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UnitedHealthcare SignatureValueTM Offered by UnitedHealthcare of California HMO Pharmacy Schedule of Benefits Prescription Units or up to a 90-day supply) This Schedule of Benefits provides specific details about it may be Medically Necessary for you to receive a your prescription drug benefit, as well as the exclusions certain medication without trying an alternative drug first. and limitations. Together, this document and the In these instances, your Participating Physicians will Supplement to the Combined Evidence of Coverage and need to provide evidence to UnitedHealthcare in the Disclosure Form as well as the medical Combined form of documents, lab results, records or clinical trials Evidence of Coverage and Disclosure Form determine that establish the use of the requested medications as the exact terms and conditions of your prescription drug Medically Necessary. Participating Physicians may call or fax Preauthorization requests to UnitedHealthcare. Applicable Copayments will be charged for prescriptions What do I pay when I fill a prescription? that require Preauthorization if approved. You will pay only a Copayment when filling a For a list of the selected medications that require prescription at a UnitedHealthcare Participating UnitedHealthcare’s Preauthorization, please contact Pharmacy. You will pay a Copayment every time a UnitedHealthcare’s Customer Service department. prescription is filled. Your Copayments are as shown in the grid above. There are selected brand-name medications where you When prescribed by your Participating Physician as will pay a generic Copayment of just $20. A copy of the Medically Necessary and filled at a Participating Selected Brands List is available upon request from Pharmacy, subject to all the other terms and conditions UnitedHealthcare’s Customer Service department and of this outpatient prescription drug benefit, the following may be found on UnitedHealthcare’s Web site at Disposable all-in-one prefilled insulin pens, insulin cartridges and needles for nondisposable pen devices are covered when Medically Necessary, in accordance Selected generic Formulary, brand-name Formulary and with UnitedHealthcare’s Preauthorization process. non-Formulary medications require a Member to go Federal Legend Drugs: Any medicinal substance through a Preauthorization process using criteria based which bears the legend: “Caution: Federal law upon Food and Drug Administration (FDA)-approved prohibits dispensing without a prescription.” indications or medical findings, and the current availability of the medication. UnitedHealthcare reviews Generic Drugs: Comparable generic drugs may be requests for these selected medications to ensure that substituted for brand-name drugs unless they are on they are Medically Necessary, being prescribed UnitedHealthcare’s Selected Brands List. A copy of according to treatment guidelines consistent with the Selected Brands List is available upon request standard professional practice and are not otherwise from UnitedHealthcare’s Customer Service department or may be found on UnitedHealthcare’s Web site at www.uhcwest.com. Because UnitedHealthcare offers a comprehensive Formulary, selected non-Formulary medications will not Miscellaneous Prescription Drug Coverage: For the be covered until one or more Formulary alternatives, or purposes of determining coverage, the following items non-Formulary preferred drugs have been tried. are considered prescription drug benefits and are UnitedHealthcare understands that situations arise when covered when Medically Necessary: glucagons, insulin, insulin syringes, blood glucose test strips, Questions? Call the Customer Service Department at 1-800-624-8822. lancets, inhaler extender devices, urine test strips and information, refer to Section Five of your medical anaphylaxis prevention kits (including, but not limited Combined Evidence of Coverage and Disclosure to, EpiPen®, Ana-Kits® and Ana-Guard®). See the medical Combined Evidence of Coverage and Drugs prescribed by a dentist or drugs when Disclosure Form for coverage of other injectable prescribed for dental treatment are not covered. medications in Section Five under “Your Medical Drugs when prescribed to shorten the duration of Oral Contraceptives: Federal Legend oral Enhancement medications when prescribed for the contraceptives, prescription diaphragms and oral following nonmedical conditions are not covered: medications for emergency contraception. weight loss, hair growth, sexual performance, athletic State Restricted Drugs: Any medicinal substance performance, cosmetic purposes, anti-aging for that may be dispensed by prescription only, according cosmetic purposes, and mental performance. Examples of drugs that are excluded when prescribed for such conditions include, but are not limited to, Penlac®, Retin-A®, Renova®, Vaniqa®, Propecia®, While the prescription drug benefit covers most Lustra®, Xenical® or Meridia®. This exclusion does not medications, there are some that are not covered or exclude coverage for drugs when Preauthorized as limited. These drugs are listed below. Some of the Medically Necessary to treat morbid obesity or following excluded drugs may be covered under your diagnosed medical conditions affecting memory, medical benefit. Please refer to Section Fiveof your including, but not limited to, Alzheimer’s dementia. medical Combined Evidence of Coverage and Infertility: All forms of prescription medication when Disclosure Form titled “Your Medical Benefits” for more prescribed for the treatment of infertility are not information about medications covered by your medical covered. If your Employer has purchased coverage for infertility treatment, prescription medications for the Administered Drugs: Drugs or medicines delivered or treatment of infertility may be covered under that administered to the Member by the prescriber or the benefit. Please refer to Section Five of your medical prescriber’s staff are not covered. Injectable drugs are Combined Evidence of Coverage and Disclosure Form titled “Your Medical Benefits” for additional administered during a Physician’s office visit or self- administered pursuant to training by an appropriate Injectable Medications: Except as described under health care professional. Refer to Section Five of your the section “Medications Covered by Your Benefit,” medical Combined Evidence of Coverage and injectable medications, including, but not limited to, Disclosure Form titled “Your Medical Benefits” for self-injectables, infusion therapy, allergy serum, more information about medications covered under immunization agents and blood products, are not covered as an outpatient prescription drug benefit. Compounded Medication: Any medicinal substance However, these medications are covered under your that has at least one ingredient that is Federal Legend medical benefit as described in and according to the or State Restricted in a therapeutic amount. terms and conditions of your medical Combined Compounded medications are not covered unless Evidence of Coverage and Disclosure Form. Outpatient injectable medications administered in the Physician’s office (except insulin) are covered as a Diagnostic Drugs: Drugs used for diagnostic medical benefit when part of a medical office visit. purposes are not covered. Refer to Section Five of Injectable medications may be subject to your medical Combined Evidence of Coverage and UnitedHealthcare’s Preauthorization requirements. For Disclosure Form for information about medications additional information, refer to Section Five of your covered for diagnostic tests, services and treatment. medical Combined Evidence of Coverage and Dietary or nutritional products and food Disclosure Form under “Your Medical Benefits.” supplements, whether prescription or nonprescription, Inpatient Medications: Medications administered to a including vitamins (except prenatal), minerals and Member while an inpatient in a Hospital or while fluoride supplements, health or beauty aids, herbal receiving Skilled Nursing Care as an inpatient in a supplements and/or alternative medicine, are not Skilled Nursing Facility are not covered under this covered. Phenylketonuria (PKU) testing and treatment Pharmacy Schedule of Benefits. Please refer to is covered under your medical benefit including those Section Five of your medical Combined Evidence of formulas and special food products that are a part of a Coverage and Disclosure Form titled “Your Medical diet prescribed by a Participating Physician provided Benefits” for information on coverage of prescription that the diet is Medically Necessary. For additional medications while hospitalized or in a Skilled Nursing Facility. Outpatient prescription drugs are covered for The drug is approved by the FDA. (2) The drug is Members receiving Custodial Care in a rest home, prescribed by a participating licensed health care nursing home, sanitarium, or similar facility if they are professional. (3) The drug is Medically Necessary to obtained from a Participating Pharmacy in accordance treat the medical condition. (4) The drug has been with all the terms and conditions of coverage set forth recognized for treatment of a medical condition by one in this Schedule of Benefits and in the Pharmacy of the following: (a) The American Hospital Formulary Supplement to the Combined Evidence of Coverage Service Drug Information, (b) One of the following and Disclosure Form. When a Member is receiving compendia, if recognized by the federal Centers for Custodial Care in any facility, relatives, friends or Medicare and Medicaid Services as part of an caregivers may purchase the medication prescribed by anticancer chemotherapy regimen: (i) The Elsevier a Participating Physician at a Participating Pharmacy Gold Standard's Clinical Pharmacology; (ii) The and pay the applicable Copayment on behalf of the National Comprehensive Cancer Network Drug and Biologics Compendium; (iii) The Thompson Investigational or Experimental Drugs: Medication Micromedex DRUGDEX, or (c) Two articles from prescribed for experimental or investigational major peer reviewed medical journals that present therapies are not covered, unless required by an data supporting the proposed Off-Label Drug Use or external, independent review panel pursuant to uses as generally safe and effective. Nothing in this California Health and Safety Code Section 1370.4. section shall prohibit UnitedHealthcare from use of a Further information about Investigational and Formulary, Copayment, technology assessment panel, Experimental procedures and external review by an or similar mechanism as a means for appropriately independent panel can be found in the medical controlling the utilization of a drug that is prescribed for Combined Evidence of Coverage and Disclosure Form a use that is different from the use for which that drug in Section Five, “Your Medical Benefits” and Section has been approved for marketing by the FDA. Denial Eight, “Overseeing Your Health Care” for appeal of a drug as investigational or experimental will allow the Member to use the Independent Medical Review System as defined in the medical Combined Evidence Medications dispensed by a non-Participating Pharmacy are not covered except for prescriptions required as a result of an Emergency or Urgently Over-the-Counter Drugs: Medications (except insulin) available without a prescription (over-the-counter) or for which there is a nonprescription Medications prescribed by non-Participating chemical and dosage equivalent available, even if Physicians are not covered except for prescriptions ordered by a Physician, are not covered. All required as a result of an Emergency or Urgently nonprescription (over-the-counter) contraceptive jellies, ointments, foams or devices are not covered. New medications that have not been reviewed for Prior to Effective Date: Drugs or medicines safety, efficacy and cost-effectiveness and purchased and received prior to the Member’s approved by UnitedHealthcare are not covered unless effective Date or subsequent to the Member’s Preauthorized by UnitedHealthcare as Medically Replacement of lost, stolen or destroyed medications Non-Covered Medical Condition: Prescription medications for the treatment of a non-covered medical condition are not covered. This exclusion Saline and irrigation solutions are not covered. does not exclude Medically Necessary medications Saline and irrigation solutions are covered when directly related to non-Covered Services when Medically Necessary, depending on the purpose for complications exceed follow-up care, such as life- which they are prescribed, as part of the home health threatening complications of cosmetic surgery. or Durable Medical Equipment benefit. Refer to your medical Combined Evidence of Coverage and Off-Label Drug Use. Off Label Drug Use means that Disclosure Form Section Five for additional the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is different than that for which the FDA approved the Sexual Dysfunction Medication: All forms of drug. UnitedHealthcare excludes coverage for Off medications when prescribed for the treatment of Label Drug Use, including off label self-injectable sexual dysfunction, which includes, but is not limited drugs, except as described in the medical Combined to, erectile dysfunction, impotence, anorgasmy or Evidence of Coverage and Disclosure Form and any hyporgasmy, are not covered. An example of such applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: (1) Smoking cessation products, including, but not limited to, nicotine gum, nicotine patches and nicotine nasal spray, are not covered. However, smoking cessation products are covered when the Member is enrolled in a smoking cessation program approved by UnitedHealthcare. For information on UnitedHealthcare’s smoking cessation program, refer to the medical Combined Evidence of Coverage and Disclosure Form in Section Five, “Your Medical Benefits, in the section titled “Outpatient Benefits”, under “Health Education Services” or contact Customer Service or visit our Web site at www.uhcwest.com. Therapeutic devices or appliances, including, but not limited to, support garments and other nonmedical substances, insulin pumps and related supplies (these services are provided as Durable Medical Equipment) and hypodermic needles and syringes not related to diabetic needs or cartridges are not covered. Birth control devices and supplies or preparations that do not require a Participating Physician’s prescription by law are also not covered, even if prescribed by a Participating Physician. For further information on certain therapeutic devices and appliances that are covered under your medical benefit, refer to your medical Combined Evidence of Coverage and Disclosure Form in Section Five, titled “Your Medical Benefits” under “Outpatient Benefits” located, for example, in subsections titled “Diabetic Self Management”, “Durable Medical Equipment,” or “Home Health Care and Prosthetics and Corrective Appliances.” Workers’ Compensation: Medication for which the cost is recoverable under any workers’ compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient is not covered. Further information about workers’ compensation can be found in the medical Combined Evidence of Coverage and Disclosure Form in Section Six under “Payment Responsibility.” UnitedHealthcare reserves the right to expand the Preauthorization requirement for any drug product. Questions? Call the HMO Customer Service department at 1-800-624-8822 or TDHI 1-800-442-8833. 2011 United HealthCare Services, Inc.

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