes or supports the expedited request, we must expedite our decision. Finally, you have the right to
file a grievance with us if you have any type of problem with us or one of our network providers that does
not involve coverage for an item or service. If your problem involves quality of care, you also have the right
to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the
Evidence of Coverage (EOC) for the QIO contact information.
As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request a coverage
determination, which includes the right to request an exception, the right to file an appeal if we deny
coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage
determination if you want us to cover a Part D drug that you believe should be covered. An exception is a
type of coverage determination. You may ask us for an exception if you believe you need a drug that is
not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket
cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug.
If you think you need an exception, you should contact us before you try to fill your prescription at a
pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage
for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you
have the right to file a grievance if you have any type of problem with us or one of our network pharmacies
that does not involve coverage for a prescription drug. If your problem involves quality of care, you also
have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please
refer to the Evidence of Coverage (EOC) for the QIO contact information.
What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to
participate in a program designed for your specific health and pharmacy needs. You may decide not to
participate but it is recommended that you take full advantage of this covered service if you are selected.
Contact AARP MedicareComplete Plus (HMO-POS) for more details.
What Types of Drugs May be Covered Under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are
not limited to, the following types of drugs. Contact AARP MedicareComplete Plus (HMO-POS) for more
details.
Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who
could be the patient) under doctor supervision.
Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
12
Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent
kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
Injectable Drugs: Most injectable drugs administered incident to a physician's service.
Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant
was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare
Part A coverage, in a Medicare-certified facility.
Some Oral Cancer Drugs: If the same drug is available in injectable form.
Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
Inhalation and Infusion Drugs provided through DME.
Where Can I Find Information on Plan Ratings?

The Medicare program rates how well plans perform in different categories (for example, detecting and
preventing illness, ratings from patients and customer service). If you have access to the web, you may
use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or
"Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans
in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer
service number is listed below.
Please call SecureHorizons by UnitedHealthcare for more information about

AARP MedicareComplete Plus (HMO-POS).
Visit us at www.AARPMedicarePlans.com or, call us:
Customer Service Hours:
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m - 8:00 p.m Eastern
Current members should call toll-free 1-800-643-4845 for questions related to the
Medicare Advantage Program and Medicare Part D Prescription Drug program.
TTY/TDD: 711
Prospective members should call toll-free 1-800-547-5514 for questions related to the
Medicare Advantage and Medicare Part D Prescription Drug Program.
TTY/TDD: 711
For more information about Medicare, please call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days
a week. Or, visit www.medicare.gov on the web.
This document may be available in a different format or language. For additional information, call
customer service at the phone number listed above.
Este documento puede estar disponible en diferentes formatos e idiomas. Por favor, llame al número
de Servicio al Cliente dado anteriormente si necesita obtener más información.
本資訊可以不同形式或語言提供。如需更多資訊，請撥打上文所列的電話號碼，與客戶服
務部聯絡。
If you have special needs, this document may be available in other formats.
13
Section II - Summary Of Benefits
If you have any questions about this plan's benefits or costs, please contact SecureHorizons by UnitedHealthcare
for details.
Benefit Original Medicare AARP MedicareComplete Plus
(HMO-POS)
Important Information
1 Premium and Other In 2010 the monthly Part B Premium General

Important was $96.40 and may change for 2011 $0 monthly plan premium in addition
Information and the yearly Part B deductible to your monthly Medicare Part B
amount was $155 and may change for premium.
2011. Most people will pay the standard
If a doctor or supplier does not accept monthly Part B premium in addition to
assignment, their costs are often their MA plan premium. However,
higher, which means you pay more. some people will pay higher Part B and
Part D premiums because of their
Most people will pay the standard
yearly income (over $85,000 for
monthly Part B premium. However,
some people will pay a higher premium singles, $170,000 for married
because of their yearly income (over couples). For more information about
Part B and Part D premiums based on
$85,000 for singles, $170,000 for
married couples). For more information income, call Medicare at
1-800-MEDICARE (1-800-633-4227).
about Part B premiums based on
TTY users should call 1-877-486-2048.
income, call Medicare at
1-800-MEDICARE (1-800-633-4227). You may also call Social Security at
TTY users should call 1-877-486-2048. 1-800-772-1213. TTY users should call
1-800-325-0778.
You may also call Social Security at
1-800-772-1213. TTY users should call This plan covers all Medicare-covered
1-800-325-0778. preventive services with zero cost
sharing.
In-Network
$3,380 out-of-pocket limit.
This limit includes only
Medicare-covered services.
2 Doctor and Hospital You may go to any doctor, specialist In-Network

Choice or hospital that accepts Medicare. No referral required for network
(For more doctors, specialists, and hospitals.
information, see Out of Service Area
Emergency Care -
Plan covers you when you travel in the
#15 and Urgently
U.S.
Needed Care - #16.)
Inpatient Care
14
(HMO-POS)
Inpatient Care (continued)
3 Inpatient Hospital In 2010 the amounts for each benefit In-Network

Care period were: No limit to the number of days covered
(includes Substance Days 1 - 60: $1100 deductible by the plan each benefit period.
Abuse and Days 61 - 90: $275 per day For Medicare-covered hospital stays:
Rehabilitation Days 91 - 150: $550 per lifetime
Services) reserve day These amounts will Days 1 - 7: $295 copay per day
change for 2011. Call Days 8 - 90: $0 copay per day
1-800-MEDICARE (1-800-633-4227) $0 copay for each additional hospital
for information about lifetime reserve
days. day.
Lifetime reserve days can only be used

once.
A "benefit period" starts the day you
go into a hospital or skilled nursing
facility. It ends when you go for 60
days in a row without hospital or
skilled nursing care. If you go into the
hospital after one benefit period has
ended, a new benefit period begins.
You must pay the inpatient hospital
deductible for each benefit period.
There is no limit to the number of
benefit periods you can have.
4 Inpatient Mental Same deductible and copay as In-Network

Health Care inpatient hospital care (see "Inpatient You get up to 190 days in a Psychiatric
Hospital Care" above). Hospital in a lifetime.
190 day lifetime limit in a Psychiatric For Medicare-covered hospital stays:
Hospital. Days 1 - 7: $295 copay per day
Days 8 - 90: $0 copay per day
5 Skilled Nursing In 2010 the amounts for each benefit In-Network

Facility (SNF) period after at least a 3-day covered Plan covers up to 100 days each
(in a hospital stay were: benefit period
Medicare-certified Days 1 - 20: $0 per day No prior hospital stay is required.
skilled nursing Days 21 - 100: $137.50 per day
facility) These amounts will change for 2011. For Medicare-covered SNF stays:
100 days for each benefit period. Days 1 - 34: $100 copay per day
A "benefit period" starts the day you
go into a hospital or SNF. It ends when
you go for 60 days in a row without
hospital or skilled nursing care. If you
15
(HMO-POS)
Inpatient Care (continued)
go into the hospital after one benefit
period has ended, a new benefit period
begins. You must pay the inpatient
hospital deductible for each benefit
period. There is no limit to the number
of benefit periods you can have.
6 Home Health Care $0 copay. In-Network

(includes medically $0 copay for each Medicare-covered
necessary home health visit.
intermittent skilled
nursing care, home
health aide services,
and rehabilitation
services, etc.)
7 Hospice You pay part of the cost for outpatient General

drugs and inpatient respite care. You must get care from a
Medicare-certified hospice.
You must get care from a
Medicare-certified hospice.
Outpatient Care
8 Doctor Office Visits 20% coinsurance In-Network

$10 copay for each primary care
doctor visit for Medicare-covered
benefits.
$30 copay for each in-area, network
urgent care Medicare-covered visit.
$35 copay for each specialist visit for
Medicare-covered benefits.
9 Chiropractic Routine care not covered In-Network

Services 50% of the cost for each
20% coinsurance for manual
Medicare-covered visit.
manipulation of the spine to correct
subluxation (a displacement or Medicare-covered chiropractic visits
misalignment of a joint or body part) are for manual manipulation of the
if you get it from a chiropractor or spine to correct subluxation (a
other qualified providers. displacement or misalignment of a
joint or body part) if you get it from a
chiropractor or other qualified
providers.
16
(HMO-POS)
Outpatient Care (continued)
10 Podiatry Services Routine care not covered. In-Network

$35 copay for each Medicare-covered
20% coinsurance for medically
necessary foot care, including care for visit.
medical conditions affecting the lower $35 copay for up to 6 routine visit(s)
limbs. every year
Medicare-covered podiatry benefits
are for medically-necessary foot care.
11 Outpatient Mental 45% coinsurance for most outpatient In-Network

Health Care mental health services. $40 copay for each Medicare-covered
individual therapy visit.
$30 copay for each Medicare-covered
group therapy visit.
12 Outpatient 20% coinsurance In-Network

Substance Abuse $40 copay for Medicare-covered
Care individual visits.
$30 copay for Medicare-covered group
visits.
13 Outpatient 20% coinsurance for the doctor In-Network

Services/Surgery 20% of the cost for each
Specified copayment for outpatient
hospital facility charges. Copay cannot Medicare-covered ambulatory surgical
exceed than Part A inpatient hospital center visit.
deductible. 20% of the cost for each
Medicare-covered outpatient hospital
20% coinsurance for ambulatory
facility visit.
surgical center facility charges
14 Ambulance 20% coinsurance In-Network

Services $200 copay for Medicare-covered
(medically necessary ambulance benefits.
ambulance services)
15 Emergency Care 20% coinsurance for the doctor General

(You may go to any $50 copay for Medicare-covered
Specified copayment for outpatient
emergency room if
hospital emergency room (ER) facility emergency room visits.
you reasonably
charge. Worldwide coverage.
believe you need
emergency care.) ER Copay cannot exceed Part A If you are admitted to the hospital
inpatient hospital deductible. within 24-hour(s) for the same
17
(HMO-POS)
Outpatient Care (continued)
You don't have to pay the emergency condition, you pay $0 for the
room copay if you are admitted to the emergency room visit
hospital for the same condition within
3 days of the emergency room visit.
NOT covered outside the U.S. except
under limited circumstances.
16 Urgently Needed 20% coinsurance, or a set copay General

Care
NOT covered outside the U.S. except $40 copay for Medicare-covered
(This is NOT urgently needed care visits.
under limited circumstances.
emergency care, and
in most cases, is out
of the service area.)
17 Outpatient 20% coinsurance In-Network

Rehabilitation $35 copay for Medicare-covered
Services Occupational Therapy visits.
(Occupational
$35 copay for Medicare-covered
Therapy, Physical
Physical and/or Speech and Language
Therapy, Speech and
Therapy visits.
Language Therapy,
Respiratory Therapy $35 copay for Medicare-covered
Services, Social/ Cardiac Rehab services.
Psychological
Services, and more)
Outpatient Medical Services and Supplies
18 Durable Medical 20% coinsurance In-Network

Equipment 20% of the cost for Medicare-covered
(includes items.
wheelchairs, oxygen,
etc.)
19 Prosthetic Devices 20% coinsurance In-Network

(includes braces, 20% of the cost for Medicare-covered
artificial limbs and items.
eyes, etc.)
18
(HMO-POS)
Outpatient Medical Services and Supplies (continued)
20 Diabetes 20% coinsurance In-Network

Self-Monitoring $0 copay for Diabetes self-monitoring
Nutrition therapy is for people who
Training, Nutrition training.
have diabetes or kidney disease (but
Therapy, and
aren't on dialysis or haven't had a $0 copay for Nutrition Therapy for
Supplies
kidney transplant) when referred by a Diabetes.
(includes coverage
doctor. These services can be given by $0 copay for Diabetes supplies.
for glucose monitors,
a registered dietitian or include a
test strips, lancets,
nutritional assessment and counseling
screening tests,
to help you manage your diabetes or
self-management
kidney disease.
training, retinal
exam/glaucoma test,
and foot exam/
therapeutic soft
shoes)
21 Diagnostic Tests, 20% coinsurance for diagnostic tests In-Network

X-Rays, Lab and x-rays $0 to $10 copay for Medicare-covered
Services, and lab services.
$0 copay for Medicare-covered lab
Radiology Services
services 0% to 20% of the cost for
Medicare-covered diagnostic
Lab Services: Medicare covers
procedures and tests.
medically necessary diagnostic lab
services that are ordered by your $16 copay for Medicare-covered
treating doctor when they are provided X-rays.
by a Clinical Laboratory Improvement 20% of the cost for Medicare-covered
Amendments (CLIA) certified diagnostic radiology services (not
laboratory that participates in
including x-rays).
Medicare. Diagnostic lab services are
done to help your doctor diagnose or 20% of the cost for Medicare-covered
rule out a suspected illness or therapeutic radiology services.
condition. Medicare does not cover
most routine screening tests, like
checking your cholesterol.
Preventive Services
22 Bone Mass No coinsurance, copayment or In-Network

Measurement deductible. $0 copay for Medicare-covered bone
(for people with
Covered once every 24 months (more mass measurement.
Medicare who are at
often if medically necessary) if you
risk)
meet certain medical conditions.
19
(HMO-POS)
Preventive Services (continued)
23 Colorectal No coinsurance, copayment or In-Network

Screening Exams deductible for screening colonoscopy $0 copay for Medicare-covered
(for people with or screening flexible sigmoidoscopy. colorectal screenings.
Medicare age 50 and
Covered when you are high risk or $0 copay up to 1 additional
older)
when you are age 50 and older. screening(s) every year.
24 Immunizations $0 copay for Flu, and Pneumonia and In-Network

(Flu vaccine, Hepatitis B vaccines. $0 copay for Flu and Pneumonia
Hepatitis B vaccine - vaccines.
You may only need the Pneumonia
for people with
vaccine once in your lifetime. Call your No referral needed for Flu and
Medicare who are at
doctor for more information. pneumonia vaccines.
risk, Pneumonia
vaccine) $0 copay for Hepatitis B vaccine.
25 Mammograms No coinsurance, copayment or In-Network

(Annual Screening) deductible. $0 copay for Medicare-covered
(for women with screening mammograms.
No referral needed.
Medicare age 40 and
older) Covered once a year for all women
with Medicare age 40 and older. One
baseline mammogram covered for
women with Medicare between age 35
and 39.
26 Pap Smears and No coinsurance, copayment, or In-Network

Pelvic Exams deductible for Pap smears. $0 copay for Medicare-covered pap
(for women with smears and pelvic exams
No coinsurance, copayment, or
Medicare)
deductible for Pelvic and clinical breast $0 copay up to 1 additional pap
exams. smear(s) and pelvic exam(s) every year
Covered once every 2 years. Covered
once a year for women with Medicare
at high risk.
27 Prostate Cancer 20% coinsurance for the digital rectal In-Network

Screening Exams exam. $0 copay for Medicare-covered
(for men with
$0 for the PSA test; 20% coinsurance prostate cancer screening.
Medicare age 50 and
for other related services.
older)
Covered once a year for all men with
Medicare over age 50.
20
(HMO-POS)
28 End-Stage Renal 20% coinsurance for renal dialysis In-Network

Disease
20% coinsurance for Nutrition Therapy 20% of the cost for renal dialysis
for End-Stage Renal Disease $0 copay for Nutrition Therapy for
End-Stage Renal Disease.
Nutrition therapy is for people who
have diabetes or kidney disease (but
aren't on dialysis or haven't had a
kidney transplant) when referred by a
doctor. These services can be given by
a registered dietitian or include a
nutritional assessment and counseling
to help you manage your diabetes or
kidney disease.
29 Prescription Drugs Most drugs are not covered under Drugs covered under Medicare Part
Original Medicare. You can add B General
prescription drug coverage to Original 20% of the cost for Part B-covered
Medicare by joining a Medicare chemotherapy drugs and other Part
Prescription Drug Plan, or you can get B-covered drugs.
all your Medicare coverage, including Drugs covered under Medicare Part
prescription drug coverage, by joining D General
a Medicare Advantage Plan or a This plan uses a formulary. The plan
Medicare Cost Plan that offers will send you the formulary. You can
prescription drug coverage. also see the formulary at
www.AARPMedicarePlans.com on the
web.
Different out-of-pocket costs may
apply for people who
have limited incomes,
live in long term care facilities, or
have access to Indian/Tribal/Urban
(Indian Health Service).
The plan offers national in-network
prescription coverage (i.e., this would
include 50 states and DC). This means
that you will pay the same cost-sharing
amount for your prescription drugs if
you get them at an in-network
pharmacy outside of the plan's service
area (for instance when you travel).
21
(HMO-POS)
Total yearly drug costs are the total
drug costs paid by both you and the
plan.
The plan may require you to first try
one drug to treat your condition before
it will cover another drug for that
condition.
Some drugs have quantity limits.
Your provider must get prior
authorization from AARP
MedicareComplete Plus (HMO-POS)
for certain drugs.
You must go to certain pharmacies for
a very limited number of drugs, due to
special handling, provider coordination,
or patient education requirements that
cannot be met by most pharmacies in
your network. These drugs are listed
on the plan's website, formulary,
printed materials, as well as on the
Medicare Prescription Drug Plan Finder
on Medicare.gov.
If the actual cost of a drug is less than
the normal cost-sharing amount for
that drug, you will pay the actual cost,
not the higher cost-sharing amount.
If you request a formulary exception
for a drug and AARP
MedicareComplete Plus (HMO-POS)
approves the exception, you will pay
Tier 3: Non-Preferred Generic and
Non-Preferred Brand Drugs cost
sharing for that drug.
In-Network $0 deductible.
Initial Coverage You pay the following until total yearly

drug costs reach $2,840:
Retail Pharmacy Tier 1: Preferred Generic Drugs
22
(HMO-POS)
$5 copay for a one-month (31-day)
supply of drugs in this tier
$15 copay for a three-month (90-day)
Tier 2: Generic and Preferred Brand
Drugs
$135 copay for a three-month
(90-day) supply of drugs in this tier
Non-Preferred Brand Drugs
Tier 4: Specialty Tier Drugs
33% coinsurance for a one-month
33% coinsurance for a three-month
Long Term Care Tier 1: Preferred Generic Drugs

Pharmacy
Drugs
Mail Order Tier 1: Preferred Generic Drugs

supply of drugs in this tier from a
preferred mail order pharmacy.
23
(HMO-POS)
supply of drugs in this tier from a
non-preferred mail order pharmacy.
Drugs
from a preferred mail order
pharmacy.
from a non-preferred mail order
pharmacy.
pharmacy.
pharmacy.
pharmacy.
pharmacy.
Coverage Gap After your total yearly drug costs reach

$2,840, you receive a discount on
brand name drugs and pay 93% of the
plan's costs for all generic drugs, until
your yearly out-of-pocket drug costs
reach $4,550.
Catastrophic Coverage After your yearly out-of-pocket drug

costs reach $ 4,550, you pay the
greater of:
24
(HMO-POS)
A $ 2.50 copay for generic (including
brand drugs treated as generic) and
a $ 6.30 copay for all other drugs, or
5% coinsurance.
Out-of-Network Plan drugs may be covered in special

circumstances, for instance, illness
while traveling outside of the plan's
service area where there is no network
pharmacy. You may have to pay more
than your normal cost-sharing amount
if you get your drugs at an
out-of-network pharmacy. In addition,
you will likely have to pay the
pharmacy's full charge for the drug and
submit documentation to receive
reimbursement from AARP
MedicareComplete Plus (HMO-POS).
Out-of-Network Initial You will be reimbursed up to the full

Coverage cost of the drug minus the following
for drugs purchased out-of-network
until total yearly drug costs reach
$2,840:
Tier 1: Preferred Generic Drugs
Drugs
You will not be reimbursed for the
difference between the Out-of-Network
25
(HMO-POS)
Pharmacy charge and the plan's
In-Network allowable amount.
Out-of-Network You will be reimbursed up to 7% of the

Coverage Gap plan allowable cost for generic drugs
purchased out-of-network until total
yearly out-of-pocket drug costs reach
$4,550.
You will be reimbursed up to the
discounted price for brand name drugs
purchased out-of-network until total
yearly out-of-pocket drug costs reach
$4,550.
Out-of-Network After your yearly out-of-pocket drug

Catastrophic Coverage costs reach $ 4,550, you will be
reimbursed for drugs purchased
out-of-network up to the full cost of
the drug minus your cost share, which
is the greater of:
A $ 2.50 copay for generic (including
brand drugs treated as generic) and
a $ 6.30 copay for all other drugs, or
5% coinsurance.
30 Dental Services Preventive dental services (such as In-Network

cleaning) not covered. In general, preventive dental benefits
(such as cleaning) not covered.
$35 copay for Medicare-covered dental
benefits.
31 Hearing Services Routine hearing exams and hearing In-Network

aids not covered. $35 copay for Medicare-covered
diagnostic hearing exams
26
(HMO-POS)
20% coinsurance for diagnostic hearing $0 to $35 copay for up to 1 routine
exams. hearing test(s) every year
$0 copay per hearing aid
$300 plan coverage limit for hearing
aids every two years.
32 Vision Services 20% coinsurance for diagnosis and In-Network

treatment of diseases and conditions $0 copay for one pair of eyeglasses
of the eye. or contact lenses after cataract
surgery.
Routine eye exams and glasses not $0 to $35 copay for exams to
covered. diagnose and treat diseases and
conditions of the eye.
Medicare pays for one pair of $35 copay for up to 1 routine eye
eyeglasses or contact lenses after exam(s) every year
cataract surgery. $30 copay for contacts
$0 copay for up to 1 pair(s) of lenses
Annual glaucoma screenings covered every two years
for people at risk. $30 copay for up to 1 frame(s) every
two years
$105 plan coverage limit for contact
lenses every two years.
$70 plan coverage limit for eye glass
frames every two years.
33 Welcome to When you join Medicare Part B, then In-Network

Medicare; and you are eligible as follows. $0 copay for the required
Annual Wellness
During the first 12 months of your new Medicare-covered initial preventive
Visit physical exam and annual wellness
Part B coverage, you can get either a
visits.
Welcome to Medicare exam or an
Annual Wellness visit.
After your first 12 months, you can get
one Annual Wellness visit every 12
months.
There is no coinsurance, copayment
or deductible for either the Welcome
to Medicare exam or the Annual
Wellness visit.
The Welcome to Medicare exam does
not include lab tests.
27
(HMO-POS)
34 Health/Wellness Smoking Cessation: Covered if ordered In-Network

Education by your doctor. Includes two The plan covers the following health/
counseling attempts within a 12-month wellness education benefits:
period if you are diagnosed with a Written health education materials,
smoking-related illness or are taking including Newsletters
medicine that may be affected by Nursing Hotline
tobacco. Each counseling attempt $0 copay for each Medicare-covered
includes up to four face-to-face visits. smoking cessation counseling session.
You pay coinsurance, and Part B
deductible applies. $0 copay for each Medicare-covered
HIV screening.
$0 copay for the HIV screening, but
you generally pay 20% of the HIV screening is covered for people
Medicare-approved amount for the with Medicare who are pregnant and
doctor's visit. HIV screening is covered people at increased risk for the
for people with Medicare who are infection, including anyone who asks
pregnant and people at increased risk for the test. Medicare covers this test
for the infection, including anyone who once every 12 months or up to three
asks for the test. Medicare covers this times during a pregnancy.
test once every 12 months or up to
three times during a pregnancy.
Transportation Not covered. In-Network

(Routine) This plan does not cover routine
transportation.
Acupuncture Not covered. In-Network

This plan does not cover Acupuncture.
Point of Service You may go to any doctor, specialist Out-of-Network

or hospital that accepts Medicare. Point of Service coverage is available
for the following benefits:
- Inpatient Hospital Acute
Inpatient Hospital Psychiatric
Skilled Nursing Facility (SNF)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Partial Hospitalization
Home Health Services
Primary Care Physician Services
Chiropractic Services
Occupational Therapy Services
Physician Specialist Services
Mental Health Specialty Services
28
(HMO-POS)
Podiatry Services
Other Health Care Professional
Psychiatric Services
Physical Therapy and Speech/
Language Pathology Services
Outpatient Diag Procs/Tests/Lab
Services
Diagnostic Radiological Services
Therapeutic Radiological Services
Outpatient X-Rays
Outpatient Hospital Services
Ambulatory Surgical Center (ASC)
Services
Outpatient Substance Abuse
Cardiac Rehabilitation Services
Ambulance Services
DME
Prosthetics/Medical Supplies
Diabetes Monitoring Supplies
Blood
Health Education/Wellness
Immunizations
Routine Physical Exams
Pap Smears and Pelvic Exams
Prostate Screening
Colorectal Screening
Bone Mass Measurement
Mammography Screening
Diabetes Monitoring
Nutrition Therapy for Diabetes and
Renal Disease
Comprehensive Dental
Eye Exams
Eye Wear
Hearing Exams
$325 copay per hospital day.
For Inpatient Psychiatric Hospital
stays:
For each SNF stay:
Days 1 - 40: $175 copay per SNF day
Days 41 - 100: $0 copay per SNF day
$15 copay for
Primary Care Physician Services
Other Health Care Professional
Routine Physical Exams
29
(HMO-POS)
$40 copay for
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Occupational Therapy Services
Physician Specialist Services
Podiatry Services
Physical Therapy and Speech/
Language Pathology Services
Cardiac Rehabilitation Services
Eye Exams
Hearing Exams
30% of the cost for
Home Health Services
Diagnostic Radiological Services
Therapeutic Radiological Services
Outpatient Hospital Services
Ambulatory Surgical Center (ASC)
Services
DME
Prosthetics/Medical Supplies
Diabetes Monitoring Supplies
Pap Smears and Pelvic Exams
Prostate Screening
Colorectal Screening
Bone Mass Measurement
Mammography Screening
Diabetes Monitoring
Nutrition Therapy for Diabetes and
Renal Disease
Eye Wear
$10 copay or 30% of the cost for
Outpatient Diag Procs/Tests/Lab
Services
$21 copay for
Outpatient X-Rays
$75 copay for
Partial Hospitalization
$200 copay for
Ambulance Services
$35 to $45 copay for
Mental Health Specialty Services
Psychiatric Services
30
(HMO-POS)
Outpatient Substance Abuse
$0 copay for
Blood
Immunizations
50% of the cost for
Chiropractic Services
Optional Supplemental Package #1

Premium and Other General
Important Information Package: 1 - Dental Platinum Rider:
$32 monthly premium, in addition to
your $0 monthly plan premium and the
monthly Medicare Part B premium, for
the following optional benefits:
Preventive Dental
Dental Services General

Plan offers additional comprehensive
dental benefits.
In-Network
$0 copay for up to 1 cleaning(s)
every six months
$0 copay for up to 1 fluoride
treatment(s) every six months
$0 copay for up to 1 oral exam(s)
every six months
$0 copay for up to 1 dental x-ray(s)
$1,000 plan coverage limit for dental
benefits every year.
Optional Supplemental Package #2

Premium and Other General
Important Information Package: 2 - Fitness Rider:
$13 monthly premium, in addition to
your $0 monthly plan premium and the
monthly Medicare Part B premium, for
the following optional benefits:
31
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Additional Information
Member Appeals and Grievances Process
Members of our Medicare Advantage health plans have the right to request an organization determination
including the right to file an appeal and the right to file a grievance. Medicare Advantage health plan
organizations must identify, track, resolve and report all activity related to an appeal or grievance.
Medicare Advantage Member Appeals

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

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

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

An appeal must be filed in writing directly to us. You may call Customer Service for additional information.
To learn how to file an appeal, contact Customer Service.
Fast Reviews
You have the right to request and receive fast decisions affecting your medical treatment in “time-sensitive”
situations. A situation is time-sensitive if waiting for a decision to be made within the standard timeframe
could seriously harm your health or your ability to function. If your doctor provides a written or oral statement
supporting your need of a fast review we will automatically give you a fast review. A decision will be issued as
Y0004Y0066_100618_124951 CMS Approved 07022010
quickly as possible but no later than 72 hours after receiving the request.
Medicare Advantage Member Grievances

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

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

You may file a grievance or someone else may file a grievance on your behalf. You must appoint the individual
to act as your representative to file the grievance for you. To learn how to name a representative, contact
Customer Service.
1
35
How can a Grievance be filed?
A grievance for Quality of Care may be filed verbally by contacting Customer Service. All other grievances
must be submitted in writing.
Fast Grievances
You have the right to file a fast grievance. We will respond to fast grievances within 24 hours of receipt.
You may file a fast grievance if you disagree with our decision to deny your request for a fast review. You
may also file a fast grievance if we notify you that we are extending our timeframe to make an organization
determination or reconsideration decision, or if we downgrade your expedited appeal request to standard due
to not meeting expedited criteria.
For Members with Medicare Part D Drug Coverage through our Plan
Coverage Determinations
We will make an initial decision as to whether or not we will provide the Part D drug you are requesting or pay
for the Part D drug you already received. This initial decision is called a “coverage determination.”
Exceptions
You or your doctor may ask us to make an exception to our Part D coverage determination. You may request
an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a
non-preferred drug at a lower out-of-pocket cost. Generally, we will only approve your request for an exception
if the alternative Part D drug is included in your plan’s formulary or the Part D drug in the preferred tier would
not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your
doctor or other prescriber must submit a statement supporting your exception request. In order to help us
make a decision more quickly, the supporting medical information from your doctor or other prescriber should
be sent to us with the exception request. If we approve your exception request for a Part D non-formulary
drug, you can’t request an exception to the copayment or coinsurance amount we require you to pay for the
drug. If you think you need an exception, you should contact us before you try to fill your prescription at a
pharmacy.
Part D Drug Appeals

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

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

36
SecureHorizons by UnitedHealthcare - H2182
Medicare Health Plan Ratings

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

 means very good
 means good
 means fair
 means poor
Summary Rating of
Plan too new to be measured
Health Plan Quality
This summary rating gives an overall score on the health plan’s quality and
performance on 33 different topics in 5 categories:
Y0066_100827_H2182_001_Plan Rating File & Use 09072010
• Staying healthy: screenings, tests, and vaccines. Includes how often

members got various screening tests, vaccines, and other check-ups that
help them stay healthy.
• Managing chronic (long-term) conditions. Includes how often members with
different conditions got certain tests and treatments that help them manage
their condition.
• Ratings of health plan responsiveness and care. Includes ratings of member
satisfactions with the plan.
• Health Plan member complaints, appeals, and choosing to leave the health
plan. Includes how often members have made complaints against the plan
and how often members choose to leave the plan.
• Health plan telephone customer service. Includes how well the plan handles
member calls.
37
Medicare Prescription Drug Plan Ratings

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

 means very good
 means good
 means fair
 means poor
Summary Rating of
Not enough data to calculate summary score
Prescription Drug
Plan Quality
This summary rating gives an overall score on the drug plan’s quality and
performance on 19 different topics in 4 categories:
• Drug plan customer service: Includes how well the drug plan handles calls
and makes decisions about member appeals.
• Drug plan member complaints, members who choose to leave, and
Medicare audit findings: Includes how often members complain about
the drug plan and how often members choose to leave the drug plan.
• Member experience with drug plan: Includes member satisfaction information.
• Drug pricing and patient safety: Includes how well the drug plan prices
prescriptions and provides accurate pricing information on the Medicare
website. Includes information on how often members with certain medical
conditions get prescription drugs that are considered safer and clinically
recommended for their condition.
This information is gathered from several different sources, including results
from Medicare’s regular monitoring activities, reviews of billing and other
information that plans submit to Medicare, and Medicare’s member surveys.
38
Dental Platinum Rider
If you’re looking for extra dental protection and coverage, our SecureHorizons® optional supplemental
dental rider may be right for you. The Platinum Rider is available for an additional monthly premium
of $32.
What Dental Benefits Do How Do I Enroll?

I Receive? You must be enrolled in a SecureHorizons® health
With the Platinum Rider, you get: plan in order to purchase a rider. Purchasing a rider
is optional. Please contact Customer Service at the
• 100% coverage for preventive and diagnostic number listed on the back of your Member ID Card
services such as oral exams, X-rays and routine to enroll in a rider.
cleanings. Partial coverage for basic services
such as fillings and for major services such as When is the Enrollment
crowns, dentures, root canals and oral surgery. Effective Date?
There is a $100 member deductible and a $1,000 If your completed enrollment request is received
calendar year maximum. Deductible does not apply by the last day of the month, your benefits will be
to preventive and diagnostic services. effective the first day of the following month. For
example, if you call Customer Service and enroll on
Can I See Any Dentist? March 31, your benefits will begin on April 1.
Choose your dentist from a large national network If you are an existing plan member, you may enroll
of providers. You may change network dentists at any time during the year. Please note that you can’t
any time however you will need to complete any be enrolled in more than one dental rider at a time
dental service currently in progress. Please see during the calendar year, including the Deluxe Rider.
your Provider Directory for a listing of
participating dentists.
When you receive your Covered Dental Services
from an Out-of-Network Dentist, the plan pays
according to a Maximum Allowable Fee Schedule*.
You pay all fees in excess of this amount.
Y0066_100812_073716 File & Use 09052010
Please refer to your Evidence of Coverage to learn

more about the full range of covered services,
including a dental procedural and fee chart.
*Allowable Fee Schedules vary according to geographic area and is a set amount that may not be equal to the
Dentist’s full fee. For further details, please contact Customer Service.
39
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For
more information contact the plan.
UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP
MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of the
AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. AARP is
not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related
products, service insurance or programs. You are strongly encouraged to evaluate your needs.
AAEX11MP3244438_000
40
SilverSneakers Fitness Rider ®
The SilverSneakers® Fitness Rider can help you take charge of your health and maintain an active
lifestyle. This award-winning program is available for an additional $13 monthly premium.
Take advantage of the following How Do I Enroll?

SilverSneakers® services: You must be enrolled in a SecureHorizons® health
plan in order to purchase a rider. Purchasing a rider
• A basic fitness center membership at over
is optional. Please contact Customer Service at the
10,000 participating locations.
number listed on the back of your Member ID Card
• Access to cardio equipment, resistance to enroll in a rider.
machines, free weights and a heated pool
at certain locations. When is the Enrollment
• SilverSneakers classes for Medicare-eligible Effective Date?
beneficiaries who want to improve their strength, If your completed enrollment request is received
flexibility, balance and endurance (available at by the last day of the month, your benefits will be
select locations). effective the first day of the following month. For
example, if you call Customer Service and enroll on
• Access to any participating fitness center while
March 31, your benefits will begin on April 1.
traveling throughout the United States.
To find participating locations in your area, please
visit www.SilverSneakers.com.
The SilverSneakers® Fitness Program is a winner of
the 2004 Healthcare and Aging Network Award of
the American Society on Aging.
Y0066_100811_124823 File & Use 09012010
41
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For
more information contact the plan.
SilverSneakers® is a registered trademark of Healthways, Inc. Healthways, Inc., is an independent company.
Consult a health care professional before beginning any exercise program.
UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP
MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty fee to AARP for use of the
AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. AARP is
not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related
products, service insurance or programs. You are strongly encouraged to evaluate your needs.
AAEX11MP3244453_000
42
2011 Disclaimers
Your Plan may contain one or more of the following:
NurseLineSM
OptumHealthSM is a health and well-being company that provides information and support as part of your
health plan. NurseLineSM nurses cannot diagnose problems or recommend specific treatment and are not a
substitute for your doctor’s care. NurseLineSM services are not an insurance program and may be discontinued
at any time.
SilverSneakers®
SilverSneakers® is a registered trademark of Healthways, Inc. Healthways, Inc., is an independent company.
The SilverSneakers® program is made available as part of this Plan’s benefits to those insured through this
Plan. Neither AARP nor UnitedHealthcare endorse or are responsible for the services or information provided
by this program. Consult a health care professional before beginning any exercise program.
Silver & Fit

Silver & Fit is provided by American Specialty Health Networks, Inc. and Healthyroads, Inc., subsidiaries of
American Specialty Health Incorporated.
Evercare™ Hospice
Evercare™ Hospice and Palliative Care is committed to the policy that all persons shall have equal access
to its programs, facilities, and employment without regard to race, sex, religion, color, age, national origin,
disability, sexual orientation or other protected factor. Evercare™ Hospice and Palliative Care is offered by
Evercare Hospice, Inc.
General Information
Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on
January1, 2012.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits.
For more information contact the Plan.
Y0066_100722_182504 File & Use 08022010
This document is available in alternate formats or languages. For more information please contact the Plan at
1-800-547-5514, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.
Este documento está disponible en diferentes formatos o idiomas. Para obtener más información, por favor
comuníquese con el Plan llamando al 1-800-547-5514, TTY: 711, de 8:00 a.m. a 8:00 p.m.,
los 7 días de la semana.
本文件可以其他形式或語言提供。如需更多資訊，請與本計劃聯絡，電話號碼是
1-800-547-5514，TTY: 711，每週七天，上午八時至晚上八時。
Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare
Advantage Organization with a Medicare contract.
43
Covering the Country
Our Prescription Drug Coverage Goes Where You Go
Our Plans Are Accepted by More Than

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

Please review our 2011 Drug List on the following pages.
OVEX11NA3240730_000
Y0066_100709_094119 File & Use 07192010
Save Money With Home Delivery
When you join one of our plans, you can take advantage of a mail service benefit from
Prescription Solutions, the plans’ Preferred Mail Service Pharmacy. This means you won’t have
to wait in line at a pharmacy to get your maintenance medications.* They can be delivered right to
your mailbox. Prescription Solutions® Mail Service makes it fast, easy and safe. After you select
your health plan, review your Welcome Kit for details.
*Maintenance medications are typically those drugs you take on a regular basis for a chronic or long-term condition.
Plans are insured or covered by an affiliate of UnitedHealthcare Insurance Company, a Medicare Advantage Organization with
a Medicare contract and a Medicare-approved Part D sponsor.
You are not required to use the plan’s Preferred Mail Service Pharmacy to obtain a 90-day supply of your maintenance
medications. You can also use a network retail extended day supply pharmacy or a network non-preferred mail service
pharmacy, but you may pay more out-of-pocket compared to using the Preferred Mail Service Pharmacy. You should pay the
same out of pocket at a network retail extended day supply pharmacy and a network non-preferred mail service pharmacy.
Please call Customer Service, at the number located on the back of your member ID card for up-to-date information on which
pharmacies are in the network.
Your prescriptions should arrive in about seven days from the date the completed order is received by Prescription Solutions.
If Prescription Solutions needs to contact you or your prescribing physician to clarify information on your order or to request
prescriptions from your physician, delivery may take longer. If you prefer rush delivery, medications can be shipped overnight
for an additional charge.
Prescription Solutions will contact you if they anticipate there will be an extended delay in the delivery of your medications. If
you need your medications immediately, Prescription Solutions can coordinate a refill with a local retail pharmacy. Standard
delivery is no charge to U.S. addresses, including U.S. territories.
Prescription Solutions is an affiliate of UnitedHealthcare Insurance Company and UnitedHealthcare Insurance Company of
New York.
2011 Drug List
# Acyclovir (Capsule, Tablet), T1 Alkeran, T4
8-Mop, T4 Acyclovir (Oral Suspension), T2 Allopurinol, T1
A Acyclovir Sodium, T2 Allopurinol Sodium, T2
Abelcet, T4 Adacel, T2 Alocril, T3
Abilify, T3 Adagen, T4 Alomide, T3
Abilify Discmelt Adcirca, T4 Alora, T3
(10 mg Dispersible Tablet), T3 Adderall XR, T3 Aloxi, T4
Abilify Discmelt Adriamycin, T2 Alphagan P, T2
(15 mg Dispersible Tablet), T4 Advair Diskus, T2 Alrex, T2
Abraxane, T4 Advair HFA, T2 Altabax, T3
Acarbose, T1 Aerobid-M, T3 Alvesco, T3
Accolate, T3 Afeditab CR, T1 Amantadine HCl, T1
Acebutolol HCl, T1 Afinitor, T4 Ambisome, T4
Acetadote, T3 Aggrenox, T2 Amcinonide, T1
Acetaminophen/Caffeine/ A-Hydrocort, T2 A-Methapred, T2
Dihydrocodeine Bitartrate, T2
AK-Con, T1 Amevive, T4
Acetaminophen/Codeine, T1
Akne-Mycin, T3 Amifostine, T4
Acetasol HC, T2
AK-Tob, T1 Amikacin Sulfate, T2
Acetazolamide
Ala Scalp, T3 Amiloride HCl, T1
(12-Hour Capsule), T2
Ala-Cort, T1 Amiloride/Hydrochlorothiazide, T1
Acetazolamide (Tablet), T1
Alamast, T3 Aminophylline (Injection), T2
Acetazolamide Sodium, T2
Albenza, T2 Aminophylline (Tablet), T1
Acetic Acid, T1
H0755Y0066_100715_165108 CMS Approved 08252010
Albuterol Sulfate Aminosyn, T3

Acetic Acid/Hydrocortisone, T2
(Nebulizer Solution), T1 Aminosyn 7%/Electrolytes, T3
Acetylcysteine, T1
Albuterol Sulfate (Syrup, Tablet), T1 Aminosyn 8.5%/Electrolytes, T2
Actemra, T4
Albuterol Sulfate ER, T1 Aminosyn II
Acthib, T2
Alcaine, T3 (10% Injection,
Acticin, T1 7% Injection,
Alclometasone Dipropionate, T1
Actimmune, T4 8.5% Injection), T3
Alcohol 5%/Dextrose 5%, T2
Actiq, T4 Aminosyn II 8.5%/Electrolytes, T2
Alcohol Preps, T1
Activella, T3 Aminosyn II M/Dextrose, T3
Aldara, T3
Actonel, T2 Aminosyn II/Dextrose, T3
Aldurazyme, T4
Actoplus Met, T2 Aminosyn M, T3
Alendronate Sodium, T1
Actos, T2 Aminosyn-HBC, T3
Alferon N, T3
Acular, T2 Aminosyn-HF, T2
Alimta, T4
Acular LS, T2 Aminosyn-PF, T3
Alinia, T3
Brand name drugs are bolded • Generic drugs are listed in light font
This is not a comprehensive list of drugs covered by your Plan. This list is subject to change.
47
Amiodarone HCl (Injection), T2 Antizol, T4 Arranon, T4
Amiodarone HCl (Tablet), T1 Anzemet (100 mg Tablet), T4 Arthrotec, T3
Amitiza, T2 Anzemet (50 mg Tablet), T3 Arzerra, T4
Amitriptyline HCl, T1 Apidra, T2 Asacol, T2
Amlodipine Besylate, T1 Apokyn, T4 Ascomp/Codeine, T1
Amlodipine Besylate/ Apraclonidine, T2 Asmanex, T3
Benazepril HCl, T1 Apri, T1 Astelin, T2
Ammonium Chloride, T3 Apriso, T2 Astepro, T2
Ammonium Lactate, T1 Aptivus, T4 Astramorph, T2
Amnesteem, T2 Aralast NP, T4 Atamet, T1
Amoxapine, T1 Aranelle, T1 Atenolol, T1
Amoxicillin, T1 Aranesp Albumin Free Atenolol/Chlorthalidone, T1
Amoxicillin/ (100 mcg/0.5 ml Injection, Atgam, T4
Potassium Clavulanate, T1 100 mcg/1 ml Injection,
Atripla, T4
Amoxicillin/Potassium Clavulanate 150 mcg/0.3 ml Injection,
200 mcg/ 0.4 ml Injection, Atropine Sulfate, T1
ER, T2
200 mcg/1 ml Injection, Atrovent HFA, T3
Amphetamine/Dextroamphetamine
(24-Hour Capsule), T2 300 mcg/0.6 ml Injection, Attenuvax, T2
300 mcg/1 ml Injection, Augmented Betamethasone
Amphetamine/Dextroamphetamine 500 mcg/1 ml Injection,
(Tablet), T1 Dipropionate
60 mcg/0.3 ml Injection, (Cream, Gel, Ointment), T1
Amphotec (50mg Injection), T3 60 mcg/1 ml Injection), T4
Augmented Betamethasone
Amphotericin B, T2 Aranesp Albumin Free Dipropionate (Lotion), T2
Ampicillin, T1 (25 mcg/0.42 ml Injection,
Avandamet, T3
Ampicillin Sodium 25 mcg/1 ml Injection,
40 mcg/0.4 ml Injection, Avandaryl, T3
(10 gm Injection,
1 gm Injection), T2 40 mcg/1 ml Injection), T3 Avandia, T3
Ampicillin Sodium Arcalyst, T4 Avastin, T4
(125mg Injection), T2 Aredia (30 mg Injection), T3 Avelox (Injection), T3
Ampicillin-Sulbactam, T2 Aredia (90 mg Injection), T4 Avelox (Tablet), T2
Ampyra, T4 Aricept Avelox ABC Pack, T2
Anadrol-50, T4 (5 mg Tablet, 10 mg Tablet), T2 Aviane, T1
Anagrelide HCl, T1 Aricept ODT Avinza, T2
(5 mg Dispersible Tablet, Avita (Cream), T1
Anastrozole, T2
10 mg Dispersible Tablet), T2
Ancobon, T4 Avita (Gel), T2
Arimidex, T3
Androderm, T2 Avodart, T2
Arixtra
Androgel, T2 (10 mg/0.8 ml Injection, Avonex, T4
Androxy, T2 5.0 mg/0.4 ml Injection, Azactam, T2
Anestacon, T1 7.5 mg/0.6 ml Injection), T4 Azactam in Dextrose, T3
Antabuse, T2 Arixtra Azactam in Iso-Osmotic
Antara, T2 (2.5 mg/0.5 ml Injection), T3 Dextrose, T3
Aromasin, T3
48
Azasan, T3 Betaxolol HCl, T1 Butorphanol Tartrate (Injection), T2
Azasite, T2 Bethanechol Chloride, T1 Butorphanol Tartrate
Azathioprine, T1 Betimol, T3 (Nasal Spray), T2
Azathioprine Sodium, T1 Betoptic-S, T3 Byetta, T2
Azelastine HCl (Nasal Spray), T2 Bicalutamide, T2 Bystolic, T2
Azelastine HCl Bicillin C-R, T3 C
(Ophthalmic Solution), T2 Bicillin L-A, T3 Cabergoline, T2
Azilect, T2 BiCNU, T3 Calcipotriene, T2
Azithromycin (Injection), T2 BiDil, T2 Calcitonin-Salmon (Nasal Spray), T2
Azithromycin Biltricide, T2 Calcitriol (1 mcg/ml Injection), T2
(Oral Suspension, Tablet), T1 Calcitriol (2 mcg/ml Injection), T2
Bisoprolol Fumarate, T1
Azopt, T2 Calcitriol (Capsule, Oral Solution), T1
Bisoprolol Fumarate/
Azor, T2 Hydrochlorothiazide, T1 Calcium Acetate, T2
B Bleomycin Sulfate, T2 Camila, T1
BACiiM, T2 Blephamide, T2 Campath, T4
Bacitracin (Injection), T2 Blephamide S.O.P., T2 Campral, T3
Bacitracin (Ophthalmic Ointment), T1 Boniva (Injection), T3 Camptosar, T4
Bacitracin/Neomycin/Polymyxin, T1 Boniva (Tablet), T2 Canasa, T2
Bacitracin/Polymyxin B, T1 Boostrix, T2 Cancidas, T4
Baclofen, T1 Borofair, T1 Capastat Sulfate, T4
Bactocill in Dextrose, T4 Botox, T4 Capex, T3
Bactroban (Cream), T3 Brevicon, T3 Captopril, T1
Balacet 325, T2 Brimonidine Tartrate, T1 Captopril/Hydrochlorothiazide, T1
Balsalazide Disodium, T2 Bromocriptine Mesylate, T2 Carac, T3
Balziva, T1 Budeprion SR, T1 Carafate (Oral Suspension), T3
Banzel, T3 Budeprion XL, T1 Carbamazepine
Baraclude (Oral Solution), T3 Budesonide (Chewable Tablet, Tablet), T1
Baraclude (Tablet), T4 (Nebulizer Suspension), T2 Carbamazepine
Benazepril HCl, T1 Bumetanide (Injection), T2 (Oral Suspension), T2
Benazepril HCl/ Bumetanide (Tablet), T1 Carbamazepine ER, T2
Hydrochlorothiazide, T1 Buphenyl, T4 Carbatrol, T2
Benicar, T2 Buprenorphine HCl, T2 Carbidopa/Levodopa, T1
Benicar HCT, T2 Buproban, T1 Carbidopa/Levodopa CR, T1
Benztropine Mesylate (Injection), T2 Bupropion HCl, T1 Carbidopa/Levodopa ODT, T2
Benztropine Mesylate (Tablet), T1 Bupropion HCl SR, T1 Carbinoxamine Maleate, T1
Betamethasone Dipropionate, T1 Buspirone HCl, T1 Carboplatin, T2
Betamethasone Valerate, T1 Busulfex, T4 Carimune Nanofiltered, T4
Betaseron, T4 Butalbital/Acetaminophen/ Carisoprodol, T1
Beta-Val, T1 Caffeine/Codeine, T1 Carisoprodol/Aspirin, T1
49
Carisoprodol/Aspirin/Codeine, T2 Cephalexin, T1 Ciprodex, T2
Carteolol HCl, T1 Cerebyx, T3 Ciprofloxacin, T1
Cartia XT, T1 Ceredase, T4 Ciprofloxacin ER, T2
Carvedilol, T1 Cerezyme, T4 Ciprofloxacin HCl, T1
Casodex, T3 Cerubidine, T3 Cisplatin, T2
Catapres-TTS, T3 Cervarix, T3 Citalopram Hydrobromide
Cedax, T3 Cesamet, T4 (Oral Solution), T2
CeeNU, T3 Cesia, T1 Citalopram Hydrobromide
Cefaclor, T1 Cetirizine HCl, T1 (Tablet), T1
Cefaclor ER, T1 Cetraxal, T3 Cladribine, T4
Cefadroxil (Capsule, Chantix, T3 Claforan
Oral Suspension), T1 (1 gm Injection,
Chemet, T3 2 gm Injection), T3
Cefadroxil (Tablet), T2 Chloramphenicol Sodium Claravis, T2
Cefazolin Sodium, T2 Succinate, T2
Clarithromycin
Cefazolin Sodium/Dextrose, T1 Chlordiazepoxide/Amitriptyline, T1 (Oral Suspension), T2
Cefdinir (Capsule), T1 Chlorhexidine Gluconate Oral Clarithromycin (Tablet), T1
Cefdinir (Oral Suspension), T2 Rinse, T1
Clarithromycin ER, T1
Cefepime, T2 Chloroquine Phosphate, T1
Clemastine Fumarate, T1
Cefotaxime Sodium, T2 Chlorothiazide, T1
Cleocin (75 mg Capsule), T3
Cefotetan, T3 Chlorothiazide Sodium, T2
Cleocin Galaxy, T3
Cefoxitin Sodium, T2 Chlorpromazine HCl, T1
Cleocin Pediatric Granules, T3
Cefoxitin Sodium/Dextrose, T3 Chlorpropamide, T1
Cleocin Phosphate, T3
Cefpodoxime Proxetil, T2 Chlorthalidone, T1
Climara Pro, T3
Cefprozil, T1 Chlorzoxazone, T1
Clindagel, T3
Ceftazidime, T2 Cholestyramine, T1
Clindamycin HCl, T1
Ceftriaxone Sodium, T2 Chorionic Gonadotropin, T2
Clindamycin Phosphate
Ceftriaxone/Dextrose, T2 Ciclopirox (Gel,Shampoo), T2 (Cream, Gel, Lotion, Swab,
Cefuroxime Axetil Ciclopirox (Suspension), T1 Topical Solution), T1
(Oral Suspension), T2 Ciclopirox Nail Lacquer, T2 Clindamycin Phosphate (Foam), T2
Cefuroxime Axetil (Tablet), T1 Ciclopirox Olamine, T1 Clindamycin Phosphate
Cefuroxime Sodium, T2 Cilostazol, T1 Add-Vantage, T2
Cefuroxime/Dextrose, T1 Ciloxan, T3 Clindamycin/Benzoyl Peroxide, T2
Celebrex, T2 Cimetidine, T1 Clindesse, T3
Cellcept (Capsule), T3 Cimetidine HCl (Injection), T2 Clinimix E/Dextrose, T3
Cellcept Cimetidine HCl (Oral Solution), T1 Clinimix/Dextrose
(Oral Suspension, Tablet), T4 Cimzia, T4 (2.75%/D5W Injection, 4.25%/
Cellcept Intravenous, T3 D5W Injection, 5%/D15W
Cipro (Oral Suspension), T3
Injection, 5%/D20W Injection,
Celontin, T3 Cipro HC, T3 5%/D25W Injection), T3
Cenestin, T3 Cipro IV, T3 Clinimix/Dextrose
50
(4.25%/D10W Injection, 4.25%/ Copegus, T4 Dantrolene Sodium, T2
D20W Injection, 4.25%/D25W Cordran, T3 Dapsone, T2
Injection), T1
Cordran SP, T3 Daptacel, T2
Clinisol SF 15%, T2
Cordran Tape, T3 Daraprim, T2
Clobetasol Propionate (Foam), T2
Cortef, T3 Daunorubicin HCl, T1
Clobetasol Propionate
Cortisone Acetate, T1 DDAVP (Injection), T4
(Gel, Ointment, Topical Solution), T1
Cortisporin, T3 Decavac, T2
Clobetasol Propionate E, T1
Cortisporin-TC, T3 Demeclocycline HCl, T2
Clobex, T3
Cortomycin, T1 Demser, T4
Cloderm, T3
Cosmegen, T3 Denavir, T3
Clolar, T4
Coumadin (Injection), T3 Depade, T2
Clomipramine HCl, T1
Coumadin (Tablet), T2 Depo-Estradiol, T3
Clonidine HCl (Tablet), T1
Creon, T2 Depo-Medrol
Clonidine HCl (Weekly Patch), T2
Crestor, T2 (20 mg/ml Injection), T3
Clorpres, T3
Crixivan, T2 Depo-Provera
Clotrimazole, T1 (400 mg/ml Injection), T3
Cromolyn Sodium
Clotrimazole/Betamethasone Derma-Smoother/FS, T3
(Nebulizer Solution), T2
Dipropionate, T1
Cromolyn Sodium Dermotic, T2
Clozapine, T2
(Ophthalmic Solution), T1 Desipramine HCl, T1
Codeine Sulfate, T1
Cryselle, T1 Desmopressin Acetate, T2
Cogentin, T3
Cubicin, T4 Desogen, T3
Co-Gesic, T1
Cuprimine, T3 Desonate, T3
Cognex, T3
Cutivate (Lotion), T3 Desonide, T1
Colcrys, T3
Cyclessa, T3 Desowen/Cetaphil, T3
Colestipol HCl (Granules), T2
Cyclobenzaprine HCl, T1 Desoximetasone, T2
Colestipol HCl (Tablet), T1
Cyclophosphamide, T2 Dexamethasone, T1
Colistimethate Sodium, T4
Cyclosporine, T2 Dexamethasone Intensol, T1
Colocort, T2
Cyclosporine Modified, T2 Dexamethasone Sodium Phosphate
Coly-Mycin M, T4 (Injection), T2
Cyklokapron, T2
Coly-Mycin S, T3 Dexamethasone Sodium Phosphate
Cymbalta, T2
Combigan, T2 (Ophthalmic Solution), T1
Cyproheptadine HCl, T1
Combipatch, T3 Dexasporin, T1
Cystadane, T4
Combivent, T2 Dexchlorpheniramine Maleate, T1
Cystagon, T3
Combivir, T4 Dexilant, T3
Cytarabine, T2
Compro, T1 Dexmethylphenidate HCl, T1
Cytarabine Aqueous, T1
Comtan, T2 Dexrazoxane, T4
D
Comvax, T2 Dextroamphetamine Sulfate, T1
D.H.E. 45, T4
Constulose, T1 Dextroamphetamine Sulfate ER, T2
Dacarbazine, T2
Copaxone, T4 Dextrose 10%, T2
Danazol, T2
51
Dextrose 10%/NaCl 0.2%, T2 Diltiazem HCl ER Dronabinol (10 mg Capsule), T4
Dextrose 10%/NaCl 0.45%, T2 (12-Hour Capsule, Dronabinol (2.5 mg Capsule), T2
Dextrose 2.5%/NaCl 0.45%, T2 24-Hour Capsule), T1
Dronabinol (5 mg Capsule), T4
Dextrose 5%, T2 Diltiazem HCl ER
Droxia, T3
(24-Hour Tablet), T2
Dextrose 5%/ Duetact, T2
Electrolyte #48, T3 Dilt-XR, T1
Duramorph, T2
Dextrose 5%/KCl 0.075%, T2 Diltzac, T1
Durezol, T3
Dextrose 5%/NaCl 0.2%, T2 Diovan, T2
Dyrenium, T3
Dextrose 5%/NaCl 0.225%, T2 Diovan HCT, T2
Diphenhydramine HCl
E
Dextrose 5%/NaCl 0.33%, T2 E.E.S. 400, T1
(Capsule, Elixir), T1
Dextrose 5%/NaCl 0.45%, T2 E.E.S. Granules, T2
Diphenhydramine HCl
Dextrose 5%/NaCl 0.9%, T2 (Injection), T2 Econazole Nitrate, T1
Dibenzyline, T3 Diphenoxylate/Atropine, T1 ED K+10, T1
Diclofenac Potassium, T1 Diphtheria/Tetanus Toxoid Edecrin, T3
Diclofenac Sodium, T1 Pediatric, T2 Effient, T2
Diclofenac Sodium EC, T1 Dipyridamole, T1 Elaprase, T4
Diclofenac Sodium XR, T1 Disopyramide Phosphate, T1 Elestat, T3
Dicloxacillin Sodium, T1 Diuril, T3 Elidel, T3
Dicyclomine HCl Divalproex Sodium Eligard, T3
(Capsule, Oral Solution, Tablet), T1 (Delayed Release Tablet), T1 Eliphos, T3
Dicyclomine HCl (Injection), T2 Divalproex Sodium Elitek, T4
Didanosine, T2 (Sprinkle Capsule), T2
Elixophyllin, T2
Diflorasone Diacetate, T1 Divalproex Sodium ER, T2
Ellence, T4
Diflucan in NaCl, T3 Divigel, T3
Elmiron, T3
Diflunisal, T1 Doribax, T3
Eloxatin, T4
Digoxin (Injection), T2 Doryx, T3
Elspar, T3
Digoxin (Oral Solution, Tablet), T1 Dorzolamide HCl, T1
Emcyt, T3
Dihydroergotamine Mesylate, T2 Dorzolamide HCl/
Timolol Maleate, T2 Emend, T2
Dilantin, T2
Dovonex (Cream), T3 Emsam, T3
Dilantin Infatabs, T2
Doxazosin Mesylate, T1 Emtriva, T3
Dilatrate SR, T3
Doxepin HCl, T1 Enablex, T2
Dilaudid
Doxil, T4 Enalapril Maleate, T1
(1 mg/ml Injection, 2 mg/ml
Injection, 4 mg/ml Injection), T3 Doxorubicin HCl, T2 Enalapril Maleate/
Hydrochlorothiazide, T1
Dilt-CD, T1 Doxycycline Hyclate
(100 mg Tablet, Extended Enbrel, T4
Diltiazem CD, T1
Release Capsule, Injection), T2 Endocet, T1
Diltiazem HCl
(24-Hour Capsule, Tablet), T1 Doxycycline Hyclate Endodan, T1
Diltiazem HCl (Injection), T2 (20mg Tablet, Capsule), T1 Engerix-B, T2
Doxycycline Monohydrate, T2 Enjuvia, T2
52
Enpresse, T1 Estradiol/ Femtrace, T3
Entocort EC, T3 Norethindrone Acetate, T1 Fenofibrate, T1
Enulose, T1 Estring, T3 Fenofibrate Micronized, T1
Epinephrine HCl, T2 Estrogel, T3 Fenoprofen Calcium, T1
Epipen, T2 Estropipate, T1 Fentanyl (Patch), T2
Epirubicin HCl, T2 Estrostep Fe, T3 Fentanyl Citrate (Injection), T2
Epitol, T1 Ethambutol HCl, T2 Fentanyl Citrate Oral
Epivir, T2 Ethosuximide, T2 Transmucosal, T4
Epivir HBV, T2 Ethyol, T4 Fentora, T4
Eplerenone, T2 Etidronate Disodium, T2 Fexofenadine HCl, T1
Epogen Etodolac, T1 Finacea, T2
(10,000 units/ml Injection, Etodolac ER, T1 Finasteride (5 mg Tablet), T1
2,000 units/ml Injection, Etopophos, T4 Firmagon (120 mg Injection), T4
3,000 units/ml Injection,
Etoposide, T2 Firmagon (80 mg Injection), T3
4,000 units/ ml Injection), T3
Eurax, T3 Flagyl ER, T3
Epogen
(20,000 units/ml Injection), T4 Evista, T2 Flarex, T2
Epogen Exelderm, T3 Flavoxate HCl, T2
(40,000 units/ml Injection), T4 Exelon, T3 Flebogamma, T4
Epzicom, T4 Exforge, T2 Flecainide Acetate, T1
Equetro, T3 Exforge HCT, T2 Flovent Diskus, T2
Eraxis, T4 Exjade, T4 Flovent HFA, T2
Erbitux, T4 Extavia, T4 Fluconazole, T1
Ergoloid Mesylates, T2 F Fluconazole in Dextrose, T2
Ergotamine Tartrate/Caffeine, T1 Fabrazyme, T4 Fludara, T4
Errin, T1 Factive, T3 Fludarabine Phosphate, T4
Ertaczo, T3 Famciclovir, T2 Fludrocortisone Acetate, T1
Ery, T1 Famotidine Flunisolide, T1
Eryped, T2 (Injection, Oral Suspension), T2 Fluocinolone Acetonide, T1
Ery-Tab, T2 Famotidine (Tablet), T1 Fluocinonide, T1
Erythrocin Lactobionate, T3 Fanapt, T3 Fluocinonide-E, T1
Erythrocin Stearate, T3 Fanapt Titration Pack, T3 Fluorometholone, T1
Erythromycin, T1 Fareston, T3 Fluorouracil
Erythromycin Base, T1 Faslodex, T4 (Cream, Topical Solution), T2
Erythromycin/Benzoyl Peroxide, T1 Fazaclo, T2 Fluorouracil (Injection), T1
Erythromycin/Sulfisoxazole, T1 Felbatol, T3 Fluoxetine DR, T2
Estrace (Cream), T3 Felodipine ER, T1 Fluoxetine HCl, T1
Estraderm, T2 Femara, T2 Fluphenazine Decanoate, T2
Estradiol, T1 Femhrt, T3 Fluphenazine HCl
Femring, T3 (Concentrate, Elixir, Tablet), T1
Estradiol Valerate, T2
53
Fluphenazine HCl (Injection), T2 Gabitril Gentamicin Sulfate/NaCl
Flurbiprofen, T1 (12 mg Tablet, (100 mg Injection,
16 mg Tablet, 60 mg Injection,
Flurbiprofen Sodium, T1
2 mg Tablet), T3 80 mg Injection), T2
Flutamide, T2
Gabitril (4 mg Tablet), T3 Gentamicin Sulfate/NaCl
Fluticasone Propionate, T1 (70 mg Injection,
Galantamine Hydrobromide
Fluvoxamine Maleate, T1 (24-Hour Capsule), T2 90 mg Injection), T2
FML, T2 Galantamine Hydrobromide Gentasol, T1
FML Forte, T2 (Oral Solution, Tablet), T2 Geodon (Capsule), T2
Fomepizole, T4 Gamastan S/D, T2 Geodon (Injection), T3
Foradil Aerolizer, T2 Gammagard Liquid, T4 Gleevec, T4
Fortaz, T3 Gamunex, T4 Glimepiride, T1
Forteo, T3 Ganciclovir, T4 Glipizide, T1
Fortical, T2 Gardasil, T2 Glipizide ER, T1
Fosamax (Oral Solution), T3 Gauze Pads, T2 Glipizide/Metformin HCl, T1
Foscarnet Sodium, T2 Gavilyte-C, T1 Glucagen Hypokit, T3
Fosinopril Sodium, T1 Gavilyte-G, T1 Glucagon Emergency Kit, T2
Fosinopril Sodium/ Gavilyte-N/Flavor Pack, T1 Glyburide, T1
Hydrochlorothiazide, T1 Gelnique, T3 Glyburide Micronized, T1
Fosphenytoin Sodium, T2 Gemfibrozil, T1 Glyburide/Metformin HCl, T1
Fosrenol, T3 Gemzar, T4 Glycopyrrolate, T2
Fragmin Generlac, T1 Glycron
(10,000 units/1ml Injection, (1.5 mg Tablet,
Gengraf (Capsule), T2
25,000 units/1 ml Injection, 3 mg Tablet,
7,500 units/0.3 ml Injection), T4 Gengraf (Oral Solution), T4
6 mg Tablet), T1
Fragmin Genotropin, T4
Glyset, T3
(2,500 units/0.2 ml Injection, Genotropin Miniquick
5,000 units/0.2 ml Injection), T3 Granisetron HCl (Injection), T2
(0.2 mg Injection), T3
Freamine HBC, T3 Granisetron HCl (Tablet), T2
Genotropin Miniquick
Freamine III (3% Injection), T3 (0.4 mg Injection, Granisol, T2
0.6 mg Injection, Grifulvin V, T2
Freamine III (8.5% Injection), T3
0.8 mg Injection, Griseofulvin Microsize, T2
Furadantin, T3 1.2 mg Injection,
Furosemide (Injection), T2 Gris-Peg, T3
1.4 mg Injection,
Furosemide 1.6 mg Injection, Guanabenz Acetate, T1
(Oral Solution, Tablet), T1 1.8 mg Injection, Guanfacine HCl, T1
Fusilev, T4 1 mg Injection, Guanidine HCl, T3
2 mg Injection), T4 Gynazole-1, T3
Fuzeon, T4
Gentak, T1 Gynodiol, T3
G Gentamicin Sulfate
Gabapentin, T1 (Cream, Ointment,
H
Ophthalmic Solution), T1 Halflytely Bowel Prep, T2
Gentamicin Sulfate (Injection), T2 Halobetasol Propionate, T1
54
Halog, T3 7.5 mg-650 mg Tablet, Intralipid (30% Injection), T3
Haloperidol, T1 Oral Solution), T1 Intron-A
Haloperidol Decanoate, T2 Hydrocodone/ Acetaminophen (10 mu Injection, 10 mu Pen
(10 mg-750 mg Tablet), T2 Injection, 5 mu Pen Injection,
Haloperidol Lactate, T2
Hydrocodone/Ibuprofen, T1 18 mu Injection), T4
Havrix, T2
Hydrocortisone Intron-A (3 mu Pen Injection), T3
Hectorol, T2
(Cream, Lotion, Ointment, Invanz, T3
Heparin Sodium Tablet), T1 Invega, T3
(1,000 units/ml Injection,
Hydrocortisone (Enema), T2 Invega Sustenna
5,000 units/ml Injection), T2 Hydrocortisone Butyrate, T1 (117 mg/0.75 ml Injection,
Hydrocortisone Valerate, T1 156 mg/1 ml Injection,
Heparin Sodium
234 mg/1.5 ml Injection), T4
(2,000 units/ml Injection, Hydromorphone HCl (Injection), T2
2,500 units/ ml Injection), T2 Invega Sustenna
Hydromorphone HCl (Tablet), T1
(39 mg/0.25 ml Injection,
Heparin Sodium DCU, T2 Hydroxychloroquine Sulfate, T1 78 mg/0.5 ml Injection), T3
Heparin Sodium/D5W, T2 Hydroxyurea, T1 Invirase, T4
Heparin Sodium/NaCl, T2 Hydroxyzine HCl (Injection), T2 Ionosol-B/Dextrose 5%, T3
Heparin Sodium/NaCl 0.9% Hydroxyzine HCl (Syrup, Tablet), T1 Ionosol-MB/Dextrose 5%, T3
Premix, T2
Hydroxyzine Pamoate, T1 Ionosol-T/Dextrose 5%, T3
Hepatamine, T2
I Iopidine
Hepatasol, T3
Ibuprofen, T1 (1% Ophthalmic Solution), T3
Hepsera, T4
Idamycin PFS, T4 Ipol Inactivated IPV, T2
Herceptin, T4
Idarubicin HCl, T4 Ipratropium Bromide
Hexalen, T4 (Nasal Spray), T1
Ifosfamide, T2
Humalog, T2 Ipratropium Bromide
Ifosfamide/Mesna, T4
Humatrope, T4 (Nebulizer Solution), T1
Imipramine HCl, T1
Humira, T4 Ipratropium Bromide/Albuterol
Imipramine Pamoate, T2
Humulin, T2 Sulfate (Nebulizer Solution), T1
Imiquimod, T2
Hycamtin, T4 Iressa, T4
Imovax Rabies (H.D.C.V.), T2
Hydralazine HCl (Injection), T2 Irinotecan, T2
Increlex, T4
Hydralazine HCl (Tablet), T1 Isentress, T4
Indapamide, T1
Hydrochlorothiazide, T1 Isochron, T1
Indomethacin, T1
Hydrocodone/Acetaminophen Isolyte-H/Dextrose 5%, T3
Indomethacin ER, T2
(10 mg-325 mg Tablet, Isolyte-M/Dextrose 5%, T2
10 mg-500 mg Tablet, Infanrix, T2
Isolyte-P/Dextrose 5%, T3
10 mg-650 mg Tablet, Infergen, T4
Isolyte-S, T3
10 mg-660 mg Tablet, Infumorph, T3
2.5 mg-500 mg Tablet, Isolyte-S/Dextrose 5%, T3
Innopran XL, T3
5 mg-325 mg Tablet, Isonarif, T2
5 mg-500 mg Tablet, Insulin Syringes, Needles, T2
Isoniazid (Injection), T2
7.5 mg-750 mg Tablet, Intelence, T4
Isoniazid (Syrup, Tablet), T1
7.5 mg-325 mg Tablet, Intralipid (20% Injection), T2
7.5 mg-500 mg Tablet, Isordil Titradose (40 mg Tablet), T3
55
Isosorbide Dinitrate, T1 KCl L
Isosorbide Dinitrate ER, T1 (0.4 meq/1 ml Injection, Labetalol HCl (Injection), T2
10 meq/100 ml Injection,
Isosorbide Mononitrate, T1 Labetalol HCl (Tablet), T1
2 meq/1 ml Injection,
Isosorbide Mononitrate ER, T1 30 meq/100 ml Injection), T2 Laclotion, T1
Isotonic Gentamicin, T2 KCl (10 meq/50 ml Injection), T2 Lacrisert, T3
Isovate, T1 KCl 0.15%/NaCl, T2 Lactated Ringer’s, T2
Isradipine, T1 KCl 0.3%/NaCl 0.9%, T2 Lactated Ringer’s Irrigation, T2
Istalol, T3 KCl ER, T1 Lactulose, T1
Istodax, T4 KCl/D10W/NaCl, T2 Lamictal, T3
Itraconazole, T2 KCl/D5W, T2 Lamictal ODT, T3
Ixempra Kit, T4 KCl/D5W/LR, T2 Lamictal Starter Kit, T3
Ixiaro, T2 KCl/D5W/NaCl, T2 Lamisil (Pack), T3
J Keflex (750 mg Capsule), T3 Lamotrigine, T2
Jantoven, T1 Kelnor, T1 Lanoxin
Janumet, T2 (0.1 mg/ml Injection), T3
Kenalog, T3
Januvia, T2 Lanoxin (Tablet), T2
Kepivance, T4
Je-Vax, T2 Lansoprazole, T2
Keppra (Injection), T4
Jolivette, T1 Lantus, T2
Keppra (Oral Solution, Tablet), T3
Junel, T1 Leena, T1
Ketek, T3
Junel Fe, T1 Leflunomide, T1
Ketoconazole, T1
K Ketoprofen, T1
Lessina, T1
Kadian Letairis, T4
Ketoprofen ER, T2
(100 mg 24-Hour Capsule, Leucovorin Calcium (Injection), T2
10 mg 24-Hour Capsule, Ketorolac Tromethamine
(Injection), T2 Leucovorin Calcium (Tablet), T1
20 mg 24-Hour Capsule,
30 mg 24-Hour Capsule, Ketorolac Tromethamine Leukeran, T2
50 mg 24-Hour Capsule, (Ophthalmic Solution), T2 Leukine, T4
60 mg 24-Hour Capsule, Ketorolac Tromethamine (Tablet), T1 Leuprolide Acetate, T2
80 mg 24-Hour Capsule), T2 Kineret, T4 Levalbuterol
Kadian (Nebulizer Solution), T2
Kionex, T2
(200 mg 24-Hour Capsule), T4
Klor-Con 10, T1 Levaquin
Kaletra (100-25 mg Tablet), T3 (Injection, Oral Solution), T3
Klor-Con 8, T1
Kaletra Levaquin (Tablet), T2
(200-50 mg Tablet, Klor-Con M10, T1
Levemir, T2
Oral Solution), T4 Klor-Con M15, T2
Levetiracetam (Injection), T4
Kanamycin Sulfate, T2 Klor-Con M20, T1
Levetiracetam
Kaon-Cl-10, T1 Kristalose, T3
(Oral Solution, Tablet), T2
Kariva, T1 Kuric, T1
Levobunolol HCl, T1
Kuvan, T4
Levocarnitine, T2
Kytril (Tablet), T4
Levora, T1
56
Levorphanol Tartrate, T2 Losartan Potassium/ Maprotiline HCl, T1
Levothroid, T2 Hydrochlorothiazide, T1 Margesic-H, T1
Levothyroxine Sodium, T1 Loseasonique, T3 Marinol (10 mg Capsule), T4
Levoxyl, T1 Lotemax, T2 Marinol (2.5 mg Capsule), T3
Lexapro, T2 Lotrel Marinol (5 mg Capsule), T4
Lexiva (Oral Suspension), T3 (10 mg-40 mg Capsule, Marplan, T3
5 mg-40 mg Capsule), T3
Lexiva (Tablet), T4 Matulane, T4
Lotronex, T4
Lidocaine, T1 Maxair Autohaler, T3
Lovastatin, T1
Lidocaine HCl Maxalt, T2
(Gel, Topical Solution), T1 Lovaza, T3
Maxalt-MLT, T2
Lidocaine HCl (Injection), T2 Lovenox
(100 mg/1 ml Injection, Maxipime (2 gm Injection), T3
Lidocaine Viscous, T1 120 mg/0.8 ml Injection, Mebendazole, T1
Lidocaine/Prilocaine, T1 150 mg/1 ml Injection, Meclizine HCl, T1
Lidoderm, T2 300 mg/3 ml Injection, Meclofenamate Sodium, T1
Lincocin, T3 60 mg/0.6 ml Injection,
Medroxyprogesterone Acetate
80 mg/0.8 ml Injection), T4
Lindane, T2 (Injection), T2
Lovenox
Liothyronine Sodium (Injection), T2 Medroxyprogesterone Acetate
(30 mg/0.3 ml Injection,
Liothyronine Sodium (Tablet), T1 (Tablet), T1
40 mg/ 0.4 ml Injection), T3
Lipitor, T2 Mefloquine HCl, T1
Low-Ogestrel, T1
Liposyn II, T3 Megace ES, T3
Loxapine Succinate, T1
Liposyn III Megestrol Acetate, T1
Lumigan, T2
(10% Injection, 20% Injection), T3 Meloxicam (Oral Suspension), T2
Lunesta, T2
Liposyn III (30% Injection), T1 Meloxicam (Tablet), T1
Lupron Depot
Lisinopril, T1 (11.25 mg Injection, Melphalan HCl, T4
Lisinopril/Hydrochlorothiazide, T1 3.75 mg Injection), T3 Menactra, T2
Lithium Carbonate, T1 Lupron Depot Menest, T2
Lithium Carbonate ER, T1 (22.5 mg Injection, Menomune-A/C/Y/W-135, T2
Lithium Citrate, T1 30 mg Injection, Mentax, T3
7.5 mg Injection), T4
Lithobid, T2 Meperidine HCl (Injection), T1
Lupron Depot-PED, T4
Lithostat, T3 Meperidine HCl
Lutera, T1 (Oral Solution, Tablet), T1
Lo/Ovral, T3
Luxiq, T3 Meprobamate, T2
Locoid, T3
Lyrica, T2 Mepron, T4
Locoid Lipocream, T3
Lysodren, T4 Mercaptopurine, T1
Lodosyn, T3
Loestrin, T3
M Merrem, T3
Macrodantin, T3 Meruvax II, T2
Loestrin Fe, T3
Magnesium Sulfate, T1 Mesalamine, T2
Lokara, T1
Magnesium Sulfate in D5W, T2 Mesna, T2
Loperamide HCl, T1
Malarone, T3 Mesnex (Tablet), T4
Losartan Potassium, T1
Malathion, T2 Mestinon (Syrup), T3
57
Mestinon Timespan, T3 Metoprolol/Hydrochlorothiazide, T1 Mozobil, T4
Metaproterenol Sulfate, T1 Metrogel, T3 MS Contin
Metaxalone, T2 Metronidazole (Capsule, Lotion), T2 (200 mg 12-Hour Tablet), T4
Metformin HCl, T1 Metronidazole Multaq, T3
Metformin HCl ER, T1 (Cream, Gel, Tablet), T1 Mupirocin, T1
Methadone HCl Metronidazole in NaCl 0.79%, T1 Mustargen, T4
(Concentrate, Oral Solution, Metronidazole Vaginal, T1 Mycamine, T4
Tablet), T1 Mexiletine HCl, T1 Mycobutin, T3
Methadone HCl (Injection), T3 Miacalcin (Injection), T3 Mycophenolate Mofetil, T2
Methadose, T1 Micardis, T3 Mydral, T1
Methamphetamine HCl, T2 Micardis HCT, T3 Myfortic, T3
Methazolamide, T1 Miconazole 3, T1 Myobloc, T3
Methenamine Hippurate, T2 Microgestin, T1 Myozyme, T4
Methergine, T2 Microgestin Fe, T1 Mytelase, T3
Methimazole, T1 Midodrine HCl, T2 N
Methocarbamol, T1 Migergot, T2 Nabumetone, T1
Methotrexate, T1 Millipred (Tablet), T3 NaCl, T2
Methotrexate Sodium, T2 Minitran, T1 NaCl 0.45% Viaflex, T2
Methscopolamine Bromide, T2 Minocycline HCl (Capsule), T1 NaCl 0.9%, T1
Methyclothiazide, T1 Minocycline HCl (Tablet), T2 Nadolol, T1
Methyldopa, T1 Minocycline HCl ER, T2 Nadolol/Bendroflumethiazide, T1
Methyldopa/Hydrochlorothiazide, T1 Minoxidil (Tablet), T1 Nafcillin Sodium, T2
Methyldopate HCl, T1 Mirapex, T2 Naftin, T3
Methylin (Tablet), T1 Mirtazapine, T1 Naglazyme, T4
Methylin ER, T1 Mirtazapine ODT, T1 Nalbuphine HCl, T2
Methylphenidate HCl, T1 Misoprostol, T1 Nallpen/Dextrose, T3
Methylphenidate HCl SR, T1 Mitomycin, T2 Naloxone HCl, T1
Methylprednisolone, T1 Mitoxantrone HCl, T2 Naltrexone HCl, T2
Methylprednisolone Acetate, T2 M-M-R II, T2 Namenda, T2
Methylprednisolone Moexipril HCl, T1 Namenda Titration Pak, T2
Sodium Succinate, T2
Moexipril/Hydrochlorothiazide, T1 Naphazoline HCl, T1
Metipranolol, T1
Mometasone Furoate, T1 Naproxen, T1
Metoclopramide HCl (Injection), T2
Monodox (75 mg Capsule), T3 Naproxen DR, T1
Metoclopramide HCl
MonoNessa, T1 Nardil, T2
(Oral Solution, Tablet), T1
Morphine Sulfate (Injection), T2 Nasonex, T2
Metolazone, T1
Morphine Sulfate Natacyn, T2
Metoprolol Succinate ER, T1
(Oral Solution, Tablet), T1 Nateglinide, T2
Metoprolol Tartrate (Injection), T2
Morphine Sulfate ER, T1 Navane (20 mg Capsule), T3
Metoprolol Tartrate (Tablet), T1
Moviprep, T3 Nebupent, T3
58
Necon, T1 Nitro-Bid, T3 O
Nefazodone HCl, T1 Nitro-Dur Ocella, T1
Neo-Fradin, T3 (0.3 mg/hr 24-Hour Patch, Octagam, T4
Neomycin Sulfate, T1 0.8 mg/hr 24-Hour Patch), T3
Octreotide Acetate
Neomycin/ Nitrofurantoin Macrocrystalline, T1 (1,000 mcg/ml Injection), T4
Polymyxin B Sulfates, T2 Nitrofurantoin Monohydrate, T1 Octreotide Acetate
Neomycin/Polymyxin/ Nitroglycerin (100 mcg/ml Injection,
Bacitracin/Hydrocortisone, T1 (24-Hour Patch, Injection), T1 200 mcg/ml Injection,
Neomycin/Polymyxin/ Nitrolingual Pumpspray, T3 500 mcg/ml Injection), T4
Dexamethasone, T1 Nitrostat, T2 Octreotide Acetate
Neomycin/Polymyxin/ Nizatidine (Capsule), T1 (50 mcg/ml Injection), T3
Gramicidin, T1 Nizatidine (Oral Solution), T2 Ofloxacin
Neomycin/Polymyxin/ (Ophthalmic Solution,
Nora-BE, T1
Hydrocortisone, T1 Otic Solution), T1
Norditropin, T4
Neomycin/Polymyxin/ Ofloxacin (Tablet), T2
Norethindrone Acetate, T1
Hydrocortisone, T1 Ogestrel, T1
Noritate, T3
Nephramine, T3 Olux-E, T3
Normosol-M in D5W, T2
Neulasta, T4 Omeprazole, T1
Normosol-R, T3
Neumega, T2 Omnitrope, T4
Normosol-R in D5W, T2
Neupogen, T4 Oncaspar, T4
Noroxin, T3
Neurontin (Oral Solution), T3 Ondansetron HCl (Injection), T2
Nortrel, T1
Nevanac, T3 Ondansetron HCl (Oral Solution), T2
Nortriptyline HCl (Capsule), T1
Nexavar, T4 Ondansetron HCl (Tablet), T1
Nortriptyline HCl (Oral Solution), T2
Nexium, T2 Ondansetron ODT, T1
Norvir (Capsule, Tablet), T3
Nexium I.V., T3 Onglyza, T2
Norvir (Oral Solution), T4
Next Choice, T1 Onsolis, T4
Novamine, T2
Niacor, T1 Ontak, T4
Novantrone, T4
Niaspan, T2 Opana, T2
Novarel, T2
Nicardipine HCl (Capsule), T1 Opana ER, T2
Novolin, T2
Nicardipine HCl (Injection), T2 Optipranolol, T3
Novolog, T2
Nicotrol Inhaler, T3 Orap, T2
Noxafil, T4
Nicotrol NS, T3 Orencia, T4
Nulytely/Flavor Packs, T2
Nifediac CC, T1 Orfadin, T4
Nutropin, T4
Nifedical XL, T1 Orphenadrine Citrate, T2
Nutropin AQ, T4
Nifedipine, T1 Orphenadrine Citrate ER, T1
NuvaRing, T2
Nifedipine ER, T1 Orphenadrine/Aspirin/Caffeine, T2
Nyamyc, T1
Nilandron, T3 Ortho Evra, T3
Nystatin, T1
Nimodipine, T4 Ortho Micronor, T3
Nystatin/Triamcinolone, T1
Nipent, T4 Ortho Tri-Cyclen Lo, T3
Nystop, T1
Nisoldipine, T1 Ortho-Cept, T3
59
Orthoclone OKT3, T4 Parcaine, T1 Phenytek, T2
Ortho-Cyclen, T3 Parcopa, T3 Phenytoin, T1
Ortho-Est, T1 Paromomycin Sulfate, T1 Phenytoin Sodium, T2
Ortho-Novum 7/7/7, T3 Paroxetine HCl Phenytoin Sodium Extended
Osmoprep, T3 (Oral Suspension), T2 (100 mg Capsule), T1
Ovcon, T3 Paroxetine HCl (Tablet), T1 Phenytoin Sodium Extended
Oxacillin Sodium, T3 Paroxetine HCl ER, T2 (200 mg Capsule,
Paser, T3 300 mg Capsule), T2
Oxaliplatin, T4
Pataday, T2 Phoslo, T2
Oxandrin (10 mg Tablet), T4
Patanase, T2 Phospholine Iodide, T2
Oxandrin (2.5 mg Tablet), T3
Patanol, T2 Photofrin, T4
Oxandrolone (10 mg Tablet), T4
PCE, T3 Physiolyte, T1
Oxandrolone (2.5 mg Tablet), T2
Pediarix, T2 Physiosol Irrigation, T3
Oxaprozin, T1
Pedi-Dri, T1 Pilocarpine HCl, T2
Oxcarbazepine, T2
Pedvax HIB, T2 Pilopine HS, T2
Oxistat, T3
Peganone, T3 Pindolol, T1
Oxsoralen, T3
Pegasys, T4 Piperacillin Sodium, T3
Oxsoralen Ultra, T4
Peg-Intron, T4 Piperacillin Sodium/
Oxybutynin Chloride, T1 Tazobactam Sodium, T2
Oxybutynin Chloride ER, T1 Penicillin G Potassium, T2
Piroxicam, T1
Oxycodone HCl, T1 Penicillin G Potassium in
Iso-Osmotic Dextrose, T2 Plasma-Lyte, T3
Oxycodone/Acetaminophen, T1 Plasma-Lyte/D5W, T3
Penicillin G Procaine, T3
Oxycodone/Aspirin, T1 Plasma-Lyte-R, T2
Penicillin G Sodium, T2
Oxycodone/Ibuprofen, T2 Plavix, T2
Penicillin V Potassium, T1
Oxycontin, T2 Podofilox, T2
Pentam 300, T3
Oxytrol, T2 Polycin B, T1
Pentasa, T3
P Poly-Dex, T1
Pentazocine/Acetaminophen, T1
Pacerone Polyethylene Glycol 3350, T1
(100 mg Tablet, Pentazocine/Naloxone HCl, T2
Pentopak, T1 Polymyxin B Sulfate, T2
400 mg Tablet), T3
Pentostatin, T4 Poly-Pred, T3
Pacerone (200 mg Tablet), T1
Pentoxifylline ER, T1 Portia, T1
Paclitaxel, T2
Perindopril Erbumine, T1 Potassium Citrate
Pamelor, T4
Extended-Release, T1
Pamidronate Disodium Periogard, T1
Pramipexole Dihydrochloride, T2
(30 mg/10 ml Injection, Permethrin, T1
90 mg/10 ml Injection), T2 Prandimet, T3
Perphenazine, T1
Pamidronate Disodium Prandin, T3
Perphenazine/Amitriptyline, T1
(6 mg/1 ml Injection), T3 Pravastatin Sodium, T1
Pexeva, T3
Pandel, T3 Prazosin HCl, T1
Pfizerpen-G, T3
Panretin, T4 Pred Mild, T2
Phenadoz, T1
Pantoprazole Sodium, T2 Pred-G, T2
60
Pred-G S.O.P., T2 Procrit Protopic, T3
Prednicarbate, T1 (10,000 units/ml Injection, Protriptyline HCl, T2
Prednisolone, T1 2,000 units/ml Injection,
Provigil, T3
Prednisolone Acetate, T1 4,000 units/ml Injection), T3 Pulmicort
Prednisolone Sodium Phosphate, T1 (Nebulizer Suspension), T3
Procrit
Prednisone, T1 (20,000 units/ml Injection), T4 Pulmicort Flexhaler, T2
Prednisone Intensol, T1 Procrit Pulmozyme, T4
Prefest, T3 (40,000 units/ml Injection), T4 Pyrazinamide, T1
Pregnyl w/Diluent Benzyl Alcohol/ Proctocream-HC, T1 Pyridostigmine Bromide, T1
NaCl, T2 Procto-Pak, T1 Q
Premarin (Cream, Tablet), T2 Proctosol HC, T1 Qualaquin, T3
Premarin (Injection), T3 Proctozone-HC, T1 Quasense, T1
Premasol (10% Injection), T3 Proglycem, T3 Quinapril HCl, T1
Premasol (6% Injection), T2 Prograf Quinapril/Hydrochlorothiazide, T1
Premphase, T2 (0.5 mg Capsule, Quinidine Gluconate, T3
Prempro, T2 1 mg Capsule), T3 Quinidine Gluconate CR, T1
Prenatal Vitamins, T1 Prograf (5 mg Capsule), T4 Quinidine Sulfate, T1
Prevalite, T1 Prograf (Injection), T3 Quinidine Sulfate ER, T1
Previfem, T1 Prolastin, T4 Quixin, T3
Prezista Proleukin, T4 QVAR, T2
(400 mg Tablet, Promacta, T4
R
600 mg Tablet), T4 Promethazine HCl (Injection), T2 Rabavert, T2
Prezista (75 mg Tablet), T3 Promethazine HCl Ramipril, T1
Priftin, T3 (Suppository, Syrup, Tablet), T1
Ranexa, T2
Primaquine Phosphate, T3 Promethazine VC, T1
Ranitidine HCl (Capsule, Tablet), T1
Primaxin, T3 Promethegan, T1
Ranitidine HCl (Injection, Syrup), T2
Primidone, T1 Prometrium, T3
Rapaflo, T3
Primsol, T3 Propafenone HCl, T1
Rapamune (Oral Solution), T3
Pristiq, T3 Proparacaine HCl, T1
Rapamune (Tablet), T4
Privigen, T4 Propoxyphene HCl, T1
Razadyne (Oral Solution), T3
Proair HFA, T2 Propoxyphene/Acetaminophen, T1
Rebetol, T4
Probenecid, T1 Propoxyphene-N/Acetaminophen, T1
Rebif, T4
Probenecid/Colchicine, T1 Propranolol HCl, T1
Rebif Titration Pack, T4
Procainamide HCl, T1 Propranolol HCl ER, T1
Reclipsen, T1
Procalamine, T3 Propranolol/Hydrochlorothiazide, T1
Recombivax HB, T2
Prochieve, T3 Propylthiouracil, T1
Regonol, T1
Prochlorperazine, T1 ProQuad, T2
Regranex, T4
Prochlorperazine Edisylate, T2 Prosol, T3
Relenza Diskhaler, T3
Prochlorperazine Maleate, T1 Protonix (Injection), T3
Relion, T3
61
Relistor, T3 Risperidone (Oral Solution), T2 Selzentry, T4
Remicade, T4 Risperidone (Tablet), T1 Sensipar (30 mg Tablet), T2
Remodulin, T4 Risperidone ODT, T2 Sensipar
Renagel, T2 Rituxan, T4 (60 mg Tablet, 90 mg Tablet), T4
Renamin, T3 Rivastigmine Tartrate, T2 Serevent Diskus, T2
Renvela, T2 Robaxin (Injection), T3 Seromycin, T3
Rescriptor, T3 Rocephin, T3 Seroquel, T3
Reserpine, T1 Romycin, T1 Seroquel XR, T2
Restasis, T2 Ropinirole HCl, T1 Serostim, T4
Retin-A Micro, T3 RotaTeq, T2 Sertraline HCl (Concentrate), T2
Retrovir IV Infusion, T3 Rowasa, T3 Sertraline HCl (Tablet), T1
Revatio, T4 Roxicet (Oral Solution), T3 Silver Sulfadiazine, T1
Revlimid, T4 Roxicet (Tablet), T1 Simponi, T4
Reyataz, T4 Rozerem, T3 Simulect, T4
Ribapak, T4 Rythmol SR, T3 Simvastatin, T1
Ribasphere S Singulair, T2
(200 mg Tablet, Capsule), T2 Sabril, T4 Sodium Bicarbonate, T1
Ribasphere Saizen, T4 Sodium Fluoride, T1
(400 mg Tablet, Sodium Lactate, T2
Samsca, T4
600 mg Tablet), T4
Sanctura XR, T3 Sodium Polystyrene Sulfonate, T2
Ribavirin
Sancuso, T4 Solaraze, T3
(200 mg Tablet, Capsule), T2
Sandimmune Solia, T1
Ribavirin
(400 mg Tablet, (Capsule, Oral Solution), T3 Solu-Cortef, T3
600 mg Tablet), T4 Sandostatin Solu-Medrol, T3
Ridaura, T3 (1,000 mcg/ml Injection), T4 Somatuline Depot, T4
Rifampin (Capsule), T1 Sandostatin Somavert, T4
(100 mcg/ml Injection, Soriatane, T4
Rifampin (Injection), T4
200 mcg/ml Injection,
Rifater, T3 500 mcg/ml Injection, Sorine, T1
Rilutek, T4 50 mcg/ml Injection), T4 Sotalol HCl (Injection), T2
Rimantadine HCl, T1 Sandostatin LAR Depot, T4 Sotalol HCl (Tablet), T1
Ringer’s Injection, T2 Santyl, T3 Sotret
Ringer’s Irrigation, T1 Saphris, T3 (10 mg Capsule,
20 mg Capsule,
Riomet, T3 Savella, T2 40 mg Capsule), T2
Risperdal Consta Savella Titration Pack, T2 Spectracef, T3
(12.5 mg Injection, Seasonale, T3
25 mg Injection), T3 Spiriva Handihaler, T2
Seasonique, T3 Spironolactone, T1
Risperdal Consta
Selegiline HCl, T1 Spironolactone/
(37.5 mg Injection,
50 mg Injection), T4 Selenium Sulfide, T1 Hydrochlorothiazide, T1
Risperdal M-Tab, T3 Selfemra, T2 Sporanox (Capsule), T4
62
Sporanox (Oral Solution), T3 Sutent, T4 Tetanus/Diphtheria Toxoids-
Sprintec, T1 Symbicort, T2 Adsorbed Adult, T2
Sprycel, T4 Symbyax, T3 Tetracycline HCl, T1
Sronyx, T1 Symlin, T3 Tev-Tropin, T4
SSD, T1 Synagis, T4 Thalomid, T4
Stagesic, T1 Synalgos-DC, T3 Theo-24, T2
Stalevo, T2 Synarel, T4 Theochron, T1
Stavudine, T2 Synercid, T4 Theophylline ER, T1
Stavzor, T3 Synthroid, T2 Thermazene, T1
Stelara, T4 Syprine, T3 Thiola, T3
Sterile Water Irrigation, T1 T Thioridazine HCl, T1
Stimate, T3 Tabloid, T3 Thiotepa, T3
Strattera, T3 Tacrolimus Thiothixene, T1
Streptomycin Sulfate, T3 (0.5 mg Capsule, 1 mg Capsule), T2 Thymoglobulin, T4
Stromectol, T2 Tacrolimus (5 mg Capsule), T4 Thyrolar, T2
Suboxone, T3 Tamiflu, T2 Ticlopidine HCl, T1
Sucraid, T4 Tamoxifen Citrate, T1 Tikosyn, T3
Sucralfate, T1 Tamsulosin HCl, T1 Timentin, T3
Sulfacetamide Sodium (Lotion), T2 Tarceva, T4 Timolol Maleate, T1
Sulfacetamide Sodium Targretin (Capsule), T4 Tindamax, T2
(Ophthalmic Solution), T1 Targretin (Gel), T4 Tis-U-Sol, T1
Sulfacetamide Sodium/ Tasigna, T4 Tizanidine HCl, T1
Prednisolone Sodium Phosphate, T1 Tasmar, T4 Tobi, T4
Sulfadiazine, T2 Taxotere, T4 Tobradex
Sulfamethoxazole/ Tazicef, T2 (Ophthalmic Ointment), T2
Trimethoprim (Injection), T2 Tobradex
Tazorac, T3
Sulfamethoxazole/Trimethoprim (Ophthalmic Suspension), T3
Taztia XT, T1
(Oral Suspension, Tablet), T1 Tobramycin Sulfate (Injection), T2
Tegretol, T2
Sulfamylon, T3 Tobramycin Sulfate
Tegretol-XR, T2
Sulfasalazine, T1 (Ophthalmic Solution), T1
Tekturna, T2
Sulfatrim, T1 Tobramycin Sulfate/NaCl, T1
Tekturna HCT, T2
Sulfazine EC, T1 Tobramycin/Dexamethasone, T1
Terazosin HCl, T1
Sulindac, T1 Tobrasol, T1
Terbinafine HCl, T1
Sumatriptan Succinate Tobrex
(Injection), T2 Terbutaline Sulfate (Injection), T2 (Ophthalmic Ointment), T2
Sumatriptan Succinate (Tablet), T1 Terbutaline Sulfate (Tablet), T1 Tobrex
Sumavel Dosepro, T4 Terconazole, T1 (Ophthalmic Solution), T3
Suprax, T3 Testosterone Cypionate, T2 Tolazamide, T1
Surmontil, T3 Testosterone Enanthate, T2 Tolbutamide, T1
Sustiva, T3 Tetanus Toxoid Adsorbed, T2 Tolmetin Sodium (Capsule), T1
63
Tolmetin Sodium (Tablet), T2 Trifluridine, T2 Ursodiol (Capsule), T2
Topiramate, T1 Trihexyphenidyl HCl, T1 Ursodiol (Tablet), T1
Toposar, T2 TriHiBit, T2 Uvadex, T3
Toprol XL, T3 Tri-Legest Fe, T1 V
Torisel, T4 Trilipix, T2 Vagifem, T3
Torsemide (Injection), T2 Trilyte, T3 Valacyclovir HCl, T2
Torsemide (Tablet), T1 Trimethobenzamide HCl Valcyte, T4
TPN Electrolytes FTV, T2 (Capsule), T1 Valproate Sodium, T2
Tracleer, T4 Trimethobenzamide HCl Valproic Acid, T1
Tramadol HCl, T1 (Injection), T2
Valtrex, T2
Tramadol HCl ER Trimethoprim, T1
Vancocin HCl, T4
(100 mg Tablet, 200 mg Tablet), T2 Trimethoprim Sulfate/
Vancomycin HCl, T2
Tramadol HCl/Acetaminophen, T1 Polymyxin B Sulfate, T1
Vancomycin HCl Iso-Osmotic
Trandolapril, T1 TriNessa, T1
Dextrose, T3
Trandolapril/Verapamil HCl, T2 Tripedia, T2
Vandazole, T1
Transderm-Scop, T3 Tri-Previfem, T1
Vanos, T3
Tranylcypromine Sulfate, T2 Trisenox, T3
Vaqta, T2
Travasol, T3 Tri-Sprintec, T1
Varivax, T2
Travatan, T2 Trivora, T1
Vectibix, T4
Travatan Z, T2 Trizivir, T4
Vectical, T3
Trazodone HCl, T1 Trophamine (10% Injection), T3
Velcade, T4
Treanda, T4 Tropicamide, T1
Velivet, T1
Trecator, T3 Truvada, T4
Venlafaxine HCl, T1
Trelstar Depot, T4 Twinject, T3
Venlafaxine HCl ER
Trelstar LA, T4 Twinrix, T2 (24-Hour Capsule), T2
Tretinoin (Capsule), T4 Twynsta, T3 Venlafaxine HCl ER
Tretinoin (Cream), T1 Tygacil, T3 (24-Hour Tablet), T3
Tretinoin (Gel), T2 Tykerb, T4 Ventavis, T4
Tretin-X, T3 Typhim Vi, T2 Verapamil HCl (Injection), T2
Trexall, T3 Tysabri, T4 Verapamil HCl (Tablet), T1
Triamcinolone Acetonide, T1 Tyzeka, T4 Verapamil HCl ER, T1
Triamcinolone Acetonide in Tyzine, T2 Vesicare, T2
Absorbase, T1 U Vexol, T3
Triamcinolone in Orabase, T1 U-Cort, T1 Vfend, T4
Triamterene/ Ulesfia, T3 Vibativ, T4
Hydrochlorothiazide, T1 Uloric, T2 Vibramycin
Tricor, T2 Unasyn (3 gm Injection), T3 (Oral Suspension, Syrup), T3
Triderm, T1 Unithroid, T1 Vidaza, T4
Trifluoperazine HCl, T1 Uroxatral, T2 Videx Pediatric, T3
64
Vigamox, T2 X Zinacef (7.5 gm Injection), T3
Vimpat (Injection), T3 Xalatan, T3 Zinacef in Iso-Osmotic
Vimpat Xenazine, T4 Dextrose, T3
(Oral Solution, Tablet), T3 Xibrom, T3 Zinacef in Iso-Osmotic
Vinblastine Sulfate, T1 Diluent, T3
Xifaxan, T3
Vincasar PFS, T2 Zinecard, T4
Xolair, T4
Vincristine Sulfate, T2 Zmax, T3
Xolegel, T3
Vinorelbine Tartrate, T2 Zofran (Injection), T4
Xyrem, T2
Viracept (Powder), T3 Zofran (Oral Solution, Tablet), T4
Y Zofran ODT, T4
Viracept (Tablet), T4 Yasmin, T3
Viramune (Oral Suspension), T3 Zolinza, T4
Yaz, T3
Viramune (Tablet), T2 Zolpidem Tartrate (10 mg Tablet), T1
YF-Vax, T2
Virazole, T4 Zolpidem Tartrate (5 mg Tablet), T1
Z Zometa, T4
Viread, T3
Zaleplon, T1
Visicol, T3 Zonisamide, T1
Zanosar, T3
Vistide, T4 Zorbtive, T4
Zantac
Vivaglobin, T4 Zostavax, T3
(50 mg/50 ml Injection), T3
Vivelle-Dot, T2 Zosyn
Zavesca, T4
(2-0.25 gm/50 ml lnjection,
Vivitrol, T4 Zazole, T1 3-0.375 gm/50 ml Injection), T3
Vivotif Berna, T2 Zelapar, T3 Zovia, T1
Voltaren (Gel), T2 Zemaira, T4 Zovirax (Cream, Ointment), T3
Votrient, T4 Zemplar, T2 Zyflo CR, T3
Vpriv, T4 Zenpep, T3 Zylet, T2
Vytorin, T3 Zerlor, T2 Zymar, T2
Vyvanse, T3 Zetia, T2 Zyprexa, T2
W Ziagen, T3 Zyprexa Zydis, T2
Warfarin Sodium, T1 Ziana, T3 Zyvox (Injection), T4
Welchol (Pack), T2 Zidovudine, T2 Zyvox
Welchol (Tablet), T2 Zinacef (Oral Suspension, Tablet), T4
(1.5 gm Injection,
750 mg Injection), T3

OVEX11MP3245293_000
65
Enrollment Materials
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you to verify the Medicare Advantage Plan was fully
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Did the sales agent show you the Summary of Benefits (SB) inside this booklet? £ yes £ no
Did the sales agent give you their contact information? (name, phone or business card) £ yes £ no
Did the sales agent give you a receipt from the Enrollment Form? £ yes £ no
Only for PFFS plans:
Did the sales agent ask if you receive both Medicare and Medicaid benefits? And that
PFFS plans may not always be a good option for people with Medicare and Medicaid? £ yes £ no
Did the sales agent fully explain the meaning of “deeming”? £ yes £ no
Only for Dual SNP plans:
Did the sales agent tell you that your Enrollment Form will not be processed until your
Y0004Y0066_100618_122454 CMS Approved 08032010

Medicaid status is confirmed? £ yes £ no
Only for Chronic plans:

Did the sales agent tell you that your Enrollment Form will not be processed until your
chronic illness has been confirmed and it may take up to 21 days? £ yes £ no
Only for HMO, HMO-POS, and PPO plans:

Do you understand you must use contracted health care providers to get the in-network
benefits, copays and coinsurances? £ yes £ no
Do you understand if you use out-of-network health care providers you will likely pay
higher out-of-pocket costs? £ yes £ no
Only for Medicare Advantage plans including Prescription Drug coverage:

Did the sales agent explain the plan’s Drug List and Drug Tiers, inside this booklet? £ yes £ no
Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole? £ yes £ no
Do you understand you must use a UnitedHealthcare contracted pharmacy? £ yes £ no

68 a Medicare Advantage organization with a Medicare contract.
Scope of Sales Appointment
Confirmation Form
To be completed by person with Medicare or Authorized Representative.
Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not
want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may
also discuss a Medicare Supplement policy with you.)
 Stand-alone Medicare Prescription Drug Plans (Part D)

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

Medicare Advantage (Part C), Medicare Advantage
 Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all
Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in
the Plan’s network except in an emergency.
Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available
in a local or regional area in which you pay less if you use doctors, hospitals, and providers that
belong to the network. You can use doctors, hospitals, and providers outside of the network for an
additional cost.
Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you
may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms
and conditions.
Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides
more focused and specialized health care for specific groups of people, such as those who have
both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical
conditions.
Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible Medicare
Advantage Plan and a bank account. The Plan deposits money from Medicare in the account. You
can use it to pay your medical expenses until your deductible is met.
Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of
the Plan’s network without a referral, your Medicare-covered services will be paid for under the
Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services).
Y0004Y0035Y0066_100720_114616 CMS Approved 08272010
1 of 2
By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of
products you initialed above. The person that will be discussing Plan options with you is not employed by
the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan,
and they may be compensated based on your enrollment in a Plan.
Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan,
Prescription Drug Plan, or other Medicare Plan.
Beneficiary Signature ____________________________________________________________________

If you are the authorized representative, you must sign above and provide the following information:
PLEASE PRINT
Name (First_Last) ________________________________________________________________________
Address ________________________________________________________________________________
Phone number _ _________________________________________________________________________
Relationship to Beneficiary _ _______________________________________________________________
PLEASE PRINT
To be completed by Agent
Agent Name (First_Last) Agent Phone
Agent ID # Date of Appointment
Beneficiary Name (First_Last) Beneficiary Phone
Beneficiary Address
Agent’s Signature
To be completed by Agent, if Scope of Appointment was obtained at time of appointment:

Reason SOA was not completed prior to Appointment – please check all that apply
 Unplanned Attendee
 Walk-In
 New SOA required (consumer requested other Health Product information)
 Other
If Other, please explain_ ___________________________________________________________________
______________________________________________________________________________________
To submit Scope of Appointment documents:

Send Email To: scopeappt@uhc.com; no subject line or body of email required.
Include one PDF per email. Do not attach any other documents.
OR
Send Fax To: 877.825.1914

a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
2 of 2 SHEX11MP3241167_000
Scope of Sales Appointment
Confirmation Form
To be completed by person with Medicare or Authorized Representative.
Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not
want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may
also discuss a Medicare Supplement policy with you.)
 Stand-alone Medicare Prescription Drug Plans (Part D)

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

Medicare Advantage (Part C), Medicare Advantage
 Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all
Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in
the Plan’s network except in an emergency.
Medicare Preferred Provider Organization (PPO) Plan — A type of Medicare Advantage Plan available
in a local or regional area in which you pay less if you use doctors, hospitals, and providers that
belong to the network. You can use doctors, hospitals, and providers outside of the network for an
additional cost.
Medicare Private Fee-For-Service (PFFS) Plan — A type of Medicare Advantage Plan in which you
may go to any Medicare-approved doctor or hospital that accepts the Plan’s payment and terms
and conditions.
Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides
more focused and specialized health care for specific groups of people, such as those who have
both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical
conditions.
Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible Medicare
Advantage Plan and a bank account. The Plan deposits money from Medicare in the account. You
can use it to pay your medical expenses until your deductible is met.
Medicare Cost Plan — A type of health plan. In a Medicare Cost Plan, if you get services outside of
the Plan’s network without a referral, your Medicare-covered services will be paid for under the
Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services).
Y0004Y0035Y0066_100720_114616 CMS Approved 08272010
1 of 2
By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of
products you initialed above. The person that will be discussing Plan options with you is not employed by
the Federal government but is employed or contracted by a Medicare Health Plan or Prescription Drug Plan,
and they may be compensated based on your enrollment in a Plan.
Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan,
Prescription Drug Plan, or other Medicare Plan.
Beneficiary Signature ____________________________________________________________________

If you are the authorized representative, you must sign above and provide the following information:
PLEASE PRINT
Name (First_Last) ________________________________________________________________________
Address ________________________________________________________________________________
Phone number _ _________________________________________________________________________
Relationship to Beneficiary _ _______________________________________________________________
PLEASE PRINT
To be completed by Agent
Agent Name (First_Last) Agent Phone
Agent ID # Date of Appointment
Beneficiary Name (First_Last) Beneficiary Phone
Beneficiary Address
Agent’s Signature
To be completed by Agent, if Scope of Appointment was obtained at time of appointment:

Reason SOA was not completed prior to Appointment – please check all that apply
 Unplanned Attendee
 Walk-In
 New SOA required (consumer requested other Health Product information)
 Other
If Other, please explain_ ___________________________________________________________________
______________________________________________________________________________________
To submit Scope of Appointment documents:

Send Email To: scopeappt@uhc.com; no subject line or body of email required.
Include one PDF per email. Do not attach any other documents.
OR
Send Fax To: 877.825.1914

a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
2 of 2 SHEX11MP3241167_000
Enrollment Form 1
2011 Individual Enrollment Form
When You Are Ready to Enroll

ontact your local sales agent to help you choose the best plan for you and
C
complete this Individual Enrollment Form, or
Call a SecureHorizons® sales agent to have them help you enroll over the
phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week.
TTY users: call 711.
Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form,
sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR
71903-9973
I understand the person who is discussing plan options with me is a sales agent, broker or other
person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid
based on my enrollment in a plan.
If you currently have health coverage from an employer or union, joining one of our plans could
affect your employer or union health benefits. You could lose your employer or union health coverage
if you join our plan. Read the communications your employer or union sends you. If you have
questions, visit their Web site, or contact the office listed in their communications. If there isn’t any
information on whom to contact, your benefits administrator or the office that answers questions about
your coverage can help.
Turn the Page to Enroll
Y0066_100723_233355 CMS Approved 09142010

Enrollment Form 1
Please contact SecureHorizons® if you need information in another language or format (Audio Tape).
For Sales Representative/Agency Use Only

&
New Member Plan Change Employer Group ID Number Branch ID

How was this application taken? Appointment Mail-In Other
1. Applicant Information (Please type or print in black or blue ink.)
Last Name First Name Middle Initial
Birth Date / / Gender Male Female Mr. Mrs. Ms.

Home Telephone Number Alternate Phone Number (optional)
( ) ( )
Permanent Residence Street Address (not a P.O. Box)
City State ZIP Code County
Mailing Address (only if different from your Permanent Residence Street Address)
City State ZIP Code

&
E-mail Address (optional)

Please e-mail me plan information and updates.
2. Medicare Insurance 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 appears on Medicare Card)
1-800-MEDICARE (1-800-633-4227) – – –
NAME OF BENEFICIARY
JANE DOE Medicare Claim Number Letter(s)
MEDICARE CLAIM NUMBER SEX
000-00-0000-A FEMALE
IS ENTITLED TO EFFECTIVE DATE Part A (Hospital) effective date / /
HOSPITAL (PART A) 07-01-1986
MEDICAL (PART B) 07-01-1986
SIGN
HERE Jane Doe

Part B (Medical) effective date / /
You must have Medicare Part A and Part B to join a Medicare Advantage Plan.
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1 of 6 AAEX11MP3241235_000
3. Your Payment Options (If applicable)
Enrollment Form 1
If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late
enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic
deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the
first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If
&
you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify
for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs
including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will
not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even
know it. For more information about this extra help, contact your local Social Security Administration office, or call the
Social Security Administration at 1-800-772-1213. TTY users should call 1‑800‑325‑0778. You can also apply for extra
help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug
coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, it is
recommended you choose the coupon book or EFT option.
If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my
(If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover.
If you would like to set up EFT, please enclose a blank check with VOID written on the front.)
Monthly Social Security benefit check
E lectronic Funds Transfer (EFT) from your bank account each month.
Enclose a VOIDED check or provide the following
Account Holder Name Bank Routing Number
Bank Account Number Account Type Checking Savings
Coupon Book
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4a. Benefit Plan Selections — Choose Only One

Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit
AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Value (HMO) AV
AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Premier (HMO) APR
AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Mosaic (HMO) AM
AARP® MedicareComplete® Plan 3 (HMO) A3
HMO plans with medical benefits only
AARP® MedicareComplete Essential® (HMO) AE
Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit
AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR
AARP® MedicareComplete Choice® Plan 1 (PPO) AC1
A ARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2
PPO plans with medical benefits only

A ARP® MedicareComplete Choice® Essential (PPO) ACE
A ARP® MedicareComplete Choice® Essential (Regional PPO) ACP
Point of Service (HMO-POS) plans with a medical and Part D drug benefit
AARP® MedicareComplete® Plus (HMO-POS) AP
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AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1
HMO-POS plans with medical benefits only

AARP® MedicareComplete® Plus Essential (HMO-POS) APE
2 of 6 AAEX11MP3241235_000
4b. Complete the following if the plan chosen includes routine dental coverage
Enrollment Form 1
Name of dental provider Provider ID# (please refer to Provider Directory)
Are you currently a patient of this dentist? Yes No
4c. OPTIONAL Supplemental Benefit Plans
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These plans are not available in all service areas.

Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums.
If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below).
Fitness Rider Deluxe Rider
If available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans
below.
High Option Dental Rider Optional Dental Rider Dental 260 Rider
Dental Facility # (please refer to the Provider Directory)
Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans.
5. Primary Care Physician (PCP), Clinic or Health Center Selection
Refer to your Provider Directory or the plan Web site to select a PCP. Provider ID#
PCP name
Are you now seeing or have you recently seen this doctor? Yes No
6. Please Read and Answer These Important Questions
Do you have End-Stage Renal Disease (ESRD)? Yes No
If you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant,
please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney
&
transplant. (Use Form 2728 if available.)

If “yes”, are you currently a member of a health care company? Yes No
If “yes”, name of company Member ID#
Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes No
If “yes”, name of institution
Address of institution
City, State, ZIP Code
Telephone number of institution ( ) Your date of admission to the institution / /
Are you enrolled in your state Medicaid program? Yes No
If “yes”, please provide your Medicaid ID number
Do you or your spouse work? Yes No
Do you or your spouse have any health insurance other than Medicare, such as private insurance,
Workers’ Compensation or Veterans Administration (VA) benefits? Yes No
If you have other health insurance, what kind do you have?
What is the name of the health insurance?
Group # ID#
Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State
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Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes No

Plan name of other coverage
Member ID# for this coverage
Group ID# Effective Date (optional)
3 of 6 AAEX11MP3241235_000
7. Alternative Formats (Check only one)
Enrollment Form 1
If available, I prefer to receive materials in the following format Spanish Chinese
Large Print (English Only)
Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed
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above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.
Statements of Understanding
By Completing This Enrollment Form, I Agree to the Following

1. A
ARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must
keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not
otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare
Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other
Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of
any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have
Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to
pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is
generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes
only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every
year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE
(1‑800‑633‑4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.
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2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move.
I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a
plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out
of the country except for limited coverage near the U.S. border.
3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I
disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the
Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in
order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment
under the Plan.
4. B y joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to
Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the
Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release
it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this
Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on
this Enrollment Form, I may be disenrolled from the Plan.
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4 of 6 AAEX11MP3241235_000
Statements of Understanding (continued)
Enrollment Form 1
5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked
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for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug
coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am
asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium
may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may
visit www.medicare.gov or 1-800-MEDICARE (1‑800‑633-4227); (hearing impaired users should call 1-877-486-2048),
24 hours a day, 7 days a week.
6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other
Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid
Program and the Medicare Savings Program.
Additional Statements of Understanding for Each Specific Plan
AARP® MedicareComplete® from SecureHorizons (HMO)

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

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

I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available
both in and out-of-network, and I understand I must use in‑network providers to enjoy the lowest cost sharing. Some
non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally,
some out-of-network services may be limited by county or state and require prior authorization.
Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer,
submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud.
Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or
criminal liability.
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5 of 6 AAEX11MP3241235_000
8. Please Read This Important Information
Enrollment Form 1
I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state
where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form,
Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.
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You must sign and date this Individual Enrollment Form in order for it to be processed.
If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law
to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive
health care related information on his/her behalf and that documentation of this authority is available upon request by the
Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes.
Signature of applicant/member/authorized representative Date
/ /
If you are the authorized representative of the applicant, you must provide the following information and sign above.
Name Relationship to applicant
Address Telephone Number

( )
City State ZIP Code Alternate Phone Number (optional)
( )
9. For Sales Representative/Agency Use Only

Selling Staff Member/Agent ID Initial Receipt Date
&
Selling Staff Member/Agent Name Proposed Effective Date
Agent Telephone Number
Signature (if assisted in enrollment)
10. Election Period

AEP ICEP IEP IEP2 (MAPD Plans Only) OEPI SEP (SEP Reason Code )
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6 of 6 AAEX11MP3241235_000
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Important Enrollment Information
I-Enroll Tracking Number
Effective Date
Medicare ID
Plan Name
Sales Agent ID
Sales Agent Name
Sales Agent Phone Number
Health Plan/PBP Number

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This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group
receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two
weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT.
Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail
within two weeks.
Talk to your local sales agent for answers or to enroll.
If you do not have a local sales agent, please call Visit our web site at
1-800-547-5514, 8 a.m. - 8 p.m. local time, www.AARPMedicarePlans.com
7 days a week. TTY users call 711.
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Visit our Web site at:
The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by
an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal
government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee
to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its
members. AARP is not the insurer. You do not need to be an AARP member to enroll.
AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged
to evaluate your needs.
AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers,
representatives or advisors.
Y0066_100723_233355 CMS Approved 09142010 AAEX11MP3241235_000

Enrollment Form 2
When You Are Ready to Enroll

ontact your local sales agent to help you choose the best plan for you and
C
complete this Individual Enrollment Form, or
Call a SecureHorizons® sales agent to have them help you enroll over the
phone. Toll-free: 1-800-547-5514, 8 a.m. – 8 p.m. local time, 7 days a week.
TTY users: call 711.
Note: If you do not have an agent assisting you with enrolling, please complete the Enrollment Form,
sign and date it and send the enrollment copy to: SecureHorizons, P.O. Box 29650, Hot Springs, AR
71903-9973
I understand the person who is discussing plan options with me is a sales agent, broker or other
person employed by or contracted with UnitedHealthcare Services, Inc. The person may be paid
based on my enrollment in a plan.
If you currently have health coverage from an employer or union, joining one of our plans could
affect your employer or union health benefits. You could lose your employer or union health coverage
if you join our plan. Read the communications your employer or union sends you. If you have
questions, visit their Web site, or contact the office listed in their communications. If there isn’t any
information on whom to contact, your benefits administrator or the office that answers questions about
your coverage can help.
Turn the Page to Enroll
Y0066_100723_233355 CMS Approved 09142010

Enrollment Form 2
Please contact SecureHorizons® if you need information in another language or format (Audio Tape).
For Sales Representative/Agency Use Only

&
New Member Plan Change Employer Group ID Number Branch ID

How was this application taken? Appointment Mail-In Other
1. Applicant Information (Please type or print in black or blue ink.)
Last Name First Name Middle Initial
Birth Date / / Gender Male Female Mr. Mrs. Ms.

Home Telephone Number Alternate Phone Number (optional)
( ) ( )
Permanent Residence Street Address (not a P.O. Box)
City State ZIP Code County
Mailing Address (only if different from your Permanent Residence Street Address)
City State ZIP Code

&
E-mail Address (optional)

Please e-mail me plan information and updates.
2. Medicare Insurance 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 appears on Medicare Card)
1-800-MEDICARE (1-800-633-4227) – – –
NAME OF BENEFICIARY
JANE DOE Medicare Claim Number Letter(s)
MEDICARE CLAIM NUMBER SEX
000-00-0000-A FEMALE
IS ENTITLED TO EFFECTIVE DATE Part A (Hospital) effective date / /
HOSPITAL (PART A) 07-01-1986
MEDICAL (PART B) 07-01-1986
SIGN
HERE Jane Doe

Part B (Medical) effective date / /
You must have Medicare Part A and Part B to join a Medicare Advantage Plan.
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1 of 6 AAEX11MP3241235_000
3. Your Payment Options (If applicable)
Enrollment Form 2
If you have a plan premium AND/OR we determine that you owe a late enrollment penalty, (or if you currently have a late
enrollment penalty), the amount can be automatically deducted from your Social Security benefit check. The automatic
deduction from your monthly Social Security benefit check may take two or more months to begin. In most cases, the
first deduction will include all premiums due from your enrollment effective date up to the point withholding begins. If
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you don’t choose this option, you can sign up for Electronic Funds Transfer (EFT). People with limited incomes may qualify
for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs
including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will
not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even
know it. For more information about this extra help, contact your local Social Security Administration office, or call the
Social Security Administration at 1-800-772-1213. TTY users should call 1‑800‑325‑0778. You can also apply for extra
help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug
coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, it is
recommended you choose the coupon book or EFT option.
If there is a plan premium, and/or a late enrollment penalty, deduct the total amount from my
(If you do not select a payment option, you will receive a coupon book for the amount that Medicare doesn’t cover.
If you would like to set up EFT, please enclose a blank check with VOID written on the front.)
Monthly Social Security benefit check
E lectronic Funds Transfer (EFT) from your bank account each month.
Enclose a VOIDED check or provide the following
Account Holder Name Bank Routing Number
Bank Account Number Account Type Checking Savings
Coupon Book
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4a. Benefit Plan Selections — Choose Only One

Health Maintenance Organization (HMO) plans with a medical and Part D drug benefit
AARP® MedicareComplete® (HMO) AC AARP® MedicareComplete® Value (HMO) AV
AARP® MedicareComplete® Plan 1 (HMO) A1 AARP® MedicareComplete® Premier (HMO) APR
AARP® MedicareComplete® Plan 2 (HMO) A2 AARP® MedicareComplete® Mosaic (HMO) AM
AARP® MedicareComplete® Plan 3 (HMO) A3
HMO plans with medical benefits only
AARP® MedicareComplete Essential® (HMO) AE
Preferred Provider Organization (PPO) plans with a medical and Part D drug benefit
AARP® MedicareComplete Choice® (PPO) ACC AARP® MedicareComplete Choice® (Regional PPO) ACR
AARP® MedicareComplete Choice® Plan 1 (PPO) AC1
A ARP® MedicareComplete Choice® Plan 2 (Regional PPO) AC2
PPO plans with medical benefits only

A ARP® MedicareComplete Choice® Essential (PPO) ACE
A ARP® MedicareComplete Choice® Essential (Regional PPO) ACP
Point of Service (HMO-POS) plans with a medical and Part D drug benefit
AARP® MedicareComplete® Plus (HMO-POS) AP
&
AARP® MedicareComplete® Plus Plan 1 (HMO-POS) AP1
HMO-POS plans with medical benefits only

AARP® MedicareComplete® Plus Essential (HMO-POS) APE
2 of 6 AAEX11MP3241235_000
4b. Complete the following if the plan chosen includes routine dental coverage
Enrollment Form 2
Name of dental provider Provider ID# (please refer to Provider Directory)
Are you currently a patient of this dentist? Yes No
4c. OPTIONAL Supplemental Benefit Plans
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These plans are not available in all service areas.

Please review the Summary of Benefits to confirm availability and to learn about any applicable premiums.
If available, you can choose both the Fitness AND the Deluxe Rider (or a Dental Plan below).
Fitness Rider Deluxe Rider
If available and you did not select the “Deluxe Rider” option above, you can choose ONE of the dental plans
below.
High Option Dental Rider Optional Dental Rider Dental 260 Rider
Dental Facility # (please refer to the Provider Directory)
Dental 467 Rider Dental Platinum Rider You do not need to select a Dental Facility for these plans.
5. Primary Care Physician (PCP), Clinic or Health Center Selection
Refer to your Provider Directory or the plan Web site to select a PCP. Provider ID#
PCP name
Are you now seeing or have you recently seen this doctor? Yes No
6. Please Read and Answer These Important Questions
Do you have End-Stage Renal Disease (ESRD)? Yes No
If you answered “yes” and you don’t need regular dialysis any more, or if you have had a successful kidney transplant,
please attach a note or records from your doctor showing you don’t need dialysis or have had a successful kidney
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transplant. (Use Form 2728 if available.)

If “yes”, are you currently a member of a health care company? Yes No
If “yes”, name of company Member ID#
Are you a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes No
If “yes”, name of institution
Address of institution
City, State, ZIP Code
Telephone number of institution ( ) Your date of admission to the institution / /
Are you enrolled in your state Medicaid program? Yes No
If “yes”, please provide your Medicaid ID number
Do you or your spouse work? Yes No
Do you or your spouse have any health insurance other than Medicare, such as private insurance,
Workers’ Compensation or Veterans Administration (VA) benefits? Yes No
If you have other health insurance, what kind do you have?
What is the name of the health insurance?
Group # ID#
Do you have any other prescription drug coverage such as private insurance, TRICARE, VA benefits, State
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Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage? Yes No

Plan name of other coverage
Member ID# for this coverage
Group ID# Effective Date (optional)
3 of 6 AAEX11MP3241235_000
7. Alternative Formats (Check only one)
Enrollment Form 2
If available, I prefer to receive materials in the following format Spanish Chinese
Large Print (English Only)
Please contact SecureHorizons® at 1-800-547-5514 if you need information in another format or language than those listed
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above. Our office hours are 8 a.m. – 8 p.m. local time, 7 days a week. TTY users should call 711.
Statements of Understanding

1. A
ARP® MedicareComplete® is a Medicare Advantage Plan and has a contract with the Federal Government. I must
keep my Medicare Parts A and B by continuing to pay the Part B premiums and, if applicable, Part A premiums, if not
otherwise paid for under Medicaid or by another third party. I can only be in one Medicare Advantage Plan or Medicare
Advantage Prescription Drug Plan at a time. By enrolling in this Plan, I will automatically be disenrolled from any other
Medicare Health plan or prescription drug plan of which I may be a member. It is my responsibility to inform the Plan of
any prescription drug coverage that I have or may get in the future. For MA-only Plans: I understand that if I don’t have
Medicare Prescription Drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to
pay a late-enrollment penalty if I enroll in Medicare Prescription Drug coverage in the future. Enrollment in this Plan is
generally for the entire year, unless Special Election Periods apply. Once I enroll, I may leave this Plan or make changes
only at certain times of the year when an enrollment period is available (Example: October 15–December 7 of every
year), or under certain special circumstances, by sending a request to the Plan or by calling 1-800-MEDICARE
(1‑800‑633‑4227); (hearing impaired users should call 1-877-486-2048), 24 hours a day, 7 days a week.
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2. I understand that I must live in the service area and if I move out of the service area, I must notify the Plan of the move.
I understand that if I permanently move out of the service area, I will be disenrolled from the plan and can enroll in a
plan in my new service area. I understand that people with Medicare aren’t usually covered under Medicare while out
of the country except for limited coverage near the U.S. border.
3. I understand that as a member of this Plan, I have the right to appeal Plan decisions about payments or services if I
disagree. I understand that I will be bound by the benefits, copayments, exclusions, limitations and other terms of the
Plan. It is my responsibility to read the Evidence of Coverage when I receive it to know which rules I must follow in
order to get coverage with this Medicare Advantage Plan and the amounts for which I will be responsible for payment
under the Plan.
4. B y joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to
Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge the
Plan will release my information, including my prescription drug event data if applicable, to Medicare, who may release
it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this
Enrollment Form is correct to the best of my knowledge. I understand that if I intentionally provide false information on
this Enrollment Form, I may be disenrolled from the Plan.
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4 of 6 AAEX11MP3241235_000
Statements of Understanding (continued)
Enrollment Form 2
5. I understand that if I previously had prescription drug coverage or any insurance that included drugs, I may be asked
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for proof that my previous prescription drug coverage was at least as good as Medicare’s standard prescription drug
coverage (creditable prescription drug coverage). I can send copies of my proof with this form or I can wait until I am
asked for it. I don’t have to send proof to enroll. However, if I am asked for my proof and I don’t provide it, my premium
may be increased because of a late enrollment penalty. For more information about the Late Enrollment Penalty, I may
visit www.medicare.gov or 1-800-MEDICARE (1‑800‑633-4227); (hearing impaired users should call 1-877-486-2048),
24 hours a day, 7 days a week.
6. Counseling services may be available in my state to provide advice concerning Medicare Supplement Insurance or other
Medicare Advantage or Prescription Drug Plan options as well as medical assistance through the state Medicaid
Program and the Medicare Savings Program.
Additional Statements of Understanding for Each Specific Plan
AARP® MedicareComplete® from SecureHorizons (HMO)

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

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

I understand that beginning on the date AARP® MedicareComplete® Plus plan coverage begins, benefits are available
both in and out-of-network, and I understand I must use in‑network providers to enjoy the lowest cost sharing. Some
non-emergency care from non-contracted providers may not be covered at all under the Point of Service Plan. Additionally,
some out-of-network services may be limited by county or state and require prior authorization.
Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer,
submits an Enrollment Form or files a claim containing a false or a deceptive statement, has committed insurance fraud.
Commission of insurance fraud may result in disenrollment or denial of benefits and may subject the individual to civil or
criminal liability.
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5 of 6 AAEX11MP3241235_000
8. Please Read This Important Information
Enrollment Form 2
I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state
where I live) on this Enrollment Form means that I have read, understand and agree to the contents of this Enrollment Form,
Statements of Understanding and the Additional Statement of Understanding (for the plan I have chosen) on this form.
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You must sign and date this Individual Enrollment Form in order for it to be processed.
If signed by an authorized representative of the applicant, this signature certifies the person is authorized under state law
to complete this Enrollment Form and make health care decisions on behalf of the applicant and is authorized to receive
health care related information on his/her behalf and that documentation of this authority is available upon request by the
Plan or by Medicare. I will notify the Plan if the authority to receive health care related information changes.
Signature of applicant/member/authorized representative Date
/ /
If you are the authorized representative of the applicant, you must provide the following information and sign above.
Name Relationship to applicant
Address Telephone Number

( )
City State ZIP Code Alternate Phone Number (optional)
( )
9. For Sales Representative/Agency Use Only

Selling Staff Member/Agent ID Initial Receipt Date
&
Selling Staff Member/Agent Name Proposed Effective Date
Agent Telephone Number
Signature (if assisted in enrollment)
10. Election Period

AEP ICEP IEP IEP2 (MAPD Plans Only) OEPI SEP (SEP Reason Code )
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6 of 6 AAEX11MP3241235_000
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Important Enrollment Information
I-Enroll Tracking Number
Effective Date
Medicare ID
Plan Name
Sales Agent ID
Sales Agent Name
Sales Agent Phone Number
Health Plan/PBP Number

&
This copy verifies you met with an agent who sells UnitedHealth Group Products. Once UnitedHealth Group
receives the Enrollment Form, you will receive a copy of your original Enrollment Form in the mail within two
weeks. This copy is for your records only. PLEASE DO NOT RESUBMIT.
Please contact your sales agent if you do not receive a copy of your original Enrollment Form in the mail
within two weeks.
Talk to your local sales agent for answers or to enroll.
If you do not have a local sales agent, please call Visit our web site at
1-800-547-5514, 8 a.m. - 8 p.m. local time, www.AARPMedicarePlans.com
7 days a week. TTY users call 711.
&
Visit our Web site at:
The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered by
an affiliate of UnitedHealthcare, a Medicare Advantage organization with a Medicare contract with the Federal
government. AARP® MedicareComplete® Plans carry the AARP name, and UnitedHealthcare pays a royalty fee
to AARP for use of AARP intellectual property. Amounts paid are used for the general purposes of AARP and its
members. AARP is not the insurer. You do not need to be an AARP member to enroll.
AARP does not recommend health-related products, services, insurance or programs. You are strongly encouraged
to evaluate your needs.
AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers,
representatives or advisors.
Y0066_100723_233355 CMS Approved 09142010 AAEX11MP3241235_000

Roadmap After Enrollment Good
Continue On Your Path to… Health
Steps How You Get It Description

Agent
1 Receipt of
Enrollment Form
Confirms you submitted an Enrollment Form.
Mailed We will mail you a copy of your completed

2 Copy of Completed
Enrollment Form
Enrollment Form for your personal
records only.
Acknowledgement of Mailed We received your completed Enrollment

3 Receipt of Application
Letter
Form. (Please note: Medicare must approve
your Enrollment Form)
Mailed
4 Notice to Confirm
Enrollment
Notice that Medicare has approved your
Enrollment Form. Your enrollment is complete.
Phone
5 Outbound Education
& Verification Call
Verifies the Medicare Advantage plan was
fully explained by your sales agent.
Y0004Y0035Y0066_100707_110218 File & Use 07192010
Mailed You may receive a letter on how to get

6 Premium Assistance extra help with your Medicare premiums
and other health care costs, if you qualify.
Mailed
7 Member ID Card
Bring this new Member ID card when you
visit your doctor, hospital or pharmacy.
Mailed Includes important information about your

8 Welcome Kit benefits, such as: Evidence of Coverage
and Provider Directory.
You will receive this call to inform us about

Phone your health history. This information will
9 Health Risk
Assessment Call
not affect your ability to enroll in this plan.
Your answers will help us develop a health
program to fit your needs.

This is an advertisement.
Y0004Y0066_100707_142434 CMS Approved 08202010 AAGA11PO3242216_000

2011 Enrollment Kit

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Hospitals Doctors Rx Drugs

Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton counties

Y0004Y0066_100707_142434 CMS Approved 08202010

We’re Here For You

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

Original Medicare consists of Medicare Parts A and B

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

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

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

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,

Y0004Y0066_100622_141023 CMS Approved 08032010

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,

The UnitedHealth Passport® Program is Included in Your Plan.

The gray states on the map to the right show the

Y0066_100716_122643 File & Use 08032010

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,

You may choose to contact your doctor to confirm if he or she is in the

I’m a Member…What’s Next?

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

Y0066_100720_090630 File & Use 08102010

Please secure your Original Medicare card

Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates,

AARP® MedicareComplete® Plus (HMO-POS)

Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth,

You Have Choices in Your Health Care

How Can I Compare My Options?

Where is AARP MedicareComplete Plus (HMO-POS) Available?

Who is Eligible to Join AARP MedicareComplete Plus (HMO-POS)

Can I Choose My Doctors?

Where can I Get My Prescriptions if I Join This Plan?

Does My Plan Cover Medicare Part B or Part D Drugs?

What is a Prescription Drug Formulary?

What is a Medication Therapy Management (MTM) Program?

What Types of Drugs May be Covered Under Medicare Part B?

Where Can I Find Information on Plan Ratings?

Please call SecureHorizons by UnitedHealthcare for more information about

1 Premium and Other In 2010 the monthly Part B Premium General

2 Doctor and Hospital You may go to any doctor, specialist In-Network

3 Inpatient Hospital In 2010 the amounts for each benefit In-Network

Lifetime reserve days can only be used

4 Inpatient Mental Same deductible and copay as In-Network

5 Skilled Nursing In 2010 the amounts for each benefit In-Network

6 Home Health Care $0 copay. In-Network

7 Hospice You pay part of the cost for outpatient General

8 Doctor Office Visits 20% coinsurance In-Network

9 Chiropractic Routine care not covered In-Network

10 Podiatry Services Routine care not covered. In-Network

11 Outpatient Mental 45% coinsurance for most outpatient In-Network

12 Outpatient 20% coinsurance In-Network

13 Outpatient 20% coinsurance for the doctor In-Network

14 Ambulance 20% coinsurance In-Network

15 Emergency Care 20% coinsurance for the doctor General

16 Urgently Needed 20% coinsurance, or a set copay General

17 Outpatient 20% coinsurance In-Network

Outpatient Medical Services and Supplies

18 Durable Medical 20% coinsurance In-Network

19 Prosthetic Devices 20% coinsurance In-Network

20 Diabetes 20% coinsurance In-Network

21 Diagnostic Tests, 20% coinsurance for diagnostic tests In-Network

22 Bone Mass No coinsurance, copayment or In-Network

23 Colorectal No coinsurance, copayment or In-Network

24 Immunizations $0 copay for Flu, and Pneumonia and In-Network

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

• Staying healthy: screenings, tests, and vaccines. Includes how often