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AARP Medicare Plans from UnitedHealthcare

2022 Medicare Prescription Drug Plan Details

AARP MedicareRx Preferred (PDP)

Prescription Drug Benefits

This table gives you basic information about the prescription drug benefits that may be available with this
Medicare plan with prescription drug coverage. You can also create a drug list for the prescription drugs you take
or edit a drug list you've already created. For more details, see the Comprehensive Formulary (PDF) under
Prescription Drug Coverage in the Plan Documents section below.

Drug Copays and Discounts

 Annual Prescription Deductible

$0

If your plan has an

annual deductible, you (or others on your behalf) will pay your drug
costs up to the amount of this deductible before moving into the
Initial Coverage Stage.

Preferred Pharmacy Network

Cost Sharing (30 days)

$5 copay

Standard Network Pharmacy

Cost Sharing (30 days)

Tier 1: Preferred Generic Drugs

$15 copay
Preferred Mail Order Pharmacy
(90 days)
$0 copay

Standard Mail Order Pharmacy

(90 days)
$45 copay

Tier 2: Generic Drugs Preferred Pharmacy Network

Cost Sharing (30 days)

$10 copay

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Standard Network Pharmacy

Cost Sharing (30 days)

$20 copay
Preferred Mail Order Pharmacy
(90 days)
$0 copay
Standard Mail Order Pharmacy
(90 days)
$60 copay

Preferred Pharmacy Network

Cost Sharing (30 days)

$45 copay

Standard Network Pharmacy

Cost Sharing (30 days)

Tier 3: Preferred Brand Drugs

$47 copay
Preferred Mail Order Pharmacy
(90 days)
$120 copay

Standard Mail Order Pharmacy

(90 days)
$141 copay

Tier 3: Select Insulin Drugs

Preferred Pharmacy Network
Cost Sharing (30 days)

$35 copay

Standard Network Pharmacy

Cost Sharing (30 days)

You will pay a

maximum of $35 for a 1-month supply of insulin during the $35 copay
deductible, Initial Coverage and Coverage Gap or “Donut Hole” Preferred Mail Order Pharmacy
(90 days)
$105 copay

stages of your benefit. You will pay 5% of the cost of your insulin in
the Catastrophic Stage. This cost-sharing only applies to members Standard Mail Order Pharmacy
(90 days)
$105 copay

who do not qualify for a program that helps pay for your drugs
(“Extra Help”).

Tier 4: Non-Preferred Drugs Preferred Pharmacy Network

Cost Sharing (30 days)

40% coinsurance

Standard Network Pharmacy

Cost Sharing (30 days)

45% coinsurance
Preferred Mail Order Pharmacy
(90 days)
40% coinsurance

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45% coinsurance
Tier 5: Specialty Tier Drugs
Coverage Gap Stage
Catastrophic Coverage Stage
Preferred Retail Pharmacy Network
Standard Mail Order Pharmacy
(90 days)
Preferred Pharmacy Network
Cost Sharing (30 days)
33% coinsurance
Standard Network Pharmacy
Cost Sharing (30 days)
33% coinsurance
During the Coverage Gap
Stage, you (or others on your
behalf) will pay no more than
25% of the negotiated price for
drugs. You generally stay in this
stage until your out-of-pocket
cost reaches $7,050.
You may pay less if your plan
has additional coverage in the
gap.
Always use your Medicare
Prescription Drug plan member
ID card during the coverage gap
to get the plan's discounted drug
rates. The money you spend
using your card counts toward
your out-of-pocket costs.
After your total out-of-pocket
costs reach $7,050, you will pay
the greater of $3.95 copay for
generic (including brand drugs
treated as generic), and $9.85
copay for all other drugs, or 5%
coinsurance.
You may be able to save on
your prescription copays when
you use our Preferred Retail
Pharmacy Network.
UnitedHealthcare works with
many retail pharmacies to offer
lower copaysfootnotefootnote1.
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Footnotes

footnotefootnote1Member may use any pharmacy in the network but may not receive preferred retail
pharmacy pricing. Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas.
Copays apply after deductible.

Your Drug List

This table helps you estimate what your drug costs might be with this Medicare plan with prescription drug
coverage. Get cost sharing and other helpful information, or create a drug list from the drugs you take.

Your Drug List Edit Coverage Details

Restasis EMU 0.05%

1 per Month, refill Every 1 Month

T3
QL

Initial Coverage Stage Copay or Coinsurance*

$45

Estimated Total Annual Costs: View details $1,174.34

Current Pharmacy Edit

Preferred Retail pharmacy

*Copay and coinsurance costs shown for Initial Coverage Stage. Your copays and coinsurance may change based
on the drug payment stage you are in. 

Drugs that are not on the plan's formulary and listed as "NC" (not covered) in the chart above may have quantity
limits if we approve a formulary exception for you. Please contact UnitedHealthcare to see if quantity limits
apply.

If you get Extra Help from Medicare to help pay for your Medicare Part D costs, your total costs may be lower
than what you see here.

Learn more about drug payment stages

Drug Coverage Details Legend

 
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T#Drug Tier Drug Tier: Drugs on your formulary (drug list)

are organized into different groups called tiers. Each tier has a different copay. For example, you may have
little or no copay for a Tier 1 drug, but may have to pay a larger copay for a Tier 3 or 4 drug.

NCNot Covered Not Covered (NC)

If a drug you entered in
this table is not in a plan's formulary (drug list), it will be listed as "Not Covered" (NC) in the table. Note:
If a drug isn't covered by a plan, you may be able to request an exception. If your exception is approved,
the drug still might have quantity limits. Your plan can give you more information.

STStep Therapy Step Therapy

There may be effective,
lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more
of these other drugs before the plan will cover your drug. If you have already tried other drugs or your
doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug. If you do
not get approval from the plan for a drug with a requirement or limit before using it, you may be
responsible for paying the full cost of the drug.

QLQuantity Limits Quantity Limit

The plan will cover only
a certain amount of this drug for one copay or over a certain number of days. These limits may be in place
to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the
limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity. If
you do not get approval from the plan for a drug with a requirement or limit before using it, you may be
responsible for paying the full cost of the drug.

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LALimited Access Limited Access

Drugs are considered
"limited access" if the FDA says the drug can be given out only by certain facilities or doctors. These
drugs may require extra handling, provider coordination or patient education that can’t be done at a
network pharmacy.

PAPrior Authorization Prior Authorization

The plan requires
you or your doctor to get prior approval for certain drugs. This means the plan needs more information
from your doctor to make sure the drug is being used and covered correctly by Medicare for your medical
condition. Certain drugs may be covered by either Medicare Part B (doctor and outpatient health care) or
Medicare Part D (prescription drugs) depending on how it is used. If you don’t get prior approval, the plan
may not cover the drug.

7DSeven Days Supply An opioid drug used for the

treatment of acute pain may be limited to a 7 day supply for members with no recent history of opiod use.
This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a
recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan. If
you do not get approval from the plan for a drug with a requirement or limit before using it, you may be
responsible for paying the full cost of the drug.

DLDispensing Limit Dispensing limits apply to this drug.

This drug is limited to a 1 month supply per prescription.

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PDSSPart D Senior Savings Model You will pay a

maximum of $35 for a 1-month supply of insulin during the deductible, Initial Coverage and Coverage
Gap or “Donut Hole” stages of your benefit. You will pay 5% of the cost of your insulin in the
Catastrophic Stage. This cost-sharing only applies to members who do not qualify for a program that helps
pay for your drugs (“Extra Help”).

 
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Plan Documents

PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don't already have this
viewer on your computer, download it free from the Adobe website.

English

General Plan Information

Enrollment Form (PDF)Opens in new tab

Summary of Benefits (PDF) Opens in new tab
Evidence of Coverage (PDF)*Opens in new tab
Star Ratings (PDF)Opens in new tab
Annual Notice of Changes (ANOC) (PDF)2 Opens in
new tab

Prescription Drug Coverage

Comprehensive Formulary (PDF) (Updated

10/12/2021)Opens in new tab
Prior Authorization Criteria (PDF) Opens in new tab
Step Therapy Criteria (PDF)Opens in new tab
Formulary Additions (PDF)Opens in new tab
Formulary Deletions (PDF)Opens in new tab
Alternative Drugs List (PDF)Opens in new tab

Pharmacy Directory

Online       
pharmacy directory

Other Languages

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General Plan Information

Formulario de Inscripción (PDF)Opens in new tab

Resumen de Beneficios (PDF)Opens in new tab
Comprobante de Cobertura (PDF)*Opens in new tab
Clasificación de la Calidad del Plan (PDF)Opens in new
tab
Aviso Annual de Cambios (PDF)2 Opens in new tab

Prescription Drug Coverage

Formulario Completo (PDF) (Actualizado

10/12/2021)Opens in new tab
Lista de Medicamentos Alternativos (PDF)Opens in
new tab

Pharmacy Directory

Directorio
       de Farmacias en Internet

網站查詢網上藥房名冊
      

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