Santa Clara County - Care1st Health Plan

PRE-ENROLLMENT 

BOOK 2013 

Care1st AdvantageOptimum Plan (HMO) 

SANTA CLARA CouNTY 

H5928_13_066_MK CMS Accepted

Dear Medicare Beneficiary: 

Thank you for considering one of Care1st Medicare Advantage Health Plans (HMO, HMO SNP) for 

your health care needs. Taking charge of your health is one of the many ways that you can control your 

health and health care options. The information enclosed will help you to explore the benefits of being a 

Care1st member. 

Like most people, we know that you are looking for health care coverage that meets your needs and 

is affordable. With that in mind, we have designed our Medicare Advantage and Special Needs Plans 

around YOU! You will get more of the benefits you want and need to keep you healthy while maintaining 

your lifestyle. 

By choosing Care1st, you’ll receive the benefits of a great company with proven leadership, integrity, 

and a dedicated staff that is ready to serve you. And, there’s more! 

Care1st was created and is still run today by doctors. We believe our members needs come first. We 

focus on caring for the “whole you” so that you can live a healthier daily life. With over 10,000 physicians 

and 100 hospitals in our network, we’re certain that you will find the doctor that is right for you 

and your specific needs. 

The information in this folder will help you to explore the benefits of being a Care1st member. 

As a guide, we encourage you to review the Summary of Benefits as it provides detailed coverage that 

our plans offer. 

Are you ready to enroll? 

Simply complete the Individual Enrollment Form and return it to Care1st. 

Choosing health care coverage is a big decision and can be confusing. We are happy to help answer any 

questions you may have. Don’t hesitate to call. No question is too big or too small, “Yes, it is all about 

you”. 

If you’re ready to enroll, simply complete the Individual Enrollment Form and return it to Care1st or 

you can call us and we can help you enroll telephonically. 

Marketing Department 

1-800-847-1222 (TTY 1-800-735-2929) 

8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 

8:00 a.m. to 8:00 p.m., Monday - Friday, February 15 – September 30 

We look forward to welcoming you to the Care1st family. 

Care1st Health Plan • P.O. Box 4239, Montebello, CA 90640 

Care1st Health Plan (HMO, HMO SNP) is a Medicare Advantage organization with a Medicare contract. 


Thank you for Your 

Interest in Care1st 

A Medicare approved HMO plan 

TABLE OF CONTENTS 

1. Welcome Letter 

2. Thank you for Your Interest in Care1st / 

Table of Contents 

3. Care1st Health Plan 2013 Service Area Map 

4. Frequently Asked Questions and Answers 

about Medicare Advantage Plans 

5. 2013 Care1st Benefit Chart - a condensed list of 

some of the benefits you will receive as a Care1st 

member. 

10. Sample Enrollment Form - demonstrates the 

information you need to include on your 

application. 

11. Summary of Benefits 

12. Drug List - a comprehensive list of the drugs 

covered by Care1st and their tier levels. 

13. Delta Dental Flyer - important information 

about the Care1st dental program and provider. 

14. Outbound Education & Verification (OEV) Call 

6. Nurse Advice Line 

7. Transportation Information 

8. Understanding Enrollment Periods - 

explanation of the different times of year when 

you can enroll or make changes to your plan. 

9. Ready to Enroll - guidelines and instructions to 

help you through the enrollment process. 

15. What to Expect After Enrollment - providing 

details about the enrollment process and 

timelines. 

16. Visit Us Online - information about our website 

at www.Care1stMedicare.com. 

17. Multi Language Information - if you require 

enrollment information in another language, 

please follow the instructions provided. 

SC


Service Areas 

2 0 1 3 

Alameda 

(partial) 

San 

Francisco 

HMO & HMO SNP 

HMO Plan Only 

San 

Joaquin 

Stanislaus 

Santa Clara 

CALIFORNIA 

Call Member Services for 

questions or benefit information: 

1-800-544-0088 (TTY 1-800-735-2929) 

8:00 a.m. to 8:00 p.m., seven days a week, 

October 1 – February 14 

8:00 a.m. to 8:00 p.m., Monday - Friday, 

February 15 – September 30 

care1stmedicare.com 

Los 

Angeles 

Orange 

(partial) 

San Bernardino 

(partial) 

San 

Diego 

Riverside 

(partial) 

Care1st is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program in counties where D-SNP 

Services are available. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 

(TTY 1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 p.m., Monday - Friday, 

February 15 – September 30. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los 

Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 8:00 p.m., Lunes a Viernes, 

Feb. 15 - Sep. 30. 

我們可免費以其它語言為您提供這資訊。請致電會員服務部免費熱線 :1-800-544-0088 ( 聽障和語障人士可致電 1-800-735-2929), 

由 10 月 1 日至 2 月 14 日 , 我們的辦公時間為每週七天 , 上午 8:00 點至晚上 8:00 點。由 2 月 15 日至 9 月 30 日 , 我們的辦公 

時間為週一至週五 , 上午 8:00 點至晚上 8:00 點。 


Service Area Zip Codes 

Alameda County 

94501; 94502; 94601; 94602; 94603; 94604; 94605; 

94606; 94607; 94608; 94609; 94610; 94611; 94612; 

94613; 94614; 94617; 94618; 94619; 94620; 94621; 

94623; 94624; 94661; 94662; 94701; 94702; 94703; 

94704; 94705; 94706; 94707; 94708; 94709; 94710; 

94712; 94720 

Los Angeles County 

All Zip Codes 

Orange County 

90620; 90621; 90622; 90623; 90624; 90630; 90631; 

90632; 90633; 90638; 90680; 90720; 90740; 90742; 

90743; 92609; 92610; 92617; 92619; 92620; 92626; 

92637; 92646; 92647; 92648; 92649; 92655; 92657; 

92673; 92683; 92685; 92694; 92697; 92698; 92701; 

92702; 92703; 92704; 92705; 92706; 92707; 92708; 

92725; 92735; 92801; 92802; 92803; 92804; 92805; 

92806; 92807; 92808; 92809; 92812; 92814; 92815; 

92816; 92817; 92821; 92822; 92823; 92825; 92831; 

92832; 92833; 92834; 92835; 92836; 92837; 92838; 

92840; 92841; 92842; 92843; 92844; 92845; 92846; 

92850; 92868; 92870; 92871; 92885; 92886; 92887; 

92899 

Riverside County 

91718; 91719; 91720; 91752; 91760; 92028; 92201; 

92202; 92203; 92210; 92211; 92220; 92223; 92230; 

92234; 92235; 92236; 92240; 92241; 92247; 92248; 

92253; 92254; 92255; 92258; 92260; 92261; 92262; 

92263; 92264; 92270; 92274; 92276; 92282; 92292; 

92320; 92324; 92373; 92399; 92501; 92502; 92503; 

92504; 92505; 92506; 92507; 92508; 92509; 92513; 

92514; 92515; 92516; 92517; 92518; 92519; 92521; 

92522; 92530; 92531; 92532; 92536; 92539; 92543; 

92544; 92545; 92546; 92548; 92549; 92551; 92552; 

92553; 92554; 92555; 92556; 92557; 92561; 92562; 

92563; 92564; 92567; 92570; 92571; 92572; 92581; 

92582; 92583; 92584; 92585; 92586; 92587; 92589; 

Riverside County (Continued) 

92590; 92591; 92592; 92593; 92595; 92596; 92599; 

92860; 92877; 92878; 92879; 92880; 92881; 92882; 

92883 

San Bernardino County 

91701; 91708; 91709; 91710; 91730; 91737; 91739; 

91761; 91762; 91763; 91764; 91784; 91786; 92301; 

92307; 92308; 92313; 92316; 92318; 92324; 92334; 

92335; 92336; 92337; 92344; 92345; 92346; 92350; 

92354; 92357; 92359; 92368; 92369; 92371; 92373; 

92374; 92376; 92377; 92392; 92394; 92395; 92399; 

92401; 92402; 92403; 92404; 92405; 92406; 92407; 

92408; 92410; 92411; 92412; 92413; 92414; 92415; 

92418; 92420; 92423; 92424; 92427 

San Diego County 

All Zip Codes 

San Francisco County 

All Zip Codes 

San Joaquin County 

All Zip Codes 

Santa Clara County 

All Zip Codes 

Stanislaus County 

All Zip Codes

Do You Have 

Medicare Questions? 


Care1st (HMO, HMO SNP) has answers. 

What are the different parts of Medicare A, 

B, C and D? 

Medicare Part A covers inpatient hospital care, skilled 

nursing facility, home health care and hospice care. 

Medicare Part B covers outpatient care, such as 

doctor’s office visits, specialist’s office visits, lab 

services, durable medical equipment and preventive 

services. You pay a Part B premium each month. 

Medicare Part C are Medicare Advantage plans which 

are approved by Medicare and offered by private 

companies. Medicare Advantage Plans provide all of 

your Part A and Part B coverage. Medicare Advantage 

plans may offer extra coverage, such as vision, hearing, 

dental and/or health and wellness programs. 

Medicare Part D is your prescription drug coverage. To 

get prescription drug coverage you must join a plan 

such as Care1st. Each plan can vary in cost and drugs 

covered. 

How do I join Care1st Medicare Advantage 

Plans? 

Call Care1st at 1-800-847-1222 and a representative 

can assist you right over the phone. (TTY) 1-800-735- 

2929. Seven days a week, 8:00 a.m. to 8:00 p.m. PT. 

Can I obtain specialty services? 

When you need specialty care or additional services 

your PCP cannot provide, he or she will give you a 

referral. There are certain services which you can get 

on your own, without a referral as long as you get 

them from a network provider. 

Does Care1st offer transportation services? 

You are covered for transportation services to all 

routine, specialty, laboratory, and dental medical 

appointments. Some restrictions may apply. 

What should I do if I’m out of Care1st’s 

coverage area and need emergency 

services? 

Care1st provides worldwide emergency coverage. 

If you have an emergency when you are not in our 

service area, you can obtain emergency services at 

the nearest emergency facility (doctor’s office, clinic or 

hospital). Emergency services do not require a referral 

or an okay from your PCP doctor. 

Can I obtain care after normal business 

hours? 

It is important you always carry your Care1st ID card 

with you. If you that think you have an emergency, 

call 911 or go to the nearest emergency room. Call 

your doctor if you need medical care, and he or 

she can help you arrange care. Care1st also offers a 

Nurse Advice Line. The call is free and easy. You get 

advice right away. A nurse will ask about your health 

problem. You do not have to call the Nurse Advice 

Line before getting healthcare. 


What if I’m a Medicare member with 

Care1st and also have Medi-Cal benefits 

elsewhere? 

If you are a Medi-Cal member and eligible for 

Medicare, then it is important to know that Medicare, 

not Medi-Cal is your primary insurance. If you are 

interested in combining your benefits, please call 

Member Services for more information on the 

additional benefits available. 

How is my private health information 

protected? 

There are federal and state laws that protect the 

privacy of your medical records and personal health 

information. We protect your personal health 

information under these laws. Any personal health 

information that you give us when you enroll is 

protected. We will make sure that unauthorized 

people don’t see or change your records. 

What benefits and services are not 

covered? 

Care1st plans cover all of the medically-necessary 

services that are covered by Medicare Part A and Part 

B. The following items and services aren’t covered 

under the Original Medicare Plan or by our plans: 

• Services that aren’t reasonable and necessary, 

according to the standards of the Original 

Medicare Plan, unless these services are otherwise 

listed by our Plan as a covered service 

• Experimental or investigational medical and 

surgical procedures, equipment and medications, 

unless covered by the Original Medicare Plan or 

unless, for certain services, the procedures are 

covered under an approved clinical trial 

• Surgical treatment of morbid obesity unless 

medically necessary and covered under the 

Original Medicare plan 

• Private room in a hospital, unless medically 

necessary 

• Private duty nurses 

• Personal convenience items, such as a telephone 

or television in your room at a hospital or skilled 

nursing facility 

• Nursing care on a full-time basis in your home 

• Custodial care unless it is provided in conjunction 

with covered skilled nursing care and/or skilled 

rehabilitation services. This includes care that helps 

people with activities of daily living like walking, 

getting in and out of bed, bathing, dressing, eating 

and using the bathroom, preparation of special 

diets, and supervision of medication that is usually 

self-administered 

• Homemaker services 

• Charges imposed by immediate relatives or 

members of your household 

• Elective or voluntary enhancement procedures, 

services, supplies and medications including but 

not limited to: Weight loss, hair growth, sexual 

performance, athletic performance, cosmetic 

purposes, anti-aging and mental performance 

unless medically necessary 

• Cosmetic surgery or procedures, unless needed 

because of accidental injury or to improve the 

function of a malformed part of the body. All 

stages of reconstruction are covered for a breast 

after a mastectomy, as well as for the unaffected 

breast to produce a symmetrical appearance 

• Chiropractic care is generally not covered, (with 

the exception of manual manipulation of the 

spine), and is limited according to Medicare 

guidelines 

• Orthopedic shoes unless they are part of a leg 

brace and are included in the cost of the brace. 

Exception: Therapeutic shoes are covered for 

people with diabetic foot disease 

• Supportive devices for the feet. Exception: 

Orthopedic or therapeutic shoes are covered for 

people with diabetic foot disease 

• Radial keratotomy, LASIK surgery, vision therapy 

and other low vision aids and services 

• Self-administered prescription medication for 

the treatment of sexual dysfunction, including 

erectile dysfunction, impotence, and anorgasmy or 

hyporgasmy

• Reversal of sterilization procedures, sex change 

operations, and non-prescription contraceptive 

supplies and devices 

• Naturopath services 

• Non-emergency services provided to veterans in 

Veterans Affairs (VA) facilities. However, in the case 

of emergency services received at a VA hospital, 

if the VA cost-sharing is more than the costsharing 

required under our Plan, we will reimburse 

veterans for the difference. Members are still 

responsible for our Plan cost-sharing amount 

• Any of the services listed above that aren’t covered 

will remain not covered even if received at an 

emergency facility. For example, non-authorized, 

routine conditions that do not appear to a 

reasonable person to be based on a medical 

emergency are not covered if received at an 

emergency facility 

What can I do if I move out of your service 

area? 

If you move out of the service area or are away from 

the service area for more than 6 months, you cannot 

remain a member of our Plan. Please call Member 

Services to find out if the place you are moving to or 

traveling to is in our Plan’s service area. 

How can I assign a representative to act in 

my behalf? 

You have the right to ask someone such as a family 

member or friend to help you with decisions about 

your health care. If you want to, you can use a special 

form to give someone the legal authority to make 

decisions for you if you ever become unable to make 

decisions for yourself. If you want to have an advance 

directive, you can get a form from your lawyer, 

from a social worker or from some office supply 

stores, or from other sources including the internet 

and advocacy groups. If you only wish to give the 

authority to represent you in dealings with Care1st for 

enrollment, claims and other administrative matters, 

you can visit our website www.Care1stMedicare. 

com download and complete the “Appointment of 

Representative”. Please note that copies of an advance 

directive, Appointment of Representative, or similar 

documents must be sent to Care1st to be effective for 

Care1st purposes. 




1-800-544-0088 (TTY 1-800-735-2929) 


October 1 – February 14; 




Care1st is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program in counties where 

D-SNP Services are available. The benefit information provided is a brief summary, not a complete description of benefits. For more 

information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, 

and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 

1-800-544-0088 (TTY 1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 

p.m., Monday - Friday, February 15 – September 30. Esta información está disponible gratuitamente en otros idiomas. Comuníquese 

con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 

8:00 p.m., Lunes a Viernes, Feb. 15 - Sep. 30. 



時間為週一至週五 , 上午 8:00 點至晚上 8:00 點。

it is all about you. 

2013 

BENEFITS CHART 

For more information call 

1-800-847-1222 (TTY 1-800-735-2929), 





BENEFIT 


AdvantageOptimum 

(HMO) 

Premium $0 

Out-of-Pocket Limit (In-Network $3,400 

Medicare-covered benefits) 

InpatIent ServIceS 

Inpatient Hospital (Acute) 

Days Covered Per Benefit Period 

Inpatient Psychiatric Hospital 

Inpatient Mental Health Care 

$50 copay days 1 - 3; 

$0 copay days 4- 90; (unlimited additional days) 

$50 copay days 1 - 8; $0 copay days 9- 90; 

$400 OOP MAX per benefit period 

Skilled Nursing Facility (SNF) $0 copay days 1 - 20; $50 copay days 21- 100; 

(no prior hospital stay required) 

Cardiac And Pulmonary 

$10 copay 

Rehabilitation Services 

Emergency Care 

$50 copay 

(Waived if admitted) 

Worldwide coverage up to $25,000 per year 

Urgently Needed Care 

$15 copay In network 

$25 copay out of network 

(Waived if admitted) 

Partial Hospitalization 

$0 copay 

OutpatIent ServIceS 

Home Health Services 

$0 copay 

Primary Care Physician (PCP) $0 copay 

Chiropractic Services (Medical) $5 copay 

Chiropractic Services (Routine) $10 copay / up to 15 visits 

Occupational Therapy 

$10 copay 

Physician Specialist 

$5 copay


2013 


BENEFIT 

Outpatient Mental Health 

(Individual / Group) 

Podiatry (Medical) 

Routine Podiatry 

Psychiatric Services 


Physical Therapy and Speech 

Therapy Services 

Outpatient Diagnostic Procs/ 

Tests/Lab Services (Tests, X-Rays, 

and Lab Services) 

Radiology 

(Diagnostic / Therapeutic) 

Outpatient Hospital 

Ambulatory Surgical Center 

(ASC) Services 

Outpatient Substance Abuse 


Outpatient Blood Services 

addItIOnal BenefItS 

Ambulance 

Transportation 

Durable Medical Equipment 

(DME) 

Prosthetic / Medical Supplies 

Diabetes Supplies 

Renal Dialysis 

Acupuncture 

$10 copay 

$5 copay 

$10 copay 

$10 copay 

$0 copay 

$0 copay (D) / 10% coinsurance (T) 

$20 - $50 copay 

$20 - $50 copay 

$10 copay 

$0 copay 



(HMO) 

$100 copay (Waived if admitted) 

$0 copay /24 round-trips to plan approved locations 

$0 copay Medicare Covered item; 

20% coinsurance non-Medicare covered item 

20% coinsurance 

$0 copay Self-Management Training/Nutrition Therapy/ 

Monitoring Supplies; 

20% coinsurance (Therapeutic Shoes or Inserts) 

$10 copay 

$5 copay / up to 15 visits


2013 


BENEFIT 

Medicare Covered Preventive 

Services (Mammography/ 

influenza vaccines no referral) 

Health Education 

Nursing Hotline 

Kidney Disease Education 

Diabetes Self-Management 

Training 

Dental Services (Preventive) 

Eye Exams 

Eye Exam (Routine) 

Eyewear 

Hearing Exams 

Hearing Aids 

$0 copay 



(HMO) 

$0 copay 

$0 copay 

$0 copay 

$0 copay (Training at PCP) 

$5 copay (Training at Specialist) 

Preventive (Routine): $0 copay for: unlimited oral exams every year; 

*1 cleaning every 6 months; 

*1 x-ray every two years; 

$5 copay for 1 fluoride treatment every 6 months; 

*Copays apply for additional dental benefits. 

$0 copay Medicare covered eye benefits (exams to diagnose and treat eye 

diseases/conditions) 

$5 copay routine eye exams (1 every year) 

$0 copay - $150 limit for glasses every 2 years/refraction test covered 

$10 copay Medicare covered benefits; 

$10 copay routine exams (1 every year); $0 copay Fitting/Evaluation for 

Hearing Aid 

$0 copay for (2) hearing aids every two years; $500 limit every year


2013 


BENEFIT 



(HMO) 

preScrIptIOn BenefItS 

Medicare Part B Drugs 

(Part B & Chemotherapy) 

Preferred Generic Drugs, T1 

Non-Preferred Generic Drugs, T2 

Preferred Brand Drugs, T3 

Non-Preferred Generic and Non- 

Preferred Brand Drugs, T4 

Specialty Tier Drugs, T5 


Initial Coverage Limit After $2,970 

(Tiers 1 & 2) 

$0 copay 

$5 copay 1 month supply; 

$10 copay 3 month supply 






Care1st Health Plan (HMO) is a Medicare Advantage organization with a Medicare contract. The benefit information provided is a brief summary, not 

a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/ 

co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare 

Part B premium. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY 1-800-735-2929), 

8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 p.m., Monday - Friday, February 15 – September 30. Esta 

información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), 

de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 8:00 p.m., Lunes a Viernes, Feb. 15 - Sep. 30. 

H5928_13_120_MK Accepted


Nurse 

Advice Line 

The Care1st (HMO, HMO SNP) 

Nurse Advice Line is a service 

available to all Care1st members. 

The call is free and easy. 

A caring nurse will listen to 

your health problem. 

The nurse can help you decide: 

• If you need to see the doctor. 

• If it is safe to wait or if you need care 

right away. 

• What to do if your symptoms get 

worse. 

• What you can start doing at home to 

feel better. 

For life- or limb-threatening emergencies, 

always call 911 or your local emergency 

services. You do not have to call the Nurse 

Advice Line before getting health care. 

Call the Care1st Nurse Advice Line at: 

1-800-544-0088 (TTY 1-800-735-2929) 







D-SNP Services are available. The benefit information provided is a brief summary, not a complete description of benefits. For 

more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, 

copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 



con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana, Oct. 1 - Feb. 14; 8:00 a.m. to 








S E R V I C E S 

$ 

0 

copay for each round trip to plan-approved locations.* 

Care1st (HMO, HMO SNP) is proud 

to offer transportation services 

to our members. Transportation 

is provided as-needed for nonemergency 

healthcare visits. 

Note: Call Care1st to reserve your ride. 

Reservations must be made at least 24 hours 

in advance. 

1-87-RIDEC1ST (1-877-433-2178) 

(TTY users call 1-800-735-2929) 







D-SNP Services are available. The benefit information provided is a brief summary, not a complete description of benefits. For 

more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, 

copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 



con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 






Understanding Medicare 

Enrollment Periods 

2012 

OCT NOV DEC 

2013 

JAN 

FEB 

MAR APR MAY JUN JUL AUG SEP 

OCT 

Annual 

Election Period 

Oct 15 to Dec 7 

Medicare 

Advantage 

Disenrollment 

Period 

Jan 1 - Feb 14 

Lock-In Period 

Feb 14 - Oct 14 

Special Election Period and Initial Coverage Election Period, for those that qualify, is open all year. 

Open Enrollment Period for Institutionalized Individuals is open all year. 

There are different types of enrollment periods throughout the year when individuals may enroll or make 

changes to their Medicare plan. 

ANNUAL ELECTION PERIOD (AEP) 

Available October 15th through December 7th 

During this time you may join, drop or switch to the 

Medicare Advantage plan that is best for you. 

MEDICARE ADVANTAGE DISENROLLMENT PERIOD 

(MADP) 

Available January 1st through February 14th 

During this period if you have a Medicare Advantage 

plan you can leave your plan and return to Original 

Medicare. If you make the choice to switch to 

Original Medicare, you have until February 14th to 

sign up for a prescription drug plan. 

During the Disenrollment Period you cannot switch 

from Original Medicare to a Medicare Advantage 

plan or switch from one Medicare Advantage plan to 

another. 

LOCK IN PERIOD 

February 14th through October 14th 

During this time you cannot make changes to your 

Medicare plan unless you meet the requirements for 

the Special Election Period or Open Enrollment for 

Institutionalized Individuals. 

SPECIAL ELECTION PERIOD (SEP) 

Available all year to qualifying individuals 

During this time you may join, drop or switch your 

Medicare Advantage plan if you move out of the 

plan’s service area, lose your employer or union 

coverage, you enroll in a PACE program or have 

a chronic condition that allows you to enroll in a 

Special Needs Plan designed to specifically treat 

individuals with your condition. 


Understanding Medicare 

Enrollment Periods 

INITIAL COVERAGE ELECTION PERIOD (ICEP) 


This election period revolves around an individual’s 

65th birthday or the 25th month of disability. It is 

associated to one’s entitlement to both Medicare 

Part A, B and D. This period begins three months 

before the individual’s first entitlement to both 

Medicare Part A, B and D and ends on the later of: 

1. The last day of the month preceding entitlement 

to both Part A, B and D, or; 2. The last day of the 

individual’s Part B initial enrollment period. 

OPEN ENROLLMENT PERIOD FOR 

INSTITUTIONALIZED INDIVIDUALS (OEPI) 


If you are institutionalized and need to enroll in or 

disenroll from a Medicare Advantage Special Needs 

Plan for institutionalized individuals. 



1-800-544-0088 (TTY 1-800-735-2929) 







D-SNP Services are available. This information is available for free in other languages. Please contact Member Services: 1-800- 

544-0088 (TTY 1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 p.m., 

Monday - Friday, February 15 – September 30. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con 

Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 8:00 

p.m., Lunes a Viernes, Feb. 15 - Sep. 30. 




Are you ready to enroll? 


STEPS TO TAKE TO GET YOURSELF 

READY TO ENROLL: 

PICK YOUR PCP 

Pick your Primary Care Physician 

(PCP). Use our Provider Directory, 

or visit us online at 

www.Care1stMedicare.com or 

call us for a list of PCPs near you. 

HOW TO APPLY: 

APPLY BY PHONE 

Call Care1st at 1-800-847-1222 

(TTY 1-800-735-2929) 

8:00 a.m. to 8:00 p.m., 7 days a week, 


8:00 a.m. to 8:00 p.m., Monday - 

Friday, February 15 – September 30 

REVIEW Rx INDEX 

Take a moment to review our drug 

index provided to ensure that your 

medications are covered. Or visit 

our website to review our drug 

formulary or call us for verification 

of our drug listing. 

LOCATE MEDICARE ID CARD 

When you are applying, make sure 

to have your Medicare ID card 

available, or some form of proof 

that you are entitled to Medicare. 

If you have questions about 

becoming a Care1st member, call: 

1-800-847-1222 (TTY 1-800-735-2929) 


October 1 – February 14; 8:00 a.m. to 8:00 p.m., 

Monday - Friday, February 15 – September 30 

www.care1stmedicare.com 

APPLY IN PERSON 

Meet with your local Care1st 

Representative. 

APPLY BY MAIL 

Fill out the enclosed application 

form completely and mail in the 

provided postage-paid envelope. 

Care1st Health Plan 

ATTN: ENROLLMENT DEPT 

601 Potrero Grande Drive 

Monterey Park, CA 91755 

APPLY ONLINE 

Medicare beneficiaries may also 

enroll in Care1st through the 

CMS Medicare Online Enrollment 

Center located at 

http://www.medicare.gov. 


Services are available. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 




Feb. 15 - Sep. 30. 





Medicare advantage individual 

enrollMent election ForM 

Please contact Care1st if you need information 

in another language or format (Braille). 

to enroll in care1st, Please Provide the Following information: 

care1st advantageoptimum Plan (HMo) 

Alameda $28/month ✔Los Angeles $0/month San Bernardino $0/month 

Orange $0/month San Diego $0/month San Francisco $28/month 

Santa Clara $0/month San Joaquin $0/month Stanislaus $0/month 

care1st totaladvantage Plan (HMo) Los Angeles $0/month 

care1st totaldual Plan (HMo SnP) 

Alameda $0-$29.80/month* Los Angeles $0-$29.80/month* Orange $0-29.80/month* 

San Bernardino $0-$29/month* San Diego $0-$29.80/month* 

San Francisco $0-$29.80/month* Santa Clara $0-$29.80/month* 

*Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for 

original Medicare services. 

LAST Name: FIRST Name: Middle Initial: 

Doe John 

R. 

✔Mr. Mrs. Ms. 

Birth Date: Sex: 

Home Phone Number: Alternate Phone Number: 

(_ 03 _/_ 23 _/_ 1 9_ 4_ 5 _) ✔M 

F ( 555 ) 555-5555 ( 555 ) 777-7777 

(MMDDYYYY) 

Permanent Residence Street Address (P.O. Box is not allowed): 

222 Anywhere S t. 

Any Town 

City: 

CA 

State: 

93510 

ZIP Code: 

Mailing address (only if different from your Permanent Residence Address): 

Street Address: P.O. Box 123 

City: State: ZIP Code: 

emergency contact: __________________________________________________________ 

Jane Doe 

Phone number: _________________________ 

555-555-5555 relationship to You: _____________ 

Wife 

E-mail Address: johnrdoe@website.com 

Please Provide Your Medicare insurance information. 

Please take out your Medicare card to complete 

this section. 

MEDICARE 

HEALTH INSURANCE 

• Please fill in these blanks so they match your red, 

white and blue Medicare card. 

-OR- 

• Attach a copy of your Medicare card or your letter 

from Social Security or Railroad Retirement Board. 

You must have Medicare Part A and Part B to join a 

Medicare Advantage plan. 

SAMPLE ONLY 

Name: John ____________________________ 

R. Doe 

Medicare Claim Number Sex______ M 

444 _ _ _ - _ 44 _ - _ 4444 _ _ _ ___ 4 

Is Entitled To 

HoSPital (Part a) 

Medical (Part B) 

Effective Date 

_____________ 

MM-DD-YYYY 

_____________ 

MM-DD-YYYY 

WHITE – Enrollment Copy YELLOW – Member’s Copy 

H5928_13_006_EN CMS Approved

Paying Your Plan Premium 

You can pay your monthly plan premium (including 

any late enrollment penalty that you currently have or 

may owe) by mail each month. You can also choose to 

pay your premium by automatic deduction from your 

Social Security or railroad retirement Board (rrB) 

benefit check each month. If you are assessed a Part-Dincome 

related Monthly adjustment amount, you will be 

notified by the Social Security Administration. You will 

be responsible for paying this extra amount in addition 

to your plan premium. You will either have the amount 

withheld from your Social Security benefit check or be 

billed directly by Medicare or the rrB. do not pay 

Care1st the Part D-IRMAA. 

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 office, or call Social Security at 

1-800-772-1213. TTY users should call 1-800-325-0778. 

You can also apply for extra help online at www. 

socialsecurity.gov/prescriptionhelp. 

If you qualify for extra help with your Medicare 

prescription drug coverage costs, Medicare will pay all 

or part of your plan premium. If Medicare pays only a 

portion of this premium, we will bill you for the amount 

that Medicare doesn’t cover. 

If you don’t select a payment option, you will get a 

coupon book. 

Please select a premium payment option: 

Get a coupon book. 

✔ Automatic deduction from your monthly Social 

Security or Railroad Retirement Board (RRB) benefit 

check. (The Social Security/RRB deduction may take 

two or more months to begin after Social Security or 

RRB approves the deduction. In most cases, if Social 

Security or RRB accepts your request for automatic 

deduction, the first deduction from your Social Security 

or RRB benefit check will include all premiums due 

from your enrollment effective date up to the point 

withholding begins. If Social Security or RRB does 

not approve your request for automatic deduction, we 

will send you a paper bill for your monthly premiums.) 

Please read and answer these important questions. 

1. Do you have End-Stage Renal Disease (ESRD)? Yes ✔ No If you have had a successful kidney 

transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor 

showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to 

contact you to obtain additional information. 

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal 

employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. 

Will you have other prescription drug coverage in addition to Care1st? Yes ✔ No 

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage: 

Name of other coverage: ID# for this coverage: Group # for this coverage: 

3. Are you a resident in a long-term care facility, such as a nursing home? Yes ✔ No 

If “yes”, please provide the following information: 

Name of Institution: _______________________ 

Address and Phone Number of Institution (number and street)__________________________ 

4. Are you enrolled in your State Medicaid program? Yes ✔ No 

If yes, please provide your Medicaid number: 

5. Do you or your spouse work? ✔Yes No 

Please choose the name of a Primary care Physician (PcP), clinic or health center: 

Physician’s name 

Dr. Robert Jones 

id number 

55555 

Medical group / iPa name 

Misc. Medical Group 

Are you an existing patient of this doctor? ✔ Yes No 



Please check one of the boxes below if you would prefer us to send you information in a language other 

than english or in another format: Spanish Chinese Vietnamese 

Contact us if you need a format like Braille, audiotape or large print. 

Please contact Care1st at 1-800-544-0088 if you need information in another format or language than what is listed 

above. Our office hours are from 8:00 a.m. to 8:00 p.m. seven days a week. TTY users should call 

1-800-735-2929. 

Please read this important information 

if you currently have health coverage from an employer or union, joining care1st could affect your employer 

or union health benefits. You could lose your employer or union health coverage if you join Care1st. Read the 

communications your employer or union sends you. If you have questions, visit their website, or contact the office listed 

in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that 

answers questions about your coverage can help. 

Please read and Sign Below 

By completing this enrollment application, i agree to the following: 

Care1st is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare 

Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan 

will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to 

inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for 

the entire year. 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. 

Care1st serves a specific service area. If I move out of the area that Care1st serves, I need to notify the plan so I can 

disenroll and find a new plan in my new area. Once I am a member of Care1st, I have the right to appeal plan decisions 

about payment or services if I disagree. I will read the Evidence of Coverage document from Care1st when I get it 

to know which rules I must follow to get coverage with this Medicare Advantage plan. 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. 

I understand that beginning on the date Care1st coverage begins, I must get all of my health care from Care1st, except for 

emergency or urgently needed services or out-of-area dialysis services. Services authorized by Care1st and other services 

contained in my Care1st Evidence of Coverage document (also known as a member contract or subscriber agreement) 

will be covered. Without authorization, neitHer Medicare nor care1st Will PaY For tHe ServiceS. 

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with 

Care1st, he/she may be paid based on my enrollment in Care1st. 



elease of information: By joining this Medicare health plan, I acknowledge that Care1st will release my 

information to Medicare and other plans as is necessary for treatment, payment and health care operations. 

I also acknowledge that Care1st will release my information including my prescription drug event data 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 form, I will be disenrolled from the plan. 

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 application means that I have read and understand the contents of this application. If 

signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized 

under State law to complete this enrollment and 2) documentation of this authority is available upon request 

from Medicare. 

Signature: John R. Doe today’s date: 

MM-DD-YYYY 

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

name: __________________________________________________________________________________ 

address: ________________________________________________________________________________ 

Phone number: (_____) ________________ 

relationship to enrollee:___________________________ 

Office Use 

only 

Name of staff member/agent/broker (if assisted in enrollment):________________________________ 

Plan Representative Signature: _________________________________________________________ 

Plan Representative Name (print): ______________________________________________________ 

Plan Representative Number: __________________________________________________________ 

Plan Representative Phone Number: _____________________________________________________ 

Application Received Date: ____________________________________________________________ 

Eff. Date of Coverage: Enrollee ID#: Application #: Batch #: 

____________________ ___________________ ___________________ ___________________ 

ICEP/IEP: AEP: SEP (type): Not Eligible: 

____________________ __________________ ___________________ ___________________ 



Medicare advantage 

individual enrollMent election ForM 

Step 1: 

Step 2: 

Step 3: 

Please fill out the application completely. 

Use a ballpoint pen and press hard to make two copies. 

Sign and date the last page of the application. 

Keep the bottom yellow copy for your file. 

If you have any questions regarding this application, please call: 

1-800-847-1222 

(TTY 1-800-735-2929) 

Hours: 8:00 a.m. to 8:00 p.m. 

Seven days a week 

care1st Health Plan 

P.O. Box 4549 

Montebello, CA 90640 

www.care1st.com/ca/medicare 

Member Services: 1-800-544-0088 

(TTY 1-800-735-2929) 

Hours: 8:00 a.m. to 8:00 p.m. 

Seven days a week 



Summary of Benefits 

January 1, 2013 - December 31, 2013 

Care1st AdvantageOptimum 

Plan (HMO) 

California: 

Santa Clara County H5928-016 

H5928_13_038_MK_AOSB_SC Accepted

IntroductIon to Summary of BenefItS – Section 1 

Introduction to Summary of Benefits 

Thank you for your interest in Care1st AdvantageOptimum Plan (HMO). Our plan is offered by CARE1ST HEALTH PLAN/Care1st 

Medicare Advantage Plan, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with the Federal government. 

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 Care1st AdvantageOptimum Plan (HMO) 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 Care1st AdvantageOptimum Plan (HMO). 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 Care1st AdvantageOptimum Plan (HMO) at the telephone 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 Care1st AdvantageOptimum Plan (HMO) 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 Care1st AdvantageOptimum Plan (HMO) AVAILABLE? 

The service area for this plan includes: Santa Clara County, CA. You must live in in this area to join the plan. 

Santa Clara County: all zip codes 

WHO IS ELIGIBLE TO JOIN Care1st AdvantageOptimum Plan (HMO)? 

You can join Care1st AdvantageOptimum Plan (HMO) 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 Care1st AdvantageOptimum Plan 

(HMO) unless they are members of our organization and have been since their dialysis began. 

1

Introduction to Summary of Benefits – Section 1 

CAN I CHOOSE MY DOCTORS? 

Care1st AdvantageOptimum Plan (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part 

of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, 

visit us at www.care1st.com/ca/medicare. Our customer service number is listed at the end of this introduction. 

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK? 

If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare 

Plan will pay for these services except in limited situations (for example, emergency care). 

WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? 

Care1st AdvantageOptimum Plan (HMO) 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.care1st.com/ca/medicare. Our customer service number is 

listed at the end of this introduction. 

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? 

Care1st AdvantageOptimum Plan (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. 

WHAT IS A PRESCRIPTION DRUG FORMULARY? 

Care1st AdvantageOptimum Plan (HMO) 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 members 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.care1st.com/ca/medicare. 

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. 

2


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. 

WHAT ARE MY PROTECTIONS IN THIS PLAN? 

All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change 

from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may 

continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, 

Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare 

coverage. If a plan decides not to continue for an additional calendar year, 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 Care1st AdvantageOptimum Plan (HMO), 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 Care1st AdvantageOptimum Plan (HMO), 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 

3


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 Care1st AdvantageOptimum Plan (HMO) 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 Care1st AdvantageOptimum Plan (HMO) 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 osteoporosis drugs for some women. 

-- 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 physicians service. 

-- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified 

facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. 

-- 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 administered through Durable Medical Equipment. 

4


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 “Health and 

Drug Plans” then “Compare Drug and Health Plans” 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 Care1st Medicare Advantage Plan for more information about Care1st AdvantageOptimum Plan (HMO). 

Visit us at www.care1st.com/ca/medicare or, call us. 

Customer Service Hours for October 1 through February 14: 

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

Customer Service Hours for February 15 through September 30: 

Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Pacific 

Current members should call toll-free or locally (800)-544-0088 for questions related to the Medicare Advantage Program and / or questions 

related to the Medicare Part D Prescription Drug program. (TTY/TDD (800)-735-2929) 

Prospective members should call toll-free or locally (800)-847-1222 for questions related to the Medicare Advantage Program and / or 

questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (800)-735-2929) 

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 other formats such as Braille, large print or other alternate formats. 

This document may be available in a non-English language. For additional information, call customer service at the phone number listed 

above. 

Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número 

de teléfono indicado arriba. 

5

Summary of BenefItS – Section 2 

If you have any questions about this plan’s benefits or costs, please contact Care1st Medicare Advantage Plan for details. 

BenefIt 

orIGInaL medIcare 

care1st advantageoptimum Plan (Hmo) 

Santa cLara county 

IMPORTANT INFORMATION 

1 Premium and Other 

Important Information 

In 2012 the monthly Part B 

Premium was $99.90 and may 

change for 2013 and the annual 

Part B deductible amount was 

$140 and may change for 2013. 

If a doctor or supplier does not 

accept assignment, their costs 

are often higher, which means 

you pay more. 

Most people will pay the standard 

monthly Part B premium. 

However, some people will pay a 

higher premium because of their 

yearly income (over $85,000 for 

singles, $170,000 for married 

couples). For more information 

about Part B premiums based on 

income, call Medicare at 

1-800-MEDICARE 

(1-800-633-4227). TTY users 

should call 1-877-486-2048. You 

may also call Social Security at 

1-800-772-1213. TTY users 

should call 1-800-325-0778. 

General 

$0 monthly plan premium in addition to your monthly Medicare Part 

B premium. 

Most people will pay the standard monthly Part B premium in 

addition to their MA plan premium. However, some people will pay 

higher Part B and Part D premiums because of their yearly income 

(over $85,000 for singles, $170,000 for married couples). For more 

information about Part B and Part D premiums based on income, call 

Medicare at 1-800- MEDICARE (1-800-633-4227). TTY users should 

call 1-877- 486-2048. You may also call Social Security at 

1-800-772- 1213. TTY users should call 1-800-325-0778. 

In-Network 

$3,400 out-of-pocket limit for Medicare-covered services. 

6


BenefIt 




IMPORTANT INFORMATION (Continued) 

2 Doctor and Hospital 

Choice 

(For more information, see 

Emergency Care - #15 and 

Urgently Needed Care - 

#16.) 

You may go to any doctor, 

specialist or hospital that accepts 

Medicare. 

In-Network 

You must go to network doctors, specialists, and hospitals. 

Referral required for network hospitals and specialists (for certain 

benefits). 

SUMMARY OF BENEFITS 

INPATIENT CARE 

3 Inpatient Hospital Care 

(includes Substance Abuse 

and Rehabilitation Services) 

In 2012 the amounts for each 

benefit period were: 

Days 1 - 60: $1156 deductible 

Days 61 - 90: $289 per day 

Days 91 - 150: $578 per lifetime 

reserve day 

These amounts may change for 

2013. 

In-Network 

No limit to the number of days covered by the plan each hospital stay. 

For Medicare-covered hospital stays: 

- Days 1 - 3: $50 copay per day 


$0 copay for additional hospital days 

Except in an emergency, your doctor must tell the plan that you are 

going to be admitted to the hospital. 

7


BenefIt 




INPATIENT CARE (Continued) 

3 Inpatient Hospital Care 

(includes Substance Abuse 

and Rehabilitation 

Services) 

(continued) 

Call 1-800-MEDICARE 

(1-800-633-4227) for information 

about lifetime reserve days. 

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. 

8


BenefIt 





4 Inpatient Mental 

Health Care 


benefit period were: 

Days 1 - 60: $1156 deductible 

Days 61 - 90: $289 per day 

Days 91 - 150: $578 per lifetime 

reserve day 


2013. 

You get up to 190 days of 

inpatient psychiatric hospital care 

in a lifetime. Inpatient psychiatric 

hospital services count toward 

the 190-day lifetime limitation 

only if certain conditions are met. 

This limitation does not apply 

to inpatient psychiatric services 

furnished in a general hospital. 

In-Network 

You get up to 190 days of inpatient psychiatric hospital care in a 

lifetime. Inpatient psychiatric hospital services count toward the 

190-day lifetime limitation only if certain conditions are met. This 

limitation does not apply to inpatient psychiatric services furnished in 

a general hospital. 

$400 out-of-pocket limit every benefit period. 

For Medicare-covered hospital stays: 



Except in an emergency, your doctor must tell the plan that you are 

going to be admitted to the hospital. 

9


BenefIt 





5 Skilled Nursing 

Facility (SNF) 

(in a Medicare-certified 

skilled nursing facility) 


benefit period after at least a 

3-day covered hospital stay were: 

Days 1 - 20: $0 per day 

Days 21 - 100: $144.50 per day 


2013. 

100 days for each benefit period. 

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 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. 

General 

Authorization rules may apply. 

In-Network 

Plan covers up to 100 days each benefit period 

No prior hospital stay is required. 

For SNF stays: 



10


BenefIt 





6 Home Health Care 

(includes medically 

necessary intermittent 

skilled nursing care, home 

health aide services, and 

rehabilitation services, etc.) 

$0 copay. General 


In-Network 

$0 copay for Medicare-covered home health visits 

7 Hospice You pay part of the cost for 

outpatient drugs and inpatient 

respite care. 

General 

You must get care from a Medicare-certified hospice. Your plan will 

pay for a consultative visit before you select hospice. 

You must get care from a 

Medicare-certified hospice. 

OUTPATIENT CARE 

8 Doctor Office Visits 20% coinsurance General 


In-Network 

$0 copay for each Medicare-covered primary care doctor visit. 

$5 copay for each Medicare-covered specialist visit. 

11


BenefIt 




OUTPATIENT CARE (Continued) 

9 Chiropractic Services Supplemental routine care not 

covered 

20% coinsurance for manual 

manipulation of the spine 

to correct subluxation (a 

displacement or misalignment 

of a joint or body part) if you get 

it from a chiropractor or other 

qualified providers. 

10 Podiatry Services Supplemental routine care not 

covered. 

20% coinsurance for medically 

necessary foot care, including 

care for medical conditions 

affecting the lower limbs. 

General 


In-Network 

$5 copay for each Medicare-covered chiropractic visit 

$10 copay for up to 15 supplemental routine chiropractic visit(s) every 

year 

Medicare-covered chiropractic visits are for manual manipulation of 

the spine to correct subluxation (a displacement or misalignment of a 

joint or body part) if you get it from a chiropractor. 

General 


In-Network 

$5 copay for each Medicare-covered podiatry visit 

$5 copay for each supplemental routine podiatry visit 

Medicare-covered podiatry visits are for medically-necessary foot 

care. 

12


BenefIt 





11 Outpatient Mental 

Health Care 

35% coinsurance for most 

outpatient mental health services 

Specified copayment for 

outpatient partial hospitalization 

program services furnished 

by a hospital or community 

mental health center (CMHC). 

Copay cannot exceed the Part A 

inpatient hospital deductible. 

“Partial hospitalization program” 

is a structured program of 

active outpatient psychiatric 

treatment that is more intense 

than the care received in your 

doctor’s or therapist’s office 

and is an alternative to inpatient 

hospitalization. 

General 


In-Network 

$10 copay for each Medicare-covered individual therapy visit 

$10 copay for each Medicare-covered group therapy visit 

$10 copay for each Medicare-covered individual therapy visit with a 

psychiatrist 

$10 copay for each Medicare-covered group therapy visit with a 

psychiatrist 

$0 copay for Medicare-covered partial hospitalization program 

services 

13


BenefIt 





12 Outpatient Substance 

Abuse Care 

20% coinsurance General 


In-Network 

$10 copay for Medicare-covered individual substance abuse 

outpatient treatment visits 

$10 copay for Medicare-covered group substance abuse outpatient 

treatment visits 

13 Outpatient Services 20% coinsurance for the doctor’s 

services 


outpatient hospital facility 

services Copay cannot exceed 

the Part A inpatient hospital 

deductible. 

20% coinsurance for ambulatory 

surgical center facility services 

General 


In-Network 

$20 to $50 copay for each Medicare-covered ambulatory surgical 

center visit 

$20 to $50 copay for each Medicare-covered outpatient hospital 

facility visit 

14 Ambulance Services 

(medically necessary 

ambulance services) 



14


BenefIt 





14 Ambulance Services 

(medically necessary 

ambulance services) 

(continued) 

In-Network 

$100 copay for Medicare-covered ambulance benefits. 

If you are admitted to the hospital, you pay $0 for Medicare-covered 

ambulance benefits. 

15 Emergency Care 

(You may go to any 

emergency room if you 

reasonably believe you 

need emergency care.) 

20% coinsurance for the doctor’s 

services 


outpatient hospital facility 

emergency services. 

Emergency services copay 

cannot exceed Part A inpatient 

hospital deductible for each 

service provided by the hospital. 

You don’t have to pay the 

emergency room copay if you 

are admitted to the hospital as an 

inpatient for the same condition 

within 3 days of the emergency 

room visit. 

Not covered outside the U.S. 

except under limited circumstances. 

General 

$50 copay for Medicare-covered emergency room visits 

$25,000 plan coverage limit for supplemental emergency services 

outside the U.S. and its territories every year. 

If you are admitted to the hospital within 1-day for the same 

condition, you pay $0 for the emergency room visit. 

15


BenefIt 





16 Urgently Needed Care 

(This is NOT 

emergency care, and 

in most cases, is out of 

the service area.) 

20% coinsurance, or a set copay 

NOT covered outside the 

U.S. except under limited 

circumstances. 

General 

$15 to $25 copay for Medicare-covered urgently-needed-care visits 

If you are admitted to the hospital within 1-day for the same 

condition, you pay $0 for the urgently-needed-care visit. 

17 Outpatient Rehabilitation 

Services 

(Occupational Therapy, 

Physical Therapy, 

Speech and Language 

Therapy) 



In-Network 

There may be limits on physical therapy, occupational therapy, and 

speech and language pathology visits. If so, there may be exceptions 

to these limits. 

$10 copay for Medicare-covered Occupational Therapy visits 

$10 copay for Medicare-covered Physical Therapy and/or Speech and 

Language Pathology visits 

16


BenefIt 




OUTPATIENT MEDICAL SERVICES AND SUPPLIES 

18 Durable Medical 

Equipment 

(includes wheelchairs, 

oxygen, etc.) 



In-Network 

0% to 20% of the cost for Medicare-covered durable medical 

equipment 

You may pay less if you purchase these items from the plan’s 

preferred manufacturers/vendors. Contact the plan for a list of nonpreferred 

and preferred manufacturers/vendors. 

19 Prosthetic Devices 

(includes braces, 

artificial limbs and eyes, 

etc.) 



In-Network 

20% of the cost for Medicare-covered prosthetic devices 

20 Diabetes Programs 

and Supplies 

20% coinsurance for diabetes 

self-management training 

20% coinsurance for diabetes 

supplies 

General 


In-Network 

$0 copay for Medicare-covered Diabetes self-management training 

17


BenefIt 




OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 

20 Diabetes Programs 

and Supplies 

(continued) 

20% coinsurance for diabetic 

therapeutic shoes or inserts 

$0 copay for Medicare-covered: 

- Diabetes monitoring supplies 

Diabetic Supplies and Services are limited to specific manufacturers, 

products and/or brands. Contact the plan for a list of covered 

supplies. 

20% of the cost for Medicare-covered Therapeutic shoes or inserts 

If the doctor provides you services in addition to Diabetes selfmanagement 

training, separate cost sharing of $0 to $5 may apply 

21 Diagnostic Tests, X-Rays, 

Lab Services, and 

Radiology Services 

20% coinsurance for diagnostic 

tests and x-rays 

$0 copay for Medicare-covered 

lab services 

Lab Services: Medicare covers 

medically necessary diagnostic 

lab services that are ordered 

by your treating doctor when 

they are provided by a Clinical 

Laboratory Improvement 

Amendments (CLIA) certified 

laboratory that participates in 

Medicare. Diagnostic lab services 

are done to help your 

General 


In-Network 

$0 copay for Medicare-covered: 

- lab services 

- diagnostic procedures and tests 

- X-rays 

- diagnostic radiology services (not including X-rays) 

10% of the cost for Medicare-covered therapeutic radiology services 

18


BenefIt 





21 Diagnostic Tests, X-Rays, 

Lab Services, and 

Radiology Services 

(continued) 

doctor diagnose or rule out a 

suspected illness or condition. 

Medicare does not cover most 

supplemental routine screening 

tests, like checking your 

cholesterol. 

22 Cardiac and Pulmonary 

Rehabilitation Services 

20% coinsurance for Cardiac 

Rehabilitation services 

20% coinsurance for Pulmonary 

Rehabilitation services 

20% coinsurance for Intensive 

Cardiac Rehabilitation services 

This applies to program services 

provided in a doctors office. 

Specified cost sharing for 

program services provided by 

hospital outpatient departments. 

General 


In-Network 

$10 copay for Medicare-covered Cardiac Rehabilitation Services 

$10 copay for Medicare-covered Intensive Cardiac Rehabilitation 

Services 

$10 copay for Medicare-covered Pulmonary Rehabilitation Services 

19


BenefIt 




PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS 

23 Preventive Services, 

Wellness/Education and 

other Supplemental 

Benefit Programs 

No coinsurance, copayment or 

deductible for the following: 

- Abdominal Aortic Aneurysm 

Screening 

- Bone Mass Measurement. 

Covered once every 24 months 

(more often if medically 

necessary) if you meet certain 

medical conditions. 

- Cardiovascular Screening 

- Cervical and Vaginal Cancer 

Screening. Covered once every 

2 years. Covered once a year 

for women with Medicare at 

high risk. 

- Colorectal Cancer Screening 

- Diabetes Screening 

- Influenza Vaccine 

- Hepatitis B Vaccine for people 

with Medicare who are at risk 

- HIV Screening. $0 copay for the 

HIV screening, but you generally 

pay 20% of the Medicareapproved 

amount for the 

doctors visit. HIV screening is 

covered for people with 

Medicare who are pregnant and 

General 


$0 copay for all preventive services covered under Original Medicare 

at zero cost sharing. 

Any additional preventive services approved by Medicare mid-year 

will be covered by the plan or by Original Medicare. 


In-Network 

The plan covers the following supplemental education/wellness 

programs: 

- Health Education 

- Nursing Hotline 

See page 38 for additional information about Preventive Services, 

Wellness/Education and other Supplemental Benefit Programs. 

20


BenefIt 




PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS (Continued) 





(continued) 

people at increased risk for 

the infection, including anyone 

who asks for the test. Medicare 

covers this test once every 12 

months or up to three times 

during a pregnancy. 

- Breast Cancer Screening 

(Mammogram).Medicare 

covers screening mammograms 

once every 12 months for all 

women with Medicare age 40 

and older. Medicare covers one 

baseline mammogram for 

women between ages 35-39. 

- Medical Nutrition Therapy 

Services 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 

and may include a nutritional 

assessment and counseling to 

help you manage your diabetes 

or kidney disease 

21


BenefIt 









(continued) 

- Personalized Prevention Plan 

Services (Annual Wellness 

Visits) 

- Pneumococcal Vaccine. You 

may only need the Pneumonia 

vaccine once in your lifetime. 

Call your doctor for more 

information. 

- Prostate Cancer Screening 

Prostate Specific Antigen (PSA) 

test only. Covered once a year 

for all men with Medicare over 

age 50. 

- Smoking and Tobacco Use 

Cessation (counseling to stop 

smoking and tobacco use). 

Covered if ordered by your 

doctor. Includes two counseling 

attempts within a 12-month 

period. Each counseling attempt 

includes up to four face-to-face 

visits. 

- Screening and behavioral 

counseling interventions in 

primary care to reduce alcohol 

misuse 

- Screening for depression in 

adults 

22


BenefIt 









(continued) 

- Screening for sexually 

transmitted infections (STI) 

and high-intensity behavioral 

counseling to prevent STIs 

- Intensive behavioral counseling 

for Cardiovascular Disease 

(bi-annual) 

- Intensive behavioral therapy for 

obesity 

- Welcome to Medicare 

Preventive Visits (initial 

preventive physical exam) When 

you join Medicare Part B, then 

you are eligible as follows. 

During the first 12 months of 

your new Part B coverage, you 

can get either a Welcome to 

Medicare Preventive Visit or an 

Annual Wellness Visit. After your 

first 12 months, you can get one 

Annual Wellness Visit every 12 

months. 

23


BenefIt 





24 Kidney Disease and 

Conditions 

20% coinsurance for renal 

dialysis 

20% coinsurance for kidney 

disease education services 

General 


In-Network 

$10 copay for Medicare-covered renal dialysis 

$0 copay for Medicare-covered kidney disease education services 

PRESCRIPTION DRUG BENEFITS 

25 Outpatient 

Prescription Drugs 

Most drugs are not covered 

under Original Medicare. You can 

add prescription drug coverage 

to Original Medicare by joining a 

Medicare Prescription Drug Plan, 

or you can get all your Medicare 

coverage, including prescription 

drug coverage, by joining a 

Medicare Advantage Plan or a 

Medicare Cost Plan that offers 

prescription drug coverage. 

Drugs covered under Medicare Part B 

General 

20% of the cost for Medicare Part B chemotherapy drugs and other 

Part B drugs. 

Drugs covered under Medicare Part D 

General 

This plan uses a formulary. The plan will send you the formulary. You 

can also see the formulary at www.care1st.com/ca/medicare 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) providers. 

24


BenefIt 




PRESCRIPTION DRUG BENEFITS (Continued) 

25 Outpatient 


(continued) 

The plan offers national in-network prescription coverage (i.e., this 

would include 50 states and the District of Columbia). 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). 

Total yearly drug costs are the total drug costs paid by both you and a 

Part D 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 Care1st 

AdvantageOptimum Plan (HMO) for certain drugs. 

The plan will pay for certain over-the-counter drugs as part of its 

utilization management program. Some over-the-counter drugs are 

less expensive than prescription drugs and work just as well. Contact 

the plan for details. 

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. 

25


BenefIt 





25 Outpatient 


(continued) 

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 Care1st 

AdvantageOptimum Plan (HMO) approves the exception, you will pay 

Tier 4: Non-Preferred Brand cost sharing for that drug. 

In-Network 

$0 deductible. 

Initial Coverage 

You pay the following until total yearly drug costs reach $2,970: 

Retail Pharmacy 

Tier 1: Preferred Generic 

- $0 copay for a one-month (30-day) supply of drugs in this tier 

- $0 copay for a three-month (90-day) supply of drugs in this tier 

Not all drugs on this tier are available at this extended day supply. 

Please contact the plan for more information. 

Tier 2: Non-Preferred Generic 





26


BenefIt 





25 Outpatient 


(continued) 

Tier 3: Preferred Brand 





Tier 4: Non-Preferred Brand 





Tier 5: Specialty Tier 

- 30% coinsurance for a one-month (30-day) supply of drugs in this 

tier 

- 30% coinsurance for a three-month (90-day) supply of drugs in this 

tier 



Long Term Care Pharmacy 


- $0 copay for a one-month (31-day) supply of generic drugs in this 

tier 

27


BenefIt 





25 Outpatient 


(continued) 


- $5 copay for a one-month (31-day) supply of generic drugs in this 

tier 


- $30 copay for a one-month (31-day) supply of brand drugs in this tier 


- $50 copay for a one-month (31-day) supply of brand drugs in this tier 



tier 

Please note that brand drugs must be dispensed incrementally 

in long-term care facilities. Generic drugs may be dispensed 

incrementally. Contact your plan about cost-sharing billing/collection 

when less than a one-month supply is dispensed. 

Mail Order 







28


BenefIt 





25 Outpatient 


(continued) 












- 30% coinsurance for a three-month (90-day) supply of drugs in this 

tier 



Coverage Gap 

After your total yearly drug costs reach $2,970, you receive limited 

coverage by the plan on certain drugs. You will also receive a discount 

on brand name drugs and generally pay no more than 47.5% for the 

plan’s costs for brand drugs and 79%of the plan’s costs for generic 

drugs until your yearly out-of-pocket drug costs reach $4,750. 

29


BenefIt 





25 Outpatient 


(continued) 

Additional Coverage Gap 

The plan covers many formulary generics (65% to 99% of formulary 

generic drugs) through the coverage gap. 

The plan offers additional coverage in the gap for the following tiers. 

You pay the following: 

Retail Pharmacy 


- $0 copay for a one-month (30-day) supply of all drugs covered in this 

tier 

- $0 copay for a three-month (90-day) supply of all drugs covered in 

this tier 





tier 


this tier 



30


BenefIt 





25 Outpatient 


(continued) 

Long Term Care Pharmacy 


- $0 copay for a one-month (31-day) supply of all generic drugs 

covered in this tier 


- $5 copay for a one-month (31-day) supply of all generic drugs 

covered in this tier 

Please note that brand drugs must be dispensed incrementally 

in long-term care facilities. Generic drugs may be dispensed 

incrementally. Contact your plan about cost-sharing billing/collection 

when less than a one-month supply is dispensed. 

Mail Order 



this tier 





this tier 



31


BenefIt 





25 Outpatient 


(continued) 

Catastrophic Coverage 

After your yearly out-of-pocket drug costs reach $4,750, you pay the 

greater of: 

- 5% coinsurance, or 

- $2.65 copay for generic (including brand drugs treated as generic) 

and a $6.60 copay for all other drugs. 

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 Care1st AdvantageOptimum Plan (HMO). 

Out-of-Network Initial Coverage 

You will be reimbursed up to the plan’s cost of the drug minus the 

following for drugs purchased out-of-network until total yearly drug 

costs reach $2,970: 







32


BenefIt 





25 Outpatient 


(continued) 





tier 

You will not be reimbursed for the difference between the Outof-Network 

Pharmacy charge and the plan’s In-Network allowable 

amount. 

Out-of-Network Coverage Gap 

You will be reimbursed up to 21% of the plan allowable cost for 

generic drugs purchased out-of-network until total yearly out-ofpocket 

drug costs reach $4,750. Please note that the plan allowable 

cost may be less than the out-of-network pharmacy price paid for 

your drug(s). 

You will be reimbursed up to 52.5% of the plan allowable cost for 

brand name drugs purchased out-of-network until your total yearly 

out-of-pocket drug costs reach $4,750. Please note that the plan 

allowable cost may be less than the out-of-network pharmacy 

price paid for your drug(s). 

Additional Out-of-Network Coverage Gap 

The plan covers many formulary generics (65% to 99% of formulary 

generic drugs) through the coverage gap. 

33


BenefIt 





25 Outpatient 


(continued) 

You will be reimbursed for these drugs purchased out-of-network up 

to the plan’s cost of the drug minus the following: 



tier 



tier 

You will not be reimbursed for the difference between the 

Out-of-Network Pharmacy charge and the plan’s In-Network allowable 

amount. 

Out-of-Network Catastrophic Coverage 

After your yearly out-of-pocket drug costs reach $4,750, you will be 

reimbursed for drugs purchased out-of-network up to the plan’s cost 

of the drug minus your cost share, which is the greater of: 

- 5% coinsurance, or 

- $2.65 copay for generic (including brand drugs treated as generic) 

and a $6.60 copay for all other drugs. 

You will not be reimbursed for the difference between the Outof-Network 

Pharmacy charge and the plan’s In-Network allowable 

amount. 

34


BenefIt 




OUTPATIENT MEDICAL SERVICES AND SUPPLIES 

26 Dental Services Preventive dental services (such 

as cleaning) not covered. 

General 


In-Network 

$0 copay for the following preventive dental benefits: 

- oral exams 

- up to 1 cleaning(s) every six months 

- up to 1 dental x-ray(s) every two years 

$0 to $570 copay for Medicare-covered dental benefits 

- $5 copay for up to 1 fluoride treatment(s) every six months 

Plan offers additional comprehensive dental benefits. 

See page 38 for additional information about Dental Services. 

27 Hearing Services Supplemental routine hearing 

exams and hearing aids not 

covered. 

20% coinsurance for diagnostic 

hearing exams. 

General 

Authorization rules may apply 

In-Network 

$0 copay for up to 2 hearing aid(s) every two years 

$10 copay for Medicare-covered diagnostic hearing exams 

$10 copay for up to 1 supplemental routine hearing exam(s) every 

year 

$0 copay for up to 1 hearing aid fitting-evaluation(s) every year 

$500 plan coverage limit for hearing aids every year. 

35


BenefIt 





28 Vision Services 20% coinsurance for diagnosis 

and treatment of diseases and 

conditions of the eye. 

Supplemental routine eye exams 

and glasses not covered. 

Medicare pays for one pair of 

eyeglasses or contact lenses after 

cataract surgery. 

Annual glaucoma screenings 

covered for people at risk. 

General 


In-Network 

$0 copay for 

- one pair of Medicare-covered eyeglasses or contact lenses after 

cataract surgery 

- up to 1 pair(s) of glasses every two years 

- $0 copay for Medicare-covered exams to diagnose and treat 

diseases and conditions of the eye. 

- $5 copay for up to 1 supplemental routine eye exam(s) every year 

$150 plan coverage limit for eye wear every two years. 

See page 38 for additional information about Vision Services. 

Over-the-Counter Items Not covered. General 

The plan does not cover Over-the-Counter items. 

36


BenefIt 






(Routine) 

Not covered. 

General 


In-Network 

$0 copay for up to 24 round trip(s) to plan-approved location every 

year 

See page 38 for additional information about Transportation Services. 

Acupuncture Not covered. General 


In-Network 

$5 copay per acupuncture visit up to 15 visit(s) every year 

37


ADDITIONAL PLAN INFORMATION 

This section provides additional details on some of the benefits listed in Section II. The numbered items below correspond to the same 

numbers in Section II. For more information, please call Care1st AdvantageOptimum Plan (HMO) at the phone numbers listed on page 5, or 

visit http://www.care1st.com/ca/medicare. 

23 - Preventive Services, Wellness/Education and other Supplemental Benefit Programs (see page 20-24) 

No authorization required for health educational classes offered by Care1st Health Plan. There is no copay for educational classes provided 

by plan-approved locations. There is no limit to the number of educational classes for the plan year. Authorization rules apply to health 

educational classes not sponsored by Care1st Health Plan. 

26 – Dental Services (see page 35) 

Routine Dental Benefits 

$0 copay for oral exams, cleaning and x-rays apply to services received from a general dentist. $5 copays for fluoride treatments apply to 

services received from a general dentist. Additional copays may apply for full set of dental x-rays received more often than every two years, 

and/or specialized diagnostic x-rays such as multiple vertical bitewing views. 

Refer to the current Dental Member Handbook for details. 

Comprehensive Dental Benefits 

Plan authorization/referral applies only to Medicare-covered Dental Services. No plan authorization/referral is required for all other 

Comprehensive Dental Services. Prior benefit authorization may be required from your dental benefit provider for certain dental services. 

Refer to the current Dental Member Handbook for details. 

28 - Vision Services (see page 36) 

Care1st covers the refraction test once every two years when the eye doctor has determined that the member may need prescription 

glasses. Member has the option to pay for additional upgrade items such as progressive lenses, lens coating or tinting, and frames not 

classified as “standard.” 

Routine Transportation (see page 37) 

Care1st offers 24 round-trip transportation services per year to plan-approved locations such as doctors’ offices in order to access medical 

services. Transportation must be arranged 24 hours in advance by contacting the Care1st Member Services Department at 1-87-RIDEC1ST 

(1-877-433-2178) (TTY 1-800-735-2929), 8 a.m. to 6 p.m. Monday through Friday. 

38

2013 

Drug List 



2 

This page intentionally left blank.

2013 

Drug List 

8-MOP, T3 

# 

A 

A-Hydrocort, T2 

A-Methapred (40 or 125 MG/2 ML) 

Vial, T2 

Abacavir, T3 

ABELCET, T3 

ABILIFY (2, 5, 10 or 15 MG) Tablet, 

T3 

ABILIFY (1 MG/ML) Solution, T3 

ABILIFY (9.75MG/1.3) Vial, T3 

ABILIFY (20 or 30 MG) Tablet, T5 

ABILIFY DISCMELT (10 or 15 MG), 

T5 

Acarbose (25, 50 or 100 MG), T2 

Acebutolol HCL (200 or 400 MG), 

T2 

Acetaminophen W/Codeine, T2 

Acetaminophen-Codeine (15, 30 

or 60 MG), T2 

Acetasol HC, T2 

Acetazolamide (125 or 250 MG) 

Tablet, T2 

Acetazolamide (500 MG) Capsule 

ER, T4 

ACTHIB, T3 

ACTIMMUNE, T5 

ACTONEL (5, 35 or 150 MG) Tablet, 

T4 

ACTOS (15, 30 or 45 MG) Tablet, T3 

Acyclovir (200 MG/5 ML) Oral 

Susp, T2 

Acyclovir (400 or 800 MG) Tablet, 

T2 

Acyclovir (200 MG) Capsule, T2 

Acyclovir Sodium, T2 

ADACEL Vial, T3 

ADACEL Disp Syrin, T3 

ADAGEN, T5 

Adapalene Gel, T2 

Adapalene Cream, T2 

ADCETRIS, T5 

ADCIRCA, T5 

ADVAIR DISKUS (100-50, 250-50 or 

500-50 MCG), T3 

ADVAIR HFA (45-21, 115-21 or 230- 

21 MCG), T3 

Afeditab CR (30 or 60 MG), T2 

AFINITOR (2.5, 5, 7.5, or 10 MG), T5 

AGGRENOX, T4 

Ak-Con, T2 

Ala-Cort, T2 

Ala-Scalp Hp, T2 

ALBENZA, T3 

Albuterol, T2 

Albuterol Sulfate (2 or 4 MG) 

Tablet, T2 

Albuterol Sulfate (4 or 8 MG) Tab 

ER 12H, T2 

Albuterol Sulfate (1.25 MG/3 ML 

or 2.5 MG/3 ML) Vial, T2 

Albuterol Sulfate Syrup, T2 

Alcaine, T2 

Alclometasone Dipropionate 

Cream, T2 

Alclometasone Dipropionate 

Oint., T2 

ALDURAZYME, T5 

Alendronate Sodium (5, 10, 35, 40 

or 70 MG), T1 

Alfuzosin HCL, T2 

ALIMTA, T5 

ALINIA, T4 

Allopurinol (100 or 300 MG), T2 

ALORA (.025, .05, .075. 1 MG/24 

HR), T3 

ALPHAGAN P, T3 

Alprazolam (.25, .5. 1 or 2 MG), T2 

Altavera, T2 

Alyacen (1 MG-35MCG or 7 days x 

3) Tablet, T2 

Amantadine Capsule, T2 

Amantadine Tablet, T2 

Amantadine Syrup, T2 

AMBISOME, T3 

Amcinonide Cream, T2 

Amcinonide Lotion, T2 

Brand-name drugs are listed in upper case. Generic drugs are listed 

in lower case. Pharmacy Benefits are subject to a covered list which 

is subject to change. Limitations, copayments, and restrictions may 

apply. Refer to the Care1st Comprehensive formulary and Evidence 

of Coverage for more information. 

T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

3

Amcinonide Oint., T2 

AMERICAINE, T2 

Amikacin Sulfate (100 MG/2 ML or 

1000 MG/4 ML), T2 

Amiloride HCL, T2 

Amiloride-Hydrochlorothiazide, 

T2 

Aminocaproic Acid Vial, T2 

Aminocaproic Acid (500 or 1000 

MG) Tablet, T2 

Aminocaproic Acid Solution, T2 

Aminophylline Liquid, T2 

Aminophylline (100 or 200 MG) 

Tablet, T2 

AMINOSYN (3.5% or 7%), T3 

AMINOSYN II (7% or 15%), T2 

AMINOSYN-HBC, T3 

AMINOSYN-PF, T3 

Amiodarone HCL (200 or 400 MG), 

T2 

AMITIZA (8 or 24 MCG), T3 

Amitriptyline HCL (10, 25, 50, 75, 

100 or 150 MG), T2 

Amlodipine Besylate (2.5, 5 or 10 

MG), T1 

Amlodipine Besylate-Benazepril 

(2.5 MG - 10 MG, 5 MG - 10 MG, 5 

MG - 20 MG or 10 MG - 20 MG), T1 

Amlodipine Besylate-Benazepril (5 

MG - 40 MG or 10 MG - 40 MG), T2 

Ammonium Lactate Cream, T2 

Ammonium Lactate Lotion, T2 

Amnesteem (10, 20 or 40 MG), T4 

Amox Tr-Potassium Clavulanate 

(200 - 28.5 MG or 400 - 57 MG) Tab 

Chew, T2 


(250 - 125 MG, 500 - 125 MG or 

875 - 125 MG) Tablet, T2 


(200 - 28.5 MG, 250 - 62.5/5,400 

- 57 MG/5 or 600 - 42.9/5) Susp 

4 

Recon , T2 

Amoxapine (25, 50, 100 or 150 

MG), T2 

Amoxicillin (500 or 875 MG) 

Tablet, T2 

Amoxicillin (125 or 250 MG) Tab 

Chew, T2 

Amoxicillin (250 or 500 MG) 

Capsule, T2 

Amoxicillin (125, 200, 250 or 400 

MG/5ML) Susp Recon, T2 

Amphetamine Salt Combo (5, 7.5, 

10, 12.5, 15, 20, or 30 MG), T2 

Amphotericin B, T2 

Ampicillin Sodium (125 MG, 2 or 

10 G), T3 

Ampicillin Trihydrate (250 or 500 

MG) Capsule, T2 

Ampicillin Trihydrate (125 or 250 

MG/5 ML) Susp Recon, T2 

Ampicillin-Sulbactam (3 or 15 G) 

Vial, T2 

Ampicillin-Sulbactam Vial Port, T2 

AMPYRA, T5 

ANACAINE, T2 

ANADROL-50, T5 

Anastrozole, T2 

ANDRODERM (2 or 4 MG/24 HR), 

T3 

ANDROID, T2 

Androxy, T2 

Anergan 50, T2 

Antipyrine-Benzocaine, T2 

ANTIVENIN LATRODECTUS 

MACTANS, T5 

ANTIVENIN MICRURUS FULVIUS, 

T5 

ANUSOL-HC, T2 

APEXICON, T2 

APEXICON E, T2 

APOKYN, T5 

Apri, T2 

APTIVUS Solution, T5 

APTIVUS Capsule, T5 

Aranelle, T2 

ARANESP (25, 40, 60 or 10 MCG / 

ML) Vial, T3 

ARANESP (25 MCG/.42, 40 MCG/.4, 

60 MCG/.3 or 100 MCG/.5) Disp 

Syrin, T3 

ARANESP (200 or 300 MCG/ML) 

Vial, T5 

ARANESP (150 MCG/.3, 200 

MCG/.4, 300 MCG/.6, 500 MCG/ 

ML) Disp Syrin, T5 

ARCALYST, T5 

ARICEPT, T3 

ARMOUR THYROID (15, 30, 60, 90, 

120, 180 or 240 or 300 MG), T3 

ARZERRA, T5 

ASACOL, T3 

Ascomp With Codeine, T2 

ASMANEX (110 or 220 MCG (30)), 

T4 

Astramorph-PF (.5 or 1 MG/ML), 

T2 

ATELVIA, T4 

Atenolol (25, 50 or 100 MG), T1 

Atenolol-Chlorthalidone (50 or 

100 MG-25 MG), T1 

ATGAM, T3 

Atorvastatin Calcium (10, 20, 40 or 

80 MG), T1 

Atovaquone-Proguanil HCL (62.5 - 

25 MG or 250 - 100 MG), T3 

ATRIPLA, T5 

Atropine Care, T2 

ATROVENT HFA, T3 

Aurodex, T2 

AVANDIA (2, 4 or 8 MG), T3 

AVASTIN, T5 

AVELOX, T4 

AVELOX ABC PACK, T4 

Aviane, T2 

Avita, T2

AVODART, T4 

AVONEX, T5 

AVONEX ADMINISTRATION PACK, 

T5 

Azathioprine, T2 

Azelastine HCL Drops, T2 

Azelastine HCL Spray/Pump, T2 

AZILECT (.5 or 1 MG), T4 

Azithromycin (250, 500or 600 MG) 

Tablet, T2 

Azithromycin (100 or 200 MG/5 

ML) Susp Recon, T2 

Azithromycin Packet, T2 

Azithromycin Vial, T2 

AZOPT, T3 

Aztreonam, T2 

Azurette, T2 

B 

Bacitracin, T2 

Bacitracin-Polymyxin, T2 

Baclofen (10 or 20 MG), T2 

Balsalazide Disodium, T4 

Balziva, T2 

BANZEL (200 or 400 MG) Tablet, 

T4 

BANZEL Oral Susp, T4 

BARACLUDE Solution, T3 

BARACLUDE (.5 or 1 MG) Tablet, T5 

Baycadron, T2 

BCG VACCINE (TICE STRAIN), T3 

Benazepril HCL (5, 10, 20 or 40 

MG), T1 

Benazepril-Hydrochlorothiazide (5 

- 6.25, 10-12.5, 20 - 12.5 or 20 - 25 

MG), T1 

Benztropine Mesylate (.5, 1 or 2 

MG), T2 

Betamethasone Dipropionate 

Cream, T2 


Lotion, T2 


Oint., T2 

Betamethasone Dipropionate Gel, 

T2 

Betamethasone Valerate Oint., T2 

Betamethasone Valerate Cream, 

T2 

Betamethasone Valerate Lotion, 

T2 

Betanate, T2 

BETASERON, T5 

Betaxolol HCL (10 or 20 MG) 

Tablet, T2 

Betaxolol HCL Drops, T2 

Bethanechol Chloride (5, 10, 25 or 

50 MG), T2 

Bicalutamide, T2 

BICILLIN C-R (1.2 MM or 900 - 300 / 

2 ML), T3 

BICILLIN L-A (600000 / ML, 1.2 MM 

/ 2ML or 2.4 MM / 4 ML), T3 

BILTRICIDE, T3 

Bisoprolol Fumarate ( 5 or 10 MG), 

T2 

Bisoprolol-Hydrochlorothiazide 

(2.5, 5 or 10 - 6.25 MG), T2 

Bleomycin Sulfate, T2 

Bleph-10, T2 

BONIVA, T4 

BOOSTRIX Vial, T3 

BOOSTRIX Disp Syrin, T3 

BREVIBLOC (2.5 G / 250 ML or 2 G / 

100 ML), T3 

Briellyn, T2 

Brimonidine Tartrate (0.15 or 0.2 

%), T2 

Bromfenac Sodium, T4 

Bromocriptine Mesylate (2.5 or 5 

MG), T2 

Budeprion SR (100 or 150 MG), T2 

Budeprion XL, T2 

Budesonide EC, T3 

Bumetanide (0.5, 1 or 2 MG) 

Tablet, T2 

Bumetanide Vial, T2 

BUPHENYL Powder, T3 

BUPHENYL Tablet, T3 

Buprenorphine HCL (2 or 8 MG), 

T4 

Buproban, T2 

Bupropion HCL (75 or 100 MG), T2 

Bupropion HCL SR (100, 150 or 

200 MG), T2 

Bupropion XL (150 or 300 MG), T2 

Buspirone HCL (5, 7.5, 10, 15 or 30 

MG), T2 

Butalb-Caff-Acetaminoph-Codein, 

T2 

Butalbital Compound-Codeine, T2 

BYETTA (5 MCG / .02 or 10 MCG / 

.04), T4 

C 

Cabergoline, T2 

Calcipotriene, T2 

Calcitonin-Salmon, T4 

Calcitriol (.25 or .5 MCG), T2 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

5

Calcium Acetate, T2 

Calcium Folinate, T2 

Camila, T2 

CAMPATH, T3 

CAMPRAL, T4 

CANASA, T3 

CANCIDAS (50 or 70 MG), T5 

CAPASTAT SULFATE, T3 

CAPRELSA (100 or 300 MG), T5 

Captopril (12.5, 25, 50 or 100 MG), 

T1 

Captopril-Hydrochlorothiazide (24 

MG - 15 MG, 25 MG - 25 MG, 50 

MG - 15 MG or 50 MG - 25 MG), T1 

Carbamazepine Tablet, T2 

Carbamazepine (100, 200 or 300 

MG) CPMP 12 HR, T2 

Carbamazepine Tab Chew, T2 

Carbamazepine Oral Susp, T2 

Carbamazepine XR (200 or 400 

MG) , T2 

Carbidopa-Levodopa (10 MG - 100 

MG, 25 MG - 250 MG) Tablet, T2 

Carbidopa-Levodopa (25 MG - 100 

MG or 50 MG - 200 MG) Tablet ER, 

T2 

Carbidopa-Levodopa-Entacapone 

(12.5 - 50 MG, 18.75 - 75 MG, 25 - 

100 - 200, 31.25 - 125, 37. 5 - 125 

or 50 - 200 -200), T3 

CARIMUNE NF NANOFILTERED, T5 

Carisoprodol (250 or 350 MG), T2 

Carteolol HCL, T2 

Cartia XT (120, 180, 240 or 300 

MG), T2 

Carvedilol (3.125, 6.25, 12.5 or 25 

MG), T1 

CAYSTON, T5 

Caziant, T2 

CEENU (10, 40 or 100 MG), T3 

Cefaclor (250 or 500 MG), T2 

Cefaclor ER, T2 

Cefadroxil Tablet, T2 

6 

Cefadroxil Capsule, T2 

Cefadroxil (250 or 500 MG/5 ML) 

Susp Recon, T2 

Cefazolin, T2 

Cefazolin Sodium (500 MG, 1 or 10 

G), T2 

Cefdinir, T2 

Cefepime HCL (1 or 2 G), T2 

Cefotaxime Sodium (500 MG, 1, 2 

or 10 G), T2 

Cefpodoxime Proxetil (100 or 200 


Cefpodoxime Proxetil (50 or 100 

MG/5 ML) Susp Recon, T2 

Cefprozil (125 or 250 MG/5 ML) 


Cefprozil (250 or 500 MG) Tablet, 

T2 

Ceftazidime (500 MG, 2 or 6 G), T2 

CEFTAZIDIME (1 or 2 G/50 ML), T3 

Ceftriaxone (1 or 2 G/50 ML) Froz. 

Piggy, T2 

Ceftriaxone (250 MG, 1 or 10 G) 

Vial, T2 

Cefuroxime (250 or 500 MG) 

Tablet, T2 

Cefuroxime Sodium (750 MG, 1.5 

or 7.5 G), T2 

CELEBREX (100 or 200 MG), T4 

CELESTONE, T3 

CELLCEPT, T5 

CELONTIN, T3 

CENESTIN (0.3, 0.45, 0.625, 0.9 or 

1.25 MG), T3 

Cephalexin (250 or 500 MG) 

Tablet, T2 

Cephalexin (125 or 250 MG/5 ML) 


Cephalexin (250 or 500 MG) 

Capsule, T2 

CEREDASE, T5 

CEREZYME, T5 

CERVARIX, T3 

CHANTIX (0.5 or 1 MG), T4 

Children’s Clear-Atadine, T1 

Chloral Hydrate, T2 

Chlordiazepoxide-Amitriptyline 

(12.5 MG-5 MG or 25 MG-10 MG), 

T2 

Chlorhexidine Gluconate, T2 

Chloroquine Phosphate (250 or 

500 MG), T2 

Chlorothiazide (250 or 500 MG), 

T2 

Chlorpromazine HCL Oral Conc., 

T2 

Chlorpromazine HCL Ampul, T2 

Chlorpromazine HCL (10, 25, 50, 

100 or 200 MG), T2 

Chlorthalidone (25 or 50 MG), T2 

Chlorzoxazone, T2 

Chlorzoxazone W/ 

Acetaminophen, T2 

Cholestyramine, T2 

Choline Mag Trisalicylate, T2 

CHORIONIC GONADOTROPIN, T2 

Ciclopirox Cream, T2 

Ciclopirox Gel, T2 

Ciclopirox Suspension, T2 

Ciclopirox Solution, T2 

Cilostazol (50 or 100 MG) Tablet, 

T2 

Cimetidine Vial, T2 

Cimetidine (200, 300, 400 or 800 

MG), T2 

Cimetidine HCL, T2 

Ciprofloxacin, T2 

Ciprofloxacin ER (500 or 1000 MG), 

T2 

Ciprofloxacin HCL (100, 250 or 750 


Ciprofloxacin HCL Drops, T2 

Ciprofloxacin HCL Tablet, T2 

Citalopram HBR (10, 20 or 40 MG), 

T2

Citalopram HBR Solution, T2 

Claravis (10, 20, 30 or 40 MG), T4 

CLARINEX, T3 

Clarithromycin (250 or 500 MG) 

Tablet, T2 

Clarithromycin (125 or 250 MG/5 

ML) Susp Recon, T2 

Clarithromycin ER, T2 

Clemastine Fumarate Tablet, T2 

Clemastine Fumarate Syrup, T2 

Clinda-Derm, T2 

Clindamax Gel, T2 

Clindamax Lotion, T2 

Clindamycin HCL (150 or 300 MG), 

T2 

Clindamycin Phosphate Gel, T2 

Clindamycin Phosphate Lotion, T2 

Clindamycin Phosphate Med. 

Swab, T2 

Clindamycin Phosphate Solution, 

T2 

Clindamycin Phosphate Vial, T2 

Clindamycin Phosphate Cream/ 

Appl, T2 

Clobetasol Propionate Foam, T2 

Clobetasol Propionate Cream, T2 

Clobetasol Propionate Oint, T2 

Clobetasol Propionate Solution, 

T2 

Clobetasol Propionate Gel, T2 

Clomipramine HCL (25, 50 or 75 

MG), T2 

Clonazepam (.5, 1 or 2 MG) Tablet, 

T2 

Clonazepam (0.125, 0.25, 0.5 MG 

or 1 or 2 MG) Tab Rapdis, T2 

Clonidine HCL (0.1, 0.2 or 0.3 MG), 

T1 

Clopidogrel, T1 

Clorazepate Dipotassium (3.75, 7.5 

or 15 MG), T2 

Clotrimazole, T2 

Clotrimazole Solution, T2 

Clotrimazole Cream, T2 

Clotrimazole-Betamethasone 

Lotion, T2 

Clotrimazole-Betamethasone 

Cream, T2 

Clozapine (25, 50, 100 or 200 MG), 

T2 

Co-Gesic, T2 

Codeine Sulfate (15, 30 or 60 MG), 

T2 

COLCRYS, T3 

Colestipol HCL (1 or 5 G), T2 

Colistimethate Sodium, T2 

Colocort, T2 

COMBIPATCH (.05-.14/24 or .05- 

.25/24), T3 

COMBIVENT, T3 

COMBIVIR, T5 

COMPLERA, T5 

Compro, T2 

COMTAN, T3 

COMVAX, T3 

Constulose, T2 

COPAXONE, T5 

Cormax Oint., T2 

Cormax Solution, T2 

Cortisone Acetate, T2 

COUMADIN (1, 2, 2.5, 3, 4, 5, 6, 7.5 

or 10 MG), T3 

CPM 12, T2 

CREON (3-9.5-15K, 6K-19K-30K, 

12K-38K-60 or 24-76-120K), T3 

CRIXIVAN (200 or 400 MG), T3 

CROFAB, T5 

Cromolyn Sodium Ampul-Neb, T2 

Cromolyn Sodium Drops, T2 

Cromolyn Sodium Solution, T3 

Cryselle, T2 

CUPRIMINE, T3 

Cyclafem (1 MG-35MCG or 7 Days 

x 3), T2 

Cyclafem, T2 

Cyclobenzaprine HCL (5 or 10 

MG), T2 

Cyclopentolate HCL, T2 

Cyclophosphamide (25 or 50 MG), 

T2 

Cyclosporine (25, 50 or 100 MG) 

Capsule, T2 

Cyclosporine Solution, T2 

Cyclosporine Modified (25 or 100 

MG), T2 

CYKLOKAPRON, T3 

CYMBALTA (20, 30 or 60 MG), T4 

CYSTADANE, T3 

CYSTAGON (50 or 150 MG), T3 

CYTOGAM, T5 

Cytra-2, T2 

Cytra-3, T2 

Cytra-K, T2 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

7

D 

DACOGEN, T5 

DALIRESP, T4 

Danazol (50, 100 or 200 MG), T2 

Dantrolene Sodium (25, 50 or 100 

MG), T2 

Dapsone (25 or 100 MG), T3 

DAPTACEL, T3 

DARAPRIM, T3 

Deferoxamine Mesylate, T2 

Demeclocycline HCL (150 or 300 

MG), T2 

DENAVIR, T3 

Denta 5000 Plus, T2 

Dentagel, T2 

Depade, T2 

DEPEN, T3 

DEPO-MEDROL, T4 

DEPO-PROVERA, T3 

Desipramine HCL (10, 25, 50, 75, 

100 or 150 MG), T2 

Desloratadine, T3 

Desmopressin Acetate (0.1 or 0.2 


Desmopressin Acetate Spray/ 

Pump, T2 

Desmopressin Acetate Solution, 

T2 

DESONATE, T4 

Desonide Oint, T2 

Desonide Lotion, T2 

Desonide Cream, T2 

Desoximetasone Gel, T2 

Desoximetasone Oint, T2 

Desoximetasone (.05% or .25%) 

Cream, T2 

DETROL (1 or 2 MG), T3 

DETROL LA (2 or 4 MG), T3 

Dexamethasone (0.5, 0. 75, 1, 1.5, 

2, 4 or 6 MG) Tablet, T2 

Dexamethasone Elixir, T2 

Dexamethasone Acetate, T2 

8 

Dexamethasone Sodium 

Phosphate Drops, T2 

Dexamethasone Sodium 

Phosphate (4 or 10 MG/ML) Vial, 

T2 

Dexmethylphenidate HCL (2.5, 5 

or 10 MG), T2 

Dextroamphetamine Sulfate (5, 10 

or 15 MG) Capsule ER, T2 

Dextroamphetamine Sulfate (5 or 

10 MG) Tablet, T2 

Dextroamphetamine- 

Amphetamine (5, 10, 15, 20, 25 or 

30 MG), T2 

Dextrose 5%-1/2NS-KC (20, 30 or 

40 MEQ/L), T2 

Dextrose 5%-1/3NS-KCL, T2 

Dextrose 5%-1/4NS-KCL (10, 20 or 

30 MEQ/L), T2 

Dextrose 5%-NS-KCL, T2 

Dextrose 5%-Potassium Chloride 

(20, 30 or 40 MEQ/L), T2 

Dextrose In Lactated Ringers 

(2.5%-1/2 or 5%), T2 

Dextrose In Ringers Injection, T2 

Dextrose In Water Vial, T2 

Dextrose In Water (10%, 20%, 40% 

or 70%) IV Solu., T2 

Dextrose In Water PGY VL PRT, T2 

Dextrose In Water Disp Syrin, T2 

Dextrose With Sodium Chloride 

(2.5%-0.45%, 5 %-0.225%, 5 

%-0.33 % or 5%-0.45%), T2 

Diazepam Solution, T2 

Diazepam (2.5 MG, 5-7.5-10 MG or 

12.5-15-20 MG) Kit, T2 

Diazepam (2, 5 or 10 MG) Tablet, 

T2 

Diclofenac Potassium, T2 

Diclofenac Sodium (50 or 75 MG) 

Tablet DR, T2 

Diclofenac Sodium Tablet ER 24H, 

T2 

Diclofenac Sodium Tablet DR, T2 

Diclofenac Sodium Drops, T2 

Dicloxacillin Sodium (250 or 500 


Dicyclomine HCL Capsule, T2 

Dicyclomine HCL Tablet, T2 

Didanosine (125, 200, 250 or 400 

MG), T2 

DIFFERIN Med. Swab, T3 

DIFFERIN Lotion, T3 

DIFFERIN Gel, T3 

Diflorasone Diacetate Oint, T2 

Diflorasone Diacetate Cream, T2 

Diflunisal, T2 

DIGIFAB, T5 

Digitek (125 or 250 MCG), T1 

Digitek, T1 

Digoxin (125 or 250 MCG) Tablet, 

T1 

Digoxin Ampul, T2 

DIGOXIN, T3 

Dihydroergotamine Mesylate, T2 

DILANTIN Tab Chew, T3 

DILANTIN (30 or 100 MG) Capsule, 

T3 

DILANTIN-125, T3 

Dilt-CD, T2 

Dilt-XR (120, 180 or 240 MG), T2 

Diltia XT (120, 180 or 240 MG), T2 

Diltiazem 24HR CD (120, 240 or 

300 MG), T2 

Diltiazem 24HR ER, T2 

Diltiazem ER (360 or 420 MG) 

Capsule ER, T2 

Diltiazem ER (60, 90 or 120 MG) 

Capsule ER 12 H, T2 

Diltiazem HCL (30, 60, 90 or 120 

MG), T2 

Diltzac ER (120, 180, 240, 300 or 

360 MG), T2 

DIOVAN (40, 80, 160 or 320 MG), 

T4

DIOVAN HCT (80-12.5, 160-12.5, 

160-25, 320-12.5 or 320-25 MG), 

T4 

DIPENTUM, T3 

Diphenhydramine HCL (25 or 50 


Diphenhydramine HCL Vial, T2 

Diphenoxylate-Atropine Liquid, 

T2 

Diphenoxylate-Atropine Tablet, T2 

DIPHTHERIA-TETANUS TOXOID, T3 

Dipyridamole (25, 50 or 75 MG), 

T2 

Disopyramide Phosphate (100 or 

150 MG), T2 

Disulfiram (250 or 500 MG), T2 

Divalproex Sodium (125, 250 or 

500 MG) Tablet DR, T2 

Divalproex Sodium Cap Sprink, T2 

Divalproex Sodium ER (250 or 500 

MG), T2 

Docetaxel (20 MG/2 ML, 20 MG/1 

ML or FNL 20 MG/2 ML), T5 

Donepezil HCL (5 or 10 MG) Tab 

Rapdis, T2 

Donepezil HCL (5 or 10 MG) 

Tablet, T2 

Dorzolamide HCL, T2 

Dorzolamide-Timolol, T2 

DOVONEX, T3 

Doxazosin Mesylate (1, 2, 4 or 8 

MG), T1 

Doxepin HCL Oral Conc, T2 

Doxepin HCL (10, 25, 50, 75, 100 or 

150 MG) Capsule, T2 

Doxy-Lemmon Tablet, T2 

Doxy-Lemmon Capsule, T2 

Doxycycline Hyclate (75 or 100 

MG) Capsule DR, T2 

Doxycycline Hyclate (50 or 100 


Doxycycline Hyclate Tablet, T2 

Doxycycline Hyclate Vial, T2 

Doxycycline Monohydrate (50 or 

100 MG), T2 

Dronabinol (2.5, 5 or 10 MG), T4 

DROXIA (200, 300 or 400 MG), T3 

E 

E.E.S. 400, T2 

Econazole Nitrate, T2 

Ed Doxy-Caps, T2 

Ed K+10, T2 

EDURANT, T5 

Effer-K, T2 

ELAPRASE, T5 

ELIDEL, T3 

ELIGARD (7.5, 22.5, 30 or 45 MG), 

T3 

Eliphos, T2 

ELITEK, T5 

Elixophyllin, T2 

EMCYT, T3 

EMEND (40, 80 or 125 MG) 

Capsule, T3 

EMEND Cap DS PK, T3 

EMEND Vial, T3 

Emoquette, T2 

EMSAM (6, 9 or 12 MG/24 HR), T4 

EMTRIVA Capsule, T3 

EMTRIVA Solution, T3 

Enalapril Maleate (2.5, 5, 10 or 20 

MG), T1 

Enalapril-Hydrochlorothiazide (5 

MG-12.5 MG or 10 MG-25 MG), T1 

ENBREL Kit, T5 

ENBREL Pen Injctr, T5 

ENBREL Disp Syrin, T5 

Endocet (5-325 MG, 7.5 -325 MG, 

10-325 MG, 7.5-500 MG or 10-650 

MG), T2 

Endodan, T2 

ENGERIX-B (10 MCG/0.5 or 20 

MCG/ML) Disp Syrin, T3 

ENGERIX-B Vial, T3 

Enoxaparin Sodium (30MG/0.3ML, 

40MG/0.4ML, 60MG/0.6ML, 

80MG/0.8ML, 100 MG/ML, 

120MG/.8ML or 150 MG/ML), T3 

Enpresse, T2 

Epiklor, T2 

Epinephrine, T2 

Epitol, T2 

EPIVIR, T3 

EPIVIR HBV Tablet, T3 

EPIVIR HBV Solution, T3 

Eplerenone (25 or 50 MG), T4 

Eplerenone, T4 

EPOGEN (2000, 3000, 4000, 10000 

or 20000 ML), T3 

Epoprostenol Sodium (0.5 or 1.5 

MG), T5 

EPZICOM, T5 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

9

ERAXIS (WATER DILUENT), T5 

ERGOMAR, T3 

Ergotamine-Caffeine, T2 

ERIVEDGE, T5 

Errin, T2 

ERWINAZE, T5 

Ery, T2 

Erythrocin Stearate, T2 

Erythromycin Solution, T2 

Erythromycin Med. Swab, T2 

Erythromycin Gel, T2 

Erythromycin Capsule DR, T2 

Erythromycin (250 or 500 MG) 

Tablet, T2 

Erythromycin Oint., T2 

Erythromycin Ethylsuccinate 

Tablet, T2 

Erythromycin Ethylsuccinate Oral 

Susp, T2 

Erythromycin-Benzoyl Peroxide, 

T2 

Erythromycin-Sulfisoxazole, T2 

Escitalopram Oxalate (5, 10 or 20 

MG), T2 

Escitalopram Oxalate Solution, T2 

Esmolol HCL, T2 

Estradiol (0.5, 1 or 2 MG) Tablet, T2 

Estradiol (.025,.0357 .05, .06, .075 

or .1 MG) 24 HR Patch, T2 

Estradiol-Norethindrone Acetat 

(1-0.5 or 0.5-0.1 MG), T2 

Estropipate (.75, 1.5 or 3 MG), T2 

Ethambutol HCL (100 or 400 MG), 

T2 

Ethosuximide Syrup, T2 

Ethosuximide Capsule, T2 

ETHYOL, T5 

Etidronate Disodium (200 or 400 

MG), T2 

Etodolac (200 or 300 MG) Capsule, 

T2 

Etodolac (400, 500 or 600 MG) Tab 

ER 24 HR, T2 

Etodolac (400 or 500 MG) Tablet, 

T2 

EVISTA, T3 

EXELON Solution, T3 

EXELON (4.6 or 9.5 MG) 24 HR 

Patch, T4 

Exemestane, T2 

EXJADE (125, 250 or 500 MG), T3 

EXTAVIA, T5 

Ezogabine (50, 200 or 400 MG), T5 

F 

FABRAZYME, T5 

Famotidine Piggyback, T2 

Famotidine (20 or 40 MG) Tablet, 

T2 

Famotidine Vial, T2 

FANAPT (1, 2, 4, 5, 8, 10 or 12 MG) 

Tablet, T4 

FANAPT Tab DS PK, T4 

FARESTON, T3 

FASLODEX, T4 

FAZACLO (12.5, 25, 100, 150 or 200 

MG), T3 

Fe C, T2 

Felbamate Oral Susp, T4 

Felbamate (400 or 600 MG), T4 

Felodipine ER (2.5, 5 or 10 MG), T2 

Fenofibrate (67, 134 or 200 MG) 

Capsule, T2 

Fenofibrate (54 or 160 MG) Tablet, 

T2 

Fenoldopam Mesylate, T2 

Fenoprofen Calcium, T2 

Fentanyl (12, 25, 50, 75 or 100 

MCG/HR), T2 

Fexofenadine HCL (30, 60 or 180 

MG), T2 

Finasteride, T2 

FIRMAGON (80 or 120 MG), T4 

Flecainide Acetate (50, 100 or 150 

MG), T2 

FLOVENT HFA (44, 110 or 220 

MCG), T3 

Fluconazole (50, 100, 150 or 200 


Fluconazole (10 or 40 MG/ML) 


Fluconazole In Saline, T2 

Flucytosine (250 or 500 MG), T2 

Fludrocortisone Acetate, T2 

Flunisolide, T2 

Fluocinolone Acetonide (0.01 or 

0.025%) Cream, T2 

Fluocinolone Acetonide Solution, 

T2 

Fluocinolone Acetonide Oint., T2 

Fluocinolone Acetonide Oil Drops, 

T3 

Fluocinonide Cream, T2 

Fluocinonide Gel, T2 

Fluocinonide Oint, T2 

Fluocinonide Solution, T2 

Fluorometholone, T3 

Fluorouracil (2 or 5%) Solution, T2 

Fluorouracil Cream, T2 

Fluoxetine DR, T2 

Fluoxetine HCL (10, 20 or 40 MG) 

Capsule, T2 

Fluoxetine HCL Solution, T2 

Fluoxetine HCL (10 or 20 MG) 

Tablet, T2 

Fluphenazine Decanoate, T2 

Fluphenazine HCL Elixir, T2 

Fluphenazine HCL Oral Conc, T2 

Fluphenazine HCL (1, 2.5, 5 or 10 


Fluphenazine HCL Vial, T2 

Flurbiprofen (50 or 100 MG), T2 

Flurbiprofen Sodium, T2 

Flutamide, T2 

10

Fluticasone Propionate Spray 

Susp, T2 

Fluticasone Propionate Cream, T2 

Fluticasone Propionate Oint., T2 

Fluvoxamine Maleate (25, 50 or 

100 MG), T2 

FOCALIN XR (5, 10, 15, 20, 25, 30, 

35 or 40 MG), T4 

FOLOTYN, T5 

Fomepizole, T5 

Fondaparinux Sodium (2.5 MG/0.5 

ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML 

or 10 MG/0.8 ML), T3 

FORTAZ IN ISO-OSMOTIC 

DEXTROSE (1 G/50 ML or 2 G/50 

ML), T3 

FORTEO, T5 

FORTICAL, T4 

Fosinopril Sodium (10, 20 or 40 

MG), T2 

Fosinopril-Hydrochlorothiazide 

(10-12.5 or 20-12.5 MG), T2 

FRAGMIN (2500/0.2, 5000/0.2 ML, 

7500/0.3 ML, 10000, 12500/0.5, 

15000/0.6 or 18000/.72 ML) Disp 

Syrin, T4 

FRAGMIN Vial, T4 

FREAMINE HBC, T3 

Fructose, T3 

FULVICIN U/F, T3 

Furosemide (10, 20, 40 or 80 MG) 

Tablet, T1 

Furosemide Disp Syrin, T2 

Furosemide Vial, T2 

FUZEON, T5 

G 

Gabapentin (100, 300 or 400 MG) 

Capsule, T2 

Gabapentin (600 or 800) Tablet, T2 

Gabapentin Solution, T2 

GABITRIL (2, 4, 12 or 16 MG), T4 

GAMUNEX-C, T5 

Ganciclovir (250 or 500 MG), T5 

Ganciclovir Sodium, T3 

GARDASIL Vial, T3 

GARDASIL Disp Syrin, T3 

GASTROCROM, T3 

GAUZE PADS, T2 

Gavilyte-C, T2 

Gavilyte-N, T2 

Gemcitabine HCL, T5 

Gemfibrozil, T2 

Generlac, T2 

Gengraf (25 or 100 MG) Capsule, 

T2 

Gengraf Solution, T2 

GENOTROPIN (5 or 12 MG/ML) 

Cartridge, T5 

GENOTROPIN (0.2, 0.4, 0.6, 0.8, 1, 

1.2, 1.4, 1.6, 1.8 or 2 MG/0.25 ML) 

Disp Syrin, T3 

Gentak Drops, T2 

Gentak Oint., T2 

Gentamicin Sulfate Oint., T2 

Gentamicin Sulfate Drops, T2 

Gentamicin Sulfate Vial, T2 

GEODON, T3 

Gildess Fe (1.5-0.03 MG or 1 MG- 

20 MCG), T2 

GILENYA, T5 

GLEEVEC (100 or 400 MG), T5 

Glimepiride (1, 2 or 4 MG), T1 

Glipizide (5 or 10 MG), T1 

Glipizide ER (2.5, 5 or 10 MG), T1 

Glipizide-Metformin (2.5-250, 2.5- 

500 or 5-500 MG), T1 

GLUCAGEN, T3 

GLUCAGON EMERGENCY KIT, T3 

Glyburide (1.25, 2.5 or 5 MG) , T1 

Glyburide Micronized (1.5, 3 or 6 

MG), T1 

Glyburide-Metformin HCL (1.25- 

250, 2.5-500 or 5-500 MG), T1 

Glycopyrrolate (1 or 2 MG), T2 

GLYSET (25, 50 or 100 MG), T3 

Granisetron HCL Tablet, T2 

Granisetron HCL (1 MG/ML or 100 

MCG/ML) Vial, T2 

GRIFULVIN V, T3 

GRIS-PEG (125 or 250 MG), T3 

Griseofulvin, T2 

Guanfacine HCL (1 or 2 MG), T2 

Guanidine HCL, T2 

H 

HALAVEN, T5 

Halobetasol Propionate Cream, T2 

Halobetasol Propionate Oint., T2 

Haloperidol (.5, 1, 2, 5, 10 or 20 

MG), T2 

Haloperidol Decanoate (50 or 100 

MG/ML), T2 

Haloperidol Lactate Oral Conc, T2 

Haloperidol Lactate Vial, T2 

HAVRIX Disp Syrin, T3 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

11

HAVRIX Vial, T3 

HCTZ/Reserpine/Hydralazine, T2 

Heather, T2 

HECTOROL (0.5, 1 or 2.5 MCG) 

Capsule, T3 

HECTOROL Vial, T3 

HEPAGAM B, T5 

Heparin Sodium Disp Syrin, T2 

Heparin Sodium (1000, 5000, 

10000 or 20000 ML) Vial, T2 

Heparin Sodium In 5% Dextrose 

(25000/250 or 25000/500), T2 

Heparin Sodium-NS, T2 

HEPATASOL, T2 

HEPSERA, T5 

HEXALEN, T5 

Homatropaire, T2 

HUMALOG Vial, T3 

HUMALOG Insuln Pen, T3 

HUMALOG MIX 50-50 Vial, T3 

HUMALOG MIX 50-50 Insuln Pen, 

T3 

HUMALOG MIX 75-25 Vial, T3 

HUMALOG MIX 75-25 Insuln Pen, 

T3 

HUMATROPE (6, 12 or 24 MG) 

Cartridge, T5 

HUMATROPE Vial, T5 

HUMIRA Pen IJ Kit, T5 

HUMIRA Kit, T5 

HUMORSOL (0.125% or 0.25%), T3 

HUMULIN 70-30 Vial, T3 

HUMULIN 70-30 Insuln Pen, T3 

HUMULIN N Vial, T3 

HUMULIN N Insuln Pen, T3 

HUMULIN R, T3 

Hycort, T2 

Hydralazine HCL (10, 25, 50 or 100 

MG), T2 

Hydralazine W/HCTZ, T2 

Hydrochlorothiazide (12.5, 25 or 


12 

Hydrochlorothiazide Capsule, T1 

Hydrochlorothiazide/Reserpine 

(0.125-25MG or 0.125-50MG), T2 

Hydrocodone Bit-Ibuprofen, T2 

Hydrocodone-Acetaminophen 

Capsule, T2 


(5-163/7.5 or 7.5-500/15) Solution, 

T2 


(10-325, 10-500, 10-650, 10-660 or 

10-750 MG) Tablet, T2 


(2.5-325 or 2.5-500 MG) Tablet, T2 

Hydrocodone-Acetaminophen (5- 

325 or 5-500 MG) Tablet, T2 


(7.5-325, 7.5-500, 7.5-650 or 7.5- 


Hydrocortisone (1% or 2.5%) 

Cream, T2 

Hydrocortisone Enema, T2 

Hydrocortisone Lotion, T2 

Hydrocortisone (1% or 2.5%) Oint., 

T2 

Hydrocortisone (5, 10 or 20 MG) 

Tablet, T2 

Hydrocortisone Butyrate Solution, 

T2 

Hydrocortisone Butyrate Cream, 

T2 

Hydrocortisone Butyrate Oint., T2 

Hydrocortisone Plus, T2 

Hydrocortisone Valerate Cream, 

T2 

Hydrocortisone Valerate Oint., T2 

Hydrocortisone-Acetic Acid, T2 

Hydromorphone HCL Ampul, T2 

Hydromorphone HCL (2, 4 or 8 


Hydromorphone HCL (2 or 10 MG/ 

ML) Vial, T2 

Hydroxychloroquine Sulfate, T2 

Hydroxyurea, T2 

Hydroxyzine HCL (10, 25 or 50 


Hydroxyzine HCL Syrup, T2 

HYPERHEP B S-D Vial, T5 

HYPERHEP B S-D (110/0.5 ML or 

220 Unit/1) Disp Syrin, T5 

HYPERLYTE CR, T3 

HYPERLYTE R, T3 

HYPERRAB S-D Vial, T5 

HYPERRHO S-D (250 or 1500 Unit) 


HYPERTET S-D, T5 

I 

Ibuprofen (600 or 800 MG), T2 

Ibuprohm, T2 

Imipenem-Cilastatin Sodium (250 

or 500 MG), T2 

Imipramine HCL (10, 25 or 50 MG), 

T2 

Imipramine Pamoate (75, 100, 125 

or 150 MG), T2 

Imiquimod, T2 

IMOGAM RABIES-HT, T5 

IMOVAX RABIES VACCINE, T3 

INCIVEK, T5 

INCRELEX, T5 

Indapamide (1.25 or 2.5 MG), T2 

Indomethacin (25, 50 or 75 MG), 

T2 

INFANRIX, T3 

INFANRIX PF, T3 

INFERGEN, T5 

INLYTA (1 or 5 MG), T5 

INSULIN SYRINGE, T2 

INTELENCE (25, 100 or 200 MG), 

T5 

INTRALIPID (10, 20 or 30%), T3 

INTRON A (10 MM/0.2 ML, 3 

MM/0.2 ML or 5 MM/0.2 ML) Pen IJ 

Kit, T5

INTRON A (6 MM, 10 MM or 18 MM 

Unit) Vial, T3 

INTRON A 50 MM Unit Vial, T5 

Introvale, T2 

INTUNIV (1, 2, 3 or 4 MG), T3 

INVEGA (1.5, 2, 6 or 9 MG), T4 

INVEGA SUSTENNA (39 MG/0.25 

ML, 78 MG/0.5 ML, 117 MG/0.75 

ML or 156 MG/ML, T5 

INVIRASE (200 or 500 MG), T3 

IPOL, T3 

Ipratropium Bromide Solution, T2 

Ipratropium Bromide (21 or 42 

MCG) Spray, T2 

Ipratropium-Albuterol, T2 

ISENTRESS, T5 

Isonarif, T2 

Isoniazid (100 or 300 MG) Tablet, 

T2 

Isoniazid Syrup, T2 

ISOPTO HOMATROPINE, T2 

Isosorbide Dinitrate (2.5 or 5 MG) 

Tab Subl, T1 

Isosorbide Dinitrate (5, 10, 20 or 


Isosorbide Dinitrate Tablet ER, T1 

Isosorbide Mononitrate (10 or 20 

MG), T2 

Isosorbide Mononitrate ER (30, 60 

or 120 MG), T2 

Isradipine (2.5 or 5 MG), T2 

ISTODAX, T5 

Itraconazole, T2 

IXIARO, T4 

J 

JAKAFI (5, 10, 15, 20 or 25 MG), T5 

Jantoven (1, 2, 2.5, 3, 4, 5, 6, 7.5 or 

10 MG), T1 

JANUMET (50-500 or 50-1000 MG), 

T3 

JANUMET XR (50-500, 50-1000 or 

100-1000 MG), T3 

JANUVIA (25, 50 or 100 MG), T3 

JE-VAX, T3 

JENTADUETO (2.5-500, 2.5-850 or 

2.5-1000 MG), T3 

JEVTANA, T5 

Jolessa, T2 

Jolivette, T2 

Junel (1 MG-20MCG or 1.5-0.03 

MG), T2 

Junel Fe (1 MG-20 MCG or 1.5-0.03 

MG), T2 

JUVISYNC (100-10, 100-20 or 100- 

40 MG), T3 

K 

K Effervescent, T2 

KALETRA (100 - 25 MG) Tablet, T3 

KALETRA Solution, T5 

KALETRA (200-50 MG) Tablet, T5 

KAPVAY, T3 

Kariva, T2 

Kelnor 1-35, T2 

KEPIVANCE, T5 

KETEK (300 or 400 MG), T4 

Ketoconazole Cream, T2 

Ketoconazole Shampoo, T2 

Ketoconazole Tablet, T2 

Ketoprofen (50 or 75 MG) Capsule, 

T2 

Ketoprofen Cap 24 H Pel, T2 

Ketorolac Tromethamine (15 or 30 

MG/ML) Cartridge, T2 

Ketorolac Tromethamine (0.4 or 

0.5%) Drops, T2 

Ketorolac Tromethamine Tablet, 

T2 

Ketorolac Tromethamine (15 MG/ 

ML or 60 MG/2 ML) Vial, T2 

KINERET, T5 

KINRIX, T3 

Kionex, T2 

Klor-Con, T2 

Klor-Con 10, T2 

Klor-Con 8, T2 

Klor-Con M15, T2 

Klor-Con M20, T2 

Klor-Con-EF, T2 

KUVAN, T5 

L 

Labetalol HCL (100, 200 or 300 

MG), T2 

Laclotion, T2 

LACRISERT, T3 

LACTATED RINGERS, T4 

Lactulose Syrup, T2 

Lactulose Solution, T2 

LAMICTAL (BLUE), T3 

Lamivudine (150 or 300 MG), T2 

Lamivudine-Zidovudine, T5 

Lamotrigine (25, 100, 150 or 200 







T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

13

Lamotrigine Tab DS PK, T2 

Lamotrigine (5 or 25 MG) TB CHW 

DSP, T2 

LANOXIN PEDIATRIC, T3 

Lansoprazole (15 or 30 MG) 

Capsule DR, T2 

Lansoprazole (15 or 30 MG) Tab 

Rap DR, T2 

LANTUS, T3 

LANTUS SOLOSTAR, T3 

Latanoprost, T2 

LATUDA (20, 40 or 80 MG), T4 

Leena, T2 

Leflunomide (10 or 20 MG), T2 

Lessina, T2 

Letrozole, T2 

Leucovorin Calcium (5, 10, 15 or 


Leucovorin Calcium Vial, T2 

LEUKERAN, T3 

LEUKINE (250 or 500 MCG/ML), T5 

Leuprolide Acetate, T3 

Levetiracetam (250, 500, 750 or 


Levetiracetam Vial, T2 

Levetiracetam Solution, T2 

Levetiracetam-NACL (500 

MG/0.1L, 1000 MG/100 or 1500 

MG/100), T2 

Levlen 28, T2 

Levobunolol HCL (0.25 or 0.5%), 

T1 

Levofloxacin Solution, T2 

Levofloxacin (250, 500 or 750 MG) 

Tablet, T2 

Levofloxacin-D5W, T2 

Levonorgestrel, T2 

Levora-28, T2 

LEVOTHROID (25, 50, 75, 88, 100, 

112, 125, 137, 150, 175, 200 or 300 

MCG), T3 

Levothyroxine Sodium (25, 50, 75, 

88, 100, 112, 125, 137, 150, 175, 

200 or 300 MCG), T2 

LEVOXYL (25, 50, 75, 88, 100, 112, 

125, 137, 150, 175, or 200 MCG), 

T3 

LEVULAN, T3 

LEXAPRO (5, 10 or 20 MG) Tablet, 

T4 

LEXAPRO Solution, T4 

LEXIVA Oral Susp, T3 

LEXIVA Tablet, T5 

LIALDA, T3 

Lidocaine, T2 

Lidocaine HCL Ampul, T2 

Lidocaine HCL Ampul Luer, T2 

Lidocaine HCL Disp Syrin, T2 

Lidocaine HCL JEL (ML), T2 

Lidocaine HCL JEL/PF APP, T2 

Lidocaine HCL Solution, T2 

Lidocaine HCL (5 or 10 MG/ML) 

Vial, T2 

Lidocaine HCL In 5% Dextrose (2 

or 8 MG/ML), T2 

Lidocaine HCL Viscous, T2 

Lidocaine-Prilocaine, T2 

LIDODERM, T4 

Lidomar Viscous, T2 

Lindane Lotion, T2 

Lindane Shampoo, T2 

Liothyronine Sodium (5, 25 or 50 

MCG), T2 

Lisinopril (2.5, 5, 10, 20, 30 or 40 

MG), T1 

Lisinopril-Hydrochlorothiazide 

(10-12.5, 20-12.5 or 20-25 MG), T1 

Lithium, T2 

Lithium Carbonate (150, 300 or 


Lithium Carbonate Tablet, T2 

Lithium Carbonate (300 or 450 

MG) Tablet ER, T2 

Lokara, T2 

Loperamide, T2 

Loratadine, T1 

Lorazepam (0.5, 1 or 2 MG), T2 

Losartan Potassium (25, 50 or 100 

MG), T1 

Losartan-Hydrochlorothiazide (50- 

12.5, 100-12.5 or 100-25 MG), T1 

LOTEMAX, T3 

LOTRONEX (0.5 or 1 MG), T5 

Lovastatin (10, 20 or 40 MG), T1 

LOVAZA, T4 

LOVENOX, T4 

Low-Ogestrel, T2 

Loxapine (5, 10, 25 or 50 MG), T2 

LUPRON DEPOT, T3 

LUPRON DEPOT (11.25, 22.5, 30 or 

45 MG), T5 

LUPRON DEPOT-PED (7.5, 11.25 or 

15 MG), T5 

Lutera, T2 

LYRICA (25, 50, 75, 100, 150, 200 or 

225 MG), T4 

LYSODREN, T3 

M 

M-M-R II VACCINE, T3 

Maprotiline HCL (25, 50 or 75 MG), 

T2 

Marlissa, T2 

MARPLAN, T3 

MATULANE, T5 

MAXALT (5 or 10 MG), T3 

MAXALT MLT (5 or 10 MG), T3 

MAXIDEX, T3 

Meclizine HCL (12.5 or 25 MG), T2 

Meclofenamate Sodium (50 or 100 

MG), T2 

Medroxyprogesterone Acetate 



(2.5, 5 or 10 MG) Tablet, T2 

14


Vial, T2 

Mefloquine HCL, T2 

Megestrol Acetate Oral Susp, T2 

Megestrol Acetate (20 or 40 MG), 

T2 

Meloxicam (7.5 or 15 MG), T2 

Melphalan HCL, T5 

MENACTRA, T3 

MENEST (0.3, 0.625, 1.25 or 2.5 

MG), T3 

MENOMUNE-A-C-Y-W-135, T3 

MENVEO A-C-Y-W-135-DIP, T3 

Meperidine HCL Solution, T2 

Meperidine HCL (50 or 100 MG) 

Tablet, T2 

MEPRON, T5 

Mercaptopurine, T2 

Mesalamine, T2 

MESNEX, T3 

Metaproterenol Sulfate Syrup, T2 

Metaproterenol Sulfate (10 or 20 


Metformin HCL (500, 850 or 1000 

MG), T1 

Metformin HCL ER (500, 750 or 

1000 MG), T1 

Methadone HCL (5 or 10 MG/5 

ML) Solution, T2 

Methadone HCL (5 or 10 MG) 

Tablet, T2 

Methadone HCL Tablet Sol, T2 

Methadone HCL Vial, T2 

Methadone Intensol, T2 

Methadose Tablet Sol, T2 

Methadose Tablet, T2 

Methazolamide (25 or 50 MG), T2 

Methenamine Mandelate (500 MG 

or 1 G), T2 

Methimazole (5, 10 or 20 MG), T2 

Methocarbamol (500 or 750 MG), 

T2 

Methotrexate, T2 

Methyclothiazide, T2 

Methyldopa (250 or 500 MG), T2 

Methyldopa-Hydrochlorothiazide 

(250-15 or 250-25 MG), T2 

Methyldopa-Hydrochlorothiazide, 

T2 

Methylphenidate ER (10 or 20 MG) 

Tablet ER, T2 

Methylphenidate ER (18, 27, 36 or 

54 MG) Tablet ER 24, T3 

Methylphenidate HCL (5, 10 or 20 

MG), T2 

Methylprednisolone (4, 8, 16 or 32 


Methylprednisolone Tab DS PK, T2 

Methylprednisolone Acetate (40 

or 80 MG/ML), T2 

Methylprednisolone Sod Succ (40, 

500 or 1000 MG), T2 

Metipranolol, T2 

Metoclopramide HCL (5 or 10 MG) 

Tablet, T2 

Metoclopramide HCL Vial, T2 

Metoclopramide HCL Solution, T2 

Metolazone (2.5, 5 or 10 MG), T2 

Metoprolol Succinate (25, 50, 100 

or 200 MG), T2 

Metoprolol Tartrate (25, 50 or 100 

MG), T1 

Metoprolol-Hydrochlorothiazide 

(50 MG-25 MG, 100 MG-25 MG or 

100-50 MG), T1 

Metronidazole Capsule, T2 

Metronidazole Cream, T2 

Metronidazole Gel, T2 

Metronidazole Gel w/ Appl, T2 

Metronidazole Lotion, T2 

Metronidazole Piggyback, T2 

Metronidazole (250 or 500 MG) 

Tablet, T2 

Metryl (250 or 500 MG), T2 

Mexiletine HCL (150, 200 or 250 

MG), T2 

Miconazole 3, T2 

MICRHOGAM PLUS, T3 

Microgestin (1 MG-20 MCG or 1.5- 

0.03 MG), T2 

Microgestin Fe (1 MG-20 MCG or 

1.5-0.03 MG), T2 

Midodrine HCL (2.5, 5 or 10 MG), 

T2 

MIFEPREX, T3 

Migergot, T2 

Milrinone In 5% Dextrose, T2 

Mimvey, T2 

Minitran (0.1, 0.2, 04. or 0.6 MG/ 

HR), T2 

Minocycline HCL (50, 75 or 100 


Minocycline HCL (50, 75 or 100 


Minoxidil (2.5 or 10 MG), T2 

Mirtazapine (15, 30 or 45 MG) Tab 

Rapdis, T2 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

15

Mirtazapine (7.5, 15, 30 or 45 MG), 

T2 

Misoprostol (100 or 200 MCG), T2 

Misoprostol, T2 

Mitoxantrone HCL, T2 

MOBAN (10, 25 or 50 MG), T4 

Modafinil (100 or 200 MG), T3 

Moexipril HCL (7.5 or 15 MG), T2 

Mometasone Furoate Oint., T2 

Mometasone Furoate Cream, T2 

Mometasone Furoate Solution, T2 

Mononessa, T2 

Morphine Sulfate Disp Syrin, T2 

Morphine Sulfate (10, 20 or 100 

MG/5 ML) Solution, T2 

Morphine Sulfate (5, 10, 20 or 30 

MG) Supp. Rect, T2 

Morphine Sulfate (15 or 30 MG) 

Tablet, T2 

Morphine Sulfate Vial, T2 

Morphine Sulfate ER (15, 30, 60, 

100 or 200 MG), T2 

Mst 600, T2 

MULTAQ, T4 

Mupirocin, T2 

MYCOBUTIN, T3 

Myconel, T2 

Mycophenolate Mofetil Tablet, T2 

Mycophenolate Mofetil Capsule, 

T2 

MYFORTIC (180 or 360 MG), T3 

MYTELASE, T3 

Myzilra, T2 

N 

NABI-HB, T5 

Nabumetone (500 or 750 MG), T2 

Nadolol (20, 40 or 80 MG), T1 

Nafcillin Sodium Vial, T2 

Nafcillin Sodium Vial Port, T2 

NAGLAZYME, T5 

16 

Nalidixic Acid, T2 

NALLPEN-ISO-OSMOTIC 

DEXTROSE, T2 

Naloxone HCL Ampul, T3 

Naloxone HCL (0.4 MG/ML or 1 

MG/ML) Disp Syrin, T3 

Naltrexone HCL Tablet, T2 

NAMENDA Tab DS Pak, T3 

NAMENDA Solution, T3 

NAMENDA (5 or 10 MG) Tablet, T3 

Naphazoline HCL W/Antazoline, 

T2 

Naproxen Oral Susp, T2 

Naproxen (250, 375 or 500 MG) 

Tablet, T2 

Naproxen (375 or 500 MG) Tablet 

DR, T2 

Naproxen Sodium (275 or 550 

MG), T2 

Nateglinide (60 or 120 MG), T2 

Necon (1MG-50 MCG, 0.5-0.035, 1 

MG-35 MCG, 10-11 or 7 days x 3), 

T2 

Nefazodone HCL (50, 100, 150, 

200 or 250 MG), T2 

NEGGRAM, T3 

Neo-Fradin, T2 

Neomycin Sulfate, T2 

Neomycin W/Dexamethasone, T2 

Neomycin-Bacitracin-Poly-HC, T2 

Neomycin-Bacitracin-Polymyxin, 

T2 

Neomycin-Polymyxin-Dexameth 

Drops Susp, T2 

Neomycin-Polymyxin-Dexameth 

Oint., T2 

Neomycin-Polymyxin-Gramicidin, 

T2 

Neomycin-Polymyxin-HC (3.5-10K- 

1 or 3.5-10K-10), T2 

Neomycin-Polymyxin-Hydrocort, 

T2 

NEPHRAMINE, T3 

NEPTAZANE (25 or 50 MG), T2 

NEULASTA, T5 

NEUMEGA, T5 

NEUPOGEN (300 MCG/0.5 or 480 

MCG/0.8) Disp Syrin, T5 

NEUPOGEN Vial, T5 

Nevirapine Oral Susp, T2 

Nevirapine, T2 

NEXAVAR, T5 

Next Choice, T2 

NIASPAN (500, 750 or 1000 MG), 

T4 

Nicardipine HCL (20 or 30 MG), T2 

NICOTROL, T3 

NICOTROL NS, T3 

Nifediac CC (30, 60 or 90 MG), T2 

Nifedical XL (30 or 60 MG), T2 

Nifedipine ER (30, 60 or 90 MG), T2 

NILANDRON, T3 

Nitrofurantoin (50 or 100 MG), T2 

Nitroglycerin Patch (0.1 MG/HR, 

0.2 MG/HR, 0.4 MG/HR or 0.6 MG/ 

HR), T2 

NITROSTAT (0.3, 0.4 or 0.6 MG), T3 

Nizatidine (150 or 300 MG), T2 

Nora-Be, T2 

NORDITROPIN (4 or 8 MG), T5 

NORDITROPIN FLEXPRO, T5 

NORDITROPIN NORDIFLEX (10 

MG/1.5 ML, 15 MG/1.5 ML or 30 

MG/3 ML), T5 

Norethindrone, T2 

Norethindrone Acetate, T2 

Norgestimate-Ethinyl Estradiol, T2 

Norgestrel-Ethiny Estra, T2 

Nortrel (0.3-0.03 MG, 0.5-0.035 or 

1 MG-35 MCG), T2 

Nortriptyline HCL (10, 25, 50 or 75 


Nortriptyline HCL Solution, T2 

NORVIR Solution, T3 

NORVIR Tablet, T3

NORVIR Capsule, T3 

NOVOLIN 70-30, T3 

NOVOLIN 70-30 INNOLET, T3 

NOVOLIN N, T3 

NOVOLIN N INNOLET, T3 

NOVOLIN R Vial, T3 

NOVOLIN R Insuln Pen, T3 

NOVOLOG Insuln Pen, T3 

NOVOLOG Vial, T3 

NOVOLOG MIX 70-30 Vial, T3 

NOVOLOG MIX 70-30 Insuln Pen, 

T3 

NULOJIX, T5 

NUTRILYTE II, T3 

NUTROPIN, T5 

NUTROPIN AQ Vial, T5 

NUTROPIN AQ Cartridge, T5 

NUTROPIN AQ NUSPIN, T5 

Nyamyc, T2 

Nystatin Cream, T2 

Nystatin Oint., T2 

Nystatin Powder, T2 

Nystatin Powder (EA), T2 

Nystatin (100 or 500 K Unit) Tablet, 

T2 

Nystatin-Triamcinolone Cream, T2 

Nystatin-Triamcinolone Oint., T2 

Nystop, T2 

O 

Ofloxacin Drops, T2 

Ofloxacin (200, 300 or 400 MG) 

Tablet, T2 

Ogestrel, T2 

Olanzapine (2.5, 5, 7.5, 10 or 15 


Olanzapine (20 MG) Tablet, T5 

Olanzapine Vial, T2 

Olanzapine ODT (5, 10, 15 or 20 

MG), T2 

Ondansetron HCL Solution, T2 

Ondansetron HCL (4, 8 or 24 MG) 

Tablet, T2 

Ondansetron ODT (4 or 8 MG), T2 

ONFI (5, 10 or 20 MG), T4 

ONTAK, T3 

Oralone, T2 

ORAP (1 or 2 MG), T4 

ORENCIA, T5 

ORFADIN (2, 5 or 10 MG), T3 

Orsythia, T2 

Otimar Drops Susp, T2 

Otimar Solution, T2 

Otocidin, T2 

Oxaliplatin, T5 

Oxandrolone (2.5 or 10 MG), T2 

Oxaprozin, T2 

Oxcarbazepine (150, 300 or 600 


Oxcarbazepine Oral Susp, T2 

OXSORALEN, T3 

OXSORALEN-ULTRA, T3 

Oxybutynin Chloride Syrup, T2 

Oxybutynin Chloride Tablet, T2 

Oxybutynin Chloride ER (5, 10 or 

15 MG), T2 

Oxycodone Concentrate, T2 

Oxycodone HCL Solution, T2 

Oxycodone HCL Capsule, T2 

Oxycodone HCL (5, 10, 15 or 30 


Oxycodone HCL-Acetaminophen 

(7.5-500 MG, 10 MG-325 MG or 10 

MG-650 MG), T2 

Oxycodone HCL-Aspirin, T2 

Oxycodone-Acetaminophen 

Capsule, T2 

Oxycodone-Acetaminophen (5 

MG-325 MG or 7.5-325 MG), T2 

OXYCONTIN (10, 15, 30 or 60 MG), 

T4 

P 

Pacerone (100, 200 or 400 MG), T2 

Pamidronate Disodium (30 MG/10 

ML or 90 MG/10 ML), T2 

PANCREAZE (4.2 K-10 K, 10.5 

K-25K, 16.8-40-70 or 21-37-61 K), 

T3 

Pancrelipase 5,000, T3 

PANRETIN, T5 

Pantoprazole Sodium (20 or 40 

MG), T2 

Parcaine, T2 

Paromomycin Sulfate, T2 

Paroxetine HCL (10, 20, 30 or 40 

MG), T2 

PASER, T4 

PATANOL, T3 

PAXIL, T3 

Pedi-Dri, T2 

PEDIARIX, T3 

PEDVAXHIB, T3 

Peg 3350-Electrolyte, T2 

Peg-3350 And Electrolytes, T2 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

17

Peg-3350 With Flavor Packs, T2 

PEGANONE, T3 

PEGASYS Vial, T5 

PEGASYS Kit, T5 

PEGASYS PROCLICK, T5 

PEGINTRON (50 MCG/0.5, 80 

MCG/0.5 or 120 MCG/0.5), T5 

PEGINTRON REDIPEN (50 MCG/0.5, 

80 MCG/0.5, 120 MCG/0.5 or 150 

MCG/0.5), T5 

PEN NEEDLE (29 GX 5/16” or 31 GX 

5/16”), T2 

Penicillin G Potassium, T2 

PENICILLIN G SODIUM, T2 

Penicillin Gk-Iso-Osm Dextrose, T2 

Penicillin V Potassium (125 MG/5 

ML or 250 MG/5 ML) Soln Recon, 

T2 

Penicillin V Potassium (250 or 500 


Pentamidine Isethionate, T4 

PENTASA (250 or 500 MG), T4 

Pentazocine-Acetaminophen, T4 

PENTOLAIR, T2 

Pentoxifylline, T2 

Periogard, T2 

Permethrin, T2 

Perphenazine (2, 4, 8 or 16 MG), 

T2 

Perphenazine-Amitriptyline (4 

MG-10 MG, 4 MG-25 MG or 4 MG- 


Perphenazine-Amitriptyline (2 

MG-10 MG or 2 MG-25 MG) Tablet, 

T2 

Pfizerpen, T2 

Phenadoz (12.5 or 25 MG), T2 

Phenazopyridine HCL (100 or 200 

MG), T2 

Phenelzine Sulfate, T2 

Phenobarbital Elixir, T2 

Phenobarbital (15, 16.2, 30, 32.4, 

60, 64.8, 97.2 or 100 MG) Tablet, 

T2 

Phenylephrine HCL (2.5 or 10 %) 

Drops, T2 

PHENYTEK (200 or 300 MG), T3 

Phenytoin, T2 

Phenytoin Sodium Ampul, T2 

Phenytoin Sodium Disp Syrin, T2 

Phenytoin Sodium Extended (100, 

200 or 300 MG), T2 

Philith, T2 

Phospha 250 Neutral, T2 

PHOSPHOLINE IODIDE, T3 

Pilocarpine HCL (5 or 7.5 MG) 

Tablet, T2 

Pilocarpine HCL (1, 2 or 4 %) 

Drops, T2 

PILOPINE HS, T3 

Pindolol (5 or 10 MG), T1 

Piroxicam (10 or 20 MG), T2 

Podocon-25, T3 

Podofilox, T2 

Polyethylene Glycol 3350, T2 

Polymyxin B Sul-Trimethoprim, T2 

Portia, T2 

Potassium Bicarbonate, T2 

Potassium Chl-Normal Saline, T2 

Potassium Chloride (8 or 10 MEQ) 

Capsule ER, T2 

Potassium Chloride (20 or 40 

MEQ/15 ML) Liquid, T2 

Potassium Chloride Tablet ER PRT, 

T2 

Potassium Chloride Tablet EFF, T2 

Potassium Chloride (8 or 10 MEQ) 

Tablet ER, T2 

Potassium Chloride In D5LR, T2 

Potassium Citrate (5 or 10 MEQ), 

T2 

Potassium Citrate-Citric Acid, T2 

POTIGA (50, 200 or 400 MG), T5 

PRADAXA (75 or 150 MG), T4 

Pramipexole Dihydrochloride 

(.125, .75 .25, .5, 1 or 1.5 MG), T2 

PRANDIN (.5, 1 or 2 MG), T3 

Pravastatin Sodium (10, 20, 40 or 

80 MG), T2 

Prazosin HCL (1, 2 or 5 MG), T2 

Prednisolone Acetate, T2 

Prednisolone Sodium Phosphate 

Drops, T2 

Prednisolone Sodium Phosphate 

(5 MG/5 ML or 15 MG/5 ML) 

Solution, T2 

Prednisone Tab DS PK, T2 

Prednisone (1, 2.5, 5, 10 or 20 MG) 

Tablet, T2 

PREMARIN Cream/Appl, T3 

PREMARIN (0.3, 0.45, 0.625, 0.9 or 

1.25 MG) Tablet, T3 

PREMASOL (6 or 10 %), T2 

PREMPHASE, T3 

PREMPRO (0.3-1.5, 0.45-1.5, 0.625- 

2.5 or 0.625-5 MG), T3 

Prenatal Plus, T2 

Prevalite, T2 

Previfem, T2 

PREZISTA (75 MG), T3 

PREZISTA (150, 400 or 600 MG), T5 

PRIFTIN, T3 

PRIMAQUINE, T3 

PRIMAXIN I.M., T3 

Primidone (50 or 250 MG), T2 

PRISTIQ ER (50 or 100 MG), T4 

PROAIR HFA, T3 

Probenecid, T2 

Probenecid-Colchicine, T2 

Procainamide HCL Capsule, T2 

Procainamide HCL (250 or 500 

MG) Tablet SA, T2 

Prochlorperazine Edisylate, T2 

Prochlorperazine Maleate (5 or 10 


18

Prochlorperazine Maleate Supp. 

Rect, T2 

PROCRIT (2000, 3000, 4000 or 

10000 ML), T3 

PROCRIT (20000 or 40000 ML), T5 

Procto-Pak, T2 

Proctosol-HC, T2 

Proctozone-HC, T2 

PROFASI, T3 

Progesterone (100 or 200 MG), T2 

PROGLYCEM, T3 

PROGRAF, T3 

PROLASTIN, T5 

PROLEUKIN, T5 

PROLIA, T4 

PROMACTA (25, 50 or 75 MG), T5 

Promethazine HCL (12.5 or 25 MG) 

Supp. Rect, T2 

Promethazine HCL Syrup, T2 

Promethazine HCL (12.5, 25 or 50 


Promethazine HCL Vial, T2 

Promethegan (12.5, 25 or 50 MG), 

T2 

PRONESTYL, T3 

Propafenone HCL (105, 225 or 300 


Proparacaine HCL, T2 

Propranolol HCL (60, 80, 120 or 

160 MG) Cap SA 24 H, T2 

Propranolol HCL (10, 20, 40, 60 or 


Propranolol-Hydrochlorothiazid 

(40 MG-25 MG or 80 MG-25 MG), 

T2 

Propylthiouracil, T2 

PROQUAD, T3 

PROSTIGMIN, T3 

PROTONIX IV, T3 

Protriptyline HCL (5 or 10 MG), T2 

PROVENTIL HFA, T3 

PROVIGIL (100 or 200 MG), T3 

PULMICORT FLEXHALER (90 or 180 

MCG), T3 

PULMOZYME, T5 

Pyrazinamide, T2 

Pyridostigmine Bromide, T2 

Q 

Quasense, T2 

Quetiapine Fumarate (25, 50, 100, 

200, 300 or 400 MG), T2 

Quinapril HCL (5, 10, 20 or 40 MG), 

T2 

Quinapril-Hydrochlorothiazide 

(10-12.5, 20-12.5 or 20-25 MG), T2 

Quinidine Gluconate, T2 

Quinidine Sulfate Tablet ER, T2 

Quinidine Sulfate (200 or 300 MG) 

Tablet, T2 

QVAR (40 or 80 MCG), T3 

R 

RABAVERT, T3 

Ramipril (1.25, 2.5 5 or 10 MG), T2 

RANEXA (500 or 1000 MG), T3 

Ranitidine HCL (150 or 300 MG) 

Capsule, T2 

Ranitidine HCL Vial, T2 

Ranitidine HCL Syrup, T2 

Ranitidine HCL (150 or 300 MG) 

Tablet, T2 

RAPAMUNE Solution, T3 

RAPAMUNE (0.5 MG) Tablet, T3 

RAPAMUNE (1 or 2 MG) Tablet, T5 

REBIF (22 MCG/.5 ML, 44 MCG/.5 

ML or 8.8-22 (6)), T5 

RECLAST, T4 

Reclipsen, T2 

RECOMBIVAX HB (5 MCG/0.5 ML 

or 10 MCG/ML) Disp Syrin, T3 

RECOMBIVAX HB (5 MCG/0.5 ML 

or 40 MCG/ML) Vial, T3 

Rectasol-HC, T2 

REGRANEX, T5 

RELENZA, T4 

RELISTOR Vial, T4 

RELISTOR Disp Syrin, T4 

Remeven, T2 

REMICADE, T5 

REMODULIN (1, 2.5, 5 or 10 MG/ 

ML), T5 

RENAGEL (400 or 800 MG), T4 

RENVELA, T4 

Reprexain (2.5-200, 5-200 or 10- 

200 MG), T2 

RESCRIPTOR Tab Disper, T3 

RESCRIPTOR Tablet, T3 

Reserpine (0.1 or 0.25 MG), T2 

RESTASIS, T4 

RETROVIR, T3 

REVATIO Vial, T5 

REVATIO Tablet, T5 

REVLIMID (2.5, 5, 10, 15 or 25 MG), 

T5 

REYATAZ (100, 150, 200 or 300 

MG), T3 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

19

RHOGAM PLUS, T3 

RHOPHYLAC, T4 

Ribasphere Capsule, T2 

Ribasphere (200, 400 or 600 MG) 

Tablet, T2 

Ribavirin Capsule, T2 

Ribavirin Tablet, T2 

RIDAURA, T3 

Rifampin (150 or 300 MG), T2 

Rifampin (600 MG), T4 

RIFATER, T3 

RILUTEK, T5 

Rimantadine HCL, T2 

Ringers Injection, T2 

RISPERDAL CONSTA (12.5 MD/2 

ML, 25 MG/2 ML, 37.5 MG/2 ML or 

50 MG/2 ML), T3 

Risperidone Solution, T2 

Risperidone (0.25, 0.5, 1, 2, 3 or 4 


Risperidone M-Tab (0.5, 1, 2 or 3 

MG), T2 

Risperidone ODT (0.25 or 4 MG), 

T2 

RITUXAN, T5 

Rivastigmine (1.5, 3, 4.5 or 6 MG), 

T2 

Ropinirole HCL (0.25, 0.5, 1, 2, 3, 4 

or 5 MG), T2 

ROTATEQ, T3 

Roxicet, T2 

S 

SABRIL Tablet, T5 

SABRIL Powd Pack, T5 

SAIZEN (5 or 8.8 MG) Vial, T5 

SAIZEN Cartridge, T5 

Salsalate (500 or 750 MG), T2 

SANDOSTATIN LAR (10, 20 or 30 

MG), T5 

SANTYL, T3 

SAPHRIS (5 or 10 MG), T4 

20 

SAVELLA Tab DS PK, T3 

SAVELLA (12.5, 25, 50 or 100 MG) 

Tablet, T3 

Selegiline HCL Capsule, T2 

Selegiline HCL Tablet, T2 

Selenium Sulfide Suspension, T2 

Selenium Sulfide Shampoo, T2 

SELZENTRY (150 or 300 MG), T5 

SENSIPAR (30, 60 or 90 MG), T3 

SEREVENT DISKUS, T3 

SEROMYCIN, T3 

SEROSTIM (4, 5 or 6 MG), T5 

Sertraline HCL (25, 50 or 100 MG) 

Tablet, T2 

Sertraline HCL Oral Conc, T2 

S, T2 

Sf 5000 Plus, T2 

Silver Sulfadiazine, T2 

SIMULECT, T4 

Simvastatin (5, 10, 20, 40 or 80 

MG), T1 

SINGLE USE SWAB, T2 

SINGULAIR Tablet, T3 

SINGULAIR (4 or 5 MG) Tab Chew, 

T3 

Sodium Bicarbonate (0.9 MEQ/ML 

or 1 MEQ/ML) Disp Syrin, T2 

Sodium Bicarbonate (0.9 MEQ/ML 

or 1 MEQ/ML) Vial, T2 

Sodium Chloride IV Soln, T2 

Sodium Chloride Irrig Soln, T2 

Sodium Chloride Pgy VL PRT, T2 

Sodium Citrate & Citric Acid, T2 

Sodium Fluoride, T2 

SOLARAZE, T3 

SOMAVERT (10, 15 or 20 MG), T5 

Somnote, T2 

Sorine (80, 120, 160, 240 or 500 

MG), T2 

Sotalol (80, 120, 160 or 240 MG), 

T2 

Sotret, T4 

SPIRIVA, T4 

Spironolactone (25, 50 or 100 MG), 

T2 

Spironolactone-HCTZ, T2 

Sprintec, T2 

SPRYCEL (20, 50, 70, 80, 100 or 140 

MG), T5 

Sps, T2 

Sronyx, T2 

Ssd, T2 

Stagesic, T2 

STALEVO 100, T3 






Stannous Fluoride, T2 

Stavudine (15, 20, 30 or 40 MG), 

T2 

STRATTERA (10, 25 or 40 MG), T3 

STROMECTOL, T3 

SUBOXONE (2 MG-0.5 MG or 8 

MG-2 MG) Film, T4 

SUBOXONE (2 MG-0.5 MG or 8 

MG-2 MG) Tab Subl, T4 

SUCRAID, T3 

Sucralfate Tablet, T2 

Sucralfate Oral Susp, T2 

Sulfacetamide Sodium Oint., T2 

Sulfacetamide Sodium Drops, T2 

Sulfacetamide-Prednisolone, T2 

Sulfadiazine, T2 

Sulfamethoxazole-Trimethoprim 

Oral Susp, T2 


(400 MG-80 MG or 80-160 MG) 

Tablet, T2 


Vial, T2 

Sulfasalazine, T2

Sulfasalazine DR, T2 

Sulfazine, T2 

Sulindac (150 or 200 MG), T2 

Sumatriptan (5 or 20 MG), T2 

Sumatriptan Succinate (25, 50 or 


Sumatriptan Succinate Pen Injctr, 

T2 

Sumatriptan Succinate Cartridge, 

T2 

SUPRAX, T3 

SUSTIVA (50, 100, 200 or 600 MG), 

T3 

SUTENT (12.5, 25 or 50 MG), T5 

SYLATRON (296, 444 or 888 MCG) 

, T5 

SYMLIN, T4 

SYMLINPEN 120, T4 

SYMLINPEN 60, T4 

SYNAREL, T5 

SYNTHROID (25, 50, 75, 88, 100, 

112, 125, 137, 150, 175, 200 or 300 

MCG), T3 

, 

T 

TABLOID, T3 

Tacrolimus (0.5, 1 or 5 MG), T2 

TAMIFLU (30, 45 or 75 MG) 

Capsule, T4 

TAMIFLU Susp Recon, T4 

Tamoxifen Citrate (10 or 20 MG), 

T2 

Tamsulosin HCL, T2 

TARCEVA (25, 100 or 150 MG), T5 

TARGRETIN Capsule, T5 

TARGRETIN Gel, T5 

TASIGNA (150 or 200 MG), T5 

TASMAR, T3 

Tazicef (1 or 2 G) Vial, T2 

Tazicef (1 or 2 G) Vial Port, T2 

TAZICEF IN DEXTROSE, T2 

TAZORAC (0.05 or 0.1 %) Gel, T4 

TAZORAC (0.05 or 0.1 %) Cream, 

T4 

Taztia XT (120, 180, 240, 300 or 


TE ANATOXAL BERNA, T3 

TEGRETOL XR, T3 

TEKTURNA (150 or 300 MG), T3 

TEKTURNA HCT (150-12.5, 150-25, 

300-12.5 or 300-25 MG), T3 

Temazepam (15 or 30 MG), T2 

TENIVAC, T3 

Terazosin HCL (1, 2, 5 or 10) 

Capsule, T2 

Terbinafine HCL Tablet, T2 

Terbutaline Sulfate (2.5 or 5 MG) 

Tablet, T2 

Terbutaline Sulfate Vial, T2 

Terconazole (0.8 or 0.4 %) Cream/ 

Appl, T2 

Terconazole Supp. Vag, T2 

TETANUS DIPHTHERIA TOXOIDS, 

T3 

TETANUS TOXOID ADSORBED, T2 

TETANUS-DIPHTERIA-DECAVAC, 

T3 

TETCAINE, T2 

Tetracaine HCL, T2 

Tetracycline HCL (250 or 500 MG), 

T2 

THALOMID (50, 100, 150 or 200 

MG), T5 

THEO-24 (100, 200, 300 or 400 

MG), T3 

Theochron (100, 200 or 300 MG), 

T2 

Theophylline Solution, T2 

Theophylline (400 or 600 MG) 

Tablet ER, T2 

Theophylline Anhydrous (100, 

200, 300 or 450 MG), T2 

Theophylline In 5% Dextrose (200 

MG/0.1L, 200 MG/50 ML or 800 

MG/.25L), T2 

THERACYS, T3 

THERMAZENE, T2 

THIOLA, T3 

Thioridazine HCL Oral Conc., T2 

Thioridazine HCL (10, 25, 50 or 100 

MG), T2 

Thiothixene (1, 2, 5 or 10 MG), T2 

THYROLAR-1, T3 

THYROLAR-1/2, T3 

THYROLAR-1/4, T3 



TICAR (1 or 30 G) Vial, T3 

TICAR Piggyback, T3 

TICAR IN DEXTROSE (2 G/50 ML, 3 

G/100 ML or 4 G/100 ML), T3 

Ticlopidine HCL, T2 

TIKOSYN (125, 250 or 500 MG), T4 

Tilia Fe, T2 

TIMENTIN, T3 

Timolol Maleate (0.25 or 0.5%) 

Drops, T1 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

21

Timolol Maleate (5, 10 or 20 MG) 

Tablet, T2 

Timolol Maleate (0.25 or 0.5%) Sol- 

Gel, T2 

TIROSINT (13, 25, 50, 75, 88, 100, 

112, 125, 137 or 150 MCG), T4 

Tizanidine HCL (2 or 4 MG), T2 

TOBI, T5 

Tobramycin Sulfate Vial, T2 

Tobramycin Sulfate Drops, T2 

Tobramycin-Dexamethasone, T2 

Tolazamide (250 or 500 MG), T2 

Tolbutamide, T2 

Tolmetin Sodium Capsule, T2 

Tolmetin Sodium (200 or 600 MG) 

Tablet, T2 

Tolterodine Tartrate (1 or 2 MG), T3 

Topiragen (25, 50, 100 or 200 MG), 

T2 

Topiramate (15 or 25 MG) Cap 

Sprink, T2 

Topiramate (25, 50, 100 or 200 


Topotecan HCL, T3 

Torsemide (5, 10, 20 or 100 MG), 

T2 

TPN ELECTROLYTES, T3 

TRACLEER (62.5 or 125 MG), T5 

TRADJENTA, T3 

Tramadol HCL, T2 

Tramadol HCL-Acetaminophen, T2 

Trandolapril (1, 2 or 4 MG), T2 

Tranexamic Acid, T3 

Tranylcypromine Sulfate, T2 

TRAVAMULSION, T3 

TRAVASOL (8.5 or 10 %), T2 

TRAVATAN Z, T3 

Trazodone HCL (50, 100, 150 or 

300 MG), T2 

TRECATOR, T3 

TRELSTAR (3.75 MG/2 ML, 11.25 

MG/2 ML or 22.5 MG/2 ML), T5 

Tretinoin (0.025. 0.05 or 0.1 %) 

Cream, T2 

Tretinoin (0.025 or 0.01 %) Gel, T2 

Tretinoin Capsule, T5 

Tri-Legest Fe, T2 

Tri-Previfem, T2 

Tri-Sprintec, T2 

Triamcinolone 1% Cream, T2 

Triamcinolone Acetonide (0.025, 

0.1 or 0.5 %) Cream, T2 

Triamcinolone Acetonide (0.025 or 

0.1 %) Lotion, T2 

Triamcinolone Acetonide (0.025 or 

0.1 or 0.5%) Oint., T2 

Triamcinolone Acetonide Paste, 

T2 

Triamterene-HCTZ (37.5 MG or 50 

MG-25 MG) Capsule, T1 

Triamterene-HCTZ Tablet, T1 

Triamterene-Hydrochlorothiazid, 

T1 

Triazolam (0.125 or 0.25 MG), T2 

Tricitrates, T2 

TRICOR (48 or 145 MG), T4 

Triderm, T2 

TRIDESILON Cream, T2 

TRIDESILON Oint., T2 

Trifluoperazine HCL (1, 2, 5 or 10 

MG), T2 

Trifluridine, T2 

Trihexyphenidyl HCL (2 or 5 MG) 

Tablet, T2 

Trihexyphenidyl HCL Elixir, T2 

TRIHIBIT, T3 

TRILEPTAL, T3 

Trilyte With Flavor Packets, T2 

Trimethoprim, T2 

Trimipramine Maleate (25, 50 or 

100 MG), T2 

Trinessa, T2 

TRIPEDIA, T3 

TRISENOX, T3 

Trivora-28, T2 

TRIZIVIR, T5 

TROPHAMINE, T2 

Tropicamide (0.5 or 1 %), T2 

TRUVADA, T5 

TWINRIX Vial, T3 

TWINRIX Disp Syrin, T3 

TYGACIL, T3 

TYKERB, T5 

TYPHIM VI, T3 

TYZEKA, T5 

TYZINE Spray, T3 

TYZINE (0.05 or 0.1 %) Drops, T3 

U 

U-Cort, T2 

UNITHROID (25, 50, 75, 88, 100, 

112, 125, 150, 175, 200 or 300 

MG), T3 

Urea (40 or 50%) Cream, T2 

Urea Lotion, T2 

Urea (40 or 45%) Gel, T2 

Ursodiol, T2 

V 

Valacyclovir (500 or 1000 MG), T2 

VALCYTE, T5 

Valproate Sodium, T2 

Valproic Acid Solution, T2 

Valproic Acid Capsule, T2 

Vancomycin HCL (1 or 10 G) Vial, 

T2 

Vancomycin HCL (125 or 250 MG) 

Capsule, T5 

VANDETANIB (100 or 300 MG), T5 

VAQTA Disp Syrin, T3 

VAQTA Vial, T3 

VARIVAX VACCINE, T3 

VELCADE, T5 

VELETRI, T5 

Velivet, T2 

22

Venlafaxine HCL (25, 47.5, 50, 75 

or 100 MG), T2 

Venlafaxine HCL ER (37.5, 75 or 

150 MG), T2 

VENLAFAXINE HCL ER (37.5, 75, 

150 or 225 MG), T4 

Verapamil ER (120, 180 or 240 MG) 

Cap 24 H PEL, T2 

Verapamil ER (120, 180 or 240 MG) 

Tablet ER, T2 

Verapamil ER PM (100, 200 or 300 

MG) Cap 24 H PCT, T2 

Verapamil HCL Cap 24 H PEL, T2 

Verapamil HCL (40, 80 or 120 MG) 

Tablet, T2 

VERDESO, T4 

VERIPRED 20, T2 

VICTOZA 3-PAK, T4 

VICTRELIS, T5 

VIDAZA, T5 

VIDEX, T3 

VIGAMOX, T4 

VIIBRYD Tabs DS PK, T4 

VIIBRYD (10, 20 or 40 MG) Tablet, 

T4 

VIMPAT Solution, T4 

VIMPAT (50, 100, 150 or 200 MG) 

Tablet, T4 

VIMPAT Vial, T4 

Viorele, T2 

VIRACEPT (250 or 625 MG), T5 

VIRAMUNE, T3 

VIREAD Powder, T5 

VIREAD (150, 200, 250 or 300 MG) 

Tablet, T5 

VIVOTIF BERNA, T3 

VOTRIENT, T5 

VPRIV, T5 

W 

Wal-Itin, T1 

Warfarin Sodium (1, 2, 2.5, 3, 4, 5, 

6, 7.5 or 10 MG), T1 

Water, T2 

WELCHOL Tablet, T4 

WELCHOL Powd Pack, T4 

WINRHO SDF (1500/1.3 ML or 

5000/4.4 ML), T5 

X 

X-Viate Lotion, T2 

X-Viate Cream, T2 

XALKORI (200 or 250 MG), T5 

XENAZINE (12.5 or 25 MG), T5 

XOLAIR, T5 

XYREM, T5 

Y 

YERVOY, T5 

YF-VAX, T3 

YODOXIN (210 or 650 MG), T2 

Z 

Zafirlukast (10 or 20 MG), T2 

Zaleplon (5 or 10 MG), T2 

ZAVESCA, T5 

Zazole (0.4% or 0.8%), T2 

ZELBORAF, T5 

ZEMAIRA (2 MCG/ML, 5 MCG/ML 

or 1000 MG) Vial, T5 

ZEMPLAR (1, 2 or 4 MCG) Capsule, 

T3 

Zenchent, T2 

Zenchent Fe, T2 

ZENPEP (3-10-16, 5-15-27 K, 10- 

34-55, 15-51-82, 20-68-109 or 

25-85-136), T3 

ZERIT, T3 

ZETIA, T3 

ZIAGEN Tablet, T3 

ZIAGEN Solution, T3 

Zidovudine Tablet, T2 

Zidovudine Syrup, T2 

Zidovudine Capsule, T2 

Ziprasidone HCL (20, 40, 60 or 80 

MG), T2 

ZMAX PEDIATRIC, T3 

ZOLADEX (3.6 or 10.8 MG), T5 

ZOLINZA, T5 

Zolpidem Tartrate (5 or 10 MG), T2 

ZOMETA Vial, T5 

ZOMETA Infus. BTL, T5 

ZONALON, T3 

Zonisamide (25, 50 or 100 MG), T2 

ZORBTIVE, T5 

ZORTRESS (.25, .5 or .75 MG), T4 

ZOSTAVAX, T3 

Zovia 1-35E, T2 

Zovia 1-50E, T2 

ZOVIRAX Oint., T3 

ZOVIRAX Cream, T3 

ZYTIGA, T5 

ZYVOX Tablet, T5 

ZYVOX Susp Recon, T5 

ZYVOX IV Soln, T5 






T1 = Tier 1 

T2 = Tier 2 

T3 = Tier 3 

T4 = Tier 4 

T5 = Tier 5 

23

Call Member Services for questions or benefit information: 

1-800-544-0088 (TTY 1-800-735-2929) 





www.care1stmedicare.com 

Care1st (HMO, HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program 

in counties where D-SNP Services are available. The benefit information provided is a brief summary, not a complete description of 

benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. 

Limitations, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member 

Services: 1-800-544-0088 (TTY 1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 

a.m. to 8:00 p.m., Monday - Friday, February 15 – September 30. Esta información está disponible gratuitamente en otros idiomas. 

Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 

8:00 a.m. to 8:00 p.m., Lunes a Viernes, Feb. 15 - Sep. 30. 





Dental Benefit 

Care1st (HMO, HMO SNP) Health Plan is pleased 

to be able to offer dental benefits in 2013 to our 

members. Delta Dental Plan has been providing and 

administering dental benefits since 1954. 

Clients and enrollees rate Delta Dental more 

favorably on reputation, value, quality of care and 

customer service than any other brand. They deliver 

an exceptional customer experience with fast 

and accurate claims processing, ease of use and 

administration, and personalized service. 

Four out of five dentists nationwide are contracted 

Delta Dental dentists, giving enrollees convenient 

access and quality assurance through the nation’s 

largest dentist network. 

DELTA DENTAL COVERS: 

• Routine dental care 

• Oral exams - $0 copay 

• Dental X-rays - $0 copay 

• Prophylaxis (cleaning) - $0 copay 

Additional Dental Care Services: Refer to the Dental 

Member Handbook for copayment amounts. 

• Non-routine/emergency services 

• Diagnostic services 

• Restorative services (Crowns) 

• Endodontics and Periodontics 

• Prosthodontics 

• Oral and Maxillofacial Surgery 

• Orthodontics 

• Emergency treatment of dental pain 

Please refer to your Dental Member Handbook for full 

information about your dental benefit. Benefit limits, 

authorizations and referrals may apply to certain dental 

services. No plan authorization/referral is required for dental 

services, but prior benefit authorization may be required from 

your dental benefit provider. Additional copays may apply 

for a full set of dental x-rays received more often than every 

two years. Dental copays are subject to change. Refer to 

the current Dental Member Handbook for details. Medicarecovered 

dental care associated with Medicare-covered 

events, e.g. trauma, requires a referral from us. If services for 

a listed procedure are performed by the assigned Contract 

Dentist, the Enrollee pays the specified Copayment. Listed 

procedures which require a Dentist to provide Specialist 

Services, and are referred by the assigned Contract Dentist, 

must be preauthorized in writing by Delta Dental. 

Care1st is a Coordinated Care plan with a Medicare contract 

and a contract with the California Medicaid program in counties 

where D-SNP Services are available. The benefit information 

provided is a brief summary, not a complete description of 

benefits. For more information contact the plan. Benefits and/ 

or co-payments/co-insurance may change on January 1 of 

each year. Limitations, copayments, and restrictions may 

apply. This information is available for free in other languages. 

Please contact Member Services: 1-800-544-0088 (TTY 

1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, 

October 1 – February 14; 8:00 a.m. to 8:00 p.m., Monday - 

Friday, February 15 – September 30. Esta información está 

disponible gratuitamente en otros idiomas. Comuníquese con 

Servicios para los Miembros: 1-800-544-0088 (TTY 1-800- 

735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 

a.m. to 8:00 p.m., Lunes a Viernes, Feb. 15 - Sep. 30. 

我們可免費以其它語言為您提供這資訊。請致電會員服務部 

免費熱線 :1-800-544-0088 ( 聽障和語障人士可致電 1-800-735- 

2929), 由 10 月 1 日至 2 月 14 日 , 我們的辦公時間為每週七天 , 

上午 8:00 點至晚上 8:00 點。由 2 月 15 日至 9 月 30 日 , 我們的辦 

公時間為週一至週五 , 上午 8:00 點至晚上 8:00 點。 



Outbound Education & 

Verification (OEV) Call 

After receiving your application, a Care1st (HMO, 

HMO SNP) Health Plan plan representative will call 

you to review your application and answer any 

questions you may have. They will also explain 

Care1st guidelines and procedures. 

This call is required by Medicare and will not affect 

the status of your application. Your sales agent will 

not be present during the time of the call. 

Topics that will be discussed include: 

☐ Care1st Health Plan is an HMO Plan. What does 

this mean for our members? 

☐ Care1st is a Medicare Advantage Prescription 

Drug Plan. Care1st is not original Medicare and it 

is not a Medigap or Medicare supplemental 

insurance plan. 

☐ Use your Care1st member ID card for receiving 

services. Do not use your red, white and blue 

Medicare card. 

☐ Care1st offers a list of services and their cost sharing 

amounts. We will make sure you have this list. 

☐ Care1st offers a network of doctors, specialists, 

hospitals, and other providers that provide 

healthcare services to plan members. Familiarize 

yourself with these approved providers because you 

must use our in network providers to get your 

health care services. These health care providers in 

the plan’s network can change at any time, so 

check our website at www.Care1stMedicare.com or 

call Member services for the most up-to-date list. 

☐ Care1st has a network of pharmacies. In most 

situations, we’ll only pay for your prescriptions if 

you use a pharmacy in our network. 

☐ We will explain Care1st’s membership enrollment 

cancellation policy. 


D-SNP Services are available. The benefit information provided is a brief summary, not a complete description of benefits. For more 

information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, 

and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 




Feb. 15 - Sep. 30. 





What to Expect 

After Enrollment 

STEPS AFTER ENROLLMENT: 

1. ENROLLMENT FORMS 

RECEIVED 

Your enrollment is sent to 

Care1st (HMO, HMO SNP) by 

phone, mail, fax, agent or via 

the internet. 

MEMBER ID 


4. MEMBER ID CARD 

Within 10 days of your 

confirmed enrollment you will 

receive your Member ID card. 

You need to bring your new 

Member ID card with you to 

all doctor, hospital and 

pharmacy visits. 

2. CONFIRMATION 

Within 10 days of enrollment, 

you will receive a confirmation 

of enrollment letter in the 

mail. This letter will also serve 

as confirmation that Medicare 

has approved your 

enrollment forms. 

5. WELCOME PACKAGE 

You will receive a package 

containing important plan 

documents. They include 

the Evidence of Coverage, Drug 

Formulary and Provider 

Directory. 

3. VERIFICATION CALL 

Within 10 days of enrollment 

you will receive a phone call 

to confirm that your Medicare 

Advantage Plan was explained 

completely by your sales agent. 

During this call you will be asked 

to confirm that it was your 

intent to enroll in the plan. 

6. PREMIUM ASSISTANCE 

If you qualify for the state’s “Extra 

Help”, you will receive a “LIS” 

(Low Income Subsidy) letter 

within 10 days of verified 

enrollment. 

If you have questions about enrollment, call: 1-800-544-0088 

(TTY 1-800-735-2929) 





Services are available. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY 

1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 p.m., Monday - Friday, 



Feb. 15 - Sep. 30. 






Visit Us 

Online! 

Your Care1st (HMO, HMO SNP) 

Resource Site: 

www.Care1stMedicare.com 

Our website is your resource for the most up-to-date information. 

You’ll find: 

• Provider listings for specialists and primary care 

physicians 

• Retail Pharmacy list 

• Drugs and formulary information 

• Service area 

• Member materials including Statement of 

Benefits, Evidence of Coverage and Annual 

Notice of Changes 

• Out-of-Network Coverage information 

and much more... 

Bookmark our page or add 

us to your favorites for quick 

and easy access. 

www.Care1stMedicare.com 

For questions about our website, call: 

1-800-544-0088 (TTY 1-800-735-2929) 

8:00 a.m. to 8:00 p.m., seven days a week, October 1 – 

February 14; 8:00 a.m. to 8:00 p.m., Monday - Friday, 




D-SNP Services are available. This information is available for free in other languages. Please contact Member Services: 1-800-544- 

0088 (TTY 1-800-735-2929), 8:00 a.m. to 8:00 p.m., seven days a week, October 1 – February 14; 8:00 a.m. to 8:00 p.m., Monday 

- Friday, February 15 – September 30. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios 

para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 7 días a la semana , Oct. 1 - Feb. 14; 8:00 a.m. to 8:00 p.m., Lunes 

a Viernes, Feb. 15 - Sep. 30. 





Multi‐language Interpreter Services 

English: We have free interpreter services to answer any questions you may have about our 

health or drug plan. To get an interpreter, just call us at 1‐800‐544‐0088. Someone who speaks 

English/Language can help you. This is a free service. 

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta 

que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, 

por favor llame al 1‐800‐544‐0088. Alguien que hable español le podrá ayudar. Este es un 

servicio gratuito. 

Chinese Mandarin: 我们提供免费的翻译服务 , 帮助您解答关于健康或药物保险的任何疑 

问。如果您需要此翻译服务 , 请致电 1‐800‐544‐0088。我们的中文工作人员很乐意帮助 

您。这是一项免费服务。 

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問 , 為此我們提供免費的翻譯 

服務。如需翻譯服務 , 請致電 1‐800‐544‐0088。我們講中文的人員將樂意為您提供幫助。 

這是一項免費服務。 

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling‐wika upang masagot ang anumang 

mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang 

makakuha ng tagasaling‐wika, tawagan lamang kami sa 1‐800‐544‐0088. Maaari kayong 

tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. 

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos 

questions relatives à notre régime de santé ou d'assurance‐médicaments. Pour accéder au 

service d'interprétation, il vous suffit de nous appeler au 1‐800‐544‐0088. Un interlocuteur 

parlant Français pourra vous aider. Ce service est gratuit. 

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức 

khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1‐800‐544‐0088 sẽ có 

nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . 

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem 

Gesundheits‐ und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1‐800‐544‐0088. 

Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. 

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 

서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1‐800‐544‐0088 번으로 

문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 

운영됩니다. 

H5928_13_003_GEN File & Use 08112012

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного 

плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы 

воспользоваться услугами переводчика, позвоните нам по телефону 1‐800‐544‐0088. Вам 

окажет помощь сотрудник, который говорит по‐pусски. Данная услуга бесплатная. 

إننا نقدم خدمات المترجم الفوري المجانية للإجابة عن أي أسئلة تتعلق بالصحة أو جدول الأدوية لدينا.‏ للحصول على 

سيقوم شخص ما يتحدث العربية 

هذه مترجم فوري،‏ ليس عليك سوى الاتصال بنا على 

بمساعدتك خدمة 

Arabic: 

. مجانية 

.0088-544-800-1 

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande 

sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1‐800‐544‐ 

0088. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio 

gratuito. 

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer 

questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, 

contacte‐nos através do número 1‐800‐544‐0088. Irá encontrar alguém que fale o idioma 

Português para o ajudar. Este serviço é gratuito. 

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen 

konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1‐800‐ 

544‐0088. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. 

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w 

uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z 

pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1‐800‐544‐0088. Ta 

usługa jest bezpłatna. 

Hindi: हमारे ःवाःथ्य या दवा की योजना के बारे में आपके िकसी भी ूश्न के जवाब देने के 

िलए हमारे पास मुफ्त दुभािषया सेवाएँ उपलब्ध हैं. एक दुभािषया ूाप्त करने के िलए, बस हमें 1- 

800-544-0088 पर फोन करें. कोई व्यिक्त जो िहन्दी बोलता है आपकी मदद कर सकता है. यह 

एक मुफ्त सेवा है. 

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするため 

に、無料の通訳サービスがありますございます。通訳をご用命になるには、1-800-544- 

0088 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービ 

スです。 

. 

H5928_13_003_GEN File & Use 08112012

This is an advertisement. 

PRE-ENROLLMENT 

BOOK 2013 

Care1st AdvantageOptimum Plan (HMO) 

SANTA CLARA CouNTY 

Care1st Health Plan 

P.O. Box 4239, Montebello, CA 90640 

For enrollment inquiries please call: 

1-800-847-1222 

8:00 a.m. to 8:00 p.m., 7 days a week, Oct. 1 - Feb. 14 

8:00 a.m. to 8:00 p.m., Monday to Friday, Feb. 15 - Sep. 30 

Hearing Impaired Assistance TTY 

(through California Relay Service) 

1-800-735-2929 

8:00 a.m. to 8:00 p.m., 7 days a week, Oct. 1 - Feb. 14 

8:00 a.m. to 8:00 p.m., Monday to Friday, Feb. 15 - Sep. 30 

Care1stMedicare.com

Santa Clara County - Care1st Health Plan

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